Refinement and initial validation of a

multidimensional composite scale for use in

assessing acute postoperative pain in cats
Juliana Tabarelli Brondani, DVM, PhD; Stelio Pacca Loureiro Luna, DVM, PhD;
Carlos Roberto Padovani, BMath, PhD

Objective—To refine and test construct validity and reliability of a composite pain scale for
use in assessing acute postoperative pain in cats undergoing ovariohysterectomy.
Sample Population—40 cats that underwent ovariohysterectomy in a previous study.
Procedures—In a previous randomized, double-blind, placebo-controlled study, a compos-
ite pain scale was developed to assess postoperative pain in cats that received a placebo
or an analgesic (tramadol, vedaprofen, or tramadol-vedaprofen combination). In the present
study, the scale was refined via item analysis (distribution frequency and occurrence), a
nonparametric ANOVA, and item-to-total score correlation. Construct validity was assessed
via factor analysis and known-groups discrimination, and reliability was measured by as-
sessing internal consistency.
Results—Respiratory rate and respiratory pattern were rejected after item analysis. Fac-
tor analysis resulted in 5 dimensions (F1 [psychomotor change], posture, comfort, activity,
mental status, and miscellaneous behaviors; F2 [protection of wound area], reaction to
palpation of the surgical wound and palpation of the abdomen and flank; F3 [physiologic
variables], systolic arterial blood pressure and appetite; F4 [vocal expression of pain], vocal-
ization; and F5 [heart rate]). Internal consistency was excellent for the overall scale and for
F1, F2, and F3; very good for F4; and unacceptable for F5. Except for heart rate, the identi-
fied factors and scale total score could be used to detect differences between the analgesic
and placebo groups and differences among the analgesic treatments.
Conclusions and Clinical Relevance—Results provided initial evidence of construct valid-
ity and reliability of a multidimensional composite tool for use in assessing acute postopera-
tive pain in cats undergoing ovariohysterectomy. (Am J Vet Res 2011;72:174–183)

T reatment of pain in cats historically has been ne-

glected.1–5 However, there is evidence that this sce-
nario is changing.6 One of the primary causes for this
problem may be the inherent difficulty in identifying
and quantifying the intensity of pain in a cat. The lack
of available and validated pain assessment tools for this
species may result in clinicians providing inadequate
pain relief.
The cornerstone for adequate pain treatment is the
availability of accurate pain assessment methods. Re-
liability and validity for pain assessment are vital for
use in recognizing pain, quantifying pain intensity, and
evaluating treatment effectiveness.7 Therefore, it is nec-
essary to develop pain instruments with established
reliability and validity for use in clinical practice and
research.
Received October 5, 2009.
Accepted January 13, 2010.
From the Department of Veterinary Surgery and Anesthesiology,
School of Veterinary Medicine and Animal Science, and the
Department of Biostatistics, Institute of Biosciences, UNESP
Universidade Estadual Paulista, 18618-970 Botucatu, SP, Brazil.
Supported by FAPESP – São Paulo Research Foundation.
Presented in part as a poster at the 10th World Congress of Veterinary
Anaesthesia, Glasgow, Scotland, September 2009.
Address correspondence to Dr. Brondani (jtbrondani@yahoo.com).
HR Heart rate
Abbreviations
RR Respiratory rate
SABP Systolic arterial blood pressure
Multiple instruments have been used for the as-
sessment of pain in small animals; however, few have
been validated for use in dogs,8–10 and to the authors’
knowledge, none of these pain-scoring systems has
been tested for validity and reliability in cats. The vi-
sual analogue scale is frequently used for pain assess-
ment in cats11–13; nevertheless, reliability and validity
of this scale have not been assessed in this species. A
major difficulty with visual analogue scales is that they
are subject to several observer biases in the absence of
specific or objective criteria for pain rating.14,15
To investigate the validity and reliability of an
instrument requires knowledge of the various com-
ponents and methods by which they may be tested.16
Validity is the effectiveness with which a test or scale
measures the property being investigated.10 However,
it should be clear that validation is not performed for
the measuring instrument but instead for the measur-
ing instrument in relation to the purpose for which it
is used.17

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 Validity may be estimated via several methods. Var-
ious terms have been used to describe the assessment of
validity, but it is traditionally subdivided into content,
construct, and criterion validity.10,18,19 However, it has
been recently proposed20 that validation is a process of
hypothesis testing and should not be constrained by the
aforementioned concepts.
Content validity is the judgment as to whether an
instrument samples all of the relevant or important con-
tent or domains.20 Criterion validity considers whether
scores on the instrument agree with a definitive crite-
rion-referenced measurement of the same theme21; in
other words, it compares the test with other measures
or outcomes already validated. Criterion validity may
be divided into concurrent and predictive validity, de-
pending on whether the criterion refers to a current or
future state.21 It should be mentioned that both content
and criterion validity have limitations: the former be-
cause it is only based on judgment of experts regard-
ing the content of the items, and the latter because of
a lack of relevant criterion variables for comparison.
On the other hand, construct validity has generalized
applicability because it focuses on the extent to which
a measure performs in accordance with theoretical
expectations.17
Construct validity refers to how well an instru-
ment actually measures the construct it is intended to
measure.22 Construct validity is often provided in the
form of factor analyses and evidence for the ability of
the measure to discriminate among groups.21 Construct
validity can be evaluated in numerous ways because it
is possible to perform several predictions on the basis of
a theory or construct.20
Reliability concerns the degree to which the results
are consistent across repeated measurements.17 In other
words, reliability assesses whether a test is measuring
a factor in a reproducible manner. Reliability can be
based on a single administration of the measure (inter-
nal consistency) or by examining the reproducibility of
a measure administered > 1 time (stability).20
The purpose of the study reported here was to re-
fine and test construct validity and reliability of a com-
posite pain scale used for assessing acute postoperative
pain in cats undergoing ovariohysterectomy. Construct
validity was investigated via factor analysis and known-
groups discrimination. Exploratory factor analysis was
used because no a priori hypothesis about the corre-
lations among the variables could be proposed. The
hypothesis supporting the known-groups discrimina-
tion was that the factor scores and the total score for
the scale could be used to distinguish cats with pain
(placebo group) from cats treated with analgesics or to
discriminate among the various analgesic treatments.
Reliability was assessed via internal consistency of the
scale. It was assumed that although the scale was multi-
dimensional, the total score could be used if there was a
correlation between the factors and acceptable internal
consistency of the overall scale.
Materials and Methods
Sample population—Data for 40 client-owned
cats that underwent ovariohysterectomy in a previ-
ous study23 were used in the study reported here. Cli-
AJVR, Vol 72, No. 2, February 2011 175
09-10-0348r.indd 175
ent consent had been obtained for use of the cats in
that study,23 and that study had been approved by an
institutional animal research ethics committee (No.
123/2003).
Study procedures—The present study had 2 phas-
es. Phase 1 consisted of refinement of the composite
scale previously developed in the aforementioned
study23 for use in assessing acute postoperative pain in
cats undergoing ovariohysterectomy. Phase 2 involved
the initial assessment of construct validity and reliabil-
ity of the refined composite pain scale.
Development of composite pain scale—The com-
posite pain scale for use in assessing acute postopera-
tive pain in cats was developed in a previous study23
for use in evaluating the analgesic efficacy of tramadol,
vedaprofen, or the tramadol-vedaprofen combination
in 40 cats undergoing elective ovariohysterectomy. The
pool for the scale items was selected from instruments
available in the literature and specifically designed for
use in the assessment of acute pain in dogs,8,9 cats,24,25
or both.26 After the initial selection of items from the
available scales, some items were modified and provid-
ed with better descriptions on the basis of the clinical
experience of the authors and pain indicators in cats
reported in the literature.27
The first version of the scale for the previous study23
consisted of 7 physiologic (HR, RR, respiratory pattern,
SABP, rectal temperature, salivation, and pupil size)
and 10 behavioral (facial expression, posture, comfort,
movement, reaction to palpation of the surgical wound,
reaction to palpation of the abdomen and flank, vocal-
ization, behavior, mental status, and appetite) items.
Ordinal items were ranked numerically on the basis
of information obtained from the literature8,9,24–26 and
the investigators’ clinical experience, with 0 indicating
normal or no change and the highest value indicating
the most marked change. Nominal items were assigned
a value of 0 or 1 for absence and presence of change,
respectively. Observers were instructed to choose the
single value within each item that best fit the condition
of a cat. Scores for each item were summed to calculate
a total score.
The first version of the scale was used in the pre-
vious study23 to assess acute postoperative pain in 40
cats that underwent ovariohysterectomy. Cats were al-
located into 4 groups (10 cats/group) and were treated
with analgesics (tramadol, vedaprofen, or tramadol-
vedaprofen combination) or a placebo.23 Anesthesia
was induced with propofol and maintained with isoflu-
rane to perform the surgery. One hour after the end of
surgery, all cats were completely recovered from anes-
thesia. One investigator who was unaware of the treat-
ment group for each cat administered the drugs and as-
sessed postoperative pain by use of the aforementioned
composite pain scale at regular intervals for 7 days.
Refinement of the composite pain scale (phase
1)—On the basis of results of the previous study,23 the
first refinement of the scale in the present study was per-
formed to modify the structure and content. Items that
did not have variability (salivation and facial expres-
sion), that had interference from the analgesics (rec-
1/20/2011 12:53:47 PM
 tal temperature and pupil size), or that were dependent
on other variables (behavior) were removed from the
composite pain scale. Because squinted eyes was the
only facial expression modified by pain, it was includ-
ed in the item miscellaneous behaviors; miscellaneous
behaviors also included other behavioral changes (eg, tail
wagging, contracting and extending the pelvic limbs, con-
tracting the abdominal muscles, and licking or chewing
on the wound area) observed during the study. The item
identified as movement was replaced by activity, and cat-
egories were discriminated better. The item mental status
was changed from a nominal item to an ordinal item.
After the first refinement, the instrument was
transformed to an ordinal scale, except for the nominal
item respiratory pattern. This transformation increased
the possibilities for the use of data in statistical analysis.
The refined data were resubmitted to statistical analysis
to improve application of the data. A new detailed con-
tent analysis was then performed. Some items and cat-
egories of the scale were specified better and clarified.
Item analysis
A series of statistical analyses were conducted to
investigate the relevance of the remaining items of the
scale. The statistical analysis was based on data col-
lected during the immediate postoperative period (first
hour after the end of surgery) and at the second day
after surgery (mean for evaluations conducted 24, 28,
and 32 hours after surgery) for the previous study.23 All
of the cats were completely recovered from anesthesia
by 1 hour after the end of surgery. The analysis was
performed for these 2 time frames because the behav-
ioral and physiologic changes were modified during the
postoperative period by a reduction in pain intensity
or as a result of adaptation to pain. Therefore, relevant
items were discriminated to assess pain in the immedi-
ate postoperative period and at the second day after sur-
gery. Items that were rejected in ≥ 3 statistical analyses
were removed from the composite pain scale.
Frequency distribution
Variation of the response within each item and
during the interval between the first hour after the end
of surgery and the second day after surgery was veri-
fied via the frequency distribution of the scores of each
item. Items that had low variability and that did not
change over time were rejected.
Occurrence distribution
Data were initially transformed for dichotomous
items, where 0 was absence of pain and any value other
than 0 was considered presence of pain. Items that could
not be used to identify the presence of pain and distin-
guish groups that received analgesic treatments (trama-
dol, vedaprofen, or tramadol-vedaprofen combination)
from the placebo group were rejected. The Goodman
test28 was used to analyze the frequency and occur-
rence distributions. Values of P < 0.05 were considered
significant.
Nonparametric ANOVA
The ability of an item to identify treatment with
tramadol (with or without vedaprofen) or treatment
176
09-10-0348r.indd 176
with vedaprofen (with or without tramadol) was in-
vestigated by use of nonparametric repeated-measures
ANOVA for 2 factors (group and time). The ability of each
item to differentiate the time of assessment (first hour af-
ter the end of surgery and the second day after surgery)
was also investigated. Significance was set at values of P
< 0.05.
Item-to-total score correlation coefficient
Item-to-total score correlations were evaluated by
calculating the nonparametric Spearman rank correlation
coefficients between each item and the sum of all items
for the scale. This correlation coefficient assessed the rele-
vance of each item in the instrument and identified items
that contributed strongly to the score for the overall scale.
Items with a correlation coefficient < 0.4 were rejected.
Validity and reliability testing (phase 2)—Con-
struct validity and reliability testing of the refined com-
posite pain scale were evaluated.
Construct validity of factor structure
Factor analysis is a mathematical procedure used
to reduce sets of interrelated variables to a small num-
ber of underlying factors that usually cannot be directly
observed. Factor analysis is able to determine the num-
ber of factors (dimensions or domains) that are repre-
sented by different variables.29 Factor analysis provides
a determination of the dimensionality of the scale.19
Principal-components analysis with varimax rota-
tion was performed to examine the underlying factor
structure. The varimax rotation method allowed us to
obtain factors with the greatest potential of interpret-
ability. The identification of factors was based on the
Kaiser criterion,30 which suggests retaining all com-
ponents with an eigenvalue > 1. The factor structure
was determined by attributing any items that had fac-
tor loadings > 0.5 and communality > 0.7 to a specific
factor. Factor-to-total score and interfactor correlations
were analyzed by use of the Spearman rank correlation.
Construct validity of known-groups discrimination
Known-groups discrimination involves determin-
ing whether there can be significant discrimination of
pain scores among groups of subjects with specific char-
acteristics who are expected to differ in their amount of
pain. A nonparametric ANOVA for 2 factors (group and
factor) was performed to enable us to detect whether
the factors identified in the factor analysis were able to
distinguish pain of differing severity. It was determined
whether the factors could discriminate cats with pain
(placebo treatment) from cats treated with analgesics
(tramadol, vedaprofen, or tramadol-vedaprofen combi-
nation) or distinguish among cats receiving the various
analgesic treatments. Additionally, because the scale
can be used with a total score instead of a factor score,
the Kruskal-Wallis test followed by use of the Dunn
method was applied to investigate whether the total
score was able to distinguish between or among groups.
Reliability of internal consistency
Internal consistency refers to the degree of in-
terrelation among the items in the measure.31 It was
AJVR, Vol 72, No. 2, February 2011
1/20/2011 12:53:48 PM
 assessed by calculating the Cronbach α coefficient,
which measures reliability in terms of the ratio of
true score variance to observed score variance.32 Al-
though a high degree of internal consistency is as-
sociated with unidimensionality, a set of items can
be somewhat interrelated and multidimensional.33
Because the factor analysis identified > 1 dimension,
the internal consistency of each factor was initially
calculated by use of the following modified equation
for the Cronbach α coefficient:
day after surgery. Respiratory rate was rejected at the
first hour after the end of surgery and at the second day
after surgery because it had low variability and did not
change over time.
Occurrence distribution
At the first hour after the end of surgery, RR and
vocalization could be used to discriminate the placebo
group from the analgesic-treated group, but it could
not be used to identify the presence of pain. Reaction

Σ
κ
to palpation of the surgical wound could be used to
α F = (k/[k – 1])•(1 – [{ •Ci2•si2}/s2TF]) identify pain but not to distinguish the placebo group
i=1 from the analgesic-treated group. Respiratory pattern
was the only item rejected at the first hour after the
where k is the number of items of the factor (although end of surgery because it could not be used to identify
each factor was represented only by items with factor the presence of pain nor distinguish the placebo group
loading > 0.5, the factor included all items of the scale), from the analgesic-treated group.
Ci2 is the square of the factor loading of i items, si2 is the
variance of i items, and s2TF is the total variance of the fac- Table 1—Results of item analysis of a composite pain scale
used for assessing acute postoperative pain in cats undergoing
tor. Factors that did not have minimally acceptable inter- ovariohysterectomy for evaluations conducted at the first hour
nal consistency were deleted from the scale, and the classi- after the end of surgery and at the second day after surgery in a
cal raw Cronbach α coefficient32 based on item correlation previous study.23
was calculated for the overall scale. Values for the α coeffi- First hour after Second day after
cient were categorized as follows: 0.60 to 0.64, minimally Item the end of surgery surgery
acceptable; 0.65 to 0.69, acceptable; 0.70 to 0.74, good;
HR CD B C D*
0.75 to 0.80, very good; and > 0.80, excellent.34 RR A C D* A B C D*
Respiratory pattern B C D* B C D*
Results SABP — B C D*
Posture — BD
Refinement of the composite pain scale (phase Comfort — B C D*
Activity — —
1)—Results were determined for phase 1.
Reaction to palpation of the — —
surgical wound
Item analysis Reaction to palpation of the — C
Items rejected in ≥ 3 of the statistical analyses were abdomen and flank
deleted from the scale (Table 1). Vocalization C B C D*
Mental status — C
Appetite C B C D*
Frequency distribution Miscellaneous behaviors — B C D*
Reaction to palpation of the surgical wound did Exclusion criteria were as follows: A = Frequency distribution,
not change over time. Low variability was observed for B = Occurrence distribution, C = Nonparametric ANOVA, and D =
respiratory pattern, vocalization, and miscellaneous be- Item-to-total score correlation coefficient.
haviors at the first hour after the end of surgery and for *Variable was excluded from the final version of the composite
pain scale because it was rejected in $ 3 statistical analyses.
respiratory pattern, SABP, posture, comfort, activity, vo- — = Not rejected in any statistical analysis.
calization, and miscellaneous behaviors at the second
Table 2—Spearman rank correlation coefficient for item score to total score of a composite pain scale for
use in assessing acute postoperative pain in cats undergoing ovariohysterectomy for evaluations conducted
at the first hour after the end of surgery and at the second day after surgery in a previous study.23

First hour after Second day

the end of surgery after surgery
Item r P value r P value
HR 0.280* 0.080 0.245* 0.127
RR 0.346* 0.029 0.238* 0.138
Respiratory pattern 0.331* 0.036 –0.224* 0.163
SABP 0.684 , 0.001 0.301* 0.058
Posture 0.915 , 0.001 0.362* 0.021
Comfort 0.885 , 0.001 0.342* 0.031
Activity 0.942 , 0.001 0.546 ,0.001
Reaction to palpation of the surgical wound 0.834 , 0.001 0.892 , 0.001
Reaction to palpation of the abdomen and flank 0.700 , 0.001 0.788 , 0.001
Vocalization 0.483 0.001 0.267* 0.095
Mental status 0.849 , 0.001 0.554 , 0.001
Appetite 0.607 , 0.001 0.208* 0.198
Miscellaneous behaviors 0.709 , 0.001 0.074* 0.644

*Item was rejected on the basis of r , 0.4.

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 Table 3—Results of analysis via a rotated component matrix by use of the principal component
extraction method and varimax rotation with the Kaiser criterion of a composite pain scale used for
assessing acute postoperative pain in cats undergoing ovariohysterectomy in a previous study.23

Factor loading*
Item Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Communality†
HR 0.056 0.005 0.021 –0.033 0.968‡ 0.942
SABP 0.179 –0.472 0.574‡ 0.333 0.278 0.773
Posture 0.848‡ –0.282 0.385 0.114 0.046 0.962
Comfort 0.860‡ –0.258 0.349 0.077 –0.008 0.934
Activity 0.815‡ –0.321 0.390 0.193 0.049 0.959
Reaction to palpation of 0.577 –0.629‡ 0.063 0.317 0.074 0.839
the surgical wound

Reaction to palpation of the 0.344 –0.868‡ 0.176 0.028 –0.056 0.906

abdomen and flank
Vocalization 0.221 –0.092 0.050 0.916‡ –0.075 0.905
Mental status 0.832‡ –0.219 0.153 0.279 0.041 0.842
Appetite 0.395 –0.096 0.837‡ –0.085 –0.064 0.877
Miscellaneous behaviors 0.653‡ –0.193 –0.208 0.507 0.296 0.851

Eigenvalue 3.932 1.723 1.556 1.450 1.126 NA
Variance (%) 35.8 15.7 14.1 13.2 10.2 NA
Accumulated variance (%) 35.8 51.5 65.6 78.8 89.0 NA

*Factor loading represents correlations between the variables and factors. †Communality represents the
proportion of the variance for each item that can be explained by the factor. ‡Item was substantially loaded
for the factor.
NA = Not applicable.

At the second day after surgery, activ-

ity, reaction to palpation of the abdomen
and flank, and mental status could be used
to discriminate the placebo group from the
analgesic-treated group; however, it could
not be used to identify pain. Reaction to
palpation of the surgical wound could be
used to identify the presence of pain and
to distinguish the placebo group from the
analgesic-treated group. Heart rate, RR, re-
spiratory pattern, SABP, posture, comfort,
vocalization, appetite, and miscellaneous
behaviors were rejected at the second day
after surgery because they could not be
used to identify the presence of pain nor
to distinguish the placebo group from the
analgesic-treated group.

Nonparametric ANOVA Figure 1—Schematic depiction of rank Spearman correlation coefficients for interfac-
Heart rate, RR, respiratory pattern, tors, factor-to-total score, and item-to-total score for a 4-factor model of a composite
vocalization, and appetite were rejected at pain scale for use in assessing acute postoperative pain in cats undergoing ovario-
hysterectomy. All coefficients reported were significantly (P < 0.001) different from
the evaluation conducted 1 hour after the 0. *Total score did not include the excluded items HR, RR, and respiratory pattern.
end of surgery. Comfort, activity, reaction
to palpation of the surgical wound, reaction to pal- ble 2). Heart rate, RR, and respiratory pattern were re-
pation of the abdomen and flank, mental status, and jected because their correlation coefficients were < 0.4.
miscellaneous behaviors could not be used to identify Item-to-total score correlation at the second day after
treatment with vedaprofen. At the evaluation on the surgery ranged from 0.074 to 0.892. Heart rate, RR, re-
second day after surgery, only reaction to palpation spiratory pattern, SABP, posture, comfort, vocalization,
of the surgical wound could be used to discriminate appetite, and miscellaneous behaviors were rejected.
treatment with tramadol or vedaprofen. Posture and
activity remained in the composite pain scale because Validity and reliability testing (phase 2)—Results
they could be used to distinguish between the times of were determined for phase 2.
assessment.
Construct validity of factor structure
Item-to-total score correlation coefficient Inappropriate items (RR and respiratory pattern)
Item-to-total score correlation at the first hour after were removed on the basis of the previously defined
the end of surgery ranged between 0.280 and 0.942 (Ta- criteria. Exploratory factor analysis was then performed

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 Table 4—Median (minimum and maximum) values of factor scores and total score of a composite pain scale for use in assessing acute
postoperative pain in cats undergoing ovariohysterectomy and receiving various analgesic treatments (10 cats/group) in a previous
study.23
Factor Placebo
1 12.041 (6.361, 15.344)
a
2 –6.393a (–8.620, –2.776) –2.122b (–6.623, 0.005)
3 5.178 (1.693, 6.650)
a
4 3.747a (2.540, 7.992)
5 3.085 (1.668, 4.607)
Total score† 18.500a (9.000, 25.000)
*Values were considered significant at P , 0.05. †The total score did not include HR, RR, and respiratory pattern.
a–d
Within a row, values with different superscript letters differ significantly (P , 0.05).
with the 11 remaining items for the evaluation at the
first hour after the end of surgery.
Three components attained eigenvalues > 1.0 on
the unrotated factor solution; however, the interpre-
tation of the pattern matrix (with varimax rotation)
resulted in a 5-factor solution with eigenvalue magni-
tudes of 3.93, 1.72, 1.55, 1.45, and 1.12. All items had
satisfactory factor loadings and communality (Table 3).
Factor-to-total score and interfactors correlations were
high (Figure 1).
Dimensions were labeled F1 (psychomotor change
[posture, comfort, activity, mental status, and miscel-
laneous behaviors]), which accounted for 35.8% of the
total variance; F2 (protection of wound area [reaction
to palpation of the surgical wound and reaction to pal-
pation of the abdomen and flank]), which accounted
for 15.7% of the total variance; F3 (physiologic vari-
ables [SABP and appetite]), which accounted for 14.1%
of the total variance; F4 (vocal expression of pain [vo-
calization]), which accounted for 13.2% of the total
variance; and F5 (HR), which accounted for 10.2% of
the total variance.
Construct validity of known-groups discrimination
The total score and scores for F1, F2, F3, and F4
could be used to distinguish the placebo group from the
analgesic-treated group as well as to distinguish among
groups receiving the various analgesic treatments. Fac-
tor 5 (HR) could not be used to distinguish the pla-
cebo group from the analgesic-treated group or to dis-
tinguish among groups receiving the various analgesic
treatments (Table 4). On the basis of this result, the
total score did not include values for HR or items re-
jected in the item analysis (RR and respiratory pattern).
Reliability of internal consistency
Internal consistency of each domain (subscale)
as expressed by the modified Cronbach α coefficient
was excellent for F1 (0.8985), F2 (0.8841), and F3
(0.8025); very good for F4 (0.7662); and unacceptable
for F5 (0.2835). On the basis of these results, HR was
removed from the composite pain scale. The Cronbach
α coefficient for the overall scale with the remaining
items was 0.8672, which indicated excellent internal
consistency.
The final version of the composite pain scale rep-
resented 10 items scored categorically and distributed
in 4 domains (subscales; Table 5). The total score was
based on a sum of 4 subscales and ranged from 0 (no
AJVR, Vol 72, No. 2, February 2011 179
09-10-0348r.indd 179
Tramadol Vedaprofen Tramadol-vedaprofen P value*
1.852 (0, 11.473)
b
9.738 (4.061, 12.347)
c
1.067 (0, 2.512)
b
, 0.001
–5.386a (–6.869, –2.919) –1.150c (–2.065, 0.010) , 0.001
1.014 (0, 6.176)
b
2.949 (1.215, 6.516)
c
0.100d (–0.082, 2.570) , 0.001
0.723b (–0.033, 3.303) 3.164a (1.178, 6.716) 0.455c (–0.066, 0.987) , 0.001
1.778 (0, 4.329) 1.510 (0.697, 3.810) 1.600 (0, 3.274) . 0.05
4.000b,c (0, 18.000) 15.000 a,c (6.000, 18.000) 2.000b (0, 5.000) , 0.001
pain) to 28 (maximum pain). Alternatively, the total fi-
nal score could be adjusted to a scale of 0 to 100 by
multiplying the total score by 3.47 (ie, total score X
[100/28] = adjusted score). This procedure can facili-
tate the ranking of pain intensity because it is generally
accepted that when a scale of 0 to 100 is used, scores
< 30, from 30 to 70, and > 70 are considered indicative
of mild, moderate, and severe pain, respectively.
The short form of the scale designed for use in eval-
uating acute pain during the late postoperative period
(> 24 hours after surgery) was composed of 5 items
(posture, activity, mental status, reaction to palpation
of the surgical wound, and reaction to palpation of the
abdomen and flank). The total score of this short form
ranged from 0 (no pain) to 15 (maximum pain).
Discussion
The study reported here was focused on the refine-
ment and initial psychometric evaluation of a com-
posite postoperative pain scale for cats. Reliability and
validity of pain assessment tools are important criteria
when selecting instruments for use in clinical practice
and for research purposes.16 The results provided ini-
tial evidence of construct validity and internal consis-
tency of a multidimensional composite tool for use in
assessing acute postoperative pain in cats undergoing
ovariohysterectomy.
Behavioral and physiologic measures have been
used to assess pain in cats in clinical and research set-
tings.24,25,35 Although behavioral observation is the pri-
mary approach for the assessment of pain in animals,
physiologic indicators (such as increases in HR and
SABP and changes in RR and respiratory pattern) can
be used to provide information about an animal’s re-
sponse to noxious stimuli.36 Therefore, construction of
the scale included the selection of behavioral and phys-
iologic items supported by the relevant literature8,9,24–27
as well as pain behaviors observed in the previous
study23 conducted to assess postoperative pain in cats.
Refinement of the pain scale by use of item analy-
sis allowed the selection of the most appropriate items
to measure pain in cats in the immediate and late (>
24 hours after surgery) postoperative period. Resira-
tory rate and respiratory pattern had poor performance
and were deleted from the scale. Although physiologic
measures are considered to be more objective than are
behavioral measures, they generally have been incon-
clusive for use in determining the presence of pain in
animals37–40 and children.41 Hence, emphasis has fo-
1/20/2011 12:53:48 PM
 Table 5—Final version of a composite pain scale for assessing acute postoperative pain in cats undergoing an ovariohysterectomy.

Factor Item Description Score

Psychomotor Posture Cat is in any usual posture for the species; cat looks comfortable and relaxed. 0
change Cat is lying in lateral recumbency; pelvic limbs are extended or partially extended 1
and muscles are tense.
Cat is in sternal recumbency with arched back and head held low; cat may be in 2
any position, but it has tense muscles and is reluctant to move.
Cat adopts different postures in an attempt to find a comfortable position. 3
Comfort Cat is awake or asleep; when stimulated, it is interested in its surroundings. 0
Cat is quiet and dissociated of its environment; when stimulated, it is not interested 1
in its surroundings. Cat may be sitting in the back of the cage or facing the back of the cage.
Cat is uncomfortable, agitated, and restless; it lies down and stands up continuously. 2
Activity Cat moves in a normal manner. 0
Cat is quieter than usual. 1
Cat is reluctant to move. 2
Cat frequently changes its body position. 3
Mental status* Observation of mental status A. 0
Observation of 1 of mental status B, C, D, or E. 1
Observation of 2 of mental status B, C, D, or E. 2
Observation of 3 or 4 of mental status B, C, D, or E. 3
Miscellaneous Observation of none of the listed behaviors. 0
behaviors† Observation of 1 of the listed behaviors. 1
Observation of 2 of the listed behaviors. 2
Observation of 3 or 4 of the listed behaviors. 3
Partial score __

Protection of Reaction to Cat does not react when the surgical wound is touched or pressed, or response 0
wound area palpation of the to palpation is similar to that during preoperative evaluation (if preoperative value
surgical wound was recorded).
Cat does not react when the surgical wound is touched but flinches and may 1
vocalize when surgical wound is pressed.
Cat flinches and may vocalize when the surgical wound is touched; cat withdraws 2
and turns its head toward the wound and may vocalize or try to bite when surgical
wound is pressed.
Cat withdraws with fast and intense head movement toward the wound and may vocalize 3
or try to bite when surgical wound is touched or pressed.
Cat vocalizes or tries to bite when the observer approaches and does not permit touching 4
of the surgical wound.
Reaction to Cat does not react when abdomen and flank are palpated or there is no change from 0
palpation of the preoperative palpation response (if preoperative value was recorded); abdomen
abdomen and flank‡ is not tense.
Cat vocalizes or tries to bite when abdomen and flank are palpated; abdomen is tense. 1
Cat vocalizes or tries to bite when the observer approaches; cat does not permit any 2
touching of the abdomen or flank.
Partial score __

Physiologic SABP§ 0% to 15% above preoperative value. 0
variables 16% to 29% above preoperative value. 1
30% to 45% above preoperative value. 2
. 45% above preoperative value. 3
Appetite Cat eats the usual amount of food. 0
Cat eats less than the usual amount of food. 1
Cat is not interested in food. 2
Partial score __

Vocal Vocalization Cat purrs when touched or meows and interacts with observer, but it does not groan, 0
expression hiss, or growl.
of pain Cat vocalizes (groan, hiss, or growl) when observer approaches, but it calms down when 1
touched.
Cat vocalizes (groan, hiss, or growl) when observer approaches, and it does not calm 2
down when touched.
Cat vocalizes (groan, hiss, or growl) spontaneously. 3
Partial score __
Total score __

Guidelines for use of the composite pain scale—The observer should choose only 1 value within each item that best fits the cat’s condition. Initially,
the cat’s behavior may be assessed from outside the cage. Observe whether the cat is at rest or moving, interested or not interested in its surroundings,
and silent or vocalizing. Then assess specific behaviors (miscellaneous behaviors). Open the door of the cage and call the cat’s name to encourage it
to approach to allow assessment of evoked behaviors and interaction with the observer. Assess its reaction (friendly, aggressive, scared, indifferent,
or vocal). Touch the cat and interact with it while observing whether it is receptive. If the cat is resting, encourage it to move by placing it in a standing
position. Observe whether the cat moves spontaneously or is reluctant to move. When possible, the cat should be removed from the cage to assess
activity. Observe the cat’s response after stimulating its interest in its surroundings by playing with it, offering it food, or talking to it. Gently place the cat in
lateral or ventral recumbency and measure SABP. Finally, assess the cat’s reaction when the area around the surgical wound is touched and then gently
pressed; perform the same procedure with the abdomen and flank, if appropriate.
*Categories were as follows: A = Satisfied (cat is alert and interested in its surroundings; it is friendly and interacts with the observer), B = Uninterested
(cat does not interact with the observer), C = Indifferent (cat is not interested in its surroundings), D = Anxious (cat is nervous or frightened and attempts to
hide or escape), and E = Aggressive (cat is aggressive and tries to bite or scratch the observer after the slightest manipulation). †The 4 behaviors were as
follows: the cat wags its tail excessively, contracts and extends its pelvic limbs or contracts the abdominal muscles, has partially closed eyes (ie, squinted
eyes), or frequently licks or chews the wound area. ‡Only for abdominal surgery. §It is necessary to record a preoperative (baseline) value for comparison.

180 AJVR, Vol 72, No. 2, February 2011

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 cused on the observation of changes in behavior when
developing scales for use in cats.
Results of the item analysis for the late postopera-
tive period indicated that a smaller number of items
were relevant for evaluating pain when compared with
results for the immediate postoperative period. In the
late postoperative period, only posture, activity, mental
status, reaction to palpation of the surgical wound, and
reaction to palpation of the abdomen and flank were
not rejected in the item analysis. The reduction in the
number of relevant items to evaluate pain at > 24 hours
after surgery may be a reflection of an animal’s adap-
tation to pain (with a reduction in the range of pain
behavior expression) or a reduction in the severity of
pain during the postoperative period because some be-
havioral changes may be evident only in animals with
great pain intensity. Discrimination between the rele-
vant items to assess pain in the immediate postopera-
tive period versus at > 24 hours after surgery provided
the development of a short form specifically for use in
evaluating pain in cats at > 24 hours after surgery.
Initially, construct validity of the scale was inves-
tigated by use of a commonly applied method (explor-
atory factor analysis that determined the dimensionality
of the scale). Factor analysis is a statistical method used
for scale development to evaluate whether all variables
measure a single dimension or > 1 dimension or fac-
tor.19 Pain expression is considered to be a multidimen-
sional phenomenon,42 and instruments that evaluate
multiple domains are more accurate than are scales that
measure only 1 dimension of pain, namely its intensity
(eg, simple descriptive scale, numeric rating scale, and
visual analogue scale).43 In humans, the McGill Pain
Questionnaire is a self-assessment instrument used to
evaluate sensory and affective pain qualities.44
Factor analysis revealed that the pain scale items
loaded on 5 important and interpretable factors, which
indicated the multidimensionality of the instrument.
Five dimensions were highlighted (psychomotor
change, protection of wound area, physiologic vari-
ables, vocal expression of pain, and HR). These 5 fac-
tors accounted for 89% of the total variance. However,
because HR did not have acceptable internal consis-
tency and could not be used to discriminate between
groups, it was deleted from the final version of the
scale. The 4 remaining factors contributed to 78.8% of
the total variance. A useful factor model should capture
a good amount of the total variance in the data,45 as was
observed in the present study.
Factors F3 (physiologic variables) and F4 (vocal
expression of pain) included only 2 items and 1 item,
respectively. Although factors defined by only 1 or 2
items are not considered desirable,45 these 2 factors re-
mained in the scale because they were not rejected in
the item analysis, had acceptable internal consistency,
and could be used to discriminate between groups.
A test’s dimensionality has important implications
for the scoring evaluation and use of the test. Multi-
dimensional tests with correlated dimensions have a
score for each subscale and may have a total score for
the scale. Both subscale score and total score for the
scale require psychometric evaluation.46 The scale re-
ported here was designed to be used with the total score
AJVR, Vol 72, No. 2, February 2011 181
09-10-0348r.indd 181
to indicate pain intensity; however, identification of the
subscales via factor analysis allowed each domain to be
evaluated separately. This approach may be of interest
in both clinical and research settings.
The advantage of assessing each domain separately
in clinical practice is that when there is any technical
difficulty for assessment of a determined dimension,
that dimension may be omitted and not considered in
the total score. For example, an arterial blood pressure
monitor may not be available or a cat may be agitated
when personnel are attempting to measure blood pres-
sure. For those circumstances, F3 (physiologic vari-
ables), which includes SABP and appetite, can be re-
moved from the scale, and the clinicians may evaluate
pain in cats on the basis of behavioral changes alone.
In analgesic research, evaluation of the scores for
the factors (considering the factor loading for each
item) increases the quality of information because a
certain analgesic treatment may differentially affect the
factors. For example, one analgesic may be more effi-
cient for control of pain at rest or during movement
(F1 [psychomotor change]), whereas another one may
be more effective for reducing local hyperalgesia (F2
[protection of wound area]). Therefore, measuring the
factor score may assist clinicians and researchers in
identifying treatments that are efficacious for certain
aspects of pain.
On the other hand, in addition to the score for
each subscale, multidimensional scales with correlated
dimensions may be used to generate a total score for the
scale.46 Use of an overall (global) score is possible even
though the scale was multidimensional because there
was a high correlation between dimensions and the to-
tal pain score. In addition, internal consistency of the
overall scale was excellent. It is useful to create an over-
all pain score when the goal of assessment is to deter-
mine the overall severity of pain. Because of the psycho-
metric properties of the scale reported here, either the
total score or the score for each factor may be used.
Construct validity also was assessed via known-
groups discrimination. This kind of validity determines
the extent to which the measure differs between groups.19
The instrument should be used to distinguish groups that
would be expected to have differences in scores.45 Except
for F5 (HR), the identified factors had reasonable discrim-
inating properties and appeared to be sensitive enough
that they could be used to distinguish pain of different se-
verities. The factors could be used to detect differences be-
tween the analgesic-treated and placebo-treated group as
well as among the groups receiving the various analgesics.
This suggested that the scale may have value as a discrimi-
native instrument, which is an essential requirement for
clinical43 and research purposes.
Factor F5 (HR) had limited validity as a measure of
acute postoperative pain in cats. This factor was exclud-
ed from the scale because it was unreliable and did not
have discriminating power. It has been reported23,35,37,40
that HR is a poor indicator of pain in cats. This may be
explained by the fact that HR may be influenced by a
number of factors other than pain, such as stress and
the use of analgesic drugs.47
The SABP was the only physiologic measure that
remained in the final version of the scale. In contrast
1/20/2011 12:53:49 PM
 to the other physiologic variables, SABP has been cor-
related with acute postoperative pain in cats.23,37 Results
of item analysis revealed that SABP was relevant for as-
sessing pain only during the early postoperative period
but not > 24 hours after surgery. These results indicated
that the value of physiologic measures as indicators of
postoperative pain is limited48 because the autonomic
response appears to adapt with time despite the persis-
tence of pain.47
In addition to construct validity, the scale was test-
ed for reliability. Internal consistency approaches can be
used to estimate the reliability of multiple-item tests.46
Analysis of the modified Cronbach α coefficient indi-
cated that internal consistency was excellent for F1, F2,
and F3 and very good for F4. The internal consistency
for the overall scale was also excellent. This degree of
internal consistency allowed items in each factor to be
assessed as a group to provide a score and also to sum
the score for the items to generate a total score for the
scale. On the other hand, F5 had unacceptable internal
consistency and was deleted from the instrument.
The need for rescue analgesia may be used in ad-
dition to pain intensity scores to evaluate the efficacy
of analgesic drugs. In the previous study,23 interven-
tion analgesia was administrated to cats with a score
> 33% of the total score for the scale. This value was
empirically selected on the basis of scores that would
indicate moderate pain and require intervention anal-
gesia. However, additional studies would be necessary
to investigate the cutoff point for the provision of relief
from pain.
The study reported here had several limitations.
The sample size of 40 cats may be considered small.
The scale was refined, and the psychometric properties
were tested by use of the Portuguese language; thus, it
is necessary to conduct further studies to assess valid-
ity of the scale when it is translated into English. The
psychometric properties of the total scale and subscales
were evaluated in cats undergoing ovariohysterectomy,
which is the most commonly performed surgery in
research studies11–13,23,25,49 conducted to assess the effi-
cacy of analgesics in cats. Therefore, this initial valida-
tion of the scale would be applicable only for research
studies. The psychometric properties of the total scale
and subscales should also be tested in clinical settings
with animals undergoing various surgeries to confirm
its validity under those circumstances. Few studies
have been published on the use of vedaprofen and tra-
madol in cats; however, the analgesic efficacy of these
drugs (especially tramadol) has been indicated in the
literature.23,49–51,a,b Although the statistical analysis de-
tected relevant differences among items, none of the
scaling methods was used to define weights for the
items and categories of the scale. In the final version of
the scale, all items were weighted equally. In the same
manner, the order of the categories was selected arbi-
trarily on the basis of results of a literature review and
the investigators’ experiences.
Another limitation of the final version of the instru-
ment is that it is an ordinal scale in terms of measure-
ment properties. In this type of scale, it is assumed that
the intensity of pain is reflected in the total pain score
(defined as the sum of the scores for each of the items).
182
09-10-0348r.indd 182
Thus, it is only possible to evaluate whether a cat has
more or less pain, but it is not possible to quantify how
much more or how much less, such as for an interval
scale. Although the ordinal instrument has sufficient
precision for clinical purposes, interval measurements
provide a more precise assessment, which is desired for
research purposes.52
Results of the study reported here provided initial
evidence of the construct validity and reliability of a
multidimensional composite pain scale for use in as-
sessing acute postoperative pain in cats undergoing
ovariohysterectomy. Further studies are needed to con-
firm these results because construct validity is an ongo-
ing process. Because this was an initial study, the next
step is to collect additional validity data (including re-
sponsiveness to analgesic effects and the assessment of
the degree of agreement between 2 or more observers
(interrater reliabilibilty) and stability over time (intra-
rater reliability).
a. Chen HC, Radzi R, Rahman NA, et al. Analgesic effect of trama-
dol combined with tolfenamic acid in cats after ovariohyster-
ectomy (abstr), in Proceedings. Annu Meet Am Coll Vet Anesth
2007;27.
b. Horspool LJ, Hoeijmakers M, van Laar P, et al. The efficacy and
safety of vedaprofen oral gel in postoperative pain management
in cats (abstr), in Proceedings. Voorjaarsdagen Cong 2001;161.
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