Pet Health Articles

Multi-Modal Pain Management

multi-modal-pain-treatmentMy dog was just diagnosed with osteoarthritis (OA).  My veterinarian talked to me about something she calls “multi-modal” therapy.  What is multi-modal therapy?

For many years, OA in dogs was treated primarily (and often only) with a non-steroidal anti-inflammatory drug (NSAID). Over time, however, it has become apparent that an NSAID alone does not provide as much pain relief as hoped. Pain research has also advanced, suggesting that a more appropriate choice for managing the chronic pain of OA is targeted therapy, addressing various specific areas and tissues in the body, and utilizing specific pain management tools. 

 

What role do NSAIDs play in multi-modal OA treatment?

NSAIDs are just one of the options leveraged for multi-modal OA management. Just as the name implies, NSAIDs provide anti-inflammatory effects that target the affected joints to help restore function. In addition, NSAIDs provide pain relieving effects in those joints.

"NSAIDs serve as the cornerstone
of pain management of OA"

NSAIDs serve as the cornerstone of pain management of OA in those patients who can take them safely. It is always wise to evaluate a dog’s overall metabolic profile with bloodwork to confirm that administering an NSAID is appropriate and to look for hypothyroidism, which can affect how medications are metabolized. Once a full multi-modal pain management plan is in place, your veterinarian may be able to lower the dose of NSAID  to minimize the risk of an adverse event, and to reserve a full therapeutic dose for any acute inflammatory pain event (e.g. surgery, sprain/strain, laceration).

Some dogs with OA who receive multi-modal therapy are able to cease their use of NSAIDs altogether.

 

What other treatments are typically included in a multi-modal therapy plan for OA?

The treatment plan for a specific dog with OA will always be determined by that dog’s veterinarian and tailored to the specific needs of that particular dog. That said, there are many tools at the veterinarian’s disposal for applying the principles of multi-modal therapy. These include:

  • Disease-Modifying Ostheoarthritis Drug (DMOAD)
  • Nutrition
  • Nutraceuticals
  • Adjunctive medications
  • Physical medicine

 

What does a DMOAD do for a dog with OA?

The DMOAD used in dogs with OA provides the dog with poly-sulfated glycosaminoglycans (PSGAGs). PSGAGs are the “building blocks” of cartilage. By healing micro-injuries to the cartilage, the PSGAGs have an indirect anti-inflammatory effect, contributing to pain relief.  A DMOAD is delivered by injection under the skin twice weekly for four weeks, then once weekly for four weeks, then 2 – 3 times per month for maintenance, and most of the time, the dog owner can deliver the injections at home.

 

How can nutrition help a dog with OA?

The first nutritional step for a dog with OA is weight normalization.  In fact, weight loss in overweight dogs with OA has been proven to contribute significantly to pain relief. In order to help your dog lose weight, it’s important to consult with your veterinarian about creating an appropriate nutrient profile to help the dog lose weight.  Just reducing the portion of maintenance food can actually malnourish your dog.

Once weight and body composition are normalized, it is then important to reach for a nutrient profile that has been proven in clinical studies to help manage OA. Your veterinarian is your best source of guidance when choosing the most appropriate nutrition for your dog with OA.

 

What are nutraceuticals and how do they help to manage OA in dogs?

Nutraceuticals are nutritional supplements that behave in the body like pharmaceuticals (medications). There are several nutraceuticals that have been demonstrated in clinical studies to help dogs with OA feel and function better. Your veterinarian can prescribe the most appropriate nutraceuticals for your dog. It’s important to choose products that have been evaluated in clinical studies and determined to be effective.

 

What about adjunctive medications?

Amantadine and gabapentin have been used to complement NSAID in multi-modal therapy plans for canine OA. Both of these medications work at the level of the spinal cord to modulate pain. Either one or both may by leveraged for treatment.

 

What is considered physical medicine?

The term “physical medicine” encompasses any therapy that involves the veterinarian addressing the tissues directly with her hands. Needle work using acupuncture or trigger point release might be used, and spinal manipulation using chiropractic techniques may be recommended.

Physiotherapy/rehabilitation encompasses a broad scope of physical medicine that may include therapeutic laser, joint mobilization, medical massage, stretching, therapeutic exercise, and hydrotherapy (this is not an exhaustive list). The trained rehabilitation practitioner will create the most appropriate treatment plan based on the needs of the individual dog.

"The key to understanding
multi-modal therapy for dogs with OA
is to appreciate that there is
no single “magic bullet"

The key to understanding multi-modal therapy for dogs with OA is to appreciate that there is no single “magic bullet”. A multi-modal treatment plan acknowledges that OA is a complex disease requiring a complex approach. The chosen modalities work together better than any one modality can work on its own. Your veterinarian is in the best position to choose treatments that will have the best overall effects to manage your particular dog’s OA. Every multi-modal treatment plan is tailored to meet the needs of the individual patient and then adjusted as treatment progresses.

Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CRPP
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