Hi, my name's Madonna Livingstone, thank you for joining me this evening for the lecture on chronic pain and rodents. This is a radiograph of a guinea pig with osteosarcoma and the proximal tibia. Just to show you that it is just a skeleton, and I'll go into that in a little bit more detail as we go on, but pretty much anything that you can see in more familiar species you are going to see in rodents.
And if you do approach these creatures in a body systems based approach, then you're, it is a little bit less scary. It makes, diagnostics more obvious and treatment approaches more obvious. But today we're, we're going to be concentrating on chronic pain.
So what some vets, obviously not the vets that are listening to this webinar, but what some vets struggle with is why should they care about rodents, because a lot of them are traditionally short-lived species. But we do need to realise that the human-animal bond is not species specific. It really can be any type of animal.
And at the end of the day, if an owner has sought your time and your expertise with their pet, but if the owner has come in with their beloved animal and not immediately said to you. I want to nee it. They're there because they want your opinion.
They're there because they want your help. It is not our job to X-ray their pockets, it's not our job to make financial decisions for them. It's our job to do our clinical exam to the best of our abilities, to discuss our findings, to give our treatment options and help the owner .
Make the best decision for them and their animal within the financial limitations that they may or may not have. But not only that, we have to remember that animals in the UK are protected under the 2006 Animal Welfare Act. And one of the points in that welfare Act is that freedom from pain.
So we are legally obliged to ensure that the animals under our care have adequate pain management. OK, so I just want you to pause for a second to think about that because I, I know certainly I wasn't taught very well at university on chronic pain management and, It has become one of my many obsessions in veterinary medicine is is trying to Look for chronic pain in all my, my patients regardless of species and adequately manage that. So what is pain, I think it is useful to get into some definitions before we, we crack on with the more nitty gritty of how to treat chronic pain.
Well, if we look at the definition from the human side, from the international associations. Study pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in turns as such damage, OK?
Or again from the human side. Pain is whatever the patient tells us it is. Pain is is a very individual experience and the same types of pain will impact an individual differently.
OK. And that is the same in animals. But we're gonna be talking about rodents, and rodents are prey species, and in prey species, they have evolved to need to be.
And that's an evolutionary adaptation, because if you hide a weakness or flip it in the head, if you show that you're weak, a predator's more likely gonna pick you off because you're an easy meal, OK? So that makes it much more difficult to see pain in these species because they are not showing it in an innately human way. They are lying to us and telling us that they're absolutely fine.
However, and what, and also sorry I should have said. If you are a prey species, you've evolved to be food, because everything is fit for something in the wild. So you can't show that you're weak because that fear, that instinctive fear of predation is, is always going to be there.
A lot of the species we keep as pets have not been in captivity for very long. Dagus only really came into captivity in the 1950s, OK? However, Pain assessment is easier in rodents if we remember that all vertebrates have the same anatomical and physiological pain pathways.
So if it's gonna hurt you. It's gonna hurt them. If it's, if it's a chronic condition that humans find painful, rodents are gonna find it painful, and so are our dog and cat patients, and although this is a, a lecture on rodents, I want to point out that the vast majority of what we're gonna talk about is completely translatable to other species.
Rodents are used as human models for pain. Including chronic pain and the effects that chronic pain has on the brain, OK? So that's, that's fact.
So if we're using rodents to look at how pain impacts people, well then it, it's having the same impact to rodents, otherwise we wouldn't be using them, OK? And the brain regions that are activated in human pain when they look at active imaging studies are also activated in rodent brains. And chronic pain causes a loss of grey matter in the brain, and that leads to increased pain sensitivity.
So the same level of pain is experienced as being worse. So let's look at some definitions of acute pain versus chronic pain. And from the human side, the definition of acute pain is mild to severe pain of 3 to 6 months maximum duration and always within an expected helic time.
But could I just point out, if we're dealing with a rat with an expected lifespan of maximum 3 years. And in my experience, 18 to 24 months is a much more average lifespan for pet rats. 3 to 6 months of pain is a huge chunk of their lifespan for acute pain.
What causes acute pain, well, it's relatively easy to detect because illnesses will cause acute pain, trauma, surgery, infections will cause it, but we have to be aware that high levels of acute pain. Puts that animal at an end see stress of chronic pain developing. But acute pain is predictable and it's got a relatively short period and it may cause behavioural changes.
Chronic pain? Sorry, having technical issues there. Chronic pain?
The definition is mild severe pain of a duration longer than 6 months, past expected healing time and maybe lifelong. It's harder to detect. It doesn't have an anticipated start or predictable end, and they're more than likely going to show behavioural adaptations as a way of coping with chronic pain.
OK. And acute pain has a protective function? Cause that's what's, you know, that it's, it's going to protect the area to give you a chance to heal, so it's making you aware that area is damaged and it and it needs, needs to be cared for.
But chronic pain has no protective function and that is, it's a a form of maladaption of your pain system. So undiagnosed and untreated pain is a massive welfare concern. This is a radiograph of adegu.
You do not need to be a degu savvy vet to look at that radiograph and realise that there are bilateral severe osteoarthritis. But not only that, it has a narrow disc space and it's fine, OK. So it's got a massive impact on quality of life because these animals are actively trying to lie to us and tell us they're fine.
And chronic pain has impacts on social interactions. It can disrupt social interactions. Remember that most of the species, the red species that we'll be dealing with are innately social creatures, and there's been various studies that have shown that social contact can help them cope with painful or adverse circumstances, albeit it's acute pain.
So if the animal is reducing its social interactions because it feels vulnerable and it's in chronic pain, well, that can also lead to chronic stress. Sleep disturbances, we know that inflammatory pain, chronic inflammatory pain, especially leads to sleep disturbances. What's the most common inflammatory pain that these rooms have been experienced, osteoarthritis.
Emotional impact causes depression and anxiety. Designing? You to This is a prey species.
These are prey species we're dealing with. And in the wild, if you don't groom your coat, you no longer care if you live or die, because in the wild, your coat is a requirement for thermal regulation to keep you warm, to keep you waterproof. So if you're not grooming yourself, you're going to be more risk of chilling, hypothermia, death.
So as a younger vet, I was equally as guilty as many others, it's at just stopping with the thought after, oh it's not grooming itself properly. Without them thinking of the actual implication of that to that and. Chronic pain decreases the ability to for memory and cognitive abilities, not just in people, all of these things happen in bodies too.
And whereas with your myomorphos, your rats, your mice, your garbils, your hamsters. It's only their incisors that grow continuously throughout life, their cheek teeth don't, but has triy morph rodents such as chinchillas, degus, and guinea pigs, their cheek teeth also grow continuously throughout life. And uncontreated, I'm sorry, uncontrolled chronic pain decreases their appetite.
But it's subtle, OK, it's subtle, it could be as much as or as little as a few strands of hay less every day, but those small subtle chronic appetite changes go unnoticed. Noticed the weight loss is slow and prolonged, and their guts are still moving absolutely fine. But they develop secondary dental disease because they're not eating the same, therefore their teeth are not wearing the same.
So if you see dental issues as a new condition, and aged who's stricken worse or rabbits for that matter, look for the source of chronic pain. So here's a 9 year old chinchilla. He came in and we've got an overgrowth of the, the molars, if we in chinchillas, if we draw a line from the upper border of the maxillary incisor to 3/4 of the length of the, or the height of the tympanic bully, there should be nothing over that length, the yellow line there.
It has to be the a radiograph of diagnostic quality. What I mean by that, your tympanic bully should be virtually overlying and just your mandibles should be virtually overlying because if you can see both of them really easily, you can see them both in this on this radiographic, but it's almost perfect. Not quite, but it's good enough, .
But if it's, if it was a complete oblique where you could easily see two distinct tympanic bullying, two distinct mandibular mandibular remi, that's not diagnostic quality for these lines. So you can see that we don't have overgrowth of the axillary wis. Green lines in a normal chinchilla with the normal dental arcades would be continuous.
You draw one green line down the cranial border, the rostal border I should say, of the maxillary premolar and the mandibular premolar, and those lines should meet each other. But when you get dental disease, when you get clinical chronal overgrowth, you often get this stepping here. But this chinchilla has never done a disease before.
And if you are a species with teeth that will contily throughout life, if you're genetically prone to dental disease and or you've been fed on a poor diet, you are going to develop dental disease at your. H, not an old age. So if you're seeing it as an old age the first time, there is something else underlying, so look for the chronic pain sources.
And in this chinchilla we had narrow disc space and the spine, and you can see the plates are sclerotic and the, the ventrodosal view confirmed it as well, but we also had bilateral osteoarthritis in our stifles. And since our, our clinic has taken a much more proactive approach to finding and treating chronic pain, our incidence of dental disease and his trichomorphoidents in rabbits has dramatically reduced. However, we have to remember the observer effect in rodents.
Because not only are they very good at lying to their owners and lying to us, we need to remember that the stress of the journey can mask the pain, the stress of being in a car, the stress of being in a waiting room full of predators, the stress of of the signs and the smells can be overwhelming and adrenaline courses are massive analgesics. But not only that, handling by unfamiliar people can trigger stress-induced analgesia in rodents, and that's opiate-based, which leads to decreased sensitivity to pain during the clinical exams. They don't tend to react or react as much as you would maybe expect them to.
And that opiate effect can last for 45 minutes. And sorry gentlemen, but the studies have shown that the opiate effect is much worse. With unfamiliar male vets and veterinary nurses or lab technicians or veterinary technicians, OK, they're much rats are much more likely to defecate and increase rate indicating stress and release higher levels of opiates when handled by males.
OK, so we've got our definitions that the way we're aware of, of the limitations that we have due to their amazing ability to. But how do we get start to get into nitty gritty of that? Well so pain assessment starts in history and history taking is not species specific.
So, you know, we ask what preventative healthcare do you practise, where do you keep your animal, how much exercise does it get, what diet is it on, does it still eat the same diet? Is it still, taking. It's favourite treats is it's still doing things the like they're still toileting the same what is worrying you.
OK. But ask probing questions to or if it's a species that claims like rats and chinchillas, and they, are they still claiming as much? Are they still playing or real running as much?
Are they still interacting with the cage mates the same way? Are they still sleeping in their favourite hammock? Because for example, if you know that all the rats in the mischief normally bundle into the one hammock, but you've noticed that one or two of them have started sleeping in a lower hammock, then it's potentially due to pain.
Is the sleeping position normal because usually rodents will tuck themselves up into a ball when they sleep, but if they've got pain, they won't always do that in a more likely in their sight. Are they still burrowing and nest building as much? That's an innate required behaviour for a lot of these species.
Not guinea pigs, any pigs don't burrow, but the rest of them. And are the same, they still producing the same faecal size and number, because if one of them is producing smaller faeces than what's normal for it or its cohort, that can be a sign of reduced appetite due to pain. And we have to remember that they, the animal guys, not the owners, are trying to lie to us.
So any change in their behaviour or preferences, no matter how subtle, should be viewed as significant. And because a lot of rodents are nocturnal. Then the best paid assessment of their spontaneous behaviours are when they're at home and the best sources of this information to the owners.
So ask if there's been any subtle changes. Some owners are frightened to tell us in case we think they're being ridiculous because it seems so small without realising the massive implication that tiny change potentially has. OK, so we've got the animal in our in our consultant now.
We've taken a history and we're observing. And behaviour before the exam, we look at how the animals moving the glinting eyes, the coat really rough looking, and it is not a happy animal. Whereas conversely, the, the animal on the left is sleek, its eyes are wide open, and it's showing an interest in what I'm doing.
The day and night does not care what I'm doing, OK? That's not normal, since this is the first time I've met these day goose. So how is the behaving?
Well, any prey species should be interested in the environment, it should be scanning for predators, it should be investigating, it should be looking to see where their boat holes are, because it's trying to keep itself safe, and it's trying to pretend it's normal. So if for the time. You see them, they can't do that.
They're in Avene. They are really, really sick. OK.
And is there any evidence of self trauma or self-mutilation, because these guys can neuropathic pain as well, and self-mutilation is gonna be much more common, common, sorry, in the areas of a painful neuropathy. So what tools can can help you with eye shape, I, I use that a lot. There's a grimma scales have been validated for a lot of species including humans, they're useful.
They are useful, but they're only validated for acute pain. And they're not validated for all types of acute pain. The, there is some evidence with some types of chronic pain, it does help, and it can be used.
So I think it's something to be aware of. I think it's something to check and to look for. And once you, you get your eye in, no pun intended, it, it is definitely, definitely valuable.
But it's not just because that exist is normal, as I'll show you later on doesn't necessarily mean that I was not. So mice, there's been a one validated for mice with grimace scales. It's not just eye position, there's lots of other things, but for me eye position's the easiest one, so that's the one I'm talking about.
So your pet mice, have got just like other rodents, very round eyes, but as the pain levels increase, they start to squint. Now they call it orbital tightening. For me it's their squint in their eyes, they're squint in their face because it hurts.
OK. Rats, this is one of my rat patients. My husband asked me if I'd photoshopped this.
No, this one's rats had a variety of hats that they used to wear when they came out. And there's one with a top hat as well. So this has not been photoshopped.
This is genuinely one of my patients. But pet rats should have lovely big round eyes as well. And again, there's a validated, for acute pain and rats grow a scale, and you can see that as the animal is in increasing levels of pain, the eye is squinting.
Gerbils, there's very little in the pain, very little in the literature. And I should have said, everything that I'm talking about in this webinar comes after a very in-depth literature search where I, I read, well over 100 research papers and all sorts of types of pain to do with rodents and other species, and there's very little in the literature on gerb pain scoring and gerbils and actually effectiveness of analgesia gerbils. However, In my experience, I see a lot of pet gerbils and pet gerbils have lovely big round eyes, and as they start to feel a bit rubbish and a bit under the weather and painful, the eyes get a bit squintier, they don't groom themselves as much.
The time you look like the gerbil on the right, you, you know, if you're not dead already, you want to be bless up. Hamsters are trickier, because Edmonton Neal 2021 looked at indicators of postoperative pain Syrian hamsters. OK, that's acute pain, and they try, they developed a a Syrian grim scale by adapting from the rat and the mouse grim scales, but the outcome of the study is they couldn't find a consistent but liable behaviour to evaluate and pain the hamsters.
So it does make assessment of pain more challenging in our hamster for patients. So I tend to earn a side of caution with hamsters, to be honest, I earn a side of caution with with all my own patients, but hamsters and guinea pigs in particular are really difficult to pay for. However, again, in my experience, they have lovely big round eyes.
This little hamster here has an ear infection, it's left eyes lis nice and round, it's right eye squinting because it's got an earache on that side. This hamster, is extremely unwell. Guinea pigs, round eyes, when they're, when they have painful conditions, they're often squinting and yes that's an example of acute pain but I couldn't find my chronic pain pictures of eye positioning guinea pigs, you see that guinea pig, it's a trauma traumatic eye ulcer and it is squinting and when it was cured, so I went back to a nice round position.
Chinchillas, the chinchilla on the left, there's no pain, scale in chinchillas. There is some studies on the effective analgesia in chinchillas, you can see the chi chinchillas normally have a lovely round eye. This chinchilla on the right, you saw the radiograph of it earlier.
Chronic, spinal issues and joint issues, and it is squinting its eyes slightly in that picture. And just like with us, some sometimes pain make your eyes water. Well, that happens in rodents and animals as well.
And this chinchilla had to grieve forearm, not because it needs a lacking a lot and up disease. We saw grafts, it doesn't have any root disease, but because it has been, OK, and we actually know it's one of this particular chinchillas tells when it's pains need medications needing adjusted, which sometimes happens during cold spells, it gets. And back to day goose, and you saw this picture earlier, but yes, degus usually have lovely big round eyes, and then as their eye they get more painful, they stop brooming and the eyes become more squinty.
Thank. But frustratingly with chronic pain, they can have normal eye position. So these rats that chronic pain, they've got a lovely big round eyes, they stay good, George, who you'll meet later on also in chronic pain now.
Eagle-eyed, amongst you will notice his eyes aren't completely round, but if you've got a wriggly day go and you're under a lot of stress, I can completely understand why somebody would look at this degu during a consult and not necessarily pick up on the fact that he is partially squinting his eyes. And this gerbil, yeah, his coat's a bit rough, but his eye position's not too bad. And, and here's Milo who has chronic pain they do with complete, you know, not completely round eyes.
But for being hyper practical, these quote it's not completely clean. Let's be realistic, realistic though guys. Even many humans have chronic pain and to look at me wouldn't know, I have chronic pain, which is probably one of the many, one of the reasons I'm so passionate about it.
And people don't know unless I choose to tell them or unless I'm having an acute pain flare-up of, of my chronic pain issues. So That we have to look at their behaviour and behavioural changes may be subtle, and they might have occurred over such a long period of time where thinks pet's just getting old. You can see it we're dog cat patients all the time and having to educate everyone's like, no, it's not that your dog can't jump up on the sofa anymore because it's old.
It can't jump up on the sofa anymore because it's got osteoarthritis and it's in so much pain from it it's choosing not to do it because it's too sore to do so you take that pain away, I bet you the dog wants to get back on the sofa again. It's just the same for rodents. And unless the animals have an acute flare-up, the chronic pain, problems, it's gonna be easy to miss if we do not actively think to look for it.
And I firmly believe that is our one of our job roles. We should be actively looking for chronic pain because these species cannot tell us. OK.
So how do we do that? We've taken our history, how do we go onto our clinical examination. We'll offer treats.
I have little jars of bribery and corruptions. I call them all human grades treats. I've sunflower hearts, I've got granola, I've got pine nuts, and, it can also, we do it with our dog cat patients, we offer them treats, and that helps turn the anxiety level down in their brain if they'll eat it.
And if they're friendly, examine on your arm or a towel. On the table. It's really important you provide a non-slippery surface.
Remember these are prey species. Not, no animal likes a slippery surface. But if you've evolved to be a preatum and you've evolved to be put, you have an innate requirement to escape from a predator at a split second notice.
You cannot achieve that if you're on a slippery surface. That is why they're more likely to to panic. That is why they're more likely to struggle.
Because they don't feel secure, OK, whereas you give them something to grip onto, then it really make them feel calmer, if they feel calmer, you're more likely to pick up on these subtle changes. And think body systems, this is what I tell my students, this is what I tell my colleagues. Really they are just all walking body systems.
The species specific adaptations are relatively few and far between and it's easier to learn the differences than try to learn it all over again. Because at the end of today, it really is just eyes, ears, oral cavity, teeth, skin, respiratory tract, heart, abdominal palpation, musculoskeletal system, genital region, mammary glands with a different wrapper on the outside. And if it's a species of cheek teeth that grow content out of life at the end of the clinical exam, I will do an oral examination by ing.
So I'm just gonna show you this, this video of me performing a skeletal pain check in a rat. OK. So the thing to remember is the, it's just a skeleton, so it doesn't really matter what species you're performing the checking, it's exactly the same, check and range of movements that you would expect, from your dogs and cats.
Personally, I tend to do most of my clinical exams with rats in my arms, and on my knee, and they absolutely love their, their ears, he darling, being tickled, so I usually just spend a wee second, . Making them feel safe, but for the purposes of this video I'm gonna do it on the towel just because it'll be easier for people to see. The first check I do with rats in particular, is I check the flexibility of their tail, because rats have a partially prehensile tail, and when we, Move it through our fingers, they should, thank you for my kisses darling, they should curve their tail round and they lose that as they start to get osteoarthritis of the tail, and then you give them medication and it comes back.
So it's, it's a really quick and easy way to see if we've got so many underlying osteoarthritis in the tail, and it's a nice way for owners to check as well. You are particularly lucky, my darling, you are indeed. OK.
So other than that species specific, . Check the rest of the clinical exam for skeletal pain in a rat is exactly the same as it would be for a dog cat, so personally I always start at the head and work my way back. So we're gonna do hi baby, I know this is weird, we're gonna play a funny game, we're gonna look up to the ceiling.
And then we're gonna look down, and then we're gonna touch our nose. Off her shoulder, and we're gonna do the same on the other side, and then we're gonna kick, and we're gonna kick. And what we're doing is we're checking for resistance and moving in one direction compared to the other, or we're having to play put more pressure behind one limb to get it to extend compared to the contralateral limb, which did indicate pain.
OK, and then we're gonna do a spinal palpation, so I'm just bringing this gorgeous little creature towards me and there's there is a slight flinch there. And I'm just gonna check and see if that's repeatable cos if it is repeatable then that is the first sign of spinal pain. Which could be osteoarthritis, it isn't repeatable, so this little rat was just giving it, nope, fed up anti Madonna, don't want you poking there.
And then we checked range of movement in the hind legs, we're just pushing on the femur, which is quite high up in rats. So push, kick. And but right, baby.
OK And by flinch, I'm, I'm talking about flinching in the paxial muscles, OK, not in the skin because it's a reaction in the paxial muscles as as you're pushing down. And when you get good at picking up trigger points and in the muscles, you will actually feel the spasm in the muscle before you see the flinch. But I, I always talk about it.
To the owners as I'm doing it to, show them what I'm doing and to bring them into it. And if I'm kicking in one direction, because I do say, oh, let's play a silly game when I'm doing head, examinations and neck examinations, and I do kick kick, and it makes owners feel more secure because they laugh, they find it funny. And then they're not quite as worried that I'm gonna hurt their animal.
But as I'm moving one limb that's stiff compared to the other, I will say things like, Oh darling, 00, you don't want me doing that at all, do you? Oh, look at this one, it's moving so much easy because more easily, because we're trained to look for these things, it's easy for us to pick up when when we're switched on to it. Owners are.
OK, so I verbalise it to bring them on their animals journey with me. OK. OK.
So here's a rat that has osteoarthritis in its tail just to show you the difference. It is a different rat. It's just the same.
And it was just to demonstrate how in early osteoarthritis we can lose that flexibility of the tail. Or, and flexibility is maybe the wrong term to use, whereas the tail's partially prehensile and rats, you can see that when I move this wee one's tail through my fingers, the tail isn't curving round my fingers the way it should be doing. It's kinda acting flaccid.
And that's what you, you'll tend to see and with pain relief. The partial prehensileness comes back. And then it's back to being like our wee tail's giving you a cuddle again.
Because the first rat, when I was handling it and changing it from hand to hand, you could see that the tail was curving round my wrist to help balance the rat. And the second video is the spinal pain in a rabbit. Just a few seconds to show you.
And, and the, the rat did actually this particular rat did vocalise with pain when I was doing it. I don't think it it played there, the, the squeak and that was repeatable as well and it responded really well to analgesia. And just to prove it can be done in hamsters as well.
It's not been grooming itself very well. You can see that his, his coat's not in the best condition, so we're just gonna do start off with the neck. I'm gonna go look up to the ceiling, baby.
And then we're gonna look down to the floor. And let's have a wee turn right, oh, we don't want to do that. And really does not want to move to the left.
OK. Right, we're gonna OK And then we're just gonna do a wee spinal palpation. Oh, yeah, that's a bit sore.
And range movement in the hind leg kick. A little bit stiffer on that side, and we'll check thoracic compliance. I know, darling, this is a weird game, isn't it?
That's fine. And one is 3 years old, your hamsters are much more likely to bite you again in my experience she's like. But even if it's, if it's a bity animal, well, use a shell to cover that examine it through it, keep control of the head, or put the animal in a plastic tub, a clear plastic tub, watch how it walks, watch its gait, watch its weight distributions that lead into one side slightly.
Is it, is its standing with a limb slightly abducted, we should, we should have their limbs underneath them. And therapeutic analgesic trials are completely valid options. If you get an animal that's aggressive, which could be pain induced, you can do a trial that is not the wrong thing to do.
We can do it in really regular patients as well. I tend to do a lot of it on my knees which this up a little bit just to makes them feel a little. OK.
And then tried to touch their this is George off their shoulders you'd seen in the picture where he was slightly squinting he is a chronic he is a good differ. He is completely wriggly. We sight even at the best of times, I can't get it as far right.
OK, so we've got some neck pain. Oh, and he doesn't, I know you don't like the palpation there. So we'll do one side at a time and there's twitching of that ear.
A regular patients that it's a patient. And taking time with them. Good range of movement there.
So we'll check the the spine because it's I tend to cut them to myself forward. I know from his X-rays that he's got multiple narrow disc spaces. I don't know if you saw that, but I can certainly feel twitching.
Oh, right, right there. I know baby. Good boy.
I know. Every time I get to the same repeatable when I get to the same bit. I'm getting twitching and pain.
I know. So it's just about having patience when they're wriggly, when he's got a little cyst there. I know it's OK.
And how do I know that it's pain when he starts wriggling away while I'm feeling spasm in the muscle just before he shoots. Right, let's check these hips, darling. I know.
Having the eyes. Spinner Rooney, son. Press on the stifle, and he has bilateral stifle osteoarthritis, we know this.
Oh, you crying. So you vocalise there and he is much stiffer. I cannot fully extend at all.
Check the movement in his tail. It it's the same range of. This is a lovely beach chinchilla who might shout at me because he's cheeky.
I'm gonna look up to the ceiling and play a funny game. I know we're gonna look down. I know Iggle bum.
This is an insulin dependent diabetic head off of your shoulder. He is challenging to work we're gonna kick. We're gonna push on that elbow we'll kick.
And you also have to just check the range of movement in the front legs and then we're gonna restrain them just to my body to make him feel secure while I do my spinal palpation. Checking for a wee flinch. Little bit of a flinch, tender over the sacrum, but other than that, fine.
And then hind limb kick, right, we'll spin you around baby. Good boy. Don't nip me, that's rude.
He, he does quite like to be cheeky and give me warning that from time to time, but it'd be exceptionally rare for him to draw blood. OK. So I've convinced you now, you've done your clinical exam, you've convinced animals in pain, what now, what, what do we do with that information?
Well. We, we, there's a big move towards multimodal analgesia in all species including humans, . It's especially relevant exotics because a lot of the drugs we're we're using are unlicensed and they might even have limited scientific data to back their use.
And Hawkins in 2006 wrote balance analgesia should be considered in virtually every exotic patient because the use of multimodal therapy may maximise analgesic efficacy and minimise the potential for individual drug toxicity in these patients. And there's lots of papers out there that show that containing a couple of classes of analgesics that hit the pain pathway different parts could provide way more analgesia than either of those drugs would provide as a sole agent. And I often find as well that you get away with lower doses of each agent, when you use them in combination as you would would necessarily as a sole agent.
So. What, what my colleagues have asked me over the years you know what my students asked me, how does, how do I decide what painkillers to start on. I don't decide what to do because you don't go in and then through the pharmacy at them.
That's, you know, you don't use a JCB to cracking up. It it's. How did he died.
Well, initially I think what hurts. What type of pain am I dealing with? So, but no susceptive pain, which if you're anything like me you can never keep what these some of these names in your head, and no susceptive pain broken down somatic pain which is from your skin, so that includes things like chronic otitis external, otitis media or types of internal muscle tendon, bone, joint pain, OK.
Like example osteoarthritis, you get your visceral pain from bowel pain, remember your joint pain and herbiforous rodents can cause slowing of the bowels which can cause gut stasis, which can cause blow and that can cause bowel pain. Kidney stones and bladder stones can come from chronic joint pain and the basis that they're not. Emptying their bladder properly because it's painful to posture and then you get hyper saturation of the urine and crystallisation of the calcium and sandy, chronic pancreatitis and various cysts.
So these are some examples of this. Then you get your neuropathic pains that's the damage from the nerves, nerve pain. That'll be like facial nerve pain from theitis mediastroke and turn.
But remember your dental nerve pain and, and your, your tremorphos and if you've got root disease going the wrong, sorry, roots going in the wrong direction, they're gonna be impinging pain, sorry nerves in the bone and causing nerve pain, but also slipped discs. And central sensitization, which is that's maladaption. OK, so that's where your pain receptors going into overdrive and you get heightened.
Perception of pain, so something that would normally be painful anyway, suddenly becomes absolute agony, so that's hyperalgesia or something that would normally be innocuous and non-painful like somebody patting them their pet. Becomes painful suddenly, allodynia, so people allodynia is things like that they'll describe it as they couldn't bear to have the bed clothes, their blankets on lying on part of their body or even their clothes. Animals experience this as well.
But remember it's not so clear cut because some patients have multiple pain types, some patients have all pain types, and not all patients have the same pain types at all points. But that's why we have to do regular periods. So how do I choose what multimodal analgesics I start with?
Well, depending on what my, what I find is what I treat. So say I have an animal that comes in and I'm finding joint pain. Well then I'll, I'll probably start with a non-opiate, plus my subjunctive care, but if I get an animal that comes in and I have severe spinal pain and joint pain, I'm more likely gonna go in with a neuropathic painkiller and, anti-inflammatory.
OK, lush my so. And then if they're not improving or the pain is getting worse, you start to add in painkillers and each recheck, OK, giving enough time to the body to adjust. And remember it can take 8 to 12 weeks to get full pain one down if you've got a sense of sensitization.
So I usually schedule my first pain check for 2 weeks later because you usually get an indication at that point. Whether you're heading in the right direction or not, you would expect to see some clinic improvement from your perspective on pain scoring and checking how that by pain scoring it's a personal pain score as in your range of movement and flinching and just keep the clinical notes, but that doesn't necessarily translate to what the. Is seen in the house, so I will ask them to look at the things the pet normally enjoys doing, and is it still doing those things or is it started doing them again?
What's injunctive care, that's basically anything that's not an NC or an opiate, so that's things like, or paracetamol. So that'll be things like your . Anti-epileptic drugs to antidepressants or benzodiazepines if the muscle relaxants, that kind of thing.
So what are your drug options? You, well, your NSAIDs, meloxicam's gonna be the the most commonly used one, remember, most of these drugs are not licenced, they're using and most species we're talking about and in the UK a lifetime cascade form should be signed, and watchers out with the UK should defer to the regulations in their country, UK. We've got paracetamol, .
We have opiates like morphine, tramadol, which we do not use in chinchillas. Sands and man's Sander and man's I think it was, did a paper that showed that there was no analgesic effect and even at high doses to try and higher doses to get some analgesic effect it actually cause transient adverse neurological effects in chinchillas, so we do not use tramadols and chillers, and we've got methadone if we've got an acute flare-up of or chronic pain. Neuroppotin, we don't really know why it works, there's multiple theories out there, but it has been proven to have isofluine sparing effects in dogs and rats.
We've got our NMDA receptor blockers, and man and ketamine, we've got gabapentin and amitriptyline, we've got full pentophyle which is that for dogs, but there's a beautiful paper that showed that when you gave prontole along with tramadol. It actually increased damages and capabilities of the tramadol. So sometimes I have added that in ageing rodents as a general stimulant, but also to help.
So it's not an allergy on its own, but it helps increase the analgesic abilities of another dog. Vitamin B complex has been shown in primates, humans, dogs, rats, and rodents to help attenuate. Chronic inflammatory and neuropathic pain, so that's a, that's a good one to add in and you know works really move it then they just pee out the excess.
Please, please, please warn owners that it can turn the urine fluorescent yellow or fluorescent orange, otherwise you wouldn't have a lot of freak out owners. The cannabinoids, World Health organisation, Judy's still out, because there's conflicting information and pain studies in the human side, there's conflicting studies in the veterinary side as well. I know there's something special to start using it, using it.
And the UK cannabinoids are legally. OK, what doses can you use? Well, good books to go to Carpenters, is, is really it's one of my favourite textbooks for doses, 2020, exotic animal 2022 exotic animal formula.
I think I've got about 3 editions and, OK, it might. There was plug, but my old textbooks coming out this year, on exotic daisy demystifying small exotic mammals which you can get, what we go through dosing, and medicine and lots of other things. But because I, I love you all dearly, I thought I wouldn't be mean enough just to tell you what books to go look up and, and these next two slides, show 6 months of work with me trawling through lots and lots and lots of different scientific papers.
for myself rather than only going to the textbooks, textbooks are very useful, but, I wanted to see what that up to date information was, and amalgamating it into an easy to follow guide. Now, sometimes I will start at the lower end, especially if I'm using multimodal analgesia. So all rodents from loxicam.
0.6 to 2 mes per kg, it is now in UK lot scan is licenced in guinea pigs. However, it's licenced at a ridiculously low dose.
They just had to show it in some of it's full of it. I don't know a single exhaust that uses it at the licenced dose. So my starting dose of gua pigs is 0.6 mg per keg.
It's always twice a day, but there is some really good evidence that some rats need up to 5 gigs per kg. And some mice and dip in mice in the locks so don't be frightened to go up. Remember that injections and rodents should always be given over the flanks, not over the dorsum, and that's because rodents have a really high storage of brown fat in the dorsum and that can actually cause erratic absorption rates for drugs.
So, it's better to go on the flights. Your paracetamol, the Bors, 25 to 50 mg per kg, 2 to 3 times a day, a study that showed, and I've got all the references that if people want them, I can send them, 50 mg per kg has an anti-anxiety effect in that, but if you give them paracetamol at 300 mg per kg, which is published in some textbooks as a dose. 300 megs per kg caused anxiety and removed the rat's ability to experience pleasure.
Which is not what we're wanting to do, guys, so 25 to 50 mg per kg, but for your strim rodents, I tend to go for a lower dose, 15 to 25 mg per kg. Tramadol for all the rodents apart from chinchillas, 10 to 30 mg per kg, 2 to 4 times a day. However, interestingly.
Taylor child 2016 found that there is a sex difference in analgesia, and a lot of the studies you read actually use male rats, and now we know even in the we know in the human side as well, it's not just. A joke that men and and and women respond differently to pain. We actually do experience pain differently and we experience the effects of analgesics differently and we're starting to see that on the the animal side, male rats need 40 eggs per pig.
Of Tramadol to get analgesia, whereas female rats, it's 20 to 30 minutes perk, OK, the buprenorphine, again, there's the sex differences where they actually in the buprenorphine, the sex differences that female rats did not find get much analgesia at this close rate. The male rats did. Opiates in rats can cause peka, and that can cause them to eat their bedding.
And we think it's due to gastric disturbances and the feeling of nausea because just because these animals cannot vomit does not mean they can't feel nauseous. But given that can help with that. OK.
OTM means oral transmucosalally guys, and if you're gonna get OTM, buprenorphine, use the same dose vials, not the multi-dose vial. It's not that the multi-dose vial won't be effective, but the preservative is better. Gabapentin, all rodents 10 to 30 mg per kg.
However, some rodents, especially rats, can lose the effectiveness of gabapentin within a few weeks. That actually happens in people as well. But sodium valpate, which is an anti-epileptic drug, it can be used as a rescue to rescue the analgesic affected rats if needed, and actually, Sodium valpy has been shown to have inflammatory effect, anti-inflammatory effects and that's also.
Amantadine, rats all use 25 mg per kg, on the basis of Utal's paper, cos it had, improved cognitive ability and antidepressant like effect and and chronic stress with chronic pain in rats, but other rodents I'll use 3 to 5 mgs perking once a day. I'm a tripling I don't use often. I tend to only use it in cases where there's self-mutilation to kind of break that self-injurious, cycle.
In theory, if you've got them on tramadol, you need to be worried about serotonin storm, there's not yet been shown to happen and in animals but just be aware of it, they are often. 2 per kg of c, sometimes once a week is fine. Sometimes it's every 48 hours, it depends.
And acupuncture, acupuncture works beautifully, I know the negative side effects, has scientific basis, but I can talk about acupuncture for that hour on its own. Consideration. Remember the species specificness of teachers and they, they cannot tolerate sugar.
You can induce diabetes in these two species by giving sugar. You might think, well, I don't like giving sugar. Well, adding high fruit purines or a fruit smoothies to their medications that they're getting regularly is giving you sugar, so we can't do that.
Short term burrito might be required, but for longer term we want to train them to accept in food or buy syringe voluntarily. That's what our aim should be, and you can use things like, the Emirate nivore, for your biomorph to encourage them to take it or your herbivores, can get the Leiber herbivore or oxbo or supreme. Whichever one you like.
Acupuncture works really well and for a lot of roads you can do conscious if they really wiggly ones then you need to do it, when they're under withvis of fluorine, very, very, quick tutorial to it. It works by stimulating endogenous opiates because the studies have shown if you give them the, if you give them naloxone, the reverse analgesic effect of of acupuncture. Not.
That it works by triggering your fast pain fibres. People are speaking you get two types of pain fibre, you're fast and you're, you're fast are the ones that you put your hand in something and burning and and you you you experience pain, you go out burning hot, you move away. It doesn't matter if your elbows in agony, you're gonna move away or your hand's gonna get burnt, OK, whereas your chronic pain fibres are your so pain fibres there, that's, that's what the chronic pain.
So your fast pain fibres shut off, your chronic pain fibres are dampening down. So that's another way that acupuncture works by dampening down your chronic pain fibres, but it also increase increases blood flow to the areas from healing. What about joint supplements, yeah, there's good evidence now, but it's more about the, the, the quality of the chondroitin rather than the actual chondroitin salt.
It's the most important factor, so we need to stress that. Our clients that need to be really high grade quality choroitin and not all sources of that will be high grades and the recommended doses of chondroitin and oin is between 150 to 450 mg per per day, but there was a study in 2022 that showed that the addition of 20 mg of procurement to. 20 mg per kg of procurement to 100 mg per kg per day condroitin was significantly more effective than jointin alone and in the co-st administration then attenuated cartilage damage, better, alleviated inflammatory responses, delayed the progression of osteoarthritis and then improved the thickness of the synoval and allowed a quicker return to joint usage.
So we should be advising procurements being added as long as well as. As Johnson has been changes in chronic pain, weight management, and this rat was in the newspaper, and a competition from PDSE I think it was to lose weight and you look at it, not only is it morbid obese to look at its face, look at the squinting in its sizes. That was a miserable rat in case it's gonna have chronic.
Issues, but educate, not shame. I am the generation that or or one of the generations that we raised with shame as a a penitent. But once we know better we do better, and I know now not to shame and to use education and a lot of humans equate food with love.
So they're not making their pets obese to be bad, they just need a different need to express their love. OK, ensuring the floor of the enclosure and the exercise areas are one slip. And give advisor to deep layers of substrate and to help cushion the joints to reduce concussive force.
And if it's a species that has the wheel, check the size, guys. OK, there's too many rodents that are running the wheels that are far too small for them. This hamster should its back is arched in abnormal position.
It will run for hours and that that causes damage to the spine. They should the wheel should be big enough to run with a straight back. Pet remedy can help reduce stress as a plug in.
I, I love it. I keep it in my face, I keep it in all my words actually. Providing heat discs like snuggle saves during cold spells to help reduce pain associated with cold.
We feel pain, more pain in our joints if you've got arthritis, for example, or spinal disease, when it's cold and damp outside, so do they. They just can't tell us. And remember guinea pigs have an absolute requirement for increased vitamin C levels when they're any they need high vitamin C because they can't choose their own, but if they're got anything wrong with them, they need threefold increase, so increase fit and sea levels, but not in the water.
I recently challenged a very well known company who put that I do use a lot of their products who make a, a, a product for going in the water with vitamin C. And I said well how can you advertise this, you're recommending it to vets and owners. But what about the stability, we know that vitamin C degrades within a matter of hours in the water.
What makes yours different? So after a few months they got back to me and they told me that they looked at their stability and it lasts for 6 to 12 hours. So let's say 6 hours, because I'm not interested in the up to 12 hours, I'm, I'm interested in the absolute minimum length of time.
An owner would have to be changing their guinea pig's water 4 times a day to ensure that animals get an adequate vitamin C. That is ridiculous. There's no way that's that's feasible in the long term.
So we shouldn't be getting our owners to put it in the water. What we should be doing is ensuring we're providing it in the diet, and, broccoli and strawberries have massive high levels of vitamin C. Compared to oranges, they have way more vitamin C in a dry, unit would be and it increases higher, higher, water intake too.
Scatter feeding through snuffle mats will gently increase their exercise as well, as helps stimulate them too. And we have to remember just because we get the drugs does not mean that animals free. Manage your owner's expectations, advise them, and you may need to repeatedly, and gently point out, remember when I told you at the first visit, it can take 8 to 12 weeks to get pain wind down and that's when we have the right drugs, the right combination of drugs at the right dose and the right frequency, cause humans when they are worried and stressed, do not take out information effectively and.
I am, I am now the belief that's why a lot of orders think we've not told them something, not because they've not been listening because they physically cannot take that information on board. So I frequently use the technique of remember when we had this conversation, rather than saying I've already told you this, cos that can be quite confrontational, whereas saying, saying, remember when we had chatted about this is a gentler way of saying it. So the day go on the left and the day go on the right are the exact same day.
This is George, you can see that I said at the beginning the webinar about how it was so easy to miss the, the gentle splinting of his eyes when you're busy, when you're stressed, and when the animal's worrying about. And this is George, a few days ago coming in for his pain wee check after I'd adjusted his analgesics, you can see he's grooming better. The only reason his coat looks different colour is because the light is brighter, .
On the right, but he's got lovely round eyes. OK, schedule regular pain checks until it's stable causes pain is what the patient tells us it is, but we have to examine them to listen. And it's got to be about quality not quantity of life, guys, have honest, frank conversations with your owners.
If I have a patient who finds handling and medicating incredibly stressful. And cannot be trained for whatever reason, I will recommend euthanasia. Because otherwise that animal is existing, not living.
And if it's has uncontrolled pain. That is a real concern. So have, have conversations and be honest with your owners that they do appreciate it.
Thanks for listening. I hope you've enjoyed it. Feel free to email me with any questions or comments.
