Why should I pain score? Kate White MA Vet MB, DVA, DiplECVAA, MRCVS

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1 Why should I pain score? Kate White MA Vet MB, DVA, DiplECVAA, MRCVS

2 Pain scoring Analgesics are still used sparingly by vets and owners Is this due to lack of recognition of pain? Pain scoring should be part of everyday clinical practice All staff should undergo training to learn to assess and score pain

3 Pain scoring Pain can be considered the 5 th vital sign Pain scoring systems should be validated Mid 1980s (USA teaching hospitals) 40% dogs & cats received post op analgesia 1990s (Canada) % dogs undergoing neutering received analgesics

4 Pain scoring In the 1990s (Australia) 4-6% of animals being neutered received analgesics In UK (1996) 53% bitches received analgesics for spay, and 32% dogs for castration In New Zealand in 2005 there was a further reported increases in the use of analgesics Veterinary Schools curricula are changing & place more emphasis on pain scoring & analgesia

5 Limitations of pain assessment Animals demonstrate pain in different ways Some behaviours are strongly suggestive of pain No behaviour in isolation is pathognomicfor pain, and absence of a behaviour does not mean absence of pain Use objective and subjective assessments together Know what is normal for the animal

6 Limitations of pain assessment Disease can affect the behaviours Behaviours should be observed prior to and during interaction with the patient There will be variability! Some behaviours are associated with general ill health Some behaviours can be very subtle to detect

7 Pain behaviours Vocalization Mobility and posture Interactive behaviours and attitude Appetite, urination & defecation Physiological signs associated with pain

8 Pain scales Simple descriptive scales Numerical rating scales Categorised numerical rating scales (UMPS)

9 Pain scales -limitations Categorised numerical rating scales (UMPS)

10 Pain scales Visual analogscales (& dynamic interactive VAS) Composite scales (e.g. Glasgow CMPS)

11 The short form of the Glasgow Composite Pain Scale Quick & reliable 30 descriptor options 6 behavioural categories Pain score is sum of rank scores CMPS-SF analgesic intervention 6/24 or 5/20

12 Other scales Date Time Colorado State University Veterinary Medical Center Feline Acute Pain Scale Pain scale for cats Pain Score 0 Rescore when awake Animal is sleeping, but can be aroused - Not evaluated for pain Animal can t be aroused, check vital signs, assess therapy Example Psychological & Behavioral Response to Palpation Body Tension Content and quiet when unattended Comfortable when resting Interested in or curious about surroundings Not bothered by palpation of wound or surgery site, or to palpation elsewhere Minimal Psychological & behavioural elements, Signs are often subtle and not easily detected in the hospital setting; more likely to be detected by the owner(s) at home Earliest signs at home may be withdrawal from surroundings or change in normal routine In the hospital, may be content or slightly unsettled Less interested in surroundings but will look around to see what is going on Decreased responsiveness, seeks solitude Quiet, loss of brightness in eyes Lays curled up or sits tucked up (all four feet under body, shoulders hunched, head held slightly lower than shoulders, tail curled tightly around body) with eyes partially or mostly closed Hair coat appears rough or fluffed up May intensively groom an area that is painful or irritating Decreased appetite, not interested in food Constantly yowling, growling, or hissing when unattended May bite or chew at wound, but unlikely to move if left alone May or may not react to palpation of wound or surgery site Responds aggressively or tries to escape if painful area is palpated or approached Tolerates attention, may even perk up when petted as long as painful area is avoided Growls or hisses at non-painful palpation (may be experiencing allodynia, wind-up, or fearful that pain could be made worse) Reacts aggressively to palpation, adamantly pulls away to avoid any contact Mild Mild to Moderate Reassess analgesic plan Moderate Reassess analgesic plan wound palpation, & body tension 4 RIGHT Prostrate Potentially unresponsive to or unaware of surroundings, difficult to distract from pain Receptive to care (even mean or wild cats will be more tolerant of contact) Tender to palpation Warm Tense May not respond to palpation May be rigid to avoid painful movement LEFT Moderate to Severe May be rigid to avoid painful movement Reassess analgesic plan Comments 2006/PW Hellyer, SR Uhrig, NG Robinson

13 Pain scales for chronic pain Liverpool Osteoarthritis in Dogs Questionnaire (LOAD) Information on validation can be found at Owner questionnaire containing 23 questions covering detailed aspects of exercise tolerance and mobility levels. Canine Brief Pain Inventory (CBPI) Can be downloaded from Owner questionnaire. Asks for a score to be assigned to 11 questions relating to pain and how this affects ability to perform daily functions Helsinki Chronic Pain Index (HCPI-E2) Can be downloaded from Separate questionnaires for vet and owner covering demeanour and mobility levels Client Specific Outcome Measures (CSOM) Quality of Life Assessment (Wiseman-Orr/GUVQuest) Series of questions to quantify quality of life, as a measure of chronic pain This is only for the dog owner

14 Pain scales Pain scales are a very useful tool, but should not be used in isolation Pain scales should not replace sound clinical judgement