understanding pain in context of health triad

why is behavioural medicine relevant to pain cases

Pain is perceived in the brain

• Limbic system involvement in the physiology of pain

Emotional disturbance influences perception of pain

Presence of pain alters expression of emotional responses to a range of stimuli

Emotional disorders (which includes disorders of the pain emotional system) reduce available emotional capacity

Cases involving pain benefit from a comprehensive veterinary healthcare approach considering all aspects of the health triad

physcial health aspects of acute pain

accidental

surgical

physical health aspects of chronic pain

orthopaedic pain

ear pain

oral pain

visceral pain

skin related pain

neuropathic pain

Consideration of soft tissue related chronic pain is not limited to injuries associated with sport or to dogs

Surgical and trauma patients and those individuals with compromised gait, sometimes associated with morphological abnormalities, can also develop soft tissue discomfort

cognitive health aspects of pain

Pain can have cognitive impact through the process of learning

Pain is an emotion and can become associated with other stimuli through classical conditioning

pain can also be involved in operant conditioning leading to increased or decreased probability of behaviours occuring again

emotional health aspects of pain

The Heath Model of Emotional Health considers the importance of two aspects of emotional health

• Emotional valence

• Emotional arousal

what is the significance of the valence of emotional pain

behavioural change can be the result of emotional effects of pain

pain is protective emotion related to fear-anxiety system

In the context of chronic pain the emotions of fear- anxiety and frustration can also be relevant further increasing protective emotional input

Related to the other aspects of the emotional health of each individual:

1. emotional capacity (size of sink)

2. other emotional input (flow from either the cold or the hot tap associated with triggers not associated with their pain condition)

3. emotional drainage (functioning of the outlet pipe from the sink)

need for emotional management

High emotional input will increase the potential for the protective emotional impact of the pain to have noticeable effects

• presence of an emotional disorder

• presence of other physical illness

• stimulating interactions

=protective, such as being exposed to fear inducing situation

= engaging, such as play or social interaction

This can lead to variation in the reported pain at times when emotional input from other sources is increased

Emotional management should therefore be considered as part of the therapeutic approach to chronic pain cases

Any restriction on emotional drainage can also increase the impact of increased protective emotional input

Restriction of species specific drainage behaviours

Sleep disturbance – seen in association with chronic pain

emotional disease and sleep disturbance

Emotional illness is associated with sleep disturbance in human patients

Individuals who get less than 5 hours of sleep a night, on average, have a 2- to 3-fold greater risk of anxiety or depression compared to those who get 7 hours of sleep a night

Research in the veterinary field into the relationship between sleep and emotional disturbance is limited

emotional implications

REM sleep in humans is thought to modulate emotional arousal via a

noradrenaline reduction mechanism

An individual has a greater capacity to cope with emotional arousal of any sort (protective or engaging) the day after they achieve sufficient REM sleep during their night-time rest

Overnight amygdala adaptation is proportional to the duration of sound REM sleep

cognitive implications

REM sleep also enables emotional memory processing

The aim is to retain emotional memories which are important for survival, without retaining the intense emotional experience along with that memory

Reduction in REM sleep has the potential to detrimentally influence emotional and cognitive health and thereby influence physical health, including chronic pain conditions

sleep hygiene

advice about sleep hygiene is considered to be an important part of the advice for human patients with chronic health conditions

can equally important in veterianry patients with chronic pain

To determine the relative contribution from emotional health consider

Presence of behavioural response and body language consistent with

protective emotion

Evidence of high emotional arousal – displacement behaviours

Evidence of compromised emotional drainage

how can we identify and monitor pain

Identification of pain requires knowledge of species specific communication systems

Validated pain scoring systems use a combination of facial expression, body posture and behavioural responses

behavioural responses to pain

behaviour is an output - signal of underlying health

physical

• behavioural responses will be related to form of chronic pain e.g - mobility impact, body system impact, sensation impact

cognitive

• behavioural responses will be established through learning

• often have contextual component

emotional

• emotional valence

• emotional arousal

behavioural respinses tree analogy

importance of recognising appeasement

Appeasement behaviours are information gathering behaviours

Caregivers may report that the dog is more clingy or describe them as “demanding” or “attention seeking”

Ignoring or rejecting these behaviours can lead to

• Increased anxiety

• Frustration

In patients with chronic pain these protective (negative) emotions can exacerbate pain

Protective emotions lead to behavioural responses which are designed to resolve the situation

When behaviours are unable to resolve pain there can be a perception of failure which triggers frustration

Frustration increases the speed, intensity and confrontational nature of behavioural responses

This can increase risk for caregivers, veterinary professionals and others

Recognising the full range of potential responses and ensuring a perception of success for the patient at the lowest possible intensity of the most appropriate branch reduces this risk

what can chronic pain lead to

limitations of mobility which may result in

• issues of indoor toileting

• exacerbation of fears and anxieties where avoidance is not possible due to restricted mobility

increased anxiety resulting in

• physical avoidance strategies

• social avoidance strategies - decrease in play and social interaction

behavioural changes as a result of physical pain

Reluctance to walk on certain surfaces

Gait changes

Impact of gastrointestinal discomfort

Response to manipulation

During physical examination remember that there can be emotional factors which alter an animal’s response to manipulation

• The style of handling

• The animal’s emotional health (other than pain)

Behavioural output is the result of the predominant emotion – not the only emotion

detection of chronic pain

When MSK related chronic pain is mentioned there is a tendency

to look for a locomotory effect i.e. lameness or alteration in mobility

Other signs may be overlooked, such as excessive licking or grooming and other repetitive behaviours, sit position, toileting behaviour

visceral pain

Pain associated with internal organs or viscera

Visceral pain >> potential or actual tissue damage

Organs most frequently affected:

• Gastrointestinal tract

• Oesophagus

• Stomach and small/ large intestines

• Pancreas

• Gallbladder

• Urogenital tract

• Urinary bladder

• Prostate

What sorts of behavioural presentations can be associated with visceral pain?

Some behavioural change may be directly related to the physical aspects of the discomfort

Examples include:

• Lip licking

• Air gulping

• Retching

• Praying posture

• Rigid posture / gait

• Reaction to touch

Visceral pain involves dull vague sensations which are poorly

localised

Behavioural responses can therefore be vague as well

They can include:

• Alterations in response to food

• Difficulty settling and sleeping

• Lack of interest in previously enjoyable activities

In some cases the pain is referred and the behavioural response is not

readily linked to the origin of the discomfort

Examples include:

• Overgrooming

Another feature of behavioural responses to visceral pain is that they can be repetitive in nature

Examples include

• “Fly catching”

• Surface licking

Visceral pain is associated with increased protective emotion and behavioural presentations may be related to this

Examples include

Confrontational behaviour associated with

• Touch

• Threat to resources

Avoidant behaviour associated with

• Touch

• Interactions

inhibited behaviour

appeasement behaviour

What sorts of behavioural presentations can be associated with neuropathic pain?

Neuropathic pain is associated with altered sensations

This can lead to a range of behavioural responses:

• Facial grimacing (pain face)

• Head rubbing

• Head shaking

• Skin nibbling / rippling

Feline conditions involving neuropathic pain include

• Feline orofacial pain syndrome

• Feline hyperaesthesia syndrome

sometime lead to

• alterations in breathing

• changes in response to interaction

• resistance to movement = gait and posture changes

Some of the alterations in sensation and resulting impact on posture and gait can also exacerbate the emotions of fear-anxiety and frustration

A perception of instability on certain surfaces can increase anxiety

Neuropathic pain can alter the dog’s reaction to being handled or disturbed

A repulsion response might be the most problematic from a caregiver perspective

Pain is a protective emotion and can also lead to behaviours of avoidance, inhibition or appeasement

Alterations in social relationships can occur in association with pain of

varying types

Anticipation of pain can lead to alterations in social interaction

Reduced object play

Reluctance to engage in social play

Avoidance of physical proximity

Presence of pain can decrease tolerance of members of other social

groups in cats

Anticipation of pain leading to use of protective repulsion behaviours

and increase social tension in multi-pet households

how does comprehensive healthcare affect treatment

When the behaviour is directly related to the physical component of the pain

• Treat appropriately with medication, surgery, physiotherapy and environmental modifications etc

When the behaviour is related to the emotional and cognitive burden of pain

• Alter emotional bias to modify pain perception

= Improve engaging emotional bias

= Increase triggers for engaging emotions

• Improve perception of coping success to reduce frustration

• Decrease or control triggers for protective emotion

• Use cognitive approaches to alter behavioural responses

• Improve emotional drainage

When the behaviour is related to the memory of pain

• Form new behavioural associations in contexts of previous pain