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Starting Off Right: A Good History to Help Identify Pain

Shelly J. Olin, DVM, DACVIM (SAIM), University of Tennessee

M. Katherine Tolbert, DVM, PhD, DACVIM (SAIM), University of Tennessee

November / December 2016|Peer Reviewed

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Starting Off Right: A Good History to Help Identify Pain

Part 3 of a 3-part series

TEACHING TARGET:

VETERINARY PATIENTS OFTEN HIDE SIGNS OF PAIN COMPLETELY OR SHOW ONLY SUBTLE SIGNS, SO EDUCATING VETERINARY TEAM MEMBERS AND CLIENTS TO RECOGNIZE PAIN IS ESSENTIAL FOR EARLY TREATMENT.

The detrimental effects of untreated pain in veterinary patients and their recovery from illness, injury, and surgery are well-documented.1 Managing pain should be considered a standard of care, but recognizing the signs can be challenging and pain is likely still undertreated in dogs and cats.

Behavior changes are some of the most common signs of pain but can easily be overlooked2,3; therefore, during the medical interview, the veterinary team must thoroughly question clients about their pet’s behavior changes.

Owners may be unaware of the clinical signs associated with their pet’s pain because animals sometimes hide the signs, present only subtle clues,2 become reclusive, or develop abnormal behaviors.4 Pain also may be associated with underlying disease, occur in the absence of obvious tissue damage, and persist after an inciting cause is resolved.3,5

Spectrum of Signs

Pain severity can range from acute and severe to insidious and mild. Some signs (eg, lethargy, decreased appetite) are extremely nonspecific, but others (eg, pronounced movement and posture changes, especially with vocalization) are more overt. A dog with a painful abdomen may sit hunched over or in a prayer position; a cat with neck pain may appear stiff and be reluctant to move the neck; a dog with orthopedic or musculoskeletal pain may limp, rise slowly, or stand or walk with difficulty. 

More subtle signs (eg, decreased appetite, disposition changes [aggression, restlessness, hiding], trembling, ptyalism) may not be recognized as pain indicators.6 Owners also may not recognize chronic pain because they think changes are due to normal aging.2 

Painful cats can be especially challenging. They may interact less with owners and become more reclusive, hide, or be less mobile,2,3 which, unfortunately, even veterinarians can find difficult to assess. One study found 90% of cats had radiographic evidence of degenerative joint disease (DJD), yet only 4% of these cats had clinically detectable lameness.7 A subsequent study of 23 cats with radiographic DJD showed that cats were significantly more active, more willing and able to jump, and increased their grooming after analgesic therapy was initiated.8 Thus, owners may retrospectively recognize signs of pain only after adequate treatment.

Different Manifestations

Pain manifests differently in dogs and cats, so the veterinary team should develop a comprehensive understanding of the differences to better guide their questioning of the owner.3

For example, the owner of an indoor cat with progressive osteoarthritis may notice changes in litter box habits such as urinating or defecating outside the litter box to avoid stepping over the edge of the box.9 If recognized early, a simple solution would be to provide analgesics and use a litter box designed for low-impact entry placed in an easily accessible location that does not require effort (eg, going up or down stairs).

Owners should also be questioned about decreased grooming, another possible sign of pain in cats,2,3,6 whereas increased grooming of a particularly painful area is occasionally noted in both cats and dogs.3 Dogs, however, tend to exhibit more overt clinical signs of pain, including pacing, restlessness, lip smacking, or barking or whimpering.3,10 Questioning and educating owners about behavior pain indicators, especially in aging pets, is critical to facilitate early intervention.2

Physical Examination

In addition to a complete history, it is important to observe the patient in the practice and perform a thorough physical examination to support pain identification. Using a validated pain scale for the species of interest helps decrease interobserver subjectivity and can improve pain management.4,11,12

Pain Scales

Conclusion

Owners are often very astute about their pets’ normal personality and behaviors, but given the many types of pain manifestation and species differences, they may miss subtle signs of pain. Therefore, educating owners about the possible signs and the importance of communicating changes to the veterinary team is essential. Likewise, educating all veterinary team members who obtain patient histories to recognize signs of pain is the cornerstone of identifying and treating pain promptly.

References and Author Information

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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