In Part 2 of our 3-part series on Pain Management, Assisi Animal Health spoke with Dr. Troy about the case studies she submitted to gain her certification with the IVAPM (International Veterinary Academy of Pain Management). Part 1 focused on her IVAPM certification, and in Part 3, Dr. Troy will discuss her use of the Assisi Loop in her practice.
Assisi: To become a Certified Veterinary Pain Practitioner, you had to submit two peer reviewed case studies. Would you talk a little bit about what you submitted?
Dr. Troy: One was a dog with chronic osteoarthritis. He is a Labrador Retriever named Max. He had arthritis in every leg, and he also had problems in his back. He was a tough case because his mom, while a very helpful woman, was resistant to medication. As it turned out, she would give half the prescribed medication, and then when he didn't respond, we didn't always know the whole story.
I finally had to have a sit-down, face-to-face with her and say, "Let's talk about what you're giving him," and she finally told us. She was just cautious, like a lot of people are, about drugs. So, we had to have a nice long talk about the pros and cons of drugs, and what we can do to help, and what our additional options are. I don't like people to think, in an otherwise healthy dog, it's an either/or situation - either drugs, or physical rehab. Because we don't see it as alternatives, we see it as integrative.
How best have you found to explain the integrative approach to pet owners?
I designed this arthritis management program. It's a picture, a diagram, to make it easy for clients to read, and instead of being linear, it's a circle. You can cheat across the circle anywhere you want. For instance, drugs in one category, and hydrotherapy in another category, and electromagnetic therapy in another category. I designed it in a circle so that nothing really leads to anything else, so we don't have a start and we don't have an end. We can go through this circle any way we want, in any order we want, to try and be effective for the patient.
In Max's case, we were working on his mom with the meds, and we decided we needed to do some additional therapies with him. He'd gotten to a point where his anxiety was high, along with his pain. So he came to us every day for a week and we treated him with therapeutic laser, we also did cryotherapy - we have a unit that does ice and pressure because his knees were so sore - hydrotherapy, acupuncture, and then he went home with a Loop, and she Looped him twice every night.
By the end of that week, he was like a different dog. He was mobile, he was not whining, he was not anxious. Then, of course, he'd have these little dips and times where he stumbled down the stairs and things like that.
So he was a perfect example of good integrative pain management because we weren't just using one solitary way of managing him. He's now 14. He had an operation on one knee. He had back surgery done two months ago because he was almost not walking at all from the disc disease, and he did remarkably well with the back surgery. He's back to walking pretty well again - for a 14-year-old Labrador with arthritis in all four legs.
The challenge with cases like him is to decide on a daily basis, "What bothers him the most today?" Is it his bad elbows, is it his bad neck, is it his bad hips, his bad knees, or his bad lower back? That's where educating the client becomes important, and determining what extent they're willing and able to participate in assessing their pets at home. Does he feel hot here, does he feel room temperature here? Does he pull away when you touch him here? When he stands, does he lean more on this leg and off that leg? We have to look for very subtle clues because you can't ask him, "Does your left leg hurt, or does your right leg hurt?"
So you're educating them in how to assess that in their own pet.
Yes, to the best of everyone's ability. I have some clients that say, "Oh yeah, I'll palpate my dog," and others that are like, "Nope, I'm just going to tell you if he can get up and down. That's all I'm going to tell you." And then a lot of clients in between.
I use the Cincinnati Orthopedic Disability Index [CODI]. It's a standardized scoring method for movement, and it's really basic, but I have clients fill it out. It's a scoring sheet that they take home, and it has a list of six activities, like standing, sitting, going to the bathroom, getting on the bed, walking indoors, those kinds of things. Really basic things. It has a score of one to five - he has no trouble doing it, he has a little trouble doing it, he has a lot of trouble doing it, he can barely do it, or he can't do it at all. And they just put a check in the box. And then maybe there's something specific for that dog, like going in and out of the doggie door, or getting out to the potty area, or getting in the back of my pickup - depending on the individual dog, there's a space to fill out specifics for that dog.
I like to have my clients with pets who come in with multiple limb dysfunction fill that out - and then I hide it. Then, eight weeks to 10 weeks later, I have them fill out another one, and then I compare. Because some clients will come in and say, "You know doc, I'm really not seeing any difference," and so I'll say, "Well, fill this out for me," and then we compare them. What happens with a lot of them is, they say, "Yeah, actually, he can get back on the bed, I don't have to lift him up any more" or "Yeah, he's standing to eat, when before he was lying to eat." So sometimes, because the results are not dramatic, sometimes they're more subtle, you have to walk families through.
Some families want dramatic improvement, and some families are just willing to accept what they get. And those families, of course, are the easiest ones to deal with. But, I think, of the two priorities I have, after first educating my staff, the second is educating the client so that they can recognize pain. And I have clients whose pets have since passed on, after we've done a lot of pain management with that particular pet, and now, when they get another one, they're so proactive, it's just wonderful. They're like, "See, he's shifting weight off a little bit, he's groaning a little bit to get up, yep, can we get some x-rays and find out? Because the sooner we find it, the sooner we treat it." And so, even if a dog isn't showing a lot of dysfunction, a lot of pain or limping, if I find an orthopedic problem on x-ray, I start treating them. Because I don't want to wait until they're painful. I want to prevent them from getting painful. It just takes educating the client.
And what about the other case that you worked on?
The other case I wrote up was a hemilaminectomy Basset Hound that belonged to a multi-generational family - parents were senior citizens, and the son was a middle-aged adult, probably in his 40s. She's a big 60-pound dog. I wrote her up because she was a frustrating case, because she would have good days and bad days. She was neurologically progressing, but every time she'd come in, her pain was worse.
She was a frustrating case because the truth came out that the senior member of the family not only was not giving her her medication, but he was exercising her and not telling anyone. So we would just get her to the point where she was comfortable and we could take the next step forward, and she'd come in the following week and she would be in horrible pain. And we'd keep saying, "Are you guys doing anything different?" And the wife and the son would say no.
Well, apparently the family schedule was such that the wife would be out of the house for a few hours twice a week, and the adult son was out every day because he worked. So the senior father would take her on what he called a "drag," because she didn't walk. He would let her drag her legs to go to the park and see her friends.
And so I wrote that case up not because she was a medical miracle, because she wasn't, but to emphasize that you cannot help these dogs without first helping these clients. This one was frustrating because three of us doctors were involved with it, and six staff members were involved, and we all kept asking, "What are we missing? Does she need to be cut again?" We kept thinking, maybe she's blown another disc! And finally there was this come-to-Jesus meeting where the truth finally came out in front of his wife and his son and all of us.
It was taxing on my self-control because this had been going on for about five weeks. I stepped out of the room to let the family discuss it, because I said, "This is a family situation that you guys need to talk about, because we're clearly not all on the same page here." And then when I came back in and calmed myself down a little bit, I said, "Now we're going to start from the beginning. Now that we have a clean slate, we're going to start over in a non-judgmental way," because I'm pretty sure the son had taken care of Dad really, really well at that point.
No dragging allowed!
No dragging allowed. So that's why I wrote that case up, because we cannot help these dogs if we don't help these people. I did get a little criticism from it from the review panel, because they thought it was a pretty straightforward case, until they kept reading - and at my discussion point, when we discuss "How could this case have been handled differently," I told them the reason I had chosen this was because I felt it was really important to illustrate that the best-laid plans can go awry with poor communication, and we cannot be successful with our patients if we are not successful with our clients.
It expands the integrative medical model to include the social system that the animal is living with.
Absolutely! My mother had a stroke just recently, so I've been exposed to it all on the human side, and you're exactly right. There's a social worker that wants to know - "What's her house like? Who's there with her? Does she have any pets? Is she safe?" All these things that I don't think about for my patients, but I start to think about them now.
Who's going to be home to let her out when you're at work for 14 hours a day? She's a 13-year-old dog. Those kinds of things, it's so routine and expected in the human field, but not so much in the veterinary field. So we've come now to telling people that we treat you and your pet - if you can't lift your dog, we'll find you a device that will help you lift your dog. Or if your dog is slipping on the floor, we'll find a device - whether it's booties or nail covers or yoga mats or a harness - that will help you get your dog out of your home and out where it can potty, if that's all we can do. So we try and do everything we can to counsel the families on how to make their dog's recovery successful, along with providing therapy for the patient.
It's like you're part of the family.
Very much so. Our rehab patients especially, because we see them so often. I also find it in my general practice. I've been practicing long enough that I'm now on my second generation of puppies to adults to seniors, and families say, "Gosh, we're going through this again, aren't we," and I say, "Yes, we are - and we've got the tools to do it gracefully." And to me, that's what it's all about - to age with grace and no pain. Because pain is bad.
Thanks to Dr. Troy for taking the time to talk to us about a few of her more challenging case studies. Watch for Part 3 of this series, in which she'll tell us how she uses the Assisi Loop in her practice and how it has helped individual patients.
Dr. Erin Troy is the owner of Muller Veterinary Hospital and The Canine Rehabilitation Center in Walnut Creek, California.
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