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ASSESSING PAIN IN CATS AND DOGS (HOW PAIN AFFECTS BEHAVIOR)
Mary Ellen Goldberg LVT, SRA, CCRVN, CVPP, NTS-lab animal medicine (research anesthesia) and VTS-physical rehabilitation
VetScopo 2019

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IVAPM
Your Ultimate Resource For Animal Pain Management

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Woolf, CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management, Ann Intern Med. 2004;140:4451-451

Pain is:
-Multidimensional sensory experience
-Unpleasant
-Hurting and soreness – varies
-Intensity (mild, moderate, or severe)
-Quality (sharp, burning, or dull)
-Duration (transient, intermittent, or persistent)
-Referral (superficial or deep, localized or diffuse)

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Composition of Pain
-Cognitive
-Emotional
-Suffering
-Avoidance motor reflexes
-Autonomic output alterations
- “Demands all our attention”
Woolf, 2004

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Categories of Pain

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Types of Pain
-Acute – serves a protective role by enabling healing and tissue repair and usually is considered to end within 3months. Muir WW and Woolf CJ. Mechanisms of pain and their therapeutic implications, JAVMA, 2001, 219(10):1346-1356

-Chronic – induces biochemical and phenotypic changes in the nervous system that escalate and alter sensory inputs, resulting in physiologic, metabolic, and immunologic alterations that threaten homeostasis and contribute to illness and death.Maier SF, Watkings LR. Cytokines for psychologists: implications of bidirectional immune- to- brain communication for understanding behavior, mood, and cognition. Psychol Rev 1988;105: 83-107

-Neuropathic – is a maladaptive phenomenon caused by pathologic neuroplasticity and can become a disease of the neurologic system by persisting beyond resolution of an inciting cause. Von Hehn CA, Baron R, Woolf CJ. Deconstructing the neuropathic pain phenotype to reveal neural mechanisms. Neuron, 2012 73:638-52.

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Pain Types
-Acute GI pain
-Chronic OA pain
-Neuropathic post onychectomy pain

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Some detrimental effects associated with inadequate pain management (Orskov, 2010)
Altered Mentation
Reduced Appetite
Reduced Immune Function
Prolonged Recumbency
Altered Physiological Parameters
Unnecessary suffering
e.g. anxiety, dullness, aggression
weight loss and tissue breakdown for energy
e.g. Cortisol: tissue breakdown and delayed wound healing
increased risk of wound infections
ischemia, vascular thrombosis, urinary / fecal retention
e.g. lick granulomas
interference with patient assessment
e.g. animal welfare

Orskov T. Pain Assessment in Cats and Dogs, Irish veterinary journal, 2010, 63(6):362-364

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World Small Animal Veterinary Association (WSAVA) Tenets of Pain Assessment and Recognition (Mathews, Kronen, Lascelles et al, 2014)
-Pain assessment should accompany every patient assessment
-Treat predictable pain – pain associated with surgery is 100 predictable
-Pain assessment is key to determining the degree and duration of pain treatment but should not replace the adage of treating predictable pain
-Perioperative pain extends beyond 24 hours and should be managed accordingly
-Practice preventive (preemptive) pain management – initiate appropriate treatment before a procedure to prevent the onset of pain, and continue this to prevent occurrence of pain for the duration of time commonly recommended for the problem or which the patient requires
-Response to appropriate treatment is the gold standard to measure the presence and degree of pain.

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PAIN ASSESSMENT SHOULD BE A ROUTINE COMPONENT OF EVERY PHYSICAL EXAMINATION
Pain Assessment
-Pain assessment is the “fourth vital sign”
-Pain scoring tools
Acute ? Chronic
Canine ? Feline

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Behavioral Keys
1. Maintenance of normal behaviors
2. Loss of normal behaviors
3. Development of newbehaviors

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Pain vs Dysphoria

Reversal of opioid
0.01 mg/kg naloxone IV
0.1 mg/kg butorphanol IV
dexmedetomidine (0.5-2mcg/kg)
acepromazine (0.01-0.02mg/kg)

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Behavioral changes associated with acute pain incats: (Mathews, Kronen, Lascelles et al, 2014)
. Reduced activity
. Loss of appetite
. Quietness
.Hiding
. Hissing and growling (vocalization)
. Excessive licking of a specific area of the body (usually involving surgical wounds)
. Guarding behavior
. Cessation of grooming
. Tail flicking
. Aggression
. Cats in severe pain are usually depressed, immobile and silent. They will appear tense and distant from their environment

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Appropriate Pain Management

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Behavioral Signs of pain in dogs: (Balakrishnan and Benasutti, 2012)
Category
Attitude/Mentation
Body Movement
Facial Expression
Guarding
Posture
Respiratory Pattern
Vocalization

Scared, submissive appearance; Unwilling to eat or interact with people; Inability to lay down
Constant trembling with / without stimulation and / or handling
Flinching from fingertips lightly brushed over the body
Tense facial muscles with furrowed brows; Lips drawn back; Grimace with unfocused or fearful look in eyes; Dilated pupils; Ears flattened against head
Guarding or biting at a painful area; Tensing abdomen when palpation is attempted; Growling when approached
Back or abdominal pain: hunched up or tense appearance; severe abdominal pain: Prayer position (standing on the hindlimbs, with sternum and forelimbs flat on the floor); May move to back of cage or into corner
Short, Shallow breathing pattern
Crying, whining, whimpering

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Appropriate Pain Management

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Acute Pain Scales for Dogs and Cats that IncorporateBehaviors

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Behaviors of chronic pain in cats (Goldberg, 2017a)
-Decreased grooming
-Reluctance to jump
-Inability or reluctance to climb or descend stairs
-Inability to jump as high before
-Urinating and soiling outside the litter tray
-Increased or decreased sleep
-Avoiding human interaction
-Hiding
-Dislike of being stroked or brushed

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Chronic Pain in Cats

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Categories for assessment of chronic pain in cats(Goldberg, 2017a) (Mathews et al., 2014)
. General mobility (e.g. ease of movement, fluidity of movement)
. Performing activities (e.g. playing, hunting, jumping, using a litter tray)
. Eating, drinking
. Grooming (e.g. scratching)
. Resting, observing, relaxing (how well these activities can be enjoyed bythe cat)
. Social activities involving people and other pets
. Temperament

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Chronic Pain in Cats

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Feline Chronic or Neuropathic Pain Conditions (Goldberg, 2017a)
. Degenerative joint disease/ osteoarthritis
. Feline orofacial pain syndrome (FOPS)(Goldberg, 2017a) (Heath et al., 2010)
. Post-amputation which includesonychectomy (Goldberg, 2017a)(Mathews, 2008)
. Diabetic neuropathy (Goldberg, 2017a)(Mathews, 2008)
.Feline hyperesthesia syndrome (Goldberg,2017a) (Ciribassi, 2009)
. Feline interstitial cystitis (Goldberg,2017a) (Mathews, 2008)
. Gingivostomatitis (Goldberg, 2017a)(Cannon, 2015)
. Inflammatory bowel disease (IBD) (Mathews, 2008)
. Pancreatitis/pancreatic pain (Mathews,2008)
. Spinal Cord Trauma/ Intervertebral discherniation (Mathews, 2008)
. Pelvic Fractures (Mathews, 2008)
. Trauma: accidental or surgical (Mathews,2008)

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Feline Neuropathic Pain
Feline Orofacial Pain Syndrome
Feline Hyperesthesia Syndrome

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Causes of Feline Cancer Pain (Goldberg, 2017a) (Fox, 2014)
1. Is directly produced by the tumor
2.Is due to the various treatment modalities
3. Is related to chronic debility
4. Is due to unrelated, concurrent disease processes
. lymphoma (lymphosarcoma
. alimentary (gastrointestinal)
. cranial mediastinal (chest)
. extranodal
. squamous cell carcinoma
. soft-tissue sarcoma
. feline injection site sarcoma (FISS)

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Cancers in Cats . Feline Lymphomaand FISS

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Behavioral Considerations for Chronic Pain in Dogs
. Increasingly diminished function and mobility that indicate progressive disability
. Diminished exercise tolerance and general activity
. Difficulty standing, walking, taking stairs, jumping or getting up
. Decreased grooming
. Changes in urination or defecation habits

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Chronic Pain in Dogs

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Positive behaviors reduced with chronic pain(Goldberg, 2017b) (Hielm-Bjkman et al, 2009)
. Decreased socialization/play with human family
. Decreased socialization/play with other dogs
. Decreased movement (quality and quantity)
. Decreased interest in hygiene/grooming
. Decreased tail wagging
. Hypo-or anorexic
. Decreased curiosity

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Chronic Pain in Dogs

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Negative behaviors more frequent with chronic pain (Goldberg, 2017b)
-Aggression towards humans and / or other dogs
-More dependent on owner, jealous, “clingy”
-Sleeping more
-Does not come up to greet owner
-Fearful
-Guarding behavior, guards body parts
-Biting painful areas
-Licking painful areas or dorsal aspects or front limbs
-sudden, excessive negative reaction (compulsive behaviour)
-Under – or overactive

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Chronic Pain in Dogs and Cats

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Abnormal posture or movement seen with chronic pain (Goldberg, 2017b)
-Reluctance to move (walk, trot, gallop, jump)
-Inability to turn in one or both directions
-Hind legs tucked under abdomen
-Tail between hind legs
-Ears back
-Restlessness, wandering, circling
-Rigid posture and gait
-Sitting or lying down in the middle or walks
-Head hanging: will not lift or turn head (neck pain)
-Praying position (abdominal pain)
-Decreased weight bearing (limb pain)
-Sitting abnormally (e.g. knee out in stifle pain)
-Trembling or shaking

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Postures with Chronic Pain in Dogs

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Mental and physiological behavior(Goldberg, 2017b)
. Depressed, sad, and / or anxious demeanor
. Visible white sclera around the iris (not always pain, some breeds show this all the time)
. Panting or tachypnea or tachycardia without exercise

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Other (Goldberg, 2017b)
. No change in behaviour
. Decreased vocalization and/or quiet whining or whimpering
. Increased vocalization including screaming or howling with breakthrough pain or manipulation of painful area
. Allodynia
. Hyperesthesia or hyperalgesia

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THE CONTINUUM OF PAIN…
Hypersensitization
Physiologic Pain
Acute Pain
Hyperalgesia
Chronic Pain
Dysthesia
Expanded field
Allodynia
Neuropathic Pain
IASP: “…primary lesion or dysfunction in the nervous system”
Adaptive
Maladaptive

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Hyperesthesia and Allodynia
Hyperesthesia
-Hyperesthesia is a condition in which someone becomes highly sensitized to sensory stimuli.
Allodynia
-Pain when touch should be nonpainful

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Hypersensitization in a nutshell

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Canine Chronic Neuropathic Pain Conditions (Goldberg, 2017b)
. Degenerative joint disease/osteoarthritis
. Intervertebral Disc Disease (Fingeroth & Thomas,2015)
. Post amputation (Mathews, 2008)
. Ocular Conditions (Fox, 2010)
. Otic Conditions (Fox, 2010)
. Trauma: accidental and surgical (Mathews, 2008)

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Neuropathic Pain in Dogs
Chronic otitis externa
Amputation
Osteoarthritis

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Neuropathic Pain from Glaucoma

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Tumors associated with pain (Goldberg,2017b) (Lucroy, 2013)
-Primary bone tumors such as osteosarcoma, fibrosarcoma. Chondrosarcoma or hemangiosarcoma
-Tumors metastatic to bone. Such as prostate carcinoma or mammary carcinoma
-Multiple myeloma
-CNS tumors, particularly spinal tumors.
-Inflammatory mammary carcinoma. Although large mammary tumors may also be painful
-Lower urinary tract rumors and those involving the prostate may be painful
-Oral tumors, especially if invasive bone
-Invasive cutaneous tumors
-Intra-abdominal tumors. Particularly if placing traction on the root of the mesentery. Causing
-Complete or partial obstruction of the intestinal tract or resulting in distension of the capsule of solid organs.

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Canine Osteosarcoma

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Multifactorial clinical measurement instruments for chronic pain for Dogs and Cats that Incorporate Behaviors (Epstein et al, 2015)
. Helsinki Chronic Pain Index (HCPI)
. Canine Brief Pain Inventory (CBPI)
. Cincinnati Orthopedic Disability Index (CODI)
. Health-Related Quality of Life (HRQL)
. Liverpool Osteoarthritis in Dogs (LOAD)
. Feline Musculoskeletal Pain Index (FMPI)

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CBPI and CODI Scales

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HRQL and LOAD Scales

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FMPI Index

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Veterinary Nurses Must Be:
. Experts on assessing any pain
. Primary advocate for our patients
. Educate owners
. Employ stress free handling techniques

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Listen to Me .
THANK YOU

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