Laurie's Blogs.

Well, I’m biased about this paper already, as I was asked for my input on the original survey before this went out to the ‘actual’ survey subjects.  So, I figured that this would be a good topic that goes along with my Four Leg Rehab Minute this week.  (All very timely!)

Here’s the abstract… Let’s start there:

Objective: To compare the therapeutic approach of surgical specialists, sports medicine and rehabilitation specialists, and veterinarians with rehabilitation certification when treating bicipital tendon disease or tenosynovitis in dogs and to combine this information with existing research to develop a treatment algorithm that provides a framework for treating bicipital tenosynovitis.

Sample: 223 respondents to an internet survey of board-certified veterinary surgeons (VS), board-certified sports medicine and rehabilitation therapists, and veterinarians with rehabilitation certification.

Methods: The survey was promoted via multiple listservs, specialist college newsletters, and private relevant social media sites. Answers were compiled and submitted for statistical analysis.

Results: Compared to rehabilitation therapists (RTh), surgeons placed less value on the stabilizing function of the biceps tendon and its role in preventing other shoulder morbidities. Similarly, compared to RTh, surgeons were more inclined to select surgery as the primary therapeutic approach and attributed a less optimistic prognosis to conservative therapy outcomes. There were multiple differences between surgeons and RTh in executing a conservative therapy program, with RTh more likely to recommend therapeutic exercise, extracorporeal shockwave, regenerative medicine, therapeutic ultrasound, exercise restriction, photobiomodulation, and pulsed electromagnetic field therapy. RTh were less likely to prescribe NSAIDS or inject corticosteroids. Despite the above noted differences, there were also multiple areas of agreement.

Clinical relevance: Consensus agreement, combined with existing research, was used to create a treatment algorithm suggesting how to best address multiple manifestations of bicipital tendinopathy. Such guidelines can be considered to direct therapeutic strategies for this common condition.

Now, let’s dive deeper…

I’ll start with the hypothesis statements:

“We hypothesized that, compared to RTh, VS would attribute less significance to the BT’s role in providing shoulder stability, be more likely to advocate surgery as a first-line therapeutic approach, and be less optimistic when prognosticating the outcomes of CTx (Conservative Treatment). Furthermore, we hypothesized that there would be significant differences between VS and RTh in the application of a CTx program. Finally, we hypothesized that DB [doubled boarded in rehab and veterinary surgery} opinions would fall somewhere between those of VS and RTh.”

And by reading the abstract, you now also know what they found in regards to their hypotheses.  

Next, I liked the starting sentences of the discussion portion of the paper:

“Clinical opinion can be affected by a number of factors including confirmation bias, education background, and access or exposure to different treatment options. The adage “if all you own is a hammer, everything looks like a nail,” may well apply here; VS are trained to resolve medical issues through the use of surgery, and RTh are trained in nonsurgical techniques.”

In regard to therapies recommended, therapeutic exercise ranked the highest in regards to conservative management. Extracorporeal shockwave ranked third as the most recommended treatment, and it is backed up by research to show effectiveness.  Photobiomodulation, which was recommended often by the rehab therapists, has also been shown in research to be effective for tendon management.  Conversely, research demonstrates that therapeutic ultrasound does not show effectiveness beyond placebo.  PEMF has not been studies, and acupuncture benefits are inconsistent.  Hyaluronic acid  may play a role in tendon healing and decrease adhesion formation.  Manual therapy may improve comfort but there is no evidence that it facilitates tendon healing.

Given the lack of canine research on the subject of biceps tendon management, it is prudent to look at relevant human literature and basic research on tissue repair to formulate a plan for treating biceps tendinopathy.

Following is the summarization of recommendations:

• “Surgery should not be the primary therapeutic approach when the BT is healthy or if the amount of fiber tearing is ≤ 20%. This recommendation is based on the unanimous consensus opinion of VS, RTh, and DB.
• For situations in which the BT is 75% torn, surgery is likely the best initial therapeutic approach. CTx remains an option, but owners need to be informed of the guarded prognosis. This recommendation is based on the consensus opinion of VS and DB but a dissenting opinion from RTh.
• For cases with tears between 20% and 75%, a case-by-case decision, ensuring best communication about advantages and disadvantages with the owners is likely the best approach. This recommendation is based on the unanimous consensus opinion of VS, RTh, and DB that CTx is the best initial therapeutic response; however, there was disagreement between the 3 groups about whether a surgical prognosis exceeded that of CTx.
• NSAIDs should only be used for short-term pain control and avoided completely when comfort allows; protracted use may delay healing. NSAIDs are not indicated in chronic cases.
• Intra-articular corticosteroids are not an appropriate long-term conservative treatment and are contraindicated when the treatment goal includes tissue repair.
• Intratendinous corticosteroid injections must not be performed. If the end goal is tendon necrosis, a biceps tenotomy should be considered instead, using the least invasive approach available.
• Injections of PRP might be useful, but there is currently a lack of evidence in the published literature when treating biceps tendinopathy in dogs.
• Cage rest is discouraged unless required to enforce compliance with exercise restriction.
• Consider multimodal CTx built on a foundation of therapeutic exercise combined with activity restriction that returns to normal in a staged manner over several months.
• Modalities such as ESWT, regenerative medicine, and photobiomodulation should be considered.
• At this time, there is insufficient evidence to recommend therapeutic ultrasound, PEMF, or acupuncture. Manual therapy may provide increased comfort but does not facilitate tendon repair.”

And there you go!  Now, you are all caught up on a very recent, very relevant ne paper that an influence what you do and how you might advocate to surgeons and with clients about what to do for their dogs with a Biceps Tendon tear!

Reference:

Lane DM, Pfeil DV, Kowaleski MP. Synthesis of surgeon and rehabilitation therapist treatment methods of bicipital tenosynovitis in dogs allows development of an initial consensus therapeutic protocol. J Am Vet Med Assoc. 2023 Nov 1:1-8.