V2I2 (Spring 2012)

Integrative Peer Reviewed

veterinary care

Adaptogenic herbs

How they help treat HPAT axis exhaustion Page 24

Integrative oncology Form a strong working relationship with a veterinary oncologist to give your patients a better-than-fighting chance

spring ISSUE 2012

www.IVCJournal.com

Talking titers More than a decade of clinical experience shows them to be a reliable way of monitoring immunity to many infectious diseases

Pain management Using conventional and complementary therapies along with weight management, exercise, diet and supplements

Chiropractic case report

Demonstrating that chiropractic is an effective physical modality in the treatment of mobility problems

Are you burned out?

Recognizing, preventing and treating veterinary burnout is crucial to your continued success and well being

What’ s new?

• Ground breaking feline studies • Gene mutation discovery • Heads up for California chiropractors integrative veterinary care

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contents FEATURES

12

Integrative oncology

12

Human cancer centers are already using an integrative approach to oncologic care. Many veterinarians are going in the same direction, but more studies and clinical trials are needed to help us better understand how conventional and complementary treatments can work together to optimally treat animal patients.

16

Talking titers

20

Though some veterinarians challenge the validity of vaccine titer testing, published studies and more than a decade of clinical experience have shown it to be a reliable way of monitoring immunity to many of the most important infectious diseases.

20

30 38

Integrative pain management

For optimal results, both conventional and complementary therapies should be utilized along with close attention to weight management, exercise, diet and supplements.

24

Adaptogens for the HPAT axis

This exceptional category of herbs has many veterinary applications.

Let’s look at their effectiveness for hypothalamic-pituitary-adrenal-thyroid exhaustion.

30

The worm turns

Equine parasites are now resistant to many of the drugs currently in use. The time has come to rethink deworming by adding some alternative strategies to the treatment arsenal.

34

Nutrition nook Digestive enzymes

46 4

integrative veterinary care

These key nutrients can be used for pancreatic and GI issues, but are also beneficial for healthy patients eating heat-processed pet foods.

38

Integrative practice The integrative umbrella

More clients are asking for CAVM, but how do we respond when we don’t have ideal scientific evidence to back up these therapies? Here are the tools to weather this dichotomy.

42

Feline diabetes mellitus

A look at insulin stabilization and home monitoring, as well as long term management and complications.

46

Chiropractic case report

This dog’s experience demonstrates that chiropractic is an effective physical modality in the treatment of mobility problems.

50

Are you burned out?

Your profession may be hazardous to your health. Recognizing, preventing and treating veterinary burnout is crucial to your continued success and well being.

56

Undiagnosed lameness

It’s a common complaint, but in many cases, the culprit is poor saddle fit and balance.

60

Tech Talk Bach Flower Remedies

Though their efficacy isn’t backed up by much science, these remedies have nevertheless found a place in many integrative practices as a way to shift emotional states to aid recovery, and to help with behavior or training problems.

advisory board Columns & departments

5 Advisory board 6 What’ s new?

41 Industry innovations 39 Spotlight 49 Veterinary resource guide

Dr. Richard Palmquist, DVM, graduated from Colorado State University in 1983.

He is chief of integrative health services at Centinela Animal Hospital in Inglewood, California, president and research chair of the AHVMA, and an international speaker in integrative veterinary medicine. Dr. Palmquist is a consultant for the Veterinary Information Network (VIN) and co-director of the AHVMA Foundation. He has published two books, one for conventional veterinarians and a second for clients discussing how integrative thinking works.

Michelle J. Rivera, MT, VDT, is an instructor at the University of Wisconsin and The Healing Oasis Wellness Center, a post-graduate educational institution offering state-approved programs. She is co-owner of The Healing Oasis Veterinary Hospital, offering massage, rehabilitation, chiropractic and Chinese and Western Herbology.

Michelle completed the Chinese Herbal Medicine program from the China Beijing International Acupuncture Training Center, and is certified in Chinese Medicine by the Wisconsin Institute of Chinese Herbology.

58 Marketplace 59 Events

Dr. Joyce Harman, DVM, MRCVS, graduated in 1984 from Virginia Maryland Regional College of Veterinary Medicine. She is certified in veterinary acupuncture and chiropractic and has completed advanced training in homeopathy and herbal medicine. Her practice in Virginia uses holistic medicine to treat horses.

Her publications include The Horse’s Pain-Free Back and Saddle-Fit Book – the most complete source of information about English saddles.

Dr. Steve Marsden, DVM, ND, lectures for the IVAS, the AHVMA and the AVMA, and is co-founder of the College of Integrative Veterinary Therapies. He is a director of the National College of Natural Medicine, and authored the Manual of Natural Veterinary Medicine. Dr. Marsden is extensively trained in alternative medicine, including Chinese herbology, acupuncture and naturopathic medicine. He has a veterinary and naturopathic practice in Edmonton, Alberta.

In 2010, Dr. Marsden was named Teacher of the Year by the AHVMA.

Dr. Jean Dodds, DVM, received her veterinary degree in 1964 from the Ontario Veterinary College. In 1986, she moved to Southern California to establish Hemopet, the first non-profit national blood bank program for animals. Dr. Dodds has been a member of many national and international committees on hematology, animal models of human disease, veterinary medicine, and laboratory animal science. She received the Holistic Veterinarian of the Year Award from the AHVMA in 1994.

Dr. Christina Chambreau, DVM, graduated from the University of Georgia Veterinary College in 1980. She is a founder of the Academy Of Veterinary Homeopathy, was on the faculty of the National Center for Homeopathy Summer School and has been the holistic modality adjunct faculty liaison for the Maryland Veterinary Technician Program. Dr. Chambreau teaches classes in homeopathy for animals, and lectures on many topics. She is co-author of the Homeopathic Repertory: A Tutorial.

Bill Bookout is a founding member of the NASC, serving as president and chairman of the board since 2002. He is founder and president of Genesis Ltd., a company that provides feed and health products for animals. He spent 15 years in the human medical device, drug and animal health industries. Bill received his Bachelor’s degree in physical sciences from the University of Wyoming, and an MBA from Pepperdine University. He has been selected by Health Canada to serve on the Expert Advisory Committee for Veterinary Natural Health Products.

integrative veterinary care

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what’ s new Gene mutation discovery disease in Tibetian terriers is called adult-onset neuronal ceroidlipofuscinosis (NCL). Within the dogs’ cells in the brain and eye, material that should be “recycled” builds up and interferes with nerve cell function. Due to this buildup, around the age of five years old, the dog begins to exhibit dementia, impaired visual behavior, loss of coordination, and shows unwarranted aggression.

University of Missouri researchers believe both man and animal will benefit from their discovery that the same gene mutation found in Tibetan terriers can also be found in a fatal human neurological disorder related to Parkinson’s disease.

Fabiana Farias, a doctoral candidate in Area Genetics at the University of Missouri, found the mutation as part of her thesis research. The

Nosebands under pressure The International Society for Equitation Science (ISES) has released a statement saying that the practice of over tightening nosebands to avoid penalties in competition is covering up poor training at the expense of horse welfare. Recent research suggests that horses wearing tight nosebands undergo a physiological stress response, are sensitized to bit pressure, and may have reduced blood flow with potential to cause injuries and tissue damage including nasal bone deformities, even when padding acwcompanies the noseband such as in the case of so-called crank nosebands.

Restrictive nosebands can prevent the horse from displaying unwanted behaviors such as opening, gaping or crossing the jaw, and are enabling competitors to mask signs of tension. ISES recommends a return to the established practice of placing “two fingers” under the noseband to demonstrate that it has not been over-tightened. equitationscience.com

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integrative veterinary care

While there are many forms of NCL in humans, the symptoms are similar in people and dogs, and the disease is ultimately fatal for both. Utilizing the canine genome map and DNA samples from dogs diagnosed with NCL, the researchers were able to pinpoint the specific gene that causes NCL. The mutation they discovered in dogs, however, causes a hereditary form of Parkinson’s disease in humans. This suggests that the recycling that goes awry in NCL may also be involved in degenerative diseases like Parkinson’s.

Now, DNA from dogs can be tested to identify the presence of the mutated gene, and that test can ensure that Tibetan terrier breeders do not pass it on to the next generation. The researchers also believe they may be able to test potential human therapies on the animal population because they can use the DNA test to identify affected dogs before they start to show symptoms.

Heads up for California chiropractors Under a new bill approved by the state Senate, California would prohibit chiropractors from treating allergies. Senate Minority Leader Bob Huff, a Republican from Diamond Bar, says some chiropractors have claimed they can use lasers to diagnose and treat hypersensitivity to certain foods, medicine and environmental allergies, without evidence that the treatments work.

His bill prohibits chiropractors from treating allergies because the state defines it as practicing medicine. It also bans chiropractors from advertising that they can treat allergies. The ban includes but is not limited to laser therapy. The bill is supported by the California Medical Association but opposed by the state Board of Chiropractic Examiners and the California Chiropractic Association.

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New classroom building approved The Texas A&M University System Board of Regents has approved the addition of a $120 million classroom building and small animal hospital expansion project to the system’s capital plan.

This represents a major expansion for the Texas A&M College of Veterinary Medicine & Biomedical Sciences (CVM).

The new building will house state-of-the-art classroom and teaching laboratory space that will enhance the learning environment for students. Combined with the expansion of the small animal hospital, the new facilities will provide opportunities for innovations in teaching and will nurture collaboration and creativity. In addition, they are expected to be a notable factor in recruiting the best faculty, staff and students.

Ground-breaking feline studies Morris Animal Foundation is funding scientists who are using cutting-edge technologies to change the way veterinarians diagnose and treat cats. In one study, Dr. Steven Dow of Colorado State University is evaluating the effectiveness of mesenchymal stem cell therapy to treat cats with chronic kidney disease. This therapy has been successful in reversing and stabilizing kidney function in rodents with renal disease, and Dr. Dow hopes the same is true for cats. If these studies generate positive data, the results will have a significant impact on the development of new ways to manage feline CKD. Another study is looking for ways to prevent cytauxzoonosis, a life-threatening disease in cats caused by the Cytauxzoon felis parasite, which is transmitted by ticks. Without proper diagnosis and treatment, the mortality rate for infected cats is 97%; even with the best available treatment, about 40% of infected cats will die. Researchers believe a vaccination is the only practical control strategy, and scientists at North Carolina State University, let by Dr. Adam Birkenheuer, are conducting a study to help identify which genes are the best vaccine candidates. www.morrisanimalfoundation.org

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integrative veterinary care

Equine behaviorist honored Recognized internationally as one of the foremost authorities on equine behavior, Dr. Robert M. Miller has been named the recipient of the 2012 Western Horseman Award.

When Dr. Robert Miller’s video Imprint Training of the Foal was released in 1986, horsepeople around the country seemed to form two camps. The ideas presented by Dr. Miller challenged the assumptions of many horsemen that coddling a newborn foal would limit his/her potential. Others saw a breakthrough in understanding equine behavior and began adopting Dr. Miller’s kinder, gentler approach.

The subsequent release of a book with the same title propelled Dr. Miller into the center of the emerging “natural horsemanship” movement and made him one of the most sought after lecturers at veterinary schools, equine symposiums and clinics on equine behavior. A decade later he made an updated video titled Early Learning – The Complete Training of the Newborn Foal During Its Imprinting and Critical Learning Periods.

Vet focuses on working dogs

new Spot-on named in class action Yet another class action has been filed in federal court in Newark, New Jersey against a manufacturer of spot-on flea and tick products.

FidoPharm, which makes PetArmor, has been added to the list of companies being sued. PetArmor was launched a year ago and is described by

the

manufacturer

as

containing the same active ingredients as Frontline, a well known veterinarian

AKC Canine Health Foundation (CHF) funded researcher Cindy Otto, DVM, PhD, of the University of Pennsylvania was presented with an American flag flown in Afghanistan in recognition of her commitment to the health of working dogs.

recommended product.

Over the past four years, more than 75,000 complaints have been made to the EPA regarding spot-on flea and tick products.

The plaintiffs of the class actions allege that the pesticides in

The flag was presented to Dr. Otto by Major Janice L. Baker, US Army Veterinary Corps. While Major Baker could not provide the specifics of the mission under which the flag was flown, she informed Dr. Otto that they “carried this flag and displayed it proudly over some of the most hostile areas of the country in support of missions utilizing military working dogs, in honor of you and your colleagues, who are dedicated to the medicine, research and promotion of health of working dogs.�

spot-on products cause death, paralysis, seizures and skin lesions and that these adverse affects are not stated in the advertising or marketing.

More information regarding the class action lawsuits filed against FidoPharm and others may be obtained at www.spotoncomplaints.com.

integrative veterinary care

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New cancer treatment now available in US Electrochemotherapy involves the passage of electric current via a specific medical device to allow a chemotherapy drug to be taken up directly into the tumor; thereby killing it and sparing normal tissues. The procedure is done under brief anesthesia and is typically a single treatment similar to localized radiation therapy, but without the radiation side effects, need for multiple treatments and high cost. Success in veterinary oncology has been well documented overseas against melanomas, soft tissue sarcomas, mast cell tumors, squamous cell carcinomas, brain tumors and mammary tumors.

Find out more at www.vschv.com.

The Veterinary Specialty Center of the Hudson Valley (VSCHV) now has the ability to perform Electrochemotherapy (ECT) in the treatment of canine and feline cancers.

ECT has long been available in Europe with over 80 centers currently treating cancers in people. There are a few veterinary centers that are treating pets with great success in Brazil, France, Italy, Ireland, Slovenia and the UK.

New research focus in epidemiology at OVC A new research focus at the Ontario Veterinary College (OVC) will advance evidence-based health care for pets by answering important questions about nutrition and health in cats and dogs.

In partnership with Banfield Pet Hospital, the OVC has created a two-year post-doctoral position in companion animal epidemiology that will expand the scope of the college’s renowned work in veterinary epidemiology.

Dr. Chika Okafor, a veterinarian from Michigan State University College of Veterinary Medicine, is the recipient of the post-doctoral position. “Because we analyze populationbased data over time, epidemiologists can answer questions about health outcomes that cannot be answered in smaller studies of individual animals,” Dr. Okafor says. He will have the opportunity to use OVC’s expertise in epidemiology to synthesize information from Banfield’s proprietary electronic medical records system that collects data from its network of veterinary hospitals.

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integrative veterinary care

Dr. Okafor looks forward to his research work at OVC.

“We look forward to uncovering nutritional relationships with health and diseases,” says Dr. Elizabeth Lund, a veterinarian with Banfield. www.ovc.uoguelph.ca

integrative veterinary care

11

Human cancer centers are already using an integrative approach to oncologic care.

Many veterinarians are going in the same direction, but more studies and clinical trials are needed to help us better understand how conventional and complementary treatments can work together to optimally treat animal patients.

Oncologists Dr. Mona Rosenberg and Dr. Mary Davis review thoracic radiographs. Having a good working relationship with a veterinary oncologist is an important part of integrative cancer treatment.

In my 24 years of practicing oncology, most of it in Southern California, I have had the pleasure of being exposed to Complementary and Alternative Medicine (CAM). While not all board certified veterinarians are open to the idea of combining Eastern and Western medicine, I believe this sentiment is changing. A high percentage of the pet owning public, at least here in California, is interested in ensuring the best medical care for their pets by exploring a combination of approaches.

This puts the onus on all veterinarians to be open minded and willing to explore new methodologies to maintain wellness and treat illness.

The top human cancer centers in this country have long recognized the advantages of using an integrative approach to oncologic care. Memorial Sloan Kettering, MD Anderson, Mayo Clinic‌the list goes on. These are trusted resources for cancer treatment, cutting edge research and clinical trials. Therefore, the model for a collaboration of veterinary oncologists and holistic practitioners already exists; we do not have to re-create the wheel. Yet we must improve our relationships with each other in order to effectively implement this combined approach to care.

I have been working with CAM specialists for most of my career. Veterinary Cancer Group, which I founded 20 years ago, has two comprehensive cancer centers and three satellite clinics. Both our comprehensive centers have holistic practitioners on staff one day a week. We

12

integrative veterinary care

by Mona P. Rosenberg, DVM, DACVIM

also work with quite a few established complementary small animal practices in our area. This has been mutually advantageous to all involved, though in my mind, the real winner is the patient who gets to benefit from the combined approach.

Lack of studies causing resistance

Some pushback likely stems from the paucity of evidencebased scientific studies. Both CAM veterinarians and those who practice Western medicine all started their careers with the same training. And we all have the same goals: to provide the best possible quality of life for our patients. There will always be room for using timehonored techniques we learned in the trenches or were taught to us by our mentors or during “back hall consults�.

These tried and true methodologies work for us, making it less important whether or not there is a strong basis for this approach in the literature. But when faced with a treatment that is foreign to us, based on our education and training, it is much easier to accept it if there is convincing scientific evidence to support its use.

Some of the challenges we face include how to bring together Eastern and Western medicine. For example, evidence on the human side indicates that high doses of antioxidants may interfere with the mechanisms of action of radiation and chemotherapy (JNCI, 2008). This not only applies to the combination of supplements and traditional cancer treatments; for instance, we cannot use metronidazole in patients undergoing radiation

therapy because this drug acts as a radiosensitizer, significantly increasing the side effects associated with radiation. Therefore, it is imperative we develop knowledge based on sound scientific principles to ensure we are doing the best for our patients, and not using treatments that counteract each other.

Here’s another example. Green tea extract (GTE) has been shown to mitigate the side effects of some chemotherapy drugs in people. Yet in a recent study in tumor-bearing mice, it negated the tumor-killing effects of the drug Velcade, used for patients with multiple myeloma. The GTE binds to the Velcade, preventing the drug from exerting its effect on its intracellular target. In other instances, GTE enhanced the tumor cell kill when combined with certain chemotherapeutics in preclinical and mouse models.

Unfortunately, this means we need to be extremely cautious when we consider combining these types of treatments until well designed clinical trials can be carried out.

Designed specifically for geriatric pets, Cholodin® may help with the following symptoms: Disorientation, confusion • Loss of appetite • Increased sleep time

•

Impaired hearing

Poor, thin, or dry coat Inappropriate urination

Clinical research – what’s being done?

The Mayo Clinic has been conducting clinical research using CAM therapies for the last 30 years. A total of 27 clinical trials have been carried out, 21 of which are published or currently in press. Many have looked at alleviating symptoms caused by cancer or conventional treatment (i.e., radiation or chemotherapy induced mucositis, incidences of hot flashes due to menopause, improved cognitive function post curative intent chemotherapy for breast cancer patients, etc.).

The experience at the Mayo Clinic shows that veterinary medicine can also conduct meaningful trials to help advance our knowledge and, ultimately, the care we are able to provide our four-legged patients.

In fact, Veterinary Cancer Group is in the process of designing a clinical trial evaluating the incidence of diarrhea in patients undergoing pelvic irradiation using a proprietary homeopathic to treat the diarrhea, since we know we cannot use metronidazole. Additional studies beg to be developed by the oncologic specialist working with the CAM specialist.

We participate in many clinical trials, most of which have full or partial funding. These have primarily been with pharmaceutical companies who are interested in evaluating a new therapy in animals in hopes of eventually being able to market the same drug to human cancer patients.

We have also participated in a

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Therefore, it is imperative we develop knowledge based on sound scientific principles to ensure we are doing the best for our patients, and not using treatments that counteract each other.

number of trials aimed at the development of drugs specifically for animals (e.g., Palladia). There are many supplements and nutraceuticals manufactured specifically for animals. It behooves these companies to financially back randomized, double blinded, placebo controlled studies of their products.

This would especially be beneficial in combination with conventional cancer therapies.

If you are already working with an oncologist, great! If not, based on my personal experience, the bonds you develop with him/her (and s/he with you), will benefit everyone.

Our patients deserve the best care we can provide. I am excited about the future of combining conventional and complementary veterinary medicine, as I truly believe we can achieve our goals by doing so. Please join me in forging improved relationships between oncologists and CAM specialists. Brainstorm ideas and challenge the manufacturers to support clinical trials. Our patients and the families who love them are counting on us!

Mona Rosenberg, DVM, DACVIM, (Oncology) is the owner, CEO and Chief of Staff of Veterinary Cancer Group. She brings a wealth of expertise and experience to the practice. After receiving her DVM degree from the University of California, Dr. Rosenberg completed her internship and residency at the Animal Medical Center in New York. A diplomate of ACVIM in oncology since 1992, she is also an active member of Veterinary Cancer Society and SCVMA. As the head of the oncology residency program at Veterinary Cancer Group, Dr. Rosenberg plays a hands-on role in preparing the next generation of veterinary oncologists.

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Lymphoma in the dog is a very chemotherapeutically responsive neoplasm.

Yet despite numerous studies evaluating the use of different chemotherapeutics in different combinations over different lengths of time, the survival times for this cancer have not significantly improved in 30 years.

Perhaps we could improve upon these statistics if we were able to utilize higher drug doses. But if we were to employ higher doses, our incidence of side effects would increase dramatically. As a board certified oncologist, I am not willing to subject my patients to intolerable adverse events.

The goal has to be quality of life, and none of us is willing to have the treatment become worse than the disease. But what if we were able to increase drug dosages without increasing side effects? Perhaps this could be achieved by the combined use of complementary therapies.

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Talking

Titers

Though some veterinarians challenge the validity of vaccine titer testing, published studies and more than a decade of clinical experience have shown it to be a reliable way of monitoring immunity to many of the most important infectious diseases. \\\\ by W. Jean Dodds, DVM

\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ Producing effective and safe vaccines for prevalent infectious diseases in animals has become increasingly challenging.

In veterinary medicine, evidence implicating vaccines in triggering immune-mediated and other chronic disorders (vaccinosis) is compelling.

are being addressed today because the widespread use of vaccination programs has effectively reduced the risk of disease while simultaneously increasing the population’s “herd immunity”.

Serologic vaccine titer testing While some of these problems have been traced to contaminated or poorly attenuated batches of vaccine that revert to virulence, others apparently reflect the animal’s genetic predisposition to react adversely upon receiving the single (monovalent) or multiple antigen “combo” (polyvalent) products routinely given to pets. Animals of certain susceptible breeds or families appear to be at increased risk for severe and lingering adverse reactions to vaccines. In cats, while adverse vaccine reactions may be less common, aggressive tumors (fibrosarcomas) can occasionally arise at the site of vaccination.

We need to acknowledge, however, that these concerns

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Some veterinarians continue to challenge the validity of using vaccine titer testing to assess whether individual animals are protected against the common, clinically important infectious diseases. Nevertheless, titer testing has been around for more than a decade now, and published studies along with extensive clinical experience have shown them to be useful and reliable for monitoring immunity to canine distemper virus (CDV), canine parvovirus (CPV-2), canine adenovirus (CAV-1 and -2), feline panleukopenia virus (FPV), and rabies virus (RV).

Modified-live virus (MLV) vaccines for the first four listed viruses induce sterile immunity when the animal has been

properly immunized, thereby rendering him immune to viral replication and re-infection upon exposure. Serum titer levels for these diseases are directly proportional to the degree of clinical protection. By contrast, titers for feline herpes virus (rhinotracheitis virus) and feline calicivirus are less reliable.

All licensed rabies vaccine are inactivated, killed products, so they cannot replicate in the host animal, but still convey longlived immunity.

The antibody tests performed most often to monitor immunity are CDV, CPV-2 and FPV, especially after completion of the puppy and kitten vaccination series.

Today, vaccine titer tests are routinely offered by university teaching hospitals, state and provincial diagnostic laboratories, and private laboratories. There are now also two USDAapproved in-hospital tests available that provide a positive or negative result: Canine TiterCHECK®, Synbiotics Corp. (Pfizer Animal Health, www.synbiotics.com) and VacciCheck®, ImmunoComb (Biogal-Galed, www.biogal.com).

The antibody tests performed most often to monitor immunity are CDV, CPV-2 and FPV, especially after completion of the puppy and kitten vaccination series (at least two to four weeks later, and then a year later). Once an animal’s titer has stabilized, it should remain constant for many years. Importantly, this animal has immunity to prevent clinical disease, and doesn’t need to be revaccinated, especially when the vaccine could cause an adverse reaction (hypersensitivity or other adverse event). Actually, one should avoid vaccinating animals that are already protected.

It has been said that the antibody level detected is “only a snapshot in time”. That’s simply not true; it is really a “motion picture that plays for years”.

The presence of any measurable serum antibody titer indicates the presence of “immune memory” and signifies protection from disease. However, titers do not distinguish between immunity generated by vaccination and/or by exposure to the disease, and one should expect the magnitude of immunity produced just by vaccination to be lower (but still adequate).

Interpreting results Some laboratories may report results with an actual titer measurement, or as less than, equal to, or greater than a measured titer, while others simply indicate a result that’s either positive (antibody is present) or negative (no antibody was detected). The positive titer test result is fairly straightforward, but a negative result is more difficult to interpret, because it is not the same thing as a zero titer and doesn’t necessarily mean the animal is unprotected. A negative result usually means the titer has failed to reach the threshold of providing protective immunity. For the clinically important viral diseases of dogs and cats (CDV, CPV-2, CAV-1, FPV), a negative or zero antibody titer indicates the animal is likely to be unprotected against these diseases.

Please remember that some dogs and cats are genetically unable to mount protective immunity to these agents.

They are termed low- or non-responder animals, and are still susceptible to contracting these diseases, so exposure risk should be minimized. The estimated frequency of nonresponders for CPV is 1:1,000 and for CDV is 1:5,000.

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Reasons for Vaccine Titer Testing * • To determine if the animal is protected (suggested by a positive test result).

It has been said that the antibody level detected is “only a snapshot in time.”

That’s simply not true; it is really a “motion picture that plays for years.”

• To identify a susceptible animal (suggested by a negative test result).

• To determine whether an individual animal has responded to a vaccine.

• To determine whether an individual vaccine is effectively immunizing animals. * from Schultz RD, Ford RB, Olsen J, Scott F.

Vet Med, 97:1-13, 2002 (insert).

Black Labrador retrievers and Akitas are more likely to be nonresponders to CPV, whereas greyhounds are more often non-responders to CDV. To date, there have been no documented non-responder cases to CAV-2 vaccine, and relevant data are not available for FPV in cats.

Finally, what does more than a decade of experience with vaccine titer testing reveal? Published studies in refereed journals show that 90% to 98% of dogs and cats that have been properly vaccinated develop measurable antibody titers to the infectious agent measured. Thus, using vaccine titer testing as a means to assess vaccine-induced protection will most likely result in the animal avoiding needless and unwise booster vaccinations.

\\\\\\\\\\\\\\\\\\ References • Day MJ, Schultz RD. Veterinary Immunology, Principles and Practice. London, UK: Mason Publishing /The Veterinary Press; 2011.

• Gore TC, Lakshmanan N, Williams JR, et al. “Three-year duration of immunity in cats following vaccination against feline rhinotracheitis virus, feline calicivirus, and feline panleukopenia virus.” Vet Therapeutics 7:213-222, 2006.

• Lappin MR, Andrews J, Simpson D, et al. “Use of serologic tests

When a measurable immune memory has been established, there is no reason to introduce unnecessary antigen, adjuvant, and preservatives by administering booster vaccines. By measuring titers every three years or more often, if desired, one can determine whether a given animal’s circulating immune response has become inadequate, so that an appropriate vaccine booster can be administered.

to predict resistance to feline herpesvirus 1, feline calicivirus, and feline parvovirus infection in cats.” J Am Vet Med Assoc 220: 38-42, 2002.

• Mouzin DE, Lorenzen MJ, Haworth, et al. “Duration of serologic response to three viral antigens in cats.” J Am Vet Med Assoc 224: 61-66, 2004.

• Richards JR (chair) et al. “The 2006 American Association of Feline Practitioners Feline Vaccine Advisory Report.” J Am Vet Med Assoc 229:1405-1441, 2006, www.aafponline.org.

• Schultz RD, Thiel B, Mukhtar E, et al. “Age and long-term protective immunity in dogs.” J Comp Path 142: S102-S108, 2010.

• Scott FW, Geissinger CM. “Long-term immunity in cats vaccinated with an inactivated trivalent vaccine.” Am J Vet Res 60: 652-658, 1999.

Dr. Jean Dodds, DVM, received her veterinary degree in 1964 from the Ontario Veterinary College. In 1986, she moved to Southern California to establish Hemopet, the first non-profit national blood bank program for animals. Dr. Dodds has been a member of many national and international committees on hematology, animal models of human disease, veterinary medicine, and laboratory animal science. She received the Holistic Veterinarian of the Year Award from the AHVMA in 1994.

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• Tizard I, Ni Y. “Use of serologic testing to assess immune status of companion animals.” J Am Vet Med Assoc 213: 54-60, 1998.

• Vascellari M, Melchiotti E, Bozza MA et al. “Fibrosarcomas at presumed sites of injection in dogs: characteristics and comparison with non-vaccination site fibrosarcomas and feline post-vaccinal firosarcomas.” J Vet Med 50 (6): 286-291, 2003.

• Welborn, LV (chair) et al. 2011 AAHA Canine Vaccination Guidelines. J Am An Hosp Assoc 47(5):1-42, 2011.

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For optimal results, both conventional and complementary therapies should be utilized along with close attention to weight management, exercise, diet and supplements.

by Rob Butler DVM, CVA, CVCH, CVFT

Three key factors hen dealing with chronic pain, integrative pain management takes advantage of all the tools a veterinarian may have available.

These encompass both conventional and alternative/complementary therapies to keep patients comfortable while improving or maintaining mobility and health. It is unlikely that a single modality, pharmaceutical or supplement can achieve this optimal state of comfort and health on its own.

For integrative pain management to be most successful, each patient must be assessed individually based on his environment, lifestyle, level of fitness and health so that an appropriate treatment plan may be implemented. As veterinarians, I believe we do ourselves, as well as our clients and patients, a disservice if we fail to take the time to fully address each of these areas in order to formulate the best options for every individual animal. For many of us, this will be best accomplished by scheduling an appropriate time for a complete pain management assessment and consultation.

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When dealing with chronic pain, most conventional as well as alternative focused practitioners will likely agree on the importance of the following:

1 2 3

The need to achieve or maintain ideal body weight and condition. ppropriate activity levels to keep joints and tissues mobile A and maintain suitable muscle mass. properly balanced diet that includes supplements to A promote lean body weight while providing a source of high quality protein, antioxidants, a therapeutic level of Omega 3 fatty acids, and glycosaminoglycans.

Without an emphasis on the above three factors, optimal results are unlikely with additional treatment strategies. For obese pets, weight reduction may have the most significant effect on chronic pain by reducing the level of systemic inflammatory mediators and reducing the load on individual joints and associated tissues. I believe, therefore, that an integrative

approach to managing chronic pain must start with weight control along with specific dietary recommendations and a plan for an appropriate level of activity.

Comfort and mobility An integrative pain management program should also assess the best and safest options available to maintain comfort and mobility.

I believe that non-steroidal anti-inflammatory drugs (NSAIDs) have too often been relied on as the primary means of managing chronic pain. I have personally seen several cases in which the use of NSAIDs by themselves has had either poor or sub-optimal results. I have also seen owners who have been given overly high expectations for the use of a single nutritional supplement as the primary means of keeping their pets comfortable. We need to be realistic in setting expectations for our clients, with the likely reality that most patients will require a combination of therapies for the best success long term.

10 recommendations for improving owner compliance and clinical results

1 2

tart with a clear explanation of what will likely be required, including S the importance of diet, exercise and appropriate supplementation. rovide some immediate pain relief so owners can see their P pets’ ability to respond to therapy. This also allows patients to become more mobile so that appropriate activity can be maintained. Immediate pain relief may include acupuncture, laser therapy, initial short term use of NSAIDs, or any combination of these or other therapies.

3 4

Herbal and homeopathic therapies can be individually tailored to each patient’s needs where appropriate.

P harmaceutical drugs have a valuable role to play when used appropriately. NSAIDs should be used for the shortest required duration, or when necessary, maintained at the lowest dose needed. At least twice-yearly blood screening, particularly for kidney and liver function, should be done for animals on long term NSAIDs. Narcotic and other adjunct pharmaceuticals such as Tramadol and Gabapentin can help improve overall response and reduce the required dose of NSAIDs.

Django Django was an 11-year-old neutered male German shepherd with persistent proprioceptive deficits following surgery three years earlier for IVDD at T12-13 and L1-L2. On presentation, Django was having difficulty walking, seemed in pain when rising, and was less interested in going for walks. On occasion, he was also defecating in the house.

On physical examination, Django had decreased muscle mass in both hind limbs and was sensitive on palpation along the thoracic and lumbar spine, with a limited range of motion in both hips. He was currently at a suitable lean body weight.

Recent blood work including CBC and biochemical profile revealed no concerns. His owners declined X-rays due to his temperament and their concerns over sedation and costs. His current diet consisted of a commercial lamb and brown rice kibble to which the owners were adding kelp and herring oil along with the occasional raw food patty.

Django’s initial treatment plan included:

•

A homemade diet, properly balanced and formulated to contain therapeutic levels of EPA as well as antioxidants, and the addition of a green lipped mussel supplement as a source of glycosaminoglycans and other anti-inflammatories.

• Twice weekly sessions of acupuncture coupled with Class 4 laser therapy. Acupuncture points were chosen primarily on the distal limbs, while the laser therapy concentrated on the thoracic and lumbar spinal region.

Django’s owners noticed significant improvement after the first treatment. He continued to improve over the course of six treatments with no further fecal accidents and at least 50% improvement in overall energy and activity levels.

Django continued to have periodic treatments over the next few months before presenting with some acute pain, including left hind end lameness and arched back. Further treatment included: • Therapeutic laser for thoracic and lumbar spinal areas.

• Aquapuncture utilizing a combined homeopathic mixture of Traumeel® and Zeel® injected into local acupuncture points around the left stifle and hip.

• Meloxicam dosed at 0.1 mg/kg once daily for two to three weeks.

Django again improved significantly and after a couple treatments went back to maintenance laser therapy on a monthly basis.

Continued on next page.

Laser therapy can provide immediate pain relief.

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Continued from previous page.

The following spring, he started having some fecal incontinence again and also showed increased signs of discomfort in his back end. Treatment included: • Meloxicam dosed at 0.1 mg/kg once daily.

• Gabapentin 200 mg twice daily.

• Underwater

treadmill and other rehab therapy performed weekly.

• Continued maintenance with laser therapy every few weeks.

Django did very well with this therapy for several months when he suddenly presented with very acute cervical and shoulder pain.

Treatment this time included: • Continuation of Meloxicam and Gabapentin.

•C ombined acupuncture and laser therapy.

Acupuncture, when combined with other therapies, is a key pain management tool.

• T CM herbal formula designed for cervical neck pain.

5 6 7 8

Therapeutic lasers can offer a convenient and cost effective means for long term pain management, as most sessions can be performed by a veterinary technician in less than 20 minutes.

A cupuncture can provide significant benefits and may be coupled with laser therapy for an even greater overall effect in some patients. hiropractic therapy can significantly improve mobility and C help manage pain in many patients.

B iotherapeutic homeopathic drugs such as Traumeel® and Zeel® have good scientific evidence to support their use in veterinary patients. Some patients may respond as well to these as to conventional NSAIDs – at times even better – particularly when they’re administered by injections, IV, SQ, IM or into specific acupuncture points.

9 10

I njectable disease modifying drugs such as Adequan® or Cosequin® can provide additional long term benefits and reduce the need for NSAIDs or other pharmaceuticals. he importance of daily activity/exercise cannot be T overemphasized. For patients with more pronounced

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Once again, Django had an excellent response and did well for a few more months before presenting with sudden marked tetraparesis, unwilling to walk on his own and uninterested in eating.

Electro-acupuncture was performed along the thoracolumbar spine and hind legs, and a single IV injection of Traumeel® was administered. Following this treatment, Django got up on his own and was able to walk out of the clinic. He seemed remarkably better next day. This treatment was repeated the following day.

Django was maintained on Metacam®, Gabapentin, Traumeel® oral tablets, Cervical Formula and a Glucosamine, MSM and Chondroitin product until he was eventually euthanized a couple months later.

This case demonstrates the success of a multimodal, integrative pain management program that likely allowed this dog to remain mobile and comfortable for well over a year beyond what was otherwise possible.

mobility issues, muscle wasting or neurologic deficits, rehabilitative therapies such as underwater treadmill, supported swimming, massage therapy or Chinese Tui-na should be recommended.

Dr. Rob Butler DVM, CVA, CVCH, CVFT, is a 1988 graduate of Ontario Veterinary College and a co-owner of the Guelph Animal Hospital in Guelph, Ontario. He is certified in Veterinary Acupuncture, Chinese Herbal Therapy and Food Therapy.

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Adaptfor•the o•gensaxis hpat

by Constance A. DiNatale, DVM

This exceptional category of herbs has many veterinary applications. Let’s look at their effectiveness for hypothalamic-pituitaryadrenal-thyroid axis exhaustion.

A

daptogens help humans and animals deal with toxic environments as well as adrenal stress and depletion. By bolstering the body’s adaptability, we balance the hormonal system, including glucose metabolism, pituitary feedback loops, the reproductive system, the immune system and thyroid function.

Because of this action, adaptogens are effective for treating cases of hypothalamus-pituitary-adrenal-thyroid (HPAT) axis exhaustion. Inadequate nutrition, weak digestion, lack of sleep, chronic disease and physical and emotional stress all contribute to this condition. The result is lack of energy, weight gain, weight deposition in inappropriate places, hair loss, muscle weakness, low hematocrit, and low white cell counts. Companion animals may “talk” or run in their sleep.

When we feed highly processed diets to our companions, expose them to household toxins, apply toxins to their skin and digestive tracts on a monthly basis, and fail to provide them with adequate exercise, we cause a reduction in their anabolic hormone activity, including thyroid hormone, and push the body into insulin resistance.

Stress and aging Stress inhibits the HPAT axis, causing lowered T4 production and decreased T4 to T3 conversion. Blood fat and glucose may be elevated, leading to insulin resistance. The prolonged elevated cortisol levels seen in stress cause a decrease in growth hormone levels that leads the body to increase deposition of visceral fat, and decrease lean body mass and bone mineral density. These catabolic processes lead to signs of premature aging.

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Normal aging has been shown to cause sleep disturbance in some individuals due to elevated evening cortisol levels.

The decrease of growth hormone in aging is also associated with changes in body fat. Leptin, a hormone produced by adipocytes, lets the brain know when fat storage needs to be protected or utilized. Leptin resistance occurs when a person or animal is stressed, overeats, eats late at night, snacks frequently, and has inadequate exercise. With severe caloric restriction, fat cells produce large amounts of leptins that circulate in the blood, but the brain does not receive the signals. This may cause insulin resistance, high blood pressure, high cholesterol, metabolic syndrome, thyroid problems, cognitive dysfunction, and may increase the incidence of some cancers.

How adaptogens can help Stress causes us to use more fuel to run our bodies. This leads to increased free radicals, which damage our bodies. Adaptogens usually have antioxidant properties, making them valuable for decreasing free radical damage and improving oxygen utilization. They help optimize neuroendocrine response to stress, and help cells produce fuel more efficiently. mRNA and tRNA are activated by adaptogens, and the immune system is able to recover from and prevent illness. Reproductive hormone balance improves at all life stages.

Choosing the appropriate adaptogens for the individual will shorten recovery time and restore homeostasis much more quickly than using a generic approach. Adding nervines and other helpers can provide a synergistic effect.

When sourcing adaptogens, I like Herbalist & Alchemist out of Washington, New Jersey (herbalist-alchemist.com).

11 adaptogens for HPAT axis exhaustion

1

Withania somnifera (Ashwaganda) Ashwaganda is anti-inflammatory and immuno-supportive. It is amphoteric, antioxidant, antispasmotic and antiemetic. It is used for treating tumors, as a hypoglycemic agent and as a neuroendocrine tonic.

Ashwaganda regulates the hypothalamic-pituitary-adrenal axis and is a general tonic, though not stimulating.

“Somnifera” means “sleep making.” It is useful for cases of severe nervous and physical exhaustion, where sleep and rest are seemingly impossible. It is used for debility, chronic exhaustion and convalescence. It treats bronchitis, asthma, edema, high cholesterol, low thyroid, infertility and impotence. It is an immuno-regulator for multiple sclerosis, cancer and immune dysfunction. It helps puppies and kittens that do not thrive. It protects against toxic damage, making it valuable for chemotherapy and radiation patients. It is useful for stabilizing chronic connective tissue inflammation.

N.B.: All dosage amounts in this article are for a medium-sized dog unless otherwise stated.

3

Eleutherococcus senticosus (Siberian ginseng) The root provides the medicine. This shrub grows in northern China and eastern Russia, and is not in the ginseng family despite its name. In TCM, it is considered a Spleen and Kidney Qi tonic. Eleutherococcus is amphoteric, antiviral and antitumor. It is a nervine and immune potentiator. It stimulates macrophages, is a cardiotonic, and is hepatoprotective. This well-studied herb helps one work through stress. Influenza and illnesses are resisted, and sleep is easier to attain. Patients with severe debility and anxiety find rest and calm. It can normalize blood pressure and blood sugar.

Eleutherococcus increases T-helper cells and natural killer cells. Its immune modulatory effect is well researched.

It is especially useful for recovering from the flu, nervous exhaustion and depression. It reduces joint inflammation and assists the urinary system with detoxification.

Dose: The powder is dosed 150 to 350 mg BID; the liquid 30 to 55 drops. For a cat, 8 to 12 drops.

Continued on next page

Dose: Dry herbs are dosed 1 to 2 grams; tinctures are dosed at 0.5 to 1 ml BID.

2

Ganoderma lucidium (Reishi mushroom, Ling Zhi Cao) Ganoderma is sweet, a bit bitter, and thermally neutral in Traditional Chinese Medicine (TCM). It nourishes the Heart and Blood, tonifies Qi, and calms the mind. This herb has a long history of use in China and Japan, and has become popular for treating cancer, HIV and chronic fatigue. The polysaccharides ganodermic A and ganodermic B in mushrooms help with immune system regulation, and can protect the marrow when chemotherapy is employed. Ganoderma calms anxiety, promotes sleep, protects and restores the liver, and is an antioxidant. It helps coronary blood flow and can lower cholesterol. It helps after chronic lung disease to repair residual damage. Ganoderma stops wheezing and coughing. It may decrease airway hypersensitivity reactions via its antihistamine activity. It tonifies the parasympathetic nervous system, allowing the body to pull out of a chronic sympathetic state.

Dose: Give 600 to 1,000 mg BID. For cats, I typically mix Ganoderma 10 ml vials with royal jelly and Astragalus (Huang qi) for use with FIV, FeLV and other debilitating illnesses. integrative veterinary care

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Adaptogens usually have antioxidant properties, making them valuable for decreasing free radical damage and improving oxygen utilization. They help optimize neuroendocrine response to stress, and help cells produce fuel more efficiently. mRNA and tRNA are activated by adaptogens, and the immune system is able to recover from and prevent illness.

4

Rhodiola rosea The rhizome, said to have a rose-like fragrance, is the part used medicinally.

Rhodiola is adaptogenic, antidepressant, anxiolytic, antioxidant, antiviral, immunostimulant, nervine, neuroprotective, tonic and cardioprotective. It prevents stress-induced heart damage, improves cardiac output, and is used for arrhythmias.

Rhodiola is also used for anemia, fatigue and insomnia. It benefits anxiety, moodiness and depression. It is used for neurasthenic conditions, benefits the central nervous system, and increases memory, endurance and production. Its ability to inhibit monoamine oxidase and influence opioid peptides such as beta endorphins may explain why it appears to help balance serotonin and dopamine. It heals grief and sadness.

Dose: Dry root is dosed at 100 to 300 mg/day; tincture at 1 to 2 ml/day.

5

Rehmannia glutinosa This herb is antipyretic, anti-inflammatory and adaptogenic. Both the processed root (Shu di huang) and unprocessed root (Sheng di huang) are used. Sheng di huang is cold and bitter and used to decrease fever, staunch bleeding, and remove deep (Blood) heat from the body. It is useful for skin rashes and decreases thirst. It moistens the intestines and opens the bowels.

Shu di huang is sweet and slightly warm. It promotes red blood cell production, and treats dizziness. Both forms nourish Yin and Blood and generate fluids in the body. Both are used for diabetes; the raw form for severe thirst and the processed form for nourishing and maintaining. The prepared form is greasy, moistening and cloying, while the raw form is bitter and cold. Both should be used cautiously in animals with weak digestion.

Dose: 5 to 8 grams of the dry root decocted daily, or 45 to 90 drops of tincture daily.

Two traditional Chinese formulas that are incredibly useful in practice contain Shu di huang. The first is Liu wei di huang wan, which contains herbs to keep the body cool and replenish fluids.

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It also has herbs to protect the digestion from being damaged by the heavy, dense nature of the Rehmannia. The second formula is Zhi bai di huang wan, which is the same formula with two additional herbs to clear more heat and generate fluids. The latter formula is ideal for the severe PU/PD signs seen with hyperthyroid cats, diabetics, and elderly, nocturnal terriers. One sees vocalizing at night, excessive painting, red skin, hot ears and agitation. Liu wei di huang is useful for maintaining these patients once Zhi bai di huang has cooled them off. Liu wei is also used for animals with increased thirst, panting episodes and anxiety, which occurs mostly in the late afternoon and evening.

6

Astragalus membranaceas (Milk vetch, Huang Qi) The root is used for medicine. It is sweet and slightly warming. Astragalus is adaptogenic, cardiotonic, immunostimulant, diuretic, tonic, hypotensive, and antioxidant. In TCM, Astragalus is considered a Qi and Blood tonic. It is used to tonify the Spleen, heal tissues and discharge pus.

This herb is a lovely adjunct treatment to all things cancer: add it to cancer treatments and for chemotherapy and radiation support.

It will help boost low white cell numbers, and is used in recovery after severe blood loss, especially for resultant fever. Astragalus is used when the appetite is poor, organs are prolapsed, and there is shortness of breath. Ischemic heart disease, manifesting in angina, showed marked improvement in patients taking Astragalus, as compared to Salvia miltorrhiza, nifedipine or control. It has been used classically for excess sweating in debilitated states.

Dose: Decoct 10 to 15 grams of dry root per day; tinctures are dosed at 2 to 3 ml per day.

7

Schizandra chinensis (Wu Wei Zi) The berries and seeds are used as medicine. Energetically, Schizandra is warm and dry. It is adaptogenic, antioxidant, anti-inflammatory, antiasthmatic, hepatoprotective, astringent, and an immune stimulant.

Traditionally, Schizandra is used as an astringent for Jing leaking out, as with spermatorrhea, diarrhea, leucorrhea, urinary incontinence, and excessive sweating. Its mild central nervous system stimulant activity makes it a nice choice to treat exhaustion, and there are many studies backing its use for hepatitis B and C. It combines well with licorice for asthma, and combines with Ganoderma for fatigue and altitude sickness.

Use Schizandra to generate fluids and relieve thirst when there is intense dry mouth and thirst in chronic disease.

Dose: Give 0.25 to 0.5 grams of dry powder per day; tinctures 0.5 to 1 ml BID.

8

Glycyrrhiza glabra (Licorice root) This herb is used in both Chinese and Western herbal traditions. The root is the portion of the plant used. It is antiviral, anti-inflammatory, adaptogenic and hepatoprotective. Licorice strengthens exhausted adrenals and helps with chronic viral infections. It shows its brilliance for linings and their respective coatings. It helps with chronic inflammation, especially gastrointestinal, urinary and throat inflammation. It is soothing and calming for ulcers and colitis attacks. It repairs the gastrointestinal lining and helps relieve painful spasms. Licorice supports and protects the liver, and is part of the solution to decrease inflammation and calm the immune system in chronic hepatitis.

Used in TCM to harmonize a formula, it carries the herbs to all parts of the body, showing its usefulness as a universal rebuilder.

Dose: 1 to 4 grams decocted daily; tinctures are dosed at 1 to 2 ml daily.

9

Oplopanax horridum (Devil’s club) Oplopanax is antibacterial, antifungal, antiviral, adaptogenic, hemostatic, emetic and antipyretic. It is an important plant for Native Americans, used to treat arthritis, rheumatism, diabetes, respiratory problems, digestive complaints, and as a purgative and emetic. It has been used topically for infected wounds and snakebites.

Oplopanax teaches proper boundaries. Like a sweet, old Labrador who lets the other animals take his food and toys, one needs this plant when being taken advantage of. It’s also used for lingering respiratory illness following an acute episode, deep inhibited coughs that need to rise to the surface, and acute respiratory infections – it is a strong respiratory stimulant and expectorant.

Dose: Tinctures are dosed at 15 to 30 drops BID. integrative veterinary care

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Applying adaptogens to clinical cases

Case #2:

Case #1: ts d breed dog presen ayed female mixe g is on do e Th .

A nine-year-old sp tes be history of dia with a six-month is still very thirsty, owner reports she the h ug tho n, insuli the dog has high ow sh ips str . Urine ing on increasing and urinates a lot be ite sp de the urine, d feels warm to levels of glucose in an e e pants all the tim does not have e doses of insulin. Sh sh petite is good and the touch. Her ap digestive issues. . herbal prescription diet and make an We prescribe a good to put together the following formula be One approach could oz bottle: 2 a in using tinctures • Oplopanax – 13 ml • Withania – 24 ml • Eleutherococcus – 8 ml ml • Rehmannia – 15 problems digesting digestion will have Animals with poor ing the Chinese us r tte be may be annia section.

Rehmannia, and hm Re ntioned in the body adjust to formulations me the ntain herbs to help annia.

These formulas co hm Re of ty ali qu leting the heavy fluid-rep

10

Centella asiatia (Gotu kola) The aerial parts of the plant are used. It is antioxidant, andaptogenic, antibacterial, antiviral, anti-inflammatory, antiulcerogenic and anxiolytic. It’s a cerebral tonic, circulatory stimulant, diuretic, nervine and vulnerary. It is used today to encourage wound healing, and aids in repairing and rejuvenating the nerves and brain. Look for mental fog and lack of focus. It may be used with Gingko biloba to tonify, which will improve circulation, thus enhancing the effects.

Besides its benefits for the nervous system, it also is good for blood cleansing, and can be used for chronic skin conditions and for those who form abscesses easily or develop ulcers.

It may help normalize connective tissue metabolism, so is useful in treating autoimmune syndromes, scleroderma and keloid formation.

Dose: Dry leaves 200 mg BID; tinctures 20 drops BID.

A ten-year-old neutered male golden retriever present s with bloodwork showing low thyroid. He has chronic digestive issues including occasional vomiting and diarrhea. He has low energy and seems dull. His feet and ears are warm, though his owner says he likes to sleep on the tile floor. After putting him on a good diet, we make him a cocktail to go home with. His tincture mix might be the following: • Withania – 15 ml • Avena – 15 ml • Astragalus – 14 ml

• American ginseng – 8 ml • Glycyrrhiza – 8 ml

Case #3: A 17-year-old male neutered terrier presents with nocturnal pacing and a stiff gait. Radiographs reveal mild to moderate arthritic changes in the lumbar spine and hips.

He is on glucosamine/chondroitin/MSM and fish oils, and the owner sometimes gives an anti-inflammatory. A possible tincture combination would be: • Centella – 19 ml •Withania – 17 ml • Ganoderma – 13 ml

• Eleutherococcus – 8 ml • Avena – 8 ml • Rehmannia – 5 ml

Withania was included in all three cases, not for its necessity, but to showcase the broad applications that can benefit from a single herb in this exceptional category.

11

Avena sativa

(Oat berry and straw) This herb is antispasmodic and a diuretic, stimulant, nervine and adaptogen. In TCM it is a Kidney Qi tonic. It restores the urogenital system and is brilliant for nourishing and calming the nervous system. When the oat berry is immature and green, it has a milky stage, which produces an amazingly effective nerve tonic that brings clarity and grounding. A tincture of milky oats is a remedy that produces powerful medicine from even a few drops.

Oats are useful for those with weak, debilitated digestion and in cases of gastroenteritis, ulcers and dyspepsia. It helps those with chronic debility regain their strength and become mentally and physically substantial again. It also has restorative effects on the reproductive system and treats uterine and ovarian disorders.

Dose: 1 to 2 ml daily.

This article was originally presented in part at the AHVMA 2011 annual meeting.

Constance DiNatale, DVM, graduated from the University of Florida in 1992. She is certified in acupuncture from Chi Institute and from IVAS. She utilizes Western and Eastern herbal therapies, chiropractics, diet therapy, and other holistic methods at her small animal practice in Winter Park, Florida. She teaches at Chi Institute, and lectures for various veterinary groups on acupuncture, herbal medicine, TCVM food therapy, and diet formulation.

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Equine parasites are now resistant to many of the drugs currently in use. The time has come to rethink deworming by adding some alternative strategies to the treatment arsenal.

by Joyce Harman, DVM, MRCVS

E

quine deworming is going through a transition in the conventional veterinary world.

For three decades, it has been done using a six to eight weekly rotation schedule of anthelmintics.

But parasite resistance has been identified with many of the drugs in current use, and there are no new classes of drug on the horizon.

For many years, Craig Reinemeyer, DVM, PhD, has been studying equine parasites, parasite resistance to anthelmintic drugs, and better ways to control parasites. His work is finally becoming mainstream, but it will still be many years before the horse world changes its longstanding habits permanently. However, the adaptation of Dr. Reinemeyer’s earlier work is refreshing. Fecal egg counts are performed on a regular basis to determine which horses on a farm shed eggs and which do not, or have very low counts. Deworming is only performed on horses that show a need for it.

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Deworming drugs Available drugs fall into three classes, and resistance has been shown in all: 1.

2.

3.

Macrocyclic lactones __ ivermectin and moxidectin Benzemidazoles __ fenbendazole Pyrimidines __ pyrantel

If drugs are used, select those that do not have resistance on that particular farm. Extensive drug use on a farm may result in contamination of the soil with drug residues, as well as parasite resistance on that farm. Conflicting results are found in research studies concerning microbial and dung beetle action on manure when drugs are present.

There is evidence that the drugs affect manure breakdown by killing the bugs that degrade the manure.

Anyone with an organic farm may be especially concerned about this residue in the soil.

Parasites are universal Many horse owners as well as veterinarians consider that the only acceptable level of parasites is zero.

However, parasites evolved in nature to co-exist with a host. If the host is dead, the parasite is without a home, so the most successful parasites have a non-destructive relationship with their hosts. Wild horses (and other animals) around the world have never received chemical deworming, yet they survive, reproduce and raise young. How wild horses naturally control parasites can help determine better management practices for domestic horses.

allowing parasites to overpopulate in the animal. Even wild animals whose natural range is decreasing experience this. Horses are social animals that live in a herd, moving and eating 20 hours a day compared to domestic horses that may live in single stalls or paddocks, not moving much and having food rationed to certain times of the day.

2

Wild horses range over a large region and therefore do not graze around the “roughs” or areas where manure has been left and parasite eggs hatch into larvae. Horses in confinement are often forced to graze

Deworming with an integrative approac h needs to include management c hanges on the far m, fecal egg count c hec ks, and the use of natural products to decrease the parasite load in the pasture.

The parasites people are concerned about are the small strongyles, since the large strongyles that were common before modern anthelmintics came into use have been basically eliminated. Large strongyles did cause serious and devastating colics. Small strongyles, however, are not much of a clinical problem, unless the horse is in extremely poor condition and has a very heavy parasite load.

Why they become an issue Parasites become a problem for domesticated horses for several reasons besides drug resistance.

1

One is that confinement produces a low level of stress in the equine that can affect the immune system,

close to or in an overgrazed pasture, directly on those long clumps of grass harboring larvae.

3

Wild horses have a healthy gut ecosystem of beneficial bacteria and other microorganisms where parasites can live in balance. Modern horses have often been treated with antimicrobials and other drugs that have a negative effect on the gut ecosystem as well as the immune system, leaving the animals more susceptible to parasite overload.

An integrative perspective

parasite load in the pasture. The goal of modern deworming is to control the parasite load in the pasture through management and the identification and treatment of individual horses that shed high levels of eggs into the manure.

Treatment of individuals with high egg counts can then be done using natural deworming agents.

It has been my experience that horses in high stress competitive environments that shed eggs are harder to control with natural treatments, due to the ongoing levels of stress. So drug treatments may need to be done periodically.

Management changes in confinement situations include the removal of manure on a regular basis. Composting is the best way to remove the eggs from the environment. Spreading manure in pastures just carries the eggs around the farm and increases exposure to all horses.

Clients can break up manure by harrowing during hot, dry weather (over 90ºF), or during pasture rotation when the horse is off the pasture. This will allow the eggs to hatch and the larvae to dry up before they’re ingested by the horse. Freezing does not kill the eggs, so tell clients not to break up manure during the winter and definitely not in the spring and fall.

Deworming with an integrative approach needs to include management changes on the farm, fecal egg count checks, and the use of natural products to decrease the

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Homeopathic solutions Classical, single remedy homeopathy A number of homeopathic remedies have been used for specific types of parasites. These are placed in water buckets and used over a period of five days around the time of the full moon, or for a few weeks at a time.

a) For tapeworms: • Granatum 3X – any age • Cina 3X – young horses • Chenopodium 3X – mature horses b) General worms – strongyles: • Santonium 3X • Cina 3X – best with young horses c) Ascarids – usually just in young horses: • Abrotanum 3X

Combination homeopathy Equiopathics “Wrm Clr®” (manufactured

by Washington Homeopathic Products for Equiopathics, LLC) needs to be administered for three weeks during the initial course.

Homeopathics do not kill parasites; they improve gut health so the parasites do not wish to live there.

Heads up One word of caution about black walnut.

It is a traditional herb used by many cultures for parasite control. It is also a well known toxin in horses, and causes laminitis when horses are bedded on shavings made from the wood. Horses have also foundered when exposed to black walnut in the pasture. Some people have used black walnut extracts and other products successfully, and companies do sell it for use in horses. However, it is my opinion, and that of many others’, that it is not worth the risk when there are plenty of alternative herbs to use.

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The next step is to check fecals on all horses. Identify the high and low shedders. To establish a baseline for a horse or group, it is necessary to check fecals on a regular basis through the year – at least quarterly. Horses that consistently have a similar egg count through the year can be placed on a list of shedders, non-shedders and those in between.

Horses that consistently show a low or negative egg count can be listed as non-shedders and do not need to be dewormed with any product. Some horses never need to be dewormed! Horses with a moderate egg count should be dewormed until the count drops to the low range and stays there for several fecals. These horses can contaminate the pasture.

After using a deworming product, check the fecals again in ten to 14 days to be certain the protocol worked. The egg count should be at least 90% decreased. Horses that are shedders should be rechecked in six to eight weeks and dewormed again if needed. When parasite loads are high, it may be necessary to use chemical dewormers until the situation is under control. High shedders may benefit from a fiveday dose protocol of Panacur®, which clinically seems to be the safest larvicidal deworming protocol in this author’s practice.

Natural deworming compounds can be used in many cases. If the horses are under stress or are living on heavily contaminated properties, however, natural methods may not work, or may need to be supplemented with chemicals at times. Many companies sell products claiming 100% efficacy. This is impossible, knowing the complexities of the living horse and environmental issues. It is also impossible for a natural product to be given as a single dose and be strong enough to clear parasites in a similar way to a single drug dose.

Complementary therapies

1

Probiotics and prebiotics help restore the natural balance of healthy bacteria in the gut. In creating a natural health program for a horse, a two to three month course of these should be considered.

Horses that have been ill, have poor immune systems, or have been treated extensively with antibiotics may need to use these products routinely. There is no harm in long-term use of pre and probiotics as long as they contain natural ingredients and no preservatives.

2

Natural deworming is usually done with herbs, homeopathics (see sidebar) or mechanically with diatomaceous earth (DE), a fine powder from the shells of diatoms or microscopic algae.

The edges are very sharp and act mechanically to slice the outer skin of the parasite, adult, egg or larvae. DE can actually absorb moisture from the parasite into its fine structure.

Once this occurs, the parasite dies. Because the damage is mechanical, there is no chance of resistance. There is some theoretical concern about intestinal irritation, but that has not been clinically apparent in many years of using products containing DE. Diatomaceous earth is often mixed with vermifuge herbs. This can enhance the effectiveness of the product.

DE can also be offered free choice to horses, and in many cases, but not all, horses will eat the DE, usually just before the full moon as the parasites are becoming more active. One such product mix is NOMS, by Advanced Biological Concepts.

Many herbs have an anthelmintic or vermifuge action. Some are relatively harsh or slightly toxic and should be used for short periods or mixed with herbs that soothe the digestive tract, such as marshmallow, slippery elm or those that help prevent cramping such as chamomile or valerian. Some herbs are contraindicated in pregnancy. A well-trained, experienced equine herbalist, not a well-intentioned horse person who has looked up herbs that clear parasites, should formulate any herbal formula.

Some of the herbs that have vermifugal actions include garlic, peppermint, common thyme, cinnamon, Echinacea, hyssop, tansy, cayenne, fennel, wormwood, elecampane, cloves, southernwood, and mugwort. One successful certified organic herbal deworming product is Verm-x, from a British company by the same name.

Chinese medicine also has herbs with vermifuge action.

The companies that sell those herbs generally sell directly to the profession and not over the counter. Jing Tang Herbal and Institute for Traditional Medicine are companies that have useful Chinese herbal products.

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nutrition nook

Digestive Enzymes These key nutrients can be used for pancreatic and GI issues, but are also beneficial for healthy patients eating heat-processed pet foods.

• • • by Jean Hofve, DVM

The thousands of enzymes produced by the body aid in a wide variety of chemical reactions. There are two major classes of enzymes: metabolic and digestive. Digestive enzymes are produced primarily in the pancreas and released into the duodenum to help digest food coming from the stomach. The intestines themselves also secrete amylase and other digestive enzymes.

Their function in digestion Three main types of enzyme help break down macronutrients in food: 1. Protease, to break down protein 2. Lipase, to digest fat.

3. Amylase, to process carbohydrates.

Most mammals produce amylase in the saliva, but dogs and cats do not. This reflects their expected diet of meat and organs from prey. Herbivores and omnivores have flat molars that crush and chew food, but the carnivore’s dentition is perfectly designed to capture and kill prey, and to rip and tear meat from bone. Carnivores don’t spend much time chewing; nor do they consume many carbohydrates, so there is no need for amylase in the mouth.

In addition, all cells carry within them the means for their own destruction in the form of lysozymes. These packets of enzymes break open upon cell death, and help break down (digest) the contents of the cell, either for recycling (in a living body) or

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integrative veterinary care

decomposition. Because the natural prey diet of canines and felines is consumed raw, these lysozymes may also contribute to efficient digestion of food.

The argument could be made that a carnivore’s GI transit time is too fast for lysozymes to have a meaningful impact on digestion. However, when a carnivore kills a large prey animal, that carcass is likely to sit for a while (it takes about two weeks for a mountain lion to consume a whole deer). Wild canids commonly take advantage of the lysozomal process by burying parts of the carcass, and digging them up and eating them weeks later. In those scenarios, both internal lysozymes and various external organisms (bacteria, fungi) contribute to the food breakdown normally performed by the pancreas.

While experimentation has shown that pancreatic extracts work best for EPI, plant or fungal source enzymes may be a better choice for other digestive issues. They tend to resist digestion better than pancreatic extracts, and function in a wider range of pH. The case for routine supplementation When heat destroys (“denatures”) the natural shape of enzymes, they become nonfunctional. In dogs and cats that eat heatprocessed pet food, those enzymes are absent; the pancreas must provide all the enzymes needed to digest the food.

In addition, commercial dry kibble is also much higher in carbohydrates than the carnivore’s natural prey diet. While cats’ and dogs’ pancreatic and intestinal tissues can and do produce amylases that are fully capable of digesting carbohydrates, the lack of salivary amylase reminds us that nature did not intend carbs to be their primary source of nutrition.

“E v i d e n c e ...strongly s u g g e s t s that eating foods devoid of e n z y m es as a r esul t of c ook i ng, food i r r a d i a t i o n , an d microwaving causes an enlargement of the pancreas and also

stresses associated endocrine glands....” writes Gabriel Cousens, MD, in his book Conscious Eating. “In all of nature, the human pancreas is three times larger, as compared to total body weight, than that of any other animal. What is interesting is that when mice are fed cooked foods, the ratio of their pancreas weight to total body weight becomes approximately that of a human’s. When they are switched back to a raw-food diet, their pancreas shrinks back to normal size. The most obvious conclusion is that the pancreas becomes hypertrophied, or enlarged, because it is forced to keep up a high digestive enzyme output.”

Research in animals has shown that the production of digestive enzymes is independent of diet.

That is, animals are biologically programmed to produce specific types and amounts of digestive enzymes in response to food ingestion, regardless of what food they actually eat. Only major evolutionary shifts, such as changing from omnivorous to insectivorous lifestyles, affect these systems. Our carnivorous pets have not, and cannot, adapt their digestive functions to processed diets, which, after all, have only been widely used for a few decades.

Moreover, recent research shows that in humans with gastrointestinal disease, but more importantly, even in normal individuals, supplementation with

An unusual clinical use for protease The proteolytic enzyme bromelain, from pineapple, is used to reduce inflammation from infection and injuries. The University of Maryland suggests that bromelain can be used to decrease swelling, bruising, healing time and pain after surgery and physical injuries, such as tendonitis, sprains and strains, and other minor muscle injuries. In Europe, bromelain is used to treat sinus and nasal swelling following ear, nose and throat surgery or trauma. The dose for this special use is 50 mg to 100 mg per ten pounds of body weight, divided into two doses; mix with cool water and administer orally for up to ten days. integrative veterinary care

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Clinical uses of digestive enzymes

digestive enzymes substantially increased digestion in the lumen of the small intestine, and improved the bioavailability of proteins and carbohydrates. Especially in view of the highly processed diet that most of our pets are eating, this implies that most healthy adult dogs and cats can benefit from a digestive enzyme supplement.

Digestive enzymes help pets digest and assimilate food better – any food. This does several things your clients will appreciate:

In veterinary medicine, there are several medical conditions in which digestive enzymes may be deficient or absent. Exocrine pancreatic insufficiency (EPI), pancreatic hypoplasia, and pancreatitis all affect the production of digestive enzymes, and potentially other products of the pancreas as well, such as insulin and glucagon. Inflammatory bowel disease (particularly lymphocytic-plasmacytic gastroenteritis) may impact the production and/ or release of digestive enzymes. It is worth remembering that in cats, pancreatitis is often overlooked and likely vastly underdiagnosed.

Additionally, cats have a more limited enzyme capability in their digestive tracts that does not favor starch digestion and absorption; this may make them more susceptible to developing diabetes mellitus when free-fed the standard high-starch kibble diet.

1. Saves them money – because their pets will be getting more nutrition from the same food, they may be able to feed less, and therefore stretch their budgets a little more.

2. Reduces the amount of stool because less food is wasted through improper digestion.

3. Improves the quality of the stool.

4. Makes their pets feel more satiated, which can reduce begging.

5. Makes their pets healthier because they are getting more of the nutrition they need.

Digestive enzymes for pets typically come in capsules or powdered form, making it easy to sprinkle on or mix with wet food. For most pets, the best enzymes come from plants or fungi (yeast), because they can survive the trip through the stomach’s acidic environment. Make sure the enzymes you choose contain at least protease, lipase and amylase (many also contain cellulase, which is useful if the food contains fibrous vegetables or grains).

Digestive enzymes are certainly useful for dogs and cats with any type of digestive or pancreatic issues. But don’t forget that clinically normal patients can greatly benefit from them as well.

Jean Hofve, DVM, earned her Doctor of Veterinary Medicine at Colorado State University. In addition to conventional veterinary training, she studied veterinary homeopathy, homotoxicology, Reiki, and other holistic modalities. She has

We are just starting to realize that digestive enzymes may be useful in situations besides overt maldigestion. There is also evidence that diabetic animals may benefit from digestive enzymes.

researched pet food and feline nutrition for nearly two decades, and is an expert on holistic pet health and the com-

In EPI, enzyme replacement consists of dried porcine pancreatic extracts. However, much of the effectiveness of such extracts is lost due to partial digestion of the enzymes in the stomach. While experimentation has shown that pancreatic extracts work best for EPI, plant- or fungal-source enzymes may be a better choice for other digestive issues.

They tend to resist digestion better than pancreatic extracts, and function in a wider range of pH.

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mercial pet food industry.

She is an official advisor to AAFCO, the organization U.S. and Canada. Dr. Hofve coauthored the book Holistic Cat Care. that sets pet food rules and standards in the

References Cousens G. Conscious Eating. Germany: Georg Thieme Verlag. 2001. de-Oliveira LD, Carciofi AC, Oliveira MCC, et al. “Effects of six carbohydrate sources on diet digestibility and postprandial glucose and insulin responses in cats.” J Anim Sci. 2008, 86:2237-2246. Available online at: http://jas.fass.org/content/86/9/2237.

Howell E. Enzyme Nutrition: the food enzyme concept. New Jersey: Avery Publishing Group. 1985.

Kienzle E. 1993. “Carbohydrate metabolism of the cat. 1. Activity of amylase in the gastrointestinal tract of the cat.” J. Anim. Physiol. Anim.

Nutr. (Berl.) 69:92–101.

Medhekar R. “The First Quantitative Evidence Proving The Efficacy Of Supplemental Enzymes.” 2004. www.enzymeessentials.com/ TNO_Research_Web.pdf. Accessed 3/2/12.

Ramírez-Otárola N, Sabat P. “Are levels of digestive enzyme activity related to the natural diet in passerine birds?” Biol Res. 2011;44(1):81-8.

Scherk M. “Feline Pancreatitis: Underdiagnosed and Frequently Overlooked.” International Veterinary Emergency and Critical Care Symposium. 2010.

Schondube JE, Herrera-M LG, Martínez del Rio C. “Diet and the evolution of digestion and renal function in phyllostomid bats.” Zoology (Jena). 2001;104(1):59-73.

University of Maryland Medical Center, Medical Reference Library. www.umm.edu/altmed/articles/bromelain-000289.htm. Accessed 3/6/12.

Williams DA. “Exocrine Pancreatic Insufficiency.” British Small Animal Veterinary Congress. 2009.

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integrative practice

The

Integrative Umbrella

More clients are asking for CAVM, but how do we respond when we don’t have ideal scientific evidence to back up these therapies?

Here are the tools to weather this dichotomy.

by Richard E. Palmquist, DVM, Past President AHVMA, Co-Director AHVMA Foundation

Veterinary medicine is a massive endeavor.

Veterinarians are collectively responsible for all knowledge that could be used to maintain or rebuild health, or to relieve suffering and improve quality of life for the animals placed in our care. Since the knowledge and data used to treat our patients and perform our duties as veterinarians is incomplete, we are often asked to address situations that are, to say the least, unique. As professional students at Colorado State University, we were taught that the material we learned would be outdated quickly and that we must learn to find and assess data if we intended to be the best clinicians possible. No truer words were ever spoken.

The Best Approach Complementary and alternative veterinary medicine (CAVM) relates to tools that are rapidly expanding in their use in our profession. Since many veterinarians are not trained in these techniques, they find it hard to understand how they might be useful, and since research in CAVM is not funded in amounts proportional to other realms of veterinary medicine, it is not surprising that

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integrative veterinary care

there is some confusion about how to best approach this subject.

Groups like the AHVMA Foundation are working to improve these deficiencies. On a broad, national basis, the AVMA guiding policy on CAVM states: “The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method. Circumstances commonly require that veterinarians extrapolate information when formulating a course of therapy. Veterinarians should exercise caution in such circumstances. Practices and philosophies that are ineffective or unsafe should be discarded” (AVMA Guidelines 2007).

Veterinarians from the heights of professional academia to the trenches of clinical practice are generally in agreement with this sentiment. In a 2011 survey, deans of veterinary schools agreed that “CAVM is an important topic that should be addressed in veterinary medical education, but opinions varied as to the appropriate framework” (Memon, Sprunger).

Many veterinary schools in that survey offer courses and laboratories involving CAVM, and all agreed that such education should be carried out within an evidence-based medicine environment. One school requires a course in CAVM to graduate. Veterinary schools are expanding their trained faculty and ability to better understand CAVM modalities, and this is a good thing because public demand for CAVM is rising at an ever increasing rate. In the recent economic downturn, practices offering CAVM and integrative medicine reported having steady demand while many other practices shrank.

The umbrella analogy Fundamentally, all veterinarians are seeking tools they can reliably use to assist them in their mission to improve animal health. The entire field of human and veterinary medicine could be envisioned as a large umbrella, which when properly used assists and protects those using it.

We all know about umbrellas. They are one of those simple tools we often take for granted, but if we study the umbrella, we gain some insight into veterinary medicine as well.

A tool requires a user. Someone must wield the tool. This requires good judgment both in the use of the tool as well as in its selection. In the hands of a person with good judgment, a tool is far more useful and far safer. The user can also abuse a tool if she lacks good judgment. This can cause others to have a bad opinion of the tool, when in fact it was the user’s abuse of that tool that led to poor outcomes.

A tool requires training and experience in its maintenance, care and use (Tan, et al 2011).

Training and practice are required to properly use any tool we select in our profession. The better the tool is researched, the better the knowledge we have for its use. And knowledge of proper use coupled with good judgment allows us to use our tools with the greatest success. Training reduces abuse, which is a word that actually means “against its purpose, or improper use”. Properly balancing intuition and training is necessary for optimal success (Balla, et al 2009).

A tool requires that all parts be functioning properly for its proper use. If we consider our medical umbrella to have various parts, then we can see that the use

of an incomplete umbrella might lead to some discontent or disagreement. Each portion of the body of the umbrella could symbolize a particular portion of medical knowledge: anatomy, physiology, pharmacology, surgery, biochemistry, epigenetics, genetics, physics, acupuncture, chiropractic, herbal medicines, neurology, cardiology, dermatology, gerontology, oncology, etc. In this analogy, we can easily predict that a clinician given an incomplete umbrella would be less than satisfied. He or she would actively seek to find, replace, redesign or otherwise improve the incomplete umbrella.

While holding the incomplete umbrella, some

Outside the box As veterinary clinicians, we regularly apply knowledge across species without ideal evidence, and we try new things when other therapies are failing (Toews 2011). Ethically, we promise to use our tools for the best outcomes of our patients, and we strive to reduce suffering and improve quality of life. We use amoxicillin in cats even though the FDA approved label states “for dogs only”. We give subcutaneous fluids to renal failure cats even though no clinical trials exist for the procedure. We use acupuncture to reduce suffering even though it was unheard of in this country prior to 1960.

A friend of mine, Dr Barbara Royal, successfully treated a zebra and several camels in Chicago zoos with acupuncture. There certainly were not any clinical trials available for her reference, but she responded to the call for help and used her intuition and clinical expertise to assist a species she was never trained to treat (Royal 2012).

It is not possible to create evidence-based professional tools that cover all cases at all times and base these on established information, because that information infrastructure simply is not available (Murphy 2003). That is part of the excitement of being a veterinarian, as we take new tools, apply them in unique ways, and share them with others interested in reducing suffering and improving outcomes.

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Each portion of the body of the umbrella could symbolize a particular portion of medi c al k n o wl e dge : a n a t o m y, physiology, pharmacology, surgery, biochemistry, epigenetics, genetics, p hysi c s, ac u pu nc tu re, ch i ro pr a ct i c, herbal medicines, neurology, cardiology, dermatology, gerontology, oncology, etc.

users would feel that something was not right and would strive to improve their tools, while others would possibly feel this was just the way things are and be happy with the status quo.

A tool can be used in less than optimal conditions, but under periods of stress or duress it can fail the user. In that moment, the user can become upset and demand change. Some users will blame the tool and simply throw it away, while others will find the weakness and realize the rest of the umbrella is still needed. Burnout is an important issue arising from such challenges (Shanafelt, Dyrbye 2012).

If we can just add to the missing parts, then things improve and move forward. Research is the handle of our umbrella. Without proper research, we cannot identify and properly include all the parts needed for the umbrella to be fully functional. Research supports and gives strength to the umbrella of medicine, so that those with good judgment can properly use the tool.

Without research and validation, the entire tool will fold up in bad weather. As we begin to evolve into translational medicine in the veterinary profession, we will find this process accelerates. It is possible to pioneer areas, develop interdisciplinary evidence by integrating known data, and validate it for more rapid and proper patient care (van den Hoonaard 2009; Burgio 2010; Moore, et al 2011). The truly exciting fact is that as we approach a “one health” or “one world” form of integrated health care for humans and animals, the importance of research in all areas of science will expand exponentially (Zinsstag, et al 2011).

We would question someone who would use their other tools to destroy the entire umbrella, or who would prevent others from attempting to make it more functional. Likewise, we would admire those who work to maintain the umbrella’s strength and

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usefulness. The integrative veterinary medical movement is simply taking areas of CAVM and cooperatively applying properly done research until those parts can be identified and included in the protective parts of the umbrella (Sackett 1997). It is a very organic process that begins with an interest in helping others, proceeds to an investigation of its components, and ends with the addition of knowledge that assists your activities. This gives all veterinarians better tools to withstand the storms of clinical practice, while maintaining advancement of those fields through the generally accepted evidence-based veterinary medical model.

Dr. Richard Palmquist, DVM, graduated from Colorado State University in 1983. He is chief of integrative health services at Centinela Animal Hospital in Inglewood, California, president and research chair of the AHVMA, and an international speaker in integrative veterinary medicine. Dr. Palmquist is a consultant for the Veterinary Information Network (VIN) and co-director of the AHVMA Foundation.

He has published two books, one for conventional veterinarians and a second for clients discussing how integrative thinking works.

References AHVMA Foundation. foundation.AHVMA.org. Accessed 2.1.12 “AVMA Guidelines for Complementary and Alternative Veterinary Medicine”. Approved 2001 and updated 2007. avma.org/issues/policy/comp_alt_medicine.asp. Accessed 3.18.12.

Balla JI, Heneghan C, Glasziou P, Thompson M, Balla ME. “A model for reflection for good clinical practice”.

J Eval Clin Pract. 2009 Dec; 15(6):964-9.

Burgio LD. “Disentangling the translational sciences: a social science perspective”. Res Theory Nurs Pract.

2010; 24(1):56-63.

Memon MA, Sprunger LK. “Survey of colleges and schools of veterinary medicine regarding education in complementary and alternative veterinary medicine”. J Am Vet Med Assoc. 2011 Sep 1; 239(5):619-23.

Moore CG, Carter RE, Nietert PJ, Stewart PW. “Recommendations for planning pilot studies in clinical and translational research”. Clin Transl Sci. 2011 Oct; 4(5):332-7. doi: 10.1111/j.1752-8062.2011.00347.x.

Murphy SA. “Research methodology search filters: are they effective for locating research for evidencebased veterinary medicine in PubMed?” J Med Libr Assoc. 2003 Oct; 91(4):484-9.

Royal B. The Royal Treatment: A Natural Approach to Making Your Pets Wildly Healthy. Emily Bestler/Atria Books, a division of Simon and Schuster, New York. 2012 (from prerelease manuscript).

Sackett DL. “Evidence-based medicine”. Semin Perinatol. 1997 Feb; 21(1):3-5.

Shanafelt T, Dyrbye L. “Oncologist Burnout: Causes, Consequences, and Responses”. J Clin Oncol. 2012 Mar 12.

Tan LB, Chinnappa S, Tan DK, Hall AS. “Principles governing heart failure therapy re-examined relative to standard evidence-based medicine-driven guidelines”. Expert Rev Cardiovasc Ther. 2011 Sep; 9(9):1137-46.

Toews L. “The information infrastructure that supports evidence-based veterinary medicine: a comparison with human medicine”. J Vet Med Educ. 2011 Summer; 38(2):123-34.

Van Den Hoonaard DK. “Moving toward a three-way intersection in translational research: a sociological perspective”. Qual Health Res. 2009 Dec; 19(12):1783-7.

Zinsstag J, Schelling E, Waltner-Toews D, Tanner M. “From ‘one medicine’ to ‘one health’ and systemic approaches to health and well-being”. Prev Vet Med. 2011 Sep 1; 101(3-4):148-56.

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Until now, veterinary medicine could only manage symptoms of chronic renal failure in an attempt to maintain quality of life while the disease progressed. However, a two-year open ended study involving 19 cats with CRF may present a solution. It showed that 89.9% of cats on RenAvast™ experienced improved values or stabilization of Stages 1-4 blood urea nitrogen (BUN) and creatinine (CREA). A full 94.7% of cats in the study had hematocrit (HCT) values that improved or did not fall below the reference range, while all the cats had phosphorus (PHOS) and urine specific gravity (USG) values that improved or did not deteriorate.

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Diagnosing pancreatitis made easier Pancreatitis is one of those diagnoses that is incredibly difficult to make before it’s too late. The symptoms are vague, and current tests are hard to perform, unreliable, or both.

With support from the AKC Canine Health Foundation, researchers from the University of California, Davis recently set out to investigate the sensitivity and specificity of a new blood test for pancreatitis, and compare it to several other blood tests that might be useful in detecting the disease. The developers of the test known as Spec cPL had determined its sensitivity as 63.6%, but they hadn’t figured out how specific it was – which meant it was difficult to tell how accurate any positive results might be.

The scientists found that Spec cPL was relatively sensitive and specific, depending on the specific cut off values used for the tests. A trade off was found when they chose different cut off levels – increasing the sensitivity of the test came at the expense of specificity, and vice versa.

However, Spec cPL provided better diagnostic results than any of the other tests they tried, giving hope that it might one day ease the diagnosis of canine pancreatitis.

Further research is still needed, particularly as the study contained few dogs with healthy pancreases, which could affect the calculated specificities. Still, this research moves us one step closer to a reliable blood test for canine pancreatitis – a safer, easier way to start treatment and improve the quality of dogs’ lives. akcchf.org integrative veterinary care

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Feline Diabetes Mellitus A look at insulin stabilizati on and home monitoring, as well as long term management and complications.

by Dr Lea Stogdale, DVM, Diplomate ACVIM Small Animals

I

n Part 1 of this article (IVC, Winter 2012), I covered the diagnosis of feline diabetes mellitus, and how early DM can be managed with diet, medication and herbs. Now I’ll discuss insulin stabilization and home monitoring, the complications that can occur with the disease, and the reasons why some cats don’t recover.

Insulin requirements Feline DM is treated with Rx insulin injections twice a day (BID) combined with home BG monitoring. Cats metabolize insulin twice as fast as dogs or humans, and ideally, a cat with DM should be eating a very low carbohydrate diet twice a day. Hence the ultra-long-acting human insulins, Glargine “Lantus” or Detemir “Levemir”, work best for these cats.

• Rx Glargine = “Lantus”: This acid pH insulin precipitates in the neutral pH of the body and is absorbed slowly. The initial dose is 1 to 2 IU/cat twice a day. It lasts 12 to 18 hours. The bottles are

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10 ml and fairly expensive.

• Rx Detemir = “Levemir”: The Detemir insulin is strongly protein bound (that is, albumin bound) and slowly released. The initial dose is 1 to 2 IU/ cat twice a day. It lasts 18 to 21 hours. One box contains 5 x 3 ml vials. Detemir appears to be better tolerated than “Levemir” in some cats, and may have less variability. As Detemir is strongly protein bound, there is the potential for drug interactions.

Other drugs commonly used in cats that are also strongly protein bound include the injectable longacting penicillins, long-acting cephalexin, and Rx Propofol, an injectable anesthetic.

I now prefer “Levemir” insulin in my diabetic cats.

I find the BG nadir occurs, on average, about three to six hours after injection, and there is a fairly flat BG curve. On “Lantus” and “Levemir”, over 80% of my newly diagnosed diabetic cats recover within three months. I purchase the box of “Levemir” and dispense the 3 ml vials to owners.

BG testing Should BG be tested just before or after injecting the insulin? The BG that indicates the dose of insulin is the nadir or lowest level. I recommend that owners initially test three to six hours after injecting insulin approximately once a week, at midday or evening.

They also need to test if the cat is acting strangely, is weak or not eating. • I recommend that all owners of diabetic patients home monitor if possible. In cats, this is usually done by ear vein prick, although the footpad can also be used. Home BG monitoring is best for the patient. I do a Diabetic Consultation (this can be done by a trained Animal Health Technologist). I request that the owners phone in their BG result and plan. I charge for Home Monitoring Phone Consultations either ahead or later. • The occasional cat requires veterinary BG monitoring, usually due to attitude. In these cats, I recommend the owner give the cat an anti-anxiety medication (Rx Clonazepam 0.5 mg, 1/2 to 1 tablet) about an hour before the clinic visit. Rx Clonazepam does not affect BG, but it enhances cooperation and reduces the stress of the visit so the BG is more representative of the cat’s glycemic control.

In most diabetic cats, a low carbohydrate diet and glycemic control with insulin injections will result in gradual recovery within three weeks to three months. Often, my diabetic

In most diabetic cats, a low carbohydrate diet and glycemic control with insulin injections will result in gradual recovery within three weeks to three months. cats have recovered before we have done a BG curve.

However, in those cats whose BG becomes stable, and is not decreasing, I do recommend that owners perform a BG curve, testing at three, six and nine hours after the morning insulin injection. If the nine-hour BG is not higher than the six-hour BG, I request a 12-hour BG, just prior to the next insulin injection. This BG curve tells us approximately when the nadir or lowest BG occurs, and hence, when the integrative veterinary care

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I recommend that all owners of diabetic patients home monitor if possible. owner should be spot testing. At the nadir, we aim for a normal BG of 3.5 to 6.0 mMol/L = 65 to 110 mg/dL.

Why do some cats not recover?

Owner problems: • C at is eating some dry food or high carbohydrate canned food • O besity and little exercise • L ong-standing unstabilized diabetes Veterinary problems: • Short-acting insulins with high BG for hours twice a day • BG done in vet clinic, which causes repeated stress hyperglycemia • Infection, especially gingivitis or urinary tract infection

aiming for a T4 of 20 to 30 nMol/L = 1.5 to 2.2 ug/dL. If I am unable to control the T4 medically, then I perform Sx bilateral thyroidectomy, taking care to preserve the parathyroid glands. These cats do extremely well. Of course, the gold standard is radioactive iodine, but this procedure is not available in every city, it’s expensive, and cats cannot be receiving insulin injections nor have significant chronic kidney disease.

• Rx Prednisone, Prednisolone or Dexamethasone – If the diabetic cat requires glucocorticoids for another medical problem, they should be given twice a day along with the insulin injections. As long as the cat is on steroids, he will not recover from the diabetes. Neither Rx Depo-Medrol nor Rx Prednisone should be used in cats. Rx Depo-Medrol predisposes cats to diabetes even more than daily steroids, due to the excessively high level reached initially. Rx Prednisone is poorly hydroxylated to the active form prednisolone in the cat. Rx Dexamethasone has the advantage of being active (not a precursor) and is tasteless, so can be crushed and mixed into the cat’s food. Cats on steroids will require a higher dose of insulin. The aim is the same – normoglycemia.

Medical problems: • Hyperthyroidism with T4 > 35 nMol/L = 2.7 ug/dL – I initially use Rx Methimazole, 5 mg, 1/4 tab BID for three days. Depending upon the initial T4, I may test the level or increase the Rx Methimazole to 1/2 tablet BID. After four weeks, I measure T4, collecting the blood about four hours after the morning pill. I prefer to run a CBC, Chemistry and T4, or at least serum creatinine with the T4. Based on the result, I adjust the Rx Methimazole dose,

• Hypersomatotropism (gigantism) – These cats have excessive growth hormone secretion from their pituitary glands. They are big cats with large heads, and are insulin resistant, often requiring 5 to 10 units BID. However, their diabetes is quite stable and they do very well.

• Hyperadrenocorticism (Cushing’s Syndrome) – This p r o b l e m i s r a r e (two to three cases per vet in a

Diabetic complications • Cataracts – don’t occur; no glucose oxidase in lens • Microangiopathy – doesn’t occur • Increased infections – gingivitis, urinary tract infection • Hind leg plantigrade stance – recovers with a delay • Diabetic cats do very well, but diabetes makes any other medical problem difficult to manage, especially chronic kidney disease, since insulin is excreted by the kidneys.

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lifetime). These cats are characterized by insulin resistance, recurrent infections, and thin skin that tears easily but heals amazingly well. They remain polyphagic, polydipsic and polyuric. They develop muscle wasting and weakness. They are quite characteristic clinically, and they have elevated alkaline phosphatase levels. Diagnosis is confirmed

by ACTH stimulation test. Treatment is done with Rx Trilostane and Melatonin.

feline health. To enable recovery, low carbohydrate food is essential once a cat has become diabetic.

Detemir insulin enhances this recovery. Of course, once a cat has been diagnosed as diabetic, he must always remain on low carbohydrate cat food.

Dr. Lea Stogdale, DVM, Diplomate ACVIM, graduated from the Faculty of Veterinary Science, University of Melbourne, Australia in 1970. She worked in general practice in Australia and England before teaching veterinary medicine in South Africa and Saskatoon for eight years.

Summary Diabetes mellitus in cats is a disorder that can largely be prevented by avoiding or limiting dry cat kibble, as discussed in Part 1. Appropriate protein feeding is the most important thing we can do for

Dr. Stogdale passed the veterinary small animal internal medicine specialty 1981 to become a Diplomate in the American College of Veterinary Internal Medicine. She has worked in emergency and pet practice for 25 years, taking a special interest in diabetes of dogs and cats, complementary medicine and nutrition (aesopsvetcare.wordpress.com). board exams in

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by Neal J. Sivula, DVM, PhD

S

This dog’s experience demonstrates that chiropractic is an effective physical modality in the treatment of mobility problems.

cooby Doo is an 11-year-old male neutered Australian shepherd mix that presented with a twoyear history of stiffness when rising and after play.

He was having difficulty getting up and walking for any distance without limping. He had not had an orthopedic examination in the past, but a short course of a nonsteroidal anti-inflammatory had not improved the lameness.

Presentation and physical exam On presentation, Scooby Doo was bright and alert with an outgoing personality. Initial gait analysis indicated that his stride length was shorter than normal in both rear limbs. He also appeared to have decreased flexion and extension of his thoracolumbar spine when moving. In the examination room, he sat down slowly and with care. His posture was normal.

A physical examination was conducted. Scooby Doo’s temperature, pulse rate and respiratory rate were all within normal limits.

The rest of the physical examination was also normal with the exception of the orthopedic and neurologic aspects:

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• The orthopedic examination revealed some discomfort on palpation of the paraspinal musculature of the lumbar spine. There was also a general reduction in the flexion and extension of the lumbar spine. A slight reduction in strength was detected in both rear legs as well as the tail. The rest of the orthopedic examination was within normal limits.

• The neurologic examination revealed no problems with the cranial nerves. Mentation was normal. The only abnormality was a slight proprioceptive deficit identified in both rear limbs.

Reflexes in all the limbs were normal.

Chiropractic examination A chiropractic examination was then conducted. The static examination again confirmed there was pain in the paraspinal muscles along the lumbar spine. This area of the lumbar spine was also cool to the touch. The spinous processes of the following vertebrae were found to be in an abnormal position at rest: C1, C2, C5, T3, T6, T7, T11, T13, L2, L3 and L4. In addition, the right tuber coxae was found to be higher than the left tuber coxae, and the sacral apex was found to be left of midline.

The motion of the spine was then assessed through palpation.

Reduced movement was identified in all the vertebrae mentioned above. The right tuber coxae would not move ventrally, and the sacral apex could not be moved to the right.

The chiropractic listings for the problems found were ASL, C2BL, T3P, T6PL, T7PL, T11PR, T13PL, L2P, L3P, L4P, Right PI and Sacral Apex Left.

The decision was made to do a chiropractic adjustment on Scooby Doo. Afterwards, the motion palpation was repeated to confirm the chiropractic issues had been resolved. His gait was analyzed and found to have improved. His stride length in the rear limbs had improved and his spinal movement appeared to be more fluid.

Follow-up adjustments Scooby Doo was re-examined ten days later. His owners reported that he seemed more comfortable in general and was more willing to go for longer walks without limping. On examination, he appeared to move well with only a slightly reduced stride length in the rear limbs. He was more willing to sit, with less hesitation than during his first visit. No pain was palpable in the lumbar spine. Strength had improved in both rear limbs as well as the tail. There were no neurologic problems detected.

The chiropractic examination still revealed problems throughout the spine and pelvis. The chiropractic listings found were ASL, C3BL, T5PL, T11P, L2P, L4P, Right PI and Sacral Apex Left. Another chiropractic adjustment was done and Scooby Doo was sent home with no exercise restriction.

A third examination was performed three weeks later. The owners reported an increase in mobility and energy since the previous visit. Gait analysis was normal, and Scooby Doo sat in the exam room with ease. No pain was found on spinal palpation.

The chiropractic examination again identified problems in all parts of the spine and pelvis. The chiropractic listings identified were ASL, C5BR, T11P, L4PR and Sacral Base Posterior.

Another chiropractic adjustment was performed and a recheck examination was scheduled for two months later.

Examination specifics The specific chiropractic examination consists of gait analysis, posture analysis, static palpation and motion palpation. The elements of both the chiropractic examination and treatment (adjustment) have been adapted from chiropractic in humans.

1

Gait and posture analysis from a chiropractic standpoint are no different than those used in Western medicine. They allow

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Legalities and qualifications Both chiropractors (a Doctor of Chiropractic) and veterinarians can perform chiropractic in animals, subject to laws governing practice in each state.

States may require referral of the patient to a chiropractor, or clients may be able to take their animals to a chiropractor without referral.

Regardless of which professional is used, both should have formal training in chiropractic for animals. Numerous training programs exist throughout the world, with most either being approved by the American Veterinary Chiropractic Association or the International Veterinary Chiropractic Association. At present, the training programs are approximately 220 hours, with examination required for certification.

2 3

the practitioner to document deficiencies and help identify potential areas with chiropractic issues.

The static examination is simply the palpation of the spine and extremities at rest. Resting spinal morphology and position is assessed as well as any heat, pain or swelling in the spine or extremities. This prepares the practitioner for the most important part of the examination, motion palpation.

Motion palpation involves moving each vertebra and the bones of the extremities through their normal range of motion. This requires the doctor to have a knowledge of both normal anatomy as well as what the normal range of motion should be in each area of the spine as well as the extremities. Normal spinal motion involves movement in flexion and extension, lateral flexion, and rotation (three planes of movement). Vertebrae can have an abnormal position at rest (identified during the static examination) with normal movement or abnormal movement, or they can have a normal resting position yet have abnormal movement in one or more planes. The doctor then decides whether these are simply chiropractic problems (chiropractic subluxations – a dis-relationship between bones of the spine) or if they could be more serious orthopedic issues that require further diagnostics.

Dr. Sivula gives Scooby Doo an adjustment.

of the vertebrae at rest, using a reference point, and some describe the abnormalities found based on abnormal spinal movement.

The listing system used for Scooby Doo is an adaptation of the Gonstead System, which uses a reference point for each vertebra to describe its position at rest. In the cervical spine, the reference is the position of the vertebral body itself in relation to the other normal vertebrae. For example, the C3BL listing indicates that C3 was found to be positioned abnormally to the left of the other vertebrae on static palpation. In the thoracic and lumbar spine, the spinous process is the reference point.

A listing of T11P indicates that the spinous process of T11 is found to be more posterior (or dorsal) at rest than normal.

Chiropractic adjustment involves manually correcting the subluxations found during the examination. There are over 150 different chiropractic techniques used in humans, and many of these have been adapted for use in animals. The chiropractic adjustment has been defined as a high speed, low amplitude force applied to the spine or extremity in order to restore normal motion.

In summary, chiropractic is a useful physical modality in the treatment of mobility problems. It can also be helpful in the treatment of many internal medical problems. The doctor performing chiropractic should be trained in its use in animals in order to assure the process is both safe and effective.

Neal J. Sivula, DVM, PhD, graduated from the Ohio State University in 1988 as a Doctor of Veterinary Medicine. He subsequently completed an internship and residency in large

University of Minnesota, and An interest in integrative small animal care prompted Dr. Sivula to start Dancing Paws Animal Wellness Center in Richfield, Ohio, in 2001.

He is certified in animal chiropractic by the American Veterinary Chiropractic Association, is a former board member of the American Veterinary Chiropractic Association, an active member within the AHVMA, and past president of the American Academy of Veterinary Acupuncture. animal internal medicine at the

Listing systems There are multiple listing systems for describing the problems found during the chiropractic examination. These systems allow for proper record keeping and the communication of abnormalities to owners and colleagues. Some involve describing the abnormalities

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earned his

PhD

in veterinary medicine and epidemiology.

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49

by liz hassinger, DVM

Your profession may be hazardous to your health.

Recognizing, preventing and treating veterinary burnout is crucial to your continued success and well being.

hen we consider the risks of being a veterinarian, most of us think of zoonotic diseases, bite wounds, kicks, and lifting injuries. These are the hazards most veterinarians learn about during veterinary school and in continuing education seminars.

Sadly, our profession has traditionally kept quiet about the elephant in the room: veterinary burnout.

We are all at risk, and once it sets in, we become highly susceptible to mental and physical health conditions, some of which are life threatening, such as substance abuse, heart disease and suicide.

It is important to understand this job related hazard, not only for our own self care, but so we can recognize symptoms in coworkers and friends.

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By developing an awareness of these issues, we become compassionate colleagues within the veterinary community, where the health and well being of doctors is supported.

What is burnout?

According to psychologist Christina Maslachยน, who was the first to define the phenomenon of caregiver burnout in the early 1980s, the signs are: Emotional exhaustion: a feeling that there is very little, or nothing at all, left to give to clients, family and community. The caregiver becomes more detached from patients and coworkers. There is an overall decline in social contact.

Depersonalization of others: we develop negative attitudes towards our work, and may fail to truly connect to our patients, clients and coworkers. Hostility and negative feelings may permeate our lives.

A feeling of reduced personal accomplishment (lowered self esteem): the caregiver develops feelings of inadequacy and a loss of self respect.

A caregiver suffering from burnout will often lose interest in his/her own wellness care. This can lead to poor nutrition, lack of sleep and decreased exercise, which in turn may lead to deeper pathologies in the physical and mental planes. Without recognition and intervention of some sort, many caregivers will develop stress related ailments, substance abuse, anger issues, clinical depression and even suicidal thoughts.

Compassion fatigue Within the general category of burnout is a subset of stress, known as compassion fatigue. In their book Compassion Fatigue in the Animal-Care Community, Figley and Roop explain that compassion stress is the demand to be compassionate, empathic and effective while trying to be helpful to those who are suffering.2 Compassion fatigue is exhaustion due to compassion stress, which occurs when the caregiver is traumatized by trying to help. The authors conclude that compassion fatigue is a form of post-traumatic stress disorder (PTSD) and that symptoms include re-experiencing the events, avoiding reminders of the events, and physical distress while recalling an event. When we lie in bed at night, replaying in our minds a stressful event that marred our day, we are experiencing compassion fatigue.

Ironically, this “fatigue” often keeps us from sleeping well!

Acknowledge all your successes, and realize that not all cases will have a successful outcome.

Suicide risk is high in veterinary medicine All persons who work in caregiving professions are susceptible to burnout. However, in a recent review article in the UK’s Veterinary Record, Bertram and Baldwin looked at studies from California, England, Scotland, Norway and Australia, and concluded that veterinarians are four times as likely to die from suicide than the general population – this is approximately two times the rate noted in other health care professions!3 integrative veterinary care

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11suggestions for self care

Factors that may influence the rate of suicide among veterinarians include: High risk for burnout: Platt’s extensive review of 36 studies on veterinary burnout identified 12 areas of potential occupational stress for veterinarians: long hours, workload, financial issues, client demands/expectations, work-life balance, area of work, euthanasia, lack of professional support, job dissatisfaction, career change (either within the profession or to another profession), general work-related stress, and “other factors”.4

Access to means of suicide: Veterinarians have easy access to lethal drugs and working knowledge of the means of administration. Suicidal thoughts are more often completed when the patient has easy access to lethal means.

Exposure and attitudes toward euthanasia: Veterinarians face death in the course of their work, as a routine occurrence.

During their careers, most are personally responsible for bringing an end to thousands of lives. Veterinarians are more likely than the general public to favor the topic of euthanasia in human medicine. In addition, they tend to consider euthanasia as a treatment option when a patient is facing a terminal disease or has a poor quality of life High exposure to grief: Veterinarians are working with patients with very short lifespans, so they must experience the passing of thousands of patients during their careers, whether by euthanasia or natural causes.

Although the life expectancy is relatively short in companion animals, veterinarians are often left wishing they could have done more, or that they may have failed their patient in some way, when that patient reaches the end of his/ her life. This high level of exposure to grief, self doubt and the need to support clients is a major factor in the development of burnout and mental health issues.

Continued on page 54

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1

Natural remedies: Homeopathy, flower essences, aromatherapy, Reiki, massage and medicinal herbs can all help relieve stress and achieve balance. In most cases, it’s best to involve a practitioner with training and experience in treating humans.

2

Improve your working environment: Take a look at where you spend your days working as a veterinarian. Since you spend so much time there, do everything you can to make it healthy and supportive.

Improvements can be made with music, light, color, aromatherapy and Feng Shui. You may find it helpful to have a variety of plants and photos throughout the workspace. Plants bring an element of the earth and outdoors, while photographs can bring back happy memories and reinforce positive energy. Save and post pictures of special patients, clients and fellow veterinary professionals who have made a difference in your life. When you’re in the middle of a busy or trying day, and you catch a glance of a special memory, use that as a spark of positive energy to lift your spirits.

3

Save the good, and take out the trash: Save all thank you cards and keep a simple journal of your clinical successes and special patients. If you receive a negative comment, consider what you may have done differently, make changes if needed, then discard the burden of the negativity. When you go to bed at night, and your mind begins to churn with a negative event that trashed your day, visualize that event as a pile of waste that you take to the dumpster and walk away from.

Then recall all the successes, smiles and positive interactions you have enjoyed in your work.

4

Make a simple ritual out of the start and end of your workday: This way, your days can be compartmentalized and not spill over into every second of your personal life. In the mornings, take a few moments to sit quietly and visualize a positive day. Even a simple statement as you walk in the clinic door – “this will be a good day” – can influence the outcome.

During your day, if you encounter a difficult client, or have to perform euthanasia, take a moment afterward to clear that negative or painful energy before going to the next task. This can be done very simply by stopping to wash your hands and visualizing the experience being rinsed away from your psyche.

At the end of each workday, visualize a closure. Say to yourself: “I’ve done a great job, I’ve done what I can for one day, and now I am returning to my personal life.” Wash your hands one more time,

remove your scrubs or change your clothes, and as you walk out the door, visualize yourself closing a book and putting it away on a shelf for another day.

5

Let go of high expectations: Veterinarians tend to be over achievers as well as competitive and perfectionist. While it is important to strive to do well, no one is perfect, and try as we might, there will always be cases that will remain unresolved or have a bad outcome. It is crucial you recognize that you are tackling great challenges on a daily basis. Acknowledge all your successes, and realize that not all cases will have a successful outcome. Your current job may not be the job of your dreams, but make it the best it can be, and work towards realizing your dreams. If you find you are truly in a toxic or demoralizing position, you need to make changes.

6

Seek support and guidance from old friends and peers: Veterinarians are a unique group of professionals. Sometimes the best support and guidance will come from an old friend or colleague. Open yourself to meeting and sharing with other veterinarians. Often, the best learning experience you can have at a conference comes from conversing with others, before or after seminars.

7

Take time to stop and smell the roses: Adopting this as your mantra can become a gift to yourself and an invaluable self care tool. Along the road to or from work, when you see a lovely flower, a beautiful scene or an animal – stop for a moment and give yourself a spiritual tune-up by simply taking in the beauty that nature has provided. Recognize and give thanks for the simple pleasures that pop up all around you in the course of a day.

crucial. Depressed patients are often found to have low levels of some or all of the following nutrients: folic acid, vitamin B12, selenium, SAMe, zinc, omega 3 fatty acids, and especially vitamin D. Supplementation with these nutrients has been shown to be beneficial in the treatment of depression.

9

Exercise: Countless studies have demonstrated the mood elevating effects of exercise in the treatment and prevention of depression and substance abuse. People who exercise regularly have improved self esteem, reduced physical pain complaints and greater happiness compared to those who do not. Regular exercise can be inexpensive, and easily accessible. The biggest hurdle is that it takes effort, and when people are stressed and feeling down, the last thing they feel like is making an effort.

In order to become motivated, you might want to enlist the support of a friend, join a gym, sign up for a class, or simply commit to walking your dog more. If you must, force yourself to get started. If you find yourself unable to initiate exercise in any way, you may need a professional’s help because this is a sign of clinical depression. Yoga, Qigong and Tai chi are especially helpful as they combine physical exercise with a relaxed and contemplative state.

10

Life coaching: This can be an excellent way to prevent burnout and stress. While coaching is not psychotherapy, it can relieve mild emotional distress by helping you take action to improve your personal and professional life, which in turn helps you feel better.

11

8

Eat well: Brain chemistry is greatly affected by the foods we eat. Often when people are undergoing stress, their dietary habits change, and this may become a factor in a continuing downward spiral for their mental health. Hypoglycemia can quickly lead to changes in mental function, including symptoms of depression, anxiety, fatigue, mental confusion and irritability.

Stress can lead to either anorexic hypoglycemia, or to increased consumption of highly refined carbohydrates, which then produces reactive hypoglycemia. Alcohol consumption can also lead to hypoglycemia. Increased levels of sugar, caffeine and alcohol have all been linked to increased risk of depression.

A nourishing diet, including a variety of fresh vegetables, whole grains, high quality proteins and essential fatty acids is

Spiritual, energetic and hands on treatments: One of the greatest ways to relieve stress and heal ourselves is through increasing our own level of self understanding and spirituality.

Taking the time to introduce gratitude, hope and forgiveness into our daily thinking process can make great positive change in our lives. There are also numerous energetic or spiritual treatments and lifestyle choices that have positive effects on mental health and well being.

Examples include organized religion, Ho’oponopono, Tai chi, Qigong, meditation and Reiki.

Whether you choose to follow one or a variety of practices, the important thing is to make an effort to nourish your spirit.

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Continued from page 52 Shifting demographics in veterinary medicine: Veterinary medicine in the US is now a female dominated profession. Research in veterinary mental health issues has repeatedly shown that female veterinarians, especially younger women, are more prone than men to depression, psychological distress, burnout and suicide.5,6,7 One study of female veterinarians in the US reports that two-thirds of the women sampled experienced early signs of burnout, a rate significantly higher than the males studied. It is an unfortunate reality that unless effective outreach and support are put in place, the number of veterinarians suffering from compassion fatigue, depression, substance abuse and suicide will rise as even greater proportions of the population are made up of women.

Economic stressors: Veterinary students and recent graduates experience a great deal of stress related to student loan debt. In addition, female veterinarians experience pressure from gender discrimination. Recent AVMA survey results indicate that not only is there a disparity in starting salaries between male and female associates, but that it has become worse in recent years.8 In 2006, males started at a 6% higher salary than females, and in 2009 they started at 11% higher salary.

Lack of a professional support network: Veterinary Practice News (2010) reported that “Veterinary medicine is the only US medical profession that does not have a national monitoring program for substance abuse and mental health

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issues. Considering that medical professionals in general have a statistically higher incidence of suicide, drug and alcohol abuse, many who are passionate about veterinary wellness are asking why DVMs are excluded.� Support networks have long existed in the medical and legal professions, but in 2004 the AVMA discontinued their wellness committee, turning over the responsibility to individual state VMAs. Less than half of all US state VMAs have wellness committees, and only a handful have easily accessible resources for vets in crisis.

Healer, heal thyself?

Just as we would never diagnose and treat ourselves for a life threatening zoonotic disease, we need to seek professional help with mental health issues. However, we can and should take the time to know about these occupational hazards, to assess our own risk, monitor symptoms and take preventative measures. If we do recognize symptoms in ourselves, we need to feel comfortable seeking professional evaluation and treatment. This is often the hardest step, because of the stigma of mental health issues.

In addition to conventional counseling and pharmaceuticals, we may wish to consider homeopathy, herbal medicine, acupuncture, chiropractic care and contemplative studies. It is of utmost importance that we seek the assistance of practitioners trained and experienced in treating people with these modalities, and not self-medicate in the face of serious symptoms.

Prevention is the best medicine Most importantly, we need to be well informed about how to prevent these problems in the first place, and how to keep little issues from becoming more serious. Some simple adjustments to our lifestyles and attention to self care can help immensely to relieve the stresses that may lead to burnout. Many integrative therapies and other activities such as yoga, Tai chi, Qigong, meditation and spirituality can play an important part in the prevention and/or treatment of mental wellness issues (see sidebar).

Look for the Seal of Quality

In conclusion Wellness for the doctor is as important as wellness for the patient.

At times, we are so busy and caught up in our professional and/ or personal lives that we may not give ourselves the attention we need to maintain our own health. There are many avenues to explore to nourish your spirit. It matters not so much which road you take, but that you begin the journey. When a person is feeling very depressed or stressed, these suggestions may sound impossible, even repulsive. This is a sure sign you may need professional help. With time and treatment, it is possible for the spirit to recover from its burdens, and rise to a level of well being once again.

Dr Liz Hassinger graduated from the Tufts School of Veterinary Medicine in 1989. In 1997, she completed the IVAS course in veterinary acupuncture, and built and opened the Wolf Rock Animal Health Center, an integrative veterinary practice in Exeter, Rhode Island. Since that time, she has also completed training in homeopathy, Western and Chinese herbal medicine, and animal chiropractic. Dr Hassinger has been writing and lecturing on the topic of wellness in veterinary medicine since 2008, and serves on the AHVMA’s Council of Elders. She is currently working on the development of a veterinary wellness website, to provide a resource for American veterinarians, in collaboration with the AHVMA.

1

Maslach, C. Burnout – the Cost of Caring. Englewood Cliffs NJ: Prentice-Hall, 1982.

2

Figley Cr, Roop RG.“Compassion fatigue in the Animal-Care Community”. Humane Society of the US, pp 11, 2006.

3

Bartram DJ, Baldwin MB, The Veterinary Record, 162:36-40, 2008.

4

Platt, Hawton, Simkin and Mellanby.”Suicidal behavior and psychosocial problems in veterinary surgeons: a systematic review”. Soc Psychiat Epidemiolog. Dec 2010.

5

Fairnie HM. “Occupational injury, disease and stress in the veterinary profession”. PhD thesis, Curtin University of Technology, Australia, 2005.

6

Welsch BB. “Gender differences in job stress, burnout and job satisfaction as mediated by coping style of veterinarians in private equine practice”. Dissertation, Univ of Florida States.

J Am Vet Med Assoc 200:604–608, 1998.

7

Elkins AD, Kearney M (1992). “Professional burnout among female veterinarians in the United States”. J Am Vet Med Assoc 200:604–608.

8

AVMA online news post: www.avma.org/onlnews/javma/jun04/040601z.as.

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Make sure the animal supplements you select display the NASC Seal of Quality

For more information visit www.NASC.cc integrative veterinary care

55

Undiagnosed

lameness

It’s a common complaint, but in many cases, the culprit is poor saddle fit and balance.

by Jochen Schleese, CMS, SFT, CEE

With complex physiological issues, veterinarians may recommend treatments to alleviate symptoms. The horse benefits greatly when the health care team works together, combining knowledge to understand underlying factors. This series will discuss concepts to assist professionals in the diagnostic process.

A common equine injury is to the suspensory ligaments, caused by poor (or incorrect) riding. Classical principles of dressage training and movement are being replaced by flashiness, hyperflexion and the “show trot”. When a horse is ridden in a flashy trot, his back is pushed down, the saddle balance falls too far back, and the rider sits behind the centre of gravity, causing excessive pressure over the last floating ribs.

This causes a chain reaction: the saddle stuffing compresses in the rear, the rider collapses into a chair seat, and the excess pressure on the horse’s sacroiliac joint makes it nearly impossible for him to engage from behind, stepping under himself correctly. At least eight contributors affect the horse’s centre of gravity, which in turn affects the balance of the saddle and rider.

Signs of poor saddle fit • Base of neck pushed down • Incorrect bend, curling or twisting in neck • Tail hanging crooked or “pinched-in” • Hollow back • Whites of eyes showing • Excessive chomping at bit when ridden • Ears laid back • Tongue busyness • Stumbling or tripping • Four-beat canter or pace • Bucking or rearing • Resistance to go forward • Refusals • Girthiness

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integrative veterinary care

The saddle’s purpose is to distribute the rider’s weight evenly over the saddle support area, while balancing the rider over the horse’s centre of gravity. The horse is more comfortable in a well-balanced saddle because the rider’s weight is distributed over a larger surface area. The saddle must not be driven into the shoulder, or back on the loin. In a balanced saddle, the rider uses the four curves in her back as natural “shock absorbers”, sits balanced on the seat bones, and is able to lean forward and backward without swinging the legs.

When the saddle is too high in front – off the withers – or too low in the back, this causes excess uneven pressure on the horse’s loins. He will be unable to come through with his back and step underneath himself into a correctly engaged frame. The rider will struggle with position or feel tipped back. If the saddle is too low in front it will pinch the horse’s shoulder, restrict movement, causing discomfort (saddle may be too wide in the front or too high in the back), forcing the rider into an unnatural position potentially straining discs in her lower back.

Jochen Schleese

Certified Master Saddler who Passier, and came to Canada as Official Saddler at the 1986 World Dressage Championships. He registered the trade of saddlery in North America in 1990. Jochen’s lifelong study of equine development, saddle design, the bio-mechanics of horse and rider in motion, and the effects of ill-fitting saddles, led to the establishment of Saddlefit 4 Life in 2005 (saddlefit4life.com), a global network is a

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Animal Care Expo is an outstanding training and educational value. All full conference attendees receive: • Four meals (dinner on Monday, lunch and dinner on Tuesday and lunch on Wednesday in the Exhibit Hall) • Morning beverage breaks • Conference bag with premiums from our sponsors • Complimentary drinks during the evening receptions • Wednesday night party with drinks and entertainment •C omplimentary Internet Café available for all attendees sponsored by The ASPCA. • Continuing education professional development credits for the Society of Animal Welfare Administrators (SAWA) certification program.

• An exclusive Animal Care Expo Social Networking site where you can network pre and post conference with attendees, speakers and event staff sponsored by The Center for Shelter Dogs.

For more information: (202) 452-1100 expo@humanesociety.com www.animalsheltering.org/expo

Animal Care Expo 2012 May 21-24, 2012 - Las Vegas, NV Plan now to join experts and colleagues for this unparalleled opportunity to brush up on the basics and learn about the latest cutting-edge programs.

Introduction to Small Animal Acupressure June 1-3, 2012 - Toronto, ON This course offers you the ability to perform a complete acupressure treatment protocol

and an understanding of the Traditional Chinese Medicine (TCM) concepts and theories underlying acupressure. Since Acupressure is based on TCM, we will explore this ancient science and guide you in learning how to help your animals feel their best. The instructor for the course is Kim Bauer, lead instructor for Tallgrass Animal Acupressure Institute.

For more information: (303) 681-3033 www.animalacupressure.com

The SCAV Veterinary Conference June 17-20, 2012 – Hilton Head Island, SC This 3.5 day conference offers you almost 25 hours of continuing education.

Sessions Covering • Small Animal (Surgery, Dermatology, Oncology, Kidney Disease) • Large Animal (Ruminants/Horse) • Veterinary Technician Topics • Practice Manager Topics Come and network with veterinarians from the Southeast, Midwest and East coast.

For more information: (800) 441-7228 marie.queen@scav.org www.scav.orgwww.scav.org

P o s t y o u r e ve n t o n l in e at: IVCJournal.com integrative veterinary care

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tech talk

Bach

Flower Though their efficacy isn’t backed up by much science, these remedies have nevertheless found a place in many integrative practices as a way to shift emotional states to aid recovery, and to help with behavior or training problems.

by Dr. Barbara Fougere, BSc, BVMS, BHSc, MODT, MHSc, CVA, CVBM, CVCP, CMAVA

he Bach Flower Remedies are based on the research and findings of English physician Dr. Edward Bach. A medical pioneer in the early 1900s, Dr Bach became aware of the link between stress, emotions and illness. When treating people, he found that flower essences helped them overcome their illnesses by addressing the underlying emotional contributing factors. This connection is based on Dr Bach’s idea that negative emotional states can suppress the healing process. The contemporary science of “psychoneuroimmunology”, or the study of the connection between the mind and its influence on disease, seems to support this concept.

A century of use Dr Bach’s insight was born from medical knowledge, observation and empirical research, before the era of evidence based medicine. A recent systematic review of seven randomised trials of Bach Flower Remedies in humans concluded that they failed to provide convincing evidence that they worked any better than placebo.¹ However, the review also noted some limitations and potential biases, and also left out other studies. Another systematic review supported the safety of these remedies.²

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Even though Dr Bach developed his flower essences for people, they have been used in animals for many years by both owners and health professionals alike because they are safe, easy to find and administer, and numerous anecdotes tell us they actually can do something.

Their role in practice So do dogs and cats have emotional states that can influence their health? We know many animals have behavioral problems and we can even describe their “personalities”.

From anxiety and fear to aggression and loss, we have seen it all in our patients. We know that stress can reduce immunity, so it is not unreasonable to accept that it can influence the health of patients too.

Despite the lack of high level evidence that Bach Flower Remedies do anything more than placebo, along with the fact that animals can’t really tell us how they are feeling the way humans can, these remedies still find a role within integrative veterinary practices. The Bach Flower Remedies are essentially gentle and non-toxic. And provided they are not used inappropriately – that is, by delaying proper medical care, or trying to deal with serious behavioral disorders without utilizing additional therapies – they can help in two ways.

1

They can be used in the way Dr. Bach originally intended: on their own or to enhance any form of medicine by shifting emotional states to aid recovery or healing. As animal health professionals, we need to rely on our knowledge of the remedies, observations of the patient and from the client, as well as judgement and intuition, to prescribe the right remedy or remedies.

2

The second way they are commonly used in the veterinary context is to help with behavioral or training problems.

Careful selection of a remedy or remedies alongside behavior modification or training advice can be employed as part of a treatment protocol.

Two challenges One challenge in using Bach Flower Remedies is taking the leap of faith to try them, especially when the science is weak. Keep in mind that science is also weak in many common conventional therapies we use in practice. The fact that these remedies can be used alongside conventional medicine without any reported interactions or adverse events makes them worth considering.

The second challenge is how to select the remedies. Each Bach Flower Remedy helps deal with specific states of mind. These states include fear, terror, mental torture or worry, indecision, indifference or boredom, doubt or discouragement, overconcern, weakness, self-distrust, impatience, over-enthusiasm and pride or aloofness. Anthropomorphism and intuition, attributing emotional aspects based on our interpretation of the patient’s history and signs, are necessary to selecting remedies for individual animals.

The fact that these remedies can be used alongside conventional medicine without any reported interactions or adverse events makes them worth considering.

Guidelines for use The remedies are purchased as a stock bottle, which contains the concentrated essence. Essences are generally diluted before use, although they can be given straight from the bottle in emergencies.

Stock strength essences contain about ²/³ brandy, which most animals hate. So two to six drops of the stock are usually diluted in spring water, with about ¼ brandy as a natural preservative. If the remedy is to be used within one week, it does not need added brandy. integrative veterinary care

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Client feedback According to feedback from clients, Bach flower remedies can work surprisingly quickly, sometimes with a single use.

four times daily, or every ten to 15 minutes in emergency situations. If you choose the wrong remedy, there are no side effects and pets cannot be overdosed.

One way to test out Bach Flower Remedies at your clinic is to purchase a bottle of Rescue Remedy. This is perhaps the most well known Bach Flower Remedy. It consists of five flower essences:

One client described her dog being bothered by a stinging fly while camping. The dog became very distressed and agitated and totally focused on the fly. After a single dose, she relaxed, lying on her side and not bothered at all by the fly.

Another client described the lethargy and grief her dog experienced when her son left home. Within a day of receiving the Bach flowers, the dog’s behavior changed and he was back to his old active and happy self.

Cherry Plum

Clematis

Impatiens

The more common observation, however, is a gradual change over two to four weeks of use, sometimes longer.

Rock Rose

1

Preparation • The remedies are selected and prepared either singly or in combination (up to six remedies can be mixed together).

Star of Bethlehem

It is one of the most widely used remedies as it can be applied in any first aid, emergency, trauma or stress situation. It can be given every five to ten minutes as necessary. Ideally, dilute it with spring water only, so the taste is acceptable. Try it on at least ten patients – you will know which ones need it. Record the patient, the problem, the dose and the outcome, and see whether Bach Flower Remedies can play a role in helping patients in your care.

You might be surprised!

Learn more about Bach Flower Remedies at civtedu.org.

• To prepare a Bach Flower Remedy, place two to six drops of each selected essence (or four drops of Rescue Remedy) into a 1 oz or 25 ml bottle. Fill the bottle ¾ of the way with spring water, then add brandy, vodka or organic vinegar to fill so you have three parts water to one part alcohol. This dilution bottle should be thumped against the palm of one hand to thoroughly mix the remedies.

• The remedy is given by mouth or applied to the ears or head area. The drops can be added to drinking water (six to eight drops) each day. A dropperful can be added to the animal’s bath water, or to a mister or spray pack so that a kennel, room, cage or animal can be sprayed with the remedy.

2

Dosage This depends on the pet’s individual response. Try three to four drops by mouth or on the inside of the pinna one to

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Dr. Barbara Fougere graduated in 1986, and was named the American Holistic Veterinary Medical Association Educator for 2011. Dr. Fougere is the principle and one of the founders of the College of Integrative Veterinary Therapies. She has continued studying over the last 26 years, and has three Bachelor degrees, two Masters degrees, three post Graduate Diplomas, several Certifications and numerous other courses under her belt.

¹Ernst E, “Bach flower remedies: a systematic review of randomized clinical trials.” Swiss med Wkly 2010 Aug 24; 140. ²Thaler K, Kaminski A, Chapman A, Langley T, Gartlehner G. “Bach Flower remedies for psychological problems and pain: a systematic review.” BMC Complement Altern Med 2009 May 26; 9-16.

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