DIET & SUPPLEMENTS FOR DOGS

WITH ARTHRITIS & JOINT PROBLEMS

Where to Start
Piglet's  Story
Supplements and Natural Therapies
Diet
Chronic Pain Relief
new info added on shock wave therapy and regenerative cell therapy
Surgery
Links
Also see my WDJ article on arthritis


Disclaimer: I want to preface this webpage by stating that I am not a vet, nor do I have any formal training in nutrition or other medical fields. The information I am presenting here has been gleaned from books, from the internet, and from the knowledge and experience of others. It is not meant to replace your vet's advice or any medications they may prescribe, but hopefully will suggest additional options to think about, and other information to explore, based on your dog's condition. I welcome any feedback, or any additional information you may want to share that can be added to this website.

WHERE TO START

The number of things you can try to help your dog with arthritis can seem overwhelming, so I'm going to suggest some ways to get started.

1. GLUCOSAMINE First and foremost, I believe all dogs with arthritis or known joint problems should be on some sort of glucosamine-type therapy. This should include oral supplements that contain glucosamine (sulfate or hcl), chondroitin sulfate, green lipped mussel (perna canaliculus), hyaluronic acid, or a combination of these. It may also include the injectible form, Adequan or Cartrophen. Since these supplements are the only things that actually help protect the joints rather than just treating the symptoms, they are a must for all dogs with joint problems. Different dogs respond differently to different supplements, so find one that works for your dog rather than relying on what has worked for others, though that may be a good place to start. Give high doses at first, so you will be able to tell if it is working. If you get results, you can try reducing the dosage to see if your dog will do well on less. If you don't get results, try a different brand. See the section below on Glucosamine and other GAGs for more information.

2. DIET If possible, reduce the amount of grains and starchy carbohydrates in the diet and increase the amount of protein. This can be done by feeding a better quality food, by using canned instead of dry foods, by adding fresh foods such as eggs and meat to the diet, or by feeding a  home made diet. Many arthritic dogs improve greatly when grains are removed from the diet. One of the best things you can do for a dog with arthritis is to keep him lean. If your dog is overweight, start him on a weight loss program right away -- note that traditional high-carbohydrate weight loss products are not recommended. See Pudgy Pups for some guidelines on helping your dog to lose weight. Also see the section below on Diet for dogs with arthritis for more information, and the section on Senior and overweight dogs on my Dog Feeding page.

3. FISH OIL If I was going to suggest any single nutritional supplement for dogs with arthritis, it would be fish oil (fish body oil, such as Salmon Oil or EPA oil, not cod liver oil). Fish oil provides omega-3 fatty acids that help reduce inflammation. They are beneficial no matter what type of diet you feed. Note that omega-3 fatty acids are fragile and break down quickly when exposed to light, heat or air, so just feeding a food that has omega-3 fatty acids added is not usually helpful. Give as much as 1000 mg fish oil (300 mg EPA/DHA) per 10 lbs of body weight daily. Because fish oil depletes vitamin E in the body, you should also give vitamin E supplements whenever you supplement with oils of any kind. Give around 100 IUs  to a small dog, 200 IUs to a medium sized dog, up to 400 IUs for a large dog, anywhere from daily to once or twice a week.

4. PAIN RELIEF If your dog is in pain, look for ways to relieve it naturally before turning to NSAIDs. DLPA is the first thing I would try, it made a definite difference for my dog and is very safe to use. For worse pain, consider using Tramadol, a synthetic narcotic that can also be used in conjunction with NSAIDs. I would also be trying a variety of natural anti-inflammatories, to see if any of them seem to make a difference. I'm always trying something new with my Piglet. If one supplement doesn't seem to help, I simply move on to another one when I run out. Anything that does seem to help I continue using. See the section on Chronic Pain Relief below for more information on drugs used to help dogs with arthritis pain.

5. ALTERNATIVE THERAPIES Many people have reported success using acupuncture for arthritis. Unfortunately, I am not one of them, and at least in my area, acupuncture is very expensive (over $100 per visit), so it's not the first thing I would recommend trying unless you have access to it at a more reasonable rate. If your dog does respond to acupuncture, you can also consider gold bead implants, which are a form of permanent acupuncture. Chiropractic can also be helpful in many cases, although again, I have not had success with it myself. I do not recommend VOM (veterinary orthopedic manipulation), a form of chiropractic that makes unrealistic claims and in our case had no benefit at all, but other forms may be very helpful for many dogs.

PIGLET'S STORY

My dog Piglet had surgery for elbow dysplasia on both elbows before her second birthday, followed by surgery for a ruptured cruciate at age 3. She was on daily Rimadyl/Etogesic with occasional doses of prednisone up until age 7. At that time, I switched her to a raw, grain-free diet with natural supplements. She improved so much that I was able to discontinue all medications. At age 10, she ruptured her other cruciate and again had surgery (April, 2002). It took about three months for us to build back up to her usual 2 mile daily walks, but she did extremely well, became just as active as ever, and was still on no medications for her arthritis, despite the fact that x-rays confirmed severe degenerative joint disease in both elbows. At age 11, she became lamer in one elbow, and after many months of struggling to get her back to where she had been before, I put her back on NSAIDs (Metacam). She continued to be slower than before and I had to cut back on walks because she couldn't go as far. After about a year, she improved again, and while still slower than she used to be, could  go on full length walks again at age 13. Then I discovered a very small tumor in her foot, between her toes. It was removed immediately, and when she recovered, she began taking very long walks, longer than ever before. Now, at age 14, she walks 1 1/2 to 2 hours at a time, going sometimes 3-4 miles, almost every day. I suspect that the tumor had been bothering her to walk on. It never hurts to keep looking for other possible causes of lameness, even when you know your dog has bad joints.

Here is what I have done with her:

From the age of 7 to 11, Piglet was in better shape with no medications than she had been at a younger age, and she did not slow down much at all. At age 11 1/2, her left elbow became quite a bit worse, and she began slowing down. In general, she has been very active and fit, but our walks decreased from an hour a day, to half an hour a day, down to 15 minutes on bad days, at age 12 1/2. She then improved again (I think she had injured her left elbow and it gradually got better), and at age 13, she went back to about 45 minutes a day. At age 14, following surgery to remove a small tumor, she began taking longer walks than ever. She slowed down again at age 15, but then gradually improved following shock wave therapy. Moderate exercise is good for dogs with arthritis, as long as you don't overdo it (tired muscles make for lax joints, which is not good).

SUPPLEMENTS AND NATURAL THERAPIES

Glucosamine and other GAGs (Glycosaminoglycans)

Glucosamine is one of several supplements that help rebuild cartilage and restore synovial (joint) fluid. These types of supplements may be helpful in preventing disease as well as treating it. Note they treat the actual problem, and not just the symptoms. They include Glucosamine Sulfate, Glucosamine HCl, Chondroitin Sulfate, Green-Lipped Mussel (Perna  Calaniculus), Sea Cucumber (such as NutriSea's Vetri-LOX, Sea Jerky and related products), other forms of cartilage (including from food sources, such as chicken necks and bovine trachea), hydrolyzed collagen protein, and the injectables Adequan and Cartrophen (Adequan is used in the US, Cartrophen is used elsewhere). Note that these supplements may be more effective when given away from meals (at least one hour before or two hours after), but can be given with food if preferred. These supplements may also work better when they include a small amount of manganese.

When giving glucosamine and chondroitin for arthritis, start out at high doses: at least 500 mg glucosamine plus 400 mg chondroitin for a small dog, 1000/800 for a medium-sized dog, and 1500/1200 for a large dog daily (up to double that amount to start with). If you see improvement, you can try backing off to a smaller dosage. Some dogs do well on less, some need the higher amount to get relief. If you don't see any improvement in four weeks, try a different brand. Different dogs seem to do better with different brands. Glucosamine/chondroitin can be given with food, but may be more effective if given at least one hour before or two hours after feeding.

There are many arguments about which form of Glucosamine is best. I have yet to see anything I find convincing, as most of the arguments are made by commercial companies in support of their own products. However, if giving Glucosamine HCl, it should always be combined with Chondroitin Sulfate for better uptake, whereas Glucosamine Sulfate can be given alone. It is best if supplements also include Manganese, which can help increase absorption.

It is unknown whether giving glucosamine helps to prevent arthritis, but there is no harm in doing so. If you are looking for plain glucosamine, for a dog not yet in need of anti-inflammatories, the Greyhound Gang rescue organization offers high quality supplements at very low prices, with proceeds going to benefit rescue (they also offer MSM, Vitamin C and other supplements).

Some people report success with injectible glycosaminoglycans, such as Adequan (US) or Cartrophen (elsewhere) even when oral glucosamine and chondroitin have not worked (they can also be used together). Note that Adequan is giving intramuscularly (IM), while Cartrophen is given subcutaneously (sub-q). There appears to be no reason for this difference. I have heard of a number of people and vets giving Adequan sub-q with comparable results (sub-q injections are less painful for the dog and easier for the owner to give at home, if desired). See my post for more info on this topic.

Hyaluronic Acid
There is also a  substance related to glucosamine called Hyaluronic Acid (also called Sodium Hyaluronate) that has been helpful for some dogs. Hyaluronic Acid has been used in intra-articular (into the joint) injection form for horses with great success. There is some question how effective it is when given orally.
I've seen dosage recommendations that range from 2 to 20 mg per day for large dogs.
See the human product Synthovial 7 (and this study) and the product made for dogs by the same company called Hyaflex for more information (either product should be OK to use; the pet product has 2 mg HA per dropper, while the human product has 3 mg per dropper, so you would adjust the dosage accordingly). The Healthshelf site has directions on the amount to give and may have a better price as well.
HylaSport Canine is a new product for dogs from a company who has made products for horses; I've heard one direct report of this product helping.
Trixsyn is a similar product, which one person reported helping their dog considerably.
The liquid glucosamine product K9Liquid Health Glucosamine & HA (best price found here) also contains hyaluronic acid.
One person reported using the horse product Lubrisyn for their dogs with great success, including a Dane with Wobbler's and a GSD with severe HD, she gives 1 1/2 tsps daily to each dog.
In the UK, look for Conquer K9 and Chondrogen EQ (also available in the US).
Hyaluronic acid may be much more effective when injected directly into the joint (intra-articular), but this must be done under anesthesia. One version, Legend, can also be given IV (when given via IV, treatment may be repeated weekly for a total of three treatments). It is approved only for horses, but has been used to treat other animals, including dogs. A veterinarian who treats both horses and dogs might know what the dosage should be.
The injectible form is sold for horses under the brand name Hylartin V (and maybe others). One person reported using the injectible form on their dog and said that the improvement from one injection lasted for about 3 months.
See New Options for Old Problems - Relief from Arthritis for more information on these supplements.

Natural Anti-Inflammatories

When the dog becomes symptomatic, usually inflammation is involved, so you can use supplements that help relieve inflammation. These include but are not limited to the following: At this point, it appears that grains may increase inflammation and can make the dog much more painful, so a home made diet that does not include grains can also be helpful.

Supplements that have been successful for others include:

See the human-oriented article on Joint Support for additional information on several of the supplements mentioned here.

Other Therapies

Many people have had success with Acupuncture and Chiropractic treatments, and also Massage Therapy, which you can learn to do yourself at home (the book that was recommended to me by the physical therapists who worked on Piglet after her knee surgery is Canine Massage by Hourdebaigt). Hydrotherapy using swimming or underwater treadmills is becoming more available and can be very helpful, especially following surgery.

If acupuncture helps your dog, you may want to consider using Gold Bead Implants, which work like permanent acupuncture. See the Gold Beads Implant Directory for articles with more information and a list of some of the vets who perform this treatment.

There is an experimental treatment for dogs with Ossifying Spondylitis, or with IVD/IDD (Intervertabral Disk Disease) called RVI (Rubeola Virus Immunomodulator). It is actually a type of vaccine that has been used with horses and has only recently started being tested for use with dogs. I have heard one first hand report of a dog with spondylitis who improved greatly on this treatment regime.

DIET

Some dogs improve greatly simply by removing grains from the diet. There are a number of new grain-free foods available these days, which I note in the Commercial Foods section of my web site. Remember that it is very important to keep a dog with arthritis lean, as extra weight will contribute to the problem and its progression. See Pudgy Pups for a good article on helping your dog to lose weight. Also see the section on Senior and overweight dogs on my Dog Feeding web page.

If you are feeding a home-prepared diet, here are some notes from Ian Billinghurst's seminar about how to feed an arthritic dog, along with my own comments (in brackets):

Note that I feed more meat, including red meat, and fewer veggies than is recommended above. I also use fish oil (body oil, such as salmon oil or EPA oil, not cod liver oil) instead of flaxseed oil, as it is better utilized by the dog, and does not contain the pro-inflammatory omega-6 fatty acids that flaxseed oil has.

Piglet's diet is around 35-40% raw meaty bones (including canned fish with bones -- jack mackerel, pink salmon, sardines -- once a week), 5% liver and kidney, 25% fruit and veggies, and the rest is muscle meat, eggs, yogurt, etc. I do include garlic, ginger and celery in her veggie mixture, to help with arthritis. I try to feed as much variety as I can, including red meat.

It is important that dogs with arthritis get adequate, but not excessive amounts of calcium, vitamin D and magnesium. If you are feeding a commercial diet, there should be no need to supplement with any of these. If you are feeding a home made diet, it might be helpful to supplement with small amounts of vitamin D (such as from cod liver oil) and magnesium. If your diet includes raw meaty bones, they should not account for more than around 50% of the diet. If your diet does not include bones, then you need to add calcium at the rate of around 1,000 mg per pound of food (1/2 teaspoon of ground eggshell yields about 1,000 mg of calcium).

CHRONIC PAIN RELIEF

Sections include:

DLPA

DLPA (DL-Phenylalanine) is a nutritional supplement that helps with chronic pain. I know of one elderly and feeble Newfoundland who was helped greatly with this supplement, and there are reports on the web of other dogs being helped as well. My Piglet initially responded very well to DLPA, then got worse again, though I continue to give it to her (150 mg twice a day). It appears to be very safe. It is best given away from food, but can be given with meals if needed.

I have seen a variety of dosage recommendations, including the following:
3 to 10 mg/kg which converts to 1.5 to 5 mg per pound of bodyweight (I believe this is twice a day)
    To convert your dog's weight in pounds to kilograms, divide by 2.2 (my 33 pound dog weighs 15 kg)
125 to 500 mg twice a day
500 mg once or twice a day
250 to 500 mg twice a day
5-10 mg per pound of body weight two to three times a day -- this recommendation is in the book Homeopathic Remedies for Cats and Dogs by Don Hamilton, DVM. In humans, very high doses (over 1500 mg/day) of DLPA may cause numbness, tingling or other signs of nerve damage, so this is something to be aware of if you do use high doses.

DLPA is mostly available in 500 mg capsules, occasionally I have seen it in 375 mg capsules. When smaller doses are needed, you might use Arthroplex (available at Wellvet and HolisticPetInfo), which is a glucosamine supplement that also contains DLPA (DL-Phenylalanine, 75 mg per capsule). I also found a product called Curcumin Plus (formerly Phenocane) that could be used for smaller dogs. It is manufactured by Golden Tones (formerly Health Advances Dr. Donsbach) and also sold under the OxyLife brand name, and is available at  Seacoast Vitamins, H&M Herbs, and Pure Prescriptions. Curcumin plus is a mixture of curcumin (250-350 mg), boswellia (175 mg) and DLPA (75 mg). Curcumin (also called turmeric) and boswellia have natural anti-inflammatory properties.

See the following for more information:
DLPA in the nutritional control of arthritis and chronic pain
Phenylalanine
DLPA

Note that DLPA should not be given with MAOIs (such as Anipryl/l-deprenyl/selegiline, or Amitraz, found in the Preventic collar and used to treat demodectic mange), as it can cause a severe increase in blood pressure in humans. It is fine to combine DLPA with other pain meds, including Tramadol and everything else listed on this web page.

Here are some places that carry DLPA, also called DL-Phenylalanine:

http://www.vitacost.com/Twinlab-DLPA
http://www.vitacost.com/NSI-DL-Phenylalanine
http://www.puritan.com/ (search for DL-Phenylalanine)
http://www.swansonvitamins.com (Item #SW873)

TRAMADOL

Tramadol (Ultram) is a synthetic opioid that appears to be safer than most narcotics, and is easier to get as it is not a controlled substance. It is apparently much less likely to cause dependence and can be used long term for chronic pain, although withdrawal effects can occur and you should avoid abruptly stopping the drug if it is used for very long. Like the other drugs mentioned, it may work best when combined with NSAIDs. See the following articles for more info (note that some are human oriented):

Tramadol
Chronic Pain Management
Tramadol (scroll down)
A Risk-Benefit Assessment of Tramadol in the management of pain
Ultram FAQ
Trouble with Tramadol
What is the correct dosage for oral tramadol in dogs?

Note that Tramadol should not be given with MAOIs (such as Anipryl/l-deprenyl/selegiline, and the Preventic Tick Collar, which contains Amitraz, another MAOI). It should be used with caution when combining with SSRIs (such as Prozac, Zoloft and Paxil) or TCAs (such as Elavil and Clomicalm) due to the risk of serotonin syndrome. It may also be dangerous if combined with St. John's Wort. Tramadol is metabolized 70% thru the liver and 30% thru the kidneys, so dosage must be reduced when using with a dog that has liver or kidney disease. Tramadol in high doses has been known to lead to seizures. It should be used with extreme caution in animals that are prone to seizures. Tramadol can cause constipation. Give a stool softener if needed.

Although drugs used to treat pain are generally reserved for use after NSAIDS no longer work or cannot be tolerated, there is a school of thought that says perhaps they should be used sooner, since they are safer. They can also be used together, to reduce the dosage of NSAIDs.

I did some price checking on Tramadol, and found a huge variance in prices. Costco had by far the best price, and you can order prescription drugs from them without being a member, though they do not ship to Arkansas, Illinois, Louisiana, Michigan, Nebraska, and Tennessee. Walmart now includes Tramadol in the $4 generic drug program, making them even cheaper than Costco. Target does the same. Masters Marketing in the UK also has great prices.

NSAIDs

If you find you must use NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) to control pain in your dog, be very cautious. All of them can cause gastric upset and ulceration, and should only be given with food. It is safest to do blood work before starting any NSAID, and about two weeks after starting, to be sure that it is not affecting the liver or kidneys. If you use these drugs long term, you should continue to moniter blood work at least every six months to a year (more often if problems are suspected or more likely due to the health status of the dog).

See below for more information on various NSAIDs. Note that COX-2 selective drugs are newer, and were expected to be safer, as they reduce the risk of gastic ulceration, but they can still cause other side effects, including liver and kidney failure. It is most important to know if a drug is COX-2 selective when switching from one NSAID to another. See the paragraph below on switching NSAIDs for more information.

Never combine NSAIDs (including aspirin) with each other, or with prednisone, as the risk of gastric ulceration is greatly increased.

If you use any of these drugs, discontinue and notify your vet immediately if your dog shows any signs of problems whatsoever. These may include any of the following: vomiting, diarrhea, dark or bloody stools, changes in appetite, changes in the frequency or amount of urination and drinking, drooling, difficulty swallowing, yellowing of the whites of the eyes, or any behavioral change such as aggression or lethargy, disorientation, staring off into space, circling, lack of coordination when walking, or hyperactivity.

Never give your dog human medications other than aspirin, as listed above. Drugs such as Advil (ibuprofen) and Aleve (naproxen) cause serious gastric ulceration and can be very dangerous for dogs. Tylenol (acetaminophen) is sometimes used for dogs, but can cause irreversible liver damage in a few, and is deadly to cats. Tylenol is not an anti-inflammatory and so would not be recommended for arthritis anyway. It is considered a COX-3 inhibitor, and can be combined with NSAIDs for greater pain relief if needed.

Switching from one NSAID (including aspirin) to another, or from an NSAID to prednisone (or vice versa), can be dangerous. It is best to wait AT LEAST a week in between, preferably longer, before starting the new drug. This is particularly important when you are switching FROM one of the older generation NSAIDS that are COX-1 inhibitors (not COX-2 selective), including Aspirin and White Willow Bark. Etogesic also inhibits COX-1. Metacam and Rimadyl are somewhere in the middle, being mildly COX-2 selective and relatively COX-1 sparing. I heard from one vet that fatal reactions to Deramaxx were much more likely in dogs that had been given Aspirin in the preceding 7-14 days. If you are switching from one COX-2 selective drug to another, such as from Rimadyl to Deramaxx, or from a COX-2 selective drug to Aspirin, then the danger is less, and you may be able to switch after just 24 hours. If you need pain relief in between switching from one NSAID to another, consider using Tramadol.

NSAIDs often can cause gastric ulceration and stomach upset, which is why they should always be given with food. There is a drug you can give concurrently with any NSAID to help prevent these side effects. It is called Misoprostol (Cytotec). Vetinfo says "Misoprostol decreases gastric acid secretion and has other protective properties that help prevent ulcers. There are several published dose ranges, which do not totally agree, but the overlap point seems to be at about 3mcg/kg two or three times a day. Your vet may need to tailor this dosage for your particular dog's needs. It is important to remember to follow other directions intended to reduce gastric irritation, such as giving the NSAID with or shortly after meals and at the dosage schedule recommended by your veterinarian." See the following for more info:
Misoprostol and More: Making NSAIDs easier on your dog's gut
More on NSAIDs and your dog's gut

Other drugs used to help reduce the potential for stomach ulceration and GI upset include sucralfate (Carafate) and slippery elm (herbal supplement that coats and soothes the digestive tract). The antacids cimetidine (Tagamet), omeprazole (Prilosec), and ranitidine (Zantac) may help symptoms but do not really treat the underlying problem.

See the following for more information on the use of NSAIDs for treating arthritis:
Managing Chronic Pain: The NSAIDs
Treatment of Osteoarthritis
Arthritis
A Warning Concerning Arthritis Medications and Dr. Rogers on Rimadyl
Non-steroidal Anti-inflammatory Drugs for Small Animal Practitioners (scroll halfway down the page to find this section)
Non-steroidal Anti-inflammatory Drugs from Antech Diagnostics
NSAID Adverse Reactions
More News About Rimadyl (includes article from the Wall Street Journal)
Even pain killers for dogs have serious risks
Rimadyl: News, Views & Advisories
EtoGesic vs. Rimadyl
Novartis to roll out painkiller for dogs (Deramaxx)
Annual and Cumulative Veterinary Adverse Drug Experience (ADE) Reports

HOMEOPATHICS

Although I have not tried these myself, some people have reported success using homeopathic remedies for arthritis pain, including Zeel and Traumeel (go here for a better price on both), which claim to be alternatives to NSAIDs.

SHOCK WAVE THERAPY 

My article, Shock Wave Therapy for Dogs With Arthritis, was published in the Whole Dog Journal in the May, 2008 issue. I will post it on my web site in November, 2008. If anyone would like to see a copy before then, email me privately (my contact info is at the bottom of the page).

Extracorporeal shock wave therapy (ESWT) has been used in horses since the late 1990s to stimulate healing of musculoskeletal injuries, including bone fractures and tendonitis (bowed tendons). It has also been used with people since 1992 to treat heel spurs, plantar fasciitis, tennis elbow,  femoral head necrosis, and other disorders. Beginning in 1999, it has been used in dogs to treat arthritis pain, hip dysplasia, and other musculoskeletal conditions. Note that the treatment will not slow the progression of arthritis, it only affects the pain.

Shock wave therapy requires sedation or general anesthesia, along with pain medication, as the treatment itself can be mildly to severely painful depending on the intensity that is used. It can also be quite noisy, which may be frightening to the patient. Treatment lasts just a few  minutes per treatment site. Recent x-rays are needed in order to determine exactly where treatment should be centered.

Early studies show that up to 80% of dogs with arthritis will show marked improvement with this therapy. One to four treatments are done at intervals of 10 to 30 days apart. Benefits may last anywhere from several months to over a year before the treatment needs to be repeated. This is considered a conventional (not holistic) therapy, but it is still experimental. It is not yet widely available, at least not for dogs, but you could contact your closest veterinary school to see if they offer this treatment, or contact the manufacturers of the machines to see if there are vets in your area who are offering this therapy for dogs. See below for a list of the places I know about who are offering shock wave therapy for dogs, and contact information for the manufacturers.

Shock waves are focused sound (acoustic) waves that produce maximum energy at a specific site within the body. There are three types of shock wave therapy: electrohydraulic, piezoelectric and electromagnetic. No significant difference in effectiveness between these has been demonstrated. Electrohydraulic devices have been the most studied in the US and are the only ones approved by the FDA for use with people.

There is a fourth type of device that produces radial pressure waves, which are different from shock waves. Radial pressure waves are lower intensity than shock waves, and are unfocused. Maximum energy is produced at the skin surface and dissipates from there. For that reason, radial pressure wave therapy (RPWT) is more suited to soft-tissue applications near the surface. More treatments with less time in between are needed when using RPWT. It may be done under light sedation, as it is less painful due to the lower intensity of the waves. Little research on RPWT has been done in the US, but it has been studied more in Europe.

Here are some web sites with more information:

Shock Wave Therapy Can Help Promote Bone Healing and Reduce Pain
From the University of Illinois Veterinary Teaching Hospital: "In addition to providing healing and anti-inflammatory properties, shock wave therapy works two ways to reduce pain. Its anti-inflammatory action reduces the amount of inflammatory biochemicals that cause pain. 'In addition, this therapy seems to temporarily disrupt nerve impulse transmission,' thus reducing the perception of pain, Dr. Byron explains. These pain reducing properties can be very useful for treating dogs and horses with arthritis."

Shock wave therapy - more shock than wave?
"ESWT has been advocated for treatment of osteoarthritis in the dog and horse. Canine patients with osteoarthritis of the stifle had higher peak vertical forces and increased range of motion as compared to control dogs. ESWT decreased lameness in 80% of horses treated for osteoarthritis of the tarsometatarsal and distal intertarsal joints. Shockwaves do not appear to slow the progression of OA, but it does appear to decrease the pain. This may be accomplished by decreasing synovitis or by reduction of sensory nerve conduction."

A dog wheelchair for Ivan
Notes from someone who tried this therapy for her dog with severe spondylosis: "I have been telling Ivan he is just about the poster boy for handicapped pets.com...elbow dysplasia on both front legs (his right front since only 9 months old), ACL surgery on right hind when less than 3 years old, ACL partial tear on his left stifle (that has healed better than the one that had surgery) hypothyroid since 2 1/2 years old, spondylosis requiring a wheelchair (which shockwave therapy, acupuncture and summer warmth allowed him to walk without for about 4 1/2 months in 2005!  :^)  ) and yet he just keeps on wagging his tail and being happy."

Advances in Extracorporeal Shock Wave Therapy for Dogs
Extracorporeal Shock Wave Therapy: What? Why? Safety?

What I've heard from people who have tried it
A 13-year-old Lab with arthritis in both hips, her spinal column, and right hock, and who had just torn a ligament in her right knee. Vet recommended two treatments, three to four weeks apart, and expected to see 80% improvement that would last six to seven months. The vet treated the hips, hocks and knees with shock wave therapy. Within a few days of the first treatment, the dog was going for walks without limping or her legs buckling under her, wagging her tail and playing with toys again. There was some regression after two weeks, but improvement resumed following the second treatment three weeks after the first. Eight months later, she continues to enjoy long walks, but is slower than she used to be.
A 3-year-old dog at the same clinic with severe elbow problems had a single treatment and the improvement lasted a year and a half before another session was needed.

An 11-year-old, 45 lb mixed breed dog was so lame in one front leg that she could no longer put weight on it. The problem had been very long-term, gradually increasing in intensity over the years. Two shock wave treatments were done, one month apart. No improvement was seen until 2-3 weeks following the second treatment, when the dog suddenly began "running around like a puppy again." The improvement continued for about a year and a half, with just occasional mild limping. She then began getting worse and the owner is planning another treatment.

I tried shock wave therapy with my dog, Piglet, when she was 15 1/2 years old. One treatment was done in August, 2007, followed by a second treatment a month later (1,000 pulses per elbow each time). It appears to have helped a little, but not a lot. Starting 2-3 weeks after the second treatment, Piglet began taking longer walks again -- some lasting 1 to 2 hours, while most walks in the prior six months had been 30-45 minutes. She is still slow, walking rather than trotting, but she is exploring more and resting less. The vet commented that Piglet has more bony growth around her joints than most animals he sees (her arthritis is very severe), which may possibly have limited the amount of improvement that could be achieved. The vet who treated Piglet says he sees marked improvement in about 90% of the animals he treats (which include horses and one goat).

If anyone else tries this therapy, I'd appreciate it if you would let me know the results (see bottom of page for my contact info).

Practices I've found offering this therapy (in alphabetical order by state):

Here are the devices I know about. To find a vet in your area, you can try contacting the equipment manufacturers or distributors:

REGENERATIVE STEM CELL THERAPY 

Regenerative cell therapy is a new and experimental form of treatment for arthritis and soft tissue (tendon and ligament) injuries in both large and small animals. It involves injecting stem cells directly into the affected joints (intra-articular), or occasionally injecting them intravenously, if many sites need to be treated or the sites are not reachable. This is done in a two-step process:
  1. First, a small incision is made in your dog's abdomen (or elsewhere) under general anesthesia to withdraw some fat, which is sent to a laboratory in San Diego where the stem cells are extracted and sent back.
  2. The extracted stems cells are then injected into the joint while the dog is heavily sedated or under short-acting anesthesia.
This therapy is being offered commercially to veterinarians by a company called Vet-Stem. Excerpts from the web site:
Vet-Stem is now available for dogs.

In the same way that Vet-Stem Regenerative Cell (VSRC) therapy has demonstrated successful therapeutic outcomes in horses with tendon and ligament injuries, fractures, and joint disease, it is now being used to treat osteoarthritis in dogs.

Since 2005, selected clinics have treated dogs with osteoarthritis and orthopedic soft tissue injuries. Initial studies demonstrate that intra-articular administration of VSRCs significantly decreases pain and improves comfort in the majority of cases. Duration of the benefit from a single injection varies from several months to more than one year.

Clinical trials for osteoarthritis of the canine elbow, hip, and stifle [knee]  are ongoing with successful results soon to be published.

A press release from September, 2007 states, "Vet-Stem’s clients in the United States have already treated over 2500 horses and over 100 dogs with arthritis, tendon, and ligament injuries with a success rate of over 70% return to normal performance."

Arboretum View Animal Hospital has some additional information about their requirements for dogs being treated with stem cell therapy (I do not know which of these requirements are from Vet-Stem and which from the specific animal hospital).

The Vet-Stem web site lists veterinarians offering this therapy, including several orthopedic and surgical specialists in my area who have excellent reputations. I spoke with one of them, who told me that he has not yet tried this therapy, but saw films of an older Akita who improved dramatically with it. He estimated the cost would be in the neighborhood of $2,500, which includes around $1,200 for the lab to process the stem cells, in addition to the general anesthesia costs and pre-surgery blood tests and x-rays that would be needed. This vet felt that the treatment was too experimental to justify doing it on my 16-year-old dog, and she's doing well enough now (following shock wave therapy) that I don't feel it's necessary. There is also a good chance that it might not be possible to get the needle into her joints to inject the stem cells due to the excessive amount of bony build-up around her elbows from the arthritis.

If there is no one in your area offering this therapy, you may want to try talking to your own vet, or to orthopedic specialists or holistic vets (who are often more open to new methodologies) in your area, to see if any  would be willing to try it with your dog, since it requires no special training and is quite safe to do.

If anyone tries this therapy with their dog, I would be very interested in hearing about your experience (my contact info is below at the bottom of the page).

Links to articles about stem cell therapy:
A Dog's Stem Cell Life
Hope for pets dogged by pain
Vet-Stem says, "Arthritis begone!" (One California company’s quest to curb joint pain)
Vet-Stem weighs in on their own stem cell derived pain product for arthritis

Pulsed Signal Therapy

Pulsed Signal Therapy (PST) Non-invasive, painless therapy consists of nine treatments administered anywhere from 8 to 24 hours apart, each lasting half an hour. Claims significant improvement in over 70% of patients. Cost is "comparable to that of long-term NSAIDS like Rimadyl." See PST-Vet Small Animal Treatment Centers to locate a provider in your area. Note that many of the centers listed at that site offer other modalities such a those described below.

I did quite a bit of research on PST in June, 2008, before deciding to try it on Piglet. In my opinion, there is little science behind this treatment, though a few studies have shown that pulsed electromagnetic field (PEMF) therapy can help with delayed healing of bone fractures. PST is a form of PEMF that was patented by Richard Markoll. Unfortunately, Mr. Markoll has been involved in all of the "studies" on PST, which I do not find reliable. Most are more about marketing than about science. PEMF has been studied and is widely used in Europe for pain management and treatment of osteoarthritis. See the following for examples:
Pulsed electromagnetic field therapy in the management of knee OA
Pulsed magnetic field therapy for osteoarthritis of the knee--a double-blind sham-controlled trial
Exposure to a specific pulsed low-frequency magnetic field: a double-blind placebo-controlled study of effects on pain ratings in rheumatoid arthritis and fibromyalgia patients

The vets who use PST have been very impressed with the results, seeing improvement in 80% or  more of the dogs treated, and the improvement is often profound, even "miraculous." PST works better for hips than it does for elbows, according to the vets who use it, but they feel it can definitely decrease pain and increase range of motion for dogs with elbow dysplasia. Treatment for elbow problems may need to be repeated in one to two years, which is not usually necessary for other joints.

Piglet is having PST done by Dr. Erin Troy at the Canine Rehabilitation Center in Walnut Creek, CA. The cost is $800, plus $50 for the required veterinary consultation. Dr. Troy feels that PST likely works best when there is enough cartilage remaining in the joint for the PST to stimulate, but unfortunately it's not possible to measure how much cartilage is there. PST also works best if the legs are extended, opening up the joints, which is easier to do on some dogs than on others. Because Piglet's arthritis is so advanced, it is questionable how much cartilage she has left. In addition, she is not the type of dog who will relax in a treatment situation (although her elbows don't bend very well any longer, meaning that her legs are more extended when she lies down than would be true for a healthy dog). For these reasons, I feel that PST is a longshot to help her, but it will not hurt, and I believe it's worth a try. We start therapy 7/7/08. Maximum improvement  takes up to 16 weeks, though positive changes can be seen  much sooner with some dogs. I will report back if I see any improvement.

While researching PEMF, I came across a number of sites that sell devices you can use at home. Again, none have any science behind them, and I feel most probably have little value. However, if PST is not available in your area, they might be worth a try. The best option I found for dogs is the Bio-Puls Magnetic Therapy Bed and Electromagnetic Therapy Jacket, made by Respond Systems. These items are expensive, but they offer a rental option for three months or more that allows you to try them out (if you decide to keep them, the rental price is applied to your purchase). The New England Canine Rehabilitation & Fitness Center appears to be using this jacket, based on their pictures, but I was unable to get additional information from them.

Note that PST and PEMF are not the same as static magnet therapy, which does not appear to have any scientific support. Pulsed electromagnetic fields would have a different effect on the body than magnets.

If anyone has tried PST, or the Bio-Pulse bed or jacket, or any other form of PEMF, I would be interested in hearing from you (my contact information is at the bottom of the page).

Other Therapies

I came across several other therapies while researching the two above, but I have little information on them. If anyone has tried them with their dog, please let me know (my contact information is at the bottom of the page).
Laser Therapy Painless. Applied 6 times over a 3 week period, followed by monthly maintenance treatments, according to The Spaw. See K9 Rehab Center for another description. Also the section on High-Tech Pain Management -- Low Level Laser (page 2).

Neuromuscular Electrical Stimulation (NMES) Electrical stimulation used to prevent atrophy post-injury or surgery or to increase strength in atrophied muscles.

Transcutaneous Electrical Nerve Stimulation (TENS) Uses electrical impulse to reduce pain. I had trouble finding much information on this. I think it may be the type of electrical stimulation that is often employed in conjunction with acupuncture.

Therapeutic Ultrasound Non-invasive treatment offers short-term pain relief, so probably more applicable for acute conditions rather than chronic ones. Direct contact with skin is required, meaning the area must be shaved and ultrasound gel used.

These sites have more information on the above therapies:
Physical and Alternative Therapies in the Management of Arthritic Patients Talks about the use of heat and cold therapy, therapeutic ultrasound, neuro-muscular electro-stimulation, shock-wave therapy, osteopathy and acupuncture.

The orthopaedic patient: conservative treatment, physiotherapy and rehabilitation Discusses thermotherapy (heat and cold), massage, transcutaneous electrical nerve stimulation (TENS), extracorporeal shock wave therapy (ESWT) and more.

TOPS Veterinary Rehab Information on cryo (ice) and heat therapy, neuromuscular electrical stimulation, pulsed signal therapy, therapeutic ultrasound, and more.

The Spaw Canine Sports Medicine and Rehabilitation Information on  cryo (ice) and heat therapy, neuromuscular electrical stimulation, laser therapy, pulsed signal therapy, therapeutic ultrasound, and more.

Getting the Dog Moving After Surgery Article from the Journal of the American Animal Hospital Association that discusses cryotherapy, range of motion exercises, heat, neuromuscular electrical stimulation, therapeutic exercises, pain control and more.

Rehabilitation and Conditioning for Animals See links on right side of page for more information on ice and heat, ultrasound therapy, and more.

Thera-Paw Health and Rehabilitation Links include a number of canine rehab centers listed by state.
 

NARCOTICS

When you reach a point that even NSAIDs do not help enough, narcotic therapy may be an option.

See Tramadol above for information on a narcotic-like drug that many people are using to treat chronic pain with good success.

Hydrocodone can be used in combination with NSAIDs to provide additional pain relief. Vicodin, which is a combination of Hydrocodone and Acetominophen is sometimes used, but should not be combined with NSAIDs due to the danger of toxicity from the Acetominophen. Codeine can also be used, though it is not as effective. Oxycodone or a  Fentanyl (Duragesic) patch are other narcotics that can be used for pain, but tend to have more of a narcotic effect and so are best used only for short periods, but even that may make a big difference. Click here for more info (scroll down). All narcotics are addictive, so they are best used intermittently rather than every day.

ANTIDEPRESSANTS and OTHER DRUGS USED TO CONTROL CHRONIC PAIN

Amitriptyline (Elavil Rx), which is a tricyclic antidepressant (TCA), seems to help in chronic pain when used alone or in conjunction with narcotics. Use caution when combining with Tramadol (don't use high doses of each together). Amitriptyline is available inexpensively thru Costco and Walmart.

Neurontin (gabapentin) is an anti-convulsant medicine which is also used for chronic pain. This is not a licensed medication in dogs but is licensed as a neurogenic pain killer in humans and has been used for dogs as well. The dose is 5-12 mg/kg (2.5-5.0 mg/lb) 2-4x times daily. Sedation may be seen at high doses. Neurontin can also be given with NSAIDs, steroids or narcotics. See Chronic Pain and this summary for more info on its use in dogs for treating chronic pain. Also see The Other AEDs for more information on the use of this drug in dogs for epilepsy. Note this drug can be expensive, but the generic version is available inexpensively from Costco.

Amantadine is now being used to help control chronic pain in dogs. It is a drug normally used to treat Parkinson's disease. It works as an NMDA receptor antagonist, similar to some opioids, but is not a narcotic itself. It offers little in the way of pain control itself, but potentiates (makes the effect stronger) other drugs used for pain control, so it has to be used concurrently with other pain control drugs. It can be used concurrently with Tramadol, NSAIDs, corticosteroids, gabapentin and opioids. It is inexpensive. You will need to use the liquid version for all but large dogs. I was able to get the liquid version from Costco (it's not listed on their web site, but they were able to order it for me). See the following for more info:

Evolving Roles of NSAIDs in Clinical Practice "When other drugs are required, our first choice is generally amantadine (3 mg/kg once daily). Owners commonly report a significant improvement when amantadine is given."
Chronic Pain"Amantadine is the most commonly used oral NMDA receptor antagonist. It was originally developed as an antiviral compound, and has also been used to treat extrapyramidal drug reactions and Parkinson’s disease in humans. The standard dose used to block receptors in dogs and cats is 3-5 mg/kg SID. It may be given on a continual basis if needed, though in most cases it can be given daily for 7-14 days and then discontinued until pain worsens again. Amantadine is available as 100 mg capsules and a 10 mg/ml oral liquid. Elimination is almost exclusively via the kidneys, so dose reductions should be considered in cases of severe renal failure. Side effects are rare, but can include agitation or diarrhea."
VIN "I have used tramadol, amantadine, and tylenol with or without codeine chronically in dogs on pred (for other reasons) as well as omega 3EFA and SamE."
Osteoarthritis & Your Pet "Drugs such as amantadine (NMDA inhibitor), narcotics such as tramadol and morphine, acetaminophen (Tylenol {to be used in dogs only—never in cats}, combinations of these drugs provide a quality of life to a pet that would otherwise be miserable."
Amantadine "It is used in conjunction with your primary analgesic to prevent dorsal horn windup. It has no significant analgesic effects of its own, so must be considered a supplement for those animals that opoids and/or NSAIDs are not quite doing the job. The dose most use is 3mg/kg once daily. It is available in 100mg tablets or a syrup. . . . It has been used as an adjunct to NSAIAs to treat pain due to osteoarthritis dogs weighing 25-40 kg at a dosage of a single 100 mg capsule daily."
Amantadine and Amitriptyline (Elavil) -- Additional information on usage in dogs.
Dextromethorphan may work similarly to amantadine (above) to potentiate other drugs. This drug is available as an over-the-counter cough medicine, but make sure you find one that has no other active ingredients, as many cold remedies can be dangerous to dogs. Possible choices include Robitussin CoughGels, Dexalone and Vicks Formula 44 Cough Relief liquid. Recommended dosage of dextromethorphan for pain is 0.5 - 2 mg/kg (0.25 - 1 mg/lb) of body weight, given three to four times a day, according to VASG (scroll down near the bottom of the page to see the sections on NMDA receptor antagonists and dextromethorphan). Note this drug is metabolized though the liver, while amantadine is processed through the kidneys, so the choice of which to try might depend on whether your dog has kidney or liver problems.

Be very cautious about combining drugs used to control chronic pain. Be sure your vet knows all the drugs your dog is on, including aspirin, before adding any of the above. Many of these can be used together for greater pain relief, but there are also dangerous interactions between some of them. Note that the Preventic Tick Collar uses Amitraz, an MAOI that may be dangerous when combined with anti-depressants or certain pain relieving drugs.

DOXYCYCLINE

I have heard that an antibiotic, Doxycycline, may be helpful for arthritis. I have not heard from anyone who has tried this therapy on their dog, but one person reported her own osteoarthritis in her knee, hip and fingers improved markedly when she was on long term doxy for other reasons. Apparently it has an anti-inflammatory effect that can be as great or greater than commonly used NSAIDs such as Rimadyl that can be more dangerous. There is a possibility that it may also be effective because of treating infections in the joint that contribute to arthritis.  It is available inexpensively thru Costco and Walmart.See the following articles for more information:

Common Drug found to reduce cartilage loss in knee osteoarthritis Doxycycline treatment resulted in a 33 percent decrease in the rate of cartilage loss as shown in the X-rays. Although, doxycycline slowed the progression of cartilage damage in the arthritic knee, it did not significantly affect the knee that was not arthritic at the outset of the trial.
Osteoarthritis (Human oriented, see the bottom of the page) "Laboratory research suggests that certain tetracycline antibiotics, such as doxycycline, may have a role to play in treating osteoarthritis. Laboratory studies are reporting that, at low concentrations, the drug reduces the production of collagenases, which are enzymes critical to disease development and progression."
Putting Some Muscle into Osteoarthritis "Doxycycline is a more effective inhibitor of MMP-13 than of the other cartilage collagenases, gelatinase or stromelysin. Oral administration of this drug reduces joint damage in animal models of osteoarthritis."
Improving outcomes in osteoarthritis "In a canine model of osteoarthritis (19), doxycycline reduced the incidence and severity of cartilage lesions and the activity of collagenase and gelatinase in the cartilage."
Osteoarthritis"Tetracyclines: doxycycline, minocycline - when used in dogs with cranial cruciate ligament rupture repair, there was a decrease in cartilage ulceration on the weight bearing areas of the medial femoral condyle."
Doxycycline, An Antibiotic, May Be Treatment For Osteoarthritis

LINKS TO MORE INFO

The following sites have additional information about control of chronic pain in dogs:

International Veterinary Academy of Pain Management
AAHA/AAFP Pain Management Guidelines for Dogs & Cats
Chronic Pain Management
Dealing with your Pet's Pain: Severe Acute and Chronic Pain
Pain in Dogs
Arthritis in Dogs
Medication and Your Dog
Managing Pain in Dogs
Chronic Pain Management: Current Practices and Emerging Treatments
Response to question about chronic pain management for a dog that cannot tolerate NSAIDs
Kiska Case Study
Medications -- note this is a human oriented site, so not everything there will apply to dogs. The anti-rheumatic drugs would be used to treat rheumatoid arthritis, not osteoarthritis. Also, most human NSAIDs are very dangerous to dogs, as their stomachs are more sensitive and more likely to develop gastric ulceration, which can be deadly, so never try giving these drugs without your vet's specific instructions.

SURGERY

There are email lists called OrthoDogs and CanineHD at Yahoo Groups that offer additional information about surgery for joint problems. Also see AbleDogs and Dodgerslist for dogs with back problems. There is a list called TPOthat talks about surgical options for hip dysplasia and cruciate ligament repairs (also see the site at http://www.lauriebryce.com/tplo/ for a great deal of information and links about orthopedic surgery).

Note I am not advocating TPLO surgery for cruciate ligament injuries (and that is not what I had done on Piglet) -- it works well for some dogs, but I've heard of others where the joint doesn't heal properly and the dog is worse off than before. The skill of the surgeon may be a factor. I have also heard a number of reports, both directly and indirectly, of dogs developing bone cancer following this surgery, as well as other long-term complications. Removal of all implants six months to a year following the surgery may help to reduce this risk. See TPLO Awareness for more information.

MSU has recently begun offering arthroscopic cruciate ligament (knee) surgery for dogs. This is combined with traditional cruciate repair, involving sutures to stabilize the knee.

If your dog has orthopedic surgery, there are a couple of things you should be aware of that your vet may not be current on. The first is pain management, see my my section on Pre- and Post-Op Care for more information (I also have links at the bottom of that section to braces, slings and carts). The second is that recent research shows that it is important to start doing physical rehabilitation right away, at least in the case of knee surgery, rather than waiting six weeks. Contact me privately if you want a copy of the rehab instructions the surgeon gave me when Piglet had her second knee surgery in 2002 (contact information at bottom of page).

Conservative management may be tried in place of surgery if your dog has a cruciate ligament (knee) injury. If no improvement is seen within six to eight weeks, you should then move on to surgery. It is imperative that activity be limited during this time. It is my opinion that a ruptured cruciate will do better with surgery than without, but if there is any doubt about the diagnosis (which cannot be done via x-ray alone), then it may make sense to wait. As long as activity is restricted, no harm should come from waiting for up to two months. See Treating Canine Ligament Injury Without Surgery for more information.

See Other Therapies above for more information on rehabilitation following injury or surgery.

LINKS

Treatments for Arthritic Pain in Dogs -- List of supplements to use with arthritic dogs
Treating Arthritis -- Alternative Treatments by Dr. Susan Wynn
Nutritional Management of Canine Osteoarthritis -- studies showing how PUFSs (fish oil), antioxidants and various oral chondroprotective agents (green-lipped mussel, glucosamine and chondroitin) help with arthritis pain
Physical and Alternative Therapies in the Management of Arthritic Patients -- talks about use of heat and cold therapy, therapeutic ultrasound, neuro-muscular electro-stimulation, shock-wave therapy, osteopathy and acupuncture.
Joint Support -- a review of the medical evidence for alternative arthritis supplements
Vitamin C and Ester-C Studies -- studies showing that Vitamin C helps with arthritis, spondylosis and hip dysplasia in dogs
Ester-C: Miracle Cure for Hip Dysplasia??? -- more studies showing that Vitamin C can help with arthritis
Back Disorders Information & Support -- links to info on all kinds of back and joint problems, including nursing aids, support groups, physical therapy, and so much more
Arthritis-- good overview of conventional information on arthritis in dogs
Growth-Associated Bone Disorders in the Dog -- overview of various orthopedic problems in young dogs

Three articles on pain management by Christie Keith:
Pain in Dogs and Cats: Basics and Introduction
Pain in Dogs and Cats: What You Can Do About It
Serious Chronic and Acute Pain, and Surgery

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This page last updated 7/20/2008