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Diagnosis of Pain in Small Companion Animals

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Diagnosis of Pain in Small Companion Animals American Journal of Animal and Veterinary Sciences Original Review Paper Diagnosis of Pain in Small Companion Animals 1 1 1 2 Giorgia della Rocca, Alice Catanzaro, Alessandra Di Salvo and Mary Ellen Goldberg 1Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Italy 2Executive Secretary International Veterinary Academy of Pain Management, Instructor VetMedTeam, LLC, Boynton Beach, FL, USA Article history Abstract: It is now widely accepted that animals are able to experience pain Received: 19-12-2014 in a similar way to humans. Acute and/or chronic pain is associated not only Revised: 25-12-2014 with many surgical procedures, but also with various medical diseases, Accepted: 30-12-2014 where pain may increase morbidity and mortality. Moreover, some types of pain (e.g., neuropathic pain) can be considered as an illness in themselves. Corresponding Author: Giorgia della Rocca Recognizing pain and assessing its intensity are both essential for its Dipartimento di Medicina effective management: If pain is not recognised, then it is unlikely to be Veterinaria, Università degli treated. Two major problems account for the difficulties in pain diagnosis in Studi di Perugia, Italy veterinary patients: (1) animals are not able to verbalise and cannot refer Tel: +390755857605 to the state of pain they are experiencing and (2) almost all animal species E-mail: [email protected] tend instinctively to mask signs of pain and weakness. Therefore, pain recognition in a diseased animal may be challenging. However, practitioners can rely on different strategies, which can be put in place to reveal the presence of pain in their patients. A presumptive diagnosis, a clinical exam, the evaluation of psychomotor changes and pain expressions, the attribution of pain scores and the response to therapy are all tools which, especially when used in combination, can help the veterinary practitioner recognise a subject suffering from pain and allow a correct approach to therapy. This review summarizes the current available information regarding the methodology that could be applied in small companion animals for a correct diagnosis of pain, offering veterinarians with some “easy to use” tools to apply in their daily practice. Keywords: Pain Recognition, Companion Animals, Diagnostic Strategies Introduction inflammatory pain and neuropathic pain lose their adaptive purposes and may be considered as an illness in Pain is a complex, subjective and emotional themselves (Orlandini, 2005). experience, due to the activation of the nociceptive When pain is particularly severe and prolonged, it system followed by modulation and integration of the may produce a series of physiological changes that, in nociceptive input at the spinal and supraspinal level. turn, may increase the morbidity and mortality rate. Naturally occurring for adaptive purposes (protection Long-term pain (i.e., persistent and chronic pain) is often against potentially dangerous stimuli), pain is associated invalidating, leading to a deterioration of the lifestyle of with several medical and surgical conditions, where, at a the patient (Grant, 2006a). certain extent, it maintains its adaptive role (facilitating Scientific research has confirmed that nearly all healing and protecting against further damage). animals possess the anatomical and physiological Depending on the cause, pain may be acute, features that enable them to perceive pain (Grant, 2006). persistent or chronic. Therefore, the treatment of pain should become an Acute pain accompanies all inflammatory processes integral part of a good veterinary practice. and usually disappears as soon as the damaged tissue Recognising pain and assessing its intensity are heals. Persistent pain is due to the persistence of an mandatory for its correct management. inflammatory status and accompanies chronic processes In humans, self-reporting and discussion of both the such as osteoarthritis or cancer. Chronic pain is due to a sensory and affective aspects of the pain experience damage or to a dysfunction of the nervous system represent the “gold standard” in the diagnosis of a (neuropathic pain) and it’s often long lasting. Persistent painful condition. The ability to self-report actually © 2015 Giorgia della Rocca, Alice Catanzaro, Alessandra Di Salvo and Mary Ellen Goldberg. This open access article is distributed under a Creative Commons Attribution (CC-BY) 3.0 license. Giorgia della Rocca et al . / American Journal of Animal and Veterinary Sciences 2015, 10 (2): 57.66 DOI: 10.3844/ajavsp.2015.57.66 facilitates pain treatment in most human patients. For number of factors, such as the individual pain animals, as for humans who cannot self-report (e.g., threshold, previous painful experiences, the neonates, paediatric patients and those with cognitive concomitant presence of other sources of pain, the impairment), other assessment tools must be put in place breed, age and gender of the animal and the surgeon’s (National Research Council, 2009). experience, among others (Mich and Hellyer, 2009). In non-human species, there are two important Indeed, a presumptive scoring usually leads the use of a pain therapy that is proportional to the attributed level factors limiting the recognition of the presence of pain of pain (Mathews, 2000; Mich and Hellyer, 2009). by the clinician or the pet owner: (1) animals cannot transform their experiences into words; (2) almost all Clinical Exam animal species tend to hide the presence of pain, as In the WSAVA Guidelines for recognition, showing pain could be a sign of weakness which put the assessment and treatment of pain (Mathews et al ., 2014) individual at a disadvantage. The evaluation of the and in the AAHA Pain Management Guidelines for Dogs presence and intensity of pain in animals is, therefore, far and cats (Hellyer et al ., 2007; Epstein et al ., 2015), pain more difficult than in people, leading to a certain has been considered as the “4th vital sign”, together with limitation in carrying out a proper pain therapy. temperature, pulse and respiration. Within a clinical No “Gold standards” exist to assess pain in animals. evaluation, all patients should, therefore, always be However, various strategies, especially when used in assessed for the presence and intensity of pain. A combination, may help the practitioner recognise an thorough clinical evaluation is mandatory, in order to animal in pain and in need of analgesic therapy. reveal any modification of the organ's functions related These strategies should include: (i) a presumptive to the presence of pain. diagnosis; (ii) a clinical exam (searching for specific Pain can modify physiological, neuroendocrine and physical and biochemical findings); (iii) the evaluation metabolic parameters. It can produce changes in the of psychomotor changes and pain expressions; (iv) the heart and respiratory rate, blood pressure, capillary attribution of pain scores; and (v) the evaluation of the perfusion, ventilation, gastrointestinal motility, response to the analgesic therapy. urinary functions, muscle contractility and nervous activity, as well as changes in glucose content, protein Strategies for Pain Diagnosis in Companion and lipid metabolism, water-electrolyte balance, blood concentrations of cortisol, β-endorphin, Animals catecholamines, glucagon, ADH, insulin, etc. (Grant, Presumptive Diagnosis 2006a; Ledowski et al ., 2012). Physical examination should thus focus on the When dealing with animal pain, a presumptive cardiovascular and respiratory system, the digestive and diagnosis is a good initial strategy. urinary tract, the nervous system and the musculoskeletal As in humans, the level of pain perceived by animals apparatus. Laboratory investigations should also be is likely to be proportional to the extent of the damage performed in order to detect any changes in the following a traumatic or surgical stimulus or due to a neuroendocrine and metabolic parameters attributable to medical pathologic condition. In other words, we may the presence of pain. presume that the greater the insult, the greater the Table 2 summarises the main physiological, inflammatory response and the number of terminations biochemical and neuroendocrine changes that can be or nerve trunks involved and, therefore, the greater the present in a painful animal. However, it must bear in perceived pain (Mathews, 2000). mind that clinical and laboratory findings in themselves Thus, different levels of pain (from mild to do not constitute sure pain indicators, as they are excruciating) may be associated with many illnesses or influenced by many factors other than pain, such as any surgical procedures occurring in the veterinary setting. stressful condition (Mich and Hellyer, 2009). Some procedures, such as thoracotomy, joint surgery, Within the clinic exam, an “algologic exam” should many ocular procedures and all interventions requiring be taken into account. Applied in the human clinical extensive tissue trauma should be considered extremely setting (Orlandini, 2005), it could be transferred, at painful on principle. However, relatively non-invasive techniques (e.g., intravenous catheterisation) can also least in part, to the veterinary medicine. The “algologic cause a certain level of pain (Mathews, 2000). exam” should enable the veterinarian to ascertain not Table 1 lists some examples of anticipated pain levels only the location and severity of pain, but also the type associated with surgical procedures, illness, or injuries. of pain (inflammatory
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