Fear Free™ approach to pain management in companion animals

The veterinarian developed Fear Free ™ approach for pain management is a way to improve outcomes and create a rewarding therapeutic experience.

Fear, pain, anxiety and stress may coexist in animal patients, challenging even the most experienced diagnostician and care provider. A painful animal may be fearful of examination, which could lead to a masking of symptoms due to elevated adrenaline or cortisol. The animal may also be overreactive in anticipation of painful handling, or may exhibit fear-based aggression. The body language signals of the fearful and painful animal are similar, and they can be difficult to differentiate. Approaching the case management of the painful (or potentially painful) patient in a way that minimizes confounding emotional and behavioral triggers leads to improved outcomes and a rewarding therapeutic experience. Enter the Fear Free ™ approach.

What is the Fear Free ™ approach?

The Fear Free ™ initiative was created by Dr. Marty Becker to benefit animals, their people and all veterinary professionals by reducing patient fear, anxiety and stress (FAS). Fear Free implements a range of specific behavioral and handling techniques, incorporates environmental modifications at home and in the clinic, and employs multi-modal alternative and conventional pharmaceuticals as indicated.

In a Fear Free practice, every patient has an emotional record and owners are counselled about how to make the trip to the veterinarian a calmer event. Once in the clinic, thoughtful traffic flow and scheduling reduce the situational escalation of stress, and the environment is managed so every sensory experience is as low-stress as possible. Frequent food rewards and distraction with toys and other pleasant experiences build successful interactions. Communication, gentle handling, frequent patient assessment and adaptable therapeutic plans involve the entire veterinary team.

Implementing Fear Free in your practice may be as simple or extensive as resources allow. The training builds naturally on the foundation of compassionate care, articulating specifically integrated steps and procedures. Fear Free certification is available to veterinarians, the veterinary support team, students and facilities. Commitment to the mindset and the holistic approach is a key step, and many improvements may be made even with existing equipment and infrastructure. The versatility and flexibility of the approach are showcased in the context of pain management by two Fear Free certified practices (Aspetuck Animal Hospital and The Cat Clinic); a Fear Free designed educational space (Norwalk Community College Veterinary Technology Program Live Animal Lab); and the author’s holistic consulting practice.

Fear Free Scale

In full-service hospitalsFear Free factors

Aspetuck Animal Hospital has been AAHA certified since 2011, and Fear Free certified since 2016. Dr. Michael Gorra, a 1997 graduate of the Cornell College of Veterinary Medicine, recently spoke about how Fear Free and Low-Stress Handling® have changed his practice, staff, patient care and approach to the painful patient.“It’s made a big difference in our flow and how we do things, and how we look at challenges,” he says. “Even if we don’t get to the point where [our patients] are happy, wagging their tails with their ears up — at least we can do things safely and not make things worse…. What I have found is that my lay staff dive right into it…. They really feel empowered that they’re truly making a difference.”

The hospital implemented multi-modal proactive pain management even before its Fear Free training. Nonsteroidal anti-inflammatories, gabapentin, tramadol and trazadone are frequently prescribed in combination. Sometimes medications are given prior to a procedure that is expected to be painful, in order to decrease sensitization and wind-up. Multi-modal therapy including anxiolytics has decreased the practice’s need to prescribe opiates for painful patients.

In addition to conventional pain management, Dr. Trish Grinnell, a 1997 graduate of the Cornell College of Veterinary Medicine, is certified in Veterinary Acupuncture and incorporates this modality: “I do acupuncture as general pain management. I had a friend who would do acupoints on all emergency patients to help calm them, but most of my acupuncture patients are pretty fear-free in the first place. Or if they start out nervous, they relax over time.”

examples of this approach
Right: NCC’s Live Animal Lab with rolling Tristar privacy screens, Snyder quiet-latch cages, walk-on scale (with mannequin) and FAS posters
Left: In the Live Animal Lab with veterinary technology students, Opal is enjoying peanut butter, a favorite treat.

Dr. Gorra adds how Fear Free Touch Gradient and Considerate Approach techniques have improved his ability to identify when an animal might be in non-procedure-based pain. “[They have] allowed me to evaluate what is really going on with the animal,” he says. “If the dog is freaked out, I’m not going to get an accurate reading on where the back pain, joint pain, abdominal pain is. Is the heart rate elevated due to a medical issue, because they hurt, or because they’re hyped up? We de-escalate when we can, and that begins at home with the owner.” For example, owners are encouraged to bring their animals to the hospital hungry so they will be enthusiastic about food rewards. Owners may wait in the car with their pets rather than the waiting room if the animal’s FAS score is 3 or above, and enter through a back entrance directly into an exam room to avoid other animals.

examples of this approach
Left:Veterinary Assistant Cailie has prepared cages for inpatients, including a privacy towel sprayed with Feliway.Right: Dr. Gorra with a homemade hiding space for caged cats. Felines also often feel secure in low-sided exam baskets. Above:Soft colors, shelves and terraces, vertical stratification, and hiding areas. Right: NCC’s Live Animal Lab Cat Zone, for felines only, complete with raised Snyder quiet-latch cages, Feliway diffuser, towel warmer and plug-in aquarium

In the feline-only practice

Using the Fear Free approach, feline-only practices have the opportunity to manage the medical, surgical and behavioral needs of feline patients without interspecies stress. Although cats are obligate carnivores and consummate hunters, they are an emotionally and metabolically sensitive prey species with a highly developed flight instinct and ability to mask pain. Owners are frequently unaware that their cats may be in pain or stressed, and may believe that stress-induced behaviors like trembling, vocalizations or open-mouth breathing are normal. Good client education, preparation at home, considerate transportation, minimization of antagonistic environmental cues (auditory, olfactory and visual), providing stratified hiding spaces, and accurate reading of behavioral cues may all help contribute to a calm and productive feline examination experience.

The Cat Clinic of Danbury has been Fear Free certified since 2017. Dr. Barbara Fanning, a 2006 graduate of the University of Tennessee College of Veterinary Medicine and The Cat Clinic’s owner, estimates that the Fear Free approach has improved the clinic’s ability to help 90% or more of its patients, including cats that could barely be handled before. An understanding of how quickly cats can turn fear and stress into undesirable behavior means there are no “bad cats” at the clinic. Before their visit, a Calm Kitty Kit that includes gabapentin, Zylkene® and a Feliway wipe is dispensed for most cats. In many cases, owners report an improvement in their cat on Zylkene alone, and are able to continue these benefits since hydrolyzed milk proteins are safe for long-term use.

Dr. Fanning and her veterinary team work closely with cat owners to determine the least stressful handling situation for their felines. Many cats are “afraid of everything…if we don’t know there’s pain, and we touch something that hurts, are they painful or are they acting out because they’re terrified?”

She describes her examination of a cat whose chief complaint was lameness and whose hind leg was trembling. Dr. Fanning, her helper and the owner worked together gently and easily with the cat, maintaining continuous gentle touch, proceeding slowly and cautiously, supporting his body in a secure position, trying to find step-by-step what didn’t hurt and saving the painful leg for last. Although the presentation was acute, which meant the patient hadn’t been given the benefit of the Calm Kitty Kit, he was examined in a warmly-lit room with a Feliway-sprayed towel on the exam table and iCalmCat music playing.

“Applying Fear Free methods really makes a huge difference,” says Dr. Fanning. “Instead of fighting and man-handling them, we keep that wind-up from happening. They can tolerate things a lot longer and not be so afraid.” If the patient described above became too painful to work with comfortably, or too frightened, he would have been sedated with an injectable sedative like butorphanol or Dexdomitor®. Without the wind-up to a terrified state, lower doses of sedatives and anesthetics can be used.

Dr. Fanning and Dr. Gorra’s teams embrace the Fear Free approach, keeping vets and staff safe, implementing all aspects of compassionate patient care, and educating clients about the approach. Veterinary support staff may be primarily involved with many potentially stressful therapeutic interactions: restraint, sample collection, diagnostic procedures, medication, treatments and therapeutic grooming. When veterinary assistants and technicians know how to read when an animal is fearful, stressed or anxious; when they appreciate the many ways in which painful animals can act; and when they have acquired a body of relevant techniques and communication skills, they are empowered and integral members of an effective veterinary team.

In the veterinary technology curriculum

Educating knowledgeable and compassionate caregivers is the mission of Norwalk Community College’s AVMA-CVTEA accredited Veterinary Technology program, for which this author is the Program Coordinator. The Program has incorporated Fear Free into its curriculum and clinical instructional space, the Live Animal Lab. Both the Program Coordinator and its Clinical Coordinator, Valerie Ramos CVT, LVT, MBA, are Fear Free certified, as are a number of other program instructors. Many of the Program’s veterinary technology students take advantage of the Fear Free complimentary student training. The veterinary technician’s multi-faceted role is a well-supported area of Fear Free education.

The Program’s Community partners welcome its Fear Free approach and its Fear Free oriented students. For example, one of NCC’s clinical partners, the Pet Animal Welfare Society (PAWS) located in Norwalk, uses Fear Free techniques. When PAWS brings kittens to the Live Animal Lab for Intake examinations, the students complete a standard Feline Medical Record and an Emotional Record, under supervision. The Intake form was developed in collaboration with PAWS’ head technician, Matthew Berg, and records information such as specific behaviors on Intake, behavior during handling and procedures, food preferences, what worked and what didn’t, and FAS scores before, during and after handling and procedures. PAWS is delighted to have behavioral information to assist in homing their new kittens successfully. The students gain valuable experience in a holistic approach to patient care, and accept the responsibility of building positive patient experiences early on.

holistic consulting practice
Left: Their holistic consulting practice exams concluded, Maddie and Zoe eagerly await more treats.
Below:Dr. Gorra in Fear Free exam room, ready with treats and a soft non-slip exam surface.

In a holistic consulting practice

Fear Free techniques extend naturally to a variety of clinical and practice settings. The author’s holistic practice serves patients whose owners are seeking therapeutic alternatives, or whose primary care veterinarians have referred them for integrative care. Many patients have had previous traumatic clinical experiences and managing their FAS is essential to therapeutic success.

The author’s practice footprint is a single-room consulting office in a quiet location, designed to be as non-threatening as possible; patients generally regard an office call as a social visit. There is abundant natural light, soft cushions and mats, and no harsh odors or metal surfaces. Examinations are conducted to the extent that is safe and comfortable for the owner and the animal, as there are no cage facilities or support staff.

Appointments begin with the client interview, which allows the patient to acclimate to the surroundings without forced contact, and allows observation of patient behavior including curiosity, mobility, interactivity and potential guarding of painful areas. Fear Free techniques align with the patient-centered practice philosophy and have increased the scope and range of examination and diagnostics that are possible with minimal assistance.

In summary

Veterinary medicine is a caring profession for people who love animals; if we can help them without hurting or scaring them, everybody benefits. With the understanding that even non-painful routine procedures may be perceived as threatening and/or stressful, veterinary care may be delivered in a way that does not erode trust and confidence. Animals suffering acute or chronic pain, which may be exacerbated by the fear of pain or unrelated fear and anxiety, can be diagnosed and treated in a respectful, compassionate way that leads to better experiences and outcomes.

References

Chapel D. (2016). “How Your Hospital Design Can Be Fear Free”. Paper presented at the North American Veterinary Conference, Practice Management, 375-376.

Dalla Costa E, Bracci D, Dai F, Lebelt D, Minero M (2017). “Do different emotional states affect the Horse Grimace Scale Score? A pilot study”. Journal of Equine Veterinary Science, 5 4, 114 -117.

Fanning B. Personal communication. May 14, 2019.

Fear Free, LLC. FearFreePets.com. Retrieved May 31, 2019. Gorra M. Personal communication. May 28, 2019.

Grandin T, Deesing M. (May 2002). “Distress in animals: is it fear, pain or physical stress”. Manhattan Beach (CA): American Board of Veterinary Practitioners Symposium.

Grinnell P. Electronic communication. June 1, 2019.

Griffenhagen G, Jamie Kadrlik CVT, Petty M, MAV C, CVPP, D, Sheilah Robertson, BVMS, DECVAA WS. “2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats”. aaha.org/public_documents/professional/guidelines/2015_aaha_aafp_pain_management_guidelines_for_dogs_and_cats.pdf. Accessed April 1, 2019.

Harvey H. (2016). “The Big Goal of Reducing Fear-Pain-Stress in our Clinical Care”. Paper presented at the North American Veterinary Conference, Small Animal — Pain Management, 936-939.

Hermans A. (2018). “Fear Free™ and Norwalk Community College’s Live Animal Lab”. The NAVTA Journal, August/September, 15-19.

“How Do I Know When it’s Time? Assessing Quality of Life for Your Companion Animal and Making End-of-Life Decisions”. The Ohio State University Veterinary Medical Center. vet.osu.edu/vmc/sites/default/files/import/assets/pdf/hospital/companionAnimals/HonoringtheBond/HowDoIKnowWhen.pdf. Accessed May 31, 2019.

Lopez-Luna J, Al-Jubouri Q, Al-Nuaimy W, Sneddon LU. (2017) “Impact of stress, fear and anxiety on the nociceptive responses of larval zebrafish”. PLoS ONE 12(8): e0181010. doi.org/10.1371/journal.pone.0181010.

Sandkuehler J, Lee J. (2013). “How to erase memory traces of pain and fear”. Trends in neurosciences, 36(6), 343-352.

Stilwell N. (2019) “A practical approach to evaluating pain in cats”. DVM360 Magazine. veterinarynews.dvm360.com/practical-approach-evaluating-pain-cats

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