Browsing tag: pain

My last article talked about a few of the dental problems most commonly seen in cats, and how easily they can be missed by both owners and vets. Remember, a cat with dental disease will probably act just like a healthy cat, but that doesn’t mean they’re not in pain! I’ll continue now by mentioning some of the preventative measures and treatments that can help keep your cat’s mouth healthy and pain-free.

What can I do to help prevent dental disease in cats?

Of the diseases mentioned previously, periodontal disease (gum disease) is by far the most common but fortunately the easiest to help prevent. Although genetics plays some role in whether or not a particular cat is going to have bad teeth, there are several things you can do to help keep the pain and inflammation to a minimum:

Brush the teeth – OK, this is admittedly not going to work for everybody. Or even most people. Or really even more than just a few people. But it’s worth giving it a try because if you are lucky enough to have one of the most chilled out cats on the planet, tooth brushing is the gold standard in preventative dental health care. By removing the bacteria before they are able to cause disease, the whole disease process is stopped in its tracks. Just use common sense and don’t get bit – if your cat doesn’t even like to be picked up or stroked, he probably won’t take too kindly to you shoving a toothbrush in his mouth.

Dental rinses or gels – These products work by killing off some of the bacteria in the mouth before they have a chance to cause disease. For cats (who let’s face it, probably won’t let you get anywhere near their mouths), one of the most sensible options is an antiseptic liquid (often containing chlorhexidine) that you put in their drinking water which can have the added benefit of freshening your cat’s breath. In most cases, if it sounds too good to be true, it probably is so although products like this can have some beneficial effect, they are not likely to solve all of your problems.

Special dental food – Some vets still say that plain old dry kibble helps keep your cat’s teeth clean. And many food manufacturers make similar claims to that effect. Although there is likely to be some truth to this, it is probably not as effective as we like to think. Most dry food is small and easy to swallow whole, so only a small percentage of it actually gets chewed. And I’ve seen plenty of cats who have seen nothing but dry food their whole lives with horrible teeth. If you want to help prevent dental disease with your choice of food, do your research and choose one that has been scientifically proven to decrease plaque formation. These foods tend to be more expensive, larger in size so they have to be chewed thoroughly before swallowing, and made in a special way such that they achieve maximum contact with the tooth surface. Ask your vet for their preferred dental health diet, which is often only available by prescription.

Regular dental cleanings at the vet – Unfortunately, even if you could train your cat to open her mouth and sit still on command, this would probably still require general anaesthesia. Vets use the same kinds of dental instruments on cats that dentists use on people (ultrasonic scalers, polishers, and drills) and the procedure itself varies from mild discomfort (with a simple scale and polish) to severe pain (with a surgical tooth extraction) and the use of local anaesthetics is not as reliable in cats because they can’t tell us what they feel. Also, dental cleanings require a lot of water and it is essential that an endotracheal tube (soft rubber tube inserted into the trachea or windpipe after they are asleep to aid breathing) is placed to prevent water from being breathed into the lungs. Although a general anaesthetic may sound like a risk that is greater than the benefit of clean teeth, most people both overestimate the risk and underestimate the benefit. When you consider that severe periodontal disease can have potentially fatal consequences, a dental cleaning can actually help save your cat’s life. Many people are (understandably) also concerned with the cost of having their cat’s teeth cleaned. I can assure you that if vets had figured out an easier, faster or less expensive way of cleaning animals’ teeth, we would all be doing it. And by having routine dental cleanings throughout an animal’s life, you can help prevent major vets’ bills down the road from complicated surgical tooth extractions or related systemic illness. As they say, an ounce of prevention is worth a pound of cure!

How can I tell if my cat has dental disease?

Signs of severe dental disease or pain in cats include bad breath, wobbly teeth, excessive salivation or drooling, teeth chattering or strange gnawing motions. Other symptoms can include lethargy, decreased appetite, depression or hiding/not wanting to be touched, although these can be seen with almost any illness! Another important yet subtle sign is whether or not your cat actually chews their food before swallowing it. Even some cats with no teeth at all will happily eat dry food by swallowing it whole, so instead of just assuming that everything is ok, try to notice how much crunching they do with each bite. If you’re particularly observant, you may even notice your cat chewing more on one side of the mouth (the healthier side) to avoid touching a painful tooth.

You may not ever notice them in pain, but more often than not owners remark after the painful teeth are removed that their cat is acting like a kitten again. This is further proof that they show such subtle signs of pain that they are often missed by owners and even vets, and although it is nice to be able to help them feel better, how much nicer would it be to prevent these problems from occurring in the first place! If you have noticed any of the symptoms listed above or are otherwise worried about your cat’s teeth, please speak to your vet. Because until your cat learns how to phone us herself, she’s relying on you to make sure that she doesn’t have to suffer with painful dental disease in silence.

Pain and pain relief are massive topics which can – and do – fill several textbooks. It’s way beyond the scope of a blog to go into all of the detail surrounding the use of painkillers, and so all I really want to do is to outline some of the different types of pain control that we can use, both in the surgery and as day-to-day treatments.

Pain relief is one of the great success stories in medicine, and it’s no coincidence that some of my favourite drugs of all time are painkillers. Our advances mean that pain in our patients shouldn’t be accepted, and although sometimes we fail to control it, we should never stop trying.

We use a number of different types of painkiller:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Steroids
• Opioids and opioid-like drugs
• Others

NSAIDs

These are the most widely-used type of painkiller and include (for humans) aspirin, ibuprofen and paracetamol. They act by stopping inflammation.

They’re commonly prescribed for post-op pain and for joint problems and may be given for long periods of time. When you’re given painkillers to take home from the vets, they’re usually NSAIDs.

Three things to really take on board with these drugs:

1. Human drugs are not always safe for pets, so never give anything to your pet without talking to your vet first: half a paracetamol can kill a cat, a big dose of ibuprofen can do the same to dogs and even a solitary aspirin can be a lethal overdose for a toy breed, designed as it is for a much bigger animal (us). This is why we have veterinary-licensed drugs for our patients.
2. Increasing doses won’t give more pain relief, and may cause side effects. If they’re not working for your pet, talk to your vet about alternatives.
3. NSAIDs are most effective when given before the inflammation starts. It might seem odd to suggest giving painkillers before the pain even begins, but this is important in treating chronic, repeated and predictable pain like arthritis.

Two of the most common drugs we use are meloxicam and carprofen. Meloxicam usually comes as a syrup, which can be dosed very accurately, and carprofen is generally in tablet form. Both drugs may be used long term as a daily dose and both have been responsible for giving patients their lives back, sometimes for years. We’re also rediscovering paracetamol as an excellent addition to treatments in dogs.

Recently, newer NSAIDs have been introduced which are labelled either as cox-2 inhibitors (e.g. firocoxib), or else dual inhibitors (tepoxalin). Essentially, these are just descriptions of which bit of the inflammatory cascade they act upon, and they’re designed to reduce some risks of side effects that we see with other NSAIDs. It’s arguable, though, as to whether they’re better at relieving pain than some of the older drugs.

More recent still is Trocoxil, an NSAID for dogs which is only given once a month. The theory is that because it acts as a persistent block to inflammation, there’s no point where the vicious cycle of pain can really take a hold. The exact ins and outs of the drug are a bit too much to go into here, but as always, speak to your vet about this medication if you’re interested in finding out more. Do understand, though, that it’s not for every patient and your vet may have good reasons not to use it on your dog.

Steroids

Steroids are very powerful anti-inflammatories, which gives them painkilling properties. However, they also affect the immune system – many patients take them for allergies and auto-immune problems – and can have major side-effects when used long-term at high doses; they also can’t be given with NSAIDs and so for practical reasons their use as painkillers is limited. You may have experience of PLT (Predno-LeucoTropin), a medicine with a steroid component which can be great for chronic pain when other drugs seem to be failing. It’s been around for a long time, and many an experienced vet will recognise its usefulness.

Opioids

Opioids are a group of drugs which act to block the passage and brain detection of pain signals. The classic drug in this group is morphine, which still forms the basis for relief of severe pain in humans. These are very powerful painkillers indeed, although the degree of pain relief depends on whether they’re what we call a full-agonist or a partial-agonist.

Drugs like morphine, pethidine and fentanyl are full-agonists, and tend to be used only within the surgery. They are subject to close control and are never dispensed. Generally they’re given by injection, although fentanyl is available as a long-acting skin patch, which has been very successful for use in trauma patients like RTA cats.

Buprenorphine and butorphanol are partial-agonists and are often used as part of a pre-med before surgery. Buprenorphine is a great painkiller which is usually injected within the practice, but may occasionally be dispensed for oral, very short-term use. It is certainly useful in breaking pain cycles and allowing us to get onto more stable pain relief regimes. For in-patients where NSAIDs either don’t quite cut it, or else a combination therapy is needed, buprenorphine is an excellent drug.

A drug that we’ll often use long-term in out-patients is tramadol. This is a human drug which acts in a similar manner to opioids, and has a number of significant advantages:

1. It’s usually pretty safe, although it can temporarily knock some patients a little flat. Your vet should tell you about this when prescribing.
2. It’s a GOOD painkiller
3. As it has a different way of working to NSAIDs or steroids, it can be used in conjunction with many other drugs to create a better painkilling effect

Others

Other drugs that we use act in novel ways, or else are designed for other purposes but just happen to help with pain control. These are important drugs, and whilst they’re described last they’re definitely not least in importance. In brief:

• Local anaesthetics may be used in and around surgery, to numb the pain nerves. These tend to be injectable, although some creams are available which can be useful to pre-treat patients with needle phobias and the like.
• Ketamine – yes, the horse tranquiliser – has been used for years in emergency medicine as a painkiller; it’s often included in battle packs for soldiers. Its use in our patients is quite specialised and confined to hospital environments.
• Gabapentin. This is a very interesting drug indeed. It’s normally used as an anti-epileptic, but seems to have a great effect on pain of nervous origin (aka neuropathic pain), so can be useful for spinal and neurological conditions.
• Cartrophen is an anti-arthritic drug (also sometimes used in bladder problems in cats) which has a number of effects on joints. It’s usually given as four weekly injections, followed by a variable period of remission. It can be very beneficial for some arthritis patients, but may need a little forward planning in its use, as its administration isn’t recommended at the same time as NSAIDs. It’s certainly a drug worthy of close inspection in long term arthritis cases.

Integrated methods of pain control

Whilst it’s obvious that we have some great drugs for relieving pain, reliance on drugs alone in any condition is generally a limiting approach, as adding in other treatment types – or modalities – may offer greatly increased success rates.

For example, in heart disease drugs may help to keep the cardiovascular system going, but are much less effective when used by themselves than in an overall strategy including lifestyle change, weight loss, exercise programmes, regular monitoring and support networks.

Similarly, drugs may form the heart of a pain relief strategy, but shouldn’t be used as an excuse to avoid other measures that can help – and there are even times when non-drug pain control is good enough that painkillers are not needed. Whatever the non-drug modality used, the decision on when not to use painkillers is a simple one:

1. The pain is being completely controlled by non-drug methods.
2. That’s it.

Remember that phrase – pain is not acceptable in our patients. If nothing else, these blogs should have explained both why pain is a bad thing in the long run, and the sheer number of drugs that fight pain. Treating pain completely without drugs is a brilliant solution, but simply taking the edge off the pain is not enough. Equally, though, finding a number of ways to help with the pain will almost certainly mean that your pet gets more relief and is happier.

Treatment modalities which can help in chronically painful conditions include:

• Acupuncture – there’s a reasonable body of evidence for the physical effects of acupuncture and theories of how it may ‘close the gate’ on pain. It’s now widely available around the country, but must be performed by or under the direction of a vet.
• Supplements – for joint problems, there are a number of supplements containing combinations of glucosamine, chondroitin and green-lipped mussel extract, which protect the cartilage and may even get rid of the need for painkillers in early arthritis. Additionally, essential fatty acid supplements and vitamin E are both mooted as aids to tissue repair and free-radical scavenging.
• Herbal remedies containing Devil’s Claw are widely available, but be warned that the supplement can cause side effects and that clinical trials have produced highly variable results.
• Weight loss – whilst it’s obvious that in arthritis, every excess ounce is another ounce of pain, recent work has suggested that body fat has a chemical pro-inflammatory effect which may exacerbate pain generally. Reducing body fat may reduce the body’s pain responses, particularly in chronic conditions.
• Surgery – for many painful conditions, surgery is the obvious treatment to permanently remove the pain at source.
• Physiotherapy – hydrotherapy, mobilisation, massage and PROM are all very useful in promoting recovery and dealing with chronically painful conditions. Access to these services is usually by referral from your vet, and animal physios are highly qualified professionals.
• Mood enhancement – pain is depressing, so elevating mood helps patients to cope, and also makes new pain easier to deal with. A number of products are available, from pills (including zylkene, a natural extract, and amitryptilline) to pheromone sprays and diffusers (feliway, DAP), but equally, promotion of routine and enjoyable activities can be very successful.
• Prevention –as the best pain relief is prevention, a word should be said about how we avoid seeing dogs with arthritis or cats with pancreas issues in the first place. Also perhaps timely, as the Animal Health Trust, in conjunction with Edinburgh Vet School, have just announced a project into genetic testing for hip and elbow dysplasias in Labradors. Being able to breed the conditions out of our patients will have a major impact on the wellbeing of future generations (so, if your Lab is KC registered and hip scored, the AHT might just want to hear from you).
• Magnet therapy – to this day, I still don’t know if this really works, but plenty of my clients are convinced – including a large proportion of horse owners, who are about the most hard-bitten, unpersuadable people out there.

There are, of course, countless other integrated therapies, like Reiki or Homeopathy, and each will have their champions and detractors. The important factors with any of these are choice and inclusivity – it’s fine to explore all of the possibilities, but not to the detriment of the patient. As a general rule, the vet who prescribes you meloxicam won’t demand that you stay off the Reiki during treatment, and this should work both ways.

The mainstay of pain relief will always be drug therapy, but its effectiveness can be massively enhanced by looking at integrated treatments. Pain is such a debilitating problem that anything which can help to remove it has got to be worth exploring. If you feel that your pet may be in pain, especially if you’re already giving treatment, then speak to your vet about what you can do – there are so many ways to target pain that there’s bound to be something to help.

And do remember that phrase: pain is not acceptable in our patients.

If you are worried about your pet’s health, talk to your vet or use our Interactive Symptom Guide to help assess how urgent the problem may be.

Also known as Bloat, Twisted Stomach, Gastric Dilatation-Volvulus or GDV, this condition is one of the most serious emergencies in small animal practice, and it can make all the difference to the outcome if it is recognised immediately.

There are two parts to this condition, the bloat and the torsion. Bloat is when the dog’s stomach fills up with gas, fluid, froth or a mixture of all of these, to a far greater size than normal. Torsion (volvulus) is when the whole stomach twists inside the abdomen so that it is closed off at both its entrance and its exit, just like a sausage which is twisted closed at both ends.

They may both occur together, or one may lead to the other. If bloat occurs first, the enlarged stomach is at greater risk of torsion. If torsion occurs first, bloating will definitely result. No food can leave the stomach, so it ferments, and no gas can be belched up.

Annie, a Gordon Setter, suffered with bloat but survived thanks to her owner spotting the signs

The effect of the swollen stomach is that it presses on all of the other vital organs close to it. The breathing will become difficult and if the large blood vessels within the abdomen get squeezed so much that they cannot allow blood flow, then other organs will begin to shut down. The stomach wall and the spleen can become necrotic or dead due to loss of blood flow, and this releases toxins into the bloodstream. It is very painful, and if not corrected, the dog will die.

The reasons for this condition occurring are not fully understood, but there are some well known and definite risk factors. The condition happens mainly in larger breeds, particularly those with a deep-chested shape like Great Danes, German Shepherds, Setters, Wolfhounds and Boxers, but these are not the only breeds affected. It also happens more (but not exclusively) in dogs over 7 years of age, and it is more common in males than in females. The risks increase if the stomach is very full, either with food or with water, so a dog which is fed once daily and eats very quickly, or gets access to the food store and gorges itself, would be at higher risk. Exercising after eating or after a big drink also increases the risk.

Symptoms

The onset of a gastric torsion is usually very rapid. The dog can appear quite normal one minute but once symptoms start they very quickly get worse. The most common symptoms are some or all of:

• Restlessness, anxiety
• Discomfort, followed by worsening pain
• Arched back, reluctance to lie down
• Drooling saliva or froth
• Attempts to vomit (retching) with little being brought up
• Swollen abdomen, often feels hard and if tapped feels like a balloon
• Rapid breathing
• Pale coloured gums and tongue
• Collapse
• Shock, possible death

It is vital to get veterinary attention as soon as possible if you suspect bloat or torsion. Always phone your surgery or your emergency service first as it will save valuable time if you go to the right place where the staff are prepared for your arrival.

Occasionally, there can be a slower onset. This may mean that the stomach has bloated without twisting, but there is still a high risk of torsion occurring so advice should be sought from your surgery.

Diagnosis & Treatment

Diagnosing the condition can be very straightforward if a dog is showing all of the classic symptoms. X-rays may be needed to confirm it. Blood tests will probably be taken to find out how serious the changes in the blood are, because changes in the circulating levels of salts in the blood can be life-threatening. These will be treated with intravenous fluids given quickly and at high volumes. A stomach tube may be passed, but this will not be successful if the stomach has twisted because the tube will not be able to get through the obstructed entrance. The vet may decide to decompress the stomach (let some gas out) by inserting a needle into the dog’s side. The order in which these procedures may be carried out will depend on just how ill the dog is.

A surgical operation will be needed to untwist the stomach, to check for damage to the organs and to try to prevent it from happening again. Some will need immediate surgery and others will need to be stabilised first to improve their chances of survival. Some dogs have to have part of the stomach or the spleen removed if the damage has been severe. The surgery is very high risk especially if the dog is already in shock because of the effects on the circulation and breathing.

When successful surgery is carried out, with the stomach and spleen returned to their normal position or repaired if damaged, it is common to perform a procedure to try to stop the condition occurring again, known as a gastropexy. There are different ways of doing this, but the aim is to anchor the stomach to the abdominal wall so that it is unable to twist. It could still bloat, but hopefully the consequences would not be so serious.

The survival rate following this condition varies a lot, but sadly, many dogs die each year from gastric torsion. The survival rate is better in younger dogs and if immediate treatment is given.

Prevention

• Be aware of the signs to look out for
• Feed larger dogs two or three smaller meals a day
• Do not allow your dog to exercise after eating or after a big drink
• Try to discourage rapid eating by separating competitive dogs at feeding time
• Try a specially shaped feeding bowl designed to slow eating down
• The effects of type of food and feeding from a raised bowl are under constant review and more research will show whether these are significant or not

Martha with her young friend Tilly

I suspect that most vets never forget the first case of gastric torsion that they see. Mine was in a Great Dane, which I worked on all night with the help of two nurses. That one was fortunate and survived. It was a great moment for all of us when it left the surgery mid-morning the next day. The nurses jokingly told me that there was another one on the way in but I didn’t believe them, at least, not until I saw it walk in, arriving just as the first one left. Since then I have treated many dogs with gastric torsion and it is always memorable and always a challenge.

My own boxer Martha died of this condition last year despite very prompt attention and all preventative measures being in place. Sadly, her age was against her and our only consolation is that her suffering was very short-lived.

If you are concerned about your dog’s health, talk to your vet or use our interactive Dog Symptom Guide to help decide what to do next.

Pain. Everybody knows what it feels like, and – apart from a few determined individuals – we tend to avoid it. But what is it? The International Association for the Study of Pain (IASP) defines it as:

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Or, in other words, when you damage yourself it hurts. And if you’re feeling down already, it hurts more. And if you’re not feeling down already, then pain may make you feel down. And then it will hurt more.

The IASP mainly looks at pain in humans, but it’s a long time since we stopped trying to pretend that animals either don’t feel pain like we do, or else don’t get upset about it. They do, and their inability to communicate pain effectively (or else our inability to properly listen) means that for a lot of animals, pain is a chronic, miserable constant in their lives, despite help being close to hand.

There are tiny pain receptors all over the body, inside and out, attached to nerve fibres. When a tissue is damaged, they’re triggered to send impulses up to the brain, which senses them and registers the feeling we call pain. Hard to describe, but we all understand what it is and we’ve all got experience of it. Pain receptors are usually well embedded in tissues, and usually need a fair bit of triggering – otherwise, any form of touch would be painful.

When we describe pain in ourselves, we often use terms like sharp, jabbing, dull or throbbing, and they can give an indication of how bad it is. But in a more fundamental sense, we differentiate into two types: physiologic and pathologic.

Physiologic pain is ‘protective’ – it’s the pain we get when picking up a hot pan. Very quickly, the body registers the ‘ouch’ and the pan is dropped, hopefully before too much damage is done. Without this kind of reflexive response, we’d just keep on holding the pan until our hands were badly damaged.

Physiologic pain, more or less, is our friend.

Pathologic pain, on the other hand, is the pain that comes from existing damage, such as a broken leg or a arthritis. Whilst it can initially be useful to draw our attention to the condition, it becomes debilitating quite quickly and can be a problem in its own right. It’s this kind of pain that we need to deal with in our patients: the pain that is ever-present or recurrent, at whatever level. If we don’t, the pain becomes responsible for stress, depression and a reduced quality of life.

For example, the pain of arthritis can actually make the condition worse:

1. being unwilling to move around makes the joints stiffen up through lack of use
2. lack of exercise piles on the weight, putting more pressure on the joints
3. increased pressure on the joints means more pain, so less movement, more stiffening and more weight gain

A vicious cycle is created where the problem becomes worse and worse under its own steam – and pain is as the root of it. Whilst we can’t cure the arthritis itself, by removing pain and getting our patients moving we can reverse the stiffness and get some weight off.

Pathologic pain can have its uses, but isn’t always our friend.

How do we recognise pain?

In order to be able to keep our pets out of pain, we must be able to recognise the signs of pain. Remember, though, that absence of signs doesn’t guarantee that there’s no pain – if in doubt, assume it’s there.

Understanding how a pet feels depends on a number of things:

• Empathy
• Understanding of normal behaviour
• Observation

Some owners are just better at spotting pain. Some patients are better at showing it. But unless we look for it, we’re never going to find it.

Dogs tend to be the easiest patients in which to spot pain: their outward responses to pain are more similar to ours than for most species. They’re designed for pack-living, and their conditioning in our homes makes them more likely to be willing to show pain to us, and even to seek help with it. I have, over the years, seen a small number of ‘malingerers’ who were hopping lame at home, but completely normal when away from their owners – generally because being hopping lame at home meant cuddles and treats and all things good.

Do beware, though, of behavioural changes as the only signs of chronic pain in dogs. When our collie, Juno, was a younger dog, a combination of being overweight (yes, shame on me), hip dysplasia and the appearance of screaming toddlers with grabby hands made her mildly aggressive – which, for Spoony, was so out of character that it was immediately apparent. Early recognition of the central issue, along with pain control measures (weight loss, acupuncture, educating the kids) sorted it all out quickly.

Cats are different, very different. When in pain, they tend to isolate and may just become distant and/or grumpy. There may be aggression towards inanimate objects, or self-directed as overgrooming to the point of self-harm, and accidentally touching the sore spot will usually lead to bloodshed, none of which will be the cat’s. But cats are relatively worse at expressing pain in other ways which are immediately recognisable. Drop in food intake is, though, a classic sign of pain in cats.

Rabbits and other herbivores (traditionally, the prey animals) can be very difficult to recognise as being in pain. Their entire survival in the wild depends on not looking weak – predators will tend to go after the stragglers first, to reduce energy expenditure and risk in obtaining food. Survival in the wild depends on being invisible as a target, so hiding signs of pain is standard in these patients. Sometimes, you have to look very hard to find it, which doesn’t mean that the pain isn’t significant. It’s entirely connected that these are the species whose general welfare gives us the most worry.

General signs of pain in animals include:

• Reduced mobility or abnormal movement – if it hurts to move, pain is reduced by not moving. Equally, if a pet is moving in an odd way, then it’s because moving in a normal way hurts. A major, major problem that we encounter is the attitude that reduced mobility is a normal part of ageing – so pain is often not recognised in older patients. It’s amazing what a trial on painkillers can do to change minds.
• Guarding and defence – hiding away or trying to protect the bit that hurts. A common entry on clinical notes is ‘guarding the abdomen’ which usually relates to a tenseness in the belly when we’re trying to palpate.
• Inappetance – most animals will either eat less or stop eating altogether when in pain. When the pain is settled, we often see rebound eating, where intake is increased for a while. This can be a cardinal sign for assessing response to treatment.
• Adipsia or polydipsia – most animals will also drink less, although some, often as a response to stress, will drink too much. Patients with abdominal pain will often swallow great bowlfuls of water, possibly because of a temporary soothing effect.
• Altered interaction – many animals will hide away and reduce their interactions with other members of the household; others, particularly dogs, will become more needy and seek more interaction. Normally friendly relationships may explode into world war three and, rarely, vice-versa. It’s not so much how the interactions change, but that they change in the first place.
• General distress – other signs of distress include increased breathing rate, increased pulse rate, abnormal breathing (cats DON’T pant as a normal behaviour), vocalisation (howling, mewing, whimpering), a certain glassiness of the eyes, hunched body position, bubbling at the mouth (reptiles), fluffing of the feathers or over-stimulation and anxiety from normal noises and events.

Even allowing for all of these symptoms, pain can be a vague and difficult thing to spot. One of our classic presentations in the consult room is ‘S/he’s just not right’, where a patient just isn’t him- or herself. It’s astonishing how many of these patients have some kind of pain complex, and full marks from me to any owner who can spot when their pet is just not happy, however subtle. Nothing ever happens for no reason, and absence of any particular symptom in a depressed patient should always trigger suspicion of pain as a cause.

What factors make pain worse?

Inflammation is a big one. Inflammation is the swelling you get around, say, a cut or a sprain. It’s also the reason why a sprained ankle tends to hurt more the next day than it does at the time of injury. Inflammation is the body’s reaction to detecting damage and is its way of drawing the immune system in to start repairing things. Once damage is detected, a sequence of events is triggered called the inflammatory cascade, which goes a bit like a line of dominoes – once started, it takes on a life of its own. The end result is the release of a lot of chemicals which promote blood flow into the area and, importantly here, an increased sensitivity of the local pain receptors so that almost any pressure sets them off.

A good illustration of this is to imagine someone poking you lightly in the arm. For most of us, it’s not painful, just annoying (and strangely familiar for those with brothers and sisters). However, if you’d been to the doctors for a jab earlier in the day, suddenly the touch is extremely painful. The inflammation around the injection site has switched all the pain receptors on to the point where even light pressure sets them off. This phenomenon is at the heart of much of the chronic pain that our patients suffer from, with conditions like arthritis. Drugs which try to stop the inflammatory cascade are called anti-inflammatories.

Other things that make pain feel worse are:

• The amount of time that it’s been going on for – most of us are fairly stoic, at least at first, but sooner or later an inability to get comfortable, to sleep, to do the things we want to, all start to get us down. It’s the same for our pets.
• Having more than one painful bit – two plus two in this case tends to make five.
• Previous experience of pain. Our pets have a phenomenal memory for pain, which translates to a fear of repeating the experience. Pain at the vets can put a patient off us for life, which is why we try to make the first couple of visits as stress-free as possible.
• Being in a bad mood already. If you walk down the street on a happy day and stub your toe, it hurts. If you’re already in a bad mood, the world seems to cave in. This is where the vicious cycle of pain and depression starts to bite: being in pain causes stress and depression, and stress and depression make pain feel worse.

Pain control is one of the most progressive aspects of veterinary medicine, which means that pain in our pets is no longer acceptable. It might not always be possible to get right on top of it, but that doesn’t mean we should ever be happy about it – and there are now so many available treatments that giving up is simply not a reasonable option.

In the next instalment, I want to discuss the various drugs that we can use in dealing with pain in animals, and how they might fit together. After that, we’ll briefly go on to integrated (non-drug) treatments and how they can make all the difference to some patients.

If you are worried about any symptoms in your pet, please talk to your vet or use our Interacitve Symptom Guide for advice on how urgent the problem may be.

Are you and your pet healthy?

It’s an odd question, which you’ll probably answer depending on how you feel, especially if you’re suffering with, say, a cold or a broken leg. And if your pet is currently having treatment, it’s easy to say that he or she isn’t healthy, but would that automatically be the case? Is a contented cat with well-controlled hyperthyroidism any worse off than a depressed horse? Is a puppy with a rash any healthier than a very old dog without any obvious issues?

Defining health is like trying to catch fog in a net. To start, there are lots of different viewpoints of what it actually means, and it soon becomes apparent that perfect health is an impossible ideal, faced as we are by so many challenges every second of our lives. Unless you’re holding your breath, you’ll have breathed in a lot of germs just since you started reading this, one of which may make you ill next Tuesday. How depressing – unless, of course, you were hoping to avoid that work meeting next Tuesday, in which case the world is suddenly a brighter place.

Context matters with these things: a gut full of bacteria is normal; a lung full of bacteria isn’t. Worms aren’t something you’d want to have, but it’s not that long since diet pills for ladies contained tapeworm eggs, in order to maintain that ‘healthy’ figure. We spend more time, effort and money on polyfilla to mask signs of ageing than we do on exercise and decent diet, because we think that a wrinkle-free face on an unfit body is healthier-looking than someone who looks their age only from the neck up.

So what might it mean to be healthy? Is there one theory which brings it all together? Can it be defined without a blood test? More to the point, how does your vet define it, and can he or she explain it to you? I’d like to discuss three theories of health which could really alter your perception of what it means, for you and your pet. They might seem complicated to look at, but in reality they’re very simple, like all the best ideas:

• Biomedical Health
• Activities of Living
• Self-Care Deficit

Biomedical refers to the presence of disease: imagine if I had a Star Trek type scanner, which I could wave at you and it would tell me if you were biomedically healthy in terms of infection or organ function. But I wouldn’t have a clue about how happy you were, how many friends you had and whether you played sport last Saturday. Aren’t these important as part of a healthy life?

So three very clever people called Roper, Logan and Tierney came up with the Activities of Living. These are twelve basic activities (since expanded by other theorists), ranging from eating, drinking and breathing, through social interactions and sexual expression, to dying, as normal parts of a healthy life. It’s not enough to be free of disease: in order to be truly healthy, one has to be able to take part in all of the activities (even dying, but hopefully only at the end of a long and fruitful life).

Dorothea Orem produced the wonderful Self-Care Deficit Theory, which simply means that anything you can’t do to look after yourself is called a self-care deficit: so if you can’t put your own socks on, that would be a deficit. Orem considered that where a deficit was identified, enough help should be given to overcome it, but no more. So, when my collie Juno was recently struggling with getting out of her basket after a vestibular attack, she got just enough support to make it happen, but that was all. She had to make some effort herself, and that meant that she overcame the problem more quickly.

These are brilliant theories, but what really made them great was combining them and incorporating them into medical care. You often hear the term holistic applied to alternative therapies and lifestyles, but its true definition has its roots in this kind of care: veterinary medicine shouldn’t just be about curing disease, but about enabling patients to live as full a life as possible. The veterinary profession has identified with this ideology since it first evolved, but the recent introduction of these theories into the education of young vet nurses and vets has cemented their importance. So, there’s now a very good chance that your local vet practice is already putting the principles of holistic care into practice:

1. We do, of course, look at your pet’s health from a biomedical point of view
2. Then we may go further and look at how they get on with the Activities of Living.
3. If there are any that they can’t manage (apart, usually, from sexual expression), we may look at their inability to do it – or self-care deficit – and work out how we can help to put it right.

In this way, health is about more than just a negative lab test, and the common presentation of “he’s just not right” can be looked at more fully.

If Tiger, the car-chasing cat, is hospitalised with a broken pelvis, his care won’t just be about pain relief: it’s possible to put food into a cat even against his will, but the real trick is to make him happy enough to want to eat it. So the team will look at what activities would make him a whole, happy cat again, and what his self-care deficits for each activity are. And they’ll give him the help to bridge those gaps: so if he can’t self-groom all over, they’ll do the bits he can’t reach; if he can’t wee, they’ll take care of that. When the gaps between what he can do and what he needs to be able to do have dwindled to nothing, he’ll be healthy again. A lot of that work can be done at home, so when Tiger is discharged, there should be a good chat about what can be done to carry on the process.

If Tess, the old Labrador with arthritis, has lost her spark even with painkillers, the practice may have ways to get that spark back – finding new ways to play and to interact, stimulating (as though a Lab would ever need it) interest in food and people. We should look at her expectations out of life – and she won’t want to run for ten miles in the rain each day – and make sure that she’s not being limited by her routine.

And for concepts designed for a rabbit, look no further. Rabbit welfare in terms of general lifestyle and care is one of the most pressing problems we face in veterinary medicine: the lives of some (but by no means all) of these creatures are simply miserable. So if you’ve got a rabbit stuck in a small hutch all day, dig out a copy of the Activities of Living and see how you score as an owner.

We’re pretty good at keeping our pets free of disease. Where we might need some work is in making sure they’re truly healthy. Dogs can’t tell the difference between a cheap collar and an expensive one, but they do know all about quality time and the importance of a good play session. So it might be that looking at our pets’ health helps us to look at our own, and who knows where that could lead?

If you are worried about any aspect of your pet’s health, talk to your vet or use our Interactive Symptom Guide to help assess the urgency of the problem.

Pyometra is a condition affecting unspayed bitches (and less commonly cats) where the womb, or uterus, becomes infected. In mild cases it can come on fairly slowly with only slight changes in the uterus, but the worst cases happen very quickly and the womb becomes swollen like a balloon, but filled with pus. These are urgent and life-threatening.

Pyometra happens when the lining of the uterus (the endometrium) changes under the influence of the bitch’s hormonal cycle. It nearly always happens a few weeks after she has been in season and is more common in older bitches. The use of certain hormonal drugs to postpone seasons has been linked with an increased risk of pyometra. Rarely, a spayed bitch can develop a similar infection in the remaining part of the uterus, called a “stump pyometra”, but this is uncommon.

The first symptoms are not very specific, with the bitch appearing a little unwell and off her food. Usually the thirst will increase and there may be some vomiting, but not all symptoms happen in all cases. If the cervix (the junction between the uterus and the vagina) remains open, there is often an unpleasant vaginal discharge. If the cervix is closed, the discharge cannot escape and these cases are more serious. The temperature may be raised, and when toxins enter the bloodstream the bitch will become seriously ill. In a small number of cases, kidney failure and death will result.

It is usually easy to diagnose a pyometra from a combination of the history and the physical examination. If there is any doubt, x-rays or ultrasound scans can help in the diagnosis. Blood tests can also help by confirming high levels of infection-fighting white blood cells.

The treatment for pyometra is the surgical removal of the uterus and ovaries, also called ovaro-hysterectomy or spay. It is a more difficult operation in a bitch with pyometra than the regular spay operation in a young healthy bitch. The uterus is often enlarged and fragile. If it should leak or burst, there is a high risk of peritonitis. Having said that, the operation is nearly always successful. It is usually carried out immediately after diagnosis, unless the bitch needs to be stabilised first to allow her a better chance of coming through the operation.

After-care would include antibiotics and possibly fluids by drip if the bitch was very poorly. Exercise will be restricted for a minimum of 10 days while the wound heals, and pain relief will be given.

There have been attempts to treat pyometra with drugs rather than surgery, but it is unlikely that severe cases would respond to anything but surgery. In mild cases which improve for a time there is every chance that the condition will come back after the next season.

It is often said by owners after the bitch has recovered from a pyometra operation that they are healthier than they have been for years. In these cases the condition had probably been grumbling for a long time but not enough to worry anyone until recently. The changes in the bitch’s behaviour which had been put down to advancing years are reversed, often giving a whole new lease of life.

The best way to prevent pyometra is to spay whilst the bitch is young and healthy. Unless you really want puppies, with all the responsibility and expense that goes with them, it is best to spay either before the first season or about three months after it. Your own vet can advise on the best time for your particular bitch. The added advantages of spaying young are the reduced risk of mammary tumours and the avoidance of further seasons and unwanted pregnancies. There could be a slightly increased risk after spay of developing urinary incontinence, and some bitches develop a fluffy coat instead of a sleek shiny one. These drawbacks are greatly outweighed by the benefits.

It is always a good idea to take note of changes in your dog’s behaviour or general wellbeing. Noticing small changes in appetite or thirst could be crucial in diagnosing this type of condition early. If you are worried about any of these symptoms, always ring your veterinary surgery for advice.

Our Interactive Symptom Guide can help you check out any unusual symptoms and advise on how soon you should visit your vet. Earlier diagnosis usually means more successsful treatment.

Stiffness in older dogs may be due to osteoarthritis which could be treated.

This week I met a lovely 12 year old Labrador called Amber, who has been suffering for some time now with osteoarthritis. She is on a combination of two treatments, which keep her quality of life good although her condition is getting worse.

This is a very common complaint in dogs, especially middle-aged and elderly ones, but the good news is that the treatments available are improving all the time.

One of the most common findings in a routine examination of an older dog is stiffness of one or more joints. On questioning the owner, we often find that there is occasional lameness or difficulty getting into the car, or stiffness for the first few minutes of exercise before the dog “gets going”. One of the most likely causes of such symptoms, although not the only one, is osteoarthritis or degenerative joint disease. Most people just call it arthritis, although there are other kinds of arthritis as well.

Medium to large breeds are most commonly affected by arthritis, but it can happen in any size of dog. Usually the onset is quite slow and may not be noticed at first by owners, or just put down to the inevitable process of ageing. Unfortunately this can mean that owners are not aware that their pet is in pain, or underestimate how much pain they have. Owners are often surprised when it is suggested that their dog has arthritis that would benefit from treatment, and equally surprised by the improvement they see when treatment starts. A very common reaction is that he/she is “like a new dog”. This is mainly because their joint pain has been removed or reduced.

Arthritis is a degenerative condition of the joints, where the cartilage overlying the bone becomes rough instead of smooth and movement of the joint becomes difficult and painful. The fibrous capsule surrounding the joint becomes thickened and restricts the amount of movement the joint can make. New pieces of bone called osteophytes can grow on the damaged surface, further restricting movement. The joints may make clicking or crunching noises when the dog walks, and the joints may also be swollen.

Diagnosis of arthritis is by a mixture of examination of the dog, history taking (asking the owner about the dog’s exercise tolerance etc) and further examinations such as x-rays. It may not always be necessary to take x-rays, but it can be very helpful to rule out other conditions which might also be treatable, but would require a completely different type of treatment. As well as helping to make the right diagnosis, the changes seen can help decide on the best treatment. While the dog is anaesthetised, the joints can be manipulated much more thoroughly than when the dog is awake, so a more thorough examination can be made.

Regular short walks are advised for affected dogs.

Once the diagnosis of arthritis has been made, treatment can begin. Before even thinking about drugs, the vet will want to consider whether changes need to be made to the dog’s weight and exercise regime. Being overweight puts increased strain on all the leg joints, so slimming down if necessary should be considered as part of the treatment. Rest can also be very important. Regular, frequent, short walks will be tolerated much more easily than an occasional long run.

Often the first line of treatment involves “chondroprotective agents” like glucosamine and chondroitin. These can be given in tablet form or can be included in the diet. They help to repair the cartilage and maintain the lubricating fluid of the joint, the synovial fluid. Two points worth remembering about these are, firstly, that the full effects may not be seen until six weeks after starting, and secondly, the formulations on sale for human use may not be as effective in dogs as those formulated for dogs.

Another very common group of drugs used to treat arthritis are called non-steroidal anti-inflammatories, or NSAIDs for short. These reduce pain and inflammation and can be given as tablets, liquids or injections. These drugs are generally very safe, but if used for a long time it is sensible to monitor the dog’s liver function as a healthy liver is needed to metabolise these drugs. A routine blood test is carried out every 6 months or as recommended by your own vet. Like all drugs there can be side effects, including the possibility of diarrhoea and vomiting in some dogs. If your dog develops any new symptoms while taking any drugs, it is advisable to seek advice from your veterinary surgery.

In some more serious cases other drugs may need to be used, such as steroids or strong painkillers.

Surgical treatments can also be used in the treatment of arthritis. Operations which have been common in human medicine for many years, like hip replacements, are now more widely available to dogs too. In severe cases of hip arthritis, this can allow enormous improvements in quality of life. In younger dogs where arthritis may be the result of a developmental problem in a joint, surgery may be recommended. Not all veterinary practices carry out these sorts of procedures so your dog might need to be referred to a local specialist in orthopaedics.

Amber is a lucky dog in that her symptoms are well controlled even though her exercise is restricted. She has an examination and a weight check every 3 months and a blood test every 6 months. She spent a lot of our consultation lying on her back having her tummy tickled, and I had no doubts that she is still leading an enjoyable life.

If you are concerned about arthritis, stiffness or lameness in your dog, or any other health issues, contact your vet or use our Interactive Dog Symptom Guide to help you decide what to do next.

Gizmo and his vet, Reg.

Gizmo was a lovable cat who had been known to the practice for many years. She was one of those vocal Orientals who sounded like a baby crying. In fact she had reached the tremendous age of 21 years with no major health problems until his teeth started to loosen and she had difficulty eating.

We are always extremely cautious with giving anaesthetics to aged cats so we took some blood tests for organ function which came back completely normal. She came through his dental with flying colours.

A couple of months later she came back with a very painful leg, swollen around the left knee (stifle). When we X-rayed the leg our worst fears were confirmed: Gizmo had bone cancer. We took further X-rays and there was no sign of spread to any other part of her body.

Bone cancer in dogs is highly malignant and has often already spread by the time the diagnosis is made. Although chemotherapy and amputation are options, survival time can be very poor.

Cats are a slightly different proposition and their form of bone cancer (osteosarcoma) tends to stay more confined and is slower to spread.

My instinct with Gizmo being 21 was to recommend her being put to sleep but her owner was determined that we should do everything possible for her providing that he did not suffer. Prior to the surgery we were having great trouble keeping Gizmo free of pain and at home she was on strong oral pain relief every couple of hours. I agonised over the decision to operate but was eventually persuaded to go ahead by his owner’s dedication to him and the fact that Gizmo behaved like a cat half her age.

Gizmo after amputation of a hind leg.

The surgery went well and Gizmo recovered very quickly and was much more comfortable with the leg removed and surprisingly mobile. She lived on for another seven months when unfortunately the cancer returned in his pelvis and reluctantly at this point we had to admit defeat.

Looking back, my colleagues thought I had lost my reason undertaking this surgery on such an old cat but I think the extra quality of life which Gizmo went on to have justified going ahead. Anaesthetics and pain relief are so much better these days than they were twenty years ago. She was certainly one of those cats who seemed to inspire the old folklore about a cat having nine lives and she will never be forgotten by all of us who knew her.

If you are concerned about pain, swelling, lumps or any other problems in your cat, please contact your vet or use our interactive Cat Symptom Guide to help you decide what to do next. For more information about insurance which could ensure the cost of operations like this one are covered, please see our pet insurance pages.

One recent morning, in the middle of the snowy weather, it was a real struggle to get to work. The main roads were open and gritted, but the side roads were hazardous with patches of snow and ice. After a difficult journey, I was surprised to find that the nurse was already checking in a patient. A motorist had found a seriously injured fox which had been hit by a car.

He hadn’t seen the accident happen, so he did not know how long the fox had been lying by the road, and we can only hope that no-one was injured in the accident. All the cars in front of him had pulled out round the fox, but he had stopped. On finding the fox was still alive, he picked it up and put it in his boot and brought it to the surgery.

Great care should be used if handling an injured wild animal because, understandably, they are liable to panic and to bite if frightened and in pain, and will not understand that you are trying to help them. In most cases it is better to telephone for advice first from either your local veterinary surgery or the RSPCA. If the animal is to be moved, it is much safer with the right protective clothing and equipment. However, this fox offered no resistance.

We examined the fox and found it was a young adult male which was in reasonable condition before the accident. Unfortunately it was barely conscious and had at least one hip fracture. A more detailed examination and x-rays would be needed to find out what other injuries it had, but as our fox was not yet well enough he was given pain relief by injection and placed in a warm, quiet, kennel in a darkened room.

Unfortunately this particular story does not have a happy ending because our fox died later in the morning. However, I am glad that he was not left to suffer and to freeze slowly to death by the side of the road. If he had survived the initial trauma of the accident, decisions about further treatment would have been made based on what was in his best interests, including whether he could make a successful return to the wild after a period of recovery.

Different veterinary practices may have different policies on the treatment of wildlife. Some may offer treatment in the practice, while others may refer animals to nearby treatment centres such as the RSPCA or other charities, depending on the facilities in the area. Often there are local people known to practices who may take in particular types of wildlife for rehabilitation such as injured birds, hedgehogs, badgers etc. In coastal areas there are specialist charities which deal with injured or stranded dolphins, seals and whales, and with oiled birds.

Some wild animals or birds which appear to be in difficulties may be best left where they are rather than being moved. Fledgling birds in particular are often still under the watchful eye of a parent even if they appear to be abandoned, so if you find one and are not sure what to do, try to get some telephone advice before moving or handling it.

If you are worried that your dog or cat may have been hit by a car, contact your vet or use our Interactive Pet Symptom Guide for advice on what to do next.

Joe Inglis BVSc MRCVS is the vet for the One Show, This Morning and BBC Breakfast. He runs his own line of natural pet food called Pet’s Kitchen

I often find myself sympathising with my patients, and feeling for their distress and pain when they are suffering from illnesses or injuries – and never more so than when their problem involves their eyes. There’s something about injuries and diseases of eyes that really affects me more than almost any other type of problem and I can really empathise with how my patient must be feeling. Having an ulcer or other injury to an eye must be horribly painful, not to mention the psychological impact of dealing with the loss of some or all of your sense of sight.

When Sylvester the cat came into the consulting room last week and clambered miserably out of his wicker basket, my heart sank and I felt an immediate sense of shock and distress when I saw his problem. His left eye was barely recognisable, with a large grey ulcer dominating the cornea and angry red blood vessels invading the usually clear surface of the eye from the sides. This was not Sylvester’s first visit to the surgery for this problem, but it was the first time that I’d seen him, and I immediately knew that we needed to do something drastic if we were going to save his eye – and bring his obvious suffering to an end. Looking at his records it was clear that this ulcer had been grumbling on for a couple of weeks by this stage, and despite ongoing treatment with medicated drops it was getting worse rather than better.

At this stage we had a couple of options to consider. One was to refer Sylvester to an eye specialist, but this was quickly ruled out by his owner on the ground of cost and lack of pet insurance cover. The second option would be to continue with medical therapy, taking a swab to find out exactly which bacteria were causing the ongoing damage and preventing the ulcer from healing and potentially changing the eye drops once these results were known. The downside of this course of action was that it would do little to alleviate Sylvester’s discomfort in the short term, but after talking to his owner and explaining that the only other option would be surgery to remove the eye, we agreed that we would try this first.

So I took a swab from Sylvester’s eye and sent it away to the laboratory to see what they could tell us about the infection. While we waited for the results we did what we could to manage Sylvester’s discomfort with painkillers and anti-inflammatories, and then as soon as the results were in we started him on an aggressive course of antibiotics that were targeted specifically at the bacteria the swab had isolated. At this stage I was still optimistic that we could save Sylvester’s eye, but unfortunately things didn’t work out as planned and despite our new treatment regime, the ulcer stubbornly refused to respond and after a week of treatment it became clear to me that we were left with only one option – to remove Sylvester’s eye.

Breaking this news to his owner was not easy, but she did appreciate that it wasn’t fair to let him continue to suffer as he was doing given the now very slim chance that we would be able to save his eye. After a couple of long – and emotional – consultations, we agreed to go ahead and last Friday Sylvester came into the surgery for his operation.

Sylvester the cat under anaesthetic after the operation to remove his eye

Removing an eye is an operation I really don’t enjoy, as I can’t help but really feel for the poor animal that is losing such a crucial part of their anatomy, and the operation itself is also technically tricky and pretty gruesome. Sylvester’s operation went as well as I could expect, but it was not one that I finished with a sense of satisfaction – I felt good that we had brought Sylvester’s suffering to an end, but I also felt as though we’d failed him by having to resort to such a procedure.

If you have any concerns about your cat’s eye please contact your vet or use the interactive cat symptom guide to help you decide what to do next.