What Pain Can Teach Us
How the veterinary community can overcome misconceptions and mismanaged treatment to provide pets with healthier lives.
Dr. Melina Zimmerman loves that there is both constant evolution and continuous learning throughout one’s career in veterinary medicine – particularly when it comes to pain management. “As human and veterinary medicine is advancing, we are constantly finding new ways to treat pain, and there is more and more evidence through scientific studies that is becoming available and helping us do a better job treating pain,” said Zimmerman, DVM, DACVAA, CVPP, CVMA, CCRP and owner of The Doggy Gym, a state-of-the-art veterinary practice in Monmouth County, New Jersey.
Dr. Zimmerman’s career has always leaned toward an emphasis on pain management. When she started working at a small animal private practice, she observed pain management appointments and realized how much she could make a difference in patient and owner care. Dr. Zimmerman got involved with the International Veterinary Academy of Pain Management (IVAPM) and earned additional certification in pain management by becoming a Certified Veterinary Pain Practitioner. That led her to pursuing an acupuncture certification.
“As I got more into pain management, I realized that so many of my patients were feeling better, but could really benefit from physical rehabilitation,” she said. So, she pursued additional training in physical rehabilitation and became a Certified Canine Rehabilitation Practitioner through the University of Tennessee. She started a pain management and physical rehabilitation program at the practice she was at while also working as an anesthesiologist.
As she reevaluated what she wanted to do with her career, Dr. Zimmerman decided to leave that practice and start The Doggy Gym – a standalone pain management and physical rehabilitation practice.
“At The Doggy Gym, I’m able to spend all of my time and focus on my patients and their families to help them have a more comfortable and active life,” she said. “It’s great because I’m able to work with other veterinarians, from general practitioners to specialists, and I also have time to promote pain management education to veterinary professionals and pet parents at conferences, labs, and other platforms.”
Problematic thinking
Like Dr. Zimmerman, Tamara Grubb, DVM, PhD, has made understanding pain in animals the foundation of her professional journey. In her work, Dr. Grubb owns an anesthesia/analgesia and continuing education consulting practice that serves both small and large animals. She is a diplomate of the American College of Veterinary Anesthesia and Analgesia, a national and international educator and lecturer, a certified acupuncturist, an adjunct professor of anesthesia and analgesia, and the president-elect of the IVAPM. So, you can imagine her exasperation that even today, many pet owners – and even some practitioners – aren’t convinced that animals actually feel pain.
“That seems to be especially true for chronic pain, since it can be very insidious in onset and development so often not noticed by pet caregivers,” said Dr. Grubb.
Another leading misconception is that pain isn’t problematic in animals like it is in people. This is because they are very good at hiding their pain.
“The answer to both misconceptions is that the mammalian pain pathway is very similar across species, so if a stimulus is painful to a human, it is painful – and problematic – for an animal,” she said. “And pain in all mammals – and probably most species – causes a myriad of adverse effects like negative impacts on health, behavior and welfare.”
The first step toward combatting those misconceptions is advocacy. The “I” in IVAPM – International – has also been a point of emphasis for the organization, as it is expanding its global reach with more presence at international meetings and more international resources on its website. IVAPM’s other efforts include resources for pet owners, and continuous education, such as the Certified Veterinary Pain Practitioner (CVPP), the only pain-focused micro-credentialing program in veterinary medicine. As of late, the organization has expanded its CVPP program and is working to increase the number of CVPPs. “It is exciting to see how many people are interested in helping patients in pain,” Dr. Grubb said.
Responding to treatment
Dr. Zimmerman sees a variety of pain-related cases at The Doggy Gym from animals with orthopedic or neurologic injuries, congenital abnormalities, recovering from surgeries, and with debilitating conditions. “This brings young animals through geriatric ones through the doors every day.”
Dr. Zimmerman starts each treatment plan with getting the patient’s comfort level under control first. This can be accomplished through medicine, both pharmacologic and non-pharmacologic options. “One thing to remember is that exercise itself has been shown to be hypoalgesic,” she said. “That being said, I always try to come up with a multi-modal plan for each individual patient to maximize their overall comfort and strength levels.”
Pet owners play an important part in treatment. First, veterinarians can be more proactive in treating chronic pain by educating the pet caregivers on what pain looks like, Dr. Grubb said. “Teach them that animals don’t scream in pain and that they usually eat even if they are in pain.”
‘Not screaming and still eating’ is a very common comment from pet caregivers as to how they know – they think they know – that their pet is not in pain. “We need to teach them that we don’t see pain, we see the impact of pain – which is primarily on behavior and mobility. Limping does mean that the pet is very likely in pain. Hiding or reactivity (sometimes called aggression) in a previously active or friendly pet is often a sign of pain.” The veterinary community must provide that information on their websites, Facebook pages, or anywhere that pet caregivers might see the information.
For most health conditions, and especially for chronic health conditions like chronic pain, the disease – the pain – isn’t happening in the clinic, Dr. Grubb said. It is happening in the home. The only way that veterinary professionals can treat chronic pain is for the caregiver to first learn to recognize pain and then learn to manage pain at home using the veterinarian’s instructions. “The office visits are assessments of how the pet is responding to treatment, but they are only glimpses into the window of the chronic disease,” she said. “I can’t over-emphasize the importance of caregiver support, tools, and resources. Those resources make the difference between failure and success for both the caregiver and the pet.”
One helpful development for cats is the recent release of the American Association of Feline Practitioners (AAFP) Chronic Pain Education Toolkit, an online resource designed to equip veterinary professionals with the insight and tools needed to effectively address this critical issue.
The toolkit offers:
• In-depth understanding of chronic pain: Veterinarians and team members can learn more about the pathology, types, and prevalence of chronic pain in cats, enabling them to better predict and identify its presence.
• Enhanced assessment tools: Veterinary teams can explore various assessment methods, including those involving both the veterinary professional and the cat caregiver, to gain a comprehensive picture of the cat’s condition.
• Science-based treatment strategies: Effective therapy goals with practical applications are offered, incorporating pharmaceuticals, nutrition, and environmental modifications.
• Patient and caregiver support: Valuable insights into supporting the cat and the caregiver throughout the management process, fostering a collaborative and successful approach.
An important concept regarding assessment of pain is that we don’t see pain itself, we see the impact of pain on the cat’s mobility, behavior, and quality of life, and it is very important that veterinarians use tools that assess those things, Dr. Grubb said. It is also important to use tools that have been proven to identify pain – specifically chronic pain in this instance – in the species of interest. With chronic pain, providing tools that the caregiver can easily and predictably use at home is critical to both the initial diagnosis and the assessment of ongoing treatment efficacy.
All the tools included in the Toolkit were chosen for their focus, proven efficacy, and ease of use by the caregiver, according to the AAFP. The Toolkit includes sections on defining chronic pain, prevalence and conditions that cause chronic pain, assessment, therapy goals, role of each therapy, patient support, and caregiver report. Veterinary professionals can navigate the website by clicking on each tab or can download the whole Toolkit as a PDF.
“One of AAFP’s many strengths is the focus on science-based medicine and medical techniques across the scope of health conditions,” Dr. Grubb said. “The strategies and treatments, both pharmacologic and nonpharmacologic, listed in the Toolkit are all not only science-based but also clinically supported by members of the Toolkit committee.” The readers can be assured that the most effective treatments are recommended in the Toolkit, which promotes not only successful pain control but also decreases caregiver burden by ensuring that a minimum number of treatments should provide pain relief, she said. “This is in contrast to unproven or minimally effective treatments that might lead the caregiver to administration of multiple treatments multiple times per day, which can quickly become unsustainable.”
The patient and caregiver support sections are particularly helpful, Dr. Grubb said. “The Toolkit goes way beyond just recognition, diagnosis and treatment of pain in the patient and includes topics like nutritional needs and environmental modification. Both are very important for the overall health and well-being of the cat. The caregiver support section, which I haven’t seen in any other document, is very robust and empathetic, and really addresses common caregiver concerns and pitfalls. Support of the caregiver is critical for support of the cat, and I think this is one of the most useful sections in a document that is stuffed full of very useful information.”
Other resources that teach about chronic pain in cats on the clinic’s website or social media, using the Cat Friendly Veterinary Interaction Guidelines since rough handling can exacerbate pain, and having a Cat Friendly Practice (catvets.com/cfp) or individuals who have obtained a Cat Friendly Certificate (catvets.com/certificate).
Pain management and the distributor rep
Most general veterinary practitioners have so much to do that pain management is often not front and center. “Dentistry, surgery, internal medicine and HR – it’s hard to find time to do everything,” Dr. Grubb said.
Here the distributor rep can add value by providing information on the latest products and services being introduced to the market, consultation of the best pairings and how other veterinary practices are incorporating pain management into their clinical work and leads on resources and continuing education courses available through manufacturers.
“I love my distributor reps!” said Dr. Zimmerman. “They are so helpful in teaching me and my staff about the products we use on a daily basis.”
Indeed, the best practice that veterinarians can use is training the entire team to be focused on pain. “So having the receptionist talk about pain and pain management and supporting the technicians in their efforts and interest in focusing on pain management, getting that whole team together, is probably the determining factor that will lead to success,” Dr. Grubb said.
September is Animal Pain Awareness Month
IVAPM’s biggest initiative every year is promotion of September as Animal Pain Awareness month. “September is pain awareness month in human medicine too so it is a good opportunity to highlight that our pets and patients are feeling the same thing that humans are feeling when they are in pain,” said Dr. Grubb. “Of course every month should be pain awareness month!”
Pain management in the acute setting
Pain is a complex process with numerous components contributing to the overall pain level and duration. In the acute setting, the analgesic protocol needs to be robust and address those various contributors to be effective, Dr. Grubb said. The most effective way to control pain is to utilize multimodal analgesia, meaning different drug classes and nonpharmacologic therapy in the protocol. This allows pain to be prevented or at least controlled at a number of sites in the pain pathway, which is a very powerful way to provide what is termed “balanced analgesia”. Preventive analgesia, meaning utilizing analgesics before the pain is caused, is also important. “An interesting fact that may be new knowledge to some people is that robust analgesia for acute pain can also decrease the development of chronic pain. Chronic post-surgical pain, or CPSP is unfortunately fairly common in humans and we have evidence that it also occurs in animals.”
