INTEGRATIVE MEDICINE

CURRENT TRENDS IN USE

COMMON CLIENT QUESTIONS AND CONCERNS

ACUPUNCTURE – HOW IT WORKS, WHEN TO USE IT, HOW TO GET STARTED?

SOME INTEGRATIVE MODALITIES TO CONSIDER IN YOUR CONVENTIONAL PRACTICE

MY TOP 3 SUPPLEMENTS/HERBS THAT CONVENTIONAL PRACTITIONERS SHOULD BE USING

Cheryl A. Cross, DVM, DACVP (Anatomic) Clinical Assistant Professor, Integrative Medicine The University of Tennessee College of Veterinary Medicine

1.

HOW TO ATTRACT WEIRDOS….. WITHOUT BEING WEIRD The top questions my best IM clients ask

1. Questions about food and diets a. Client education about terminology is incredibly helpful (see “What Foods These Morsels Be” – a guide to approved terms) b. Have the client ask the questions of the food companies (see Questions for Food Companies) c. The number one thing I try to tackle is obesity – often the most preventable risk factor our patients have (see body condition score chart attached) i. I give clients the sheet and ask them to score their pet ii. I have the pets back for routine weigh-ins free of charge 1. Goal weight loss 0.5 – 2% per week for cats and dogs d. Believe it or not, I sell a lot of Rx diets i. Why? How? 1. I tell clients it is like handing them a bottle of penicillin – I can guarantee what is in there and what isn’t in there 2. My most prescribed diets are JM, J/d, DM e. The Raw Diet Questions i. If they are very young or very old in the household, I forbid ii. I point out the risks there are to the humans in the house, largely iii. I insist on AAFCO balanced – many raw diets are too high in fat iv. Cost! f. The Grain Free Issue i. Axelsson E et al. “The genomic signature of dog domestication reveals adaptation to a starch-rich diet” Nature, Online January 23, 2013, DOI: 10.1038/nature11837 1. Researchers looked at the full genome of wolves and domesticated dogs and pinpointed where they differ. They isolated 36 regions that likely represent targets of selection during dog domestication. Half of these regions harbor genes tied to brain development or signal processing that occurs in the brain. The researchers also identified ten genes in other genetic regions that play key roles in the digestion and metabolism of starches and fats. They have put the genes tied to digestion to the test, determining that all three genes governing the three major steps of the breakdown of complex starches are used more effectively in dogs. ii. How tightly regulated are commercial diet claims anyway? g. Homemade Diets i. Can be wonderful for the right pet and owner ii. Great for attentive owners fearful about recalls or who want to control ingredients/additives/preservatives iii. Homemade diets can be useful for… 1. Elimination diets for food allergies 2. Increasing palatability for sick patients 3. Managing disease combinations that do not have a commercially available option 4. Renal disease + pancreatitis 5. Food allergy + renal disease 6. Obesity + hyperlipidemia + food allergy iv. Must be balanced v. Do not trust internet diets vi. Drawbacks? 1. Cost and time in the kitchen 2. No nutrient analysis and food trials 3. We insist on PE and minimum database after 1 month on diet and q 6 months afterward vii. Where to go for homemade diets that are balanced by a nutritionist? 1. University of Tennessee a. [email protected] b. www.vet.utk.edu/clinical/sacs/nutrition.php 2. UC Davis a. www.vmth.ucdavis.edu/vmth/services/nutrition/nutrition.html 3. Balance IT a. www.balanceit.com 4. Veterinary Nutrition Consultations, Inc. a. www.petdiets.com h. Vaccines i. I do offer titers 1. Cornell Diagnostic Lab or Hemopet for DAP 2. Kansas State Diagnostic Lab for Rabies ii. Client and pet selection is critical iii. Client education and risk assessment is critical iv. I tell clients if the titers are unimpressive, we must vaccinate v. I tell clients the legal ramifications if we do not vaccinate for rabies vi. The vaccine I routinely encourage in the at-risk dog? Intranasal bordatella i. Internet supplements/nutraceuticals/herbs i. Most formulas “kitchen sink” the herbs ii. Typically clients pay more than they would talking to a vet and get better quality iii. Susan Wynn “veterinary herbal medicine” has nice materia medica iv. Steve Marsden’s quick consult “Natural Veterinary Medicine” has some recommendations listed by system

SITTING ON PINS AND NEEDLES 2. Everything you ever wanted to know about acupuncture... and probably more! a. Introduction i. Long history of use – most likely 2000-4000 years old ii. Original practice a part of Chinese Medical Diagnosis 1. Chinese herbal medicine, Tui-Na, Food therapy 2. A very reductionist model would say it emphasized living in harmony with nature iii. Intended to keep workers healthy, not treat once sick iv. Many variations in style v. Medical Acupuncture a more modern approach 1. Trigger point therapy, neuromuscular approaches vi. Current teachings in vet med revolve around TCVM and MA typically 1. Being taught and used in a few veterinary schools (brief introductions) 2. Typically used as a standalone therapy when in vet schools and by some practitioners b. Mechanisms of action i. Complete MOA unknown 1. Cascade release of endorphins and monoamines 2. Alters peptide-rich milieu 3. Gate theory of pain transmission 4. Releases fascial planes 5. Treats trigger points 6. Dampens central windup ii. fMRI information shows it is more than placebo iii. Excellent for pain (musculoskeletal > visceral) 1. EAP 2. Moxibustion iv. Human studies – depression, anxiety, seizures, OA v. Most veterinary studies are on OA and pain (IVDD, etc) vi. Neuromodulatory and immunomodulatory vii. I always discuss “resting and digesting” with clients c. Studies are very contradictory and frustrating – why? i. Acupuncture in research is really not the same as in practice 1. Randomization 2. Static protocols 3. Sham needling 4. Blinding and bias 5. All approaches – TCVM to MA – emphasize individualization of tx d. Patient selection and disease selection i. Pain > internal disease (in theory) ii. Non-local points and local points iii. I ask clients to commit to a series (usually 4-6 tx one week apart) iv. I often combine acupuncture with laser therapy, or sometimes laser>acup e. Where to learn more i. www.ivas.org ii. www.tcvm.org iii. www.colovma.org iv. www.civtedu.org

EASY BREEZY BEAUTIFUL INTEGRATIVE MEDICINE 3. How to get started tomorrow a. Laser therapy i. Effects are not thermal ii. Chromophores 1. Melanin, water, hemoglobin, cytochrome C oxidase 2. End point of transcription/translation and “appropriate cell turnover” 3. Research has been done looking at potentiation or exacerbation of neoplasia a. Powell et al. The effect of laser irradiation on proliferation of human breast carcinoma, melanoma, and immortalized mammary epithelial cells. Photomedicine and Laser Surgery, 2010, 28(1):115-123. 4. Wavelength is important a. Optical window for therapy is red to infrared (600-700nm) 5. Treatable Conditions a. Infrared Wavelengths (800-1000nm)- Deep Tissue Penetration: i. Sprains & strains ii. Wounds and abrasions iii. Hematomas iv. Ligament & tendon injuries v. Inflammation vi. Joint injuries vii. Myofascial trigger points, pain points and deep-tissue acupuncture points viii. Chronic & acute pain ix. Non-union & small-bone fractures x. FIC (FLUTD) xi. Neuropathies b. Visible Red Wavelengths (630-700nm) - Shallow Tissue Penetration: i. Wounds & abrasions ii. Allergic reactions iii. Skin disease (pemphigus, allergic dermatitis, pyoderma) iv. Superficial acupuncture points v. Mucous membranes vi. Post-surgical wounds vii. Otitis c. Advantages: i. Ease of use ii. Ease of training 1. Wavelength (nm) 2. Power (Watt or J/s) 3. Treatment time (seconds) iii. Suggested doses (variable) 1. Analgesic effect: a. Muscle pain: 2 to 4 joules/cm2 b. Joint pain: 4 to 8 joules/cm2 2. Anti-inflammatory effect: a. Chronic: 4 to 8 joules/cm2 iv. Safety 1. Eye wear 2. Not in pregnancy 3. Not over malignancies? 4. Not over growth plates? 5. Not in animals on steroids? 6. Wash off iodine/furacin/pigmented medicines 7. Clip the fur?? 8. Do not apply over tattoos v. Efficacy vi. Easy to use in a variety of patients vii. Respond Luminex Ultra 1. Red and Infrared lasers in one unit b. Pulsed Electromagnetic Field (PEMF) therapy i. Extremely low frequency fields generated by external magnetic coils that induce electric fields in the body’s conductive tissue through inductive coupling ii. Produce eddy currents iii. Wraps, mats, or beds 1. easy to use at home iv. Biophysical interactions between the PEMF signals and biological tissues are not well understood 1. Most accepted MOA suggests external magnetic stimuli interact with cells either via transmembrane receptors or ion channels, initiating one or more signal transduction cascades or cell functions v. Anti-inflammatory and chondroprotective via upregulation of adenosine cell receptors vi. Increase in growth factor synthesis vii. Studies have variable design methods – hard to interpret as a group viii. FDA approved for non-healing, non-union fractures ix. OA x. Wound healing xi. OC lesions xii. Contraindications 1. Pacemakers/implanted defibrillators c. Acupressure/Home Massage Programs for owners i. Often good for client and patient ii. Slow, moderate pressure stimulates rest and digest 1. Pressure = blanch the fingernail 2. Toe tugs, running the spine 3. “Four Paws/Five Directions” by Cheryl Schwartz a. nice intro on TCVM points b. acupressure “recipes” and theory

I’VE GOT AN HERB FOR THAT! 4. Some of my favorite underutilized herbs/supplements for conventional practice a. Omega 3 fatty acids (fish oils) are beneficial for several disease processes i. Renal disease ii. Atopy iii. Arthritis iv. Multiple published dosing options 1. 1000mg capsule/10 pounds 2. 40mg EPA/kg 3. I start typically at 40-60 mg/kg EPA+ DHA a. GNC triple strength for large dogs b. DVM Pharmaceuticals or “snip tips” – a vet only product c. Keep in the fridge d. Watch for GI side effects e. High doses can alter platelet aggregation, especially in cats b. glutinosa i. Common Names: Chinese foxglove, di huang, sheng di huang (raw root of rehmannia), shu di huang (cured root of rehmannia), shojio (Japanese), saengjihwang (Korean) ii. Classic Chinese herb for “Kidney and Yin deficiency” – “thirsting and wasting” disorder iii. Selected Constituents: Bitter constituents (iridoids, including ajugol, rehmanniosides), phenylethanoid glycosides (verbascoside, echinacoside), sugars, sterols, etc. iv. Clinical Action: Antioxidant, aperient, bitter tonic, anti-inflammatory, antipyretic, antibacterial, diuretic, hepatoprotectant v. Kidney disease 1. In a study in which acute renal failure was induced in rats in an ischemia- reperfusion model, rehmannia root extract improved creatinine clearance, urine sodium excretion, and urine osmolality. In addition, administration of rehmannia influenced expression of certain renal electrolyte and fluid transport channels (Kang, 2005). In a diabetic nephropathy rat model, rehmannia extract reduced increases in BUN and glucose, as well as histopathologic changes in kidneys (Yokozawa, 2004). 2. In a Chinese case series, a combination of astragalus and rehmannia may have improved the clinical status of people with chronic nephritis, with significant improvement observed for 91% of the treatment group compared with 67% of the control group (Su, 1993). The classical formula liu wei di huang enhanced renal blood flow and reduced hypertension in rats (Li, 1974). 3. Rehmannia 6 vs Rehmannia 8 a. “R 8” has 2 additional “warming” herbs vi. Hemostasis a. Improvement of proliferation and differentiation on hematopoietic stem cells and bone marrow erythropoiesis progenitor cells b. Antagonism of coagulation time prolonged by aspirin vii. Anti-neoplastic properties a. Significantly enhanced T lymphocyte proliferation in vivo in tumor bearing mice and exerted an inhibition on tumor growth b. Rehmannia markedly increased P53 and C-fos gene expression increased intracellular gene expression in Lewis pulmonary cancer tissue viii. Immunomodulatory ix. Endocrine stabilizing 1. In laboratory animal studies, administration of the root seemed to reverse adrenal hormone production and morphologic changes associated with long- term steroid administration. 2. Diabetes a. Rats rendered hyperglycemic through various means were administered rehmannia extract and experienced lower blood glucose levels (Zhang, 2004a). The authors found that an extract high in stachyose was most effective (Zhang, 2004b). x. Atopic dermatitis 1. In humans and dogs, formulas that contain rehmannia reduce pruritus and other signs of atopic dermatitis. The human formula contained 10 herbs, including rehmannia, and was called zemaphyte. The veterinary formula consisted of three herbs: , white peony (), and licorice (Glycyrrhiza glabra). Investigators at the University of Minnesota studied 50 atopic dogs in a randomized, double-blind, placebo- controlled trial (Nagle, 2001). Dogs were given the formula just described or a placebo that contained dextrose and food coloring; they were assessed by veterinarians and owners. In all, 37.5% of the herb group improved, compared with 13% of the placebo group, but this was not a statistically significant difference. Deterioration of the itch score was significantly worse in the placebo group at the final visit, and more dropouts were reported in the placebo group because of worsening of clinical signs. No significant differences were observed in surface damage, seborrhea, coat condition, or general demeanor. xi. Contraindications: None described xii. Toxicology and Adverse Effects: AHPA class 2d. Contraindicated with diarrhea and indigestion. Safe—generally used over the long term, usually in formulas. Diarrhea was described in a small number of subjects in Chinese studies. xiii. Drug Interactions: None reported. xiv. Dosage: 1. Small Animal: a. Dried herb: 50-400 mg/kg, divided daily (optimally, TID) b. Decoction: 5-30 g per cup of water, administered at a rate of ¼-½ cup per 10 kg (20 lb), divided daily (optimally, TID) c. Tincture (usually 25%-35% ethanol) 1 : 2-1 : 3: 1.0-2.0 mL per 10 kg (20 lb), divided daily (optimally, TID) and diluted or combined with other herbs. Higher doses may be appropriate if the herb is used singly and is not combined in a formula. References Kang et al, 2005 .Rehmannia glutinose ameliorates renal function in the ischemia/reperfusion-induced acute renal failure rats. Biol Pharm Bull, 28, pp. 1662–1667 Li, 1974. Chinese Herbal Medicine, US Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Washington, DC , pp. 21–23 DHEW Publication No. (NIH)76–732. Nagle et al., 2001. A randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of a Chinese herbal product (P07P) for the treatment of canine atopic dermatitis. Vet Dermatol, 12 (2001), pp. 265–274. Su et al., 1993. Clinical and experimental study on effects of man-shen-ling oral liquid in the treatment of 100 cases of chronic nephritis. Zhongguo Zhong Xi Yi Jie He Za Zhi, 13 (1993), pp. 269–272 259–260. Yokozawa et al., 2004. Amelioration of diabetic nephropathy by dried Rehmanniae Radix (Di Huang) extract. Am J Chin Med, 32 (2004), pp. 829–839. Zhang et al., 2004. Hypoglycemic effect of Rehmannia glutinosa oligosaccharide in hyperglycemic and alloxan-induced diabetic rats and its mechanism. J Ethnopharmacol, 90, pp. 39–43. Zhang et al., 2004. Stachyose extract from Rehmannia glutinosa Libosch. to lower plasma glucose in normal and diabetic rats by oral administration. Pharmazie, 59, pp. 552–556.

c. Yunnan Baiyao (Paiyao) i. Classic formulation consisting predominantly of Astragalus and Panax notoginseng ii. Hemostatic powder – comes as a plaster and capsule also iii. Developed 1902 1. "Qu Huanzhang Panacea" which became Yunnan Baiyao ("White medicine from Yunnan” a. Battlefield remedy b. “Absorbs excess bleeding, invigorates the blood, enhances healing” c. Exact proportions and ingredients unknown (?) d. Oral dose prior to surgery e. Our surgeons have “dumped” into the abdomen f. Prior to nasal biopsies g. Hemangiosarcoma h. Dose is somewhat empirical; I use: i. Large dog – 3 capsules TID ii. Md dog – 2 capsules TID iii. Small dog/cat – 1 capsule TID iv. I use this often and usually when I need it, animals are dying and better to over- than under-dose

Reference Tang, Z et al (2009). "Effects of the preoperative administration of Yunnan Baiyao capsules on intraoperative blood loss in bimaxillary orthognathic surgery: a prospective, randomized, double-blind, placebo-controlled study." International journal of oral and maxillofacial surgery 38 (3): 261–6.

d. D-mannose i. Mannoside simple sugar found in cranberries, pineapple, other sources ii. Largely excreted in the urine 1. We used caution in diabetics/have had no issues with hyperglycemia 2. Prevents biofilm and thus bacterial bladder wall adherence 3. No noted/reported side effects 4. “Pure Encapsulated” – powder a. 1 scoop = ½ tsp. i. Large dog – ½ scoop TID (1/4 tsp) ii. Medium dog – ¼ scoop TID (1/8 tsp) iii. Small dog/cat – 1/16 tsp () TID – a “pinch” References http://www.modernmedicine.com/modernmedicine/Clinical%2BPharmacology/Investigational-agent-for-chronic-UTI-successful- i/ArticleStandard/Article/detail/751515?contextCategoryId=40184 Alton, G et al (1998). “Direct utilization of mannose for mammalian glycoprotein biosynthesis”. Glycobiology 8(3): 285-295.

Official Term Definition Term? A food that is made of raw ingredients, also called Bones and Raw Biologically Food (BARF). Raw is defined as “Food in its natural or crude state appropriate No not having been subjected to heat in the course of preparation as raw food food.” (Association of American Feed Control Officials, 2011 Official Publication, p.361) A food that does not contain any grains or grain-derived protein. It implies that the protein is derived solely from animal sources, but does not imply low carbohydrate or high protein as the food may Grain-free No contain non-grain carbohydrate. Grain is defined officially as “(Part) Seed from cereal .” (Association of American Feed Control Officials, 2011 Official Publication, p.359) Gourmet No A food that is allegedly composed of higher quality ingredients. Human grade refers to the quality of the finished product and is applied to a product that is legally suitable and approved for consumption by a human being in accordance with the Food and Drug Administration (FDA) Code of Federal Regulations (CFR) Human grade No Title 21. “Made with Human-grade Ingredients” does not mean that the finished product is actually, legally human grade. An ingredient may start off being fit for human consumption, but once processed in a pet food plant in accordance with regulations for animal feed-grade products, it is no longer “human-grade”. “A feed or ingredient derived solely from plant, animal, or mixed sources, either in its unprocessed state or having been subject to physical processing, heat processing, rendering, purification, extraction, hydrolysis, enzymolysis, or fermentation, but not having Natural Yes been produced by or subject to a chemically synthetic process and not containing any additives or processing aids that are chemically synthetic except in amounts as might occur unavoidably in good manufacturing practices.” (Association of American Feed Control Officials, 2011 Official Publication, p.360) “A formula feed or a specific ingredient within a formula feed that has been produced and handled in compliance with the requirements of Organic Yes the USDA National Organic Program (7 CFR Part 205).” (Association of American Feed Control Officials, 2011 Official Publication, p.360) Premium No A food that is allegedly composed of higher quality ingredients. Foods that are unprocessed and unrefined or processed and refined as little as possible before being consumed. Whole foods do not Whole foods No contain added ingredients (e.g. salt or fat). The term is often confused with organic food, but whole foods are not necessarily organic, nor are organic foods necessarily whole foods.

Body Condition Scoring (BCS) Systems. 5 Description 9 Point Point 1/5 Dogs: Ribs, lumbar vertebrae, pelvic bones and all bony prominences 1/9 evident from a distance. No discernible body fat. Obvious loss of muscle mass.

Cats: Ribs visible on shorthaired cats; no palpable fat; severe abdominal tuck; lumbar vertebrae and wings of ilia obvious and easily palpable.

1.5/5 Dogs: Ribs, lumbar vertebrae and pelvic bones easily visible. No 2/9 palpable fat. Some evidence of other bony prominence. Minimal loss of muscle mass.

Cats: Shared characteristics of BSC 1 and 3. 2/5 Dogs: Ribs easily palpated and may be visible with no palpable fat. 3/9 Tops of lumbar vertebrae visible. Pelvic bones becoming prominent. Obvious waist.

Cats: Ribs easily palpable with minimal fat covering; lumbar vertebrae obvious; obvious waist behind ribs; minimal abdominal fat

2.5/5 Dogs: Ribs easily palpable, with minimal fat covering. Waist easily 4/9 noted, viewed from above. Abdominal tuck evident.

Cats: Shared characteristics of BSC 3 and 5. 3/5 Dogs: Ribs palpable without excess fat covering. Waist observed behind 5/9 ribs when viewed from above. Abdomen tucked up when viewed.

Cats: Well proportioned; waist observed behind ribs; ribs palpable with slight fat covering; abdominal fat pad minimal.

3.5/5 Dogs: Ribs palpable with slight excess fat covering. Waist is discernible 6/9 viewed from above but is not prominent. Abdominal tuck apparent.

Cats: Shared characteristics of BSC 5 and 7. 4/5 Dogs: Ribs palpable with difficulty; heavy fat cover. Noticeable fat 7/9 deposits over lumbar area and base of tail. Waist absent or barely visible. Abdominal tuck may be present.

Cats: Ribs not easily palpable with moderate fat covering; waist poorly distensible; obvious rounding of abdomen; moderate abdominal fat pad 4.5/5 Dogs: Ribs not palpable under very heavy fat cover, or palpable only 8/9 with significant pressure. Heavy fat deposits over lumbar area and base of tail. Waist absent. No abdominal tuck. Obvious abdominal distension may be present.

Cats: Shared characteristics of BSC 7 and 9. 5/5 Dogs: Massive fat deposits over thorax, spine and base of tail. Waist 9/9 and abdominal tuck absent. Fat deposits on neck and limbs. Obvious abdominal distention.

Cats: Ribs not palpable under heavy fat cover; heavy fat deposits over lumbar area, face and limbs; distention of abdomen with no waist; extensive abdominal fat pad

Questions for a Pet Food Company:

1. Do you have a Veterinary Nutritionist or some equivalent on staff in your company? Are they available for consultation or questions? 2. Who formulates your diets and what are their credentials? 3. Which of your diet(s) is AAFCO Feed Trial tested? Which diet(s) has been AAFCO Nutritional Analyzed? 4. What specific quality control measures do you use to assure the consistency and quality of your product line? 5. Where are your diets produced and manufactured? Can this plant be visited? 6. Can you provide a complete product nutrient analysis of your best-selling canine and feline pet food including digestibility values? 7. Can you give me the caloric content per can or cup?