August 29, 2017

Tools for Pain Assessment in Companion Animals

Panelists B. Duncan X. Lascelles, BVSc, PhD, DACVS; Mark Epstein, DVM, DABVP, CVPP; Margaret Gruen, DVM, MVPH, PhD, DACVB; Sheilah Robertson, BVMS, PhD, DACVAA, DACAW; and Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR, share their views of practical assessment tools to determine pain level in companion animals, including the use of diary, video, and photo documentation to assess quality of life.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: We’re talking about early diagnosis, here, early intervention and what we can do to prevent disease progression. But let’s come down to some practical aspects. I think we started off earlier talking about assessment tools—ie, questionnaires. Mark, what do you use to help with that early diagnosis and, maybe, to help put a number on the degree of impairment?

Mark Epstein, DVM, DABVP, CVPP: It starts with our technicians in an exam room. We have a healthy pet checklist where the owners are supposed to select the things that they’re observing or not observing. It’s all kinds of behaviors. It might be PU/PD (polyuria/polydipsia) in another patient. There are a few that really point to diminished mobility or diminished activities of daily living. That prompts us to switch the conversation over.

And the clinical metrology instrument that we’ve used, for a number of years, has been a client-specific outcome measure (CSOM) called the Cincinnati Orthopedic Disability Index. It takes about 5 or 7 minutes to do. So, yes, it chews up some time, but it normalizes the mobility on a scale of 0 to 100—100 being normal and 0 being immobile. And that is because it’s the clients driving, “Here’s what I’m seeing at home.” And ‘here’ is whether it’s having no effect or a lot of effect and big changes where we can’t do it at all anymore.

Then it translates into a number that we can follow over time, particularly once we start intervening with therapy and/or if we haven’t changed therapy in a while, where maybe that number starts to go back down. But because it’s done by interview, it’s not something the client fills out. I think there are other CSOMs that clients would fill out. Cloud-based technology would make that very helpful, but we do it by interview. So, they’re starting off in the exam room and, often, either on a recheck or over the phone—that’s the one that we’ve used for a number of years. And there are a number of tools now that are coming out that are validated that use that kind of client-specific outcome measure.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: So, it sounds like you’re using a combination of checklist approaches?

Mark Epstein, DVM, DABVP, CVPP: To identify at-risk patients.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Right, and then an assessment tool?

Mark Epstein, DVM, DABVP, CVPP: Correct.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Margaret, when we talk about these assessment tools, we talk about—in terms of preferring to use validated tools—what validation is and why we should care about whether a tool, like a questionnaire, is valid or not, from the point of view of everyday clinical practice.

Margaret Gruen, DVM, MVPH, PhD, DACVB: Right. A validated tool allows everyone to be speaking the same language. I fill it out ‘here’ and Bryan fills it out ‘there,’ and we are able to, then, compare our responses. So, it allows for some comparability. The validation process looks at whether the tool is measuring what you think it’s measuring. Does it respond to either progression of disease or treatment? Do you see it change in the way that you believe that it should change? How well does it match up with our objective measures? Does it, and does it match up with them in a way that’s clinically important to the veterinarians and to the owners?

There are a number of validated tools out there and I think that it does help people watch over time and compare results. I think that the client-specific ones are great in many ways because those are the things that matter to the owners. I wondered about the use of video or intermittent activity monitoring, because now we have these wearables with the Cloud technology and everybody can have an accelerometer. You could do that once a year—take a video so that you really have a way to objectively look at it, because I think one of the big problems is those subtle changes over time become normal. That’s the new normal, so you forget what they looked like before.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: Yes. I work with more of a geriatric population now, but I think it’s really important—and we haven’t brought it up yet—that we recognize that the disease we’re talking about leads to euthanasia, in many cases, because we have done everything we can and the quality of life and the impact of the pain is not acceptable to anybody. We’d like to ask the dog what they would like, but I think it’s really important to have an assessment for that cat or for that dog. And I think it’s good for owners to keep a diary—a health, quality-of-life, and pain diary that they can track over time.

I think it’s also important to encourage them to take photographs. Or everybody has a Smartphone, so we can encourage them to take some videos because we are going to be getting into those difficult discussions of what our endpoint is. Sometimes they need that prompt—to go back and look at the video or the photograph, and the diary from a year ago, where the dog did lots of its favorite things and now, today, it spends very little of its time doing its favorite things. You can compare the photograph from a year ago and the photograph from today. The sarcopenia impacted it. It’s really struggling to get up. The subtle changes each day, like you said, become the new norm. So, I think there needs to be a bank of things that you can look back at to help with those decisions.

Mark Epstein, DVM, DABVP, CVPP: I’ll echo that, only to add an echo of what Margaret said, as well. We’re veterinarians. We want a number on a piece of paper, right? We want to have some kind of objective measurement, and I think the activity monitors show promise in that. We do have one that we’ve been using in practice. The challenge is, right now, that it’s only one of a few. If it’s an individual patient monitoring against itself—so, it’s its own control over a long period of time—and that thing is taking a data point every hour or 2 hours over years, that’s an enormous amount of data. We just don’t have the analytics yet to get that big data and put it into a number to have it interpretable and actionable—much less using it for response to therapy. I think a mid-ground would be to put it on for a week, once-a-year or once every 6 months. That’s another way to go about it—so, more manageable data. We haven’t done that yet, but I think there’s a lot of promise in that kind of tool.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Just expanding on that, how easy or difficult have you found it to be to integrate the proprietary software with the practice management software? Can you, at the moment?

Mark Epstein, DVM, DABVP, CVPP: I can only comment on my practice management software. I think that it doesn’t. We have to import whatever data we have or attach it to the file right now. I think that’s, again, where Cloud-based systems may be the secret sauce for that eventually. But then, you worry about the integrity of the software and the data in there, and the idea of somebody getting into it. I’m already scared of that.

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: If you look at anything that’s looking at gait, which is some of the stuff that I like to begin with, all of these can take time. And so, where the clinical use and clinical applicability can really build in the future is in making it so that it’s easy for us and our clients to use it and easy for us to get the information quickly and interpret it. That is a huge thing—the interaction between different software programs and getting the number that you need quickly and effectively. You’re reducing your manpower and the time that you have to spend to do it, but that can make big differences and can improve the way that we monitor these guys.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: I think it’s also important to get numbers. And maybe it’s not even numbers that don’t just say the dog or the cat is better or worse?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: Sure, absolutely.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: We need this whole spectrum—from the very good quality of life to the very bad quality of life. We need a continuous spectrum and not just, “they’re better,” or, “they’re worse.” We’re really looking at endpoints here that are humane endpoints. If we’re talking about a research animal, there will already be a humane endpoint set up for that study. But in clinical practice, we don’t really talk about those humane endpoints that we are going to reach one day when we’re talking to our clients. Maybe that’s because it’s a very difficult conversation to have? But in any research study, those clinical endpoints, or humane endpoints, are already in place before you start the study.

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: And that’s the challenging and fun part of practice—every patient is an individual. That’s going to be different for every patient, but you need something to go on. You need at least that number. If you are able to get it quickly, it can effectively and easily make a big difference in how we manage our patients.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: So, a health-related quality of life questionnaire would be really useful to have when figuring out what needs to be done?

Mark Epstein, DVM, DABVP, CVPP: There is one.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: There’s still more that needs to be done to bring that into the practice setting. And also, with activity monitoring, I think there’s no doubt that we’d all agree activity is intuitively connected to pain or comfort. But we’ve got to find a way to bring those data into the practice in a way that we can manage them and see them.

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