pain management Flashcards
(136 cards)
1
Q
Pain definition
A
-Pain is an unpleasant sensory and emotional
experience associated with tissue damage
-subjective to each individual
-pain responses can be measured including: behaviour, growth, stress, and many variables
2
Q
veterinary oath 4 points
A
➢ promote animal health and welfare,
➢ prevent and relieve animal suffering,
➢ protect the health of the public and the environment, and
➢ advance comparative medical knowledge
3
Q
castration cattle requirements
A
-To avoid unwanted breeding, reduce aggression
and improve carcass quality.
Code of Practice requirements (Beef cattle, 2013):
▪ Castrate calves as young as practically possible (preferably <1 week)
▪ Castration must be performed by competent personnel using proper instruments
▪ Seek guidance from your veterinarian on method, timing and pain control
▪ Use pain control to mitigate pain associated with castration in bulls older than 6 months
Code of Practice requirements (Dairy cattle, 2023): The procedure must be done as early as possible using local anesthesia and systemic analgesia
4
Q
castration pain
A
-all methods cause pain
-preferred method based of age and experience
-less pain in younger animals
-surgical/ burdizzo method causes acute pain, banding results in more chronic pain.
-inflammation and swelling lasts longer with band vs surgical
5
Q
Dehorning / Disbudding codes
A
To decrease the risk of injury for handlers and other cattle, and minimize the economic loss due to carcass bruising
-requirements:
▪ BEEF: Disbud calves as early as practically possible (<2-3 months)
DAIRY: Horn bud removal must be done by 2 months of age.
▪ BEEF: Dehorning must be performed by competent personnel using proper instruments
DAIRY: Banding is not an acceptable method of dehorning.
▪ BEEF: Seek guidance from your veterinarian on pain control. Use pain control to mitigate pain associated with dehorning after horn bud attachment
DAIRY: When removing buds or horns, local anesthesia and systemic analgesia must be provided. If larger horns must be removed, bleeding must be controlled.
6
Q
branding
A
-Permanent animal identification, easy to identify from a distance, and legally accepted as proof of ownership.
-It may be required by community pastures, lending institutions or for export.
-Dairy cattle must not be branded (Dairy cattle Code of practice)
-requirements (Beef Cattle):
▪ All cattle must be identified using an approved ear tag
▪ It must be performed with the proper equipment, restraint and by competent personnel (hot iron vs freeze branding).
▪ Do not brand wet cattle due to risk of scalding
7
Q
pain mitigation in branding
A
-less invasive in young animals, smaller wound, quicker recovery
-performed by competent operator, clean tools
-should not be performed when the animal is experiencing other stressors (castration)
8
Q
drugs for pain control in bovine
A
-Anesthetics causes short-lived numbness in a local region. Requires precise administration and time to
be effective.
-Analgesics (NSAIDs): Block/inhibit pain systemically for hours/days. User-friendly administration (i.m., s.c., oral, pour-on)
-Multimodal analgesia
is the best approach
9
Q
meloxicam injectable for bovine
A
-metacam, rheumocam
-NSAID with anti inflammatory and anti pyretic and analgesia
-label claim: diarrhea, pain following disbudding, mastitis, abdominal surgery
-plasma half life:cattle 17.5 hr calves 26 hr
-20 day Meat residue time
10
Q
meloxicam oral for bovine
A
-label claim: For alleviation of pain and inflammation following surgical and
band castration in cattle
-should be administered approximately 1-2 hours
prior to castration procedure.
-Plasma half-life: Cattle 28 h, Calves 40 h
-Meat withdrawl time 35 days
11
Q
Flunixin meglumine (banamine) bovine
A
-Commercial name: Banamine, Flunazine, Vetonixin
Label claim: Control of fever associated with BRD, endotoxemia and acute bovine mastitis. Also indicated for
the control of inflammation associated with endotoxemia, foot rot
-Plasma half-life: Cows 3.1 h, calves 6.8 h. Topical: 6.4 h.
-Warnings: Treated animals must not be slaughtered for
use in food for at least 6 days.
12
Q
ketoprofen bovine
A
-Label claim: Symptomatic treatment of fever, pain and inflammation associated with a variety of conditions
including: respiratory tract infections, endotoxemia, simple gastrointestinal disorders, and traumatic
musculoskeletal injuries
-Plasma half-life: cows 2 h, calves 0.4 h.
-Warnings: Treated animals must not be slaughtered for
use in food for at least 24 hours
13
Q
lidocaine bovine
A
-Commercial name: Lido-2, Lidocaine HCL 2% and epinephrine USP, Lurocaine
-Label claim: Local anesthetic agent which can be used for infiltration, nerve blocking or epidural anesthesia
-Warnings: Treated animals must not be slaughtered for use in food for at
least 5 days.
-Buffered: With Sodium bicarbonate 3:1 to 10:1
14
Q
Anesthesia bovine for dehorning and castration
A
-Dehorning: Cornual nerve block with local anesthesia,
plus pre-emptive analgesia/anti-inflammatory drugs
-Castration: Intratesticular / ring block spermatic cord-
neck scrotum / Epidural
15
Q
the four Ss of livestock pain management
A
-Suppress: When possible, make changes so a procedure is no longer necessary. E.g.: polled genetics.
-Substitute: Refine how the procedure is performed to reduce pain. E.g. disbudding, alternative ID
methods, immune castration,…
-Soothe: Use analgesics and anesthetics to prevent pain before the procedure starts. E.g.: NSAIDS,
lidocaine, xylazine,…
-Supplement: Back up the initial pain mitigation with a longer-acting analgesic. E.g.: Long lasting NSAID,
lidocaine bands,..
16
Q
rat/ rabbit/ ferret grimace scale
A
-orbital tightening
-nose/cheek flattening, less bulging
-ear changes, pointed shape forwards or outwards
-whisker changes, move forward, away from face
17
Q
analgesia in small mammal exotics opioids
A
-ferrets: lower dose of opioids compared to other small mammels (similar to cats)
-Buprenorphone in guinia pigs and chinchilas are (herbivors) so less absorption and need 10x the dose of a cat.
-oral transmucosal administration in guinia pigs have limited absorption but can be adminsitered more often.
-tramadol NOT for chinchillas
-opioids mostly used in hospital
18
Q
NSAIDs in small mammals (exotics)
A
-meloxican
-PK in ferrects dosage closer to small animal.
-elimination half life 8 hours needs to be administered 2x a day.
19
Q
lidocaine for small mammal analgesia
A
– Can be administered as a Constant Rate Infusion (CRI), alone, or in
association with other agents
– Toxic dose reported in rabbits: 4 mg/kg
– CRI 100 μg/kg/min has been demonstrated to provide better analgesia
than buprenorphine (0.06 mg/kg IV q8 hrs) for routine spay
– Visceral pain
■ Lidocaine and bupivacaine can be used for local blocks and epidural
20
Q
analgesia protocol small mammels
A
■ Opioid choice based on estimated intensity of pain
* Buprenorphine has plateau effect moderate pain
* Intense pain (fracture, visceral or orthopedic surgery…):
hydromorphone, morphine or fentanyl
■ Multi-modal analgesia plan
* Opioid + NSAID
* Opioid + lidocaine CRI in rabbits
21
Q
opiods in avians
A
-psittacines have K receptors so buturphanol. short half life. can also use tramadol.
-raptors: u receptors, dont use butorphanol. use hydromorphone at higher dosage.
-tramadol in raptors.
22
Q
NSAIDS in psittacines
A
-high metabolism so higher dose than mammals
-meloxican: for analgesia and arthritis.
-Not effective:
– Flunixin-meglumine in budgies and Patagonian conure (Musser, JAVMA 2013)
– Carprofen in HAP
23
Q
NSAIDs in raptors
A
-Diclofenac has been proven toxic in multiple raptor species (mostly vultures, but
also Steppe eagles
-many NSAIDS toxic in raptors
24
Q
reptile analgesia metabolism
A
-pain from burns, bites
-slow metabolism, lower dosages, longer duration and slower absorption
-metabolism depends on environment
25
pain in reptiles
-pain the same as mammals
-have pain pathways, behavior response.
-show aggression in preditor species.
-will often hide signs of pain
26
reptiles opioids
-chelonians:(turtles: u agonists , morphine, or hydromorphone but may cause resp effects. tramadol is good.
-lizards: pure u agonists. dont use butorphanol use morphine
-snakes: depends on species. butorphanol or morphone.
27
the chinese medicine vet theory for acupuncture
-focuses on flow of energy Qi
-Qi flows along meridians
-meridians on body surface are connected with inner organs
Blockage/Stagnation/Impairment of Qi results in disease, discomfort
- Manipulation of Qi achieved by acupuncture along meridians
- Stimulation of specific acupuncture points can release blockage of Qi flow
28
Acupuncture Meridians
-Pathways along which Qi and Blood circulate
* Connect internal organs with external body
* Maintain harmony and equilibrium due to smooth Qi flow
* 12 paired meridians corresponding to 12 organs (6 Yin, 6 Yang)
* Lung, Heart, Pericardium, Spleen, Kidney, Liver
* Large intestine, Small intestine, Triple burner, Stomach, Bladder, Gall bladder
* 2 additional non-paired meridians: Governor vessel and Conception vessel
* Meridians used for diagnosis and treatment
29
TCVM Diagnosis
Diagnositc acupuncture point exam DAPE: palpate along meridian and specific points to see abnormalities. Then come up with a list of points which are abnormal and come up with plan.
-elvaluate yin and yang, 5 elements of sheng and ko cycle.
30
western theory of acupuncture where points are located
-many or most points are located: where nerve bundles penetrate the fascia. close to BV and surrounded by small nerves (NAV bundle)
-at motor points where nerves exit or enter muscle.
31
western theory of acupuncture how it works
* Needle insertion results in microtrauma,
neurovascular reactions
* Release of substance P and histamine
* Stimulates ascending influences on the CNS
* Stimulates descending changes- i.e. axon reflexes
32
Western Theory: The Pain Model of acupuncture
-local effects of needle insertion: Capillary dilation and immune activation
* Tissue repair activation
* Local and supraspinal control
* Reduce inflammation
* Normalize circulation
-systemic effects of needle: effects on pain perception/ modulation, release endorphins. increase serotonin levels. infuences mylenated A-B fibers. and C fibers.
33
Western Theory: The Pain Model
Gate Theory
* Acupuncture acts at several levels to modulate peripheral and CNS response to painful stimulus
-has positive effect locally on pain from axon reflex pulling gate shut and reducing pain signals to the brain.
34
Acupuncture Effects/ results
* Pain relief, decreased inflammation
* Modification of other neuro-hormonal
pathways; eg. HPA, HPG axes?
* Modification of organ function?
35
dry needling
* Needles placed at certain points chosen after
general physical, lameness evaluation,
diagnostic acupuncture point exam, +/- TCVM
diagnosis
* Needles left in place for 10 – 30 minutes in
most cases
* Needle manipulation
36
Electroacupuncture
* Needles placed and low power, variable
frequency current applied between
needles with electrostimulator
* Electrostimulation for 15 – 120** minutes
* Enhances effects, especially pain relief
37
Acupoint Injection
* Hypodermic needles placed at acupuncture points
and a substance injected
* Saline (Aquapuncture)
* Vitamin B12 solution
* Low dose drug (Pharmacopuncture)
* Enhance, prolong effect of acupuncture (??)
* Reduce effective dose, risk of adverse effects of
some drugs (sedation)
38
Moxibustion
* Needles placed at acupuncture points
* Moxa (dried leaves of Artemisia spp,
“mugwort”) placed on needle and ignited
* Some practitioners burn moxa sticks over
acupuncture points without needles
* Heat may enhance acupuncture effect (??)
39
Laser acupuncture
* Low energy laser used on acupuncture
points (LLLT)
* Non-invasive, easier and faster than
conventional needling
* Very popular for athletic horses with
muscle soreness, stiffness (not just at acupuncture points!)
40
Acupuncture Complications
-Horses (Large Animals)
* Adverse Behaviour*
* Broken Needles
* Infection
-Small animals
* Ingestion of needles*
* Pneumothorax
* Broken Needles
* Infection
41
O2 content and O2 delivery
O2 delivery= O2 content x cardiac output
42
Factors affecting O2 delivery
* PaO2 (partial pressure O2)
* Hb concentration
* CO
* Diffusion from capillaries to
mitochondria
* Oxygen affinity of Hb
* Local blood flow
43
HYPOXEMIA
* FIVE causes of HYPOXEMIA:
* Decreased FIO 2
* Hypoventilation
* Shunt
* V/Q Mismatch
* Diffusion Impairment
- Hypoxic Drive:
* Takes over if PaO2 is less than 60 mmHg
* May result in hypocapnia
* Built in safety mechanism
44
45
how to sample blood for blood gas
-if we want to ssess lung function
* Take an arterial blood gas sample. NOT VENOUS
* Arterial blood has left the lungs and not passed through tissues
* If we want to assess body pH (acidosis-alkalosis)
* We can take a `mixed venous` sample
* Must have mixed blood from all body regions
* Take from pulmonary artery, but not easy
* Clinically acceptable to use the jugular vein
46
errors in sampling blood gas
-taking sample from wrong site.
-air bubble
-blot clots
-Arterial and Venous mixed samples
* Run samples immediately or put on ice (not longer 2 hours)
47
what do blood gas analyzer measure
* Electrodes measure:
* pH
* Partial Pressure O 2 (pO 2)
* Partial Pressure CO 2 (pCO 2)
* Do not measure Nitrogen, Nitrous oxide
* Co-oximeter measures:
* Hemoglobin content
* Saturation of hemoglobin molecule with O
-elctrolytes
48
how to evaluate blood gas
-look at pH
-* Does pCO 2 explain the change in pH?
* If not, what other conditions will produce H + ions?
* Define respiratory or metabolic acidosis
* Alkalosis not very common
* Look at pO 2 , sO 2 and O 2 Ct
* What concentration of O 2 is the patient breathing?
* Is patient on hypoxic drive?
* Is there enough Hb?
* How is O 2 delivery to the tissues maintained
49
measuring hypoxemia and pulmonary dysfunction
-anemia: good CO: pulse ox-normal, arterial gas normal, PaO2 LOW
-pulmonary dysfunction, good CO: pulse ox LOW, aterial gas LOW, paO2 LOW
50
chronic pain
Negative impact on:
◦ Quality of life & welfare
◦ Owner-animal bond
Can present with myriad clinical signs:
◦ Onset can be subtle with slow progression
◦ Behavior change, may only be evident at home but absent on exam.
-Requires a multimodal and holistic approach
51
nutrition in chronic pain
-Inflammation: Diet or nutrients can potentially modulate inflammation & oxidation
-Nutritional deficiencies: Efficacy of drugs may be diminished, impaired function or lethargy.
-Some chronic painful diseases benefit from nutritional management (osetoarthritis)
-pain effects muscle condition, decreased intake. frailty contributes to pain.
-Excess body fat -> systemic inflammation & metabolic abnormalities
-nutritional Influence on development (e.g. bone/joints) and health
52
nutritional assessment for pain
-diet history
-key nutritional factors for patient: goal is to prevent disease, slow progression and alleviate clinical signs.
-appetite & food intake: preferences, intake, nutritional status
-Body condition score (normal, mild, moderate or severe loss) estimates body fat %. cats want 5/9 dogs 4-5/9
-muscle condition: local and generalized
53
Nutritional Imbalance & Joint Diseases
-Developmental Orthopedic Disease (DOD)
◦ Nutritional management plays :a MAJOR role in prevention
-Osteoarthritis:
◦ Nutritional deficiencies in people contribute
◦ Antioxidants, B-vitamins, Minerals
◦ Nutraceuticals - may modulate presentation & progression
-Body composition
◦ Excess body fat -> pro-inflammatory, increased physical stress, etc.
◦ Inadequate body fat or muscle -> frailty -> weakness, instability, ↓ immune function
54
3 key nutritional factors increase risk of DOD
1. Excessive calories (not protein) growth is too rapid
◦ Excess stress on developing (soft) joints (even if puppy is not ‘fat’)
2. Calcium intake – deficiency or excess
◦ Puppies (esp. < 6 mo.) can’t regulate intestinal uptake of Ca2+
3. Unbalanced diets negatively affect growth
◦ Nutrient deficiencies, excesses, or inappropriate ratios
55
Large & Giant Breed Puppy
Recommendations to Minimize DOD
1. Maintain lean BCS (4/9) AND follow normal growth curve
2. Diet for Large Breed Puppies. No vitamin/mineral supplements: adding could throw off Ca:P ratio of 1:1 leads to unbalance.
3. Feed large breed growth diet until skeletal maturity complete
◦ Large/giant breed dogs – recommended for at least 18-24 months.
56
excess body fat leading to pain
Excess body fat in pets is common, but detrimental:
◦ Increases biomechanical stress
◦ Increases systemic inflammation
◦ Adipose tissue releases adipo(cyto)kines
ontributes to:
-Developmental orthopedic diseases during growth
- Development &/or exacerbation of joint injuries and osteoarthritis (OA)
- Increased incidence or severity of multiple other diseases
57
Osteoarthritis Requires a
Multimodal Approach
1 owner education
2 nutrition
3 modification of home and environment
4 pharmaceuticals
5 rehab therapy
58
OA nutritional plan
Core recommendations:
◦ Weight ‘optimization’ (don’t forget muscle condition)
◦ ‘Adequate’ EPA+DHA (Omega-3s)
◦ ‘joint’ diets or marine oils
◦ Overall diet should be complete and balanced
◦ Secondary options:
◦ Other nutraceuticals & supplements
59
Weight Optimization
& Nutrition for chronic pain management of OE
-(i.e., losing body fat) is the MOST EFFECTIVE therapy to improve mobility.
◦ Ideal BCS is great, but partial improvement still helps!
◦ Benefits observed with as little as 6.1% weight loss
-diet needs to be sustainable, dont just say feed less need to evaluate total intake.
60
muscle loss in chronic pain
Muscle loss leads to more pain and decreased mobility -> further loss
-occurs for many reasons: age, atrophy, dietary, rapid weight loss
-prevent: exercise, diet (good protein quality, total digestibility), EPA + DHA
61
Nutraceuticals & Osteoarthritis
Benefits may be:
Anti-inflammatory, anti-oxidative, anti-catabolic, or analgesic
Hope for potential ‘chondroprotectives’ or disease-modifying agents
that favor formation & maintenance of cartilage over destruction
◦ Protect cartilage, chondrocytes, and/or synthesis of certain
macromolecules by chondro- & synoviocytes
◦ Inhibit degradative enzymes and inflammatory mediators
◦ Remove or prevent formation of fibrin, thrombi or plaques in synovium or
subchondral blood vessels
62
Nutraceuticals for ‘joint support
Strong evidence = consensus on definite recommendations
◦ EPA + DHA (omega-3 fatty acids)
Negative or null evidence = no longer recommended
◦ Glucosamine & Chondroitin
Omega-3 PUFAs EPA+DHA have BEST OVERALL EVIDENCE as nutraceutical
-EPA and DHA are anti inflammatory and lead to increased resolvins and protectins. replaces archindonic acd AA in cell membranes.
-main source is always fish oil, krill, algae. need high concentration of EPA/DHA.
63
chronic pain time frame
Any pain lasting more than 3 months
Acute pain states can present chronically (e.g. root tooth
abscess)
Slow onset
Avoidance behavior masks pain identification
Veterinary assessment challenging
Acute pain measures not accurate
Behaviour problems are a common sequelae
64
types of chronic pain
1. Somatic inflammatory pain
2. Visceral
3. Neuropathic
* Can occur concurrently
65
pain fibers in chronic pain
-C fibers: unmyelinated, dull, poorly localized persistent pain. CHRONIC
-A delta fibers: myelinated, sharp, well localized
66
Treatment of Somatic Pain
Nociceptive stimulus usually evident
Usually well localized BUT not always
Dull, aching, throbbing, sore
NSAIDs (early stage)
NGF monoclonal antibody (Solensia / Librela)
Platelet rich plasma (PRP) therapy
Ancillary treatments important
-multimodal therapy, allergy treatment.
67
Chronic inflammatory (somatic) Pain
-ratio is A:C 1:2
Dermal, articular or musculoskeletal
E.g. Osteoarthritis, burns, trauma, surgery,
chronic infection, gingival disease, dental pain,
allergies
Inflammatory mediators
Persistent inflammatory pain can lead to other types of pain
E.g. neuropathic
68
Chronic Visceral Pain
Aδ:C ratio 1:10
Visceral afferent fibers travel with
parasympathetic nerves
E.g vagus nerve
Large overlapping receptor fields
Difficult to localize
Referred pain is common
E.g. Peritonitis, gastric ulceration, irritable bowel syndrome (IBD), pancreatitis, cancer, etc.
Gnawing, squeezing, cramping
69
Treatment of Chronic Visceral Pain
Treat the inciting cause
Dietary change may help: low CHO, high
protein and fat
Omega-3 fatty acids
Antispasmodic agents
Opioid agonist-antagonist or partial
agonists
NSAIDs, TCAs, SSRIs
70
Neuropathic Pain
Pain initiated or caused by a primary lesion or dysfunction in the peripheral or central
nervous system
Can be present in many conditions
E.g. cancer, chronic inflammatory disease
(including osteoarthritis), interstitial cystitis (cats)
Difficult to diagnose in animals
E.g. phantom limb pain
Shooting, burning, electric-like sensation, tingling, stabbing
71
Treatment of Neuropathic Pain
Generally start with NSAID trial: Add analgesic adjuvants such TCAs
Opioids may be helpful in some situations
Partial effectiveness
Multimodal approach more effective than
single therapy
72
rehabilitation
The use of noninvasive techniques to return non-human animals to functional
activity after injury. It includes the
application of heat and cold, ultrasound, electrical stimulation, low level lasers, and the use of stretching,
massage, therapeutic exercises, and
aquatic therapy.
73
cartilage with disuse and immobilization of joint
-decreased synovial fluid and diffusion
of nutrients
Decrease in
chondrocytes and
extracellular matrix
If splinted in flexion,
reversible thinning of
cartilage, if in extension irreversible changes
similar to osteoarthritis
(Erosion of cartilage,
osteophyte production)
74
what you want to avoid damage when immobilizing and splinting limbs
-splint in flexion
-don't want a fully rigid fixation (small amounts of movement will reduce cartilage damage)
-do passive range of motion without weight bearing to decrease stregnth loss in tendons and ligaments.
75
muscle response to disuse
Rapid atrophy and loss of strength
Weight-bearing is critical to maintain muscle mass
It takes at least 2 x as long to regain muscle as the immobilization time
-Type I (slow twitch ) fibers are more susceptible to
atrophy due to
immobilization
› Type I fibers are found in large numbers in postural muscles (eg. quads)
type II less likey
76
tendons and ligaments reaction to disuse
Rapidly lose strength when splinted
› Passive range of motion without weight-
bearing helps increase tensile strength
and realign fibers
› Insertion point of tendon/ligament on
bone is the weakest point
› After a year of remobilization tendons
and ligaments are still not at full strength
77
bone reaction to immobilization and disuse
› Bone production
decreases but
resorption continues
at normal or
increased rate
› Bone loss is more
pronounced in the
distal limb
› Bone loss is worse in
trabecular (spongy) bone than cortical bone
› Immature dogs lose bone faster, but also regain it faster once using limb
78
goals of rehabilitation
Reduce pain and inflammation in early
stages of healing
Minimize changes caused by disuse and
immobilization
Return the patient to normal activity by
making their range of motion,
proprioception and strength as normal
as possible
79
Myofascial Pain
= a regional pain syndrome characterized by myofascial trigger
points (MTP) in palpable taut bands of
skeletal muscle that refer pain to a distance.
-myofascial trigger points
80
myofascial trigger points
-dense, hyperirritable taut bands of muscle.
-pain on palpation
Can be a significant source of pain
Can contribute to central sensitization
Associated with motor dysfunction
Reduce athletic performance
Treated with acupuncture, massage,
laser, therapeutic ultrasound
81
crynotherapy
› Used during acute inflammatory phase (first 5 days) to decrease swelling, decrease activity of inflammatory factors and decrease tissue metabolism
› Provides analgesia by reducing nerve
conduction velocity and decreasing the
activation of A-delta fibers and C fibers
-cold and compression works best
82
heat as a modality in rehabilitation
Used in subacute and chronic inflammatory phases (starting after 5
days) to:
› Relax muscles
› Increase bloodflow to muscles
› Increase venous and lymphatic drainage
› Increase flexibility of superficial tissues before stretching
83
how heat works to decrease pain
› Increasing bloodflow to ischemic areas and
reducing muscle spasm
› Stimulation of cutaneous thermal receptors,
which decreases pain transmission to the
brain at the level of the dorsal horn in the
spinal cord
84
therapeutic ultrasound
The application of sound waves at
higher frequencies than can be heard
Cannot be done with a diagnostic ultrasound machine
Can reach up to 5 cm depth
Can choose either heating or non- heating settings
-heat should not be used in acute inflammation, in chronic conditions will promote inflammatory response and healing
85
indications for ultrasound rehabilitation
*To improve joint mobility
*To improve tendon and bone healing
*To reduce scar tissue, adhesions and
muscle spasms
*To treat calcified tendons
86
electrical stmulation E-stim 2 types
› Transcutaneous electrical neuromuscular
stimulation (TENS) is used for analgesia: stimulates endorphilns, blocks pain transmission, improves BF, decreases EDEMA
› Neuromuscular electrical stimulation (NMES)
is used for strengthening, stimulates muscle to contract, prevent muslce atropy and improve joint motion, helps circulation and reduce edema.
87
low level lazer/ cold lazer
-Laser light photons absorbed by
mitochondria and increase ATP production
Also see increase in nucleic acid
synthesis, cell division and fibroblast
proliferation
Good evidence for wound healing, some analgesia, self trauma, lick granulomas, burns.
88
low level laser rehab mechanism
Likely several mechanisms of analgesia
including:
› Modulating tissue levels of nitric oxide and
prostaglandins
› Anti-inflammatory effects
› Neural mechanisms that alter nerve
conduction velocities
› Increased release of endogenous endorphin
89
shockwave in rehab
The application of high velocity and high
pressure sound waves
Promotes tissue healing and analgesia
2 types
› Focused – increased depth of penetration,
requires sedation or anesthesia
› Radial – equal effectiveness to focused for
superficial structures, no sedation required
90
shockwave rehab mechanism
Tension and compression within tissues
result in cavitation bubbles within the
tissue
› Collapse of bubbles results in release of
energy, release of free radicals, increased
membrane permeability
› Can stimulate faster healing of soft tissues
and non-union fractures
91
shockwave rehab schedule and uses
Typical treatment schedule – once a
week for 3 treatments
Effects often last several months
Common uses in dogs:
› Osteoarthritis
› Chronic tendinopathies
› Non-union fractures
92
aquatic therapy underwater treadmill
-exercise post surgery day 3 or orthepedics day 7.
-tredmill best for extension of hip.
Helps improve range of motion and
mobility
Promotes weight loss
93
range of motion
-important to acheive normal after injury **most important part of rehab plan
-abnormal range can lead to abnormal locomotion.
-measured goniometer
There are 3 types of range of motion
exercises:
› Passive range of motion
› Active-assisted range of motion
› Active range of motion
94
stretching in rehab
Tissues taken just beyond normal ROM
Typically held for 15 – 30 sec and
repeated up to 20 times during a session
Stretching too fast or with excessive
force can damage tissues
95
massage rehab
goals:
› reduce muscle spasms
› reduce swelling
› pain relief
› relaxation
› release trigger points
96
types of cases which respond
-Post-operative
orthopedics
-Neurologic cases
-Degenerative myelopathy (helps maintain doesnt stop disease)
-soft tissue injuries
-osteoarthritis
-ICU patients
-cats
97
chronic cancer pain
- Pain arising from damage to the body by the cancer and
from the body’s response to the cancer (hyperalgesia, allodynia, ongoing pain, breakthough pain)
Cancer pain is best addressed by treating the cancer
Mainstays of cancer treatment are surgery, radiation therapy, chemotherapy
Cancer pain becomes chronic when the cancer cannot be cured or adequately controlled
98
Palliative intent cancer treatment
The goal of palliative treatment is to alleviate pain or discomfort associated with an incurable tumor.
-if you cannot alleviate pain= euthanasia
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Canine Appendicular Osteosarcoma what causes the pain
-Nociceptors in periosteum, bone and bone marrow
- Mechanical stimulation (tumor)
- Increased pressure within the bone: Microfractures, Stretching of the periosteus, Compression of the nerves due to collapse of the bone, Reactive muscle spasm, Nerve root infiltration
-Chemical stimulation (tumor and body): Prostaglandins, Inflammatory cytokines.
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Canine Appendicular Osteosarcoma characteristics
Biological behaviour: Locally invasive, Highly metastatic to distant sites (lung, bones)
-Definitive treatment: Surgery (amputation, limb spare) or radiation (stereotactic
radiation) for primary tumor
Chemotherapy to delay distant metastases
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how treatment of Canine Appendicular Osteosarcoma works
Amputation removes source of pain
Stereotactic radiation therapy (SRT) alleviates pain
(reduces mechanical and chemical stimulation of
nociceptors)
- Chronic cancer pain is best treated using multimodal
analgesia and multimodal treatment (targeting different pain pathways and using more than one therapy for treatment)
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drugs to decrease inflammation in chronic cancer pain
-NSAIDs that inhibit cyclooxygenases (COXs)
-COXs are enzymes that lead to production of prostaglandins ->inflammation
Prostaglandins are also involved in hyperalgesia and allodynia
First drug for most cancer pain unless contraindicated
Meloxicam, deracoxib, other
Grapiprant (prostaglandin receptor antagonist
-not used in patients that are on a steroid
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drugs to decrease pain signal in cancer
Gabapentin
5-10 mg/kg PO BID (can increase to TID and increase dose)
Sedation or ataxia can be dose-limiting
Amantadine
3-5 mg/kg PO SID to BID
? agitation, diarrhea
-others: tramadol, fetanyl (in patient), bisphosphontes
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Radiation Therapy for Chronic Cancer Pain
- The goal of palliative radiation therapy is to alleviate a symptom such as
pain, obstruction or bleeding in a patient with an incurable tumour
- Indications:
- Is the goal to alleviate pain or discomfort from an incurable tumour?
- Does the pet’s family fully understand the goal of treatment?
- Is the tumour the source of the clinical symptom?
- Is the patient’s condition stable enough for radiation treatment?
Contraindications:
Probability of pain improvement is low, and euthanasia is recommended
Metastatic disease (distant or regional) is not a contraindication to
treatment
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Radiation Therapy for Chronic Cancer Pain mechanism
Mechanism of action of radiation therapy:
Photons (high energy x-rays) damage DNA leading to cell death
Direct killing of tumour cells
Direct killing of host cells
Results in a decrease in mechanical and chemical
stimulation of nociceptors
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summary of chronic cancer pain management
Cancer pain can be alleviated by curing the tumour
Chronic cancer pain may occur when the tumour cannot be cured or put into remission
Goal is to improve quality of life, not quantity
Use of multimodal analgesia and multimodal treatment
achieves best outcome
The best endpoint to assess success of treatment of
chronic cancer pain is quality of life
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what supplement is the best for osteoarthritis and how much?
-omega 3s = EPA + DHA
-1-110 mg/kg for OA
-around 3400-4000 mg per day for severe OA less for anti-inflammatory
-DO NOT EXCEED 4800 MG per day
-fish oil/ marine based are best quality.
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FLUNIXIN MEGLUMINE HORSES
-banamine
* Anti-endotoxic
* Anti-inflammatory
* Prevent intra-abdominal adhesion formation
-great for colic pain
Side effects:
* Gastrointestinal
* Renal
* Intestinal healing delayed
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PHENYLBUTAZONE HORSES
* Musculoskeletal pain (Acute & chronic)
-needs to be dosed properly.
* Side effects:
* Gastrointestinal
* Renal
*can lead to Right dorsal colitis:
* Consider the weight of your patient DONT OVERDOSE
* PLEASE restrict owner access
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FIROCOXIB horses
- Cox 2 selective
* Spares the GI and renal systems
* Less potential complications/side effects
-used for:
* Osteoarthritis pain
* Long term pain management
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ACETAMINOPHEN horses
* Not an NSAID
* Adjunct therapy
* Analgesic
* Antipyretic
* Dose 30mg/kg PO BID
* Best if used in conjunction with an NSAID
* Laminitis, lameness
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GABAPENTINOIDS horses
-Gabapentin (Oral bioavailability in horses is poor)
*horses use Pregabalin
* Better oral bioavailability in horses
* Chronic pain – Laminitis, trauma
* Dose 2-4mg/kg PO BID – TID
* Can take a couple of day to see affect
* Usually start with high dose, then tape
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ALPHA 2 AGONIST horses
*Xylazine, detomidine, romifidine
* Sedatives
* Visceral analgesics
*but lead to Reduce GI motility
* Cardiovascular effects
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ALPHA 2 AGONIST method of action and xylazine in horses
-Sedation: Activation of CNS α2-receptors
-Synergism with opioids: Alpha-2 agonists and butorphanol
-Xylazine:
* Short half-life
* Moderate to severe pain
* Subjectively assess pain severity (“diagnostic aid”)
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levels of pain and treatment horses
-Mild: NSAIDS
-Moderate: NSAIDS, Gabapentinoids, Opioids, Alpha 2 agonists, Local anesthetics, CRI
-Severe (treatable)
* Opioids
* Opioids + Alpha-2 agonists
* Local anesthetics
* CRI
* Surgery
-Severe (uncontrollable)
* Euthanasia
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NSAIDS in horses
* Anti-inflammatory
* Anti-pyretic
* Analgesic
* Visceral vs. musculoskeletal pain
* Flunixin meglumine
* Phenylbutazone
* Ketoprofen
* Firocoxib
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OPIOIDS: Butorphanol
horses
-kappa agonist, Mu antagonist
* Butorphanol Most commonly used in horses
* Analgesic
* Mild to moderate visceral pain - Not appropriate for severe pain
* Sedative
* Reduces GI motility
* Analgesic dose 0.1 – 0.2mg/kg q2-4hrs
* Cost prohibitive
-xylazine leads to excitement so adding butorphanol can help horses stand better ex. joint injections.
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opiods horses buprenorphine
Longer duration of action
* Local anesthesia – Include in nerve block
-partial Mu agonist
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OPIOIDS
F UL L MU AG O N I S T S horses
* Morphine:
* Intramuscular, CRI, epidural
* Side effects can be severe in horses (IV)
* Excitement
* Disorientation
* Ataxia
* Ileus
* Can administered with alpha-2 agonist or Acepromazine
- Fentanyl - Patch
- Hydromorphone
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NMDA receptor antagonist horses pain
-ketamine
* Decreases glutamate binding to NMDA receptor in the dorsal horn
-doesn't stop pain but stops the perception of pain pathway
* Use in acute and chronic pain (block central sensitization)
* Intramuscular (low dose), CRI or epidural
* Side effects: Excitement, stall walking
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local anesthetics horses lidocaine
LIDOCAINE
* Local vs systemic administration (CRI)
* Potentiates analgesic actions of opioids and alpha-2 agonists (great with xylazine)
* Effects on gastrointestinal motility (prokinetic)
* Treatment for postoperative ileus
* Anti-inflammatory
* Decreases requirements for inhalant & injectable anesthetics
* Concurrent administration with flunixin allows for a decrease in
flunixin dose (improved intestinal healing)
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laminitis in horses
-chronic pain
-common disease, rotation of the coffin bone within the hoof capsule, lamina are inflamed and separating.
-inflammation has no where to go in hoof so severe pain and hard to control.
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acceptable euthanasia criteria
-induce loss of consciousness and death with minimal pain and distress
-reliability
-irreversibility
-safety of personnel
-species age, health
-emotional effect on people
-legal requirements
-PPE while working
-environmental impacts
-experimental or food animal impacts
-drug availability and human abuse potential
-many more
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ideal euthanasia 3 points
1. Depression of neurons necessary for life
function – loss of consciousness
Can include anesthesia
2. Hypoxia (cardiac and respiratory arrest)
3. Physical disruption of brain activity and destruction of neurons necessary for life
(loss of brain function).
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chemical agents for euthanasia INHALANT AGENTS
INHALANT AGENTS
Isoflurane (irritating)
Halothane, sevoflurane (non-noxious odour)
Nitrous oxide increase to speed of onset.
-chamber method <7 kg make sure large enough container to prevent hypoxia.
-human exposure downside
-confirmation of death required
Not appropriate for reptiles, amphibians, diving birds
and mammals
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chemical agents for euthanasia inhalants
- Carbon monoxide / dioxide:
Used for dogs/cats in some humane societies and for
rodents, birds
Species dependent aversion
- CO (Acceptable):
Signs of agitation, convulsions, muscle spasms,
vocalization common (dogs/cats)
SOURCE IS IMPORTANT, SLOWER BETTER
Blocks O2 uptake by RBCs
- CO2: (controversial)
30-40% needed for unconsciousness in dogs
60% in cats
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CO2 for euthanasia
CONTROVERSIAL but acceptable with conditions.
Pain carbonic acid (respiratory / ocular
membranes)
Breathlessness (respiratory acidosis) = panic
Direct simulation of amygdala = fear response
7.5% CO2 INCREASES the pain threshold
>30% anesthesia followed by death
>200mm Hg (blood concentration)
Acceptable with conditions (unconsciousness prior
to exposure preferred)
Gradual fill recommended
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non inhalation chemical euthanasia methods
-injectable/ oral
- Barbiturates drug class =Pentobarbital drug.
- Rapid, smooth
Possible excitement and agonal gasp
Consider adding propofol (or other sedation)
Controlled drug need a licensed veterinarian
Must be given IV
Confirmation of death required
Risk for scavenging (wildlife)
-in birds anesthetize first
-reptiles inject then keep for 2-3 days before releasing to owner. (hard to tell if dead)
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noninhalent pharmaceutical agent in euthinasia T-61
-local anesthetic, general anesthetic and neuromuscular blocking agent (paralysis)
-NOT CONTROLLED DRUG
-has to be given IV needs proper administration, has pain on administration.
-Mammals:
Dysphoria if injected too quickly
Respiratory paralysis (suffocation) before loss of consciousness.
- Birds:
Anesthesia immediate + EEG loss <6 seconds (good in birds)
- AVMA (acceptable) vs CCAC (not recommended)
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horse euthanasia
-pentobarbital:
IV required
Sedation or anesthesia recommended, thick slow liquid to inject need to be still.
Risk to scavengers, has to discard of body.
- Intrathecal lidocaine after anesthesia:
-blocks Na channels all and in CNS
Longer to respiratory, cerebral, brainstem, and
cardiovascular arrest compared IV barbiturates
Audible heart beat 5 minutes vs <1 min takes longer to die.
EEG 2 min vs 20 sec
Sedation required
Little risk to predators eating.
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NONINHALANT PHARMACEUTICAL AGENTS in euthanasia: Tricaine methane sulfonate (MS-222)
Suitable for fish and most amphibians
ADD Sodium bicarb required to buffer
NOT controlled drug
Used as an anesthetic
Some reptiles IC (AVMA vs unacceptable CCAC) some cannot be emersed need to breath
NEED Secondary method required to ensure death
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physical methods of euthanasia
- Captive bolt, gunshot, cervical dislocation, decapitation, electrocution*, kill traps*,
thoracic compression*, exsanguination*,
and pithing*
*Acceptable with conditions
Training and skill critical
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Penetrating captive bolt in euthanasia
Ruminants, horses, swine, laboratory rabbits, dogs, birds
Concussion and trauma to the cerebral hemisphere and
brainstem
Adequate restraint is important to ensure proper
placement of the captive bolt
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Euthanasia by a blow to the head
Acceptable for neonatal animals with thin craniums: Neonates, young piglets, small birds
Single sharp blow delivered to the central skull
bones with sufficient force can produce immediate
depression of the central nervous system and
destruction of brain tissue
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gunshot/ captive bolt positioning
-base of ear go from the side to reach brainstem in horse.
-cattle: 2 inch above eyes
-sheep and pigs: between eyes
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emergency situations euthanasia guidelines AMVA
Exsanguination should ONLY be considered if the animal is unconscious!
Cardiac puncture not acceptable in a conscious animal
