June 8, 2023 — Drs. Kelly Diehl and Nina Kieves talk about osteoarthritis in cats and dogs including clinical signs, diagnosis, treatment and what pet parents can do to keep their furry friends comfortable and active!
Resources:
Ow, that hurts - osteoarthritis in dogs and cats
Researchers test gene therapy as a new way to treat dogs with osteoarthritis
Morris Animal Foundation osteoarthritis studies and news
TEDx presentation on dogs and arthritis
0:00:10.7 Dr. Kelly Diehl: Welcome to Fresh Scoop Episode 57, Osteoarthritis therapy for dogs and cats. I'm your host, Dr. Kelly Diehl, Morris Animal Foundation, Senior Director of Science Communication, and today we'll be talking with Dr. Nina Kieves, Dr. Kieves is an Associate Professor of Small Animal orthopedic surgery and the Director of the Sports Medicine and Rehabilitation service at The Ohio State University. Welcome, Nina.
0:00:43.5 Dr. Nina Kieves: Thanks for having me.
0:00:43.7 DD: Before we get started, I always ask everyone, tell us a little bit about yourself, kind of what led you to become a veterinarian, and then ultimately a surgeon.
0:00:53.4 DK: Yeah, so I certainly... Like many of us who are in the field, grew up with animals at home, I have a picture of myself doing a physical exam on my cat when I was probably four years old hanging up in my office, so I always had a love for animals and science. I certainly thought about human medicine as well for a little bit, but just really always came back to wanting to be able to help our four-legged ones, and certainly the clients as well, right. And that human-animal bond. You're not just helping your patient, you're helping that whole family, and so that was a big appeal for me. In terms of surgery and sports medicine in particular, I grew up doing a lot of work in the workshop at my parents' factory, so I always did a lot of hands-on stuff. So orthopedic surgery and fixing things was always a pretty natural fit for me. I dabbled in a lot of things, as we all do, but ultimately I always kept coming back to that and certainly loved working with the sporting and working dogs, and so that just really was a pretty good fit for me.
0:02:03.2 DD: Well, great. Diving into today's podcast, I wanted to ask you, I think most of us listening, like we've heard the terms arthritis, osteoarthritis, rheumatoid, which I hear all the time from my neighbors when they talk about their pets, they're like, Oh, they have rheumatoid. And I think it's really confusing. Can you help sort through these terms for us?
0:02:28.2 DK: Absolutely, yeah. There are so many terms that get thrown out and so many acronyms we love to shorten things, so we say osteoarthritis or OA, it's abbreviated very frequently, very synonymous with a degenerative joint disease or DJD or just shorten it to arthritis, so all of those are relatively interchangeable when we think about it, rheumatoid arthritis is really a term for humans, and so people will get that and it's a bit different than your typical osteoarthritis or OA, I will typically call it, it's a little shorter and easier, but that (rheumatoid arthritis) is immune mediated, and so we do have some rheumatoid -ike arthritis diseases in our dogs and cats, but it's much less frequent than in the human population.
0:03:23.5 DD: Okay, and today we're going to mostly be focusing on osteoarthritis or OA. And people often think about arthritis, and we'll focus on that because that's... You're right, that's what we see in dogs and cats, and what my neighbors get the terms confused, it's really they're talking about OA.
0:03:43.3 DK: Typically, that's correct, yes.
0:03:46.2 DD: And I know this is asking a lot. And I sent Nina some of the questions ahead of time, so hopefully she's prepared, but talk a little bit about the structure of the joint. I think we have to start there before we get into a more in-depth discussion.
0:04:03.6 DK: Yeah, absolutely. So when we think about the joint, we can almost think of it as an organ, so there's a lot of things at play together, and depending on what joint specifically we're talking about, there may be some nuances or differences. But in general, we're going to have the cartilage surface and in the joint, that's a very specific kind of cartilage called articular cartilage, and that's important to know because the body just can't make new articular cartilage. And so in any species, if you've broken that down or had damage to that articular cartilage, unfortunately, you're never going to get that native cartilage back. And so, you get what you're born with, and so we would like to try to preserve it as much as we can, and one day after billions of dollars of research, someone will win the Nobel Prize for being able to do that, but right now we just can't replace it, and so that's a big deal when that gets injured.
0:05:03.0 DK: And then we also have all the supporting structures, so the ligaments, the bone right underneath the cartilage, it is called subchondral bone, and that plays a role, and then depending on where we are, we may have additional cartilages like in the knee joint, we have two little donuts called the meniscus, people are probably potentially familiar with that because we have them as well, and that's something that can get injured, and so it's more than just the cartilage, it's also the lining of the joint, which is called the joint capsule or the synovium, and all of those interplay together when we have arthritis in terms of symptoms and treatments that we can use to try to address it.
0:05:45.7 DD: And what are... Now that you've talked about the joint structures, what are the pathologic processes that actually are involved in osteoarthritis, what actually happens when we're talking...
0:06:00.3 DK: Yeah, that's a great question and we could spend multiple podcasts talking about it, but it's relatively complex, but the bottom line is, it's generally... And we can think of it as an inflammatory process going on in the joint, where we have a switch from the balance of things that break down tiny little proteins and the matrix that builds up things versus building it up. And so, we end up being in a state where things are breaking down more rapidly than we can keep up with it, and so we get breakdown of the cartilage itself as well as that underlying bone, and if it gets exposed and we end up getting just a lot of inflammation in the joint. Which can cause a lot of discomfort.
0:06:46.2 DD: Okay, and what are the most common joints affected by osteoarthritis? Dogs versus cats.
0:06:55.1 DK: Yeah, so a great question. They're actually relatively similar in terms of the species differences, subtle differences, but in general, we think of the big joints, and so in the front leg, that would be the shoulder and the elbow joint, certainly, we do get a little wrist arthritis, but much less common, and they actually tolerate it pretty well in the wrist, and then in the back leg, we typically will see it in the hip and the knee joint, and then sometimes in the ankle as well, and the most common joint in the dog is probably the knee and the hip, and then a little bit different in the cat where the elbow and the hip are most commonly affected, but we certainly actually see the elbow being affected in the dog relatively commonly as well, but probably the knee and the hip are going to be a little bit more common for dogs.
0:07:47.4 DD: Okay. And I know that the signs can be different between dogs and cats, and I know this has bedeviled many of us. I hate to age myself, but I will here, I was taught in veterinary school like cats didn't even get osteoarthritis, we know that's ridiculous and not true, but tell us the differences and why sometimes cats can be a little tougher to diagnose.
0:08:13.3 DK: Yeah, absolutely, so dogs, we usually can pick up on it as owners and veterinarians, so they're a bit different in that when they have arthritis, it's typically secondary to something happening in that joint, and so we call that secondary arthritis. So, for example, in the knee, that's often secondary to tearing the cruciate ligament, which is essentially their version of the ACL, so most people know what that is or sadly had injury to that themselves, hip dysplasia or elbow dysplasia. So, something is causing it to happen. And when they get sore, they'll lose range of motion, and they'll have mobility issues and potentially exhibit lameness sometimes even as bad as toe touching or not wanting to put full weight on that leg versus our cats where about 50% of them get more primary arthritis.
0:09:10.6 DK: So that's like humans, where we'll just get arthritis in our knee, for example, and cats can get spontaneous primary arthritis as well, they certainly will get it secondary to things like dogs as well, and so as veterinarians, we want to look and see if there's a cause for it, because if we treat that underlying cause, we can slow progression, but they may just get it and when they have things going on, they're often more subtle about hiding it, that's just the nature of a cat, and so it may be something as simple as not wanting to groom as much on the back-end, so their hair coat might be a bit unkempt, it may be something you're happy about, so you might think, Oh, I finally taught Ginger not to jump on the counter anymore.
0:09:55.5 DK: But I speak from experience, it is impossible to train them not to jump on the counter, and it may just be that they're too uncomfortable to jump to a height that used to be very comfortable for them, they may not want to be petted as much where their area of discomfort is. So, if they like to get arthritis in their hips and even their lower back or the lumbosacral region, so they may not want that tail scratch anymore, and they may have issues with husbandry things like using the litter box appropriately. So, if they're too painful to get in and out appropriately, especially if it's one of those jump in from the top ones, then it may be something completely outside the normal maim and sore type of symptom and be something related to inappropriate urination around the house.
0:10:47.8 DD: Okay, those are really, really good points. I think, I know cats can be tricky as you said... Okay, now I'm going to put Nina on the spot by starting with treatment for osteoarthritis, start with some big categories when you think of arthritis treatment... Big stuff that you start with.
0:11:11.8 DK: So, I always teach my students, and also my clients, that we think of four big categories of treatment - one being weight management, and so that's actually going to be the most important in terms of addressing symptoms for the patient, and we know that very well from the human literature as well as actual canine literature, that weight loss and being at a healthy weight does the most in terms of addressing symptoms of arthritis for our patients. So that's one big category. Second would be activity modification, and within that category, I love things like physical therapy, but also addressing what is comfortable for that particular patient versus another, and so each animal is going to be very individual within that category, and then our third category is pain management, and that's where we can talk about oral medications and things like that, your anti-inflammatory medications that are frequently prescribed for pain relief associated with arthritis, and then the fourth is sort of the potpourri of other... In that category, I put things like joint supplements and nutraceuticals as well as joint supplements and potentially surgery, depending on where we're at with things.
0:12:39.6 DD: Okay, when confronted with a patient with osteoarthritis, and you just talked a little bit about this, what is kind of your strategy... Let's say you have my 10 and a half-year-old Labrador who sometimes gets a little gimpy on her left front leg, how do you approach that patient?
0:12:58.4 DK: Yeah, so for me, obviously, I'm the veterinarian, and so a good thorough physical exam, I want to make sure that I am isolating the appropriate joint, so I know where to localize it, some amount of imaging, so typically that's going to start with an X-ray, just to confirm that there are changes there. But I also want to make sure, is there something that I can intervene so potentially with a surgical procedure, if it needs to be done, because if there is something that I can intervene with, I can really slow progression. There may not be, or we may choose not to, whatever, for whatever reason, but it's good to know if there is something that I can actually do or fix, and then it's going to be really multimodal, putting all of those things in those categories together. So, if that patient is obese or overweight, coming up with an appropriate diet plan for the patient to begin the process of weight loss, a lot of client education goes along with that, it's something that we have a long conversation about to make sure they're getting the appropriate nutrition as well as working on that weight loss. Typically, I'm going to prescribe a pain reliever, and for me, the first line of pain relievers that I reach for is a non-steroidal anti-inflammatory drug, or sometimes we call those NSAIDs, and those are your version of our over-the-counter Advil type medications, and so they are ibuprofen-like.
0:14:33.3 DK: Certainly, we want to be aware that some human medications can be toxic to our pets, and so just going and buying something over the counter is something you definitely want to talk with your veterinarian about, and so a prescription veterinary product is often safer, and so I'll start with one of those, if that is working for them, great. We usually see a response pretty rapidly - I like that class of drug because it can be given as needed once we get things under control, so just like us, you kind of have a rough day, you take one, it works. You don't necessarily have to take it again for a while, whereas some of the other oral medications that we can use for pain relief, and certainly do add in for patients who need more than just one medication, some of those do need to be given very regularly to be effective. And so, it's always nice to have something that we can give as needed once we get things under control. So that's where I really start. Certainly, I do a lot of sports medicine and physical therapy, so I do often recommend that, and if that's something that clients are willing and able to do, can make a big difference for the patient, and then we'll consider things like joint injections down the road, if we need to.
0:15:48.7 DD: Okay, so it can... It sounds like it can vary, obviously, between patients and sometimes if you were presented with someone who's really struggling with their osteoarthritis, it might be helpful to get some pain medication on board to begin with, but then maybe can be reduced if I'm interpreting correctly.
0:16:11.1 DK: Yeah, absolutely. Yeah. A lot of times when we're first seeing them, we really want to get them comfortable, it's kind of that circle, so if they're uncomfortable, they don't want to move, if they don't want to move, they're actually probably getting worse, so a happy joint is a moving joint, so mobility and moving is actually very helpful to joint health and actually makes them more comfortable than sitting and doing nothing, but we have to get them to a place where they're comfortable enough to do that, and so the pain management is really an important part of that, especially at the beginning, but our ultimate goal with things like physical therapy and building muscle mass and improving joint mobility and range of motion, getting some weight loss going is to hopefully not need oral pain relievers on a regular basis, and certainly that arthritis will always be there. And so, as needed is definitely something that is very, very okay to say, Hey, this is going to be a medication we give for the rest of your pet's life, but our goal is to give it as little as possible by doing some of the other things.
0:17:21.3 DD: Right. Because some of those drugs have, we know, side effects. Before we go into rehab, which I wanted to talk with you a little bit more in depth with because that's your specialty, can you talk a little bit more, you had mentioned NSAIDs, what are some of the other drugs that maybe people have heard about or are encountering with their vet or they're talking to their neighbor that are used in conjunction with these other modalities?
0:17:48.6 DK: Yeah, absolutely, so there are numerous other classes of drugs, and so I'll go through some of them, one of them is a drug called amantadine, and so that may be something people have heard of, I find that to be relatively effective for arthritis pain in particular, we do use it in conjunction with the NSAIDs, and it helps us to be able to reduce the dose of the NSAIDs, and so that's one I really like. It does have to be given quite regularly though, so unlike the NSAID that's more of a give as needed, that one does need some time to build up in the system to be effective, but once we get it going, we often see a very good response from that medication. Another drug that people probably have heard of is something called gabapentin or pregabalin is another very similar medication, and so that initially has been used for more neurologic pain, but we can also try it for arthritis pain, and so it depends patient to patient how effective it might be, but it works more at a central sensitization versus at the joint level, and so adjunctly, in combination, we can see some better response than without it, and so that's one that we can try as well.
0:19:14.0 DK: It also does take a little time sometimes to build up, and again, more of a consistent medication than as needed one, but certainly one that we can reach to as well, and then there's a few others that as we need, we can add in, but those are probably the three biggest ones that we'll use for arthritis pain relief.
0:19:33.9 DD: Okay, and I'm going to ask you about this because people may be thinking about it, and I know it's pretty charged right now, which is the use of opioids and veterinary medicine. I can honestly say when I was in practice, we didn't use it very much for pain, but... Can you talk about that?
0:19:51.3 DK: Yeah. Absolutely, certainly, it's always a big issue for us as well, in terms of controlled drugs and potential abuse by the human client, but we will use narcotics or opiates very, very frequently in the hospital, more for perioperative and post-operative pain management. And so that's certainly how it's used most frequently on the human side of medicine as well as using it in the hospital for that acute surgical pain or when we really need to try to break the cycle. But it's not something we often will send home for arthritis pain, it is actually not a very good drug for that, and typically on our side of things, it also makes the pet very sedated, and so when we're talking about pain management for arthritis patients, we want them to be active and having a good quality of life, and so giving them a medication that just makes them pretty snoozy for the most part is probably having a large effect and impact on quality of life and what they're doing, and so we really just see them sleep a lot when we give those. So, it's not really a great category of medication for arthritis pain.
0:21:04.8 DD: Great, well, thanks for talking about that, because I think it comes up once in a while when I'm talking with folks for sure. So, let's go to rehabilitation, because this is something... Again, I'm going to date myself. No way would we have talked about this when I was in vet school, except for horses, I actually saw horses...right, swimming, and that's been around for a long time, but talk about sort of what the role of physical therapy is in... For both cats and dogs in osteoarthritis.
0:21:34.7 DK: Absolutely, so if you, yourself have arthritis or you know somebody who does, which is almost everybody who listens to this podcast, I'm sure we do physical therapy right from the get-go for anything. And so, you go in, you get diagnosed with arthritis or some sort of tendon or ligament injury, your doctor is most likely going to prescribe you some form of physical therapy, and that's really where we've been very behind in veterinary medicine in doing that, but we certainly are picking up speed in that regard. And so we do have board-certified specialists in sports medicine and rehabilitation, and so there's a lot out there and a lot of research being done, so I think we have the science now to prove that it does help, so in terms of arthritis in particular, a lot of times, our symptoms are coming from discomfort to that joint, and so we do want to address that with our pain relievers, but we also see a lot of muscle loss and range of motion loss in the joint, and so the modalities that we can use in physical therapy really help address pain in different ways in terms of different pathways.
0:22:49.6 DK: And so we use things like acupuncture or laser, which is low-level light therapy or pulsed electromagnetic field therapy, some people probably do that themselves and are familiar with that, but those are different ways to modulate discomfort. And then if we can get the patient feeling better in terms of that, we can work on mobility of the joints, so whether that be with hands and actual mobility using massage or range of motion, passive range of motion exercises, or getting them into an underwater treadmill where we take a lot of the weight off of the joint, where they might be uncomfortable on land, they're comfortable to do it in the water, and they're able to really get those joints moving, that helps with that joint health that we're talking about.
0:23:44.9 DK: So when they're putting weight on the joint, it's getting that natural lubrication back into the system and can help get that range of motion better, and then it also helps build up the muscle, so if you have weak muscles or low muscle mass, then that contributes to mobility issues and the physical therapy can really help with that, and yes, we do get cats in the treadmill, they will tolerate it. We put them in little life jackets, and they do great, but yeah, there's a lot of different modalities, but it's ultimately about rebuilding muscle mass and improving range of motion of the joint.
0:24:24.3 DD: Well, and I'm going to put in a little plug for cats, we recently, and I'll put this in the show notes, we recently wrote an article in conjunction with some folks for a Canadian journal, where I have pictures of cats in water. It takes a little bit of doing but there are things... And I think how are you in your clinic, are you seeing more cats, are people kind of getting on board with that now?
0:24:51.5 DK: Yeah, we certainly are. We have a handful of chronic long-term ones, but it's also been educating our practitioners too to know, Hey, we do it, and we love having cats as patients and we're always excited when they come in, but the first thing is, is recognizing that they get arthritis and then knowing that, Hey, we have things we can do for them. I know we've kind of moved past oral pain relievers and the other pain management, but for cats, we also have a new category of drug or medication that's FDA approved for arthritis pain in cats, it's a monoclonal antibody, and it's actually a once a month injection, and that's been a real nice addition to our arsenal for pain relief for cats with arthritis because they are much more sensitive to those NSAIDs that we use very frequently in dogs, and so it's been nice to have the addition of that new pain reliever available to us and it's on its way for dogs, but just not quite there yet.
0:25:52.8 DD: If I'm thinking correctly, this is... It's good to know that it's in the United States, because I think it's been in the UK, right? Both of the dog and the cat.
0:26:01.8 DK: Yep. The dog and the cat have been approved in the UK and other European Union countries for quite some time, and then it's moved to Canada, and then we have it for cats in the US now, but not dogs yet.
0:26:14.5 DD: That's going to be... And I also think, as all of us who have cats know they're a pain to pill.
0:26:19.4 DK: That they are. That they are.
0:26:24.9 DD: And I can't tell you how many things I have found them spat out all over.
0:26:30.3 DK: Oh, it's amazing. Yeah, yeah, you move that couch to dust and like 'Look what else is under there'.
0:26:39.6 DD: Yeah, so I think this is going to be a great of great boon for their treatment and hopefully we'll see the same for dogs soon. So, we've been talking about advances, but what are some of the big questions that still remain as... That you see as a practitioner in osteoarthritis, you would love to see answered or people are working on?
0:27:01.2 DK: Yeah, we're doing a lot of treatment trials, just looking for other alternatives, so those NSAIDs are very, very effective when we can give them, but there are certainly a population of patients that can't take them and don't tolerate them. So one of the primary contraindications of giving those is if they have kidney disease, and that's why we don't give them to cats very often, because a large number of older cats will get kidney disease, and so developing new medications that are effective for pain relief that use different pathways that are more localized to the joint, we're doing some research right now using different modalities on things like shockwave therapy, but also some allogenic stem cells, and so there are certainly a lot of things in the pipeline that we still need to figure out that really are targeting the pain relief, but also potentially regenerating some of that articular cartilage surface to give that joint, it's normal gliding function back, and that would be really the holy grail of treating arthritis is to make that joint normal because right now we're just treating symptoms associated with it, we're not really stopping or halting or reversing the damage in any way, and so that's where I think the majority of our research is focused on right now.
0:28:29.9 DD: I have a quick question for you that's a little out of the blue, but sometimes I get this question, I'm sure you do too, which is, is there any way to prevent osteoarthritis and is there any science behind anything preventive?
0:28:44.8 DK: Yeah, there's unfortunately not, especially for dogs because they're usually getting it secondary to something, and so once they tear the ACL, they've torn it, they're getting that arthritis no matter what. So unfortunately, we don't have a way to prevent that from happening. A lot of it is genetic predisposition, and so it's a hard thing to stop from happening at all, versus once they have it, there's absolutely things we can do to slow progression, so being at a healthy weight being the number one thing, addressing the underlying cause, if we can. So again, I use the ACL as an example, because if we can stabilize that knee, that's going to help slow progression, and so yes, once it's there, there's things we can do to try to halt it from getting worse more quickly, but there's unfortunately nothing we can do right now to completely stop it from happening.
0:29:45.1 DD: Right. And what are you working on personally in your lab and your research?
0:29:51.4 DK: Yeah, so right now our group is evaluating, like I said, shockwave therapy specifically for lower back pain. So, dogs and cats as well. We're studying dogs (that) get herniated discs just like people do, so a lot of people can relate to that stiff lower back, and so we're looking right now at a study looking at how shockwave therapy can help with mobility and pain related to lumbosacral disc disease, and so that's hopefully going to wrap up here in the next few months. That's just a small pilot study, but we've had good luck with that in horses and it's used a little bit in people as well, and so that is a nice one because it's not a surgical treatment, it's something that we just do with a little bit of sedation and don't have to do really a whole lot for them aside from a short little nap while we give the treatment, which lasts about three minutes or so. So that's one big one, and then we're wrapping up a study right now on elbow arthritis using adjunct stem cell injections to see if that slows the progression of arthritis as well. So those are the two big ones that we're studying right now in terms of treatment of arthritis, but we're also doing a study looking at using that medication gabapentin for pain relief in acute knee injuries, and how effective is that actually for pain management.
0:31:20.7 DD: Well, great. Well, we're coming up on the end of our time, Nina. So, what would be your take-home message to the people listening, it's a lot of veterinarians, but we have pet owners and vet students and technicians, and what would you say about arthritis and treatment and modalities?
0:31:39.6 DK: Yeah, I think ultimately, the biggest take-home is every patient is an individual, and so working with the client and knowing what the goals are for that individual animal, is this a dog that needs to go out hunting six hours a day, three times a week, or is this, a dog that is going to have a lower impact and be happy to not go running and doing those kinds of things, and so knowing the goal of the client is hugely important, but then being a clinician who brings a multimodal approach is also really key, just saying... Here's an NSAID prescription, off you go, I think is doing a big disservice to our pet population, there's so much more we can do once we start talking about options, and so having that whole kind of a triad of pain management, activity modification and weight management is really the big ones for me, and then knowing, Hey, there's options that we can do as well with joint injections and supplements and things like that, that can provide adjunct relief for your symptoms, and let's see which ones are going to be best for your particular animal at home.
0:33:00.8 DD: And that's a great reminder. I think just to know that there are options and that it's not necessarily, well, this is just aging and we're going to just accept it, I think knowing for cats... For cats as well. Now, there are lots and lots of things we can do.
0:33:18.8 DK: Absolutely, absolutely. And client education, we get dogs that come in and owners are like, Oh yeah, he's just slowing down, but really he's slowing down because he's uncomfortable and has some arthritis, and we can make a big difference and impact in those pets' lives by doing a good physical exam as the veterinarian, identifying that that is there and then providing a tailored treatment plan.
0:33:43.5 DD: Great. Well, that does it for this episode of Fresh Scoop, and once again, thanks to Dr. Nina Kieves for joining us. We'll be back with another episode next month, we hope you'll find just as informative, and the science of animal health is ever changing as we know we need cutting edge research information, whether we're treating patients as veterinary caregivers or as pet parents. And of course, that's why we're here, you can find us on iTunes, Spotify, Google podcast and Stitcher. And if you like today's episode, please take a moment to rate us because that helps folks find our podcast, and as always, to learn more about Morris Animal Foundation's work go to morrisanimalfoundation.org. There you'll see just how we bridge science and resources to advance the health of animals. You can also follow us on Facebook, Twitter, and Instagram, and I am Dr. Kelly Diehl, and we'll talk soon.
