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Pain management beyond medication

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01 May 2016, at 1:00am

Gwen Covey-Crump discusses the control of pain and explains how a combined approach of pharmacological and non- pharmacologic therapies is required along with skilled recognition.

“UNDER-RECOGNISED AND UNDER-MANAGED CHRONIC PAIN can result in premature euthanasia. Conversely, proper recognition and management of chronic pain can be as life-preserving as any other medical treatment in veterinary medicine” – AAHP/AAFP Pain Management Guidelines for Dogs and Cats 2015. 

To control pain effectively, a combined approach of pharmacological and non-pharmacologic therapies is required along with skilled recognition of pain.

Different types and sources of pain exist simultaneously and interact within the patient to contribute to the overall pain experience.

Use of non-pharmacological adjuncts to pain management may help to minimise medication-related adverse effects while assisting the return to more normal function for the pet.

Such techniques range from the apparently mundane or obvious to those where more specialist training is required.

Gentle handling is important to gain the trust of both the patient and client, to maximise comfort and to avoid anxiety. Careful examination combined with skilled observation of patient response and perceptive questioning of the client will give the clinician a more accurate picture of pain.

Client engagement and management of expectations is key and recovery is accelerated with client commitment and involvement in therapy at home. 

Home improvement may consist of provision of non-slip rugs, choices of bedding substrates and locations, raised feeding bowls and launching points to favourite “perches” for cats.

Nutrition and weight optimisation is crucial for reducing load on musculoskeletal structures while maintaining muscle bulk to support the locomotor system. Furthermore, adipose tissue produces a range of pro-inflammatory cytokines and alterations to the neuroendocrine system (Grif n et al, 2010). 

Long-term diet restriction to maintain lean body mass has been associated with a delayed onset and reduced incidence of degenerative joint disease (Smith et al, 2006).

Provision of an anti-inflammatory diet*, appropriately balanced for protein, fat and carbohydrate, helps to maintain organ function and preserve muscle mass in the ageing or sedentary patient.

Supplementation with essential fatty acids is associated with improved function in clinical osteoarthritis (Corbee et al, 2013; Moreau et al, 2013).

Inefficient technique

A classic mistake in managing the obese patient is to enforce a calorie- restricted diet which does not consider the older patient’s need for high-quality protein and appropriate fats.

This is not only an inefficient technique to encourage loss of adipose tissue but may actually encourage further muscle wastage which may only be recognised once weight loss has occurred.

Physiotherapy aims to restore strength and function through use of passive and active techniques: manual joint mobilisation, myofascial release, massage, heat or cold therapy and directed exercises.

Therapeutic laser and ultrasound may be employed to aid healing and promote trigger point release and break down of scar tissue.

Neuromuscular electrical stimulation (NMES) can be used in specific cases to improve individual muscle strength and transcutaneous electrical nerve stimulation (TENS) can provide useful analgesia. Knowledgeable use of splints and supports can aid return to function.

Myofascial Trigger Point Therapy – trigger points are irritable spots within tight bands of muscle and fascia which develop through misuse, overuse, trauma to muscle and reaction to injury. On compression they give rise to pain which may radiate and can have wide-ranging and remote effects. Therapeutic laser, ultrasound, manual pressure and stretch, acupuncture needling and injection of the point with local anaesthetic, can provide immediate pain relief though the procedure itself will cause transient discomfort.

Acupuncture should be strongly considered as part of a multi-modal pain management approach (Epstein et al, 2015). It works at a peripheral level via interaction with the collagen matrix, tissues and nerve endings to promote local analgesia and healing. Neurotransmitters involved in pain modulation are released in the spinal cord.

Electro-acupuncture appears to have an effect comparable to opioid (Gropetti et al, 2011) and may modulate the NMDA receptor, having a synergistic effect with NMDA receptor antagonist drugs (Yang et al, 2011).

Segmental effects act via Aδ bres (fast pain) which synapse on inhibitory cells of the spinal cord, suppressing incoming C-fibre (slow pain) pain signals to create regional analgesic effects, and ascending pathways to modulate inhibitory effects mediated by higher centres.

Acupuncture can also have effects on local blood ow and the autonomic nervous system and subsequently the visceral organs.

The importance of client engagement in their pet’s care should not be underestimated. In the world of customer service and relations a great effort is made to make a potential customer feel enthusiastic, involved, listened to and valued. The same techniques can be applied to encourage a client owner to take control of their pet’s pain management.

An integrated team approach involving all practice members – vet, veterinary nurse, receptionist – and the client, combined with regular assessment and re-evaluation, ensures a robust approach to pain management with the bonus of enhancing the relationship between practice, vet, client and animal.

In summary, it can be seen that effective chronic pain management is about far more than simply prescribing medication. Much can be done to encourage a return to more normal function.

However, major barriers exist including the time taken to execute these techniques and follow-up on patient progress. The client and veterinary team are significant assets in the challenges to be faced.

* There is no real research describing an anti-inflammatory diet for dogs and cats but dietary guidelines for humans indicate that an anti-inflammatory diet should include a high-quality protein source combined with an enhanced dose of omega-3 fatty acids preferably from sh oil, minimisation of re ned carbohydrate, avoidance of grains, and a moderate intake of animal and vegetable fats. Any dietary change should be gradual.

References

  • Corbee, Barnier, van de Lest et al (2013) The effect of dietary long-chain omega-3 fatty acid supplementation on owner’s perception of behaviour and locomotion in cats with naturally occurring osteoarthritis. J Anim Physiol Anim Nut 97: 846-853.
  • Epstein, Rodan, Griffenhagen et al (2015) AAHA/AAFP Pain management Guidelines for Dogs and Cats. J Am Anim Hosp Assoc 51: 67-84. https://www.aaha.org/public_do...professional/guidelines/2015_aaha_aafp_pain_ management_guidelines_for_dogs_and_cats.pdf. 
  • Fry, Neary, Sharrock et al (2014) Acupuncture for analgesia in veterinary medicine. Top Comp Anim Med 29 (2): 35-42. 
  • Grif n, Fermor, Huebner et al (2010) Diet- induced obesity differentially regulates behavioural, biomechanical, and molecular risk factors for osteoarthritis in mice. Arthritis Res Ther 12: R130. 
  • Gropetti, Pecile, Sacerdote et al (2011) Effectiveness of electro-acupuncture analgesia compared with opioid administration in a dog model; a pilot study. Br J Anaesth 107 (4): 612- 618.
  • Moreau, Troncy, del Castillo et al (2013) Effects of feeding a high omega-3 fatty acids diet in dogs with naturally occurring osteoarthritis. J Anim Phys Anim Nutrit 97: 830-837. 
  • Smith, Paster, Powers et al (2006) Lifelong diet restriction and radiographic evidence of osteoarthritis of the hip joint in dogs. J Am Vet Med Assoc 229: 690-693.
  • Yang, Kim, Koo et al (2011) Synergistic antinociceptive effects of N-methyl-D-aspartate receptor antagonist and electroacupuncture in the complete Freund’s adjuvant-induced pain model. Int J Mol Med 28: 669.