OK. Today's presentation is about pain. The title is Pain is Inevitable and Suffering is Optional.

My subtitle is more fun. The strain of pain lies mainly in the brain. That's not my invention.

That's from someone else, but it actually is quite apt to what we're talking about today. So without further ado, let's talk a bit more about pain. And first of all, I'll just give you a little bit of background on who I am and and why, why I'm doing this, .

A few years ago together with my partner, I set up Perry. It's a mobile K9habilitation service, and together with our little dog Spiky, we run this business and we're independent, we're family owned. We run a vet led and very pathetical mobile canine habilitation service for the counties in the south, so Sussex, Surrey, and Hampshire, and As such, we, we offer a personalised bespoke home-based service and we do lots of different things.

The main part obviously being canine rehabilitation, which includes manual techniques, modalities, and home exercise plans, but we also do acute and chronic pain management, which is why I'm talking to you guys about pain today. A big part of that is the management of osteoarthritis, but we also do Western veterinary acupuncture and Western veterinary herbal medicine. So we've got quite a few things between us that we, we can offer.

And, and this is our team, me, my fiance, and my little dog Spiky. So let's get straight into pain. Now, what is pain?

And there are various definitions of pain available. One of them is pain is a highly unpleasant sensation caused by illness or injury, which is quite apt. Another, another possible definition will be pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Now this is actually a better one, I think, because it is not just about the feeling of pain, but also about the emotion of pain. And as we'll see later, that has a large influence on how pain is experienced and not just actual tissue damage, but even potential tissue damage can cause pain in humans as well as in animals, and that's really important to realise as well. And one of the most important things as well, especially for dogs, is pain is frightening.

It's frightening for us. It's frightening for dogs and other patients, and it can be actual or potential damage, as we said earlier. Now there is a big, big difference between acute pain and chronic pain, not only in what it is and how it is interpreted in the body and the brain, but also how we, how we treat it.

Accute pain is a useful pain. It's adaptive pain and it is actually there to prevent chronic pain. And the clearest example of this would be that if you put your hand on a, on a heater.

It hurts and you very quickly will will pull your hand back. That is very useful because it will prevent you from getting burned. Chronic pain, however, is maladive pain.

It has no biological use. It is actually pretty useless, you could say, and it's due to alter processing in the central nervous system, and the signs may be very subtle, but the effect on a person or a patient is absolutely massive, and chronic pain would be something like people that suffer for years and years with lower back pain, and the same happens in dogs as well. And chronic pain much more important than acute pain, and we're talking a little bit about both.

I sort of joke to people sometimes, especially my partner, that pain is just in the head. In other words, you can control it. It's up to you.

It's, it's, it's down to you how you process pain and how you interpret pain. Now that doesn't always go down well, but actually it is true, and there are lots of different steps. In the perception of pain, and it starts with nociception, which is the actual activation of pain receptors in the periphery.

For instance, if you walk on a piece of Lego or you get a needle in your toe, that's the initial sort of activation of pain receptors in your toes. The next part is transduction, and that's where the stimulus is converted into an electrical signal. Now that electrical signal is then transmitted from the periphery towards the spinal cord.

And whilst at the spinal cord level, and especially in the dorsal horn of the spinal cord, modulation takes place and signals both from the periphery as well as from the central nervous system, the brain can change that transmission. They can modulate it either upwards or downwards. Then we get projection where the nerve signal travels from the spinal cord towards the brain.

And finally, there's the actual perception of pain. Now that takes place in the cortex of the brain and that causes the conscious perception of pain. And during all these processes, pain can be altered with treatments and drugs and so on.

What's important to realise. All the different steps and they are put together in this picture. At the bottom, we see the nosyception and then the transduction of that that signal into a nerve signal which then moves up transmission up to the spinal cord.

It is then modulated and then projected and perceived in the brain. There are different types of pain and nociceptive and nociceptive inflammatory pain is probably one of the most commonly experienced types of pain, like for instance in an inflamed joint, in osteoarthritis, in in other joint pain. We also have neuropathic pain, and that's when nerves are under pressure and that can be with tumours in the spinal cord, but also very, very more commonly in intervertebral disc disease, for instance.

And another very important aspect or type of pain is that of central sensitization. It's also very often called pain windup. And it is a feature where a small persistent pain becomes magnified over time.

And a nice way to explain that is it causes an expanded and an exaggerated pain field. Now this is very, very important because long standing low grade chronic pain will nearly always end up as central sensitization. And a patient with that kind of pain will constantly be in pain that gets worse and worse and worse over time.

We'll come back to that when we talk about treatment. And of course there is mixed pain. Several types of pain can happen at the same time.

So it's also important to realise there are different components to pain. It influenced the treatment methods that we choose, and it, it has a big influence on, on, on how the pain is experienced. For instance, the main thing is the sensory component, the actual no receptive pain sensation, and that's usually in the periphery.

Again, for instance, in an inflamed joints. And we can use drugs, we can use acupuncture, we can use laser and perhaps some other modalities to reduce the sensory component of the pain. Importantly, there's also the emotional component, and this is more how the patient feels about the pain.

This is the major reason why two different individuals, whether animal or people, can have exactly the same injury and actually experience the pain in a very different way. Part of that may be their anatomical makeup, their nerves, their connections and their hormones and so on. But a big part of that is the emotional component of pain.

And we can influence the emotional components of pain with drugs and acupuncture mainly. There's also a cognitive component. Now this is more realised in people than in animals, but I think the further we go, the more we realise that in our animal patients there's also a cognitive component to pain, and it's how the patient thinks about the pain.

Now, in dogs especially, we might use Activities and games literally to take their mind off the pain and we all know that if you are in some kind of pain, if you are very, very focused on doing a particular task, you might temporarily nearly forget about the pain that is to do with the cognitive component of pain. And finally, there is a motor component. Pain can affect movement and the behaviour of a patient, and we can use various techniques to manage the environment or the diet or use assistive devices to reduce the the the the motor component of pain and thereby helping our patients.

And this is one of our patients, doesn't seem to be in that much pain. So what's the difference between pain and suffering? So many clients come into the waiting room, or sorry, into the consulting room and will say, I really don't want my dog to suffer.

However, if we tell them that their dog is having severe osteoarthritis and must be in pain, they often find it hard to believe that. But they are very, very adamant. They don't want their dog to suffer.

So what is the difference? Well, pain is the actual physiological process, and that is relatively similar to most patients, although it's not necessarily experienced in the same way. And we always already touched on this when we talked about the emotional component of pain.

Suffering is really that part, the emotional side of pain, how it's perceived, and that is due to the brain, and that is different for every patient. And in human medicine they're coming around more and more now to say pain is what the patient says it is. And in the past, people may have been put off by doctors saying, you know, don't be silly.

That isn't very painful. It can't be so painful. But for that particular patient it very well may be, and it's exactly the same in our animal patients.

Each individual is different and they might experience pain in a very different way. And the most important thing to realise when we're talking about dogs or other animal patients, you cannot teach a dog to not be afraid of pain, and I can't stress that enough. Pain is a stressful situation and it's a frightening situation, and dogs will be scared if they are in pain.

And no matter what you do with that dog or how you train the dog, you cannot teach him to not be afraid of pain. It's an inherent reaction in the body. So it's very, very important that we treat pain as best we can and that we thereby prevent suffering as well.

So central sensitization, we touched on this earlier, and it's important to know a little bit more about central sensitization. It's also called secondary sensitization or pain windup. And as already said, it's the process of pain being amplified and exaggerated over time.

Lots of different ways in which this can happen, and it's got to do with receptors, chemicals, hormones, and signing, signalling molecules, and it can lead to a small but persistent pain being amplified over time and exaggerated over time, and it can bear very little relation to the original pain stimulus. And a patient who is suffering from central sensitization might appear as a very painful and a frightened and worried pet. As we said earlier, the emotional component is very, very important in this, and you cannot teach a dog to not be afraid.

So constant pain is very, very frightening and leads to very high levels of stress. This slide will explain in a little bit more detail how sensitization works and both on the periphery as well as centrally. And when I say centrally, that's mainly in the dorsal horn of the spinal cord as shown on this slide and between the tissue injury and inflammation and the periphery, the nosyception and the transmission and so on and so forth.

In the dorsal horn, especially of the spinal cord is where the central sensitization takes place and that leads to an exaggerated and expanded pain field. Recently, we've started to become more and more interested in the gut microbiome. The gut itself, the health of the gut, and most importantly, the microflora or the microbiome as it's now called, is increasingly thought to be partly responsible for lots of different bodily functions, not just digestion.

The gut actually produces neurotransmitters and hormones. They can influence the pain process. Therefore, if we are doing a full pain assessment in the patient, we need to take into consideration the health of the gut and the microbiome.

More and more is being known about this, more and more is being studied about it, and certainly more studies are still needed to fully understand the relation between gut health and pain, but more and more is coming out, and I certainly are taking this into consideration in my patients on a daily basis. So what are the symptoms of pain? Now, you all know that most clients coming into the consult room will say things like, oh, I don't think he's in pain, he's not crying.

Vocalisation in people is of course one of the first things we do if we are in pain. We are very happy to tell our partner or the other people we're living with that we are in some discomfort. Dogs, not so much.

They show pain in very, very many ways, but mostly in different ways than vocalisation. So for instance, their posture may change. They might have a hunched appearance.

They might have a lower head carriage. They might have their tail down. They may be laying down more and so on.

Activity levels can change. Animals can either be more restless or less likely to move, and there can be trembling. There can be limping, which is obviously more noticeable in dogs than in cats, and even panting.

Their facial expression can change. Now that's not always easy to to assess, but most people that have a good relationship with their pets will be able to tell that they are in some pain just by looking at them, and they may have flattened ears. They may have pulled back corners of their mouth.

They may look wide eyed or have a grimace on their face. Their daily habits can change. For instance, dogs can be less social and especially cats will be less social or spend more time sleeping.

Both of them can be affected as far as their appetite is concerned. Grooming habits can change again, especially in cats, this is more commonly seen where they have an unkempt coat or less shine on their coats that can purely be due to pain. There can be self trauma, licking, biting, and scratching.

You've all seen the dog that comes in with just a lot of brown hair over the carpet where I've been licking consistently over time. Potentially due to pain in that joint. Self-protection is another way.

For instance, animals can hide from you or avoiding the stairs, getting in the car, don't want to play. They don't want certain body parts to be touched, for instance, or cats can shy away from being petted. And then finally, aggression and vocalisation, and they're actually fairly rare.

Aggression like growling, biting, or just acting out of character, is one of the last things a pet will do due to pain, as is vocalisation, whining, whimpering, yelping, groaning, howling, and so on. So opposite to what most owners think, it's probably one of the last things a dog will do when they're in pain, and it's really important to realise that. This is just a slide showing all the various things we can, we can see in patients with pain, more or less most of the things we've just talked about.

Again, vocalisation, probably the least common one in those. So how do we assess pain? Well, that's the million dollar question.

Very often people are known to say things like, Oh, my dog is disguising his pain, or don't dogs hide their pain? Well, they don't disguise or hide it really, but they are pretty good at coping with pain, much better than people in general. And again, most symptoms are behavioural rather than vocal.

Just important to stress that again. Very often owners are unaware that pet is in pain, and it's up to us as veterinary surgeons to make sure that they understand that pet may actually be in quite a lot of pain, especially if it's chronic pain and therefore stressed. And dogs like people can all experience pain differently.

So if a previous dog seemed to cope with its arthritis pretty well, it may be that the next dog is not coping well at all. It's very difficult to assess the amount of pain and even more difficult to assess the quality and the experience of the pain, especially the emotional part of the pain, but even the behavioural side of pain is very difficult to assess for us and even more so for the owner. Now there are tools available to help with the assessment of pain like the Glasgow Composite Pain scale, the cane and pain index, the Liverpool osteoarthritis in dogs, or the cane and osteoarthritis staging tool.

All these can help you to put a number to the pain, which will help mainly if the pain is assessed by the same person in the same patient over time for comparison rather than an absolute number. And of course you'll see that some of these are specifically designed to assess the pain in osteoarthritis, whereas the first two on this list take more into account the the emotional component of pain. So let's talk about the treatment of pain, which of course is extremely important in all of this, and there are many, many ways in which we can treat or control or manage or at least modify pain in pets.

And it's of course to prevent suffering and stress in the long term. And the easiest ways we can talk about all the different types of treatment for pain would be to use the ABCDE acronym. A stands for analgesia, and for analgesia, we will see later we use mainly drugs, but also analgesic techniques.

B is for body weight, and we can use diet and exercise and things like hydrotherapy to help with that. C stands for lots of different things, control, comfort, compliance, common sense, complications, and we usually use things like assistive devices, massage, and environmental modification to deal with those. D stands for disease modification, and we're talking about nutraceuticals, injections into the joint, surgery, of course, and things like stem cell treatments.

And E for exercise and both hydrotherapy as well as specifically designed home exercise programmes can help with this. So let's go through them one by one. A is for analgesia.

Analgesia, of course, means no pain or at least less pain in most of our patients, and we use mainly drugs for that, but also analgesic methods. And if we're talking about the drugs, the list is nearly endless. By far and away, the most common group in this is the COX inhibiting non-steroidal anti-inflammatory drugs or NSAIDs, and we're talking about drugs like meloxicam, carcofen, or becoip, yocoip, etc.

All these drugs are relatively similar. They reduce pain, swelling, inflammation, redness, heat, all the, the common sort of consequences of inflammation. And of course there are lots of advantages and disadvantages to any of these drugs, and you all know this.

Grapire is a non-Ox inhibiting NSAID, which in my experience can be very useful in some patients. The newer injectable monthly drugs of the map and Fronve map, the dog and the cat injectables have initially had a lot of good reports, although a few more negative reports are coming out, especially on social media. But they have been a game changer in lots and lots of patients.

Then there's good old fashioned paracetamol. Now, yes, it is old, it is maybe slightly old fashioned, it's also cheap and it's actually pretty safe in dogs only, of course, never in cats. We have the opioids and methadone, morphine, codeine, etc.

Are very, very often used in veterinary medicine and very, very useful. Amantadine and memantine are very often used together with NSAIDs, and it's particularly good for central sensitization. Tramadol is a little bit controversial.

It's a synthetic opioid. I think it used to be very, very popular. It's becoming a little bit less popular.

More and more specialists are doubting the efficacy of tramadol. Personally, I rarely use tramadol. Gabapentin and pregabalin again are particularly good for central sensitization.

And there are some other drugs that are particularly popular at the moment like ketamine, amitriptyline, and topiramate can make a difference as well. And then the less said about this at this moment in time, the better, probably, but CBD, which of course is different from the THC, CBD cannabidi is a relatively newcomer in paying leave. It's a bit of a can of worms mainly because there is little known about effective dosages, safety and and and preparations and so on, but watch this space.

And the analgesic methods to help with pain relief are herbal medicine. Now Western and Chinese herbal medicine has been used for hundreds and hundreds and hundreds of years, and actually till about 50 years ago was the mainstay of pain medication in human medicine, and in some countries in the world it still is, and it can be very, very effective. There are lots of examples.

Devil's claw is one of them that a lot of people are familiar with. Now these herbal medicines must be prescribed with some specific training and knowledge about herbal medicine. It is a holistic approach and it can be very, very useful.

Physiotherapy, lots of different techniques in physiotherapy can be used for pain relief. My favourite is the laser, ultrasound, TENS machine, shock wave therapy, thermo therapy, so often cold, hydrotherapy, myotherapy, teou, the list is endless. In my job as a rehabilitation practitioner, I use all of these techniques on a regular basis, and they can be extremely useful.

And then there's acupuncture, and of course, again there is Western and Chinese acupuncture, and it works through 4 different effects the local, the segmental, the heterosegmental, and general effects of acupuncture. And an easy way to explain this, especially to clients, would be to say that acupuncture tricks the brain into experiencing the pain in a less severe way. Some patients respond better than others, exactly the same as in people, but it can be extremely useful.

Little spiky. Right, let's talk about body weight. Now, excess body weight, we all know, can have a detrimental effect on health in lots and lots of different ways, but it can also affect well-being and life span negatively, and the two mechanisms are not just the mechanical effects of the joints and muscle and bones, which is obvious and logical and quite easy to understand.

But fat, especially white adipose tissue, can produce excessive amounts of chemical factors and hormones that cause chronic inflammation. So it's not just the weight itself, it's the actual fats that can have a negative influence on how pain is being perceived. Now when we're talking to clients about animals, it's actually better to use things like body scores than body weight.

Especially in people, obesity is a big issue, and there's a large sort of emotional component to that as well. And if you tell clients that pets are overweight or obese, it can lead to quite a bit of hesitation, right? If you talk about their body score or their body condition, it's a little bit easier to have that conversation.

So for instance, rather than telling the clients that pet has to lose weight, it might be better to say we're going to try together to optimise your pet's body condition. It's a nice tip for in the console room. The letter C stood for control, comfort, compliance, common sense, complications, and so on.

And for instance, control is about controlling the activity and the exercise. A lot of people will be not so keen to reduce the. They do with a dog, but if you explain to them that the slipping and sliding and running and jumping and twisting and turning they like to do with their pets when they go out playing in the field can actually be detrimental to them, especially if they're suffering from things like osteoarthritis, they will take it into consideration.

Instead, You can use other things like games, puzzle feeders, and distractions to keep the pets still occupied. People worry a lot about the fact that they will not be able to do quite as much exercise or the type of exercise they like. Comfort can be increased massively by using rugs in the in the house, especially if there is lots of smooth flooring, by using carpet runners, by having a thick or comfortable bed, by raising the bowl in patients with neck pain, for instance.

Compliance is very important, and we all know from various studies that owner compliance with medication is quite low. It's very, very important that people stick to the regime which is set by the vet. And for instance, we have lots of clients that say, oh, I only give them metaca when they obviously in pain.

Well, as we talked about earlier, the central sensitization, it's one of those classic examples where people don't do. Control of a small amount of pain on an ongoing basis where it inevitably will lead to the central sensitization and the worst experience for the pet. Common sense is important as well.

We need to help people make decisions about the daily routine, maybe advise them about having a ramp to get the dog in and out of the car, to use some steps to get on and off the sofa, and to use a stair gate to prevent him going up up the stairs, and so on. And of course complications are important. We need to make sure that if we use any drugs that we are fully aware, as are the owners of any potential side effects, that we do regular checkups, that we do blood tests for liver and kidney disease, and so on and so forth.

And these are some of the examples of things that can help. We've got the nice beds, the runners, the car ramp, the stair gate, and various puzzle feeders for dogs to keep them mentally stimulated. And in the far corner on the right, I've got a big red cross on the chucker, which I talk about to clients all of the time.

It's one of those favourite things of dog owners and one of my least favourite things for dogs, at least those with any kind of issues. D stood for disease modification. One of the groups is nutraceuticals.

Now they are food supplements that have a potential to influence joint cartilage. At the moment there is still very little peer reviewed scientific evidence for any of these nutraceuticals, but they are very, very widely used, especially by the public. And most of these contain things like glucosamine, chondroitin sulphate, MSM, turmeric, green lip mussel, omega 3 oils, Davos clobuweia, and many, many more.

At the moment, the evidence is still very poor. The biggest evidence we have is for the omega 3 oils. Pentos and polysulfate is the weekly injection that is usually done in a series of 4, which is supposed to influence the cartilage.

It was very popular at one point. I think nowadays it's a little bit less used, but it can still be very useful in certain patients. We got PRP or platelet rich plasma.

It's a fraction of the patient's own blood, contains very high levels of factors which may help a joint. Very often PRP is used together with stem cell therapy or together with hyaluronic acid or steroid injections into the joints. PRP can also be used for soft tissue injuries and can have a major positive effect.

Hyaluronic acid preparations are injected straight into the joint in particular injections. They not only lubricate the joint temporarily, but they help produce beneficial factors that can reduce the inflammation in the joint. And finally, stem cell therapy, cells from the patient's own body, often from fat, are extracted, activated, and cultured and multiplied, and then re-injected into the joints.

The main effects of stem cell therapy is that it reduces inflammation and it modulates the immune response rather than it regrowth parts of the body which clients often think. And these are some of the methods that I used. For disease modification.

Exercise. Now, in the past, human and animal patients were very, very often advised to rest if they had any kind of injury or orthopaedic problem, for instance, and arthritis and so on. We actually now know that this is very, very often detrimental.

And can cause more joint stiffness, muscle weakness, muscle atrophy, reduced flexibility, reduced range of movements, weight gain, frustration, and boredom. All of that in various ways can actually increase the pain. So what we recognise now is that we need to do a modification or modulation or moderation of exercise rather than stop it.

So exercise needs need to be modified, altered, or mainly controlled. Therefore, an individualised patient specific. And condition specific, especially individually designed exercise programme is highly essential for clinical improvement and mental stimulation.

And as part of my job as a rehab practitioner, my home exercise programme is a large part of what I advise clients to do for their pets, no matter what the condition is. So these are some of the exercises, especially in the rehabilitation programmes that we will talk about with clients or explain about. And this of course is my little spiky.

So what does all of this mean for you as a vet in general practise? Well, I think first of all, we all need to understand the basics of pain, how it is perceived, the different types of pain, the different components of pain. We need to know what the effect of that pain can be on our patients, not only the physical part, but more importantly, perhaps the emotional part of that pain.

And we need to be able to recognise the symptoms of pain, not only for ourselves but to explain it to the owners. We need to talk about the changes that they may see in appearance, their stance, their facial expression, mostly their behaviour, their mood, their gait and movements. Most people are pretty switched on when they notice that dog is lame.

In cats, not so much. We ask them about and we look at changes in fitness levels and muscle mass and endurance and of course changes to how they react to being touched or handled either at home or in the consult room. And of course you need to be able to then advise the client or direct them to a specialist vet or a pain management therapist.

In conclusion, I think pain overall is quite a difficult. OK the subject. The signs of pain is improving all of the time.

We know so much more than before. For instance, one of the things I talked about was the microbiome. More and more information is coming out all the time.

We know more about drugs and drug interactions and safety levels and dosages and so on. There are so many ways nowadays in which we can help our patients. There is no excuse.

Let me repeat that there is no excuse at all to not treat pain properly in our patients. And as vets, we should all be part of a whole team of clinicians and therapists looking after the dogs and cats, cooperating with each other, communicating with each other, helping each other, getting the very best out of this. Thank you so much for your attention.

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