By Dr. Becker
Little Tia is a 13 year-old (her age is an estimate) Maltese I had the pleasure of meeting in August 2003. Tia was rescued as a stray in February 2003, so she had only been with her new family about six months when she became my patient.
When I first met Tia, she had dental disease and bilateral luxating patellas (floating kneecaps affecting both knees). She was on a progressively supportive joint protocol and an oral hygiene protocol to deal with these issues and meet her body's changing needs.
Tia Develops a Heart Murmur
In July 2009 when Tia was about nine, during her regular wellness exam she was diagnosed with a grade 1 (mild) heart murmur. To make sure her heart was functionally normal, we did an echocardiogram (page 1) that indicated no serious problems, and no medication was required.
A little over a year later, in November 2010, Tia had an episode of syncope (a fainting spell) and her mom took her to an ER vet. It was discovered that her heart murmur had suddenly become much worse (page 2). A follow-up echocardiogram showed a deteriorating heart condition (page 3). Tia was prescribed Pimobendan, a veterinary heart drug, and a low dose (50 mgs) of ubiquinol, which is the reduced form of CoQ10.
At a wellness exam in March 2011, we did a proBNP test on Tia, and her score at 751 showed her heart muscle was not stretching (or enlarging, a bad thing) as a result of her valve disease (a positive sign) (page 4). But in November that same year, she began coughing, which is a classic sign of heart disease. Tia's mom returned with her to the veterinary ER, where her x-rays showed no fluid in her lungs, but did show an enlarged heart.
Tia was started on Furosemide, a diuretic, and Benazepril (page 5), an ACE inhibitor that dilates blood vessels and reduces stress on the heart.
At Age 12, Tia Sustains a CCL Tear
In December 2012, Tia tore her right CCL (cranial cruciate ligament), which is the canine equivalent of a human anterior cruciate ligament (ACL). Dogs with luxating patellas are at increased risk of tearing this ligament.
Tia's aging body and muscle atrophy probably also contributed to the CCL tear. She was never physically active, but did run up and down the stairs at home. Out of shape "house dogs" are at increased risk of injuring themselves during short bursts of activity. Their tendons and ligaments tend to be weak and are easily overburdened by something as ordinary as running up stairs.
For Tia, Surgery Isn't an Option
Tia's mom and I discussed the possibility of surgically repairing her CCL and the fact that she could have anesthetic complications due to her heart disease. We repeated the proBNP test and this time she failed with a score of 1770 (page 6).
I suggested Tia's mom increase her ubiquinol dose to significantly above what is typically recommended. There are no side effects from providing high amounts of this all-natural coenzyme, and it can often dramatically improve heart health when recommended above suggested doses. Tia's ubiquinol was increased to 200 mgs twice daily.
I also suggested we manage her CCL injury without surgery, choosing physiotherapy as a treatment modality instead. Tia began rehabilitation and oral joint support, including a product from Canada called Joint Formula, EFAC, and proteolytic enzymes to manage inflammation.
I also recommended regular aerobic exercise for Tia. Initially, her mom had a common concern – is it safe to exercise a dog with a heart condition? It's important to recognize the heart is striated muscle and like an animal's biceps muscle, it needs healthy aerobic exercise to remain strong. The intensity and duration of exercise is moderated based on the level of heart disease, but all animals are meant to move, which strengthens the "pump," like in humans.
Lack of the Right Kind of Exercise is a Problem for Many Small Dogs
I believe one of the reasons we see more age-related heart valve disease in small dogs is because their owners believe they don't need rigorous cardiovascular workouts throughout their lives. Many pet owners believe their small dogs get ample "exercise" by walking around the house, and nothing could be further from the truth. All healthy dogs need a minimum of 20 minutes of daily, heart thumping, nonstop cardio. As pets age, the run turns into a brisk walk, which eventually turns into just a walk -- but an animal's heart healthy requirement for aerobic exercise does not diminish with age.
I believe Tia's sedentary lifestyle contributed to her heart condition, and it's never too late to turn over a new, healthy lifestyle leaf. We would rehab Tia's heart at the same time we were rehabbing her CCL. We started her on acetyl L-Carnitine as an additional heart healthy supplement before she began physiotherapy.
Tia's Protocol for Improved Joint and Heart Health
Because Tia's torn CCL could not be fully repaired without surgery, our goal was to reduce pain, strengthen her healthy, but now stressed left CCL (which is at greater risk of tearing), and slow the inevitable degenerative changes that come with an unstable joint.
The good news: Tia is tiny. Small dogs can have good quality of life with conservative management of a CCL tear. The larger the dog, the more chronic lameness and eventual disuse and degeneration will occur. Many dogs become chronically lame and their quality of life is dramatically reduced without surgical management of CCL injuries.
This is a very different scenario from humans, who don't need surgical intervention in many cases and can continue a great quality of life without it. This is because the human knee joint has very different biomechanics from the canine knee joint. In humans, the tibia, which articulates with the femur, is a flat plateau. Dogs have a very steep tibial angle, so there is constant instability in the knee joints of dogs with CCL damage.
Tia's home activity was restricted to prevent additional damage to her knees. She was not allowed to climb stairs, jump up on the couch or run on slippery floors. Her only activity for the first four weeks was physiotherapy (see video below).
At Tia's four week recheck, her limp was visibly improved, she was toe touching on her injured leg and she had much less pain on palpation of her knee joint (called a "drawer" test). We continued the same protocol and rechecked her again four weeks later. She was weight bearing on her injured leg, walking comfortably around the exam room and was beginning to build muscle mass in her right quadriceps and hamstrings, a very good sign. Tia had more energy and was clearly a happier girl at this visit.
Also at this appointment, Tia's mom elected to recheck her proBNP test to see if the substantially higher doses of ubiquinol were assisting in improving her overall heart health. Tia's results were much improved. Her BNP, which started at 751, then spiked to 1170, was back down to 886 (page 7). This was excellent news and Tia's parents were very happy to continue the higher dose of her ubiquinol supplement.
Tia's exercise restrictions were reduced to no running on slippery floors (cover hardwood and tile with nonskid rugs), no jumping up onto things, and no off-leash, outdoor running. I also gave Tia's parents the green light to begin short walks with her on a leash, outside.
Tia continues to be a happy geriatric dog. Her mom is looking forward to spring, when Tia can go outside to exercise as well.
Tia's story illustrates the fact that often, surgical risks prevent the best medical protocols from being executed. In Tia's case, we had to move along to Plan B -- nonsurgical options -- when the ideal Plan A (surgically fixing the rupture) posed too great an anesthetic risk. Rehabilitation is often an excellent Plan B for many musculoskeletal conditions where surgery is not an option. This proved to be true for Tia as well. And adding a nutraceutical for heart health to her protocol also proved to dramatically improve Tia's cardiac blood work, which should help improve her long-term prognosis.