I recently had a case which illustrates alternative therapies commonly present themselves in my daily practice. A patient, an older large breed dog, came in for an annual exam. He was in good general health but moderately overweight, and the only complaint was gradually progressive weakness in his hind legs. This is common in large older dogs and is often due to arthritis in the spine or hind legs. In this case, the patient had been diagnosed with a ruptured cranial cruciate ligament years before. At that time he was unable to use the leg and surgery had been recommended.
Surgery is the treatment of choice for a ruptured cruciate ligament. Weight loss, physical therapy, and possibly medications are all helpful and important, but without surgery a large dog will have permanent instability in the knee and will develop progressive arthritis. The acute pain of a recent ligament rupture will change to the nagging, chronic pain of degenerative joint disease, and the patient will learn to compensate for the disability, but the joint will not be fully functional or comfortable without repair.
There are a variety of surgical procedures available, and the evidence is not definitive as to which is the best, though most work well. Sometimes surgery is not possible because of the cost or other conditions the patient may have, but in this case surgery was not performed because of a misconception generated in part by the use of an alternative herbal remedy.
A veterinarian who practices primarily alternative therapies (mostly TCM and acupuncture but an assortment of others as well) had recommended Sleepytime herbal tea for treatment of the dog’s presumed arthritis. The main ingredient, chamomile flowers, is sometimes recommended for reducing anxiety, soothing an upset stomach or skin ailments, though like most herbal products one can find a recommendation for using it in dozens of unrelated conditions. It is reported to have anti-inflammatory properties and is one of a number of herbal ingredients in some products marketed for arthritis in dogs.
So what’s the evidence for using chamomile for arthritis? None that I can find. The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach states:
There is little convincing evidence to support the therapeutic effectiveness of chamomile extracts. Encouraging evidence is emerging for a specific combination preparation in patients with functional dyspepsia. Given the risk of allergic reactions and the few rigorous clinical trials that have been conducted, it is not entirely clear whether the potential benefits outweigh the possible risks.
Neither this resource, nor PubMed, nor the Natural Medicine Comprehensive Database list any clinical trials in any species for chamomile as a treatment for arthritis. There are a couple of in vitro studies which suggest it might interfere with some enzymes that are involved in inflammation, but that is a far cry from proof of any clinical benefit in dogs with degenerative joint disease.
Are there any risks? Probably few. I happen to really like Sleepytime tea for the taste, and it has been a popular herbal tea for decades. It certainly is unlikely to be a significant health risk when brewed and drunk in the ordinary way. Severe allergic reactions to chamomile extracts have been reported in humans, but these are not apparently common, and there is no data on whether this is an issue for dogs.
So once again, the remedy itself is probably harmless and probably useless. Then what’s the problem? Well, the owners of this dog believed it helped their pet. The lameness gradually decreased over weeks to months of time, as it would be expected to do without any treatment at all. The owners took this as evidence the therapy was working and that surgery or real medical therapy was not needed. So now the dog has progressive arthritis and decreased use of one of its legs due to a lack of appropriate treatment for a very treatable problem. And this is largely because of the owners misperception and misplaced faith in a useless therapy. Such is often the way seemingly benign interventions like this can do harm.
Thank you skeptvet for posting a personal case review.
I wonder how this has, or is going to turn out. Do to the increasing pain and debilitation, are the owners going to pursue useless alternatives again, or conventional treatment (i.e., for inflammation and pain control)?
I also wonder, and realize you cannot answer, if the alt vet ever told the owners that without surgery, DJD was inevitable and a very progressive disease without surgery.
Looks like whatstheharm.net will have to start listing veterinary issues now too 🙂
Djd was inevitable without surgery…..
I” believe” the data shows about 90 percent of people and dogs do ok with or without surgery. People promote dogs need cruciate surgery when humans do not but I have seen no proof that’s true. There are prospective studies out there that show human cruciate surgery makes the knee worse not better. I have seen vets promote they think the surgery works for big dogs because the surgery forces the dog to rest the knee. If so that could explain the success of the new more painful knee surgeries in dogs and why its been reported people active in sports seem to benefit from cruciate surgery. .
Art Malernee dvm
Fla lic 1820
Art Malernee dvm
Fla lic 1820
I don’t get that impression at all from the literature. The vast majority, of course, is focused on comparing surgical procedures to each other. But a couple of old studies seemed to indicate pretty clearly that surgery was more successful than conservative management for large dogs. So while we don’t have the perfect study, I think the evidence favors surgical treatment where possible. And, of course, the mechanics of the human and canine knee are dramaticallly different, so I think extrapolation from humans to dogs is not that sound a strategy for this condition.
1. MJ Pond and JR Campbell. The canine stifle joint I. Rupture of the anterior cruciate ligament: An assessment of conservative and surgical treatment. JSAP 13:1-10, 1972
2. PB Vasseur. Clinical results following non-operative management for rupture of the cranial cruciate ligament in dogs. Vet Surgery 13:243-246, 1984.
Eighty-five dogs were diagnosed as having rupture of the cranial cruciate ligament. They were managed by restriction of activity to leash walks for 3 to 6 weeks, weight loss if indicated, and analgesic medication as needed. Twenty-four of 28 dogs that had a body weight of 15 kg or less (85.7%) were considered to be clinically normal (no lameness and normal range of motion in stifle, 21 dogs) or improved (3 dogs) after an average follow-up period of 36.6 months. Lameness in the remaining four dogs persisted or worsened over an average period of 8.2 months (minimum 6 months), and surgical replacement of the cruciate ligament was performed. Eleven of 57 dogs that had a body weight of 15 kg or greater (19.3%) were classified as normal (4 dogs) or improved (7 dogs) after an average follow-up period of 49.1 months. Lameness in the remaining 46 dogs persisted or worsened over an average period of 10.2 months (minimum 6 months), and surgical replacement of the cruciate ligament was performed.
3. Vet Surg. 2010 Apr;39(3):350-4.
Second look arthroscopic findings after tibial plateau leveling osteotomy.
Hulse D, Beale B, Kerwin S.
SourceDepartment of Small Animal Medicine and Surgery, College of Veterinary Medicine, Texas A&M University, College Station, TX 77843-4474, USA. firstname.lastname@example.org
OBJECTIVE: To describe the long-term (range, 2-69 months) arthroscopic appearance of intraarticular structures of the stifle after tibial plateau leveling osteotomy (TPLO).
STUDY DESIGN: Case series.
ANIMALS: Dogs (n=63) that had repeat arthroscopic examination of the stifle after TPLO for treatment of a cranial cruciate ligament (CCL) deficient stifle.
METHODS: Medical records (2002-2008) of dogs that had repeat arthroscopic examination to evaluate intraarticular structures after previous TPLO for treatment of CCL injury. Regions of interest were the CCL, caudal cruciate ligament, articular cartilage, and menisci. Signalment, weight, and time to 2nd look arthroscopy were recorded. Radiographs were reviewed to measure pre- and postoperative tibial plateau angle, and craniocaudal limb alignment.
RESULTS: There were 17 partial CCL tears with early fiber tearing and 46 stifles with a complete CCL tear or incompetent partial CCL tear. Stifles with an early partial tear had normal to near normal appearance of intraarticular structures. Most dogs with a complete or incompetent partial CCL tear had axial or abaxial grades 3 or 4 articular cartilage abrasion of the medial or lateral femoral condyle.
CONCLUSION: Intraarticular structures appeared normal or near normal in dogs with early fiber tearing (caudolateral or craniomedial fibers). Most dogs that had a partial tear with an incompetent remaining CCL or a completely ruptured CCL had grades 3 or 4 articular cartilage abrasion.
CLINICAL RELEVANCE: Early diagnosis of a CCL injury and treatment by TPLO may be protective against further CCL disruption lending stability to the joint and decreasing the incidence of meniscal injury and articular cartilage damage.
Are any references prospective? I would be interested in reading any human or dog prospective cruciate studies that conclude that Cruciate surgery works. I enjoyed doing the surgery but stopped after a literature review. There are double blind knee surgery study’s in human medicine but they were not cruciate surgeries and the sham surgery may not have hurt as much as the real knee surgery. If the sham surgery hurts less or for a shorter time people will say the surgery was not randomized properly and any positive result could be from pain causing rest. The theory reminds me of firing horses were some thought it worked because the horse rested the leg.
Well, the Vasseur paper above was prospective, and it seemed to indicate outcomes for conservative management in large dogs much poorer than usually reported in studies of surgical procedures. However, I don’t believe there is a prospective head-to-head comparison of surgery with conservative treatment or no treatment. I think it would be a good study to do, though there would be some ethical difficulty since most surgeons believe surgical therapy is more effective based on the above research, so deliberately denying this therapy to some dogs could be seen as unethical.
Again, we’re faced with incomplete and imperfect evidence. I think what we have gives a reasonable indication that surgery is better than medical management, but the issue is by no means beyond dispute. And regardless, in this case the animal did not have acceptable comfort and function, and there is no reason to think the chamomile was a useful or appropriate treatment.
I would think the “ethical difficulty” for the surgeon would be promoting a surgery that if following FDA guidelines would be little more than a surgical scar that denotes a unproven remedy.
Art Malernee dvm
Fla lic 1820
Looks like they finally did a human randomized cruciate surgery vs no surgery trial in Sweeden and got the results one would expect if the surgery does not work.
Art Malernee dvm
Fla lic 1820
Acupuncture worked miracles for my large dog at eleven years old. Dogs cannot lie so we do not need any medical studies to prove that my eleven year old weimaraner who is now 15 was not able to walk in her back end suddenly. I was told of a local vet who uses two kinds of acupuncture to treat dogs.
It was not a matter of time. It was not a matter of restricting her, etc. I was told that it would take three treatments and it absolutely did. After the first treatment she went from not walking in her back end to a sloppy drunken sailor walk, the next week she was better and the following week she was fine. I did not have to go back for acupuncture for seven months.
I did what the Vet told me to do for specific exersizes and massage- we added vitamin D and other supplements and enzymes to her diet . She had me put a shoe only on the foot of the weakest leg. Not only did she build more more muscle in that leg, but she also stopped scraping her foot as she walked.
I continue the acupuncture every so often for health issues such as bladder weakness at her age. Again, it worked miracles !!!!!! She went from soaking her bed to being able to tell me when she needs to go out to go to the bathroom. She lets me know while sleeping at night also. She no longer soaks her bed within a few days.
I am so happy for her as she is able to have a quality life and I was able to help her with so many issues that my other older dog struggled with since I began bringing her to a holistic vetrinarian.
What we have here is faith, pure and simple, not evidence. It’s understandable, of course, but it’s the same kind of faith based on experience that has supported every failed medical therapy in history, so it doesn’t really mean what you so passionately believe it does.