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PEER REVIEWED Article
Feline Acute Pain Series
ASSESSMENT
OF ACUTE
PAIN IN CATS
Sheilah Robertson, BVMS (Hons), PhD,
MRCVS, Diplomate ECVAA, ACVAA, ACAW, &
ECAWBM (Welfare Science, Ethics and Law)
Michigan State University

it’s not just how it feels but how it makes you feel.
—Professor Jackie Reid, University of Glasgow

P
ain is a multifactorial experience, with sensory Objective Measures of Pain
(“ouch”) and affective (emotional) components.1 Physiological changes, such as changes in heart rate, blood
Untreated pain can delay recovery, decrease quality pressure, and plasma cortisol, occur in response to sympa-
of life, and disturb the human–animal bond.1 Pain also thetic stimulation caused in part by pain.7 However, clini-
increases the body’s stress response to traumatic injury and cal experience should be used when assessing these objec-
causes alterations in metabolic and endocrine function. tive measures of pain because fear, stress, anesthesia, and
It is now well established that animals and humans have pharmacologic interventions also cause these parameters
similar neuro-anatomical pathways for the transduction, to change.7
transmission, and modulation of pain.1 A fundamental part
of quality, compassionate veterinary care is prevention and Pain Assessment Scales for Cats
management of pain and, therefore, it must be quickly rec- Currently there is no gold standard for assessing acute
ognized, assessed, and treated by the veterinary team. pain in cats. Several research groups, including Brondani
and colleagues, are in the process of developing and vali-
IDENTIFICATION OF PAIN IN CATS
Unfortunately, cats cannot verbally communicate to us
that pain exists or where it is located—the veterinary team
must determine these answers. In this species, pain assess-
ment relies on owners’ communication with clinic staff,
clinical judgement, and measurement of various parame-
ters that have been shown to correlate with pain.
Pain scoring scales2-4 and pain management guidelines
for cats1 have been developed for use in veterinary medi-
cine. Standardized pain scoring scales and pain manage-
ment guidelines promote a standard of care for hospital-
ized patients and facilitate optimal pain management, even
though different personnel care for a patient during its
stay. However, pain assessment is subjective, and changes
in pain may be subtle and difficult to evaluate without an
experienced eye.
Signs of pain and response to drugs vary greatly between
Figure 1. Gentle palpation of a surgical wound in a cat;
patients based on genetics, breed, and age.3,5,6 For this rea-
note the lack of response from the cat, which indicates
son, pain should be assessed visually and physically, pro-
appropriate analgesic use.
viding the animal cooperates during handling.

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| Assessment of Acute Pain in Cats

PAIN SCORING SYSTEM COMPONENTS

Table 1. Characteristics of an Optimal Pain The characteristics of an optimal pain scoring system for
Scoring System for Cats cats are listed in Table 1. It is now accepted that, in non-
verbal patients, pain scoring systems must be heavily based
• Simple and easy to use on behavior observation. These scales are multidimension-
• Identifies type, source, cause, and duration of pain
al and often referred to as composite pain scales.8
• Clearly defines assessment criteria for all observers,
including owners and veterinary team
SELECTING & USING SCORING SYSTEMS
• Sensitive to small changes in pain over time
• Describes where assessment should take place— When considering a scoring system, it is important to
homes versus veterinary clinic select a system that will suit the needs of the clinic. The
• Guides the user toward a treatment plan system should be:
• Analyzes the system’s strengths and weaknesses 1. User friendly—consider those who will be scoring pain,
• Validated for use in cats such as veterinary technicians and owners; the system
should be suitable for their needs.
2. When possible, used by the same individual each time
dating pain scales for clinical use.8 A survey of veterinary pain is assessed in a single patient in order to mini-
nurses reported that only 8.1% of veterinary practices used mize variation in scores, which can occur when several
a pain scoring system, yet 80.3% agreed it was a useful observers are involved.
clinical tool.9 3. Used in conjunction with the patient’s behavioral his-
Some scales that have been used to assess pain in cats tory in order to identify the cat’s “normal” behavior and
include: changes in behavior that may indicate pain.
• Visual Analog Scale (VAS): Consists of a line 100 mm 4. An integral and consistent part of the postoperative
long that has 0 (no pain) on one end and 100 (extreme record.
pain) on the other.10 Based on visual observation, the user
marks the point on the line that best correlates with the
patient’s pain intensity. The VAS is scored by measuring A
the distance between “0” and the user’s mark.
• Numerical Rating Scale: Pain is scored on a numerical
scale; for example, 0 to 5 or 0 to 10 based on different
observational and physical characteristics.3,4
• Descriptive Scale: Allows user to describe cat as having
no, mild, moderate, or severe pain.11
These scales are unidimensional and, although easy to
use and interpret, they are not very useful in distinguishing
subtle changes in pain, which prevents observers from “see-
ing the whole picture” or, in other words, noting the nuanc-
es that would provide a better assessment of the animal’s
wellbeing. When using these scales, the variability in pain
scoring among veterinary staff looking at the same patient
can be as high as 35%,12 which highlights the difficulties
encountered when different personnel care for a patient. B
Dynamic Interactive Visual Analog Scales (DIVAS)
have been used in cats in an attempt to improve on the
above scales.13 These scales use a 100-mm line, but the final
assessment is based on observation and interaction with
the cat, including palpation of wounds or other known
painful areas.

Importance of Palpation
Wound palpation is a frequently overlooked component
of assessing comfort levels in animals following surgery.
If analgesics have been used appropriately, the cat should
not flinch or bite when gentle pressure is applied on and
around a surgical wound (Figure 1). During palpation,
gently restrain the cat’s head for protection in case the cat Figure 2. Prior to surgery, the cat is in a fearful position
responds, and assess the response—from no response to (A), while postsurgery, the cat’s position indicates pain
the cat flinching, hissing/growling, turning toward han- due to its hunched, arched back and facial expression of
dler, or turning and attempting to bite. squinting, slanted eyes and pulled back whiskers (B).

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 Assessment of Acute Pain in Cats |

Table 2. A List of Categories & Clinical Signs for A

Recognizing Acute Pain in Cats
CATEGORY NO PAIN IN PAIN
Posture Relaxed Tense, stiff, rigid
Slightly curled up Stretched out or tucked up
Comfortable Crouched and/or hunched
Behavior Bright and alert Licking lips and/or
Head up salivating
At front of cage Head down
Grooming Hiding and/or at back of
Active and/or playing cage
Interactive with Cannot get comfortable B
people Licking at wounds
Aggressive
Vocalization Purrs when petted Growl and/or hiss
Normal, chirpy meow Long deep meow
Purring
Palpation of No response to Quick turning, flinching
Wound pressure Biting, aggression
Vocalization
Demeanor Interactive with Avoids people
people Avoids petting
Enjoys being petted Figure 3. Facial expression is an important
indicator of pain: a comfortable cat will be
Facial Open and relaxed Squinting, slanted, or bright and alert (A), while a painful cat may
Expression 8,15 eyes closed eyes keep its head down and demonstrate squint-
Head up Head down ing, slanted, and/or closed eyes; pushed back
Whiskers pulled back ears; and pulled back whiskers (B).

5. Applied both pre- and postoperatively—comparison of
the cat’s behavior before and after surgery, and noting
changes, is the best indicator of pain.
6. Part of the follow-up after injury or surgery; assessments
should be repeated often to ensure the cat is recovering
comfortably and appropriately, and responding to inter-
vention.
ROLE OF BEHAVIOR IN ASSESSMENT
A trip to a veterinary clinic and interaction with veterinary
staff can be very stressful for some cats; this stress results
in changes in physiologic parameters that are also seen
with pain.14 In addition, differentiating pain from fear and
anxiety can be challenging because some behaviors and
postures associated with pain and fear/anxiety are similar
(Figure 2). The more familiar you become with observ-
ing animal posture and behavior, the easier this process
becomes.
To assess behavior in cats:
• Identify the presence or absence of normal behavior and
new or abnormal behaviors
• For cats presented due to injury, ask the owner about the
cat’s normal behavior
• For cats presented for a surgical procedure, observe and
document preoperative, “normal” behavior, which can
then be compared to postoperative behavior
• Remember that it is not always the behavior itself, but
rather the changes in behavior (Figure 3) that help deter-
mine whether a cat is in pain and requires an analgesic.
Table 2 provides a comprehensive list of key categories
and clinical signs that should be assessed when determin-
ing whether a cat is in pain.
Behavioral domains, along with additional indicators,
such as blood pressure, have been used to create the UNE-
SP-Botucatu Multidimensional Composite Pain Scale
for Assessing Postoperative Pain in Cats, available at
animalpain.com.br/en-us/. The scale, complemented by
videos demonstrating specific pain behaviors, results in
a numerical pain score, and the website provides videos
that can be used to assess a veterinary professional’s abil-
ity to use the scale. Initially, this system may take consid-
erable time to complete but, with experience, it can be
done rapidly.
ASSESSMENT OF EFFECTIVE PAIN MANAGEMENT
Pain assessment tools should help you develop a treatment
plan, and should also indicate whether or not the interven-
tion is effective. If, after an intervention, the pain score
decreases, then treatment was effective, but continued
monitoring is needed to ensure the patient remains com-
fortable. Treatment of acute pain in cats will be discussed
in the next issue of Today’s Veterinary Practice.

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| Assessment of Acute Pain in Cats

another opioid or a different

class of drug, or using a com-
A B bination of drugs.
3. After additional pain medica-
tion is administered, improve-
ment in behavior should be
observed (Figure 4).
4. Remember, veterinarians have
a responsibility to adminis-
ter enough pain medication to
keep the cat comfortable.1

Duration of Treatment
The duration of treatment
of acute pain depends on the
degree of inflammation, which
is related to the amount of tissue
trauma. It is critical to manage
pain for the duration of active
inflammation.18 For example,
postsurgical inflammation can
cause pain for days (eg, ovar-
iohysterectomy) or weeks (eg,
major orthopedic surgery).
If uncertainty exists about
whether a cat still requires pain
intervention, use pain assessment
Figure 4. Cat with optimal pain management (A)—at the cage front, alert, and inter- and response to treatment as
acting with the staff—and in pain (B)—at the back of the cage and hunched up, with diagnostic tools. One of the big-
eyes squinted shut. gest mistakes in veterinary pain
management is providing good
Role of Analgesics pain control for a short time after tissue damage; then with-
Mechanistically, tissue damage from surgery or injury drawing analgesics before inflammation has started to sub-
causes release of inflammatory mediators at the site of the side. If sufficient inflammation is present, sensitizing the
wound. Inflammatory mediators sensitize the nerve end- nerve endings, it causes re-initiation of the pain pathway
ings around the wound, a process known as transduction. and results in ongoing pain for the cat. There should be
This information is then transmitted along the peripheral analgesic coverage for the entire healing process.
nerves to the central nervous system and then to higher
centers where, in the conscious animal, it is perceived as SUMMARY
pain. Pain medications alter the pain pathway to reduce Accurate pain assessment is essential for appropriate pain
pain perception. management. Key components to pain assessment include:
• Behavior and the cat’s interaction with humans
Analgesic Requirements • Posture and facial expression
Quite often it is difficult to determine how much and what • Observation of the cat pre- and postoperatively
type of pain medication should be administered to control • Discussion with the owner about the cat’s usual behav-
pain in cats. Pain can be perceived differently in individual ior, if observation is not possible before injury/surgery
cats and the same degree of inflammation can cause vary- • Treatment and re-evaluation, if there is uncertainty about
ing amounts of pain. Pain medications also have unique whether the cat is in pain.
effects on different animals due to metabolism, tissue Can pain be appropriately assessed and treated in cats?
specificity, and individual variation.5,6,16,17 Yes. The more attentive the health care provider is to sub-
To properly assess the effectiveness of pain management: tle changes in animal behavior, the more accurate pain
1. Perform frequent assessments by identifying whether recognition will be. There are excellent pain medications
clinical signs associated with acute pain in cats (Table available for cats, which ultimately allow for the delivery
2) are present. of compassionate and humane care.
2. If, after analgesic administration, the cat is still display- Read the next article in this series—Management of
ing signs of discomfort and pain, treat again and reas- Acute Pain in Cats—in the March/April 2014 issue of
sess. Treatment may involve using the same opioid as Today’s Veterinary Practice. n
originally administered, changing the dose, switching to
(Continued on page 83.)

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 Assessment of Acute Pain in Cats |

(Feline Pain continued from page 35.)

VAS = visual analog scale; DIVAS = dynamic interactive

visual analog scale;

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Sheilah Robertson, BVMS

(Hons), PhD, MRCVS, Diplomate
ECVAA, ACVA, ECAWBM (Wel-
fare Science, Ethics and Law), &
ACAW, is an associate professor
in the Michigan State University
College of Veterinary Medicine’s
Department of Small Animal Clinical Sciences.
She is co-author of the AAFP/AAHA Pain Man-
agement Guidelines and ISFM/AAFP Consensus
Guidelines: Long-Term Use of NSAIDs in Cats.

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