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1/31/16
1
Integrative Medical Approach to Common Clinical Problems
in Small Animals
Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT
Assistant Professor, Integrative Medicine School of Veterinary Medicine
Louisiana State University
Outlines
Introduction to Complementary and Integrative Veterinary Medicine (CIVM)
Guidelines using CIVM
CIVM for common problems
Osteoarthritis
Cognitive Dysfunction Syndrome
Separation Anxiety
Atopic Dermatitis
Bleeding
Unconventional Medicine
Alternative Med
Use of other modalities instead of conventional medicine
• Integrative Med
– Combines conventional medicine and CAM therapies for which there is some scientific evidence of safety and effectiveness
� Complementary Med
� Use of other modalities in conjunction with conventional medicine
Complementary and Alternative Medicine “ A group of diverse medical and health care systems,
practices, and products that are not presently considered to be part of conventional medicine ”
Integrative Medicine
• Mounting scientific evidence on the safety and efficacy
• Combination of conventional
medicine with safe and
evidence-based CAM to
maximize therapeutic outcomes and achieve optimal
health and healing
� Whole body approach -“Wholistic” � Not just the disease or clinical signs � All aspects of life
� Relationships
� Physical
� Mental
� Emotional
� Spiritual
� Homeopathic medicine: “Like Cures Like”
� “additional to western medicine” � “not taught in medical schools” � “usually lies outside the official health
sector” (WHO) � “neither taught widely in US medical
schools nor generally available in US hospitals” (Eisenberg, NEJM, ’93)
� “practices of unregistered (non-licensed) practitioners” (GMC)
Integrative Medicine
Integrative Medicine in US Med & Vet Schools
New wave in health care
Part of curriculum at 50 major US med schools Stanford, Yale, Johns Hopkins, Harvard, etc
American Board of Integrative Medicine
CVM: UF, UT, CSU, UC Davis, LSU, UMN, Cornell, Iastate*, MSU*, NCSU*, VA-MD*, WISC*, WSU*
2000 survey: 10/24 schools that offered CIVM course
2011 survey: 17/24 vet schools had CIVM course
This case exemplifies the adage “when your only tool is a hammer, every problem looks like a nail.” It clearly demonstrates the limits of a purely pharmaceutical approach to health issues.
Harvard Stanford Johns Hopkins Yale Duke Pennsylvania UCSF
Americans are using complimentary and alternative medicine (CAM) with increasing frequency and top hospitals and leading medical schools in the U.S. are adding integrative medicine to their programs in response to this demand. In his article “Top Hospitals Embrace Alternative Medicine”, US News & World Report contributor Avery Comarow names just a few of the hospitals that have integrative programs -Mayo Clinic, Duke University Medical Center, Children’s Memorial Hospital and the University of California-San Francisco Osher Center for Integrative Medicine. You can read more about Mr. Comarow’s report on the widespread use of complementary and integrative therapies here. There are currently 44 academic medical centers that comprise The Consortium of Academic Health Centers for Integrative Medicine. The Consortium is charged with advancing the practices of integrative healthcare within academic institutions. Some of these members include Stanford University, Yale University, Johns Hopkins University and Harvard Medical School. This entry was posted on Thursday, May 27th, 2010 at 7:04 pm and is filed under Recent News. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.
1/31/16
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Goals of CIVM Integrative Medicine: a combination of the best and most appropriate therapies for you from the worlds of both traditional western medicine (Allopathy), Functional Medicine and Alternative Medicine. Sometimes Integrative Medicine is called Complementary Medicine in that it works alongside Allopathy, each bringing valuable therapies to you. Dr. Andrew Weil pioneered the introduction of Integrative Medicine to most Americans.
Comprehensive approach to health care Enhance conventional medical care
� Wellness and illness prevention
� Evidence-based, safe, and ethical CIVM therapies
� Individualized plan for patient using the best of all available modalities
� Minimize the use of prescription drugs and conventional therapies
� Cost savings and less side effects
� Integrated NOT replacement!
Emphasis on prevention, nutritional diet and lifestyle change
Reasons for CIVM
Enhance the effectiveness of conventional medicine
Provide relief of clinical signs
Treat conditions that failed to respond to medicine
Avoid or reduce the side effects of some medicines
Minimize the use of medicines
Enhance mental and physical health
Hospice and palliative care
Common CIVM Therapies
Current examples of CIVM, not limited to:
• Aromatherapy, Bach flower remedy therapy
• Low-energy photon therapy, magnetic field therapy
• Chinese Medicine, acupuncture, acupressure
• Homeopathy
• Rehabilitation, manual or manipulative therapy
• Nutraceutical therapy, phytotherapy
• Stem cell therapy, prolotherapy
What Do We Do In CIVM?
As a specialty referral First seen by rDVM: Hx, PE, Dx tests, Dx
Full History & PE
Discuss all treatment options
Have owner consent
Safe, effective and proven Nutritional supplements and botanicals
Veterinary devices
Critically evaluate literature
Integrative Medicine for Osteoarthritis
OA: The Vicious Cycle
Decreased exercise
Muscle atrophy
Increased stress on joint capsule, ligaments and cartilage
Cartilage damage
Inflammatory mediators
Decreased nociceptive threshold and hyperalgesia
Acute pain is a symptom,
Chronic pain is a disease
PAIN
1/31/16
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OA: The Vicious Cycle
Decreased exercise
Muscle atrophy
Increased stress on joint capsule, ligaments and cartilage
Cartilage damage
Inflammatory mediators
Decreased nociceptive threshold and hyperalgesia
Acute pain is a symptom,
Chronic pain is a disease
PAIN
Physical Therapy
PT
Weight Loss
Adequan Glucosamine Chondroitin
MSM HA
GLM
Drugs Acupuncture
Laser T. Ultrasound Shockwaves Omega-3 FA
Acupuncture
Insertion on needles into specific points on the body to cause a desired healing effect
Acupoint body
needle
Physiological Changes
Beta-endorphin Nerve regeneration
Unblock Qi Balance Yin Yang
Immune cells
Tian He. Autonomic Neuroscience. 2015
29 RCTs, 17,922 patients
Back & neck pain, osteoarthritis, chronic headache, shoulder pain
ACP is effective for the treatment of chronic pain
True ACP significantly different from control and sham ACP
Laser Therapy
é Blood flow
é ATP production é angiogenesis and capillary production
Wavelength-specific form of photobiomodulation 660, 810, 980 nm
Use laser diode to create wavelengths
Interacting chemically and biologically with tissue
• Relieve pain • Reduce inflammation
• Accelerate wound healing • Stimulates cartilage growth
ê prostaglandins & inflammatory mediators é macrophage activity & leukocytic phagocytosis é blood flow
é endorphin
ê inflammatory mediators
é fibroblast activity and collagen production
! nociceptors
Favors LLLT Favors Placebo
7 RCTs (N=394)
VAS for pain after treatment was significantly lower in the LLLT group compared with placebo
1 day after LASER 3 days after surgery
3 day after LASER 4 day after LASER
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Therapeutic Ultrasound
Utilizes sound waves to cause vibrations to relieve pain and improve joint function Improve blood flow
Increases protein synthesis
Stimulates fibroblast activity
Aids in soft tissue and bone remodeling
Breakdown scar tissues
ò Studies show that it can improve strengthening benefits when combined with exercise in OA in knees. (Huang & Yang 2005; Huang & Lin 2005)
ò Activates chondrocytes to increase collagen synthesis (Korstjens et al 2004 & 2008; Naito 2010)
ò Improves fracture healing (Santana-Rodriguez 2010; Shakouri 2010; Esteki 2010; Korstjens 2004; Gebauer 2002)
Meta-analysis suggested US is more effective
than control for pain relief and function
improvement in knee OA (Zeng C, et al, 2014)
Other Modalities
TENS Low electrical current (2-4 or 60-200Hz)
Affect NERVES
Decrease pain perception
Gate theory
2-5 times/week
ò “TENS”
ò Affect NERVES
ò Pain relief
ò Gate-theory
ò Acute pain: 60-200 Hz
ò Relief is short-lasting
ò Chronic pain: 2-4 Hz
ò Longer lasting pain relief
(takes a chronic condition and changes it back to its acute phase).
Extracorporeal Shockwave ~1,000X the magnitude of ultrasound
Modulates a change in inflammatory response
3 treatments every 2–3 weeks.
Requires sedation (painful)
Therapeutic Exercises
Pain relieve
Minimize disuse changes
Return to normal activities Range of motion (ROM) Balance Strength Endurance
Fletcher, 13 y/o, MN, Border Collie
Chronic hip dysplasia & OA
Carprofen caused increased BUN & Creatinine
Tried Tylenol, Gabapentin, Tramadol, etc
Walking very slowly, stumbling, acting disoriented
Cognitive dysfunction?
QOL
pain on hip & lumbar palpation
“Fletcher”
Plan
Acupuncture 1X/week
Add Rehab in 2nd visit
Outcomes:
Significant less pain
Get up easier & walk better
More alert
“new dog”
Integrative Medicine for Cognitive Dysfunction Syndrome
and Separation Anxiety
1/31/16
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Cognitive Dysfunction Syndrome
13% of dogs age 8-11; 50% of dogs age of 11-12; 68% of dogs over 15 year old
Brain atrophy, increased amyloid plague, reduced blood flow
Inflammation?
Assessment: DISHA Disorientation Interaction Sleep/wake House-soiling (learning/memory) Activity (increase or decline) ANXIETY! DISHA-A
Start Tx as early as possible!
CDS Management
Slow neuronal damage and cell death
Multimodal approach: Drugs
Diet Supplements
Exercises / Rehabilitation
TCVM: Acupuncture, Herbal medicine
Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine
CDS Management: Drugs
Selegiline MAOB inhibition, antioxidant Increase dopamine level in brain Vomiting and diarrhea; restlessness, lethargy Contraindicated with numerous drugs 0.5 - 1 mg/kg PO once daily
Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine
Propentofylline Vasodilator and anti-inflammatory
Improve blood circulation in brain
<10 kg: 200 mg/day
>10kg: 400 mg/day
CDS Management: Diet
Hill’s b/d Mitochondrial co-factors, Ω-3 FA
Antioxidants (vit. E, flavonoids/carotenoids, l-carnitine, α-lipoic acids)
Effects of diet 8 weeks (Landmark); 6 months (Attention)
Effect of diet plus enrichment > enrichment > diet
Purina Bright Minds Antioxidant, OFA, MCT
Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine
CDS Management: Supplements
Omega-3 Fatty Acids DHA>EPA, 70-150mg/kg SID
S-adenosyl-methionine
Regulate neurotransmitter levels, increase glutathione
Improved both CDS dogs and cats, 20mg/kg SID
Medium chain triglycerides (coconut oil)
Provide ketone bodies for aging neurons
Improved CDS in dogs
Environment enrichment & Exercises
Housing with another dog, playing daily with toys
Hill’s B/D – mitochondria, antioxidant, OFA
Purina Bright Minds – antioxidant, OFA
Omega-3 Fatty Acids – DHA>EPA, 70-100mg/kg SID
Apoaequorin (Neutricks) – Calcium Buffer
S-adenosyl-methionine – methyl donor
Medium chain triglycerides (coconut oil) – mitochondria
Environment enrichment
Acupuncture – opiates, GABA, serotonin, blood flow Provide ketone bodies as an
alternate source of energy for aging neurons
CDS Management: Supplements
Senilife® (CEVA) Phosphatidylserine, Gingko biloba, vit E, vit B6, resveratrol
Aktivait (Vetplus) Phosphatidylserine, omega-3 FA, vit E & C, l-carnitine, alpha-lipoic acid, coenzyme Q and selenium
Apoaequorin (NeutricksTM) Calcium buffering protein found in jellyfish
Neuroprotection against aging
Shen Calmer (JingTang) 0.5 g per 10 pounds BID
Hill’s B/D – mitochondria, antioxidant, OFA
Purina Bright Minds – antioxidant, OFA
Omega-3 Fatty Acids – DHA>EPA, 70-100mg/kg SID
Apoaequorin (Neutricks) – Calcium Buffer
S-adenosyl-methionine – methyl donor
Medium chain triglycerides (coconut oil) – mitochondria
Environment enrichment
Acupuncture – opiates, GABA, serotonin, blood flow
1/31/16
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Separation Anxiety & Phobia
Very common conditions in young, elderly, CDS Barking and howling Chewing, digging and destruction Escaping Pacing
Often need anti-depressants Fluoxetine, paroxetine Diazepam, alprazolam Clomipramine, amitriptyline
Trazodone Selegiline
Behavioral modification program
Diazepam (valium), alprazolam (xanax) Amitriptyline (Elavil), clomipramine (clomicalm) Fluoxetine (prozac),
Integrative Medicine for Separation Anxiety
Pheromone
L-Theanine – GABA, dopamine
Alpha-casozepine – GABA
L-tryptophan – serotonin
Melatonin – sleep aid
Thunder-shirt/ Static cape
Music – classical (through a dog’s ear)
Catnip
Aromathepray – chamomile, lavender
Zylkene is a complementary feed for cats and dogs which contains a natural product, derived from casein, a protein in milk. It is a molecule well known to promote the relaxation of newborns after breastfeeding. Launched in October 2013, Zylkene has become a familiar product for veterinary surgeons, behaviorists, nurses and pet owners for use in helping pets cope when facing unusual and unpredictable situations or before occasions such as a change in their normal environment.
GABA 100 mg, L-tryptophan 100 mg, L- theanine 100 mg, B vitamins
Thiamine 62.5 mg L-Theanine 21.12 mg
Colostrum Calming
Complex 10.56 mg
Thiamine 134 mg Colostrum Calming Complex 22 mg L-Theanine 21 mg
Magnolia & Phellodendron 75 mg L-Theanine 35 mg
Dried Whey Protein Concentrate†
25 mg
L-theanine <10 kg received 25 mg >10 kg received 50 mg 30 min before stressful event
Acupuncture for CDS
12 Studies : 3 human, 9 animals
Showed to be effective in improving
intelligence and ameliorating
depression and anxiety in various pathological conditions
Improve cerebral blood flow
Promote dopamine
Enhance neurotrophin signaling
Reduce oxidative damages
Regulate glucose metabolism
Decrease Aβ proteins level in the brain
Integrative Medicine for Atopic Dermatitis
Atopic Dermatitis
Affect 10-15% of the canine population
Itching, smelling, erythema, hair loss
Relieving skin itch and inflammation remains a challenge
Integrative therapies reduce inflammation and pruritus, and prevent relapse Supplementation
Acupuncture
Laser
TCVM
Skin disease is a COMMON reason that dogs are presented to a veterinary clinic
Complaints of itching, smelling and hair loss are listed – most common is itching
Regardless of presentation, all dogs with significant skin disease need a skin scrape, (superficial and/or deep) dermatophyte culture and surface cytology performed
Integrative therapies reduce inflammation and
1/31/16
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Integrative Medicine for Atopic Dermatitis
Adjunct to standard treatment
Omega 3 Fatty Acids – EPA > DHA
Probiotic – regulate immunity
Essential oil – anti-inflammation, anti-pruritic
Chinese herbals – anti-inflammation
Acupuncture – anti-inflammation, calm
Laser – anti-inflammation
Scientific evidence in dogs/cats is needed
Omega 3 Fatty Acids
16 dogs with idiopathic atopy or flea allergy
6-week crossover design with a 3-week washout period
TX: 180 mg of EPA and 120 mg of DHA/10 lb
Significant improvements in pruritis, self-trauma, and coat
character over time
Topical Unsaturated Fatty Acids And Essential Oils
7 dogs with atopic dermatitis vs 5 normal dogs
Spot-on once weekly for 8 weeks
Validated lesion score (CADESI), VAS pruritus score
Mean CADESI scores significantly decreased
Pruritus scores significantly decreased
Chinese Herbal Medicine for Atopic Dermatitis
120 dogs with perennial atopic dermatitis
PYM00217 : R. glutinosa, P. Lactiflora, G. uralensis
100, 200, or 400 mg/kg daily or placebo for 12 weeks
CADESI evaluated at 0, 4, 8, and 12 weeks
200 mg/kg dose had a statistically significant reduction
(23.4%) in CADESI
Probiotic for Atopic Dermatitis
42 dogs with atopic dermatitis
double-blinded, placebo-controlled trial
L. sakei probio-65 (n = 32), or placebo (n = 10) once a day continuously for 8 weeks.
1g (<5kg) or 2g (>5kg) of powder
2x106 CFU/g of L. sakei
CADESI & PVAS evaluated every 28 day
Probiotic significantly reduced CADESI & PVAS
Acupuncture for Recurrent Otitis
Randomised controlled trial, 1-year follow-up
31 dogs with recurring otitis
Rate of acute otitis episodes
ACP: 14 (93%) dogs were free of relapses
Placebo: 7 (50%)
1/31/16
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Yunnan Baiyao
Increases primary hemostasis through promotion of platelet adhesion and aggregation
Treat and prevent external or internal bleeding
Inhibitory effects on canine HAS cell lines
Meta-analysis (55 RCT), helpful in treating uterine hemorrhage, ulcerative colitis and skin ulcer [Yang B. 2014]
1 capsule (0.25 g) per 10-20 lb BID-TID
87 patients
Tx vs Ctrl
Yunnan Baiyao, orally for 3 days before Sx
Mean total blood loss:
330.5 vs. 420.3 ml (p < 0.001)
No allergic reactions, thromboembolic events or other side effects
Take Home Messages
Growing specialty with high demand
Complement conventional treatments
Improve outcome and quality of life Pain management
Neurological disorders
Behavioral problems
Many chronic diseases
Hospice care
Safe and effective
Quality control of supplements is needed
High quality studies
Integrative Medicine
Veterinary Acupuncturists • Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT
• Rebecca McConnico, DVM, PhD, DACVIM, CVA
• Martha Littlefield, DVM, MS, CVA
Rehabilitation Therapists • Ronald Koh, DVM, MS, CVA, CCRP
• Jennifer Bridges, MS, CCRP
Massage Therapist • Maxon Graham, BS, ESMT/CSMT
Technician • Suzie Dauzat, RVT