Pain management is something which should be at the forefront of patient care in our day-to-day working life, regardless of the condition. There are two types of pain:
- Neuropathic pain – this pain arises directly from a nerve or from an abnormality in central processing
- Nociceptive pain – this pain arises from an intense noxious stimulus
When we are thinking about chronic conditions associated with pain, such as osteoarthritis or long-term skeletal conditions, it is important to understand which of the two factors are involved, or whether both are involved.
If pain is left untreated or treated inappropriately it can lead to chronic pain syndrome, which is where the animal develops central sensitisation. If central sensitisation occurs, it causes a patient to exhibit extreme pain responses including:
- Hyperalgesia – an exaggerated response to a painful stimulus (eg excess vocalisation if a toe gets trodden on)
- Allodynia – a response of pain to a normally non-painful stimulus (eg stroking of your pet in certain areas)
If pain is left untreated or treated inappropriately it can lead to chronic pain syndrome, which is where the animal develops central sensitisation
Monitoring pain response and progression, either positively or negatively, is important and can be done in practice with physical examination, but also by using pain scoring charts and lifestyle charts with owners to monitor responses in the home environment. By gathering information, you can then start to form a complete pain management plan.
It is important to have a whole-system approach, and not just to rely on medications to relieve pain. There are many modifications around the home and in day-to-day life which can help, but the use of complementary therapies can also be of use.
Alternative therapies easily available in practice or at home
Cryotherapy
Cold should be used in the acute stages of inflammation, so this is normally within the first two to four days. The use of cryotherapy helps to reduce pain by reducing inflammation and oedema formation, as well as reducing blood flow and haemorrhage. Cryotherapy has effects between 1 and 4cm of depth, depending on the adipose tissue in the region being iced. You can use commercial gel ice packs, or home-made crushed ice in a sandwich bag. Either way it is important to remember to protect the skin of the animal, so cover the icing implement with a tea towel, for example; I often recommend placing the ice pack inside a pillow case. Some sources will recommend wetting the fabric protection cover first, which will serve to chill the area quicker so you will not need to leave the object in place so long.
The use of cryotherapy helps to reduce pain by reducing inflammation and oedema formation, as well as reducing blood flow and haemorrhage
As a general rule, cryotherapy in the form of ice packing should be done three to four times per day, for no longer than 10 minutes per session. Cryotherapy ice packs can be used on recovery from a surgical procedure, as they only cool one small part of the patient so should not result in hypothermic effects; however, I would recommend temperature monitoring. It is often the case that cryotherapy is used following orthopaedic procedures, but care should be taken when using ice packs over an area in which an implant is in place superficial to the skin or in a patient with little subcutaneous tissue, as chilling of an implant will conduct the cold inwards.
Heat therapy
Heat therapy helps to reduce pain by relaxing secondary muscle spasms and increasing blood flow to the area, which subsequently improves muscle perfusion and the removal of pain-inducing metabolites and inflammatory by-products. There are some important considerations when using heat therapy regarding safety: it should not be used over devitalised tissue, over areas of malignancy or on an open wound.
Heat is used once the acute inflammatory phase is over, so generally from days four to five onwards. Heat therapy has been used for centuries to help both acute and chronic conditions. Superficial heating is most commonly used and can also be extended to use at home, with heat penetration reaching a depth of 1 to 2cm.
There are some important considerations when using heat therapy regarding safety: it should not be used over devitalised tissue, over areas of malignancy or on an open wound
The heat source, be it a heated gel pack, hot water bottle or heat pad, should be covered with a towel prior to the application to protect the skin. Heat therapy should be performed for 15 to 30 minutes, ideally two to three times per day, normally before exercise or physical therapies in animals with chronic conditions.
Passive range of motion
Passive range of motion (PROM) is moving a joint or muscle through its full range of motion. Often in cases of chronic and even acute pain, the patient will alter the movement of not only the area with the issue, but subsequently other body regions as well, due to compensatory movement. This can result in tightening of muscles, ligaments and tendons as well as the formation of adhesions within articular capsules and joints. All of these things can cause pain and discomfort in their own right. This is something which is often overlooked in patients who are recumbent or who have severe mobility issues, and it is something which we as veterinary professionals can easily perform on our patients and even teach owners to do at home. Sometimes the patient is too painful to want to move through the range of motion voluntarily or sometimes they are not physically capable, such as in cases of paresis. In these patients it should be part of our daily care routine to move affected joints gently and carefully through a normal range of motion.
Massage
Physiotherapy originates from early massage, and some massage techniques can be useful in rehabilitation and pain relief by increasing circulation to the area, aiding in the removal of noxious chemicals, mobilising adhesions and releasing endorphins.
The most commonly and easily used form of massage is stroking and effleurage […] not only for the pain-relieving properties, but also because it is very soothing and calming
The most commonly and easily used form of massage is stroking and effleurage (gentle pressure stroking), not only for the pain-relieving properties, but also because it is very soothing and calming which can be beneficial if the patient is sensitive to touch and has altered pain responses. The pressure applied during stroking should be even and in the direction of the nearest set of superficial lymph nodes.
Massage should not be used on regions with acute inflammation, neoplasia, open wounds or unstable fractures.
Magnetic
Clients often ask about the use of magnets in the management of pain, as they have been used in human pain management for decades, and there are companies who make pet-specific magnetic dog beds, dog coats and pet beds. The truth is there is little if any scientific proof for the use of magnetics, neither is there any explanation of how their properties may help alleviate pain, although it is thought by many to do with increased blood flow. For this reason, it has to be something which is not a recommended adjunct, but will do no harm if trialled alongside other modalities.
Pain management in the veterinary practice
There are some more specialised modalities which can greatly help in pain management; however, their use must be by trained professionals only and include:
Laser
Therapeutic lasers are class 3A or 3B lasers. There is much supportive evidence for the use of lasers in people for pain relief, but the evidence in animals is still limited. It is believed that the cell membrane is the primary absorber of the energy from the laser, which then generates increased cellular effects and alterations of cellular metabolic processes.
Ultrasound
For ultrasound therapy, the fur must be clipped away from the area of focus and a coupling agent must be used between the transducer and the patient’s skin. Ultrasound has been recommended during all phases of healing because it enhances or stimulates the body’s normal sequence of events, which subsequently improves the efficiency of the repair process.
Ultrasound has been recommended during all phases of healing because it enhances or stimulates the body’s normal sequence of events
Electrical nerve stimulation
Most people will recognise this modality from the commonly used human application, a TENS machine. TENS stands for transcutaneous electrical nerve stimulation, and it works by triggering or exciting the sensory nerves, which in turn stimulate the endogenous opioid system or the pain pathway mechanism.
Therapeutic exercises
Therapeutic exercise programmes can also be implemented and it could be argued that these therapeutic exercises will also perform a part in the management of pain by increasing joint movements, blood flow and proprioception.
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