OK. So, good morning, everybody. I hope you're really enjoying the virtual congress, and the presentations.

I really enjoyed that one by, Debbie just then. But no, I don't, I don't actually work with, with horses myself. And today, we're gonna be talking about the subject of pain, but I am gonna be talking about it, in both species.

So, I've titled it What Who Says I'm not in pain? Because I think one of the big challenges when we're looking at the importance of considering pain in behaviour cases, is that it can be really difficult to identify the role of pain. We can, therefore, need to look really carefully at behavioural responses and, and spend a lot of time observing our patients in great detail.

Something that can be really difficult, of course, in a consultory context, something we'll touch on as we go through this presentation. So starting off by what is pain, that might sound like a really obvious question, because we're very familiar, aren't we, as vets about it being a physiological response to a noxious stimulus. We're used to knowing about that sensory and that motor component to the pain response.

But we also need to remember that there is a cognitive and an emotional component. Pain as well. And pain's talked about as having these four quadrants or 4 components.

So what we're looking at when we look at the role of pain in behavioural medicine is the interplay between those 4 components, including that emotional and that cognitive, diagonal as well. So, I wanna just think a little bit about acute pain, concentrate mainly on chronic pain, but, of course, acute pain needs to be considered in this context as well. And the commonly encountered sources of acute pain, then are going to be those that are rather accidental, so it fits in with the, the wounds we were just talking about.

Or, of course, surgical, surgically induced pain, what we have done through our own surgical intervention. And what's the importance of acute pain in terms of behaviour? Well, of course, there are short term, very practical consequences of acute pain, and I'm sure we're very familiar with overt confrontational behaviour that's shown by our patients when we need to handle them or manipulate them when they are in acute pain.

And, of course, their reaction to that handling is often used as part of the way of assessing the level of acute pain in our patients. We also need to remember there are going to be individual differences. Not all animals are what we might call active responders to pain.

So, for example, cats are really renowned for their passive expressions of pain. And some dog breeds as well, are talked about as being stoic or having a high pain threshold, whereas others, we may associate. With more excessive reactions to acute pain.

We need to remember, of course, that the way in which they demonstrate pain, pain being emotionally a protective emotion, and therefore, one that can be expressed in the various ways that protective emotions are expressed. So, pain is a form of the fear anxiety system, and they can respond. Using repelling behaviours, go away, leave me alone, which we see very readily as those confrontational behaviours.

But of course, they can also show inhibition, that just collecting information, as this cat is doing in this picture here. You can see there's sensory input of information for this cat. So, there is a response to the pain.

But it's not an active confrontational response. We might see avoidance as well, trying to avoid us coming near them, which may be more obvious. And with dogs, who are socially obligate mammals, we may also see appeasement trying to get closer and interact, even though they're in pain, because they're using that active information gathering response to their emotional state.

So the differences that we see are associated with the individual animal, but also associated with the difference in selection of behavioural response to their pain. And as well as the short term implications with acute pain, we also do need to consider the longer term practical consequences. So, we need to think about the fact that they are also learning whilst experiencing pain.

So, we talk about the health triad, the emotional, physical, and cognitive health being all parts of Healthcare, and remembering that when we have an animal in acute pain, maybe post-surgically, for example, that that's a learning opportunity, and that they can maintain some behavioural signs associated with the pain, even once that acute pain episode is either over because of healing, or managed through pain relief. And the consequence of the classical conditioning that can occur, so the associative learning, is that any interaction or any event, or the presence even of a particular individuals that coincide with the experience of that pain can become associated with that. And therefore become triggers for the fear anxiety system in their own right.

So, we need to think about our acute pain patients, about the management of that pain, in order to also limit the potential for unwanted associative learning. There are lots of ways, of course, of monitoring acute pain. We have the Glasgow Composite Pain scales, both for dogs and for cats.

And we have a range of other ways in which we can monitor for acute pain. The Colorado State University acute pain scale for cats, for example. Bohringer and Sheila Robertson did a lot of work on looking at body posture and facial expression, particularly eyes, in order to monitor acute pain in our patients.

Now, what's important as well is the management of pain has the potential to have emotional, and cognitive consequences. So what's important is that we, engage in very adequate pre, peri and post-operative analgesia. Cause if we don't do that, if there are problems with analgesic control around surgery, there is a possible ability of the development of so-called chronic post-surgical pain.

Of course, chronic pain, as we'll explore a bit more in a moment, is a maladaptive state of pain and has serious implications in terms of the emotional health of that patient. So, by managing our analgesia during surgery, both before, during, and after, we can lower the risk of chronic post-surgical pain. The other thing that's interesting, there's some work being done by a lady called Irene Tracey, who works at Oxford University.

I had the privilege of listening to her speak at the meeting, the College of anaesthesia and Analgesia meeting. She's a fascinating person. She was also on Desert Islandists on Radio 4, giving another fascinating.

Insight into her work. But she works on this link between emotion and pain. And one of the things that she's done a lot of work on is the influence of negative emotional state on your perception of acute pain, but also on the potential for that to be a risk for chronic post-surgical pain.

So, the work that Irene's done in human animals is, is fascinating, and leads us to really think. Carefully about our patients, because so often at the point of induction of anaesthesia, our patients are in a negative emotional bias, either because of their illness or because of their experience or lack of experience of the veterinary practise. We can often have patients in a negative emotional bias at the point when we induce anaesthesia.

So, it's really important that we think. About the potential for that to influence their perception of that acute pain, but also potentially have a role in the risk factors for chronic pain post-surgically. So, that leads us to think really carefully about pre-medication, about handling during induction.

So we're seeing the difference here between handling styles at the top that may induce some More negative emotional state, whereas that less minimal handling approach, leading to a potential for there to be a less negative emotion induced. The same, of course, for cats. And also, if we're in a situation of using things like masks, the way in which we restrain that animal, whilst it's going through that induction process is crucial, combined with What we gave as pre-medication.

And maybe even thinking about whether we have given suitable premedication at home, things like the use of trazodone in dogs or bunzodiazepines, or the use of gabapentin in cats pre-vet visit, in order to act as an anxiolytic prior to the point of coming in for that premedication. Appropriate handling and management of their emotional state during recovery is also important. So, if we have animals who are hospitalised, not only about their pain relief, but also about the way in which we interact with them and and handle them, and how much we know about them as individuals in terms of their likely emotional response to being hospitalised can be really important in this overall management and limiting the potential for going on to have more serious, implications of chronic pain in association with their behavioural, output and what and how they behave at home.

So I want to go on then to concentrate in this presentation on chronic pain. And when we think about chronic pain, we've got a range of different potential sources of chronic pain that could be interesting to us in terms of understanding behavioural change. So, when we think about chronic pain, I think most of us automatically think about orthopaedic pain.

And, of course, orthopaedic pain, OA and DJD are really important for us, working in the field of behavioural medicine. We are frequently treating, chronic pain in, in the association with these conditions in our patients who have behavioural presentations. But other sources of chronic pain are also important to consider.

For example, things like ear. Very, very common for there to be not only chronic nature to ear pain, but also to have the potential for there to have been learned associations with that pain, leading to behavioural responses such as avoidance of handling around the head, for example. That may go on to have consequences that the client presents as behavioural change in terms of not being able to get on leads or harnesses.

And so, because the animal doesn't want to be touched around the head. So, other things, dental pain. Dental pain, I think, is often underestimated.

And one of the things we've noted in patients, particularly feline patients, is the, the reporting from caregivers after dental intervention to say there's been significant change in the temperament or personality of the cat, and in their tolerance of being handled, for example. So, for example, cats who've had, oral disease, or have had fractured teeth, for example. And then they've come in and had dental work done, but when they go home, not only are they not as sore around their mouth, but the clients find that they change their interaction with people.

They're more friendly. They make, joking comments about, did you do a personality transplant whilst you did that dental? And so, that is a very significant source of pain to be considered when there's behavioural change.

Also, abdominal or visceral pain of various sorts, things like pancreatitis, for example, or gut pain. Also skin related discomfort, and also neuropathic pain in the form of conditions such as illustrated here in the cavalier, of course, Kiri malformations during the myia situations with the Burmese cat, illustrated here, we also have the potential for. Feline or a facial pain syndrome.

And also here, of course, acrylic, dermatitis Legion. Association of chronic pain, and then leading to, again, behaviours that may be presented primarily as behavioural change need to be considered. The other thing that's really important in our canine patients is to remember that they are particularly prone to soft tissue related discomfort.

So pain that is a myofascial or associated with muscular pressure. And this is particularly important, of course, in our canine patients who engage in sport, whether that's fly ball, agility. Or, greyhound racing.

Because these individuals are often put into situations where they are making movements repetitively, and they're putting particular strain, you know, on their musculature. And we need to remember that pain, chronic pain associated with mobility is not always related to orthopaedic disease. So, this chronic pain situation raises this question of what is chronic pain?

Why is chronic pain even in existence? Does it have a purpose? Well, actually, chronic pain has no evolutionary benefit.

It's a maladaptive state. It's a disease state. And that's why we've come a long way in recent years in talking about the need to treat chronic pain.

The chronic pain is not something that we can just ignore or something that we can overlook, not only because of the behavioural aspect, which obviously what I'm talking about, but also in terms of overall welfare, and also in terms of the risk of it escalating in terms of sensitization when left untreated. So why do we have chronic pain? What are the factors that affect the presence of chronic pain in the population?

There are many, but some of them, are related to the sort of work that we do. So, surgical procedures, whether it's us as veterinary surgeons, or whether it's human surgeons, we do surgical procedures which lead to tissue damage, which clearly would result in death if they were in a Non-domestic environment, these not these domesticated species. Or if humans were not in medical care.

So the way in which we manage our surgical procedures is crucial. Also, one of the problems with chronic pain is that it often stems from a lack of treatment of disease in the early stages. So, things like osteoarthritis, which is Often diagnosed quite late in the progression of the disease.

Or things like ear disease, which can be overlooked at the, caregiver level and not brought to our attention early enough. Or when it is brought to our attention, we forget to deal with the pain component of that condition. So, lack of treatment of disease at an early stage can be a factor.

Also, of course, we have the problem with domesticated, animals, and non-human animals, that there is human control over breeding, which is resulting in some situations, in confirmations which predispose those animals to chronic pain. And I'm sure we can think of various examples here of animals that have been bred in ways in which their skeletal formation. Or their musculature and the way it works, or, their movement is compromised by their confirmation and then leads to the risk of chronic pain.

And in addition, we need to think about the environments in which animals live as domesticated pets in relation to their species specific behavioural needs. And sometimes inappropriate housing in either a physical or a social sense can result in physical and emotional compromise associated with the development of chronic pain. So why behavioural medicine?

Why are we talking about pain in behavioural medicine? Well, pain, of course, is perceived in the brain, and the limbic system is involved in the physiology of pain. And therefore, emotional disturbance influences the perception of that pain process.

So, of course, behavioural medicine being the veterinary discipline, which concentrates on the functioning of the limbic system in relation to emotional responses, has a direct involvement in the situation of pain and pain management. Presence of pain alters the expression of emotional responses. So, we find with individuals, osteoarthritis work done by Doctor Kevin McPeak, who's a veterinary specialist in behavioural medicine, at Edinburgh University now.

He looked at, sound-related fear in patients with osteoarthritis, and it's now, commonly accepted that If animals have chronic pain from DJD and OA, that there's a risk factor for accentuated sound-related fear in those patients. Also, emotional disorders, which involves those disorders of pain, reduce the so-called emotional capacity of the individual, and we'll look at that in a little bit more detail this morning. So behavioural medicine is the discipline that deals with the link between emotional health and physical disease.

And those of us specialising in behavioural medicine treat animals who have issues related to the functioning of their limbic system, and therefore, that overlaps with the issue of pain. And pain is always what the patient expresses it is. That's a phrase which has been adapted from human medicine, where they talk about pain being what the patient says it is.

But of course, for our non-human animals, that may not be verbally expressed. So how do non-human animals express pain? They can do it in a variety of ways, but behavioural change is a very important indicator.

Things like reluctance to walk on certain surfaces. We have a number of cases that present as fear behaviours associated with not wanting to go into particular rooms of the house, for example, or being reluctant to go into certain locations, which actually are attributable to a reluctance to walk on certain surfaces because of chronic pain. We also have gait changes, which may not be obvious.

Subtle gait changes are very common in presentation of chronic pain. And they may actually present as behavioural change. So, difficulty in going on walks, for example, or changes in the way in which they interact with other animals in the household because of a difference in their gait.

And we spend hour upon hour watching video footage, as I'll explain in a moment. Also, of course, it could be that there's a response to manipulation, but it's important not to think that that is the only way, or to think that absence of response to manipulation is going to tell us that pain is not a factor. Because we need to remember that pain, as part of the fear and.

Anxiety system can lead to an inhibition behavioural response. So, when you manipulate that painful joint, the animal may go into an inhibitory response and show no reaction at all to that manipulation. That does not mean that pain does not exist.

The other thing that's important is that during physical examination, other emotional factors can alter their response to handling, particularly if that physical examination is taking place in a consulting room. So, it could be the style of our handling has actually led to overriding fear, anxiety, disassociated from the pain, which Then results in inhibitions. So this cat being inappropriately handled, this scruffing here, for example, or inappropriate heavy handling of cats, is likely to send them into an inhibition response, because cats use inhibition or avoidance as their primary responses to protective emotion.

And when we do that, we may Lower the possibility that we may detect through physical responses, any pain in the consulting room. And the same, of course, the dogs, with dogs, we may see selection of appeasement behaviour, where the dog engages more with the individual during the examination. And that may lead to a misunderstanding of the presentation.

And if they have other emotional health issues, so if they are an animal with a natural cognitive bias, and emotional bias towards protective emotions where they've learned and they have emotional responses associated with feeling the need to protect. Themselves, which is disassociated from the pain. This is an underlying emotional problem, then that also will make it far more difficult for the animal to express pain in a consulting room through responses to handling or manipulation.

The other thing is that our clinical examination must always be interpreted in the light of the context. So we need to know what happened just prior to that individual coming into the consulting room. Was that animal needing to walk across a car park, it's terrified of cars and the Individual needed to be lifted and manhandled to get it across the car park, which increased its negative emotional bias before you ever got it in the consulting room.

Or is it through previous learning of the, veterinary context being a negative environment? So when we're doing our clinical examination, we also need to interpret the body language and the behavioural responses of the individual to assess whether or not our physical examination for pain is actually going to be beneficial. Pardon me.

And when it comes to chronic pain, pain assessment, therefore, in a routine, general practise consultation is extremely difficult to achieve. House visits may be beneficial for pain assessment or virtual visits using things like Zoom, but even then, there are limitations. And when we are in our normal lives, not during COVID, but when we're doing house visits, we can be in the home for 2 to 3 hours.

And even so, we still spend a lot of time watching video as supplement to the investigation. I had a video like this, which was supplied by a caregiver, the German Shepherd was our patient. .

It this well, but. That movement issue and being suspicious of some chronic. OK .

We And breathed badly. Or we may supplement with videotaping and our rehabilitation. That's what we did.

Next Observing their movement and looking for those. So diagnosis. You also take videos when we're at the home, so I'll just show you some examples.

So this is the same dog. The, the colouring of the dog is very different. I don't know why that is.

It's to do with the light, but it's actually the same dog. So, here, I'll just turn the sound off on, on these. It's not important to hear the sound.

So we're looking here at the movement of this dog. Hopefully you can see some difference in musculature at the back end as well. But you can see that on the flat, There's quite, it's quite subtle, the change.

But if we look at the same individual on steps, and you can see him going down the steps here, and then we're actually getting him to go up and down these steps to watch, you can see that that accentuates that gate problem and the same. The often pass videos going up and down steps either in the top or often happen. To assess their movement.

But whilst we concentrate a lot on lameness or alteration of movement for our diagnosis of chronic pain, we also need to remember there may be other signs. That in there at the centre. So chronic change in the behaviour of representation.

But we also, as I say, use home videos as well. This cat video is actually in slow motion, so I'm gonna forward it properly. So we're starting to move, it takes ages in these slow motion videos for them to actually start moving.

But when you do see the cats start going up the stairs, you start again, slow motion video can be extremely helpful in improving our detection of abnormal movement. But as I said, it's not only movement. So other signs of chronic pain may be overlooked.

So things like excessive licking or grooming behaviours, other repetitive behaviours, such as circling like this, but also repetitive behaviours associated with pain are seen in things like, or a facial pain syndrome. So I will leave the sound on for this video, because it really is quite important to hear how this cat is responding. Oh Hey honeyball.

Hi honeyba. Hey, hey. You can see the caregiver there trying to intervene, trying to make it better.

This, this cat has feline facial pain syndrome. You can see that repetitive clawing at the mouth was what the cat was presented for. Other things like sit postures.

So if we're looking at sit postures that are indicative of the potential for pain. We also ask questions about toileting behaviour, particularly, in dogs. So, we ask them, what caregivers about how the dogs, deposit when to things.

So we look at them holding spot in that they have a. I Deposits in multiple locations. I Thank you.

And Yeah. So it's an indicator that we need to investigate more. And often, when we do that, when we are investigating, we need to think about extending our questionnaires to start with.

So, as well as asking about the presence of behaviours, the other thing we're gonna ask about is the absence of behaviours. Particularly in cats, we You know that chronic pain is associated with less movement, with lowered levels of grooming behaviour. So dishevelled coats, for example.

Not going to usual resting places if those have been elevated locations. And we also may see the absence of behaviour as a presentation of chronic pain in our canine patients as well. So behavioural change can be the result of the emotional effects of pain.

So pain, it's an emotional motivation, as we've just said, related to the fear anxiety system. It's related to protection of the individual in a physical sense. And the activation is really related to any environmental stimuli which are related.

To either actual or potential tissue damage. Remembering that pain, like fear, anxiety has either the component where it's a response to the presence of pain, or to the anticipation as anxiety is an anticipatory form of that protective emotion. Pain also can be anticipatory in nature.

And the behavioural responses we said earlier, ones we think about are particularly the more active responses. So in a veterinary examination room, we often think about the animal who's trying to pull away, and we think about pain, trying to avoid interaction with us. I've used the terminology avoidance from the sink analogy, the sync model of understanding emotional health, but put in brackets here, flight, which is a term you may be more familiar with.

But of course we we restrict the ability to use fight because we need to get our clinical examination done. And then of course repulsion, and I think that's the one we most readily identify with the potential for pain. But the other two that we mentioned earlier, the inhibition may also be shown in the consulting room here this staring inhibition is the gathering of information to try to resolve protective emotion.

Try and find out more. About the situation that is perceived as being threatening. And so when we have our patients staring at us, we have this concentrated auditory, taking in of information, it's really important not to overlook that.

And, as I said, appeasement, where dogs actually appear to be more proactively interacting with us. So if they are leaning into us, or if they're trying to sniff at faces or lick to gather scent information, not this, not just ignoring that, but making sure we realise that could be an indicator of increased protective emotional bias, one of which may be pain. And appeasement is sometimes thought of at home as demanding behaviour.

So, some of the animals that we see with pain as a component in behavioural cases have been presented for so-called demanding or attention-seeking behaviour. These behaviours are actually information gathering behaviours. So, caregivers reporting their dog is more clingy than usual.

It's following them more is, showing signs of separation. Re-related problems, they may also be, a, a flag for us to consider pain because of the fact that if the dog is using appeasement as its coping strategy, then when the caregiver is not present, there will be an increase in anxiety and potentially an increase in that pain perception in the absence of the caregiver, which then manifests itself as a so-called separation problem. Ignoring and rejecting those demanding behaviours, if people are given misinformation about this being attention seeking and sometimes given misinformation related to the dominance myth where people believe these attention seeking behaviours are related to a high level of status, that often the advice that they're given is to ignore or even to reject the animal when it's engaging in this behaviour.

But actually if you reject or ignore information gathering behaviours that are rooted in anxiety or pain, you will increase the anxiety and the negative bias and also increase the potential for frustration, which is the emotion that's triggered when you can't achieve an expected outcome. In patients with chronic pain, these negative emotions of increased anxiety and frustration will also exacerbate the perception of the pain itself. So it's really important that we not only teach our caregivers, but also our veterinary professionals to be able to be more aware of body language and facial expression.

Because the expression of pain is not likely to be verbal in the same way. So that, this idea that the pain is what the patient says it is in human medicine is translated into this pain is what we our patients express it is, because we need to have good understanding of their species-specific communication. As well as their gross behavioural changes, which may actually present to you as a behavioural case, we also need to look for passive responses such as inhibition, behavioural responses that are actually appeasement, which may be misinterpreted as being very friendly or very needy or very demanding, and also more subtle communication signals associated with emotional arousal, so what we call displacement behaviours.

So relying on just caregiver recognition of chronic pain is certainly not appropriate in determining whether or not to use medical treatment. Animals in pain need to be treated, particularly when it's chronic pain, which is a disease state. It's not acceptable to instruct caregivers to give pain relief when they think that the animal needs it.

The problem with this is the risk of sensitization, and humans are not in a position to make a judgement over the use of pain relief, not particularly not based on their own perception of medication use and whether they would think they would need it. If they were limping like that. And so often we hear caregivers saying, well, in behavioural cases, when we detect pain, oh, yes, yeah, yeah.

I did get given some non-steroidal, anti-inflammatory drugs. And I give them when I feel he needs it. But, you know, he's not actually limping.

Therefore, I don't really think it's necessary. But that can result in unintentional withholding a very necessary treatment for our patients. So sometimes the behavioural changes that are associated with chronic pain are dramatic.

Sometimes we can readily identify them with the underlying pathology. So, for example, if we have confrontational responses when arthritic joints are manipulated, or when a Another animal, goes too close to an animal that has osteoarthritis or DJD, or an inability to get into the car because of something like osteoarthritis, a physical effect of that chronic pain, that may be quite readily associated. But in others, the behavioural changes are very subtle, and we may also need to do what we call chronological history taking, using a timeline to facilitate the gathering of information before we can reveal the association.

So things like altered elimination behaviours are a flag for us in our behavioural history taking, asking questions about how often they eliminate, but also the posture they adopt when eliminating, that's particularly important as well for cats. Also, the frequency, or as I said just before, with the dogs, as to whether they eliminate in small parcels of faeces in lots of places, or one large deposition of faeces from a stable squat position. Alter roaming behaviours is another flag, and also alterations in interaction with their caregiver.

Sensitivity to sound, I mentioned earlier as well, is another thing that we would always ask about in terms of our behavioural history and think about that as a potential red flag for the involvement of pain. The other thing to think about is this concept of emotional arousal. So, the outward manifestation of a behavioural change is dependent on the valence.

So that's on whether the emotions are protective or engaging. And we've talked about the protective nature of pain as an emotional response. But it's also reliant on the salience of the stimulus.

So, how In how, significant that pain is to that individual. So, if it's a high salence, the perception of that pain is significant. And remember, that may be out of proportion to the lesion, and in chronic pain may be actually disassociated from the lesion altogether.

So, chronic pain can occur without the presence of a detectable lesion. It's also dependent on the emotional state of the individual at the point when it experiences that pain. So we have the valence, we have the salience of the stimulus, and then we have the emotional state of the individual.

Earlier on, I mentioned the sinNC model for understanding emotional health in, in our non-human companions. And according to that model, increased residue increases the risk of flooding. So this is, the diagram from the sink model.

And the risk of flooding, and flooding is where the animal can no longer cope with the emotional situation that it's in, is is related to High inflow. So, it's related to a large input of that protective emotion through pain. That's related to the salience of that chronic pain for the individual.

It's related to the size of the sink of the individual. So that will be related to their genetics and their early rearing, and their capacity for emotional arousal. It's also related to their drainage.

It's related to how well they Cover what their emotional resilience is. And that will be related to factors such as sleep. And we know that sleep deprivation is a massive problem in the canine pet population.

Dogs need to sleep between 16 and 18 out of 24 hours, and very few domestic dogs get enough sleep. So that could also be a factor in relating to the amount of emotion that these animals are holding onto in. In terms of what we term the residue, so that's how, how high the level is in this metaphorical sink.

And so, salience of the pain, the individual's genetic makeup and early experiences and overall emotional capacity, their drainage and their residue are all going to be important as to whether the chronic pain in this individual is significant in terms of affecting emotional health and giving behavioural consequences. And anything that increases the level of residue in the emotional sink makes it more likely that the animal will exceed its capacity when it's challenged with a particular stimulus. So, it makes sense that if you have a sink that is already full with residue that could come from another emotional health.

Health issue, or from the pain. So it could be an generalised anxiety disorder that exists in this individual, which is taking up some of that emotional capacity. And then, when the chronic pain happens on top of that, that that's the point when they're unable to cope.

Or it could be that the pain itself is the emotional issue. But it can also be the emotional consequences of that physical issue, and we're talking today about pain, but of course there are other physical health issues which also are important and lead to behavioural change because of this association. So when we look at chronic pain, it's really important to remember that this is a multidisciplinary problem.

So, dealing with pain is, of course, something we readily associate with our colleagues in anaesthesia and analgesia, who have a vital role to play in these cases. But also, we need to think. Our, our colleagues as well in surgery, our colleagues in neurology, behavioural medicine, and also in rehabilitation and sports medicine.

All of these individuals have a contribution to this, treatment of chronic pain, whether it's presented with behavioural presentation initially, or with physical presentation. And when there is behavioural consequence, behavioural modification from our suitably qualified non-veterinary behaviourists, so the Animal behaviour and Training Council is a place to look for suitably qualified people, but also the er Fellowship of Animal behaviour clinicians. There's also ASAB, the Association for Study of Animal behaviour, who have the qualification of certified clinical Animal behaviours.

So CCAB, very important letters to look for when you're looking for a non-veterinary colleague to refer to. And of course in some cases of chronic pain, a surgical approach may be indicated to resolve that underlying source if we do have an identifiable lesion. But in many of the situations, it's a medical approach that's also important.

And investigating, treating and managing any underlying medical condition is obviously crucial in order to tackle any behavioural expression that may have been presented by the caregiver. So giving effective and appropriate analgesia is crucial. And because in chronic pain, we have this potential for a lack of link with a .

With a, an actual lesion, we also need to remember that trialling with analgesia, doing analgesic trials, can be a really important part of the diagnostic process. So, this poor correlation between chronic pain and our imaging derived information means that these therapeutic trials can be very helpful. While we're doing those, it's also important to think about how we monitor that pain.

And there are many of these scoring systems that are available, which increase caregiver observation, help them to be more aware of what they're looking for, and also improves their reporting to us, which enables us to monitor the response to treatment. And there are, as I say, a number of scoring systems available. I've listed a few of them here.

The one that we use a lot is the canine brief pain inventory. We also sometimes use the Helsinki score. There's a very good review article here from today's veterinary practise, from NABC.com.

So there's a a link for you there, to gain access to that as an overview. And the other thing I would really strongly urge you to do is visit a website called Zero PainPhilosophy.com.

It's, organised by Doctor, Matt Gurney and his colleagues. It's an extremely useful, website, very vital tool for you in practise for understanding, chronic pain. Also acute pain, it's not just about, it's also about anaesthesia.

So, Matt and his colleagues are anaesthesia and analgesia specialists, so extremely useful resource. Also, we have a more challenging situation with monitoring chronic pain in our feline patients, but we do have scores. We have the North Carolina state score, particularly for musculoskeletal pain.

But, of course, in our feline patients, it's also can be beneficial to use clinical specific outcome measures, and that can be extremely useful tailored to the needs of that individual patient. So the emotional implications of the advice we give with our pain patients is also something to consider. Another overlap between behavioural medicine and other disciplines, particularly, we think of orthopaedic, but also remember that we may give advice about managing chronic pain from a visceral point of view.

But when we think about the sorts of things we might give as advice, let's take that, orthopaedic situation as an example. Quite often we say that we want to restrict exercise. Well, yes, that may be an important thing to do, but we need to think about the potential for there to be emotional implications of advice that we give.

So thinking about restriction of exercise, if we say on lead only, then that has the potential to lead to frustration. So, with individuals who are used to exploring their environment through Desire seeking or used to engaging in social play with other individuals or object play through desire seeking, motivation and chasing a ball, then being on lead only can lead to frustration. And it's important to give other advice about the sorts of places where you might exercise in this on lead format, making sure you don't go to venues where the expectation is too.

Be let off. Don't walk in the same locations where there's a learned association. This is where my ball is thrown, or this is where I meet my friends.

Don't walk with those dogs they have a high expectation to socially play with. People tend to think, I want to keep their life as normal as possible. I want them to still see their friends.

But if by seeing their friends, they have to be frustrated, that emotionally could be damaging. Thinking about creating another thing we quite commonly give as advice, can also lead to anxiety because of uncertainty, because of a novel experience. There's an extremely good book available called No Walks, No Worries written by Sean Ryan and Helen Zul.

Very good, document to advise clients to look at, particularly if you're doing elective surgery where you could actually do some preparation for having this alteration in exercise. We can do some crate training, for example, so they see the crate as a safe and secure location. Need to remember crates can also lead to frustration through association with desire seeking being unfulfilled, inability to spend time with their social companions.

So the positioning of the crate, which room it's in, those sorts of things are useful to consider. And we talked about a multi-disciplinary approach. So, in addition to any surgical or medical approaches, we may also be thinking about physio, thinking about physiotherapy in terms of things like hydrotherapy, but also in terms of physical therapies.

We actually have, our rehab trainer within our behavioural medicine refer. Practise is now in the 2nd year of her master's in physiotherapy, because we've recognised how important it is as a behavioural practise, to have a physiotherapist on our staff because of this interplay between our behavioural, presentations and pain. And acupuncture is also may play a role for these patients.

And then we also need to think about the implications of the advice that we give in terms of environmental modification. So, one of the things that we're often needing to do, as well as treating and any associated emotional disease, which we do have in some of these patients, treating their chronic pain, and also modifying the environment such that they can function better within that environment. Now, environmental advice can be divided into different types.

So it's important to differentiate between environmental optimisation, environmental modification, and environmental enrichment. So environmental optimisation is catering for the species-specific behavioural needs of the individual. And environmental optimisation is always necessary for every individual.

Environmental modification is what we're talking about in these chronic pain cases, and I'll show some examples in a second. Environmental enrichment is the addition of, things to the environment which increase emotional motivation, primarily, and the idea of environmental enrichment is to increase the positive or engaging emotional bias. But you need to remember that in some behavioural cases, enrichment is actually counterproductive because enrichment turns on emotional input.

Going back to that diagram I showed you, where we said that problems occurred if you had a high inflow related to a small sink and poor drainage, because it Results in more arousal, more residue. If you enrich an environment, particularly in chronic pain cases, actually enriching the environment can run the risk of increasing emotional inflow to the point where it contributes to emotional compromise. So, optimisation always necessary.

The modification important in these cases, but enrichment may actually be counterproductive. So excessive emotional stimulation leading to high levels of arousal can actually exacerbate the pain response. So very simple alterations to the environment in terms of modification can be hugely beneficial, make a massive difference to the impact of chronic pain.

Another website for you to think about. Is the, canine arthritis Management website, and Doctor Hanna Hannah Capan's website. They produce some very useful caregiver focussed material for the caregiver to access, and also information for us as veterinary professionals as well.

And, of course, although canine arthritis management is, is there, as a massive resource for our dog patients, we also need to remember that environmental modification may be also necessary for our feline patients. So, enabling them to access elevation, which is so important for them in control of their emotional health. So if they're unable to get up onto things because of their mobility issues and their chronic pain, issues, then providing steps or providing beds like this that just slightly elevated, that still give that sensation.

Improving access to litter trays by, providing trays with scooted fronts or these homemade storage box form of litter trays to make sure that these cats can access the tray readily. Because if they can't and they start house soiling, there are other emotional implications. So, once we've identified, that pain is part of a behavioural presentation, then we must also treat that, treat that as we've talked about in a very multimodal approach.

But then we also need to think about the potential for behavioural therapy to also be needed. So, treatment of the emotional component. And that may be through a combination of behavioural modification, potentially the use of medication as well in a psychoactive sense.

So, things like anxiolytics, for example. We also need to consider the potential for the development of anticipation of that pain, and think about how we may need to use learning theory approaches, counter-conditioning, and desensitising approaches to limit that. And also think about the potential for other learned associations with the pain, particularly contextual associations if the pain has been experienced within the veterinary practise, for example.

We also need to consider that you may get more obvious expression of other behavioural motivations once the pain is under control. So sometimes as you treat the pain, other behavioural expressions become problematic. So things like, desire seeking behaviours of counter surfing and stealing, they were unable to jump up at the surface before because of pain, now they can.

We also talked about the fact that anxiety related appeasement may become more obvious because the pain may have been leading to more inhibitory responses, but also we may find that the the treatment of the pain doesn't remove the appeasement behaviours, and actually there is some other underlying anxiety related condition that we need to identify and treat. So, other comorbid, non pain related emotional disorders such as anxiety or frustration may also be uncovered in the process of treating their pain and lead us to have to focus more on the behavioural medicine approach. So pain is complex.

Pain is not only a sensory and a motor response, it also has a cognitive and an emotional dimension. Consideration of pain is absolutely essential when dogs and cats present with behavioural change. The University of Lincoln, it has released quite a lot of data on this link.

They say that 68% of the 50 most recent cases have involved pain. And also, we need to remember that there's an absence of potential diagnosis in a more conventional state that may lead to us missing the potential significance of pain. So, I want to finish by leaving you with a reference that I would urge you all to read, which is this one from, Daniel Mills and his team.

Pain and behavioural Problems in Cats and Dogs, which was published in Animals in 2020. And I want to, with very kind permission of Hannah Kapan, just leave you with this video to watch. So this will just take, a couple of minutes.

So I'm gonna sit back and just allow you to watch and digest the content of this video, courtesy of Hannah Kapan. How can I be of help? Can you describe how you're feeling to me?

OK, can you show me? Can you point to where the problem is? I'm afraid I can't help you if you don't tell me.

Stop. You're in pain. So the message is pain is always what the patient expresses it is, and when in doubt, we should always treat.

Thank you.