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Pain Physiology and Assessment in Small Animals Emma Archer RVN Dip AVN Surgical VTS Anesthesia Anaesthesia Technician Animal Health Trust Why is pain assessment important? There are many answers to this question… The most obvious answer to this question is because our patients are unable to talk, so it is up to us to read and interpret their body language. This is not always an easy task, and requires knowledge of different species, breeds, and ideally of the individual patient themselves. Sometimes they may be trying to tell us they are in pain, and we need to interpret the signs they are giving and their body language. Equally, they may be trying to hide their suffering from us – something some species have evolved over thousands of years to do. Another reason is that it is part of our duty of care, and part of our responsibility as nurses. We owe it to our patients to look after them as a whole, not just a series of body parts and systems – this is where the holistic approach comes into its own and is what makes someone a good nurse. Treating pain makes patients more co-operative and less aggressive and facilitates procedures such as intravenous (IV) catheter placement and radiography. Identifying and treating pain is important because… 1 Pain contributes to stress, which can cause immunosuppression, fluid retention, increased risk of gastroduodenal ulceration and delayed wound healing. These lead to longer hospital stays, unhappy patients and higher costs. A patient in pain is less likely to eat, leading to anorexia, negative energy balance and catabolism, ileus in rabbits and electrolyte imbalances. Reduced mobility due to pain increases the risk of decubital ulcers, thromboembolism, lung atelactasis and pneumonia. Acute pain that is left untreated can develop into chronic pain, which is much more difficult to manage. The pain pathway is flexible or ‘plastic’ and is able to change. Repeated activation of the nociceptive pathway results in sensitisation, causing an increased sensitivity to noxious stimuli (hyperalgesia), and stimuli that were previously non-painful to become painful (allodynia). Therefore it is obviously best avoided in the first place. Pain will cause behaviour changes that are likely to make the patient more difficult to nurse. These behaviours may become associated with the clinic and cause problems on future visits. A patient that experiences a pain-free hospital stay is likely to be much more manageable, and occasionally even relish their visits to see the veterinary staff who gave them so much fuss and TLC! Pain is NEVER beneficial to the patient. Physiology of Pain Understanding the pain pathway, and the changes that occur in response to repeated painful stimuli is important to manage pain effectively in our patients. 2 Nociception refers to the detection of a noxious (unpleasant) or painful stimulus, whereas ‘pain’ implies an actual perception and emotional response to pain, after input to the brain from the spinal cord and periphery. Pain pathway There are several parts to the pain pathway; nociception which is the detection of a painful stimulus. This is made up of 3 parts; transduction, transmission and modulation), and perception. The pain pathway starts in the body tissues, where nociceptors, (which are nerve endings located throughout the skin, muscles, blood vessels, periosteum, viscera and the peritoneum), detect and respond to noxious chemical, mechanical or thermal stimuli. Transduction is the conversion of this noxious stimulus into a nerve impulse by nocieptors. There is a threshold which must be exceeded for the impulse to be activated, preventing it from being activated by nonpainful stimulus. Transmission is the carriage of impulses along the nerve fibres to the central nervous system (CNS). Animals have an intrinsic analgesic system, this inhibits some of the afferent pain signals and the perception of pain (modulation). Perception occurs in the brain and is the conscious and emotional experience of pain produced by nociceptor information and many other body inputs. Sensitisation Because the pain pathway has plasticity (ie, is flexible) rather than being rigid, once the pain pathway has been stimulated it can change the way it responds to further painful stimuli. Peripheral sensitisation After a tissue is damaged by a noxious stimuli, inflammation occurs. The damaged tissue releases many different chemicals and inflammatory mediators, such as prostaglandins and histamine. This ‘inflammatory soup’ stimulates more nociceptors in the area, widening the painful area, but it also lowers the nociceptor threshold. This results in the pain pathway responding more violently to a noxious stimulus, so a previously non-painful stimulus becomes painful as it is now reaches the new lower nociceptor threshold (allodynia), and a painful stimulus provokes a greater and more prolonged pain (hyperalgesia). 3 Central Sensitisation A bombardment of painful impulses causes changes in the dorsal horn neurones in the spinal cord. This causes the neurones to become hyperexcitable and exaggerate further pain impulses. The neurones start to process non-painful inputs as pain signals. Central sensitisation also results in secondary peripheral hyperalgesia where further nociceptors are recruited in undamaged tissue causing a more intense and more prolonged pain response. The result is a larger area that feels pain and a massive intensification of pain, which is very difficult to control. Activation of the N-methyl-Daspartate (NMDA) receptor in the spinal cord, is an important event in central sensitization. The NMDA receptor contributes to the transmission of noxious input from the periphery to the CNS following repeated input of noxious stimuli. It is not activated initially, but after repeated noxious stimulus activation occurs and there is a sudden increase in the amount of noxious input to the spinal cord and on to the brain where it is perceived as pain. Assessing pain in small animals Assessing whether or not an animal is in pain sounds like it should be quite a simple subject but it is actually very complex. Most species of animals have evolved over thousands of years to hide the fact that they are suffering. A rabbit in the wild will soon be picked off by a hungry fox if it is squealing, or obviously lame. Cats are incredibly good at masking pain and it is well known that when they are hurt, e.g. after a road traffic accident (RTA) many cats with horrible injuries manage to take themselves off somewhere to find solitude and lick their wounds. Loyal dogs that wag their tails to greet their owners just hours after major surgery may be doing so because this is how they behave, not because they are pain free. Because of these differences in behaviour compared to how us humans would act, many myths have developed over the years. The three most perpetuated are: 1. “Animals don’t feel pain like we do” 4 This is not true, they have the same neurological pathways as us, and they can also remember previous painful incidents. It is only their behaviours for expressing pain that are different to ours. 2. “Animals can cope so much better with pain than us” Something to remember here is “an animal tolerating pain is not the same as an animal free of pain”. Stoic breeds such as Labradors have the same nerve pathways as the more sensitive breeds such as Greyhounds, but they express their behaviours very differently. Of course there will be some animals that have a greater tolerance of pain than others, just as the same is true for people, but it doesn’t mean they should cope without analgesia. Also, severe acute pain, such as after falling from a balcony, may not be felt at the moment of injury, but will definitely kick in within a matter of hours once the adrenaline wears off. 3. “If they are too comfortable they will move around too much and further hurt themselves” This is just an excuse for poor veterinary care! Pain should never be used to restrain an animal when we have bandages, crates or kennels and sedatives. Pain actually delays healing, and in fact an animal in pain is more likely to chew at the wound and selftraumatise than a comfortable patient. Another argument against this viewpoint is that analgesics are unlikely to completely block the pain sensation anyway. They make the patient more comfortable but if they get up and bound around on their broken leg, even after morphine it’s probably going to hurt. In fact only local anaesthetics are truly analgesic, the rest would maybe be better described as hypoalgesic. Fortunately the number of people believing these myths is decreasing and pain management is now a very popular topic for continuing professional development. The number of available analgesic drugs has also increased. 5 The veterinary nurse is likely to be the first to notice the hospitalised animal in pain, we are at the forefront and it is up to us to understand the topic, notice the signs, inform the veterinary surgeon, and if necessary badger them to prescribe analgesics. Being in the practice environment changes the way animals behave and this may mask signs of pain. Try and get a good history and if possible observe the patient before an elective surgery so that it is easier to spot signs of pain. The most common signs of pain that seem to be shared by most species are decreased appetite and decreased activity. Activity in this sense does not just mean walking/running, but applies to general daily behaviours such as grooming and playing etc. In addition to the above, there are typical behaviours that may be associated with different levels of pain: 1. Escape behaviour +/- vocalisation – Acute pain/injury 2. Protective, guarded, can’t seem to settle in one position – General/post op pain or discomfort. 3. Depression, lethargy, body condition loss – Chronic pain. Of course any change in behaviour can be associated with disease too, but if pain is suspected it is worth remembering these signs. The smaller animal are probably the most under-diagnosed and under-treated for pain. Decreased normal activities and loss of appetite remain the most prominent signs. They may also become immobile and possibly squeak or squeal when handled. With rabbits and guinea pigs anorexia can lead to gut stasis so must be addressed as a priority. Other signs of a rabbit in pain include teeth grinding, hunching, lack of interest in their environment/owner, paying lots of attention to one area (licking, scratching), possibly aggression and closing their eyes. 6 Rats may lie low to the floor, arch their backs or twitch while resting. You may notice an increase in porphyrin secretion around the eyes and nose, which could be due to increased stress and/or decreased grooming. Exotics are a very specialist area and may be best referred! The best way to approach whether or not you think any species may be in pain is to use the ‘Principle of Analogy’. This is basically if you think a procedure or situation would cause a human pain then it will cause an animal pain too. There will be some procedures we just cannot relate to (e.g. tail docking) so you must also take a scientific approach and consider which types of tissue have been traumatised, how bad the wound is, and if there has been any nerve damage. A person’s own experiences of pain will always affect this approach to a certain extent, as well as how much natural empathy they have. Also some things are more obviously painful, e.g. a squealing puppy with a corneal foreign body compared to a stoic old Labrador with arthritic hips. Young animals tend to show pain more readily too. Everyone (hopefully) would give analgesics to a victim of an RTA, stick injury or burn, but what about the less obvious conditions? Otitis externa, glaucoma, corneal ulcers, renal disease, and meningitis– these are all likely to be very painful and need both the disease and the pain treated together, but the pain is often overlooked. Pain will also inhibit sleep, so next time you recover a patient that seems to wake up unexpectedly fast, immediately stands up, is probably panting and maybe looking tired but refusing to lie down, it is probably in pain. Do a pain check and also take into account they may need the toilet, or maybe the bedding is unsuitable. So if pain inhibits sleep it follows that if an animal is sleeping soundly (not just resting or catnapping) don’t wake them up to do a pain check. It has been shown in humans that there is also a strong psychological element to pain, and that negative emotions such as fear, isolation, separation anxiety, rage and frustration travel along similar pathways to the brain as pain does. It is reasonable to assume the same in animals. Anything that adds to a patient’s discomfort such as being hungry or thirsty, feeling sick, unsuitable bedding and excessive environmental noise will 7 all have the same detrimental effect as pain. This is again where empathy and a holistic nursing approach are needed. Good hospital record keeping is essential for both carrying out the pain assessment, and assessing the effect of any analgesia given. This should be done throughout the animals stay, and also at the post-op checks. Many people place far too much significance on vocalisation when in fact this is rarely demonstrated until the pain is already severe. Also they may not realise that dogs may wag their tails, and a cat may purr despite being in pain. Common signs of pain Cats Hunched in sternal Dogs Rabbits Reduce appetite/anorexia Reduced appetite Unusual aggression Hunched position recumbency Unusual aggression Reduced or absent appetite Seeking more contact than Immobility usual Reluctance to move Low head carriage Teeth grinding Failure to use litter tray Over grooming/ self trauma squinting Squinting eyes Inability to settle Rapid respiratory rate Flattened ears Lack of good quality sleep Over grooming/chewing painful area Failure to groom Guarding of painful area Unusual aggression Over grooming or chewing Tense abdomen Vocalisation painful area Withdrawal from contact Lameness Vocalisation vocalisation 8 Chronic Pain Chronic pain remains overlooked and under-treated in many animals. It is also very difficult to manage once established. As a profession we are still getting to grips with chronic pain in animals, and we need to work with the public and educate owners as we learn ourselves. Cats probably come off worse at the moment. One study (Hardie et al 2002) showed that 90% of cats over the age of 12 years have Degenerative Joint Disease (DJD). It is often joked that this is difficult to spot in cats, as one of the main signs is becoming less active – hard to notice in an animal that spends 16-20 hours out of 24 asleep! But you may notice that they pull themselves up on the sofa rather than jump up, and maybe they are not sleeping on the top of the wardrobe like they used to. Perhaps they don’t seek your company as much and are not as ‘chatty’ as they once were. If a client mentions an apparent behaviour problem in that their cat passes faeces near the litter tray but not quite in it, then consider osteoarthritis. The poor cat either cannot quite climb into the litter tray, or just manages to make it into the tray but cannot physically squat so it pops out over the side! Chronic renal and dental pain can also go a long time undetected, observe for cats pawing at the mouth or under-grooming. Conversely over-grooming, such as a dog developing a lick granuloma on their carpus from constantly licking, may be a sign of pain in that area. Chronic pain, which is pain that lasts longer than expected for a particular disease or after an injury has healed (or as a rough guide lasts for over 3 months) can actually shorten an animal’s life, and the longer it goes on the harder it will be to control, so it’s important to start analgesics sooner rather than later. Also consider complementary methods of pain relief such as physiotherapy, acupuncture, hydrotherapy and heat. Pain scoring Pain scoring systems are useful not only to detect the presence of pain, but also to help select the appropriate type, dose, frequency and adequacy of analgesia, and the timings for additional requirements. Pain scores standardize pain assessments and reduces inter-observer variability as well as providing a written record of pain assessment. There 9 are many different pain scoring systems that can be used, or adapted for use in your practice depending on your requirements. It is important to remember when pain scoring that each animal is different and reacts differently to pain. The ideal pain scoring system should not only be able to detect the presence of pain, but also the magnitude (intense, throbbing, etc) and type of pain (neuropathic, visceral etc) as well as how it makes that animal feel (scared, depressed etc). It should be reliable, sensitive, easy to use and interpret, multidimensional (preferably looking at undisturbed behaviour, behaviour on interaction and physiological parameters) and ideally, validated. Pain scoring is very difficult in animals and the perfect pain score system does not yet exist, although there is lots of ongoing work in human and veterinary fields to establish an ideal scoring system. Animal pain scoring systems are adapted from human pain management and are mainly for management of acute pain. Regardless of the type of scoring system used, assessment should occur regularly and be performed by a person experienced in understanding signs of pain. Where possible consecutive scores should be performed by the same person, to minimize observer variation, it is also useful to have observed the dogs normal temperament and behavior prior to the painful stimulus. Simple descriptive scale (SDS) An SDS is the most basic type of pain scoring system, which looks at the patients’ behaviour. There are normally 3-5 grades of pain defined by a short description. It is very simple, and therefore user friendly, but not very good at detecting small changes or differences in pain, and it is very subjective. Example of an SDS 0 No pain 1 Happy, but slight flinch on wound palpation 2 Happy, but tense & flinches on stroking around wound 3 Hunched, looks uncomfortable, but can touch wound 4 Painful, hunched, depressed, vocalising, unable to stroke or touch near wound Visual Analogue Scale (VAS) 10 Consisits of a line 100 mm in length, with ‘no pain at all’ on one end, and the other end corresponding with ‘the worst possible pain’. The observer marks a point on the line that corresponds to the pain intensity for that patient. It is more sensitive than the SDS, although still very subjective. It is used widely in both human pain management and veterinary studies, although it does require an experienced observer to give a reliable score. . No pain at all Worst possible pain Dynamic & Interactive Visual Analogue Scale This a modified VAS, where the observer marks a point on the 100mm line, and the distance from the start of the line in mm is the pain score. It normally incorporates undisturbed behaviour, with behaviour on interaction and wound palpation, so is more sensitive than the basic VAS. This is important as a dog lying asleep in their kennel may not demonstrate signs of pain, but after interaction and manipulation it may become clear that pain is present. Numerical Rating Scale (NRS) This is similar to VAS but the observer chooses a number on a scale Worst possible pain No pain at 0all 1 2 3 4 5 6 7 8 9 10 Glasgow Composite Pain Score Is a multidimensional pain scoring system, taking into account both undisturbed behaviour and behaviour on interaction. It is a more complex version of an NRS. It tries to take into account emotional effects and intensity of pain. It is made up of a number of 11 separate assessments of different aspects of behaviour that can be associated with pain. Each category has 4-6 descriptions, and each score is added up to give an overall score. It is currently the only validated pain score in dogs (none are validated in cats), so it is perhaps the scoring system of choice for acute main management, although it is quite time consuming and knowledge of pain is required. It also does not take into account physiological parameters. It was, and still is, being developed at Glasgow vet school, and can be downloaded from the Glasgow university website, where they recommend giving analgesia if a pain score is > 6/24. www.gla.ac.uk/faculties/vet/smallanimalhospital/ourservices/painmanagementandacupu ncture/ University of Melbourne Pain Scale This is a variable rating scale taking into account both undisturbed behaviour, and behaviour on interaction, as well as physiological parameters, such as pulse rate, respiratory rate, pupil size, salivation and body temperature. Initial work implies that it is effective, and it looks like it will be validated for use in dogs soon, although it is quite time consuming and complex and knowledge of pain assessment is required. Physiological parameters are often not included in pain scores because interpretation can be affected by other factors including, the patient’s cardiovascular status (ie hypovolaemia), fear and sedatives. To summarise, most patients in your practice will have had some sort of injury or surgery resulting in pain. Regular and effective assessment of pain, then treatment, is vital for a successful outcome in critical patients. Reference Hardie EM, Roe SC, Martin FR. Radiographic evidence of degenerative joint disease in geriatric cats: 100 cats (1994-1997). J Am Vet Med Assoc 2002; 220(5): 628-632 Further Reading Pain Management in Small Animals- A Manual for Veterinary Nurses and Technicians. Grant D (2006) Butterworth Heinemann; 12 Pain Management for the Small Animal Practicioner (2000). Tranquilli WJ, Grimm KA, Lamont LA. Part of the Teton New Media ‘Made Easy’ Series. Anaesthesia for Veterinary Nurses. Welsh E. (2003) 1st Edition Oxford: Blackwell Science 13 PAIN EVALUATION CHART – DOGS Patient name Case number Analgesics Date(s) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Please tick the answer that you feel is appropriate to the dog you are assessing. If more than one answer is appropriate, tick all that apply. From outside the kennel, look at the dog’s behaviour and answer the following questions. 1. Look at the dog’s posture, does it seem… Rigid Hunched or Tense Neither of these 2. Does the dog seem to be… Restless Settled 3. If the dog is vocalising, is it… Screaming Groaning Crying or whimpering Not vocalising/none of these 4. Look at the dog’s chart, has it… Not eaten anything Picked at it’s food Eaten well 5. If the dog is paying/trying to pay attention to it’s wound (even if it has a collar on), is it… Chewing Licking, looking or rubbing Ignoring the wound 6. Does the dog seem to be… 14 Aggressive Depressed Disinterested Nervous, anxious or fearful Quiet or indifferent Happy and content Happy and bouncy *READ LAMINATED SHEET – INSTRUCTION A (Ophthalmology patients only) 7. Assess the following conditions and give a score for each… Blepharospasm Blinks (no. in 30 seconds) Lacrimation Conjunctival hyperaemia TIME INITIALS * READ LAMINATED SHEET – INSTRUCTION B 8. Does the dog seem to be… Aggressive Depressed Disinterested Nervous, anxious or fearful Quiet or indifferent Happy and content Happy and bouncy *READ LAMINATED SHEET – INSTRUCTION C 9. During this procedure did the dog seem to be… Stiff Slow/reluctant to rise or sit 15 Lame None of these Assessment not carried out *READ LAMINATED SHEET – INSTRUCTION D 10. When touched did the dog… Snap Growl or guard the area Cry Flinch/become tense Look round sharply None of these 11. In your opinion, would you classify the dog as… Painful Uncomfortable Comfortable Taking everything you’ve assessed into account, and using the guide below, allocate a number between 1-10 for how painful you consider the dog to be, and tick if pain relief was given. It is also worth reading the NCP to see how the dog has been in itself. Any additional comments you would like to make can be written on the patient’s kennel chart. ▲ 1 2 3 4 5 6 7 8 9 10 ▲ No pain Extreme pain Low pain Painful PAIN SCORE PAIN RELIEF GIVEN? TIME INITIALS 16 Very painful ADDITONAL COMMENTS/NOTES 17 PAIN EVALUATION CHART – CATS Patient name Case number Analgesics Date _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Please tick the answer that you feel is appropriate to the dog you are assessing. If more than one answer is appropriate, tick all that apply. From outside the cat’s pod, look at the cat’s behaviour and answer the following questions. 2. Look at the cat’s posture, does it seem… Crouched or rigid Hunched or Tense Neither of these 2. Does the cat seem to be… Restless Settled 3. Is the cat… Sitting in the litter tray Meowing abnormally None of these 12. Look at the cat’s chart, has it… Not eaten anything Picked at it’s food Eaten well 13. If the cat is paying/trying to pay attention to it’s wound (even if it has a collar on), is it… Chewing Licking, looking or rubbing Ignoring the wound 14. Does the cat seem to be… 18 Aggressive/hissing/spitti ng Depressed Disinterested Nervous, anxious or fearful Quiet or indifferent Contented Happy and affectionate *READ LAMINATED SHEET – INSTRUCTION A (Ophthalmology patients only) 7. Assess the following conditions and give a score for each… Blepharospasm Blinks (no. in 30 seconds) Lacrimation Conjunctival hyperaemia TIME INITIALS * READ LAMINATED SHEET – INSTRUCTION B 8. Does the cat seem to be… Aggressive/hissing/spitti ng Depressed Disinterested Nervous, anxious or fearful Quiet or indifferent Contented Happy and affectionate *READ LAMINATED SHEET – INSTRUCTION C 9. During this procedure did the cat seem to be… Stiff Slow/reluctant to rise or sit 19 Lame None of these Assessment not carried out *READ LAMINATED SHEET – INSTRUCTION D 10. When touched did the cat… Become defensive Hiss Growl or guard the wound Flinch/become tense Look round sharply None of these 11. In your opinion, would you classify the cat as… Painful Uncomfortable Comfortable Taking everything you’ve assessed into account, and using the guide below, allocate a number between 1-10 for how painful you consider the cat to be, and tick if pain relief was given. It is also worth reading the NCP to see how the cat has been in itself. Any additional comments you would like to make can be written on the patient’s kennel chart. ▲ No pain Extreme pain 1 2 Low pain 3 4 5 Painful PAIN SCORE PAIN RELIEF GIVEN? TIME INITIALS 20 6 7 8 Very painful 9 10 ADDITONAL COMMENTS/NOTES AHT Pain scoring instructions DOGS INSTRUCTION A. Observing the animal, use the following scoring system to assess the level of discomfort (0 = none, 1 = mild, 2 = moderate, 3 = severe) Blepharospasm Score 0, 1, 2, 3 Blinks Count the number in 30 seconds Lacrimation Score 0, 1, 2, 3 Conjunctival hyperaemia Score 0, 1, 2, 3 INSTRUCTION B. Now approach the kennel door and call the dog’s name. Then, if the patient’s condition allows, open the door and encourage the dog to come to you. From the dog’s reaction to you try and assess their character. INSTRUCTION C. Now look at the dog’s response to stimuli. If a mobility assessment is possible, open the kennel and put a lead on the dog. If the dog is sitting down, encourage it to stand and then come out of the kennel. Walk slowly up and down the area outside the kennel. If the dog was standing up in the kennel and has undergone a procedure that may be painful in the perianal area, ask the dog to sit down. INSTRUCTION D. Assess the dog’s response to touch. If the dog has a wound, apply gentle pressure using two fingers in an area approximately 2 inches around it. If the position of the wound is impossible to touch, then apply the pressure to the closest point to the wound. If there is no wound, apply the same pressure to the stifle and surrounding area. 21 1 No pain 2 3 Low pain 4 5 6 Painful 7 8 Very painful 22 9 10 Extreme pain AHT Pain scoring instructions CATS INSTRUCTION A. Observing the animal, use the following scoring system to assess the level of discomfort (0 = none, 1 = mild, 2 = moderate, 3 = severe) Blepharospasm Score 0, 1, 2, 3 Blinks Count the number in 30 seconds Lacrimation Score 0, 1, 2, 3 Conjunctival hyperaemia Score 0, 1, 2, 3 INSTRUCTION B. Now approach the pod door and call the cat’s name. Then, if the patient’s condition allows, open the door and encourage the cat to come to you. From the cat’s reaction to you try and assess their character. INSTRUCTION C. Now look at the cat’s response to stimuli. If a mobility assessment is possible, open the pod and lift the cat out onto the floor or table. If the cat is lying down, encourage it to stand and then come out of the pod. If the cat was standing up in the kennel and has undergone a procedure that may be painful in the perianal area, observe if the cat is able to sit down. INSTRUCTION D. Assess the cat’s response to touch. If the cat has a wound, apply gentle pressure using two fingers in an area approximately 2 inches around it. If the position of the wound is impossible to touch, then apply the pressure to the closest point to the wound. If there is no wound, apply the same pressure to the stifle and surrounding area. 1 No pain 2 3 Low pain 4 5 6 Painful 7 8 Very painful 23 9 10 Extreme pain 24