Guiding Principles of Pain Assessment
In the following sections, we put forward a Pain Assessment Toolbox for use by the veterinary team. In designing the Pain Assessment Toolbox, the advisory panel determined the following guiding principles:
- First, the practice team must consciously create a shared approach to pain management and client communication—particularly for the assessment, interpretation, and explanation of acute and chronic pain.
- Second, the concept of the physical exam must extend beyond handling to include observation of posture, gait, and behavior.
- Third, an emphasis on behavioral observations, including those reported by the owner, will not increase the time needed for exams.
- Finally, across all principles, the assessment of pain is different between cats and dogs, requiring different tools, observations, and communication techniques.
These principles function with the knowledge that the presentation differs between acute and chronic pain, requiring a distinctly different approach for assessment and communication with pet owners. Compared with chronic pain, assessment of acute pain is typically more straightforward for both the veterinarian and the pet owner. In acute pain conditions, the response to palpation and generally recognizable signs are more easily observed. For pet owners, however, there is often a discrepancy between identification of acute and chronic pain. Owners often focus on watching for signs of acute pain rather than the gradual behavioral changes indicative of chronic pain. This discrepancy highlights the importance of the first pain assessment principle—a shared approach to pain management and client communication. Because owners may be unaware of or underestimate the presence of chronic pain, client education and engagement is critical to both the identification of and appreciation for the need for chronic pain treatment. The practical application of this principle differs for cats and dogs. For cats, many of the important behavioral signs of chronic pain are most detectable in the home, so detection is more effective with owner input. For dogs, a shift in client perception is needed to appreciate the potential for chronic pain to develop even in young dogs and the need for lifelong management.
The second and third pain assessment principles present a shifting mindset regarding the physical examination, extending it beyond the hands-on evaluation to include observations of the spontaneous behaviors of the patient. For the clinician, assessments of visually obvious problems and hands-on palpation remain critical to evaluation of the patient. Yet equally important are the more subtle aspects of patient behavior that may be evaluated as soon as the veterinarian or veterinary technician and animal enter the exam room. These behavioral signs can often be observed while conversing with the client, and with experience and practice, these observations need not add any time to the examination. Under the principle that any extra energy expended by an animal to alter a behavior is done to preserve comfort, changes in how a dog walks or sits or how a cat jumps down from an exam table can provide information that aids our diagnosis.
Our ability to point out these behavioral changes to owners can encourage them to watch for these pain-related behaviors at home. This is especially important for cats, in whom the most common cause of chronic pain—degenerative joint disease/OA—presents primarily as behavioral changes that owners are best positioned to detect.