Hello and welcome to this webinar Beyond the Limp, where we're gonna look at how pain shapes behaviour and how veterinary practises can help with that. My name's Sarah Heath and I'm a RCVS and European EBVS veterinary specialist in behavioural medicine. So we're gonna start by thinking about what pain is, and I'm going to do so thinking about pain using the comprehensive veterinary healthcare part of the Heath model.
It's illustrated here where we have physical health, that normal functioning of the body, the emotional health through both the, The valence, the type of emotion and the arousal level, and the cognitive health through the individual's ability to think, learn and remember, all interlinking with each other in a very bilateral fashion. So in other words, they're all interacting with each other, they're all equally important. And pain is a really good example of this because pain has of course got physical components to it, the sensory and motor dimensions of pain.
But it also has emotional and cognitive components. When we think about pain, there are different types of pain and that obviously is important when we think about both diagnosis and treatment and we'll look at some different forms of pain and how they have different manifestations in a behavioural sense as well. When you think about identifying and monitoring pain, it really requires an understanding of the species.
So identifying pain is going to rely on us understanding how cats, dogs and other species show different signs of pain related to their natural behaviours. And indeed, a lot of the validated pain scoring systems that are available use behavioural information. So they use a combination of things.
In the acute pain scoring, we often see facial expression and body posture being used. While in chronic scoring systems like the canine Brief Pain Inventory, we extend that into more broad behavioural responses that are looked at as a way of scoring an individual in terms of their pain. So I want to look at behavioural responses to pain and think about er obviously the behaviour being an output.
Behaviour is never a diagnosis, behaviour is a sign like coughing or sneezing. So it's a sign of underlying health, but health in all of its dimensions. When we think about the physical component.
Then acute pain, of course, is associated with accidents or trauma or surgery and quite readily because there's a contextual component to that, in other words, it happens when there has been accident, trauma or surgery, we can identify acute pain from that circumstance as well as from the level of injury. When we think about chronic pain, then there are many different forms and illustrated here in this graphic from my colleague Professor Claire Rusbridge where she looks about musculoskeletal, visceral, neuropathic, different types of pain, including chronic, post-surgical or post-traumatic pain, that's going to be related back to the previous presence of acute pain. And so when, we think about these different types of chronic pain, for example, we can see that we might see an impact on behaviour through mobility if we've got things like osteoarthritis, for example, musculoskeletal pain.
Also, we may have body system impacts, so if we've got visceral discomfort, then we might might see body systems impacted, for example, we may see signs of gastrointestinal disease. And then when we have neuropathic pain involved, we're likely to see behaviours associated with sensation impact from that pain. But there's also a cognitive component.
Pain is impacted through the process of learning. Sometimes that's through classical conditioning, where a pain inducing stimulus leads to pain, and then we have, like we see in Pavlov's dogs, the presence of a context. So in Pavlov's dogs, of course, we had the food leading to salivation and then the context of the metronome tone.
So the context of pain-inducing stimuli might be for example, pain induced in a training context sadly or in a veterinary context, or maybe when they're going out for a walk if they've got osteoarthritis and then that context becomes associated through cognition such that the context itself then leads to that pain response. In terms of emotion. Now if we think about cognition, we also need to think about operant conditioning.
This is where we have a cue that leads to an action and a consequence, and then the consequence of the action influences the probability of whether that animal will perform the same action in the presence of that cue in the future. So, if we have an animal who has a verbal cue to sit and then lowers into a sit position. But as they do so because of chronic post-surgical or traumatic pain, they have pain now that influences that probability, then the probability is decreased that they will respond to the verbal sit cue by sitting in the future.
So when we look at behavioural output as a sign of pain, these cognitive components are going to lead to learned associations which result in a contextual component to the behaviour. So for example, the dog behaves in a certain way when you ask it to get into the car or when it's in the presence of certain people, for example. And then we have the emotional component.
And when we think about this, behavioural responses are going to relate to both the valence, the type of emotion, and also the level of arousal. If we think for a moment about pain as an emotion. It is a protective emotion.
It's an emotion that increases the survival of the individual by protecting it from discomfort and also from potential tissue damage. So, pain is a protective emotion and animals respond to those sorts of emotions by displaying behaviours which increase their potential sensation of safety. And we can divide behavioural responses to protective emotion into 4 different types.
They've got 2 different aims. So let's look at the first aim. So the first aim is to increase distance from whatever it is that could potentially be causing that pain or reducing interaction with whatever that is that could be causing the pain.
And they can do that either by repelling, that's hissing, growling, spitting, maybe even getting to the point of biting or avoiding. Avoidance may be physical, so they may actually move away, but it may also be things like pulling a limb away while we're palpating it. It can also be more subtle avoidance like looking away, avoiding eye contact, for example.
So these are ways of trying to increase distance. And decrease interaction. And I think both of these are quite readily associated in our minds as veterinary professionals with the potential for pain.
So if an animal is a bit grumpy or an animal doesn't want to interact, we might quite readily then think about the potential for pain. But the other way in which an individual can deal with protective emotion is to increase information about the trigger. So find out more about whatever it is that is potentially causing them pain or discomfort.
And they can do that passively through what we call inhibition. So where they use their sensory systems to take in information, but they don't show a response themselves. And these are all animals where pain could be a potential, where they are in a more shut down type behavioural response, but could be missing.
Interpreted, particularly in a veterinary context, if we're relying on palpation to find pain, then we may miss this sort of inhibition response. They may seem to not be responding to the palpation, and we can misinterpret that as an absence of pain. And then we have more active gathering of information through what is referred to as appeasement, where the individual tries to gather information.
And this can happen in the veterinary context as well, when we're looking for pain, we may find that instead of using repulsion or avoidance, this individual actually tries to get more information from us, leans into us or starts to try and lick at us in the cases, case of the dog using licking to gather information. So as well as gross behavioural changes just related to the physical effects, the limp that we talked about in the title that we want to look beyond, it's also important to look for a range of these potential impacts. Yes, those more traditionally recognised responses of repulsion and avoidance, but also that more passive response of inhibition or the behaviour of appeasement.
Appeasement can be particularly important when we're thinking about clients, giving us information about what's happening with this patient at home. Appeasement are information gathering behaviours as I just said, and the caregiver may actually report these individuals as being clingy or might describe them as being really demanding or even use the term attention seeking. And one of the problems is that if this is overlooked, then the response from the caregiver can sometimes be to either ignore or reject the behaviour because they're seeing it as being a bit naughty, a bit demanding, for example.
But the problem is that if we ignore or reject appeasement behaviours, we actually increase the uncertainty for the individual and we can instil frustration, they're not succeeding. And if we increase these, we're increasing protective emotion, and if the animal already has chronic pain, which is a protective emotion in its own right, Then the addition of anxiety and frustration can actually make that pain worse. So I want to introduce you to the tree analogy from the Heath model to look at why it's important to consider all of these potential responses and understand that they are of equal importance.
What we want to do with pain cases is really try and detect it as early as possible so that we can institute treatments which will be effective and we can minimise the impact of pain on quality of life. So, on this tree, we represent the 4 responses I've talked about with the 4 branches, and we say that when an animal's in a protective state, they're trying to climb a tree to find a safe location. So, we're looking at this little nook and cranny between the main branch and the side branch, a little X here showing this position of safety and security.
So we can either increase distance and increase distance and decrease interaction or we can increase availability of information using the four responses we've just talked about. Now on each of these branches, we have increasing intensity from the bottom to the top. So we can see here like on the repulsion branch from a grumble going up to a bite or from the from the inhibition branch from a watch going all the way up to a physical freeze.
And when we think about these. We must remember that it's not the intensity of the emotion that chooses the branch. So in other words, it's not true to say that an animal that's in a lot of pain will bite me, whereas an animal who's in a little bit of pain might just be staring at me.
The selection of the behavioural response is not related to the intensity of the emotion. So, you can have an animal who's in just as much pain, who's freezing as one who's biting you. And also we need to remember that there's an interplay between these branches.
So for example, if one of them is unsuccessful, so an animal has inhibited in response to that pain, but has got to the point of physically freezing and is still being poked and prodded and is still, Experiencing that pain, it's not resolving and they don't feel safe, then they will jump to one of the other branches at the same intensity. So they don't go back down and start again at the bottom of another branch. Instead, they're going to leap to another.
So if we've got that animal in our consulting room and we are trying to use palpation to ascertain whether there's any pain, they've tried freezing and it's not worked, they may suddenly start to lick our faces or they may express a bit of urine to communicate, to exchange information through appeasement. Or if we loosen our handling, they may try and jump off the table or get to the door or try and get away. But equally, they may go into a repulsion response, and this is why it's so important for us to identify pain at the earliest stage and to remember the significance of all of these potential responses.
So protective emotions are designed to resolve a situation. So when a behaviour is unable to resolve that pain, in addition to choosing another branch at the same intensity, there will also be a perception of failure, and that can trigger frustration. This is an emotion which increases the speed and the intensity, but also the confrontational nature of a behavioural response.
So if we don't recognise these other signs, we increase risk for caregivers at home, but also for veterinary professionals in our consult room. And also recognising that full range of potential responses means that we can ensure a perception of success for the individual. So we can help them to find that safe place at the lowest possible point on the most appropriate branch and decrease the risk to others.
Now when we think about chronic pain and we think about now we've said repulsion definitely is not the only thing that we will see, they're not necessarily going to be overtly grumpy or challenging or confrontational. Chronic pain can also lead to other behavioural responses. For example, chronic pain can limit mobility.
If it does so, we may see problems, for example, of indoor toileting, cats. Who have musculoskeletal pain may find it very difficult to get in and out of the litter tray, they've got elbow OA, they may find it difficult to cover urine and faecal deposits. We also may find that they become more fearful or anxious, and there's a lot, work done by Kevin McPeak, who's a veterinary behavioural medicine specialist at Edinburgh University and he's done a lot of work looking at the link between sound related fear of behaviours, particularly things like fireworks, for example, and the presence of musculoskeletal disease.
We also may get increased anxiety resulting in avoidance behaviours, physical avoidance, so, Not wanting to go into a certain area, for example. We may also see social avoidance, not wanting to play or not wanting to socially interact. We also can find that some of these animals who have chronic pain actually develop ritualised behaviours.
So they try to use a behavioural response to cope with their pain and then because it's not immediately successful, they get engaged in that same behavioural response in a very repetitive or compulsive fashion. And so behaviours like tail chasing, shadow chasing, repetitive chewing of themselves or licking of surfaces or the air are sometimes seen in situations of chronic pain. So pain in the human field is always talked about as being what the patient says that it is.
But I want us to think here about the fact that for our patients, it's always what they express that it is. And their behavioural change may be expressing the physical effects, so we may see things like reluctance to walk on certain surfaces or gait changes, although they can be very subtle, and therefore we need to be quite diligent in our investigation to look for gait changes. We may also see changes related to the physical expression of visceral pain, so impact of gastrointestinal discomfort, and we may see response to manipulation, that tried and tested way of looking for pain may be effective, but it's not guaranteed.
Because during a physical examination, there are other factors which alter an animal's response to manipulation. The way in which we handle may be influencing whether or not they show a response to that pain. So it could be that if we inappropriately scruff a cat, for example, and we increase its perception of being unsafe, that we actually diminish our potential to see pain through our more traditional physical examination.
Also, we need to think about whether this animal has any other form of emotional health disorder other than pain. Does it have an anxiety disorder that could be influencing how it's reacting, particularly in the veterinary context of the consult room. And really importantly, we need to remember that behavioural output is the result of a predominant emotion, but not the only one.
So whilst we may expect a painful patient to show a behavioural output, which is clearly indicative of protection, protective emotion, we need to remember that if we have stimulation in this environment, which leads to high levels of engagement, so for example, we are playing with the individual. That that can actually lead to an overriding of the behavioural responses we're expecting because now, the engaging emotion is predominant, the pain is still present, but the engaging emotion is predominant, then the behaviour we're going to see is going to be related to engaging emotion. Now going back to our title, when we think about musculoskeletal pain, then we often do think about a locomotory effect, the limp or the lameness.
And yes, of course, that is one of the ways we can detect chronic pain. But I said earlier we need to be careful that we don't miss subtle changes and if we only look at an animal walking on the flat, hopefully you can all see that this animal does have some level of abnormal gait. But if we see him go down the stairs, we start to see that exaggerated.
We see it more clearly being displayed in the context of going. Up and down the stairs. And that's not just true for our dog patients, it's also true for our feline patients as well.
And so, we may want to do a more extensive examination of gait than we can do just in our consulting room, because the changes may be quite subtle, and we need to put them into context where it is more likely that we can see them. Videos can also be really helpful because we can slow them down and we can look at that gait at different speeds. But as well as the limp or the lameness, we also need to remember that there could be other signs, excessive licking, for example, or.
Repetitive behaviours, this is an animal I saw with shadow chasing behaviour, which had lumbosacral disease, so these are examples of the different sorts of responses we might be looking for as well as the limp or the lameness. Posture can be very important. As well as positioning for defecation in dogs, so looking at how they get into a squat position to defecate, but also whether they can maintain that over time.
We're also going to think about the caregiver's perception of behaviour change. So not only are we going to be using the information we can get in a veterinary consult, but also we're often going to be drawn, er our attention's going to be drawn to these individuals because the caregiver sees something. They may see a change in behaviour that they haven't linked in any way to discomfort, but we want to be on the lookout for the potential for this being an early sign of discomfort and something that we want to get to treating as soon as possible.
So I've talked about Kevin McPeak's work and started becoming scared of fireworks. We may have an individual who's reluctant to go for walks and isn't obviously related to gait and therefore we may be bringing that animal in from the caregiver's perspective as going, he's a bit agoraphobic, I don't think he really likes going for walks anymore, I don't know what's wrong with him. They may say he's become a bit grumpy, maybe grumpy with other dogs when he's on a walk and previously he's been really sociable, or maybe he's just not himself at home, he's just not very confident anymore, doesn't seem to want to say hello to people.
These changes can be quite nebulous, but it's really important to be on the lookout for them as potential indicators for pain. I want to just briefly mention the other types of pain, so musculoskeletal, we certainly think of as maybe the most common one, but it's certainly not the only one and in our experience within our practise, visceral pain and neuropathic pain are also really important. Obviously visceral pain is where it's associated with internal organs or viscera, most commonly affected, the GI tract, or parts of it there and the urogenital tract, so these are common sources of visceral pain in individuals who, Actually presented with behavioural change.
And some of those changes might be directly related to the physical impact. So, for example, we may see things like lip licking in gastrointestinal discomfort. Some of these videos.
Taken from TikTok. That was a frightening experience, going to source videos from, from TikTok, but they do show things like air gulping here, lip licking. We may get as far as wretching, and then we may also see for other types of internal.
Or visceral pain, we may see things like the praying posture, which we readily associate with pancreatic discomfort, rigid posture, or gait, which is related to them tucking in that abdominal region. And they may also be quite reactive to touch as well. But one of the things about visceral pain is that it often it's quite difficult to localise it.
It's like a dull sort of pain, it's quite vague in its nature and therefore the behavioural responses can also be quite vague. They can include the caregiver reporting that they're just different around their food. It may be that they don't seem to be settling or sleeping, they may also find it difficult to get into a posture where they're comfortable enough to go into a situation of sleeping.
So if they've got things like er reflux causing discomfort, they may find it very difficult to sleep in a horizontal posture. They may show a lack of interest in previously enjoyable activities, going for a walk and playing. And also in some cases with visceral discomfort, it may be displaced or referred to another part of the body.
For example, we may see over grooming behaviour because of visceral discomfort from the bladder. And we may also see that repetitive nature that I've already talked about. So we may see things like fly catching, we may also see.
Like, sir, sorry about TikTok noise there, we can also see surface licking, licking of furniture or licking of the wall. So visceral pain is of course a protective emotion. We may see those four behavioural responses, confrontational behaviour when we try to touch them or when we try to threaten their resources, particularly when it's gastrointestinal related.
We may see avoidant behaviour as well when we touch them or interact with them. And they may become inhibited. The caregiver might report that as being not very engaging or staring at them.
And they may also be reported as being clingy. The other form of pain I wanted to touch on is neuropathic pain. Obviously this is the one where there are altered sensations, we get a range of different potential behavioural responses.
We certainly in the acute phases of neuropathic pain may see things like the pain face or the facial grimace. We can see head rubbing, that can sometimes be misinterpreted as a behavioural response or, Pardon me, head shaking, which may be associated with suspicion of pain in the ear, for example, and then skin nibbling or skin rippling. These are all potential manifestations of neuropathic pain.
It's not just dogs where we need to think about that, we also need to think about that in cats, and I'll leave the, the volume on this for a second so that you can actually hear it. Not a very pleasant noise, but here quite readily, we can associate discomfort, I think, when we hear that sort of response. This is an individual with aurofacial pain syndrome.
And then we also have cats that show this sort of behaviour associated with, for example, hyperestesia syndrome. So when we think about neuropathic pain, we can also get presentations from the caregiver, for example, they may see signs that they think are more physical, they may come in saying that there's things like altered breathing, but they may also think about social interaction and report to you that the animal is less comfortable when we're being touched or in social contact. That may even go into more of a repulsion response.
And it can lead to resistance to movement and gait or postural changes. So when we have gaits and postural changes, we need to remember it's not necessarily musculoskeletal pain, it could be involvement of neuropathic discomfort. And some of those alterations in that sensation may also lead to them feeling less safe, particularly, for example, on slippy, slidy surfaces.
So again, we think about slippy, slidy surfaces exaggerating musculoskeletal. Pain, but also if you've got alterations in sensation associated with that, surface, that can cause more anxiety and it can exacerbate the frustration related to neuropathic discomfort as well. So neuropathic pain, is it going to have an effect on those er behavioural responses we talked about?
Well, certainly we might see repulsion er because of altered sensation, for example, if they're er hyperalgesic or have allodynia, they may respond differently, be more likely to become repelling. And of course we may also see avoidance, inhibition or appeasement, those other equally valid ways of displaying a sensation of pain. Alterations in social relationships we've talked about throughout all those forms of pain and we can see anticipation of discomfort also playing a role in social interaction.
So for example, we may have dogs who become quite difficult around other dogs because they are anticipating the potential for discomfort if that other dog socially interacts with them, for example, by banging into them in social play. We also may get reduced object play, particularly in the context of playing with people or playing with other dogs, which is interpreted by the caregiver as being more antisocial. So social play and object play can be impacted.
And also physical proximity and this can lead to a lot of problems for caregivers thinking their dog doesn't like them anymore or he's he's sloping off, he doesn't spend as much time with us, he doesn't want to sit right next to us on the sofa, he wants to sit the other end. That sort of behavioural change may be something a caregiver notices but isn't going to report necessarily as a suspicion of pain. Presence of pain can also decrease their tolerance of other members of their own species, so not just their human caregivers, but particularly for example, in groups of cats, we might see decreased tolerance of the proximity of the other cat.
It can also have impact on. Their access to things like resources. And anticipation of pain can also be important in causing repelling behaviours or social tension within multi-pet households, whether that's the same species or between species.
The absence of behaviour, this is another consideration and we talk about this quite a lot in a feline context, so we talk about the cat who is not grooming, the cat who is not getting up into high up resting places, so it's the absence of certain behaviours that we'd expect that leads us to thinking about pain. But we must also not forget that potential presentation in dogs as well. So so far we've looked at the diagnosis of pain using behavioural understanding.
And once a potential link's been identified between pain and behaviour, it's really important that we think about that comprehensive healthcare approach, the physical and the emotional and cognitive, and that's gonna need a multidisciplinary involvement from a veterinary perspective. And here we see represented the different, Disciplines, not exclusively, but all the disciplines that are likely to have a role in the care of painful patients. Of course, we can think about surgeons, emergency care, veterinary neurologists.
We can think about our anaesthesia analgesia colleagues and their very important role in pain relief, both through acute and chronic. Pain episodes. We also think about behavioural medicine, which is what we're going to be concentrating on today.
And then our colleagues in veterinary nursing have a massive role to play in establishing pain care across the spectrum of all aspects of health, and we have also veterinary rehabilitation and sports medicine. As well as thinking about it from a multidisciplinary veterinary approach, we also might want to think about a multiprofessional approach. For example, hydrotherapy, physiotherapy, and then also behavioural medicine, either through Using veterinary behavioural medicine input, but also our colleagues of the people like certificated clinical animal behaviourists who are working alongside veterinary professionals to provide some of this extra dimension of treatment for these cases.
So that's the looking at the diagnostic potential of pain being important in the world of pain. What about thinking about how we treat. So when we think about the treatment of pain, we also need to think about that multidimensional approach.
We need to make a decision as to whether treatment is necessary based on whether this individual can actually resolve the pain, physical, emotional and cognitive, on their own without help. So for example, if we think about acute pain, there may be many situations where we don't need medication involvement because we can resolve the pain without the use of medication. For example, a thorn in the pad wouldn't necessarily lead us to reach for medication for this individual.
However, if we have acute pain which is unmanageable or excessive, so for example through surgery or through trauma. Then of course we do need to think about treating that pain, not only for its immediate impact on the individual and its quality of life now, but also because if we don't manage acute pain that cannot be resolved by the individual on its own appropriately, we run the risk of chronic post-surgical and post traumatic pain. And chronic pain is a disease.
This must always be treated because the individual is not gonna be res able to resolve chronic pain through its own behavioural responses or through withdrawing itself from the source of the pain. For example, so chronic pain must always be treated. And in some cases, environmental adjustments or adjunctive therapies may be successful for those individuals and for others, we may be going into the realms of medication or surgery if they are required.
So I want to think about the veterinary approach then to pain cases and thinking again about our comprehensive veterinary healthcare approach. So firstly, we're going to investigate, treat or manage any underlying physical health condition which is contributing to the pain. Secondly, we're gonna think about giving effective and appropriate analgesia, and we don't have time to go into this in great detail today, so I want to signpost you to zero pain philosophy, where you can get some really good advice about, pain treatment, both in terms of acute and chronic pain.
I also want to mention therapeutic trials because pain is an individual experience. In the case of chronic pain, we've also got a really poor correlation between things like imaging and pain, and in that situation it can make it very difficult for us to be sure whether pain is involved, particularly when our primary presentation is behavioural. And so therapeutic trials of medication can be really helpful.
And then monitoring that individual using validated scoring systems or individual patient specific outcome measures is going to be really important. We want to do that as soon as we have a suspicion. That chronic pain may be present, we also want to use that during the process of a therapeutic trial, and it will increase caregiver observation and reporting, it may even bring to light other behavioural manifestations of the pain that we've so far not seen, and also it enables the veterinary surgeon to monitor that response to treatment and to determine how important pain is in the aetiology of that behavioural change.
So let's go back then to comprehensive veterinary healthcare. Yes, we are going to do the physical health component, but we also want to think about emotion and cognition. I want to go to the heath model again and think about the the second analogy.
We talked about the tree already. I want to talk here about the sink. Because I want to think about this approach to our pain cases in relation to emotional valence represented in the sink model by the different taps, so the different, the hot water equating to the protective emotions and the cold water, equating, The engaging emotions and then the mix attack because these are not mutually exclusive emotions.
And so we want to consider the valence of emotion, but also the level of arousal in the sink analogy that's represented by the amount of emotion in the sink. So this is really important when we come to think about how we might treat and manage these cases. So from an valence perspective, we use the work of Jack Panksepp, Estonian biologist who identified what he termed positive and negative emotions in the Heath model.
They've been renamed the engaging and protective emotions because we want to be really clear that negative emotions are not bad or detrimental and we need them to survive. Jack Pett wasn't suggesting they were negative in terms of being bad. He used that word.
In relation to the removal of something and positive in relation to the addition of something, but I found in my clinical work that caregivers found it really difficult to understand that a negative emotion could be a good beneficial thing. So protective emotion is easier for them to understand, oh yes, I understand that I want emotions to protect me and I want emotions that will engage me and both of those are going to be helpful. So let's look then at pain.
Pain is one of those protective emotional motivations. How is it beneficial? Well, it's beneficial in the situation of acute pain, and it enables us to remove our foot from that drawing pin, for it enables that dog to pull that thorn out of their pad.
That is where acute pain is protecting the individual. So pain is a protective emotion. That enhances survival for the individual.
But what's the significance of the valence of pain when we're thinking about chronic pain? When we're thinking about pain, which is no longer being beneficial for the individual. Well, when we think about this, we can think about the behavioural changes being related to the emotional impact of that protective system.
Now, in acute pain, let's just deal with that for a second. Then when we see these changes, actually we use that as part of the scoring. So you remember we talked about acute scoring scales that use that sort of behavioural response to tell us that.
Acute pain is present, for example, in the photograph you can see here. So it's, again, very adaptive at that point. In acute pain, the fact that we see a behavioural response because they're protective can help us to identify that pain and treat it appropriately.
When we come into chronic pain, we've got to remember that that pain is not self-resolvable, and in chronic pain, often the animal is in a situation where they are anxious, so anxiety may be related to the fact that they don't feel stable on their legs cos they've got chronic musculoskeletal pain as we talked about earlier, but also there's the potential for frustration. Because it's non-resolvable, they're not able through pure behavioural change to resolve that pain. They need some other intervention, medication potentially, even surgery in some cases, also environmental adjustments.
So, Chronic pain can be complicated by the presence of fear, anxiety, frustration, which increase the input from that protective emotional tap if you like. The other thing to remember though is that that pain is a very individual experience. So the impact of that increased protective emotional input through pain can vary and it's related to other aspects of the emotional health of that individual.
So in the sink analogy, whether or not you're going to flood because of an increase in input is partially related to the size of your sink. That's what we term the emotional capacity. It's related to the history of the individual.
It's related to their genetics, to their prenatal state. In other words, what happened to them when. They were in utero, how they were influenced by the emotional state of their mother at that stage of development.
It's also about how they were reared, where they were reared, who they were with, and about their subsequent life experiences. So that size of sink needs to be considered when we're thinking about the impact of pain on an individual. Other emotional input may also be influencing how they relate to that pain.
For example, in situations when they have increased input from engaging emotion, they may actually find the pain more significant. So when they are socially playing with another dog, they may enjoy that, they. Maybe some really good emotional input from the engaging tap, but it fills the sink more and makes them more at risk of flooding.
Or it may be they have other hot tap input that's not related to the pain, that in addition to being painful, they're also frightened of fireworks. The two things are individually important as well as going together to exacerbate one another. And then the other thing is the drainage.
Is it that they're unable to get rid of the emotion that's coming in? And because of this, we have to think about emotional management being part of the treatment of our pain cases. High emotional input will increase the potential for protective emotional impact, so if they've got another emotional disorder and we miss it, they've got a, a generalised anxiety disorder and we're not treating that, then we can limit our potential for success in treating the pain.
Also, if they have other physical illnesses, But as well as that, we need to think about stimulating interactions. Could it be that they are being exposed to something that frightens them? And they have pain, so going back to, for example, the firework dog.
Or could it be that they're playing with another dog or they're going for a walk and that's making them more engaged and they're having higher input from the cold tap, but because of that, their pain, which is concurrent, is more important to them, leads to more significance. So we get variation in reported pain at times when emotional input from other sources is increased and that can make it really difficult for a caregiver to know whether the animal's in pain or not. You'll often hear them say, I don't really know because some days I think, gosh, he's really looks like he's painful and other days he seems absolutely fine.
And the pain may be the same in both of those situations, but the other emotional input is impacting on the significance and therefore the potential for the caregiver to detect it. So emotional management needs to be considered as part of the therapeutic approach to our chronic pain cases. How do we determine the relative contribution from emotional health in these cases?
Well, we can look at behavioural responses and output. Using the sync analogy, we can think about whether we've got the presence of behavioural responses and body language which suggest a predominance of protective emotion. Have we got signs of repulsion, avoidance, inhibition or appeasement?
We can also look for behavioural signs that there's very high levels of emotional arousal. What behaviours? Well, we think of this in the sink analogy as the overflow hole.
We call these the displacement behaviours. So we think about behaviours that show that there is emotion going through that metaphorical, overflow hole. So we see things like self licking.
We see scratching behaviour or lip licking, we see yawning, shaking as if wet. These are all signs, and this is the examples here are of our canine patients. These are all signs that there is a lot of emotion in the sink, shown here with this high level of water in the sink or emotion, but it doesn't tell us which one.
This just tells us there's a lot of emotion in the sink. And the other thing to think about is evidence of compromised emotional drainage. Is there anything about this individual that suggests they may not be getting rid of emotion as accurately or appropriately as they should?
For example, are they showing any change in species specific drainage like chewing for dogs, or in all species, are they showing evidence of sleep deprivation or changes in quality? So I want to look at these, all the, the, all of these elements and think about what we would need to do. So if there's evidence of protective bias, our aim then is to decrease the input first of all from any pain.
So that's where we go back to our treatment of pain using our er medications and other adjunctive therapies which we'll detail a little bit more in a moment. We also though want to think about any other protective emotions and make sure that we're minimising those. Have we identified some other emotional disorder, are we treating that?
Can we protect the individual from situations in which they are likely to have more protective emotional input? And we need to be aware that some of our veterinary interventions in some of our cases might actually be increasing protective emotional input. So for example, if we've said we'd like you to restrict exercise to only on lead exercise, we might have some emotional implications from that.
For example, you might get frustration. If that individual is used to exploring its environment when it goes for a walk, then putting it on a lead may limit that and cause some frustration, that's a protective emotion. Also, if they go on a walk and they see other dogs they're very friendly with and they usually socially play with, but now they're on a lead, that may cause them frustration.
So when we say to individuals, would you please just walk the dog on a lead, we may also want to say in certain circumstances, for example, don't go to the environment that your dog really enjoys investigating and try not to go on that walk with his best friend dogs, particularly if they're going to be allowed to enjoy the walk off lead and this dog's going to be on lead. Other ways in which we might restrict exercise because we're worried about pain, we might put them in a crate. Crates can also lead to anxiety.
They can increase uncertainty. That can mean that we've got more protective input. Also, they might become frustrated, particularly if they're very sociable.
They like to usually spend their time lying on the sofa with the caregiver, and now they're in a crate and unable to get up on the sofa, they may get frustrated. So when we think about emotion. Treatment for pain cases, we need to think about reducing that protective input and also not contributing to protective input unwittingly through some of the advice that we give and mitigating the potential for that.
What about if we've seen evidence of high arousal, so we've seen displacement behaviours? Well, in that case, we want to think about how do we lower a level of water in the sink. What are the things we can do?
Firstly, we turn taps off or down. So the first thing we want to do is reduce all emotional input. That is both engaging and.
Protective, and we need to be really careful that we don't inadvertently actually increase arousal through wanting to increase that engagement. Now, enrichment is often talked about in situations where animals are in some kind of compromised state, and we talk about environmental enrichment being really helpful. But in the situation of pain, enrichment can sometimes be counterproductive.
If we excessively stimulate even the engaging emotion, that can lead to high levels of emotional arousal and can exacerbate this problem. Even though what we're doing we think is enjoyable. So I want to think about the emotional implications of the advice we give in terms of what we do with the environment and differentiate between environmental optimisation, environmental modification and environmental enrichment.
So enrichment is the addition of environmental elements that are above and beyond the requirements for survival. As I've just said, in the situation of pain management, sometimes this can be counterproductive. Optimisation is catering for species specific behavioural needs in order to facilitate survival, and this is always necessary.
So we always want to optimise the environment for all patients in all contexts. We also though, sometimes modify environments and that's very important when we think about pain cases. And I want to point you in the direction of a resource called Canine Arthritis Management run by Doctor Hannah Capppan.
This is an excellent resource for caregivers of canine patients where they give lots of examples of the sorts of environmental modifications. That can be really helpful for these patients, but don't forget, our feline patients as well, they may also hugely benefit from environmental modification. Things like steps up to their resting places, things like litter trays that allow them easier access.
So moving on then, we've talked about when we've seen signs of protective bias, we've seen signs of high arousal, that there's evidence of restrictive emotional. Drainage. Potentially, we might see situations where there is less availability of species specific drainage opportunity, for example, if we've got oral discomfort, they may not want to chew, but we also may see signs associated with sleep disturbance.
Disturbance of sleep can either be in terms of quality or duration, and those both can be affected in situations of chronic pain. And why is sleep disturbance so important? Well, emotional illness is associated with sleep disturbance.
This has been well documented in human patients. One study showed that patients in the human field who had 5 hours of sleep as opposed to 7 hours of sleep had a 2 to 3-fold greater risk of anxiety or depression. And although research is slower in the veterinary field in relation to sleep, we do now have many people who are interested in this field.
Carrie Tooley, who is a veterinary behavioural specialist in the UK who did her residency with myself, during her residency, this was her er residency project and as a specialist in her own right, she has a particular interest in the link between sleep, duration and disturbance and problematic behaviour. And why is it so important? Well, sleep is important from an emotional perspective, as I've just illustrated with the sink, this idea of emotional drainage.
And there's something called the noradrenaline reduction mechanism, which has been identified as being associated with REM sleep. Now, there's more publications about this in the human field, and I've put a reference here for you. If you're particularly interested, you can go and read more about this.
But basically this. Reduction of noradrenaline, this overnight amygdala adaptation as it's called in human medicine, is really important in terms of resetting that emotional capacity through sleep. And obviously overnight is comes from human terminology in our species, they don't necessarily sleep overnight in the way that we do, they sleep at other times as well.
So this is all about the availability of REM sleep. So that this mechanism can be activated and emotional drainage can occur. But there's also cognitive implications of sleep disturbance.
REM sleep is also important in processing the emotions associated with memory. And so the aim is to retain the memory without retaining the intensity of emotion. And you may be familiar with this in trauma therapy in human patients through things like EMDR therapy.
The idea is that if we can process that emotion to remove the intensity of the emotion but keep the memory, then the survival of the individual will be enhanced. And REM sleep is where this occurs. So if we get a reduction in REM sleep, it has the potential to detrimentally affect the emotional and cognitive health of the individual, particularly in situations of chronic pain.
And sleep hygiene is something that's talked about in human animals and is equally important in our veterinary patients. So how does this comprehensive healthcare affect treatment? If the behaviour is directly related to a physical component, we're gonna start our treatment with medication, surgery, physiotherapy, hydrotherapy.
When the burden is also related in terms of emotion and cognition, we want to alter the emotional bias. We want to improve engaging emotional bias through safety and security. Yes, we do want to increase triggers for engaging emotion, but be really careful to avoid excessive arousal.
We want to increase the perception of coping success so that if they're in, for example, acute pain, they can resolve that pain so that they don't become frustrated. And we want to decrease or control any triggers for protective emotion. We might want to use cognition to alter the behavioural responses, and we certainly want to improve emotional drainage.
Also, we may have behaviour that's related to the memory of pain and then we might need to work on forming new behavioural associations. Now you'll notice I've highlighted two things here in red, improving engaging emotional bias through providing safety and security and improving emotional drainage. And I want to just finish by thinking about the use of pheromones in relation to those two aims in particular.
So, we have one synthetic canine pheromone available, which is based on an analogue of the dog appeasing pheromone, the adaptyl range, and then we also have three synthetic feline pheromones, the Flyway range of classic Friends and Optimum. So how are these relevant in our pain case management? Firstly, the appeasing pheromones increase a sensation of personal safety and security.
One of the things we highlighted in red on that previous slide. Feline facial pheromone also increases perception of safety within the environment. So both of these elements of pheromone intervention can increase engaging emotional bias.
The other thing to think about though is that as well as increasing engaging bias through providing that sensation of safety and security, they can also increase the quality and the duration of sleep. And so we think about putting these er pheromone diffuser devices close to the animal's resting places. We want to enhance a place where they should feel safe and secure in their resting location, but we also want to increase the quality and the duration of their sleep to aid in emotional drainage.
What about the use of nutraceuticals? Well, within the adaptable range, there is a nutraceutical, the adapttyl chew, and there's also in the Feloway range, the adapt the nutraceutical of Happy Snack. So these are not pheromone products.
I know that can be confusing for caregivers because of the naming. But these are nutraceuticals and each of them aims to increase engaging emotional bias through influencing the levels of neurotransmitters. And so by using these, we can increase the availability of neurotransmitters such as serotonin and dopamine.
We can also increase availability of, of GABA activity. So we may do that er for example in the er Happy snacks we've got the Clostrum component, we've got the alpha casin component. That is going to help us to increase that engaging bias.
Again, one of the red elements that we had highlighted on that previous screen. So the diagnostic procedure in pain needs to take into consideration this vast array of presenting signs. We need to think about the fact that the absence of detectable changes on imaging, for example.
Or the lack of suitability for surgical correction doesn't mean that there's no pain involved. And even when we're thinking mainly about musculoskeletal pain, lameness or limping is not the only behavioural sign we need to consider. We need to think about other mechanical consequences, posture, defecation position, accessing resting places or latrines.
But as well, when we think about our diagnostic process, we need to go outside of the musculoskeletal, think about visceral neuropathic pain, and think about the range of those potential behavioural responses because of their protective nature, the appeasement and the inhibition as well as the avoidance or repulsion. And those responses are also related to emotional and cognitive health, we need to think about those. We need to look beyond the limp.
This is a paper I would really er advise you to read if you haven't already, which is a really good summary of why it's important to think about behavioural change when you're considering the diagnosis of pain. But finally we need to think about that therapeutic approach that also needs to consider the health triad. From a physical perspective, we need to think about appropriate surgery and medication.
We need to think about the use of physical therapies such as hydrotherapy and physiotherapy. We also might think about acupuncture from our veterinary colleagues. From a cognitive perspective, we need to think about establishing new associations with those previously painful contexts.
And then we need to think about emotion. In this context, behavioural modification is going to be an important part of that, referral to a veterinary surgeon specialising in behavioural medicine or to one of our non-veterinary colleagues working in clinical animal behaviour. We may want to use medications which work across the emotional and the physical.
Things like venlafaxine, which is very important for neuropathic pain in humans. So venlafaxine and its cousin duloxetine are used a lot in human chronic pain management where there is neuropathic pain involvement and it is an interesting medication in the vet. Field as well.
We may also need to think about other SSRI type medications as well, serotonergically, boosting medications which are going to be helpful in other forms of chronic pain. So we may be thinking about the expertise of behavioural medicine and analgesia and analgesia specialists working together. We want to think about nutraceuticals as I've just mentioned, to enhance the neurotransmitters which are going to enable that individual to have a more engaging bias and to feel safer and more secure.
And we should also think about using pheromones as part of this multidisciplinary, er multiprofessional approach to managing pain. So consideration of the health triad is key to comprehensive healthcare in the veterinary context because physical, emotional, and cognitive health factors coexist. When we're dealing with cases which involve pain, the consideration of all three parts of that triad is needed, both during diagnosis and treatment of these individuals.
Thank you.
