Pain Case of the Month: Vito—Successful and Methodical Treatment of a Routine Pain Case

This case demonstrates how photobiomodulation therapy (PBMt, oftentimes referred to as laser therapy) was used as an adjunct to traditional veterinary medicine to heal a crushing injury to the carpus of a canine patient.

Vito presented with hip pain and muscle loss in his hind legs.

by Loris Barale, DMV

Introduction

This case demonstrates how photobiomodulation therapy (PBMt, oftentimes referred to as laser therapy) was used as an adjunct to traditional veterinary medicine to heal a crushing injury to the carpus of a canine patient. PBMt is not intended to replace conventional veterinary medicine but is a very valuable and effective adjunct modality to consider. It is safe and with no known side effects when treatments are carried out appropriately and at an appropriate total target dose for the specific site and condition. Tissues that are painful, inflamed, or need to be healed are all valid candidates for PBMt. Tissues treated will potentiate the body’s ability to heal itself and enable the patient to recover more quickly and with less maladaptive pain.

Signalment and History

The patient, an eight-year-old spayed female Great Pyrenees (67.4 pounds), had been missing in the Nevada desert for four days when the owner found her with her right foreleg caught in a trap. The paw was very swollen, and the patient was only toe-touching lame on that limb. The owner gave the patient a human aspirin and took her to the local emergency overnight hospital.

The veterinarian at the emergency clinic was unable to accurately palpate the metacarpals and phalanges because of the amount of soft-tissue swelling. The affected site was reported to be warm, with the skin having no visible laceration but very red over the metacarpal area and more purple over the digits. The primary concern was for vascular compromise. The owner was advised that it may take several days for the wound and extent of injury to fully declare themselves. It was determined that the patient may require surgery to debride necrotic tissues. Radiographs taken revealed soft-tissue swelling of the carpus, metacarpals, and digits. Complete assessment of the radiographs was limited by oversaturation of the distal phalanges. The patient was hospitalized for overnight care but remained markedly lame on the right foreleg. Upon release from the emergency clinic, the owner was advised to seek continued care with his regular veterinarian and that follow-up radiographs be repeated in 10 to 14 days to reevaluate the skeletal structures for evidence of septic osteomyelitis.

Diagnosis and Exam Findings

The patient presented limping, painful, and non-weight-bearing on the right foreleg with a pronounced contraction of the carpal joint and marked inflammation with discoloration and tissue edema ranging from the carpus and continuing distally and circumferentially including the metacarpals and all digits. The patient was self-mutilating by licking and nibbling at the site actively and had an overall reduced quality of life in comfort level and ability to ambulate.
The patient presented the following day for continued care. The client reported that the swelling at the paw had gotten worse since the patient had been discharged from the emergency clinic and that the paw remained hot to the touch and with red discoloration to the skin. At presentation to us, the patient showed significant weight-bearing lameness, with the digits warm and the palmar surface moist and effusive to the touch with a yellowish hue. There were no necrotic areas. The client was advised to start the nonsteroidal anti-inflammatory drug that evening, continue epsom salt soakings, and start ice treatments. The client was also advised to start PBMt if there was little or no improvement over the next 48 hours.

The patient presented to us for the second time 14 days later. She had remained non-weight-bearing on the right foreleg since the initial insult. The affected region remained swollen and in a contracted position where the patient walked on the dorsal surface. The patient did not lay the paw flat out to walk, was visibly limping, and was painful in that area. The veterinarian concluded that the crushing injury had caused tendon contracture and residual neuropathy. The client was advised to continue ongoing medications, start gabapentin, and start PBMt.

Treatments

PBMt started two weeks post-insult after continued lack of improvement seen from conventional medical care.

The approximated tissue surface area of 100 cm² was treated with a total target dose of 987 joules per treatment, thus 9.87 J/cm².

The site was treated with a contact massage technique to maximize absorption and in a circumferential manner while putting the joint through a range of motion during the entire treatment as best as the patient would allow without undue pain or resistance.
Treatment frequency was daily until a clinical effect was seen in a palliative way (decreased lameness, improved gait with adequate weight bearing, improved range of motion, and body language indicating an acceptable level of comfort), then every other day until resolution or a peak plateau effect was seen in both pain management and mobility improvement. Because of scheduling constraints from the client, treatments were carried out as indicated in Table 1.

Discussion

While PBMt was used as an adjunctive modality, it is important to note the lack of improvement on the patient’s part for weeks after traditional modalities had been initiated. Only once PBMt was initiated did the patient’s status immediately and consistently follow a positive glide path until resolution was attained. PBMt proved to be the keystone, the turning point for a patient not effectively responding to conventional medical modalities. By using PBMt, resolution was attained for this patient who did not respond effectively to conventional medicine. The injured site, which was initially painful, damaged, and not functional, healed well and the patient regained her full quality of life via a palliative response and regained full use of the limb.

Resolution was attained and the patient continues to do well without any reports of setbacks. While it is not a magic wand or panacea, it is the closest thing to such for some patients, especially the ones with limited options because of concurrent organ debilitation or the ones who are not effectively responding to traditional medical modalities. Although we have come a long way since research and delivery were initiated, we still have much to learn to fully harness the potential of this modality.

PC_02.jpg PC_03.png

Figure 1
Radiographs showed changes in both the acetabulum and the head of the femur in both joints.

Figure 2
This chart shows the progression in Vito’s pain measurements in two-week increments.

Discussion by Mike Petty, DVM, CCRT, CVPP, DAAPM

There are many medical applications for laser therapy, but we don’t always think of them as we are putting together a treatment plan. In this case, it was an orthopedic and soft tissue injury that was not adequately responding to conventional therapy.

There are many other conditions that cause pain where a laser can also be used as part of the total treatment protocol: anal sacculitis, otitis, sinus infections, and skin infections just to name a few. Reach out to your laser company for what is often free CE on the use of their product or watch for conference and online CE opportunities. Dust off your laser and start getting a return on investment!

If you want to emulate this case, I encourage you to download and learn how to use the Canine Osteoarthritis Staging Tool. This tool utilizes the entire veterinary team, including the owner, in a systematic process of diagnosing, staging, and treating osteoarthritis. You can find more about it on the Elanco website.

Mike Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty offers commentary on each Pain Case of the Month.

 

Loris Barale, DMV, graduated from Dipartimento di Scienze Veterinarie, Università di Torino, Grugliascoin, Turin, Italy, in 2003. Since 2010, his interests have moved to the diagnosis and treatment of chronic pain. He is a member of the International Veterinary Academy of Pain Management. In 2016, he completed the executive master’s degree in anesthesia and pain therapy for dogs and cats with the Unione Italiana Società Veterinarie, American College of Veterinary Anesthesia and Analgesia, and Association of Veterinary Anesthetists and the head of the Unione Italiana Società Veterinarie work group on the study of pain. He is the author of a recent publication in the Open Veterinary Journal, “Preliminary Clinical Experience of Low-Level Laser Therapy for the Treatment of Canine Osteoarthritis-Associated Pain: A Retrospective Investigation on 17 Dogs.”

 

Photo credits: Photos courtesy of Loris Barale

Advertisement

Close

Subscribe to NEWStat