A tech's guide to feline pain: recognition and management

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Recognizing and treating feline pain was the focus of a presentation by Tasha McNerney, BS, CVT, CVPP, VTS (Anesthesia) during the 2024 Fetch dvm360 Conference in Kansas City, Missouri. The primary objective of her session was to ensure all veterinary staff were capable of consistently recognizing feline pain. She covered identifiable differences in acute and chronic pain, physical and behavioral indicators, and how to help a patient that is in pain.¹

McNerney began her presentation by addressing the veterinary technicians in the audience, explaining the crucial role that they play in pain recognition. Technicians should monitor patients for any overt signs of pain, while also paying attention to the owner’s account of their day-to-day activity for any hints of possible pain. She advised that practices assign 1 technician as their dedicated pain advocate, responsible for communicating with both clients and clinicians. They should also follow up with clients following visits, adjusting treatment as necessary.¹

Acute and chronic pain

There are several external signs to note when a patient is experiencing acute pain, including growling, vocalizations, reduced activity, hiding, decreased grooming, decreased appetite, and self-inflicted wounds. Chronic pain, on the other hand, can be harder to recognize as the pain scales are not the same. McNerney attributed this to animals adapting to chronic pain, displaying fewer external signs over time. She also noted that, in the same way it impacts the lives of humans, living with chronic pain can affect animal’s personality, behavior, emotions, stress levels, and more. She encouraged the use of the feline musculoskeletal pain index (FMPI) as a pain-scoring tool for cats with chronic pain.¹

She discussed osteoarthritis (OA) more in-depth, as a common catalyst for feline chronic pain. Some signs of pain in patients with OA might include joint effusion, swelling, and muscle atrophy.¹ “This is not usually where I go to touch the cat and then they hiss at me, right?” McNerney explained. “That’s usually more [of] an acute pain, or where a chronic neuropathic pain has now changed their behavior.”

Cats with untreated chronic pain can become increasingly territorial, they might feel more threatened, and they might display marking behavior. It’s also likely that they show less interest in hunting and playing, and become less active around their normal play times, because it’s difficult for them to move around. McNerney pointed out that most pet owners falsely attribute signs of stiffness and slowing down to natural aging, when they’re in fact signs of chronic pain.¹

She explained that any noted changes in a cat’s behavior should set off a red flag for technicians. If a pet owner mentions their cat’s sudden bad behavior, including urinary or fecal "accidents,” increased aggression, or sudden refusal to follow commands, technicians should begin inquiring further. The following are some key questions that should be asked¹:

• Is your pet eating normally?
• Is your pet hiding more often?
• Is your pet taking regular walks?
• Are they able to go up/down stairs?
• Is your pet using the litterbox normally?

If short on time, she encouraged asking owners to fill out the Zoetis' OA Checklist for assessing pain in cats. Answers could indicate that further investigation is required to determine whether their pet is experiencing pain.² Pet owners should also be provided with resources so they can access additional information if needed.

“So, ‘she’s cranky because she’s old,’” McNerney said. “No, most of the time, they’re not ‘cranky because they’re old,’ they’re cranky because they have some underlying, painful condition that we are not appropriately managing.”

A multimodal approach

McNerney encouraged a multimodal approach to pain management regardless of whether it’s acute or chronic pain. She explained the importance of providing analgesics and stresses the importance of using multiple types of drugs that target different mechanisms of pain. Different medications used to treat pain act on different parts of the pain pathway, with several drug classes acting on multiple parts of the pathway, which illustrates the importance of using multimodal analgesia.¹

By combining analgesic drugs from different classes and employing analgesic techniques that target different mechanisms of pain, relief can be maximized at lower analgesic doses, which also reduces the risk of adverse effects. Additionally, she recommends the use of local blocks, as they are effective at the source of the nerve signal in transduction.

“Now, if we give drugs like buprenorphine or some opioids, that’s going to change our perception and modulation of those pain signals, but nothing is really going to cut that transmission of those pain signals like a local anesthetic,” McNerney said. “So, that’s why I challenge all of you guys, any surgery, any dentistry, anything that is going to be painful, I want you to provide a local block to those patients… and that’s going to make a huge difference.”

For chronic pain specifically, pain management should be the priority, to reduce discomfort and improve quality of life. Although non-steroidal anti-inflammatory drugs can be used, she advised cautions regarding long-term adverse effects in cats. Alternatively, she recommended anti nerve growth factor (NGF), which has been proven effective for treating OA. Frunevetmab injection (Solensia; Zoetis) is also endorsed, though she acknowledged not all pet owners can bring their cats in for injections. Amantadine works as an NMDA receptor antagonist and can be used to break up breakthrough pain.

Low stress veterinary visits

McNerney explained the importance of regulating a feline patient’s stress levels during visits. When a cat is stressed, their stress catecholamines surge and occupy the same receptors that are targeted by the drugs. To counter this, more drugs are administered, which results in more adverse effects. For that reason, it’s important to keep stress levels low throughout veterinary visits.¹

She recommended quiet rooms and ensuring separation of cats and dogs in waiting areas. Cat should be placed directly on the counter, or another elevated surface, never on the floor, and towels sprayed with pheromone spray can be placed over carriers. To ensure comfort, patients should be provided comfortable beds, recovery rooms should be kept generally warmer, and she recommended hanging on to old cardboard boxes for use as hiding spaces. Gabapentin can be used as a sedation option, either during a visit, or sent home with pet owners to be administered prior to visits. Gabapentin can be used in combination with trazadone, and occasionally clonidine, for pets with severe behavioral challenges.¹

Scoring a patient’s pain

McNerney recommended the University of Colorado Pain Scoring System, which is commonly used despite not being validated, for analysis of acute pain during the post operative period. The system uses a numerical rating to assess pain. She also endorsed the Glasgow Feline Composite Measure Pain Scale (CMPS-Feline), which has been validated with multiple studies. This scale comes in the form of a questionnaire, assessing the patient’s behaviors with a numerical value, with results above a predetermined threshold indicating that the patient is technically painful.¹

Her favorite recommendation, however, is the Feline Grimace Scale (FGS), which is also validated, and available in the form of a smartphone app. The scale evaluates feline facial characteristics—ear position, orbital tightening, muzzle tension, whisker positioning, and head positioning—and should be used to assess acute pain. Similar to the CMPS-Feline, any score above a threshold (4/10, in this case) advises intervention with analgesia.

Conclusion

McNerney reiterated that technicians are key to successful recognition and treatment of feline pain. It’s crucial to be able to recognize the presence of either acute and chronic pain in a patient, and the difference between the two, before establishing a multimodal treatment method for the patient’s comfort. Following visits, it’s important to communicate with clients to create comprehensive plans to manage the animal’s pain and maintain a good quality of life.

She advocated for the International Veterinary Academy of Pain Management (IVAPM) for those interested in learning more about pain management. McNerney also recommends IVAPM’s program to become a Certified Veterinary Pain Practitioner (CVPP), which can be completed in 2 to 3 years.

Reference

1. McNerney T. Recognizing and treating feline pain. Presented at: Fetch dvm360 Conference; August 23-25, 2024; Kansas City, MO.
2. OA Checklist. Is your cat showing signs of AO-related pain? Zoetis. Accessed September 6, 2024. https://www.zoetispetcare.com/checklist/osteoarthritis-checklist-cat?utm_source=google&utm_medium=paid_search&utm_campaign=pos_00038_006118&utm_content=oa_checklist&gad_source=1&gclid=Cj0KCQjw0Oq2BhCCARIsAA5hubXcG_wC_He9kMX7kxjp47YdFr7arlLrQh95JT97FAtNOEMpwhKGFsAaAmDfEALw_wcB