September is designated as pain month for the American Chronic Pain Association. The aim is to increase the awareness of painful conditions so we decided to look at a recent successful case to illustrate this.
Jack is a 13 year old cross breed who suffers from lumbosacral pain. Jack’s owner first noticed that he started to suffer from anxiety rather than pain. At its worse, this anxiety would lead him to have irritable bowel syndrome and bloody diarrhoea, due to the stress. When he became really stressed he would seek out places to hide. Whilst his owner would describe him as a worried dog, this really intensified over this period of time and led him to become aggressive towards the other dog in the house, which was completely out of character. When we see cases with behavioural changes such as this, we always look for pain as an underlying cause.
We often assume that when we examine dogs they will tell us when they are in pain. But you have to be seriously painful to actually cry out in pain – so vocalisation is actually quite a crude measure of pain. When examined, Jack showed slight discomfort to palpation of the area, leading us to believe there was probably more pain than he was letting on.
If we consider lumbosacral pain, this is the dog equivalent of us having low back pain. It’s pain related to where the spine joins the pelvis and can have its origins in a number of different tissues – bone, ligaments, muscle and intervertebral discs. If we classify this pain there are likely elements of both inflammatory and neuropathic pain here.
During these periods Jack also experienced seizures. An MRI scan of the brain showed no underlying cause of the seizures and it was assumed that these were stress related due to the pain.
Our first line in painful cases would usually be a non-steroidal anti-inflammatory (NSAID) based on the fact that they are licensed for osteoarthritis in dogs and are generally very effective. Due to the nature of Jack’s gastro-intestinal system he did not tolerate NSAIDs very well and so the next step was a combination of gabapentin 10mg/kg BID and paracetamol BID. Jack made a slight improvement with this combination although the biggest step forward in managing his symptoms came when we started acupuncture. Generally, dogs with LS disease respond positively to acupuncture.
The chosen acupuncture points were located on the bladder meridian in the region of the lumbar spine (BL 23, 25, 28) and bladder points to the epaxial muscles of the neck. Jack tolerated manual acupuncture really well and each session lasted 20 minutes. During each session he became totally relaxed and enjoyed a snooze! This picture is taken during one of the sessions where he is having acupuncture.
Since starting acupuncture he has made a dramatic improvement. His signs of stress have totally disappeared with no episodes of IBD or seizures. The frequency of gabapentin was reduced from TID to BID with his level of comfort remaining stable. Mentally and physically his owner describes him as a different dog who is super chilled out for 48 hours after acupuncture and then is a normal dog in between acupuncture sessions.
With chronic pain management a multimodal approach is always the best pathway. Multimodal has two meanings here – multimodal in terms of analgesia but also in terms of management options. A combination of analgesics, acupuncture and recognition of behavioural concerns made a real difference to Jack’s pain and markedly improved his quality of life.