How to talk to clients about arthritis

Osteoarthritis is a common syndrome seen in pets and a major cause of morbidity and mortality among our companion animals.^1–3 This is a complex, chronic disease that is still not well defined, which makes it more difficult to explain to our clients. The complicated pathophysiology creates a spectrum of anatomic changes, inflammation, and pain that requires a thoughtful, flexible approach. Every pet will have different needs, and the best route to management takes partnership and ongoing communication between the family and the entire care team. Keep in mind that if your care team is not talking to clients about arthritis, someone else (such as a supplement company, online pet supply or pharmacy, or pet store employee) will.

When should we start a discussion about arthritis?

The best time to start a conversation about arthritis is before the pet is showing clinical signs, but oftentimes, the diagnosis is made when the family notices that something is wrong. Initiating the discussion can look different depending on the stage of arthritis.

Pre-clinical: Family is unaware of the problem; pet may or may not show subtle signs

• Discuss risk factors.
  • Breed, conformation, and activity level/intended purpose.
  • Age, excess weight, and poor muscle mass.
• Discuss regular visits (at least every 6 months) and screening diagnostic imaging to establish baselines.
• Include an arthritis screen at every wellness visit, even for puppies.

Example script: “Prince has two risk factors for developing arthritis—his weight is over ideal, and he is a Golden Retriever, a high-risk breed. The good news is that we can take a proactive approach so that if Prince does develop arthritis, we can easily manage it, and he may never know he has a problem.”

One to 3 simple yes/no questions can efficiently reveal early arthritis at a time when intervention will have the greatest impact. A “red flag” response (outlined below in parentheses) should trigger additional open-ended questions or follow-up. The third question is the most important of the 3.

1. Has your pet changed any habits or behaviors in the past 6-12 months? (Yes)
2. Has your pet’s activity level or desire to exercise changed in the past 6-12 months? (Yes)
3. Is it easy for your pet to get up from lying down? (No, or hesitation)

Clinical, mild to moderate: Family may or may not be aware of the problem; pet shows consistent clinical signs (stiffness, lameness, clear exercise or behavior changes)

• Discuss signs and what is happening to the joint now.
• Discuss progression and our ability to intervene now to slow the process.
• Discuss diagnostics to document staging.
• Checkups more frequently (4-8 weeks, taper).

Example script: “Mr Tobin, thank you for sharing your observations about Sophie. My exam findings confirm that she has discomfort in her hips that is consistent with arthritis. We should take some x-rays so that we can have a better idea of how much change there is already, and that will help us decide the best therapy plan to keep her comfortable and slow this process down.”

Clinical, moderate to severe: Family and pet are very aware that there is a problem; signs interfere with activities of daily living.

• Discussion points, like mild to moderate.
• Reinforce that investing in a more intensive clinical approach now will allow less intervention in the future once the disease is stable.
• Checkups more frequently (3-4 weeks, taper).

Example script: “Dr Pope, I know that Ally is struggling, but there are many things that we can do to help her. If we start with a more intensive approach to get her pain under control quickly, then management should become easier, and we can reduce support if she maintains comfort and mobility.”

Who should talk to the client about arthritis?

Every member of the care team should be trained, within the scope of their position, to notice early signs of arthritis and be able to talk to the client about what they see and why they are concerned that this may indicate arthritis.

• Share the most common management approaches/options, so that team members can briefly answer the most basic questions and concerns.
• Empower veterinary nurses and technicians to take a greater role in arthritis management—have them be a primary contact for the family.
• Consistent messaging is critical to gaining trust and achieving compliance with best recommendations.

Example script: “Ms Johnson, I noticed that Gypsy consistently sits with her weight shifted to one hip. That may be an early indicator of arthritis. Would you mind if I ask you a few questions before you see the doctor?”

Key concepts to convey for management

The best approach is a mix of medical information, empathy, and reassurance.

• Arthritis is a chronic, progressive disease. We cannot cure it, but we can slow it down.
• Early identification can have a major impact on slowing progression.
• Weight management and appropriate exercise are the most cost-effective options that have the most positive impact.
• Management of pain and inflammation is an important consideration at every stage.
• The most successful management involves a combination of home care and in-office support.
• The pet’s needs WILL change. Regular checkups and clear communication are necessary for ongoing success.

Discussing goals and setting expectations

• Ask the client what their goals are and try to get specific answers (walk ½ mile).
• Evaluate if expectations are realistic.
  • “6 months ago” is a great start.
  • For more severe cases, set short-term goals (walk 1 block).
• Emphasize partnership and support to reassure the client that the plan can be adjusted to best suit the needs of the pet and the family.

Example script: “Mr Smith, I know it’s not easy to hear that Mica has a chronic condition that will not go away, but we are here to partner with you for his care. We can help you with the best options that will be a good fit for your family.

Presenting options and recommendations

Clients can become overwhelmed with too many options. Offer no more than 1-2 interventions in each category and no more than 3-4 total.

• Lifestyle management: Diet, exercise, environmental modification.
• Nutraceuticals.
• Pharmaceuticals.
• Modalities: Acupuncture, manual and manipulative therapy, laser photobiomodulation, extracorporeal shockwave therapy, pulsed electromagnetic field therapy.
• Regenerative therapy: Platelet-rich plasma, mesenchymal stem cell therapy.
• Intra-articular injections.
• Surgery (total hip replacement, patella stabilization, stifle stabilization following cranial cruciate ligament tear).
• Palliative radiation.

Prioritize recommendations based on scientific knowledge as well as clinical experience. Reassure the client that we will assess the response to therapy and adjust our plan.

Example script: “Mrs Janes, I would like to get Gertrude started on some medication to help reduce her pain, as well as some supplements to help slow damage to her joints. We can also provide a referral for physical rehabilitation at a nearby practice that offers many options to help her get stronger and feel better.”

Takeaway

Osteoarthritis can be challenging from a diagnostic, therapeutic, and communication standpoint. When all of this is well-managed, the result is improved quality of life and better longevity for the pet, a strong bond between the family and the practice, and great satisfaction for the care team.

References

1. Johnson SA. Osteoarthritis. Joint anatomy, physiology, and pathobiology. Vet Clin North Am Small Anim Pract. 1997; 27(4): 699-723. doi:10.1016/s0195-5616(97)50076-3
2. Bonnett BN, Egenvall A, Hedhammar A, Olson P. Mortality in over 350,000 insured Swedish dogs from 1995-2000: I. Breed-, gender-, age- and cause-specific rates. Acta Vet Scand. 2005;46(3):105-20. doi: 10.1186/1751-0147-46-105.
3. O’Neill DG, Church DB, McGreevy PD, Thomson PC, Brodbelt DC. Prevalence of disorders recorded in dogs attending primary-care veterinary practices in England. PLoS One 2014; 9(3): e90501. Published March 4, 2014. doi: 10.1371/journal.pone.0090501.