Pain in Animals Workshop 2019 Cross‐Species Measurement of Acute Pain

October 2nd and 3rd, 2019 National Institutes of Health Bethesda, Maryland

Overview

Welcome to the second PAW meeting – PAW2019!

This meeting is focused on discussing our ability to measure acute pain across the species, from the perspective of advancing veterinary medicine and from the perspective of using naturally occurring disease in veterinary species as models in translational research.

Millions of people around the world suffer acute pain every year, and use of naturally occurring models of acute pain in animals could contribute to the translational paradigm, and accelerate the discovery of effective, non‐opioid analgesic options. However, to do this successfully, we need to be able to accurately measure acute pain in animals.

Additionally, acute pain suffered by all animals is a welfare concern; inadequate pain control can negatively affect the human animal bond; and pain in farm animals may negatively impact the animal’s ability to maintain normal productivity. The cost, time, and practical application of analgesia in food animals also need to be considered in this commercial environment of food production.

Translational success has come under the spotlight. Numerous reviews have highlighted a lack of translation of basic research into new approved therapeutics for treatment of pain in humans. The use of spontaneous painful disease in animals has been highlighted as one of the changes that could be made to help improve translation of basic science to new therapeutics, acting as a bridge between preclinical and clinical studies, with the goal of reducing the failure rates of human clinical trials, thus accelerating the approval of new therapeutics. Aspects that will undermine the utility of the ‘spontaneous disease pain’ model are the lack of valid outcome measures and the lack of knowledge of opportunities.

This meeting will involve National Institutes of Health pain researchers, Industry, Food and Drug Administration, Academic researchers, human and veterinary practitioners, and those interested in pain measurement and alleviation in animals.

The strengths of all these partners will be brought together to discuss the current state of pain measurement in animals, and to formulate a roadmap of research and development priorities for the future.

Working as a team, we will all gain.

Objectives:

The primary goals of the meeting will be:

1. Discussing the current status (recent advances and current roadblocks) of acute pain measurement in animals 2. Discussing the potential for spontaneous painful conditions in animals to contribute to translational pain research for human therapeutics 3. Defining a consensus list of priorities for future research (roadmap).

From this meeting, at least two white papers will be produced that will outline a consensus list of priorities for future research. One will focus on veterinary medicine, and the other will focus on translational research

Organizing Team:

Duncan Lascelles, BVSc, PhD, MRCVS, DSAS(ST), DECVS, DACVS Professor of Surgery and Pain Management Comparative Pain Research and Education Centre, NC State University, NC

Michele Sharkey, DVM, MS Veterinary Medical Officer Center for Veterinary Medicine, FDA

Michael L. Oshinsky, PhD Program Director, Pain and Migraine NINDS/NIH

Marie Gill, MS Health Program Specialist NINDS, Systems and Cognitive Neuroscience Cluster

Dorothy Brown, DVM, MSCE, DACVS Senior Research Advisor Translational‐Comparative Medical Research Elanco Animal Health

Mike Conzemius, DVM, PhD, DACVS Professor of Surgery College of Veterinary Medicine, University of Minnesota, MN

Sheilah Robertson, BVMS (Hons), PhD Senior Medical Director, Lap of Love Veterinary Hospice, FL, USA

Hans Coetzee, BVSc, Cert CHP, PhD, DACVCP, DACAW, DECAWSEL Professor and Head, Department of Anatomy & Physiology, College of Veterinary Medicine, Kansas State University, KS, USA This meeting would not have been possible without the generous support of our sponsor, The Mayday Fund.

We are very grateful to The Mayday Fund. https://www.maydayfund.org/

Thank you

PAW2019 Glossary

This is a working DRAFT, and input is actively solicited from PAW participants.

A glossary of terms pertinent to the assessment of long‐standing pain in companion animals in relation to veterinary clinical studies, veterinary therapeutic development, and translational clinical studies. Main Contributors: Duncan Lascelles, BVSc, PhD, MRCVS, DSAS(ST), DECVS, DACVS Professor of Surgery and Pain Management Comparative Pain Research and Education Centre, NC State University, NC

Michele Sharkey, DVM, MS Veterinary Medical Officer Center for Veterinary Medicine, FDA

Michael L. Oshinsky, PhD Program Director, Pain and Migraine NINDS/NIH

Marie Gill, MS Health Program Specialist NINDS, Systems and Cognitive Neuroscience Cluster

Dorothy Brown, DVM, MSCE, DACVS Senior Research Advisor Translational‐Comparative Medical Research Elanco Animal Health

Mike Conzemius, DVM, PhD, DACVS Professor of Surgery College of Veterinary Medicine, University of Minnesota, MN

Sheilah Robertson, BVMS (Hons), PhD Senior Medical Director, Lap of Love Veterinary Hospice, FL, USA

Hans Coetzee, BVSc, Cert CHP, PhD, DACVCP, DACAW, DECAWSEL Professor and Head, Department of Anatomy & Physiology, College of Veterinary Medicine, Kansas State University, KS, USA Sources of information used include: https://www.fda.gov/drugs/informationondrugs/ucm079436.htm https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances /UC M230597.pdf https://www.iasp‐pain.org/Taxonomy#backtotop

ABBREVIATIONS

ACTTION Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks

AWA – Animal Welfare Act – regulates the treatment of animals in research, exhibition, and by dealers; enforced by the USDA, APHIS. https://www.nal.usda.gov/awic/animal-welfare-act

CBPI Canine Brief Pain Inventory

CMPS Composite Measure Pain Scale

COI Canine Orthopedic Index

CPM Conditioned Pain Modulation

DJD Degenerative Joint Disease

DNIC Diffuse Noxious Inhibitory Control

FDA Functional Data Analysis (and Food and Drug Administration!)

FMPI Feline Musculoskeletal Pain Index

HCPI Helinski Chronic Pain Index

LOAD Liverpool Osteoarthritis in Dogs

MiCAT Montreal Cat Assessment Tool

MT Mechanical threshold

NTT Nociceptive threshold testing

NWR Nociceptive Withdrawal Reflexes

OA Osteoarthritis

PVF Peak Vertical Force

RAP Radiation Associated Pain

RID Radiation-induced dermatitis

RIM Radiation-induced mucositis

TT Thermal Threshold

VI Vertical Impulse

DEFINITIONS a priori formed or conceived beforehand

ACTIVITY MONITOR A device that measures activity. Note: there is no standard measure of activity or ‘activity count’

ACTIMETRY Recording movement using an activity monitor

ACCELEROMETRY Measurement of changes in acceleration. Different methods can be employed ranging from ‘zero crossing’ to an integrated function of the intensity and duration of acceleration change.

ACTIVE INGREDIENT An active ingredient is any component that provides pharmacological activity or other direct effect in the diagnosis, cure, mitigation, treatment, or prevention of disease, or to affect the structure or any function of the body of man or animals.

BASELINE The initial assessment at the start of a study.

BASIC SCIENTIFIC RESEARCH This term is usually used to differentiate studies involving patients (clinical research) from preclinical research involving in-vitro work or work involving experimental animals. See also ‘fundamental research’.

BIAS Systematic error that misrepresents the association between the treatment and outcome

BIOLOGICAL MARKER A characteristic that is objectively measured and evaluated as an indicator or normal biological process, pathologic processes, or biological responses to a therapeutic intervention. A biomarker can be physiologic, pathologic, or anatomic characteristics or measurement that is thought to relate to some aspect of normal or abnormal biologic function or process. Biomarkers measured in patients before treatment can be used to select patients for inclusion in a clinical trial. Changes in biomarkers following treatment may predict or identify safety problems related to a candidate drug, or reveal a pharmacological activity expected to predict an eventual benefit from treatment.

BIOLOGICAL PRODUCT Biological products include a wide range of products such as vaccines, blood and blood components, allergenics, somatic cells, gene therapy, tissues, and recombinant therapeutic proteins. Biologics can be composed of sugars, proteins, or nucleic acids or complex combinations of these substances, or may be living entities such as cells and tissues. Biologics are isolated from a variety of natural sources — human, animal, or microorganism — and may be produced by biotechnology methods and other cutting-edge technologies. Gene-based and cellular biologics, for example, often are at the forefront of biomedical research, and may be used to treat a variety of medical conditions for which no other treatments are available.

BIOMEDICAL RESEARCH Scientific research that relates to, informs or applies to clinical medicine or clinical veterinary medicine.

BLINDED TRIAL A blind or blinded (also called ‘masked’) experiment or trial is where information about the test is masked (kept) from the participant +/- those involved in the work to reduce or eliminate bias, until after the outcome (results) is known. Single blind relates to the patient not knowing what intervention they are on. Double blind refers to the patient and the study personnel not knowing. Triple blind study refers to statisticians also being blinded during analyses.

CARE-GIVER PLACEBO EFFECT Effects that alter the rating of outcomes provide by clinicians, caregivers, or the family. A sham medical intervention that causes pet caregivers (owners or veterinarians) to believe the treatment they provided to the pet improved the pet’s condition

CASE STUDY Research based on one or a few patients. Good for generating hypotheses, but not appropriate for testing hypotheses.

CLINICAL OUTCOME ASSESSMENT COA measures a patient’s symptoms or clinical signs, overall mental status, or the effects of a disease or condition on how that patient functions. COAs can be used to determine whether or not a drug has been demonstrated to provide treatment benefit. A COA is composed of a measure that produces a score together with clearly defined methods and instructions for administering the COA and assessing response; a standard format for data collection; and well-documented methods for scoring, analysis, and interpretation of results in the targeted patient population. COAs can provide direct or indirect evidence of treatment benefit. For COAs that provide indirect evidence of treatment benefit, qualification also includes a review of the evidence that the COA is adequately related to how patients feel or function in daily life.

CLINICAL RESERACH Studies involving patients (human or owned animals) or material (biological samples or outcome data) collected from patients.

CLINICAL TRIAL Studies involving patients (humans or owned animals) and an intervention that is being tested (trialed).

CLINICAL METROLOGY INSTRUMENT (CMI) A clinical metrology instrument (CMI) is a sequence of items which are ascribed a score based on the subjective experiences or observations of the person completing it. These scores are then usually processed in some way to quantify the level of disease.

COHORT STUDY A research method concerned with observing events involving a particular group of patients over time.

COMPOSITE MEASURE An instrument that measures the combined aspects of the disease/condition into a single numerical value.

CONSTRUCT VALIDITY Evidence that relationships among items, domains, and concepts conform to a priori hypotheses concerning logical relationships that should exist with other measures or characteristics of patients and patient groups. Testing that is used when the tool is measuring something (a construct) that cannot be directly observed (pain, quality of life etc.). While the construct can not be directly seen, behaviors resulting from it can be observed. Obviously, it will be impossible to ‘prove’ that something that cannot be measured directly is being measured. Several approaches can be used: ・ Hypothesized factors tested with factor analysis ・ Discriminatory validity: Does the instrument discriminate between subjects with and without the condition? Does it discriminate between different severities of the condition? ・ Responsiveness of the tool to a treatment known to change what is being measured, or to a change in the condition over time ・ Correlation to overall quality of life

CONTENT VALIDITY Evidence from qualitative research demonstrating that the instrument measures the concept of interest including evidence that the items and domains of an instrument are appropriate and comprehensive relative to its intended measurement concept, population, and use. Testing other measurement properties will not replace or rectify problems with content validity.

CONTROL GROUP In the context of clinical trials, a group of subjects that are not treated with a defined intervention in a study, and used to compare the effects of an intervention or treatment. Control groups may have the condition of interest, and can be POSITIVE (given an active comparator intervention) or NEGATIVE (receive no intervention). Control groups can also be UNTREATED CONTROLS.

CONTROLLED STUDY In the context of clinical trials , a study in which non-treated subjects are included to determine if the effects measured are due to the intervention or not. To minimise bias such studies are often randomized (there is an equal chance of any individual being allocated to either the active or the control group) and (double or single blind) placebo controlled.

CRITERION VALIDITY Refers to the extent to which the measure agrees with the external standard measure. For example, the extent to which the scores of a subjective instrument correlate with some other measure – a measure accepted as the ‘gold standard’. Often, in the development of subjective assessment tools, the best approach is to use an accepted objective measure. Because pain cannot (yet) be directly measured, an objective surrogate measure can be used, e.g. an objective measure of activity if pain is expected to impact activity.

CROSS-SECTIONAL A cross-sectional study is an observational study, in which the observations (e.g. responses to a questionnaire) are made on a single occasion across a group of subjects. Cross-sectional studies generally focus on a single group of people representative of the population of interest.

DIFFUSE NOXIOUS INHIBITORY CONTROL (DNIC) Diffuse noxious inhibitory control describes a type of descending inhibitory control system in animals that is triggered by a noxious stimulus distant to the primary test stimulus. The term Conditioned Pain Modulation (CPM) describes activation of this system, wherein the test stimulus is used to assess the level of sensitivity while the ‘conditioning’ stimulus refers to the noxious stimulus used to activate DNIC.

DISCRIMINATORY ABILITY As used when referring to an instrument used as an outcome measure, it is the ability of the instrument to discriminate between different levels of disease or clinical signs.

DEFINITIONS OF PAIN AND RELATING TO PAIN

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

Acute Pain Pain that is obviously coupled with tissue injury, generally short-lived and can be considered protective in nature. Often defined as lasting less than 1 month, or less than 3 months.

Adaptive pain Pain that is obviously coupled with tissue injury, generally short-lived and can be considered protective in nature.

Allodynia Pain due to a stimulus that does not normally provoke pain.

Analgesia Absence of pain in response to stimulation which would normally be painful.

Anesthesia dolorosa Pain in an area or region which is anesthetic.

Chronic Pain Chronic pain has defined as pain that lasts beyond the normal healing time, thus lacking the acute warning function of physiological nociception. Often defined on a temporal basis – pain lasting more than 3 months.

Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked.

Eudynia Has been used to describe ‘good pain’, i.e. ‘adaptive pain’.

Hyperalgesia Increased pain from a stimulus that normally provokes pain.

Hyperesthesia Increased sensitivity to stimulation, excluding the special senses. Allodynia is suggested for pain after stimulation which is not normally painful. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.

Hyperpathia A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold.

Hypoalgesia Diminished pain in response to a normally painful stimulus.

Hypoesthesia Decreased sensitivity to stimulation, excluding the special senses.

Maladaptive pain Pain that occurs in the absence of ongoing noxious stimuli and does not promote healing and repair. Also referred to as ‘maldynia’

Maldynia Pain that occurs in the absence of ongoing noxious stimuli and does not promote healing and repair. Also referred to as ‘maladaptive pain’

Neuralgia Pain in the distribution of a nerve or nerves.

Neuritis Inflammation of a nerve or nerves.

Neuropathic pain Pain caused by a lesion or disease of the somatosensory nervous system. The presence of symptoms or signs (e.g., touch-evoked pain) alone does not justify the use of the term neuropathic.

Central neuropathic pain Pain caused by a lesion or disease of the central somatosensory nervous system.

Peripheral neuropathic pain Pain caused by a lesion or disease of the peripheral somatosensory nervous system.

Neuropathy A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.

Nociception The neural process of encoding noxious stimuli.

Nociceptive neuron A central or peripheral neuron of the somatosensory nervous system that is capable of encoding noxious stimuli.

Nociceptive pain Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Nociceptive stimulus An actually or potentially tissue-damaging event transduced and encoded by nociceptors.

Nociceptor A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli.

Nociplastic pain Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.

Noxious stimulus A stimulus that is damaging or threatens damage to normal tissues.

Pain threshold The minimum intensity of a stimulus that is perceived as painful.

Pain tolerance level The maximum intensity of a pain-producing stimulus that a subject is willing to accept in a given situation.

Paresthesia An abnormal sensation, whether spontaneous or evoked.

Sensitization Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs.

Central sensitization Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.

Central plasticity Altered responsiveness of nociceptive neurons in the central nervous system – can result in increased or decreased responsiveness.

Peripheral sensitization Increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields.

DOUBLE BLIND see: blinded trial

DRUG A drug is defined as: ・ A substance recognized by an official pharmacopoeia or formulary. ・ A substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease. ・ A substance (other than food) intended to affect the structure or any function of the body. ・ A substance intended for use as a component of a medicine but not a device or a component, part or accessory of a device. ・ Biological products are included within this definition and are generally covered by the same laws and regulations, but differences exist regarding their manufacturing processes (chemical process versus biological process.)

EFFECTIVENESS The extent to which an intervention works when introduced to the general population outside of the context of a controlled study.

EFFECT SIZE – (STANDARDIZED EFFECT SIZE) A simple way to determine the degree of improvement (or otherwise) of a particular therapy after any placebo effect has been accounted for. The effect size is calculated as the ratio of the treatment effect (mean differences in treatment group minus differences in placebo group) to the pooled standard deviation of these differences.

EFFICACY The extent to which a treatment improves outcomes under controlled conditions (e.g. in the context of a clinical trial). The efficacy is related to the effect size documented in clinical studies.

EVIDENCE BASED MEDICINE Evidence-Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer. Below is the hierarchy of study design. Designs at the top of the provided the greatest strength of evidence – least potential for bias, with study designs at the bottom of the list having the greatest potential for bias. 1. Meta-analysis of controlled trials 2. Systematic reviews of controlled trials 3. Interventional Analytic Studies (i.e. Controlled trials (RCT’s)) 4. Observational Analytic Studies • Cohort Studies • Case Control Studies 5. Descriptive Studies a. Case Series 6. Case Reports 7. Expert opinions

EXCLUSION CRITERIA Pre-defined factors that exclude a subject from a trial or study.

GOOD CLINICAL PRACTICE A standard for the design, conduct, monitoring, recording, auditing, analysis, and reporting of clinical studies. Adherence to the standard provides assurance that the data and reported results are complete, correct and accurate, that the welfare of the study animals and the safety of the study personnel involved in the study are ensured, and that the environment and the human and animal food chains are protected.

HYPOTHESIS A proposed mechanism that might explain a known fact or observation. A hypothesis may be tested by a well-designed research protocol.

INCLUSION CRITERIA The predefined characteristics that allow a subject to be entered for consideration for a trial.

INFORMED CONSENT The decision by a person or care-giver to give or not give permission for an action affecting them. The decision is based upon having all the information bearing on the situation including the advantages, disadvantages, and the various consequences involved.

KINETIC GAIT ANALYSIS Kinetic gait analysis is a method of studying these forces using ground reaction forces. Essentially, kinetic gait analysis quantifies limping with regards to the force or pressure that the animal is willing to bear.

MINIMAL CLINICALLY IMPORTANT DIFFERENCE A minimal clinically important (or relevant) difference (MCID) can be defined as the smallest difference in score on an outcome measure (e.g. pain, disability, quality of life), which is believed to be important or beneficial to the patient. This MCID can be used as a criterion to assess if a therapy has potential beneficial effects.

NOCEBO The induction or the worsening of symptoms induced by sham or active therapies

OBJECTIVE MEASURE Outcome measures that are not susceptible to observation bias.

OBSERVATION BIAS Observation bias occurs when knowledge of a study subject’s group allocation influences identification of relevant events during the study.

OUTCOME The effect of treatment on a patient, which may be measured in a number of ways. Objective measures (outcomes) are independent of subjective evaluation, e.g. biological blood tests; ground reaction forces. Subjective outcomes are based on the experience or opinion of the patient, or caregiver.

OUTCOME MEASURES The methods used to measure outcome – in this case pain or dimensions impacted by pain.

PATIENTS Humans or owned animals that are under medical care for, or have, a disease condition.

PHENOTYPE The composite of an animal’s observable or measured characteristics or traits, such as its morphology, development, biochemical or physiological properties, or behavior.

PLACEBO A sham or non-active treatment that is administered during a trial.

PLACEBO EFFECT This effect represents a beneficial response to an inert treatment that exists for reasons unrelated to the actual treatment given, but depends on the context in which the treatment is provided and the patient’s experience and expectations. Strictly, the ‘placebo effect’ is the effect of administering the placebo over and above any effect of no intervention at all.

PLACEBO BY-PROXY-EFFECT This is where a caregiver’s belief that the animal is receiving an effective medication alters the animal (e.g. by their interaction with the animal) and manifests as a real beneficial effect for the animal.

PROSPECTIVE STUDY A study where patients are selected before any data collection starts.

PROTOCOL The defined, and usually written, plan or set of steps to be followed in a study.

QUANTITATIVE SENSORY TEST (QST) Quantitative sensory testing involves the application of a stimulus at a peripheral site, and measurement of the time to reach an endpoint or elicit a reaction. In humans, various endpoints can be measured (first detection, noxious, maximum tolerated), but in veterinary medicine, the response is generally defined as a reaction such as withdrawal, or vocalization, or some other sign of central appreciation of the stimulus. Threshold refers to the point at which the response occurred, and is measure in units of the stimulus (for ramped stimuli) or time (for fixed stimuli).

RANDOMISED CONTROLLED TRIAL (RCT) (Synonym: randomized clinical trial) - An experiment in which investigators randomly allocate eligible subjects into (e.g. treatment and control) groups to receive or not to receive one or more interventions that are being compared. The results are assessed by comparing outcomes in the treatment groups and control groups.

READABILITY How easy a questionnaire is to read, based on expected reading ability of different grade levels in the US education system.

RELIABILITY: TEST-RETEST The reproducibility of the results of a tool administered on different occasions over which time a subject should not have changed.

RELIABILITY: INTERNAL CONSISTENCY When the tool is a questionnaire, its internal reliability (or consistency) is based on the results from a single administration of the tool to a cohort with the trait to be measured and is represented by correlations among the questions in the tool with and across domains.

RESPONSIVENESS The ability of an instrument (method, questionnaire etc.) to measure a significant change in what is being measured (e.g. pain) in response to an intervention known to be effective.

RESCUE/ESCAPE CLAUSE The provision, usually in a clinical trial setting, for transferring a subject to a ‘rescue’ analgesic in the event that the subject is not responding appropriately to the treatment being administered (whether placebo or active).

RETROSPECTIVE STUDY A study where patients are selected then their medical records are used to find out what has happened to them.

SUBJECTIVE MEASURE Outcome measures that are susceptible to observation bias.

SEMI-OBJECTIVE MEASURE Measurement where the instrument itself is not susceptible to observation bias, but how the instrument is used in the study can influence the results, and thus the results can be susceptible to observation bias (e.g. accelerometers per se are objective but the caregiver awareness of group allocation could influence the amount of activity they encourage or discourage in their dog thus affecting the results of the study)

SENSITIVITY The ability of a test to correctly identify those individuals with the condition – true positives. Thus a highly sensitive test gives few ‘false-negative’ outcomes.

STATISTICALLY SIGNIFICANT In research, statistical tests determine the likelihood that a result arose by chance. The scientific norm is p<0.05 for statistical significance

SPECIFITY The ability of a test to correctly identify those individuals without the condition – true negatives. Thus a highly specific test gives few ‘false-postive’ outcomes.

SUBJECTS Animals being used in a study; can be human or non-human, and may be patients (diseased) or normal.

SUBJECTIVE OUTCOME Outcome measures that are susceptible to observation bias.

SUBSTANTIAL EVIDENCE Evidence consisting of one or more adequate and well-controlled studies, such as, a study in a target species, a study in laboratory animals, a field investigation, a bioequivalence study, or an in vitro study, by experts qualified by scientific training and experience to evaluate the effectiveness of the drug involved, on the basis of which it could fairly and reasonably be concluded by such experts that the drug will have the effect it purports or is represented to have under the conditions of use prescribed, recommended, or suggested in the labeling or proposed labeling thereof.

VALIDATION Refers to whether the claims (e.g. about what an instrument measures) can be justified and supported.

VALIDITY – (external) The extent to which the research findings can be generalised to the wider population of interest and applied to different settings – a.k.a generalizability.

VALIDITY – (internal) The ability of an instrument (method, questionnaire) to measure what it is intended to measure. Or the validity of specific study results based on the study design and implementation.

VALIDATED OUTCOME MEASURE There is no defined endpoint of validity. A valid instrument is one where more research and information would not substantially change the inference about the function of the instrument. An valid outcome measure is one that shows the following components of validity: Face validity Construct validity Content validity Responsiveness validity Test-retest stability Criterion validity External validity

VISUAL ANALOGUE SCALE (VAS) This is a psychometric response scale which can be used in questionnaires. It is used for subjective assessment of the intensity of characteristics (pain) that cannot be directly measured but which are believed to range across a continuum of values. It consists of a line of usually 100mm in length, with descriptive tethers at each end. The addition of interval marks or other descriptors or numbers along the length move the VAS towards an interval scale.

Von FREY A von Frey hair is a type of aesthesiometer designed in 1896 by Maximilian von Frey. Von Frey filaments rely on the principle that an elastic column, in compression, will buckle elastically at a specific force, dependent on the length, diameter and modulus of the material. Used to test mechanical sensitivity. The term von Frey is also used to refer to modern fixed versions of von Frey hairs – usually a pipette-tip like end attached to a load cell.

Wednesday, October 2, 2019

Time Topic Speaker Page Duncan Lascelles – NC 8:00 a.m. – 8:15 a.m. Meeting Overview, Purpose, and Goals State University Current State of PAW, Publications, +/- ACTTION Drew Mannes, NIH Clinical 8:20 a.m. – 8:35 a.m. Current state of measuring acute pain: human Center Current state of measuring acute pain: dog, Brad Simon, Texas A&M 8:40 a.m. – 8:55 a.m. cat University Current state of measuring acute pain: swine, Johann Coetzee, Kansas 9:00 a.m. – 9:15 a.m. bovine State University Chris Sanchez, University 9:20 a.m. – 9:35 a.m. Current state of measuring acute pain: equine of Florida 9:40 a.m. – 10:10 a.m. Panel Discussion 10:10 a.m. – 10:30 a.m. BREAK Improving Our Ability to Measure Acute Pain & Translational Benefit John Farrar, University of 10:30 a.m. – 10:45 a.m. Placebo research over the years in humans Pennsylvania Relevance of rodent outcome measures Alban Latremoliere, Johns 10:50 a.m. – 11:05 a.m. (reflexive, operant, spontaneous) to acute pain Hopkins University conditions in humans Predictability of rodent pain models for acute Jim Eisenach, Wake Forest 11:10 a.m. – 11:25 a.m. pain analgesics in humans University 11:30 a.m. – 12:00 p.m. Panel Discussion LUNCH Breakout Session: Changing landscape of food animal welfare in 12:00 p.m. – 1:00 p.m. relation to pain relief and treating acute pain conditions - Brandon Reinbold, Elanco Adam Shriver, University of 1:00 p.m. – 1:35 p.m. Ethical Implications of Pain Research Oxford Centre for Practical Ethics Swine work as translational for human Andrew Mannes, NIH 1:40 p.m. – 1:55 p.m. development Clinical Center NIH perspective on non-rodent models of Michael Oshinsky, 2:00 p.m. – 2:15 p.m. acute pain NINDS/NIH Translational value of acute pain in companion Jim Eisenach, Wake Forest 2:20 p.m. – 2:35 p.m. animals University 2:40 p.m. – 3:00 p.m. Panel Discussion 3:00 p.m. – 3:20 p.m. BREAK USDA perspective on food animal analgesics 3:20 p.m. – 3:35 p.m. Carol Clarke, USDA for acute pain FDA/CVM veterinary acute pain approval 3:40 p.m. – 3:55 p.m. Lisa Troutman, FDA/CVM process in companion animals Time Topic Speaker Page FDA/CVM veterinary acute pain subjective 4:00 p.m. – 4:15 p.m. Emily Smith, FDA/CVM measurement in food animals Corporate perspective on acute pain Anne Malleau, Global 4:20 p.m. – 4:35 p.m. analgesics Animal Partnership 4:40 p.m. – 5:00 p.m. Panel Discussion 5:00 p.m. - 7:00 p.m. Reception – poster session and discussion

Thursday, October 3, 2019

Time Topic Speaker Page Acute Pain Measurement: Subjective How is a subjective assessment tool

8:00 a.m. – 8:15 a.m. Dottie Brown, Elanco validated? Canine/Feline POP subjective measurement: 8:20 a.m. – 8:35 a.m. Jacky Reid, NewMetrica questionnaires Canine/Feline POP measurement: EEG, Jo Murrell, University of 8:40 a.m. – 8:55 a.m. noxious stimuli, fMRI Bristol Food animal acute subjective measurement: 9:00 a.m. – 9:15 a.m. Kelly Lechtenberg bovine lameness scale 9:20 a.m. – 9:50 a.m. Panel Discussion 9:50 a.m. – 10:15 a.m. BREAK Subjective measurement in cognitively Charles Berde, Harvard 10:15 a.m. – 10:30 a.m. impaired pediatric humans University 10:35 a.m. – 10:50 a.m. Bovine POP subjective measurement Stelio Luna, UNESP Monique Pairis-Garcia, NC 10:55 a.m. – 11:15 a.m. Porcine POP subjective measurement State University Facial expression across species in 11:20a.m. – 11:35a.m. Karina Bech Gleerup assessing acute pain 11:35a.m. – 12:00p.m Panel Discussion LUNCH Breakout Session: Companion animal welfare perspective: consent 12:00 p.m – 1:00 p.m. forms, repeat study enrollment, long term follow-up, adverse events - Sheilah Robertson, Lap of Love Veterinary Hospice Acute Pain Measurement: Objective Objective pain measurement in non-verbal Kenneth Craig, University 1:00 p.m. – 1:15 p.m. pediatrics of British Columbia Duncan Lascelles, NC 1:20 p.m. – 1:35 p.m. Activity monitors for acute pain measurement State University Brad White, Kansas State 1:40 p.m. – 1:55 p.m. Remote monitoring technology: food animals University Kinetic evaluation of limb pain: companion Mike Conzemius, 2:00 p.m. – 2:15 p.m animals University of Minnesota Hans Coetzee, Kansas 2:15 p.m. – 2:30 p.m. Kinetic evaluation of limb pain: food animals State University 2:30 p.m. – 2:45 p.m. BREAK Dan Weary, University of 2:45 p.m. – 3:00 p.m. Motivational Tests British Columbia Monique Pairis-Garcia, NC 3:05 p.m. – 3:20 p.m. Complex behavioral assays State University Karen Schwartzkopf- 3:30 p.m. – 3:45 p.m. Physiological measures across species Genswein, Agriculture & Agri-Food Canada Posters

1. Pharmacological cross validation of a translational pain questionnaire 2. Automatic Equine Pain Recognition using Deep Recurrent Artificial Neural Networks 3. Behavioral and Neuroanatomical Outcomes 4. Perioperative safety and efficacy of Gabapentin 5. A STRATEGY TO TEST CANDIDATE ANALGESIC DRUG EFFECTS on acute pain- stimulated and pain depressed… 6. A Clinical Model of Perioperative Acute Pain in Dogs 7. Non-Pharmacologic, Size Selective Method of Neural Heat Block 8. Owner-assessed indices of quality of life (QoL) in rabbits 9. Automated Pain Assessment with Millisecond Resolution Marker-Less Tracking 10. The Impact of Transdermal Flunixin Meglumine on Biomarkers of Pain in Calves 11. Development and Evaluation of Two Different Lameness Models in Goats. 12. Clinical Efficacy of a Long-Acting Injectable Opioid in Perioperative Acute Pain in Dogs 13. Quantify orofacial pain in feline head and neck cancer 14. Evaluating the analgesic efficacy of carprofen, hydromorphone and nerve growth factor neutralizing antibody (anti-NGF) 15. Impact of Nonsteroidal Anti-Inflammatory Drugs on Behavior of Piglets at Castration 16. Revealing Acute and Persistent Sensitization with Reflex Kinematics – Moving Beyond Threshold 17. Analyzing horse facial expressions of pain with Equine FACS 18. antinociceptive effects of intravenous administration of three doses of butorphanol 19. A SYSTEMATIC REVIEW OF THE USE OF THE SHORT FORM OF THE GLASGOW composite measure pain scale… 20. Development of Postoperative Pain Models to Assess Acute Pain in Mice 21. Evaluation of Transmammary-Delivered Firocoxib and a Vapocoolant Spray 22. In vitro Method to Study Pain in Dogs 23.A Novel Device to Measure Acute Static Hindlimb Weight-bearing

Karina Bech Gleerup, DVM, PhD

Completed her PhD with the thesis “Pain evaluation in cattle and horses – A study of behavioural responses to pain” in 2015. In her thesis, she has described the equine pain face as well as the bovine pain face and pain evaluation schemes for both species. Karina is FACS certified (FACS is the comprehensive, anatomically-based facial measurement system developed for humans by Ekman & Friesen), which has given her an excellent perspective on the scientific approach to facial expressions of pain. Karina has given several talks on scientific conferences as well as to practicing veterinarians and horse owners on the subject pain evaluation. She is dedicated to improve welfare, focusing on pain evaluation methods that are applicable in real life and not only in research settings.

Charles B. Berde, MD, PhD Professor of Anesthesia (Pediatrics), Harvard Medical School

Dr. Berde is the Sara Page Mayo Chair in Pediatric Pain Medicine and Professor of Anaesthesia (Pediatrics) at Harvard Medical School. He completed an MD and PhD (Biophysics) at Stanford University; his Residency in Pediatrics, at Boston Children's Hospital; Residency in Anesthesiology, at Massachusetts General Hospital; and Fellowship in Pediatric Anesthesiology, at Boston Children's Hospital. Dr. Berde co-founded the Pain Treatment Center at Boston Children's Hospital, the first and most clinically active acute and chronic pain management program for children in the world. Dr. Berde’s translational research concerns local anesthetic mechanisms and the development of novel prolonged duration local anesthetics that are now in clinical trials. His clinical research concerns clinical pharmacology of analgesics and local anesthetics in children, clinical outcomes of treatment of neuropathic pain and cancer pain in children, functional brain imaging of children with neuropathic pain, and brain dynamic studies in children during general anesthesia. Translation research on novel prolonged duration local anesthetics has progressed for our laboratory to clinical trials. Dr. Berde is the author of over 130 original peer-reviewed articles and over 100 chapters and reviews. He was profiled as one of Time Magazine's "Heroes in Medicine" in 1997. He has received several awards and honors for his pioneering work in pediatric pain relief, including the 2003 Scientific Achievement Award of the Reflex Sympathetic Dystrophy Syndrome Association, the 2015 IASP Special Interest Group in Pediatric Pain Distinguished Career Award, the 2018 Myron Yaster Lifetime Achievement Award from the Society for Pediatric Anesthesia, and the 2018 John J. Bonica Award from the American Society of Regional Anesthesia and Pain Medicine.

Dorothy (Dottie) Cimino Brown MS, DVM, DACVS Elanco Animal Health

Dr. Brown received a B.S. in Zoology from the University of Maryland and her DVM from the Virginia-Maryland Regional College of Veterinary Medicine. She completed her internship and surgical residency at the University of Pennsylvania, School of Veterinary Medicine and received a Maters in Clinical Epidemiology from the University of Pennsylvania, School of Medicine. Dr. Brown has worked at Elanco Animal Health for two years and is currently the Director of Companion Animal Research and lead executional scientist for Translational Comparative Medical Research. She started her career at the University the University of Pennsylvania, where she was a Professor of Surgery, had a sponsored translational research program focusing on the measurement and management of chronic pain in companion animals, and was Executive Director of the Veterinary Clinical Investigations Center. Her focus at Elanco is on the discovery, development and registration of new drugs for animal health; and the design and implementation of translational studies with the goal of improving both human and animal health.

Carol Clarke DVM, DACLAM Research Program Manager at USDA-APHIS Animal Care

Dr. Clarke is a Diplomate of the American College of Laboratory Animal Medicine. She received her Bachelor’s degree in the Natural Sciences from Johns Hopkins University, and her D.V.M. degree from the Tuskegee School of Veterinary Medicine. Dr. Clarke served as the Attending Veterinarian of a primate facility for the Division of Veterinary Resources at the National Institutes of Health (NIH) from 1998 to 2001. In 2001, she accepted a position with the Comparative Medicine Branch of the NIH-National Institute of Allergy and Infectious Diseases (NIAID). During her 10 years with NIAID, she served as IACUC coordinator, Vice Chair of the Rodent Gnotobiotic Committee, Rodent Import Officer, and Chief of Shared and Central Facility Operations. In 2011, Dr. Clarke accepted a position with the US Department of Agriculture-Animal and Plant Health Inspection Service-Animal Care. She serves as the Research Program Manager whose duties include collaborations with other Federal agencies, reviewing petitions for regulatory changes, participation in investigative actions, developing policies, and reviewing requests to perform more than one major operative procedure. She also served as the project officer of Module #26 -Nonhuman Primate Transportation, for the National Veterinary Accreditation Program.

Hans Coetzee BVSc, PhD Department Head, Professor, and Interim Director of Nanotechnology Innovation Center of Kansas State (NICKS) and Institute of Computational Comparative Medicine (ICCM)

Dr. Hans Coetzee is a Professor and Head of the Department of Anatomy and Physiology at Kansas State University. He earned his Bachelor of Veterinary Science degree from the University of Pretoria, South Africa in 1996. After graduation he worked for four years in mixed animal practice in Northern Ireland followed by 2 years in pharmaceutical research and development at Norbrook Laboratories Ltd. He earned a specialist Certificate in Cattle Health and Production from the Royal College of Veterinary Surgeons (London) in 2000 and a doctorate in Veterinary Microbiology from Iowa State University in 2005. He holds dual board certification in the American College of Veterinary Clinical Pharmacology and American College of Animal Welfare and is a European Specialist in Animal Welfare Science, Ethics and Law. His professional interests include the development of pain assessment techniques and practical analgesic drug regimens for use in food animals. He has published 150 peer- reviewed scientific papers and received over $10 million in research funding. In his free time he enjoys spending time with his wife and his twin daughters.

Michael Conzemius, DVM, PhD, DACVS Professor, College of Veterinary Medicine Department of Veterinary Clinical Sciences, University of Minnesota

Dr. Conzemius received his DVM and PhD in Biomedical Engineering from Iowa State University. He completed his surgical residency at the University of Pennsylvania. He has served as a faculty member at the University of Pennsylvania and Iowa State University and is currently an Endowed Professor of Surgery at the University of Minnesota.

Kenneth Craig, OC, PhD., LLD, FCAHS Professor Emeritus of Psychology at the University of British Columbia and Director of the BC Pain Research Network.

Dr Craig is Professor Emeritus of Psychology at the University of British Columbia. He has had a longstanding career as a research scientist and clinical psychologist working towards better understanding and control of pain in infants, children and people with communication limitations. He is a past president of the Canadian Pain Society and has served as a member of IASP Council. His current research is supported by the Canadian Institutes of Health Research and the U.S. National Institutes of Health and focuses upon pain assessment, nonverbal communication and social parameters of care delivery.

James C. Eisenach, MD Professor, Anesthesiology, Wake Forest School of Medicine

My clinical and laboratory research has tried to better understand how pain is perceived, especially in settings where even light touch causes pain, like chronic pain from trauma, surgery, or cancer, and how we might better treat this pain or even prevent it. Our work has led over the years to new pain treatment options in settings ranging from women in labor to people suffering from severe pain and cancer. Currently, I am directing research efforts to identify ways to speed up recovery from pain after injury, whether the injury is a battle wound in a soldier or surgery to cure cancer. One line of work is examining the signals in the brain which speed recovery from pain after childbirth and how we might mimic that in both men and women to speed recovery. The other is to test the idea that simple eye exams and psychologic questionnaires can help us personalize the choice of medication to speed recovery from pain and disability after major surgery in the elderly.

John T. Farrar, MD, PhD Associate Professor of Epidemiology Perelman School of Medicine, University of Pennsylvania

Dr. Farrar has been involved in clinical research for more than 20 years, with a major focus on the study of the efficacy of pain therapeutics and on novel methodology in the design and execution of clinical trials. As a neurologist and a pharmaco- epidemiologist, he has been involved in numerous studies including randomized trials (RCTs), cohort studies, and methodologic studies of pain and associated symptoms such as fatigue, depression, and quality of life in clinical research and practice; these have been conducted with funding he has received from the National Institutes of Health, the U.S. Food and Drug Administration (FDA), private foundations, and industry sources. Currently he is the principal investigator of the Center of Excellence for Pain Education, he directs the evaluation component of Penn's current Clinical and Translational Science Award (CTSA), and he is a collaborator with the data coordinating center for the U54 multicenter Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) study. Nationally he has served on advisory boards for the FDA, on the National Academy of Science (NAS) committee on Missing Data in Clinical Trials, and on the Institute of Medicine’s (IOM) committee on Relieving Pain in America. He continues to serve roles as an ad hoc reviewer for NIH and the FDA, and as associate editor for the journal Pharmacoepidemiology and Drug Safety (PDS). His current research is focused on the evaluation of new methodologies for understanding how patients report their pain, studies in a large population of patients with pelvic pain, and functional brain imaging in people with pain. At the University of Pennsylvania, he also serves as the co-director of the Master of Science in Clinical Epidemiology program and of the Biostatistics and Epidemiology Consulting Center. He directs the Introduction to Epidemiology course for medical students. In addition, he continues to see patients, predominately in a palliative care setting.

B. Duncan X. Lascelles. BSc, BVSC, PhD, FRCVS, CertVA, DSAS(ST), DECVS, DACVS Professor of Surgery and Pain Management Comparative Pain Research and Education Centre Translational Research in Pain Program, NC State University College of Veterinary Medicine

After graduating from the veterinary program at the University of Bristol, U.K., with honors, in 1991 Dr. Lascelles completed a PhD in aspects of pre-emptive/perioperative analgesia at the University of Bristol. After an internship, he completed his surgical residency at the University of Cambridge, U.K. He moved to Colorado for the Fellowship in Oncological Surgery at Colorado State University. He is currently Professor in Small Animal Surgery and Pain Management at North Carolina State University. He is board-certified in small animal surgery by the Royal College of Veterinary Surgeons, the European College of Veterinary Surgeons, and the American College of Veterinary Surgeons. He is director of the Comparative Pain Research and Education Centre (CPREC). His research program (Translational Research in Pain [TRiP]) is dedicated to answering critical questions about pain control and pain mechanisms through high quality, innovative research. His career has been focused on developing algometry methods (methods to measure pain) in spontaneous disease animal models (pets with naturally occurring disease), and probing tissues from well-phenotyped animals with spontaneous disease to understand the neurobiology, with a strong translational focus. The aim of his research is to improve pain control in companion animals, and facilitate analgesic development in human medicine. He has authored over 180 peer reviewed research papers and reviews and 190 research abstracts, as well as over 30 book chapters.

Alban Latremoliere, M.Sc., Ph.D Assistant Professor of Neurosurgery, Johns Hopkins University

Alban Latremoliere is an Assistant Professor in the department of Neurosurgery at Johns Hopkins University (MD, USA). He graduated in Neuroscience from the University Pierre and Marie Curie (Paris, France) and performed his postdoctoral training at the F.M. Kirby Neurobiology Center at Boston Children’s Hospital and Harvard Medical School (MA, USA). Dr. Latremoliere’s laboratory focuses on the neurobiology of sensory systems, with an emphasis on pain and regeneration. The main areas of research are: 1) Assess ongoing pain in rodent models of neuropathic pain in vivo and determine the mechanisms responsible, 2) Understand the relationship between reinnervation of target tissue after peripheral nerve regeneration and functional recovery/pain sensitivity and 3) Determine how acute and chronic pain alter sleep architecture.

Kelly F. Lechtenberg, DVM, Ph.D.

Dr. Kelly Lechtenberg received his doctor of veterinary medicine from K-State in 1987 and his doctorate in ruminant nutrition in 1988. His Professional Niche is providing research services to generate data that is optimally controlled, production relevant and GCP/GLP compliant in order to help ensure that the US food supply of animal origin is safe, wholesome and produced in the most favorable conditions for the animals and environment entrusted to our care. Lechtenberg is founder and owner of Midwest Veterinary Services and CSRC Veterinary Diagnostic Laboratory of Oakland, NE; The Veterinary and Biomedical Research Center in Manhattan, KS; Beef CAMP (Center for the Advancement of Medicine and Production) in St George, KS. Zue Diligence, the most recent venture, helps link entrepreneurs of agriculture, veterinary medicine and biomedical technology with investors and industry acquisition teams to advance the quantity and quality of data available in an effort to help innovation find its highest value in timely and efficient manner. In 2005, Lechtenberg was honored as the Alumni Fellow for the College of Veterinary Medicine. He currently serves on the advisory boards for several international animal health companies, and on the board of directors for several smaller biomedical and animal health companies.

Stelio Pacca Loureiro Luna Professor, School of Veterinary Medicine and Animal Science (FMVZ) – University of São Paulo

Graduation in Veterinary Medicine Medicine (1984), Residence in Veterinary Anesthesiology (1985) and Msci (1990) at the School of Veterinary Medicine and Animal Science (FMVZ), from the University of São Paulo State (Unesp). PhD at the University of Cambridge, England, (1993). Lecturer at FMVZ, Unesp since 1987, where since 2008 is a Full Professor. Research Fellow at CNPq, level 1 since 1996, Diplomate from the European College of Veterinary Anesthesiology and Analgesia since 1995, Title of Specialist in Veterinary Anesthesiology since 2005 and in Veterinary Acupuncture since 2017 given by the Brazilian Council of Veterinary Medicine (CFMV). Certified by the International Veterinary Acupuncture Society - USA (2001). He works in the area of Veterinary Anesthesiology, focusing on assessment and management of pain, acupuncture, animal welfare and bioethics. Member of the National Council for the Regulation of Animal Experimentation (CONCEA), of the Ministry of Science and Technology (2009-2013 and 2016-). He was a member of the CFMV and CRMV-SP (2010- 2011) Ethics, Bioethics and Animal Welfare Commission (2007 to 2010), President of the Brazilian College of Veterinary Surgery and Anesthesiology (2005-2006), member of the Board of the International Veterinary Academy of Pain Management (2004-2007) and founder and First President of the Brazilian Association of Veterinary Acupuncture (1999- 2004). He is the leader of the NAVE research group (Nucleus of Veterinary Anesthesiology) at CNPq

Anne Malleau MS, MBA Executive Director, Global Animal Partnership

Global Animal Partnership is the leading animal welfare standards and labeling organization in North America. GAP has pioneered complete ‘farm to fork’ support for their partners - designed to help create humane and sustainable, profitable practices that enable GAP certified partners to flourish for generations to come. Global Animal Partnership has grown to certify 3800+ farms and ranches across 7 countries impacting the lives of more than 416 million animals annually across the globe. Anne is also an Executive Leader of Meat & Poultry – Live Production at Whole Foods Market – the leading grocer of natural and organic food in the US - where she provides farm animal production compliance support to the meat teams. She has no responsibility for any purchasing decisions.

Anne is an animal scientist with a BSc in agriculture, a MSc in poultry behavior and welfare, and a MBA in agribusiness. She has studied and worked in animal agriculture for more than 20 years. Anne currently lives and works from her farm outside of Toronto, Canada traveling often. She has two young children and enjoys crafting, cooking, gardening, and helping her husband renovate their home.

Andrew Mannes, MD, ME NIH Clinical Center, Department of Perioperative Medicine

Dr. Mannes is chief of the Clinical Center's Department of Perioperative Medicine. His current interests include developing pain therapies using gene therapy; targeting pain pathways with selective agonists, toxins, or fusion proteins; and improving the diagnosis of disease states using proteomic and genomic techniques.He has written widely in books and medical journals on such topics as advances in cancer pain management, gene therapy for pain, and neurosurgical intervention approaches to pain relief. He is board certified in anesthesiology and fellowship-trained in pain management. He collaborates with the Clinical Center's Pain and Palliative Care Service in the area of pain management and has also worked on treatment of chronic pain with investigators from several NIH intramural programs. He manages the Department of Perioperative Medicine laboratory which is focused on gaining insight into nociceptive and other sensory pathways to identify new approaches for treating pain. Following completion of a Bachelor of Science degree in Bio-Engineering at the University of Pennsylvania and a Master of Engineering degree at Dartmouth College, Dr. Mannes received his MD degree at George Washington University. He completed a transitional internship at the Presbyterian Hospital of Philadelphia followed by an anesthesia residency at the Hospital of the University of Pennsylvania. While at University of Pennsylvania, he completed a fellowship in pain management and joined the Penn faculty as an Instructor in Anesthesiology in 1994. In 2019, he received his MBA degree from the University of Maryland, University College. He was promoted to Assistant Professor of Anesthesiology in 1997 before coming to NIH. Dr. Mannes completed an NIH research fellowship in molecular biology in 1997. He has been in the Department of Anesthesia and Surgical Services since 2001. Dr. Mannes is a member of the American Medical Association and is on the editorial advisory board of Open Pain Journal.

Jo Murrell, BVSc. (hons), PhD, Dipl.ECVAA Honorary Reader, University of Bristol

Jo Murrell has spent most of her career in academia, most recently at Bristol University from 2007-2018. While at Bristol she focussed her time on pain research and clinical anaesthesia and has carried out many studies investigating pain mechanisms and clinical analgesic protocols in cats, dogs and horses. These studies have contributed to the Market Authorisation of methadone and buprenorphine in dogs and cats and buprenorphine in horses. Her work has also clearly demonstrated upregulation of pain pathways in dogs with osteoarthritis, highlighting the need for aggressive pain management in these patients. She has been a Diplomate of the European College in Veterinary Anaesthesia and Analgesia since 2002 and enjoys the challenges of clinical anaesthesia. Jo is a member of the WCVA Global Pain Council and is passionate about providing best practice in analgesia to cats and dogs. She has recently joined the team at Highcroft Veterinary Referrals, Bristol to continue her career in clinical practice.

Michael L. Oshinsky, PhD Program Director, Pain and Migraine National Institute of Neurological Disorders and Stroke

Dr. Michael L. Oshinsky joined the National Institute of Neurological Disorders and Stroke (NINDS) in 2014 as the Program Director for Pain and Migraine Research. As a Program Director at NINDS, Dr. Oshinsky is responsible for research and administrative issues related to migraine, other headache disorders, neuropathic pain, peripheral and central mechanisms that mediate pain, central processing of pain, disease-related pain disorders, and therapeutic pain devices. He also serves as the co-Chair of the preclinical pain research portion of NIH’s Helping to End Addiction Long-term (HEAL) Initiative. Dr. Oshinsky received a B.A. in Biology with a concentration in Neuroscience from Brandeis University. He earned his Ph.D. in Neurobiology & Behavior from Cornell University. He received his post-doctoral training as NIH sponsored postdoctoral fellow at the University of Pennsylvania. He was an Associate Professor in the Department of Neurology at Thomas Jefferson University from 2001-2014, before joining the NINDS. During those years he was the Director of Preclinical Research at the Jefferson Headache Center and directed an NIH funded research program aimed at developing and characterizing animal models of headache. In 2011, Dr. Oshinsky was award the Harold G. Wolff Award for headache research. Monique Danielle Pairis Garcia, DVM, PhD, DACAW Associate Professor, Global Production Animal Welfare NC State University College of Veterinary Medicine

Dr. Monique Pairis-Garcia is an Associate Professor in the Department of Population Health and Pathobiology at North Carolina State University (NCSU) with a 50% research, 30% teaching and 20% extension and service appointment. Dr. Pairis-Garcia earned her Doctor of Veterinary Medicine and Doctor of Philosophy degree from Iowa State University in Ames, IA and her bachelor’s degree in Biology from Grinnell College. Dr. Pairis-Garcia serves on the Pig Welfare Committee for the American Association of Swine Veterinarians (AASV) and The National Pork Board. Dr. Pairis-Garcia’s research interests include 1) pain management in livestock animals utilizing pharmacological interventions to minimize pain 2) Development and refinement of educational material to ensure timely and appropriate euthanasia on farm and 3) Development and implementation of audit and assessment programs to ensure positive animal welfare and handling on farm. In addition, Dr. Pairis-Garcia was board- certified by the American College of Animal Welfare in 2018 and currently writes a column for the magazine Pig Progress with a focus on swine welfare and behavior.

Jacky Reid, BVMS PhD DVA DipECVAA MRCA MRCVS Honorary Senior Research Fellow. University of Glasgow. CEO NewMetrica Ltd.

Professor Jacky Reid is an Honorary Senior Research Fellow in the University of Glasgow and CEO of the innovative research company NewMetrica Ltd. Jacky and a multi-disciplinary team of renowned academics from the University of Glasgow have dedicated over 20 years to researching the largely neglected field of pain and quality of life measurement in animals and NewMetrica was established to build on and extend this pioneering work. Jacky is a veterinary surgeon with very varied experience in the veterinary world (her PhD was a study involving hen’s eggshells) including clinical practice, clinical anaesthesia, applied clinical research and teaching. She is a recognised RCVS Specialist in Veterinary Anaesthesia, a European Veterinary Specialist in Anaesthesia and Analgesia and recipient of the BSAVA Simon Award in 2016. Since retiring from the Veterinary School in Glasgow she has enjoyed continuing, from within NewMetrica, novel pain and quality of life research with colleagues in the Glasgow Pain and Welfare Group (Professors Nolan and Scott and Dr Wiseman), which was awarded the inaugural UFAW Companion Animal Welfare Award for significant innovation or advance in animal welfare in 2009.

(James) Brandon Reinbold, DVM, PhD Principal Research Scientist, Elanco Animal Health

Brandon attended the University of Missouri-Columbia for a BS in Animal Science (1999) and DVM (2003). He then practiced for 3 ½ years in private veterinary clinics in MO and IA before entering into a microbiology PhD program with an emphasis in pharmacology at Kansas State University. After completing his PhD studies in 2009, Brandon worked for the American Veterinary Medical Association (2009-10) as an associate editor for JAVMA and AJVR. In 2011, he joined Elanco as a research scientist for food animal R&D. In 2013, Brandon joined Boehringer Ingelheim Vetmedica, Inc. as a senior scientist for ruminant- focused R&D. In January 2016, Brandon rejoined Elanco and is currently a Principal Research Scientist evaluating efficacy and safety for food animal product-related innovation. Brandon lives in Trimble, MO with his wife, Misty, and 3 children, Tilly, Clara, and Grant.

Dr Sheilah A Robertson BVMS (Hons), PhD, DACVAA, DECVAA, DACAW, DECAWBM (WSEL), CVA, MRCVS. Senior Medical Director., Lap of Love Veterinary Hospice

Dr. Sheilah Robertson graduated from the University of Glasgow in Scotland. Following time in private practice and a surgery internship she undertook specialized training in anesthesia and completed her PhD at the University of Bristol. She is board certified in anesthesia and in animal welfare by the respective American and European Colleges and holds a certificate in small animal acupuncture. In 2014 she completed her graduate certificate in Shelter Medicine at the University of Florida. In 2019 she received her certification as a Traditional Chinese Veterinary Medicine Palliative and End-of-Life practitioner by the Chi Institute of Chinese Medicine. She has published widely on the recognition and alleviation of acute pain in horses and cats. Currently she is the senior medical director of Lap of Love Veterinary Hospice, a large network of veterinarians dedicated to end-of-life care and in-home euthanasia throughout the USA. Dr Robertson is also a courtesy Professor in the Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida.

L. Chris Sanchez, DVM, PhD, DACVIM Professor, Director, Hofmann Equine Neonatal ICU, Chief Medical Officer, UF Large Animal Hospital

Dr. Chris Sanchez is a Professor of large animal internal medicine and Chief Medical Officer of the Large Animal Hospital at the University of Florida College of Veterinary Medicine. Dr. Sanchez's clinical interests include general equine internal medicine, neonatology, and gastroenterology. Her research focus has been equine gastroenterology, neonatology, and pain management with a special interest in visceral pain recognition and management. Dr. Sanchez received her DVM (1995) and PhD (2003, gastrointestinal physiology) degrees from the University of Florida. She completed an internship at Equine Medical Associates in Edmond, OK and became a Diplomate of the American College of Veterinary Internal Medicine in 1999 after completing a residency in large animal internal medicine at the University of Florida.

Karen Schwartzkopf-Genswein, PhD Senior Research Scientist, Agriculture and Agri-Food Canada | AAFC ꞏ Science and Technology Branch

Dr. Schwartzkopf-Genswein is a senior scientist whose expertise and research is in the area of Beef Cattle Welfare. She was raised on a farm in southern Alberta active in the feedlot business which was instrumental in sparking her interest of cattle, their care and management. In 1996, she obtained here PhD at the University of Saskatchewan in Applied Animal Ethology and in 2003 accepted a research scientist position in Beef Cattle Welfare with Agriculture and Agri-Food Canada in Lethbridge. Her research includes pain/stress assessment and mitigation strategies associated with routine management procedures such as transport, castration, dehorning, and lameness. She has also focused her research in the area of stress reduction and early detection of illness in feedlot cattle. Based on her research she provides expert advice to provincial, federal and international producer groups on issues related to beef welfare including the National Cattle Feeders Association, Beef Cattle Research Council, Canadian Council on Animal Care and the NCBA, and North American Food Animal Well-Being Commission. She has served (2011- 2013) as the co-chair of the Scientist Committee requested by the Canadian National Farm Animal Care Council to revise the Codes of Practice for the Care and Handling of Beef Cattle and the Transportation Codes of Practice (2018 -2021).

Dr. Schwartzkopf-Genswein is currently an adjunct professor at the University of Saskatchewan, University of Calgary, University of Manitoba and UNESP University in Sao Paulo, Brazil where she is active in supervising and mentoring students at the Bachelors, Masters, and PhD levels. She is Past President of the Canadian Society of Animal Science and was an associate editor for the Canadian Journal of Animal Science for 6 years 2004-2011.She has authored/coauthored over 200 peer reviewed manuscripts and popular press articles.

Adam Shriver, PhD Research Fellow, University of Oxford The Oxford Uehiro Centre for Practical Ethics

Adam Shriver is a philosopher with a Ph.D. from the Philosophy-Neuroscience-Psychology program at Washington University in St. Louis. Prior to Oxford, he worked at the University of Pennsylvania and the University of British Columbia. Adam’s research examines the intersection of ethics and cognitive science and he has written multiple articles about human well-being and animal welfare. In particular, Adam’s research has examined the significance of the dissociation between the affective and sensory components of pain for philosophical theories of ethics and well-being. To this end, Adam has written about the relationship between pain and pleasure, the legal and ethical questions that arise from the search for a neural signature of pain in humans, and the capacity for suffering across different species. He also has research examining the ethics of using genetic modifications in livestock. Previously, Adam organized a workshop on neuroethics and animals, and he is currently co-editing a book on the topic.

Bradley T. Simon, DVM, MSc, DACVAA Assistant Professor, Anesthesiology Texas A&M College of Veterinary Medicine & Biomedical Sciences

Dr. Bradley Simon received his Doctor of Veterinary Medicine from Ross University School of Veterinary Medicine and completed a residency in anesthesia and analgesia at the University of Pennsylvania School of Veterinary Medicine. Following his residency, Dr. Simon received his Master of Science degree from Ross University School of Veterinary Medicine with an emphasis in feline analgesia and opioid pharmacology. Currently, he is a board-certified veterinary anesthesiologist and an Assistant Professor of Anesthesiology at Texas A&M University College of Veterinary Medicine and Biomedical Sciences. He has written 16 peer-reviewed journal articles and contributor to two books on feline anesthesia and analgesia with an additional in preparation. His most notable research focuses on the effects of aging and opioid-opioid combinations on thermal antinociception in cats. He has also published several impactful reviews on the present and future of opioid analgesics and on the lack of analgesic use (oligoanalgesia) in small animal practice. Dr. Simon is a national and international lecturer and has presented at the International Conference on Opioids at Harvard University, World Small Animal Veterinary Association Conference in Colombia, World Congress of Veterinary Anesthesia in Italy, and is the current ACVAA-ACVS Surgery Summit liaison.

Emily Smith, DVM Veterinary Medical Officer in the Division of Therapeutic Drugs for Food Animals, Office of New Animal Drug Evaluation at the Food and Drug Administration (FDA) - Center for Veterinary Medicine.

Dr. Smith has worked on the Antiparasitic and Physiologic Drugs Team for the last 12 years with interests in pain management in food animals, antiparasitic drugs, biomarkers and surrogate endpoints, and clinical study design. She earned her BA in Bioveterinary Science from Utah State University and her DVM from the University of Illinois College of Veterinary Medicine.

Lisa Troutman, DVM, MS Veterinary Medical Officer at the Food and Drug Administration (FDA) - Center for Veterinary Medicine.

Dr. Troutman has worked in the Division of Therapeutic Drugs for Non-Food Animals for the last 20 years with interests in oncology, biotechnology, postoperative pain, internal medicine, and study design for clinical trials. In addition she continues to practice in a small animal hospital. She is a graduate of Cornell University, Virginia-Maryland Regional College of Veterinary Medicine and completed a master’s degree in Physiology from the University of Dayton.

Daniel Weary BSc, MSc, PhD Professor, Animal Welfare Program. NSERC Industrial Research Chair in Animal Welfare

Dan Weary is a Professor and NSERC Research Chair at The University of British Columbia. In 1997 he co-founded UBC’s Animal Welfare Program and co-directs this active research group. Dan's research focuses on developing behavioral measures for the objective assessment of animal welfare and developing practical methods of improving the welfare of animals.

Brad J. White, DVM, MS Director; Beef Cattle Institute Kansas State University

Dr. Brad White received his D.V.M. from the University of Missouri-Columbia and worked for six years in a mixed animal practice in southeast Missouri. His emphasis in practice was beef cow-calf and stocker medicine and management. He then worked for two years in beef production medicine at Mississippi State concurrent with completion of his Masters degree. He is currently on faculty at the Kansas State University College of Veterinary Medicine and serves as director of the Beef Cattle Institute. Dr. White is a member of the American Veterinary Medical Association, Kansas Veterinary Medical Association, American Association of Bovine Practitioners, and Academy of Veterinary Consultants.

Presentation Abstracts Current State of Measuring Acute Pain

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” (IASP 1996) In humans, as with animals, acute pain is the “the normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus… associated with surgery, trauma and acute illness.” (Carr and Goudas, 1999). The term acute pain refers to the initial response seen (e.g. from injury) and also to its duration.

Measuring acute pain requires the use of clinical models that produce consistent levels of pain that are safe, repeatable, lacking complexity, of low cost and facile to recruit into. In clinically based studies, surgical or interventional techniques can be appropriate. For example, the 3rd molar extraction model has seen extensive use but is not without limitations (duration, intensity). Experimental pain models using thermal, electrical, UV burn, or chemical stimuli are also used with the assumption that pain truly emulates clinical acute pain.

The “gold standard” for assessing pain from either healthy volunteers or patients continues to be traditional questionnaires based on patient self‐reporting. These tools have been well characterized in a range of age and cultural groups and report on a patient’s perception of the intensity and quality of pain and other related issues (e.g. quality of life). Current acute pain measures are therefore entirely reliant on patient subjective responses.

The ability to objectively and accurately measure pain, whether chronic or acute, is therefore an attractive goal for patient care, pain research and legal issues. However the pain perception is complex involving both the intensity and affective component in combination with anxiety, expectation of pain duration, and desire for relief, and impacts the overall experience of the patient. Current research approaches are exploring EEG, sensory testing, imaging modalities and biological markers to characterize acute pain in experimental and clinical models to tease out these components. These multimodal techniques, while providing encouraging data, are not a reliable assay for acute pain.

Thus, studying acute pain remains a challenge, being reliant primarily on subjective data. Many techniques continue to be refined with encouraging but mixed results. However, reliable, objective, measureable tools for assessing acute (or chronic) pain remains elusive.

Carr DB, Godas LC Acute Pain Lancet (353) 1999

The State of Acute Pain Assessment in Dogs and Cats Bradley T. Simon, DVM. MSc, DACVAA

The use of animals as models of pain or nociception originate back to the late 19th century with the introduction of the von Frey hair aesthesiometer (von Frey 1896). These models enhance our understanding of pain physiology and allow for the discovery of new therapeutic agents that relieve pain and suffering in humans and animals. To develop a pain model it must consist of two general components 1) a method of insult and 2) the subsequent end-point measurement (Gregory et al. 2013). Therefore, the objective of this lecture is to briefly discuss the current state of acute pain measurement or end-point measurement in dogs and cats. Several unidimensional and multidimensional (composite) pain scales are available and widely used for acute pain assessment. Composite pain scales (Glasgow Composite Measured Pain Scale [GCMPS], French Association for Animal Anaesthesia and Analgesia pain scoring system [4A-VET], and UNESP-Botucatu multidimensional composite pain scale) incorporate interactive components and behavioral categories to quantify the degree of pain a patient experiences. The GCMPS is a validated pain assessment scale in dogs and incorporates sensory and affective pain qualities with good inter-observer correlation. Despite its validity, limitations may be observed when evaluating dogs with fear or anxiety and when assessing subjective behaviors pertaining to degree of locomotion and posture (Hofmeister et al. 2018). The UNESP-Botucatu is a validated pain assessment scale for cats and evaluates pain expression, psychomotor change, and physiological changes to assess feline acute postoperative pain (Brondani et al. 2013). The 4A- VET, though not validated, possesses acceptable reliability for post-operative acute orthopedic pain assessment but low sensitivity, short duration of effective responsiveness, and may be affected by the patient’s mental status (Rialland et al. 2012). Similarly, the University of Melbourne Pain Scale assesses postoperative acute pain via behavior and physiological categories but also may not account for residual anesthetic effects or canine demeanor (Gutierrez-Blanco et al. 2015). Additional forms of unidimensional and composite pain scales used in dogs and cats include Dynamic Interactive Visual Analogue Scales (DIVAS), simple descriptive scales (SDS), numerical rate scaling (NRS), and the Colorado State Acute Pain Scale. Most of which incorporate an assessment of patient behavior and physical palpation of the surgical or painful site. Laboratory adaptations to the canine brief pain inventory questionnaire have transformed previously validated scales for chronic pain to allow for acute inflammatory and oncologic pain assessment (Brown et al. 2009; Baranowski et al. 2018). Gait analysis, force plate evaluation, and lameness scores are also used in models of acute joint inflammation, particularly when testing the efficacy of non- steroidal anti-inflammatory agents. Lastly, the use of feline facial expressions (manipulations in ear, mouth, and muzzle position) can be helpful in differentiating pain-free cats from those experiencing acute pain (Steagall & Monteiro 2019). Quantitative Sensory Testing is another modality used for assessing acute pain and determining the analgesic efficacy of drugs in dogs and cats. End-point determination in QST typically involves a withdrawal response from a noxious stimulus. Transcutaneous electrical nerve stimulator, blunt-probed pressure algometers, thermal threshold (heat and cold) probe stimulation, colorectal gut distension, and electronic von Frey anesthesiomoter have been used in research and clinical settings to assess acute pain in healthy and painful disease dogs and cats. They can also be useful in identifying hyperalgesia and allodynia (Lascelles et al. 1997; Hunt et al. 2019). Limitations associated with QST include end-points that rely on observer inferences from behavioral gestures following noxious stimuli, variances in pain thresholds amongst individuals, individual attention and motivation, and environmental factors. Functional magnetic resonance imaging and positron emission tomography-computed tomography can assess acute pain via detecting changes in cerebral hemodynamic and metabolic/biochemical activity, respectively, following a noxious stimulus when compared to a baseline or control stimulus (Hotta et al. 2005; Davis & Moayedi 2013; Guillot et al. 2015). However, the requirement for general anesthesia and logistical practicality have limited its use in veterinary medicine.

References Baranowski DC, Buchanan B, Dwyer HC et al. (2018) Penetration and efficacy of transdermal NSAIDs in a model of acute joint inflammation. J Pain Res 11, 2809-2819. Brondani JT, Mama KR, Luna SP et al. (2013) Validation of the English version of the UNESP- Botucatu multidimensional composite pain scale for assessing postoperative pain in cats. BMC Vet Res 9, 143. Brown DC, Boston R, Coyne JC et al. (2009) A novel approach to the use of animals in studies of pain: validation of the canine brief pain inventory in canine bone cancer. Pain medicine (Malden, Mass) 10, 133-142. Davis KD, Moayedi M (2013) Central mechanisms of pain revealed through functional and structural MRI. Journal of neuroimmune pharmacology : the official journal of the Society on NeuroImmune Pharmacology 8, 518-534. Gregory NS, Harris AL, Robinson CR et al. (2013) An overview of animal models of pain: disease models and outcome measures. J Pain 14, 1255-1269. Guillot M, Chartrand G, Chav R et al. (2015) [(18)F]-fluorodeoxyglucose positron emission tomography of the cat brain: A feasibility study to investigate osteoarthritis-associated pain. Vet J 204, 299-303. Gutierrez-Blanco E, Victoria-Mora JM, Ibancovichi-Camarillo JA et al. (2015) Postoperative analgesic effects of either a constant rate infusion of fentanyl, lidocaine, ketamine, dexmedetomidine, or the combination lidocaine-ketamine-dexmedetomidine after ovariohysterectomy in dogs. Vet Anaesth Analg 42, 309-318. Hofmeister EH, Barletta M, Shepard M et al. (2018) Agreement among anesthesiologists regarding postoperative pain assessment in dogs. Vet Anaesth Analg 45, 695-702. Hotta H, Sato A, Schmidt RF et al. (2005) Cerebral regional cortical blood flow response during joint stimulation in cats. Neuroreport 16, 1693-1695. Hunt J, Knazovicky D, Lascelles BDX et al. (2019) Quantitative sensory testing in dogs with painful disease: A window to pain mechanisms? Vet J 243, 33-41. Lascelles BD, Cripps PJ, Jones A et al. (1997) Post-operative central hypersensitivity and pain: the pre-emptive value of pethidine for ovariohysterectomy. Pain 73, 461-471. Rialland P, Authier S, Guillot M et al. (2012) Validation of orthopedic postoperative pain assessment methods for dogs: a prospective, blinded, randomized, placebo-controlled study. PloS one 7, e49480. Steagall PV, Monteiro BP (2019) Acute pain in cats: Recent advances in clinical assessment. J Feline Med Surg 21, 25-34. von Frey M (1896) On the Use of Stimulus Hairs. J. Neurosci. Methods, 71–131. Current state of measuring acute pain: swine, bovine Hans Coetzee BVSc, CertCHP, PhD, DACVCP, DACAW, DECAWSEL Professor and Head of the Department of Anatomy and Physiology Kansas State University, Manhattan, KS, 66506 [email protected] Societal concern about the moral and ethical treatment of food animals is increasing. In particular, negative public perception of pain associated with routine management procedures such as dehorning and castration in cattle and castration and tail docking in pigs is increasing. This has highlighted an urgent need for effective protocols to relieve pain and suffering in livestock. The American Veterinary Medical Association (AVMA) “supports the use of procedures that reduce or eliminate the pain of dehorning and castrating of cattle” and proposes that “available methods of minimizing pain and stress include application of local anesthesia and the administration of analgesics”.1 It is therefore remarkable that the first analgesic drug specifically approved for pain relief in livestock by the U.S Food and Drug Administration (FDA) was only approved in 2017. FDA Guidance Document 123 for the development of effectiveness data for non-steroidal anti-inflammatory drugs (NSAIDs) states that “validated methods of pain assessment must be used in order for a drug to be indicated for pain relief in the target species”.2 The identification and validation of robust and reproducible measurements of acute pain is therefore fundamental for the development and approval of effective analgesic drug regimens for use in livestock. This process is especially complex in a prey species, such as cattle, that inherently conceal pain. Pain is defined as “An aversive feeling or sensation associated with actual or potential tissue damage resulting in physiological, neuroendocrine, and behavioral changes that indicate a stress response”.3 In previous research, markers for the evaluation of pain and distress associated with noxious animal husbandry procedures have focused on assessing behavioral, physiological and neuroendocrine changes. A change in animal behavior has been assessed using visual pen scoring 4, videography5, vocalization5,6, chute exit speed measurement7,8, pedometers5, accelerometers9, remote triangulation devices10, mechanical nociceptive threshold (MNT) assessment and pressure mats. Physiological changes have been assessed using serum cortisol measurement11, heart rate determination12, feed intake and average daily gain12. Neuroendocrine changes have been assessed through measurement of the neuropeptide substance P6, infrared thermography (IRT)13, 14, heart rate variability (HRV)15, skin electrical impedence (electrodermal activity)8 and electroencephalography (EEG)16. Receiver Operating Characteristic (ROC) curves are graphical plots that illustrate the diagnostic ability of a biomarker as its discrimination threshold (cut-off) is varied. ROC curves are created by plotting the true positive rate (TPR) against the false positive rate (FPR) at various threshold settings. The higher the Area Under the ROC Curve (AUC under ROC), the higher the predictive value of the biomarker. AUC under ROC of 0.9 – 1,0 represents Excellent diagnostic accuracy while an AUC under ROC of 0.8 – 0.9 in Very Good and 0.7 – 0.8 is Good. Examples of AUC under ROC suggest that cortisol has the highest ability to discriminate between calves in pain from control calves at 1 h (0.98) and 4 h (0.96) after surgical castration in cattle. Discrimination between Placebo and Analgesic-treated calves was highest at 4 h after surgical castration (0.91). The use of cortisol to detect pain at 6 h after induction was highest after surgical castration (0.91) followed by dehorning (0.73) and was poorest for lameness (0.45). However, the use of cortisol to distinguish between Placebo and analgesic-treated animals was highest at 6 h after treatment in lame calves (0.85) compared to castrated calves (0.71) and dehorned calves (0.70). Substance P was only useful (AUC under ROC > 0.70) to discriminate between painful and control cows at 12 h and 24 h after lameness induction. IRT was useful (AUC under ROC >0.70) to discriminate between painful, non-painful and analgesic treated cows at 48 h after dehorning but only at 8 h (pain vs. no pain) and 12 h (pain vs. analgesia) after surgical castration. MNT was very good at distinguishing between painful and non-painful calves at 6 h and 25 h after dehorning but was only useful to distinguish painful from analgesic-treated calves at 49 h after dehorning. Contact area detected on the pressure mat was useful to distinguish between lame, non-lame and analgesic-treated cows for 72 h after lameness induction with amphotericin B. Single biomarkers of pain in livestock have several deficiencies thus necessitating the use of multiple or combinations of biomarkers. ROC curves may have value in identifying pain biomarkers and to optimize timing of sample collection. References 1American Veterinary Medical Association. Welfare implications of castration of cattle. Available at: https://www.avma.org/KB/Policies/Pages/Castration-and-Dehorning-of-Cattle.aspx. Accessed 29 August 2019. 2 FDA-CVM. US Food and Drug Administration, Center for Veterinary Medicine. Guideline No. 123. Development of target animal safety and effectiveness data to support approval of non-steroidal anti-inflammatory drugs (NSAID’s) for use in animals. Available at http://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM052 663.pdf Accessed 29 August 2019. 3 Molony, V., J.E. Kent. 1997. Assessment of acute pain in farm animals using behavioral and physiological measurements. J. Anim. Sci 75: 266 – 272. 4 McMeekan, C.M., K.J. Stafford, D.J. Mellor et al. 1999. Effects of a local anaesthetic and a non-steroidal anti- inflammatory analgesic on the behavioural responses of calves to dehorning. NZ Vet J. 47: 92-96. 5 Currah, J,M., Hendrick, S.H., Stookey, J.M. 2009. The behavioral assessment and alleviation of pain associated with castration in beef calves treated with flunixin meglumine and caudal lidocaine epidural anesthesia with epinephrine. Can Vet J, 50(4), 375–382. 6 Coetzee, J.F., B.L. Lubbers., S.E. Toerber., R. Gehring., D.U. Thomson., B.J. White., M.D. Apley. 2008. Plasma concentrations of substance P and cortisol in beef calves after castration or simulated castration. Amer J Vet Res. 69(6): 751 – 762. 7 Burrows, H.M., Dillon, R.D. 1997. Relationships between temperament and growth in a feedlot and commercial carcass traits of Bos indicus crossbreds. Australian Journal of Experimental Agriculture 37: 407-411. 8 Baldridge SL, Coetzee JF, Dritz SS, Reinbold JB, et al.. 2011. Pharmacokinetics and physiologic effects of intramuscularly administered xylazine hydrochloride-ketamine hydrochloride-butorphanol tartrate alone or in combination with orally administered sodium salicylate on biomarkers of pain in Holstein calves following castration and dehorning. Amer J Vet Res. 72(10):1305-17. 9 White, B. J., Coetzee, J. F., Renter, D.G., et al, D. 2008. Evaluation of two-dimensional accelerometers to monitor beef cattle behavior post-castration. Amer J Vet Res. 69 (8): 1005-1012. 10 Theurer ME, White BJ, Coetzee JF, et al. (2012) Assessment of behavioral changes associated with oral meloxicam administration at time of dehorning in calves using a remote triangulation device and accelerometers. BMC Veterinary Research 8 (1) :48 doi:10.1186.1746-6148-8-48 11 Coetzee JF*. 2011. A review of pain assessment techniques and pharmacological approaches to pain relief after bovine castration in the United States. Invited Review. Applied Animal Behavioral Science. 135(4). 192 – 213. 12 Coetzee JF, Mosher RA, KuKanich B, et al. (2012) Pharmacokinetics and effect of intravenous meloxicam in weaned Holstein calves following scoop dehorning without local anesthesia. BMC Veterinary Research. 8:153. doi:10.1186.1746-6148-8-153. 13 Stewart, M., J.M. Stookey., K.J. Stafford., et al. 2009. Effects of local anesthetic and nonsteroidal anti- inflammatory drug on pain responses of dairy calves to hot-iron dehorning. J Dairy Sci. 92(4): 1512-1519. 14 Bates, J.L., Karriker, L.A., Stock, M.L., et al. 2014. Impact of transmammary-delivered meloxicam on biomarkers of pain and distress in piglets after castration and tail docking. PLoS ONE 9(12): e113678. doi:10.1371/journal.pone.0113678 15 von Borell, E., J. Langbein, G. Despres, et al. 2007. Heart rate variability as a measure of autonomic regulation of cardiac activity for assessing stress and welfare in farm animals—A review. Physiol. Behav. 92:293–316. 16 Bergamasco L, Coetzee JF, Mosher RA. (2011). Quantitative electroencephalographic findings in conscious calves in response to surgical castration. Journal of Veterinary Pharmacology and Therapeutics. 34(6). 565 -576. CURRENT STATE OF MEASURING ACUTE PAIN IN HORSES L. Chris Sanchez, DVM, PhD, DACVIM College of Veterinary Medicine University of Florida, Gainesville, FL, USA

The most common clinical manifestations of acute pain in the horse are colic and lameness, thus the majority of pain assessment tools surround these types of pain. Unidimensional assessment schemes remain commonly used for musculoskeletal conditions, with the Obel system used for laminitis.1 This system has shown good intra- and inter-observer reliability2, and a modification for endocrinopathic laminitis fared similarly.3 Unidimensional assessments have also been described for colic4 and lameness5, with varying reliability. Composite scoring systems have provided good reliability and ease of use in a post-operative colic setting,6 with some systems showing improved reliability over unidimensional systems.7 Facial pain scoring systems have been described in horses and show promise for come conditions, such as acute laminitis.8-10 The addition of objective measures such as vital signs, have been incorporated into some composite scoring systems.11 Importantly, vital signs and cortisol are affected by a variety of factors in addition to pain, including hydration status, perfusion, sepsis and/or endotoxemia, fear, and anxiety; thus, they are not useful as sole indicators of pain. Continuous video assessment allows for quantification of either time budgets (locations within the stall, ear position, head position, eating, lying down, etc.) or events (vocalizing, stomping feet, shifting weight, etc.) is very specific and has been used in research settings for post-operative pain assessment,12 though are too cumbersome for user-friendly clinical application. Objective force plate measurements are similarly useful in a research setting, though have not yet fully translated to clinical application.

References 1. Obel N. Studies on the histopathology of acute laminitis, 1948. 2. Menzies-Gow NJ, Stevens KB, Sepulveda MF, et al. Repeatability and reproducibility of the Obel grading system for equine laminitis. Vet Rec 2010;167:52-55. 3. Meier A, de Laat M, Pollitt C, et al. A "modified Obel" method for the severity scoring of (endocrinopathic) equine laminitis. PeerJ 2019;7:e7084. 4. Mair TS, Smith LJ. Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 1: Short-term survival following a single laparotomy. Equine Vet J 2005;37:296-302. 5. American Association of Equine P. Guide for veterinary service and judging of equestrian events. 1991. 6. Sellon DC, Roberts MC, Blikslager AT, et al. Effects of continuous rate intravenous infusion of butorphanol on physiologic and outcome variables in horses after celiotomy. J Vet InternMed 2004;18:555-563. 7. Sutton GA, Atamna R, Steinman A, et al. Comparison of three acute colic pain scales: Reliability, validity and usability. Vet J 2019;246:71-77. 8. Gleerup KB, Forkman B, Lindegaard C, et al. An equine pain face. Vet Anaesth Analg 2015;42:103-114. 9. Dalla Costa E, Minero M, Lebelt D, et al. Development of the Horse Grimace Scale (HGS) as a pain assessment tool in horses undergoing routine castration. PLoS One 2014;9:e92281. 10. Dalla Costa E, Stucke D, Dai F, et al. Using the Horse Grimace Scale (HGS) to Assess Pain Associated with Acute Laminitis in Horses (Equus caballus). Animals (Basel) 2016;6. 11. VanDierendonck MC, van Loon JP. Monitoring acute equine visceral pain with the Equine Utrecht University Scale for Composite Pain Assessment (EQUUS-COMPASS) and the Equine Utrecht University Scale for Facial Assessment of Pain (EQUUS-FAP): A validation study. Vet J 2016;216:175-177. 12. Price J, Catriona S, Welsh EM, et al. Preliminary evaluation of a behaviour-based system for assessment of post-operative pain in horses following arthroscopic surgery. Veterinary Anaesthesia and Analgesia 2003;30:124- 137.

Understanding the Placebo Effect: Acute Pain Studies in Humans John T. Farrar, MD, PhD Departments of Epidemiology, Anesthesia (Secondary), and Neurology (Secondary) University of Pennsylvania

The word placebo comes from the Latin placere 'to please‘ and is sometimes defined as a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any direct physiological effect of the treatment. In clinical medicine and research, the mind-body placebo effect can be best thought of as a non-specific effect of a treatment as compared to a specific effect. We now understand that the brain is constantly altering our interpretation of the environment so that we can focus our attention. In addition, we are constantly being conditioned by our environment to think and act in certain ways. We know there are mind-body effects that are brain mediated processes involving specific brain regions and neuronal synapses, transmission, and systemic effects causing changes in the person’s perception of the environment, or response to that environment. Functional imaging has demonstrated what has come to be known as the pain network(1) and induction of a placebo response can reduce or eliminate these responses(2). This occurs not only in the perception of pain but with all human physiologic activity(3), but seems to have a greater role in studies involving human perception especially pain (4). Expectation plays a large role in the response of a person to a placebo (5). In addition, the more invasive the placebo condition, the more powerful the response(6). In considering the place of a placebo control group, it is vitally important that we understand that what happens to patients in the placebo treated group is only partially due to the mind-body response described above. To a large degree, a patient’s response to both treatment and placebo is due to natural history of disease (which wax and wane over time) and regression to the mean, (for non-fatal diseases, worse symptoms usually get better and better symptoms often get worse). Evaluation of published studies have demonstrated that larger placebo responses are associated with a lower likelihood of a statistically positive study (7), however, this does not prove that the higher group placebo response rates causes the study failures. Attempts to control the response in the placebo group have mixed results. Placebo run-in periods that exclude placebo group responders have not improved outcomes (8). However, identifying patients with a higher likelihood of a placebo response (9), training patients to provide more accurate pain reporting (10), and control of patient expectation (11) may benefit clinical trial efficiency. A better understanding of the role of the placebo effect in pain clinical trials is important to improve future studies. References: 1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self‐regulation on pain. PLoS Biol. 2015;13(1):e1002036. doi: https://dx.doi.org/10.1371/journal.pbio.1002036. PubMed PMID: 25562688. 2. Zubieta JK, Stohler CS. Neurobiological mechanisms of placebo responses. Ann N Y Acad Sci. 2009;1156:198‐210. doi: https://dx.doi.org/10.1111/j.1749‐6632.2009.04424.x. PubMed PMID: 19338509. 3. Dutile S, Kaptchuk TJ, Wechsler ME. The placebo effect in asthma. Curr Allergy Asthma Rep. 2014;14(8):456. doi: https://dx.doi.org/10.1007/s11882‐014‐0456‐2. PubMed PMID: 24951239. 4. Hrobjartsson A, Gotzsche PC. Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med. 2001;344(21):1594‐602. PubMed PMID: 11372012; PubMed Central PMCID: PMCSource: KIE. 103004. 5. Benedetti F, Pollo A, Lopiano L, Lanotte M, Vighetti S, Rainero I. Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses. J Neurosci. 2003;23(10):4315‐23. PubMed PMID: 12764120. 6. Kaptchuk TJ, Stason WB, Davis RB, Legedza AR, Schnyer RN, Kerr CE, et al. Sham device v inert pill: randomised controlled trial of two placebo treatments. Bmj. 2006;332(7538):391‐7. PubMed PMID: 16452103. 7. Katz J, Finnerup NB, Dworkin RH. Clinical trial outcome in neuropathic pain: relationship to study characteristics. Neurology. 2008;70(4):263‐72. PubMed PMID: 17914067. 8. Lee S, Walker JR, Jakul L, Sexton K. Does elimination of placebo responders in a placebo run‐in increase the treatment effect in randomized clinical trials? A meta‐analytic evaluation. Depress Anxiety. 2004;19(1):10‐9. PubMed PMID: 14978780. 9. Farrar JT, Troxel AB, Haynes K, Gilron I, Kerns RD, Katz NP, et al. Effect of variability in the 7‐day baseline pain diary on the assay sensitivity of neuropathic pain randomized clinical trials: an ACTTION study. Pain. 2014;155(8):1622‐31. doi: https://dx.doi.org/10.1016/j.pain.2014.05.009. PubMed PMID: 24831421. 10. Treister R, Lawal OD, Shecter JD, Khurana N, Bothmer J, Field M, et al. Accurate pain reporting training diminishes the placebo response: Results from a randomised, double‐blind, crossover trial. PLoS ONE. 2018;13(5):e0197844. doi: https://dx.doi.org/10.1371/journal.pone.0197844. PubMed PMID: 29795665. 11. Lidstone SC, Schulzer M, Dinelle K, Mak E, Sossi V, Ruth TJ, et al. Effects of expectation on placebo‐induced dopamine release in Parkinson disease. Arch Gen Psychiatry. 2010;67(8):857‐65. doi: https://dx.doi.org/10.1001/archgenpsychiatry.2010.88. PubMed PMID: 20679593.

Relevance of rodent outcome measures to acute pain conditions in humans

Alban Latremoliere, Ph.D. Johns Hopkins University. Baltimore, MD, USA.

Most attempts to develop new analgesics have failed despites good preclinical efficacy. This translational failure of rodent chronic pain models could be caused by species differences, design issues with the models, or the readout measures used to assess pain sensitivity. Reflexive withdrawal behaviors are the most commonly used behavioral paradigms to assess pain hypersensitivity in rodents. Such reflex behaviors are conserved in humans for responses to extremely high intensity stimuli, which is relevant to assess anesthetic properties. Mechanical allodynia is typically assessed with calibrated von Frey filaments or paint brush applied onto the skin and both assays work in humans. However, while the rodent endpoint consists of a reflex withdrawal, the human counterpart relies on verbal description of pain, which could represent different neural processes. Because reflexive behavioral readouts do no incorporate the cognitive or emotional aspects of pain and are prone to experimenter subjectivity, operant assays were developed to measure a more integrated response to painful stimuli. These assays reveal that aversive behaviors occur for stimuli at lower intensity than those used for reflexive assays, which could align well with the type of pain experienced by patients in their daily life, but their translational relevance needs to be validated. Finally, spontaneous pain is the major complaint from chronic pain patients. Surrogates for ongoing activity of nociceptors include administration of chemicals that cause prolonged nocifensive behavior and sensitization. While they are not medically relevant, these assays trigger similar responses in both humans and rodents and could represent useful diagnostic tools to assess sensitivity of nociceptors or changes in spinal processing. Monitoring unprovoked unilateral grooming episodes in rodents could reflect spontaneous pain attacks, but the sporadic nature of these events limits their use and reliability. In conclusion, while rodent sensory testing is likely relevant to human pain symptoms, there is a significant gap between the outcome measures used in rodents (reflex withdrawals) and humans (verbal description). Because the exact nature of the pain symptoms experienced by patients varies greatly with the etiologies of their disease, using a single readout in animal model increases the risk of false positive preclinical results. An extended classification of human pain symptoms by etiology would help selecting the most relevant combination of pain assays in animal models. Readout measures of spontaneous pain are still critically needed in both species.

Predictability of rodent pain models for acute pain analgesics in humans

James Eisenach, MD

Basic science pain research seeks to identify psychological-social-biological mechanisms and new targets for treatment of pain in humans. One would not expect a high likelihood of translation, given the reductionist approach to much of basic science, species differences, and reliance on simplistic models of disease. Nonetheless, basic pain research has arguably usually followed clinical observations or misled understanding and only occasionally translated into clinically meaningful treatments. Below are examples of each:

Following: The original description and studies of presumed neuropathic pain after spinal nerve ligation in rodents showed effective treatment by sympathectomy, but poor efficacy of intrathecal opioids, similar to clinical experience at the time. Subsequent clinical studies flipped these results, with poor response of neuropathic pain to sympatholytic maneuvers but acute efficacy from intrathecal morphine. Remarkably, the rodent literature results also flipped following these clinical observations.

Leading: Several new chemical entities and biologics have been developed based on bench work suggesting a role for calcitonin gene related peptide, nerve growth factor, transient receptor for vanilloid-1, and nicotinic receptors, for example, in the treatment of pain. None of these are commonly used or did not reach the market, due in most cases to poor tolerability.

Misleading: Several approaches based on a wealth of preclinical studies failed to alter clinical pain in humans, most spectacularly glial inhibitors and neurokinin-1 antagonists. In our own work examining spinal analgesia, we replicated efficacy in animals of intrathecal cyclooxygenase inhibitors to reduce hypersensitivity after peripheral injury or inflammation, but failed to observe analgesia in humans with acute or chronic pain after intrathecal ketorolac, despite its efficacy to reduce prostaglandin concentrations in cerebrospinal fluid. Curiously, the role of cyclooxygenase inhibitors for pain treatment continues unabated in the laboratory.

Bench research can mislead us especially when it focuses on what is easy at the expense of what is relevant. We rely on hypersensitivity to mechanical stimuli after injury in rodents whereas this is relatively uncommon in patients with chronic pain. We focus on low threshold mechanoreceptive afferents whereas these become desensitized after surgery or chronic nerve injury. We focus on C-fibers but their role in chronic pain is unclear. We aim to study the transition from acute to chronic pain, but don’t use trajectory of recovery as an outcome measure in either animals or humans. Most importantly, poor scientific rigor and selective reporting are common in many leading laboratories, resulting in failure in replication by others and misleading drug development. Changing landscape of food animal welfare in relation to pain relief and treating acute pain conditions James (Brandon) Reinbold DVM, PhD Elanco Animal Health, Greenfield, IN USA

Pain management and overall welfare in food- and fiber-producing animals is an ever- increasing concern for livestock producers, veterinary service providers, government agencies, food corporations, food service providers, and the end consumer. Regardless of how much desire there is among these stakeholders to improve the welfare of animals, there are many factors to be accounted for as well as the complexity of their interactions to achieve the end goal of relieving pain and improving animal welfare. Grassroots efforts for driving change begin with educating the end consumer, food industry, producers, researchers, and veterinarians alike. However, there are some among this diverse group of stakeholders that are attempting to accelerate change through the rollout of food policy and global initiative campaigns. Unless the goal is to curtail or end all animal production, these efforts can be good in principle but are often times outpacing the available science and tools needed to meet the policies and initiatives as written.

This food animal breakout session will provide a review of select food policy and global initiatives in the context of how they relate to the challenges of pain management and treatment in food animals. The presentation will also address the complexities of managing pain based on modern production and animal husbandry systems. The session will be made complete with a review of existing products used to manage pain, including a cursory review of how regulatory approval can be achieved.

Acknowledgement: This presentation was prepared in cooperation with Michelle Calvo-Lorenzo MS, PhD (Elanco Animal Health). Swine work as translational model for human development

Drug discovery and development frequently progress through pre‐clinical studies in vitro, and in rodents and other small animals with promising results, but subsequently fail in human trials. For rodents, the housing costs are low, the animals are easy to handle and acute and chronic pain models have been well developed for drug screening and discovery. Additional analgesic drug development has used larger animal models (e.g. non‐human primates or canine) to assess efficacy, dosing and adverse effects. These studies increase confidence and incentive to move forward with human clinical trials. Swine is however, becoming more commonly utilized for pre‐clinical drug, intervention and equipment development.

Swine have remarkably similar anatomy and pathophysiology to humans including muscles, internal organs etc. so they are the preferred model for some research (e.g. cardiology, spine, skin). Instituting their feeding parameters can produce gut physiology remarkably similar to humans (e.g. transit time and pH). In contrast, liver enzymes, important with drug function and metabolism, are less conserved between swine and human are even variable among swine breeds.

Pain models for somatic, visceral and neuropathic pain (both experimental and naturally evolving) and assessment tools, while not as broadly developed as with smaller animals, are available swine studies. Pain studies can be reliant on interventional procedures that necessitate precise drug delivery which can be difficult in smaller sized animals. Needle placement into the swine DRG or epidural space, clinically significant targets for pain management, have been described using CT or MRI placement. Swine can be purchased to approximate pediatric or adult humans so that conventional‐sized imaging and surgical equipment, instrumentation or implants can be used.

Swine have higher animal, housing, feeding, and veterinary costs, and have larger special requirements. There are some additional considerations when contemplating utilizing swine including a staff that is experienced with the routine care, are familiar with illness and can perform procedures in swine. Swine will continue to grow and can get very large with lengthy studies. Greater sized animals necessitates substantial drug product, which can be problematic if it is costly or difficult to produce. There is a low procedural attrition but swine are susceptible to perioperative complications such as cardiomyopathy or malignant hyperthermia leading to perioperative morbidity.

Swine are agricultural animals that are readily available, hardy, docile and easy to work with. The use of this model, although typically in lower powered studies, offers greater insight into a pain drug’s or interventional procedure’s efficacy and adverse effects and can be predictive for dosing in human clinical trials which are important to with increase the translational success in humans. Translational value of acute pain in companion animals?

James Eisenach, MD

The study of interventions in companion animals with chronic pain to guide translational or development efforts in better treatment of humans with chronic pain has been discussed in detail for the past decade, including at the PAW 2017 meeting, yet it is unclear that progress is being made in this regard. One clear exception is that of ablative treatments and the focus on toxicity as much as efficacy. This lack of progress undoubtedly reflects many factors, most notably the slow development of validated outcome measures and the ethical restrictions on treatments which approach those of direct study in humans.

The title of this lecture poses the question whether the situation might be any different in the acute pain setting. A majority of patients in tertiary pain clinics trace the onset of their chronic pain to a physically traumatic event which in many cases is surgery. As such, there is considerable interest in understanding the incidence of chronic pain after surgery as well as its risk factors, pathophysiology, prevention, or treatment. The field has been hampered by a focus on dichotomous outcomes (e.g., pain present or pain not present) at only one point in time even though it is clear that the incidence and severity of pain decrease within individuals over time with differing time courses. I will review work we have done and are doing regarding high time resolution study of pain and physical dysfunction resolution after surgery, including mathematical modeling and simplification of the time course of recovery as a primary outcome measure for research in this space.

How the study of companion animals after physical trauma or surgery might inform future clinical trials is unclear. Questions to be addressed would be primary outcome measures which could be quickly, easily, and repeatedly determined in order to understand the time course of recovery, aspects of recovery which are likely to reflect the same aspects in humans, and identification of unique outcomes which could be at least cautiously interpreted to reflect higher order cognitive and physical functioning in humans.

Abstract: USDA perspective on food animal analgesics for acute pain ‐ Carol Clarke, USDA

The US Department of Agriculture (USDA) is committed to minimizing pain and distress in farm animals used for food production and research. Recognition of pain/distress requires a detailed analysis of physiological and behavioral information. Physiological data is objective information that includes but not limited to: temperature, body weight, and stress hormonal levels. Behavioral information is more subjective and includes: movement, responsiveness, activity level, and expression of species‐typical behavior.

Mitigation strategies are limited for animals used in food production. Decisions to administer pain‐relieving medications during routine husbandry procedures or as part of veterinary care, require several considerations such as: clearance times, duration of procedure, and level of stress to the animal. Animals transported to slaughter are also entitled to mitigation of pain/distress. As a result, USDA accredited veterinarians conduct fit‐for‐travel assessments to ensure humane care.

The USDA enforces the Animal Welfare Act (AWA) which supports farm animal use in biomedical research. The USDA also has the authority to use farm animals in agricultural research. Standards of care as outlined in the AWA regulations and the ‘Guides’ for biomedical and agricultural research are implemented in USDA facilities. The Agricultural Research Service explores strategies for pain/distress reduction during routine husbandry procedures and the National Agricultural Library serves as a resource for alternatives to painful procedures performed in research.

Pain in Animals Workshop October 2, 2019 Food Animals: USDA Perspective

Contact information Dr. Carol Clarke, Research Program Manager USDA/APHIS‐ Animal Care 4700 River Rd Unit 84 Riverdale, MD 20737 [email protected]

Recognition of Pain and Distress Relies on the analysis of physiological (objective data) and behavioral information (subjective data).  Resource: The National Veterinary Accreditation Program (NVAP) Modules: #22 and #25 https://www.aphis.usda.gov/aphis/ourfocus/animalhealth/nvap

The USDA and Research Regulatory authority under 7 U.S.C. Agriculture  Chapter 54 § 2131 – Animal Welfare Act  Chapter 64 § 3191  Chapter 109 § 8301

The Agricultural Research Service Livestock Behavioral Research Unit (LBRU) https://www.ars.usda.gov/midwest‐area/west‐lafayette‐in/livestock‐behavior‐research

Research on beak trimming Beak trimming conducted in 1‐day old chicks. Done to reduce injury and cannibalism. Two methods are hot blade and infrared treatment. Both can be painful. Genetic selection suggested alternative. References  Dennis, R. L. and Cheng, H. W. A Comparison of infrared and hot blade beak trimming in laying hens. Int. J. Poult. Sci. 8:716‐719. 2010.  Marchant‐Forde, R. M. and Cheng, H. W. Different effects of infrared and one‐half hot blade beak trimming on beak topography and growth. Poult. Sci. 89:2559‐64. 2010.  Dennis, R. L. and Cheng, H. W. Effects of different infrared beak treatment protocols on chicken welfare and physiology. Poult. Sci. 2012. 91: 1499‐505, 2012

Standards of Care  Agricultural Research Service (ARS) facilities implement standards of care as found in the Animal Welfare Act regulations, The Guide for the Care and Use of Laboratory Animals, and the Guide for the Care and Use of Agricultural Animals Used in Research and Teaching.  In general, pain and distress can be minimized when an animal receives the proper care in terms of feeding, watering, housing, and husbandry. Humane care in this regard ensures more consistent and reproducible study results.

National Agricultural Library  Animal Welfare Information Center (AWIC) https://www.nal.usda.gov/awic o Provides free training on identifying alternatives to painful procedures o Upcoming workshops: Oct 2‐3, 2019, March 12‐13, 2020, and May 14‐15, 2020

FDA/CVM: Veterinary Approval Process for Drugs for Acute Pain in Companion Animals

Pain in Animals Workshop October 2, 2019

Lisa Troutman, DVM, MS Division of Therapeutic Drugs for Non‐Food Animals FDA/CVM

General Approval Process

• The sponsor of the investigational animal drug product must: – Demonstrate the drug product works by substantial evidence of effectiveness in the target animal as defined in §21CFR514.4

– Show the drug product is safe to the target animal when used according to the label

– Manufacture a quality drug product according to cGMPs

– Address Environmental Impact under NEPA

– Properly label

www.fda.gov 2

Substantial Evidence of Effectiveness

• Consists of one or more adequate and well‐controlled studies that demonstrate the drug has the intended effect under the conditions proposed in the labeling.

www.fda.gov 3 Acute Pain Indications

• Acute pain is typically evaluated through postoperative pain studies. • CVM does not endorse any particular evaluation system or require a particular type of surgery to support postoperative pain indications. There is no one way to measure pain. • CVM highly encourages collaboration to overcome some of the challenges with these studies.

www.fda.gov 4

Acute Pain Indications

• For the control of postoperative pain

• For the management of postoperative pain – multi‐modal pain control

• The general type of surgery (soft tissue, orthopedic, dental) may also be included in the indication if only one surgery type is evaluated.

www.fda.gov 5

Centrally vs Peripherally Acting Drug Products

• Centrally acting drug products (such as most opioids) – one study that can adequately measure pain may be sufficient to support effectiveness for a general postoperative pain indication

• Peripherally acting drug products (such as NSAIDs) – two types of soft tissue surgery and one orthopedic surgery study are needed to support effectiveness for a general postoperative pain indication. – Otherwise the indication will reflect the type of study conducted: • Control of pain associated with soft tissue surgery or • Control of pain associated with orthopedic surgery. – Inflammation may be included the indication if the drug product has anti‐inflammatory properties as well. Control of pain and inflammation associated with X. www.fda.gov 6 Study Design Considerations

• Most studies utilize a placebo control with a rescue to transition a painful animal to standard of care analgesic.

• Add‐on studies are acceptable. – Eg. All animals receive an approved NSAID for the proposed indication +/‐ investigational drug product. – Superiority analysis

• Non‐inferiority studies are challenging because of the highly subjective nature of pain detection and the measurement tools utilized. High placebo rate affects analysis. www.fda.gov 7

Study Design Considerations con’t

• Primary endpoint is generally success/failure based on the need for rescue analgesia.

• Animals typically remain in the hospital for up to 3 days for pain assessments and safety evaluations.

• Animals randomized to treatment/control group by site instead of central randomization due to variability in surgical skill and subjective nature of pain assessment.

• Appropriate surgical procedures should be used to enable measurement of pain.

• If using more than one type of surgery, possibly stratify animals based on method of assessing pain, surgical type, or more/less painful procedures. – Food for thought: Do all procedures need to come from each site? www.fda.gov 8

Study Design Considerations con’t

• May need to evaluate transition to other analgesics for safety considerations.

• May be a limitation on the type of rescue that can be used due to safety considerations. – For example if an NSAID is evaluated, the rescue analgesic should not be an NSAID. – If a long acting opioid is evaluated, another opioid should be avoided.

• Protocol should address concomitant medications including pre‐meds and anesthetics. www.fda.gov 9 Considerations for Evaluation of Pain

• Pain is typically assessed for 3 days following surgery depending on the product. – Exceptions may be for an injectable product to be administered once, only in the clinic; can assess for pain control for 24 hour period and transition to another analgesic product to go home.

• The same individual typically assesses the animal for acute pain during this time period to minimize inter‐individual subjective variability. May depend on the assessment tool used. – Veterinary personnel assess the animal for acute pain versus an owner for chronic pain.

• Consider the need to evaluate pain during immediate post‐operative time period and during anesthetic recovery (eg. first 2 hours after extubation). If too sedate or emergence agitation present, the pain evaluation is skipped for that timepoint. – Challenge – can’t skip too many timepoints initially or case may be excluded from the effectiveness evaluation. Most rescues occur during the early timepoints – Challenge – timing of surgery vs timing of evaluations and clinic personnel www.fda.gov 10

Welfare Considerations

• All animals receive a short‐acting analgesic prior to surgery so pain is controlled during the surgical procedure.

• Animals are assessed for pain early and often during the first 12 hours at a minimum to allow for rescue to an analgesic using an appropriate standard of care.

• All animals are assessed for safety. www.fda.gov 11

www.fda.gov 12 Examples NSAIDs NSAIDs con’t • Rimadyl (carprofen)* • Onsior injection (robenacoxib) – For the control of postoperative pain and – For control of postoperative pain inflammation associated with orthopedic surgery, associated with soft tissue and orthopedic ovariohysterectomy and castration in cats > 4 months surgeries in dogs of age; for up to a maximum of 3 days – For the control of postoperative pain and inflammation associated with soft tissue surgery in • Metacam (meloxicam) Injectable* dogs > 4 months of age; for up to a maximum of 3 days • Onsior Tablets (robenacoxib) – For the control of postoperative pain and – For the control of postoperative pain and inflammation associated with orthopedic inflammation associated with orthopedic surgery, surgery, ovariohysterectomy and ovariohysterectomy and castration in cats ≥ 5.5 lbs castration when administered prior to (2.5 kg) and ≥ 4 months of age; for up to a maximum surgery in cats. Administer a single, one‐ of 3 days. time SQ dose. Opioids • Simbadol (buprenorphine) • Deramaxx (deracoxib)* For the control of postoperative pain associated with – For the control of postoperative pain and surgical procedures in cats inflammation associated with orthopedic surgery and dental surgery in dogs Local Analgesics • Previcox (firocoxib) • Nocita (bupivacaine liposome injectable suspension) – For the control of postoperative pain and – For single‐dose infiltration into the surgical site to inflammation associated with soft‐tissue produce local postoperative analgesia for cranial surgery and orthopedic surgery in dogs cruciate ligament surgery in dogs – For use as a peripheral nerve block to provide regional * ‐ and generics postoperative analgesia following onychectomy in cats www.fda.gov 13

Challenges

We invite and encourage collaboration to overcome challenges for assessing pain • High placebo rate • Subjective measurement tools – need better assay sensitivity to detect pain • Inter‐individual variability in the assessment of pain – training important – limit number of people assessing the same animal for pain • Variability in reliability of assessing pain across different surgery types and evaluation instruments. • Individual animal variability in displaying pain

www.fda.gov 14

www.fda.gov 15 Translational medicine • Could utilize animal studies to help support human drug development.

• Reflects actual conditions of use with naturally occurring conditions such as cranial cruciate ligament surgeries.

• Pain assessment in companion animals is similar to pediatrics (non‐verbal, based on body language)

• Recent data demonstrate that pediatric osteosarcoma is similar to canine osteosarcoma. Amputation of the affected limb is common practice in veterinary medicine and human medicine. Could this surgical procedure be used to support human drug development and vice versa? www.fda.gov 16

Questions? Panel Discussion

www.fda.gov 17 FDA CVM APPROVAL OF DRUGS TO CONTROL ACUTE PAIN IN FOOD ANIMALS – REGULATORY CHALLENGES AND OPPORTUNITIES Emily R. Smith DVM US Food and Drug Administration, Center for Veterinary Medicine, Rockville, MD

In order for a drug sponsor to obtain a new animal drug approval, the drug sponsor must demonstrate that the new animal drug is safe and effective in the target species/class when used in accordance with the label; and is a quality product manufactured according to current Good Manufacturing Practice. Additionally, the environmental impact for each new animal drug is assessed. For new animal drugs intended for use in food-producing animals, the safety assessment includes demonstrating that residues in food products (such as meat and milk) from a treated animal are safe for human consumption. New animal drugs are approved for specific indications and conditions of use (e.g. dosage regimens, species, animal class, withdrawal times, prescription status, etc.) which are developed based on a demonstration of effectiveness while balancing any risks associated with target animal safety, human food safety, human user safety, and environmental impact. Balancing these competing priorities can be challenging, particularly for drugs intended to control acute pain in a food-producing animal. For more specifics about the New Animal Drug approval process, refer to CVM’s website1.

The effectiveness of a new animal drug (“substantial evidence of effectiveness”) must be demonstrated through one or more adequate and well-controlled studies (21 CFR 514.117(a)) that include the measurement of appropriate parameters that reliably reflect the effectiveness of the drug and provide repeatable results with inferential value. A variety of adequate and well-controlled studies may be used to fulfill this requirement including a study in a target species, study in laboratory animals, field study, bioequivalence study, or an in vitro study. These studies may include but are not limited to published studies, foreign studies, or studies using models. Although field studies are the most commonly used study type, CVM also encourages innovative, non- traditional approaches to generating effectiveness data, where appropriate, including the use of real-world data and real-world evidence and systematic reviews and meta- analyses. When model studies are used, such studies must be validated to establish an adequate relationship of parameters measured and effects observed in the model with one or more significant effects of treatment.

Designing adequate and well-controlled stud(ies) to demonstrate substantial evidence of effectiveness of a new animal drug to control acute pain in food animals presents challenges such as, but not limited to, selection of one or more controls to ensure a valid comparison to the treated group; selection of appropriate study animals which represent the labeled target species and class; establishment of adequate methods to minimize bias; selection of endpoint(s) that are well defined and reliable; and pre- defining a basis of establishing effectiveness using the selected endpoint(s) that considers both statistical significance and clinical relevance. The emphasis on animal welfare, particularly with regard to surgical procedures performed in the course of routine husbandry of food animals has resulted in an increase of research into methods for detecting and assessing the severity of pain and demonstrating improvement after

1 “From an Idea to the Marketplace: The Journey of an Animal Drug through the Approval Process, https://www.fda.gov/animal-veterinary/animal-health-literacy/idea- marketplace-journey-animal-drug-through-approval-process#Common_Misconceptions treatment in a variety of food animal species. Continued development of reliable pain assessment tools is critical to facilitate the approval of effective drugs to control acute pain in food animals. Collaboration between regulatory agencies, academia, pharmaceutical companies, and producer groups is needed to overcome the challenges of developing new animal drugs which are safe and effective to control acute pain in food animals.

How is a subjective assessment tool validated? Dorothy (Dottie) Cimino Brown MS, DVM, DACVS Senior Director, Companion Animal Research Elanco Animal Health The question of whether the veterinarian and/or caregiver believes that an animal has benefited from an intervention is clinically relevant, and can be captured in carefully designed outcome assessment instruments. The fact that these assessments are inherently subjective does not preclude their use as valid and reliable outcome measures. If proper methodology is followed, subjective states can be reliably quantified with instruments that are readily available, easy to use, and standard across studies. The methodology includes informed item generation and selection, followed by testing for reliability and validity Item Generation: Initially, instrument development involves the generation of items (questions) that represent theoretic constructs (i.e. acute pain). Items are generated by veterinarians or caregivers with direct knowledge of the condition in question and a response option scaling system is chosen. Selecting the Items: Typically, not all of the items that are developed are ultimately included in the new instrument. Some may be confusing, interpreted differently by different respondents, or not deliver the desired information. Various criteria can be used to determine which of the developed items should be retained for the preliminary instrument. Reliability: Before one can obtain evidence that an instrument is measuring what is intended (validity), it is first necessary to gather evidence that it is measuring something reliably. An assessment of internal consistency can be based on data collected from a single administration of the instrument to a large group of respondents. Assessment of the stability (i.e. reproducibility) of responses can be made by administering the instrument to the same population of respondents on 2 different occasions, or different respondents making concurrent assessments of the same population. Validity: To determine that the instrument is measuring what is intended requires more than peer judgments (face validity). Validating an instrument is a process by which the degree of confidence that can be placed on conclusions drawn about an animal based on their score from that instrument is determined. Construct validity is evaluated when the attribute being measured cannot be directly observed. For example, acute pain cannot be ‘seen’, but behaviors can be observed which, according to theories about acute pain in animals, are a result of it. There is no one single experiment or statistic which can unequivocally ‘prove’ a construct, but multiple, well-designed, hypothesis driven studies can build the body of evidence that the instrument is measuring what is intended.

It is necessary to conduct validation studies for each new instrument that is developed and the task is an on-going one. If the instrument is to be used in target population in which the instrument was not initially validated, one should demonstrate that the inferences made for the new population are as valid as for the original one. In addition, modifications of the instrument such as changes in wording of items or responses, order of items, removal or addition of items, often requires new validity studies. Canine and feline postoperative subjective measurement; questionnaires, current status, gaps, pros and cons

Pain is a uniquely personal, multidimensional experience with sensory (discriminative), evaluative and affective (emotional) components, and the contemporary approach to pain measurement focuses on the affective dimension which describes pain’s unpleasantness, ‘how it makes you feel’.

Postoperatively, composite structured questionnaires, based on behaviours that can be reported by a veterinary surgeon or nurse/technician, allow us to measure this complex emotional experience and this ability to ‘measure what matters’ comes top of the list of ‘pros’. However, the requirement for an observer adds an extra layer of complexity, which results in problems such as interobserver variability and respondent bias, both of which can be addressed to some extent through careful construction of the questionnaires and the use of specific protocols.

So that we can have confidence in the value of a postoperative questionnaire for use in clinical or trial applications, it should have published evidence of its validity and reliability, both key properties of a scientifically robust measure. Furthermore, it is helpful to have evidence for its performance (sensitivity and responsiveness) and its interpretability (intervention level for analgesia). Currently there are several composite questionnaires available for postoperative use in dogs and cats, but the majority do not meet these criteria. Those which do have been developed using psychometric methods that are well established in the field of health measurement to ensure their scientific rigour, but to maintain this standard the questionnaires must be used as is, without modification of any kind and according to a defined protocol. Unfortunately, one of the ‘cons’ of these paper‐based questionnaires is that it is very easy for users to modify the scale to suit their purpose, alter the scoring mechanism or use intervention levels based on their experience rather than a scientific foundation. Users do this with the best of intentions not realising the serious consequences this has for the scale’s validity, so going forward it will be important to provide more education on usage and provide a mechanism to prohibit modification. This could be best achieved through electronic delivery and automatic scores calculation.

There is much to be gained from future work in this field. Validity is not determined by a single statistic, but by a body of research that supports the claim that a questionnaire instrument is valid for particular purposes, with defined populations and in specified contexts. The same applies to intervention levels. Going forward, evidence could be sought for feral as well domestic populations and acute pain arising from sources and contexts other than surgery, thus broadening the scope of the scale for clinical use where the focus is on clinical decision making.

Existing scales are ordinal in nature which means that the questionnaire items are ranked in order of the amount of pain they represent and while this level of measurement is adequate for clinical purposes, the creation of interval level measurement (continuous measurement like a ruler) would facilitate more effective monitoring of acute pain and analgesic efficacy, thus producing improved outcome measures for clinical trials.

Further reading: Reid J, Nolan AM, Scott EM. Measuring pain in dogs and cats using structured behavioural observation. The Veterinary Journal. 2018 Jun 1;236:72‐9.

Canine/Feline POP measurement: EEG, noxious stimuli, fMRI Dr. Jo Murrell University of Bristol / Highcroft Veterinary Referrals UK

In animals, following the trend in human medicine, many different objective measurements have been investigated in the search for a biomarker for pain. These include neurophysiological measures such as electroencephalography (EEG) and Quantitative Sensory Testing. fMRI has been widely used in experimental studies in humans but studies in cats and dogs are lacking.

Electroencephalography: The EEG is the electrical activity recorded from electrodes placed at various locations on the head. It consists of the summated electrical activity of populations of neurones together with a contribution from the glial cells. Johnson and colleagues have carried out a number of studies in dogs to investigate EEG changes that occur with nociception during surgery in a “minimal anaesthesia model” (Murrell & Johnson 2006). In this model dogs were anaesthetized with a low concentration of halothane (0.85-0.95%) and EEG recorded in a three electrode montage during ovariohysterectomy and castration. Fast Fourier Transformation (FFT) of raw EEG data changes the data from the time domain (change in voltage against time) to the frequency domain (power within different frequency bands) and there is good evidence that following FFT, median frequency (the frequency below which 50% of the power is located) is elevated during nociception and this change can be obtunded by the administration of analgesic drugs (Trucchi et al. 2003, Kongara et al. 2012). Total power of the EEG has also been shown to decrease with noxious stimuli (Kongara et al. 2013). However many factors can affect the EEG such as drugs used for induction of anaesthesia, body temperature and depth of anaesthesia so although these neurophysiological biomarkers appear to be relatively robust and have been shown across different species, careful experimental technique is required for them to be detected. The Bispectral Index has also been measured as a biomarker for depth of anaesthesia in dogs but it is important to be aware that this machine uses human data for its proprietary algorithms and these data are unlikely to be appropriate for dogs.

Quantitative sensory testing: Evaluation of the response to externally applied physical stimuli, such as pressure, heat, or cold is termed quantitative sensory testing (QST) and it is used to provide important information regarding the functioning of the sensory systems which detect and mediate these phenomena in both humans and animals. There is a relatively long history of QST in veterinary medicine with studies first performed around the mid-1990’s by the group of Waterman-Pearson in clinical patients. Most studies have focused on changes in mechanical sensitivity following surgery, using ramped devices that are attached to the limb to deliver a controlled mechanical stimulus or hand held devices such as those manufactured by TopCat Metrology (https://www.topcatmetrology.com). Mechanical hyperalgesia, both at the site of surgery and at distant sites has been widely demonstrated after surgery using these devices with the potential for analgesic drugs to obtund hyperalgesia shown in some studies (Lascelles et al. 1997). Factors such as rate of application of force, tip diameter and site of application have all been shown to affect mechanical nociceptive threshold therefore careful experimental design is needed and when these factors vary it is difficult to compare results between studies. fMRI: fMRI uses the blood-oxygen- level-dependent (BOLD) contrast imaging, which is indicative of synaptic activity. The BOLD technique evaluates the difference in magnetic susceptibility between the oxygenated blood required by active neurons and the resultant deoxygenated blood and creates the fMRI signal from this difference. The fMRI BOLD technique is an extremely useful measure in acute and experimental pain where there are short periods of pain followed by short periods that are pain free, causing a rapidly changing hemodynamic response. This allows the study of acute pain response in pain-free volunteers but is not well suited to the monitoring of responses to changes in chronic pain. fMRI has been used to establish a neural signature of pain involving activation of structures such as the primary and secondary somatosensory cortices, anterior cingulate cortex, thalamus and insular cortex. However, note that activation of these structures is not unique to painful stimuli, and any salient stimuli (e.g. loud auditory sounds, prominent visual stimuli) will also activate a similar subset of brain structures (Mouraux et al. 2011). A major limitation of fMRI pain studies in animals is that in order to experience pain the animal must be conscious, yet although conscious dogs have been trained to lie still in MRI scanners during scanning, it is difficult to see how this could be achieved when the dog is also delivered a noxious stimulus. Perhaps dogs could be trained to lie still so that they could be scanned before and after routine surgery to investigate post-operative pain states, but it is uncertain whether haemodynamic changes in a static post-op state would be sufficient to detect changes as opposed to when an acute experimental noxious stimulus is delivered.

References Kongara et al. (2012) N Z Vet J. 60(2):129-35. Kongara et al. (2013). N Z Vet J. 61(6):349-53. Lascelles et al. (2007) Pain. 73(3):461-71. Mouraux et al. (2011) Neuroimage. 54(3):2237-49. Murrell JC and Johnson CB (2006). J Vet Pharmacol Ther. 29(5):325-35. Trucchi et al. (2003). Vet Res Commun. 27 Suppl 1:803-5.

Application of lameness scoring in the drug approval process in food animals Kelly F. Lechtenberg, DVM, PhD President, Midwest Veterinary Services, Inc. Oakland, NE 68045 Societal concern about the moral and ethical treatment of food animals is increasing. In particular, pain associated with lameness impacts cattle and swine production in both economic losses and welfare considerations. In addition to production deficits, pain and distress associated with lameness has been documented.1 Mean lameness prevalence in herds has been reported as high as 33.7% and 36.8% in Wisconsin and the United Kingdom, respectively; however, in other survey studies a less than 10% prevalence of lame cattle were reported by producers.2-4 FDA Guidance Document 123 for the development of effectiveness data for non-steroidal anti- inflammatory drugs (NSAIDs) states that “validated methods of pain assessment must be used in order for a drug to be indicated for pain relief in the target species”.5 The identification and validation of robust and reproducible measurements of acute pain is therefore fundamental for the approval of effective analgesic drug regimens for use in livestock. In efforts to improve earlier detection and treatment of lameness, locomotion scoring systems have been developed for routine utilization by farm employees.6,7 It has been suggested that earlier analgesia treatment may aid in the alleviation of acute pain perception or in the mitigation of wind-up that can lead to central sensitization.8 Behavioral changes associated with lameness are indicative of attempts by the animal to protect the affected limb from further injury.9 Changes in posture associated with lameness have been summarized in an excellent review article by Whay and form the basis of most locomotion scoring systems.9 An arched back is frequently associated with lameness and is the key behavioral change evaluated in the Sprecher lameness scoring system (1997).6 Other behavioral changes associated with lameness that can be visually scored include:15 1. Hanging or “bobbing” of the head during locomotion, 2. Shortening or lengthening of the stride, 3. Changes in the degree of abduction or adduction of the limbs with an increased deviation from the vertical seen in one hindlimb, 4. Changes in claw placement (over or under extension of the stride) resulting in the hind claw not being placed in the same location as the front claw after initiation of the stride 5. Changes in the alignment of the pin bones (tuber coxae) when walking which results in deviations from a hypothetical horizontal line when viewed from behind 6. Changes in the animal’s willingness to walk with a reluctance to move being frequently associated with lameness affecting multiple claws 7. Changes in the stance phase of the stride resulting in the animal maintaining its weight on the sound limb for as long as possible in order to minimize weight bearing time on the lame limb. The extent to which the aforementioned changes occur can be assigned a score ranging from a simple binomial score (present OR absent) to an ordinal scale based on the presence and perceived severity of one or more of these behavioral signs in the same animal. Ordinal data should be analyzed using appropriate statistical methods and should not be subjected to analysis using methods such as paired t-tests that are reserved for continuous data. In the future, Visual Analog Scales (VAS) may become more widely used as an alternative to ordinal locomotion scoring methods in a research setting since these generate continuous data. This information is considered to provide more robust outcomes when analyzed statistically because traditional methods of assessment for continuous data such as t-tests can be used. The VAS is a 100 mm (10 cm) line anchored at either end by descriptors, typically “normal” or “lame” or in humans, “no pain” or “worst pain imaginable”.7,10 The scorer marks the line between the 2 descriptors to indicate the lameness or pain intensity. A millimeter scale is used to measure the score from the zero anchor point to the scorer’s mark. This system therefore potentially provides 101 levels of “intensity” that are considered more sensitive for assessing the effects of an analgesic compound that an ordinal scale. Lame cattle have been successfully identified using overall VAS scores with VAS assessment possessing reasonable intra- and interobserver reliability; however a 5-point numeric rating system (NRS) provided a better estimate of hoof lesions.13 Additional research is necessary for further evaluation and its potential application. One deficiency of locomotion scoring systems is the potential for a lack of reproducibility between scorers. This has restricted the utility of locomotion scoring as a validated outcome measure for assessing analgesic efficacy during the drug approval process. In the authors’ experience, there is typically a 70 to 80% agreement between 2 masked scorers evaluating lameness simultaneously using the Sprecher system. Furthermore, male scorers tend to assign lower pain scores compared with female scorers. These factors have necessitated the development of alternative methods of pain assessment including the use of force plates or pressure mats as will be described in other sessions at this conference.

References 1. Whay HR, Waterman AE, Webster AJF et al.The influence of lesions type on the duration of hyperalgesia associated with hindlimb lameness in dairy cattle. Vet J 1998;156:23-29. 2. Cook NB. Prevalence of lameness among dairy cattle in Wisconsin as a function of housing type and stall surface. J Am Vet Med Assoc. 2003; 223:1324-1328. 3.Barker ZE, Leach KA, Whay HR, et al. Assessment of lameness prevalence and associated risk factors in dairy herds in England and Wales. J Dairy Sci. 2010;93:932-941. 4. Fulwider WK, Grandin T, Rollin BE, et al. Survey of dairy management practices on one hundred thirteen North Central and Northeastern United States dairies. J Dairy Sci.2008;91:1686-1692. 5. FDA-CVM. US Food and Drug Administration, Center for Veterinary Medicine. Guideline No. 123. Development of target animal safety and effectiveness data to support approval of non-steroidal anti-inflammatory drugs (NSAID’s) for use in animals. Available at http://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM052 663.pdf Accessed 29 August 2019. 6. Sprecher DJ, Hostetler DE, Kaneene JB. A lameness scoring system that uses posture and gait to predict dairy cattle reproductive performance. Theriogenology 1997;47:1179-1187. 7. Flower FC and Weary DM. Effect of hoof pathologies on subjective assessments of dairy cow gait. J Dairy Sci. 2006;89:139-146. 8. Anderson DE and Muir WM. Pain management in Cattle. Vet Clin North Am Food Anim Pract. 2005:21:623- 635. 9. Whay HR. Locomotion scoring and lameness detection in dairy cattle. In Practice. 2002; 24:444-449. 10. Williamson A and Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798-804.

Bovine post-operative pain subjective measurement Stelio P L Luna, DVM, Msci, PhD, DipECVAA Species-specific behaviors are easier to apply clinically, compared to pain assessment objective methods; however, they are individual and age-dependent, are inconstant and time-consuming. A validation process minimizes these limitations. Pain scales are developed according to an ethogram constructed in the perioperative period, combined with literature data. Reliability, responsiveness, and validity are performed to support that the instrument can be used experimentally and clinically. The most common surgical procedures in cattle are dehorning and castration. The characteristic POP signs after dehorning are shaking the head, ear movements, rubbing the head against surfaces, lying and standing frequently, lying still, foot stamp and vocalization1. Cattle suffering pain after castration reduce the time spent in eating, ruminating, walking, and interacting with the environment. Other behaviors include abnormal gait (restricted movement; short steps), standing idle, with head down or in abnormal posture, lying down in sternal recumbence with head down, extension of one or more limbs, wagging the tail, licking the surgical wound and foot stamping2. The UNESP-Botucatu scale for assessing POP in cattle after castration is a valid, reliable, and responsive instrument; the intervention point for rescue analgesia is ≥ 5 of 102. However, this instrument was developed only in Bos indicus and has not been clinically validated yet. To overcome these limitations, a recent clinical study investigated the use of this instrument in Bos taurus (Angus) and Bos indicus (Nelore) submitted to orchiectomy. The instrument showed good inter-observer reliability (≈0.75), was responsive, as pain scores increased after surgery, and may be used to assess POP both in both species. A Cow Pain Scale, composed of a behavioral and facial score, was developed in a variety of clinical scenarios in dairy cows. A score above 3 of 12 was indicative of pain3. The scale identifies cows in pain in a clinical scenario; however, it requires validation to assess POP. For the future, a new study is in progress to assess the Unesp-Botucatu scale2 in orthopedic surgery and different clinical conditions. We expect the results will provide a validated instrument to assess pain in both clinical and POP in cattle and offer a reliable method to diagnose and guide treatment in these species. Stock ML et al. Vet Clin North Am Food Anim Pract. 2013;29(1):103-133 Oliveira FA et al. BMC Vet Res. 2014;10(200):1-14. Gleerup K. Appl Anim Behav Sci. 2015;171:25-32. Pain Management in Swine

Monique Pairis-Garcia, PhD, DVM, DACAW

1

Industry expectations

Supporting the use of pain mitigation (such as anesthetic or analgesic) for tail docking and castration of piglets

Jan, 2014

2

Pain management in commercial swine

● No FDA approved drugs labelled for pain

● Economically feasible

● Realistic to implement on a large scale

3 FDA Approval

“It’s hard to establish reliable ways to detect and measure pain in food- producing animals because they have such subtle pain responses,” explained Emily Smith, a veterinarian and drug reviewer at FDA’s Center for Veterinary Medicine (CVM).

4 4

Economically feasible

• 6.1 million sows in the United States • 2.2 litters a year • 7 male pigs/litter

5

On-farm implementation

Administration route?

Pre-emptive administration?

Dosing frequency?

6 On-farm? implementation

Administration route? Pre-emptive administration? ? Dosing frequency?

7

Where do we go from here?

8

Pain Mitigation Assessment Protocol Working Group

Objective: Establish a research protocol to reliably evaluate efficacy of pain mitigation interventions in nursing male piglets during castration

9 Collaboration!

10

Collaboration!

Prairie Swine Merck Animal Kansas State Research Centre Health CVM National Pork Board

AASV

Smithfield Hog Production Iowa State AgResearch Kansas State CVM Ltd. CVM

11

PMAP Consortium Objective

12 PMAP Consortium Timeline

▪ Treatment Groups ▪ Sham castration ▪ Sham castration + Intervention ▪ Surgical castration + Placebo ▪ Surgical castration + Intervention

▪ Data collection ▪ Behavior ▪ Blood biomarkers ▪ Infrared Thermography ▪ Pressure Mat ▪ Productivity and mortality

13

Next steps?

14

Next steps

• Work directly with FDA Center for Veterinary Medicine

• Revise protocol

• Conduct GLP trial

• Revise protocol

• Conduct on-farm trial

15 Thank you!

Any questions?

16 Facial expression across species in assessing acute pain Karina B. Gleerup, DVM, PhD, post-doc researcher, Denmark Pia Haubro Andersen,DVM, PhD DVSCi, Professor, Sweden

During the past ten years, facial expressions of pain has been proposed in several species as a useful pain evaluation tool [1]. Facial expressions are suggested to provide a means for studying the affective component of pain in animals over nociception [1, 2] and seem to be present in horses even when gross pain behaviour is concealed [3]. Facial expressions of pain has been suggested to facilitate detecting animals in pain [4, 5] but also as a method for evaluating post-surgical patients [6, 7], monitoring patients in hospitals [8-10] and the latest suggestion is to evaluate facial expressions in lame horses under rider [11]. The studies within the field rely on extremely varied definitions of the pain face. Some studies include e.g. head position [11] or flehmen and yawning [8] which is traditionally considered gross pain behaviors [12]. In addition, there is a discrepancy not only in the use of nomenclature but also in the precision of the descriptions of the facial activities, which has become obvious since the publication of the detailed work on the Equine Facial Action Coding System by Wathan et al. [13]. The numerous publications on grimace scales in different species may give the impression that pain evaluation using facial expressions can stand alone, which is not necessarily true for horses and cattle where other behavioral measures have proven useful, even by direct observations [4, 12]. Facial expressions change in animals exposed to external stimuli, that may be negative as well as positive [14]. Because facial expressions are subtle and easily influenced, it is imperative to consider all external stimuli when designing studies [15]. Several studies use still frames for evaluating facial expressions while there is evidence suggesting that the dynamics are important to make the right decisions on whether signs of pain are present [16]. Altogether, a pain face as an indicator of acute pain may be a sensitive and powerful tool but it is important to consider how the use of the pain face is implemented. Correctly used by horse owners and farmers the pain face can lead to raised awareness of animals possibly in pain and consultation of a veterinarian. The veterinarian should then apply the proper diagnostics and pose the correct questions revealing whether the animal shows other pain behaviors e.g. kicking when milked [17] or problems when ridden [18]. Another use is the frequent routine application of face- based pain assessment as alerts in veterinary hospitals. Here, pain assessment involving other behavioral parameters can be performed stronger in combination with the facial expressions.[8, 12]. Observation time and resources associated with prolonged observation is a limiting factor in the veterinary hospital setting, pointing to the need for automated screening tools, which are currently being developed by computer vision technology [20]

Acknowledgements. This research was partly funded by The Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning.

1. Descovich, K.A., et al., Facial expression: An under-utilised tool for the assessment of welfare in mammals. ALTEX, 2017. 2. Kunz, M., et al., Cerebral regulation of facial expressions of pain. The Journal of Neuroscience, 2011. 31(24): p. 8730-8738. 3. Coles B, Birgitsdottir L, and A. PH, Out of Sight but Not out of Clinician’s Mind: Using Remote Video Surveillance to Disclose Concealed Pain Behavior in Hospitalized Horses, in International Association for the Study of Pain 17th World Congress. 2018: Boston, USA. 4. Gleerup, K.B., et al., Pain evaluation in dairy cattle. Applied Animal Behaviour Science, 2015. 171: p. 25-32. 5. Gleerup, K.B., et al., An equine pain face. Veterinary anaesthesia and analgesia, 2014. 6. Dalla Costa, E., et al., Development of the Horse Grimace Scale (HGS) as a Pain Assessment Tool in Horses Undergoing Routine Castration. PloS one, 2014. 9(3): p. e92281. 7. Gleerup KB, C.T., Musk, GC, Hyndman TH, Lehmann HS, Johnson CB, Laurence M, Pain face intensity for quantification of pain in Bos indicus bull calves, in 51st Congress of the International Society for Applied Ethology, M.S.H. Margit Bak Jensen, Jens Malmkvist, Editor. 2017, Wageningen Academic Publishers: Aarhus, Denmark. p. 155. 8. van Loon, J.P. and M.C. Van Dierendonck, Monitoring acute equine visceral pain with the Equine Utrecht University Scale for Composite Pain Assessment (EQUUS-COMPASS) and the Equine Utrecht University Scale for Facial Assessment of Pain (EQUUS-FAP): A scale- construction study. The Veterinary Journal, 2015. 206(3): p. 356-364. 9. van Loon, J.P. and M.C. van Dierendonck, Monitoring equine head-related pain with the Equine Utrecht University scale for facial assessment of pain (EQUUS-FAP). The Veterinary Journal, 2017. 10. Dalla Costa, E., et al., Using the Horse Grimace Scale (HGS) to Assess Pain Associated with Acute Laminitis in Horses (Equus caballus). Animals, 2016. 6(8): p. 47. 11. Dyson, S., et al., Can the presence of musculoskeletal pain be determined from the facial expressions of ridden horses (FEReq)? Journal of Veterinary Behavior: Clinical Applications and Research, 2017. 19: p. 78-89. 12. Gleerup, K. and C. Lindegaard, Recognition and quantification of pain in horses: A tutorial review. Equine Veterinary Education, 2016. 28(1): p. 47-57. 13. Wathan, J., et al., EquiFACS: the equine facial action coding system. PloS one, 2015. 10(8): p. e0131738. 14. Hintze, S., et al., Are Eyes a Mirror of the Soul? What Eye Wrinkles Reveal about a Horse’s Emotional State. PloS one, 2016. 11(10): p. e0164017. 15. Gleerup, K.B., P.H. Andersen, and J. Wathan, What information might be in the facial expressions of ridden horses? Adaptation of behavioral research methodologies in a new field. Journal of Veterinary Behavior, 2018. 23: p. 101-103. 16. Broomé, S., et al. Dynamics are Important for the Recognition of Equine Pain in Video. in Proceedings of the IEEE Conference on Computer Vision and Pattern Recognition. 2019. 17. Fogsgaard, K.K., T.W. Bennedsgaard, and M.S. Herskin, Behavioral changes in freestall- housed dairy cows with naturally occurring clinical mastitis. Journal of dairy science, 2015. 98(3): p. 1730-1738. 18. Hall, C., et al., Assessment of ridden horse behavior. Journal of Veterinary Behavior: Clinical Applications and Research, 2013. 8(2): p. 62-73. 19. Rashid, M., X. Gu, and Y.J. Lee, Interspecies Knowledge Transfer for Facial Keypoint Detection. arXiv preprint arXiv:1704.04023, 2017. 20. Andersen, P.H., et al., Can a Machine Learn to See Horse Pain? An Interdisciplinary Approach Towards Automated Decoding of Facial Expressions of Pain in the Horse, in Measuring Behaviour, R.A. Grant, Editor. 2018: Manchester, UK. p. 146 -152.

TRIALS AND TRIBULATIONS Companion Animal Welfare Perspectives in Clinical Research: consent forms, repeat study enrollment, long term follow-up and adverse events.

Discussion moderator: Dr Sheilah A Robertson BVMS (Hons), PhD, DACVAA, DECVAA, DACAW, DECAWBM (WSEL), MRCVS. Senior Medical Director Lap of Love Veterinary Hospice, Courtesy Professor University of Florida.

The goal of this session is to generate discussion on several important aspect of using client owned animals in research. Several topics and questions for discussion along with references are set out below. Preamble: As veterinarians, animal health and welfare are our primary consideration for the animals under our care. Two of the most important medical ethical principles are autonomy (respecting the patient’s own decision) and informed consent. In veterinary medicine the animal has no say in its own destiny and consent is transferred to the owner. In human medicine consent for treatment may be passed to a surrogate or “proxy” (e.g. in the case newborn infants, cognitively impaired individuals or non-verbal patient). In cases where there is limited information on which to base a treatment, we may find ourselves in a grey area between being a veterinary surgeon and a research scientist.1 Using a novel therapy may be in the best interest of the individual patient but also serve to advance veterinary science. Increasingly, companion animals in particular dogs with naturally occurring cancer are seen as a way to accelerate translational drug development.2 Due to their size, genetic diversity and a high incidence of some cancers that are similar to those in humans, this could be a win-win situation because of the poor predictive value of studies conducted in rodent models. Clinical trials using client owned animals requires careful planning, good study design and ethical review which has been addressed in part by some “best practice recommendations” and advice on how to glean meaningful data in a timely manner.3,4 Yeates provides food for though in his essay on ethical principles for novel therapies in veterinary practice.5 Informed consent is central to any discussion of veterinary clinical research. The goal is that the owner grants the clinician / researcher permission to participate with full knowledge of the possible risks and benefits to their pet.6 This may be one area where we fail. The authors of a prospective study of 53 veterinary clinical trial consent forms concluded that “no form evaluated met current health literacy recommendations for readability”.7 In the United Sates the average American adult reads at a 10 to 14 years of age level. Questions 1. Are we sure we do not influence clients to participate in clinical trials?8 2. What are the pros and cons of allowing client owned animals to participate in multiple studies? 3. Does offering financial incentives to participate influence the study outcome? 4. Do financial incentives alter the socioeconomic background and source of study participants? 5. How far should our obligations to the client and animal go in the face of an adverse event?

References 1. Everitt S. Veterinary clinical research - legal, ethical and welfare considerations. J Small Anim Pract. 2013;54(3):117-8. 2. Regan D, Garcia K, Thamm DH. Clinical, Pathological, and Ethical Considerations for the Conduct of Clinical Trials in Dogs with Naturally Occurring Cancer: A Comparative Approach to Accelerate Translational Drug Development. ILAR Journal. 2019;59(1):99-110. 3. Page R, Baneux P, Vail D, Duda L, Olson P, Anestidou L, et al. Conduct, Oversight, and Ethical Considerations of Clinical Trials in Companion Animals with Cancer: Report of a Workshop on Best Practice Recommendations. J Vet Intern Med. 2016;30(2):527-35. 4. Thamm DH, Vail DM. Veterinary oncology clinical trials: design and implementation. Vet J. 2015;205(2):226- 32. 5. Yeates JW. Ethical principles for novel therapies in veterinary practice. J Small Anim Pract. 2016;57(2):67-73. 6. Yeates J, Everitt S, Innes JF, Day MJ. Ethical and evidential considerations on the use of novel therapies in veterinary practice. J Small Anim Pract. 2013;54(3):119-23. 7. Sobolewski J, Bryan JN, Duval D, O'Kell A, Tate DJ, Webb T, et al. Readability of consent forms in veterinary clinical research. J Vet Intern Med. 2019;33(2):350-5. 8. Yeates JW, Main DC. The ethics of influencing clients. J Am Vet Med Assoc. 2010;237(3):263-7 ABSTRACT: Current Status of Objective Pain Measurement in Non-Verbal Pediatrics Kenneth D. Craig The challenges posed in development of psychometrically sound measures of pain in human infants and children share commonalities with those confronted in measurement of pain in nonhuman animals. Pain in humans is conceptualized as a distressing experience with sensory, emotional, cognitive and social features, a perspective different from commonplace unidimensional approaches to pain as a sensory experience. This subjective, multidimensional experience can only be accessed if there are observable physiological or behavioral manifestations. The domain of observable manifestations is extensive and includes both reflexive or automatic expressions and controlled or self-regulated representations. Verbal self-report is prized in humans, often without respect to its limitations. Analogous forms of nonverbal self-report probably are available in some nonhuman species. The biological and behavioral repertoire available will vary with species and stages of development, although consistencies in biologically conserved response systems and patterns, as well as differences, can be discerned. Careful species specific description of response patterns provides a basis for subsequent systematic observations. Transformations in pain expression with age reflect maturation and life experience, including social learning opportunities as human children acquire skill in engaging parental care and self-regulation. Measures that can be described as objective are needed given documentation of potential bias in expression of pain on the part of people suffering and in the judgements of observers, including clinicians, family and others. The past several decades has seen numerous proposals for “objective” observational scales of pain in infants and children, but relatively little systematic study of their psychometric properties. There is remarkable diversity and little agreement in behavioral items to be observed on commonly used scales, with many of them questionably “objective”, suggesting that further ethographic description is warranted. Consideration of the role of controlled or purposive expression draws attention to the potential for misrepresentation, either suppression or exaggeration, display patterns characterized in human children and adults, and perhaps in nonhuman species. Assessment that considers emotional, e.g., fear, and cognitive, e.g, catastrophizing, processes and contextual, e.g., social, influences on expression is important. Most scales include a focus on facial expression, given that a pattern of facial display relatively sensitive and specific to noxious events can be observed in humans who are typically developing and communication challenged throughout the life-span, from pre-term neonates to older persons with dementia. The prototypical pattern has been characterized using both experimental and clinical pain, but descriptions of facial pain grimaces on observational scales can differ strikingly from empirical accounts, as do pain estimates based upon them. There has been progress in the application of computer-based machine learning algorithms to automatically assess pain in children using facial expression and psychophysiological measures. The methodologies employed to characterize facial expression in infants and children were successfully translated into a scale for the assessment of mouse pain, with this inspiring considerable development of facial grimace scales for other nonhuman species. In sum, there has been progress, but pediatric pain measurement remains a work in progress.

Activity monitors for acute pain measurement

B. Duncan X. Lascelles BSc, BVSC, PhD, FRCVS, CertVA, DSAS(ST), DECVS, DACVS Translational Research in Pain (TRiP) Program, Comparative Pain Research and Education Center, North Carolina State University, Raleigh, NC, USA

The objective measurement of activity appears, on the surface, to be an attractive option to measuring acute pain. So far, in non‐human species, investigations of activity monitors (AM) (pedometers and/or accelerometers) in relation to pain have mainly focused on chronic conditions such as chronic lameness, osteoarthritis and pruritus. Several studies evaluating the use of accelerometers in various species have correlated activity counts with the actual behavior and movements of the animals (essentially validating them as a measure of movement). Subsequently, primarily in companion animals, studies have used activity monitors as outcome measures to assess putative analgesics for chronic pain conditions in companion animals. 1‐5

In humans, accelerometers have been used to assess recovery from acute surgical pain. Cumulative physical activity has been used to gauge recovery following laparoscopic surgery in humans (Inoue et al., 2003). Activity monitors have also been used to detect and measure specific activities, such as number of steps 6 or sitting and standing time 7, in order to assess postsurgical progress. In contrast to chronic pain conditions, relatively little research has been performed in animals using accelerometers to assess acute pain, or the effects of surgery.

Notably, several studies have been performed in calves, using accelerometers to assess the effects of acute pain and analgesic provision. 8‐11 In these studies, accelerometers have been used to assess both excessive movement in response to surgical procedures, and also reduced activities following surgery. In contrast, only two studies have utilized accelerometers as measures of postoperative pain in dogs 12,13 and none in cats. Both studies in dogs have evaluated a minimally invasive technique compared to what is considered a more invasive technique. Using simple summary measures, Culp et al. (2009) reported total activity 48 hours post‐surgery was decreased by 25% in dogs that underwent laparoscopic ovariectomy whereas dogs that underwent an open ovariectomy had a 62% decrease in activity.

It is somewhat surprising, given the face validity of decreased movement in association with acute postoperative pain, that more postoperative pain studies using accelerometers have not been conducted. However, movement postoperatively can be both increased and decreased due to discomfort and so the appropriate implementation of accelerometers as outcome measures for acute pain is likely be more nuanced. The effect of pain on activity immediately post‐surgery, as well as in the days following surgery needs to be understood in order to understand how to use accelerometers. The effect of surgical pain on specific activities needs to be understood, and algorithms developed to measure these specific activities. Despite these hurdles, accelerometry appears to be an underdeveloped and underused outcome measure in acute pain assessment.

1. Wernham BG, Trumpatori B, Hash J, et al. Dose reduction of meloxicam in dogs with osteoarthritis‐associated pain and impaired mobility. Journal of veterinary internal medicine / American College of Veterinary Internal Medicine 2011;25:1298‐1305. 2. Walton MB, Cowderoy EC, Wustefeld‐Janssens B, et al. Mavacoxib and meloxicam for canine osteoarthritis: a randomised clinical comparator trial. Vet Rec 2014;175:280. 3. Brown DC, Boston RC, Farrar JT. Use of an activity monitor to detect response to treatment in dogs with osteoarthritis. J Am Vet Med Assoc 2010;237:66‐70. 4. Gruen ME, Griffith EH, Thomson AE, et al. Criterion Validation Testing of Clinical Metrology Instruments for Measuring Degenerative Joint Disease Associated Mobility Impairment in Cats. PLoS One 2015;10:e0131839. 5. Gruen ME, Thomson AE, Griffith EH, et al. A Feline‐Specific Anti‐Nerve Growth Factor Antibody Improves Mobility in Cats with Degenerative Joint Disease‐Associated Pain: A Pilot Proof of Concept Study. Journal of veterinary internal medicine / American College of Veterinary Internal Medicine 2016;30:1138‐1148. 6. Cook DJ, Thompson JE, Prinsen SK, et al. Functional recovery in the elderly after major surgery: assessment of mobility recovery using wireless technology. Ann Thorac Surg 2013;96:1057‐1061. 7. Aziz O, Atallah L, Lo B, et al. A pervasive body sensor network for measuring postoperative recovery at home. Surg Innov 2007;14:83‐90. 8. Melendez DM, Marti S, Pajor EA, et al. Effect of meloxicam and lidocaine administered alone or in combination on indicators of pain and distress during and after knife castration in weaned beef calves. PLoS One 2018;13:e0207289. 9. Brown AC, Powell JG, Kegley EB, et al. Effect of castration timing and oral meloxicam administration on growth performance, inflammation, behavior, and carcass quality of beef calves. J Anim Sci 2015;93:2460‐2470. 10. Heinrich A, Duffield TF, Lissemore KD, et al. The effect of meloxicam on behavior and pain sensitivity of dairy calves following cautery dehorning with a local anesthetic. J Dairy Sci 2010;93:2450‐2457. 11. White BJ, Coetzee JF, Renter DG, et al. Evaluation of two‐dimensional accelerometers to monitor behavior of beef calves after castration. Am J Vet Res 2008;69:1005‐1012. 12. Culp WT, Mayhew PD, Brown DC. The effect of laparoscopic versus open ovariectomy on postsurgical activity in small dogs. Vet Surg 2009;38:811‐817. 13. Mayhew PD, Brown DC. Prospective evaluation of two intracorporeally sutured prophylactic laparoscopic gastropexy techniques compared with laparoscopic‐assisted gastropexy in dogs. Vet Surg 2009;38:738‐746.

Remote monitoring technology: Food Animal Brad J. White, DVM, MS Kansas State University, College of Veterinary Medicine, Manhattan, KS [email protected]

Key points  Monitoring cattle behavior can help determine changes in wellness and pain status  Multiple modalities are available to measure varied activities  Behavioral responses should be evaluated in aggregate to provide a more complete picture of animal response while accounting for individual variability

REMOTE MONITORING TECHNOLOGIES IN FOOD ANIMALS Stress, pain, and disease modify animal behavior, and remotely monitoring these alterations provides animal researchers valuable information. Accurate evaluation of pain reduction interventions relies on quantifiable, repeatable outcome measurements. Cattle behavioral and physiologic parameters change in response to pain events and while these differences are relatively sensitive tools they are not specific to pain response. Visual observation (direct or video recording) is the most common method used to identify potential behavioral changes, and challenges of this approach include repeatability among observers, maintaining appropriate frequency of observation, and high labor costs associated with monitoring. Remote monitoring technologies provide an option to provide continuous, objective behavioral monitoring which can provide valuable information on animal pain status.

Multiple modalities exist to remotely monitor cattle behavioral and physiologic changes. Monitoring technologies can be grouped into activity monitoring (e.g. accelerometers, pedometers), proximity / location systems (e.g. GPS, real-time location systems, feed/water intake), and remote physiologic monitoring (e.g. thermograpy, rumen temperature, tympanic bulla and intravaginal temperature). Each system has advantages and disadvantages and selection of the appropriate system is dependent on the primary outcome variable, frequency of the expected behavior or physiologic change, length of the monitoring period, type of animal monitored, and experimental design. As many of the remotely monitored changes are not specific to pain response, aggregating outcomes from multiple modalities may provide a more holistic view of behavioral and physiologic changes.

SUMMARY Remote monitoring technologies can be used to quantify differences in behavioral responses that can be associated with pain or changes in wellness status. Behavioral and physiologic responses vary by individual animal, housing situation, handling frequency and social situations; therefore, the experimental design and analytic plan should account for these factors. Selection of the appropriate method for monitoring depends on the expected outcomes, experimental design, and an optimum balance of labor and system cost.

REFERENCES S.F. Capik, B.J. White, R. L. Larson, N. Van Engen, J. Coetzee. The effect of pre-shipment meloxicam on movement, feeding, and drinking behavior of transported and non-transported cattle. Am J Vet Res. 2017. 78(12): 1437-1443.

D.D. Shane, B.J. White, R.L. Larson, D.E. Amrine, J.L. Kramer. Probabilities of cattle participating in eating and drinking behavior when located at feeding and watering locations by a real time location system. Computers and Electronics in Ag. 2016. 127:460-466.

C.A. Wheeler, B.J. White, D.E. Anderson, D. Amrine, R.L. Larson. Assessment of biometric tools for quantitative gait analysis in Holstein calves. Am J Vet Res. 2013. 74(11):1443-1449.

D.E. Amrine, M.E. Theurer, B.J. White. Remote assessment of pain and wellness status in cattle. Veterinary Clinics of North America Food Animal Practice. 2013 (29): 59-74.

M.E. Theurer, B.J. White, J.F. Coetzee, L.N. Edwards, R.A. Mosher, C.A. Cull. Behavioral changes associated with meloxicam administration at time of dehorning in calves. BMC Veterinary Research, 2012, 8:48 PMID: 22546492.

B.J. White, J.F. Coetzee, D.R. Renter, A. Babcock, D. U. Thomson, and D. Andresen. Evaluation of two-dimensional accelerometers to monitor beef cattle behavior post-castration. Amer J Vet Res Aug 2008 69(9): 1005-1012. PMID: 18672963

Kinetic Evaluation of Acute Pain in the Dog and Cat Mike Conzemius, DVM, PhD, DACVS Endowed Professor of Surgery University of Minnesota College of Veterinary Medicine St. Paul, Minnesota

We have developed specific, objective diagnostic tests (e.g. blood work, ECG, urinalysis) to evaluate many biologic changes. Change in these tests is often used to evaluate the safety and efficacy of an intervention. However, we cannot directly measure pain in animals and other nonverbal mammals. When using subjective evaluation of pain there is little positive feedback if we treat successfully and little negative feedback if we fail to treat or worsen the condition. This may help explain why, in regulatory acute pain pharmaceutical studies, the rescue rates of placebo treated dogs and cats averages only 51%. In effect, 49% of placebo treated dogs and cats had surgery, were subjectively evaluated and were judged to be not painful. Perhaps we should aim to develop and use an objective outcome measure of acute pain.

Gait analysis can be used to estimate acute pain in preclinical and clinical models; both can be done in multiple small and large species. For the purposes of this talk, I will focus on canine and feline clinical research that used gait analysis as a primary outcome measure for acute pain. First, there are several technical methods to perform gait analysis but to estimate acute pain in dogs and cats I prefer a Tekscan walkway. Three main reasons are quality assurance can be routinely tested, gait data parallels traditional force platforms and collecting the data is fast and noninvasive. Second, results using this method makes sense. For example, limb function is greater in NSAID treated dogs/cats when placebo treated dogs/cats, limb function after surgery is always worse than before surgery and limb function improves over time (days to weeks after surgery). Finally, the data leaves little room for interpretation or controversy. The patient either put more weight on the operated leg more or not.

References

1. Horstman CL, Conzemius MG, Evans R, Gordon WJ. Assessing the efficacy of perioperative oral carprofen after cranial cruciate surgery using noninvasive, objective pressure platform gait analysis. Vet Surg 2004;33(3):286-289. 2. Romans CW, Gordon WJ, Robinson DA, et al. Effect of postoperative analgesic protocol on limb function following onychectomy in cats. JAVMA 2005;227(1):89- 93. 3. Robinson DA, Romans CW, Gordon-Evans WJ, Evans RB, Conzemius MG. Evaluation of short-term limb function following unilateral carbon dioxide laser or scalpel onychectomy in cats. J Am Vet Med Assoc, 2007; 230(3), 353-8. 4. Conzemius MG, Aper RL, Corti LB. Short term outcome after total elbow arthroplasty in dogs with severe naturally occurring osteoarthritis. Vet Surg, 2003; 32:545-52. 5. Judith D Feldsein; Vicki L Wilke; Richard B Evans; Mike G Conzemius. Serum cortisol concentration and force plate analysis in the assessment of pain associated with sodium urate-induce acute synovitis, AJVR, 2010, 71(8):940-5.

Kinetic evaluation of limb pain: food animals Hans Coetzee BVSc, CertCHP, PhD, DACVCP, DACAW, DECAWSEL Professor and Head of the Department of Anatomy and Physiology Kansas State University, Manhattan, KS, 66506 [email protected]

Lameness impacts the cattle industry in both economic losses and welfare considerations. In addition to production deficits, pain and distress associated with lameness has been documented.1 Mean lameness prevalence in herds has been reported as high as 33.7% and 36.8% in Wisconsin and the United Kingdom, respectively; however, in other survey studies a less than 10% prevalence of lame cattle were reported by producers.2-4 In efforts to improve earlier detection and treatment of lameness, locomotion scoring systems have been developed for routine utilization by farm employees.5,6 It has been suggested that earlier analgesia treatment may aid in the alleviation of acute pain perception or in the mitigation of wind-up that can lead to central sensitization.7 Behavioral changes associated with lameness are indicative of attempts by the animal to protect the affected limb from further injury.8 Changes in posture associated with lameness have been summarized in an excellent review article by Whay and form the basis of most locomotion scoring systems.8 An arched back is frequently associated with lameness and is the key behavioral change evaluated in the Sprecher lameness scoring system (1997).5 A deficiency of locomotion scoring systems is the potential for a lack of reproducibility between scorers. This has restricted the utility of locomotion scoring as a validated outcome measure for assessing analgesic efficacy during the drug approval process. In the authors’ experience, there is typically a 70 to 80% agreement between 2 masked scorers evaluating lameness simultaneously using the Sprecher system. Furthermore, male scorers tend to assign lower pain scores compared with female scorers. These factors have necessitated the development of more objective methods of pain assessment involving the use of force plates or pressure mats. A commercially available floor mat-based pressure/force measurement system (MatScan, Tekscan, Inc., South Boston, MA) can be used to record and analyze naturally occurring or experimentally-induced lameness. The pressure mat is calibrated daily and each time the computer software is engaged using a known mass to ensure accuracy of the measurements at each time point. Another benefit of this system is that video synchronization can be used to ensure consistent gait between and within calves for each time point and to correlate lameness scores with pressure mat data. Research grade software (HUGEMAT Research 5.83, Tekscan, Inc., South Boston, MA) is used to determine the contact pressure, contact area, and stance phase duration in the affected claws. Surface area is calculated by area only of the loaded or “contact” sensing elements inside a measurement box. Contact pressure is calculated as force on the loaded sensing elements inside a measurement box divided by the contact area.9 Kotschwar and others found that contact surface area by Sprecher lameness score (LS) was different (p=0.018) in calves subjected to induced lameness using amphotericin B.9 Calves with LS 1 had a greater surface area compared to LS 3 and 4 calves. Furthermore, contact pressure was found to be different across Sprecher lameness score (p=0.02) with calves classified as having a LS of 3 exerting greater ground contact pressure compared with that of LS 1 calves. This was likely due to the calf weight being applied to a smaller contact surface area in calves with a higher lameness score. Following induction of an amphotericin B lameness model in 4 to 6 mo old calves, oral meloxicam (0.5 mg/kg) administered once daily for 4 days ameliorated indications of pain.10 In addition to an increased step count in meloxicam treated animals compared to placebo-treated controls, meloxicam concentrations were inversely associated with lameness scores and positively associated with pressure and contact of the ipsilateral limb.10 In another RCT, Offinger and colleagues (2013) evaluated IV meloxicam (0.5 mg/kg) administered prior to surgery and daily for 4 days post-operatively following resection of a naturally occurring septic distal interphalangeal joint.11 Meloxicam treatment improved both physiologic responses (cortisol, body temperature) and mechanical responses (lameness scores, time standing, steps taken). Following induction of a lameness model using amphotericin B, 4 to 6 month old calves were treated with gabapentin (15 mg/kg) with or without meloxicam (0.5 mg/kg) once daily for 4 days.10 Although meloxicam alone tended to demonstrate a beneficial response, analgesia was most evident in the group receiving combination therapy demonstrated by an increased stride length and force applied to the ipsilateral claw compared to placebo-treated controls.10 Recently, kinetic evaluation was used as the basis for regulatory approval for the first analgesic drug specifically labeled for alleviating pain associated with footrot in cattle (Banamine transdermal, Merck; NADA 141-450).12 30 Holstein steers (n=15 calves/ treatment), 8 months of age and weighing between 339 and 493 kg (site 1) and 326 – 470 kg (site 2). Animals were subjected to an induced lameness using Fusobacterium necrophorum. Lameness was scored prior to induction and once daily prior to enrollment (approximately 48 h after induction). Treatment success was designated as a statistically significant difference between treated and control calves at 6 (+/- 30 minutes) after administration of topical flunixin at 3.3 mg/kg. Improvement in average change in maximum total force and contact area for the right front foot between treatment and 6 h after treatment was also assessed using a real-time, gait analysis system (MatScan, Tekscan, Inc). Baseline data were included as a covariate in the model. At Site 1, mean change in maximum Force between baseline (pre-challenge) and enrollment was -31.29 kg (P<0.0001) and mean change in contact area between baseline and enrollment was -10.89 cm2 (P<0.0001). At Site 2, mean change in maximum Force between baseline (pre-challenge) and enrollment was -32.95 kg (P<0.0002) and mean change in contact area between baseline and enrollment was -15.51 cm2 (P<0.0001).12 Kinetic evaluation has also been successfully deployed to assess lameness and analgesic drug efficacy in swine. Specifically, Karriker et al (2013)13 used a static force plate to demonstrate that injection of amphotericin B induced a predictable acute lameness that resolved spontaneously and is an effective method to model lameness in sows. Furthermore, Pairis-Garcia et al (2015)14, reported that flunixin meglumine and meloxicam administration mitigated pain sensitivity in sows after lameness induction when pain sensitivity was evaluated with the embedded microcomputer-based force plate system and GAITFour pressure mat gait analysis walkway system. These findings support the use of kinematic evaluation as a validated method of pain assessment in swine after lameness induction. Recently kinetic evaluation has been used to assess pain associated with castration in cattle and piglets and parturition in adult dairy cows. Specifically, Kleinhenz et al.15 used a pressure mat to demonstrating that cows that received 1 mg/kg of meloxicam PO within 26 h of calving placed 48.9% (95% CI: 47.4% to 50.5%) of total force on the rear limbs compared to 46.3% (95% CI: 44.7% to 47.9%) in placebo-treated cows (P = 0.02). Total impulse on their rear limbs in the meloxicam-treated cows was 50.5% (95% CI: 48.6% to 52.4%) compared to 46.7% (95% CI: 44.8% to 48.7%) for cows in the placebo group (P = 0.01). No differences in contact pressure of the rear limbs were observed (P = 0.27). However, cows in the placebo-treated group had a longer stride length (101.3 cm with a 95% CI: 95.9% to 106.6 cm) vs. 90.8 cm (95% CI: 85.4% to 96.1 cm) (P = 0.03). Kleinhenz et al.16 also demonstrated that calves undergoing surgical castration placed more force onto their fore limbs (P = 0.02) indicating a shift in their weight distribution to the front limbs. However, there were no measured differences in total step contact area and step contact pressure. Calves in the control group also had lower total impulses compared to surgically castrated calves (P = 0.004). In summary, kinetic evaluation of animal gait represents a promising outcome to assess pain associated with lameness, castration and parturition in livestock. Further studies are needed to determine the extent to which these outcomes can be repeated across different age groups and analgesic drug interventions.

References

1. Whay HR, Waterman AE, Webster AJF et al.The influence of lesions type on the duration of hyperalgesia associated with hindlimb lamenss in dairy cattle. Vet J 1998;156:23-29. 2. Cook NB. Prevalence of lameness among dairy cattle in Wisconsin as a function of housing type and stall surface. J Am Vet Med Assoc. 2003; 223:1324-1328. 3.Barker ZE, Leach KA, Whay HR, et al. Assessment of lameness prevalence and associated risk factors in dairy herds in England and Wales. J Dairy Sci. 2010;93:932-941. 4. Fulwider WK, Grandin T, Rollin BE, et al. Survey of dairy management practices on one hundred thirteen North Central and Northeastern United States dairies. J Dairy Sci.2008;91:1686-1692. 5. Sprecher DJ, Hostetler DE, Kaneene JB. A lameness scoring system that uses posture and gait to predict dairy cattle reproductive performance. Theriogenology 1997;47:1179-1187. 6. Flower FC and Weary DM. Effect of hoof pathologies on subjective assessments of dairy cow gait. J Dairy Sci. 2006;89:139-146. 7. Anderson DE and Muir WM. Pain management in Cattle. Vet Clin North Am Food Anim Pract. 2005:21:623- 635. 8. Whay HR. Locomotion scoring and lameness detection in dairy cattle. In Practice. 2002; 24:444-449. 9.Kotschwar JL, Coetzee JF, Anderson DE, et al. Analgesic efficacy of sodium salicylate in an amphotericin B- induced bovine synovitis-arthritis model. J Dairy Sci 2009; 92:3731-3743. 10. Coetzee JF, Mosher RA, Anderson DE, et al. Impact of oral meloxicam administered alone or in combination with gabapentin on experimentally induced lameness in beef calves. J Anim Sci 2014;92:816-829. 11. Offinger J, Herdtweck S, Rizk A, et al. Postoperative analgesic efficacy of meloxicam in lame dairy cows undergoing resection of the distal interphalangeal joint. J Dairy Sci 2013;96:866-876. 12. Freedom of Information Summary for Banamine Transdermal solution (NADA 141-450). Available at https://animaldrugsatfda.fda.gov/adafda/app/search/public/document/downloadFoi/1944, Accessed 30 August 2019. 13. Karriker LA, Abell C, Pairis MD, Holt WA, Sun G, Coetzee JF, Johnson AK, Hoff SJ, Stalder KJ. (2013). Validation of a lameness model in sows using physiological and mechanical measurements. Journal of Animal Science. 91(1):130-6. doi: 10.2527/jas.2011-4994 14. Pairis-Garcia, M. D., Johnson, A. K., Abell, C. A., Coetzee, J. F., Karriker, L. A., Millman, S. T. and K. J. Stalder. (2015) Measuring the efficacy of flunixin meglumine and meloxicam for lame sows using a GAITFour pressure mat and an embedded microcomputer-based force plate system. Journal of Animal Science. 93 (5): 2100-2110. 15. Kleinhenz MD, Gorden PJ, Burchard M, Ydstie JA, Coetzee JF. 2018. Rapid Communication: Use of pressure mat gait analysis in measuring pain following normal parturition in dairy cows. Journal of Animal Science 97 (2), 846-850. http://doi.org/10.1093/jas/sky450 16. Kleinhenz , M.D. Van Engen N.K., Smith J.S., Gorden , P.J. Ji J., Wang C, Perkins S.C.B., Coetzee J.F.. (2018). The impact of transdermal flunixin meglumine on biomarkers of pain in calves when administered at the time of surgical castration without local anesthesia. Livestock Science. 212: 1 – 6. doi.org/10.1016/j.livsci.2018.03.016

Place conditioning, motivational and cognitive bias testing

Drawing inferences regarding the emotional component of pain:

• Reflexive responses • Conditioning experiments • Motivational testing • Cognitive bias and anhedonia testing Conditioned place aversion

Removable gates 6 h 6 h Sham Disbudding pen Middle pen pen

Ede et al., 2019: Scientific reports 9: 5344 Time spent Time in pen (s) Lying down in the pen (no.)

Sham Disbudding Sham Disbudding

Ede et al., 2019: Scientific reports 9: 5344

Analgesic pen No-analgesic Middle pen pen

Analgesic

Meloxicam Ketoprofen

Ede et al., 2019: in review Ede et al., 2019: in review

Approach‐avoidance testing

Painful pricks:

Ede et al., 2018. Sci. Reports 8:9443

Motivational testing

Ede et al., 2018. Sci. Reports 8:9443 What inferences regarding the felt, emotional component of pain can be drawn from different study types?

• Acute, spontaneous responses • Conditioning experiments • Motivational testing

Cognitive bias during post‐operative pain

Positive Negative approach do not for approach; time‐ milk reward out Cognitive bias during post‐operative pain

Positive Negative approach do not for approach; time‐ milk reward out

ambiguous ambiguous ambiguous

Do calves approach these ambiguous screens?

Generalization curve

100

80

Screens 60 approached (%) 40

20

0 positive near halfway near negative positive negative

Neave et al., 2013. PLoS ONE 8(12): e80556 Cognitive bias after disbudding

100 Before disbudding 80 After disbudding

Screens 60 approached (%) 40 * 20 *

0 positive near halfway near negative positive negative

Neave et al., 2013. PLoS ONE 8(12): e80556

and/or anhedonia Cognitive bias during post‐operative pain ^

Lecorps et al. 2019. Front Behav Neuro 13:54

Take home messages:

• Use conditioning to assess cumulative impact, in absence of the noxious stimulus • Use motivational testing to allow for stronger inferences on awareness and magnitude of affect • Use cognitive bias and anhedonia testing to allow for an assessment of mood

Weary et al., 2017. Advances in the Study of Behavior 49:27-48 Validating behavioral sampling methodologies of castration induced pain behaviors in piglets

M. Pairis-Garcia1, R. M. Park1, C. Cramer2, A. V. Viscardi3, L. E. Moraes4 H. Coetzee3 1 Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, 27606 2 Department of Animal Sciences, College of Agricultural Sciences, Colorado State University, Fort Collins, CO, 80521 3 Department of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS, 66506 4 Department of Animal Sciences, College of Food, Agriculture and Environmental Science, The Ohio State University, Columbus, OH, 43210

Castration is a common procedure performed on US swine farms to prevent unwanted breeding, reduce aggression and improve meat quality. This procedure results in pain experienced by the piglet as demonstrated by physiological and behavioral deviations from normal (Van Bierendonck et al, 2011). Consumers in the US emphasize freedom from pain as being essential for good animal welfare in livestock species (Spooner et al., 2014). Pigs in the United States are routinely castrated without any pain relief as there are currently no anesthetic or analgesic drugs specifically labeled for pain relief in swine in the U.S. To gain FDA approval for an analgesic in swine, a product must be shown to reduce pain in a target species utilizing validated methods of pain assessment.

From a scientific standpoint, the most important indicator to quantify pain is to demonstrate a change from normal behavior (Anil et al., 2005). Therefore, behavioral analysis is often regarded as the gold standard for pain evaluation in animals (Weary et al., 2006). However, our gaps in knowledge around pain behavioral analysis are two-fold: current behavior sampling methodologies have not been validated and there is no standardized pain scale for piglets. These gaps can lead to inconsistent results in studies, and therefore flawed pain mitigation recommendations. To date, the most common methods to evaluate behavior in livestock species include continuous or scan sampling of behavioral observations. Continuous sampling requires constant observation of the animals and provides the most complete and accurate dataset (Lehner 1992). However, continuous sampling is time and labor intensive, particularly in studies with large sample sizes and a high number of behaviors recorded, and may not be feasible due to technological or logistical limitations. To minimize time spent observing behavior, researchers often rely on scan sampling methodology, whereby behaviors are recorded at selected time points within a sample period and the proportion of time the animal spent performing a specific behavior is estimated (Martin & Bateson 2007).

To date, sampling methodologies to assess pain behaviors associated with castration in pigs have not been validated and vary dramatically between publications. Because previous studies used non-validated and inconsistent methodologies for behavioral observation, we do not fully understand the efficacy of pain relief in castrated piglets, nor have reliable or objective tools to quantify pain sensitivity. Therefore, the objective of this study was to validate behavioral observation methods of pain behaviors expressed in castrated piglets using three scan sampling intervals (2-min, 3-min, 5-min intervals) compared to a continuous sampling methodology. A total of 8 Yorkshire-Landrace x Duroc male piglets (5 days-old) were used in this study. Twenty- four hours prior to the trial, piglets were weighed and identified. On the day of castration, male piglets were separated from their littermates, placed in a transport cart and surgically castrated using a scalpel blade. Pain behavior durations (scratching, spasms, stiffness, tail wagging and trembling) of each piglet was continuously collected by one trained observer for the first 15 min of every hour (baseline, day 1; hour 1-8; day 2: hour 24) using the Observer XT program (Version 12.0: Noldus Information Technology, Wageningen, The Netherlands). Continuous data was then compared to the three different sampling intervals using a generalized linear mixed model. All pain behaviors were log transformed for normality. No differences were found in scratching, stiffness or trembling behaviors for all sampling methodologies (P > 0.05). Spasm behaviors were different when utilizing 3 and 5-min scans compared to continuous sampling (P < 0.001; Continuous: 0.3%; 3-min: 0.17%; 5-min: 0.2%) and tail wagging behaviors were different when utilizing 3-min scan sampling compared to continuous sampling (P < 0.001; Continuous: 4.6%; 3-min: 5.1%). The results from this study can be used to support future research studies to quantify analgesic efficacy for castration pain when utilizing pig behavior.

Citations upon request Physiological Measures of Pain Across Species

Karen Schwartzkopf-Genswein

Pain in AnimalsWorkshop

October 3, 2019 Bethesda, Maryland

Why does it matter?

• We have a moral obligation to treat animals humanely

• Relationship of welfare to animal health, food quality and safety

• Public concern for animal welfare • Consumer willingness to pay • Public disconnect from agriculture

If they could just tell us how much and when it hurts! Assessing pain • In farm animals pain is most commonly associated with routine management procedures (castration, dehorning), injury (cuts and lacerations) and or disease (colic, foot rot)

• Most procedures are done without pain control at this time

• Importance of assessment is related to developing mitigation strategies rather than identification of pain

• Expression of pain and therefore optimal measures vary by species (more so for behavior than physiology)

• Physiological measures should always be combined with behavioral measures for best pain assessment

• No “silver bullet” - all measures to date are indicators of stress but areNOT specific to pain

Important factors to consider before we measure

• Physiological indicators = severity of the lesion or trauma causing the pain

• The same indicator can be obtained via different collection media (blood, hair, feces etc.) and may alter when changes are observed as well as their concentration

• You must know what baseline levels are to make meaningful comparisons

• Stress associated with pain and other factors can be additive

• Difficult to pull apart measures of pain and stress

• Must know circulating levels of pain management drugs to make appropriate interpretation of physiological indicators

Animal factors affecting physiological measures of pain

• Genetic (breed/strain)

• Sex – eg cortisol concentrations are 15 % higher in barrows compared to gilts

• Age eg by 20 weeks of age baseline cortisol is 37% lower than at 12 weeks

• Weight

• Reproductive status Animal factors affecting physiological measures of pain

• Prior experience to handling

• Temperament

• Previous and current medical history

• Social status

• Housing environment –single s group, muddy, hot/cold

• Individual animal variation

Non-animal factors affecting physiological measures of pain • Time of day

• Type of handling (low stress, frequency)

• Type of sampling method

• Acute versus chronic pain

• Pain severity

• Location of pain (abdominal, foot, limb or joints)

• Timing of sample collection relative to painful event/procedure

Performance, morbidity and mortality indicators

• Changes in body weight (average daily gain, final body weight)

• Feed efficiency

• Commonly used in cattle, sheep, and swine

• Physical manifestation of reduced feed intake or energy expenditure to maintain homeostasis

• Increased incidence of morbidity and mortality –indirect effectsof stress on immunosuppression and loss of homeostasis Body Weight

Initial BW: NS + 4 kg Cast *** Med ** Cast × Med Cast × Wk *** Med × Wk Cast × Med ×Wk

Feed Intake

Cast *** Med *** Week 1 + 2 Cast × Med Cast × Wk *** Med × Wk Cast × Med ×Wk

Growth Sympathetic nervous system responses

• Responses are not a direct measure pain but indicate how unpleasant the painful experience is

• Stress and pain stimuli activate SNS and HPA

• Hormones secreted and routinely measured in research studies include:

• Adrenaline –Best measured 5 min after stimuli – limits usefulness

• Noradrenaline – released by damaged tissue (up to 1 h after stimuli) • Size of adrenal glands

HPA Activation • Initiates metabolic and inti-inflammatory responses

• Last longer than those of the SNS – Best measured within 5-10 min and up to several hours or days after the stimulus

• CRH, ACTH, Cortisol – most commonly measured

• Magnitude of the response agrees with the degree of stress/pain

• Vasopressin

• Angiotensin II

HPA Activation • Initiates metabolic and inti-inflammatory responses

• Last longer than those of the SNS – Best measured within 5-10 min and up to several hours or days after the stimulus

• CRH, ACTH, Cortisol – most commonly measured in cattle, sheep, pigs, and goats

• Magnitude of the response agrees with the degree of stress/pain

• Vasopressin

• Angiotensin II Effect of Glucocorticoids • Glucocorticoids produce a variety of effects depending on:

• amount of hormone secreted • duration of secretion • peripheral blood concentration of cortisol binding globulin • relative abundance of glucocorticoid receptors in the target tissue • tissue in which they exert their effect • extent of excretion of glucocorticoid metabolites

• Glucocorticoids are immunosuppressive and anti-inflammatory • Reduce circulating numbers and generation of blood leukocytes (lymphocytes, monocytes and eosinophils) • = delayed wound healing, immune deficiencies and enhanced susceptibility to infection

Salivary cortisol

Salivary Cortisol

** Treatment‐Time Interaction P =0.09 Hair cortisol 0.45 0.4 a a 0.35 ab b 0.3 c d c d 0.25 d 0.2 0.15 0.1 0.05 Hair cortisol concentration, pg/mL 0 28 56 Days CTR‐NM CTR‐M BAND‐NM BAND‐M SURG‐NM SURG‐M

Cardiac and Respiratory Indicators

• Respiration rate (rapid and shallow) –

• Tachycardia – Cattle >90 bpm - Sheep > 90 bpm - Goats >95 bpm • Record ECG

• Systolic diastolic and arterial pressure high – may be more sensitive than ACTH or cortisol

• Analgesics such as xylazine and butorphanol can reduce heart rate

Other Indicators

• Body temperature

• EEG

• Pilo-erection

• Pupil dilation

• Sweating

• Reflex responses Immunity indicators • CBC

• Neutrophil: lymphocyte ratios

• Interleukins and cytokines

• Acute phase proteins - blood protein conc. modified in response to inflammation, infection, and physical or psychological stress

• Synthesized by the liver and released into the systemic circulation to restore the homeostasis

Haptoglobin Meloxicam*Time

5 * * Sal 4 Melox

3

2 *

1 Haptoglobin (g/L Haptoglobin )

0 01236

Days

Haptoglobin

** *

Treatment‐Time Interaction P < 0.001 Results: Maximum temp neck of scrotum

What does it look like in infrared?

After medication Surgical @ 2 d Banding @ 35 d

wk 1 wk 3 wk 5

Other measures • Neuropeptides

120 * * No Med Melox 100

80

60 Substance P ( pg/mL ( P Substance )

0123 7

Days • Stress induced analgesia Sample management, data summary and interpretation

. Quality of data = quality of sample collection and storage

. Sample size is important as large variability within and between animals

. How data is collated can affect outcomes . Change from baseline . Time to return to baseline . AUC

Sample management, data summary and interpretation

• Affects of repeated sampling

. Changes after analgesic therapy (caution as absence of response does not mean pain was absent)

. Controls are important

. Researchers must be vigilant and present during experiments to ensure outcomes can be explained accurately

Interpretation of multiple indicators of pain – Index Required Physiogical • Infrared thermography • Salivary cortisol • Blood count • Haptoglobin • Substance P • Heart rate

Behavioral • Visual scores • Stride length • Behaviour- walking, standing, lying, tail flick, foot stamping and head turning. Example Interpretation

1 week ControlBand Knife Sub P Tail-flick Lying dur Stride length Standing and lying VAS Rumination

2 months Salivary cortisol Lying dur, Walking dur Standing dur, Eating dur VAS

4 months Salivary cortisol Tail-flick Standing bouts Stride length Lying bouts VAS Standing dur, Lying dur. Active behaviours

Biomarkers specific to pain needed

• Omics – Detection of metabolites specific to pain?

• May be procedure and species dependant

• Index

Take Home • Pain management in food animals is an important welfare concern for industry, veterinarians, scientists and the public

• Knowledge of how indicators of pain differ by species (physiological and behavioral) is required to access species specific pain

• Careful control and understanding of how animal and non-animal factors can affect the validity of physiological pain measures is essential

• Continued development of appropriate behavioral and physiological pain assessment tools is needed • Novel measures specific to pain • Pain Index Thank You