Multi-Modal Pain Management in Dogs

By Tammy Hunter, DVM; Robin Downing, DVM, DAAPM, DACVSMR, CVPP, CRPP

My dog was just diagnosed with osteoarthritis. My veterinarian talked to me about something she calls multi-modal therapy. What is multi-modal therapy?

For many years, osteoarthritis (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. NSAIDs provide anti-inflammatory and pain-relieving effects that target the affected joints, helping to restore function.

"NSAIDs serve as the cornerstone of pain management of OA
in those patients who can take them safely."

NSAIDs serve as the cornerstone of pain management of OA in those patients who can take them safely. It is essential to evaluate a dog’s overall metabolic profile with bloodwork (especially liver and kidney function) to confirm that administering an NSAID is appropriate. 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 your veterinarian’s disposal for applying the principles of multi-modal therapy. These include:

  • joint supplements and nutraceuticals (e.g., glucosamine and chondroitin sulfate, Catrophen Vet)
  • nutrition (e.g., Hill’s®Prescription Diet® j/d® diet, Royal Canin® Advanced Mobility Support) and weight loss
  • adjunctive medications
  • physical medicine

What are joint supplements and nutraceuticals?

Joint supplements and nutraceuticals used in dogs with OA provide 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. These products help support the joint and may be taken orally or as injections. Your veterinarian can prescribe the most appropriate products for your dog. It is important to choose products that have been evaluated in clinical studies and determined to be effective. See handouts “Joint Support and Disease-Modifying Osteoarthritis Drugs (DMODADs) in Dogs” and “Nutraceuticals for Joint Support in Dogs with Osteoarthritis” for more information.

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 is 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 cause malnourishment.

"The first nutritional step for a dog with OA is weight normalization."

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. Diets containing omega-3 fatty acids have been clinically proven to help reduce inflammation. Your veterinarian is your best source of guidance when choosing the most appropriate nutrition for your dog with OA.

What about adjunctive medications?

Tramadol (brand names: Ultram®, ConZip®, Durela®, Ralivia®, Rybix®, Ryzolt®, Tridural®, Zytram®), amantadine (brand names: Symmetrel®, Gocovri®, Osmolex ER®, Endantadine®) and gabapentin (brand names: Neurontin®, Aclonium®, Equipax®, Gantin®, Gabarone®, Gralise®, Neurostil®, Progresse®) have also been used to complement NSAID in multi-modal therapy plans for canine OA.

What is considered physical medicine?

The term physical medicine encompasses any therapy that involves your veterinarian addressing the tissues directly with their 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 among others. A trained rehabilitation practitioner will create the most appropriate treatment plan based on the needs of the individual dog.

Are there changes I can make around my home to help support my dog?

The supportive care required for dogs with pain from OA will vary, depending upon their level of function and their living environment. The following supportive care options apply to most canine patients with the chronic pain of OA:

  • Raised food and water dishes. Dishes placed at a level between the elbow and shoulder allow your dog to eat and drink in a spine “neutral” position. This decreases strain on the lower back.
  • Restricted access to stairs. Many dogs with joint or back pain from OA experience secondary weakness or decreased balance. It is a good idea to protect these dogs from unsupervised access to flights of stairs. Baby gates work very well for this.
  • Non-skid floor surfaces. Dogs with OA pain need and deserve to walk without worrying about their feet going out from under them. Aside from using non-skid area rugs in high traffic areas with slick floors, you may wish to consider using interlocking foam tiles like the ones used in day care centers and work-out gyms. They are easy to install, easy to remove, and easy to clean.
  • Assistive devices. Some dogs with OA do best with the occasional helping hand, such as a fabric sling or a walking wheelchair like a K-9 Cart®.

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.

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