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By Dana McMahan

You've probably seen it a thousand times: a dog at the end of its leash, dragging its hapless owner down the street. It's not just annoying to dog and owner, but dangerous, according to a new study.

The study in "JAMA Surgery" is raising awareness of the risks of dog-walking. Researchers on this first study of its kind found an uptick in the number of fractures associated with walking leashed dogs for older Americans, the study's co-author, Kevin Pirruccio, MD candidate at Perelman School of Medicine at the University of Pennsylvania, told NBC News BETTER. Most of the injuries are to the hip and upper extremities and are happening most often among women. Thirty percent require hospitalization.

How much of an increase are we talking? Between 2004 and 2017 the number of patients 65 years or older presenting to U.S. emergency departments with dog-walking related fractures grew from 1,671 to 4,396, the study said.

Does the potential for injury mean you should hang up your leash? Not at all, said Pirruccio. “Our study is not meant to discourage seniors from walking their dogs. … I would absolutely encourage a [senior] looking to bring a canine companion into their home to do so, recognizing the joys that dogs bring.”

He had some precautions in light of these results, however, starting with teaching dogs better leash manners. “I would stress the importance of obedience training and making sure that the dog is taught not to lunge while on a leash,” Pirruccio said. “I would also encourage a [senior] to add resistance training and balance exercises to their daily life, in order to improve their overall durability and minimize the chances or consequences of a fall. Lastly, if they had not yet decided on a particular dog breed, I may suggest a smaller or more easily trainable dog as a pet.”

Teaching your dog new tricks

Where do you even start with teaching a dog not to pull? I used to be the person being pulled down the street by a dog and didn't think there was any other option. But when we brought home Cassius Thunderpaws, a nine-pound half-Great Pyrenees puppy who'd grow up to be 10 times that size, I knew I needed to learn how to handle him, stat. We enlisted the help of Louisville dog trainer Tyler Ohlmann, who blew our minds with teachings like: the leash should be loose when you walk.

Ohlmann (who has three dogs at home in the 130-150+ pound range) shared his best advice for anyone struggling with a dog who pulls. For starters, he said, recognize that the pup is probably just doing what they've been taught.

It takes two to pull

“Most people walk a dog wrong,” Ohlmann said. “People think you need to hold the dog in place [so they] pull on the leash to hold the dog. That triggers opposition reflex, and the dog pushes forward. … [and] they walk. As long as the dog is pushing they get to do stuff, they get to explore, and dogs do what works … so [pulling] becomes the price they pay to go somewhere. You're literally teaching a dog to pull, which is probably a number one reason a dog is walking poorly to begin with.”

Making matters worse, Ohlmann said, are retractable leashes. From a training standpoint the flexi leads are “awful because they teach a dog to pull,” he said, since as the dog pulls, they're rewarded with more leash. Injuries (to person and dog) occur when the dog runs to the end and breaks the flywheel in the handle — most people are using a lead not appropriate for their dogs' size, he said — or pulls the lead out of the person's hand and then runs away. Even bystanders can be hurt if they get between a person and their lunging dog thirty feet of line away.

One of Ohlmann's clients learned the hard way about retractable leashes. Prior to training, Renee Beckum Abell had her 46-pound pit mix Pearl outside on a retractable leash when the dog spotted a squirrel. “All of a sudden I hear the leash spin out and before I can catch her she hits the end at a dead run,” Abell said. “She is solid muscle … it snapped my head back like I had whiplash.” Abell's first rib was dislocated and it took months of physical therapy to recover, she said. Afterwards? She enrolled Pearl in training. The former squirrel chaser “is now a completely different dog,” Abell said. “She's not perfect but as far as trying to remove body parts, it is night and day.”

Little dogs can also pack a lot of muscle

The JAMA study didn't break down whether it was large or small dogs implicated in the owner's injuries. While common sense might say big dogs are the culprits, people might be surprised, Ohlmann said, at what size dog can exert enough force to cause injury. “There are 30-40 pound dogs that could absolutely knock me down,” he said.

My own pup was stronger than I was from the time he was quite young. His power piqued my curiosity, so I researched canine strength for AKC Family Dog magazine, where I spoke with Dr. Joe Wakshlag, Diplomate, for the American College of Veterinary Sports Medicine and Rehabilitation. He confirmed that dogs are definitely stronger than the average person.

They've got all this power in their hips, legs, shoulder and back, he explained, and can generate incredible force because their center of gravity is lower and forward — and they've got four legs. They're at their strongest pulling in a straight line, so you attach a collar and leash and suddenly from the dog's perspective, “I've got this thing pulling me from up top” so they just dig in with their hind limbs.

How to walk your dog properly (so you don't get hurt)

To avoid all that pulling, you want them walking nicely by your side on a loose leash. There are all kinds of ways you can achieve that, Ohlmann said, whether it's giving them treats or talking to them only when they're not pulling, or changing directions when the dog stops watching you (the technique we used to eventually train Cash for off leash control). As an alternative to training the dog not to pull, another option is to use equipment to manage the bad behavior, he said. Acknowledging that not everyone has the “means, ability, time, and desire to take the effort to train their dog,” that doesn't mean “they should have a dog that drags them down the street or pulls their shoulder out of socket,” he said.

Whether it's a harness that turns their head or squeezes their middle or a collar that applies pressure when they pull, the aim of equipment “is to make the act of pulling unpleasant,” Ohlmann explained. “Dogs are rational creatures, so if pulling forward results in discomfort they'll do it less.”

Equipment is effective for about 80 to 90 percent of distractions, he said, but if it's a really serious problem stimuli (like a squirrel the pooch can't resist) “they may not care,” he said. They'll “launch themselves into a prong collar or head harness,” … and down goes the owner.

Before you get a dog, have a game plan in place

With all this in mind, Ohlmann said, it's key to think about whether you're willing to take on this responsibility before getting a dog. “Recognize these risks and have a clear game plan before you bring it home,” he said. Before you even decide on a breed or dog, “talk to the breeder or adoption agency,” about what's right for you, “and talk to trainers.”

Meanwhile if you already have a dog that's problematic to walk, “you took on that challenge,” when you brought the dog home, he said. “I think it's your moral obligation to try as many avenues as you can to make it work because it's not the dog's fault if it's being trained to do the wrong thing.”

Too often dogs end up in shelters because their owners can't handle them. Every dog is trainable though, Ohlmann said. Even though people think “they have the worst dog of all time ever, the truth is your dog probably is not that bad and can be helped,” he said. If you don't have time to do the training, he said, “you at least need a trainer to show you how to effectively manage” the dog's behavior.

After all, walking is good for both us and our best friends.

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