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Acupuncture is pinteresting, but is there any point?
Talk of acupuncture is popping up here and there, and veterinarians want to know more. A new study compares it with a more traditional method of managing hip dysplasia pain.
Canine hip dysplasia is a fairly common diagnosis in general veterinary practice. Current treatment modalities range from conservative management with oral medication to surgical intervention. Conservative management usually includes a nonsteroidal anti-inflammatory drug (NSAID), but issues with gastrointestinal (GI) side effects can impact the safety of long-term use. The authors of this study evaluated many previous studies and found the incidence of side effects with carprofen to be as high as 55% (n = 35/64). It is wise to continue to investigate alternative therapies.
Acupuncture is one of the alternative therapies currently used in human medicine. It is thought to reduce pain through improved blood flow, muscle relaxation and a local anti-inflammatory effect.1 There are no high-quality studies to prove the efficacy of acupuncture in small animals prior to this one, nor are there any to prove effectiveness for treating the pain of dogs with hip dysplasia.
Here's what they did
Patients that showed radiographic evidence of hip dysplasia in one or both hips, signs of pain (per the owner), and a history of at least two clinical criteria of disease (such as lameness or difficulty rising or climbing) were chosen from the hospital population. The control group consisted of 16 dogs that had no history of hip dysplasia, radiographic evidence of the disease or clinical signs of the disease.
All of the dogs in the study were sedated for a radiographic examination. The views included hips, stifles, elbow joints and all regions of the spine. The radiographs were evaluated by a radiologist according to the standards of the Orthopedic Foundation for Animals (OFA). The 54 affected dogs were randomly divided into three groups. Seventeen of these were treated with acupuncture (group 1), 20 received carprofen as the positive control (group 2) and 17 served as a negative control and did not receive acupuncture or carprofen.
The acupuncture group received one session per week for a total of five sessions within the 30-day period. The therapy was performed by veterinary acupuncturists using a dry needle technique. Dogs in group 2 were given 4.4 mg/kg of carprofen orally once daily and acted as a positive control group. The negative control group was given capsules that appeared identical to the carprofen capsules. To make sure the owners were blinded, all dogs were given oral capsules each day, even though some were placebo, and all dogs were brought to the acupuncture clinic according to the protocol. The owners did not witness whether or not acupuncture was applied. The treatment in all cases was 30 days.
Any owner who reported deterioration of a pet's condition was allowed rescue analgesia, and these patients were logged. Baseline evaluations were performed 14 days before and immediately prior to the first treatment so that any improvement could be noted before the study. The unaffected dogs were only evaluated at day zero. It is interesting to note that all of the dogs that required rescue analgesia were in the carprofen group, but there were only two that needed the additional pain coverage.
Response to treatment was assessed at two, four and six weeks, with the final assessment occurring two weeks after cessation of treatment. At each assessment, the dogs were gauged by the owner and kinetic assessment. The owners were asked to evaluate on three separate instruments: Canine Brief Pain Inventory (CBPI), Helsinki chronic pain index (HCPI) and visual analog scale (VAS) for complete evaluation. They were asked to grade on overall pain and locomotion. A dog's scores were determined significant when the CBPI was reduced by 30%.
Kinetic assessment of pain and lameness gave peak vertical force (PVF) and vertical impulse (VI) of both rear legs of the dogs, using a force plate system. The dog strode on the platform with values recorded a total of five times each, and the values were reported as a percentage of the difference between the rear legs. The data was verified with numerous normality tests to verify both the degree of hip dysplasia and 30% improvement on CBPI scores.
A few of the test subjects were removed from the data pool because of failed compliance, development of unrelated disease or loss of communication with the owner. The degree of disease for the dogs ranged from borderline to severe hip dysplasia, and the control group all rated excellent or good by OFA standards.
Here's what they found
According to the owners' responses to the CBPI questionnaire, only acupuncture showed an effect on the pain intensity in this study at week four, when compared with the findings at the beginning. Based on pain scores at week six, the owners felt that the improvement continued for two weeks after the last treatment. VAS testing to score locomotion showed that owners felt that lameness was improved for dogs in both the NSAID and acupuncture groups, but for the dogs receiving acupuncture, the improvement seemed to be sustained for two additional weeks.
The authors think that the greater analgesia afforded the acupuncture patients may relate to the ability of acupuncture to address both acute and chronic pain. Other studies have suggested that there are multimodal effects from acupuncture that related to reduction of inflammation and increased serotonin concentrations and possibly improvement in blood clotting and chondroprotection.
It is important to note that neither treatment was profoundly different from the placebo. Both treatments seemed to improve scores on lameness as subjectively assessed by pet owners, and acupuncture decreased pain scores in validated tests.
Why does it matter?
There have not been many studies to help general practitioners know what to offer to clients with suffering dogs. Everyone reaches for NSAIDs, but the researchers did find in this study that only dogs receiving NSAIDs required additional rescue analgesia; none of the acupuncture dogs needed any extra pain coverage. One of those patients receiving the carprofen consumed less than normal amounts of food, and another vomited and required removal from the trial, so the concerns about GI side effects are still present.
Like anything, it comes down to the balance between all the options and what the owner is prepared to undertake. Obviously acupuncture (weekly for a treatment period of four weeks) is labor intensive for the pet owner, but for those clients who can feasibly accomplish this, it should be considered a viable option to improve quality of life for dogs suffering from lameness and pain due to hip dysplasia. Perhaps, as always, there is a balance to be found between among different treatments, taking into account the owner, the dog and the budget.
Teixeira LR, Luna SPL, Matsubara LM, et al. Owner assessment of chronic pain intensity and results of gait analysis of dogs with hip dysplasia treated with acupuncture. J Am Vet Med Assoc 2016;249:1031-1039.
Link to the study: http://avmajournals.avma.org/doi/pdf/10.2460/javma.249.9.1031
Ma Y-t, Ma M, Cho ZH. Peripheral mechanisms of acupuncture. In: Ma Y-t, Ma M, Cho ZH, eds. Biomedical acupuncture for pain management: an integrative approach. St Louis: Elsevier, 2005;31-48.