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Veterinary rehabilitation optimizes clinical outcomes

Rehabilitation therapy for canine patients improves functional outcomes post-operatively, and helps with neurological conditions, intervertebral disc disease and soft tissue injuries.

The goal of veterinary rehabilitation is to provide pain management, promote mobility, and return a patient to the most functional outcome possible. Rehabilitation has become an important part of the treatment plan for animals recovering from orthopedic or neurological surgery and soft tissue injury, as well as for chronic osteoarthritis management, neurological conditions, and obesity management. The purpose of this article is to highlight several conditions in which rehabilitation would play an important part in optimizing a patient’s condition.

Orthopedic surgery

Femoral head ostectomy (FHO) is a surgery for which rehabilitation should be discussed and recommended to the client, preferably prior to the operation, as part of the overall treatment plan. Early postoperative rehabilitation is imperative to optimize range of motion and achieve the most functional outcome for the affected leg. This is especially important in small dogs with an FHO, since it is not uncommon for them to resist using their legs after any orthopedic surgery. In the early postoperative period (before sutures are removed), the focus is on pain management. Traditional pharmaceutical pain therapies are augmented with cryotherapy, gentle passive range of motion, and cold laser therapy. After the initial recovery period, acupuncture and musculoskeletal manipulation can help manage compensatory issues such as back pain and local hip pain. A qualified rehabilitation therapist can assist with incorporating appropriate modalities and progressing therapeutic exercises for optimal outcome. Underwater treadmill therapy is very useful in facilitating use of the limb due to the buoyancy and resistance effect of the water. The underwater treadmill is superior to swimming in recovery, because the patient is more likely to actively stretch the hip when he is walking on the treadmill; many dogs while swimming may “dangle” or not properly extend and use the hip. TPLO and MPL surgeries benefit from rehabilitation to help manage pain and encourage weight-bearing as soon as possible after surgery. Not as beneficial is the approach many clinicians take, which is to recommend rehabilitation for patients experiencing less than optimal outcomes after surgery, including not using the leg after significant time has passed, and encountering significant atrophy and loss of function. This is unfortunate as it is harder to reverse atrophy and preserve range of motion after chronic disuse. In my experience, the best benefit of rehabilitation after stifle surgery is that dogs are less likely to tear the ligament on the nonsurgical leg, which is placed under greater stress during the recovery period. Since recovery is dynamic, it is important that pain is managed thoughout the entire rehabilitation process. A supervised rehabilitation program with controlled return to function optimizes clinical outcomes.

Neurological conditions

Degenerative myelopathy is the disease that prompted me to search for options outside traditional Western medicine, to help patients cope with the devastating decline they endure without intervention. Unfortunately, many patients present after months of being administered a laundry list of medications, dietary recommendations and supplements.  Many of these supplements and dietary interventions should, in theory, prevent progression. In the integrative medicine paradigm, there is no standalone therapy for a degenerative myelopathy patient. This is a disease that truly requires an integrative approach, and early intervention with rehabilitation is critical. A study done in the Journal of Internal Medicine showed that physical rehabilitation kept patients ambulatory on an average of 255 days longer.2 A genetic test offered through the Orthopedic Federation of Animals3 looks for the genetic markers of degenerative myelopathy. If a patient is homozygous recessive, and is exhibiting signs of neurological decline and hind end weakness, it is highly likely he has the disease. If this is the case, it is critical to develop a program to manage other concomitant painful diseases that may cause pain as weak animals compensate for the degenerative myelopathy by placing stress on the spine and front end, which are overworked trying to stay ambulatory. Spinal manipulation is helpful, as is acupuncture, in managing pain for these animals. Dogs with degenerative myelopathy are often deficient from a Chinese Medical perspective, and need a conservative physical therapy program that consists of a shorter and more frequent exercise and treatment regimen. Prolonged exercise and aggressive treatment often depletes these dogs. Therapeutic exercises for proprioception and strength, along with underwater treadmill use, are key in keeping patients with degenerative myelopathy ambulatory. Consider having assistive devices at your clinic for patients with hind end weakness. These can include harnesses that support both the front and rear end (Help ‘Em Up), toe up boots (available through handicappedpets.com), and toe grips (Dr Buzby’s). Clients often struggle with fitting harnesses, and a poorly-fitted sling or harness can rub and cause sores and irritation. Helping clients choose and fit a harness is an important service we can provide.  Also, trimming nails to an appropriate length and applying toe grips is very helpful; clients appreciate assistance with this. Walking clients through recumbent dog care, including how to prevent decubital ulcers and helping with bladder expression and assisting with bowel movements, is not often thought of, but it’s an important part of helping clients cope with the degenerative myelopathy towards the end. Most importantly, despite the plethora of supplements with antioxidant and neuro-protectant qualities that have been recommended for patients with presumptive degenerative myelopathy, the one modality that stands out for making a significant difference is physical rehabilitation.

Intervertebral disc disease

Dogs with intervertebral disc disease come in a diverse variety of presentations:
  1. For the acutely painful dog without proprioceptive deficits, consideration should be given to nonsteroidal anti-inflammatories and gabapentin. Cold laser is helpful in managing both acutely painful dogs and those with chronic pain. Care must be given when one is considering musculoskeletal manipulation at acutely affected sites. Acupuncture and electroacupuncture are helpful in managing the acutely painful patient.
  2. Owners of painful dogs with rapid proprioceptive decline must be aware that surgery is a consideration. Dogs that had surgery and received electroacupuncture and Western medicine recovered faster than those that received electroacupuncture alone.4 Cold laser in the postoperative period is helpful for healing the incision, and for pain management.
  3. It is possible to help a patient with no deep pain to achieve spinal walking, but the majority will not walk again without surgical intervention. These dogs are good candidates for carts. Assisting clients with making measurements and fitting carts is a useful service to offer. As mentioned above, a poorly-fitted cart leads to skin chafing and improper biomechanics that may cause discomfort.
It is also important to address diet in patients with intervertebral disc disease as they are often on restricted activity and more likely to gain weight during this time. Switching from a higher-carbohydrate processed kibble diet to a raw or home-cooked balanced diet is helpful. Consideration should be given to cutting daily calories fed by 25% to 30%. Omega 3 fatty acids should be considered. Along with traditional pain management (gabapentin and nonsteroidal anti-inflammatories), numerous anti-inflammatory herbal formulas contain herbs such as boswellia and curcumin. Traditional Chinese medical formulas include Acute and Chronic Back formulas from Evergreen, and Jingtang Herbs Double P formula. Pulse Magnetic Therapy is being used more and more for patients with intervertebral disc disease.

Soft tissue injuries

Veterinarians and physical therapists trained in animal rehabilitation focus heavily on pinpointing the specific soft tissues involved in an injury, so that a targeted program can be implemented. This contrasts to the old school approach of “cage rest” for a generic diagnosis of soft tissue injury. While cage rest is an important part of rehabilitation, what’s more important is incorporating controlled activity designed to help with healing, pain management and preservation of range of motion. There is a fine balance between encouraging a gradual return to function and offsetting the development of scar tissue, disuse atrophy and compensatory changes as a result of the injury. Often there are subluxations present in the spine as the animal compensates for soft tissue injury.  Weakness or injury to an extremity creates a high likelihood that the animal will sustain an injury to his core trying to compensate for the injury.

Common soft tissue injuries seen in active dogs and canine athletes

Following are some of many soft tissue injuries, along with their most common presentations: Carpal laxity:  Hyperextension at the carpus can present with varying degrees of pain, and dogs that perform in flyball and agility are predisposed. Carpal support wraps help dogs with instability. Bicipital tenosynovitis, supraspinatus tendinopathy and medial shoulder instability: These injuries result from repetitive activities and overuse of the limb. Modalities such as ultrasound, shock wave, cold laser, platelet rich plasma and stem cell therapy are utilized to facilitate healing. Home exercises are designed to challenge the tissues after the acute phase when ice, rest and gentle massage and stretching may be the only things indicated.  Manual therapy encompasses cross friction massage and stretching, home exercises to strengthen the limb, underwater treadmill, progressing to trotting and walking downhill, and wheelbarrowing on the front legs. Iliopsoas strain: Pain occurs on extension of the hip with slight abduction and internal rotation. When one of these strains is suspected, look for other issues such as anterior cruciate ligament disease, meniscal tears, hip issues and lumbosacral disease. After the diagnosis is confirmed and the dog is comfortable with appropriate pain management, a rehabilitation program can begin. Modalities include cold laser and massage. Gentle stretching focusing on hip extension can involve an active hip stretch by having the dogs’ paws up on a surface and luring him forward to open the hip. Core strengthening exercises may also be prescribed. Anterior cruciate ligament tear: Rehabilitation should be considered for dogs with partial tears if surgery is not an option. The best outcome is likely in dogs that weight than 45 pounds. Dogs that are poor surgical candidates may benefit from a custom brace. Trauma to toes: Don’t forget to look at toes as a source of lameness, especially in athletes that turn tight; longer nails can catch on equipment and surfaces when dogs dig in to turn.  Also look at the pads closely for corns.

Learning more about veterinary rehab

As with many areas of integrative medicine, there is no single cookbook protocol to rehabilitating a patient. Veterinarians, veterinary technicians and physical therapists pursue advanced training in rehabilitation to better understand what is appropriate for each individual dog’s situation. For those interested, advanced training may be pursued through the Healing Oasis Wellness Center, the University of Tennessee Northwest Seminars, and the Canine Rehabilitation Institute. In conclusion, rehabilitation therapy has proven to be safe and effective for improving functional outcomes post-operatively, for neurological rehabilitation, and soft tissue injuries. Physical therapy has long been the standard of care for these conditions in human medicine versus the veterinary medicine approach of forced rest. While there is always a place for crate rest, incorporating rehabilitation as a part of our treatment plan speeds healing and provides improved chances for long-term mobility.

References

“Safety and functional outcomes associated with short-term rehabilitation therapy in the post-operative management of tibial plateau leveling osteotomy”. Canadian Veterinary Journal. 2015 Volume 56:942-946. ofa.org/diseases/dna-tested-diseases/dm I Kathmann, S. Cizinauskas, MG Doherr, et.al. “Daily controlled physiotherapy increases survival time in dogs with suspected degenerative myelopathy”. J Vet In Medicine. 2006 July-August;20(4): 927-32.  Jean GF Joaquin, Stelio PL Luna, Juliana T Brondani, et al. “Comparison of decompressive surgery, electroacupuncture and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral dis disease with long-standing severe neurologic deficits”. J Am Vet Med Assoc. June 2010;236:1225-1229.
 
A successful and healthy veterinary practice using an indigenous healers’ approach

How integrating the idea of Shamanism into veterinary practice addresses the emotional and spiritual aspects of healing.

Most of us will agree that the word “stress” has acquired new meanings that go far beyond what it meant even ten years ago. In veterinary medicine, stress has a major impact, and compassion fatigue and burnout continue to make headlines. Stress is known to lead to a number of chronic illnesses in people. Of course, animals can be affected by stress too, and not just due to their own issues. Because we are so strongly connected to our animals, they can become overwhelmed and even ill because of our stress. Handling this in a positive way is part of the focus of our practice.

Addressing emotional-spiritual health

The emotional-spiritual aspect of health is often neglected, and may cause frustration for both clients and doctors, especially when improvement does not occur as quickly as expected. In our practice -- which is made up in large part of animals with chronic illnesses such as cancer, arthritis, skin issues and allergies of all types – clients come from all over the state. Understandably, they are eager for their companion animals to be healed, but we often see them expressing anger or a lack of understanding regarding the emotional-spiritual components of disease. They don’t yet understand that disease is not just a physical manifestation of symptoms, and that there may be other underlying issues. Our interconnectedness with the wholeness of life is sometimes easy for us to forget in our busy lives. It seems esoteric, but our connection to plants and animals, and to nature, is inherently part of us as a human species. It is in our DNA. Our ancestors did not separate themselves from this wisdom; in fact, the ancient practice of Shamanism, which crossed many cultures, honored this belief system. So how can the idea of Shamanism be integrated into veterinary practice, as a way to address the emotional and spiritual components of healing? Let’s take a closer look at the principles of this ancient practice, and how some are still relevant today.

Principles of Shamanism

Shamanism in indigenous cultures around the world dates back at least 5,000 years, and is universal in its principles. According to Sandra Ingerman, a biologist, shamanic practitioner and teacher, all shamanic practices have several beliefs in common:
  1. Everything is alive and has spirit.
  2. Humans can talk to and communicate with the spirit in all things.
  3. Shamans are able to communicate with plants and animals in diverse ways, which taught early humans about healing and medicine.
  4. There is a relationship between humans and the spirit of all beings.
How does this inform the healing treatments of our primarily dog and cat patients? Animals communicate all the time, with each other, the world, their guardians and with us as healers. Creating a space that emotionally supports and honors an animal’s message is very important, and when clients embrace this, we help them create a space for healing in their own lives, as well as that of their dogs or cats. How does this translate into practice?

Incorporating Shamanism into the exam room

At our hospital, we create a sacred space to give clients and patients a place to breathe, relax and feel safe. Our exam rooms are adorned with photographs and talismans from our ancestral lineages, both Native American and Celtic. Representations of power animals and helping spirits hang on walls. Clients can rest on a carpeted area with their animals, or on cushions and comfortable furniture in all the exam rooms. Gentle music, soothing colors and essential oil diffusers help set the tone for a healing atmosphere.

Using energy work to address emotional healing

In addition to creating healing surroundings, we use energy work, including acupuncture, laser, Healing Touch for Animals™, and Reiki, and/or remedies such as herbs, flower essences, homeopathy and essential oils, to match the energy of the patient. If an animal’s energy is severely depleted, careful steps are taken to not overwhelm his system. Initially, only one or two modalities will be chosen until improvement is seen. A great deal of trust is involved in this approach, and guardians come to understand and build on that relationship of trust -- even if the healing is an honoring of the end of life.

Relationship between pet health and client life changes

When educating our clients about this approach, we teach them to recognize their own part in it, and to view their situation with compassion. The ability to recognize the prevailing energy in our fellow humans, and connect with them as we share a space, is critical. This allows the process of healing to begin. Incorporating some of the principles of indigenous healing into veterinary practice helps open the door to the connection between physical, emotional and spiritual health.

7 things you can do every day for health and well-being

By improving your own health and well-being, you can offer the best to your patients. Here are some tips:
  1. Set boundaries. Take a one- to two-hour lunch and don’t eat at your desk. Take the time to nurture yourself.
  2. Be in nature. Go outside and breathe, feel the grass, listen to the blowing leaves.
  3. Take even a few minutes to close your eyes, breathe deeply, still your thoughts or just notice them like clouds floating by, with no attachment.
  4. Call in your helping spirits, your power animals, your angels, etc. Create a connection to the vast knowledge that is available to us all the time.
  5. Be grateful. Give thanks for the ability to help others.
  6. Forgive yourself for past mistakes.
  7. Listen to your inner voice. We all know how intuition has guided our actions for the better.

References

Polizzi N. The Sacred Science, An Ancient Healing Path for the Modern World, 2018. Ingerman S. Awakening to the Spirit World: The Shamanic Path of Direct Revelation, 2015, sandraingerman.com.
 
Herbal support for geriatric animals

Health issues, from cognitive to musculoskeletal to cardiovascular, often arise in our geriatric patients. Herbs offer beneficial affects to a variety of body systems to help prevent these problems.

Gerontology is the study of declining function as an individual ages. The big picture approach to geriatric health in veterinary medicine involves supporting the ongoing effort to maintain and repair body tissues as they become more and more inefficient. A variety of herbs can play an important role in the mitigation of aging in veterinary patients.

Causes of age-related illnesses

There are many theories of aging. According to an Anatomy & Physiology textbook1 used to teach OMD (Oriental Medical Doctor) students, aging from a Western perspective may be caused by one or a combination of the following:
  1. Limit on cell reproduction
  2. Nutrition, injury, disease and environmental factors (epigenetics)
  3. Slow-acting “aging” viruses
  4. The “aging” genes that regulate apoptosis or other cell functions (pre-programmed aging)
  5. Autoimmunity, when the immune system attacks its own tissues
  6. Mitochondrial degeneration, which means less ATP and an increase in free radical production.

The prevention of aging

Western and Traditional Chinese herbs have a strong tradition of increasing longevity and preventing aging. For centuries, they have been used as elixirs of longevity. Western herbal supplements are now routinely started in older patients; an example is the use of glucosamine for the prevention and palliation of arthritic symptoms. What more could we start recommending to our animal patients to delay the aging process before symptoms arise? Many body systems will begin to show wear and tear as animals age. The integrative veterinarian can slow this “inevitable” decline by choosing from an herbal smorgasbord of system-supportive ingredients. The primary systems needing support in aging pet include:

Cognition/special senses

Poor cognition in many pets will manifest as abnormal gaits, vocalization or incontinence, and may even be overlooked as a primary cause. Herbal preparations like Ginko biloba, Rhodiola rosea or Bacopa monniera should be part of a preventative program. Special senses like hearing, sight or even smell may diminish and suffer poor repair, declining slowly and unnoticed. Antioxidants play a major role in slowing aging within all tissues, especially the special senses.

Neuroendocrine/adrenal

Neuroendocrine and adrenal support is crucial to a healthily functioning autonomic nervous system. Rhodiola rose, Panex ginseng, Ashwagandha and Eleutherococcous can support the overall system of regulation and control. Use tonic herbal blends for everyday support and repair.

Free radical damage/mitochondrial

Free radical prevention and repair is crucial to the anti-aging process. Mitochondrial support is needed to continue supplying an ample amount of ATP, or “Chi” for the body. Herbs like bilberry, milk thistle, grape seed extract, green tea extract and lycopene taken as prophylactics can both prevent and repair the decline in these aging mechanisms.

Cardiovascular

Support can delay congestive heart disease, even in inherited mitral murmur cases. Feed the organ system vital nutrients in the form of herbs such as lycopene, hawthorn berry, Astragulus and Coleus forskolii.

Immune

The immune system is often treated as overactive, using immunosuppressive drugs. Adaptagenic herbs like green tea extract, Astragalus, Larch arabinogalactian and a variety of medicinal mushrooms can support an often-overloaded immune system.

Hepatic/detoxification management

Support is crucial for keeping waste products from building up in the body. Many pets are subjected to multiple pharmaceutical and chemical products throughout their lifetimes, which stresses these pathways. Gentle herbal tonics like green tea, turmeric, dandelion and milk thistle can repair and keep these systems operational.

Gastrointestinal

The gastrointestinal system is subjected to a variety of foods, often not from the diet of natural selection, so it can become less and less functional as the years pass. Chronic inflammation in the digestive tract can lead to malabsorption, maldigestion, cancer and many other GI mishaps. How many pets are put down because of digestive issues like anorexia and chronic diarrhea? Administration of herbs like marshmallow, rosemary, cinnamon, ginger and slippery elm, along with antioxidants can increase the health of pets significantly. Many other microbiome-supporting supplements can be very beneficial.

Musculoskeletal/connective tissue

Supporting these tissues with herbs like boswellia and turmeric may enhance the properties of glucosamine products and Adequen®.

Renal

The renal system is often neglected, yet in most humans, over 50% of functioning nephrons are lost by the age of 50.2 The kidneys serve as the organ of excretion for the majority of pharmaceuticals used over the lifespan of our patients, aging the nephrons even faster. Supportive herbs include Rheum officinale, Codonopsis and Eleutherococcous.

Top 3 aging issues most likely to lead to euthanasia

  1. Anorexia of aging/wasting disease
  2. Lack of energy/disorientation
  3. Musculoskeletal deterioration

Top 10 herbs for longevity and preventative medicine programs

1. Rosemary

Rosemary has positive effects on appetite, memory and hair growth. Processing meats at high temperatures (especially for dry food) creates HCAs (heterocyclic amines), potent carcinogens implicated in several cancers. HCA levels are significantly reduced when rosemary extract is mixed into beef before cooking, say Kansas State University researchers. "Rosemary contains carnosol and rosemarinic acid, two powerful antioxidants that destroy the HCAs," explains lead researcher J. Scott Smith, PhD.3 Rosemary extract helps prevent carcinogens that enter the body from binding with DNA, the first step in tumor formation, according to several animal studies. “Rosemary has shown a lot of cancer-protective potential,” says study author Keith W. Singletary, PhD.4

2. Turmeric

Turmeric is a strong antioxidant for the GI system and helps prevent gastritis and arthritis symptoms. Turmeric contains curcumin, a powerful anti-inflammatory that works similarly to Cox-2 inhibitors, drugs which reduce the Cox-2 enzyme that causes the pain and swelling of arthritis.5 According to a small clinical trial conducted by the Johns Hopkins University School of Medicine, curcumin can help shrink precancerous lesions known as colon polyps.6 Researchers at UCLA also found that curcumin helps clear the brain of the plaques characteristic of Alzheimer’s disease.7 Both these studies indicate anti-inflammatory properties tissue-wide. More studies need to take place in animals to fully substantiate these correlations.

3. Ginger

Ginger affects metabolic vigor and tonifies digestion. A powerful antioxidant, ginger works by blocking the effects of serotonin, a chemical produced by both the brain and stomach when you're nauseated, and by stopping the production of free radicals, another cause of upset in the stomach.8

4. Rhodiola rosea

Rhodiola rosea is helpful in maintaining muscle mass.9 This herb is also used for fatigue, poor attention span and decreased memory. A review published in the American Botanical Council’s journal reported that numerous studies in humans, animals, and in cells have shown that Rhodiola helps prevent fatigue, stress and the damaging effects of oxygen deprivation. The evidence suggests that Rhodiola has an antioxidant effect and enhances immune system function.10

5. Cordyceps sinensus

According to Andrew Weil, MD,11  Cordyceps sinensus is used as a tonic and restorative. This Chinese fungus can help overcome general weakness and fatigue and increase physical stamina, mental energy, vigor and longevity.

6. Eleutherococcus senticosus

Eleutherococcus senticosuscan help address lethargy, fatigue and low stamina, according to Dr. Weil.12 Both Cordyceps and Eleutherococcus have a long history of use in TCM.

7. Milk thistle

Milk thistle extracts have been used as traditional herbal medicine remedies for almost 2,000 years. Milk thistle contains high levels of bioflavonoids that increase immunity and slow down oxidative stress. The herb is also used for its anti-inflammatory properties. It can aid digestive function, increase bile production, boost skin health, fight the appearance of aging and help detoxify the body. A review of clinical trials evaluating the safety and efficacy of milk thistle found that it has protective effects in certain types of cancer; data shows it can also be used for patients with liver diseases and hepatitis. Milk thistle extracts are known to be safe and well-tolerated.13

8. Green tea extract

Studies have shown that tea polyphenols offer a protective effect against free radicals, cardiovascular damage, some cancers and infections.

9. Boswellia

Boswellia is known to reduce pain and inflammation in both the joints and tendon and ligament attachments. It is also known to strengthen connective tissue resiliency. Boswellia serrata offers many benefits, such as reducing body inflammation and helping to treat conditions like osteoarthritis, rheumatoid arthritisand inflammatory bowel disease. It's also a painkiller, and can help inhibit cartilage l Boswellia can be used to alleviate asthma and may have protective effects against diseases like leukemia and breast cancer.14

10. Ashwagndha and Astragalus

These are adaptogenic herbs. In TCM, Astragalus is used as an immune adaptogen. It is strongly antioxidant, antimicrobial and heart protective. Ashwagandha is used in Ayurvedic medicine for its high antioxidant levels and infection-fighting properties, and is also used to address depression and reduce the effects of stress. In addition to the herbs discussed above, nutritional supplements like CoQ10, probiotics and vitamin D3, as well as TCVM herbal tonics like Liu Wei Di Huang Wan or Sheng Mai San, are routinely used in longevity medicine. The best cure for aging issues is prevention, so offer these herbs and supplements to your clients early on.

Look for quality products

Herbal supplements are classified as dietary supplements by the U.S Dietary Supplement Health and Education Act, which means they’re not tested to prove their safety and efficacy, unlike prescription drugs. Some manufacturers sell herbal products that aren’t completely pure. When buying herbs, investigate the company’s GMP and QC. This ensures you get high quality products that aren’t weakened with less expensive additives, or grown with pesticides or contaminated with heavy metals. Botanical medicine may also cause allergic reactions or interact with conventional drugs.

References

1Patton and Thibodeau. Anatomy & Physiology, 8th edition, Elsevier 2013. Pages 1118-1119. 2Patton and Thibodeau. Anatomy & Physiology, 8th edition, Elsevier 2013. Page 1120. 3Kanithaporn Puangsombat and J. Scott Smith. “Inhibition of Heterocyclic Amine Formation in Beef Patties by Ethanolic Extracts of Rosemary”, Journal of Food Science, 75, 2, (T40). 4Keith W. Singletary, Joan T. Rokusek. “Tissue-specific enhancement of xenobiotic detoxification enzymes in mice by dietary rosemary extract”. Feb 1997, Plant Foods for Human Nutrition. 5Prevention Magazine, June 2007, Page 195. 6“Curcumin in Treating Patients With Familial Adenomatous Polyposis”. National Cancer Institute (NCI), Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, Maryland, United States, 21287, September 2017. 7Prevention Magazine, June 2007, Page 195. 8Suzanna Zick.Can Ginger Ale Really Soothe Nausea?” The Atlantic, October 30, 2016. 9Frank Mayer, et al. “The Intensity and Effects of Strength Training in the Elderly”. Deutsches Aerzteblatt international, May 2011 DOI: 10.3238/arztebl.2011.0359. 10Richard P. Brown, Patricia L. Gerbarg, Zakir Ramazanov.Rhodiola rosea: A Phytomedicinal Overview” HerbalGram. 2002; 56:40-52 American Botanical Council. 11Andrew Weil MD, drweil.com/vitamins-supplements-herbs/herbs/cordyceps/. 12Andrew Weil MD, drweil.com/vitamins-supplements-herbs/herbs/siberian-ginseng/. 13Andrew Weil MD, drweil.com/vitamins-supplements-herbs/herbs/milk-thistle/. 14Dr. Mercola, articles.mercola.com/herbs-spices/boswellia.aspx.
 
Hospice home care products for pets

From mobility support to hygiene to pain management, these hospice products help improve quality of life for palliative patients at home.

A pet’s end-of-life journey can be extremely taxing for the client, both emotionally and physically. People are concerned about the suffering their pets may experience, and want to extend and improve their quality of life for as long as possible. We often see clients shift their approach from cure to comfort, with a focus on care from the time of a terminal diagnosis until the end of the patient’s life. A growing niche in veterinary medicine focuses on hospice and palliative care within a home-based setting. Clients are asking for a transition to home-based end-of-life (EOL) care – at this point, they no longer want to take their pets to a brick-and-mortar veterinary hospital. They may have already received a terminal diagnosis, or have seen such a decline in their pets’ quality of life that they just want to “keep him home and comfortable”. The growing trend towards in-home hospice and palliative care has generated a surge in products designed to improve a pet’s quality of life and aid in the management of his care.

Benefits of in-home care

There are many benefits to in-home care -- the most significant being a reduction in stress for the patient. A pet is naturally more comfortable in his home environment and, as a veterinarian, I can more accurately assess his comfort or pain without the added stress caused by transport to a veterinary clinic. I can also assess the pet’s environment and make recommendations for improving his comfort, while at the same time helping to ease some of the challenges an owner may face with EOL care.

Mobility support

Mobility issues are among the most common concerns we see in our aging canine population, whether due to osteoarthritis, neurological conditions/degeneration or other disease processes. Any non-carpeted areas in the home can be a challenge to navigate and increase the risk of injury. There are many products on the market to help with mobility – the best will be dependent on the pet’s environment and his tolerance level. For example, dogs who hate having their feet touched may not be candidates for certain footwear or related products. I have found the following to be very helpful:

1. Slip preventives

a) Buzby’s Toe Grips for Dogs – These small, durable rubber rings fit onto a dog’s toenails. The rubber engages with the floor, giving traction for the paw. A small dab of super glue may be applied to the Toe Grips for added security in pups who drag their feet. b) Pawfriction – This non-toxic adhesive is applied to the pads of the feet to prevent slipping on floors. It is easy to apply and well-tolerated by dogs. The frequency of reapplication will depend on the dog’s activity.

2. Harnesses

a) Help ‘Em Up Harness – This harness is not only comfortable for the dog, but is easy and comfortable for the owner to use. Front and back harnesses may be used separately or together. Definitely one of my favorite mobility aids. b) The Walk About Back End Harness — Another tried-and-true harness that’s helpful for dogs with limited hind end mobility. With any harness or sling-type product, care must be used when fitting the dog, and frequent checks made to watch for any rubbing or sores.

3. Wheelchairs/carts

While wheelchairs may not be for everyone, they can provide both physical and mental stimulation for some dogs, which can be invaluable. a) K9 Carts and Eddie’s Wheels – Both these companies offers durable high quality carts and wheelchairs for dogs. b) Handicappedpets.com — For times when a pet is not in a cart or wheelchair, the Drag Bag protects the hind limbs and chest from scraping against the ground. Incidentally, HandicappedPets.com is a wonderful resource for both veterinarians and clients; the website features many products to help pets and owners with a variety of conditions that affect aging animals.

4. Strollers

Mental stimulation is so important for aging pets. For dogs who can no longer go for walks, a stroller-type product can help get them outside for fresh air and mental stimulation. A growing number of products with different features and price ranges are available to dog owners. a) Booyah – This company makes several different types of pet stroller. b) Pet Gear – They also have a variety of strollers, along with other products such as ramps and stairs that may be helpful for dogs with limited mobility.

5. Footwear

For dogs that will tolerate footwear, a number of options may help in a variety of environments. Not only are we concerned with slipping on smooth surfaces, but we also need to protect the feet from dragging wounds or pressure sores. It’s important that clients realize they need to monitor the condition of their pets’ feet and not leave the booties/socks on for extended periods of time. a) Neopaws and Woodrow Wear – Both these companies make reliable products.

6. Mats and rugs

Many homes with geriatric dogs have an assortment of non-slip carpet runners and rugs across the floors to prevent slipping. Interlocking foam squares/tiles may be helpful, since their design allows them to go around corners, down hallways, etc. As a bonus, they are easy to clean. You can find them online or in home improvement box stores. Strategically-placed mats or non-slip rugs are helpful not only for navigating slippery floors, but also for jumping up and off of furniture. A well-placed mat or rug sometimes gives a pet enough confidence to jump on and off his favorite chair.

7. Navigational aids

We often see challenges in patients who are blind and have difficulty navigating their environments. Muffin’s Halo Guide for blind dogs is an aid that helps blind dogs maneuver without risk of injury. Tracerz are scent-based markers used to help a blind dog navigate his surroundings and reduce confusion within the home.

Pain management

While not home hospice products per se, integrative therapies are invaluable when managing palliative care in companion animals.
  • I have found that animals are quicker to relax during acupuncture treatments when they’re at home instead of a brick-and-mortar practice. I try to integrate acupuncture into the majority of my hospice cases.
  • Laser therapy is another valuable tool for managing pain. With proper training, in fact, small handheld laser units may be rented to the owner to allow for more frequent laser therapy sessions.
  • Using pulsed electromagnetic field therapy, the Assisi Loop can also be an important tool in the pain management toolbox. It’s also something that clients can use at home on their own.

Cognitive dysfunction, anxiety and sleep disturbances

These problems affect a large number of our geriatric patients and become a quality of life issue, not only for the pet, but for the human family as well. While many medications and supplements may help manage these issues, some in-home products are also useful. Anxiety may arise from a combination of senility and loss of senses. Any time we see symptoms of anxiety and cognitive dysfunction, it’s also important that we reassess pain management to rule out discomfort as a contribution to the behaviors. Pheromone-containing products such as Feliway for cats and Adaptil for dogs may help ease anxiety and are available in a number of different forms (sprays, diffusers, collars, etc.). As pets age, they may undergo a change in sleeping preferences and habits. Seeing a pet curled up in a cozy bed is very comforting to a client. The choices in bed styles, shapes and price points seem endless, so it’s helpful for us as veterinarians to offer clients guidance in selecting beds based on the needs of their pets. I have seen many situations where an owner is disappointed because their geriatric dog won’t use the fancy 0 orthopedic memory foam dog bed they purchased for him. It may be that the dog finds it difficult to navigate the bed; he doesn’t feel steady walking on it to lie down, so he often lies on the floor instead. A thinner bed may actually be more comfortable for these dogs. Temperature may also dictate where a pet chooses to sleep; many dogs seek heat or coolness and many old kitties prefer warmth. K&H produces a variety of cooling and heated beds for both dogs and cats. Some of the heating beds are pressure sensitive so will only warm up when the animal is on the bed. I love recommending these beds to owners who have thin, geriatric cats.

Hygiene concerns

Hygiene can be an issue in aging pets for a variety of reasons. Fecal and urinary incontinence, inappropriate elimination, pressure sores and tumors may all compromise hygiene. Educating clients on the care of wounds and sores is critical in managing these cases. A variety of diapers and belly bands are available for dogs. When using diapers for fecal incontinence, or for female dogs in general, care must be taken to keep the surrounding hair and skin as clean and dry as possible, to prevent urine scald or infection. HandicappedPets.com has a wide variety of diapers and belly bands to keep pets clean. They also offer the SleepPee bed for incontinent dogs. The design helps keep these dogs clean and dry as they sleep. We may also see inappropriate elimination in feline patients due to disease processes such as kidney failure or diabetes, as well as mobility constraints. The old kitty who has trouble going up and down stairs may need access to a litter box on all levels of the house. Sometimes, cutting down the side of the litter box can make it easier for the cat to get in and out.

Conclusion

I have had general care veterinarians ask me how I deal with compassion fatigue. My honest answer is that I experienced much more compassion fatigue while in general practice. As a mobile hospice/end-of-life care veterinarian, I get to see the best of the human-animal bond every single day, and experiencing it within a home-based setting makes it more intimate. And thanks to the growing number of products designed to help owners maintain and improve their pets’ quality of life, we’re able to make recommendations to sustain the bond we’re so privileged to witness.

Being a mobile hospice veterinarian

One of the biggest challenges I have faced as a mobile hospice/end-of-life care veterinarian is a lack of awareness of our services. Many people do not realize these in-home services are even an option! We have worked hard to cultivate relationships with our local primary care veterinary clinics – we want to work with them, not against them, in order to offer hospice/EOL services to their clients. The mobile hospice practice model is unique because our business needs are somewhat different from those of a general mobile veterinary practitioner. We need to send out notices of euthanasia to primary care veterinarians to let them know we helped their clients say goodbye to their pets. We need to correspond with local crematoriums to arrange aftercare for pets, and complete tasks such as sending off sympathy cards. We need to track our hospice cases based on trajectory of illness. We do not do vaccinations, so don’t need a system to send out reminder notices. A business software program called REX was specifically designed to meet all these needs for the mobile hospice/EOL care veterinarian. Desktop, tablet and iPhone versions all integrate to manage the practice. DVM Center is a specialized client support company that helps end-of-life care veterinarians answer their phones and schedule visits. They also offer social media support and startup services for veterinarians launching their own EOL care practice. The field of hospice/EOL care as a whole is growing and becoming recognized as its own specialty. In 2016, the International Association for Animal Hospice and Palliative Care (IAAHPC) launched a rigorous 16-month certification program, so veterinarians and licensed veterinary technicians may now become certified in Animal Hospice and Palliative Care. I believe this additional education and training is added assurance for primary care veterinarians that our advanced training has value for their clients and pets.
 
Golden yellow powder for wound healing

How golden yellow powder, an herbal medicine descended from a classical Chinese formula, helped heal a traumatic degloving wound in an Australian Shepherd.

A ten-year-old spayed female Australian Shepherd presented to the Animal Hospital of Dunedin on May 17, 2017 after suffering a traumatic degloving wound on her right rear foot. Deep tissues were exposed. After in-house laboratory values were found to be unremarkable, the dog was sedated with Dexdomitor and received an injection of Ampicillin and Rimadyl. While the dog was under sedation, it was found that a large section of tissue was missing from the site of the injury, and full closure of the wound could not be obtained. The owner declined referral for skin grafts. Lidocaine was used to block the wound site, and the area was thoroughly cleaned and debrided. Fortunately, it appeared that the deeper tissues had been spared from damage. The wound was closed using a simple interrupted suture pattern at the distal and proximal ends, as seen in Photo 1. The center of the wound was left open to heal by second intention, since it could not be closed. Before the dog woke, Golden Yellow Powder was applied to a Telfa Pad which was then bandaged to the wound. The patient was sent home with a seven-day supply of Rimadyl and a 14-day supply of Cephalexin (from a local pharmacy) with the agreement that the bandage should be changed at the hospital at least every three days, with cleaning and application of Golden Yellow Powder, until the wound healed. The first bandage change took place two days later and the wound was reported to be healing nicely. On May 23 (Photo 2), the patient was walking well, a granulation bed was forming and the tissue looked healthy. As the dog was normally highly active, the herbal formula Calm Spirit was started at this visit to quell his anxiety about being on strict rest at home. Bandage changes and applications of Golden Yellow continued on a regular basis, the wound continued to granulate in from the edges, and the dot continued to do well. The last bandage change took place on June 19 (Photo 7), about one month from the initial injury. At this time, it was decided to remove the bandage as the healing process was complete.

Herbal discussion

Golden Yellow Powder is an herbal medicine descended from Ru Yi Jin Huang San, a classical Chinese formula. Ru Yi Jin Huang San was first recorded in Wai Ke Zheng Zong, written by Chen Shi Gong during the Ming Dynasty.1 It is meant for topical use in acute inflammatory conditions accompanied by heat, swelling, pain, open wounds, and skin ulcerations, among other things.1 From a TCVM perspective, corresponding patterns are Damp-Heat, Heat Toxin, and Blood Stagnation. It is formulated in both raw powder and salve preparations. Clinical research has shown Ru Yi Jin Huang San can be effective in treating phlebitis, skin ulcers and swelling, and that it has antibacterial activity and can increase the pain threshold.1
  • The ingredient Huang Bai, when administered with Gan Cao, displays a synergistic inhibition of MRSA (Methicillin Resistant Staphylococcus Aureus), while Huang Bai alone has moderate antibacterial effects against bacteria such as Staph aureus, B-hemolytic Strep, Bacillus anthracis, Bacillus dysenteriae and Diplococcus pnuemoniae.1,2
  • Huang Lian also has a broad spectrum of antibacterial activity, against coli, Pseudomonas aeruginosa, Bordatella pertussis, Leptospira, Salmonella typhi and Mycobacterium tuberculosis, among others. It also has been shown to have anti-inflammatory and antipyretic activity.2
  • Jiang Huang addresses the pain and swelling with an injury and has a marked anti-inflammatory effect in rats.2
  • Cang Zhu and Chen Pi have been shown to have anti-inflammatory effects.1
For further ingredients, see the table below. This is an excellent case showing the benefits of using Golden Yellow Powder in the healing of a non-closed wound. The complete healing process was about one month in duration and required dedication and patience from the owner, dog and practitioner. The dog required no pain medication or antibiotic past the first prescriptions, and enjoyed an excellent quality of life during the healing process. Complications such as tissue necrosis, infection and poor healing were absent. Degloving wounds can often be fraught with complications, including delayed necrosis in tissues that may have lost blood supply, requiring repeated debridement.3 This case shows the benefits of using integrative care to achieve a quality outcome for our patients. ___________________________________________________ 1Ma, Aituan. Clinical Manual of Chinese Herbal Medicine, Ancient Art Press, Gaineville, Fl, 2016 300-301. 2Chen, John K, et al. Chinese Medical Herbology and Pharmacology, Art of Medicine Press, City of Industry, CA. 2004. 143,146, 623-624. 3The Merck Veterinary Manual, Ninth Ed, Merck & Co., Inc., Whitehouse Station, N.J., 2005. 1424.