We are pleased to introduce a 3-part series of interviews with Dr. Erin Troy, Certified Veterinary Pain Practitioner. In part 1 of the series, Dr. Troy talks about the process of getting certified in pain management and how to educate pet owners to recognize and treat pain.
Assisi Animal Health: I understand that you received the title of Certified Veterinary Pain Practitioner. Tell me a little bit about what that means and why you chose to do that.
Dr. Troy: I started the whole process into physical rehabilitation about 12 or 13 years ago, and one of the things I realized a couple of years into it, is that we can do a lot of rehabilitation therapy – but if the patients are not comfortable, we’re not going to do them any good. So, I started figuring out what I need to do first to get them comfortable – to get their pain controlled – and then rehab them. It started me on this adventure, so to speak, of starting to seek more education and training and then I fell into the IVAPM – the International Veterinary Association of Pain Management.
When I joined them, I read about this certification program. For me it was a personal and a professional goal – being 20 years out of vet school, I didn’t want to get stale and flat, I wanted to keep the learning curve up. Your brain gets a little saggy when you’ve been out of school for a while.
The depth of what it brought to my practice was the best part – it opened up our eyes to not only helping our acute pain or surgery patients with all the things we do for that, but certainly our chronic pain patients as well. For us, it became this multi-layer opportunity to provide a better level of care for our patients.
What is it that you have to go through to get this certification?
To qualify to take the test, you need 80 hours of pain-related continuing education. Five years ago, that would have been very, very difficult. Now? Pain is everywhere. (laughter) Well, pain education is everywhere. Pain is everywhere too, but education on pain in the veterinary field is far easier to find now than it ever used to be.
Within three or four years, you have to get your 80 hours of pain-related CE, and you have to document what you use in your practice with pictures and descriptions. They have a list of things that you have to meet the minimum number of including non-steroidals, drugs, all of what we use in rehab. That includes the Assisi Loop™, the laser, the hydrotherapy tank, the physio rolls that we use, masseuses and acupuncture.
You have to do two cases and they have to be of publishable quality, and you sit for an exam. Along with working 60 hours a week and having families and those kinds of things, that’s probably why there are less than 100 people in the world that have this certification.
You’ve said that you use studies in the human world to help pet owners understand their pet’s pain. Can you talk more about that?
So much of what we get is from the human world. When I talk with clients about technologies like the Loop and like laser, I have a list of references that I send them to on the web that are human. For some reason, people still put more credibility into human studies than animal studies. I have a lot of families that will read some of the studies done on the targeted pulsed electromagnetic therapy in people and say, “Cool. Where do we start? Sign me up for my dog.” I like that. I like that that exists.
The one study that I share with a lot of people was the study I read about using this technology for women following breast surgery. It was a pretty simple study. The numbers were impressive. Half the group used morphine only. Half the group used morphine and a Loop. The group that used morphine and the Loop used half the morphine than the other group did. That kind of speaks for itself. So when you try to relate that degree of pain to chronic osteoarthritis patients or trauma patients or IVDD patients, people have a much easier time understanding.
Believe it or not, there are still people out there that have said to me, “I didn’t really think that dogs felt pain.” Those are the people we need to educate. We need to educate them gently and we need to educate them with support — not be judgmental — because they wouldn’t be in our office if they weren’t looking for help, in some way.
How do you talk to pet owners about pain and help them to understand it?
I try first to ascertain which side of the fence they’re on. Are they there because they think their dog is in pain, or are they that middle-of-the-road group that says, “Doc, she’s been limping for about two weeks, but she’s not in any pain because she’s not crying.” If I had a nickel for every time I heard that. Or are they the people who come in for their every-three-year visit to get their rabies and their dog is barely hobbling in and they don’t recognize it.
The first group is pretty darn straightforward to deal with because they’ve already acknowledged that their dog is in some level of discomfort. I really try not to use the word “pain” because I find that some people feel either guilty about it or that we’re being judgmental about it, so I’ll say uncomfortable, discomfort, tender, sore and then work toward what we call “the four-letter word” around here.
We have a list of indicators of pain. It’s a great checklist for them to look at because there are things like: not covering in the litter box when the cat used to cover, or can’t get in and out of the covered litter box, or can’t get on and off the bed, sleeping in a different fashion, ears pulled back, eyes dilated, panting. There’s a big one in dogs. I say to clients, “Does your dog do any panting at home?” “Yes. He does it in the middle of winter and I don’t understand that.” I tell them, “Your dog is panting because he’s sore.”
So when families come in with a focus on getting my dog stronger or keeping my dog from falling or helping my dog be able to climb back into the car or on the bed – if I find pain, I educate the client that “I cannot get your dog stronger until I get him more comfortable.” Because you don’t want to work sore muscles. You want to get them comfortable and then you want to work them. Clients get it.
Is it important to try to catch pain as early-on as possible?
The more pain you have that’s not addressed, the more pain the pet develops, and then the harder it is to control pain. From a pharmacological point of view, if we have a dog that comes in with 3 out of 10 pain, we can control that much more successfully than if they wait another 6 months and come in with 7 out of 10 pain. Then you’re throwing everything at them – everything you’ve got including strong narcotics to get that pain down to a manageable level. So that is why we have single-handedly taken on the responsibility of educating every pet owner we can.
First of all, pain is bad. Then it’s how to know that you have pain, then how to determine where it is and what it’s from and how to treat it. If you can’t convince people that pain is bad, you’ll never get to the other steps.
Do people actually have trouble understanding the concept that pain is bad?
Some people think pain is okay. I had a woman tell me the other day, to my face – and she’s an educated woman – that she had to take her dog off of pain meds because he was running around too much. And I said, “What you’re telling me is that you would rather that he be painful and less active than pain-free and active.” She said, “Yes.” And I said, “That’s not a medical problem. That’s a behavioral problem. That’s where we put the leash on, take him for walks, and we have lots of things to deal with.” I told her that it’s not fair to use pain as a restraint device.
How do you talk to pet owners who haven’t yet embraced the idea that pain is bad?
We talk about the physiological problems with pain and what it does to the brain and what it does to the rest of the body and what compensation pain is all about. We deal with a ton of compensation pain. For instance, a dog comes in with a chronic tear to its cruciate ligament and for a variety of reasons the owners have elected not to do surgery. The owners look at me like I’m crazy when I’m palpating up around the neck and shoulders and front legs of the dog and they’re like, “No. No, doc. it’s back here.” And I tell them, “I understand it’s back there, but feel this up here. Your dog has been shifting her weight forward for so long. Now she’s got a problem in her shoulder and her elbow. It’s all connected. Pain just travels through the body.”
So when you talk about the depth of what the certification brought to your practice, the simple acknowledgment that “Pain is bad” is a big part of that piece.
Yes. Absolutely. It’s acknowledging the pain, recognizing that it is bad, learning how to assess it and learning how to prevent it. We want all our patients walking out of here looking as good as possible. Because we know they will heal better and it will be less stressful on their family.
Pain Management for Animals, Part 3
Nov 05, 2014
the final installment of our 3-part series on Pain Management, Assisi
Animal Health spoke with Dr. Troy about her use of the Assisi Loop™ in her practice. Part 1 focused on her IVAPM (International Veterinary Academy of Pain Management) certification. In Part 2, Assisi Animal Health spoke with Dr. Troy about the case studies she submitted to gain her certification with the IVAPM.
Assisi: I know the Assisi Loop is a part of your integrative strategy. What role does it play in pain management?
Dr. Troy: If I have a patient either in the general practice or the rehab practice, with a diagnosis of something more than pain – osteoarthritis, non-healed fracture, post-op cruciate ligament, post-op hip replacement, IVDD – any time I have a diagnosis with a location, it automatically makes that patient a candidate for a Loop.
So knowing the location of the pain is vital.
If I have a patient that comes in and is obviously painful but I don’t know where, I can’t pull the Loop out of my arsenal yet, because I can’t just hold it over the entire animal unless he’s very small. So that’s the first criteria for me. When I talk to the staff, I tell them it’s like laser or acupuncture – we have to have a sense of what we’re treating and where before we just throw the Loop, the laser or the needles at them.
I talk to families very frankly about [the Loop], that it’s non-invasive and that there are no side effects – two things I cannot say about drugs. There’s no blood test monitoring to go with it. There’s a good amount of human literature that supports the technology behind it, because we certainly do have some clients more discriminating than others.
I have some clients who just say, “Doc, if you think it works, I’ll use it. You don’t have to tell me a thing about it, just tell me how to use it.” And then I have others that are maybe even a little bit suspicious, and they want to have a better understanding of it. I talk with them about the validity of it as far as the studies have gone, and then the convenience of it, because you can’t get any more convenient than something you can do in your own home. And as for the cost-effectiveness of it, the outlay may be a little more than clients are used to, but when you know you get 150 treatments for the cost, and they do the math very quickly in their head. Concerning the convenience level and the effectiveness level, I think every pet owner should have one, provided they can learn how and where to use it.
What made you decide to start using the Loop?
I’ve done this with almost every piece of technology we’ve brought in – even a new drug. I will pick a very good case to use it on, and we’re very selective – we pick the client we know we’re going to get compliance and feedback from, and that has made a huge difference on how we bring new treatments in. And for me, when you sent us our first Loop, and we picked a case – it was like, “Oh my god!” Because we didn’t think it was going to work! We thought it was hocus-pocus. And we were like, “Did you see how much better he’s moving?” And I’ll never forget the case. It was a little corgi. He couldn’t tolerate any drugs and he had a really sore back, and x-rays were normal – and we were like, “Let’s try the Loop!” And sure enough, a week later he came back, we did nothing else, they rested him and they used the Loop. And he was famously better.
We did a Patient Spotlight on one of your patients a while back – can you give us a recap?
I love using it for dogs that can’t tolerate non-steroidals because I think it’s a very strong option for them – Millie Burgelin being one of them. She’s a poster child for the Loop. If it had not been for when we started the Loop on her, she would not be alive right now. She was in that much pain. When they sent me that email over that weekend, that fateful weekend last year, they said “We think the time has come” – and I said, “OK, we’ve got one more thing we can try with her.” And they did the Loop through the following week. This was a dog that could tolerate no oral drugs and has multiple-limb arthritis – and when they sent me the picture of her running down the stairs, it brought tears to my eyes. In her case, it had to be the Loop because we had done nothing else. And you don’t just “get over” [such bad arthritis].
Can you talk about some other cases that have benefited from the Loop in your practice?
I have a woman who has a FEMA search-and-rescue task force dog. He has a lot of pain from the work that he does. He works on piles of destroyed property and that kind of stuff, and he twisted his back. X-rays were fine, neurological exams, MRI was fine – he just had really really sore muscles. We talked a lot about what our therapy options were, and we did a little bit of drugs for the injured knee that he had – and then the Loop. And she used the Loop four times a day with him because we knew exactly where it was and what hurt, and it wasn’t very long into the course of treatment that she was a believer. Now she keeps it in her travel bag, so if she’s deployed with him, either for training or for work, she has it. She will use it whether she thinks he’s hurt himself or not – but just to keep him in good shape. She loves it, she loves the portability of it, she loves the effectiveness of it.
The dog I sent home with one today – just a lovely, lovely older Labrador who’s carrying too much weight, horrible osteoarthritis in her elbows – and the family lives 50 minutes minimum away from me. So I talked to them about it. I said, “For me, this is going to be the mainstay of our therapy,because you don’t have to come see me every day, you can do it at home, we know exactly where to do put it, it’s easy, and there are no side effects.” This is also a dog that can’t tolerate non-steroidals. She did so much better on them, but kidney and liver values went up and she had vomiting issues. Clients come and they think there’s nothing they can do, so these are the clients that are so grateful when they’re given the opportunity to use a technology like the Loop. They see the results for themselves.
We also use it for mast-cell tumor surgery sites and anal sac adinocarcinoma surgery sites. These are usually sites that are very tender, and skin is fragile. You can almost assure that it’s not going to be a good 10-day healing process, that it might be a 20-day or 30-day healing process. So we Loop them, because they heal so much better and they have less post-operative pain.
What we’ve done with some dogs is use a loaner Loop for dogs that are having surgery back by their anus, which is so uncomfortable and so tender back there. We send the loaner Loop out and we say, “We want you to do this for the first seven days, two to three times a day.” We give them the whole protocol, we have a signup sheet that they keep track of their treatments on. Since we’ve been doing that, I can’t tell you how much better these surgical patients look than the ones that didn’t do it before.
So it goes from maybe 20 or 30 days down to – what are you seeing?
In half. I have one client who had an anal sac tumor done on one of their dogs, and when the other dog several years later needed it, she said, “Oh no, I’m not putting him through that.” I said, “I know, it was a tough recovery. I’ve got a new protocol. Bear with me, give this a try.” And she was absolutely thrilled.
Education is such an important factor in your practice, it sounds like educating them about the Loop is just a piece of the overall education process for you. Do they tend to do well with compliance?
I would say we have an 80% compliance rate with the Loop. I’m thinking of the few failures we’ve had, and what the failures will be is someone who we’ve demonstrated it for them, we’ve talked about the technology, why we think it works, what we want them to do with it, and then maybe they missed their next two appointments because they cancelled them. And then they’ll say, “Yeah, I tried it a couple times, and it didn’t really make a difference so I haven’t done anything more.”
We tell them specifically, this is a cumulative effect, we ask them to give it a minimum of twice a day for 21 days. I tell people, “If you’re looking for a quick fix, this isn’t going to do it.” I try and paint an honest picture and I try not to send it home with anybody that I think isn’t going to be compliant, because there isn’t any point in it. I don’t see any point in taking their money. I don’t see the point in giving them a reason to badmouth the technology. I would rather set everyone up to succeed than to fail.
Of the clients that I know are compliant, we have great reports back. A lot of it depends if our diagnosis is correct. You can treat a back leg with it but if the front leg is worse off than the back leg and you’re not treating the front leg, the clients aren’t going to see a difference.
It sounds like you really value the Loop as a non-drug pain management option.
I prefer to use the Loop rather than prednisone. We do have dogs that are intolerant of all different drugs. And I’ll use them in addition, certainly if it’s too difficult for them to get anywhere, or maybe the dog’s just too gosh-darn painful to get in the car, or he’s had a relapse. I tell clients, “You’re not going to overuse it.” So if you’re worried about them being a little bit sore, or if we have a dog that’s recovering and doing well, I tell them, “Put it on the shelf – and if he goes out and does something crazy at the dog park, and he comes back and you’re worried he’s sore, Loop him. You’re not going to hurt him. Use it as pre-emptive treatment as well.”
We’ll also use it for dogs that are either mentally or physically intolerant of acupuncture. I think it’s the most cost-effective way of fighting pain as long as we know where the pain is. The dogs don’t have to get in the car, drive over here, get out of the car, come into the hospital – they can just be at home. I think it has potential, when you have the right client, for very high compliance – if we educate the client correctly. Because how can they beat it? They just can’t beat it!
A huge part of your CVPP certification was learning how to educate your clients.
Absolutely. Sometimes people look at you like, “Are you kidding me?” and I say, “No, I’m not.” It does give a lot more credibility when you say, “This is used in people. This is not hocus-pocus. This is modern medical technology that is cleared by the FDA with accepted use in people all over the country.”
If any of our hospital patients, pets that belong to staff, have any type of surgery, they all go home with a loaner Loop. And what a difference!
My business manager’s dog had a liposarcoma – a cancerous fatty tumor on his back. The surgeon took a strip of skin 17 inches long and four inches wide off of his back to get all of it. And we knew it was going to be a bear to heal – and I can’t tell you how beautifully it healed. She Looped that area three times a day. His pain was minimal, the healing was beautiful, everything about it was just perfect. And we’d all prepared ourselves that this was going to be a battle, and it was beautiful. I told her, “I know the Loop had a big part in it.”
It’s encouraging for us, too, because I have two very traditional vets in the practice who kind of raise their eyebrows every time we talk about anything that wasn’t taught in their base curriculum. We talk about things, we talk about different treatment options, and I say, “We’ve talked about the Loop before, why don’t you try the Loop on him?” And they’ll say, “Oh yeah, I just wasn’t thinking about that.” So they go talk to the client.
I like to move staff out of their comfort zone just a little bit, because otherwise you’ll never learn anything. You’ll never try anything new. This shouldn’t be new. Five years from now, this should be in every single veterinary hospital, clients should be asking for it, everybody should know what it is. Because it’s so easy and so safe and so effective.
Thanks to Dr. Troy for taking the time to talk to us about her personal experience with the Loop, and how it has benefited so many of her patients. Dr. Troy has a wealth of knowledge about veterinary pain management and we are thrilled to count her among our community of practitioners who believe in and prescribe the Assisi Loop.
Dr. Erin Troy is the owner of Muller Veterinary Hospital and The Canine Rehabilitation Center in Walnut Creek, California. Watch for Part 2 of this series where she’ll tell us about the cases she used to get her IVAPM certification. She will talk more about integrated pain management with the Assisi Loop as a part of the treatment protocol.