Cat Healthy Protocols

15- Pain Assessment and Management

Due to their evolution as a solitary, self-dependent species, cats are masters at hiding illness and geniuses at concealing pain. Signs of pain in cats are often extremely subtle, especially in comparison to dogs. As a result, clients are often incorrect in their expectations of what they will observe if their cat is in pain. While we can safely predict that many medical procedures and all surgeries performed on cats cause pain, we are much less effective at predicting the pain that cats might be experiencing from arthritis, dental disease, urogenital disease, skin disease, and a host of other sources of pain. The clinician caring for cats must be able to identify historical evidence of pain through careful questioning, as well as to identify pain during outpatient visits through careful observation. It is important to note that many cats being labeled as ‘fractious’ or ‘bad-actors’ are often acting
in a defensive mode towards clinic staff because they are in fact in pain. Looking at these patients from the perspective of pain management, we can be highly successful in reducing uncooperative behaviour in our feline patients.

Identifying Pain: Outpatient Assessment

Pain assessment should be part of every consultation and physical examination, regardless of the reason for the visit. Cats in all age groups should be assessed for evidence of pain.

Obtaining a clinical history with an aim to identifying pain in our feline patients can be challenging. The clinical signs of chronic pain may be even harder to discern, as the patient has learned to cope with the pain, often developing alternative strategies for pursuit of daily activities. Most clients expect specific and obvious signs of pain. They may expect painful cats to vocalize, limp, or otherwise show pronounced signs of their pain. They may attribute changes in behaviour related to pain as merely being due to aging. Some of the subtle behaviour changes associated with pain reflect the ten subtle signs of sickness in cats (see The Healthcare Needs of Cats).

When discussing pain with clients, even the suggestion that their cat might be in pain can be upsetting because it might make the client feel that they have been missing the signs in their cat for short or even long periods of time. It is helpful to start with a series of questions that are included as part of the history regardless of the reason for the visit.

Questions That Assess Mobility Can Be a Useful Tool

Common comments used in rationalizing changes related to pain:

Out-patient Observation and Handling

Observation of the patient during the initial consultation can be very beneficial to the clinician in identifying signs of pain. While taking the history, allowing the patient to roam freely about the consultation room will give the clinician time to observe gait, posture, body condition, and overall mental status of the patient. Changes in any of these may indicate pain. Careful handling of patients during their visit is critical. An assumption that every patient is in pain will reduce the risk of hurting a patient or generating a defensive, potentially aggressive response.

Carriers that open from the top allow gentle lifting of the cat out in cases where the cat will not voluntarily exit the carrier. Cats should not be dumped or pulled from their carriers. An attention to feline friendly handling techniques is essential. If a client has specifically noted a part of their cat’s body that is painful, particular care should be taken when assessing that body part. During the physical examination, the patient should be assessed for pain. The patient may be reluctant to be handled, have painful dental disease, dehydration, cachexia, or obvious wounds indicating pain. More subtle signs of pain during palpation may include wincing, grimacing, pinning ears backward, shifting of body weight, flicking of the tail, and attempts to escape. If a patient has a confirmed history of pain, obvious physical change indicating pain, or if the clinician has an index of suspicion that the patient may be in pain, pain medication should be administered prior to proceeding with the physical examination.

Identifying Pain: In-patient Assessment

Hospitalized patients should be monitored, assessed, and treated for pain regularly throughout their hospital stay. Initial pain assessments should be based on the observations made of the patient during their out-patient visit. Development of a clinical pain index, whether formal or informal, will standardize pain scoring within the practice. Assignment of specific individuals to conduct these assessments should be based on appropriate training, experience, and skill level.

Pain Prevention, Treatment, and Management

The most effective analgesic protocols are multi-modal in nature. Combining drugs and therapies that influence different parts of the pain pathway results in improved efficacy and reduced risk of adverse effects.

Various analgesic drugs and protocols are available for cats. For management of acute and peri-operative pain, opioids form the cornerstone of treatment. Combining opioids with other treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs), constant rate infusions and regional anesthesia, improves analgesic efficacy.

The World Small Animal Veterinary Association Global Pain Council has a list of suggested pain management protocols for different situations:
wsava.org/guidelines/global-pain-council-guidelines

Other pain management modalities may be incorporated, including:

While some objective signs of pain can be determined by questioning clients and by repeatedly observing hospitalized cats, the most reliable assessment of the presence of pain is a return to normal behaviour in response to analgesic therapy.

Frequent assessment for pain is critical, not so much to determine if analgesia should be used, but rather whether additional modalities should be incorporated, if dose adjustments are needed, and to determine an appropriate duration of treatment.

Identifying and Treating Pain: Musculoskeletal Disease

A common reason for chronic pain in cats is musculoskeletal disease, degenerative joint disease (DJD) or arthritis. Based on radiographic evaluation in a number of studies, there is strong evidence to indicate that even young adult cats can have DJD. Therefore, DJD must be considered as a potential source of pain, even in young patients. Appropriate feline friendly handling techniques and application of analgesics to reduce pain-related stress should always be foremost in the clinician’s mind. For chronic degenerative musculoskeletal disease, multi-modal analgesia and other modalities should be considered.

Analgesics which might be employed alone or in combination include:

Alternative modalities which may be used as an adjunct for DJD therapy include:

In many cases, a response to therapy may be the most successful means of convincing clients that the cat is suffering from DJD pain. Ongoing evaluation via communication with the client, regular recheck examinations, and assessment of response to therapy will improve quality of life and reduce morbidity in patients suffering from DJD.

For hospitalized cats, signs of fear and anxiety may be similar to signs of pain. For example, body temperature and blood pressure are difficult to use as assessments of pain. Some observations that can assist in the recognition of pain include:

Questions to Ask Owners about Potential Signs of Pain

References available on request

Resources

Validated pain scoring systems for cats have been more difficult to develop than for the dog. One acute pain scale and one chronic pain assessment tool are undergoing development and validation and are recommended for the general practitioner:

Acute post-surgical pain:
Glasgow Feline Composite Measure Pain Scale:
whttp://www.aprvt.com/uploads/5/3/0/5/5305564/cmp_feline_eng.pdf

Chronic musculoskeletal pain:
Feline Musculoskeletal Pain Index (North Carolina State University):
cvm.ncsu.edu/research/%20labs/clinical-sciences/comparative-pain-research/%20clinical-metrology-instruments

2015 AAFP/AAHA Pain Management Guidelines for Dogs & Cats:
Cathealthy.ca/catvetspainmanagement

2010 AAFP/ISFM Long Term Use of NSAIDs in Cats guidelines:
catvets.com/guidelines/practice-guidelines/nsaids-in-cats