VetEdPlus E-BOOK RESOURCES

Issues in
Integrative Medicine

WHAT’S INSIDE
ƒƒ Use of Acupuncture for
Pain Management
ƒƒ Evaluating Fresh Diets
in Practice
ƒƒ Laser Therapy: Fact or Fancy?
ƒƒ Rehabilitation Modalities
for Pain Management and Healing

A SUPPLEMENT TO ƒƒ Laser Therapy for Treatment of

Joint Disease in Dogs and Cats
ƒƒ The Therapeutic Power of
Monoclonal Antibody Therapy
 E-BOOK PEER REVIEWED

Use of Acupuncture
for Pain Management
Ronald Koh, DVM, MS, CVA, CVCH, CVFT, CCRP, Assistant Professor
Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana

Successful pain management encompasses pharmacologic HOW DOES ACUPUNCTURE WORK?

and nonpharmacologic interventions. This is especially Acupuncture is the stimulation of certain points on the
true for chronic, neuropathic, or persistent pain.1 body that correspond to neurovascular bundles, blood
While pharmacologic options remain the mainstays, plexuses, sites of nerve branching, and motor endplate
nonpharmacologic interventions are an important part zones (TABLE 1).21 Recent evidence suggests that the
of a comprehensive pain management plan. effects of acupuncture are likely mediated by the
nervous system at peripheral, spinal, and supraspinal
Acupuncture is a safe, nonpharmacologic intervention levels.6,22 Neurophysiologic effects of analgesia in
with minimal adverse effects that most animals tolerate response to acupoint stimulation include release of
well.2,3 It has become more accepted for pain relief in endogenous opioids and neurotransmitters (e.g.,
veterinary medicine. In fact, the pain management endorphin/endomorphin, enkephalin,
guidelines published by the American Animal Hospital 5-hydroxytryptamine), activation of the descending pain
Association, American Association of Feline inhibitory pathway, and inhibition of inflammatory
Practitioners, and World Small Animal Veterinary mediators (e.g., cyclooxygenase-2, interleukin-1β,
Association endorse acupuncture as a safe adjunct interleukin-6).6,22 Acupuncture also causes micro-trauma
treatment for pain management in dogs and cats that and vasodilation to improve local circulation and
should be strongly considered as a part of a multimodal catalyze healing.23 Recent evidence suggests inhibition of
pain management regimen.4,5 microglial activation by acupuncture may play a key
role in neuropathic pain diseases.24
shutterstock.com/Diego Moreno

Acupuncture can be used independently or integrated

into conventional analgesia protocols. It has significant
analgesic effects on inflammatory, neuropathic, cancer, CLINICAL EFFICACY
and visceral pain states.6 It can help ease acute pain In 1 noncontrolled study, acupuncture alone or
from neuromusculoskeletal injuries and surgery, as well combined with analgesics reduced chronic pain and
as chronic spinal and osteoarthritic pain. Veterinary improved quality of life in dogs with neurologic and
clinical trials also provide evidence for its musculoskeletal diseases.8 Results were similar for
effectiveness.2,7-20 acupuncture plus manual therapy in dogs with
musculoskeletal pain; the authors found immediate

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short-term improvement in comfort level and mobility dogs undergoing hemilaminectomy found significantly
compared with before treatment.9 lower postoperative pain scores in the acupuncture than
the control group.14
In 2 controlled studies in dogs with hip dysplasia, a
gold bead implanted at acupoints significantly reduced Two studies showed that among cats undergoing
osteoarthritic pain.10,11 A 2-year follow-up study ovariohysterectomy, the need for rescue analgesia after
revealed that gold-bead acupuncture provided long- surgery was lower in the acupuncture than the control
term pain relief, an effect not observed in dogs group.15,16 Similar results were found in dogs
receiving placebo.12 undergoing mastectomy.17

In another controlled study, neither acupuncture nor In horses, 2 controlled studies found acupuncture was
carprofen significantly differed from placebo on gait effective in treating back pain.18,19 A recent study
analysis of dogs with hip dysplasia, but only showed horses with chronic laminitis were improved by
acupuncture was associated with a decrease in validated acupuncture after receiving 2 acupuncture treatments 1
chronic pain scores.13 A controlled, blinded study in week apart.20

TABLE 1 Common Acupuncture Points Used for Variable Pain States and Locations
AFFECTED AREA OR CONDITION COMMON ACUPOINTS

General pain LI-4, LIV-3, ST-36, BL-60

Inflammation LI-4, LI-11, ST-36, GV-14, Er-jian

Calming effect GV-20, GV-21, An-shen, Bai-hui

Bone and arthritic pain BL-11, BL-23, KID-3 (combined with local acupoints)

ST-6, ST-7, LI-4, LIV-3, ST-36

Dental pain
EA: LI-4 bilateral, ST-36 bilateral

TH-21, SI-19, GB-2, ST-36, An-shen

Otitis and ear pain
EA: ST-36 bilateral, SI-19 to An-Shen

ST-36, LIV-8, BL-24, ST-25, LI-10

Abdominal or visceral pain
EA: ST-36 bilateral, LI-10 bilateral

GB-20, GB-21, GV-14, SI-3, LU-7, BL-60, Jing-jia-ji

Neck
EA: GB-20 to GB-21, Jing-jia-ji bilateral

LI-15, TH-14, SI-9, BL-11

Shoulder
EA: LI-15 to SI-9, BL-11 bilateral

LI-10, LI-11, LU-5, HT-3, TH-10, SI-9

Elbow
EA: LI-10 to SI-9, LI-11 to HT-3

LI-4, TH-5, HT-7, SI-9

Carpus
EA: LI-4 to SI-9, TH-5 to HT-7

GB-29, GB-30, BL-54, BL-40, ST-41

Coxofemoral
EA: BL-54 bilateral, GB-29 to GB-30, ST-41 bilateral

ST-35a, ST-35b, ST-36, GB-34, BL-40, BL-54

Stifle
EA: ST-36 bilateral, ST-35a/b to BL-40, BL-54 bilateral

BL-60, KID-3, LIV-3, ST-41, BL-54

Tarsus
EA: ST-41 to KID-3, BL-54 bilateral

GV-14, LI-4, ST-36, LIV-3, Bai-hui, Hua-tuo-jia-ji, Liu-feng (front or hind limbs),
Vertebral column PC-8, KID-1
(intervertebral disk disease)
EA: GV-14 to Bai-hui, Hua-tuo-jia-ji bilateral, ST-36 bilateral, KID-1 or PC-8 bilateral

1. DN: 20 to 30 min
Treatment settings
2. EA: 2 to 20 Hz (dense-disperse waves) for 20 to 30 min

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GB1
BL1 settings. Basic or advanced veterinary acupuncture
BL54 GB29 courses are available at the Chi Institute of Traditional
GB25 ST2 Chinese Veterinary Medicine, or through the
GB30 International Veterinary Acupuncture Society.

Before acupuncture, underlying pain or medical

SP10 conditions are always diagnosed as part of conventional
SP9 LIV14 PC6 care. Once standard treatment measures are underway,
SP6 LU7
ST35 LI11 acupuncture can be used as an integrative modality to
PC8
LIV3
BL60 LI4
reduce acute or chronic pain. For outpatients, it can be
offered at the clinic, once or twice a week. For
GB41 HT7 LI1
BL67
ST36 LIV2 inpatients, it can be performed in the hospital, once a
day before discharge. Practices that do not offer
FIGURE 1. Location of common acupoints on a dog. acupuncture can refer patients to veterinarians with
Acupoints are where nerves and blood vessels converge.
CVA (certified veterinary acupuncturist) credentials.

Veterinarians who perform acupuncture must obtain

METHODS OF STIMULATION informed consent beforehand. The discussion of
Acupoints can be stimulated by dry needle (DN), acupuncture in the context of conventional medicine
electroacupuncture (EA), aqua-acupuncture (AQ), laser must focus not only on the efficacy of acupuncture but
acupuncture (LA), moxibustion, and material also expectations and potential adverse effects. A
implantation (FIGURE 1).2,7 Each method traditionally multimodal approach with acupuncture may allow for
serves a different purpose. DN involves the insertion of a reduction in dose of conventional analgesics and
fine, sterile needles into acupoints. These needles vary therefore a decrease in their adverse effects.6 For
in size (28- to 36-gauge) and length (0.25 to 1.5 patients that are resistant to pain medications or cannot
inches). The needles are typically left in place for tolerate their side effects, acupuncture can be a
approximately 10 to 30 minutes. reasonable alternative treatment.

In EA, acupoints are stimulated by applying electricity As with any therapy, not every patient responds to
through needles for 10 to 30 minutes. EA has more acupuncture; therefore, realistic expectations need to be
profound and prolonged analgesic effects than other set for clients. The author often requires clients to
techniques.6 It is useful for neuralgia, nervous system commit to sessions once or twice a week for at least 4
injury, and persistent pain.6,7 Low-frequency EA (2 to to 6 treatments, especially for chronic conditions.
10 Hz) produces longer-lasting alleviation of Although many patients may not need even 4
inflammatory pain and inhibits nerve injury–related treatments to experience benefits, shorter durations and
allodynia/hyperalgesia more potently than do higher lower intensities of treatment may result in suboptimal
frequencies (100 Hz).6 outcomes. Acupuncture has both immediate and
cumulative analgesic effects following repeated
With AA, 0.1 to 0.5 mL of sterile fluid (e.g., saline, treatments.25
vitamin B12) is injected into acupoints. It is commonly
used after DN or EA to prolong the effect of acupoint
stimulation. SAFETY AND CONTRAINDICATIONS
Acupuncture is safe when performed correctly by
LA, the modern practice of stimulating acupoints using licensed veterinarians certified in veterinary
low-level energy of wavelengths (630 to 960 nm), may acupuncture. Common minor adverse effects after
shutterstock.com/AlinArt

provide anti-inflammatory and antinociceptive effects.15 acupuncture include tiredness, increased water intake,
soreness, muscle spasm, and minor bleeding, which
typically resolve quickly.2,3 Other rare complications
HOW IS ACUPUNCTURE include infection, dermatitis, and broken needle
INTEGRATED? fragments. Acupuncture needles should not be placed
Veterinarians who have received formal training can on infected or inflamed skin, open wounds, or sites of
incorporate acupuncture into conventional practice tumor and fractures; around the abdomen of a

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pregnant animal; or in specific points that may

contribute to premature parturition (i.e., ST-36, SP-6, Glossary
BL-40, BL-60, and BL-67).2 Deep needle insertion into
acupoints around the lung fields (e.g., SP-21, LIV-13, BL bladder
LIV-14, GB-24, BL-12 to BL-19) is contraindicated. GB gallbladder
Acupuncture should be used cautiously or avoided in GV governing vessel
patients with clotting abnormalities. Do not apply EA HT heart
across the thorax area (heart position) in animals with KID kidney
heart disease or pacemakers.2 Be cautious when using LI large intestine
acupoints around the eyes.
LIV liver
LU lung
CASE EXAMPLES PC pericardium
SI small intestine
Case 1: Chronic Pain Associated SP spleen
With Polyarticular Osteoarthritis ST stomach
A 13-year-old female spayed Weimaraner had TH triple heater
osteoarthritis in multiple joints (elbows, carpi, hips,
and stifles) and back pain. Despite the combination of
firocoxib, gabapentin, tramadol, and glucosamine-
chondroitin, her pain was worsening and her mobility
was deteriorating. She developed urinary incontinence doses of dexamethasone, fentanyl constant rate
and was awoken more often during the night. infusion, cytosine arabinoside, and gabapentin. On day
4 of hospitalization, he was referred for acupuncture
An internist suggested acupuncture as a last resort treatment. Despite medications, his neck was still
before euthanasia. The dog received acupuncture twice severely painful on manipulation and he continued to
weekly for 4 weeks initially, then every 2 to 4 weeks. have nonambulatory tetraparesis.
After 3 treatments, the dog could rise up and walk
without assistance and sleep normally. Her urination Shortly after his first acupuncture treatment, he could
incontinence was resolved after 6 treatments. She stand on his own unassisted and his cervical pain was
continued to receive acupuncture monthly for pain markedly improved—he could move his neck without
management. She died at home at age 16. yelping. His fentanyl was discontinued the next day
because of an improved pain level. The next day, after
Her acupuncture treatment consisted of the following: his second acupuncture, he became ambulatory on 4
1. DN: GV-20, TH-5, SI-9, GB-34, BL-40, LIV-3, Bai- limbs with minimal assistance. He continued to make
hui significant progress over the next 3 days with daily
2. EA: LI-4 to LI-11, ST-36 to ST-41, BL-11 bilaterally, acupuncture. On day 7, he had full range of motion of
BL-23 to Shen-shu (crossing), BL-54 bilaterally; 2 to his neck and was ambulatory with mild ataxia.
20 Hz for 20 minutes
3. AA: TH-4, LU-5, LI-10, SI-9, BL-23, BL-54, ST-36, His acupuncture treatment consisted of the following:
BL-39, KID-3; 0.1 to 0.2 mL per acupoint 1. DN: GV-20, LU-7, SI-3, LI-4, LIV-3, ST-36,
Jing-jia-ji
2. EA: GV-16 to Bai-hui, GB-20 to GB-21 (crossing),
Case 2: Pain and Neurologic BL-23 bilaterally, PC-8 bilaterally, KID-1 bilaterally;
Deficits Associated With 2 to 20 Hz for 20 minutes
Meningoencephalitis of 3. AA: Jing-jia-ji, GV-14, Liu-feng; 0.1-0.2cc per
Unknown Cause acupoint
A 4-year-old male neutered Yorkshire terrier was
diagnosed with meningoencephalitis of unknown cause
at the cervical region. He had nonambulatory SUMMARY
tetraparesis with severe cervical pain and was Given the low risk for adverse effects and observed
hospitalized. He received IV fluids, immunosuppressive benefits for acute and chronic pain, acupuncture can

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References
1. Greene SA. Chronic pain: pathophysiology and treatment implications.

For patients that are resistant Top Companion Anim Med 2010;25(1):5-9.
2. Fry LM, Neary SM, Sharrock J, Rychel JK. Acupuncture for analgesia in
to pain medications or cannot veterinary medicine. Top Companion Ani Med 2014;29:35-42.
3. le Jeune S, Henneman K, May K. Acupuncture and equine
tolerate their side effects, rehabilitation. Vet Clin North Am Equine Pract 2016;32(1):73-85.
4. Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain
acupuncture can be a reasonable management guidelines for dogs and cats. JAAHA 2015;2:67-84.
5. Mathews K, Kronen PW, Lascelles D, et al. Guidelines for recognition,
alternative treatment. assessment and treatment of pain: WSAVA global pain council
members and co-authors of this document. J Small Anim Pract
2014;55:E10-E68.
6. Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-
electroacupuncture on persistent pain. Anesthesiology
2014;120(2):482-503.
7. Roynard P, Frank L, Xie H, Fowler M. Acupuncture for small animal
neurologic disorders. Vet Clin North Am Small Anim Pract 2018
play a large role in pain management and can be Jan;48(1):201-219.
incorporated into veterinary practice as part of a 8. Silva NEOF, Luna SPL, Joaquim JGF, et al. Effect of acupuncture on
multimodal approach. With the increasing number of pain and quality of life in canine neurological and musculoskeletal
diseases. Can Vet J 2017;58(9):941-951.
clinical trials and laboratory research, we better 9. Lane DM, Hill SA. Effectiveness of combined acupuncture and manual
understand the mechanism of action and therapeutic therapy relative to no treatment for canine musculoskeletal pain. Can
Vet J 2016;57(4):407-414.
effects of acupuncture. Nonetheless, larger randomized
10. Jaeger GT, Larsen S, Søli N, Moe L. Double-blind, placebo-controlled
controlled trials are needed to verify its efficacy in trial of the pain-relieving effects of the implantation of gold beads into
veterinary medicine. dogs with hip dysplasia. Vet Rec 2006;158(21):722-726.
11. Hielm-Björkman A, Raekallio M, Kuusela E, et al. Double-blind
evaluation of implants of gold wire at acupuncture points in the dog
as a treatment for osteoarthritis induced by hip dysplasia. Vet Rec

ACUPUNCTURE RESOURCES 2001;149:452-456.

12. Jæger GT, Larsen S, Søli N, et al. Two years follow-up study of the
■■ World Association of Traditional Chinese Veterinary pain-relieving effect of gold bead implantation in dogs with hip-joint
arthritis. Acta Vet Scand 2007;49:1-7.
Medicine (AATCVM): watcvm.org
13. Teixeira LR, Luna SP, Matsubara LM, at al. Owner assessment of chronic
■■ American Academy of Veterinary Acupuncture pain intensity and results of gait analysis of dogs with hip dysplasia
(AAVA): aava.org treated with acupuncture. JAVMA 2016;249(9):1031-1039.

■■ American Holistic Veterinary Medical Association 14. Laim A, Jaggy A, Forterre F, et al. Effects of adjunct
electroacupuncture on severity of postoperative pain in dogs
(AHVMA): ahvma.org undergoing hemilaminectomy because of acute thoracolumbar
intervertebral disk disease. JAVMA 2009;234(9):1141-1146.
■■ National Center for Complementary and Integrative
15. Marques VI, Cassu RN, Nascimento FF, et al. Laser acupuncture for
Health (NCCIH): nccih.nih.gov postoperative pain management in cats. Evid Based Complement
■■ Xie’s Veterinary Acupuncture, 1st ed. Alternat Med 2015;2015:653270.
16. Ribeiro MR, de Carvalho CB, Pereira RHZ, et al. Yamamoto new scalp
■■ Veterinary Acupuncture: Ancient Art to Modern
acupuncture for postoperative pain management in cats undergoing
Medicine, 2nd ed. ovariohysterectomy. Vet Anaesthes Analges 2017;44(5):1236-1244.
17. Gakiya HH, Silva DA, Gomes J, et al. Electro-acupuncture versus
morphine for the postoperative control pain in dogs. Acta Cir Bras
2011;26:346e351.
18. Xie H, Colahan P, Ott EA. Evaluation of electroacupuncture treatment
of horses with signs of chronic thoracolumbar pain. JAVMA
Ronald Koh 2005;227(2):281-286.
An assistant professor and section chief of the 19. Rungsri P, Trinarong C, Rojanasthien S, et al. Effectiveness of electro-
Integrative Medicine and Rehabilitation Service at acupuncture on pain threshold in sport horses with back pain. Am J
the Louisiana State University School of Veterinary Trad Chinese Vet Med 2009;4:22-26.
Medicine, Ronald Koh received his veterinary degree 20. Faramarzi B, Lee D, May K, Dong F. Response to acupuncture
in Taiwan and completed a specialty internship and treatment in horses with chronic laminitis. Can Vet J 2017;58(8):823-827.
master’s program in acupuncture at University of 21. Zhou F, Huang D, Ying X. Neuroanatomic basis of acupuncture points.
Florida College of Veterinary Medicine in 2010 and In: Xia Y, Cao X, Wu G, Cheng J (eds). Acupuncture Therapy for
Neurological Diseases. Berlin: Springer; 2010:32-80.
2012, respectively. He will be finishing his residency
22. Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms
in Veterinary Sports Medicine and Rehabilitation
of actions. Am J Chin Med 2008:36(4):635-645.
in 2019. His clinical interests include using
23. Lundeberg T. Peripheral effects of sensory nerve stimulation (acupuncture)
acupuncture, integrative therapies, rehabilitation,
in inflammation and ischemia. Scand J Rehabil Med 1993;29:61-86.
nutrition, and supplements for pain management,
24. Lin L, Skakavac N, Lin X, et al. Acupuncture-induced analgesia: the role
neurological disorders, geriatric conditions, and of microglial inhibition. Cell Transplant 2016;25(4):621-628.
palliative and hospice care.
25. Xiang A, Cheng K, Shen L. The immediate analgesic effect of
acupuncture for pain: a systematic review and meta-analysis. Evid
Based Complement Alternat Med 2017:3837194.

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Evaluating Fresh Diets

in Practice
Justin Shmalberg, DVM, DACVN, DACVSMR
University of Florida College of Veterinary Medicine

Dietary trends for dogs and cats closely mirror those of WHY DO OWNERS FEED
their owners, and it is no surprise that home-prepared FRESH DIETS?
meals and their commercialized derivatives are now Pet owners increasingly select diets based on an
encountered in practice. These diets pose potential assessment of ingredient quality and sourcing, safety
benefits as well as challenges, and clients increasingly and transparency, and customization and variety.1,2
expect veterinarians to demonstrate knowledge of them. Fresh diets, especially home-prepared diets, are
uniquely positioned to allow this assessment and
permit owner choice. Other motivations for feeding
WHAT IS A FRESH DIET? these diets are diverse, including the factors below.3-8
Fresh diets are broadly defined as diets that are not
shelf-stable at room temperature, such as:
Distrust of Commercial Pet Foods
■■ Home-prepared cooked diets Consumer distrust is primarily driven by recalls, of
■■ Home-prepared raw diets which there were more than 40 in 20189 for issues such
■■ Commercial made-to-order diets (generally cooked as elevated vitamin D levels, low thiamine (vitamin
and provided refrigerated) B1), and contamination with Salmonella or Listeria
bacteria. Many owners cite the melamine recalls after
Some owners consider fresh diets to be only those significant numbers of dogs and cats developed acute
shutterstock.com/AUKARAWATCYBER

prepared in a certain window of time before feeding. kidney injury.10,11 This distrust in commercial options
The following diets therefore may or may not be was identified in 51% of dog owners in an oncology
considered “fresh”: service, and 67% of raw-feeding owners displayed
similar sentiment.12,13
■■ Commercial premixes (cooked or raw ingredients are
added by the owner)
■■ Commercial refrigerated diets (raw or cooked) Ingredient Quality
■■ Commercial frozen diets (raw or cooked) Owners now evaluate ingredients on a number of
potential metrics, such as sustainability, animal welfare,
organic standards, and growing region. Visual

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assessment of ingredients remains important to Specific Health Conditions

consumers, and extruded kibble or homogenized or Concerns
canned food does not readily permit this. Some owners Fresh diets are commonly used in the management of
cite reports of unlabeled ingredients.14 Others distrust hyporexic pets with renal disease, gastrointestinal
synthetically derived vitamins and minerals, which are disease, or cancer.12,21-23 Home-prepared fresh diets have
exempted from Association of American Feed Control been recommended for the diagnosis and management
Officials (AAFCO) regulations for natural foods and of adverse food reactions.24 Such diets may also be used
may be sourced from outside the United States.15 by owners of sporting or working dogs with the
thought of improving performance or providing
supplemental protein, fat, or calories; sled dogs are
Skepticism Regarding Current commonly fed a hybrid diet of commercial foods and
Nutritional Guidelines raw meat, and racing greyhounds may be fed raw
The basis for “complete and balanced” pet foods is the foods.25,26 Fresh diets may affect the microbiome
available nutritional literature, which is limited for differently than extruded diets, which could influence
some nutrients and was often gathered under gastrointestinal or overall health, and they are often
experimental conditions with extruded or purified highly digestible.27,28 Clients may choose fresh diets in
diets.15,16 Owners feel that dogs fed unbalanced fresh the hopes of preventing disease by promoting health.2
diets—that is, diets not conforming to current
recommendations—show no outward signs of disease
and that present knowledge is incomplete to set
thresholds for some nutrients. It is true that some Pet owners increasingly select
nutrient minima may be inaccurate and some
deficiencies or excesses affect health more than others.16,17 diets based on an assessment of
ingredient quality and sourcing,
Palatability safety and transparency, and
Many owners report that their dogs only eat (or customization and variety.1,2
strongly prefer) fresh foods. This anecdotally appears
more prevalent in small dogs. Improved palatability is
likely influenced by a combination of factors, such as
increased moisture, protein, fat, aroma, and even the Raw Food Claims
owner’s perception.18,19 A number of specific claims about raw food are
discussed in greater detail elsewhere.28,29 There is
insufficient evidence that a raw diet is superior to the
Preservative Avoidance same diet when cooked.
Synthetic preservatives such as ethoxyquin, BHA, BHT,
and TBHQ were historically used in commercial pet
foods given their effectiveness, but controversies still HOW COMMON ARE HOME-
surround their safety.7,20 Natural preservatives, such as PREPARED AND COMMERCIAL
tocopherols, rosemary extract, and citric acid, are now FRESH DIETS?
commonly used, but fresh diets may reduce or The overall prevalence of home-prepared diet use
eliminate the need for preservatives. among pet owners remains unclear, but 3 studies have
provided limited data:

Customization or Rotation ■■ In one study, home-prepared diets were fed as the

Home-prepared diets allow owners to change protein sole source of nutrition to 2% to 3% of dogs and 0%
and carbohydrate sources readily. Many commercial of cats in the general population, but noncommercial
fresh diets provide diets with similar nutrient foods provided at least 25% of the diet for 17% of
composition but different ingredients. Dietary rotation dogs and 6% of cats.30
of any type certainly allows for greater nutrient variability, ■■ In another study, breeders fed home-prepared diets
which may confer health benefits and may mitigate to 11% of dogs across all life stages, and the practice
suboptimal nutrient levels for a particular animal. was more common in giant-breed dogs.31

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■■ Inthe third study, 7% percent of owners with dogs ■■ 100% of renal diets and diets suggested for cancer
presenting to an oncology service fed home-prepared failed to meet recommendations.21,42
cooked diets, 4% fed prepared raw diets, and 18%
fed a combination of diets, including a home- The impact of the deficiencies identified in the above
prepared diet.12 studies would be expected to range in severity.
Nutrients that were commonly identified as being
Commercial fresh diets represent millions in annual below established recommendations included:
sales, with most companies targeting healthy animals.32 ■■ Amino acids, specifically methionine, tryptophan,
Some fresh food companies now offer therapeutic diet and phenylalanine21,42
lines (both cooked and raw) intended for veterinary ■■ Calcium21,41,43
supervision and sold through established retail channels ■■ Zinc21,41
or, increasingly, shipped directly to the owner.2 The ■■ Vitamin D41-43
market share of fresh diets is expected to increase. ■■ Choline21,41,42

Insufficient amino acids could adversely affect muscle

PROBLEMS WITH mass, produce taurine deficiency, or contribute to poor
HOME-PREPARED DIETS? coat quality. Inadequate vitamin D and calcium could
When severely unbalanced, home-prepared diets have influence bone development in growing animals, and
been implicated in clinically significant pathology, zinc plays a role in skin and immune function. Choline
including: may be spared by other nutrients in the diet but plays a
■■ Nutritional secondary hyperparathyroidism. The role in lipid handling and methyl group donation.16
absence of calcium in the diet of growing puppies has Clinical signs of nutrient deficiency are often present
caused fibrous osteodystrophy and other skeletal only when severe, making assessment in the clinic
abnormalities.33-35 Low dietary vitamin D is often difficult. Some deficiencies require special screening
concurrently identified. The condition is rare in laboratory tests (ionized calcium, parathyroid hormone
adult dogs but has been documented.36,37 levels, vitamin D testing, amino acid levels).
■■ Thiamine deficiency38
■■ Electrolyte abnormalities34
■■ Taurine deficiency, a cause of dilated HOW CAN HOME-PREPARED
cardiomyopathy34,36,39 FRESH DIETS BE IMPROVED?
Two important recommendations should be made
Adverse effects are likely underreported, as dietary to owners committed to preparing their own diets:
change frequently corrects discovered abnormalities. 1. Offer referral to a board-certified veterinary
nutritionist for evaluation and reformulation of the
Owners appear to infrequently consult recipes for their diet. A list of diplomates available for consultation is
home-prepared diets, but recipes are available on the available at acvn.org, and the estimated cost of diet
internet and in print from veterinary and non- formulation ranges from $150 to $500. An
veterinary sources.30,40,41 Such recipes often lack alternative is a computer-generated recipe conforming
specificity, which could affect nutrient composition, to nutrient guidelines (e.g., balanceit.com).
and owners often change recipes without 2. Advise the owner to consider a commercially
guidance.21,22,41 A few evaluations have compared available fresh diet with an AAFCO statement for the
recipes to nutritional recommendations, with the appropriate life stage.
following findings:
If an owner declines the above options, the following
■■ 95% of maintenance diets did not meet questions can help screen diets for the most commonly
recommendations for at least one essential nutrient, encountered sources of dietary deficiencies. Owners
diets from non-veterinary sources were more should be counseled that most diets from internet
deficient, and rotational strategies were unlikely to sources and other recipes fail to meet established
balance diets.41 nutrient recommendations, and puppies and kittens
■■ 90% of tested home-prepared diet recipes provided should always have a referral or be fed a commercial
by veterinarians for food allergy did not meet food given their more critical nutrient tolerances.
nutrient recommendations.24 1. Is the diet composed primarily of meat (50% or

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more by weight)? Dogs and cats have no individually named vitamins and trace minerals, and/or
requirement for dietary carbohydrate but do have dried organ meats.
requirements for amino acids and fatty acids that are
often lower in vegetable sources. Contraindications
to such a diet should be considered (e.g., renal HOW SHOULD COMMERCIAL
disease, canine pancreatitis). FRESH DIETS BE EVALUATED?
2. Is supplemental calcium added to the food? Most Fresh diets should be evaluated similarly to all
meats are high in dietary phosphorus but low in commercial pet foods.3,28,44 Suggested metrics for
calcium. The following doses can be used as general evaluation include:
guidelines: ■■ Does the product provide an AAFCO statement
■■ Adult cats: 0.4 g calcium daily = ⅓ teaspoon for the appropriate life stage of the patient?
of calcium carbonate Products labeled for intermittent or supplemental
■■ Adult dogs: 2 g calcium per 1000 calories (the feeding should not be fed long-term without
amount of food consumed by an average veterinary guidance, nor should products without an
50-pound pet dog) = 1⅔ teaspoon of calcium AAFCO statement.​
carbonate ■■ Has the diet been analyzed to confirm the nutrient
Diets containing bones or bone meal likely contain levels provided, and is a detailed nutrient profile
both calcium and phosphorus, but the amounts may on a caloric basis available? Ideally, foods that are
be excessive, especially for large-breed puppies. These formulated to meet requirements are also tested for
minerals and other macronutrients can be measured confirmation of expected values, which is not a
in a sample of the food by a commercial feed statutory requirement. Feeding trials may be
laboratory. performed, but such trials typically only identify
3. Is there a multivitamin product in the recipe? major deficiencies. Foods should always be compared
Once-daily human multivitamins are preferred over on a caloric basis.45
pet multivitamins, unless the latter is specifically ■■ Who formulated the diet, and what are their
designed, evaluated, or endorsed by a nutritionist for qualifications? Ideally, diets would be formulated or
use in balancing home-prepared diets. Many reviewed by a nutritionist (PhD or board-certified
common pet vitamins contain minimal quantities of DVM) with experience in the type of food being
essential nutrients. Once-daily human multivitamins produced.
are typically dosed at about ¼ tablet per 25 pounds ■■ Does the company operate its own manufacturing
of patient body weight. facility? Companies producing their own food are
Organ meats are used in some diets to provide expected to maintain more control over the process,
trace vitamins and minerals, but their adequacy in but this has not been objectively evaluated.
fulfilling the nutrient needs of a dog or cat can be
difficult to evaluate based on weight of inclusion or Fresh foods, by nature, are more perishable than
percentage of the recipe without specific analysis. extruded or canned diets. Therefore, owners should be
4. Are there supplemental fatty acids in the diet? encouraged to ask additional questions regarding food
Most diets benefit from supplemental EPA and DHA quality and safety:
(omega-3 fatty acids) unless the diet contains large ■■ How is the food best stored, and how is
amounts of fish (e.g., tuna, salmon). A dose of 300 temperature controlled during storage and
mg of EPA and DHA combined (1 standard fish oil shipping? Fresh foods are susceptible to increased
capsule) per 25 pounds of body weight is generally bacterial growth and oxidation if exposed to
sufficient for maintenance purposes. Most prepared temperature fluctuations.
diets naturally contain adequate amounts of linoleic ■■ How are the ingredients sourced? Owners may have
acid, an essential omega-6 fatty acid. additional questions relating to their preferred
evaluation rubric for ingredients.
The above recommendations do not ensure nutritional ■■ What safety and quality measures are present in
adequacy for every condition or every animal, but do the manufacturing facility? A comprehensive food
help to prevent the most significant deficiencies safety protocol should be followed to reduce the
identified in diets. If owners elect to use a commercial potential for contamination. This should include
premix, the product should be evaluated for sources of routine testing for pathogens such as Salmonella and
vitamins and minerals, such as calcium or bone meal, Listeria, the latter of which can reproduce under

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13. Morgan SK, Willis S, Shepherd ML. Survey of owner motivations

refrigerated conditions.46 and veterinary input of owners feeding diets containing raw animal
products. PeerJ 2017;5:e3031.
■■ What strategies are used to control bacterial
14. Olivry T, Mueller RS. Critically appraised topic on adverse food
growth and pathogens? Raw foods contain higher reactions of companion animals (5): discrepancies between
bacterial concentrations than extruded diets if ingredients and labeling in commercial pet foods. BMC Vet Res
2018;14:24.
untreated, but so do many fresh cooked products. 15. Association of American Feed Control Officials. Association of
Pasteurization and pH-adjusting inclusions (such as American Feed Control Officials (AAFCO) 2018 Official Publication.
Champaign, IL: AAFCO; 2018.
acetic and citric acids) can reduce bacterial
16. National Research Council, Division on Earth and Life Studies, Board
numbers.28,47 Bacteriophages appear to be in use by at on Agriculture and Natural Resources, Committee on Animal Nutrition
least one company, but there is controversy over the & Subcommittee on Dog and Cat Nutrition. Nutrient Requirements of
Dogs and Cats. Washington, DC: National Academies Press; 2006.
regulatory status of this approach.48 17. Wedekind KJ, Blumer ME, Huntington CE, et al. The feline iodine
requirement is lower than the 2006 NRC recommended allowance.
J Anim Physiol Anim Nutr 2010;94:527-539.
18. Delaney SJ. Management of anorexia in dogs and cats. Vet Clin North
FRESH DIETS ARE THE Am Small Anim Pract 2006;36:1243-1249, vi.
NEW REALITY 19. Houpt KA, Smith SL. Taste preferences and their relation to obesity in
dogs and cats. Can Vet J 1981;22:77-85.
Current recommendations are that all patients should
20. Gross KL, Bollinger R, Thawnghmung P, Collings GF. Effect of three
receive a screening nutritional assessment.49 Consumer different preservative systems on the stability of extruded dog
demand and market forces indicate that home-prepared food subjected to ambient and high temperature storage. J Nutr
1994;124:2638S–2642S.
and commercial fresh diets will be increasingly 21. Larsen JA, Parks EM, Heinze CR, Fascetti AJ. Evaluation of recipes for
encountered during this assessment. Knowledge of the home-prepared diets for dogs and cats with chronic kidney disease.
JAVMA 2012;240:532-538.
diversity of options in this group of diets, as well as their
22. Johnson LN, Linder DE, Heinze CR, et al. Evaluation of owner
merits, will help practitioners provide the best evidence- experiences and adherence to home-cooked diet recipes for dogs.
J Small Anim Pract 2016;57:23-27.
based guidelines to clients, match recommendations to
23. Segev G, Fascetti AJ, Weeth LP, Cowgill LD. Correction of
the motivations of the owner, and support the specific hyperkalemia in dogs with chronic kidney disease consuming
nutritional needs of the patient. commercial renal therapeutic diets by a potassium-reduced home-
prepared diet. J Vet Intern Med 2010;24:546-550.
24. Roudebush P, Cowell CS. Results of a hypoallergenic diet survey
of veterinarians in North America with a nutritional evaluation of
homemade diet prescriptions. Vet Dermatol 1992;3:23-28.
References
25. Templeman J, Mai S, Cargo-Froom C, Shoveller AK. Assessment
1. Packaged Facts. Pet food: 3 key trends for 2019 (press release). 2019. of current musher practices across the sled dog industry with an
packagedfacts.com/about/release.asp?id=4445. Accessed February 1, emphasis on nutritional programs implemented. Am J Anim Vet Sci
2019. 2018;13(1):16-26.
2. Packaged Facts. 5 Trends shaping $26 billion pet food market in 2018 26. Morley PS, Strohmeyer RJ, Tankson JD, et al. Evaluation of the
and beyond (press release). 2017. packagedfacts.com/about/release. association between feeding raw meat and Salmonella enterica
asp?id=4273. Accessed February 1, 2019. infections at a greyhound breeding facility. JAVMA 2006;228:1524-
3. Remillard RL. Homemade diets: attributes, pitfalls, and a call for action. 1532.
Top Companion Anim Med 2008;23:137-142. 27. Algya KM, Cross TL, Leuck KN, et al. Apparent total tract
4. Parr JM, Remillard RL. Handling alternative dietary requests from pet macronutrient digestibility, serum chemistry, urinalysis, and fecal
owners. Vet Clin North Am Small Anim Pract 2014;44:667-688, v. characteristics, metabolites and microbiota of adult dogs fed
extruded, mildly cooked, and raw diets. J Anim Sci 2018. doi:10.1093/
5. Weeth LP. Home-prepared diets for dogs and cats. Compendium
jas/sky235
2013;35:E1-E3.
28. Freeman LM, Chandler ML, Hamper BA, Weeth LP. Current knowledge
6. Berschneider HM. Alternative diets. Clin Tech Small Anim Pract
about the risks and benefits of raw meat–based diets for dogs and
2002;17:1-5.
cats. JAVMA 2013;243:1549-1558.
7. Michel KE. Unconventional diets for dogs and cats. Vet Clin North Am
29. Shmalberg J. Novel trends in small animal nutrition: a practical guide.
Small Anim Pract 2006;36:1269-1281, vi–vii.
Todays Vet Pract 2013;3:38-45.
8. Michel KE, Willoughby KN, Abood SK, et al. Attitudes of pet owners
30. Laflamme DP, Abood SK, Fascetti AJ, et al. Pet feeding practices
toward pet foods and feeding management of cats and dogs. JAVMA
of dog and cat owners in the United States and Australia. JAVMA
2008;233:1699-1703.
2008;232:687-694.
9. U.S. Food and Drug Administration. U.S. Food and Drug Administration
31. Connolly KM, Heinze CR, Freeman LM. Feeding practices of dog
animal health and veterinary recalls and withdrawals. fda.gov/
breeders in the United States and Canada. JAVMA 2014;245:669-676.
animalveterinary/safetyhealth/recallswithdrawals/. Accessed February
1, 2019. 32. Caley N. Raw potential. Pet Business May 2017.
10. Cianciolo RE, Bischoff K, Ebel JG, et al. Clinicopathologic, histologic, 33. Taylor MB, Geiger DA, Saker KE, Larson MM. Diffuse osteopenia and
and toxicologic findings in 70 cats inadvertently exposed to pet food myelopathy in a puppy fed a diet composed of an organic premix and
contaminated with melamine and cyanuric acid. JAVMA 2008;233:729- raw ground beef. JAVMA 2009;234:1041-1048.
737. 34. Hutchinson D, Freeman LM, McCarthy R, et al. Seizures and severe
11. Brown CA, Jeong KS, Poppenga RH, et al. Outbreaks of renal failure nutrient deficiencies in a puppy fed a homemade diet. JAVMA
associated with melamine and cyanuric acid in dogs and cats in 2004 2012;241:477-483.
and 2007. J Vet Diagn Invest 2007;19:525-531. 35. Dittmer KE, Thompson KG. Vitamin D metabolism and rickets in
12. Rajagopaul S, Parr JM, Woods JP, et al. Owners’ attitudes and domestic animals: a review. Vet Pathol 2011;48:389-407.
practices regarding nutrition of dogs diagnosed with cancer 36. Shmalberg J. Nutritional secondary hyperparathyroidism and taurine
presenting at a referral oncology service in Ontario, Canada. J Small deficiency in a dog fed a home-prepared diet during Chinese food
Anim Pract 2016;57:484-490. therapy. Am J Trad Chinese Vet Med 2013;8:69-72.

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37. de Fornel-Thibaud P, Blanchard G, Escoffier-Chateau L, et al. Unusual 49. WSAVA Nutritional Assessment Guidelines Task Force Members.
case of osteopenia associated with nutritional calcium and vitamin D WSAVA nutritional assessment guidelines. J Small Anim Pract
deficiency in an adult dog. JAAHA 2007;43:52-60. 2011;52:385-396.
38. Kritikos G, Parr JM, Verbrugghe A. The role of thiamine and effects of
deficiency in dogs and cats. Vet Sci 2017;4:59.
39. Fascetti AJ, Reed JR, Rogers QR, Backus RC. Taurine deficiency in
dogs with dilated cardiomyopathy: 12 cases (1997–2001). JAVMA
2003;223:1137-1141.
40. Strombeck DR. Home-Prepared Dog & Cat Diets: The Healthful
Justin Shmalberg
Alternative. Ames, IA; Iowa State University Press; 1999.
41. Stockman J, Fascetti AJ, Kass PH, Larsen JA. Evaluation of recipes of
Justin Shmalberg, DVM, DACVN, DACVSMR, is a
home-prepared maintenance diets for dogs. JAVMA 2013;242:1500- clinical associate professor of integrative medicine at
1505. University of Florida College of Veterinary Medicine.
42. Heinze CR, Gomez FC, Freeman LM. Assessment of commercial diets His service specializes in the incorporation of
and recipes for home-prepared diets recommended for dogs with nutrition, rehabilitation, hyperbaric oxygen therapy,
cancer. JAVMA 2012;241:1453-1460. and acupuncture with conventional care; he holds
43. Streiff EL, Zwischenberger B, Butterwick RF, et al. A comparison of certifications in acupuncture and herbal medicine.
the nutritional adequacy of home-prepared and commercial diets for
Dr. Shmalberg’s research interests include nutritional
dogs. J Nutr 2002;132:1698S-1700S.
oncology, sports and rehabilitative nutrition,
44. WSAVA Global Nutrition Committee. World Small Animal Veterinary
Association Global Nutrition Committee: Recommendations on
evaluations of new small animal dietary trends, and
Selecting Pet Foods. wsava.org/WSAVA/media/Arpita-and-Emma- the safety and efficacy of Chinese herbal products.
editorial/Selecting-the-Best-Food-for-your-Pet.pdf. Accessed He received his DVM from University of Wisconsin-
February 1, 2019. Madison. Dr. Shmalberg completed an internship in
45. Shmalberg J. Beyond the guaranteed analysis: comparing pet foods. veterinary acupuncture at University of Florida along
Todays Vet Pract 2013;3:43-45.
with a residency in small animal clinical nutrition.
46. Jemmi T, Stephan R. Listeria monocytogenes: food-borne pathogen
and hygiene indicator. Rev Sci Tech 2006;25:571-580.
47. Ouattara B, Simard RE, Holley RA, et al. Inhibitory effect of organic
acids upon meat spoilage bacteria. J Food Prot 1997;60:246-253.
48. Soffer N, Abuladze T, Woolston J, et al. Bacteriophages safely reduce
Salmonella contamination in pet food and raw pet food ingredients.
Bacteriophage 2016;6:e1220347.

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This article is from NAVC’s 2019 VMX Conference Proceedings.

Laser Therapy: Fact or Fancy?

John C. Godbold, Jr., DVM
Stonehaven Veterinary Consulting
Jackson, Tenn.

THE SCIENCE OF LASER THERAPY: The term most descriptive of the complex mechanisms
PHOTOBIOMODULATION and the cascade of physiologic events that follow laser
Laser therapy is the result of electromagnetic energy therapy is photobiomodulation. Photobiomodulation
interacting chemically and biologically with tissue, describes the way photons interact with target tissues. It
causing “photobiomodulation.” Electromagnetic energy accurately describes a nonthermal interaction within
affecting biologic processes is not a novel concept—it the tissue, dependent on endogenous chromophores
fills our environment as photosynthesis occurs in plants that absorb the energy in photons and elicit
and literally surrounds us as vitamin D is formed in our photophysical and photochemical events.
skin cells.

Lasers produce a single wavelength (monochromatic) THE RESULTS OF

beam of light, which is collimated as it is generated. PHOTOBIOMODULATION
Laser light has the property of being coherent, The effects of photobiomodulation are a result of
or in phase, which in simple terms means it is photons—packets of electromagnetic energy—
uniform and very orderly light. Laser therapy interacting with cells.
uses a simple beam of light—monochromatic,
coherent, collimated light—to penetrate deeply In the clinical setting, therapy lasers that emit near
into tissues and produce positive tissue changes. infrared light are most often used. Different from LEDs
(light-emitting diodes), therapeutic diode lasers emit
Laser therapy has had many contradictory and invisible light in the 800- to 1000-nanometer (nm)
confusing names. The terms cold laser therapy, range. These therapeutic wavelengths are less absorbed
low-level laser therapy, class III laser therapy, and class by water and other nontarget chromophores within the
IV laser therapy have all been used. Unfortunately, tissue and therefore achieve greater depth of penetration.
these terms describe the devices being used rather than They also interact with target chromophores to produce
the effect they have on tissue. Terminology based on photochemical changes within the tissue.
the tissue effect is more descriptive and accurate.

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Key to photobiomodulation is the absorption of

photonic energy by chromophores within cells. The
chromophore cytochrome oxidase is concentrated In the clinical setting, therapy
within mitochondria; it absorbs the energy in photons
and delivers it into metabolic processes, including the
lasers that emit near infrared light
Krebs cycle. This results in increased ATP production, are most often used. Different
as well as increased levels of nitric oxide and reactive from LEDs (light-emitting
oxygen species, important in cellular signaling.
Metabolic activity increases, and cell growth and diodes), therapeutic diode lasers
reproduction are accelerated. emit invisible light in the 800-
Other complex mechanisms occur at the same time.
to 1000-nanometer range.
There is an increased release of endogenous opioids;
beta-endorphin levels rise. There is a direct effect on
nerve tissue producing suppression of nociceptors and
an increase in stimulation threshold. Neuron impulses for causing biologic damage. Classification is based
are reduced, reducing pain. Researchers describe a on wavelength, power, and exposure time.
“neural blockade” that results from the slowing of
mitochondrial transport along axonal fibers. Therapy lasers, like most medical lasers, are usually
class III or class IV. Class III therapy lasers have a
A marked and rapid effect on inflammation is due to maximum power of 500 mW (0.5 W). Class IV
modulation of chemical mediators, with a decreased therapy lasers are those over 500 mW in power.
release of proinflammatory substances such as
prostaglandins. A transient vasodilation results in Class III therapy lasers are applicable for treatment
increased circulation and oxygenation of the tissue. In of superficial lesions and wounds. These lasers
addition, there is a similar effect on lymph vessels, can be used for treatment of deeper tissue and
activating the lymph drainage system and reducing edema. musculoskeletal conditions, but due to their
lower power level, longer treatment times are
Significant stimulatory effects on the healing process needed to achieve effective target doses.
are induced. As with the anti-inflammatory effect,
chemical mediators are involved, with an increased Class IV therapy lasers are usually diode lasers
release of pro-healing cytokines such as transforming emitting light in the 800- to 1000-nm wavelength
growth factor and platelet-derived growth factor. range. The longer wavelengths in this spectrum have
Angiogenesis is stimulated, fibroblast replication and the deepest tissue penetration and produce excellent
migration increase, collagen production increases, and photobiomodulation. With these devices, effective
wound contraction is accelerated by the conversion of treatments can be delivered in an acceptable amount
fibroblasts into myofibroblasts. of time, even when treating deep tissue conditions in
large patients.
There is a similar stimulatory effect on bone healing.
Angiogenesis is stimulated at the fracture site,
accompanied by an elevation of osteogenic factors in TREATING ANIMALS WITH
the damaged tissue, resulting in accelerated LASER THERAPY
development of new bone and faster fracture healing. Incorporation of laser therapy into routine pain control
protocols is appropriate. As an adjunct to medical
protocols, laser therapy is helpful after surgery and
LASERS FOR dental procedures. Most postprocedure patients require
PHOTOBIOMODULATION a single treatment immediately after the procedure.
Regulatory agencies classify lasers based on their Examples are patients undergoing elective surgeries,
ability to do harm if used improperly. Different minor dental procedures, and closure of minor wounds.
agencies use somewhat different systems, but in Postprocedure patients with more extensive tissue
general, lasers are classed into 1 of 4 broad hazard disruption should receive additional treatments (2 to 6)
classes (I, II, III, IV) depending on their potential daily or every other day.

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Patients with a wide variety of acute problems benefit Medicine; Photobiomodulation, Photomedicine, and Laser
from laser therapy. Acute conditions are treated once or Surgery; Journal of Photochemistry and Photobiology B:
multiple times, until resolution of the condition. Biology; Journal of Clinical Laser Medicine & Surgery;
Patients with acute conditions that include pain, and Lasers in Medical Science.
inflammation, a healing process, or a combination of
any of these are candidates for laser therapy.
HEALING WITHOUT HARM
Chronic conditions involving pain, inflammation, and Virtually any medical laser has potential to do damage
healing may also be helped, although the treatments if used improperly. Proper training about a device, and
have to extend over a longer time and are frequently how to use it safely, gives practitioners and staff the
followed by ongoing treatments to maintain effect. confidence that patients can be treated without harm.
Patients with chronic conditions that include pain,
inflammation, a healing process, or a combination of In 2011, the American National Standards Institute
any of these are candidates for laser therapy. revised guidelines for the safe use of lasers in healthcare.
ANSI Z136.3 – 2011 Safe Use of Lasers in Health Care
Successful treatment design for chronic conditions is the foundation of laser safety in veterinary medicine.
follows accurate diagnosis and assessment of chronicity. Practices are encouraged to be familiar with ANSI Z136.3
Practitioners must avoid having a “one-size-fits-all” and to have a designated, trained, and certified laser
treatment design for chronic condition patients. safety officer responsible for their laser safety program.
Patients with chronic conditions are treated in 3 phases:
induction, transition, and maintenance. Evaluation of Eye protection is critical when using class IIIB or class
an acceptable response to treatment depends on the IV therapeutic lasers. All persons in the treatment area
patient signalment, the condition, and the expectations should wear appropriate safety glasses and pay strict
of the clinician and the owner. attention to avoiding direct exposure of their eyes.

The eyes of patients should also be protected with

safety glasses (clients love this) or goggles made
specifically for animals, or by covering their eyes
Eye protection is critical when with a dark cloth, a hand, or any material that
the patient will tolerate. Some patients will not
using class IIIB or class IV tolerate any covering of the eyes. For these patients,
therapeutic lasers. All persons in sedation is recommended, or if the patient is still
and not moving, treatment can be administered
the treatment area should wear with the therapist instantly ready to divert the laser
appropriate safety glasses and beam in a safe direction if the patient moves.
pay strict attention to avoiding
direct exposure of their eyes. CONTRAINDICATIONS
For over 40 years, a list of contraindications has
accumulated and been passed down, often repeated in
publications and in device manuals, without
consideration of whether it is valid. Currently, the one
EVIDENCE-BASED DATA absolute contraindication is exposure of the retina by a
When first introduced to laser therapy, most direct or reflected beam transmitted through the pupil.
veterinarians ask for evidence-based data. Initially, Scattered photons reaching the retina through adjacent
much of the knowledge practitioners had about laser tissue treatment are not the concern; penetration
therapy was experience-based information shared through the pupil is.
within the profession. Now veterinarians can find
supporting evidence-based data in peer-reviewed Since there is no knowledge about how different
publications and scientific literature. The results of in wavelengths of light interact chemically with
vitro and in vivo studies and clinical trials are readily medications, and one does not want to alter the rate of
available in publications like Lasers in Surgery and absorption of medications, do not treat over areas into

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which medication or vaccines have been injected. Apply

laser therapy to tissue before injecting; then, do not
treat the area again until the injection has been absorbed. Do not treat areas of active
It is contraindicated to treat over a malignancy, or the
hemorrhage since a transient
surgical site from which a malignancy has been vasodilation is induced.
removed. There is contradictory data from the
laboratory indicating that some malignant cell lines are
stimulated, some are inhibited, and
photobiomodulation has no effect on others. There is 2014, a review of publications over the last 40 years
no contraindication for treating a site distant to a found photosensitization and laser therapy linked only
malignancy, and it is valid to treat areas of malignancy, 4 times and no adverse effects ever reported.
with informed owner consent, for pain management in
hospice care.
Suggested Readings
Historically, treating over a gravid uterus has been ƒƒ Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy
versus photobiomodulation therapy. Photomed Laser Surg
contraindicated. This was based on studies done decades 2015;33(4):183-184.
ago in which chicken embryos showed cellular changes ƒƒ Anders JJ, Wu X. Comparison of light penetration of continuous wave
when exposed to high doses of visible red light through 810nm and superpulsed 904nm wavelength light in anesthetized rats.
Photomed Laser Surg 2016;34(9):418-424.
an eggshell window. This has no practical application ƒƒ Bartels KE. Therapy laser safety. In: Riegel RJ, Godbold JC, eds. Laser
to the clinical treatment of patients. Near infrared light Therapy in Veterinary Medicine: Photobiomodulation. Ames, IA: Wiley;
2017:31-32.
is neither mutagenic nor teratogenic, and an embryo or
ƒƒ Chung H, Dai T, Sharma SK, et al. The nuts and bolts of low-level laser
fetus within a gravid uterus is well protected from (light) therapy. Ann Biomed Eng 2012;40(2):516-533.
photons that are readily absorbed by multiple layers of ƒƒ Enwemeka CS. Intricacies of dose in laser phototherapy for tissue
repair and pain relief. Photomed Laser Surg 2009;27(3):387-393.
chromophores in the surrounding tissues.
ƒƒ Godbold JC, Riegel RJ. Contraindications, special considerations,
and precautions. In: Riegel RJ, Godbold JC, eds. Laser Therapy in
Do not treat areas of active hemorrhage since a transient Veterinary Medicine: Photobiomodulation. Ames, IA: Wiley; 2017:67-72.
ƒƒ Hamblin MR, Demidova TN. Mechanisms of low level light therapy. Proc
vasodilation is induced. Once hemorrhage has stopped, SPIE 2006;6140(612001):1-12.
laser therapy will not reactivate the hemorrhage. ƒƒ Jacques SL. Optical properties of biological tissues: a review. Phys Med
Biol 2013;58(11):R37-R61.
ƒƒ Kemper KJ. “Let there be light.” Research on phototherapy, light
Treatment over active epiphyses, the testicles, or the therapy, and photobiomodulation for healing: alternative therapy
thyroid glands all require similar consideration. becomes mainstream. Complement Ther Med 2018;41:A1-A6.
Treatment with high doses for a prolonged time has ƒƒ Riegel RJ, Godbold JC. Fundamental information. In: Riegel
RJ, Godbold JC, eds. Laser Therapy in Veterinary Medicine:
been demonstrated to produce change in these tissues. Photobiomodulation. Ames, IA: Wiley; 2017:13-14.
However, negative effects are not reported with lower ƒƒ Zein R, Selting W, Hamblin MR. Review of light parameters and
photobiomodulation efficacy: dive into complexity. J Biomed Opt
dose treatment over shorter periods. 2018:23(12):1-17.

Several historical contraindications are false. Treatment

over areas of hyperpigmentation and over tattoos is safe
with appropriate monitoring of skin temperature and John C. Godbold, Jr.
delivery technique. Dr. Godbold graduated from Auburn University
School of Veterinary Medicine in 1978. In 1980, he
established Stonehaven Park Veterinary Hospital in
Treatment over implants is safe and indicated. Near Jackson, Tennessee, where he practiced full time
infrared photons have no effect on metal implants. for 33 years while developing a special interest in
Photobiomodulation improves the health of the soft laser surgery and laser therapy. Dr. Godbold now
works with Stonehaven Veterinary Consulting,
tissue around implants, contributing to implant
generating and delivering educational content for
success. Do exercise care when treating over very colleagues and assisting equipment manufacturers
superficial metal implants because of the very small with the development of new laser and light-
amount of overlying soft tissue. based technologies. He is co-editor and a chapter
contributor of the 2017 textbook Laser Therapy in
Veterinary Medicine: Photobiomodulation.
Finally, the historical contraindication of treating
patients on photosensitizing medications is invalid. In

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Rehabilitation Modalities
for Pain Management and
Healing
Leilani Alvarez, DVM, DACVSMR, CVA, CCRT, AVCHM
Animal Medical Center, New York, N.Y.

Physical rehabilitation is an emerging area of veterinary that can be used to help reduce pain, enhance tissue
medicine. Multiple training programs offer certification healing, and improve patient function, as well as
in canine rehabilitation, board certification with the highlights associated evidence of efficacy (TABLE 1).
American College of Veterinary Sports Medicine and
Rehabilitation, and credentialing with the Academy of Which modality to choose depends largely on specific
Physical Rehabilitation Veterinary Technicians. patient needs and the condition being treated.
Rehabilitation modalities can be particularly useful as Although modalities can sometimes be used
part of a multimodal pain management program. simultaneously, the synergistic or countereffects they
Rehabilitative methods can improve patient comfort may have on each other remain unknown. For this
and quality of life, especially in cases where reason, you should consider the main goal of therapy
pharmaceutical pain relievers are contraindicated. This and choose the most appropriate modality for
article reviews some of the more common modalities addressing that goal.

TABLE 1 Summary of Clinical Evidence of Efficacy of Rehabilitation Modalities

for Treating Various Conditions in Dogs, 2012-2019
EFFECT LASER PEMF ECSW
shutterstock.com/InBetweentheBlinks

Improved ambulation after hemilaminectomy +/−

Reduction of pain/pain medication administration + ++

Improved pelvic limb function after TPLO +/−

Alleviation of patellar desmitis +

Improved wound healing −− +

Improved bone healing − +

Reduced lameness in dogs with osteoarthritis + +

Reduced lameness in dogs with shoulder tendinopathies ++

+ indicates number of studies with results supporting efficacy; − indicates number of studies with results showing lack of efficacy.
ECSW=extracorporeal shockwave; PEMF=pulsed electromagnetic field; TPLO=tibial plateau–leveling osteotomy.

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are exposed for a longer time at specific wavelengths. In

general, lower wavelengths are more effective for
superficial tissues (~600 nm) and higher wavelengths,
for deeper tissues (up to 3 to 5 cm, or 800 to 900 nm).

Several recently published studies evaluated the efficacy

of using photobiomodulation in veterinary
medicine.1-10 The results can be difficult to interpret
because of the large number of different products on
the market and variations in protocols and outcome
measures. Thus, we should be cautious when making
conclusions. Some authors question whether
FIGURE 1. Class 4 laser and targeted pulsed
photobiomodulation can help improve recovery after
electromagnetic field therapy being administered to a hemilaminectomy in dogs. Draper et al. found that
canine athlete with myofascial trigger points. This particular dogs receiving a low-level Class 3B laser (810-nm
laser is ideal for providing massage and heat therapy
simultaneously with the laser. Combined heat, laser, and wavelength for 1 minute daily for 5 days) regained the
massage can help relieve tense muscles. ability to ambulate significantly faster than untreated
dogs (3.5 vs 14 days).1 In contrast, using the same laser
and protocol, Bennaim et al. found no difference in
LASER THERAPY/ outcome between laser and placebo groups.2 In another
PHOTOBIOMODULATION prospective study evaluating wound healing, Kurach et
Perhaps the most commonly used rehabilitative al. found no apparent beneficial effects for dogs with
modality is laser therapy, which stands for light experimentally induced incisions and subsequent
amplification by stimulated emission of radiation exposure to a Class 2 laser (635-nm wavelength laser
(FIGURE 1). This modality has more recently been for 5 minutes for a total dose of approximately
called photobiomodulation, primarily because 1 J/cm2).3 When Kennedy et al. evaluated this same
therapeutic lasers modulate biological cellular activity laser in a prospective study, they found no beneficial
as opposed to other nontherapeutic lasers (e.g., grocery effects on pain, radiographic healing, or pelvic limb
store scanners or laser pointers) that do not have a function in dogs who received this Class 2 laser before
biological effect. and 10 times after tibial plateau-leveling osteotomy
(TPLO) for the first 96 hours at 2.5 J/cm2 and then
One proposed mode of action for therapeutic laser is weekly at home for 4 weeks (at 1.5 J/cm2).4 However,
stimulation of the respiratory chain in the those studies may have failed to demonstrate lack of
mitochondria. The respiratory chain is a complex of efficacy because they used a lower class of laser. Usually,
genes that provide instructions for proteins involved in rehabilitation practitioners use Class 3B lasers and
oxidative phosphorylation. As light enters the cell, it is above. A small study demonstrated improved scores in
absorbed by cytochrome c oxidase (the next-to-last step incisional scars in 4 dogs who received postoperative
in the mitochondrial respiratory chain process) leading
to increased production of adenosine triphosphate.
Cells also release low levels of ROS (reactive oxygen
species), resulting in endogenous anti-oxidant
production by the cell and release of nitrous oxide,
which leads to vasodilation and increased perfusion. Lasers are classified according
to risk for eye injury. The
Lasers are classified according to risk for eye injury. The
higher the class of laser, the greater the risk for eye higher the class of laser,
injury and thermal damage to eyes and/or other tissue. the greater the risk for eye
Class 4 lasers are defined as those with power output of
500 mW and above. In general, therapeutic lasers with
injury and thermal damage
potential for photobiomodulation are Class 3 and to eyes and/or other tissue.
above and require protective eyewear. Lower-class lasers
can have photobiomodulation potential when tissues

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PULSED ELECTROMAGNETIC
FIELD THERAPY
The most notable benefits Another rehabilitation modality that has recently
gained popularity and become widely available to
of PEMF include pain rehabilitation and general practitioners is pulsed
relief, increased wound electromagnetic field (PEMF) therapy (FIGURE 1). This
healing, and reduced soft technology has been available for over a century;
however, it became more popularized in the 1980s
tissue pain and edema. when the Food and Drug Administration approved
low-powered PEMF devices as bone growth
stimulators. Since then, the technology has been
further developed and targeted. There are many devices
on the market, including PEMF beds and devices that
photobiomodulation daily for 7 days at 8 J/cm2 with a provide more targeted therapy, such as a loop device.
Class 3B laser compared with 5 dogs who did not Of note, the particular signal of the device affects its
receive photobiomodulation.10 therapeutic potential. Variations exist in pulse width,
pulse frequency, size and geometry of the antenna, and
Another study that evaluated the effects of laser on duration of the signal. The targeted shortwave forms
dogs after TPLO found improved pelvic limb function (27 mHz, 2-ms pulse width, 2-Hz pulse frequency) are
(determined by measuring peak vertical force with a thought to be more effective. Practitioners are advised
pressure mat system).5 Those dogs received a single to ask PEMF manufacturers what specific signal is used
Class 4 laser dose with dual 800- and 970-nm by their product and what evidence they have to
wavelengths, at 6 W for a unified dose of 3.5 J/cm2 support their dosage recommendations. In general,
over a 100-cm2 area.5 In another recent prospective acute conditions should be treated 3 to 4 times daily
blinded study, dogs with naturally occurring elbow for 5 to 10 days until pain resolves. Chronic conditions
osteoarthritis demonstrated reduced lameness, pain can be treated once or twice daily or even less
scores, and nonsteroidal anti-inflammatory drug frequently, depending on response. The postulated
dosages compared with placebo-treated dogs.6 The mode of action for the signal emitted by the loop
treated dogs received photobiomodulation therapy with device is upregulation of the voltage-dependent binding
a Class 4 laser twice weekly for 3 weeks and then weekly of calcium to calmodulin. This binding enhances
for 3 weeks at a dose of 10 to 20 J/cm2 per joint.6 release of constitutive nitrous oxide synthase, leading to
vasodilation and an anti-inflammatory cascade.
As previously stated, use of wide-ranging doses and
various laser devices make it difficult to base The most notable benefits of PEMF include pain relief,
conclusions on these limited data. Larger prospective, increased wound healing, and reduced soft tissue pain
randomized, controlled clinical trials are needed before and edema (TABLE 1). Two recent randomized and
any conclusions about the therapeutic benefits of laser controlled clinical trials demonstrated benefits of
use in companion animals can be reached. PEMF use on recovery of dogs after
hemilaminectomy.11,12 In particular, Alvarez et al.
In human medicine, data are also not conclusive. A demonstrated reduced client administration of opioid
systematic review of the treatment of plantar fasciitis in medications during the initial 7-day postoperative
people showed reduced pain and improved function; period for dogs who received PEMF therapy compared
however, laser doses varied widely among studies, with those who received placebo.11 In addition, 6-week
making it difficult to determine best treatment postoperative wound scores were better for treated than
parameters.7 Another recent systematic review and control dogs.11
meta-analysis of photobiomodulation effects on bone
healing in humans showed improvement in pain and With regard to potential side effects, PEMF is perhaps
function; however, the level of evidence is considered one of the most benign of the rehabilitation modalities.
low to very low, and no effect on radiographic healing However, its use is contraindicated for patients with
of the fracture line was found.8 Similarly, results of a pacemakers or arrhythmias and those with active
systematic review of low-level laser on pressure ulcers in hemorrhage.
humans were conflicting and not conclusive.9

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EXTRACORPOREAL available evidence to support that use. Focal superficial

SHOCKWAVE THERAPY signal devices may be more effective for treating
Shockwave therapy was first introduced as a method for myofascial trigger points, whereas electrohydraulic
breaking up urinary calculi (lithotripsy). Since then, devices with higher energy and deeper penetration may
the technology has advanced and is widely used in be more appropriate for treating nonunion fractures,
human and veterinary medicine for treatment of osteoarthritis, or other deeper tissue disorders. Several
nonunion or delayed union fractures, wound healing, prospective studies that used higher energy and deeper
tendinopathies, arthritis, and other conditions. Among signal devices demonstrated efficacy for treating patellar
rehabilitation modalities in the veterinary field, the desmitis after TPLO,13 acceleration of bone healing,14
level of evidence for efficacy is perhaps highest for and osteoarthritis15; retrospective studies demonstrated
extracorporeal shockwave (ECSW) therapy (TABLE 1). efficacy for treating shoulder tendinopathies
The mode of action is emission of acoustic waves at (FIGURE 2).16,17 Contraindications include use on
high velocity and pressure. A large amount of energy is patients with immune-mediated joint disease, septic
deposited in the tissues, creating cavitation bubbles that arthritis, neoplasia, diskospondylitis, unstable fractures,
subsequently collapse and lead to increased cellular and neurologic deficits.
permeability and expression of cytokines and growth
factors. Because the pressure waves of ECSW are
emitted at lower frequency than those of therapeutic TAKE-HOME POINTS
ultrasonography, they cause no thermal effect. The ■■ Rehabilitation modalities are used to help reduce
analgesic effects most likely result from nociceptor pain and enhance tissue healing.
stimulation and endorphin release. ■■ Choice of rehabilitation modality should be based on
the patient’s needs, the condition being treated, and
A variety of ECSW devices, with varying effectiveness, level of evidence.
are available. In particular, devices can vary by depth of ■■ Laser: Prospective clinical trials in veterinary
penetration and focal area. Therefore, devices should be medicine are reported for hemilaminectomy,
chosen according to the condition being treated and TPLO, and elbow osteoarthritis. Results are not
conclusive enough to use for clinical decision
making.
■■ PEMF: Most notable published veterinary benefits
include pain relief, increased wound healing, and
improved recovery after hemilaminectomy.
■■ ECSW: Sufficient evidence in dogs exists to
warrant use for nonunion or delayed union
fractures, tendinopathies, and arthritis.
■■ Overall, rehabilitation modalities can be part of a
multimodal pain management program and can
improve patient comfort and function in a
noninvasive manner.

References
1. Draper WE, Schubert TA, Clemmons RM, et al. Low-level laser
therapy reduces time to ambulation in dogs after hemilaminectomy: a
preliminary study. J Small Anim Pract 2012;53(8):465-469.
2. Bennaim M, Porato M, Jarleton A, et al. Preliminary evaluation of the
effects of photobiomodulation therapy and physical rehabilitation on
early postoperative recovery of dogs undergoing hemilaminectomy for
treatment of thoracolumbar intervertebral disk disease. Am J Vet Res
2017;78(2):195-206.
3. Kurach LM, Stanley BJ, Gazzola KM, et al. The effect of low-level
laser therapy on the healing of open wounds in dogs. Vet Surg
2015;44(8):988-996.
4. Kennedy KC, Martinez SA, Martinez SE, et al. Effects of low-level laser
FIGURE 2. High-energy extracorporeal shockwave therapy therapy on bone healing and signs of pain in dogs following tibial
being administered to a dog with chronic supraspinatus and plateau leveling osteotomy. Am J Vet Res 2018;79(8):893-904.
biceps tendinopathy.

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5. Rogatko CP, Baltzer WI, Tennant R. Preoperative low level laser 12. Zidan N, Fenn J, Griffith E, et al. The effect of electromagnetic fields
therapy in dogs undergoing tibial plateau leveling ostetomy: a on post-operative pain and locomotor recovery in dogs with acute,
blinded, prospective, randomized trial. Vet Comp Orthop Traumatol severe thoracolumbar intervertertebral disc extrusion: a randomized
2017;30(1):46-53. placebo-controlled, prospective clinical trial. J Neurotrauma
6. Looney AL, Huntingford JL, Blaeser LL, et al. A randomized placebo- 2018;35(15):1726-1736.
controlled trial investigating the effects of photobiomodulation 13. Gallagher A, Cross AR, Sepulveda G. The effect of shockwave therapy
therapy (PBMT) on canine elbow osteoarthritis. Can Vet J on patellar ligament desmitis after tibial plateau leveling osteotomy.
2018;59(9):959-966. Vet Surg 2012;41(4):482-485.
7. Dos Santos SA, Sampaio LM, Caires JR, et al. Parameters and effects of 14. Kieves NR, MacKay CS, Adducci K, et al. High energy focused shock
photobiomodulation in plantar fasciitis: a meta-analysis and systematic wave therapy accelerates bone healing: a blinded, prospective,
review. Photobiomodul Photomed Laser Surg 2019;37(6):327-335. randomized canine clinical trial. Vet Comp Orthop Traumatol
8. Neto FCJ, Martimbianco ALC, de Andrade RP, et al. Effects of 2015;28:425-432.
photobiomodulation in the treatment of fractures: a systematic review 15. Souza AN, Ferreira MP, Hagen SC, et al. Radial shock wave therapy
and meta-analysis of randomized clinical trials. Lasers Med Sci 2019 in dogs with hip osteoarthritis. Vet Comp Orthop Traumatol
April 13. doi: 10.1007/s10103-019-02779-4 [Epub ahead of print]. 2016;29(2):108-114.
Accessed June 2019. 16. Becker W, Kowalesky MP, McCarthy RJ, et al. Extracorporeal
9. Machado RS, Viana S, Sbruzzi G. Low-level laser therapy in the shockwave therapy for shoulder lameness in dogs. JAAHA
treatment of pressure ulcers: systematic review. Lasers Med Sci 2015;51(1):15-19.
2017;32(4):937-944. 17. Leeman JJ, Shaw KK, Mison MB et al. Extracorporeal shockwave
10. Wardlaw JL, Gazzola KM, Wagoner A, et al. Laser therapy for incision therapy and therapeutic exercise for supraspinatus and biceps
healing in 9 dogs. Front Vet Sci 2019;5:349. tendinopathies in 29 dogs. Vet Rec 2016;179(15):385.
11. Alvarez LX, McCue J, Lam NK et al. Effect of targeted pulsed
therapy on canine postoperative hemilaminectomy: a double-blind,
randomized, placebo-controlled clinical trial. JAAHA 2019;55(2):83-91.

Leilani Alvarez
Dr. Alvarez is the Director of Integrative and
Rehabilitative Medicine at the Animal Medical
Center (AMC) in New York City. She is board
certified in Veterinary Sports Medicine and
Rehabilitation; is certified in acupuncture
and canine rehabilitation; and has a Master’s
degree in Chinese herbal medicine. Dr.
Alvarez graduated from the University of
Georgia College of Veterinary Medicine and
completed her internship and residency at
AMC. She lectures frequently at national and
international meetings. She is actively involved
in prospective clinical trials and has published in
peer-reviewed journals and books. Her research
interests include neurologic rehabilitation,
geriatric medicine, regenerative therapies, and
joint supplements.

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Laser Therapy
for Treatment of Joint Disease
in Dogs and Cats
Janice L. Huntingford, DVM, MS, DACVSMR
Essex Animal Hospital, Essex, Ontario, Canada

Photobiomodulation (PBMT), or laser therapy, is a modulation of immune and inflammatory responses.2

rapidly growing treatment modality used for a variety PBMT has been used in human and veterinary medicine
of medical conditions in companion animals. PBMT is to improve wound healing, treat snake bites, decrease
painless, noninvasive, and easily administered in a pain and inflammation resulting from musculoskeletal
primary care setting.1 Therapeutic laser devices are conditions, improve neurologic function after trauma
estimated to be used by 20% of all companion animal or injury, treat stomatitis and other oral inflammatory
practices in North America.1 conditions, treat intraoperative and postoperative
inflammation, and enhance healing of sport-related
PBMT accelerates healing in a number of tissues, injuries.1 The focus of this article, however, is on
provides analgesia, and decreases inflammation through treatment of joint conditions in companion animals.

TABLE 1 PBMT Glossary*

TERM DEFINITION

Coherent Photons travel in the same phase in time and space

Collimated Light divergence is minimized over a distance

Duty cycle Percentage of total emission time to total treatment time in a pulsed laser

Fluence, J/cm 2
Energy absorbed per area treated

Frequency, Hz Number of waveforms in a defined time interval

Irradiance, W/cm2 Power intensity

Joule Energy unit used to measure dose or rate of energy delivery

Monochromatic Light of 1 wavelength

Spot size Radius of the laser beam

Watt Unit of power measured as 1 J/second

Wavelength, nm Distance between crests of electromagnetic waves

*Hz=hertz; J=joule; nm=nanometer; PBMT=photobiomodulation therapy; W=watt.
Adapted from a table published in “Photobiomodulation Therapy in Veterinary Medicine: A Review” in Topics in Companion Animal Medicine.7

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WHAT IS PHOTOBIOMODULATION vasodilation.4,5 The fundamental step that eventually

THERAPY? results in the production of increased ATP is
Since its development, PBMT has been referred to by photostimulation of the enzyme cytochrome c in the
many names; terms such as cold laser, low-level laser mitochondrial respiratory chain. Cytochrome c absorbs
therapy, phototherapy, and low-level light therapy light in the spectrum of 500 to 1000 nm (therapeutic
appear in the literature and have caused confusion. window) and breaks the bond with NO, which allows
Participants at a nomenclature consensus meeting bonding with oxygen and production of cytochrome c
recommended that the term photobiomodulation be oxidase at an optimal rate. Cytochrome c oxidase is
adopted to mean “a form of light therapy that utilizes responsible for the formation of ATP. Additional
nonionizing forms of light sources, including lasers, electrons are accepted by oxygen to produce ROS.
light-emitting diodes (LEDs), and broadband light, in
the visible and infrared spectrum.”3 PBMT is defined as PBMT reduces the pain and inflammation of
a “therapeutic use of light, absorbed by the osteoarthritis and joint disease through several
chromophores found in the body, to stimulate mechanisms of action. PBMT has been shown to
nonharmful and nonthermal reactions within the cell reduce cyclooxygenase 2 and bradykinin production
that result in a beneficial therapeutic outcome.”3 (bradykinins induce pain by stimulating afferent
Although PBMT describes the effects of the therapeutic nociceptors).6 Cytokines and growth factors that have
modality, the term LASER (commonly lowercased) is anti-inflammatory, anti-oxidative, and anti-apoptotic
an acronym for light amplification by stimulated properties are increased. PBMT reduces the production
emission of radiation. Veterinary lasers can be used for of inflammatory markers such as interleukin 1 beta,
either therapeutic or surgical applications, depending tumor necrosis factor alpha, and prostaglandin E2.6
on the laser. PBMT decreases neutrophils in joint fluid, relieves
pain, and increases joint mobility and function.6
PBMT decreases inflammation in tendons and
HOW DOES PBMT WORK? ligaments while increasing tensile strength, collagen
Studies have shown that PBMT alters the inflammatory fibril size, and fibroblast production.7 Research has
response and affects cell signaling.4,5 The main factors shown that after cruciate transection and subsequent
underlying the laser’s therapeutic effects are increased tibial plateau-leveling osteotomies, PBMT reduces
reactive oxygen species (ROS), adenosine triphosphate cartilage degeneration and synovial inflammation and
(ATP), and nitric oxide (NO). Increased ROS activates improves peak vertical force.7 It has also been shown to
the endogenous anti-oxidant enzyme systems; increased accelerate bone healing and promote recovery of
ATP supplies cells with energy for reparation; increased atrophied muscles.7 All these PBMT effects can be
NO promotes angiogenesis, modulates the amplified when combined with multimodal therapy for
inflammatory and immune responses, and mediates the treatment of joint disease.

TABLE 2 Laser Classification*

CLASS DESCRIPTION

1 ƒƒ Not hazardous to the eyes and requires no eye protection.

ƒƒ Examples: laser printers and CD players.
1M ƒƒ Not hazardous to the eyes unless using optical instruments such as binoculars or microscopes.
2/2M ƒƒ Limited to 1 mW of power.
ƒƒ No protective eyewear is needed, but extended viewing is not recommended.
ƒƒ This class includes point-of-sale scanners.
3R ƒƒ Have output of up to 5 mW.
ƒƒ Are not a fire hazard.
ƒƒ Only an optical hazard if focused or viewed for an extended period of time. This class includes laser pointers.
3B ƒƒ Have output of up to 500 mW and wavelengths from 300 nm up to the far infrared.
ƒƒ Requires protective eyewear.
ƒƒ This class includes therapy lasers from 5 to 500 mW.
4 ƒƒ Have output greater than 500 mW.
ƒƒ Can burn skin or cause permanent eye damage.
ƒƒ Protective eyewear must be worn when operating these devices.
*Adapted from a table published in “Fundamental information” in Veterinary Medicine: Photobiomodulation.8

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can be used for surgical applications.1,6 Wavelengths of

BOX 1 Benefits of Laser Therapy 800 to 1000 nm can achieve appropriate depth of
for Joint Disease penetration to treat most musculoskeletal conditions.
 Pain reduction
  educed markers of inflammation in
R
the joint Power and Duration
 Reduced swelling and edema Penetration depends on wavelength and tissue
 Increased joint mobility and function
type, not laser power (watts [W]) or laser intensity
(irradiance) at the tissue surface (W/cm2). Using a
 Stimulation of collagen synthesis
higher-powered laser delivers more photons to the
 Decreased dosage or frequency of
pharmaceutical use for patients with
penetration depth and also determines the time needed
chronic disease to deliver the energy. Lower-powered lasers must be
Adapted from “Musculoskeletal Disorders and used for a longer time to achieve the same dose. Very
Osteoarthritis” in Laser Therapy in Veterinary Medicine:
Photobiomodulation.6 low-powered lasers will have no measurable results
even when used for long periods of exposure.1,6

Dosage
LASER FUNDAMENTALS
AND CLASSIFICATIONS Manual
Fundamental PBMT terms and definitions are Another consideration with regard to PBMT is
summarized in TABLE 1.7 All lasers are classified dosage applied to the tissue. Dosage is expressed
according to potential to cause optical damage by as the amount of energy (joules [J]) delivered to a
wavelength, power, and exposure duration. Classes 3B certain surface area (cm2). When calculating the
and 4 can be used safely; however, classes 1, 1M, 2/2M, correct dose, the therapist must consider the size of
and 3R are not appropriate for any use in veterinary the patient, body type, coat length and color, skin
rehabilitation. TABLE 2 describes laser classifications.8 color, and depth of the condition to be treated. When
joint conditions are being treated, the dose can be
influenced by the size of the patient, whether the
Tissue Penetration fur is clipped, and the joint involved.1,6,7 In general,
One of the most critical elements of laser therapy is the larger the patient, the larger the dose required
depth of penetration. Laser light is monochromatic, for a therapeutic effect. For most joints, 8 to 12 J/
collimated, and coherent, enabling it to penetrate cm2 will work well; however, for some joints (e.g., the
through tissues to a cellular level. When light interacts elbow), a higher dose may be required.9 TABLE 3
with biological tissue, it is either absorbed, scattered, lists commonly used doses for joints1 and BOX 1
or reflected. summarizes the benefits of PBMT for joint disease.

Wavelength Preset
A therapy laser will emit light in the 620- to 1200-nm Many of the newer laser units have preset protocols for
range, often called the therapeutic window. treating various conditions. The operator inputs
Wavelengths that minimize scattering and reflection as parameters such as size, coat length and color, and area
well as absorption by unwanted chromophores will and condition treated, and the machine uses this input
provide optimal penetration into the tissue and ensure to calculate the fluence required. Settings can be
a better therapeutic result.1 Melanin, hemoglobin, and manually changed if the therapist wishes to adapt or
oxyhemoglobin chromophores absorb shorter change the dose. Protocols vary with the manufacturer,
wavelengths (600 to 800 nm), making these and it is in the best interest of the patient for the
wavelengths better for superficial areas. Wavelengths practitioner to understand laser dosimetry. However,
above 1000 nm are primarily absorbed by water, the presets on newer machines have increased safety
making tissue penetration difficult. Surgical lasers, such features and enable veterinarians to confidently delegate
as the CO2 laser, produce wavelengths around 10,600 delivery of the therapy to well-trained persons.6
nm, which are strongly absorbed by water and therefore

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TREATMENT TECHNIQUES A
Before beginning treatment, ensure that the patient is
wearing protective eyewear and is comfortable and
appropriately positioned, providing good access to the
area being treated. If that area is a joint, ensure access
to all sides of the joint. Passive range of motion therapy
before and after PBMT is a good idea to ensure
improved function.

Treatment techniques will vary according to the

condition treated, the joint treated, and the type of
laser used. In general, clipping the area will allow the
FIGURE 1. Patient undergoing laser therapy. Note the
best penetration of light to the underlying tissues; protective eyewear, soft surfaces, and minimal restraint.
however, if clipping is not possible then the dosage
needs to be adjusted. Be cautious not to overheat the
coat or skin if using lasers with higher wattage or
wavelengths less than 900 nm. For acute or chronic painful joint conditions, it is
useful to begin with an induction phase of treatment,
When treating joints, treat a broad area. For example, followed by more frequent treatment sessions until a
treat the specific joint and surrounding muscles and significant effect is noticed. For patients with acute
tendons as well as satellite areas of pain. Treating a joint injury or a flare-up of chronic arthritis, daily
comprehensive area will ensure a more consistent treatment is recommended. After clinical signs have
outcome.1 improved significantly, then treatments can be reduced
to twice weekly for 2 to 3 weeks and then further
Treatment technique will vary with the laser used. reduced to maintenance according to the patient’s
Lower-powered lasers (less than 1 W) can use a response. It is not unusual for patients with
point-to-point method in which a dose is delivered for osteoarthritis to receive treatment every 3 to 6 weeks,
up to 30 seconds in 1 location before the probe is depending on response. In general, 4 to 6 treatments
moved. This method can be more time-consuming, are needed to see improvement, although 8 to 10
depending on which joint is being treated and whether sessions may be needed for patients with multiple joint
multiple joints are involved. Higher-powered lasers use involvement or severe disease. Be sure that clients are
a scanning method that delivers the dose over a large aware that each patient responds differently to PBMT.6
area, ensuring that the handpiece is moving during
treatment. The therapy can be delivered with a contact
or off-contact method, depending on the unit. The USE OF PBMT WITH METAL
contact method allows for tissue compression and can SUTURES AND IMPLANTS
cause deeper penetration. The off-contact method is Smooth metal implants and staples will primarily
frequently used over bony prominences or excessively reflect diffuse near-infrared light; thus, heating of the
painful areas.1 implants is not a concern. However, with small patients
(e.g., cats and small dogs) the implant will be covered

TABLE 3 Common Laser Doses for Small Animal Joints*

JOINT DOSE
Carpus 1-4 J/cm2
Elbow 4-8 J/cm2 but may be up to 20 J/ cm2 for chronic conditions
Shoulder 8-10 J/cm2
Hip 10-12 J/cm2 or higher for large breed dogs
Stifle 4-8 J/cm2 for small dogs; 10-12 J/cm2 for large breed dogs
Tarsus 1-4 J/cm2
*Adapted from a table published in “Therapeutic Laser in Veterinary Medicine” in Veterinary Clinics of North America: Small Animal Practice.1

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by superficial tissue only. Because of the light References

reflection, these areas will need an increased dose; 1. Pryor B, Millis DL. Therapeutic laser in veterinary medicine. Vet Clin
North Am Small Anim Pract 2015;45(1):45-56.
therefore, to ensure patient comfort, adjustments need
2. Chung H, Dai T, Sharma SK, et al. The nuts and bolts of low-level laser
to be made to decrease the power or time of treatment. (light) therapy. Ann Biomed Eng 2012;40(2):516-533.
Because the light does not penetrate the hardware, 3. Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy
versus photobiomodulation therapy. Photomed Laser Surg
apply the laser 360 degrees around the limb. Do not 2015;33(4):183-184.
hover the laser over sutures; instead, apply the laser to 4. Lubart R, Eichler M, Lavi R, et al. Low-energy laser irradiation
both sides of the suture line.6 promotes cellular redox activity. Photomed Laser Surg 2005;23:3-9.
5. Prindeze NJ, Moffatt LT, Shupp JW. Mechanisms of action for light
therapy: a review of molecular interactions. Exp Biol Med (Maywood,
NJ) 2012;237:1241-1248.
PRECAUTIONS FOR PBMT USE 6. Miller LA. Musculoskeletal disorders and osteoarthritis. In: Reigel
RJ and Godbold JC Jr., eds. Laser Therapy in Veterinary Medicine:
Keep in mind the following safety precautions when Photobiomodulation. Ames, IA: John Wiley and Sons; 2017:132-149.
using PBMT:1 7. Hochman L. Photobiomodulation therapy in veterinary medicine: a
review. Top Companion Anim Med 2018;33(3):83-88.
1. Use protective eyewear (for patient and therapist),
8. Riegel RJ, Godbold JC Jr. Fundamental information. In: Riegel RJ
specific for the laser being used. and Godbold JC Jr., eds. Laser Therapy in Veterinary Medicine:
2. Do not treat over a pregnant uterus or open Photobiomodulation. Ames, IA: John Wiley and Sons; 2017:9-18.
9. Looney AL, Huntingford JL, Blaeser LL, Mann S. A randomized
fontantelles. blind placebo-controlled trial investigating the effects of
3. Do not treat over malignancies. photobiomodulation therapy (PBMT) on canine elbow osteoarthritis.
Can Vet J 2018;59(9):959-966.
4. Remove all metal from the patient (e.g., jewelry,
leashes, collars).
5. Use caution with dark skin (melanin increases
absorption by chromophores). Use your hand to
monitor skin temperature while PBMT is being
Janice L. Huntingford
applied.
Dr. Huntingford is a 1984 graduate of the Ontario
Veterinary College, University of Guelph, in Guelph,
Ontario, Canada. She is certified in chiropractic,
SUMMARY acupuncture, rehabilitation, and pain management.
She is the owner and medical director of the Essex
PBMT is a valuable modality that can be used to treat a Animal Hospital, Canine Rehabilitation and Fitness, in
variety of joint conditions in dogs and cats. For PBMT Essex, Ontario. In 2015, she became a Diplomate of
to be effective, the dose must be appropriate for the the American College of Veterinary Sports Medicine
particular condition, joint, and patient. Additional and Rehabilitation; in 2018, she received a masters
degree in Traditional Chinese Veterinary Medicine.
veterinary clinical studies are required to document Dr. Huntingford is a consultant for the VIN Rehab/
further benefits and determine optimal parameters for Sports Medicine/Chronic Pain Board and lectures
all applications. nationally and internationally on a variety of holistic
topics, including rehabilitation and geriatric medicine.
She has co-authored several textbook chapters and
published a number of peer-reviewed manuscripts. In
her spare time, she enjoys spending time on her farm/
winery with her chef husband, Harold, and their pugs,
cats, horses, and a few adult children.

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The Therapeutic
Power of Monoclonal
Antibody Therapy
Darren Berger, DVM, DACVD, Assistant Professor
College of Veterinary Medicine, Iowa State University, Ames, Iowa

Although biotherapeutics have been used in The major advantages of biotherapeutic agents
human medicine for more than 30 years, they over traditional drugs are the agents’ specificity,
are still relatively new in veterinary medicine.1 which facilitates precise action (ideally with
Recent advances in the veterinary arena include minimal unintended effects), and their long
updated labeling and industry acquisition and half-lives, which allow infrequent dosing.1
collaboration to develop new biologic agents.
This article reviews biologic therapy as it relates In human medicine, mAbs represent the area of
specifically to monoclonal antibodies (mAbs) biotherapy that offers the greatest array of
and covers the only fully licensed and potential therapies. This is also the therapeutic
commercially available product, lokivetmab arena most likely to see peak growth in products
(CYTOPOINT™), which is made by Zoetis. brought to the veterinary marketplace for clinical
use in treating arthritis, autoimmune disease,
allergic conditions, infectious disease, and
PRINCIPLES OF BIOTHERAPY oncologic disorders.2
Biotherapy differs from traditional
pharmacotherapy in that it mimics the body’s
shutterstock.com/Dasha Iunskaya

normal immune response to treat disease or MONOCLONAL ANTIBODIES

protect against adverse events.2 Biologic agents
are commonly categorized into 3 groups: Production
1. Peptides and small proteins (hormones and mAbs are essentially identical to naturally
cytokines) occurring antibodies produced and secreted by
2. Nonimmune proteins (replacement enzymes plasma cells in the body. However, in a normal
and blood factors) immune response to stimulation by an infectious
3. Therapeutic antibodies and Fc receptor–like agent or disease, numerous plasma cells produce
proteins thousands of antibodies that recognize multiple

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epitopes on a particular antigen. mAbs arise from a complement-dependent cytotoxicity or antibody-

single plasma cell line and recognize the same target dependent cell-mediated cytotoxicity) or enhance
region on an antigen. clearance of the foreign agent by antibody-dependent
phagocytosis.1,2 The backbone or immunoglobulin (Ig)
Production of mAbs was historically accomplished by isotype also affects the specific mechanism of action
immunizing mice, isolating the desired B cells, and and half-life of an individual mAb.5
fusing these cells with an immortal myeloma cell line
(the hybridoma technique).3 However, when these murine Like any protein, mAbs undergo denaturation and
antibodies were injected into nonmouse subjects, they proteolytic enzymatic breakdown in the stomach if
stimulated significant undesired immune reactions. To given orally. Thus, all therapeutic mAbs are
resolve this problem, genetic engineering and recombinant administered by intravenous, subcutaneous, or
DNA techniques have been developed, and speciated intramuscular injection. Once injected, they have long
(humanized, caninized, or felinized) mAbs that are half-lives similar to those of naturally produced
greater than 90% similar to those of the target species’ antibodies (roughly 20 days).2
composition can now be created.3,4 This level of speciation
limits the use of the products to only the labeled species Unlike traditional drugs, mAbs do not need to undergo
but also decreases the risk of adverse effects. biotransformation so that they can be inactivated or
excreted from the body; rather, as biologic agents that
mimic normal physiologic products, they are
inactivated through pathways similar to that of the
natural product. mAbs undergo intracellular catabolism
As of September 2018, within the lysosome, where they are broken down to
amino acids that can either be recycled for the synthesis
the label indication is that of new proteins or be renally excreted. This inactivation
lokivetmab has been shown to pathway provides mAbs a tremendous advantage over
traditional drugs in that they are unlikely to result in
be effective for the treatment adverse drug–drug interactions when administered to
of allergic dermatitis and patients concurrently receiving other medications.
atopic dermatitis in dogs.
Safety
As with anything new, biotherapy carries with it
concern about the unknown. Many practitioners worry
Mechanism of Action about a wide array of potential adverse events from
Therapeutic mAbs exert their biologic effect mAb therapy, most of which are unlikely, as mAbs are
predominantly via one of three mechanisms. The first is very target specific and have unique metabolic aspects.
through the binding or “soaking up” of soluble Because mAbs do not have intracellular activity, it is
extracellular targets (i.e., cytokines) before these targets easier to predict adverse events before clinical trials,
arrive at a cellular receptor.2 This action prevents the based on the anticipated blockade of the target, and it
target molecules from activating cellular receptors and is a generally accepted concept that mAbs tend to be a
is the primary mechanism by which lokivetmab exerts safer form of treatment than traditional drugs. This
its effect. improved risk–benefit ratio is grounded by the fact that
the likelihood of a mAb reaching the market is roughly
The second mechanism is to simply bind a target 4 times greater than that of a newly developed
receptor on the cell surface and block activation of pharmacologic agent.1
signal transduction; mAbs that act through this
pathway are classified as antagonistic.2 Many currently The overall safety of any particular mAb is largely
approved human products act through this determined by the mAb’s target and level of speciation.
mechanism.2 Adverse events that have been encountered with
therapeutic mAbs in human medicine are listed in BOX
The third mechanism is to bind to an infectious agent 1; these events are, for the most part, predictable based
or cancer cell and either activate cell lysis (via on the mechanism and target of the specific product.

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LOKIVETMAB
To date, several mAbs have received conditional or full
license approval. They include biologics for cancer BOX 1 Adverse Events Observed
in Human Medicine With mAb Therapy1,6
therapy (blontuvetmab [Blontress®] and tamtuvetmab
[Tactress®]) (aratana.com), osteoarthritis (ranevetmab  Injection site discomfort

and frunevetmab), and canine allergic dermatitis  Lethargy

(lokivetmab). However, at this time, the only fully  Fever
licensed commercially available product is lokivetmab.  Gastrointestinal upset
 Production of anti-drug antibodies
Lokivetmab is a caninized anti–interleukin-31 (IL-31)
 Anaphylaxis
mAb that works by neutralizing soluble IL-31 produced
 Reactivation of infectious diseases
predominantly by lymphocytes. It was developed after
IL-31 was shown to play a role in development of  Thrombocytopenia

canine pruritus.7 IL-31’s potential role in the  Leukopenia

development of pruritus associated with atopic  Hypothyroidism
dermatitis has been further substantiated by more  Pulmonary events
recent studies.8,9  Autoimmune disease
 Neoplasia (tumor necrosis factor-α specific products)

Indication and Use  Pruritus

Lokivetmab is approved and licensed through the U.S.  Erythema and rash

Department of Agriculture. The original label  C ardiotoxicity

indication was to aid in the reduction of clinical signs  Tumor lysis syndrome
associated with atopic dermatitis. As of September  Cytokine release syndrome
2018, the label indication is that lokivetmab has been
shown to be effective for the treatment of allergic
dermatitis and atopic dermatitis in dogs.

Lokivetmab is provided in 1-mL sterile, ready-to-use Safety data generated in this clinical trial revealed no
vials (10, 20, 30, or 40 mg/mL). Individual vials are hypersensitivity-related reactions to the single injection
meant for single use and should be administered to a immediately after dosing, no evidence of treatment-
patient in their entirety via subcutaneous injection. The induced immunogenicity, and no specific safety
current labeled target dose is 2 mg/kg, which can be concerns associated with treatment.10
repeated every 4 to 8 weeks as needed.
A second study provided additional safety data from
canine patients with atopic dermatitis receiving 2 doses of
Clinical Trials lokivetmab (1.0 to 3.3 mg/kg) compared with placebo.11
Since lokivetmab’s release, several published studies and This study enrolled 245 dogs, and 2 injections were given
research abstracts have assessed its clinical efficacy and 28 days apart. Adverse events observed in greater than 2%
safety in dogs. The first study was a dose-determination of participants included secondary skin or ear infections,
study using client-owned dogs to assess efficacy and pruritus, gastrointestinal (GI) upset (anorexia, vomiting,
safety of a single subcutaneous injection over a 56-day and diarrhea), and lethargy. Both treatment groups
period.10 In this study, dogs were randomly assigned to experienced GI upset and lethargy at a similar rate,
receive a dose of lokivetmab (0.125, 0.5, or 2 mg/kg) which resolved spontaneously or with supportive care;
or placebo. Efficacy was evaluated by the clinician and no immediate hypersensitivity or injection site reactions
the owner using objective scales. The study showed that were reported. However, 2.5% of lokivetmab-treated
clinical parameters were improved at the 2 higher doses dogs developed treatment-induced immunogenicity. No
compared with placebo and that the level and duration adverse interactions with concomitant medications were
of response correlated with the dose given. In addition, observed in this study.11
pharmacokinetic data from this study revealed that the
half-life for lokivetmab was 16 days, with peak serum A third investigation evaluated the safety and efficacy
concentration reached at 9.8 days after administration. of lokivetmab compared with cyclosporine over a

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3-month period, then followed 81 dogs for an with lokivetmab.13 Adverse events were reported in 11
additional 6 months as part of a continuation study.12 of 132 dogs (8.3%) treated with lokivetmab; the most
Overall, lokivetmab-treated patients compared common adverse effect reported was lethargy within 72
favorably with those treated with cyclosporine. No hours of receiving the injection (8 of 11 patients).13
significant differences between groups were appreciated
in measured clinical outcome parameters. The
continuation phase demonstrated continued efficacy, CONCLUSION
with 76.3% of animals assessed to have a normal level Taken together, the clinical studies show that
of pruritus after the ninth month of treatment. This lokivetmab appears to be a safe and effective treatment
study had safety results similar to those of the first 2 option for dogs with allergic dermatitis. In addition,
clinical trials, with GI upset occurring significantly less lokivetmab offers several advantages over traditional
frequently in dogs treated with lokivetmab than in drugs (cyclosporine, oclacitinib, and glucocorticoids)
those treated with cyclosporine. No hypersensitivity used in the management of allergic dogs; namely, it can
reactions or immediate post-dosing injection site be given to dogs of all ages, with any concomitant
reactions were appreciated during the 9-month study. medication, and with any concurrent medical condition.
Treatment-induced immunogenicity was seen in 2% of This therapy offers some exciting new opportunities in
dogs during the initial 3 months but in no new dogs treating dogs with allergic dermatitis.
during the continuation phase.12

The final published report at this time is a retrospective References

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monoclonal antibodies. Nat Rev Drug Discov 2010;9:325-338.
with lokivetmab over a 1-year period at a dermatology
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3. Enomoto M, Mantyh PW, Murrell J, et al. Anti-nerve growth factor
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dosage and response, but a trend was observed that 4. Moyaert H, Van Brussel L, Borowski S, et al. A blinded, randomized
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larger dogs were more likely to be classified as to ciclosporin in client-owned dogs with atopic dermatitis. Vet
Dermatol 2017;28:593-e145.
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that almost 96% of dogs responded within the first 72 2014;157:31-41.

hours after administration, with more than half 6. Baldo BA. Adverse events to monoclonal antibodies used for cancer
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(55.9%) experiencing improvement by 24 hours. 2013;2(10):1-15.
Additionally, dogs with pruritus considered “severe” or 7. Gonzales AJ, Humphrey WR, Messamore JE, et al. Interleukin-31: its
role in canine pruritus and naturally occurring canine atopic dermatitis.
“very severe” before treatment were more likely to be Vet Dermatol 2013;24:48-e12.
classified as treatment successes. Of note, 71.4% of 8. Marsella R, Ahrens K, Sanford R. Investigation of the correlation of
serum IL-31 with severity of dermatitis in an experimental model of
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oral JAK inhibitor, were considered treatment successes e28.
9. Messamore JE. An ultrasensitive single molecule array (Simoa) for the
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10. Michels GM, Ramsey DS, Walsh KF, et al. A blinded, randomized,
placebo-controlled, dose determination trial of lokivetmab (ZTS-
00103289), a caninized, anti-canine IL-31 monoclonal antibody in client
Darren Berger owned dogs with atopic dermatitis. Vet Dermatol 2016;27:478-e129.
Darren Berger is assistant professor of dermatology at 11. Michels GM, Walsh KF, Kryda KA, et al. A blinded, randomized,
Iowa State University’s College of Veterinary Medicine. Dr. placebo-controlled trial of the safety of lokivetmab (ZTS-00103289), a
Berger’s research interests include clinical pharmacology caninized anti-canine IL-31 monoclonal antibody in client-owned dogs
with atopic dermatitis. Vet Dermatol 2016;27:505-e136.
and the clinical management of canine atopic dermatitis
and equine hypersensitivity disorders. A graduate of Iowa 12. Moyaert H, Van Brussel L, Borowshi S, et al. A blinded, randomized
clinical trial evaluating efficacy and safety of lokivetmab compared to
State University, he worked as a small animal general ciclosporin in client-owned dogs with atopic dermatitis. Vet Dermatol
practitioner before completing a dermatology residency 2017;28:593-e145.
with Dermatology for Animals in Gilbert, Arizona. 13. Souza CP, Rosychuck RA, Contreras ET, et al. A retrospective analysis
of the use of lokivetmab in the management of allergic pruritus in
a referral population of 135 dogs in the western USA. Vet Dermatol
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