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Chronic pain: changing the unhappy situation

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01 May 2017, at 1:00am

Veterinary Practice talks to Louise Clark of Davies Veterinary Specialists about how she has developed an interdisciplinary approach to managing patients with chronic pain

ASKED TO PICK THE NEXT CLINICAL DISCIPLINE to emerge as a distinct veterinary specialism, there is no doubt that the management of chronic pain would be a popular choice for many practitioners. All vets know how frequently animals will enter their consulting room with a musculoskeletal, oncological or neuropathic condition that is likely to cause constant discomfort. Historically, it has to be said that such patients have received a rather disappointing standard of care, but that is not through lack of compassion or interest – it is because practitioners simply haven’t had the tools necessary to identify and assess the effects of chronic pain, or even reliable means to alleviate it. However, this unhappy situation may be changing and part of the reason for that is Louise Clark and the team at Davies Veterinary Specialists. She was one of the first veterinary surgeons in the UK to complete the MSc in managing clinical pain in humans and animals run by the University of Edinburgh. The skills and knowledge gained through that training are helping in further advancing both the science and clinical practice of dealing with such cases in her role as head of anaesthesia at the referral practice based in Higham Gobion, Bedfordshire. The Edinburgh qualification is run as a distance learning course, but with many opportunities to work online or directly with the other students from a range of different medical backgrounds – doctors, dentists, palliative care nurses, physiotherapists, etc. Louise benefited from developing an appreciation of the importance of an interdisciplinary approach to managing patients with chronic pain and soon realised that veterinary staff are not alone in struggling to deal with them. She points out that veterinary surgeons start their careers better prepared for dealing with such patients than their NHS colleagues. A study by the interdisciplinary British Pain Society showed that a typical veterinary curriculum provides almost double the amount of time that medical students are offered to train in understanding and treating chronic pain. Acute pain is a different matter – “I think we are pretty well on top of that,” Louise says. Most practitioners will appreciate the importance of, say, post-operative analgesia to aid recovery and there can’t be many who still cling to the view that discomfort will keep surgical patients quiet and aid recovery by discouraging them from moving around. Louise qualified from the Glasgow veterinary school in 1997 and attained the European diploma in veterinary anaesthesia and analgesia in 2003 after working in practice and in a residency at Edinburgh. She was an anaesthetist at the Animal Health Trust before joining the DVS referral practice in 2007. “When I was doing the diploma, I felt that the emphasis was much more on anaesthetic aspects and not enough on the pain part. I was wanting to improve my understanding of pain rather than just analgesic pharmacology, which was how I found out about the MSc.” One of three other veterinarians to complete the Masters’ programme at that time was Fergus Coutts, who runs pain management clinics from practices in Stirling and Aberdeen. He has also developed a module for training in the management of musculoskeletal pain in small animals which he is now teaching students on that course, as well as to candidates for the MVetSci Advanced Clinical Practice programme offered by Edinburgh. He says that an awareness of the value of postgraduate training in  aiding the management of chronic pain cases is growing, and similar options will eventually become available from other institutions. However, in the meantime, the only other course currently available is the Western Veterinary Acupuncture and Chronic Pain Management general practice certificate offered by Improve International. Dr Coutts says the training he received on the Edinburgh programme has influenced his handling of cases in practice. “That is because it is a mechanismbased approach rather than ‘this is what you do for osteoarthritis or a bad back’. There is also an emphasis on how the pain affects behaviour, what is called the biobehavioural model of pain management. It is not just whether the animal is lame, but how that lameness makes the animal feel and how having a sore joint will affect the animal’s life.” In January, DVS opened a new facility, the Therapy and Fitness Centre, which applies the similar theories about the need for a multidisciplinary approach to patient care. “If you have a dog with elbow osteoarthritis, it isn’t just a matter of joint replacement surgery or drugs; there are a lot of other options in between,” Louise says. “The right approach for that particular patient may involve input from veterinary colleagues in the orthopaedics team, the hydrotherapists, physiotherapists and techniques such as acupuncture. It is very much an individual approach for that patient, particularly those like one that we are dealing with now, which don’t tolerate NSAIDS very well.” She acknowledges that a first opinion practice is unlikely to have this broad range of staff with different skills immediately to hand. “But we wouldn’t expect them to. What we are doing is empowering the referring practice to deal with this type of case themselves. The referring vet is an essential part of the team because they are the ones who have built up the relationship with the client that is needed to take things forward.” Asked if she has learned anything new in the short time that the service has been operating, Louise says yes. “It is how remarkably committed clients are to their pets. Obviously, as a referral practice we are slightly different, but I’m sure that clients of a typical first opinion practice will be just as concerned about improving their pets’ quality of life.” Indeed, she says pet owners will often understand better than their vets that chronic pain isn’t simply a medical issue. “They know their dog and if it is no longer able to jump up on the sofa where it has always slept, then they know that is really frustrating for their pet.” Dealing with patients in chronic pain will be a task for the whole first opinion practice team, she says. “The VNs have a vital role to play in this. The first issue in osteoarthritis patients, for example, is weight control and that is a nurse responsibility. Encouraging the owner to sort out the pet’s diet will reduce the physical stress on the animal’s joints and reduce inflammation which is linked to the cytokines produced in adipose tissue.” Although the prospects for a pet suffering chronic pain may be brighter than they were in the past, there are still some major gaps to be filled. Louise points towards the treatment available for feline patients. “There are many reasons why cats are more challenging. They aren’t exercised in the same way as dogs, so it is more difficult to detect any changes. They are also more subtle in the way they express their response to pain and as far as treatment goes, we don’t have as many options for licensed drugs.” Hence, Louise is helping gather data for the ongoing project at Glasgow veterinary school which aims to develop reliable methods for assessing chronic pain in companion animals. The Glasgow pain scale – CMPSF-SF – has become the accepted method for monitoring signs of acute pain in surgical cases. But through the Vetmetrica HRQL project, the team led by Andrea Nolan and Jacky Reid is now working on validating the methods needed to identify and measure chronic pain in a practice setting. Tackling these problems is a multinational, as well as a multidisciplinary task. Louise hopes to attend the first major international conference dedicated to this field, planned in November at the US National Institutes of Health in Bethesda. It aims to draw up a road map for future research into measuring chronic pain in dogs and cats. As the organisers explain on their website (https://paw2017.com), progress in this area would help improve the quality of life for human patients as well as pets. “One of the changes that could be made [from advances in the veterinary area] is to help the 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.”