CHRONIC diseases which have no cure and persist for the lifespan of the patient present a special set of problems to clinicians which we find difficult to deal with.
Such conditions may change with time and produce an array of different clinical signs which challenge our problemsolving approach, especially when the main impact of the disease is on the lifestyle or well-being of the patient.
In the absence of the possibility of resolution or cure we have to palliatively manage the clinical signs, but the effort that we put into this is often limited and defined by the patient’s apparent ability to “cope” with the problem.
When the condition is characterised by pain this becomes a difficult challenge especially if we are dealing with chronic pain, which is difficult to assess and often well disguised by the patient.
We are often aware of the complex pain and mobility problem in a disease like osteoarthritis and we are also aware there are many interventions that have evidenced success in improving the function of animals with this problem. There are also many interventions and treatments with limited or no evidence for effectiveness which are still commonly used to manage the problem.
When the condition is addressed at a specialist level, although there is an understanding of the value of multimodal treatment, what actually dominates the plan is dependent on the specialist’s area of expertise.
By consequence if referral is made to a surgeon, corrective surgery or joint replacement is advocated; a rheumatologist, medical or intraarticular therapy; a pain specialist, a multimodal analgesic plan; a physical therapist, mobilisation exercises, modalities like laser or ultrasound and exercise and hydrotherapy programmes; a nutritionist, obesity control and prevention by calorierestricted diets and use of supplements and so on.
There is also the new emerging field of regenerative medicine with stem cell and autologous platelet therapy being advocated and practised by new specialists in this field. This whole scenario crystallises the nature of the problem.
Osteoarthritis is a very widespread and common disease in the pet population which is best addressed early and locally. How can a busy general practitioner decide which of the specialist treatments cited above is best in an individual case?
An integrated approach is being increasingly used to define the best method to proceed in an individual case where multiple treatment options exist.
Composite analgesic effect
It is known that many interventions for osteoarthritis have an analgesic effect and that this may be summative when they are used in combination. This can be considered as having a composite analgesic effect.
We are well aware of the potential of multimodal analgesic regimes where different analgesic medications are used in combination but other effects should also be considered.
Reducing bodyweight by 8% in an obese dog will have a similar effect on clinical signs as using a NSAID (Marshall et al, 2010). Also the inclusion of EPA in the appropriate formulation and dose in the diet can reduce the effective dose of NSAID by 25% after 12w use (Fritsch et al, 2010) and it has been demonstrated that dogs treated with EPA are seven times more likely to have an improvement in weight bearing compared to controls after nine weeks’ administration (Rousch et al, 2010).
Similarly, mobility exercises, laser therapy and acupuncture can produce analgesic benefits in OA patients. Simple things like environmental modification such as using ramps to allow animals to get in and out of high tailgate cars can substantially reduce the risk of aggravating an already diseased joint and exercise itself has been estimated to have a powerful pain-reducing effect on its own (Brosseau et al, 2010) but can only be possible with analgesia being provided from another source in the initial stages. This composite effect is the rationale behind multimodal management.
But what relevance does this have to the small animal veterinary surgeon working in a restricted timescale struggling with a list of cases suffering from osteoarthritis?
Here we introduce an “electronic expert decision management assistance tool” which can deliver this multispecialist integrated approach into all practices.
This new management tool is easy and quick to use and can fit into a regular consultation schedule but is better deployed in specific arthritis clinics to screen potentially affected dogs or to suggest multimodal strategies for dogs already diagnosed with OA.
It incorporates a surprising level of sophistication, delivering six-point management plans following the Aim. OA model. This system focuses on six key separate domains for management: A – Analgesia; B – Bodyweight and Nutrition; C – Care and Environment; D – Disease Modification; E – Exercise and Wellbeing and F – Follow-up, which stresses the need to make a new appointment at the end of each session for a scheduled re-visit to assess the impact of the plan.
Using the system
The system is web-based and consists of a series of questions for the owner that can be answered in the waiting room on an iPad or a web-enabled device, and a series of questions for the vet based on the clinical examination (Figure 1).
The survey takes only a few minutes to complete. The program then uses an algorithm to generate suggestions for each of the six areas for management.
The application itself is complex and includes an assessment system for individual cases; an analysis system for the disease itself; an algorithm to match a problem to potential solutions; offers options across multiple specialist areas; a full range of mobility and exercise options; a record system for both practice and client; a communication and instruction system and an easy to understand outcomes system for owners.
Despite this degree of complexity an assessment exercise, complete with a management plan with instruction print-outs for the owner, can be accomplished in less than 15 minutes.
The system is unique in assessing the problem and then suggesting interventions that are compatible with this, including a full range of physiotherapy and exercise options.
Over 100 individual mobility exercises are included targeting range of motion, core stability, proprioception and strengthening to complement the more traditional aspects of OA management which address pain control and dietary support.
Priorities for management are identified by a simple traffic light system (Figure 2). The practice can look at the options and select, modify or add their own instructions to construct the plan.
To facilitate the process even further, a practice using this system can customise the individual components including medical therapies, diet and disease management modalities to those which are used in the practice. This means that plans they create will only offer these elements. Each plan and print-out is identified by the practice logo as unique to the practice.
The owner of the patient will receive a detailed plan customised to their own dog detailing a unique set of instructions for them to follow and a date for their next visit. This also contains the traffic light system which informs them of the key areas which the practice plan is working on.
This plan will include dietary instructions and specific mobility or general exercise instructions for them to follow before their next visit. Mobility exercises are presented with simple instructions to allow these to be performed on a daily basis at home (Figure 3).
This fully instructs and informs the owner and they are able to participate in the management plan at the level they wish. This is all achieved from the app with the minimum amount of time generating these instructions by the practice. Time at the practice can be more effectively spent on explaining the problem or encouraging the owner.
Recording and viewing details
The system automatically creates a detailed treatment record for the patient over time which is stored and can be retrieved and reviewed at any time. The owner is able to view the specific instruction plans by using their own unique log-in and also to view a graphical display of their pet’s progress (Figure 4).
Data can be reviewed by the practice periodically to demonstrate what instructions they are employing most commonly and also to investigate what is working and what is not.
Additional data can be obtained by using exercise monitors or clinical metrology instruments (LOAD; Glasgow Chronic Pain Scale) combined with the decision system, to give more information about progress.
Summary
Using this system will improve results by widening the approach to management of osteoarthritis in general practice. The app makes the system time-efficient and able to fit into a busy practice time schedule.
The Aim.OA system brings an expert-driven planning and management option into every practice. It seeks to help the practice deliver the best options and service to its patients and clients in a completely new interactive format.
The integrated approach to OA is proven to deliver better results as it takes a wider view of the exact nature of the problem. The results themselves can be measured in patient response, owner compliance and satisfaction.
It also has a positive impact on practice staff who often are very busy but value the chance to make an impact on an important problem affecting many of the patients and owners of the practice.
This is a paradigm change in the way we approach any chronic disease. It brings an integrated expert system to bear on the problem while being time-efficient to administer, consistent in treatment, persistent in providing management options over the course of the disease and improving owner understanding and compliance. Welcome to the future of chronic disease management.
References
1. Brosseau, L. et al (2010) Intensity of exercise for the treatment of osteoarthritis. Cochrane Library 7.
2. Fritsch, D. A. et al (2010) A multicenter study of the effect of dietary supplementation with fish oil omega-3 fatty acids on carprofen dosage in dogs with osteoarthritis. J Am Vet Med Assoc 236: 535.
3. Marshall, W. G., Mullen, D., DeMeyer, G., Baert, K. and Carmichael, S. (2010) The effect of weight loss on lameness in obese dogs with osteoarthritis. Veterinary Research Communications 34: 241-253.
4. Rousch, J. K. et al (2010) 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 236: 67.
