CuraCore Academy Talks
IRPM v TPLO CHART
March 2022
Hi MOVE students, this is Narda Robinson, one of your instructors. I am going to describe in a brief video how best to use the chart that you have here that compares integrative modalities, integrative rehabilitation and physical medicine, IRPM modalities, with the mechanisms that they impart, specifically in this case for cranial cruciate ligament disease, and compare it briefly to the tibial plateau leveling osteotomy or TPLO procedure. So go ahead and download that. You can print it, you can post it on your wall at your practice. And mainly I wanted you to have a handy chart that was not only full of check marks about what these individual items do, but also the references. So there’s four pages of references and that’s what the numbers in the chart indicate, so we’ll go over that as well.
So let’s get started. So our objectives, as I just said, are to compare and contrast the mechanisms of IRPM versus surgery TPLO, and describe how this approach is used for cruciate here. But in other classes we will watch how the modalities and their mechanisms of action apply to the mechanisms of disease for different clinical conditions. And here is the chart, and you can see there the check marks. So for each modality, I just looked up what were one or two references that could substantiate the clinical effects that we see, listed on that upper row. And so it’s not extensive. It’s not comprehensive. But it’s just an indicator, because there’s so much research that I could have gone on for many days listing all of the citations. But I just wanted to encapsulate it to help you choose from all these different treatments that we can recommend for animals and for their people to employ or apply at home, or to pursue at the clinic.
This is the rationale for why we might choose one over the other, but first we have to identify what actually is the problem. So we’re talking here about cranial cruciate ligament injury or disease in dogs. And you know a lot of times that’s presumptive because we really don’t know what the status is of that cruciate ligament. As we see here on the right then, there could be a number of conditions. There are various ligaments as you know. There are different tendons, muscles, there’s circulatory, neurogenic, all kinds of aspects, edema, and the tissue. So what are the lymphatics doing? So all kinds of considerations that we as IRPM practitioners are going to be evaluating with myofascial palpation.
I’d like to grab my dog here, so palpation, identifying where is the source of pain. What’s the characteristic of it? Is it inflammatory? Is it neuropathic? Is it myogenic? What is that? And where is it? How extensive is it? What are the compensatory pain patterns resulting from it? How do we address those? So we’re not just going to think of one area. We’re going to think of the whole dog.
So what needs fixing? Well what’s involved here? And these are human stock photos from Shutterstock, most of them but not all of them, because they really help us depict and relate as humans to what’s going on in the knee. So there’s pain. There’s pain locally. And then that can become widespread as we adjust our walking behavior, as we get more sedentary, and all that. Same with the dog inflammation. And we know all the characteristics of that rubor dolor calor
Tumor, and then the loss of function as well. So swelling was one of those and that’s going to be throwing things off. It’s going to reduce function. There’s tissue injury, whether or not you’ve had surgery or will have surgery. There’s tissue injury that has happened as a result of whatever mechanical strain, whatever kind of trauma, whatever kind of just degradation and prolonged inflammatory kind of cascade that’s been going on in that joint.
Myofascial dysfunction is something that most orthopedists don’t really know about unless they’ve taken another course to teach them about the soft tissues and the soft tissue pain. So it’s up to you to do your myofascial palpation and really determine what muscles, what strain patterns, what may be referred pain patterns are involved, so that you can treat it with your IRPM approaches.
Now when you have any kind of joint pathology you’re going to eventually get some weakness because you’re going to unweight or you’re going to have some kind of neuropathic involvement. And so you become deconditioned. You get easily fatigued, you have strain patterns elsewhere from where the original problem was. And your endurance is compromised, which then leads to stress and distress, because you’re sort of immobilized. You can’t get your activities of daily living completed. And if you’re an animal you know you could be facing death because maybe this is too much, too costly, too daunting for your person to deal with.
Another aspect is the circulatory compromise that happens as a result of muscle tension of neurovascular mayhem going on because of maybe some compression. Or if there was a surgery there could have been a lot of blood loss. And there can be infection. And the inability of those vessels to not only bring good oxygenated blood with maybe some antibiotics, but also to get rid of the metabolic end products, to get rid of the waste, metabolic waste, in the lymphatic tissue and in the venous system. So we want good inflow and outflow. And that doesn’t always happen, especially if an animal is considered to be needing crate rest or imprisonment in a small area and cannot bear weight as they need to and nourish the joints and all of those other components in that structure that really need weight bearing to get the blood gushing through.
Neurologic compromise. That can happen with or without surgery. So neurologic compromise might have been the inciting factor because perhaps there was something that caused a muscle strain, some kind of movement that is then compressing on a nerve and reducing the amount of afferent volleys to the brain spinal cord and then disrupting the ability of that sensory motor control over joint integrity. That has to come from the brain and spinal cord. So we’ll be looking at that as well. And then when all this happens you just get more instability on top of whatever instability you might have had before.
So what is to be done? Well if you go to a surgeon it is likely that they will say you need a TPLO -tibial plateau leveling osteotomy- for the dog. Or that’s what you should prescribe as a veterinarian. Or you’re told in vet school this is the gold standard. Well you know we need to look at that more because I certainly don’t feel that that is the case. I feel it is extremely traumatic, unnecessarily traumatic, and does damage.
So what’s the evidence that TPLO is the gold standard above non-surgical integrative rehabilitation and physical medicine? Zero. Empty. So is it safe? Well let’s talk about that. So Complications of Tibial Plateau Leveling Osteotomy and Dogs from 2012. Yeah it’s from 2012. It’s about 10 years ago now but didn’t stop anybody from doing it. And now you can go on a boat or a weekend course or whatever it is, as a GP, and learn this yourself, which has problems. So I’ll just read the abstract for anybody that’s listening to this just while you’re walking around. “The tibial plateau leveling osteotomy is one of the most common surgical procedures used to treat cranial cruciate ligament disease in dogs. Complications occurring during or after TPLO can range in severity from swelling and bruising to fracture and osteomyelitis (and I would add death and amputation, so there’s a lot worse things that can happen after fracturing, osteomyelitis, including cancer, then what do we do? We’re gonna amputate, we’re gonna euthanize, we’re gonna do chemo radiation. The problems just keep mounting and compounding. It’s like interest on your house or something.) 10 to 34, so up to a third of or a little bit more of TPLO surgical procedures are reported to experience a complication.”
How many of you have been told that? If you’re a practitioner and you’ve brought your own dog in, like do you expect really to have one out of three have a complication? And approximately two to four percent require revision surgery to address the complication. I mean but are you told this? Like in the old days when they say, med school or maybe vet school too, look at your right, look at your left, one of you three are going to flunk out. So it’s really that high. Approximately two to four as we said require revision surgery. So who pays for that? The client. Why couldn’t they have tried to avoid it in the first place? Why aren’t they told the facts?
That’s what the chart is about. You will have the facts. And you will have references, and know that that’s only the beginning. That you can explore any of these further by going on pubmed.gov and searching acupuncture, inflammation, massage, myofascial dysfunction, pulsed electromagnetic field therapy, and so on. You can build out more references for that chart.
And also for those of you in the MOVE course, we’re going to take a deeper look at each of the modalities that are listed there. So although the risk factors for many complications have not been fully assessed, now we have 10 more years for more risk factors to be assessed. “The best available evidence suggests that the complications of TPLO can be reduced with increased surgeon experience, careful surgical planning, and accurate execution of the surgical procedure.” Yeah if you’ve been through a surgery residency and beyond that’s different than your weekend course on the boat in the Cayman islands and learn how to do it. “Identification of known or suspected risk factors in intraoperative technical errors allow subsequent action to be taken that is aimed at decreasing postoperative morbidity. There is a need for prospective studies.” Yes there is. But there’s also a need for studies that compare surgery to non-surgery and see what is more effective.
But non-surgery is not just putting them on pain relieving substances and keeping them in a box. Non-surgery is all this stuff and this is why. Okay so Risk Factors for Severe Postoperative Complications and Dogs with Cranial Cruciate Ligament Disease: a Survival Analysis. This is from 2021. So look at this. “Three surgical techniques, lateral fabellotibial suture, tibial plateau leveling osteotomy, and tibial tuberosity advancement. Most common severe postoperative complications were surgical site infections or complications relating to the implant. And then severe post-operative complications occurred in 31 percent of the stifles treated with TPLO, 22 percent of the stifles treated with the suture, 25 from TTA.” Okay. Complications exist. And now look at what surgeons that write about TPLO say. Yep, “it’s one of the most common causes of pelvic limb lameness” is this cranial cruciate ligament disease. And yeah, “TPLO has been well described.” They say “it neutralizes tibiofemoral shear force by altering the tibial plateau.” So bringing it flat after sawing the bone and then moving that top of the tibia. Okay so yeah, that’s fairly invasive. “And subsequently restores normal limb function.”
It’s not normal when you’ve changed the bony architecture. It’s not normal when you have a plate in here. It’s not normal when the majority of dogs post-op develop patellar tendon thickening and other problems. It’s not normal to develop these severe post-operative complications that can then do whatever kind of mayhem to the joint. It’s not normal when you then have one joint that has been changed and acts like more of a peg leg, and the other one has to adapt, and the other one, and the other one. And then your back has to adapt as well.
And what kind of strain and force changes does that exert on the intervertebral discs? Which make me think of the relationship between TPLO and intervertebral disease. Because I see so many older dogs have had TPLOs and have intervertebral disc disease. Is a relation is there? A relationship we don’t know? Hasn’t been studied? But it’s always curious to me what happened first. Or was there a missed intervertebral disc disease with neurologic problems that was interpreted as a lameness? Then they got TPLO. Well that didn’t really fix it. That made it worse.
So with this abstract from this article, you know it paints a rosy picture of the TPLO. No wonder so many people just refer for it automatically. Pelvic limb lameness? Send them to ortho. Okay. “Widely acceptable to dogs ranging from small breed to giant breed.” Yeah well really even a small breed dog, why are you doing this to the smallest breed dogs, never mind the bigger ones, which I would have a problem with, but the smallest ones, or cats. Why are they getting TPLOs? “Does not appear to have some of the limitations that exist with alternative surgical options.” Well, none of them have been shown to be superior, clearly. And again from surgeons, “this review concludes the TPLO is an excellent treatment option for any dog with CCL rupture due to the excellent long-term outcome and higher rate of owner satisfaction as previously reported.”
Yeah, well let’s look at those long-term outcomes, and as we do that, all right, Association of Tibial Plateau Leveling Osteotomy with Proximal Tibial Osteosarcoma in Dogs: a Long-term Outcome. I don’t think the clients are that happy about that all. So they studied these animals and case controlled them and all that but in the center there, “results after adjusting for body weight in the multi-variable model dogs with a history of TPLO were 40 times as likely to develop proximal tibial osteosarcoma as were dogs with no history of TPLO.” And then should you become deconditioned and sedentary and fatter, then “each kilogram increase in body weight was associated with an 11 percent increase in the odds of coming down with osteosarc.”
So why rush into surgery?
Breathe and then think of integrative rehabilitation. So how do we do that. We don’t imagine chi. We don’t think that chi moving is responsible for helping our animals improve with acupuncture. We don’t just press a button on the laser machine and say “well somehow this light is going to do stuff and I don’t know how it works, I don’t even know what my machine can do really, specifically, but I know that I shine it on the knee, or I have my tech do it, and it seems to work well.”
Let’s not do that. So we’re going to determine approaches based on goals. We’re going to see acupuncture, which works through neuromodulation and connective tissue revision, as we will explore later in the course. CBD as an example of a cannabinoid that can have pain relieving, anxiety relieving, neuroprotective effects. Shockwave therapy, which is the application of acoustic waves onto tissue, which can be good for tissue repair. Hyperbaric oxygen therapy has been used, and that just helps the oxygen amount in the tissues increase. Then we have massage, which is good for a whole host of things, in many ways similar to acupuncture, less specific on the neuromodulation, but still has body-wide effects. Neuromuscular electrical stimulation, whose high point benefit is to increase that muscle strength and endurance. And orthotics and bracing to help them get on their legs again, to do things as the tissues are healing. And we’re controlling pain. The pulsed electromagnetic field therapy like the Assisi loop, that can help not only the tissues improve but also relieve pain. And photomedicine, a lot of overlap again with acupuncture and massage, but can be a little bit more handy and easy to do for the tissue repair and lack of swelling, but still both are important. Platelet-rich plasma for its growth factors, and we don’t know fully what else, or exactly how best to prepare it, but it seems to be helping with some of that tissue repair, and perhaps stability, just because it’s less painful. But it’s not going to regrow your cruciate ligament. The TENS unit as an electrotherapy approach like electro acupuncture, and kind of like neuromuscular electrical stimulation, but more for pain control in general, some tissue effects. And then we have therapeutic exercise, which you have to know how to do properly, because if you’re just in a sort of assembly line kind of rehabilitation context, then you could easily be over exercising animals, or having them pursue movements that are not good for them, or they are not ready for. And if you don’t have somebody working with that animal specifically monitoring muscle activation, monitoring the neuromotor effects, and the programming or patterning that you’re finding there, then you won’t know if that exercise or movement therapy is doing what you intended to do for that animal. So it has to be one-on-one to be done correctly. We cannot have assembly line rehab. Unfortunately that happens too often. And then therapeutic ultrasound can have its own effects. Again we’re having acoustic waves come into the tissue and helping with some of the pain, and also some of the tissue health. Then of course there’s underwater treadmill. Get them walking again. Get them supported by that water and have some resistance, carefully identified where we want that water level, but that can help with their deconditioning, to help them become conditioned. It too can also be overdone, so you have to be careful with that.
So here is the chart, and as we see the comparison we can look at acupuncture. And acupuncture checks all the boxes except for that increased muscle strength or endurance. But by controlling pain, inflammation, reducing swelling, improving joint motion, reducing myofascial dysfunction, all of those other things, then that patient may be more ready to get up and go, whether that’s in the underwater treadmill or some type of other movement, or just walking around the house. Cannabidiol as a cannabinoid has also some value in controlling pain, reducing inflammation, calming the patient, and possibly improving proprioception and joint stability by means of helping reduce the neural inflammation, helping those nerves be supported and protected and recover. So then we have shockwave therapy which can reduce pain and stiffness and promote healing, and also improve circulation, and you know potentially neuroprotection by means of its regenerative value. HBOT, the oxygen therapy hyperbaric, mostly for tissue healing.
So as we go through each of these, when you’re in your clinic seeing an animal, I designed this so that it can help you understand what are the strengths of each modality, what might we put together as a treatment without going crazy and just throwing everything in there, to best meet the needs of that patient at that time, that the client is capable of doing, or affording, or interested in.
So massage checks most of the boxes except the neuroprotection and functional connectivity. It’s not so specific for nerves but all the others I could find evidence for. So that’s really a value. Neuromuscular electrical stimulation, mainly for the muscle strength, keep that going. And then for soft tissue healing. A brace, while it only has two checks in here, yeah if your knee is more stable that’s going to help with pain, and it’s going to help with you growing that muscle stronger, so that you are more stable and can pursue the other therapies, and not just be stuck in a box for weeks on end.
Pulsed electromagnetic field therapy has a number of values too as you see here with pain, inflammation, healing, circulation, and potentially some of the proprioceptive value. Photomedicine has quite a few things, but what that doesn’t have that acupuncture has, is that direct impact on the myofascial strain patterns. If you have a Class 4 I think that that is probably the most effective for helping to relax muscles in the broad body because it just takes less time. And I actually do like the heating. But I don’t like the preset parameters as many of you have heard me say. I think they’re way too high, but if you do it correctly, a lot of these practices depend on that practitioner knowledge. Are they approaching scientifically, whole body, in a comprehensive fashion? Those of you through my acupuncture course know of my MAIN approach- medical acupuncture and integrated neuromodulation- where we’re looking at the central, peripheral, and autonomic pathways, as well as the myofascial connective tissue. So we want to approach a lot of different avenues but laser therapy is really important. PRP- platelet-rich plasma, has been shown to be important for pain control, for promoting tissue healing, and maybe helps with joint stability. But it’s not increasing the connection of that cruciate ligament, but it’s doing something, and it probably has some circulatory value as well.
TENS is another electrical therapy, as we had said, so there’s a lot of overlap with acupuncture. But it’s not as discreet in terms of which nerves you’re impacting. And it’s not going to get the myofascial dysfunction in the same way that acupuncture can. Therapeutic exercise checks all the boxes. Just has to be done right by somebody that is caring and attentive to that patient’s needs. So you need to know how to monitor whether that patient is succeeding or they’re decompensating. Therapeutic ultrasound has a number of values in terms of healing and just those tissue effects, pain, inflammation, swelling, all that.
And underwater treadmill is very good for the endurance, as we said, and can control the other problems just by that joint motion and exercise. Again could be overdone or done poorly, so we need adequate training. Underwater treadmill controls pain, decreases inflammation and stiffness, but that’s because you are moving and you’re in water, and there’s a certain amount of hydrostatic pressure there so that can increase your muscle strength and endurance. It can improve your functional connectivity, your proprioception, and joint stability. So it has wonderful potential. Again needs to be done in a careful manner.
What about the TPLO for pain, inflammation, swelling, tissue health? No. What about myofascial dysfunction, the strain patterns, muscle strength or endurance? Not really. I mean it might help initially after the post-operative operative recovery period because they can use that limb again. It’s not a normal function, but what I see is that limb mainly works as a sort of wooden leg. It all sticks together so it’s not this free range of motion. There’s been plating, there’s been renovation of the architecture. And everything else has to adapt.
And no wonder the surgeons will say “you better start saving for the next TPLO,” because things are going to be thrown off. If we don’t have to do surgery, why are we funneling these dogs straight to orthopedics, and straight into surgery, and the whole host of complications that can result? It’s certainly not calming to the patient to wake up with your leg having been sawed into and then pasted together again with the bone plate. That is not helpful for your systematic physiologic regulation to have that much sympathetic activation. You are damaging the circulation, especially if you have lots of blood loss.
And then infection that’s going into the circulation, neuroprotection, and functional connectivity. Not so much. You’ve just disrupted a whole host of nerves at that pes anserinus when you lifted that soft tissue and went in with your bone saw. Improve proprioception and joint stability. I mean the TPLO itself is not a stabilizing thing in terms of just keeping that stuck it might provide some more platform for that femur to ride on, but there’s now all kinds of other problems, pivot shifts, and all kinds of things that can disrupt the stability thereof. Improve proprioception and joint stability. Well yeah again, you’re stable if you have essentially a leg that doesn’t move well and you’ve disrupted all of those nerves at that pes anserinus so I give it all Xs.
So it’s okay to say no to surgery. If you’re a veterinarian and you’re concerned about not following standard of care, then what I suggest usually to my students is give clients an accurate, evidence-informed, scientifically based, thoughtful delivery of all the information that is available. And you can use handout as help for what are the pros and cons of integrative rehab and physical medicine versus the TPLO. And let them decide. Shouldn’t they be the most informed, instead of saying “oh laser doesn’t work” or “oh no, it’s not ever going to be as good” or “oh, if you don’t get surgery there’s going to be more arthritis.” None of that is factual and yet at CuraCore Academy, at the school, we receive probably about weekly requests, either email or from the phone, from clients, that we don’t have, but clients that find us because I think I have a lot written about TPLO out there. And they’re looking for options and they’ve been told the things that surgeons often deny “oh no we never said that there would be less arthritis there, oh no we never said that you know such and such didn’t work.” So people are desperate for answers, and you can give them facts, and then you can always try a round of IRPM. Give it six to eight weeks. Is there improvement? Was this diagnosis even accurate? So with your myofascial palpation, are there trigger points that are referring pain to the knee, or elsewhere that’s causing the dog to be lame? So it really requires more thorough diagnosis, more thoughtful assessment of the whole dog, and more options for people i.e. integrative rehab. Yes. Do that. If you have questions give us a call or email us. If you’re a student in our course then you know the way to get to us. If you are not a student in our course yet and you want more information go to our website: curacore.org.
Thanks for listening.