The Pain Management Pyramid

September 25, 2018

 

 

 

A few weeks ago, we hosted a four-part webinar series by Dr Kenneth Joubert, sponsored by Elanco, focusing on pain and pain management. On a personal level, I found the series tremendously helpful and eye opening. Pain management has always been one of my greatest challenges and stumbling blocks as a therapist. We know the basics, and we have our little modalities – massage, mobilizations, laser, TENS, etc. – and they’re all great, but we can get to a point where they are not enough. (The 4-part webinar series is available to all Onlinepethealth Webinar Members. To investigate the membership click here.)

 

Sometimes the weekly or bi-weekly treatments just don’t seem to be keeping the pain under control. Your heart starts breaking because your patient – or your own dog – is suffering, and in my case, because I don’t understand pharmacology that well, I become hyper-aware of risks and side effects, and never go further. Your patient is in pain, and you feel there is nothing more you can do.

 

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. 

 

The Pain Management Process:

 

In this blog, I want to investigate and explore the pain management pyramid, as presented by Dr Kenneth Joubert. We know that this is just one aspect of pain management; Dr Kenneth gave us a comprehensive overview of pain, starting with understanding pain and what it means to an individual. He covered how pain works, how peripheral and central hypersensitization occur, how to assess and reassess pain levels in a continuous process of evaluation, the value of a correct diagnosis, and the need for a multi-disciplinary team working together. 

 

The pain management pyramid gives us a snapshot of the successive steps we can take to manage pain. 

 

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 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 pet’s 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 the 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 is often 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 reduced as the dog matures by changing 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, diarrhea or loss of appetite. They 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:

 

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 become 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 anesthesia is needed. They cause dissociative anesthesia, 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 metabolize 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:

 

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 hold the greatest advantage 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 program – 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 Webinar members on the members platform.  Please click here for more information.

 

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Dr Megan Kelly
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