11 Apr 2022
Nicola Lakeman
Job Title
Image © Mary Swift / Adobe Stock
Chronic pain is a major problem in the pet population, and is often left undiagnosed and untreated.
Reasons for this include misconceptions about how animals present with pain, owners being unaware of the treatment regimens or care plans that are available for their pet and, unfortunately, financial aspects.
OA is just one type of chronic pain. Various sources state varying amounts, but approximately 25% of dogs are diagnosed with arthritis in their lifetime, with as many as 60% of dogs having radiographic evidence of it.
Slingerland et al (2011) found that 61% of the cats in their study had OA in at least one joint and 48% of the cats had more than one joint affected by OA. Of the cats that were 14 years and older, 82% had OA in at least one joint.
Prevention is always better than cure or management, and some excellent studies exist that really highlight the difference we can make by managing bodyweight throughout life.
Smith et al (2006) showed that by restricting bodyweight, this can reduce the incidence of OA later in life. In their study, by 14 years of age, 83% (20 out of 24) of the control-fed group had developed radiographic evidence of hip OA, compared with 50% (12 out of 24) of the restricted-fed group.
Trying to convey to clients that OA is not an inevitability of getting older, and any changes in gait (limping) means pain is present, are important aspects of the arthritis clinic.
Gait analysis is something we should be undertaking for our canine friends and can be useful in highlighting subtle changes – especially in different gaits (Voss et al, 2007). These early changes can then be investigated and treated sooner.
Neuropathic pain can be exceptionally painful and very difficult to manage. Using the word “treatment” very much implies that we can cure/stop the pain; in human medicine, “management” of the pain is a closer definition.
Causes of neuropathic pain can be difficult to identify, but can be an element of OA. The inflammation and degeneration in the joint can affect the nerves. Neuropathic pain can be a chronic dull pain, but also have acute flare-ups of acute sharp pain. In humans, neuropathic pain is often described as the most painful and the most difficult to manage.
The outward clinical signs of pain can be very subtle, and can sometimes present more as signs of anxiety and depression in pets (the same as in humans). Really good clinical history taking is a very important part of the identification of chronic pain.
A strong case exists for the use of narrative medicine when history taking in these circumstances.
Narrative medicine considers all aspects, not just the medicines and the diagnostic tests that are required. The owner and pet’s narrative needs to be understood to work together towards a treatment plan. Each owner and pet will have a unique narrative that needs to be understood.
As veterinary nurses, we are excellent at acting as advocates for our patients and their owners. Many elements are needed in being a superb veterinary professional – practising evidence-based medicine and gold standard medicine being a couple of them. These elements can, in some cases, be very difficult to achieve, and this is not a failure of the veterinary professional or the pet owner.
The treatment plan (gold standard or not) just doesn’t comply with narrative of the pet or its owner. Balance is vital to achieve the best clinical outcomes for the patient.
Gold-standard treatment can mean different things to different cases; it will depend on their narrative. Understanding of the narrative will help with compliance to the treatment plan. This means that we, as veterinary professionals, are providing treatment plans that are achievable.
This all goes back to good communication skills. It doesn’t matter what form of communication is being used (in person or telemedicine) – if we are not considering the owner/pet narrative, a potential exists that we won’t achieve our clinical goals.
Treatment for chronic pain should be multimodal and pain scoring should be used to assess benefit of the medications. What works well for one might not work well for another, so monitoring efficiency should be instigated. Most veterinary surgeons will instigate one or all of these categories of management for chronic pain:
Other treatments or management regimes can include nutrition, nutraceuticals, hydrotherapy, acupuncture, physiotherapy massage and many other complementary therapies. Remember to monitor efficacy of each modality that is used.
Research has shown that owners want to see RVNs as an important and integral part of the holistic care of their animal. Chronic pain is a perfect example of this.
Chronic pain needs to be controlled with a wide range of multimodal analgesia, which will be prescribed by the veterinary surgeon. However, that is only one aspect of the care of the pet. We need to be talking to owners about environmental aspects (steps, stairs, ramps, mobility); diet; nutritional supplements; being at the correct body condition score; and aids to help with mobility. The list is endless, but owners need guidance on this; they want to see someone to help them with this.
In human medicine, if you had mobility issues you would be seeing a nutritionist; a physiotherapist; someone from occupational health and therapy – lots of different departments to help with all the different aspects of health care. In veterinary medicine, this does often fall under the remit of the RVN.
As a profession, we are getting much better at assessing this element and encouraging owners to look at the quality of life (QOL) of their pet.
This is an important element of chronic pain; the clinical signs can be subtle, but really can impact on QOL. Different assessment tools are available for this; the two most used being HHHHHMM (hurt, hunger, hydration, hygiene, happiness, mobility and more good days than bad; Villalobos, 2011), and the Cat Health and Wellbeing (CHEW; Freeman et al, 2016) assessments.
Excellent review pieces are available looking at a wide range of these scales (Flavell, 2019) and how they can be implemented into your clinics. Owners can use a wide range of these scales at home, so this is perfect for remote consultations or face-to-face consultations.
