What can be done
A Team Approach to Diagnosis and Care
At Cornell University Hospital for Animals, veterinary anesthesiologists function as members of a multidisciplinary pain-service team that can include surgeons, oncologists, internal medicine specialists, imaging specialists, and veterinary technicians. With their combined expertise, these veterinary health professionals work together to identify causes of pain and tailor a treatment plan for the most effective management of the patient's particular pain problem.
The latest clinical diagnostic procedures and equipment - such as ultrasound, CT, MRI and fluoroscopy imaging studies as well as highly advanced point of care and laboratory testing -- are used to diagnosis the causes of pain. Specialized testing including force plate analysis, diagnostic joint or nerve blocks, and electrodiagnostics (EMG/NCV) can also be utilized. The clinician must evaluate the many different aspects of an animal's condition, including impairment in daily living, interactions with family members, appetite, vitality, sleep and rest patterns, financial concerns, and mental status or psychological dysfunction. The pain-service team thoroughly reviews each patient's history, evaluates the animal's painful condition, and makes carefully planned diagnostic & treatment recommendations to owners.
All tests and treatments done at Cornell can be coordinated with your referring veterinarian's care. The team can also work to assist you and your veterinarian to design treatment at the patient's home as necessary. In addition, Cornell offers our telephone hotline/website consult for the public and a DVM-interactive consultation website, both of which provide access to advice for referring veterinarians and owners who deal with acute or chronically painful animals.
Treatment Options
A wide variety of treatments can be used to alleviate or reduce pain in animals. These include:
Medicine and drugs: Medications have been a mainstay of both disease and pain treatment in veterinary patients for the past 3-4 decades. Although we classically have thought of "pain relievers" such as aspirin or nonsteroidal type and opioid drugs being the cornerstone of reducing pain, its important to realize that many other medications such as antihistamines, local anesthetics, antibiotics, steroid and immunosuppressive drugs, certain cardiac medications, and even antiepileptic agents are being utilized to treat conditions and the pain that accompanies them. These drugs come in a variety of forms, from orally administered tablets through transmucosal compounds, crèmes, gels and other topical agents to injectable/inhaled formulations. Just as in humans, careful management of pain medication dosage and form are required to be certain there will not be an interaction with any other medication your pet may be receiving. Our service will work with CUHA's internal pharmacy, your local pharmacy and even some specialized nationwide "compounding" pharmacies to provide your pet with the appropriate medication to treat the issues at hand.
Medical techniques: Conventional techniques of endoscopy, cystoscopy, guided biopsy or fine needle sampling can be persued dependent on the animal's presenting problem or diagnosis. Many techniques such as in hospital (antibiotic/antifungal, antiemetic) infusions, fluid therapy, indwelling catheter placement, feeding tube placement, centesis for fluid removal and vascular/urinary catheterization are performed regularly in conjunction with the medical and oncology services within our intensive care wards. These medical treatments and therapies are necessary to maintain appropriate perfusion and hydration, treat inflammation and infection, and provide necessary nutritional status helpful to decreasing pain long term. Chronic medical conditions such as infections, Cushing's disease, diabetes, hypothyroidism, congestive heart failure, and renal insufficiency are often concurrently treated to allow pain therapies to work effectively.
Surgical techniques: As veterinary medicine specialists learn better and better ways to handle problems, surgical procedures once thought of as impossible for our patients become a more realistic possibility. Surgeries are designed to decompress neural elements, reconstruct and stabilize soft tissue and connective (bone) structures, and improve function or quality of life. Whether undergoing neurosurgery (disc or cranial surgery), orthopedic surgery (fracture and congenital malformation repair), soft tissue surgery (flap, grafting, corrective) or mildly less invasive procedures such as arthroscopy or cystoscopy, your pet will be cared for by a team of highly trained and specialized individuals. All cases entering the surgical environment are also treated by an anesthesiologist and veterinary technicians trained in anesthesia and surgery. This group of clinicians and technicians ensure that perioperative care of your pet is optimal, and pain relief an integral part of balanced anesthesia, albeit general anesthesia or sedation.
Oncology (chemotherapy, radiation, and surgery): Cancer diagnosis and treatment has also advanced drastically over the past few decades in veterinary medicine. With superior imaging techniques, we are now able to diagnose tumors and their related diseases (paraneoplastic syndromes) more efficiently, sooner and easier in our animal patients. With the use of surgical techniques to remove or reduce tumors, as well as superior chemotherapy agents and highly focused and sophisticated radiation protocols typically utilized in humans, the current trend is increasingly moving toward instituting palliative care much earlier in the course of disease, resulting in the application of palliative care lasting for months or even years. Vigorous attention to pain, suffering, general nursing care, comfort and quality of life is the cornerstone of good palliative moreso with these patients than with others. Emphasis with oncology patients is placed on maintaining mobility, appetite, good bowel and bladder habits, improved cognitive function, sleep patterns, and of course, continued quality family interactions. More information on our Oncology service can also be found at the Oncology Pages.
Intensive and critical care: Should your pet require hospitalization for fluid therapy, wound care, impaired function, respiratory or cardiac care, our intensive and critical care units are designed to assist in these avenues. This is a key area within the hospital that allows us to deliver more specialized intravenous and other invasive medications (epidurals, spinals, infusions) using 24 hour nursing care, advanced cardiac and respiratory monitoring, and close attention to bladder and bowel care, mobility, and stress. Physical rehabilitation techniques are used side by side with more conventional medication delivery systems, techniques, interventional methods, suctioning, and even ventilator therapy to ensure that an severe pain, stress, disease and suffering are addressed, treated, monitored and prevented in veterinary patients with advanced and/or multiproblem disease states.
Nutrition and supplementation: Thankfully, many issues in our and our pet's health can be circumvented or "treated" gradually via dietary manipulation. Nutrition problem solving includes assessment of the patient, the food and the feeding method. The goal of nutritional assessment is to establish a patient's current body condition, nutrient needs and feeding goals in light of its physiologically painful disease condition. From here, many commercial diets can be supplemented with disease modifying compounds reported to have biosynthetic, anti-inflammatory and degradative enzyme inhibition activity. Presription diets and individually prepared or homecooked diets may also be of benefit to the animal in terms of its painful disease. There continues to be great interest in the discovery of 'natural' products to alleviate many painful disease symptoms. There is a need to conduct studies and clinical trials to support in vitro evidence that these compounds may be beneficial to our clinical veterinary patients with naturally occurring disease. The subjective nature of pain however, does seem to improve with use of select supplemental agents; as such, the goal of nutraceutical and DMAs (disease modifying agents) usage is to complement conventional drug, interventional and surgical therapy to help provide pain relief long term. More information on the Nutrition Services of the Cornell University Hospital for Animals can be obtained by emailing Angie Struble, LVT, Nutrition Services at ams29@cornell.edu
Complementary Medicine: The use of complementary and alternative medical (CAM) therapies is becoming widespread. In veterinary medicine, the use of CAM has been reported in many species and has been associated with a variety of disease states and conditions including musculoskeletal, neurologic, cardiovascular, dermatologic, endocrine metabolic, and behavioral disorders. Pain alleviation is an area where many of these entities or interventions become an important "step" in palliative and curative care. To avoid unwanted interactions that negate treatment efficacy, or possibly increase unwanted side effects, it is important to know if these CAM therapies are being used concurrently with traditional therapies, and to coordinate their usage with that of more conventional therapies consistently and appropriately.
Complementary therapies currently offered at CUHA are limited to acupuncture at this time. Acupuncture has been receiving greater acceptance in the veterinary medical community throughout the United States recently. With increased awareness, there has been an increase in research leading to improved understanding of its mechanisms and indications. Dry needling, electrostimulation, and injection point acupuncture (aquapuncture) assist with pain control, hormonal balance, appetite stimulation, improved bowel and bladder function, and blood pressure control. Within our service, these methods truly "complement" standardized medical and surgical techniques of pain control, completing a "well rounded" multimodal therapy program.
Interventional or Injection treatments: A variety of substances and drugs, including local anesthetics with or without anti-inflammatories, chondroprotectants and nerve modulating agents can be injected around nerves, into painful muscles or into joints with the aid of special imaging entities such as fluoroscopy, CT, and MRI. Ultrasound and electrostimulation, two techniques currently used with high specificity in the human pain arena, are also utilized to "locate" nerves, nerve groups, or inflamed areas such as joints or "trigger points" and to place agents close to the source of pain in order to relieve spasm or hurt. These treatments, often performed in a short series of injections over the course of weeks or months can reduce and sometimes obliterate inflammation, swelling, irritation, or abnormal nerve transmissions that cause or amplify the pain from injured tissues.
Radiofrequency, cryotherapy, or neuroablative treatments: Treatments utilizing radiofrequency (which uses heat to cause limited nerve damage) or cryotherapy (deep freezing) block transmission of sensory pain signals into the nervous system to end painful sensations for longer periods of time, possibly even permanently. Sadly, there are usually motor (function) deficits which accompany this type of sensation loss, so specialized equipment is used to detect, isolate, and treat the most individualized nerves leading to a painful area in efforts to alleviate pain, yet reduce discomfort. Sedation and/or general anesthesia is often required for specified placement of probes needed to isolate the nerves and to "treat" the pain signals.
Laser therapy: Class III and IV lasers, commonly known as "low level or cold lasers," are used for both soft tissue and osseous tissue (bone) pain relief and rehabilitation. Laser therapy has many biological effects including decreased pain transmission, release of endorphins and enkephalins, enhanced connective tissue and bone growth, and increased wound healing. Although low doses of laser energy appear to stimulate tissues, higher doses may actually inhibit tissue healing; so, sound working knowledge of appropriate equipment and its proper usage are essential to allow appropriate clinical effect. Especially promising for their use in veterinary rehabilitation and pain therapy is the use of such lasers to preserve and heal cartilage and improve peripheral nerve injuries in patients with chronic debiliatative disease such as osteoarthritis.
Extracorporeal shock wave therapy: Extracorporeal shock wave therapy or ECSWT describes the use of high energy sound waves transmitted to specific body parts to stimulate the growth of tissue and blood vessel cells conducive to healing. In veterinary medicine ECSWT has been most utilized in horses for the treatment of tendon and ligament injuries, back pain, osteoarthritis and stress fractures. Acoustic waves generated outside the body are directed at localized areas of inflammation to stimulate soft tissue healing, increased bone formation, realignment of tendon fibers, and enhanced wound healing. The precise mechanisms of action are not well understood, but most clinicians agree that cellular production of growth factors is a key beneficial effect of this therapy. Sedation is often required for this therapy to avoid high energy waves contacting vital structures.
Physical rehabilitation and exercise techniques: Massage, range-of-motion exercises, therapeutic ultrasound, whirlpool and water treadmill exercises, gentle electrical stimulation in the form of TENS (transcutaneous electrical stimulation) and NMES (neuromuscular electrical stimulation) are all physical rehabilitation techniques offered to promote healing and strengthening. Physical rehabilitation techniques have a large number of applications in the restoration, maintenance, and promotion of optimal function, recovery, pain reduction, fitness promotion, and overall improved quality of life. Our rehabilitation team will address and evaluate each patient, and will also perform in house therapies and exercises designed to benefit healing from multiple medical and surgical issues. We then work together to devise an in home exercise program; coupled with rechecks and intermittent consultations, these techniques also function as intricate aspects of multimodal pain therapy.
