Thoughts on Greyhound Low Back Pain

Revisions

  1. August 10: Report on supplement additions of GlycoFlex and Hindquarter Weakness and describe Nick’s continued response to therapy.

References

  1. https://hrvethospice.com
  2. https://www.veterinarypracticenews.com/laser-vs-acupuncture-and-massage/
  3. https://en.wikipedia.org/wiki/Carprofen
  4. https://en.wikipedia.org/wiki/Gabapentin
  5. https://en.wikipedia.org/wiki/Phycocyanin
  6. https://en.wikipedia.org/wiki/Glucosamine
  7. https://en.wikipedia.org/wiki/Chondroitin_sulfate
  8. http://glycoflex.com/
  9. https://store.tcvmherbal.com/Default.asp? (Hindquarter Weakness)
  10. http://ijpsr.com/bft-article/revisiting-the-role-of-phycocyanin-in-current-clinical-practice/?view=fulltext
  11. https://ruffwear.com/collections/dog-harnesses
  12. https://www.canidae.com/dog-food/

Nick’s History

Let’s start with a review of Nick’s history.

An old injury

Back in 2009, we were at Surfer’s End beach car park in Middletown, RI. Nick managed to slip past Rhea exiting the car and went runner across the beach road. He was hit by a car and knocked down without apparent injury. Ten years after, he may have some arthritis in the hips and low back which is clearly identified in a bench check of his hip and back structure.

Keeping weight on Nick

Since we had been feeding a grain-free food (Canidae Pure), Nick has been a grazer. He would nibble on his ration throughout the day. Rhea did the same with her ration so 2 dogs were each eating 1 dog’s worth of food. When Missy joined us, she Hoovered any leftovers and Nick began to drop weight. For 4 years, I’ve tried different food and feeding schemes to keep weight on Nick. The one that works is to offer 1/2 cup at a time when asked until he stops asking.

For Nick’s health, I had to transition from traditional morning and evening feeding to feeding Nick when he wanted to eat. What I found worked was to offer 1/2 cup in the morning with his SLO oil. If he ate, good. If not, pick up and save until evening and offer about 50 grams of pot roast in addition. He’ll eat his pot roast. Save left-overs for when asked. Next ask, give 1/2 c of kibble (Canidae Pure Sea usually). Continue until he asks and leaves half. Save leftovers for next ask. Cut him off at bedtime but save leftovers.

I fed morning ration wet and evening rations dry. Or you can feed all wet. He has a preference for wet but dry is a bit more stable. I’ve not worried about cold storage as canines are carrion eaters. If road kill won’t make them sick, fermented kibble won’t make them sick.

August 2018

At Missy’s 2018 annual exam in August, Nick was along for the ride. Looking somewhat slouchy, Missy’s vet suggested we start Nick on Phycox, one of several supplements favored by small animal veterinary practitioners for joint health maintenance . Phycox is a strong anti-inflammatory and antioxidant developed to manage canine late in life low back pain.

Nick in Late Winter 2019

At Nick’s annual, the discomfort was more pronounced and weight loss was noted. We added carprofen to his medications. Nick didn’t think too much of the vet visit, presenting significant lab coat anxiety.

Nick was still doing his best to be an elderly male greyhound. He was still going out, still had regular loo habits, and was still Missy’s wingman answering Tally Ho calls to sort a blighter at the fence and occasionally giving the alarm himself.

May 2019, starts gabapentin therapy

After speaking with friends, I decided that Nick needed a different approach to his late in life wellness care than traditional outpatient care and contacted Hampton Roads Veterinary Hospice for an evaluation consultation. Nick’s discomfort had continued to increase and he was eating poorly. HRVH recommended adding gabapentin to Nick’s medications and we continued this regimen for a month. Nick showed some improvement.

HRVH is a specialist practice caring for elderly pets in home. They specialize in late in life pain management which benefits from being able to observe and treat the pet in home. Office visit anxiety is eliminated as a confounding factor and mobility and obstacle navigation can be observed in the home environment.

Treatment measures of effectiveness

I keep track of several measures of effectiveness to evaluate changes in Nick’s care.

  • How is Nick’s appetite. Is he eating well? Is he eating a full ration over the course of the evening.
  • How is Nick’s sit? Can he sit smoothly on the first try?
  • How is Nick’s standing posture? How long can he remain standing before starting to slouch? How is this changing over the day? Is posture recovering after a lie down?
  • How is his sleeping posture? Where is he sleeping? Is he stretched out of scrunched up? Is his bum hanging off the bed (ache inducing)?
  • How is he negotiating the back steps? How often does he need assistance with the steps?

Quality of life measures

I try to track his quality of life from the activities he maintains. At summer, he’s still doing the following.

  • Jumping from the back porch to the ground
  • Jumping from the ground to the porch deck
  • Charging blighters at the fence. Answering a Tally Ho call to join the course at the fence.
  • Peeing and pooing in the yard without assistance
  • Waking me at night to be let out.
  • Following me around the house on occasion. He’ll check on my location. Follows me to the loo and to bed.
  • Not jumping on bed. This stopped when I rearranged the room looking ahead to setting up a crate (not needed)
  • How often does Nick require assistance sitting or standing? Currently less than once per day. He likes the Ruffwear Web-Master harness. I tell him it’s his #ZSHQ patrol web gear.

June 2019, starts acupuncture

After a month of carprofen plus gabapentin therapy, HRVH suggested adding acupuncture to the treatment regimen. Acupuncture has a long history of use in Asia and is finding increasing favor in the US. As of this writing, medical science is beginning to investigate the therapy to determine is means of effect and to develop a better understanding of when it is beneficial and which points are effective for which conditions. Reference 2 describes what has been learned and how acupuncture is effectively used in veterinary medicine. A skeptical head moocher authorized acupuncture and we started weekly treatments. We saw changes in Nick’s behavior typical of acupuncture response. Nick would sleep through treatment and a good bit of that day. Next day, we’d see improved hip function and Nick’s appetite improved.

July 2019, starts transition to maintenance acupuncture

Nick showed significant improvement in his hip action, most notably, his sit became smooth and he could manage to complete a sit on the first try. We also noted that his confidence hoping the steps (he uses the Rocky the Flying Squirrel step technique) had improved. Appetite had improved but head moocher had also changed feeding protocol to accommodate Nick’s preferences. We’re continuing acupuncture at a bi-weekly interval and may be able to drop to monthly.

Nick is more alert and his quality of life measures have improved. He’s maintaining weight. He’s dragging me out to the loo at night. Poo accidents are down to zero again. He had been dropping some struggling to a stand. Now he powers up smoothly. A lot of this is from getting him to eat his full ration and some extra.

August 2019 Starts “Hindquarter Weakness ” Herb

At the recommendation of Nick’s pain management veterinarian, Nick began to take a traditional Chinese veterinary medicine herb formulation “Hindquarter Weakness” in addition to his traditional pain therapy of carprofen and gabapentin and his two over the counter supplements. The other notable change is that acupuncture used different points that are used to treat anxiety and appetite.

The acupuncture had an immediate effect. The day of treatment, Nick lazed about pretty intensely. His daytime naps were a full brain sleep rather than a one side sleep. After waking from napping, Nick’s jaw tremor was absent and remained absent for 3 days post treatment. When it returned, it was less frequently observed. That evening, Nick ate his complete supper rather than reserving part of his ration for later. Both indicators returned to baseline but mobility appears improved.

It is too early to render an observation about the Hindquarter Weakness herb but Nick did circle to sit for the first time in several months. I’m taking this as an indication of continued improvement.

Thoughts on Therapies

Management of late in life pain is complex and requires a systems approach rather than a symptom oriented approach. The most important thing is to get the discomfort down so that the patient is not feeling helpless and starts cutting meals. Eating well is important to maintain weight and strength. When appetite wains in response to discomfort, a downward spiral begins. The idea is to interrupt this spiral, restore the patient’s comfort and appetite, and maintain his health otherwise. This requires some geriatric expertise and a whole dog approach. That’s where Hampton Roads Veterinary Hospice comes in. Nick’s regular vet continues to diagnose and treat acute conditions and maintain his immunizations.

Home Visits

I’ll summarize my impressions so far. Late in life pain management care in a home setting is important. Taking the dog to the vet for an office visit is stressing. Dog is anxious, panty, slouchy, etc and generally presents as in worse condition than he is. This does not happen at home and we can walk the steps and patrol the garden to observe mobility and gait in a familiar setting rather than in the vet’s overstimulating back garden.

The second benefit of in-home care is that an hour is the standard visit so observation and discussion is possible that doesn’t happen in a standard 20 minute office visit. I really prefer the relaxed in-home format for this care which can be provided without need for diagnostic equipment or bulky procedural equipment. Nick’s exam happens on his feet on the floor and acupuncture is given while he is lying on a dog bed.

This approach is highly recommended. I feel the improved results from an hour encounter are worth the added cost.

Integrated pain management

Integrated pain management is an important improvement in late in life care. The combination of caprofen, gabapentin, and acupuncture produce better results than is possible with the individual therapies. Acupuncture is a good adjunct treatment that has improved Nick’s hip function. The supplements and Chinese herbs appear to help but it is important to remember that the therapies together form a system of treatment and it is possible that the combination of therapies is more effective than any of the individual therapies.

The supplement industry therapies are harder to evaluate. It may be that they have a strong placebo effect in the purchaser but they also appear to benefit the patient. Typically, I start one of these products shortly after a pain management consult and see an improvement later in the week. It is likely that reduced pain, restored appetite and improved hindquarter strength are slowly increasing Nick’s confidence in his mobility so he’s moving more and better. The Phycox and GlycoFlex are inexpensive and Nick likes the GlycoFlex as a treat. TheGlycoFlex ingredients have minimal toxicity over-consumption is not a risk to the patient. Nick gets a GlycoFlex when he returns from the garden and when he asks for an evening treat.

Caprofen and Gabapentin

Caprofen is a synthetic anti-inflammatory that sees some use in human and veterinary medicine to treat chronic and acute pain at the receptor. It is commonly used for human arthritis treatment. Gabapentin attenuates the transmission of pain in the peripheral nervous system. Together, the two give significant pain relief and have improved Nick’s use of his hips. Acupuncture also has a place in this improvement. We started the therapies one at a time and see the best hip function with the three in combination.

Nick’s butler missed a couple of bedtime doses of carprofen/gabapentin causing an increase in pain. After returning to schedule compliance Nick’s pain reduced. This can be seen clearly in a decline in his activity during the period of under-dosage and shortly after. It took a couple of days to get caught back up and return to baseline. It’s very much like me missing a dose of allergy treatment. Sinuses get angry and it is a couple of doses before they settle.

Long term carprofen treatment requires surveillance of liver function as the compound is toxic to the liver in excess. This is very similar to the liver monitoring performed when humans take statins. Gabapentin does not require surveillance but will confirm this next week.

Thoughts on Acupuncture

Head Moocher began Nick’s acupuncture on faith. If nothing else, it could have a placebo effect. As we continued, Nick responded and I found Reference 2. Since then, I have learned that the Social Security Administration is researching use of acupuncture for human low back pain, its third most costly diagnosis after heart disease and pulmonary obstructive disease. The problems with opioids (ineffective as a chronic pain relief and addictive) have driven the SSA to look for effective alternative therapy.

Glucosamine and Chondroitin

The Head Moocher did not observe a change in activity of Nick or predecessors given glucosamine/chondrotin supplementation comparable to that from carprofen-gabapentin pain management therapy.

Our recent foods are enriched in glucosamine and chondroitin. Past use of these supplements has been inconclusive. Nick’s regular veterinarian (Dr. Thompson at Bay Beach) recommended PhyCox which I like because it has anti-inflamatory ingredients in addition to the glucosamine and condroitin. These ingredients are believed to promote maintenance of the joint cartilage

This is consistent with the literature citations. The literature notes that the few trials conducted (can’t get rich on naturally occurring stuff under patent law). are of poor quality (small, short, unsound statistical design, etc).

Phycocyanin and Phycox(tm)

Phycocyanin (we use Phycox) has significant anti-inflammatory and anti-oxidant actions that may be of benefit in the treatment of arthritis. The Wikipedia article does not site any study results. Reference 8 reviews recent literature to find significant benefits of Phycocyanin as an anti-inflammatory and antioxidant in a number of clinical settings. As an element of multi-modal therapies it can provide pain relief and promote healing. Phycocyanin is low in toxicity and non-interacting so we continue to use it.

Phycocyanin has a long history of alternative medicine use via algae supplements and can be produced by fermentation processes or synthesis from precursors. Phycox uses a purified version and is of known potency so dose rate can be controlled. Because it is non-toxic, Phycox can be offered as a snack or as a food additive (how Nick prefers. It can be quite bitter to our taste). Phycox contains turmeric and other ingredients but it is phycocyanin that is of clinical interest.

GlycoFlex

This is a recent addition to Nick’s therapy that introduces perna canulicus (green lipped mussels) to the mix and offers some additional glucosamine and condroitin and other things. GlycoFlex includes Vitamin C and E as anti-oxidants and some other odds and ends. GlycoFlex has been studied for effectiveness in a manufacturer sponsored study. In the study, the control group’s hind leg strength increased by 40 percent compared to the control group which showed continued decline during the study period.

Manufacture sponsored studies should always be taken with a grain of salt as they are small and may be of unsound statistical design or improperly controlled (not double blind). This study did have a control group. To my knowledge, there have been no independent studies of this particular ingredient set. Nick will take these as a treat so I can use them to appease his manipulative streak. (After dinner he pesters hourly for a treat. But only after the evening meal has been offered.)