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Homeopathic Treatment for Arthritis in Dogs
Successful homeopathic treatment for arthritis in dogs requires an owner who can read and understand the symptoms their dog is displaying. They must then be able to convey those symptoms to their homeopathic veterinarian to allow him to choose the correct remedies to use in treating the dog. For instance, a dog experiencing joint pain and fatigue at night would need a different remedy from one suffering from early morning stiffness.
Below is a list of some of the more common remedies used for arthritis treatment in dogs and the symptoms they address.
Aconitum napellus addresses pain and inflammation brought on by exposure to cold weather.
Apis mellifica addresses joint swelling with redness and tenderness of the skin. Cold compresses often bring relief while warm compresses exacerbate the pain.
Arnica relieves pain in injured joints that then develop chronic arthritis.
Aurum metallicum addresses arthritis pain that moves around the body through muscles and joints that ease with the application of warm compresses and exercise. It also causes intense pain at night that interrupts sleep.
Belladonna addresses sudden flare-ups with throbbing pain along with reddened, inflamed joints.
Bryonia addresses throbbing pain brought on by exertion.
Calcarea carbonica addresses pain in overweight dogs who tire easily. Redness and inflammation, along with weakness and cramping often occur when exposed to cold and damp weather.
Calcarea fluorica addresses arthritis where joints are enlarged and deformed and that improves with warmth and exercise.
Calcarea phosphorica addresses aches in bones and exhaustion from exertion. It also reduces calcium deposits and bone-spurs.
Calcarea flourica helps arthritis pain that improves with heat application and exercise.
Causticum helps with arthritis that causes bone and joint deformities, tendon problems and muscle weakness. Cold and damp exacerbate the pain and there is relief when warm compresses are applied.
Culcamara helps with arthritis in overweight dogs who are also experiencing back pain and that worsens in cold weather.
Kali bichromicum addresses arthritis pain that alternates with asthma and stomach pain that occurs at odd moments. Heat exacerbates inflammation and discomfort, especially in warm weather.
Kali carbonicum helps thickened and/or deformed joints that experience increased pain during cold, damp weather.
Kalmia latiflora addresses sudden intense arthritic pain, especially pain that occurs after exercise or at night.
Ledum palustre helps arthritis that starts in the feet and moves upwards to the body, accompanied by crackling noises when the limbs are moved. It is especially helpful with significant swelling that is relieved with cold pack applications.
Pulsatilla helps with unpredictable pain that moves from joint to joint, especially in the hips and knees. Pain intensifies with warmth and recedes with cool compresses.
Rhododendron addresses arthritis swelling and pain that worsens before storms and increases with the severity of the storm. Cold and damp exacerbate the pain as does extended immobility.
Rhus toxicodendron addresses arthritis with joint pain and stiffness that is worse after a night's sleep and that responds to warmth and exercise.
Ruta graveolens addresses arthritis characterized with lameness and stiffness that is exacerbated from cold and damp weather. It also helps with tendon damage.
There are many more homeopathic remedies for arthritis available that will address each and every symptom that is affecting your dog. It is your job as a conscientious dog owner to recognize and report those symptoms to your veterinarian.
Arthritis in Dogs
Pictured is my dog Piglet at age 15. Piglet had severe degenerative joint disease in both elbows. See the link to Piglet's Story below for how I managed her condition and kept her mobile for 17 years.
Also see these articles:
Disclaimer: I am not a veterinarian, nor do I have any formal training in any medical field. The information presented here is not meant to replace your vet's advice or prescribed medications, but only to suggest additional options to explore, based on your dog's condition.
Where to Start
The number of things you can try to help your dog with arthritis can seem overwhelming, so I'm going to suggest some ways to get started.
1. WEIGHT & DIET One of the best things you can do for a dog with arthritis is to keep him lean. Ideally, your dog should be quite lean, with ribs easily felt but not hip or backbones protruding. If your dog is at all overweight, start him on a weight loss program right away -- note that traditional high-carbohydrate weight loss products are not recommended. See my article on Weight Loss Diets for some guidelines on helping your dog to lose weight. Also see the section below on Supplements and Diet Guidelines for dogs with arthritis for more information, and the section on Senior and overweight dogs on my Commercial Dog Foods page.
If possible, reduce the amount of grains and starchy carbohydrates in the diet and increase the amount of protein. This can be done by feeding a better quality food, by using canned instead of dry foods, by adding fresh foods such as eggs and meat to the diet, or by feeding aВ home made diet. Many arthritic dogs improve when grains are removed from the diet, but if this doesn't help your dog, you don't need to continue to avoid them.
Moderate exercise can also be good for dogs with arthritis, and can help with weight loss. See Exercise and the Treatment of Arthritis for more information.
2. GLUCOSAMINE I think all dogs with arthritis or known joint problems should be on some sort of glucosamine-type therapy. This should include oral supplements that contain glucosamine (sulfate or hcl), chondroitin sulfate, green lipped mussel (perna canaliculus), hyaluronic acid, or a combination of these. It may also include the injectable form, Adequan or Cartrophen. Since these supplements are the only things that actually help protect the joints rather than just treating the symptoms, they are a must for all dogs with joint problems. Different dogs respond differently to different supplements, so find one that works for your dog rather than relying on what has worked for others, though that may be a good place to start. Give high doses at first, so you will be able to tell if it is working. If you get results, you can try reducing the dosage to see if your dog will do well on less. If you don't get results, try a different brand. See Glucosamine and other GAGs for more information.
3. FISH OIL If I were to suggest any single nutritional supplement for dogs with arthritis, it would be fish oil (fish body oil, such as Salmon Oil or EPA oil, not cod liver oil). Fish oil provides omega-3 fatty acids that help reduce inflammation. They are beneficial no matter what type of diet you feed. Note that omega-3 fatty acids are fragile and break down quickly when exposed to light, heat or air, so just feeding a food that has omega-3 fatty acids added may not be helpful. Give as much as 1000 mg fish oil (300 mg EPA/DHA) per 10 lbs of body weight daily. Because fish oil depletes vitamin E in the body, you should also give vitamin E supplements whenever you supplement with oils of any kind. See Vitamin E for my current recommendations on vitamin E supplementation. See Fish Oil (Omega-3 Fatty Acids): a Proven Treatment for Canine Arthritis for information on two studies published in the JAVMA in 2010 showing how dogs with arthritis improve when given fish oil supplements.
4. PAIN RELIEF If your dog is in pain, look for ways to relieve it naturally before turning to NSAIDs. DLPA is the first thing I would try, it made a definite difference for my dog and is very safe to use. For worse pain, consider using Tramadol, a synthetic narcotic that can also be used in conjunction with NSAIDs. I would also be trying a variety of natural anti-inflammatories, to see if any of them seem to make a difference. I'm always trying something new with my Piglet. If one supplement doesn't seem to help, I simply move on to another one when I run out. Anything that does seem to help I continue using. See the section on Chronic Pain Relief for more information on drugs used to help dogs with arthritis pain.
5. ALTERNATIVE THERAPIES Many people have reported success using acupuncture for arthritis. Unfortunately, I am not one of them, and at least in my area, acupuncture is very expensive (over $100 per visit), so it's not the first thing I would recommend trying unless you have access to it at a more reasonable rate. If your dog does respond to acupuncture, you can also consider gold bead implants, which are a form of permanent acupuncture. Chiropractic can also be helpful in many cases, although again, I have not had success with it myself. I do not recommend VOM (veterinary orthopedic manipulation), a form of chiropractic that makes unrealistic claims and in our case had no benefit at all, but other forms may be very helpful for many dogs. I am not a believer in homeopathy, but some people have reported success using homeopathic remedies for arthritis pain, including Zeel and Traumeel.
Piglet's Story
My dog Piglet (whose picture appears at the top of this page) had surgery for elbow dysplasia on both elbows before her second birthday, followed by surgery for a ruptured cruciate at age 3. She was on daily Rimadyl/Etogesic with occasional doses of prednisone up until age 7. At that time, I switched her to a raw, grain-free diet with natural supplements. She improved so much that I was able to discontinue all medications. At age 10, she ruptured her other cruciate and again had surgery (April, 2002). It took about three months for us to build back up to her usual 2 mile daily walks, but she did extremely well, became just as active as ever, and was still on no medications for her arthritis, despite the fact that x-rays confirmed severe degenerative joint disease in both elbows. At age 11, she became lamer in one elbow, and after many months of struggling to get her back to where she had been before, I put her back on NSAIDs (Metacam). She continued to be slower than before and I had to cut back on walks because she couldn't go as far. After about a year, she improved again, and while still slower than she used to be, couldВ go on full length walks again at age 13. Then I discovered a very small tumor in her foot, between her toes. It was removed immediately, and when she recovered, she began taking very long walks, longer than ever before. Now, at age 14, she walks 1 1/2 to 2 hours at a time, going sometimes 3-4 miles, almost every day. I suspect that the tumor had been bothering her to walk on. It never hurts to keep looking for other possible causes of lameness, even when you know your dog has bad joints.
Here is what I have done with her:
- First, I feed a raw, grain-free diet. I also weigh all her food using a small postage scale, originally to gradually reduce her weight and now to maintain it (she weighs about 33 pounds and is lean but not skinny; she weighed 36 pounds at the age of 10 months and has been as high as 42 pounds). Keeping dogs with arthritis lean is one of the best things you can do to help them. Also, grains tend to increase inflammation and aggravate arthritis. Many dogs improve when grains are removed from the diet (most dry foods are high in grains, though there are a number of grain-free foods being offered, see my Dry Dog Foods web page for more info; note that there are also some canned foods that are grain free).
- I give fish oil(body oil, not liver oil), Vitamin E (which should always be given when supplementing oils; see Vitamin E for my current recommendations on vitamin E supplementation), and antioxidants, usually Cell Revive 880 (same as Cell Advance 880) or sometimes Thorne Veterinary Immugen. I also give a Vitamin B-50 complex daily -- note that niacinamide (a form of vitamin B3) has antioxidant and anti-inflammatory properties, and may help to rebuild cartilage. According to a vet who recommended it to me, the dosage for Piglet's size (35 lbs) is 50 mg, which is what I get in the B-50 vitamin complex that I use. See Nutrition Q & A (scroll down to the last question) for more information on niacinamide.
- It is important that dogs with arthritis get adequate, but not excessive amounts of calcium, vitamin D and magnesium. If you are feeding a commercial diet, there should be no need to supplement with any of these. If you are feeding a home made diet, it might be helpful to supplement with small amounts of vitamin D (such as from cod liver oil) and magnesium. If your diet includes raw meaty bones, they should not account for more than around 50% of the diet. If your diet does not include bones, then you need to add calcium at the rate of around 1000 mg per pound of food (1/2 teaspoon of ground eggshell yields about 1000 mg of calcium). Piglet gets raw meaty bones as about half of her diet, and I have not been supplementing with magnesium or vitamin D.
- I have rotated among Yucca Intensive, Bromelain, Quercetin, Boswellia, Turmeric (or its extract, Curcumin), Sam-E, Borage Oil and other natural anti-inflammatory herbs and Nutraceuticals. It is difficult for me to tell how much any of these have helped, but I believe all have had some benefit. Note that Bromelain is most effective when given away from meals for an anti-inflammatory effect (otherwise, it is used for digestion), and may work best when combined with Quercetin. See Natural Anti-inflammatories for more information.
- Piglet has been on a glucosamine/chondroitin supplement for most of her life. I believe this is one of the most important things you can do, as these substance don't just treat the symptoms, they can actually help rebuild cartilage and restore synovial (joint) fluid. I currently use Arthroplex, which includes bromelain, boswellia, Green Mussel (Perna Canaliculus, which is a source of chondroitin) and DLPA for chronic pain. I give these supplements away from meals, which may make them more effective.
- Piglet also gets fresh crushed raw garlic (one small clove per day, as too much can be toxic), alfalfa, organic (raw) apple cider vinegar (about half a tablespoon daily) and fresh raw ginger in her food, all of which may help with arthritis.
- Before starting Piglet on Metacam, we used Willow Bark instead of Aspirin for occasional pain relief when she overdoes it, as it is easier on the stomach. You can also use aspirin buffered with an antacid such as calcium carbonate, aluminum hydroxide, and/or magnesium hydroxide. Giving with food may help prevent stomach upset, but not ulceration. Do not combine Aspirin with Willow Bark or any NSAID, such as Rimadyl or Etogesic (see the section on NSAIDs in my Chronic Pain page for more information). Also, do not useenteric coated aspirin, which can be dangerous for dogs.
- Piglet got something called DogLeggs for Christmas. They keep her elbows warm and padded at all times. They appear to be comfortable, she wears them all of the time except when we go on our walks and during the day when it is hot, and she seems to enjoy them.
- In June, 2003, I started Piglet on a supplement called Arthroplex, and have been very happy with the results. For a couple of months, she had been favoring her left elbow -- it's usually her right that gives her the most trouble, so having to favor the left made her fairly lame. I chose Arthroplex because of the DLPA, but it also includes glucosamine, green-lipped mussel, bromelain and boswellia, so I discontinued the Flexile Plus and Green Mussel and instead gave her two capsules Arthroplex twice a day (maximum dosage for her size). Within four days,В she was no longer lagging on our walks, and within a week, there was no longer a noticeable limp. She also still gets Yucca Intensive and fish oil, but no other supplements for arthritis currently. Unfortunately, after about a month of doing well, Piglet got worse again. We have continued the same regimen of supplements, including the DLPA.
- In June, 2004, I tried switching from Arthroplex to SynoviG3, which several people had reported good success with. Unfortunately, it did not work for us and Piglet immediately got worse, even when I started adding DLPA back in separately. We have since returned to the Arthroplex, and also Yucca Intensive, which I had discontinued after starting Metacam. In fact, I am not sure how much the Metacam is helping, and have discontinued it for now, she seems to do as well on Arthroplex and Yucca Intensive as she did with Arthroplex and Metacam.
- In October, 2004, she went back on Metacam, which really does seem to help Piglet's mobility. She's still not very fast, but she's going on much longer walks now than she was when things were bad. She continues on Arthroplex, and I switched from Yucca Intensive to an herbal blend that has yucca, alfalfa and some other ingredients (Animals' Apawthecary Alfalfa/Yucca Blend), so that may also be part of why she's doing better. I've been having very good luck recently using herbal blends in tincture form for dogs, including products from Animals' Apawthecary (Alfalfa/Yucca Blend and Senior Blend), Tasha's and Azmira. Piglet will be 13 in December.
- In September, 2005, I found a small tumor between her toes and had it removed. When she recovered from surgery, she began taking very long walks, going 1 1/2 to 2 hours at a time, often as far as 3-4 miles. As of January, 2006, at age 14, she is walking further and longer than ever before. She is not fast, but keeps a good walking pace and does not slow down toward the end. She continues on Metacam, though I take her off it periodically and she still does pretty well, but I figure she needs all the help she can get, and since she tolerates it very well (no digestive upset at all), I keep her on it most of the time. She remains on Arthroplex and is also currently getting curcumin.
- It's December, 2006, and Piglet has just turned 15. She continues to take me on 1 to 2 hour walks every day. I let her set the pace and decide how far we go, so as not to push her, though I occasionally have to ask her to turn back when we've gone a very long way and she wants to keep going. She currently takes Arthroplex (source of glucosamine, green-lipped mussel, DLPA, boswellia, bromelain and vitamin C), high dose fish oil, turmeric, SAM-e, vitamin E, as well as alternating between the herbal Senior Blend and Alfalfa/Yucca blend (both from Animal’s Apawthecary). In addition, she takes Metacam, and I give her one dose of Tramadol in the morning to help with walks. She is also on sertraline (Zoloft) for anxiety, which may help with pain as well.
- Piglet turned 16 in December, 2007. She slowed down quite a bit early in the year, taking shorter walks at a slower pace. We tried shock wave therapy in August and September, which has helped a little, letting her take longer walks (usually 45 minutes to an hour, with occasional longer walks up to 2 hours, which she had not done for six months prior to the therapy), and sometimes at a trot rather than her usual walk. She remains quite healthy. She currently takes Arthroplex (source of glucosamine, green-lipped mussel, DLPA, boswellia, bromelain and vitamin C), fish oil, turmeric, SAM-e, vitamin E, as well as alternating between the herbal Senior Blend and Alfalfa/Yucca blend (both from Animal’s Apawthecary). In addition, she takes Metacam, and I give her one dose of Tramadol in the morning to help with walks (I would give more but have to be cautious about combining it with Zoloft, which she gets for her generalized anxiety disorder). I also began giving her amantadine a couple of months ago, which is supposed to enhance the effects of other pain medications; I'm not sure if it's made any difference or not. I was able to get it in liquid form thru Costco (needed in order to get the correct dosage, as the pills are too high). Zoloft (sertraline) may help with pain as well. I should also note that I have gradually decreased the amount she is fed and the amount of fat in her diet as her exercise level has decreased to help her maintain her body weight at 34 lbs.
- July, 2008: Piglet is now 16 1/2, an amazing age for a Shar-Pei. She remains quite healthy and still enjoys her walks, but continues to be very slow. I've decided to try Pulsed Signal Therapy (PST) in the hopes that it will help her be able to go further. I stopped giving Piglet Arthroplex, as she has high blood pressure and the DLPA it contains can make that worse -- her kidneys and heart are fine, but she has some corneal degeneration and pigmentary keratitis that interfere with her vision, and I was afraid that she might blow out her retina due to the high blood pressure (she's also now on blood pressure medication). I first tried Dasuquin as a replacement, but she seemed a little worse on that, so I switched to Sea Mussel Plus and I've been happy with that. I also added three anti-inflammatory supplements in the hopes it might make enough difference that she would not need PST, but no such luck -- she may be a little better, but not a lot. The new supplements I added were Microlactin, Boswellia, and a combination Bromelain and Quercetin (I get all of these, including Sea Mussel Plus, at vitacost.com). That's in addition to her usual supplements ofВ fish oil, turmeric (curcumin), SAM-e,CoQ10 and a multi-vitamin, and her usual medications, Metacam and Tramadol. Piglet starts PST next week, going every day for 9 consecutive days. I will update this site if I notice any improvement.
- October, 2008: Piglet has continued to be quite lame. The pulsed signal therapy (PST) did not help her at all. I tried switching her from Metacam to Previcox, which seemed to help but upset her stomach. I then tried prednisone, which helped a lot, but not being sure it was necessary, I tried another new NSAID, Zubrin. This one she tolerated well, but she returned to being quite lame. I've since switched her back to prednisone, which she is likely to remain on for the rest of her life. At almost 17, I don't have major concerns about its long term effects. Her dosage is every other day, which is also supposed to decrease side effects. Note that I kept her off all drugs for 72 hours in between each change in medication, as it's dangerous to switch from one NSAID to another, or to pred, too quickly.
- January, 2009: Piglet is now 17. She is doing well on the prednisone; although still favoring her right elbow, she is able to take long walks again, averaging around an hour a day, though she is very slow. I have discontinued all her other supplements, as it's unlikely that any natural anti-inflammatories would add anything over and above what prednisone provides, and she's developed some digestive problems that seem to do better when she's not getting supplements.
- March, 2009: Piglet is gone. She went downhill sharply in the last few weeks of her life, developing dementia and unable to cope with her limited vision. She was still mobile to the end, though very slow. She had a wonderful life, far longer than I ever dreamed when she was diagnosed with elbow dysplasia at a year old. Her condition helped me find the path to a natural diet and supplements, and to learning more about dog health and nutrition. She will always be in my heart.
Surgical Options
There are email lists called OrthoDogs and CanineHD at Yahoo Groups that offer additional information about surgery for joint problems. Also see AbleDogs and Dodgerslist for dogs with back problems. There is a list called TPO that talks about surgical options for hip dysplasia and cruciate ligament repairs (also see the site at http://www.lauriebryce.com/tplo/ for a great deal of information and links about orthopedic surgery).
Note I am not advocating TPLO surgery for cruciate ligament injuries (and that is not what I had done on Piglet) -- it works well for some dogs, but I've heard of others where the joint doesn't heal properly and the dog is worse off than before. The skill of the surgeon may be a factor. Strict activity restriction is required, and failure to do so may contribute to complications. I have also heard reports, both directly and indirectly, of dogs developing bone cancer following this surgery, as well as other long-term complications. Removal of all implants six months to a year following the surgery may help to reduce this risk. I would seriously consider TPLO surgery for large, active dogs, but probably not for smaller or less active dogs, for whom conventional surgery seems to work well. See TPLO Awareness for more information. Also see Tibial Plateau Leveling Osteotomy - TPLO for a good overview. There are other forms of leveling osteotomies available as well, such as TTA (tibial tuberosity advancement). See TPLO vs. TTA for Cranial Cruciate Ligament RepairВ for more information.
MSU began offering arthroscopic cruciate ligament (knee) surgery for dogs in 2007. This is combined with traditional cruciate repair, involving sutures to stabilize the knee.
There is a new cruciate surgical procedure developed in 2006 at the University of Missouri, called TightRope, named after the rope-like material used to link the two bones in the knee joint. While the material used is new, the procedure is similar to traditional extracapsular cruciate repair surgery, not like TPLO or TTA, which cut the bones. TightRope is considered an easier procedure than TPLO or TTA, especially for a general practitioner (as opposed to a surgical specialist). While the TightRope procedure is relatively new, the results look quite promising. It is more costly than traditional repair, but less expensive than TPLO and similar leveling osteotomy procedures. See the following for more information:
One Pro’s Take on Orthopedic Advances (quotation from a surgical specialist in November 2012): "When I came to OSU 19 years ago, TPLO surgery for cruciate disease was just starting to be talked about. Cruciate repair was mostly done by lateral suture, essentially mimicking the action of the anterior cruciate ligament,” Rochat recalled. “Cruciate repair surgery is now largely TPLOs. Another procedure, tibial tuberosity advancement, is a new alternative that is purported to be easier to do, with fewer complications, yet the evolving literature doesn’t totally support that.
“Nevertheless, while the general subjective experience is that TPLO works very well, what little objective science there is still leaves us questioning that,” Rochat continued. “Properly done, a lateral suture stabilization technique [the older style of cruciate surgery] can yield good results. Again, the quest for accurate, unbiased evidence for the best solution for cranial cruciate ligament disease continues."
If your dog has orthopedic surgery, there are a couple of things you should be aware of that your vet may not be current on. The first is pain management, see my my section on Pre- and Post-Op Care for more information (I also have links at the bottom of that section to braces, slings and carts). Also ask about using intra-articular injections of either bupivacaine or morphine during surgery, which has been shown to provide more pain relief in the first 24 hours after surgery (see Postoperative analgesia for stifle surgery: a comparison of intra-articular bupivacaine, morphine, or saline). A newer option is Nocita, a long-acting local anesthetic using extended-release bupivacaine that provides up to 72 hours of pain relief following cruciate surgery.
The second is that recent research shows that it is important to start doing physical rehabilitation right away, at least in the case of knee surgery, rather than waiting six weeks. Contact me privately if you want a copy of the rehab instructions the surgeon gave me when Piglet had her second knee surgery in 2002. See The American Association of Rehabilitation Veterinarians to locate a rehab specialist in your area. Also see Physical Therapy for Pets for an overview of how important this type of therapy can be following an injury.
Conservative management may be tried in place of surgery if your dog has a cruciate ligament (knee) injury. If no improvement is seen within six to eight weeks, you should then move on to surgery. It is imperative that activity be limited during this time. It is my opinion that a ruptured cruciate will do better with surgery than without, but if there is any doubt about the diagnosis (which cannot be done via x-ray alone), then it may make sense to wait. As long as activity is restricted, no harm should come from waiting for up to two months. See Treating Canine Ligament Injury Without Surgery for more information. Also see How to Confirm Partial ACL Tear for some technical information on how vets try to confirm ACL injuries and differentiate between hip and knee pain. There is a Yahoo Conservative Management group for discussing this option with others. Consider a stifle (knee) brace to help protect the knee and prevent reinjury during the recovery period (see Braces, Splints, Orthotics and Prosthetics for more options). Also see 10 Deadly Sins of Untreated ACLs for one veterinary surgeon's arguments in favor of surgery.
Changing Views On CCL Repair, written by a well-known vet who practices "Integrative Pain Medicine and Natural Healing," talks about the use of Prolotherapy for treating cruciate ligament laxity (looseness), but I don't know whether it would help with a torn ligament, and it's hard to find a vet who does it. Also see Questioning Canine Cruciate Ligament Surgery, by the same author, which presents a hodgepodge of arguments against surgery, though the information is scattered and appears to apply primarily to TPLO, not other forms of cruciate ligament repair. For example, she says, "about half of Labradors rupture the contralateral CCL [cruciate ligament in the opposite leg] within six months after tibial plateau leveling osteotomy [TPLO]," but she does not compare this to rates of injury for other forms of therapy, which makes the statistic meaningless, at least in terms of trying to decide between treatment modalities. The same author collaborated with others on a third article, Treatment Options for Canine Cruciate Disease, which supports surgery in most cases, particularly for dogs over 15 kg (33 pounds), but also suggests laser therapy, acupuncture, and other modes of physical rehabilitation either after surgery, or in place of surgery if surgery cannot be done (see Other Therapies for more information on these modalities).
See Other Therapies for more information on rehabilitation following injury or surgery. Also see Post Surgical Aids for information on a variety of devices that may be helpful, including e-collar alternatives, slings, braces, support harnesses, and more. Orthopets, a maker of custom braces and other orthotics, in particular has had success treating ruptured cruciate ligaments without surgery (more info under Braces, Splints, Orthotics and Prosthetics).
The University of Florida performed its first total knee replacement surgery in a dog in 2012. They are seeking additional dogs with severe osteoarthritis in the knee for a clinical study on total knee replacements for dogs. See First canine total knee replacement at University of Florida a success for more information.
Links to More Information
- There's More Options for Bad Joints in Aging Pets Overview of treatments.
- Animal Joint Care 101: Does Your Pet Have an Arthritis Treatment Checklist? Good overview on arthritis.
- Treatments for Arthritic Pain in Dogs List of supplements to use with arthritic dogs
- Arthritis in Pets (click on the article under Pet Have a Problem?) Alternative Treatments by Dr. Susan Wynn
- Nutritional Management of Canine Osteoarthritis (Denise Elliott BVSc (Hons), PhD, Dipl. ACVIM, Dipl. ACVN, Eric Servet, MEng, Vincent Biourge, DVM, PhD, Dipl. ACVN, Dipl. ECVCN), Encyclopedia of Canine Clinical Nutrition. Studies showing how PUFAs (fish oil), antioxidants and various oral chondroprotective agents (green-lipped mussel, glucosamine and chondroitin) help with arthritis pain.
- Physical and Alternative Therapies in the Management of Arthritic Patients (Serge Sawaya, PhD) Talks about use of heat and cold therapy, therapeutic ultrasound, neuromuscular electro-stimulation, shock-wave therapy, osteopathy and acupuncture.
- Joint Support A review of the medical evidence for alternative arthritis supplements
- Vitamin C is controversial, as there are studies showing that it can help, but also a recent study that showed too much vitamin C can make arthritis worse:
- Vitamin C and Ester-C Studies showing that Vitamin C helps with arthritis, spondylosis and hip dysplasia in dogs
- Ester-C: Miracle Cure for Hip Dysplasia.
- Excess Vitamin C May Worsen Osteoarthritis
Three articles on pain management by Christie Keith:
I regret that I no longer have much time to respond to questions. See my Contact page for more information. My name is Mary Straus and you can email me at either or
Adverse Effects of Pertussis and Rubella Vaccines (1991)
Chapter: 7 Evidence Concerning Rubella Vaccines and Arthritis, Radiculoneuritis, and Thrombocytopenic Purpura
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Evidence Concerning Rubella Vaccines and Arthritis, Radiculoneuritis, and Thrombocytopenic Purpura
Clinical Description and Pathologic Aspects
Symptoms referable to the musculoskeletal system are among the most common side effects of rubella and of rubella vaccine. The general term for these symptoms, arthropathy, refers to any abnormality of the joints. Arthropathy encompasses arthralgia (subjective pain in a joint or joints), stiffness (with arthralgia, commonly referred to as rheumatism), and arthritis (objective findings of swelling, redness, heat, or limitation of motion). Arthralgia is more common than arthritis following natural rubella, with both being more common in adults than in children (Lee et al., 1960). Joint symptoms related to natural rubella or rubella vaccine usually begin within 1 week of the appearance of rash in wild-type rubella infection or within 10 to 28 days after immunization. The joints involved, in order of decreasing frequency, are fingers, knees, wrists, elbows, ankles, hips, and toes. The symptoms are frequently of sudden onset and can consist of prominent stiffness and pain only; however, warmth, redness, and effusions occur, especially in the knees, fingers, and wrists (Smith et al., 1987).
The subjective nature of arthralgia makes it a difficult entity to study. Evaluation of reports of arthritis as a possible adverse consequence of rubella vaccine is complicated by the fact that arthritis and arthralgia are commonly subsumed under the heading arthropathy or "joint manifestations."
Descriptive Epidemiology
The prevalence of self-reported arthritis and arthralgia (rheumatism), without regard to cause, in the United States has been estimated from a number of national surveys, including the 1960-1962 National Health Examination Survey (National Center for Health Statistics, 1964), the 1971-1975 National Health and Nutrition Examination Survey (National Center for Health Statistics, 1973, 1978), and the 1987 and 1988 National Health Interview Surveys (National Center for Health Statistics, 1988, 1989). According to the 1988 National Health Interview Survey, approximately 13 percent of respondents surveyed reported currently having "arthritis of any kind or rheumatism." Prevalence rates increased with age, with approximately 0.2 percent of persons under age 18 years and 5.3 percent between ages 18 and 44 years reporting arthritis of any kind or arthralgia. Prevalence rates were higher in women of all ages, with 4.3 percent under age 45 years reporting these conditions in contrast to 2.5 percent of men in the same age group. Rates for whites and blacks under age 45 years—both sexes combined—are 3.7 and 2.4 percent, respectively. The combining of arthralgia and arthritis of any kind and the cross-sectional and self-reported nature of National Health Interview Survey data do not permit accurate assessment of the prevalence of chronic or recurrent arthritis in the U.S. population.
History of an Association with Rubella Vaccines
Acute arthralgia and arthritis following vaccination have been noted since the earliest studies of rubella vaccines (Barnes et al., 1972; Cooper et al., 1969; Horstmann et al., 1970; Lerman et al., 1971; Spruance and Smith, 1971; Thompson et al., 1971). These acute events have been associated to various degrees with all rubella vaccine strains and occur more frequently in adult women than in adult men or prepubertal children of either sex (Plotkin, 1988; Polk et al., 1982). Reports of chronic arthropathies following rubella vaccination have been fewer. In 1972, Spruance and colleagues reported recurrent joint symptoms in a group of children receiving one strain of rubella vaccine; however, it was not until the 1980s that more systematic investigation of the possible association of rubella vaccines with chronic arthritis was undertaken (e.g., Cunningham and Fraser, 1985; Tingle et al., 1983, 1985, 1986). The lack of controlled studies, coupled with continued anecdotal reports of chronic arthritis following rubella vaccination (ABC News "20/20" report; J. Hatem, York, Pennsylvania, personal communication, 1990; A. J. Tingle, University of British Columbia, personal communication, 1990), have maintained a level of concern over this possible association.
Evidence from Studies in Humans
Acute Arthropathy and Arthritis
Case Series and Controlled Epidemiologic Studies There is a substantial body of evidence, both from controlled and noncontrolled studies in humans, relating rubella vaccine to acute arthropathy and arthritis. The earliest evidence derives from noncontrolled retrospective and prospective studies conducted in the late 1960s and early 1970s, the former generally designed to test the efficacy of various rubella vaccine strains, rather than their side effects, and the latter as part of the routine administration of the vaccine in population-based immunization campaigns (e.g., Austin et al., 1972; Balfour et al., 1976, 1980; Barnes et al., 1972; Cooper et al., 1969; Dudgeon et al., 1969; Fox et al., 1976; Freestone et al., 1971; Grand et al., 1972; Kilroy et al., 1970; Lerman et al., 1971; Monto et al., 1970; Rowlands and Freestone, 1971; Spruance and Smith, 1971; Swartz et al., 1971; Wallace et al., 1972; Weibel et al., 1972, 1980). The vaccines examined in these studies were the HPV-77 strain (no longer in use), developed in simian tissue culture and then grown for production in dog kidney (DK) culture or in duck embryo (DEV) culture; the Cendehill strain (in limited use now), developed in rabbit kidney tissue culture; and the RA 27/3 strain (most commonly used now), developed in human diploid cells (WI38).
These and more recent studies (e.g., Peltola and Heinonen, 1986; Polk et al., 1982; Valensin et al., 1987) provide generally consistent findings with respect to the acute arthropathy and arthritis observed following rubella immunization. These include the observation that arthropathy and, less commonly, arthritis occur rarely in children but occur in 10 to 40 percent of susceptible (seronegative for rubella at the time of immunization) postpubertal women. Occurrence of these reactions increases with age, and they are less frequent in men and prepubescent children. Rates of acute arthropathy and arthritis following rubella immunization differ by vaccine strain, with the HPV-77 (DK) variant producing the most joint manifestations in all age groups (Barnes et al., 1972; Spruance and Smith, 1971; Wallace et al., 1972). The HPV-77 (DEV) and RA 27/3 strains have also been observed to produce joint symptoms, but the symptoms are more akin to the reaction following natural disease, and the arthropathy is more likely to occur in adults than in children (Polk et al., 1982; Swartz et al., 1971; Weibel et al., 1972).
In one of the few double-masked controlled studies of joint reactions to rubella vaccine conducted to date, Polk and colleagues (1982) compared reactions in 112 adult, seronegative female employees of a Boston hospital receiving either the HPV-77 (DEV) or the RA 27/3 strain in response to a rubella outbreak. Allocation to the vaccines was haphazard, because the
supply of the initial HPV-77 (DEV) vaccine was depleted midway through the immunization program and the RA 27/3 vaccine was substituted in its place. Fifty-nine of the 112 women received HPV-77 (DEV) vaccine and 53 received the RA 27/3 vaccine. Sixty women served as controls—that is, they received one or the other vaccine, but were seropositive for rubella at the time of vaccination. In the HPV-77 group, 29 percent (17 of 53) reported onset of joint manifestations and 15 percent (9 of 53) reported onset of arthritis within the first 6 weeks following vaccination. In the RA 27/3 group, 26 percent (14 of 53) reported joint manifestations and 11 percent (6 of 53) reported arthritis with onset within 6 weeks after vaccination. Among the controls, 3 percent (2 of 60) reported joint manifestations and none reported arthritis. Joint manifestations in the HPV-77 (DEV) group occurred later and lasted longer than those in the RA 27/3 group, but all cases recovered without sequelae. There were 8 days missed from work in the HPV-77 group, in contrast to 3 days in the RA 27/3 group. Using data from this study and from 22 studies published elsewhere, the authors estimated the frequencies of joint symptoms following administration of the four different vaccine strains to be as shown in Table 7-1.
The relationship of acute joint manifestations to age must be emphasized. Rubella vaccine-associated arthropathies occur rarely in prepubertal children. In one study of the HPV-77 (DEV) vaccine, none of 31 vaccinees under age 13 years experienced joint manifestations, whereas 25 percent (4 of 16) of women in their 20s and 50 percent (9 of 18) of those aged 25 to 33 had such symptoms (Swartz et al., 1971). A later study of the same vaccine strain in a larger number of subjects (Weibel et al., 1972) revealed similar results. None of 276 cases of acute joint manifestations occurred in persons under age 12 years, whereas 4 percent (6 of 157) of persons between ages
TABLE 7-1 Frequencies of Joint Symptoms in Adult Females Following Administration of Four Vaccine Strains
Proportions (%) of Adult Females Developing Acute Arthritis or Arthralgia
95% Confidence Interval
No. of Studies Cited
SOURCE: Adapted from Polk et al. (1982).
12 and 16, 9 percent (12 of 130) of persons between ages 16 and 20, 9 percent (6 of 65) of persons between ages 20 and 25, and 56 percent (14 of 25) of persons older than 25 years did. This study, unlike the previous one by Swartz and colleagues (1971), distinguished between acute arthritis and arthralgia and indicated that the former was rarer, did not occur before age 16 years, and was manifest in only 4 percent (7 of 178) of persons ages 16 through 25 years. Above age 25 years, however, acute arthritis was common, occurring in 46 percent (11 of 24) of women immunized.
In summary, these studies provide consistent evidence that acute arthropathy and, more rarely, acute arthritis can occur following rubella vaccination and that incidence rates are higher in women than in men and increase with age. None of these studies showed an association of rubella vaccines with chronic arthropathies or arthritis, but their generally limited sample sizes and lengths of study follow-up make it unlikely that if there were such an association it could have been detected. Only a few such studies have been conducted to date, and these are described below.
Chronic Arthritis
Case Reports and Case Series A case of acute arthritis following natural rubella that progressed to chronic arthritis was reported in 1968 by Martenis and colleagues, and it has been suggested that wild-type rubella virus might play a role in juvenile rheumatoid arthritis (Hart and Marmion, 1977; Martenis et al., 1968; Ogra et al., 1975). These suggestions have raised concern that a possible similar progression of acute to chronic arthritis following rubella immunization might also occur.
Lerman and colleagues (1971) reported a case of persistent arthritis 1 year after vaccination with HPV-77 (DE) strain, and Spruance and colleagues (1972) reported on 11 children suffering recurrent episodes of knee stiffness, sometimes referred to as "catcher's crouch" syndrome, 8 months after receiving HPV-77 (DK) vaccine. This syndrome has been considered to be caused by radiculoneuritis, rather than arthritis, as described later in this chapter. However, follow-up of the children 11, 48, and 66 months after vaccination indicated that 8, 4, and 3 (with 2 lost to follow-up), respectively, of the original 11 children continued to exhibit episodic morning stiffness in the knees (Spruance et al., 1977). One of the cases was evaluated by arthroscopy, and the synovium was found to be hypertrophied posteriorly; culture for rubella virus was negative. Eleven children with recurrent arthritis 36 months after vaccination with HPV-77 (DK) were reported by Thompson and colleagues in 1973, and other cases have been reported since then, some after immunization with the RA 27/3 strain (Tingle et al., 1979a,b, 1984, 1985, 1986; A. Tingle, British Columbia Children's Hospital, personal communication, 1990). Arthritis occurring first within 12 to
21 days after rubella vaccination has been reported to persist for 4 to 7 years after receipt of the HPV-77 (DE) strain, for 2 years in one woman after receipt of the RA 27/3 strain (Tingle et al., 1985), and for 3.5 years in a second woman (Tingle et al., 1984). Two additional young adult women had recurrent arthritis or arthralgia (not otherwise defined) for 18 to 24 months after receipt of the RA 27/3 strain (Tingle et al., 1986).
As part of studies that began about a decade ago into the pathogenesis of the acute arthropathy following rubella immunization and the natural disease, Tingle and colleagues (1983) attempted to correlate arthropathy with specific antibodies to rubella. Seven women with recurrent arthritis were studied retrospectively, and 24 hospital personnel were studied prospectively. The standard assay for assessment of antibodies in the IgG and IgM fractions, hemagglutination inhibition (HAI), and a more sensitive enzymelinked immunosorbent assay (ELISA) were used to study antibody at 6 weeks and 6 months after immunization. There were no differences between those recipients who experienced joint manifestations and those who did not. Later, in 10 of 37 adult women volunteers who were seronegative by HAI testing and who developed acute arthritis after RA 27/3 vaccination, Tingle and colleagues (1983) detected prevaccination antibodies by the ELISA. On the assumption that the standard test (HAI) failed to detect antibodies in some preimmune individuals who tested positive by the more sensitive ELISA, the authors suggested that the acute arthropathy could be the result of a reinfection rather than a primary infection. Pursuing this hypothesis, Tingle and colleagues studied six women with recurrent chronic arthropathy, manifested by polyarticular arthritis beginning 12 days to 3 weeks after the immunization. Chronic arthritis was noted 2 years after vaccination in one woman receiving the RA 27/3 strain and 4 to 7 years after vaccination in three women receiving the HPV-77 (DE) strain. Another woman reported chronic arthralgia more than 6 years following receipt of the HPV-77 (DE) strain. Prevaccination sera of three women in this group were positive by ELISA; the sera of the other women were negative (Tingle et al., 1985).
In a later prospective study, Tingle and colleagues (1986) compared incidence rates in two groups: the first consisted of 23 women and 23 men, ages 11 to 54 years (mean age, 19.2 years), who had natural infection with wildtype rubella virus in 1983, all of whom underwent seroconversion. Arthritis (joint effusion, limitation of movement, heat, or erythema) and arthralgia, both acute and chronic, occurred more frequently following infection with wild-type rubella virus than it did following vaccination. In the women who had the natural infection, 52 percent (12 of 23) had acute arthritis and 13 percent (3 of 23) had arthralgia only. Among the men, 65 percent (15 of 23) had some joint manifestations, 9 percent (2 of 23) had arthritis, and 48 percent (11 of 23) had arthralgia only. These signs and symptoms became manifest within 7 to 10 days after the onset of the rash. Eighteen months
later, 30 percent (7 of 23) of the women had joint manifestations; of these 7 women, 4 had arthritis and 3 had arthralgia. Among the men, 8 percent (2 of 23) had joint manifestations; of these 2 men, 1 each had arthritis or arthralgia. The second group consisted of 44 women students, ages 17 to 33 years (mean age, 23.1 years), given the RA 27/3 vaccine. They were examined at weekly intervals. Within 4 weeks after vaccination, 14 percent (6 of 44) had acute arthritis and 41 percent (18 of 38) had arthralgia only, for a total of 55 percent (24 of 44) of joint manifestations. Eighteen months later, 5 percent (2 of 44) had joint manifestations; it was not specified whether it was arthritis or arthralgia.
In a study of the 1985 epidemic of rubella, Tingle (A. J. Tingle, University of British Columbia, personal communication, 1991) examined 191 seroconverters, of whom 103 were men and 88 were women. Forty-four percent of the women (39 of 88) and 7 percent (7 of 103) of the men had acute arthritis. Twenty-four months later, 30 percent of the women still had joint manifestations; it was not specified whether it was arthritis or arthralgia.
In a retrospective analysis of vaccine reactions to the measles-mumps-rubella (MMR) vaccine administered to 700,000 children in Sweden, Taranger and Wiholm (1984) reported only one case of chronic arthritis. The patient was a 12-year-old boy who developed "juvenile rheumatoid arthritis" 2 years after receiving the vaccine. His HLA haplotype was B27, which has been associated with chronic arthritis. The authors concluded that this case of arthritis was not causally related to the vaccine, but rather was coincidental.
Two hundred eighteen cases of arthritis (ICD 9 code 716.9) occurring within 28 days of immunization with rubella monovalent, measles-rubella (MR), or MMR vaccine were reported through the CDC's MSAEFI system from 1978 to 1990, a period in which approximately 28.8 million doses of rubella vaccines were administered through public mechanisms in the United States (J. Mullen, Centers for Disease Control, personal communication, 1990). Confirmation of these cases in the form of a physician's diagnosis was not required. Of these 218 cases, 43 (20 percent) cases received at least one other vaccine at the time of rubella immunization. One year after immunization, 13 (6 percent) of the original 218 cases were reported as "not recovered" 1 ; an additional 15 cases were lost to follow-up at year 1.
1 Caution is needed in interpreting this category, because cases of arthritis with a comorbidityfor example, otitis media—reported at the time of initial immunization and persisting at 1 year would have been labeled "not recovered," even if the arthritis had resolved. Review of an earlier set of acute arthritis cases subsequently labeled "not recovered" at 1 year indicated that the majority were due to a persisting morbidity other than arthritis (J. Mullen, Centers for Disease Control, personal communication, 1991).
Controlled Epidemiologic Study Polk and colleagues (1982), in the doublemasked, controlled comparison of joint reactions in 112 seronegative women receiving HPV-77 (DEV) or RA 27/3 vaccine described above, reported no cases of chronic or recurrent arthritis or arthralgia. However, the average length of study follow-up was only 6 weeks, and thus, recurrent cases might not have been detected.
Evidence from Studies in Animals
Data from experimental studies in animals are not available, since it has not been possible to develop an animal model for rubella infection.
Possible Mechanisms
A suggestion that joint involvement is somehow related to stage of the menstrual cycle has been made, but there is no evidence in support of this hypothesis (Best et al., 1974; Lerman et al., 1971; Swartz et al., 1971).
Pathogenesis of the joint involvement is apparently direct infection of the synovial membrane, inasmuch as the virus has been recovered from the joint fluid of patients with repeated episodes of arthritis for up to 3 to 4 months after vaccination with the HPV-77 strain (Ogra and Herd, 1971). This has also been true in cases of rubella caused by the wild-type strain of the virus (Ogra et al., 1975). Chantler, Tingle, and colleagues have isolated rubella virus from peripheral blood mononuclear leukocytes of several patients with persistent post-rubella vaccine arthritis (Chantler et al., 1981, 1982; Tingle et al., 1985). Two of these patients had received the RA 27/3 strain. In one study, rubella virus was grown from the leukocytes of five of six women with arthritis for up to 5 years after receiving the HPV-77 (DEV) vaccine (Chantler et al., 1982). In a separate study, rubella virus was isolated from mononuclear leukocytes from blood, synovial fluid, or both in 7 of 19 children with chronic arthritis of unknown cause (Chantler et al., 1985). There was no history of recent rubella infection or rubella vaccination, although most of the patients had received HPV-77 (DEV) rubella vaccine in the past. The infecting rubella strain (vaccine versus wild type) was not identified and has not been identified in the other subjects reported to have arthropathy after rubella vaccination.
The role of circulating immune complexes (CICs) in the pathogenesis of rubella arthritis has been suggested in one study, in which 11 of 33 (33 percent) children with postvaccinal arthritis had CICs containing rubella antigen, in contrast to only 3 of the 19 (16 percent) who did not experience arthralgia (Coyle et al., 1982). In a study of adults—44 women vaccinated with the RA 27/3 strain and 23 men and 23 women convalescing from wild-
type rubella infection—no statistically significant differences were found in the CICs between those who had joint manifestations and those who did not. The authors concluded that their data ''do not support a direct role for raised CIC levels in the pathogenesis of rubella-associated arthritis or arthralgia" (Singh et al., 1986, p. 115).
Blood lymphocytes from 15 children who had acute arthralgia or arthritis after rubella vaccination exhibited depressed transformation responses to rubella virus compared with the responses of lymphocytes from controls who had no complications following vaccination. This finding suggests that arthritis could result from a selective depression in the subject's cell-mediated immunity at the time of the initial encounter with the virus (Chiba et al., 1976). On the other hand, the lymphocyte responses to rubella antigen in six adult women who had had recurrent arthritis for at least 9 months after HPV-77 (DEV) rubella vaccination were relatively elevated (Ford and Tingle, 1980; Tingle et al., 1983). The antigens used in the two populations may have differed. However, the two reports are not necessarily at variance, because normal or accentuated cell-mediated immunity to the virus would be expected over the course of an intermittent, recurrent infection in an otherwise normal individual. In any event, it is not clear at this time whether patients who develop arthritis, acute or persistent, after rubella vaccination have a specific immune system defect that prevents their systems from clearing the virus normally.
Acute Arthropathy and Arthritis
The body of evidence concerning the possible relation between rubella vaccine and acute joint manifestations includes a number of case series and experimental studies comparing different rubella vaccine strains. These studies indicate a consistent, direct relation of all rubella vaccine strains both to acute arthropathy and to acute arthritis, with the discontinued HPV77 vaccines being associated with the highest reaction rates. Incidence rates following administration of the current RA 27/3 vaccine strain to adult women average 13 to 15 percent. Average rates are much lower in children, increase with age, and are higher in women than in men. Both acute arthropathy and acute arthritis are conditions whose diagnoses are reasonably reliable; thus, the vaccine exposure probably truly preceded onset of these adverse events in most cases. Although acute joint manisfestations can result from a number of different causes, their association with natural rubella infection and the recovery of rubella virus from the joint fluid of persons experiencing acute arthropathy or arthritis support the biologic plausibility of a relation with attenuated rubella virus vaccine.
Chronic Arthritis
The body of evidence concerning the possible relation between vaccination with MMR vaccine or its rubella component and chronic arthritis is limited. There are several case reports and case series, one comparative case series, and one double-masked controlled study. Most of the patients described in these publications had received the HPV-77 (DEV) strain of vaccine. Three or four cases of chronic arthritis following immunization with the RA 27/3 strain have been reported in the literature. A large number of unconfirmed cases of chronic arthritis following administration of RA 27/3 strain have been reported to a single institution. All of the cases were adult females.
In the comparative case series, Tingle and colleagues (1986) reported incidence rates of joint manifestations in 67 young adult women following either natural infection with wild-type rubella virus or receipt of the RA 27/ 3 strain. They reported recurrent arthropathy more than 18 months after either natural infection or vaccination, with incidence rates of 30 and 5 percent (two patients), respectively. The latter two patients had "arthritis or arthralgia" that were not otherwise described (Tingle et al., 1986, p. 113). In a double-masked study of 112 women receiving one of two rubella vaccine strains, Polk and colleagues (1982) reported no cases of chronic or recurrent arthritis or arthralgia. However, the length of the follow-up was only 6 weeks, and cases that might have recurred later would not have been detected. In both studies, the nature of the comparison groups precludes estimation of relative risks for exposed versus nonexposed groups.
One of the women with chronic arthritis after vaccination with the RA 27/3 strain had rubella virus isolated from blood mononuclear cells and from breast milk 7 to 9 months postvaccination. A second woman who reported recurrent arthralgia 2 years and 9 months after receipt of the RA 27/3 vaccine also had rubella virus isolated from peripheral blood leukocytes (Tingle et al., 1985).
The current lack of understanding of the natural history and multiple causes of arthritis and the lack of distinction between cases of arthralgia and arthritis in some reports diminish the specificity of the putative association. It is also difficult to establish whether the vaccination truly preceded the adverse event in many cases. The association of chronic arthritis with natural rubella infection and the recovery of a rubella virus from leukocytes from peripheral blood and synovial fluid of women with prolonged arthritis following rubella vaccination suggest, however, a biologically plausible relation between rubella vaccine and chronic arthritis. Moreover, a few cases have been documented in which arthritis, which was ultimately judged to be chronic, began 2 to 3 weeks after vaccination, which is the incubation period of natural rubella and the time period in which the vaccine strain can be isolated (beginning about 1 week after injection).
Conclusions
The evidence indicates a causal relation between the currently used rubella vaccine strain (RA 27/3) and acute arthritis. Incidence rates are estimated to average 13 to 15 percent among adult women following RA 27/3 immunization with much lower levels noted among children, adolescents, and adult men.
The evidence is consistent with a causal relation between the currently used rubella vaccine strain (RA 27/3) and chronic arthritis in adult women, although the evidence is limited in scope and confined to reports from one institution. 2 Prospective, double-masked, controlled trials in which subjects are followed for at least 12 months after rubella vaccination are needed to establish this biologically plausible relation. Additional elements of a definitive study would include attempts to isolate rubella virus from the synovial fluid of affected joints of cases of arthropathy and arthritis and molecular-genetic analysis to determine whether the isolated strain is the one that was injected, a strain derived from the injected strain, or an unrelated strain.
RADICULONEURITIS AND OTHER NEUROPATHIES
Clinical Description
Radiculoneuritis is a convenient term used to describe a combination of peripheral neuropathy with dorsal root (spinal nerve) pain. The "catcher's crouch" syndrome, which is knee pain that is somewhat relieved by crouching, has been suggested as an example. This and other related conditions, including polyneuropathy, paresthesias, and carpal tunnel syndrome, occur sporadically in association with natural rubella infection (Bailey, 1962; Brodribb, 1963; Courtenay, 1962; Haire and Hadden, 1970; Heathfield, 1962; Hodges, 1940; Moylan-Jones and Penny, 1962; Witney, 1940).
Descriptive Epidemiology
Radiculoneuritis is uncommon, but it can occur at any age. Incidence rates of related neurologic conditions have been published for defined populations (Beghi et al., 1982, 1985; Stevens et al., 1988).
2 When all rubella vaccine strains, including the discontinued HPV-77 (DK) and HPV-77 (DEV) strains, are considered as a group, the evidence indicates a causal relation with chronic arthritis in adult women.
Evidence from Studies in Humans
Case Reports and Case Series
There have been reports of cases of paresthesias (Chin et al., 1971; MortonKute, 1985; Tingle et al., 1985) and pain involving the arms and the knees, the latter giving rise to the "catcher's crouch" syndrome (Deinard et al., 1973; Spruance et al., 1972; Thompson et al., 1971) following rubella vaccination. Three of these occurred after receipt of the RA 27/3 strain (MortonKute, 1985; Tingle et al., 1985). Other related conditions, reported in individual cases, are carpal tunnel syndrome following both HPV-77 (DK) strain (Chin et al., 1971; Thompson et al., 1971) and RA 27/3 strain (Tingle et al., 1985), two cases of optic neuritis following administration of the HPV-77 vaccine in one case (Kazarian and Gager, 1978) and an unstated rubella vaccine in the other (Kline et al., 1982), three cases of transverse myelitis after Cendehill vaccine, a vaccine of unknown rubella strain, and one unstated vaccine (Behan, 1977; Holt et al., 1976), and two cases of Guillain-Barrè syndrome after MMR vaccine that included the HPV-77 (DEV) strain (Gunderman, 1973).
A case of peripheral neuropathy following rubella immunization was reported in 1984 by Taranger and Wiholm (1984). The issue of peripheral neuropathies related to rubella vaccines was reviewed in an article by Schaffner and colleagues (1974), who examined reports of 299 cases. The study concentrated on 32 children with neuropathies who were followed for up to 32 months. Twenty of these children recovered fully and had no recurrences; 10 had minor complaints that persisted during the follow-up period, and 2 developed recurrences of the "catcher's crouch" syndrome after 32 and 33 weeks, respectively. The majority of the 299 total cases and the 32 cases reviewed in detail followed administration of the HPV-77 (DK) vaccine. The authors estimated the rate of these complications to be 2.2 per 1,000 doses and 0.1 per 1,000 doses for the HPV-77 (DK) and the HPV-77 (DEV) strains, respectively.
One case of radiculitis (ICD 9 code 723.4) occurring within 28 days of immunization with MR vaccine was reported through the CDC's MSAEFI system from 1978 to 1990, a period in which approximately 28.8 million doses of rubella-containing vaccine were administered through public mechanisms in the United States (J. Mullen, Centers for Disease Control, personal communication, 1990). No follow-up of the case was made, and a physician's diagnosis was not required.
The body of evidence concerning the possible relation between immunization with monovalent rubella or MMR vaccine and radiculoneuritis and
other neuropathies is limited to case reports and case series. Frequencies of peripheral neuropathies have been estimated from case series to be 2.2 and 0.1 per 1,000 doses of HPV-77 (DK) and HPV-77 (DEV) vaccines, respectively. The lack of comparison groups in these studies precludes estimation of the relative risks of neuropathies in relation to these strains. For the RA 27/3 strain currently in use in the United States, rates of radiculoneuritis and other neuropathies following its receipt are not available. Three cases have been reported after administration of this vaccine strain. Evidence for biologic plausibility consists of the observation that radiculoneuritis and other neuropathies can occur, though uncommonly, after natural infection with wild-type rubella virus.
Conclusion
There is insufficient evidence to indicate a causal relation between the currently used rubella vaccine (RA 27/3) and radiculoneuritis and other neuropathies.
THROMBOCYTOPENIC PURPURA
Clinical Description
Thrombocytopenic purpura presents as petechiae, purpura, or mucosal bleeding secondary to decreased numbers of platelets in the blood. It has been reported in association with congenital and acquired rubella (Heggie and Robbins, 1969; Morse et al., 1966). The estimated incidence is 1 case of thrombocytopenia in 3,000 cases of natural rubella (Bayer et al., 1965). This complication is not unique to natural rubella, because it is estimated that 70 percent of cases of thrombocytopenia follow various viral illnesses (Cohn, 1976). Possible mechanisms for virus-induced thrombocytopenic purpura include generation of antibodies to a viral antigen that cross-react with some similar antigen on the platelet, resulting in platelet destruction (Baldini, 1966). The virus itself or immune complexes that include the virus might damage or otherwise modify the platelet surface, making it susceptible to removal by the spleen. The contribution of antibody-mediated platelet dysfunction to bleeding in patients with idiopathic thrombocytopenic purpura, however, remains to be established (George and Shattil, 1991).
Descriptive Epidemiology
Thrombocytopenic purpura can occur at any age. No population-based incidence or prevalence rates were identified.
Evidence from Studies in Humans
Case Reports
Evidence for thrombocytopenic purpura following rubella immunization is rarer than that for natural infection and is limited to isolated case reports. Bartos (1972) described a case of thrombocytopenic purpura in a 26-year-old female immunized with a monovalent vaccine. Four other cases of thrombocytopenic purpura have been reported in a 1-year-old girl (Sharma, 1973), a 16-month-old boy and a 16-month-old girl, both of whom received the RA 27/3 strain (Azeemuddin, 1987), and an 18-month-old girl (Neiderud, 1983) following administration of the combined MMR vaccine. All five patients, who were asymptomatic for viral illness prior to immunization, developed petechiae, purpura, or mucosal bleeding 10 days to 3 weeks postimmunization. Platelets were markedly reduced, but peripheral red and white blood cell counts and morphology were normal. In the patients tested, megakaryocytes were usually increased, with an otherwise normal bone marrow. In all cases, the postimmunization thrombocytopenia was transient. No virus-containing immune complexes or anti-platelet antibodies were demonstrated in these cases.
Twenty-six cases of thrombocytopenic purpura occurring within 28 days of immunization with rubella-containing vaccines were reported through the CDC's MSAEFI system from 1978 to 1990, a period in which approximately 28.8 million doses of rubella vaccine were administered through public mechanisms in the United States (J. Mullen, Centers for Disease Control, personal communication, 1990). They were reported as idiopathic (ICD 9 code 287.3). All but 1 of the 26 cases received at least one other antigen at the time of rubella immunization. No follow-up of the cases was made, and a physician's diagnosis was not required.
The report "Compensation for Vaccine-Related Injuries" (Office of Technology Assessment, 1980) lists thrombocytopenia as a "possible" adverse event after immunization, but cites no reference or evidence for this conclusion. The Meruvax II (Rubella Virus Vaccine Live, Merck Sharp & Dohme) package insert states, ''In view of the decreases in platelet counts that have been reported, thrombocytopenic purpura is a theoretical hazard," but it also cites no evidence for this statement (Merck Sharp & Dohme, West Point, Pennsylvania).
The body of evidence concerning the possible relation between vaccination with the RA 27/3 rubella vaccine strain and thrombocytopenic purpura is limited to two or three cases reported in the literature and unconfirmed
cases reported through the CDC's MSAEFI system. The unambiguous clinical presentation of thrombocytopenic purpura would suggest that the vaccine exposure truly preceded the event. The relation is biologically plausible because thrombocytopenic purpura is believed to occur rarely as a complication of natural rubella infection.
Conclusion
There is insufficient evidence to indicate a causal relation between the currently used rubella vaccine (RA 27/3) and thrombocytopenic purpura.
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Baldini M. 1966. Idiopathic thrombocytopenic purpura. New England Journal of Medicine 274:1245-1251.
Balfour HH, Balfour CL, Edelman CK, Rierson PA. 1976. Evaluation of Wistar RA27/3 rubella virus vaccine in children. American Journal of Diseases of Children 130:1089-1091.
Balfour HH, Groth KE, Edelman CK. 1980. RA 27/3 rubella vaccine. American Journal of Diseases of Children 134:350-353.
Barnes EK, Altman R, Austin SM, Dougherty WJ. 1972. Joint reactions in children vaccinated against rubella. Study II: Comparison of the three vaccines. American Journal of Epidemiology 95:59-66.
Bartos HR. 1972. Thrombocytopenia associated with rubella vaccination. New York State Journal of Medicine 72:499.
Bayer WL, Sherman FE, Michaels RH, Szeto ILF, Lewis JH. 1965. Purpura in congenital and acquired rubella. New England Journal of Medicine 273:1362-1366.
Beghi E, Kurland LT, Mulder DW. 1982. Incidence of acute transverse myelitis in Rochester, Minnesota, 1970-1980, and implications with respect to influenza vaccine. Neuroepidemiology 1:176-188.
Beghi E, Kurland LT, Mulder DW, Nicolosi A. 1985. Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970-1981. Annals of Neurology 18:320-323.
Behan PO. 1977. Diffuse myelitis associated with rubella vaccination (letter). British Medical Journal 1:166.
Best JM, Banatvala JE, Bowen JM. 1974. New Japanese rubella vaccine: comparative trials. British Medical Journal 3:221-224.
Brodribb HS. 1963. Rubella (1962) in three boarding schools: its complications and types. British Journal of Clinical Practice 17:726-730.
Chantler JK, Ford DK, Tingle AJ. 1981. Rubella-associated arthritis: rescue of rubella virus from peripheral blood lymphocytes two years postvaccination. Infection and Immunity 32:1274-1280.
Chantler JK, Ford DK, Tingle A. 1982. Persistent rubella infection and rubella-associated arthritis. Lancet 1:1323-1325.
Chantler JK, Tingle AJ, Petty RE. 1985. Persistent rubella infection with chronic arthritis in children. New England Journal of Medicine 313:1117-1123.
Chiba Y, Sadeghi E, Ogra P. 1976. Abnormalities of cellular immune response in arthritis induced by rubella vaccination. Journal of Immunology 177(5, part 1):1684-1687.
Chin J, Werner SB, Kusumoto HH, Lennette EH. 1971. Complications of rubella immunization in children. Western Journal of Medicine 114:7-12.
Cohn J. 1976. Thrombocytopenia in childhood: an evaluation of 433 patients. Scandinavian Journal of Hematology 16:226-240.
Cooper LZ, Ziring PR, Weiss HJ, Matters BA, Krugman S. 1969. Transient arthritis after rubella vaccination. American Journal of Diseases of Children 118:218-225.
Courtenay MJF. 1962. Carpal-tunnel syndrome (letter). British Medical Journal 1:1698.
Coyle PK, Wolinsky JS, Buimovici-Klein E, Moucha R, Cooper LZ. 1982. Rubella-specific immune complexes after congenital infection and vaccination. Infection and Immunity 36:498-503.
Cunningham AL, Fraser JRE. 1985. Persistent rubella virus infection of human synovial cells cultured in vitro. Journal of Infectious Diseases 151:638-645.
Deinard AS, Hoban TW, Venters HD. 1973. Clinical reactions in children after rubella vaccination. Health Services Reports 88:457-462.
Dudgeon JA, Marshall WC, Peckham CS. 1969. Rubella vaccine trials in adults and children. American Journal of Diseases of Children 118:237-242.
Ford DK, Tingle AJ. 1980. Cell-mediated immune responses in patients with recurrent arthritis following rubella immunization. Journal of Rheumatology 7:225-230.
Fox JP, Rainey HS, Hall CE, Ray CG, Patterson MJ. 1976. Rubella vaccine in postpubertal women: experience in western Washington state. Journal of the American Medical Association 236:837-843.
Freestone DS, Prydie J, Hamilton-Smith SG, Laurence G. 1971. Vaccination of adults with Wistar RA 27/3 rubella vaccine. Journal of Hygiene 69:471-477.
George JN, Shattil SJ. 1991. The clinical importance of acquired abnormalities of platelet function. New England Journal of Medicine 324:27-39.
Grand MG, Wyll SA, Gehlbach SH, Landrigan PJ, Judelsohn RG, Zendel SA, Witte JJ. 1972. Clinical reactions following rubella vaccination. Journal of the American Medical Association 220:1569-1572.
Gunderman JR. 1973. Guillain-Barrè syndrome: occurrence following combined mumps-rubella vaccine. American Journal of Diseases of Children 125:834-835.
Haire M, Hadden DSM. 1970. Immunoglobulin responses in rubella and its complications. British Medical Journal 3:130-132.
Hart H, Marmion BP. 1977. Rubella virus and rheumatoid arthritis. Arthritis and Rheumatism 5:378-383.
Heathfield KWG. 1962. Carpal-tunnel syndrome (letter). British Medical Journal 2:58.
Heggie AD, Robbins FC. 1969. Natural rubella acquired after birth: clinical features and complications. American Journal of Diseases of Children 118:12-17.
Hodges GMW. 1940. Brachial neuritis following rubella (letter). British Medical Journal 1:548.
Holt S, Hudgins D, Krishnan KR, Critchley EMR. 1976. Diffuse myelitis associated with rubella vaccination. British Medical Journal 2:1037-1038.
Horstmann DM, Liebhaber H, Kohorn EI. 1970. Post-partum vaccination of rubella-susceptible women. Lancet 2:1003-1006.
Kazarian EL, Gager WE. 1978. Optic neuritis complicating measles, mumps and rubella vaccination. American Journal of Ophthalmology 86:544-547.
Kilroy AW, Schaffner W, Fleet WF, Lefkowitz LB, Karzon DT, Fenichel GM. 1970. Two syndromes following rubella immunization: clinical observations and epidemiological studies. Journal of the American Medical Association 214:2287-2292.
Kline LB, Margulies SL, Oh SJ. 1982. Optic neuritis and myelitis following rubella vaccination. Archives of Neurology 39:443-444.
Lee PR, Barnett AF, Scholer JF, Bryner S, Clark WH. 1960. Rubella arthritis: a study of twenty cases. California Medicine 93:125-128.
Lerman SJ, Nankervis GA, Heggie AD, Gold E. 1971. Immunologic response, virus excretion, and joint reactions with rubella vaccine: a study of adolescent girls and young women given live attenuated virus vaccine (HPV-77:DE-5). Annals of Internal Medicine 74:67-73.
Martenis TW, Bland JH, Phillips CA. 1968. Rheumatoid arthritis after rubella. Arthritis and Rheumatism 11:683-687.
Monto AS, Cavallaro JJ, Whale EH. 1970. Frequency of arthralgia in women receiving one of three rubella vaccines. Archives of Internal Medicine 126:635-639.
Morse EE, Zinkham WH, Jackson DP. 1966. Thrombocytopenic purpura following rubella infection in children and adults. Archives of Internal Medicine 117:573-579.
Morton-Kute L. 1985. Rubella vaccine and facial parasthesias (letter). Annals of Internal Medicine 102:563.
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National Center for Health Statistics. 1964. Cycle I of the National Health Examination Survey, Sample and Response, United States, 1960-62. Vital and Health Statistics, Series 11, No. 1. PHS Publication No. 1000. Public Health Service. Washington, DC: U.S. Government Printing Office.
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Ogra PL, Herd JK. 1971. Arthritis associated with induced rubella infection. Journal of Immunology 107:810-813.
Ogra PL, Chiba Y, Ogra SS, Dzierba JL, Herd JK. 1975. Rubella-virus infection in juvenile rheumatoid arthritis. Lancet 1:1157-1161.
Peltola H, Heinonen OP. 1986. Frequency of true adverse reactions to measles-mumps-rubella vaccine: a double-blind placebo-controlled trial in twins. Lancet 1:939-942.
Plotkin SA. 1988. Rubella vaccine. In: Plotkin SA, Mortimer EA, eds. Vaccines. Philadelphia: W.B. Saunders Co.
Polk BF, Modlin JF, White JA, DeGirolami PC. 1982. A controlled comparison of joint reactions among women receiving one of two rubella vaccines. American Journal of Epidemiology 115:19-25.
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Schaffner W, Fleet WF, Kilroy AW, Lefkowitz LB, Herrmann KL, Thompson J, Karzon DT. 1974. Polyneuropathy following rubella immunization: a follow-up study and review of the problem. American Journal of Diseases of Children 127:684-688.
Sharma ON. 1973. Thrombocytopenia following measles-mumps-rubella vaccination in a one-year-old infant. Clinical Pediatrics 12:315.
Singh VK, Tingle AJ, Schulzer M. 1986. Rubella-associated arthritis. II. Relationship between circulating immune complex levels and joint manifestations. Annals of the Rheumatic Diseases 45:115-119.
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Spruance SL, Metcalf R, Smith CB, Griffiths MM, Ward JR. 1977. Chronic arthropathy associated with rubella vaccination. Arthritis and Rheumatism 20:741-747.
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Thompson GR, Ferreyra A, Brackett RG. 1971. Acute arthritis complicating rubella vaccination. Arthritis and Rheumatism 14:19-26.
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500 Fifth St., NW | Washington, DC 20001
Parents have come to depend on vaccines to protect their children from a variety of diseases. Some evidence suggests, however, that vaccination against pertussis (whooping cough) and rubella (German measles) is, in a small number of cases, associated with increased risk of serious illness.
This book examines the controversy over the evidence and offers a comprehensively documented assessment of the risk of illness following immunization with vaccines against pertussis and rubella. Based on extensive review of the evidence from epidemiologic studies, case histories, studies in animals, and other sources of information, the book examines:
- The relation of pertussis vaccines to a number of serious adverse events, including encephalopathy and other central nervous system disorders, sudden infant death syndrome, autism, Guillain-Barre syndrome, learning disabilities, and Reye syndrome.
- The relation of rubella vaccines to arthritis, various neuropathies, and thrombocytopenic purpura.
The volume, which includes a description of the committee's methods for evaluating evidence and directions for future research, will be important reading for public health officials, pediatricians, researchers, and concerned parents.
- Front Matter i–xiv
- 1 Executive Summary 1–8
- 2 Histories of Pertussis and Rubella Vaccines 9–31
- 3 Methodologic Considerations in Evaluating the Evidence 32–64
- 4 Evidence Concerning Pertussis Vaccines and Central Nervous System Disorders, Including Infantile Spasms, Hypsarrhythmia, Aseptic Meningitis, and Encephalopathy 65–124
- 5 Evidence Concerning Pertussis Vaccinces and Deaths Classified as Sudden Infant Death Syndrome (SIDS) 125–143
- 6 Evidence Concerning Pertussis Vaccines and Other Illnesses and Conditions 144–186
- 7 Evidence Concerning Rubella Vaccines and Arthritis, Radiculoneuritis, and Thrombocytopenic Purpura 187–205
- Afterword on Research Needs 206–207
- Bibliography 208–282
- Glossary of Terms 283–292
- Appendix A: Strategies for Gathering Information: Adverse Effects of Pertussis and Rubella Vaccines 293–319
- Appendix B: Pertussis and Rubella Vaccines: A Brief Chronology 320–332
- Appendix C: Animal Models for the Study of Whooping Cough and the Testing of Vaccine Materials 333–336
- Appendix D: Technical Details of Power Calculations and Meta-Analyses 337–346
- Appendix E: Possible Involvement of Aluminum Salts in Erythema Multiforme, Encephalopathy, or Other Adverse Events After Pertussis Immunization 347–348
- Appendix F: Committee and Staff Biographies 349–354
- Index 355–367
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Homeopathic Treatment for Arthritis in Dogs
Successful homeopathic treatment for arthritis in dogs requires an owner who can read and understand the symptoms their dog is displaying. They must then be able to convey those symptoms to their homeopathic veterinarian to allow him to choose the correct remedies to use in treating the dog. For instance, a dog experiencing joint pain and fatigue at night would need a different remedy from one suffering from early morning stiffness.
Below is a list of some of the more common remedies used for arthritis treatment in dogs and the symptoms they address.
Aconitum napellus addresses pain and inflammation brought on by exposure to cold weather.
Apis mellifica addresses joint swelling with redness and tenderness of the skin. Cold compresses often bring relief while warm compresses exacerbate the pain.
Arnica relieves pain in injured joints that then develop chronic arthritis.
Aurum metallicum addresses arthritis pain that moves around the body through muscles and joints that ease with the application of warm compresses and exercise. It also causes intense pain at night that interrupts sleep.
Belladonna addresses sudden flare-ups with throbbing pain along with reddened, inflamed joints.
Bryonia addresses throbbing pain brought on by exertion.
Calcarea carbonica addresses pain in overweight dogs who tire easily. Redness and inflammation, along with weakness and cramping often occur when exposed to cold and damp weather.
Calcarea fluorica addresses arthritis where joints are enlarged and deformed and that improves with warmth and exercise.
Calcarea phosphorica addresses aches in bones and exhaustion from exertion. It also reduces calcium deposits and bone-spurs.
Calcarea flourica helps arthritis pain that improves with heat application and exercise.
Causticum helps with arthritis that causes bone and joint deformities, tendon problems and muscle weakness. Cold and damp exacerbate the pain and there is relief when warm compresses are applied.
Culcamara helps with arthritis in overweight dogs who are also experiencing back pain and that worsens in cold weather.
Kali bichromicum addresses arthritis pain that alternates with asthma and stomach pain that occurs at odd moments. Heat exacerbates inflammation and discomfort, especially in warm weather.
Kali carbonicum helps thickened and/or deformed joints that experience increased pain during cold, damp weather.
Kalmia latiflora addresses sudden intense arthritic pain, especially pain that occurs after exercise or at night.
Ledum palustre helps arthritis that starts in the feet and moves upwards to the body, accompanied by crackling noises when the limbs are moved. It is especially helpful with significant swelling that is relieved with cold pack applications.
Pulsatilla helps with unpredictable pain that moves from joint to joint, especially in the hips and knees. Pain intensifies with warmth and recedes with cool compresses.
Rhododendron addresses arthritis swelling and pain that worsens before storms and increases with the severity of the storm. Cold and damp exacerbate the pain as does extended immobility.
Rhus toxicodendron addresses arthritis with joint pain and stiffness that is worse after a night's sleep and that responds to warmth and exercise.
Ruta graveolens addresses arthritis characterized with lameness and stiffness that is exacerbated from cold and damp weather. It also helps with tendon damage.
There are many more homeopathic remedies for arthritis available that will address each and every symptom that is affecting your dog. It is your job as a conscientious dog owner to recognize and report those symptoms to your veterinarian.
Arthritis Remedies for Dogs
There are a number of things that you can do at home for your pet to slow down the progression of the disease and help your dog to stay healthy and as pain free as possible.
Treatment for Arthritis in Dogs
According to the ASPCA, once your pet has developed arthritis, there is no cure for the condition. However, your veterinarian can work with you to help you devise an effective pain management program for your pet. While most conventional treatments rely initially on antibiotics, painkillers, and anti-inflammatory medications, many programs are designed to also include nutritional supplements, exercise, a healthy diet, and even weight loss if necessary.
The Best Remedies for Arthritis in Dogs
The most beneficial programs pair conventional care with researched natural remedies to treat your animal holistically. According to research, nutritional supplements are some of the most effective tools in the fight against arthritis in dogs. Glucosamine, chondroitin, fish oil, vitamin E, vitamin C, and a number herbs are effective for not only relieving pain associated with arthritis but also reducing inflammation and increasing your pet’s range of motion.
1. Glucosamine
Glucosamine is a nutrient that helps treat arthritis by actually adding protection rather than just minimizing symptoms. Glucosamine is a glycosaminoglycans, a family of nutrients that function to rebuild lost cartilage and restore lost joint fluid. Research suggests that it is best to begin giving your dog high doses first to see if it responds and then decreasing. You can typically find animal nutritional supplements at a pet supply store or from your veterinarian.
2. Chondroitin
Chondroitin is in the same family as glucosamine and actually serves to restore the natural function of your pet’s joints. This supplement helps rebuild the cushion in the commonly affected joints and also lubricates the joint to prevent friction and pain. Again with these supplements, you should begin with a high dose first and work your way down based on appropriate response. Pet-safe chondroitin supplements are typically fairly easy to find as well.
3. Fish Oil
Fish oil contains important omega-3 fats. The most influential elements of fish oil are EPA and DHA, as they are the effective components of the nutrient. These compounds reduce inflammation and treat pain by lubricating the joints. When looking for an appropriate fish oil supplement, look for that contains salmon or EPA oil as these oils contain the most concentrated forms of omega-3 fatty acids. You can give your dog as much as one 300 mg supplement per 10 pounds of body weight each day. Many fish oil products actually need to be refrigerated to maintain their viability.
4. Vitamin E
Vitamin E is a supportive nutrient that your pet needs in addition to fish oil supplements. As your pet takes fish oil, its natural vitamin E levels may drop, so it is important to stabilize them with a nutritional supplement. Additionally, vitamin E has some anti-inflammatory effects that may be beneficial to arthritis treatment. The recommended doses of vitamin E vary by animal size, and range from 100 IU for a small dog to 200 IU for a medium-sized dog, and 400 IU for a large dog.
5. Vitamin C
Vitamin C is another important nutrient for treating arthritis in dogs. Calcium contains important nutritional compounds that help reduce inflammation. The nutrient also helps reestablish the appropriate function of nerve signals to better monitor pain. Look for calcium ascorbate or sodium ascorbate, ad these forms are easier on your dog’s stomach.
Here is a daily dosage guide for adult dogs:
В В В В В В В Small dogsВ В В В В В В В В В В В В В В В В В В В В В В В 500mg - 1,000mg
В В В В В В В Medium - Large dogsВ В В В В В 1,000mg - 2,000mg
В В В В В В В Giant dogsВ В В В В В В В В В В В В В В В В В В В В В В 2,000mg - 4,000mg
Start with the lowest recommended dosage and gradually increase it once or twice per year.В If the dog is producing loose stools the dosage may be a bit high so cut back slightly and increase it gradually over time.
Continue reading below to find additional suggestions from our readers for treating arthritis in your dog.
Additional Pages of Interest:
Best thing for arthritis is alfalfa.I used alfalfa capsules wrapped in cheese and gave it to my chihuahua and it healed the arthritis in her hip.
I was friends with Alan & Louise Shepard (the astronaut & wife) through a close friend at work in 1996 or so. On a trip to Wimberley, Tx, to visit thier daughter and husband (my friend), they brought a small aging mixed chihuahua with arthritis so bad he could hardly get around. I shared with them, my dad's teachings of giving aging dogs alfalfa tabs crunched up in thier food to help give the joints natural lubrication. In the following weeks I received a letter from Alan & Louise thanking me so much for the tip as their dog was rejuvenated and walking like he had not done in years. Try it, it works. 500- 1500 mg tabs in the food will do it.
Apple Cider Vinegar В
It's a miracle! I posted here on 8/03/11 that I put my 72 lb, 10 yr old dog on Apple Cider Vinegar for three days at that time and he was able to run. Since then, I've been committed to putting 1 tsp in his drinking water every morning - he has so much energy and flexibility! I wish there were a chiropractor to adjust him, because he needs it, but other than that, his youthful vigor has reappeared! THANK YOU EC for blessing us with your information. I truly thought I'd have to put my dog down he was in so much pain. Now he is free to run and play again! I also give him Glucosomine/Chondroitin every morning (1crushed pill) in his food.
I tried ACV for my dog today and it made it a little bit better. She hurt her leg when she went out to do her business this morning. She was limping when she came back in. She's a 3 year old Shepherd/Lab mix and occasionally limps when she's been laying down awhile. Two hours after the ACV and a little bit of sea salt in her water and she was at least able to touch her paw back on the floor again, before that she was hopping around.
In the afternoon I put some amalaki juice in with her food just two teaspoons full and about an hour after that she was able to put her full weight on her foot again. She's still limping slightly but that's a big improvement.
I had been given a few bottles of amalaki juice a few months ago by a friend and used it myself and was amazed at how much it had helped my shoulder. I had injured my shoulder at work years ago and assumed I developed arthritis in it because whenever I do yard work it acts up. It worked so quickly that I was amazed. I realized I could not afford the brand he gets but was able to find a much cheaper brand with almost all of the same ingredients and it worked too.
I figured I had nothing to lose so I tried it on the dog. I'm not sure if it was the salt in the water, the ACV or the amalaki juice but I'm happy she's doing better. I am still going to mix some ACV in with her food tonight though and some amalaki juice tomorrow morning with her food.
My Chocolate Lab Sam has arthritis and was recently attacked by a dog. I had started him on ACV before but forgot sometimes. He has been on it faithfully for the past 3 weeks now and is getting better and better. He is on a raw diet and I just mix it in. For those dog owners who have dogs with failing health I recommend you look at the BARF diet. I wouldn't have believed that a dog who I was told would be dead in 3 months from liver problems would completely turn around due to diet and supplements(including ACV). We are what we eat and so are our pets. It has been 11 months and Sammy is doing great!
I personally use it several times day, it works for different problems. All the dogs (7) are on it, from a disabled dachsie to three young healthy dachsies. It helps with arthritis, ear problems, wounds, itching. Adjust ph levels, prevents uti's. Gives them a healthy skin and also cleans out the bodies, like it does for humans
Blackstrap Molasses В
After reading the blackstrap molasses reviews I figured I would give it a try on my 12 yo Golden Retriever. She has arthritis in her hips and is on an anti-inflammatory. Over the past few weeks she has been declining to the point where she needed help to get up off the floor and could not do a short set of steps to get in and out. Was thinking we were getting near the end with her so I tried the molasses. She has been on it for 6 days and she is doing amazing! Still a little slow to get up, but gets up on her own with no problems. I am amazed. I started out giving her 1 Tbls twice a day on a piece of bread but after a couple of days I backed off to 1 tsp twice a day and she is still doing very well. Thank you to all who posted on here before me, if it had not been for the posts I would have been making a very hard decision now instead. Hope my review helps others!Did the Molasses make your dog puke? Cause ever since I've been giving it to him. He has vomited twice this week! But, his Arthritis has been a lot better. He weighs 80 pds, and I have been giving him 1 TS twice a day.Can't figure why it makes him sick??
I give my 70-lb boxer/pit mix 1 TBSP. In the morning for arthritis and that seems to last all day. It's amazing how quickly it transformed him. In fact, when I saw what it did for him, I started taking it myself for arthritis and it works!
After reading blogs on molasses for dogs I have put our 2 older Dobermans on it. Our 10 year old female had been having difficulty getting up, and she wasn't interested in a lot of activities. Our 9 year old male still has lots of energy but I felt it would be advisable to start him on the same regimine as a precautionary measure. Our female, after 2 weeks is doing so much better, even trying to get our male to play yesterday.
Thanks to everyone who posted on here. You have helped my eleven year old Rottweiler in ways you can never understand. I've been reading up on natural products for arthritis, began giving her organic black strap molasses and organic extra virgin coconut oil and in twenty-four hours she has become almost completely pain free and feeling like she is getting stronger each day. Thank everyone so much for your notes on what you have tried.
How much coconut oil have you been giving your dog?
My 13-year-old Beagle mix has had hip problems (displaysia) since he was about 6, tore his ACL and had knee surgery to fix it at age 8, and has suffered from arthritis pain in his hind quarters for years. We were given the typical arthritis meds from the Vet, but it didn't seem to work, and we hated taking him in for blood tests all the time. This past year he really seemed to get worse - to the point of me lifting him to his feet, carrying him outside, and bringing him food and water in bed. He moaned in his sleep, and yelped when he tried to get up on his own. I was thinking it was time for that dreaded visit to the vet.
Then someone referred me to this website. I've tried a few of the remedies (ACV, tumeric, all 3 mixed), but Blackstrap Molasses, alone made the biggest difference. About a month ago, I started giving him about 1/2-3/4 tsp Blackstrap Molasses wrapped in a small piece of bread once a day (in the morning after his breakfast. He weighs 42 lbs. ) Now, he gets up on his own, goes up and down small flights of steps on his own, runs, goes on walks, plays with his doggie sister, and doesn't moan. He jumps up to get food off the dining room table, gets into the trash. He is back to his old bad behaviors. Even my husband (who was very skeptical) says it's like night and day. This site is wonderful. Thank you!
Wasn't sure if ACV or Molasses was the best place to respond, so I'll post as follow up.
I do a lot of rescue with little dogs. I have 4 right now. One is my daughter's dog that I have been babysitting while she was on a year tour in Mosul, Iraq. She is coming for xmas this weekend & will be taking her baby home with her to Fort Hood in Texas when she returns.
We live in Colorado & am just coming out of a deep freeze for 2 weeks! During the last weekend, my Silky Terrier started whining in pain! ( 6 or 7 years old?) Even though he loves his walks outside & play in the snow, he couldn't even make a full walk around our building. The sever cold was doing something terrible to him! We've a 2bdrm upstairs townhouse, & he couldn't make it up or down the stairs, up or down on couch or bed. He'd just stand there & stare. He's never been through anything like that. His eyes were clear, gum color good, eating, drinking, peeing, but not pooping so well! I think it was too painful. I kept giving him massages & found a small bump on his lower spine. He goes really stupid when we see other dogs on our walks, so I thought maybe he did something to his spine. Looked for animal chiropractor, but too cold to get him anywhere, so kept looking as that was all I could do besides keeping him comfy.
I use earth clinic for holistic remedies for me & my pets, & believe me I've saved $1,000's in Vet bills. & I haven't been to a Doc since 2001. I'm 60.
I also comb through the people section & adjust the dosage for pets.
I already put h2o, ACV, pinch of Sea Salt in their daily water bowl, but am just amazed how well the Molasses worked for the cold weather Arthritis!
I wanted to post a Thank You follow up to earth clinic & all the wonderful people that share their experiences here!
Happy Holidays & Much Love & Blessings to All!
EC : Thanks for the great feedback! Can you let us know how much blackstrap molasses you are giving your dog and approximately how much he weighs?
Came back to add that I quit dosing for 2-3 days as weather has gotten better, then today we are in pain again. I've started him back on the Molasses tonight. I may just have to make it as a regular supplement, instead of weekly like the other pups, with his daily meals. Would have taken him to the Vet if it hadn't gotten better, but I already know it would be x-rays & cortisone shot & am trying to not do that. If it continues I will try an animal chiropractor to check it out. I'll be back to update progress in a couple of weeks. Some kind of inflammation problem. I may also try adding Turmeric in a couple of days, but don't want to constipate him just yet. I'll research dosage for that one. and let you know or please advise.
He's probably 10-15 lbs. I started with about a tablespoon on a plate. he ate it. So I cooked some rice like someone else on here said to do, & mixed in another big spoon full. A tablespoon here, a tablespoon there, just really wanted to get it into his system. I did this a couple of times into the night, & like I said, he was his old self the next day!
I think it would be pretty hard to over dose when giving natural remedies. When your animal doesn't feel good they will let you know when they've had enough. They seem to know.
Thanks again & Many blessing to all,
Hi there. When I was reading this I wondered if you would also consider getting little boots for your dogs feet in the snow? My little dog suffered through last year's blizzards in New York, and I had to get little boots to protect her feet from the snow and salt on the sidewalks and it helped her so much. Also, when she came inside, I would take the boots off and her feet would be dry--no mess at all.
I have been using Blackstrap for years, you have to be careful with it. It is high in iron and if you use it for long periods of time it can cause kidney problems. Do not use it all the time, just when needed. Just a thought.
I read the email about the dogs being given the Blackstrap Molasses and how they are vibrant and doing fine, so I decided to give my pomeranian who is suffering from arthritis some BSM on some cooked white rice. Well I'm glad I did and I am giving it to him and my other dogs over white rice every 2 days and boy do they have energy. My Pom has been jumping like he use to jump before the arthritis pain. I have a miniture chihuahua and 2 American Stafford Shireterriers and they all seem more vibrant and happy. I myself take BSM and it has worked wonders for me. My anemia is over, my tiredness is gone, I feel so much better since reading this BSM Info on this site. Thank you guys so much and may God forever Bless each of you that shared.
I've heard NOT to give dogs white rice. Only give them brown rice. Apparently, something about the white rice is really bad for dogs. That is all I know about it. Sounds like the molasses is good though.
The wonderful Theresa from Minneapolis, MN has been helping pet owners and their beloved pets around the world on Earth Clinic since 2013.
Theresa from Minneapolis was born and raised in the inner city, always wishing she had been raised on a farm.
Her love for creatures great and small began at an early age, starting with caterpillars - which continues to this day, along with an interest in all insects and 'creepy crawlies'.
Theresa's interest in pet health started with a bird keeping hobby at age 14, where she learned from another hobbyist that the simple addition of Apple Cider Vinegar (ACV) in a bird's drinking water kept fungal infections away; she was able to share this with her avian vet who in turn prescribed it to her own clients; Theresa was surprised to learn that she could teach her vet a thing or two. This important lesson - that each of us can be a teacher - was a turning point for Theresa, and fueled her quest for the knowledge held in lore, and remedies passed by word of mouth. That quest for knowledge continues to this day, as new and old remedies alike are explored. She may not have experience with a particular issue, but she will research it to the best of her ability and share what she finds freely, in the hopes that you can heal or improve your pet's health.
How To Show Theresa Your Appreciation
If you would like to thank Theresa for her helpful posts, she asks if you would please consider making a donation to one of her favorite local rescue organizations, or by making a donation to help the genius contributor, Ted from Bangkok, recover from his stroke.
I must respectfully disagree with you! I did some fact checking, and this is what I learned about it.
White rice is not really bad for dogs. In fact, because of its high digestibility, it is a good food to feed to a dog with tummy upset. White rice is close to brown rice in nutrition: brown rice has just a wee bit more nutritional benefit. White rice is superior to brown rice in terms of arsenic levels, so a better choice for young animals.
Boron, Vitamin K2 В
My 7 year old dog started showing signs of arthritis; stiffness and limping, particularly after first getting up from sleep, much subdued excitement, and refusing go on long walks, but some improvement if she was limited to short walks. I started giving here 3 mg of boron a day, and 100 mg of vitamin K2. She improved after about 4 weeks, then when I quit the treatment she got worse, only to improve again when I re-started these supplements.
Not a scientific approach, I know, but as long as she is comfortable and her old frisky self, it is good enough for me.
Chicken Cartilage В
My story is about what cartilage did for my little arthritic dog. I hope it is useful.
Last Thanksgiving I removed cartilage and skin leftover from boiling our turkey carcass, and blended it up with some hot water in my Vitamix. It made a kind of meat Jello that I have been adding to my old terrier's grain-free food. She has become like a different dog!
Before I could only walk her about a mile or two because she would get sore and become very slow. But now she can easily walk twice that distance with plenty enough energy left to jump in the car all by herself afterwards. I always used to have to lift her in and out of the car, she couldn't do it on her own.
I just now made the dog another batch of blended up cartilage, this time from a goose. I also hear Vitamin C helps you assimilate collagen into your tissues, I might try giving her some of that, too.
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Natural Remedies For Arthritis
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Polyarthritis Især Lammende i unge hunde
Ser helst dyr forsøg på at løbe og lege mens du kæmper gigt kan være svært. Men det er især hjerteskærende for ejere, hvis dyr har en form for leddegigt er kendt som juvenil Polyarthritis Syndrome. En af mange forskellige typer af polyarthritis, denne uhelbredelig sygdom rammer tidligt og krøblinge hundens lemmer, forårsager kronisk alvorlig smerte og lammelse.
Denne type arthritis begynder med en abnorm immuncelle respons, der forårsager for mange hvide blodlegemer (kroppens sygdom brandmandskabet) at invadere leddene. Når der de frigive kemikalier, der skaber hævelse, ledsmerter og feber. Dyr med polyarthritis ofte føler sig syg og er tilbageholdende med at flytte rundt. Leddegigt er specielt aggressiv i udhuler brusk, der dæmper leddene. Plus, med tiden, deformerer det knoglerne omkring leddene samt, efterlader benene deformeret og ude af stand til at bære hundens vægt. Sygdommen normalt påvirker mere end én fælles, ofte alle hunds led er involveret.
Medmindre leddene tydeligvis er hævede, kan polyarthritis være svært at diagnosticere, da symptomerne ligner mange andre lidelser. En hunds utilpashed, for eksempel, bliver ofte overset eller tilskrives andre årsager. Problemet kompliceres yderligere af, at symptomerne hos disse dyr kan komme hurtigt eller langsomt, omfatter kun et ben eller flere led, og kan forbedre spontant i en tidsperiode, eller bliver ødelæggende meget snart. Med andre ord er selvmodsigende symptomer den eneste konsekvens. En kronisk feber, kombineret med halten, er en af de bedste indikatorer for en arthritis-problem. Der er ingen specifik test for sygdommen, og derfor en sikker diagnose af polyarthritis kan kun ske efter flere tests er blevet udført og alle andre potentielle årsager udelukket.
I de fleste tilfælde er arthritis en sygdom i aldrende hunde, forårsaget af en levetid på slitage på leddene. Traumer, sygdom og dårlig ernæring også kan spille en rolle i sin udvikling. Dog med juvenil form af sygdommen, synes symptomer tidligt og er særligt invaliderende. Betingelsen er normalt behandlet med nonsteroide antiinflammatoriske lægemidler (NSAID), såsom aspirin eller ibuprofen. Din dyrlæge kan også ordinere anti-reumatiske og smertestillende medicin, plus en steroid lignende kortison til at behandle den underliggende sygdom. Smertestillende også er normalt ordineret. I almindelige tilfælde af polyarthritis sygdommen kan bringes i remission omkring halvdelen af tiden med medicin, som derefter vedligeholdt med kortikosteroidbehandling. Men i den unge form af sygdommen, er succesraten med medicin, der kun behandling meget lavere.
I de mest alvorlige tilfælde kan artroskopisk kirurgi udføres for at fjerne debris fra det fælles og reparere den resterende brusk. Afhængig af alder, størrelse og tilstand af din hund, også fælles udskiftning kirurgi kan være en mulighed.
Unik juvenil Polyarthritis Syndrome, Sundhedsproblemer, Sundhed, Gigt, genetiske sygdomme
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Top 5 Herbs for Animal Arthritis
Properly used in conjunction with an overall holistic healthcare plan, these healing herbs can have a powerful effect on your canine’s creaky joints.
Herbs have a firmly established place in alternative medicine. Used properly, they can help treat a wide range of conditions in dogs. The key term here is “properly used”. For example, those who reach for herbal remedies as direct intervention against the symptoms of arthritis, or as standalone replacements for pharmaceutical drugs, are likely to be disappointed. Although many herbs can be used to reduce inflammation and relieve pain, most are much weaker than conventional arthritis drugs when used for suppressing symptoms. But as part of a holistic regimen that looks beneath symptoms to identify the causes of arthritis, herbs can be quite effective and will bring relief by preventing or managing a dog’s underlying condition.
How herbs can help
Unlike non-steroidal anti-inflammatory drugs (NSAIDs), which address only the painful symptoms of arthritis, herbs can strengthen and support the body systems responsible for eliminating toxins that might contribute to the disease. To achieve this goal, the herbalist’s first job is to eliminate the possible causes of arthritis in a dog, then turn to improving and supporting the body’s natural corrective functions, from the inside out.
Allow me to introduce you to five of my favorite anti-arthritic, tonic herbs.
Boswellia serrata (Indian Frankincense)
A resinous gum extracted from a bush native to India, boswellia has a long history of effective use against the painful symptoms of osteoarthritis and other forms of degenerative joint disease. The herb contains boswellic acid and alpha and betaboswellic acids; these are well documented as reliable anti-inflammatory agents. Because of its demonstrated safety and efficacy in dogs and other mammals, boswellia has become a very popular ingredient of the natural pet supplements industry. Boswellia can help alleviate pain and improve joint mobility within a matter of days. It is thought to inhibit mediators of autoimmune disorders while decreasing glycosaminoglycan degradation. This in turn may help slow the progression of cartilage damage. In other words, boswellia helps the body do for itself what most conventional anti-inflammatory drugs cannot do – heal from within. The biggest and perhaps only pitfall of boswellia is its awfully bitter flavor, which makes the extract difficult to feed in therapeutically viable doses. Nevertheless, boswellia stands as one of the most effective herbal anti-inflammatories available.
Turmeric (Curcuma longa)
Numerous scientific reports support turmeric as a safe and effective anti-inflammatory remedy for arthritic dogs and other mammals. Feeding this bright yellow kitchen spice can be as simple as sprinkling a few pinches on Fido’s food, but the best results come from turmeric preparations that have been scientifically manipulated to contain unnaturally high concentrations of the herb’s active curcuminoid constituents. Human studies have shown that the anti-inflammatory and pain-relieving capabilities of turmeric extract containing at least 20% curcuminoids are comparable to those of the NSAID drug ibuprofen. And when bromelain, an enzyme derived from pineapple, is fed concurrently with turmeric, the results can be even more impressive. Bromelain is itself a powerful anti-inflammatory, and when combined with turmeric it also helps with digestion and transports turmeric’s curcuminoids into the bloodstream.
Turmeric is also a peripheral vasodilator that helps warm the body and increase circulation to joints where added blood and lymph is needed for the regeneration of healthy tissue. But that’s not all. Turmeric stimulates and protects the liver, so while it’s reducing painful inflammation, it’s also helping with the process of eliminating waste that’s contributing to the problem Step aside, NSAIDs!
Licorice root (Glycyrrhiza glabra)
I regard licorice root as perhaps the most broadly applicable antiinflammatory in my herbal medicine chest. It contains several phytosterol compounds that are thought to affect the body’s production and utilization of cortisol, a steroid hormone that helps regulate the body’s inflammatory responses to damaged joints. I find licorice especially useful when combined into a liquid compound with alfalfa (Medicago sativa) and yucca root (Y. schidigera), two other phytosterol-rich herbs that lend digestive and liver support to help with the elimination of toxins that might contribute to the progression of arthritis.
Ginger (Zingiber officinale)
Active constituents of ginger include gingerol, gingerdione and shogaol as well as sesquiterpene and monoterpene volatile oils, all of which offer medicinal attributes. In the case of arthritic joints, dried or fresh ginger root when taken internally helps relieve stiffness and pain, while acting as a peripheral vasodilator to improve circulation in and around swollen joints.
Devil’s claw
Multiple studies suggest that devil’s claw tuber may help alleviate the pain of osteoarthritis, primarily through the iridoid glycoside constituents it contains. Devil’s claw has become very popular in recent years, and appears in numerous arthritis relief formulas for dogs and other animals. However, despite its popularity, I have heard many mixed reviews from veterinary practitioners and dog owners telling me that sometimes it works, sometimes it doesn’t. The reasons behind this controversy may be related to how the herb is harvested. The tubers of this bizarre-looking little African plant must be selectively harvested from mature plants that are at least four years old, and the harvest must be done during a very specific stage of the plant’s growth cycle. The most sustainable practice is to harvest only one to a few of the tubers that extend from the plant’s base, leaving enough to assure the plant’s survival and the re-growth of new tubers. Unfortunately, increased demand for this herb has led to the premature harvest of too many tubers, and in many areas we are seeing declining populations of the plant.
Because tubers from immature plants lack sufficient concentrations of active iridoid glycoside constituents, much of the devil’s claw sold on the North American market is functionally useless. With that said, there are sustainable sources for those who seek it out; aside from its bitter flavor, properly-harvested devil’s claw is an excellent joint pain remedy.
You should always work with an experienced animal herbalist or a veterinarian trained in herbal therapies before trying these remedies on your dog. Properly sourced and administered, and used in conjunction with an overall holistic healthcare approach, these herbs can have a powerfully healing effect on your canine’s creaky joints.
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