25_34_Steagall_Acute pain.
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Journal of Feline Medicine and Surgery (2019) 21, 25–34
ACUTE PAIN IN CATS
Recent advances
in clinical assessment
Paulo V Steagall and Beatriz P Monteiro
Why so crucial?
The lack of pain assessment is one of the main reasons why analgesic
administration has often been neglected in cats.1 Without the ability to
accurately assess pain, cats may suffer from the sensory-discrimina-
tive, affective-motivational, cognitive-evaluative and physiological
consequences of pain (see ‘What are we actually assessing?’, page 26).2
Pain assessment is an elemental part of feline practice, and pivotal to
general health and welfare. It should be part of every physical exami-
nation (Figure 1), alongside temperature, pulse, respiration (TPR) and
nutritional assessment. Though crucial for proper analgesic treatment,
pain recognition is not a simple task in non-verbal patients due to their
inability to self-report.3
Our knowledge of feline
acute pain assessment has
dramatically improved in
recent years with the publica-
tion of pain scales with report-
ed validation,4–6 and studies
on factors and limitations
affecting pain recognition.7–12
Pain assessment
should be part of every
physical examination,
Figure 1 Pain assessment should be considered
alongside TPR
the fourth vital sign, after TPR assessment. Here,
abdominal palpation is being performed as part of and nutritional
a cat’s physical examination
assessment.
Paulo V Steagall1,2
MV, MSc, PhD, Dipl ACVAA
Beatriz P Monteiro2,3
DVM
1
Department of Clinical Sciences,
Faculty of Veterinary Medicine,
Université de Montréal, Saint-Hyacinthe, Canada
2
Groupe de Recherche en Pharmacologie
Animale du Québec (GREPAQ), Faculty of Veterinary
Medicine, Université de Montréal, Saint-Hyacinthe,
Canada
3
Department of Veterinary Biomedicine,
Faculty of Veterinary Medicine,
Université de Montréal, Saint-Hyacinthe, Canada
Corresponding author: paulo.steagall@umontreal.ca
DOI: 10.1177/1098612X18808103
© The Author(s) 2018
CLINICAL REVIEW
Practical relevance:  Pain assessment
has gained much attention in recent
years as a means of improving pain
management and treatment standards.
It has become an elemental part of feline
practice with ultimate benefit to feline health and
welfare. Currently pain assessment involves mostly
the investigation of sensory-discriminative
(intensity, location and duration) and affective-
motivational (emotional) domains of pain. Specific
behaviors associated with acute pain have been
identified and constitute the basis for its
assessment in cats.
Recent advances: The publication of pain scales
with reported validation – the UNESP-Botucatu
multidimensional composite pain scale and the
Glasgow feline composite measure pain scale –
and species-specific studies have advanced our
knowledge on the subject. Facial expressions have
also been shown to be different between painful
and non-painful cats, and very recently the
Feline Grimace Scale has been validated as
a tool for acute pain assessment.
Clinical challenges: Despite recent advances,
several challenges still exist. For instance, the
effects of disease and sedation on pain scoring/
assessment are unknown. Also, specific painful
conditions (eg, dental pain) have not been
systematically investigated. The development and
validation of instruments for pain assessment by
cat owners is warranted, as these tools are currently
lacking.
Aims: This article reviews the use, advantages,
disadvantages and limitations of the two validated
pain scales, and presents a practical, stepwise
approach to feline pain recognition and assessment
using a dynamic and interactive process. The
authors also offer perspectives regarding current
challenges and future directions.
Keywords: Analgesia; pain scoring systems; pain
assessment; acute
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R E V I E W / Acute pain assessment in cats

What are we actually The affective-motivational

assessing? domain plays an important role
in pain perception in humans,
Pain is a very complex experi- and cats are probably affected
ence and is typically said to in a similar manner. It is thus
be characterized by a set of three reasonable to assume that feline
‘domains’. Evaluation of the first friendly handling techniques,
of these, the sensory-discrimina- and a quiet, clean and warm
tive domain of pain, involves environment may help to
assessment of intensity, location ameliorate aversive aspects of
and duration (ie, physical quali- hospitalization and pain (Figure
ties) by means of a thorough 2).14,15 Finally, the cognitive-
physical examination, history, evaluative (third) domain of pain
knowledge of specific behaviors relates to the pain experience in
and use of a pain scale. The sec- Figure 2 A non-pharmacological therapeutic approach can the context of previous experi-
ond is the affective-motivational be easily and cost-effectively incorporated into feline practice. ences or knowledge; it is conse-
It maximizes comfort and welfare, and minimizes stress, fear
domain, which relates to the and anxiety. Recovery from anesthesia and surgery, for quently difficult to assess in
emotional consequences of pain. example, should be facilitated by a quiet location and warm cats.
and comfortable bedding
This domain is often assessed in
conjunction with the sensory-
discriminative domain.13 Pain scales allow the In feline practice, the domains of pain
evaluator to include pain-induced changes in
demeanor, such as dullness or aggression.
are evaluated via patient observation, physical
examination, and use of owner questionnaires
and pain scales.
Pa i n - re l a t e d b e h av i o r s
Key behavioral indicators of abdominal should be considered cautiously, they Specific facial expressions can also be
pain in cats have been identified.4,21 They provide important clinical guidance. Some used to differentiate painful and non-
include abnormal postures such as of these behaviors are commonly painful cats,23,24 and these are discussed
hunched guarding or splinting of the observed in acute pain and include reac- on page 30. Additionally, clinical experi-
abdomen.21 An expert consensus identi- tion to palpation, withdrawing/hiding, ence suggests that cats in severe pain are
fied 23 items that are considered as cer- decreased appetite, hunched posture, usually depressed, immobile and silent,
tainly or often sufficient to establish the lowered head position, growling, groaning, often showing ‘feigned sleep’ (Figure 5).25
existence of pain in cats.22 Although the eyes partially closed, decreased grooming Painful cats will not interact with obser-
results of this expert consensus have not and/or attention to the wound (Figures 3 vers, nor curl up to sleep, which is a normal
been validated, and thus the findings and 4).22 behavior to conserve body heat (Figure 6).
Excessive grooming of the wound has also
a been observed in painful cats.4
Factors including the type/duration of
surgery, severity of pain, hospitalization,

b Figure 3 Changes in
behavior in a cat before
(a) and after (b) the
administration of
analgesics. (a) The cat is
depressed, quiet and hiding
at the back of the cage
in a hunched posture with
changes in facial
expression; (b) the cat is Figure 4 Signs of severe abdominal pain in a patient following
now relaxed and facing the ovariohysterectomy. The cat is depressed, immobile and silent,
front of the cage in sternal in sternal recumbency with squinted eyes and head below the
recumbency with normal shoulder line
body posture and facial
expression Continued on page 27

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R E V I E W / Acute pain assessment in cats

Acute pain assessment by
subjective evaluation of changes
in behavior
The cat has both physiological and behavioral
features that are important in the assessment
of pain. However, physiological changes in,
for example, heart and respiratory rates, pupil
size and neuroendocrine assays (cortisol, glu-
cose, beta-endorphins, etc) are poorly correlat-
ed with acute pain in this species;16–19 anxiety,
stress and fear will affect these variables, par-
ticularly in the hospital setting.20 For example,
anesthesia or bandaging have been shown
to increase plasma concentrations of cat-
echolamines in non-painful cats.16,17 Therefore,
some of these physiological variables might
be important in the overall patient/disease
evaluation, but not directly for pain assess-
ment. Blood pressure is the only physiological
‘marker’ that has been correlated with
increased pain and cortisol concentrations,
but its monitoring is not always practical in a
busy clinical setting.4,18 Changes in appetite
are another important physiological indicator;
painful cats have decreased appetite.4
Conversely, some cats may not eat simply
Importance of a trained healthcare team
Veterinary technicians/nurses and animal care staff play a key role in
pain assessment. These individuals will spend more time with the patients
and often notice signs of pain that veterinarians might not otherwise detect
due, for instance, to the time constraints in their busy schedule.

Continued from page 26

a b
individual response to analgesic adminis-
tration, demeanor, age and disease should
be considered in the process of acute pain
assessment. Most importantly, changes in
behavior or the presence of abnormal

Figure 7 A healthy cat is examined prior

Figure 5 A geriatric cat with abdominal pain secondary
to constipation. Note, in particular, the appearance of the
eyes, and the orientation of the ears and whiskers: the
eyes are partially closed, the distance between the tips of
the ears is increased when compared with a non-painful
cat, and the muzzle is tense. A cat that is ‘feigning sleep’
due to a painful state, as in this case, might erroneously
be interpreted by owners and professionals unaware of
pain behaviors as simply ‘resting’
Figure 6 The curled-up position of this pain-free cat
is a normal posture to conserve body heat and is not
observed in painful cats
to surgery. (a) After observation of the cat’s
normal behavior, the cage is opened, and the
patient is calmly approached and stroked
gently. (b) The cat responds to the interaction
with the observer and shows a friendly
demeanor. This should be maintained after
surgery if the cat is not painful
Figure 8 A pain-free cat is typically interested
in its surroundings and interacts with
observers, even early after surgery
behaviors should be noted during
hospitalization, especially if pain is
suspected. It highlights the impor-
tance of thorough history taking,
physical examinations and use of
owner questionnaires to elicit infor-
mation about cats’ personalities,
which can then be taken into consid-
eration during pain assessment
(Figure 7).
A friendly cat will normally interact
with the observer, tolerate gentle
abdominal palpation and display
normal behaviors such as stretching,
playing and yawning. Depending on
their demeanor, pain-free cats have
an interest in their surroundings and
respond to stroking (Figures 7 and 8).

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R E V I E W / Acute pain assessment in cats

because they are not hungry or are ill.

Therefore, pain assessment is mostly per- UNESP-Botucatu MCPS
formed using subjective behavioral changes, The UNESP-Botucatu MCPS is a ‘physiological variables’ accounts
which can often be subtle in cats. Evoked valid and reliable tool to assess for only 12% of the total variance, it
responses (eg, reaction to palpation) via a acute pain in cats, with excellent has been determined that this item
dynamic and interactive approach with the discriminatory ability. It refers to could be omitted without compro-
cat should provide the best assessment. both sensory-discriminative and mising the global pain assessment.4
However, cats that are resting should not be affective-motivational domains of The tool was originally developed
disturbed for pain assessment. pain via its three subscales, which in Brazilian Portuguese,28 and sub-
Knowledge and observation of pain behav- together encompass 10 different sequently validated and translated
iors (see box on pages 26–27) are therefore variables: ‘pain expression’ (miscel- into English, Spanish, French and
fundamental in feline pain assessment. laneous behaviors, reaction to pal- Italian.4,29–31 Although no previous
pation of the flank and surgical experience is required for its use,
Feline acute pain scales wound, and vocalization), ‘psy- online training is recommended and
chomotor change’ (posture, com- videos are provided for this purpose
Pain scales are clinical fort, activity and attitude), and (www.animalpain.com.br). These
Use in feline
metrology instru- ‘physiological variables’ (appetite resources allow students and
practice
ments that primarily and blood pressure). Miscellaneous trainees to observe specific pain
The incorporation
evaluate the behav- behaviors include evaluation of behaviors and learn how to interact
of pain scales into
ioral expression of specific behaviors associated with with cats during pain assessment.
feline practice
pain. Rigorous valida- pain, including tail movements, It should be noted that implemen-
allows the study of
tion of these instru- contraction and extension of pelvic tation of this pain scale can be time-
pain behaviors in a
ments is required limbs or abdominal tension, squint- consuming and it has only been
more rational and
before their use is ing of the eyes and attention to the validated in cats undergoing ovario-
systematic manner.
recommended. In wound. hysterectomy.4 It is not known
Pain scales minimize
brief, the validation The original proposed cut-off for whether this tool can be applied to
the potential
process should ensure rescue analgesia was other types of pain
for biased and
that the instrument ⩾7/30, when all 10 items ✜ For a practical (eg, different surgical
subjective
measures what it is including blood pres- guide to acute pain procedures, trauma,
assessments.
intended to measure sure were scored.4 assessment using medical or neuropathic
(validity), produces However, subsequent the UNESP- pain). A short-form of
consistent results when repeated over time studies have reported a Botucatu MCPS, the UNESP-Botucatu
(reliability), and is able to detect clinically rel- cut-off of ⩾6/27 when see box on page 30 pain scale is currently
evant changes (sensitivity). Ideally, the instru- blood pressure was not and video 1 in the under validation and
ment should be compared with a similar measured.4,8,27 Given supplementary may overcome these
gold-standard tool, if one already exists.26 that the subscale material. limitations.
In general, pain scales should be practical,
user-friendly and easy to implement, inde-
pendent of who is assessing (technician/
nurse, veterinarian, student or individual under training) or the type of pain (eg, surgi-
cal, dental or medical). They should discrimi-
nate between different pain intensities (mild,
Glasgow CMPS-Feline moderate and severe), differentiate painful
The Glasgow tool was developed as a prototype – and revised following inter- from non-painful individuals and provide a
im analysis (hence r-CMPS-F) – to assess acute pain in cats. This scale has cut-off point above which interventional (res-
been shown to be valid, with some evidence of responsiveness; nevertheless, cue) analgesia is considered (or given) based
reliability testing has not been reported.5 The tool includes similar behavioral on solid statistical analysis.26 Pain scales are
categories as the UNESP-Botucatu MCPS, such as vocalization, activity, important in the repeated assessment of pain
posture, demeanor, attention to wound and response to interaction with the as a monitoring tool and for identification of
observer and palpation of the painful area.5 ‘treatment failure’. The advent of validated
The Glasgow rCMPS-F is less time-consuming and easier to use than the pain-scoring instruments will undoubtedly
UNESP-Botucatu MCPS and, according to the original study, it can be improve study design and generate more
applied to any kind of acute pain (medical, robust data in feline analgesia.
surgical, trauma, etc).5 An updated version There are two pain scales that have under-
gone validation in cats: the UNESP-Botucatu
(Glasgow CMPS-Feline) has been recently ✜ For a practical guide
published and includes facial expressions;6 multidimensional composite pain scale
to acute pain assessment
the cut-off for interventional analgesia is (UNESP-Botucatu MCPS) and the Glasgow
using the Glasgow
⩾5/20.6 This latter version should be pre- composite measure pain scale–feline
CMPS-Feline, see box on
ferred as it showed increased discriminato- (Glasgow rCMPS-F).13 The UNESP-Botucatu
page 30 and video 2 in the
ry ability when compared with the previous MCPS is the only instrument to have under-
supplementary material.
version. gone comprehensive validity, reliability and
sensitivity testing.4 The Glasgow rCMPS-F

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a b
reported validity and moderate sensitivity,5
while an updated (‘definitive’) version of the
Glasgow rCMPS-F (Glasgow CMPS-Feline)
showed improved discriminatory ability
(sensitivity).6 These two instruments have
been used in several clinical trials7,8 and are
discussed in the boxes on page 28.
Note that other scales are available, includ-
ing the visual analog scale (VAS), the numeri-
cal rating scale (NRS) and various descriptive
rating scales such as the University of
Melbourne Pain Scale and the Colorado
Feline Pain Scale, but these have not been val-
idated and should not be used at this stage for
the evaluation of pain in cats. Pain assessment
could be misleading.
Limitations and new knowledge
It is natural that pain scales evolve with time
as more is learnt about their limitations and
further validations are performed.
✜ It is now known, for example, that the
UNESP-Botucatu MCPS is influenced by the
administration of ketamine-based protocols:9
specifically, ketamine produces a confounding
effect on the ‘psychomotor’ subscale that can
lead to false increases in pain scores. These in
turn could potentially result in inappropriate
administration of rescue analgesia to pain-free
cats.9
✜ Confounding results for both the UNESP-
Botucatu MCPS and Glasgow rCMPS-F scales
have likewise been described in cats with
certain demeanors (ie, shy, or fearful and
showing aggressive behavior).10 In feline
practice, these shy or fearful individuals may
present high pain scores and it can be difficult
to distinguish whether they are truly painful or
Changes in behavior or the presence of abnormal behaviors should be noted
during hospitalization, especially if pain is suspected.
R E V I E W / Acute pain assessment in cats
Figure 9 Pain-scoring
systems are affected by
demeanor. Shy (a) and
fearful cats (b) might present
with false increases in pain
scores due to their
demeanor. Image (b) courtesy
of Dr Ryota Watanabe
Pain whether their behavior affects pain assessment
assessment (Figure 9).
✜ Pain and dysphoria may be difficult to dif-
is mostly ferentiate using these scales. Dysphoria is
usually associated with high doses of opioid
performed administration, and manifests as behavioral
using changes including resentment to handling,
restlessness and agitation, among other nega-
subjective tive emotional states. In order to distinguish
pain and dysphoria, an analgesic intervention
behavioral can be administered: a decrease in the
changes, which observed behaviors suggests the presence of
pain (ie, analgesic challenge), whereas no
can often be change or worsening of the behaviors
suggests dysphoria. In the case of the latter,
subtle in cats. reversal of the pharmacological agent or
administration of a sedative is recommended;
opioid analgesic effects will be antagonized
with the administration of an opioid antago-
nist (eg, naloxone). Continuous pain assess-
ment should be performed thereafter.
✜ Another interesting finding has been
published recently in a study by the authors’
group using both the UNESP-Botucatu MCPS
and Glasgow rCMPS-F scales to evaluate the
analgesic effects of gabapentin and bup-
renorphine in cats. Despite strong or very strong
correlation in pain scores between the two pain
scales when used by the same observer, the
decision regarding the administration of
rescue analgesia differed between the scales.8
In practical terms, one scale indicated the
requirement for rescue analgesia for some cats
while the other did not. These results are
important when considering the study of new
analgesic techniques, as they suggest that
perceived efficacy of an analgesic drug could be
related to the pain scale used for its testing.
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R E V I E W / Acute pain assessment in cats

Applying pain scales for acute pain assessment

For both pain scales (UNESP-Botucatu MCPS and Glasgow CMPS-Feline)

the cat is initially examined without being disturbed

The cat is then calmly approached, and the cage door is opened

The cat is gently handled and encouraged to move around while the incision
site or affected area, surrounding skin, flank and abdomen are gently palpated

Pain scores are recorded using the chosen pain scale, with particular regard to
the cut-off for the provision of rescue analgesia

The frequency and duration of pain assessment should be tailored to the

individual patient, taking into account the painful condition and expected VIDEOS
level of pain, and the duration of effect of the chosen analgesic(s). Studies Two educational videos describing how
suggest that cats may show signs of pain as early as 30 mins following acute pain assessment is performed in
ovariohysterectomy.7,8,27,32 The first 6 h after this surgery have been shown practice using the UNESP-Botucatu MCPS
and Glasgow CMPS-Feline are included
to be critical, when many cats require rescue analgesia. Evaluations should in the online version of this article at:
continue beyond this point, with an appropriate plan for pain relief. jfms.com
DOI: 10.1177/1098612X18808103

Facial expressions and the

Feline Grimace Scale identified and included ear position, orbital
Facial expressions have been used to evaluate tightening, muzzle tension, and whiskers and
pain in different species, and recently they head position (Figure 10).24
have been incorporated into feline pain assess- Very recently this Feline Grimace Scale has
ment.6 In a previous study, changes in ear and been shown to be a valid tool for acute pain
muzzle position had been identified in painful assessment.33 It has displayed good inter- and
versus non-painful cats (Figure 5).23 Recently, excellent intra-rater reliability, and discrimi-
development of a Feline Grimace Scale nates painful from non-painful cats. Current
revealed further differences between painful studies are investigating its responsiveness
and non-painful cats.24 Five ‘action units’ were and the cut-off for analgesic administration.

a b c

Figure 10 Changes in facial expression are good indicators of pain in cats. (a) A 12-year-old male neutered cat prior to dental extractions. The ears are upright,
the eyes are wide open, and the whiskers are relaxed. (b) Facial expressions of pain 2 h following full-mouth dental extractions. The distance between the tips
of the ears is increased, there is squinting of the eyes and the muzzle is tense. The mouth is also opened and swollen. (c) Thirty minutes after administration of
rescue analgesia (hydromorphone) the distance between the tips of the ears has returned to normal, with the ears again in the upright position. The eyes are wide
open (mydriasis is secondary to opioid administration) and the whiskers and muzzle are relaxed. Images courtesy of Dr Ryota Watanabe

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Challenges in clinical acute
pain assessment
Various challenges relating to clinical acute
pain assessment in cats have been recognized,
as listed on the right. A further important
challenge and limitation concerns the study
population used in investigations on feline
analgesia. Published studies commonly
involve healthy cats undergoing neutering.27,33
Consequently, it is not known how disease,
sedation or pregnancy, for example, affect post-
operative pain assessment and scoring in feline
practice.12 Clinically it has been shown that cats
with upper respiratory tract disease present
changes in facial expressions that are similar to
those reported in painful cats (Figure 11) as
well as similar body posture, lack of interaction
with the observer, reduced appetite and
depression.12 This population of cats may pre-
sent with clinical signs such as sneezing, ocular
discharge, blepharospasm, conjunctivitis,
rhinitis and stomatitis, which could be related
to pain and/or disease. Therefore, disease
might bias pain assessment and the need for
rescue analgesia.
Another type of bias – intrinsic or implicit –
refers to attitudes or stereotypes that involun-
tarily and subconsciously affect our under-
standing, actions and decisions. Studies have
shown that the evaluator’s gender and lan-
guage can produce intrinsic bias in feline pain
assessment.7 Ideally, the pain-scoring tool
should go through back-translation and be
validated again in the language of the user to
respect cultural semantics.30 For example, the
order of the questions and their relevance in
the instrument might change after translation
Figure 11 A female cat with upper respiratory tract disease
before ovariohysterectomy. The cat was depressed upon
presentation and had decreased appetite; note the hunched
body posture and ocular discharge. These clinical signs could
be interpreted as pain postoperatively
R E V I E W / Acute pain assessment in cats
Challenges of clinical acute pain assessment in cats
✜ Unique personality of each cat
✜ Individual response to analgesic administration
✜ Hospitalization-induced stress and fear (which can promote behavioral
changes even in pain-free cats)
✜ Inappropriate handling techniques
✜ Lack of training and continuing education in feline pain recognition
✜ Other factors such as behavioral changes after drug administration,
demeanor, etc
and validation.4,28–31 Clearly, in this respect the
UNESP-Botucatu MCPS has an advantage, as
it has been published in five languages.
Training also impacts pain assessment. In a
recent study, veterinary students recorded
lower pain scores than individuals with previ-
Depending ous experience in pain assessment.7 In a
separate study, the results of pain assessment
on who is differed between veterinary anesthesiologists
assessing pain, and graduate veterinarians versus undergrad-
uate veterinary students.11 Indeed, scores can
the outcome be significantly different and, depending on
who is assessing pain, the outcome for rescue
for rescue analgesia might change.7 This also has impli-
analgesia cations for clinical trials, as the performance of
an analgesic drug in this setting might be
might change. observer-dependent.8
Future perspectives
The future for feline acute pain assessment
looks to be promising and exciting, as we
learn more about specific pain behaviors,
and new tools are developed and validated.
Some particular perspectives are discussed
below.
✜ Studies with cat owners are important and
should be addressed. Research has shown
that cat owners are able to identify specific
behaviors up to 3 days after castration or
ovariohysterectomy, with owners reporting a
CLIENT EDUCATION:
How do I know if my cat is in pain?
The American Association of Feline Practitioners
(AAFP) has a client brochure for cat owners entitled
‘How do I know if my cat is in pain?’ which lists some
of the expected behaviors in painful cats and
empowers owners with regards to their key role in
diagnosing pain in their cats. The brochure can
be downloaded from the AAFP website:
https://www.catvets.com/
guidelines/client-brochures
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R E V I E W / Acute pain assessment in cats
decrease in overall activity level and
playfulness, an increase in the amount of time
spent sleeping and altered locomotion.34
Significantly, the pain-related behaviors
reported by cat owners were similar to what
veterinarians would expect. This highlights the
importance and value of client education
regarding pain behaviors (what to expect and
how to proceed) in order that painful cats are
brought into the clinic for appropriate
diagnosis and treatment. A useful client
education resource is described on page 31.
✜ Behavioral studies are paramount for
learning about pain-related behaviors in
specific conditions As well as learning about
pain-related behaviors in ophthalmic, dental
(see below) and neuropathic pain, among
others, these studies would corroborate if
current pain-scoring instruments are valid
in these scenarios. Additionally, behavioral
assessment via video analysis may allow
discrimination of pain intensity and the study
of hitherto unknown pain behaviors, and
determine how pain behaviors are affected by
the administration of analgesics or treatment of
primary disease.
✜ The issue of dental pain in feline practice
Global dental guidelines have recently been
published by the World Small Animal Veterinary
Association (WSAVA)35 which state that dental
The advent of validated pain-scoring instruments
pain is under-recognized and undertreated in
small animal practice. Periodontal disease
produces severe pain, inflammation, dysphagia,
sialorrhea, halitosis, weight loss and oral
hemorrhage.35 Some cats will rub or paw at the
face, particularly during eating or playing.
However, behavioral signs of oral disease-
induced pain and the effects of oral pain and its
impact on feeding behavior have not been
systematically studied in cats.35 Owners will not
usually bring their cat into the clinic unless
dental pain is severe, by which stage the
nutritional/welfare status of the patient has
been dramatically compromised. An ongoing,
multidisciplinary study involving nutrition,
dentistry, and behavioral and pain management
could address this gap in clinical knowledge.
These patients present specific pain and feeding
behaviors that are different from cats without
oral disease. Facial expressions before and after
treatment of oral disease and analgesic
administration are likewise unique (Figure 10).
In the authors’ experience, cats with severe oral
disease require up to 96 h of analgesic
administration following dental extractions.
✜ Pain scales and use of mechanical
nociceptive thresholds can provide means
of objective assessment of clinical pain.
Mechanical nociceptive threshold testing refers
to the use of calibrated devices (ie, algometers)
that are applied against parts of the body
until a behavioral response is observed
32 JFMS CLINICAL PRACTICE
KEY POINTS
✜ Assessment of acute pain in cats is
mostly based on subjective behavioral
changes.
✜ Objective assessment is not always
practical. With the exception of blood
pressure and changes in appetite,
physiological changes have not been
consistently correlated with acute pain.
✜ Key behavioral indicators of abdominal
pain have been identified.
✜ There are two pain scoring instruments
for use in cats: the UNESP-Botucatu
multidimensional composite pain scale
and the Glasgow feline composite
measure pain scale.
✜ Facial expressions change in acute
pain. These changes should be
considered in the evaluation of pain
in this species.
will improve study design and generate
robust data in feline analgesia.
(eg, withdrawal, vocalization, escape reaction).
The amount of force (ie, grams or newtons)
necessary to elicit a behavioral response is
measured and considered the mechanical
nociceptive threshold. There is an interest in
the incorporation of these non-invasive
instruments in clinical acute pain assessment.
However, results have not been consistent
among algometers and other nociceptive
devices, and many of these tools lack validity.27
Further studies on objective measurements of
acute pain assessment are warranted.
Conclusions
Feline acute pain assessment has improved
in recent years. Specific pain behaviors have
been described and the development and val-
idation of instruments to evaluate pain has
made a substantial contribution to this field.
However, these tools still have their limita-
tions. Future studies should investigate the
effects of disease and sedation on pain assess-
ment and its scoring instruments, and the
specific pain behaviors in different states/
diseases. Client education on pain behaviors
is also urgently required.
25_34_Steagall_Acute pain.qxp_FAB 10/12/2018 13:11 Page 33
Supplementary material
Video 1 Assessment of postoperative pain
using the UNESP-Botucatu MCPS in a cat 1 h
following ovariohysterectomy. This pain scale
provides a clear description of behaviors to be
observed. The cat should always be calmly
approached, and its reactions carefully moni-
tored. Blood pressure was not evaluated in
this example.
Video 2 Assessment of postoperative pain
using the Glasgow CMPS-Feline in a cat 2 h
following ovariohysterectomy. This pain scale
includes scoring of specific behaviors and
facial expressions. The cat should always be
calmly approached, and its reactions carefully
monitored.
Acknowledgements
The authors wish to thank Dr Ryota Watanabe
for video production (supplementary materi-
al), and Drs Javier Benito, Ryota Watanabe,
Graeme Doodnaught and Marina Evangelista
for their key contributions in the study of
feline pain management at the Université de
Montréal.
Conflict of interest
The authors declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this article.
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