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Dr. Coates is a veterinarian based in the other “Sunshine State” – that's Colorado to the rest of you – where she lives and plays with a varied range of animals. She shares her professional and personal experiences, Monday through Friday, here on petMD's blog, the Fully Vetted. Log in for your daily dose of her insight and wisdom.

 

Animal Joint Care 101: Does Your Pet Have an Arthritis Treatment Checklist? (Part 2)

April 13, 2010 / (22) comments


Ever heard the words,“There’s not much we can do for your pet’s arthritis?”


While that may well be true for some, the vast majority of dogs and cats CAN be treated for osteoarthritis (arthritis, for short). Though the inexorable progression of the disease may be unstoppable, their symptoms can be alleviated by a variety of not-necessarily-so-dramatic approaches to treatment.


Unfortunately, it’s my experience that the prevailing perception among pet owners, with respect to arthritis, is overwhelmingly one of downright pessimism. Convincing most of my clients that anything short of a hip replacement (or some other version of major surgery) will improve their pets is pretty much an uphill battle. Sadly, it’s this negativity — not biology — that most tends to stand in the way of their pets' improved comfort.


It’s my job in this post to prove to you, as I attempt to do for them, that positive approaches can reap big rewards. Here goes...


If you’ve got a pet over five years of age, chances are he or she is already in need of an arthritis assessment. This means you’ve got to honestly take stock of a variety of issues (Note: If you’re unsure of any of the following, take the time to make an extra appointment with your veterinarian to discuss the issue and determine your pet’s arthritis susceptibility status):

 

  • Is he large for his species (or a large breed)?
  • Is she overweight? If so, by how much?
  • Has he slowed down, or experienced exercise intolerance, reluctance to jump, muscle mass loss, or any of the other signs we discussed in the first post in this series?
  • Does she have any joint troubles? Ever suffered knee instability? Back pain? Orthopedic trauma?
  • Has your veterinarian expressed concern over any of these above issues, or ever mentioned that your pet is at high risk for osteoarthritis?


If you answered yes to any of these bullet points then you desperately need what I call an "arthritis therapy checklist." Yes, even cat owners should understand the critical importance of prevention, early detection and timely intervention when it comes to this common disease. But even if you’ve got a geriatric pet with advanced evidence of osteoarthritis, don’t despair … it’s never too late.


To that end, here’s the therapeutic checklist I urge you to examine and internalize:


1. Your veterinarian: The key to knowing how to use your veterinarian for osteoarthritis evaluation and treatment is to understand that it’s always best to see a veterinary specialist if you’ve got a pet with early signs and symptoms of orthopedic discomfort. (Board-certified veterinary surgeons are the ideal candidates for advanced orthopedic evaluations.)


Even if the symptoms arrive on cue with advancing age, it’s not always a given that arthritis cannot be mitigated by additional treatments like surgery or specific rehabilitation therapy.


2. Weight loss: This is the single biggest area in which our pets are under treated for their symptomatic arthritis, or for their yet-to-be-revealed-but-definitely-in-the-works arthritis. After all, we know that our afflicted or at-risk pets who carry excessive poundage are only compounding their current and future disease by doing so.


It’s for that reason that I strongly recommend that all of my at-risk or affected patients — even my very young but poorly built patients (think: hip dysplasia, dwarfed limbs or intervertebral disc disease) — stay on the lean side. It’s no longer good enough to attain a normal weight. Keeping them extra-lean is how their arthritis is best controlled. (Easier said than done, I know.)


3. Exercise: Unless their condition specifically dictates otherwise, exercise is a good thing. A very good thing. Keeping muscle mass at its bulkiest possible is always helpful for those whose weakness means more disuse, and a few rungs further down that downward spiral trend.


Swimming, of course, tops my go-to exercise list. Pools, underwater treadmills, lakes, rivers, bays, beaches — the bathtub, even — I could care less. Use a life vest if need be. Just start early … and do it often. Nothing works as well. But that doesn’t mean that other means to achieving the same end shouldn’t be applied if swimming is absolutely out. 


4. Supplements: For the last decade or two, glucosamine has been at the head of this category’s must-do list. Recently, however, fatty acids have proven themselves every bit as worthy. Here’s a study on this from the Journal of the American Veterinary Medical Association (JAVMA), published this past January.


The problem is, as many of my clients swear by these supplements as those that claim they do little to nothing. And while the veterinary literature supports the use of both of these supplements, the human medical literature offers a halfhearted lack thereof. All of which leads to lots of confusion among my clients, and plenty of poor compliance even when I think I’ve succeeded in convincing them that, on balance, both of these ingredients are VERY worthwhile.


5. "Alternative" therapies: Massage, acupuncture, and chiropractics have all been shown to be of benefit to arthritis patients of the canine and feline persuasion. But be warned: There are plenty of not-so-certified practitioners of these arts out there. Make sure you act on a solid recommendation, and that the highest levels of certification have been attained.


6. Simple home care: It’s my experience that most pet owners don’t recognize that plenty of factors in the home environment can make a huge difference to dogs and cats with osteoarthritis. Consider the lowly non-slip floor, for example. For dogs in particular, slippery floors and stairs make movement less safe, and definitely more stressful. Would you walk around as much as you might otherwise if you always felt like landing splay-legged and immobile might happen with any misstep? Booties and floor runners may work well in these cases. So too would be keeping all those things your pet needs on one level.


7. Drugs: There are lots and lots of choices here. Unfortunately, they’re the first approach too many of my colleagues reach for — not to mention the one too many pet owners assume is the only way to treat arthritis. Nonetheless, they are VERY helpful for most of my patients. But they’re never my first choice … that is, unless I’m faced with a patient whose parents absolutely refuse to look at things any other way. The only caveat to this is my use of Adequan. Here's more on this drug.


Except for the drugs, every other approach listed above deserves the "early and often" designation. In other words, knowing your pet's got a high risk factor for arthritis means you should be hitting all these high notes as soon as you're made aware. So what are you waiting for?

 

 

Dr. Patty Khuly

 

 

Art of the day: "A white dog." by Honou.

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COMMENTS (22)
1
Missing Treatment
by Dog Mama on 04/13/2010 05:08am

We had great experience with underwater treadmill. We are supplementing glucosamine and omega-3, we are big believers in those. Exercise, definitely. It really is scary how many dogs are obese and how many owners oblivious to it being a problem.

We are not fans of drugs, particularly NSAIDs. I am so glad to hear that drugs are not a treatment of choice for you!

Acupuncture, massage and chiropractics - thumbs up in our house.

Low level cold laser therapy is also a great thing, plus going to experiment with pulsed electromagnetic therapy.

There is one other AWESOME TREATMENT I'm not seeing here! Stem cell regenerative therapy! Really amazing and can work miracles! Seriously - please look into it.
http://dawgbusiness.blogspot.com/2009/12/stem-cells-for-dogs-oh-yeah-baby.html

2
Stem cell therapy
by Dr. Patty Khuly on 04/13/2010 08:26am

The thing about the Vet-Stem thing is...we don't have enough studies that demonstrate its efficacy. And it's not exactly non-invasive, like so many other non-traditional approaches. Add to that its expense (wow!) and it's a serious tough sell––for both pet owners and veterinarians.

Nonetheless, I've been known to recommend this approach––especially when none other was available. End-stage elbow dysplasia, for example.

Once the science is more definitive (IF this approach pans out), I'll be the first to recommend it over plenty of more invasive, less effective, more side-effect prone approaches.

3
by Andrew on 04/13/2010 08:52am

Thanks for the information on the studies Dr. Khuly. I must also point out the value of acupuncture, my dog was having some serious panosteitis pain and lameness and after just one acupuncture session there was definitely an improvement, maybe 70% and by the second he appeared fine although we continued for about a month.

As an owner of a two year old dog with some mild hip dysplasia but no symptoms at this point this issue hits home with me and I'm glad you commented on vet stem as well. Hopefully it is something that is studied more closely over the next few years, because it does seem very promising. Kind of amazes me in a way how veterinary medicine seems ahead of human medicine in some ways.

4
Osteoarthritis
by MagAngel on 04/13/2010 11:23am

Dear, Dear Dr. Khuly:

Thank you for your site. There's a place in heaven for you.
Please, if possible, email with an answer.

I have a 3 year old Golden and a 2 year old Shih-tzu, both adopted as have been all my little ones all my life. The Golden had a broken front leg before I adopted her, and I've been told by my vet that the Shih-tzu (found in the street; no owner found) has rear knee problems (I can't recall the name right now). I'd like to know, with reference to your recent arthritis articles, if giving them Glucosamine AND Omega-3 at this point in their lives would benefit them in the long run with regard to possible future arthritis.

If you cannot answer me by email, please try to address this in a future article.

Thank you.

Margherite

5
Glucosamine and FAs
by Dr. Patty Khuly on 04/13/2010 12:27pm

Margherite and others: Sorry if I wasn't clear. I tend to recommend fatty acids and glucosamine for all at higher risk for osteoarthritis.

This includes large breed dogs, extra-big cats, overweight pets and any with a joint conformation issue that predisposes them: Previous injury, conformational instabilities (as for shih-tzus with medial patellar luxations), chondrodysplasia (a cartilage deformity inherent to dwarfed animals like dachshunds, shih-tzus, bulldogs, etc.) and hip dysplasia, among others.

6
Glucosamine and FAs
by Dr. Patty Khuly on 04/13/2010 12:30pm

And yes, lest I fail to be extra clear: early and often means you start now and do it daily. Ask your veterinarian for the best brands (the quality of the manufacturer matters) and the right dose (though I find the the doses designated by the manufacturers of the animal-specific brands to be perfectly accurate).

7
Non-Slip Floors
by dogaware on 04/13/2010 02:59pm

Any suggestions for non-slip floors? I've looked at tile, wood, laminate and more. While some are definitely more slick than others, I don't feel confident that any are truly non-slip. I'm almost resigned to going with carpet again, despite its obvious disadvantages (so much harder to clean) because I don't want to risk my dog slipping on my floors.

8
Floors
by Dr. Patty Khuly on 04/13/2010 03:43pm

The key on the floor thing is that non-slip usually means hard-to-clean. For pet owners, the two things are often mutually exclusive. Same goes for veterinary hospitals where the floors are slick so we can actually manage to keep them clean and disinfected. That's why I recommend a couple of approaches:

1-Train your dogs to wear booties early. Cats will almost never wear them so that's out, but dogs *can* get used to them. The Pawz booties we discussed yesterday are especially great because they're lightweight. Though I sometimes have to cut them to make them more comfortable, their snug fit and no-slip elasticity is unparalleled. No other bootie seems anywhere near as comfortable or works quite as well.

2-Buy runners. Though you'll have to spend a mint to get gorgeous ones, you can get temporary/disposable ones at a Home Depot or Loews kind of place by using the stuff you cut from super-big rolls. Lay them down from point to point in your house and simply pick them up when you're having company.

9
by Galadriel on 04/13/2010 04:34pm

I was very pessimistic when my Tessa was diagnosed with severe degenerative arthritis of the spine--because the vet told me to be. They said there was nothing I *could* do but give her Rimadyl for the pain.

I know better now--and boy do I love Adequan--but I spent about a year doing nothing but giving her Rimadyl. In retrospect, I wish I had looked into it more quickly. But I'm also exasperated with a vet who told me there was nothing, absolutely nothing, that I could do besides use an NSAID. (We don't go there anymore, of course.)

10
by SkeptVet on 04/13/2010 04:34pm

I understand that anecdotal evidence is far more compelling, so it's always unrewardng to point out its limitations, but the sceintific evidence does not support the use of many of the therapies you recommend for canine osteoarthritis.

1. Glucosamine/chondroitin-As you mention, the extensive high-quality research accumulating for humans indicates these are almost certainly a placebo when given orally. The veterinary literature is sparse, but the better quality studies with objective endpoints do not support much benefit, and the little benefit seen is dramatically less than that provided by NSAIDS and seems much more likely to be a function of bias and observation error rather than a true biological effect. This link is for a brief review of the subject: http://www.skeptvet.com/index.php?p=1_9_Glucosamine-Chondroitin

2. Fish Oil-Again, there is lackluster evidence in humans for a benefit in arthritis, but it is possible it may have a benefit. The two papers that recently came out in JAVMA, unfortunately, present data which by and large does not support the conclusions in the abstract and discussions. I have reviewed these in detail here: http://skeptvet.com/Blog/2010/01/two-studies-of-fish-oil-for-canine-arthritis/

3. Acupuncture and Chiropractic-There is absolutely no reasonable scientific justification for claiming these are beneficial for canine arthritis. The analgesic effects of acupuncture in humans are compatible with placebo in most cases(with the possible exception of electroacupuncture, which is really a form of TENS). The literature on chiropractic suppports a moderate benefit for idiopathic lower back pain in humans and nothing else. The literature in dogs with arthritis is nearly non-existent and there are no reasonably sized or good quality studies to support either of these approaches. Again, a couple of quick reviews-
http://www.skeptvet.com/index.php?p=1_6_Veterinary-Acupuncture
http://www.skeptvet.com/index.php?p=1_8_Veterinary-Chiropractic

I understand it is hard to perceive a benefit from something based on eprsonal experience or client reports and not accept that these perceptions are unreliable. But medicine contains a history of many therapeutic interventions which people believed in based on this kind of evidence for centuries and which with real scientific study turned out to be useless or even harmful. It is especially hard to avoid recommending unsupported interventions when there is nothing real to offer, though I still believe it is wrong to do so. But in the case of arthritis, there are many proven treatments available, so adding things that don't work or that we have no good reason, beyond anecdote, to think will work isn't really helping our patients and clients. Weight loss, regular moderate exercise, NSAIDs, and physical therapy are all appropriate treatmentsshown to be safe and effective in many cases. I tink we best serve our patients when we stick with therapies that are well-supported by real evidence.

11
Floor Runners
by Harappa on 04/13/2010 10:36pm

With regard to floor runners... yoga mats are an inexpensive option and provide great traction. They can be purchased for around $10 at TJMaxx or similar type stores.

12
Our vet's experience
by k9diabetes on 04/13/2010 11:18pm

In discussing glucosamine with our vet, who I respect mightily, he said he was extremely skeptical about glucosamine at first but that he has seen it have excellent effect in some dogs. His take was that it helps some and doesn't help others but is definitely worth trying.

I have a cat with fairly severe hip dysplasia as well as arthritis in the knee joints. We have been doing a course of Adequan injections and are following with oral glucosamine. The Adequan injections definitely put more perk in his step.

We also used fish oil with our senior dog, not for arthritis so much but for other inflammatory and allergy related symptoms and felt that it was very helpful for him. Fish oil controlled his allergies better than an anti-histamine.

There can be problems with relying solely on scientific studies. Especially for conditions where the results would be very hard to measure objectively.

13
by sportsk9 on 04/13/2010 11:22pm

Cool subject and write up!!! There are a lot of great options out there now a days. I never thought that I would be able to compete in agility with my Lab with elbow dysplasia. We've found the right mix of Rx drugs, natural supplements, and a rocking brace from Thera-paws. She's going strong!

Bummer more people out there don't see the need to help their pups out until it's too late.

14
Rebuttal...
by Dr. Patty Khuly on 04/14/2010 11:53am

SkeptVet: I've heard all the arguments back and forth. The upshot is this: there is current evidence to support the use of glucosamine, fatty acids and acupuncture in animals. But I agree we still need much more. To call it "sparse" is to compare it to the bounty of human literature. This is true for any*subject in veterinary medicine...not just for supplements.

As for most subjects that prove contentious, the literature will typically be interpreted by believers and non-believers to support their claims. Me? I'd like to think I take a pragmatic approach. I'm all about giving supplements, acupuncture and massage a try as long as do-no-harm principles aren't breached.

15
Adequan!
by Dr. Patty Khuly on 04/14/2010 11:56am

Galadriel: Thanks for mentioning Adequan. After writing a whole post on why I love this super-safe product (and using it often in practice), I can't believe I forgot to mention it here. I'll go back and fix that!

For more on Adequan:
http://www.petmd.com/blogs/fullyvetted/2010/march/adequan_cats_dogs

16
Re.Rebuttal
by SkeptVet on 04/14/2010 12:37pm

The "it might or might not help but at least it's harmless" argument is a common one when dicussing the merits of unproven therapies. In some cases this is true, but in others it is not. It is not the case that these matters are simply differences of opinion in which all positions are equally valid, however.

What I object to is not using a therapy that is harmless but unproven, which I often do myself so long as the client is given truthful information about the limits of the evidence. What I object to is the confident assertion of benefit and safety where it is either unproven or demonstrably not true. We owe our clients recommendations based on the best evidence that exists, not merely our opinions. If the evidence is inconclusive, then it is certainly appropriate to follow our gut as long as we are clear with our clients that this is what we are doing. However, you seem to go clearly beyond this sort of praggmatic approach and actively endorse as beneficial treatments which have not by any stretch been demonstrated to be so.

It is also very important that we not avoid proven therapies because we think unproven ones can be relied on to do the job. I have a lot of clients who let their pets suffer unecessarily with arthritis because they are afraid of NSAIDs and believe glucosamine is sufficient therapy, which it pretty clearly isn't. This is a form of harm done by the unjustified faith in glucosamine even though the product itself is safe.

For glucosamine the evidence is moderately strong against there being benefit, but I agree it is harmless.

For fish oil, there is demonstrated benefit for other conditions (skin allergies) and minimal evidence for use in arthritis, and I agree it is harmless.

For acupuncture the evidence is strong against there being a benefit, and it is usually harmless, though there are literature reports of infections, nerve damage, even pneumothorax associated with it.

For chiropractic the evidence is strong against it having a benefit and there is strong evidence of harm for cervical manipulation and manipulation in the face of trauma andIVDD, with little evidence of harm in other cases.

17
Disagree
by Dr. Patty Khuly on 04/14/2010 03:27pm

I'll respectfully disagree that the evidence isn't sufficient to support the use of glucosamine and fatty acids. You may have disliked the study design in the papers I reference and object to the strength of the evidence they supply due to their singularity (they have not been repeated yet), but to use the human literature to support negative findings in animals isn't exactly evidence-based, either.

I'd contend there's more than black and white at work and that pragmatism is still in the eye of the beholder.

18
Alternatives
by Andrew on 04/14/2010 07:13pm

Let me preface this with the clear fact that I am no veterinarian. I am simply a law student with an interest in animal welfare and a dog that I love.

That aside, speaking strictly from my own person observation I have seen some of these alternatives work in both human and animals. First, regarding chiropractic I have seen results from this on myself with vast improvement of neck pain I suffer as a result of my daily activities, also I have seen it work with an elbow that occasionally get soreness in from years of playing baseball with poor throwing mechanics.

Next, Acupuncture, I have seen the results of this as well with my own do when he bounced back from panosteitis with just one session. This case of “pano”, was particularly bad considering the first vet he saw for it originally misdiagnosed it an as a ruptured Curciate Ligament.

Anyway, like I said I am no veterinary or animal professional but through my layperson observation of these alternatives I am convinced that they do have some value.

19
Disagree
by SkeptVet on 04/14/2010 09:40pm

Well there's always room for disagreement, and I won't claim the evidence is incontrovertible either way. However, I dispute the idea that referral to hman literature is not "evidence-based." Evidence is properly organized in a hierarchy of strength and reliability. Of course, multicenter, large-scale, properly designed and conducted RCTs in the target species are the gold standard, but we both understand those are rare in veterinary medicine, so it isn't reasonable to accpet them as the only appropriate evidence. Everything that falls below this standard in the hierarchy, from basic biologic plausibility to in vitro and animal model studies to case reports to observational studies, is still evidence, and the trick of evidence-based medicine is to use the balance of the best available evidence.

Personal experience and anecdote is at the bottom in terms of reliability, and yet it is unfortunately often at the top in terms of how people actually make up their mind. It seems from your article and the comments here that such anecdotal experiences play a big role in the popularity of glucosamine and EFA supplements for arthritis, so I think the question is hat evidence of better quality do we have to use? I think well-designed and conducted RCTs in tens of thousands of humans are probably better evidence than our personal clinical experiences with these products, though I agree they are not definitive and may not give us the right answer.

What evidence are you using besides clinical experience to support your recommendation of glucosamine? I recently reviewed the literature in this area for a publication in press, so I am at least somewhat familiar with it, and I'm not sure what you feel is supportive of this recommendation.

As for the two JAVMA papers on fish oil, while the fact they haven't been replicated is a concern, it isn't the basis for my lack of confidence in their conclusions. I won't go into the details since you can read my critique if you like, but for one study out of 39 possible measurement points on 3 were significantly different between treatment and control groups, and all of these were owner survey impressions. In the second study, owner iimpressions did not show a difference, and clinician impressions did show a change from baseline but not a difference between groups. And the only objective measure, force plate analysis, showed no change in any of the 6 measured variables, though there was a significant difference in the mean percentage change in one of the 6.

Look at it this way. You could rewrite the papers with exactly the same data and the opposite conclusions, that the fish oil didn't help, and it would not seem strange at all. You certainly could not do this for any study investigating NSAIDs, whcih clearly show benefit in repeated studies. So unless we lower the standard by which we consider something to be helpful, the evidence is not adequate to assert fish oils help. It may be someday, and they are probably harmless, but we connot honestly claim we have evidence that they are beneficial.

20
Skept Vet is right
by SBM on 04/20/2010 02:59pm

Thumbs down, Dr. Khuly. I love this blog because most of what you write is funny and insightful, and well written also. It's a pleasure to read. But you make me crazy when you start going off on these 'alternative' tracks. It's particularly frustrating when you say "oh well, it can't hurt." Advising clients to pay money for things that have been proven to have no benefit definitely hurts the client's wallet, and it hurts all veterinarians' credibility.

@Andrew: That's what panosteitis does! It goes away on it's own! One day the patient wakes up and the pain is gone. The temporal association between the acupuncture treatment and the cessation of pain does not prove that acupuncture was the cure. As a law student, you should know that there is a difference between circumstantial evidence and conclusive proof. "Correlation does not prove causation."

SkeptVet has said everything else more eloquently than I can, so I just want to say "Skept Vet is right!"

SBM

21
agreed
by marc on 04/22/2010 10:44am

I happen to agree with both Skeptivet and Dr. Khuly. Meaning, I agree there is little high-level evidence that these modalities work. Furthermore, I agree that in general there is too much alternative medicine that is prescribed that has no proven of efficacy, and ends up replacing therapies that do work. However, I also agree with Dr. Khuly in that there seems to be enough evidence to recommend using these therapies given: 1) they do not take the place of other, proven therapies and 2) they are safe.

My reasoning is that I wonder: how much evidence do we need? I liken it to the debate over cigarette smoke and its health effects. For decades, the tobacco industry was able to (correctly) say that there was no compelling evidence that cigarette smoke caused disease. In such a chaotic system as heart disease and cancer, it was indeed very difficult to prove to a high level of evidence that there was a link. Fast forward a few decades, and now we take it for granted. Same for CO2 and global warming, and dozens of other complicated, chaotic issues.

I believe arthritis pain is also a very chaotic system; there is no one source of pain, but rather a very complicated interaction of events that lead to pain and stiffness. Is the low-quality evidence we are seeing for glucosamine/chondroitin, EFAs, etc the beginning of the wave of evidence that someday will be just as overwhelming as the body of evidence we now have proving smoking is bad? Who can tell? But my point is this: where does the medical community draw the line and say "now we have enough evidence, go ahead and prescribe it"? I don't have the answer, but so long as I satisfy my two above requirements, I feel justified in recommending their use.

22
by Dr. Patty Khuly on 04/23/2010 04:31pm

Dogaware: Sorry I missed your comment earlier. I really like the cleanability of Flor tiles. These come in plenty of fancy rug patterns but they make one style called "House Pet" that can be hosed off. The other approach is to use rubber runners or Chilewich brand runners (very pricey).

If you live anywhere near Miami, I'm giving away about 18 Flor tiles in a rusty red color. You could then just line them up and pick them up to hose them off every week or so. It's a thought.

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About fully vetted

Patty Khuly, VMD, MBA

Photo of Dr Khuly

Dr. Khuly is a former petMD blogger and small animal veterinarian in Miami, Florida, where she practices medicine at Sunset Animal Clinic and serves on the board of the South Florida Veterinary Medical Association. She is a graduate of Wellesley College, the University of Pennsylvania School of Veterinary Medicine, and The Wharton School of Business.

As a significant sideline, she writes...a lot. She authors pet health columns for USA Today, The Miami Herald and Vetstreet. She also writes a popular monthly column for Veterinary Practice News and serves as regular contributor to Veterinary Economics, The Bark, and the Veterinary News Network.

Dr. Khuly lives in South Miami with her brood of hens, goats, dogs, cats...and humans.

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