Pain is Whatever the Patient Says It Is

Pain is Whatever the Patient Says It Is The characteristics of pain may vary according to patient presentation. Working on the basis that ‘pain is whatever the patient says it is’ can lead us into some challenges with our dogs and cats when assessing chronic pain, and a pain trial can help here.

 Pain trials are a valuable tool to use in managing your chronic pain cases. In this article, we review how we use pain trials, what we should consider alongside this, and we make some recommendations.

An analgesic trial, or pain trial, involves the prescription of analgesic(s) where we are suspicious of pain. The response to this intervention is then monitored to determine if the clinical signs have resolved with analgesic treatment.

So Where Do We Start?

Common questions are which analgesics to choose and how to monitor the response to those. We will review some commonly used analgesic options and discuss some tools to use to monitor progress.

We Need Outcome Measures

Diagnosis of chronic pain is often not easy and can be greatly assisted by an analgesic trial. Key to this is monitoring the response to treatment. This can be done in a variety of ways. A really simple option that I find valuable is asking the client to define some pain behaviours – these are changes in the pet’s behaviour that the owner associates with pain.

These are also known as Caregiver Specific Outcome Measures (CSOMs) or Caregiver Reported Outcome Measures (CROMs) and their use deserves some focus here. During our history taking we can often identify these behaviours and work with the client, so they understand that we are using these as outcome measures at our next consultation. I tend to identify 3–5 behaviours. I recommend reading further on this topic, by Innes.1 In this article Prof Innes highlights why CROMs should become part of our routine.

The author suggests that the everyday use of CROMs would bring benefits to animals with chronic health conditions and improve the impact that our profession can have on animal welfare.

In addition to these pain behaviours, we can also use various metrology instruments – examples being the Canine Brief Pain Inventory (CBPI) (osteoarthritis pain & cancer pain), Liverpool Osteoarthritis in Dogs (LOAD)(OA), Feline Musculoskeletal Pain Index (FMPI).

To me, a huge part of outcome measures is my physical exam. In that initial consultation, we are documenting where the pain is. Of course, the pain we detect is not always the primary source of pain and we may be identifying areas of secondary compensation, for example, muscular pain. At each and every visit we go back to basics and use that physical exam to support what the owner and the pain scores are telling us. The caveat to this are those patients where an examination is not possible due to a behavioural presentation where pain could be a factor and this increases the emphasis on the use of tools to measure pain.