Practice Profile: Nupsala MSK Clinic

For many years, Nupsala has been known as a specialist wholesaler in equine and small animal veterinary orthopaedic products, with a particular focus on regenerative medicine.

Founded in 2012 by Greg McGarrell – former chief executive of VetCell Bioscience, which was formed in partnership with the RVC and developed a range of ground-breaking cellular treatments for equines – Nupsala has led the way during the past decade in the use of biological and non-biological intra-articular and intralesional medications.

Best known for its work with horses, the company provides products, services and vet-led advice for around 90 per cent of UK equine practices; however, for many years, the team has struggled to make significant headway in the small animal sector.

But that could all be about to change, as the Nupsala Musculoskeletal (MSK) Clinic is part of a grand plan to practise what Greg and his team have long preached, and change the narrative when it comes to the way osteoarthritis (OA) is managed in companion animal practice.

He said: “It was always part of the planned and phased development of Nupsala as a business to open this musculoskeletal clinic. For many years, we have been preaching our gospel about how OA can be better managed and how the whole sector can change its approach to the disease and now this is our chance to prove it.

“We now have the only veterinary practice in the UK dedicated solely to the treatment of osteoarthritis in companion animals, somewhere we can build up our own patient profiles, so we can practise what we preach.

“Somewhere we get to see our own patient profiles without being under the same demands as the first opinion setting.

“It is not an orthopaedic referral clinic where everything goes off to get surgery. The area we focus on is the treatment and the modification of osteoarthritis using some of the technologies we supply – not all in all cases – but no doubt we will be using some of those validated technologies.

“Here, we can set the standard. We are not going to rush, so the patients coming in will be worked up properly because we don’t do anything else – no nail cuts, anal glands, vaccines, or any of that.

“Down the years, we have just got very good at a very small area, but that small area has a huge impact on animal health – especially when you remember that one in five dogs have got arthritis.”

Applied knowledge

Just two decades ago, before the inception of VetCell and its work with the RVC, and the pioneering research of Roger Smith, the tools vets had to hand to treat soft tissue injuries and OA were limited to either pharmaceuticals or surgical interventions.

At that time, little was being done in the field of what is now termed disease modification, and the approach was to either treat the symptoms with analgesia or cut out the problem and replace it with something else.

But through the work of Nupsala and the Veterinary Osteoarthritis Alliance (VOA) – a collection of leading veterinary professionals, including the renowned Stuart Carmichael, who work to share the latest knowledge and treatments for OA – all that is beginning to change, as Greg explained.

“With the knowledge we have amassed through the VOA, our understanding of the disease process, the understanding of how the technologies interact with that disease, and putting that into practice is going to happen downstairs in our clinic,” he said.

“We can apply the knowledge of the treatments we have built up over the years. We understand the treatments available because we have done all the due diligence, we have supported it – even some of it we have developed ourselves.

“So, we have this huge understanding of the technology, and then we have the time and the capability to work these patients up so that we have a fantastic foundation.

What will happen in our clinic is we will be able to collect a huge amount of really clean data that will be collected per dog, breed, sex and age, and over time patterns will start to emerge to show us what technologies and treatment strategies work for that particular disease, and that starts to give you a prognostication.

“So, in the future, other vets will be able to come to rely on this data, and that starts to bring huge benefits to the profession at large and how we tackle this disease. This is not about an additional revenue stream – one of the core values of the MSK clinic is the collection of that data to help change the narrative around OA in the companion animal sector.”

No magic bullet

To help them achieve such lofty goals, the clinic has been equipped with everything needed to assess and treat dogs and cats at various OA disease stages.

At the heart of the operation is a state-of-the-art treadmill system that can be used to provide detailed stance analysis and measure various gait parameters, including step length, length of the gait cycle, speed, cadence, stance and swing phase distribution.

The system is sensitive enough to identify lameness that is not visible to the naked eye and its use will form a central part of initial assessments, as well as to measure the efficacy of the disease modification treatments over time.

Leading the operation is Drew Tootal, a former veterinary surgeon with the Royal Army Veterinary Corps, who has spent his career caring for working dogs; duties that included performing lameness assessments, radiographic surveys looking for signs of arthritis, and providing treatment and exercise plans to help manage chronic pain.

Consults with Drew and his team of two RVNs – Arianne Beaufort and Kirsty Tesh – will be made via veterinary referral or can be booked direct by clients, and each will last at least an hour – precious time that is just not available in the first opinion setting.

Drew said: “Osteoarthritis is not well understood and that is partly because of business pressure. My wife works in general practice, and it is crazy – vets and nurses are just so stretched throughout the working day that there is just not that time for the interaction.

“Owners need to understand that a holistic approach is required and that just cannot be done within a 15-minute consult. Everyone just wants the magic bullet, but the magic bullet does not exist.

“One of the problems with OA is that it can often start early in life, and can soon become excluded by the insurance policy, or premiums keep increasing. By the time referral is required, it has become unaffordable.

“If you have an early onset OA patient that is picked up and can be covered by the insurance surgically, that is one thing, but the grumbling stiffness or the old dog the owner doesn’t want to put through surgery, only gets the cupboard emptied out on it. Whether early onset where disease can be modified, or refractory end stage to significantly improve quality of life, we can help through administration of novel intra-articular orthobiologics. We are also very interested in trying to detect sub-clinical disease in working and sporting dogs where we may be able to either modify, or in some cases reverse, arthritic change.”

Full assessment

The approach of Drew and his team at the Nupsala Musculoskeletal Clinic is to take a step back and try to give a degree of education about the disease. Ahead of all consultations, clients are asked to fill in an extensive, online lifestyle questionnaire about their pet, and once they have arrived at the clinic, they are then asked to provide more specific information about their pet via the AIM OA owner-led management tool.

AIM OA is delivered via a cloud-based app developed by Stuart Carmichael and leading canine rehabilitation practitioner David Prydie, and enables pet owners and vets to work together to build a bespoke plan for each individual patient.

Drew added: “That allows us to find out how the dog or the cat has been in the past week or so, and that is the first baseline that will show where pain level is at and where mobility is at.

“That gives us a really nice traffic light system: red, interventions are required; amber, interventions are in place, but may need tweaking; and green, interventions are in place, they are working, and they need managing and maintaining.

“Owners have to understand that OA is not curable, but can be modified, and what we are looking for is to turn all those reds to green so the owner can take away something they really understand and can get to grips with.

“Once they come in, they will have a full clinical assessment with me, so that might include walk ups and trot ups outside and it might even involve some small hurdles, some pole work and anything that lets me see how that animal is moving.

“They then come in and will have goniometry to establish range of motion as it is now, then they will have the stance analysis and then they will have the gait analysis done.

“If they have been referred by their vet, then the vet will get a comprehensive report back showing our findings, treatment summary and our recommendations.”

Multimodal approach

Those recommendations might include advice on multimodal analgesia – including the use of neuropathic pain inhibitors – while other possible interventions might involve a range of novel evidence-based treatments options, which may alter disease progression and, in some cases, prevent the need for surgery; these range from hydrogel injections, platelet rich plasma and stem cells to weight management, environmental modifications, and physio – often, it will be a combination.

By having the equipment, the expertise and the time to assess exactly how these treatments are working, the team will be able to tailor its approach on a patient-by-patient basis while building its own evidence base for the benefit of the profession at large.

Drew added: “When they come back and we repeat the analysis in exactly the same way, we can show the improvements and the difference those interventions have made. Because it is repeatable and the analysis is done in the same way each time, that means we have clean data.

“In a busy practice, the dog may see a different vet, potentially with a long time between visits, and it is just so easy to lose all the objective measures you need to manage this disease.

“We will be building a library of clean data through the clinic. The data we produce and the strategies we have here will be able to go back out into the profession – this is about driving a better standard of care for arthritic dogs and cats.

“Examples might include treatment of contralateral limbs in cruciate disease to prevent degeneration, or supporting the remaining contralateral limb after amputation.

“What drives the VOA and what we do here is about making a difference clinically.”

Team effort

But despite their years of experience in the field, and the wealth of equipment and treatments the team at Nupsala Musculoskeletal Clinic has to hand, none of it works without a team approach.

This means the primary care vet, physios, hydrotherapists and – most importantly – the owners must all be fully engaged in the process, as Greg explained.

“The treatment of OA or any musculoskeletal disease will not just involve us; it involves a range of people from physios, right through to the owner and the primary vet. Everyone needs to get involved for the dog to truly benefit,” he said.

“When it comes to OA, owners need to buy into the difference; they definitely need to see a difference and if they see the difference, they become engaged, so that is really, really important.

“We are not here just to give them advice. I think if you just tell owners: ‘you must do this’, a chance exists – especially when it comes to house modifications or a certain type of exercise – they will go back into their old routine quite quickly.

“But if we can intervene and show a physical difference to those dogs, then they get excited and also start to chase the targets; whether that is weight loss, increased flexion, or weight distribution, if you can show them whatever they are doing is making a difference, they will come back.

“We can show people working in general practice this works and tell them to get involved with the VOA, advise them to get the training and knowledge, and even do a small part of it themselves so they can see the clinical difference it is going to make.”