The most effective approach we can take to managing pain is a systematic, multi-modal approach. Understanding the pain management pyramid, and having it readily available in our practices to share with owners, can help us more effectively and systematically treat debilitating pain in our patients.
The first tier of pain management focuses on education, physiotherapy and weight management. The next tier includes natural treatments and supplementation; it progresses to the use of NSAIDs, followed by a variety of pain medications. Additional pain management can be achieved by intra-articular therapy and, finally, by salvage surgical procedures.
Let’s discuss the different tiers of pain management – where to start and how to progress with an individual patient.
The Pain Management Pyramid
Education, Physiotherapy, Weight Management and Surgery:
Once we have identified a patient in pain and diagnosed the source of the pain, we can start to develop a pain management process or treatment protocol.
The first level of pain management is education of the owner, physiotherapy, weight management and, in some cases, surgery.
Education is all about the owner. If an owner has no knowledge or understanding of their pet’s condition, they cannot make informed decisions that will help their pet. They’re also less likely to be compliant with treatments and will fail to notice the little changes and improvements that show a therapy is working.
We need to make sure that our pet owners understand their pets’ conditions, how the disease normally progresses and how to evaluate their pets’ levels of pain. You want to make sure that your owner is aware of all available treatments and the side effects and risks associated with each. This will allow you to manage owner expectations, an important consideration when dealing with matters as emotive as pain and suffering. It will also empower owners to take an active role in helping their pet and to make sound, informed decisions.
Physiotherapy, we know, is crucial. As animal rehabilitation therapists, we already know the value of our treatments when it comes to pain management and healing. We understand the importance of maintaining mobility and function through appropriate exercises, and the need to prevent secondary, compensatory pain patterns and pathologies from developing. Acupuncture, together with various manual and electrotherapy modalities, fall into this level of pain management.
Weight management is always key. Maintaining a healthy weight is essential for joint health, as obesity dramatically increases the load on joints. A healthy diet can significantly impact the body’s natural responses, reducing inflammation, so that the experience of pain and the progression of degenerative conditions is often significantly slowed. Owners may need reminding of these basics, and their role in keeping their pet healthy.
Surgery may be the first line of defense against pain and in the treatment of certain conditions – certainly for fractures, intervertebral disk disease, cranial cruciate ligament ruptures, and some other conditions. Surgery may well be an option in young dogs with hip dysplasia, where the coverage of the hip is improved and the severity of the condition is reduced as the dog matures, through changes made to the angulation of the pelvis. These are but a few conditions where surgery can be the first ‘go-to’.
Natural Treatments and Supplements
These are generally slow acting and accumulative, with improvements in pain occurring only after a few weeks of daily treatments. However, their beneficial effects will continue, and continue to improve, over a period of years. Natural treatments include dietary supplements and nutraceuticals such as glucosamine, chondroitin sulphate, green-lipped mussel extract, hyaluronic acid, omega 3 EFA/DHA, etc.
Research has absolutely shown that joint health is affected and improved by the use of nutraceuticals. However, much is still unknown and a great deal of research is needed in this area. Quality and intensity varies widely across products. The source of the ingredients and the size of molecules can affect absorption, as can the concentration of active ingredients; the actual quantity may differ from that claimed by manufacturers, and needs to fall within the therapeutic range to be effective.
Non-steroidal Anti-inflammatory Drugs
Most NSAIDs work on the cyclooxygenase enzymes COX-1 and COX-2, blocking these enzymes and reducing the severity of an inflammatory response when injury occurs. There are, however multiple pathways that can be blocked in the inflammatory process, resulting in a reduction of the pain experience.
As different NSAIDs all work slightly differently on a pharmacological level, it is common for these drugs to affect individuals uniquely; one patient may respond very well to a drug, while another may not respond at all. For this reason, it is important to assess the response of an individual patient to any given drug. If they are not responding, be prepared to try something else.
The most common risk or side effect of NSAIDs is ulceration or irritation in the gastric system. This can lead to vomiting, diarrhoea or loss of appetite. NSAIDS can also negatively affect the kidneys and liver, increasing the risk of kidney or liver failure.
The most common NSAIDs for dogs are carprofen, meloxicam, firocoxib and robenacoxib.
Opioids block the pain signal being transmitted to the brain by binding to the opioid receptors in the brain, spinal cord or other areas of the body, effectively preventing the transmission of the pain signal.
Opioids are used in cases with moderate to severe pain, and often in the management of chronic pain.
They do have side effects; these include drowsiness and lethargy, and occasionally ‘dysphoria’ – where a dog becomes restless, and tends to pace and pant. Nausea and constipation can also occur.
Common opioids include morphine, codeine, fentanyl and buprenorphine.
Opioids and NSAIDs have a very good synergistic effect, and can be used together to treat more severe pain, while lowering the effective dosage of both and thus reducing the risk of side effects.
Gabapentin, NMDA Antagonists and Tricyclic Antidepressants
Gabapentin is used as a mild sedative, as a seizure treatment and as part of multimodal pain treatment. It can have a synergistic effect when used in conjunction with an NSAID or opioid, and has been used effectively for chronic pain management.
NMDA antagonists inhibit the N-methyl d-aspartate receptors, and are often used when anaesthesia is needed. They cause dissociative anaesthesia, which can eliminate pain. The most commonly used is ketamine.
There is a risk of NMDA antagonists causing toxicity in dogs when used over a long period, as the liver may fail to metabolise the drugs. They also carry potential temperament-altering side effects.
Tricyclic antidepressants are primarily used in the treatment of anxiety and stress in dogs. These drugs relax the central nervous system, and in so doing can help to calm the transmission of pain signals. These drugs should not be used in dogs with liver or heart disease.
Intra-articular (IA) Therapy
IA therapy is commonly used in the equine industry, and much less commonly among canines. IA treatment for osteoarthritis, administered in the joint itself, has provided long-term benefits for patients, reducing pain and potentially improving the health of the joint, or slowing its degeneration. Common intra-articular treatments are corticosteroids, glucosamine/chondroitin/hyaluronic acid, interleukin-1 receptor antagonist protein (IRAP), autologous conditioned plasma (ACP) and stem cells.
End-stage surgery may include arthroscopy, joint replacements and joint fusions in the case of arthritis. The surgery chosen will depend on the cause of the pain and the severity of the pathology causing it. End-stage surgery is usually a last resort if the pain can no longer be managed in other ways.
We clearly have a variety of options, and need to become acquainted with the existence, if not the detailed mechanics, of each one so that we can offer our patients options where a single approach does not work.
When it comes to pain management, we reap the greatest benefits when we approach the challenge as a multidisciplinary team, each member working according to their strengths. We’ll need to identify the areas where pain management can be improved, continually assess the condition of the patient, and adjust the treatment programme – including dosages of medication – until a point is reached were pain management is sustained. This should involve the lowest possible dosage of medications and interventions, and the least chance of side effects.
We also need an awareness of the warning signs of complications and side effects, and to educate our pet owners and every other member of the team, so that complications are caught and dealt with swiftly.
To gain a greater knowledge and a deeper understanding of pain and its management, feel free to watch the webinars by Dr Kenneth Joubert where this topic is discussed in depth.
Webinars are available to all Onlinepethealth Small Animal members on the members platform. Please click here for more information.
Understanding pain, physiology and more.
One of the most valuable webinar series in the Onlinepethealth Small Animal members portal is a pain management series by Dr Kenneth Joubert, sponsored by Elanco.
On a personal level, the pharmacological side of pain management has always been a challenge and stumbling block for me as a therapist. Of course, I do not have to prescribe or even recommend specific medications, but having an understanding of their actions can help us to complement medication with appropriate rehabilitation.
That is where Dr Kenneth keeps on opening my eyes. Not only does he break pain physiology open in a way that is simple and completely understandable, he highlights the many options made possible when we take not only a multimodal approach, but a multi-disciplinary, team approach to pain management.
To dive into this topic in more depth, watch the following webinars in the Small Animal members portal:
Download the PDF poster of the pain management pyramid to share with your clients, as you educate them and support them on their journey.
You will also find the following topics in the Onlinepethealth Small Animal members portal, to expand your pain management knowledge and practice:
- Conservative management of chronic back pain, with Lisa Mason
- Myofascial trigger points, with Michele Broadhurst
- Pain and movement, with Lowri Davies
- The pitfalls of veterinary rehabilitation, with Lowri Davies
- Non-weightbearing to sound, with Leilani Alvarez
- A deeper look at NSAIDs, with Kenneth Joubert
- The long-term use of opioids and the alternatives, with Kenneth Joubert