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Pain can be defined as an unpleasant sensation and emotional experience that is generally linked to damaged tissue (IASP, 1994). This feeling of pain occurs when a signal originating at a receptor travels through nerve fibres to the brain for interpretation. The nervous system may also elicit a physical reaction to attempt to prevent further tissue damage.
The most common form of pain is that which arises from damaged tissue (nociceptive pain), however it can also be caused by damage to the nervous system itself (neuropathic pain). A final category, psychogenic pain, is experienced physically but is brought about by some psychological factor. Pain can be described by its severity, ranging from mild to moderate or even substantial. Lastly pain may be either acute or chronic, depending on its longevity, with chronic pain being generated by an ongoing condition and generally lasting a period of many months (Aspinalls).
All mammals have the capacity to process the impact of negative stimuli on their nervous system. Therefore, it must be assumed that animals experience pain just as humans do, even if they arent necessarily able to perceive, understand or communicate their discomfort (MSD manual).
Although animals are not able to accurately convey feelings of pain, this does not negate the possibility of them suffering or their need for analgesia. In fact, this increases the duty of care to veterinary professionals, making it essential for the assessor to be knowledgeable in pain recognition and species-specific behaviours. A familiarity with a species normal behaviour makes it easier to identify when pain-induced behaviours are being exhibited. (MSD manual)
Pain varies between species but also between individuals within that species. Like humans, each animal has a different pain threshold and different requirements when it comes to analgesia. To achieve high levels of patient care, patients should be treated individually and holistically (Ambrose, 2013), considering both mental and social factors, rather than just clinical symptoms.
Pain scoring is used to quantify pain by assigning a number to the level experienced for the purpose of monitoring ongoing treatment and correctly prescribing analgesia levels. One of its main uses is the improvement of perioperative pain management and some veterinary professionals even suggest that pain should be viewed as the fourth vital sign (Michelle Richmond). There are several different systems, some adapted for use with animals, but many created specifically for veterinary purposes. Systems consider behavioural changes and patient responses to guide the user towards the calculation of a score.
One of the five freedoms of the Animals Welfare act is the freedom from pain, injury and disease, making the recognition and effective treatment of pain essential (Rutherford 2002). Accurate pain management is vital for every patient to avoid serious health implications. There are safety implications for veterinary staff too as animals in pain can be more aggressive, posing a danger if not carefully controlled.
Another useful clinical system is the application of grimace scales. This is a method of assessing the presence or severity of pain by observing a number of facial action units (FAU). The most successful application of grimace scales has involved horses, rodents and rabbits.
Main body
A common attribute among all mammalian species is the universal ability to experience pain and rabbits are clearly no exception. Unfortunately, recognising the signs of this pain can be difficult as they are a prey species and genetically predisposed to hide common indicators. This is especially true in a veterinary setting which is an unfamiliar, stressful environment. The presence of an observer can be an additional factor causing them to further normalise their behaviour.
Recognising and controlling pain in rabbits is imperative. Varga (2014) states that the effects of pain and stress in rabbits are significant as they can trigger an endocrine stress response which releases several stress hormones. This can lead to a myriad of physiological and metabolic changes which can be more dangerous than the initial cause of the pain. In extreme cases this may lead to heart failure and even death. Staff must be able to identify the existence and severity of pain so it may be correctly alleviated, helping to minimise further risk.
Recognising pain
When dealing with rabbits, pain can be easily confused with stress or anxiety, so distinguishing between the two is crucial for veterinary professionals. Physiological measurements such as temperature, heart rate and respiratory rate can be good indictors of pain in all mammalian species. However, due to a rabbits propensity for environmental stress, these should never be used as the sole method of identifying pain. An effective way of identifying pain in rabbits is to closely monitor and understand changes in their behaviour.
Veterinary nurses should gather as much information as possible from owners about what is considered normal for their rabbit. However, there are some behavioural signs to look out for right across the species. A normal rabbit will spend much of its day grazing but one of the first signs of pain in rabbits is anorexia. Rabbits are generally inquisitive, active animals but a rabbit experiencing pain may lose interest in their surroundings and hide, hunched in a corner. Much of a healthy rabbits day is spent grooming, a behaviour that is greatly reduced in those who are suffering, often leading to a dull, unkempt coat. Other, general signs of pain in rabbits can include bruxism (teeth grinding) and the almost constant licking of painful areas.
Grimace Scales
Traditional pain scoring systems can be inadequate for an accurate assessment of pain in rabbits. However, in recent years the rabbit grimace scale has been developed which focuses on five facial action units to accurately identify acute pain. These include orbital tightening, cheek flattening, nose shape, and whisker and ear position. Grimace scales have proven a very reliable method of recognising and assessing the severity of pain in rabbits, but this relies heavily on the users experience and interpretation of the different facial changes (Keating, 2012). While considered the best single method, a study by Leach et al (2011) suggests that pain scoring cant be based on facial expression alone. One of the greatest practical impediments are the time constraints as its suggested that pain scale assessments should each last 5-10 minutes and be repeated every 2 hours. Grimace scales are virtually useless when dealing with chronic pain, as the animal becomes accustomed to its level of discomfort, it learns to better hide the signs in its facial expressions.
Inferred pain involves the assumed presence of pain even in the absence of any standard indicators. If a rabbit has a painful condition or has had a procedure that would be deemed painful in another species, then it should be assumed, even in with a lack of behavioural signs, that the rabbit is in pain. Despite pain being present, the animal is exhibiting normal behaviour to avoid predation. (Molly V)
Pre-emptive analgesia involves providing pain relief in the anticipation of some expected future pain. Often, in the case of a planned intervention a preoperative drug will be administered, which, when considering rabbits, makes a lot of sense (Barter, 2011; Weaver, Blaze, Linder, Andrutis, & Karas, 2010). Stress and pain can lead to serious complications, making certain that pain is accounted for, as well as reducing the environmental stress can significantly improve clinical outcomes (Molly V).
Conclusion
An essential skill of a veterinary nurse is that of pain recognition in a variety of animal species. As with all animals, every rabbit is different and may show different behaviours in different stages of pain or show no pain at all. Assessing pain is one of the most challenging aspects of a nurses role and pain scoring can be a useful tool in practice but shouldnt be used alone to diagnose pain. This is largely due to the subjective nature of pain scoring, different vets and nurses may score animals differently resulting in inconsistent approaches to pain management. To negate this issue, scoring should be done regularly and by the same staff member. However, in practice, this is often impossible due to time constraints and staffing issues.
While pain scores are considered a vital part of pain management, veterinary nurses must appreciate the pain score awarded does not provide the definitive, conclusive answer to the question is this patient in pain? . However, pain scoring systems can help to improve standards, identify problem areas and optimise patient care (pink book). They are also key in highlighting a need for increased analgesia, which can relieve suffering, helping to meet a patients welfare needs.
Analysing behaviour is a vital tool in pain recognition, but it must be remembered that virtually all behaviours indicative of pain in rabbits can also be caused by stress. Some behaviours may not even be noticed in a veterinary setting, with many animals reacting completely differently to their home environment.
Overall, its clear that due to the nature of prey species such as rabbits and their reactions to environmental stress that a combination of methods should always be applied. Measurements such as temperature, heart rate and respiratory rate are good indictors of pain in all mammalian species. However, in the case of rabbits these should only be used to confirm a diagnosis reached using behavioural analysis, clinical symptoms and grimace scales.
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