A low-stress handling algorithm: Key to happier visits and healthier pets

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When someone says his or her dog is “fine” when visiting the veterinarian, groomer, day care or any other animal care facility, I cringe. It is hard to believe a patient that is fearful of people, noise or other animals is “fine” in any of these circumstances (see the sidebar “When is ‘fine' not fine?” ). We as veterinarians have taken an oath to above all do no harm. It seems reasonable to extend that oath to returning patients to their owners in a better state-both emotionally and physically-than when they were received.

When is "fine" not fine?

Fine should mean a patient is in a relaxed frame of mind, is a willing and voluntary participant in the procedure, and can take treats. In other words, the patient deliberately initiates voluntary interactive and novel encounters or freely interacts nicely and enthusiastically, or DIVINE FINE.

Unfortunately, the patient may be so stoic-in a tensed, immobile stance, similar to a sawhorse-that anyone can do anything. These patients are not “fine” but often frozen, avoiding, stoic and tolerant or freaking out, insane, neurotic and emotional or their feelings inside are not expressed. This could be thought of as FAST FINE. FAST from the patient's perspective-they want it over now. Their compliance is not an indication of obedience but rather of coping instead of escalating into an aggressive state.

Fortunately, there has been a wonderful move toward low-stress handling of our patients that has been facilitated by the late Dr. Sophia Yin and her low-stress handling book.1 The most difficult part of low-stress handling is assessing when to press a little further and when a patient has had too much. Next is realizing when the patient has had too much and knowing what should be done next. 

GUIDE TO THE LOW-STRESS HANDLING ALGORITHM

This algorithm that will guide you through the process of assessing your patients and how to proceed based on their body language.

Patient assessment and treats

Each light blue box represents a change in the environment for the patient. Any time there is change, there may be an element of fear or anxiety. Identifying early signs of fear or anxiety allows implementation of strategies to ameliorate the situation.2

Each white box in the center indicates an action that should be performed before, during and after each interaction. The “Assess body language” box is a reminder to assess the patient's body language during every change in room, every interaction (including people entering or exiting the room), and during different stages of a procedure.3 During a physical examination, every time a different organ system or body part is examined, assess the patient's body language. The person restraining or feeding treats should give feedback to co-workers as he or she notices any changes as well. 

Example: During a blood draw, patient reassessment should occur at every stage of the process, from wiping the coat with alcohol (any solution), applying the tourniquet, holding the leg, transitioning the patient from weight bearing to non-weight bearing, holding off the vein, inserting the needle, repeating attempts or searching for the vein, drawing the blood, removing the needle, removing the tourniquet, applying pressure to the venipuncture site and placing a bandage over the site. The venipuncturist's preference for blood drawing should always be the location that is the least stressful for the patient, and only close observation throughout the process allows the staff to recognize the level of the patient's comfort or discomfort. 

Subtle changes in the pet's behavior, such as an increase in muscle tension, leaning away and or taking treats in an increasingly rough manner, enables continual adjustment of the technique being used in addition to increases in the value of the treat being offered when necessary, all with the ultimate goal of helping the pet make a positive association with the veterinary visit.4

The next white box is labeled “Takes treats.” Feeding treats during each stage of the visit not only creates a positive association with the veterinary hospital and their team but also enables you to gauge the patient's stress level. Distressed patients are unlikely to eat. If a patient refuses food, consider that it is highly stressed or afraid or the food you are offering does not have a high enough value to that particular individual. The first step is to increase the value of the food being offered. Be sure that you are using very delectable, high-quality food items, depending on what is safest for the individual patient. This may include low-fat deli meats such as roasted chicken or turkey, cheese, peanut butter or tuna. 

Keep in mind that some dogs will eat while remaining somewhat anxious, so just because they are eating does not mean you can continue to do whatever you wish while ignoring their other visual cues. The pet still might eventually feel threatened enough to bite. You must remain acutely aware of the patient's body language. If the patient becomes increasingly anxious or stressed, it may begin to snatch or grab the food roughly or greedily as indicated by the orange box (caution). If you see this behavior, it is a sign that you should stop what you are doing and reassess the situation. This behavior can escalate to a bite.

Offering food in this manner should not be considered bribing, but instead classically conditioning the pet with the ultimate goal of helping the pet make a positive association with the veterinarian, the staff, the clinic and procedures such as examination, injections, venipuncture and nail trims. Use caution with the timing of the food offerings since many fearful pets will become nervous when food is offered. They may learn that food being offered in this context predicts that something scary is about to follow. Initially food can be offered to distract them from what is happening, but with time, the food should be offered immediately after the handling or procedure is initiated. The association of food with the procedure in this manner results in a classically conditioned association where the bad thing (e.g. touching, muzzle, a procedure) predicts a good thing (treats, toy) as shown in the dark blue box.5

Want vs. need

When a pet is displaying tense or stressed body language (orange box) and starts snatching or taking treats roughly (orange box) or doesn't take treats (red box), everything should come to a stop as indicated by the red hexagon. The situation should be carefully reassessed. The most critical question to ask at this juncture: Is this procedure or interaction a want or a need?

A want (red box) is something that is not urgent or necessary today. Nail trims are wants. Unless the animal is ill, temperature taking is a want. If each interaction with the patient is triaged, wants are on the bottom of the list. Wants can wait. Wants can be trained through desensitization and counterconditioning (dark blue box) so that they can be performed later without causing the patient fear or distress. The fearful patient will benefit from the type of training described here-learning that handling, touching and wearing an appropriate basket muzzle are all good things. Teaching the patient cooperative husbandry and medical procedure behaviors will facilitate long-term patient and owner compliance and welfare as well as make your “need” procedures easier to accomplish in the future.6

A need (yellow box) is something that absolutely must be done, such as placing intravenous catheters in critically ill patients, in addition to performing blood work and radiographic examinations on patients where sedation or general anesthesia may put the patients' lives in jeopardy. Some might argue that every aspect of the physical examination is a need. However, if one agrees that the patient's long-term mental health is equally as important as its physical health, and both are likely to be jeopardized if the patient cannot be examined or handled without it experiencing anxiety, fear or stress, then many aspects of a routine wellness examination such as a rectal temperature or an otoscopic examination are best considered a want and not a need. 

Insisting upon doing these procedures on a fearful animal will not only stress the animal at that time but will increase its fear of future veterinary visits and worsen its behavior on future visits.7 Procedures that are needed in the future will then be unnecessarily stressful for the patient. This produces the vicious cycle of worsening fear, the need for increasing levels of restraint, and worsening behavior that not only stresses our patients but our staff as well. This further convinces the animal that visiting veterinary clinics is indeed a terrifying experience to avoid at all costs. Some hypothesize that these repeated experiences may lead to other pathological fears in these animals as well.7 What is certain, however, is that these experiences are not likely to produce animals that our clients will feel comfortable bringing to the veterinary clinic, so they will not receive potentially life-saving routine preventive care. 

Pharmaceutical intervention

If after assessing the patient, it is determined that the procedure is a need then intervention with appropriate pharmaceutical agents (yellow box) is essential.3 Agents such as anxiolytics, sedatives or general anesthesia should all be considered, depending on the necessary procedure and the level of the patient's distress.8 Many tranquilizers, such as acepromazine, should not be given alone as they provide immobilization but not anxiolysis. Thus, the patient is aware of what is going on but is rendered immobile and unable to react.9,10 Practioners may argue they have had a great deal of success using acepromazine, but if the mental and physical well being of the patient is a priority, then its use without concurrent anxiolytics could be considered unkind at best and inhumane at worst. 

Using an anxiolytic will help the patient to make a more positive association with any events that it experiences. An anxiolytic (e.g. alprazolam or trazodone) with or without a sedative (e.g. dexmedetomidine) may be all that is needed to handle some patients, thus reducing the stress on both the veterinary team as well as the patient and owner. If the patient is alert after the procedure, it is beneficial to offer food treats to create a positive association before the patient leaves (light green box-completing procedure). If, however, the patient is so distressed that approaching it even to administer a sedative is difficult, it is best for the animal go home and return on a future date with anxiolytics already on board. The expectation for the next visit should be a patient that will be fully sedated or anesthetized before any procedure is performed. 

Forewarn clients that in some cases more than one visit may be required to determine which anxiolytic dose or combination of anxiolytics may be necessary to achieve the calm state necessary to safely treat the patient. For example, if on the first visit, the patient is still too distressed to be safely handled, then the client may need to return with the patient another day, after administering a different dose or combination of medications. Administration of amnestic drugs such as opioids and benzodiazepines have been shown to prevent post-traumatic stress in people and should be used prior to discharging the fearful patient from the office after procedures that are likely to have been very frightening or stressful for the patient.11,12

The role of pheromones

Pheromones are chemicals used for intraspecific communication. Synthetic pheromone analogues are available commercially and have been found useful in reducing anxiety in dogs and cats when used in the veterinary clinic setting.3,13,14 Pheromones are available for both dogs and cats (Adaptil, Feliway-Ceva), and since they are species-specific, diffusers for each can be placed in all areas of the hospital. 

Alternatively, some clinicians choose to limit one examination room for cat use only and keep a Feliway diffuser only in that room and use Adaptil diffusers in the remaining examination rooms. In addition, towels or nonslip mats for examination tables can be sprayed with the species-specific pheromone before the examination or restraint. Some clinicians even spray the pheromones on their lab coats before examining animals. If the veterinarian and staff will then make an effort to make the animals experience at the clinic a pleasant one, the “smell” of the pheromone can become a conditioned cue that signals to the animal that they have entered a place that is “safe.”

Depending on how stressed a dog is, the use of pheromones in combination with anxiolytics prior to the next routine examination, and possibly sedation for more thorough examinations, are better options than the “brute-athane” (the use of brute force to hold or restrain an animal) of a hopefully by-gone era. 

Low-stress restraint

The final light blue box at the top is labeled “restraint.” The patient is assessed when there is no procedure (perhaps they are just being held on the table while someone is still taking the history), reassessed during a noninvasive procedure such as a physical examination (sans looking in orifices), and assessed again during invasive procedures such as looking in orifices and collecting samples. While we might not consider looking in the eyes, ears and mouth invasive, many pets do find this type of intimate contact quite threatening.

Counterconditioning activities

Once the examination is completed (light green box), or in between major procedures, dilute potentially unpleasant experiences with some quick counterconditioning. For example, after giving an injection or drawing blood, tenting the skin in the general area the patient was poked by the needle followed by treats helps to end the procedure on a positive note from the patient's perspective. If the patient is no longer taking treats, it may indicate that while the procedure was successful from our perspective (the procedure was completed or the sample was obtained), the patient may have had a negative emotional response. If this occurs, stop the examination and note that the patient will require a more proactive approach prior to the next examination. 

Scheduling “happy visits,” in which no procedure is performed, as well as desensitization and counterconditioning sessions may be prudent. Asking the dog to perform simple tricks such as sit or give a high five while tossing treats is an easy way to end on a positive note, as well as reinforcing any desirable behavior with praise and treats. 

Keep in mind some patients may not be able to sit because they are too afraid. If they glance your way when you say their name, that might be all they are capable of doing, so reward them with a treat. It is important to prevent the owner from making the dog sit (especially if the owner is repeating commands in a demanding or harsh tone); the veterinary visit needs to remain a good experience where the pet can discover that it is free to make choices that earn rewards. Always reinforce any good behavior, even if it is just standing there looking at you. After all, the animal could be trying to bite you instead.

When bigger problems are spotted

If any patient is showing extreme fear, anxiety or avoidance behavior, especially young puppies or kittens, you should be concerned and share your concern with the pet owner. Research suggests that these animals do not get better on their own2 and that intervening while they are young is more likely to result in a patient that stays in the home as opposed to one that is relinquished to a shelter. A behavior consultation (purple box) with a board-certified veterinary behaviorist earlier in a pet's life can help these patients get back on the right track, as well as educate the owner on the prevention of future problems. Early intervention saves the client and the patient undue stress and prevents the continued progression of the behavior problem.2,15

Conclusion

This algorithm outlines assessing body language, initiating contact, reassessing body language, and readjusting based on the patient's response every time the environment changes and with each interaction with the veterinary team. Being cognizant of your patient's emotional state will help you build a better relationship with both your clients and patients, thus increasing patient well-being, client compliance and job satisfaction for the entire veterinary staff. 

With practice, the steps in this algorithm become second nature and take little time, yet yield long-term benefits. Practicing and training your patients when they are young (and, hopefully, healthy) allows you to implement life-saving techniques later in life.7 A dog that is fearful and biting the veterinary team is not likely to be hospitalized for pancreatitis or liver disease or to be treated for diabetes or cancer later in life. Likewise, when a client cannot medicate a pet (whether it is oral, otic or topical) because of the pet's aggressive or unruly behavior, the pet is unlikely to receive regular or long-term veterinary care. Taking the time now to educate the owner and train the pet will enable you to realize all of the benefits of improved patient care and client compliance throughout a pet's life.

References

1. Yin S. Low stress handling, restraint and behavior modification of dogs and cats: Techniques for developing patients who love their visits. Davis, California: Cattle Dog Publishing, 2009.

2. Godbout M, Palestrini C, Beauchamp G, et al. Puppy behavior at the veterinary clinic: a pilot study. J Vet Behav 2007;2(4):126-135. 

3. Moffat K. Addressing canine and feline aggression in the veterinary clinic. Vet Clin North Am Small Anim Pract 2008;38(5):983-1003. 

4. Vollmer PJ. How to handle puppies during inoculations. Vet Med/Small Anim Clin 1980;75(5):798-802.

5. Campos AC, Fogaca MV, Aguiar DC, et al. Animal models of anxiety disorders and stress. Rev Bras Psiquiatr 2013;35(suppl 2):S101-S111.

6. Mills D, Zulich H. Appreciating the role of fear and anxiety in aggressive behavior by dogs. Vet Focus 2010;20:44-49. 

7. Döring D, Roscher A, Scheipl F, et al. Fear-related behaviour of dogs in veterinary practice. Vet J 2009;182(1):38-43.

8. Hopfensperger MJ, Messenger KM, Papich MG, et al. The use of oral transmucosal detomidine hydrochloride gel to facilitate handling in dogs. J Vet Behav 2013;8(3):114-123.

9. Simpson BS, Papich MG. Pharmacologic management in veterinary behavioral medicine. Vet Clin North Am Small Anim Pract 2003;33(2):365-404.

10. Bergeron R, Scott SL, Émond JP, et al. Physiology and behavior of dogs during air transport. Can J Vet Res 2002;66(3):211-221.

11. Charney DS, Woods SW, Goodman WK, et al. Drug treatment of panic disorder: the comparative efficacy of imipramine, alprazolam, and trazodone. J Clin Psychiatry 1986;47(12):580-586.

12. Overall KL. Manual of clinical behavioral medicine for dogs and cats. St. Louis, Missouri: Elsevier, 2013;476-477.

13. Siracusa C, Manteca X, Cuenca R, et al. Effect of a synthetic appeasing pheromone on behavoural, neuroendocrine, immune, and acute-phase perioperative stress responses in dogs. J Am Vet Med Assoc 2010;237(6):673-681.

14. Mills DS, Ramos D, Gandia Estelles M, et al. A triple blind placebo-controlled investigation into the assessment of the effect of Dog Appeasing Pheromone (DAP) on anxiety related behaviour of problem dogs in the veterinary clinic. Appl Anim Behav Sci 2006;98(1),114-126. 

15. Roshier AL, McBride EA. Canine behaviour problems: discussions between veterinarians and dog owners during annual booster consultations. Vet Rec 2013;172(9):235. 

Colleen S. Koch, DVM

Lincoln Land Animal Clinic 

Jacksonville, Illinois