1 00:00:05,189 --> 00:00:08,340 Nathalie Dowgray: Hello, welcome to the May episode of Chattering with ISFM. 2 00:00:08,960 --> 00:00:12,579 I'm Nathalie Dowgray, Head of ISFM and host of this month's podcast. 3 00:00:13,570 --> 00:00:17,220 First up this month, Yaiza Gomez Mejias is speaking with Beatriz 4 00:00:17,220 --> 00:00:21,879 Monteiro, the recent winner of the JFMS Best Resident Paper Award. 5 00:00:22,339 --> 00:00:27,110 The topic is, can cat caregivers reliably assess acute pain in cats 6 00:00:27,110 --> 00:00:28,650 using the Feline Grimace Scale? 7 00:00:29,799 --> 00:00:33,780 We're also featuring our monthly JFMS Clinical Spotlight interview, and this 8 00:00:33,780 --> 00:00:37,760 month I'm speaking with Professor Clare Rusbridge about neuropathic pain in cats. 9 00:00:42,310 --> 00:00:45,619 Yaiza Gomez Mejias: So in this award winning article, you and your 10 00:00:45,680 --> 00:00:51,539 team investigated if cat caregivers can reliably assess acute pain 11 00:00:51,760 --> 00:00:53,950 using the feline grimace scale. 12 00:00:55,120 --> 00:00:58,600 So why did you choose this particular topic and would you 13 00:00:58,600 --> 00:01:02,199 like to briefly mentioned what the feline grimace scale is? 14 00:01:03,210 --> 00:01:07,070 Beatriz Monteiro: Since I have this beautiful cat lover audience, I would just 15 00:01:07,070 --> 00:01:13,299 like to remind us all that pain should be, and it is, the fourth vital sign. 16 00:01:13,899 --> 00:01:18,810 And once we systematically assess pain in every animal, we're going 17 00:01:18,830 --> 00:01:23,030 to obviously start identifying these animals and then treating them, and 18 00:01:23,030 --> 00:01:28,390 hopefully correcting this issue of under treatment and under diagnosis of pain. 19 00:01:28,820 --> 00:01:31,750 So this is where the whole problem started. 20 00:01:32,280 --> 00:01:35,350 And then the feline grimace scale came into play. 21 00:01:35,350 --> 00:01:41,475 So it is a tool where you look at the cat's face and you look at 22 00:01:41,475 --> 00:01:45,575 five different characteristics, which we call action units. 23 00:01:46,145 --> 00:01:51,965 So this is, for example, the position of the ears, the opening of the eyes, 24 00:01:51,985 --> 00:01:55,845 the position of the head, we also look at the muzzle and the whiskers. 25 00:01:56,275 --> 00:02:02,745 So we look at these five action units and we give a score of 0, 1, or 2. 26 00:02:03,180 --> 00:02:09,310 0 when it's normal, 1 when it's mildly changed or we're uncertain, 27 00:02:09,630 --> 00:02:13,750 and a score of 2 when it's clearly changed from the normal. 28 00:02:14,170 --> 00:02:18,119 So if you have five characteristics and you can give a score of 2 for 29 00:02:18,159 --> 00:02:25,565 each, the maximum score of this scale is 10, and any cat that scores four or 30 00:02:25,825 --> 00:02:30,195 higher, it means that they are in pain and we need to do something about it. 31 00:02:30,615 --> 00:02:34,945 So for veterinary professionals, we're going to administer analgesics. 32 00:02:35,234 --> 00:02:38,475 And for cat caregivers, they should be prompted to go and 33 00:02:38,475 --> 00:02:39,905 take the cat to the veterinarian. 34 00:02:39,984 --> 00:02:42,334 So this is what the feline grimace scale is. 35 00:02:43,165 --> 00:02:47,144 We now have eight studies published on the feline grimace scale, and 36 00:02:47,144 --> 00:02:51,044 we're understanding and doing all these studies and the limitations. 37 00:02:51,494 --> 00:02:57,005 And we were very curious to know, since this is a very simple and quick 38 00:02:57,005 --> 00:03:01,244 to use tool where you just need to look at the cat's face, you don't 39 00:03:01,274 --> 00:03:03,575 necessarily need medical training. 40 00:03:03,594 --> 00:03:06,454 You're just looking at changes in the facial expressions of 41 00:03:06,454 --> 00:03:08,385 the cat and giving scores. 42 00:03:09,049 --> 00:03:13,779 Could cat caregivers also be able to do this?Because if they can, 43 00:03:14,079 --> 00:03:15,339 that would be amazing, right? 44 00:03:15,359 --> 00:03:20,329 It means that in the home environment, they can evaluate their cat and help 45 00:03:20,339 --> 00:03:23,899 them make decisions if they need to bring the cat to the vet, for example. 46 00:03:25,029 --> 00:03:32,560 So initially we did a study where we invited five very dedicated cat caregivers 47 00:03:33,130 --> 00:03:38,799 and they evaluated 100 images of cats with different degrees of pain and 48 00:03:38,799 --> 00:03:44,919 they would give feline grimace scale pain scores on these 100 images and 49 00:03:44,919 --> 00:03:47,589 they did that twice a few weeks apart. 50 00:03:48,239 --> 00:03:51,919 And from that study, we found that they were reliable. 51 00:03:51,929 --> 00:03:56,109 So those cat owners, they could evaluate pain in cats just 52 00:03:56,109 --> 00:03:57,969 like most veterinarians will. 53 00:03:58,269 --> 00:04:03,159 But then the question was, these five cat caregivers are very dedicated. 54 00:04:03,180 --> 00:04:07,249 What about the average cat caregiver out there in the world? 55 00:04:07,269 --> 00:04:10,760 Can we really say that any cat caregiver can do that? 56 00:04:11,170 --> 00:04:14,829 So that was the purpose of this study that was awarded. 57 00:04:14,849 --> 00:04:20,399 It was really like going global and trying to reach the average 58 00:04:20,420 --> 00:04:22,110 cat caregiver population. 59 00:04:22,670 --> 00:04:24,629 So that was really what we did. 60 00:04:24,900 --> 00:04:28,450 So very briefly, we selected 10 images. 61 00:04:28,450 --> 00:04:30,219 So remember in the first study we had 100. 62 00:04:31,210 --> 00:04:34,340 We had to make this simple, otherwise no one would participate. 63 00:04:34,760 --> 00:04:39,320 So we selected 10 images of cats from all of our previous studies. 64 00:04:39,840 --> 00:04:44,540 And then we invited these people to score these cats using the feline grimace scale. 65 00:04:44,870 --> 00:04:48,010 But they had to read the training manual that has all the images 66 00:04:48,010 --> 00:04:49,810 of cats and the different scores. 67 00:04:51,175 --> 00:04:54,235 And the survey was available in English and Spanish. 68 00:04:54,515 --> 00:04:58,555 And it was online and it was free for anyone that could participate. 69 00:04:58,855 --> 00:05:01,765 With a couple of eligibility criteria. 70 00:05:01,765 --> 00:05:07,085 So we had to be over age and it had to be a cat caregiver to participate. 71 00:05:07,505 --> 00:05:13,775 So a llong response to why we came to this study, but it really was a 72 00:05:13,775 --> 00:05:18,505 journey trying to help understand how we can better evaluate pain in cats. 73 00:05:18,980 --> 00:05:22,170 And then how can we transport all this information that we're 74 00:05:22,170 --> 00:05:27,410 developing in the veterinary medicine world to the cat caregiver world? 75 00:05:28,030 --> 00:05:28,580 Yaiza Gomez Mejias: Brilliant. 76 00:05:28,630 --> 00:05:29,310 Thank you. 77 00:05:29,380 --> 00:05:31,240 And it's such a helpful tool as well. 78 00:05:31,300 --> 00:05:36,350 I think we all were very happy to have something that we could give caregivers 79 00:05:36,370 --> 00:05:38,020 for them to monitor pain at home. 80 00:05:38,120 --> 00:05:40,820 And can you summarize the results? 81 00:05:40,870 --> 00:05:42,050 Beatriz Monteiro: Yes, absolutely. 82 00:05:42,310 --> 00:05:45,480 So we were comparing the scores from cat caregivers and the 83 00:05:45,480 --> 00:05:46,960 scores from veterinarians. 84 00:05:47,940 --> 00:05:52,910 One thing where we did find the statistical difference between scores was 85 00:05:52,950 --> 00:05:55,459 for the muzzle, the action unit muzzle. 86 00:05:55,869 --> 00:05:59,520 And that was not surprising because in all of our previous studies, 87 00:05:59,549 --> 00:06:03,200 we find that the muzzle is indeed the most difficult to score. 88 00:06:03,720 --> 00:06:05,490 So that was really the only difference. 89 00:06:05,520 --> 00:06:08,674 But the takeaway is that the feline grimace scale total 90 00:06:08,674 --> 00:06:09,994 score was not different. 91 00:06:09,994 --> 00:06:13,495 There were no difference in scores between veterinarians and cat caregivers. 92 00:06:13,975 --> 00:06:18,655 And the other thing that we were actually very pleased to find was 93 00:06:18,655 --> 00:06:23,235 that regardless of the demographics, there were no effect on any of 94 00:06:23,235 --> 00:06:24,924 the demographics that we studied. 95 00:06:25,324 --> 00:06:30,665 So we looked, for example, at the age of the participant, the gender, whether 96 00:06:30,675 --> 00:06:33,735 they had worked in health medicine. 97 00:06:34,260 --> 00:06:40,420 And whether they have previous experiences and none of the demographic variables 98 00:06:40,450 --> 00:06:47,100 that we investigated affected scores, so we were very pleased to see that as well. 99 00:06:47,100 --> 00:06:51,709 And I think what this translates to is that we can really extrapolate 100 00:06:51,709 --> 00:06:57,329 that pretty much any cat caregiver is able to reliably assess pain in 101 00:06:57,349 --> 00:06:59,260 cats using the feline grimace scale. 102 00:06:59,260 --> 00:07:04,525 So I think it speaks to the widespread global representation and that 103 00:07:04,534 --> 00:07:07,224 they're generally reliable to do that. 104 00:07:07,905 --> 00:07:08,735 Yaiza Gomez Mejias: Fantastic. 105 00:07:09,145 --> 00:07:13,505 So what would you recommend to those vets who are listening, who have never used 106 00:07:13,505 --> 00:07:17,814 the feline grimace scale and would like to implement its use in their clinics? 107 00:07:18,455 --> 00:07:22,835 Beatriz Monteiro: Well, go to felinegrimacescale.com We're close to 108 00:07:22,835 --> 00:07:27,855 12 languages, so hopefully we can reach many veterinarians across the globe. 109 00:07:28,565 --> 00:07:30,905 And in there, we have a lot of resources. 110 00:07:30,905 --> 00:07:35,775 Print those resources and do like a session where everyone is scoring 111 00:07:35,775 --> 00:07:38,735 these animals together and comparing these scores because I think this 112 00:07:38,735 --> 00:07:40,275 generates very good discussions. 113 00:07:40,985 --> 00:07:43,295 Nathalie Dowgray: And now I'm speaking with Professor Clare Rusbridge 114 00:07:43,555 --> 00:07:48,865 about neuropathic pain in cats, pathophysiology, diagnosis and management. 115 00:07:49,244 --> 00:07:51,724 So thank you so much for joining us today, Clare. 116 00:07:51,744 --> 00:07:55,145 And we're going to be talking about your wonderful article for our 117 00:07:55,145 --> 00:07:59,844 clinical spotlight series in JFMS on neuropathic pain in cats, the 118 00:07:59,844 --> 00:08:02,354 mechanisms and multimodal management. 119 00:08:02,794 --> 00:08:06,624 I was really keen to discuss why you think it's important that we 120 00:08:06,634 --> 00:08:11,874 separately define nociception from pain itself and the experience of pain. 121 00:08:13,164 --> 00:08:14,515 Clare Rusbridge: Thank you very much for having me. 122 00:08:14,934 --> 00:08:21,765 So nociception is the process by which painful information is conveyed through 123 00:08:21,765 --> 00:08:27,344 nociceptors, the receptors going up through the nerve into the spinal cord 124 00:08:27,905 --> 00:08:30,675 and then conveyed up to the brain. 125 00:08:31,535 --> 00:08:37,475 But the perception of pain is the brain responding to that information 126 00:08:37,855 --> 00:08:42,315 and making cognitive decisions about it, having an emotional response to 127 00:08:42,315 --> 00:08:45,754 it and perceiving that noxious insult. 128 00:08:47,005 --> 00:08:49,135 So the two are really quite different. 129 00:08:49,575 --> 00:08:54,734 You can have, for example, a withdrawal reflex, just a reflex, 130 00:08:54,915 --> 00:08:58,405 after a painful insult to the foot. 131 00:08:58,635 --> 00:09:04,085 So if we clamp artery forceps over a toe, that's the usual way of assessing that. 132 00:09:04,415 --> 00:09:09,155 The foot can rreflexly withdraw even if the spinal cord is severed. 133 00:09:10,310 --> 00:09:15,940 But pain perception is that information getting all the way to the brain and the 134 00:09:15,940 --> 00:09:17,810 animal dealing with that information. 135 00:09:19,269 --> 00:09:19,609 Nathalie Dowgray: Cool. 136 00:09:19,990 --> 00:09:22,900 Now that's, I think, a really important definition to have, that 137 00:09:22,900 --> 00:09:27,290 difference between the experience of pain versus the nociceptive response. 138 00:09:27,290 --> 00:09:31,069 And sometimes I guess there's a neuropathic component within 139 00:09:31,149 --> 00:09:32,919 a wider chronic pain issue. 140 00:09:33,460 --> 00:09:36,000 How common is that to see in cats? 141 00:09:37,599 --> 00:09:38,379 Clare Rusbridge: Very common. 142 00:09:38,790 --> 00:09:44,889 We really have two terms I'd like to introduce, the first is nociplastic 143 00:09:45,000 --> 00:09:48,510 pain and then we have neuropathic pain. 144 00:09:48,909 --> 00:09:52,585 And the nociplastic is something that people possibly won't 145 00:09:52,595 --> 00:09:53,884 have come across before. 146 00:09:54,344 --> 00:10:00,674 And it's really to take into account how you can have altered nociception. 147 00:10:00,844 --> 00:10:08,355 So altered pain information without any actual clear evidence of actual damage to 148 00:10:08,385 --> 00:10:11,325 the nervous system or to the, the organ. 149 00:10:11,515 --> 00:10:17,024 So a classic example of that in cats is cystitis, which I think 150 00:10:17,024 --> 00:10:21,535 would actually be usefully called feline bladder pain syndrome. 151 00:10:22,085 --> 00:10:26,915 So in this, we assume that there has been changes to the function of the 152 00:10:26,915 --> 00:10:33,755 nervous system that is making this chronic pain syndrome much amplified. 153 00:10:33,755 --> 00:10:37,765 So it's kind of central sensitization going on through the nervous system. 154 00:10:38,525 --> 00:10:43,314 Another example, of course, is osteoarthritis, where the pain in that 155 00:10:43,314 --> 00:10:50,339 condition is amplified by having different function to the nervous system through 156 00:10:50,339 --> 00:10:55,859 the peripheral nerve, the dorsal nerve root ganglion and the spinal cord. 157 00:10:56,319 --> 00:11:00,229 And that is distinguished from true neuropathic pain where there is 158 00:11:00,249 --> 00:11:04,579 actually damage to the peripheral or the central nervous system. 159 00:11:04,589 --> 00:11:09,340 So an example of neuropathic pain in the cat would be if they had orthopaedic 160 00:11:09,360 --> 00:11:15,285 surgery and the surgeon retracted the sciatic nerve and kept that retraction 161 00:11:15,285 --> 00:11:19,235 on for a long time and, give the sciatic nerve a little bit of a break if you 162 00:11:19,235 --> 00:11:24,425 have to retract it and not leave it retracted over a long period of time. 163 00:11:24,984 --> 00:11:29,985 So damage to that sciatic nerve can leave to postoperative neuropathic pain. 164 00:11:30,625 --> 00:11:34,470 We know there's actually damage to that nerve going on rather than 165 00:11:34,620 --> 00:11:36,540 a kind of theoretical concept. 166 00:11:36,970 --> 00:11:41,819 The other term that we often use is maladaptive pain and that 167 00:11:41,829 --> 00:11:47,619 really is another term for really describing nociplastic pain as well. 168 00:11:48,285 --> 00:11:52,215 Nathalie Dowgray: Oh, that's fantastic and I haven't come across the nociplastic 169 00:11:52,285 --> 00:11:55,925 pain definition really before, but actually, especially when I think about 170 00:11:55,965 --> 00:12:00,064 osteoarthritis in cats, that makes a lot of sense that you've got the actual 171 00:12:00,065 --> 00:12:04,210 joint pain, but often you've got this wider syndrome of other things going on. 172 00:12:04,210 --> 00:12:07,310 And it does make sense to think about it in that way. 173 00:12:07,890 --> 00:12:11,769 In terms of our diagnosis, how do we determine if a cat is 174 00:12:11,770 --> 00:12:13,890 experiencing neuropathic pain? 175 00:12:14,140 --> 00:12:17,339 Clare Rusbridge: We can really pinpoint it as having three 176 00:12:17,390 --> 00:12:21,669 kind of arms for the diagnosis. 177 00:12:21,669 --> 00:12:26,460 First of all, we need to show that there is a lesion or disease 178 00:12:26,480 --> 00:12:31,475 affecting the peripheral nervous system or the central nervous system. 179 00:12:32,024 --> 00:12:34,734 It's pretty easy if we have a good history. 180 00:12:34,744 --> 00:12:39,144 So if we know that the cat had orthopaedic surgery and retraction of the sciatic 181 00:12:39,145 --> 00:12:43,194 nerve, if we know that the cat was involved in a road traffic accident and 182 00:12:43,194 --> 00:12:49,194 damaged the nerve roots going to the brachial plexus, then that's quite easy. 183 00:12:49,504 --> 00:12:53,345 However, there are neuropathic pain syndromes, like, for example, feline 184 00:12:54,175 --> 00:12:58,154 hyperesthesia syndrome, where if you did MRI, you would find nothing to 185 00:12:58,165 --> 00:13:00,624 help you do those diagnostic tests. 186 00:13:00,904 --> 00:13:06,174 So, that's just to say diagnosis can be very confusing in some cases. 187 00:13:06,705 --> 00:13:11,005 So, the other sort of arm is, that's the first thing actually demonstrating 188 00:13:11,005 --> 00:13:16,365 there is a lesion, the second thing is finding evidence of abnormal sensation. 189 00:13:16,495 --> 00:13:20,735 So what that implies is there is an abnormal functioning in your system. 190 00:13:20,755 --> 00:13:25,265 For example, in the cat with a damaged sciatic nerve due to orthopaedic 191 00:13:25,265 --> 00:13:30,535 surgery, you may find that if you touch that area, they react really over 192 00:13:30,535 --> 00:13:34,375 the top, or they may have numbness. 193 00:13:34,835 --> 00:13:39,705 So it's one of the big ironies of neuropathic pain is that they 194 00:13:39,705 --> 00:13:46,935 may have less sensation, but be experiencing abnormal sensation. 195 00:13:47,464 --> 00:13:49,774 That would be one important facet. 196 00:13:50,004 --> 00:13:54,764 And going back to that really challenging to diagnose case, the feline hyperesthesia 197 00:13:55,124 --> 00:14:00,324 syndrome, those cats behave as if they're experiencing abnormal sensation. 198 00:14:00,324 --> 00:14:05,059 Now, obviously that's trying to make a subjective assessment of a cat's 199 00:14:05,059 --> 00:14:07,739 behaviour, which is very unreliable. 200 00:14:09,300 --> 00:14:13,519 And then we have our diagnostic tests like MRI and electrophysiology. 201 00:14:13,519 --> 00:14:16,170 Those may help, help confirm. 202 00:14:16,589 --> 00:14:21,839 But of course, especially in this time of economic downturn and crisis where 203 00:14:21,849 --> 00:14:26,579 people are managing cases on a budget or referral for those sorts of expensive 204 00:14:26,579 --> 00:14:30,974 diagnostic tests isn't an option then I think it's reasonable to add in there 205 00:14:30,974 --> 00:14:33,114 a positive response to trial treatment. 206 00:14:33,114 --> 00:14:37,254 So if you have a high index of suspicion, perhaps a two week 207 00:14:37,305 --> 00:14:40,734 course of trial treatment to see if there is a positive response. 208 00:14:41,054 --> 00:14:45,374 Now, the negative side of that is that many of these drugs that we use 209 00:14:45,425 --> 00:14:47,544 will affect the cat's emotional state. 210 00:14:47,544 --> 00:14:50,084 And we've already talked about the connection between 211 00:14:50,084 --> 00:14:52,714 the emotional state and pain. 212 00:14:53,329 --> 00:14:57,189 And you could argue that in some of these cases, like feline hyperesthesia 213 00:14:57,189 --> 00:15:01,009 syndrome, where a lot of the cats are dealing with anxiety issues, and 214 00:15:01,019 --> 00:15:06,249 you think, are these signs related to stress rather than abnormal sensations? 215 00:15:06,609 --> 00:15:08,279 And they make a response to a drug. 216 00:15:09,259 --> 00:15:12,569 And you think, was that just them being more relaxed in their environment? 217 00:15:13,419 --> 00:15:14,359 We don't know. 218 00:15:14,360 --> 00:15:18,410 And some people would argue, does it matter? 219 00:15:18,410 --> 00:15:21,969 We've got a happier cat, so maybe we've achieved the end 220 00:15:22,019 --> 00:15:24,560 without actually knowing the why. 221 00:15:24,619 --> 00:15:29,150 Nathalie Dowgray: I think that's a really good point and, and that role of, of 222 00:15:29,150 --> 00:15:33,350 sort of the treatment trial, I think for a lot of us in general practice, when 223 00:15:33,350 --> 00:15:37,610 maybe there aren't the funds available for, for some of the, the more extensive 224 00:15:37,610 --> 00:15:41,840 diagnostics, it's nice to know that is also an option for us to be able 225 00:15:42,190 --> 00:15:43,105 to take that route.And as I mentioned earlier, you had some really nice case 226 00:15:43,105 --> 00:15:45,800 examples within this paper, which I 227 00:15:48,620 --> 00:15:52,500 found, for me, really helpful to just interpret the text of what 228 00:15:52,500 --> 00:15:55,370 you're saying and then how we would apply that into practice. 229 00:15:56,010 --> 00:15:59,100 So, thank you so much for your time today, Clare. 230 00:15:59,210 --> 00:15:59,899 Clare Rusbridge: Thank you very much. 231 00:15:59,899 --> 00:16:01,140 Thank you very much for having me. 232 00:16:06,530 --> 00:16:07,750 Nathalie Dowgray: Thanks for listening everyone. 233 00:16:07,980 --> 00:16:11,969 If you're an ISFM member, don't forget you can access the full version of the podcast 234 00:16:11,970 --> 00:16:16,890 and all the other ISFM member benefits, including congress recordings starring 235 00:16:16,890 --> 00:16:21,739 Clare Rusbridge, monthly webinars, the clinical club, the discussion forum, and 236 00:16:21,739 --> 00:16:24,795 much, much more at portal.icatcare.org. 237 00:16:25,435 --> 00:16:28,575 If you're looking for more free CPD from ISFM, we do have a number 238 00:16:28,575 --> 00:16:30,365 of open access webinars in June. 239 00:16:30,785 --> 00:16:34,105 And of course we have our fabulous annual Congress in Malta at the month. 240 00:16:34,965 --> 00:16:36,945 We'll be back again next month with another episode. 241 00:16:37,205 --> 00:16:40,204 If you don't want to miss out, do make sure you've signed up to Chattering with 242 00:16:40,205 --> 00:16:42,905 ISFM on your preferred podcast platform.