See the Full Issue
October 2023
Managing Pain in a Community Clinic
In this hypothetical case, our patient, Teddy, is at a free clinic where you are volunteering for the morning, and you will have to communicate all the options to the owner without making her feel like the best ones are financially out of reach.
A Hypothetical Case Study in Access to Care and Pain Management
The community room is bustling with pets, families, and students even though it’s not quite 9 a.m. on a Sunday. Ms. Brown and her 11-year-old son, Jared, have brought Teddy in for an exam, vaccinations, and parasite preventives. They explain that Teddy is happy-go-lucky with a great appetite, but he’s slow to go up the stairs and sometimes limps on his right hind leg when he gets up from a nap. Ms. Brown shares that she feels awful about not seeking care for Teddy earlier, but she had to leave her job during the COVID-19 pandemic to help Jared navigate his schoolwork, and she is struggling to find a new job.
Teddy is a 6-year-old terrier mix weighing in at about 75 pounds, and they love him like a member of the family. You notice that when he stands his weight is shifted to his front limbs, and he sits rolled onto his perineum with both stifles moderately extended. On exam, he seems systemically healthy, but you palpate stifle effusion, crepitus, and medial buttress bilaterally. You note mild to moderate tibial thrust on the right stifle and his left stifle palpates stable. No meniscal click is noted on palpation of either stifle joint. You suspect chronic bilateral cranial cruciate tears with his right more clinically affected than the left, and he has a Body Condition Score of 7/9. Now what?
Whether Teddy is a patient of a free One Health clinic or a private/corporate general practice, the time you took getting a good history and doing a detailed exam including gait observation will help narrow the differentials significantly.
Radiographic evaluation or other advanced imaging can provide additional details and confirm the definitive diagnosis, but pain management is indicated no matter what the differentials include. With imaging or without, there are still a wealth of treatment options for his pain.
In this case, our hypothetical patient Teddy is at a free clinic where you are volunteering for the morning, and you will have to communicate all the options to the owner without making her feel like the best ones are financially out of reach.
Access to Care and Pain Management
When I coach DVM/VMD students, I share a simple pattern to help them remember options for controlling chronic pain due to osteoarthritis (OA):
- Medications
- The Big Three
- Frosting on the cake
Medication
Number one for starting to reduce pain quickly is medications, with nonsteroidal anti-inflammatory drugs (NSAIDs) being the most effective for chronic OA pain. The comfort/mobility cycle is important for the control of chronic pain, and unless we begin to mitigate pain, we can’t achieve mobility. The great part is increased mobility also takes steps toward alleviating pain, and the cycle can continue.
We all proceed with caution when prescribing NSAIDs, which is wise, but with a few simple tests and good client communication, pain medications in this category do not necessarily need to be withheld if we cannot run a full complete blood count/chemisty panel/urinalysis. Complete lab work screening is best, but if a client is financially restricted or testing isn’t available, a urine specific gravity (USG) screening showing adequate concentration can frequently determine if an NSAID may be a safe choice.
We also have additional medications available to control pain for both dogs and cats, such as gabapentin, amantadine, transdermal buprenorphine, and monoclonal antibody injections. Finding the best match for each client–patient pair has never been easier.
The comfort/mobility cycle is important for the control of chronic pain and unless we begin to mitigate pain, we can’t achieve mobility.
The Big Three
After determining if pain medications are a reasonable option, next are the Big Three:
- Weight optimization
- Environmental modification
- Exercise modification
If an animal is overweight, the biggest long-term gain in their comfort can be made with weight loss alone. If you add in modification of their environment, such as stairs, ramps, or traction surfaces, this can be lifesaving. If an animal has severe OA of the elbows, simply raising their food bowl can make mealtime significantly more comfortable. For a dog with hip dysplasia, offering traction surfaces where they sleep and navigate to get outside can mean the difference of restarting the comfort/mobility cycle instead of the client electing euthanasia due to house soiling. Environmental modification also offers significantly improved quality of life for cats. Low-entry litter boxes and steps or ramps to get to their coveted vertical spaces both have a big impact. Also, low-level heated cat beds can make a senior kitty with generalized OA feel a bit more comfortable and may help keep them moving.
The category of exercise modification is perhaps the most fun to discuss with clients. While in the past we utilized the word “restriction” when working with animals experiencing chronic pain, I encourage you to exchange that word for “modification.” Playing catch instead of fetch can allow a dog with arthritic elbows to still enjoy play time with the family and stay active. Rolling a ball up a hill rather than sending it launching is also a great way to keep the senior dogs happy and work against the secondary muscle loss that occurs with inactivity. For kitties, encouraging play with laser pointers or treat dispensers are great options to keep them moving. If full rehabilitation is an option for your clients, that service offers the most global perspective for care in this category.
Frosting on the Cake
Last but not least is the frosting on the cake category. This includes supplements and interventions such as omega-3 fatty acids (FAs), polysulfated glycosaminoglycans, acupuncture, heat/cold therapy, transcutaneous electrical nerve stimulation machine, shockwave, and massage, among others. These are often best used as additional treatments rather than a sole agent. The best outcomes involve a multimodal approach, making sure to include the client in all the decisions. Frequent reassessment with adjustment of the plan is highly recommended.
Teddy’s Treatment
For Teddy, we ran a USG at the free One Health clinic and found it was 1.041, so we felt comfortable starting an NSAID and provided that at no cost. We advised the family to reduce Teddy’s caloric intake by 10% and start with short frequent walks. We recommended rolling a ball up a hill instead of wild crazy sprints and wipe-outs, and we discussed using a step stool to help him get into the car. We explained how to use a warm pack on Teddy’s stifles (always checking it on the back of your neck for a full 10 seconds to make sure it’s not too hot) before his walks, followed by an ice pack covered in a light towel. We also talked about potentially introducing omega-3 FA supplementation once Teddy hit his ideal weight.
ReferencesAnderson, KL, et al. “Risk Factors for Canine Osteoarthritis and Its Predisposing Arthropathies: A Systematic Review.” Frontiers in Veterinary Science vol. 7 (2020): 10.3389/fvets.2020.00220. Englar, R. “The Role of the Comprehensive Patient History in the Problem-Oriented Approach.” Common Clinical Presentation in Cats and Dogs (2019): 10.1002/9781119414612.ch2. Gruen, ME, et al. “2022 AAHA Pain Management Guidelines for Dogs and Cats.” Journal of the American Animal Hospital Association vol. 58, no. 2 (2022): 55–76. doi:10.5326/JAAHA-MS-7292 |
As we prepare to transition to our next patient at the One Health clinic, we should keep some important information in mind. While we could not roll back the clock for Teddy, we can work with other clients to discuss methods for preventing OA. Overweight dogs develop OA more quickly, so a simple plan to keep a pet an ideal weight with regular activity can have significant protective effects.
As we are finishing up going over Teddy’s discharge instructions, Ms. Brown told us that having pain management options for Teddy is giving her such relief during a difficult time in her life. She confided that with the COVID-19 stressors, she was left feeling hopeless when she saw Teddy in pain and Jared has been taking on some of the worry. During the clinic, she connected with the nurses on site to put her own healthcare back on the radar. The act of someone truly listening and providing compassionate options helped her to feel empowered to make choices for her family that provided comfort for all three of them.
As a volunteer, you realize that your mindset toward offering a spectrum of care treatments has made a huge difference to a family in need. Because of your careful evaluation and clear, compassionate communication, they successfully understood and decided on the spectrum of treatments available to them to help their beloved pet live longer and happier. Already, you decide, it’s been a good morning.
Kristin Jankowski, VMD, CCRP, is a health sciences assistant clinical professor of Small Animal Community Practice and the Access to Care service chief at UC Davis Veterinary Medical Teaching Hospital. She is also an affiliated faculty member of the UC Davis One Health Institute and the Faculty Director for the Knights Landing One Health Clinic (KLOHC). She is a 1994 graduate of the University of Pennsylvania School of Veterinary Medicine. She completed her certification in canine rehabilitation through the University of Tennessee in 2014 and also completed the Purdue University certificate program for Diversity and Inclusion in Veterinary Medicine in 2021. |
Photo credits: AzmanL/E+ via Getty Images, Liudmila Chernetska/iStock via Getty Images Plus,