Feline Pain: Can You Read the Signs?

Cats are truly the underdogs of veterinary medicine. They tend to be noncompliant patients, they are misunderstood, and often keep to themselves. Behavior issues are the feline way of wanting to tell us something. But do we listen?

GettyImages-1387683028.jpgThey Tell Us—We Just Don’t Always Listen

Cats are truly the underdogs of veterinary medicine. They tend to be noncompliant patients, they are misunderstood, and often keep to themselves. When it comes to their health, they seem to want to be ignored. Medications are largely not researched or approved for cats, and honestly, we often can’t reliably administer them anyway.

That being said, behavior issues are the feline way of wanting to tell us something. But do we listen?

These amazing creatures we live and work with are incredibly regimented and often sedentary, and although they are deeply bonded with us, we understand very little about them. This is particularly true when it comes to feline pain, which is frequently neglected until it affects behavior.

Barriers to Identifying Pain

liquid_meds.jpgThere are many reasons cat owners and professionals have trouble identifying pain. Cats hide their pain. This is related to their wild instincts and is yet another obstacle to recognition. Feline chronic pain is also often not visible, even less so than their canine cousins.

One example of this is lameness with osteoarthritis. Cats are unlikely to present or display overt lameness. Several studies have confirmed that a notably low ratio of cats diagnosed with osteoarthritis (via radiograph) had presented with lameness. In addition, radiographs may not be the gold standard for cats, who may show all signs of joint pain that are not radiographically evident. They commonly have bilateral disease, which changes their gait and mobility slowly over time rather than the lameness on one limb that is often seen in dogs.

Speaking of canines, the cues used to identify chronic pain for dogs often do not translate to cats. Lagging on walks, reluctance to jump in the car, and lameness in general and especially after long walks are just a few ways pain can be identified in dogs. Being primarily sedentary animals, cats provide us with a very small window to observe pain behaviors even when we’re looking for them.

On the veterinary side, their overall anxiety in the clinic also presents challenges for pain identification. On physical examination, cats often do not react to painful or nonpainful palpation, which further adds to the litany of difficulties in detection. This becomes increasingly detrimental when trying to diagnose osteoarthritis (OA). In the veterinary setting, cats are reluctant to show gait; they cannot be viewed walking a straight line or through an examination room on a lead. Instead, feline patients will likely be found looking to hide or escape.

Should pain be identified, treatment options present additional roadblocks. Pharmacologic treatments for chronic pain have been limited, in addition to the lack of research, by different forms of delivery, small doses, and irrational fears. Other modalities of treatment, like physical therapy, may not be suited to the personality of cats in general. This vicious cycle of treatment-reluctant cats and lack of feline knowledge leads to a lot of feline pain.

Behavior and Pain

Often, significant changes in the behavior of our cats force us to pay attention. When behavior that is disruptive to the household is noted, pain should always be at the top of our differential list. 

On physical examination, cats often do not react to painful or nonpainful palpation, which further adds to the litany of difficulties in detection

Grooming behavior can indicate pain, including decreased grooming (resulting in greasy, clumped, or matted hair) and also the inverse—obsessive grooming. Perhaps the overgrooming is not just anxiety, but instead a sign of pain. A reluctance to jump onto furniture and countertops or a hesitancy to go up steps could be signs of chronic pain. Unwillingness to eat dry food can be a sign of oral pain. Perhaps weight loss is due to feeding stations located on high counters that are difficult for arthritic cats to navigate. Less obvious signs of pain might include changes in sleep patterns, hiding, lethargy, an overall decrease in appetite, and an objection to being brushed or stroked.

Often, behavioral changes are related to elimination behaviors. Cats are generally regimented about the litter pan, and as cat owners, we appreciate that. Alterations in litter habits are significant indicators that something is wrong, and they are also incredibly difficult to ignore. They may be physical or emotional or both and can signal many things. Cats with osteoarthritis pain may have difficulty accessing the pan owing to limited mobility. If the only pan is in the basement, an arthritic cat may be too uncomfortable to maneuver up and down flights of stairs and so may stop using the pan. Occasionally, cats with mobility issues will have difficulty positioning themselves or stepping into pans with high entrances and may void next to the pan. Cats with pain-related urination (urethra or bladder) will associate that pain with the box and seek elsewhere to urinate. Painful feet from declawing can deter a cat from stepping into an uncomfortable substrate.

The signs cats may display when they are experiencing pain are widely varied and vague. And, even when present, they do not provide much information as to the source or cause of the pain. But these behaviors are a cat waving a white flag. Perhaps they are telling us they can no longer hide their pain, or they know their inappropriate behavior will get our attention. One thing can be agreed upon: cat owners need to pay attention.

Case Study: George and Waffles

Dw_and_g.jpgisruptive behavior includes social issues as well. For example, intercat aggression or aggression toward humans can occur in the face of pain. The author observed a profound response to chronic feline pain with two cats in her home. George was a four-year-old male, a neutered domestic shorthair. He shared the house with several other cats (including his littermate) and two pit bulls. He and his brother were bottle fed. He showed signs of urinary pain, frequent licking, inappropriate urination, and frequent trips to the pan. He was treated at home, but also had a full obstruction that required hospitalization.

Several months before his overt urinary signs, a male domestic shorthair of unknown age (estimated to be five years old) named Waffles joined the household. He was a stray who was neutered and vaccinated. George was incredibly aggressive with Waffles, despite other cats having come into the house with relatively easy integration. This was different and was ongoing despite time and behavioral and pharmacological interventions.

It was determined that George had a urinary obstruction and subsequently received periurethrostomy surgery. George returned home with sutures and inflammation and no aggression toward Waffles; in fact, they became incredibly bonded and were always together until the day George died. This was a clear lesson. George conveyed his pain with aggression, and once his pain was corrected, he was able to embrace Waffles and enjoy a relationship with him. No interventions were ever needed again.

Pain Awareness Education

Even though many behavior changes are related to pain or disease, these subtle differentiations are often just attributed to age or identified as something else by cat owners as well as veterinary professionals. Whenever behavior is involved, cat owners are the front line of defense. They know what is normal for their cat and can note changes in behavior. So, to make sure potential signs of pain aren’t disregarded, education is the priority for recognizing feline pain.

Education begins with making everyone aware of typical and atypical signs of feline pain, such as those previously mentioned. Having literature and reliable sources readily available is an easy and effective method to begin educating. The addition of using pain checklists at checkups can start the conversation and alert everyone to changes. The veterinary team should focus on personalized education for clients to lead them to think about pain-related behaviors in their cats.

Pain and Quality of Life

g_and_waffles.jpgSometimes, chronic pain does not become obvious until the cat has become so debilitated that no treatment can restore an acceptable quality of life. When that happens, it is necessary to discuss euthanasia for humane reasons.

If chronic pain interferes with quality of life, the team needs to advocate for the patient and bring up this difficult topic. The late Bernard Rollin, PhD, who was known as the Father of Veterinary Medicine Ethics and a staunch advocate for felines, said it best in Ethical Issues in Geriatric Feline Medicine: “We need to know more and teach more regarding signs of pain and distress, and their alleviation. The role of the contemporary veterinarian is ever-increasingly assuring a decent quality of life and the absence of suffering at the end of life. Insofar as it appears that an animal judges its life by its ‘nows,’ we must assure that the final series of ‘nows,’ are not filled with pain, distress, and suffering.”

A simple translation of this might read: sometimes we can’t fix them, but we should do as much as possible to make our cats feel better. 

Want to hear more from Alison? Check out Episode 1 of Central Line: The AAHA Podcast, where Alison, who was on the task force for the 2022 AAHA Pain Management Guidelines, discusses how a team approach to pain improves patient care and the veterinary team experience. Find full audio, video, and transcript links at aaha.org/podcast.

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Alison Gottlieb, CVT, VTS(ECC), graduated from Towson State University with a bachelor’s degree in animal behavior. She earned certification in emergency and critical care in 2000. Alison has served on the board of AVECCT as a member at large and on the application committee. Alison is the cofounder and owner of Four Paws Consulting LLC, an education-based veterinary consultant.

Photo credits: Photographer/collection via Getty Images; Photos courtesy of Alison Gottlieb

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