Kristi Fender is a freelance writer and editor in Shawnee, Kansas, with a long history of covering animal health and veterinary medicine. She is the former news channel director of dvm360.com and editor-in-chief of dvm360 magazine.Read Articles Written by Kristi Fender
As most veterinary professionals know, the health of a patient is more than the sum of its various parts and systems. Besides absence of illness or injury, a pet’s well-being encompasses lifestyle, nutrition, behavior and exercise. Nobody understands this like veterinarians who take an integrative approach to patient care.
Treatments and services such as acupuncture, phototherapy, nutraceuticals and rehabilitation are becoming less “alternative” and more mainstream all the time, especially as scientific evidence accumulates. And savvy practice owners who implement these services with an eye on the bottom line can see major financial benefits to their business as well.
Two experts on integrative care share best practices in implementing integrative medicine into the clinic. Robin Downing, DVM, MS, DAAPM, DACVSMR, CVPP, CCRP, is owner of the Downing Center for Animal Pain Management (downingcenter.com) as well as a champion of veterinary bioethics. Narda Robinson, DO, DVM, MS, FAAMA, is a pioneer of veterinary acupuncture through her company CuraCore (curacore.org).
No longer do veterinarians have to choose between integrative practice and evidence-based care, especially when it comes to medical acupuncture, these experts say. In fact, there are more well-controlled clinical trials for acupuncture than for many approaches considered conventional, Dr. Robinson says.
A search on pubmed.gov using the terms “systematic review,” “meta-analysis” and “acupuncture” produces nearly a thousand results, Dr. Robinson notes, adding that the literature supports the use of this modality not only for pain but also for improving brain, spinal cord and peripheral nerve function; digestive, cardiac and urologic activities; and quality of life in patients with systemic illness and cancer.
“While the bulk of research has taken place in humans, most of the physiologic underpinnings of acupuncture have been studied on experimental animals, attesting to its translational effectiveness,” she says. Dr. Robinson adds that she sees acupuncture as a mainstay of Fear Free practice, “where the treatment of animals is not only gentle and considerate but also effective and low-risk.”
Dr. Downing relies heavily on acupuncture in her pain practice. “When we talk about acupuncture, what we’re really discussing is neuromodulation,” she says. “We’re adapting the nervous system by stimulating different points on the body using a needle that alters electric neural activity. It’s not a panacea, but it can certainly have an impact on many different disease processes.”
With Dr. Downing being located in Colorado — “where the hip come to trip,” as she puts it — clients tend to be very receptive to acupuncture and other integrative approaches, especially once they observe their pets becoming more comfortable with treatment. Plus, acupuncture benefits her bottom line because it allows her to layer appointments in a way that maximizes her income from doctor-provided services.
“The doctor’s the one who needs to figure out what acupuncture points to stimulate, the doctor needs to put the needles in place and the doctor needs to decide if there’s going to be electrical impulse in the needles,” Dr. Downing says. “But the doctor doesn’t need to be there for the whole treatment. That makes it very cost-effective because it allows me to move on and do other things. The typical treatment period in my practice is 30 minutes, and I can get a lot done in that time.”
Phototherapy, or photomedicine, is the use of light to affect tissues. This category includes laser therapy, which more recently has come to be referred to as “photobiomodulation,” as well as the use of light-emitting diodes (LEDs). “This is a younger field but one that’s steadily accruing evidence,” Dr. Robinson says.
Many of the mechanisms of photomedicine, such as tissue repair, tension release, circulatory recovery, immune support and neuromodulation, overlap with medical acupuncture, Dr. Robinson says, but the interface is obviously different. Photomedicine utilizes light to engender changes in tissue and organismal behavior instead of a needle.
Dr. Downing uses laser therapy frequently in her pain practice. “We know with photobiomodulation that we get an increase in microcirculation, a decrease in inflammation and a change in nerve conduction velocity — how nerve signals are transmitted,” she says. “Those tissues are affected by two things: wavelength and power density. That’s why it’s important for practitioners to know what they’re doing.”
For veterinarians who want to do a deep dive into photobiomodulation and understand how to utilize it effectively, Dr. Downing recommends the recently published textbook Laser Therapy in Veterinary Medicine: Photobiomodulation by Ron Riegel, DVM, and John Godbold, DVM (onlinelibrary.wiley.com).
While many practices find photomedicine beneficial to their bottom lines, it’s most effective when part of a more extensive neuromodulatory and systemic approach incorporating acupuncture and massage, Dr. Robinson says. The typical default “point-and-shoot” methodology can be ineffective at best and harmful at worst.
Nutraceuticals and Herbal Medicine
One of the most significant changes in the nutraceuticals arena has been the arrival of cannabinoid medicine for veterinary patients, Dr. Robinson says.
“I love seeing in my lectures and workshops how much intellectual curiosity many in the veterinary field have,” she says. “They’re eager to learn how cannabis works, what the endocannabinoid system is and the pharmacology of cannabinoids and terpenes. They become indignant about issues surrounding quality control and testing.”
The problem? Veterinarians don’t necessarily apply the same rigorous mentality to other herbal products, she says. “Veterinarians should think twice (or three times) when a charismatic instructor tells about the wonders of a mysterious mixture in a pretty little bottle without offering one bit of substance about the pharmacologic mechanisms of action or the risks of herb-drug interactions, contamination and product adulteration.”
Dr. Downing also says to be wary of companies that throw an ingredient into their product claiming it has a positive clinical effect when the study was conducted on another product and possibly even in a different species. “Veterinarians need to demand that manufacturers provide us with data from clinical studies utilizing their product in our target species using a vigorous scientific method,” she says. “Safety needs to be shown, too.”
That said, Dr. Downing does support some nutraceuticals she says have been shown to be safe and efficacious in clinical studies, especially for osteoarthritis, including YuMOVE ADVANCE 360 from Lintbells (yumoveadvance360.com), Duralactin from PRN Pharmacal (prnpharmacal.com), Movoflex from Virbac (us.virbac.com) and Flexadin Advanced from Vetoquinol (vetoquinolusa.com).
With the creation of the American College of Veterinary Sports Medicine and Rehabilitation (vsmr.org) and the establishment of a new specialty in 2010, rehabilitation has become more established than ever before. But practitioners don’t need to become specialized to incorporate rehab into their practices, Dr. Downing says.
She recommends the textbook Canine Rehabilitation and Physical Therapy by Darryl Millis, DVM, DACVS, CCRP, DACVMSR, and David Levine, PT, PhD, DPT, DABPTS, CCRP (caninerehabpt.com), which includes detailed instructions on range of motion, number of repetitions, the application of heat and cold and therapeutic exercise.
“There’s a tremendous number of educational tools to help veterinarians dip their toe in the pool of providing rehabilitation even if they don’t want to dive in and do the whole credential thing,” Dr. Downing says.
It’s relatively easy to get started with your existing facility and a low-level equipment investment. “You don’t have to build a new suite in your hospital or purchase an underwater treadmill,” she says. “Resistance bands, balance balls and Cavaletti poles are not expensive and they don’t take up a lot of space.”
Massage doesn’t call for any special equipment, but it does require training, Dr. Downing says. “People who do massage all the time tend to do it particularly well, especially when they’ve been formally trained,” she says. “It’s a useful training and it’s not very expensive.” Plus, clients can be trained to provide some massage techniques at home, which allows them to take an active role in helping their animals.
Dr. Robinson says many veterinarians consider using rehabilitation only after surgery or injury, but its potential is much greater. In fact, her definition includes not just physical therapy–type techniques but most of the modalities discussed above. “My version [of rehabilitation] is ‘integrative rehabilitation,’ which includes medical acupuncture, medical massage, photomedicine and judiciously selected botanical products,” she says.
Consistent and skillful application of the techniques involved in integrative care may help your patients avoid many of the more invasive procedures and drug side effects associated with mainstream veterinary medicine. With patients healthy and clients happy, your practice’s bottom line will grow — along with your joy in practice.
School of Thought: Integrative Medicine in the Veterinary Curriculum
Integrative medicine courses are now common
When deciding how to teach veterinary students about integrative medicine, Michigan State University took a novel approach, says Betsy Carr, DVM, DACVIM, PhD, DACVECC, CVA, an associate professor in the College of Veterinary Medicine. The school opted to partner with CuraCore Vet, an acupuncture training program founded by Dr. Narda Robinson to offer complementary medicine training to its veterinary students.
Students sign up during their third or fourth year and complete the online materials at their own pace. After this, they’re eligible to participate in the hands-on clinical intensive portion of the course on site at MSU. The CuraCore-MSU partnership lets students graduate with their certification completed, Dr. Carr says.
Since the program launched, the teaching hospital has seen increases in both inpatient and outpatient acupuncture services, and research endeavors have also begun.
“As certified veterinary medical acupuncturists, these students have skills that make them highly competitive job applicants,” Dr. Robinson says.
Many veterinary schools also have courses available for students interested in integrative medicine. Here’s a sampling of offerings at U.S. veterinary schools, according to information available on the schools’ websites:
Fourth-year students participate in physical rehabilitation evaluation to diagnose movement dysfunction, designing and implementing an evidence-based treatment plan to restore, maintain or enhance optimal physical function after injury, surgery or disability.
Western University of Health Sciences
Complementary/Alternative/Integrative Medicine Practice
This clinical rotation for fourth-year veterinary students focuses on alternative, complementary and homeopathic medicine in managing animal health, including the diagnosis and treatment of common diseases and conditions.
Alternative and Complementary Therapeutics
This program offers an examination of mechanisms and efficacy of alternative and complementary therapeutics used in veterinary medicine.
University of Florida
Integrative Medicine Clerkship
Students learn about acupuncture and rehabilitation and perform modalities such as laser, therapeutic ultrasound, neuromuscular electrical nerve stimulation, transcutaneous electrical nerve stimulation, shockwave therapy and underwater treadmill therapy.
Integrative Medicine and Rehabilitation Clinical Rotation
This program emphasizes clinical application of integrative and rehabilitative therapies for cases that may be expected in veterinary practice.