The Role of Dogs As a Therapeutic Intervention in Animal Assisted Therapy

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

Author Abstract

Carl M. Harper, M.D. Animal Assisted Therapy (AAT) has been employed for Instructor, Harvard hundreds of years. Over the last century AAT has been shown Medical School to be efficacious as an adjunctive treatment modality for a Department of Orthopedic wide range of pathophysiology. The most common animal Surgery employed in AAT is the dog. Those animals that are Division of Hand & Upper specifically trained for a role in AAT are termed “therapy Extremity Surgery dogs”. From the treatment of acutely psychotic psychiatric Office: 617-667-7673 patients to patients recovery from total joint arthroplasty AAT Fax: 617-667-2155 has shown itself to be a useful clinical tool. The biochemical 330 Brookline Ave, St10 basis for the success of AAT lays in its effect on several Boston, MA 02215 neuroactive peptides including oxytocin and Beta endorphin. Email: Numerous studies have shown not only an increase in [email protected] oxytocin levels in the subjects receiving AAT but also the u therapeutic animals themselves indicating the filiative nature of AAT. As more Level I studies are performed investing its’ potential role across varied pathophysiology we expect AAT to become ever more integrated into the practice of medicine in the future.

Keywords : Animal Assisted Therapy, Therapy Dog, Pet Therapy

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

1. History with livestock in a bucolic setting, similar to the patients in Gheel. Physicians believed The first documented use of animals in that by returning to a natural environment, therapeutic setting occurred in Gheel th augmented by the presence of animals, Belgium in the 9 century (p7,2). In the patients would experience an accelerated town of Gheel, handicapped members of and more seamless integration back into society were encouraged to work with society. The first modern use of animals as a livestock as part of their recuperation true therapeutic modality came in 1962 with following a wide range of pathology from the work of Levinson. Working as a child illness to significant trauma. The thought psychiatrist Levinson noted that his patients process behind the interaction was that by were markedly different when they were removing people from a convalescence interviewed in the presence of his dog house and integrating them back into the Jingles. In his initial work Levinson noted natural environment they would experience 1 that this discovery occurred by a faster and more complete recovery. The happenstance. A patient arrived for their first published use of animals for treatment appointment well after the scheduled time of the mentally ill comes from England in and was presented to Dr. Levinson while he 1796. A public scandal occurred in which was in his office (with the dog). Levinson several members of the Quaker faith noted the ease with which he was able to perished in institutions for the mentally ill. interact and treat the child in the presence of When the condition of these institutions was the dog as compared to their standard investigated, it was discovered that not only meetings. . He went on to study this concept were patients living in squalor but the of animal assisted therapy in detail, treatment that they received on the part of authoring many of the early works on the their caretakers was nothing short of brutal. subject .3 As a result, a wealthy Quaker merchant named William Tuke opened the York The last quarter of a center has seen a Retreat which treated the mentally ill with marked increase in the use of animals, an entirely new regimen. This new treatment especially dogs, in a therapeutic capacity. philosophy involved allowing freedom of Starting with Levinson’s seminal work and movement, autonomy and interaction with extending into the first formal studies of the small animals. 2 This facility was extremely impact of animal assisted therapy on the successful with the institution lasting for mentally ill, dogs have been shown to be over a century. able to affect significant change in both social interaction and emotional well-being. 4 The US Army began to employ therapy In an effort to meet the needs and dogs in the treatment of soldiers diagnosed standardize a growing field two groups were with “operational fatigue” i.e. PTSD at the formed to train both dogs and handlers in Army Air Corps Recovery Hospital in field of animal assisted therapy and Pawling New York during World War II 1 therapeutic intervention. Therapy Dogs (p19). At this facility patients interacted International was founded in 1976 by Elaine

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

Smith and a year later the Delta Foundation one-on-one as part of a treatment program was formed in 1977 (later became Delta for an individual, which is often called Society in 1981) with the express goal of animal assisted therapy (abbreviated AAT), standardizing training and ensuring the but mostly therapy dogs in the United States quality of therapy dogs and their handlers.5,6 today visit facilities to help or at least cheer up the populations of those facilities.”(p12) 9 The primary focus of this article is

2. Definitions investigating the role and efficacy of therapy With the increased use of animals in a dogs performing AAT “helping” role it has become necessary to 3. Biochemical mechanism for efficacy create definitions for various types of interaction. The type of interactions Prior to discussion of the literature discussed in this article, and indeed any concerning the efficacy and utility of interaction in which an animal is being used therapy dogs it is important to first evaluate as a clinical intervention is termed “Animal the mechanism of action by which AAT has Assisted Therapy” or AAT. Animal-assisted been proposed to function. Understanding therapy is defined by the American the neurochemical pathways that are Veterinary Medical Association as ‘‘a goal- impacted during AAT grounds the work in a directed intervention in which an animal, factual biochemical basis which is often lost meeting specific criteria, is an integral part when discussing its often subject benefits. of the treatment process’’.7 As this article is The serum levels of oxytocin, dopamine, dedicated to the discussion of dogs in a prolactin, βendorphins and cortisol have therapeutic capacity, the two main been shown to be impacted during AAT. categories in which dogs interact with These hormones all function to modulate the people are the following: service dog vs. body’s stress response, with increased levels therapy dog. of oxytocin, dopamine, prolactin and βendorphins corresponding to subjective A service dog is “any dog that is feelings of relaxation and calm while individually trained to do work or perform increased levels of cortisol correlate with a tasks for the benefit of an individual with a heightened stress and anxiety response.10 ,11 disability, including a physical, sensory, In addition, oxytocin has also been shown to psychiatric, intellectual, or other mental modulate the perception of pain and sleep in disability....The work or tasks performed by human subjects, with increased levels of a service animal must be directly related to 8 oxytocin corresponding to decreases in the handler’s disability” The is in direct patient’s pain as well as improvements in contrast to a therapy dog which is defined as sleep quality and feelings of restfulness. 12 ,13 “..a dog that, with a handler, visits The neurochemical impact of interaction individuals or groups to provide some relief with a therapy dog was first shown by from an institution, such as a hospital, or Odendaal and Meintjes, demonstrating that condition, such as cerebral palsy or dog affiliative behavior (quiet play with the Alzheimer’s. Therapy dogs may be used

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

dog involving talking, stroking, and petting their dog, close friend, or alone, showed the dog) produced a significant increase in little or no cardiovascular stress reactivity beta endorphin (3.1 to 8.0 pmol/L), oxytocin during the task with the dog present, but (2.1 to 4.0 ng/L), prolactin (9.2 to 11.6 significantly increased activity with the ng/L), and dopamine (86.5 to 107.0 pg/L), close friend present.18 A study of 240 pet- and a corresponding decrease in serum owning and non-pet-owning married cortisol (317 to 309 mmol/L). The most couples, pet (dog or cat) owners had lower profound effect seen was the doubling of resting heart rate (HR) and systolic and serum oxytocin (2.1 to 4.0 ng/L p< 0.01) diastolic blood pressure (SBP and DBP); levels in the human following the showed less HR, SBP, and DBP reactivity interaction. 14 More recently a significant during psychological and physiological increase in serum oxytocin in both dog and stress tasks; and showed faster return to owner after 15 minutes of friendly baseline than non-pet owners. For pet interaction has been shown with a owners, the lowest physiological reactivity corresponding decrease in the heart rate of and the quickest return to baseline occurred their owners. 15 when the pet was present, compared with when a spouse or friend was present. 19 This More recently, studies have been work is mirrored by other authors who have performed to evaluate the neurophysiologic shown pet presence to be associated with impact of dogs in a non-clinical setting. An lower blood pressure during a stressful task exploratory study designed to assess for older hypertensive adults, and reduced autonomic, endocrine, and neurophysiologic HR and mean arterial pressure in a sample stress indicators in a small group of healthy of normotensive adults who completed adult dog owners interacting with their own mental stressors.20 Allen and colleagues or an unfamiliar therapy dog following a randomly assigned hypertensive stock mental stress task reported consistent brokers starting angiotensin-converting patterns of relaxation. Serum cortisol enzyme (ACE) inhibitor therapy to acquire a decreased, heart rate blood and pressure pet or to a 6-month wait list control decreased, and self-reported anxiety and 16 condition. Pet owners showed higher stress response improved. These findings performance on a mental task and lower are mirrored by the work of Barker and physiological reactivity (heart rate, blood colleagues who reported reduced salivary pressure, and renin activity) than those in the (0.177 to 0.155 ug/dl p=0.004) and serum control condition. The ACE inhibitor (12.3 to 10.7 ug/dl p< 0.001) cortisol in therapy significantly reduced only resting healthcare professionals, in the absence of a blood pressure.21 stress task, following as little as 5 minutes of AAT.17 The positive benefits of the presence 4. Civilian Population of a dog outside of a clinical or therapeutic intervention have also been demonstrated. Canine AAT has been shown to have Allen showed that in studying 45 female dog wide ranging applicability in both the owners completing a mental stress task with inpatient and outpatient setting crossing

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

many specialties with varied ambulated (in steps) was calculated by pathophysiology. We will begin our pedometer, and patient satisfaction with discussion with the use of AAT in the AAT was measured by a Likert scale survey inpatient setting with patient’s recovery composed of 5 items. As compared to a from non-psychiatric conditions. In one of stratified historical sample of which 28% of the first randomized controlled trials patients refused ambulation, only 7.2% of employing AAT, 76 patients hospitalized for the study sample refused ambulation heart failure (non-operative) were randomly completely. Moreover, 18.9% of the assigned to one of the 3 groups (usual experimental group patients reversed their treatment, AAT, & volunteer). The impact initial refusal to ambulate when given the of the intervention was measured comparing opportunity to participate in AAT. Those physiological and self-reported measures of that engaged in AAT walked nearly twice as anxiety. The researchers found that many steps (120.02 vs. 235.05 steps, compared to the volunteer only group, p<0.001) as the ambulating patients in the significant decreases in epinephrine (-15.86 historical group. Self-report data indicated pg/mL, p=0.04) and norepinephrine (-240.14 that the participating patients were satisfied pg/mL, p=0.02) levels were measured both with AAT experience.23 during and after AAT. There was also a significantly greater decrease in reported Therapy dogs have also been employed anxiety for the AAT group compared with in the oncologic population. Despite early those who received the 12-minute volunteer critics’ concerns over zoonotic infections no visit. A significant decrease in systolic case reports exist of a patient developing an pulmonary artery pressure (-4.32 mmHg, p= infection secondary to interaction with a 0.03) & -5.78 mmHg, p=0.001) and therapy dog. In evaluating patients pulmonary capillary wedge pressure (-2.74 presenting for an outpatient administration mmHg, p= 0.01 & -4.31 mmHg, p=0.001) of chemotherapy a three phase study was both during (8 minutes) and after (16 developed in which the AAT session was minutes) the AAT visit was present divided into three 20-minute segments compared with the other 2 study groups. 22 involving patients watching the dog exercise In a hybridized intervention combining AAT with the handler, playing with the dog, and and an early ambulation program 69 feeding or holding the dog. Self-reported hospitalized cardiac patients were prompted measures of anxiety, depression, somatic to ambulate by a restorative aide. If the symptoms, and aggression were collected as patients refused, they were approached a well as heart rate, arterial oxygen saturation, second time with the proposal of ambulating and blood pressure. Unlike the controls, while accompanied by a therapy dog. To patients in the AAT group demonstrated a prevent bias from study effects, consent to significant decrease in depression and have the individual’s data be included was increase in arterial oxygen saturation. obtained after the ambulatory activity or Significant reductions in anxiety, after the patient’s second refusal. Distance aggression, and blood pressure were also reported however no group differences were

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

noted. 24 Another study investigated mood Although AAT has been shown to be and self-perceived physical and emotional efficacious in augmenting treatment of non- health prior to radiation treatments. AAT psychiatric conditions by far the greatest visits were compared to volunteer visits and body of literature exists evaluating AAT’s reading group visits that were all 15 minutes ability to modify or augment treatment of in duration, 3 times a week for 4 weeks. psychiatric conditions. AAT has been Changes in mood (assessed before the first employed in the acute setting for and after the last session) were compared hospitalized patients with a psychiatric within and between groups. No significant illness as well as the outpatient setting. In differences were found for any of the one of the largest studies evaluating the subscales, however, trends of decreased effect of AAT on acute psychiatric anxiety and improved emotional health were inpatients, 231 patients participating in a reported. The lack of significant changes single session of traditional recreational within and between groups may be due in therapy (RT) and RT incorporating a therapy part to the small sample size (n=10 for each dog were compared. The investigators found group), disease progression, or time of a significant reduction in anxiety following assessment. An exit survey revealed that both conditions but a significantly stronger some patients in all groups rated the effect was seen in the group that intervention as helpful and the majority incorporated the therapy dog. The average indicated they would recommend it to decrease in the number of patients another patient. 25 demonstrating psychotic disorders was ~10% (p=0.006), mood disorders was ~8% AAT has recently been evaluated as a (p=0.01) and “other” disorders 6% post-operative modality to augment (p=0.026). Only the patients with primary rehabilitation. The only randomized substance abuse disorders showed no controlled trial to date involving post- significant change in anxiety, under either operative patients investigated 72 patients condition, perhaps due to their acute stage of undergoing primary unilateral total hip or physiological withdrawal. 27 In a similar total knee arthroplasty. Patients were study investigators evaluated the effect of 4 randomized to a 15-minute visitation with a weeks of AAT on 69 hospitalized therapy dog before physical therapy or psychiatric patients and reported increased standard postoperative physical therapy social behaviors and responsiveness to regimens. Patients in the treatment group surroundings in the AAT group compared had lower VAS scores after each physical with a control group. Lastly, a study therapy session with a final VAS score involving elderly schizophrenic patients difference of 2.4 units versus control VAS, residing in long-term care facilities also 4.1 (p<0.001). Patients also had significantly reported benefits after 12 months of weekly higher HCAHPS scores and rated the AAT. Those in the AAT group had hospital significantly higher than those significant improvement in social patients who did not receive AAT functioning compared with the control group (p<0.001).26

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

as assessed via the SAFE score (24.5 to long history of utilizing animals to achieve 11.2, p< 0.01). In point of fact, the AAT tactical goals. The Army employed carrier group was the only group shown to pigeons as recently as World War I to demonstrate any statistically significant transfer vital information such as troop improvement. 28 movements and other reconnaissance. The Navy has employed a host of animals from In the outpatient setting AAT has been seals to dolphins and beluga whales to carry shown to have equal efficacy. A study was out some of its missions involving deep performed comparing a single 15 minute water operations. The modern US military session of AAT with a therapy dog to 15 currently incorporates AAT into a wide minutes of reading/looking through variety of interventional modalities from magazines with respect anxiety, fear, and therapy dogs embedded with combat units depression. A significant 37% reduction in during their “reset period” to recovery from fear and 18% reduction in anxiety were PTSD once soldiers have resumed non- found in the AAT group (p<0.05). Although combat activities. no significant differences were found for anxiety or depression, the majority of The benefit of the presence of animals, patients reported on a post intervention particularly dogs, amongst combat units has interview that they believed AAT reduced long been recognized and if not actively their anxiety and depression. 29 Including encouraged, at least tacitly permitted by the AAT in occupational therapy groups has US Army. From General George A. Custer been shown to significantly improve group who had as many as four dogs with him as attendance and attracted isolated individuals part of his entourage during his final to the group regardless of diagnosis.30 campaign to General Dwight D. Eisenhower Recently a large meta-analysis was whose Scottish terriers served as mascots for performed focusing on studies that included his general staff, the role of the dog and its randomization, a control or comparison function as esprit de corps for soldiers and condition, and self-report measure of generals alike cannot be overstated.32 As depression. The authors reported a early as World War II the US Army Air significant, medium effect size based on 5 Force began to employ what we would studies meeting their inclusion criteria, today refer to as a Therapy Dog at one of the concluding that standard intervention first modern convalescence units in augmented by AAT is associated with fewer Pawlings New York. The role of this unit depressive symptoms when compared to was to prepare solders to transition back to standard therapy alone.31 civilian life in the 1940’s. 33 On the opposite end of the proverbial spectrum, therapy dogs

5. Military Application have been deployed to front line post in Iraq Since the early 20 th century AAT has and Afghanistan working with soldiers who been embraced by the United States are employed in active combat. While military. This should come as no surprise results have not been quantified, general given that both the Army and Navy have a consensus from the occupational therapists

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

and soldiers is that having a therapy dog After soldiers have been discharged present as part of the Operational Stress from active duty several programs exist to Control (OSC) Unit was invaluable. 34 further ease the transition back to civilian life. The Warrior Transition Brigade Perhaps the most impressive component Occupational Therapy Work and Education of the military’s use and study of therapy Program (WTBOTWEP) provides soldiers dogs is focused on rehabilitating soldiers who have been diagnosed with PTSD or a once they have been removed from active traumatic brain injury (TBI) the opportunity duty. Numerous services are run out of to work with professional therapists and dog Walter Reed Army Medical Center, the handlers to themselves train a therapy dog main hospital for troops returning from for another service members. Both patients overseas. While these programs have yet to and therapists have noted that in training the produce quantifiable data to measure the dogs the soldiers’ mood, affect and ability to impact of the intervention, discussion of cope with stressful situations have greatly these programs, if for no other reason than improved. Not only does the relationship to demonstrate their scope and breadth, is with the dog provide a meaningful and valuable. The first program to be discussed therapeutic relationship, but the knowledge is incorporated within the Military that one is performing a service for a fellow Advanced Training Center (MATC). The service member has been expressed as a goal of the MATC is to evaluate soldiers large motivating factor by soldiers who have who have returned from combat having completed the program. 36 Along this sustained either physical or emotional continuum exist two organizations whose trauma (the two are not mutually exclusive) goal is to improve the lives of veterans who and provide a cohesive rehabilitation have sustained injuries as part of their program to either help them reintegrate with service. The first group, Canines for Combat their unit or transition out of active field Veterans (CCV) seeks to provide wounded duty into the care of the Veterans veterans of any foreign conflict, past or Administration. As part of this rehabilitation present, with a service dog tailored to their process soldiers are offered (provided the specific set of disabilities. The service dogs physician supervising their care approves) are specifically chosen for the needs of the access to a therapy dog/occupational veteran. The veteran and the dog are then therapist team which will assist them in any taken to the NEADS training facility where and all capacity as they begin their recovery. they undergo a 2 week course designed to This aspect of the MATC has been shown to strengthen their bond and provide high level be quite popular amongst soldiers, supervised training to ensure that the exemplified by the fact that 42% of soldiers relationship between the veteran and animal being treated with a spinal injury have is strong and secure. The final organization inquired about the use of a therapy or 35 to be discussed is Pets2Vets. Those veterans assistance dog as part of their recovery. not physically disabled and/or who do not qualify for CCV have opportunity to acquire

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

a dog, identified at select shelters and have derived benefit from AAT are trained to provide a calming presence. This inherently self-selecting as they have program, based upon basic science data expressed an interest and willingness to discussed previously which shows a positive interact with the therapy dog. With the health benefit to owning a dog, is designed limitation understood, we still require a to integrate families and soldiers together better awareness amongst healthcare through a common bond over the dog. Not providers as to the benefits of AAT and an surprisingly, anecdotal evidence shows all of understanding of the patient populations in these programs to be extremely whom AAT can be effective. To that end, efficacious. 36 following the military’s lead, AAT could stand to make progress in its incorporation

6. Future Directions into the civilian medical system. Having While AAT has been shown to be a experienced bias first hand by hospital powerful adjunct to traditional therapy, it regulators in opposition to bringing a has not received a large amount of attention, therapy dog into the clinical setting, either in the awareness of the general numerous barriers still exist to wide-scale population or in its employment by availability of AAT in the inpatient setting. healthcare professionals. The reasons for Only by performing more Level I studies this are varied, but the most obvious is that exploring the effect of AAT across a wide in order for AAT to be effective, the patient range of patient populations can we begin to needs to be receptive. Those patients who more fully employ it as an adjunctive therapeutic modality.

Medical Research Archives. Volume 5, issue 4. April 2017. The Role of Dogs as a Therapeutic Intervention in Animal Assisted Therapy

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