The Paw Project and Fear Free Together At Last!
The Paw Project’s beginning was rooted in helping relieve big cats from complications from being declawed. Thankfully, founder and director Dr. Jennifer Conrad saw the same need in domesticated felines. Don’t miss this opportunity to hear about her journey and her rebuttals against the common arguments in favor of elective feline onychectomy.
Cats in these situations also commonly experience fear, anxiety, and stress (FAS). FAS can cause a cat to mask their pain but could also result in behaviors easily mistaken for signs of pain. Partnering with your client, the cat owner, is essential to make an accurate diagnosis of pain in your feline patients.
Helping our feline patients with osteoarthritis (OA) starts at home, with our clients. As you are aware, cat owners are highly attuned to even small changes in their cat’s habits, personality, and idiosyncrasies that make them unique. Partner with your clients and teach them to screen for OA pain at home with a validated Cat OA Checklist produced by Zoetis. On this website, there are three simple screening steps that should only take your clients a few minutes to complete:
Once complete, clients can enter their email address to receive a copy of the checklist results. In some cases, clients will see the need to bring their cat into you for evaluation; others will need some encouragement to make an appointment. Consider recommending that your clients email the checklist results so you can identify those who might need to be seen.
To help prepare you for these kitties who will be coming to your office, Zoetis has created a website that provides you with resources such as helping to build cat owner awareness of feline pain, talk through the OA checklist they have completed, and feline orthopedic exam resources, including demonstration videos. This website contains a link to a printable version of the Cat OA Checklist that could be used, for example, with a client who has come into your office with their dog but has a cat at home that you haven’t seen in several years to encourage them to seek veterinary care for their feline companion.
It is important to remember that using Fear Free and Cat Friendly principles may mean that some cats who are coming to you to be evaluated for OA may require pharmaceutical help to remain calm. Keep in mind that some anxiolytic regimens may also produce analgesia and alter your exam findings. Objective diagnostic tools, such as orthopedic radiographs, are also an important part of the complete clinical evaluation.
Orthopedic exams and diagnosing OA in cats are yet more reminders that cats are not small dogs! As you partner with your cat-owning clients by asking them to screen their cats in the environment where they are most likely to show signs of OA, you will be better able to diagnose your arthritic feline patients. This partnership will greatly enhance your reputation amongst your clients who will see you as a trusted advisor to their beloved and treasured cat companion.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Sponsored by our friends at Zoetis Petcare. © 2021 Zoetis Services LLC. All rights reserved. NA-02588
Yes, You CAN Perform a Fear Free Canine Orthopedic Exam
In this webinar, Kristin Kirkby Shaw, DVM, MS, PhD, DACVS-SA, reviews the importance of diagnosing osteoarthritis (OA), how to perform canine exams, and pain management. Dr. Shaw also provides resources from the New Science of OA Pain website, which has canine and feline OA checklists, feline exam videos, and chronic pain teaching tools that can be provided for pet owners.
Brought to you by Zoetis Petcare.
Using Fear Free Principles to Improve Anesthetic Safety In Complicated Patients
Decreasing fear, anxiety, stress (FAS), and pain leads to safer anesthesia by allowing a lower dose of sedative and anesthetic drugs needed for anesthesia premedication, induction, maintenance, and recovery. Lower drug dosages are especially critical in complicated patients with underlying disease and physiologic compromise. In this discussion, Tamara Grubb DVM, PhD, DACVAA, will explore the role of Fear Free principles in anesthetic safety, especially in the compromised/complicated patient.
Brought to you by Zoetis Petcare.
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Kristin Kirkby Shaw, DVM, MS, PhD, DACVS-SA, demonstrates the use of Fear Fear principles in an orthopedic exam.
But there are also medical issues where a potential connection to a behavior problem may be less obvious. One that can be tricky to diagnose and that affects behavior in a wide range of ways is pain.
A recent article published in the journal Animals reviewed records of 100 dogs seen by the 13 coauthors and found that conservatively, a third of them involved some form of pain, and in some cases possibly up to 80 percent.
Coauthor and board-certified veterinary behaviorist Margaret E. Gruen, DVM, Ph.D., of North Carolina State University says, “We want to raise the consciousness that there are a lot of things where pain can be a contributor.” When clients come in with behavior issues, she says, “we want to be really specifically looking for discomfort, even if it’s behavior where we’re not immediately thinking, oh, that could be pain.”
It can be tricky, because pain in animals is not always obvious. “Unless you are really well versed in pain, it can be hard to pick up a painful animal in the exam room,” says Mike Petty, DVM, CVPM. “They put on a show about how well they feel. We will see dogs limp across the parking lot and then quit limping when they hit the front door.”
This means that knowing how to look for it is critical. “Primary care providers must keep an open mind that absolutely any change in their patients’ behavior that the client reports can be related in some way to pain. That means doing a good pain palpation as a part of every examination,” says Robin Downing, DVM, DACVSMR. “Only by including a pain palpation in every examination will a practitioner become proficient in identifying even subtle pain in patients.”
It’s also important to be aware of the many demonstrated connections. An increasing number of behavioral effects of pain and discomfort are being found in research. As more of these are studied, what’s “obvious” changes. “Compulsive licking in cats is a fantastic example,” says Dr. Gruen. While this was once commonly assumed to be a result of stress, after research revealed that approximately three-quarters of cats with compulsive licking actually had an underlying dermatological issue, such cats are now more likely to be treated correctly.
A less well-known example involves compulsive behaviors such as stargazing, fly-snapping, and pica. Research has shown that these can result from gastrointestinal problems in dogs.
And while inappropriate elimination as possible evidence of pain is well known in cats, it’s perhaps less frequently considered that pain can also be connected to housesoiling in dogs. “Oftentimes it’s too much effort for the dog to go and find their owner, or they dread going down the three steps into the backyard,” says Dr. Petty. “So they will sometimes go to the door and urinate or defecate there, or sometimes won’t even go to the door and just do it wherever they are.”
It’s often not easy to tell the difference between pain and cognitive decline, both of which can happen as pets age — and the two can interact as well.
“If a dog is acting weird, it might not be simple cognitive decline; it might be cognitive decline driven by pain,” says Petty. “Sometimes animals are in so much pain they can’t even think straight, so they’re much more likely to have behavioral issues.”
A sign such as apparent disorientation could be due to physical issues: a dog who seems to be stuck standing on a rug might be reluctant to cross a slippery floor because walking on it hurts. An apparent decrease in sociability could also be due to undiagnosed pain: “If you’re getting up and moving around the house, they’re less likely to follow you from room to room,” says Petty. “I always say to these clients, let’s make sure there isn’t a pain issue that pushing your dog over the edge, while we look at this cognitive issue.”
Petty thinks that teasing apart these potential causes is especially important because they often push people toward the decision to euthanize, since the dog doesn’t seem to be enjoying life and the pet-owner bond can be affected. Treating pain can help, as well as encouraging owners to modify their expectations for an aging pet. It may not be that the dog doesn’t enjoy his favorite activities anymore so much as they need to be modified: say, rolling the ball a short way instead of throwing it across the yard. He tells clients, “Think of what the dog used to like to do and tone it down.”
Because pain isn’t always obvious on examination, listening to the owner’s observations is crucial — but these may also need to be guided.
“When I speak with my clients about the possibility of pain in their pets, I alert them that any changes in behavior must lead us to at least consider pain as the culprit,” says Dr. Downing. “So, this means changes in eating and drinking, changes in getting onto furniture/beds, reluctance to ascend or descend stairs, decreased grooming (cats), restlessness at night (or the converse – – sleeping excessively), decreased interaction with human or animal family members, “grouchiness,” any changes in housetraining or litter pan use, objections to petting/brushing, decreased stamina on walks, or any other changes they may witness.”
But even for owners, these changes can also creep up so slowly that they almost don’t notice them. “It’s very common with chronic pain issues that once they’re treated, the owner says, ‘I just realized it’s been two years since he jumped on a couch,” Petty says. He strongly recommends using a questionnaire such as the Canine Brief Pain Inventory starting when pets are six or seven years old. “If you give this to every dog owner that walks in for their annual exam and have them answer these questions, you’ll be amazed at the red flags that come up.”
Lack of change where it can reasonably be expected can also be a hint, where behavior modification isn’t working. “If we have a patient who is working with someone, and they’re doing lots of appropriate things and not making progress, that’s when you want to think, let’s look even closer,” says Gruen. “Are we seeing anything that could be pain?”
Finally, it’s also important to remember that even when an underlying medical issue is identified, both medical and behavioral treatment may be needed.
“We need to know what the medical conditions are but that doesn’t necessarily mean treating that will solve the behavior problem,” says Gruen. “A good example is noise phobia.” In a dog who has some pain along with some fear of fireworks, for example, tensing up at the frightening noise may also cause physical discomfort. “That gets associated with the noise, so worsens the behavior problem.”
Similarly, when cats have urinary tract issues or pain that causes them to start avoiding the litter box, simply solving the medical problem may not be enough. “You can treat the infection, but the aversion is set up and persists,” she says.
Likewise, simply treating the behavior isn’t going to work if an underlying medical issue has been missed. “Making changes in those other pillars of the treatment plan is important and will be helpful, but it’s an uphill battle if you have an untreated medical concern,” says Gruen. “Particularly if it’s pain and discomfort, because that affect so many things.”
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
One of my mentors once told me “never tell a client what you can show them.” A client may see their pet hiding or not playing, and they will need assistance determining if their pet is painful or fearful. Using the Fear Free Strategies of Considerate Approach (CA) and Gentle Control (GC) allows the pet to be comfortable enough to exhibit OA signs in the client’s presence. With CA, a relaxing atmosphere can be created where the pet can have room to move and be observed. Adding pheromones to help keep them calm and non-slip surfaces both on and off the exam room table enables them to safely explore. In addition, with GC, veterinarians can examine the pet where he or she prefers and is most comfortable. Make sure to plan ahead by having materials easily accessible, and have assistance available in the room so the veterinarian can keep a gentle reassuring hand on the pet. Later during the physical exam, the doctor can communicate how their assessment relates to what the client sees their pet experiencing.
To be efficient and consistent communicators, teams need tools that open clients’ minds to possibilities. The Zoetis Canine and Feline OA Screening Checklists can be a discussion starting point. These checklists have “cartoons” of cats and dogs doing common activities around the home that have been identified through research as top behaviors that can indicate OA pain.1,2
This visual checklist allows the client to see their pet’s behavior changes through the animations. They can see how a healthy cat moves compared to a cat who has unhealthy changes from OA pain. With a checklist a client can tell the veterinarian what they see in comparison to the pictures, or they can review a video of what their pet is doing compared to the cartoon. By reviewing the checklist with a trained technician or veterinarian, the client can offer insight into how they view their pet’s mobility, behavior, and daily comfort. This checklist can be used prior to any exam with an email electric copy, or completed in the room by computer, phone, or as a printed hard copy. This could be a valuable addition to any biannual or annual checkup.
Age is not a disease. And we have tools, strategies and skills that make client discussion interactive, efficient and fun. Clients love to learn about their pets, they want a plan, and they want to feel confident they have made good decisions. Combining the tools of an interactive team checklist, Fear Free strategies of CA and GC and using open questions with active listening create productive discussions, save time, and produce healthier teams and pets. Go ahead talk about OA with these tools: it’s painless.
References
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Sponsored by our friends at Zoetis Petcare. NA-02335
They have different pain tolerances, just like people do (if I step on my pit bull Gwen’s toe, she never notices, but if I accidentally do the same to my Pomeranian, Turley, she’ll scream, run and hide, and not speak to me for days) but sensing pain comes hand-in-hand with having a complex neurosystem and a big brain.
The challenge for us as veterinarians is how we detect and react to their pain.
To address the complexities of animal pain and its management, the International Veterinary Academy of Pain Management (IVAPM) has declared September to be Animal Pain Awareness Month. (https://ivapm.org/animal-pain-awareness-month/) It’s also Pain Awareness Month for another group of big-brained animals – people.
Treating animal pain will always involve some guesswork until someone develops a way for dogs and cats (and horses and iguanas, etc.) to point to their anatomy and say “It hurts right here, doc.” Until that beautiful day, we have to tease out the sometimes-subtle signals of discomfort and adopt a trial-and-error approach, backed up by science whenever possible.
As an ER clinician, acute pain is what I deal with most. I do see animals with chronic pain, and try to help whenever I can, but for those patients I encourage pet owners to seek the counsel of their family veterinarian, since chronic pain will take a solid partnership spanning weeks or months – things that are impossible in the rushed setting of the ER.
With that as preamble, I’ll share some tips from 25 years of ER pain management.
AAHA, in 2015, developed guidelines for small-animal practitioners that clearly outline ways to monitor and manage pain: https://ivapm.org/wp-content/uploads/2017/03/2015_aaha_aafp_pain_management_guidelines_for_dogs_and_cats-03.10.17.pdf
Same holds true for a dog with raging pancreatitis. If he’s vomiting every time the wind blows, an NSAID will only make matters (way) worse. Opioids have minimal GI effects beyond constipation (which I have not seen as a major problem), and we use tons of opioids in the ER and ICU to manage pain. Our brains (and those of our patients) are hard-wired to receive opioids – it’s a gift from evolution and nature. Use it.
Why do brains have receptors for chemicals produced by a poppy largely grown in the Middle East? I have no idea, but for the sake of my patients I am thrilled that they do, and I make use of it every day I am on the clinic floor.
The opioid crisis has certainly made giving opioids a challenge, with increased regulation and paperwork and changes in the supply chain making some drugs unavailable. Try to keep abreast of what’s on and off the market and do your best to make sure you always have a few options for good pain control on hand. I think every hospital needs to have a full mu agonist such as fentanyl, morphine, or hydromorphone on hand for treating severe pain. Butorphanol is great as an adjunct for sedation for minor procedures like lacerations, but it’s just not potent enough for cases of moderate to severe pain.
Look for creative ways to address pain, using different techniques such as local blocks, epidurals, and topical lidocaine patches. Combining classes of drugs such as NSAIDs and opioids, in carefully selected patients, can achieve results that higher doses of either drug can’t achieve.
I have found that learning new techniques can be a great way to fend off burnout and makes me feel as if I am growing as a clinician. Learning new pain management skills aids me in fulfilling my obligation to alleviate animal suffering. Enrolling in CE classes, attending online seminars, and even brainstorming with colleagues can open new worlds to the clinician who wants to learn and grow. It can also make great financial sense to a practice, as owners now accept and even expect advanced pain-control modalities.
The IVAPM offers consultations in pain management and pathways to become IVAPM-certified as a pain management practitioner. (More info at https://ivapm.org/).
We all want our patients to live long, pain-free lives. Learning about pain and learning new ways to manage pain and recognize it will serve our patients better and help us grow as doctors and people.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Pain is not just physically unpleasant for animals. Beyond physiological symptoms such as GI dysfunction, immunosuppression and delayed wound healing, pain also affects animals emotionally and increases FAS. If not controlled, acute pain can lead to central sensitization, chronic pain states, increased morbidity and increased mortality.
If left untreated for too long, pain can become maladaptive and lead to a vicious cycle of reduced activity, weaker muscles, even less exercise, and even more pain. This course will show the importance of treating pain early and why doing so can lessen its overall impact on patients.
This course, approved for 1 RACE CE hour, was written by Ralph Harvey, DVM, MS, DACVA, UTCVM.
This course consists of 6 lessons.
That same stress and anxiety also contribute to the disease process itself. As an ER vet, I know the plumbing aspect of the disease very well and can usually get them unblocked and on more stable footing in short order. What I don’t usually have to deal with are the softer aspects of the disease – softer, but no less important. That usually falls to general practice veterinarians, who have to take the reins from ER vets like me and manage their patients long-term.
In the spirit of adhering to the Veterinarian’s Oath and reducing animal pain and suffering, I’d like to offer up some points to consider when either treating a cat with a urinary obstruction or managing a non-obstructed cat with signs of lower urinary tract disease.
This is a painful condition. Pain causes stress, which can exacerbate the disease – and make future trips to the vet even more stressful. Making sure you have incorporated appropriate analgesia when unblocking a cat, and when managing a catheterized cat in the hospital, is a vital part of treatment – and one that is often overlooked. Proper (and safely chosen) sedation, and incorporation of a sacrococcygeal block while unblocking, good pain control with buprenorphine or a full-mu opioid agonist, and home analgesia for three to five days after discharge will help to minimize the pain and anxiety of an episode of urethral obstruction. Owners will appreciate advanced pain control protocols and knowing that you are taking their pet’s emotional wellbeing into consideration. It also makes cats easier to handle in the hospital and more likely to come back for future visits – everybody wins!
Sacrococcygeal block:
Buprenorphine – while in hospital:
Buprenorphine – sublingual/outpatient: 0.01–0.02 mg/kg transmucosal q 4–12 hr
Fentanyl CRI – 1-5 ug/kg/hr IV
Note: Since many cats who are blocked may also have some degree of acute kidney injury, NSAIDs should be used cautiously or not at all in acute obstructions. They may be helpful in cats with normal renal function for non-obstructive episodes.
Imagine you are a hospitalized blocked cat: fluorescent lights, a painful catheter, Elizabethan collar, barking dogs – sounds awful, right?
Do everything you can to reduce the stress of hospitalized cats. Put yourself in the patient’s position and imagine what their existence in your hospital is like. If you don’t have a “cat room,” try and keep cats in the quietest part of the hospital, out of sight and sound of dogs. Allow time for rest and a break from medical procedures and provide a box or other structure in the kennel where the cat can hide.
Both at home and in the hospital, use of feline facial pheromones (Feliway®) may help alleviate stress and anxiety. Consider installing one in your ICU and changing it regularly. A few sprays of Feliway® on your patient’s bedding may also help. The Feliway® diffuser can be particularly helpful at home.
Make sure cats at home have distractions and safe spaces to hide from dogs, children, and other cats. During stressful times (moving, boarding, redecorating, addition of new pets or children to the home) consider advising clients to spend extra time with their cats or discuss safe sedation and anti-anxiety protocols and environmental enrichment to reduce fear, anxiety, and stress.
Stress can bring on this condition, and the things we have to do to treat it are often stressful and uncomfortable, creating a continuous positive feedback loop. Owners are stressed, vets are stressed, and (most of all) patients are stressed. Do everything you can to reduce the anxiety and discomfort of feline urologic conditions and you will not only be keeping up your part of the Veterinarian’s Oath, you’ll be practicing better medicine as well.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.