Chronic pain management is really, “all about the patient”. Chronic pain refers to a pain state any animal has been in for over a few weeks. The underlying problem causing chronic pain is generally ongoing such as osteoarthritis or back pain. These conditions generally have a feedback loop of mechanisms that reinforce the pain state. Sometimes the brain and nervous system get involved [neuropathic pain] to the point that everything, even the slightest touch is painful [allodynia] to the patient. Chronic pain is difficult to manage and clients are understandably concerned about drugs and their side effects. They are also concerned about progressive debility and how this will affect their furry loved one, and their bond together. Pain affects quality of life and relationships.
Working towards my pain management certification, I find myself pouring over research articles and the newest pain management textbooks on managing chronic pain in small animals. As I do so, I am reminded of a common clinical dilemma many therapists face. Clients often specifically call us and ask about a specific modality for pain control – such as acupuncture or laser. They may also have questions as to why a particular drug does or does not work in their dog’s case with respect to pain management. There seems to be much confusion about the selection of modalities for therapy and choice of drugs to manage chronic pain. There also seems to be more web information available to clients regarding new therapies, which understandably, leads to many questions. Many of these are good questions. We (therapists) cannot expect our clients to be pain control experts, but they are experts on their furry loved ones.
So what do I mean, when I say, chronic pain management is “All about the patient” (?). Managing pain in companion animals is a task devoid of ego. I cannot simply look at a patient and say, they need “X” for pain control (be it a physical modality/therapy or a drug), give the drug, and expect it to work. We need more rationalization than this. Before we decide what type of pain control is adequate for any given situation, we need to fully characterize the patient’s pain. This is achieved by performing a full functional and physical assessment. From this assessment, I determine where the pain is coming from – such as from the bones from osteoarthritis, or from the spine in the case of degenerative spinal lesions.
With help from the client, we also determine what the patient has been on (what they have or have not been on for medication or supplements, how they have reacted to them and whether or not they have helped). I also try to tease out any injuries or mishaps that may have occurred recently or in the past to contribute to any “acute-on-chronic” pain episodes. I also determine what other conditions the patient may have suffered from or be suffering from since pain tends to be additive (a patient with a chronic history of painful ears may be in more pain with osteoarthritis than a patient with just one of these conditions). I also like to know about bloodwork – what is normal/not normal and what are we (the regular DVM/client and I) monitoring. From these assessments, I can then characterize the patient’s pain status (ie. chronic, neuropathic, wind-up, allodynia), and this helps determine a pain management plan.
Having characterized the patient’s pain, and reviewing how the pain affects the patient’s daily life, we now want to tailor a pain management plan to that particular patient. The most ethical plan is a multi-modal and balanced plan to manage pain. To minimize potential adverse effects of drugs, we aim to make the program “multi-modal” (meaning; using many modes of therapy to help the patient; not just drugs). The program has to be “patient-centred”, with selection of modalities specific to that patient and as evidence-based as possible so we can have some degree of faith in our methods (evidence-based refers to a specific triad of scientific, patient and therapist perspectives). Care becomes less about the “drug” or physical modality in question, and more about allowing the patient to dictate what they need. Careful selection of many modalities and therapies is truly vital to managing a patient’s pain.
For example, an elderly dog suffering from back pain (due to a degenerative condition) with sore joints may benefit from regular use of a low dose anti-inflammatory, and a drug such as Gabapentin. This patient would also benefit from soft tissue therapy to manage muscle soreness with or without acupuncture or laser, therapy to assist joint health, and a plan to control their daily activities to an appropriate level that minimizes ongoing pain, including home modification and assistive devices. Joint support (nutraceuticals) may also be selected to help slow progression of osteoarthritis. The step-wise progression of how these therapies and modalities are instituted becomes just as important. We often do not toss everything into the mix all at once. We need to address pain and underlying dysfunction first, before we can improve muscle or joint function, for example. It is also wiser NOT institute too many modalities all at once; often we like to know how one modality is affecting the patient. However, the patient is sometimes in so much pain, we suggest using many modalities at once; we just select and institute them carefully.
Recognizing chronic pain in animals is often difficult for clients, as it tends to sneak up on dogs as they age. I hope to cover more about this in an upcoming article, and help clients recognize some of the more subtler signs of pain in their furry loved ones.
-Material Not to Be Reproduced or Distributed Without Prior Permission of the Author (Email Her in Writing – firstname.lastname@example.org or email@example.com). Copyright. EQUILIBRIUM. April 2017. Dr. Shannon Budiselic.