Sara Greenslit, DVM, CVA, practices allopathic and TCVM at Northside Animal Hospital in Madison, Wisc., where she also provides house call acupuncture and hospice.
Wellness: Health Care
Treating lick granulomas with cold laser.
January 12 2017
My first dog, Ouzel, a Lab mix, spent his last year worrying at a wart on his leg until it became a rough, raised, red patch—an acral lick granuloma. I tried bitter sprays, socks, steroid creams and an Elizabethan collar. I could not get him to stop. I was frustrated, he was obsessed. He died before I finished vet school and had learned about other treatment options.
The causes of this type of inflammation are many: referred pain from arthritis or disc issues, anxiety or boredom, food/flea/environmental allergies, wounds or lumps, cancer. Whatever causes it, once the licking starts, it’s hard to halt. The wound gets thicker, wider, deeper, becomes ulcerated and infected. The hair does not come back, and the skin darkens.
Lick granulomas occur most often in older, male, large-breed dogs, and treatment depends on what caused them in the first place. Deep infections often require six to eight weeks of oral antibiotics. Topical and oral steroids can help break the inflammatory cycle, and antianxiety medications can be tried. On the non-drug front, some dogs are calmed by the snug swaddle of an antianxiety vest; relaxing treats with L-theanine, an amino acid that raises dopamine— and perhaps serotonin—levels; Bach’s Rescue Remedy; a pheromone collar or diffuser; and consistent, ample exercise.
Holistic modalities are also important. Chiropractic can help disc-disease-related nerve pain, and an acupuncture approach I call “surrounding the dragon” encircles the wound with needles to reduce pain and inflammation. Finally, dog owners can elect surgery and CO2 laser, which uses highly concentrated light energy, to remove the sore.
Lick granulomas are recalcitrant and complicated, and a combination therapy may be more successful. Control rather than cure is common.
Vet medicine now has a newer tool to manage these granulomas, a Class IV laser, also called low level, or cold, laser therapy. Laser strength is described by class, and the stronger the wattage of the beam, the shorter the individual treatment. Lasers can be found in printers, CD and DVD players, bar-code scanners and light shows, but these are too weak to use medically. Toys like pointers, which some cats and dogs like to chase, are under 5 milliwatts and fall in the Class I-IIIa category. (Offtopic but important warnings here: never point any laser into the eye or at a reflective surface, like metal or glass. And laser-play can cause frustration in certain dogs, leading to obsessive-compulsive disorders.) Class II-III are used by dermatologists for skin treatments. Class IV’s light penetrates skin down into muscle, tendon, ligaments and bone.
A Class IV laser reduces inflammation, swelling, muscle spasms, stiffness and pain, and we use it at our clinic to address wound care, post-op incisions, otitis, pancreatitis, arthritis, limb edema and soft-tissue injuries. The light, which is slightly warming, also stimulates acupuncture points, which is good for patients who cannot tolerate needles. Animals tend to find the treatment relaxing.
How does light lead to recovery? On a cellular level, the laser enhances biological effects by increasing oxygen turnover in the tissues. Imagine a blood vessel as a moving sidewalk; as red blood cells cruise along under a spotlight (the laser), the beam heats the tissues and speeds up blood flow, which encourages oxygen uptake. With increased oxygen, more ATP (adenosine triphosphate) energy is made, which prompts healing. Present in every cell of the body, ATP is the body’s basic currency, energy used or stored in this nucleotide. When a group of atoms are cleaved off the side of ATP, energy is released to perform cellular activities.
Research conducted worldwide shows the widespread advantages of medical-grade lasers. Human studies found benefits for patients with fibromyalgia, tennis elbow, chronic neck pain, osteoarthritis, rheumatoid arthritis, traumatic neuropathic pain and compromised limb circulation. Wound healing and skin studies include positive effects for diabetic-ulcer healing, blood vessel growth, increased skin cell migration (fibroblasts), hair growth in canine non-inflammatory alopecia and survival of surgical skin flaps for wound coverage.
Laser treatment strength and duration are determined by the size of the area that needs to be addressed and whether the injury is acute or chronic, the wound is dermal or musculoskeletal, the fur is dark or light. After the veterinary team elects a treatment type, the machine calculates an appropriate and safe dose. Precautions are common sense: the light needs to be kept moving so that it doesn’t overheat skin, and it’s never used near a fetus or a tumor.
Laser treatments for lick granulomas focus on small areas. In fact, the less the light is diluted, the more successful the treatments tend to be. For example, if your dog has arthritis in his knees, back and wrists, it’s best to work on them one at a time.
Laser protocols for lick granulomas recommend starting treatments at two to three times a week for a few weeks, tapering to once a week, then to every two weeks as the wound shrinks over a month or so. The treatments have a cumulative effect, so it’s important to commit to the schedule.
With the addition of the Class IV laser, we now have a pocketful of treatment options for lick granulomas. Canine friends who spend their days and nights licking a limb might finally find the respite they need, which could improve our own sleep as well.
Wellness: Health Care
April 12 2016
Intervertebral disc disease (IVDD)—what some call a “slipped disc”—can smolder or it can strike full-blown, leaving your dog in excruciating pain and unable to walk. Initially, signs that a dog is afflicted can be subtle: a hesitation about going up or down stairs, paws that knuckle under or cross over, nail scuffing, an arched back, a tense abdomen. Dogs may shy from their food bowls to avoid bending their necks, or cry when picked up.
IVDD causes compression of the spinal cord and leads to weakness, pain and sometimes paralysis, and is divided into two categories: Hansen Type I and II. Type I often swoops in suddenly, usually in younger, smaller dogs ages three to six. The center jelly of the vertebral disc, called the nucleus pulposus, degenerates, then ruptures and presses on the spinal cord. Not surprisingly, the chondrodystrophic breeds (dogs with short legs and longbacks)—Dachshunds, Corgis, Lhasa Apsos, Shih Tzus and Beagles—are predisposed to this type.
Type II, which is typically seen in large dogs like German Shepherds, Labradors and Dobermans ages eight to ten, progresses more slowly. Though the disc doesn’t burst its center, it bulges between the vertebrae and impinges on the spinal cord, causing chronic pain and weakness.
To rule out fractures, bone infections and cancers, your vet will start with X-rays, but a contrast myelogram, CT or MRI (all of which are often done at specialty centers) is needed to visualize the spinal cord and determine the nature and location of the problem.
In addition to type, IVDD is described by level of severity. Roughly, grade I involves pain; grade II, unsteadiness; grade III, weakness that prevents standing or walking; grade IV, paralysis but able to feel deep pain when the toes are pinched; and grade V, complete paralysis with loss of deep pain.
Dogs with grades 1 through IV will likely be managed with pain meds, muscle relaxants and strict rest for up to a month, and are often referred for physical therapy or Class IV laser treatments. Depending on the duration of neurological deficits and amount of pain, surgery may also be recommended for dogs with grades II, III and IV. Because the disease can change quickly, even dogs diagnosed with lower-grade IVDD need sequential exams to ensure that the condition is not progressing.
When a dog is completely unable to walk, decisions have to be made swiftly. Dogs who stay in the grade V stage longer than 48 hours often remain paralyzed despite intervention, while up to 50 percent of those who have surgery in the first 24 hours may regain their ability to walk.
IVDD surgery removes compromised discs, hemorrhage and adjacent bone compressing the spinal cord. With severe disease, it’s the best chance for a dog to walk again. It does, of course, also entail expenses and risks that not everyone is able or willing to undertake. What other options do we have?
Thankfully, veterinarians have been studying other modalities to treat IVDD, acupuncture among them. In 2007, a team lead by A.M. Hayashi found that dogs of all IVDD grades recovered more quickly with electroacupuncture (EAP) combined with a standard Western medical approach than Western treatment alone (JAVMA 231: 913–918).
In 2009, A. Laim et al. reported that dogs receiving EAP and pain medications after surgery for acute IVDD were less likely to need higher doses of pain meds during the first 12 hours than those who received meds alone. These patients also had significantly lower pain scores 36 hours after treatment (JAVMA 234: 1141–1146).
A 2010 study compared three options for IVDD dogs with severe neurologic deficits of greater than 48 hours’ duration: decompressive surgery (DSX), EAP, and DSX followed by EAP (DSX + EAP). The study, led by J.G.F. Joaquim, showed that EAP was more effective than DSX + EAP, and that DSX alone was the least successful. These dogs had severe, long-standing IVDD in the thoracic and lumbar (thoracolumbar) spine, and in the past, their prognosis would have been dismal. (JAVMA 236: 1225–1229).
How does acupuncture work? While there is some debate over definitions, it’s generally accepted that acupuncture points (acupoints) concentrate clusters of free nerve endings, small blood and lymphatic vessels, and mast cells, part of the immune system. A veterinarian certified in acupuncture inserts small, sterile needles into specific points to stimulate muscles, nerves, circulation and the immune system. For IVDD, one needle may be placed at the top of the spine by the shoulders, and a second above the pelvis, which moves the qi and stagnated energy caused by the disc disease.
Functional MRIs reveal that acupuncture activates pain-associated brain stem regions. The specific mechanism of acupuncture on IVDD has not yet been fully explained, but it’s surmised that it reduces local swelling, inflammation and pain; decreases cord compression, scar formation and tissue oxygen deprivation; and restores damaged nerves.
When compared to the use of needles alone, EAP has been found to increase the body’s response to acupuncture. In EAP, needles in the skin are connected by metal clips; electro-impulses move between the clips and into the needles, producing sensations that range from a tingling to a vibration. Frequency and intensity are determined by the type of condition being treated. Sessions usually last from 10 to 30 minutes, and dogs often fall asleep during treatment.
EAP has a cumulative effect and is typically prescribed as a series of treatments, every one to two weeks for at least a few months. Appropriate Chinese herbal formulas are often prescribed at the same time to reduce pain and enhance the effects of acupuncture. Dogs then proceed to maintenance acupuncture at one- to three-month intervals to prevent recurrence.
Ideally, your dog will never go through the pain of IVDD, and you won’t have the worry. But if you do find yourself up against a down dog, it’s good to know that adding acupuncture to the treatment repertoire may help your friend get back on all fours.
Wellness: Health Care
It can’t be cured but it can be managed—partnering with your vet is the key.
July 17 2015
Failure is a harsh word. It signifies loss of hope, or defeat. So when your vet diagnoses your dog with chronic kidney failure, how can your heart not sink? That’s why some DVMs call it chronic renal insufficiency (CRI) or chronic kidney disease (CRD) instead.
Maybe you made a vet appointment because your dog spends more time at the water bowl, seems overly thin and shies away from previously loved food. Some pets with kidney disease may also have urinary incontinence, vomiting, diarrhea, bad breath, blindness, depression or lethargy—all of which may be signs that the kidneys’ multitasking capacity is impaired.
These two bean-shaped organs are responsible for water conservation, blood pressure control, salt balance, phosphorus and calcium regulation, and the initial step in red blood cell production. When their performance of these jobs begins to falter, many of the body’s functions start to tumble too. Blood levels of BUN (blood urea nitrogen), creatinine, calcium and phosphate escalate; protein spills into the urine; potassium levels fall; red blood cell counts drop; and blood pressure rises. Your dog starts to feel very unwell, indeed.
Where to Start
CRD affects one in ten dogs (compared to one in three cats), and the initial medical goals are to investigate and address an inciting cause in an effort to halt the disease. The origins of CRD are many: chronic bacterial infections, kidney stones, immune-mediated diseases, high blood pressure, congenital kidney malformations, leptospirosis, Lyme disease, grape/raisin or antifreeze poisoning, cancer. Often, we don’t find the specific reason. We also want to attend to the dog’s clinical signs—dehydration, nausea, weight loss, fatigue—with treatments fine-tuned by test results. If the dog’s getting nephrotoxic drugs like NSAIDs and certain antibiotics, we’ll take him off them too.
CRD is managed, not cured, and your vet will refine her treatment plan by regular monitoring of your dog’s health. Tests recommended every three months might involve a renal panel (CBC and chemistries), urinalysis, urine culture, urine protein/creatinine ratio and blood pressure.
The first signs of CRD—elevations in BUN and creatinine levels—typically occur when the kidneys have lost 75 percent of their function, which has made its treatment challenging. However, Idexx Laboratories now offers a blood test, SDMA (symmetric dimethylarginine), which catches CRD at the 40 percent mark and allows earlier intervention.
Treatment goals for CRD are life-long and supportive, aimed at improving quality of life and slowing disease progression. Since the kidneys perform numerous functions, various medications are used to address specific disorders. ACE (angiotensin-converting-enzyme)–inhibitors are prescribed for hypertension and/or urine protein loss, antacids like famotidine or omeprazole for GI ulcers and overly acidic stomach, maropitant and metoclopramide for nausea. When indicated, phosphate binders reduce nausea, and potassium supplements boost low levels.
Your veterinary team can teach you how to give subcutaneous fluids at home, if needed, to hydrate your dog and flush out toxins. You can also encourage your canine friend to increase his water intake by providing a pet water fountain, adding wet food to his diet, and placing clean bowls with fresh water in multiple rooms. Your vet will also likely suggest a diet change. Prescription diets like Hill’s K/D, Royal Canin Renal MP and LP, Iams Renal Plus, and Purina N/F restrict phosphorus and sodium, reduce protein and add omega-3 fatty acids with B and C vitamins, a combination that has been tested to increase lifespan and overall quality of life. Restricting protein too early, however, can lead to muscle wasting. IRIS, the International Renal Interest Society, endorses a kidney-specific diet when a dog’s creatinine level rises to 2.1 to 5 mg/dl (Stage III). You can also find online support for home-cooked CRD diets via veterinary prescription (see info box). To make it more likely that your dog will accept a new diet, make the switch slowly.
The body does not store water-soluble B-complex and C vitamins, so we need to replace them every day. When dogs have CRD, these essential nutrients wash out too easily with the dilute urine. Prescription foods compensate for these expected losses, and Renal Essentials by Vetriscience, a highly palatable and balanced supplement with vitamins, potassium, fish oil and herbs, can be given twice daily as well.
Studies document that high daily doses of oral omega-3 fatty acids enhance the function of joints, heart, skin, brain and kidneys. In one study, fish oils decreased mortality, improved renal function and diminished protein loss. The recommended dose of marine fish oil, omega-3 EPA and DHA, is 300 mg per 10 pounds of dog weight. Do not use cod liver oil, as it may have excessive A and D vitamins.
In the Manual of Natural Veterinary Medicine, Drs. Wynn and Marsden advocate traditional Chinese herbs for CRD, based on clinical experience. Studies in rats showed that Liu Wei Di Huang/Rehmannia 6 enhanced renal blood flow. Wynn and Marsden have also seen cats thrive for years when started in early-stage CRD on Shen Qi Wan/Rehmannia 8, another important formula. Rehmannia 8, with cinnamon and aconite, is warming, and this combination, when consistently used, can lower BUN and creatinine levels, reduce vomiting and thirst, boost appetite and weight, decrease urine volume, and increase urine concentration. Consultation with a TCVM vet is highly recommended for beginning and monitoring pets on Chinese herbs.
Rounding out a holistic kidney care plan, consider chiropractic to release spinal fixations and improve hind-end weakness that are common with CRD, and acupuncture to enhance the TCVM herbs’ effectiveness.
We who love dogs want our companions to live long and happy lives. If your canine has CRD, you can approach the disease from an integrative approach, maintaining quality of life and slowing kidney degeneration. Optimizing our dogs’ health may involve monitoring and close management, but they repay us with their company and more days of infinite joy.
Culture: Readers Write
Small Dogs Healing Ways
June 10 2014
2009 was a terrible time in our household, just plain grind-you-to-pulp kind of year. My partner had a soul-splattering, over-bearing job dealing with others’ money, where her only bonus was the fun eight mile commute out to the suburbs on her speedy and shiny orange bike. Then in late spring, I was diagnosed with stage II breast cancer. It was low-grade (good) but large (bad), and in my lymph node (bad), so I had to have surgery and chemo. I had only been out of vet school for a year and I suddenly had to take five months of medical leave. The cancer year is its own monster of story, for another time. But what happened during and after because of the Chihuahuas, well, that’s a tale for here.
After my mastectomy, I had to be careful around the dogs and my stitches. We had at the time one large, one medium, and one small dog. But they seemed to understand right away what was going on. Wren, the tiniest, slept on my pillow, almost in my hair, like a cat, every single moment I was in bed, which was a lot. When my hair fell out, she slept on my shoulder, curled into my hatted head.
To this day, I tend to say how Wren saved me by sleeping on me. She was my anchor.
And later, when I was healed, and zoom out three years later and we adopted Chibi, aka Tiny Dog, the six pound Chihuahua with dry eye, I realized Tiny Dog liked being in my sweater for heat and comfort, and I liked her being there for heat and comfort too. She fit exactly where my breast used to be, and I could zip her into my vest in the winter, and she’d fall asleep, content. I also had a prosthesis to wear out in public, but at home, I did not, and wore the Chihua instead.
I would never claim cancer gave me gifts. Cancer made me believe in randomness and not fate. But Wren, then Tiny Dog, made niches for themselves, a kind of commensalism, lovely for all of us. And when Tiny Dog is in my vest, she’s right against my heart tick ticking away, her pulse fluttering back in counterpoint.
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