Holistic OA management: communication and good monitoring

So, you’ve managed to get your client to realise their dog isn’t just “getting old”, but is, in fact, suffering from OA and in a state of chronic pain.

The next challenge is navigating through the vast array of different treatment choices, both conventional pharmaceutical routes and complementary treatments, which, due to owner demand, will increasingly (for better or worse) need to be acknowledged as an option. We then need to decide which treatments are or are not working for any one individual patient.

Looking at every patient as an individual really is fundamental to getting a good treatment outcome and maintaining a good relationship with the client – they know how their pet “normally” behaves and we need to respect their opinion with regards to behaviour changes.

In saying this, getting a good, objective measurement of treatment outcomes in first opinion practice can be a challenge and the problem of caregiver placebo must not be overlooked. To try and help combat this, Canine Arthritis Management (CAM) uses a system first written for the Veterinary Osteoarthritis Alliance (VOA) to help give a more objective measure of behavioural, postural and mobility changes in OA.

Pain measurement tools

A number of validated pain measurement indexes are available, but many of them take a lot of time to complete, so uptake in first opinion practice has been poor.

Currently, most of us do not attempt to quantify different levels of pain, but simply ask the client for a broad overview of how the patient is doing at home. This isn’t enough. More information is needed to manage these cases effectively.

The VOA 5x5x5 system, available for free from the VOA website and the CAM website, is a simplistic bridging tool between the current approach and using a more complex validated tool, such as the Liverpool Osteoarthritis in Dogs questionnaire or the Canine Brief Pain Inventory.

5x5x5 is not meant as a replacement for such tools. If your clinic is using them, don’t stop – they are stringently tested and validated and there is no denying they are a great way of helping owners to understand improvement or deterioration in clinical signs. However, assessment tools only work if they are actually being used and, if they’re not, perhaps 5x5x5 is a good place to start.

How is 5x5x5 going to help?

5x5x5 is a system created by CAM founder Hannah Capon, Nupsala Veterinary Services chief executive Greg McGarrell, and AimOA Sys co-founder and director Prof Stuart Carmichael.

The system categorises OA into stages that refer to the overall clinical situation of the dog, combined with the owners understanding of their pain levels. It moves chronologically from stage one, identification of suspect pain or OA by the owner or veterinary team; to stage five, end of life care.

It allows for improved communication within the veterinary team about where a patient sits within a treatment plan, thereby maximising consistency of care, as well as encouraging diagnostic testing and accurate diagnosis.

A patient seen to be “slowing down” can have any combination of orthopaedic, neurological or other systemic diseases and without knowing which of these is present we have no chance really of achieving a good outcome.

Imaging

Work up for many OA patient does not progress much beyond basic blood testing with a view to starting analgesics. Imaging may be offered, but too often is not carried out as it is presented to owners as optional: “we can take x-rays, but…” is a phrase we need to use less, having it instead replaced with recommendation of radiographs and an explanation as to why they will be of benefit.

From an owners perspective, having distinct stages helps with the understanding of disease progression and the need for constant adjustments to their pets management programme as this progression takes place. 5x5x5 will help you provide the owner with a protocol they can follow at home, with the aim of slowing progression and minimising pain.

The fact the final stage is end of life care is good motivator for many owners as they will do everything they can to avoid getting to this stage. When this stage is inevitably reached, however, they are likely to be more prepared for it and more accepting of when it is time to let go.

Encouraging owners to monitor effectively at home

As part of this more vigilant monitoring and management programme, owners should be encouraged to select a series of key indicators that demonstrate chronic pain in their individual dog. This could be be anything from being slower on walks to changes in the way the dog interacts with the owner (such as growling when being handled) – basically any differences that have been recognised as the animal has aged.

Reassessing these indicators on a weekly basis at home and each visit to the veterinary clinic, especially after a change in treatment regime, will help to identify not only when a treatment is improving the clinical signs of OA, but also identify when more needs to be done.

Through the provision of simple tools such as the 5x5x5 we can improve the identification, diagnosis and treatment of OA, as well as influence effective communication and compliance from the owner.

This process of involving owners in the treatment and monitoring plan can empower them to want to do more, which can only help in the goal of achieving a good quality and quantity of life for our patients. This is not only good for the patients, but us too, as ultimately that’s why we are in this profession.