Recognizing pain in cats

Feline experts say that cats often hide pain as a survival response. In the wild, cats are “mid-level predators” who become prey if they show signs of injury or illness. So even though studies estimate that 60% of cats aged 6 years and older have degenerative joint disease, it’s not common for cats to limp or cry out. That self-protective behavior can prevent us from recognizing their discomfort and seeking veterinary care.

So how can you tell when your cat is hurting?

Pain changes your cat’s everyday behaviors, said Duncan Lascelles, BSc, BVSC, PhD, FRCVS, CertVA, DSAS(ST), Diplomate ECVS, Diplomate ACVS, professor of surgery and pain management at North Carolina State University. He helped create some easy-to-use tools that cat owners can implement to spot those revealing changes.

“We embrace owners as team members in trying to understand whether their cats are comfortable or uncomfortable,” said Lascelles. After all, owners won’t know their cats need veterinary care if they don’t see the signs of feline pain.

Connecting Behavior to Pain

It does not take much time to learn what to watch for with your cat. All you need is a brief “information prescription,” according to a study by psychologist Lori Kogan, PhD, who studies human-animal interactions at the College of Veterinary Medicine and Biomedical Sciences at Colorado State University (CSU). Her study showed that cat owners can quickly recognize cues for feline discomfort.

Kogan’s survey study gave cat-owning participants three different scenarios of cat behavior—a cat being “snappy,” a cat with a slightly flattened ear position, and a cat who changed the way they walked.

At first, many owners attributed these changes to the cat “just getting old” or being “grumpy.” But, after a brief “information prescription” that explained that each of these behaviors could be signs of pain in cats, cat owners took the survey again and their level of concern skyrocketed

The “prescription” Kogan introduced to the cat owners was a modified version of the Colorado State University Feline Acute Pain Scale. This tool combines images and descriptions of cat behaviors —such as cats with their ears flattened against their head or narrowed eyes— to help the owners identify pain and rate it on a scale of 0 (low) to 4 (high).

• 90% of owners found the information useful for identifying their cat’s pain level
• 86% said it helped them decide if they should call the vet
• 92% found it made it easier to describe the pain to their veterinary team

“The study showed that pet owners could quickly use that information to help them identify potential pain, and it helped them articulate that pain to their vet,” said Kogan.

A more commonly used tool for helping owners recognize acute feline pain is called the “feline grimace scale.” Similar to the CSU tool, this helps owners create a pain score but is based on changes in five features of their cat’s face. And, yes, there’s an app for that!

Kogan’s survey also found a strong correlation between how owners handle their own physical pain and how they handle their cat’s pain. The people who preferred to “tough it out” and skip the doctor when they were hurting were also statistically more likely to take the same approach with their cat.

“But when we tough out our own pain, we know what we can stand and what we can’t stand, and when it crosses that line,” said Kogan. “But we can’t ask our pets. We have no idea of their level of pain. And our pets cannot tell us, so we want to err on the side of caution for our pets.”

Chronic pain looks different

The slow but persistent progression of chronic pain, like osteoarthritis in cats, can be even harder to appreciate.

“I think that response of ‘he’s just getting old’ is embedded in our society,” noted Lascelles. To help identify those subtle changes, he recommends that owners use a musculoskeletal pain screening checklist that asks six basic questions about how the cat jumps, runs, and plays in its home environment. (For more insight into these six points, you might want to watch these short, animated videos.)

“The checklist is just the same as the ones that you and I complete when we go to the doctors,” said Lascelles. “You know those lists that ask things like: ‘Have you been breathless?’ If you check yes, well, then someone should talk to you about it.”

When owners work with their cat’s veterinary team, if osteoarthritis is diagnosed and treatment is started, then something called the feline musculoskeletal pain index helps owners track the impact (hopefully positive) of treatment. This 17-item questionnaire helps pet owners and veterinary teams track pain over time, which means you’re able track progress and make adjustments to medical plans.

Seeing and sharing

In addition to checklists and pain scores, Lascelles said one of the best things cat owners can do to improve the outcome of their veterinary visit is to bring short videos and/or pictures of what your cat is doing at home.

“The veterinarian really needs as much information about what’s going on as possible,” said Lascelles. “Most diseases manifest through behavior. I want to see these behavioral changes that owners see, because the veterinarian is not going to see any of that from the clinic. And as good as we all are at describing what we see, we are not as good as a video or still images, or a combination of the two.”

Hope and modern medicine

Pain management for cats has come a long way in the last two decades. Now there are cat-specific pain relievers and more long-acting or non-pill options.

For cats with osteoarthritis, veterinarians can create a multimodal pain management plan that might include:

1. oral/transdermal medications, long-acting injections, or even surgery
2. nutritional approaches such as weight management diets and omega-3 supplements
3. lifestyle/environmental modification such pet stairs, elevated food dishes, and low-sided litter boxes
4. physical therapy as well as acupuncture, laser therapy, or massage.

Even as new medications are developed for feline pain, there is one aspect of pain management in cats that Lascelles would like to improve. “I wish there was more conversation about the future as we start treatment,” he said. “I think all of us are a little bit stuck in this idea that we have a persistent pain state and we’re going to start treatment, and that’s it. That’s the status quo,” he said. “There is this sort of negative backdrop that this is it for the rest of the cat’s life. And that’s not true, because with persistent pain, things deteriorate. As you remove that persistent pain, things get better. There is a positive future.”

Always ask this question

Beyond acute pain or the long-term discomfort of osteoarthritis, behavior changes are often the only sign of many other illnesses in cats. For instance, cats with severe dental disease or gum inflammation often continue to eat despite oral pain. But they might start scooping food out of the dish before they eat. A cat with intestinal problems may not look like his stomach hurts, but instead might become irritable when being petted. And cats with urinary tract inflammation or kidney issues often start urinating outside the litterbox.

“If your cat is doing something weird or different,” Kogan said, “I would love to help owners understand that one of the first things they should be asking is: Could this be pain?” If the answer is even a “maybe,” then it’s time to reach for a pain scale, or your cell phone to record a video for your vet. “Don’t wait for a limp,” she said.

Resources for identifying and tracking your cat’s pain:

•  Colorado State University Feline Acute Pain Scale
• Feline grimace scale and app
• 6-point musculoskeletal pain screening checklist
• Quality of life checklist
• Montreal Instrument for Cat Arthritis Testing (MI-CAT[C])
• Videos showing 24 acute pain behaviors in cats