Pain: From Diagnosis to Effective Treatment

Bernd Driessen, DVM, PhD, Dipl. ACVA & ECVPT,*, and Laura Zarucco, DMV, PhD*,
Managing pain effectively is one of the most important tasks that clinical veterinarians
perform on a daily basis. This requires accurate assessing and grading of perioperative or
posttraumatic pain followed by effective treatment. Commonly, veterinarians rely on the
interpretation of physiological indices such as heart and respiratory rates, and, in case of
musculoskeletal pain, on lameness evaluation. However, accurate assessment of pain in
horses is complicated, not only because there are as many types of pain as there are
responses to injuries, but also because criteria used to assess pain are often confounded
by other factors. More recent studies suggest that subjective and objective assessment of
species-specific pain behaviors should become an integral part of pain evaluation also in
the horse, and that physiological and behavioral data combined are more useful than
physiological measures alone to assess pain and the response to treatment in an individual
animal. Pain scoring systems have recently been adapted to the horse and may prove
useful in judging progress and response to treatment during the perioperative period.
Effective pain therapy is best accomplished by applying a multi-modal or balanced analgesia concept that involves the combination of drugs with different pharmacological
mechanisms of action and different target sites within the nociceptive system. Balanced
analgesia may also include complementary modalities of pain treatment, such as acupuncture or chiropractic manipulations, especially when dealing with conditions of chronic pain.
Clin Tech Equine Pract 6:126-134 2007 Elsevier Inc. All rights reserved.
KEYWORDS diagnosing and scoring of pain scoring, pain behaviors, balanced analgesia,
multi-modal analgesia, complementary modalities of pain therapy, horse

ain recognition remains a fundamental hurdle to provision of effective pain therapy in animals.1 There is currently no gold standard method to recognize and then quantify pain perception in animals, and none of the currently
available techniques for assessment acknowledges the importance of subjectivity in pain.2 Yet, the equine veterinarian is
forced to make a judgment on whether a horse is in pain, a
situation far different from the self-reporting utilized in
verbal human beings. The purpose of this article is to provide
veterinarians with a basic understanding of the value and
limitations of various techniques used to assess pain in horses
and then discuss the principles of analgesia based on the
physiology and pathophysiology of nociception and a multimodal and mechanism-based approach to pain therapy.

*Department of Clinical Studies-New Bolton Center, School of Veterinary

Medicine, University of Pennsylvania, Philadelphia, PA.
Department of Anesthesiology, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles.
Dipartimento di Patologia Animale, Facolt di Medicina Veterinaria
dellUniversit degli Studi di Torino, Torino.
Address reprint requests to Bernd Driessen, DVM, PhD, University of Pennsylvania, Department of Clinical Studies-New Bolton Center, 382 W. Street
Road, Kennett Square, PA 19348. E-mail: driessen@vet.upenn.edu

126

1534-7516/07/$-see front matter 2007 Elsevier Inc. All rights reserved.

doi:10.1053/j.ctep.2007.05.005

Diagnosing Pain
Animals cannot communicate verbally; thus, in veterinary
medicine, the evaluator most often relies on interpretation of
physiological indices and obvious changes in behavioral or
locomotion characteristics.3 In horses, especially when acute
or severe, pain is commonly associated with changes in autonomic nervous system function, leading to increases in
heart rate, respiratory rate, and certain biochemical or other
factors (Table 1). Although recording of those parameters is
relatively simple, objective, and minimally or noninvasive,
they are rather unspecific and often influenced by other accompanying factors such as anxiety, excitement, stress, hypovolemia, shock, sepsis, and endotoxemia.1,4,5 For example,
it is not uncommon to observe in horses no elevation in heart
rate despite other parameters clearly indicating discomfort
and pain.1 Likewise, anesthetics, sedatives, and other drugs
administered during the perioperative period limit the validity of physiological indices as pain-indicating parameters.1,2
Musculoskeletal pain caused by inflammatory disease or
trauma to muscletendon units, ligaments, joints, or osseous
structures commonly leads to impaired locomotion or lameness. The degree of lameness displayed by a horse is expected
to correlate with the degree of pain.6 To objectively assess and
quantify lameness, various force plate systems have been developed over the past three decades for measuring vertical

Diagnosis, scoring and treatment of pain

Table 1 Physiological (Autonomic) Responses to Moderate or
Severe Pain
Tachycardia
Hypertension
Tachypnea and flared nostrils
Diaphoresis (sweating)
Muscle tremors
Dilated pupils and glassy eyes
Increases in plasma beta-endorphin, catecholamine, and
corticosteroid concentrations

ground reaction force and other force parameters applied by

a horses limb on ground contact.7-11 Kinematic gait analysis,
ie, a detailed examination of high-speed video recordings has
been applied in horses to objectively assess particularly subtle to mild forms of lameness that are difficult to diagnose
using traditional lameness examination techniques.12,13 Others have adapted a human in-shoe pressure measurement
system to the equine for objective and accurate quantification
of forelimb ground reaction forces in horses.14 This method is
less costly and easier to use in the clinical setting than force
plate or kinematic gait analysis techniques and therefore
might be useful for assessing progress of musculoskeletal
pain following orthopedic treatment and analgesia, even in
the immediate postoperative period when horses are usually
subject to stall confinement.
Horses with musculoskeletal injuries, vague upper limb
lameness, or poor performance often endure pain in the
neck, back, and croup, which is difficult to assess objectively.15 Pressure algometry is a mechanical form of pain
assessment that has been used to quantify the subjective
assessment of pain-pressure thresholds or tenderness
within musculoskeletal structures.16 A pressure algometer
consists of a pressure gauge attached to a rubber-tipped
plunger that is pressed against a predetermined musculoskeletal landmark until a perceived noxious reaction is produced
(see http://www.ivis.org/proceedings/AAEP/2003/haussler/fig 1.
asp).15 In humans, pressure algometry has been used in the
clinical management of pain, especially in the diagnosis and
treatment of soft tissue or muscle pain (eg, myofascial pain
syndromes) or assessment of periarticular tenderness associated with osteoarthritis.17,18 By applying the technique of
pressure algometry in the equine, Haussler and Erb15,19,20
recently determined pain-pressure thresholds objectively
and described standardized values for assessing back pain in
horses. Although there is need for further studies, currently
available data suggest that pressure algometry provides an
easy to apply noninvasive method to objectively assess musculoskeletal pain in the horse and to monitor the effectiveness of traditional and/or complementary pain therapies.
Studies in various small, laboratory, and farm animal species have demonstrated that evaluation of behavioral changes
is superior and clinically more practical to monitoring of
physiological parameters alone for assessment of pain in animals.3,21-23 Four key types of behavioral responses to pain
have been identified: 1) spinal or supraspinal reflex responses aimed at protecting a part or the entire body from
further injury; 2) those that minimize pain and assist healing,
such as lying still in a stall or limb resting; 3) those that are
designed to elicit help from other animals or prevent another

127
subject (human or animal) from inflicting further pain, such
as vocalization or active withdrawal; and 4) those that induce
behavioral modification through learning, thus enabling the
animal to avoid recurrence of the experience, such as kicking,
biting, limb flexion, or escaping when being approached by
another animal or human.24 Recently, the number of equine
studies describing or utilizing behavioral changes as indicators of pain are increasing and provide valuable information
with regard to how pain in horses can be better diagnosed
and graded.3,5,25-29 Distinct behavioral changes have been
consistently observed in horses with different types of pain
(acute versus chronic, musculoskeletal versus visceral pain)
(Table 2).
Despite the unequivocal value of behavioral assessment as
a tool to diagnose and quantify pain, it is important to recognize not only that our present knowledge of pain behaviors in
horses is still limited,1,3 but also that described behaviors can
be influenced by factors such as temperament (age-, breed-,
sex-, stress-dependent), the nature of the horse being a prey
animal, and foraging or hunger-related activity.30 Thus, familiarity with the individual patient and information regarding the animals normal behavior before disease, trauma, or
surgery obtained from owners, trainers, riders, or other care
givers are often essential when employing behavioral assessment tools for pain evaluation and monitoring. In fact, studies in farm animals have indicated that veterinarians often
assess pain less effectively than farm personnel, which with
time develops a greater degree of familiarity with individual
animals under their care.31 In addition, not only in humans
but also in animals, behavioral changes in response to pain
can be altered by hospitalization and treatment impairment
of locomotor activity (eg, mechanical: bandage-, cast-, or
sling-related; or pharmacological: residual or side effects of
drugs administered during the perioperative period).3,32
In summary, currently available data indicate that careful
observation and recording of changes in behavioral activity
combined with objective measurement techniques, such as
physiological parameter monitoring and pressure algometry,
may be the most appropriate methods to assess pain under
clinical conditions. If consistently applied, such an approach
promises to translate into better pain management in clinical
practice.

Pain Scoring
To approach pain therapeutically, it is important to apply
reliable methods to repeatedly assess its intensity and duration, and also to record responses to treatment.1 Based on
previous studies, recording behavioral activity, either by direct or video observation, should occur frequently or continuously over prolonged periods of time.3 Intermittent (brief)
subjective evaluations may not be sensitive enough in an
individual horse to allow the identification of those behaviors
that are clearly pain or discomfort related.
Various scoring systems employing either behavioral characteristics only or both behavioral and physiological parameters have been applied to monitor pain in horses during the
perioperative period. In a study by Johnson and coworkers,33
comparing the analgesic efficacy of nonsteroidal antiinflammatory drugs (NSAIDs) in horses, pain was scored by two
evaluators (using a scale of 0-4) based on behavioral criteria

B. Driessen and L. Zarucco

128
Table 2 Behavioral Changes Observed in Horses Suffering from Different Forms of Pain3,5,29,31,46,55
Acute Pain

Chronic Pain

Forceful avoidance reaction in response to painful stimulus

Aggression (kicking, biting, head shaking, vigorous tail waving)
towards pain source
Reluctance to be handled
Restlessness
Depression with lowered head in case of prolonged sharp pain
or pain associated with eye disease (eg, corneal ulcer)
Rigid stance and head pressing
Interrupted feeding (food held in mouth uneaten)

Gait changes
Uneven limb loading causing or associated with muscle
atrophy
Changes in eating and drinking leading to weight loss
Changes in sleeping/recumbency times
Changes in social behavior
Changes (decreases) in responses to external stimuli

Musculoskeletal Pain*
Abnormal posture in stall (limbs or body held in unusual
positions)
Reduced locomotion/abnormal exploratory behavior
Changes in recumbency time (increased/decreased)
Increased weight shifting from one limb to another
Pawing
Abnormal gait
Change in head position during locomotion (head moves up
from neutral with forelimb pain; head moves down from
neutral with hindlimb pain)
Head and neck in a fixed position
Groaning and teeth grinding
Reduced interest in food and water
Restlessness
Immediate avoidance reaction to palpation of focal areas
located in myofascial structures

Visceral (abdominal) Pain*

Pawing
Flank watching, biting, or kicking at abdomen
Straining and splinting of the abdomen
Walking in circles
Repetitive lying down/standing up
Rolling/thrashing
Consistent lowering of head to levels at or below withers
Curling the upper lip (flehmen)
Reduced interest in food
Reduced exploratory behavior
Standing rigid and unmoving when near collapse
Groaning and teeth grinding

*May include also behaviors listed under acute or chronic pain dependent upon severity and duration of the pain.

(eg, level of comfort, appetite, respiratory character, pacing, and restlessness). Likewise, in two other studies investigating the analgesic potency of NSAIDs, butorphanol and
2-adrenergic drugs in horses with colic pain, behavioral
indices including sweating, kicking, pawing, rolling, lip
twitching, stretching to urinate, and attitude were subjectively scored using numerical rating scales.34,35 However, the
ability of these subjective scoring systems to reliably assess
pain in horses was not validated in these or similar equine
studies.25,26
Price and coworkers3 were among the first to develop a
scoring system for objective assessment of clinical pain in
horses undergoing orthopedic surgery. Horses undergoing
arthroscopy under general anesthesia were filmed over a period of 72 hours, beginning 24 hours before surgery and
ending 48 hours post recovery from surgery, and activity
budgets (time spent exhibiting predefined and mutually exclusive behaviors) were determined for each 24-hour period.
In addition, a set of predetermined active behaviors and postures as well as heart and respiratory rates were recorded
intermittently (ie, before surgery, after recovery from anesthesia, and in the morning and evening of the first and second
postsurgery day), using direct observation. The investigators
found both techniques as being suitable for identifying behaviors suggestive of postoperative discomfort, even though
continuous video recording appeared to be a somewhat more
sensitive method than repeated direct observation of specific
events and postures. Whereas surgery had no effect on recorded physiological parameters, the authors recognized distinct changes in behavioral activities believed to be primarily

related to pain and not to confounding factors, such as foraging or residual sedative or anesthetic drug effects.3 Horses
spent significantly less time with eating, were more often
positioned toward the back of their stall, acquired more frequently abnormal head-related postures (head level with or
below withers, ears oriented toward the side), and spent less
time lying in sternal recumbency during the initial 24 hours
post surgery when compared with their activities before surgery or to control animals. Compared with behavior before
surgery, between 24 and 48 hours post recovery, operated
horses spent also significantly less time exploring, less time in
sternal recumbency, and less time moving. Pritchett and coworkers5 recorded physiological (heart and respiratory rates,
and plasma cortisol levels) and behavioral indicators of postoperative pain in horses undergoing an exploratory laparotomy (surgery group) by comparing those data with two control groups: healthy horses that did not undergo any
intervention (control group) and those that were undergoing
magnetic resonance imaging under general anesthesia (anesthesia group). A composite numerical pain scale (similar to
the one presented in Table 3) was used to visually score
horses each time physiological parameters were recorded. In
addition, time budgets of behavior were calculated from
1-hour segments of real-time video recording beginning at
various time points during the study period. The surgery
group was characterized not only by significantly higher
heart rates and plasma cortisol concentrations but also significantly longer lasting display of painful behaviors compared with control and anesthesia groups. However, the
amount of time colic horses displayed post surgery behaviors

Diagnosis, scoring and treatment of pain

129

Table 3 Composite Numerical Pain Scale for Visual Scoring of Behavioral Activity in Horses with Pain*
Behavior Category

Obvious pain
behaviors,
Head position
Ear position

None

Occasional

Continuous

Above withers
Forward, frequent
movement

Below withers

Positioning in stall

Towards front
door observing
environment
Free movement
within stall
Regularly
Approaches door

At withers
Slightly back or to the
side, little
movement
Standing in the
center, facing sides
of stall

Locomotion
Sternal recumbency
Response to opening of
door
Response to approach
by attendant
Lifting feet

Response to food (hay

or grain) offer

Approaches
attendant with
ears forward
Voluntarily lifts
feet upon
request
Moves to door
and reaches for
food

Towards center looking

at stall door
Occasional movement

Standing still in
center/back of
stall
None

Occasionally
Staring towards door

Never
None

Looking towards
attendant, ears
forward
Lifts feet after some
encouragement
Staring towards food

Backing off

Does not move, ears

backward
Reluctant to lift feet

None

*The visual pain scale was adopted and then modified from Pritchett et al.5
Obvious pain behaviors include those listed in Table 2.
Scores combined to yield posture score.
Scores combined to yield socialization score.

indicative of abdominal pain as it occurs in acute clinical or

experimental conditions (such as pawing, walking in circles,
rolling, etc.) was small compared with the amount of time
spent without any movement (Table 2).36
The majority of pain behavioral studies in horses indicate
that there is a significant interindividual variation in the proportion of time spent displaying specific behaviors in response to superficial, musculoskeletal, or visceral pain.3,5,28,29
Nevertheless, identifying those behaviors in individual patients and then repeatedly determining the frequency of their
occurrence in successive time windows by direct or video
observation appears to provide a sensitive and valid method
of monitoring patients for their degree of pain or discomfort
as well as their response to analgesic and other treatment.
Alternatively and probably more easily established in clinical
practice, a modified version of the visual analog pain
scale originally developed by Pritchett and coworkers5 (see
Table 3) may be employed to reliably grade pain in equine
patients and to monitor both responses to analgesic treatment and disease progress.

Concept of Multi-Modal Pain

Therapy (Balanced Analgesia)
Our current understanding of the complex physiology and
pathophysiology of pain (Fig. 1) led in recent years to the
development of a more differentiated concept of pain management, also called multi-modal or mechanism-based pain
therapy or balanced analgesia as opposed to the traditional
uni-modal approach.37-39 Given the multiple mechanisms and
dynamic neurochemical processes involved in the generation

and aggravation (ie, peripheral and central hyperalgesia) of

the pain experience, it is reasonable to assume that the administration of a single dose of a single analgesic drug with a
single mechanism of action will not produce adequate and
long-term analgesic effects following traumatic or surgical
events.38,40 Rather different analgesic drugs should be administered for a minimum of 3 days following routine elective
surgical procedures and as long as required (based on repeated or continuous pain assessment) following traumatic
events.38 Balanced analgesia involves the combination of
drugs with different pharmacological mechanisms of action
and often both systemic and local (or regional) techniques of
their administration, but may also include complementary
modalities of pain treatment (Table 4). The purpose of balanced analgesia is to choose drugs and techniques that target
different sites of the neural conduit which conveys and integrates nociceptive signals from the periphery to the brain and
that act synergistically,40 thereby achieving six main goals.
These goals are: 1) blockade of nociceptive signal generation
in primary afferent terminals (tissue infiltration with local
anesthetics); 2) suppression of primary hyperalgesia (local
anesthetic agents, NSAIDs, opioids); 3) blockade of the peripheral transduction process, thereby preventing any development of secondary hyperalgesia (nerve blocks with local
anesthetics); 4) inhibition of spinal nociceptive signal transmission and inhibition of secondary hyperalgesia (epidural:
local anesthetics, opioids, 2 agonists; systemic: opioids, 2
agonists, ketamine, NSAIDs); 5) inhibition/decrease of the
pain experience by interfering with cerebral nociceptive
signal processing (systemic lidocaine, opioids, 2 agonists,
ketamine, NSAIDS); and 6) restoration of homeostasis and

B. Driessen and L. Zarucco

130

Figure 1 Ascending pathways of nociceptive impulses generated by peripheral sensory receptors (nociceptors) in
response to noxious stimulation. Once generated, impulses propagate along small-diameter (C and A) ascending
nerve fibers to the dorsal horn of the spinal cord. Nociceptive signals arriving at the spinal cord dorsal horn elicit the
release of neurotransmitters, which chemically convey nociceptive input to the spinal ascending pathways that carry
the information to the brain. In the brain, a complex integration of these signals transforms the nociceptive input into
the sensation of pain. Following tissue injury, changes in tissue pH and electrolyte composition as well as production
of inflammatory mediators and up-regulation of pro-inflammatory enzymes sensitize peripheral nociceptors toward
noxious and nonnoxious stimuli. Descending inhibitory neuronal pathways originating in the brain and terminating in
the dorsal horn of the spinal cord as well as spinal interneurons that release endogenous enkephalins modulate
nociceptive signal trafficking at the dorsal horn level. Indicated are target sides within the nociceptive conduit where
different analgesics elicit their pharmacological effects, ie, inhibit/suppress nociception and thus pain perception. The
concept of multi-modal or balanced analgesia is built on the idea that analgesics with different modes of action, when
administered together, interfere with generation, conduction, and integration of nociceptive signals more effectively
than when administered alone, and thus provide better analgesia. NE, Norepinephrine; 5-HT, serotonin; NSAIDs,
nonsteroidal antiinflammatory drugs.

normal function (all treatment modalities) (see Fig. 1). Multimodal pain therapy (balanced analgesia) represents a concept
that is very open, ie, also integrates complementary (nontraditional) modalities of treatment such as acupuncture or manipulative techniques where and whenever appropriate, and
allows new drugs and techniques of pain treatment to be
included as they become available in the future. Whatever

pharmacological or other approach and technique is chosen

in an individual multi-modal- or balanced analgesia protocol,
the ultimate objective is to achieve optimum pain control in a
particular situation, while at the same time minimizing the
risk of adverse responses to pain therapy.
Multi-modal pain therapy is already clinical practice in
equine veterinary medicine. Surgical patients frequently re-

Table 4 Multimodal Approach to Analgesia or Balanced Analgesia

Anti-Inflammatory Treatment

Systemic Analgesia

Non-steroidal anti-inflammatory drugs (NSAIDS)

Steroids

Opioids
2-Agonists
Local anesthetics (lidocaine)
Non-conventional therapeutics
- Butylscopolamine
- Ketamine

Local/Regional Anesthesia &

analgesia
Peripheral nerve blocks using topical,
infiltration, perineural, intraarticular
administration techniques:
- Local anesthetics
- Ketamine
- Morphine
Local intravenous (IVRA) administration
(Bier block)
- Lidocaine 12%
- Mepivacaine 12%
Epidural anesthesia/analgesia
- Local anesthetics
- Opioids
- 2-Agonists
Complementary therapies
- Acupuncture/electroacupuncture
- Manipulative (manual) therapy
- Chiropractic treatment

Diagnosis, scoring and treatment of pain

131

Table 5 Drugs Used for Systemic Analgesia via Continuous Rate Infusion (CRI)
Drug Class
Opioids

Drug

IV Bolus Dose
(mg/kg)

IV CRI Rate
(mg kg1 hr1)

Morphine

0.15

0.10.4

Butorphanol

0.02

0.0130.024

Fentanyl

0.000280.005

0.00040.008

Fentanyl

0.002

0.0004

2-Agonists

Xylazine
Detomidine
Medetomidine
Romifidine

Local anesthetics

Lidocaine

1.32.5 (over 1030 min)

1.83.0

Dissociative
anesthetics

Ketamine

none or 1.02.3 (over

3040 min)

0.41.5

[With lidocaine

0.2 0.3
0.006 0.009
0.003 0.007
0.003 0.005
0.01 0.04

none or 1.0

ceive a combination of analgesic drugs during the perioperative period, so for example antiinflammatory drugs, local
anesthetics, or locally administered opioids (inhibiting/
blocking ascending nociceptive pathways and primary hyperalgesia), systemic 2-agonists and/or opioids for pre- and
postoperative sedation and analgesia (activating or simulating the effects of descending antinociceptive pathways), and
ketamine as N-methyl-D-aspartate (NMDA) receptor antagonist for induction of anesthesia (inhibiting spinal neuronal
processes leading to secondary hyperalgesia). Systemic lidocaine, opioids, or 2-agonists may also be given intraoperatively as part of a balanced anesthesia protocol.
Continuous systemic infusion of analgesic drugs (Table 5)
is commonly used as part of a balanced inhalant anesthetic
protocol (ie, a combination of a potent analgesic with a lowdosed inhalant anesthetic) or in total intravenous anesthesia
(TIVA) to provide sufficient pain control during surgery. Intravenous infusion of potent analgesic/sedative agents, such
as 2-agonists alone or in conjunction with opioids, is also
used for surgical procedures in the standing sedated horse. In
these situations, those drugs are usually used in conjunction
with local or regional anesthesia to control short periods of
acute pain and facilitate surgery.
Continuous infusion of analgesic drugs is even more indicated in patients with persistent pain to provide more consistent and durable pain relief, while at the same time avoiding the risk of overdosing and/or minimizing adverse effects
typically occurring with bolus administrations in high doses
(Fig. 2).29,30 A constant rate infusion (CRI) of analgesic medication(s) shall supply sufficient amount of analgesic drugs to

1.0
0.024 0.036
0.0015 0.0035
0.1 0.4

Comments
Has been studied as adjunct to
inhalant anesthesia
Short-lived analgesic effect at lower
doses; excitatory responses at
higher doses (>0.02 mg/kg)
No unequivocal evidence for
analgesic effects
Predicted doses calculated based on
published pharmaco-kinetic data in
horses and a target plasma
concentration of >1 ng/mL
Significantly decrease requirement for
anesthetic agents, thus often used
in balanced anesthesia & total intravenous anesthesia (TIVA) protocols;
provide effective analgesia for
surgery in standing horses
Commonly used intraoperatively as
part of a balanced anesthesia
protocol, in the post-operative
period after abdominal surgery & in
horses with severe pain
At subanesthetic doses; most often
used in horses with severe acute or
chronic pain; no marked adverse
effects

0.2]

provide adequate pain relief during most of the day, requiring additional drug administration only when breakthrough
pain occurs. This, however, implies frequent or continuous
monitoring of the patient since patient-controlled analgesic
infusion systems (PCA-pumps), which are common in human pain therapy, are not applicable in the horse. Ideally
breakthrough pain medication is tailored to individual episodes of peak pain, which may vary substantially in duration
and intensity, and composes of either boluses of analgesic
drugs that are being already infused and/or additional therapeutics that synergistically enhance the analgesic efficacy of
already continuously administered drugs. Lidocaine and butorphanol infusions have been used successfully in horses
suffering from visceral pain after colic surgery or intestinal
disease such as large colon impactions. Opioids (eg, morphine, butorphanol), 2 agonists (eg, detomidine, medetomidine), ketamine alone or in conjunction with lidocaine
have been administered via intravenous infusion in horses
with persistent musculoskeletal pain as for example after
long-bone fracture repair, arthrodesis, septic joint or septic
tendon sheath treatment, or hoof-wall resection in laminitic
patients.
The two most commonly used complementary modalities
of pain therapy in horses are acupuncture and chiropractic/
manipulative therapy. Both acupuncture and electroacupuncture have been used to provide visceral, cutaneous, and
musculoskeletal analgesia in research and clinical settings.41-48 Whereas acupuncture has classically been thought
of as a major component of traditional Chinese medicine and
been developed based on empirical observations and de-

B. Driessen and L. Zarucco

132

Figure 2 Pain treatment in patients with persistent pain. While a constant rate infusion (CRI) of analgesic medication(s)
may suffice to treat the persistent pain the animal is suffering, additional drug administration is warranted when
breakthrough pain occurs. Ideally the breakthrough pain medication is tailored to individual episodes of peak pain
experience and composes of boluses of analgesics that are being already administered as CRI or of additional drugs that
synergistically improve the analgesic efficacy of infused pain therapeutics.

scriptions of naturally occurring phenomena, more recent

laboratory investigations have shown that neurohumeral,
neurophysiologic, and micromechanical mechanisms are involved in acupuncture.49,50 Acupuncture may have central,
local, and placebo effects. Many acupuncture points have
been shown anatomically to be associated with cutaneous
areas rich in free sensory nerve endings, lymphatics, capillaries, venules, and mast cells. Stimulation of certain points can
initiate neural and vascular responses, including propagated
sensations induced by triggering of afferent nociceptive fibers
that transfer along acupuncture point pathways. In addition,
acupuncture seems to stimulate a wide variety of sensory
receptors, with sensory afferents carrying the information to
the spinal cord and ultimately to the brain.50 Evidence in the
horse suggests that acupuncture also causes elevated blood
cortisol levels51 and increased spinal release of beta-endorphin.47
Currently, acupuncture is most frequently used in horses
suffering from musculoskeletal pain that is chronic and resistant to conventional drug therapy.50,52 Musculoskeletal pain,
followed by muscle spasm and contracture, may result in
muscle shortening. This in turn can result in local trigger
points, and, with chronicity and compensation, secondary
more distal trigger points can develop aggravating the pain
experience of the patient.50,52 Recently, Chu53 reviewed potential local mechanisms that may explain the efficacy of
acupuncture in musculoskeletal pain, especially those local
effects of acupuncture specific to needle penetration and/or
movement. Intramuscular movements of the needle, needle
penetration, or manipulation in classical or electrical acupuncture appears to evoke depolarization of innervated single or grouped muscle fibers, inducing micro-twitches that
can be recorded by electromyography. It is these small local
twitches, which appear to mediate, at least in part, musculoskeletal pain relief in acupuncture. They are capable of producing micro stretch effects on adjacent shortened muscle

fibers. This reduces the mechanical traction effect produced

by these shortened muscle fibers on pain sensitive structures
including intramuscular sensory nerve endings (nociceptors)
and blood vessels. The theory of stretching shortened muscle
fibers to produce pain relief has been supported by the observation that more significant musculoskeletal pain relief
can be obtained through inducing larger force twitches by
employing automated and electrical twitch-obtaining intramuscular stimulation methods. Thus, it seems that the twitch
may be the local key to pain relief, not just a diagnostic sign
for the localization of myofascial trigger points.53 It may also
explain why acupuncture in horses is particularly beneficial
in the treatment of chronic back pain, as has been repeatedly
demonstrated.42,43,48
Manipulative (manual) therapy is also of benefit for treatment of pain associated with musculoskeletal dysfunctions.50,52 Manual therapy typically includes chiropractic or
osteopathic principles and techniques, although physical
therapy and possibly massage approaches may apply as well.
Like acupuncture, manipulative techniques largely address
the problem of muscle shortening (muscle hypertonicity)
that usually involves the axial skeleton.45 Controlled forces,
so-called adjustments, are used to induce change in muscle
function and neurological reflexes, and hence reductions in
pain, muscle shortening and hypertonicity, and concurrent
improvements in joint motion.15,45,50 In experimental studies, Haussler and Erb19,20 identified the mechanical nociceptive thresholds in the axial skeleton of horses using pressure
algometry as an objective, reliable and noninvasive tool to
measure musculoskeletal pain in horses. The authors also
determined that a series of certain chiropractic treatments
can produce measurable increases in pain pressure thresholds. These reports are encouraging and call for more controlled studies investigating the therapeutic potential of chiropractic and osteopathic manipulations in horses suffering
from chronic musculoskeletal pain.

Diagnosis, scoring and treatment of pain

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