Treating Arthritis Naturally: by Ruth Roberts DVM CVA CVH

Photo via CB Photography

What can we do to help prevent joint disease in dogs, and are there natural options to treat joint pain?

We have available many good and safe medications for arthritis, but where we need to focus our effort is on preventing the issue from arising, and treating with things that have no side effects just as the dog starts to have very early signs of a problem, instead of waiting for the dog to be in pain.

Because the majority of dogs prone to arthritis are our constant companions we know 2 things that commonly happen as our friends get older: 1) They often develop arthritis of the knee/ stifle, hip, shoulders, elbows, back and feet. 2) They love to eat and often become overweight.

Unfortunately the second thing makes the first thing worse, so when we focus on preventing or treating joint disease, the place we start is with maintaining a healthy weight, or helping an overweight dog lose weight.

How do you know if your dog is overweight? If you can apply gentle pressure over the rib cage and feel ribs, this is good. If you have to push in half an inch or more to get to ribs, not so good.

You should be able to feel a waist or hourglass shape from the top of the back, as you run your hands from the shoulders to the hips. From underneath, as you run your hand from the center of the deepest part of the chest towards the hip, the stomach should curve upward toward the hips. If you find you feel a straight line, then your dog is too heavy. We use a Body Condition Score to help quantify a dogʼs physique and to provide a descriptions for normal weight animals, as well as those too heavy or thin.

How do you help your dog lose weight? There are certain things that dogs do to convince humans to feed them more. Most dogs love to eat, and they often always act like they want to eat. The first trick is to revamp these behaviors, and stop the begging, and replace them with good behaviors. If your dog is begging try substituting a toy or playtime. The next important thing is that what the bag of food says to feed is often too much. With your veterinarianʼs guidance, reduce the food and add things like green beans or carrots to fill the void. Switching to a high protein, low carbohydrate food can make a difference quickly, as can a balanced home cooked diet. Bones can help provide distraction and satisfaction, but you do need to make sure that your dog will not try to eat the bone whole, or get sick from it. Adding a vitamin supplement with a lot of B Vitamins can be helpful as well. Finally, because low thyroid function is common, ask your veterinarian about testing for thyroid function. Supplementation can make a world of difference.

There are loads of supplements available for joint pain & arthritis, and most are designed to treat a problem. Some can be used to prevent issues, or at least prevent them from happening as quickly. A Chondroitin & Glucosamine supplement is a good idea, and there are many forms available from capsule to chewable. Fish oil is helpful for controlling inflammation and adding luster to the coat and skin.

How will you know your dog is beginning to have problems? When your dog starts to slow down, or get tired more quickly, he may be maturing, but he may also be getting some discomfort starting up. If you feel the harness start to move differently in your hand, it may be a signal that your dog has changed her gate slightly, to shift off an uncomfortable hip. You all know your dogs better than anyone else ever will. If you feel something is off, it is wise to get it checked out.

What can you do if your pet is already developing arthritis or joint pain?

Again, one of the most important things to do is get your dogʼs weight under control if it isnʼt already. In Human Medicine, there are estimates that joint replacement surgery could be reduced by as much as 30 % if the patients would loose weight.

Exercise that helps stretch your pets legs and back is very helpful. Swimming is great, and locally we have Paddling Paws, a facility built just for dogs, with someone that will swim with your dog so it feels safe. Another choice is to passively stretch the legs by moving them through the normal range of motion. Also, you can move the legs gently away from the body, and then toward the body. The goal is to move the limbs through a normal motion while they are not bearing weight so the muscles can move freely, and hopefully loosen up.

Massage is very comforting and is something you can do on your own, or take your dog to a massage therapist trained to work with our four legged friends. Your dog will let you know what feels good. Start with rubbing your hands in opposite directions on top of your dogʼs back, and work your way up & down the spine. This will create some warmth and you may feel your dog stretching as you rub. Next, start at the shoulders and use your fingers and thumbs to apply gentle pressure to either side of the spine, about the distance of your thumb from the tips of the spine. work each area for about 5 to 7 of your own breaths, or longer if your dog leans into your massage. Massage the legs by gently kneading the muscles as you would bread. Work up and down the legs to get circulation flowing.

Other non-drug treatments that have been very helpful include acupuncture and therapeutic laser. Both methods provide pain relief by working with the body. Therapeutic laser causes blood flow to increase into an area, and gets the cells to dump out the junk and take on fresh nutrients. Acupuncture works by breaking up the stagnation causing the pain, and restoring balance to the body.

Nutritional supplements include a broader spectrum joint supplement that has MSM, and green muscle as well as chondroitin and glucosamine and other joint protectants. There are tons of these products available, and some work well, and some do not. get recommendations from folks you know, or your veterinarian. Fish oil stays important, and Bromelain can be a big help as well. To help with pain, Bromelain has to be taken at least an hour away from food. There are many Chinese herbal formulas to help with specific imbalances that may cause arthritis. Each dog is different, so we have to tailor a plan specific to her needs. Food therapy is very helpful in reducing inflammation, and I will discuss it in detail a little later.

If you have specific questions Iʼd be happy to answer them as best I can

Ruth M. Roberts, DVM CVA CVH

Sun Dog Cat Moon Veterinary Clinic

drruth@sundogcatmoon.com

www.sundogcatmoon.com

843-437-0063

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Another Study of Fish Oil for Canine Arthritis

In January, a couple of research studies were published in the Journal of the American Veterinary Medical Association (JAVMA) investigating the possible usefulness of dietary fish oil supplementation for treating the symptoms of arthritis in dogs.[1-2] I have previously discussed these papers in detail, but overall they were well-designed studies with mostly negative findings. However, the few statistically significant measures seen were generously interpreted as evidence for a beneficial effect of the treatment. A more accurate interpretation would be that no clear, consistent, meaningful effect was observed. Still, the few effects that were documented would justify additional research. Ideally, this research would be conducted by different researchers since the group naturally has a bias in favor of the intervention they are studying, and a number of the authors of the JAVMA studies have institutional affiliations with the Hill’s Pet Food company which manufactures the diet with supplemental fish oil tested in the study, and this raises some possibility of a conflict of interest. 

However, the same research group has now published another study looking at fish oils as a treatment for canine arthritis, this time in the Journal of Veterinary Internal Medicine.[3] This study was specifically designed to look for effects of varying levels of fish oil supplementation on subjective measures of arthritis.

A Bad Beginning
My first concern about this study is the background statement and introduction, which begin with the claim that “Food supplemented with fish oil improves clinical signs and weight bearing in dogs with osteoarthritis (OA).” The evidentiary support for this claim is twofold. First, it is supported by reference to findings in humans that fish oils may improve the symptoms of rheumatoid arthritis. There is some limited evidence that this may be the case (c.f. literature summaries available from the Agency for Healthcare Research and Quality, and Medline), however even if this were established, the relevance is questionable since this is a different disease in a different species. The authors acknowledge that “the pathophysiology of rheumatoid arthritis and OA differ,” but they let stand the implication that since both are inflammatory conditions, if fish oil helps one it might help the other. Plausible but very weak reasoning.

The second major pillar of support for the a priori claim that fish oils are proven effective as a treatment for canine arthritis is, you guessed it, the two previous papers published by the same group in JAVMA. Obviously, given my review of these papers, I don’t consider that claim to be justified by those studies. So this study begins with the assumption the treatment works, and the hypothesis is then examined that since some helps more might help even more.  Shaky ground to start from.

The Study
As with the previous work, the study was soundly designed. 212 dogs were randomly assigned to eat one of three diets with different levels of fish oils but relatively comparable otherwise. The diet with the lowest level of fish oil (Diet A) was the same as used in the previous studies, approximately 0.8% EPA+DHA on a dry matter basis. Diet B had ~ 2% of the fish oils, and Diet C about 2.9%. There was no negative control (diet without supplemental fish oils).

Subjects were allowed to use concurrent therapies, including NSAIDs and glucosamine, but no overall statistically significant difference in the rate of such usage was found between the groups of patients on the different diets. Dropout rates were moderate and higher for Food A than the other two foods (Food A-22%, Food B-13%, Food C-17%). The authors state that the inclusion evaluation data from dogs that did not complete the study did not affect the results. Owners and participating veterinarians were blinded to the treatment individual dogs were assigned to.

The assessment measures included a series of subjective physical examination parameters assessed by participating veterinarians similar to those used by the participating veterinarians in the previous studies. These were performed on Days 0, 21, 45, and 90 of the study. Two new variables were included, which were general questions the participating vets were asked at the conclusion of the study:

A. “Based on the pet owner’s input and your own clinical assessment, how would you describe the impact the study food has had on this dog’s arthritic condition?”
1. significantly slowed progression of the arthritis
2. slightly slowed progression of the arthritis
3. no effect
4. slightly accelerated progression of the arthritis
5. significantly progression of the arthritis

B. “Based on the pet owner’s input and your own clinical assessment, how has the arthritic condition of this dog changed since eating the study food?”
1. extreme improvement
2. moderate improvement
3. slight improvement
4. no change
5. slight deterioration
6. moderate deterioration
7. extreme deterioration

The authors also measured the blood levels of a variety of omega-3 and omega-6 fatty acids for all subjects.

The Results
Serum levels of omega 3 fatty acids increased significantly more for Foods B and C than for Food A, showing that greater levels in the food correlates with greater levels in the actual animal. Some omega 6 fatty acid levels were significantly lower in subjects eating Foods B and C, others were not.

In terms of the 5 clinical evaluations done by participating veterinarians, all improved significantly over time for all diets except that the score for weight bearing did not improve for Food A. Of the 5 measures, 2 improved more for Food C than for Food A, and there was no difference between Food B and Food A.

For the two subjective questions asked of the participating veterinarians, the answers showed a statistically greater improvement for Food C than for Food A, and again no difference between Foods A and B.

Sixteen adverse events were recorded, and of these 2 cases of vomiting and/or diarrhea were attributed to the intervention (one for Food A and one for Food B). What the other events were and why they were not considered related to the diets was not discussed. 

Discussion
So, do fish oils effectively treat the symptoms of canine osteoarthritis? Maybe. Improvements were seen for all foods. The measures were subjective, and the two summary questions asked of veterinarians in the study were structured in a redundant and somewhat leading way, so there are some limitations in the reliability of the conclusions based on these. Interestingly, the authors claim these results are consistent with their previous studies, but this is not entirely true. In one of the earlier studies, no veterinarian clinical examination measures improved, and only 3 out of 39 possible data points for owner evaluation improved significantly. In the other study, none of the owner evaluations changed significantly, but 3 of 5 measures evaluated by clinicians showed improvement. An objective measure, force plate gait analysis, was used in this second study, and this showed no change from baseline for any of 6 variables but a significant mean improvement for 1 of the 6 measures.

By contrast, in the current study only subjective veterinarian evaluations were used as measures of outcome, and these showed improvements in all variables for all foods. The authors point out that these improvements were “relatively modest” (aka small), but rather than attributing this to the treatment having only a modest effect, they attribute it to the insensitivity of their subjective measurement criteria. This is a bit odd since in medical research generally, subjective criteria are much more likely to show positive changes than objective criteria, even when there aren’t any real differences.

The inconsistency in the results of the various trials is a cause for concern, as it suggests the criteria for measuring any possible treatment effect may not be reliable. The trials designed to see if the treatment worked found few and inconsistent positive changes in subjective measures and almost no change in objective measures. The trial designed to see if more worked better than less found that everything worked a little, but while the difference between the diet with 0.8% fatty acid content and that with 2% was not significant for any measure, the difference between 0.8% and 2.9% was significant for 2 of 5 clinical measures and both global assessment questions asked of the participating vets. And all of this is ignoring the potential biases introduced by having all trials done by the same research group and the association with a company manufacturing a commercial food used in all of the trials.

This does not create a solid, consistent pattern of evidence to support the use of fish oils to treat canine arthritis. At best, it can be said that: the serum fatty acid level data indicates the fish oil changes the fatty acid profile of dogs in ways that would be desirable if the fish oil actually has clinically meaningful effects;  there is weak evidence to suggest there may be some such effects, though small and inconsistent; and there is little evidence of short-term harm.

All of this is useful data, of course, and generally the studies were well-conducted. However, the conclusions tend to be much stronger than is justified by the data, which is a reflection of the bias of the investigators in favor of the intervention they are researching. This is to be expected, but if a small group of researchers become the only source of clinical data on the subject, and if most vets read only the conclusions and don’t critically examine the studies and the results, it is likely to have an inappropriately large impact on clinical practices. I wouldn’t be surprised if fish oil for arthritis becomes the new glucosamine, and while I hope it turn out to work better than glucosamine does, that product had much the same kind of weak positive data from limited sources at the beginning as well, and now it has become a ubiquitous product despite subsequently stronger results suggesting it has no benefit.

References
1. Roush JK, Dodd CE, Fritsch DA, Allen TA, Jewell DE, et al. Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs. J Am Vet Med Assoc. 2010 Jan 1;236(1):59-66.

2. Roush JK, Cross AR, Renberg WC, Dodd CE, Sixby KA,, et al. Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis. J Am Vet Med Assoc. 2010 Jan 1;236(1):63-73.

3. Fritsch D, Allen TA, Dodd CE, Jewell DE, Sixby PS, et al. Dose-titration effects of fish oil in osteoarthritis dogs. J Vet Int Med 2010;24(5):1020-26.

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Can fish oil help you and your dog with easing arthritis symptoms, stiffness, and inflammation?

Can you and your dog share a dose of fish oil for arthritis? According to a February 22, 2010 press release from veterinarian, Dr. Nancy Kay, at the Speaking for Spot site and blog, fish oil may help your osteoarthritis, and also can help your dog’s osteoarthritis, especially if you have a large breed dog eight years or older. According to a recent edition of the Journal of the American Veterinary Medical Association. See the article and study, “Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis.” 

It contained two studies on the effects of omega-3 fatty acids (fish oil) for the treatment of osteoarthritis (also known as arthritis or degenerative joint disease) in dogs. Many dogs were included. The study reports a control group. Also see the NY Times article, “A Fish Oil Story.” Can you also get quality Omega 3 fatty acids from certain forms of algae (that come in tablets for humans)? Talk it over with your doctor, and for your dog, your veterinarian.

Some dogs received a placebo rather than the fatty acids. Neither the veterinarians nor the dogs’ families knew whether the dogs were receiving the Omega 3 fatty acids from fish oil or the placebo.  

Here’s what the studies showed. Compared to the placebo group, the dogs receiving omega-3 fatty acids had a significantly improved ability to rise from a resting position and play by six weeks after beginning supplementation, and improved ability to walk by 12 weeks. 

Compared to the control group, dogs receiving the fish oil had improved weight bearing on the affected limbs as assessed by force-plate analysis (an extremely humane testing method).  No significant adverse side effects from the fish oil supplementation were reported. 

Arthritis affects up to twenty percent of dogs over one year of age, especially the larger breeds. Dogs with arthritis act like people with arthritis and feel the same types of pain.

Dogs and people with arthritis act stiff and are slow to rise when they first get up in the morning, as well as after vigorous exercise.  There are many ways to treat this common canine malady including nonsteroidal anti-inflammatory medications (the equivalent of ibuprofen for humans), acupuncture, rehabilitation therapy, and supplements that increase the production of normal joint fluid. 

The effectiveness of all of these treatments, including fish oil, vary from individual to individual. Some people feel painful arthritis when they eat tomatoes, potatoes, bell peppers, or any other member of the nightshade family of vegetables or fruits.

Fish oil comes to the rescue, even krill oil. The beauty of fish oil is that there is little risk for dogs, according to veterinarians, if the dog receives an appropriate amount of fish oil. When people take too much fish oil, there’s always the danger of bleeding inside. But what about dogs?

Veterinarians now have evidence based support for recommending fish oil as a treatment for their canine patients with arthritis. Should you feed your dog your fish oil that you take for arthritis rather than commercial drugs for treating arthritis pain?

Chances are if you have a large breed dog over eight years of age, you dog has arthritis, just as you may have arthritis at your age. First talk with your veterinarian about the pros and cons of all the treatment options.  Dogs will eat fish oil supplements if you buy the kind that doesn’t have lemon flavoring. Put the fish oil in a meat ball or drizzle a little bit over the dog’s food. Also you can buy salmon without added salt for your dog, which contains omega 3 fatty acids in the salmon. Eat it yourself.

Taste of the Wild also makes a smoked salmon dry dog food containing blueberries and other foods, but does not contain any grain. According to the study, “Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis,” the objective of the study was to evaluate the effects of a food supplemented with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis. The clinical trial study was randomized, double-blinded, and controlled.

In the study, 38 dogs client-owned dogs with osteoarthritis were examined at two university veterinary clinics.

According to the abstract of the study, the dogs were randomly assigned to receive a typical commercial food (n = 16) or a test food (22) containing 3.5% fish oil omega-3 fatty acids. On day 0 (before the trial began) and days 45 and 90 after the trial began, investigators conducted orthopedic evaluations and force-plate analyses of the most severely affected limb of each dog, and owners completed questionnaires.

The change in mean peak vertical force between days 90 and 0 was significant for the test-food group (5.6%) but not for the control-food group (0.4%). Improvement in peak vertical force values was evident in 82% of the dogs in the test-food group, compared with 38% of the dogs in the control-food group.

In addition, according to investigators’ subjective evaluations, dogs fed the test food had significant improvements in lameness and weight bearing on day 90, compared with measurements obtained on day 0.

What was the conclusion? At least in the short term, according to the clinical trial, dietary supplementation with fish oil omega-3 fatty acids resulted in an improvement in weight bearing in dogs with osteoarthritis. For further information on the study of using fish oil to help dogs with arthritis, read the articles by veterinarian Dr. Nancy Kay at the Speaking for Spot site.

At the site, you will also find “Advocacy Aids”- helpful health forms you can download and use for your own dog, and a collection of published articles on advocating for your pet’s health. Speaking for Spot is available at Amazon.com, local bookstores, or your favorite online book seller.

Now, the next time you’re thinking about human nutrition for yourself and your osteoarthritis, think about trying some high quality fish oil or krill oil. Ask your doctor whether fish or krill oil will help your arthritis problems, since it probably might help your dog. But first find out what dose is best for you and your dog. Your health care professional can advise you. And the various studies on fish oil can give you factual information.

Tales of Arthritis, Fish Oil, and Not-Luxating Patella

Gida turned 10 this year, among showers of adoration and Pupcake. I wrote previously about how, in the context of her milestone birthday, some elderly seeming canine behaviors have become more apparent. Maybe it’s just me, maybe it’s not.

One of our observations was a wonky back leg; usually after walking or jumping, she’d hold up one back leg like it was uncomfortable to stand on. Off to the vet we went, hoping it wasn’t luxating patella, a common kneecap-related condition in Bostons. Though the vet suggested in the past that we keep an eye on her leg for this very reason, this time, the diagnosis is: likely arthritis. Empathy ensues from the humans, but the news doesn’t impact Gida’s day at all — incidentally one of the greatest things about animals.

The solution for now is to add fish oil to her food, per doctor’s orders.

R.M. Clemmons, a veterinarian and professor at the University of Florida, writes that fish oils can indeed be anti-inflammatory agents, worth a shot for animals with autoimmune disease or arthritis. We purchased an over-the-counter bottle, readily available at many pet-supply stores. However, Clemmons notes that sardines or ground flax seeds can be more pure sources of the same stuff. Furthermore, he says some studies found adverse effects in fish-oil capsules, due to spoiling.

At this early stage, I think Gida is digging it out of her bowl, judging by several pieces of uneaten kibble on the floor. (Vitamins ain’t ice cream for us, either, Smalldog.)

Let us know about your experiences with fish oil, supplements, or arthritic pets: solutions that worked, or whether your pet hated or loved the taste.

Image: Right Angle Images