We are pleased to introduce a 3-part series of interviews with Dr. Erin Troy, Certified Veterinary Pain Practitioner. In part 1 of the series, Dr. Troy talks about the process of getting certified in pain management and how to educate pet owners to recognize and treat pain.
Assisi Animal Health: I understand that you received the title of Certified Veterinary Pain Practitioner. Tell me a little bit about what that means and why you chose to do that.
Dr. Troy: I started the whole process into physical rehabilitation about 12 or 13 years ago, and one of the things I realized a couple of years into it is that we can do a lot of rehabilitation therapy - but if the patients are not comfortable, we're not going to do them any good. So, I started figuring out what I need to do first to get them comfortable - to get their pain controlled - and then rehab them. It started me on this adventure, so to speak, of starting to seek more education and training and then I fell into the IVAPM - the International Veterinary Association of Pain Management.
When I joined them, I read about this certification program. For me it was a personal and a professional goal - being 20 years out of vet school, I didn't want to get stale and flat, I wanted to keep the learning curve up. Your brain gets a little saggy when you've been out of school for a while.
The depth of what it brought to my practice was the best part - it opened up our eyes to not only helping our acute pain or surgery patients with all the things we do for that, but certainly our chronic pain patients as well. For us, it became this multi-layer opportunity to provide a better level of care for our patients.
What is it that you have to go through to get this certification?
To qualify to take the test, you need 80 hours of pain-related continuing education. Five years ago, that would have been very, very difficult. Now? Pain is everywhere. (laughter) Well, pain education is everywhere. Pain is everywhere too, but education on pain in the veterinary field is far easier to find now than it ever used to be.
Within three or four years, you have to get your 80 hours of pain-related CE, and you have to document what you use in your practice with pictures and descriptions. They have a list of things that you have to meet the minimum number of including non-steroidals, drugs, all of what we use in rehab. That includes the Assisi Loop™, the laser, the hydrotherapy tank, the physio rolls that we use, masseuses and acupuncture.
You have to do two cases and they have to be of publishable quality, and you sit for an exam. Along with working 60 hours a week and having families and those kinds of things, that's probably why there are less than 100 people in the world that have this certification.
You've said that you use studies in the human world to help pet owners understand their pet's pain. Can you talk more about that?
So much of what we get is from the human world. When I talk with clients about technologies like the Loop and like laser, I have a list of references that I send them to on the web that are human. For some reason, people still put more credibility into human studies than animal studies. I have a lot of families that will read some of the studies done on the targeted pulsed electromagnetic therapy in people and say, "Cool. Where do we start? Sign me up for my dog." I like that. I like that that exists.
The one study that I share with a lot of people was the study I read about using this technology for women following breast surgery. It was a pretty simple study. The numbers were impressive. Half the group used morphine only. Half the group used morphine and a Loop. The group that used morphine and the Loop used half the morphine than the other group did. That kind of speaks for itself. So when you try to relate that degree of pain to chronic osteoarthritis patients or trauma patients or IVDD patients, people have a much easier time understanding.
Believe it or not, there are still people out there that have said to me, "I didn't really think that dogs felt pain." Those are the people we need to educate. We need to educate them gently and we need to educate them with support -- not be judgmental -- because they wouldn't be in our office if they weren't looking for help, in some way.
How do you talk to pet owners about pain and help them to understand it?
I try first to ascertain which side of the fence they're on. Are they there because they think their dog is in pain, or are they that middle-of-the-road group that says, "Doc, she's been limping for about two weeks, but she's not in any pain because she's not crying." If I had a nickel for every time I heard that. Or are they the people who come in for their every-three-year visit to get their rabies and their dog is barely hobbling in and they don't recognize it.
The first group is pretty darn straightforward to deal with because they've already acknowledged that their dog is in some level of discomfort. I really try not to use the word "pain" because I find that some people feel either guilty about it or that we're being judgmental about it, so I'll say uncomfortable, discomfort, tender, sore and then work toward what we call "the four-letter word" around here.
We have a list of indicators of pain. It's a great checklist for them to look at because there are things like: not covering in the litter box when the cat used to cover, or can't get in and out of the covered litter box, or can't get on and off the bed, sleeping in a different fashion, ears pulled back, eyes dilated, panting. There's a big one in dogs. I say to clients, "Does your dog do any panting at home?" "Yes. He does it in the middle of winter and I don't understand that." I tell them, "Your dog is panting because he's sore."
So when families come in with a focus on getting my dog stronger or keeping my dog from falling or helping my dog be able to climb back into the car or on the bed - if I find pain, I educate the client that "I cannot get your dog stronger until I get him more comfortable." Because you don't want to work sore muscles. You want to get them comfortable and then you want to work them. Clients get it.
Is it important to try to catch pain as early-on as possible?
The more pain you have that's not addressed, the more pain the pet develops, and then the harder it is to control pain. From a pharmacological point of view, if we have a dog that comes in with 3 out of 10 pain, we can control that much more successfully than if they wait another 6 months and come in with 7 out of 10 pain. Then you're throwing everything at them - everything you've got including strong narcotics to get that pain down to a manageable level. So that is why we have single-handedly taken on the responsibility of educating every pet owner we can.
First of all, pain is bad. Then it's how to know that you have pain, then how to determine where it is and what it's from and how to treat it. If you can't convince people that pain is bad, you'll never get to the other steps.
Do people actually have trouble understanding the concept that pain is bad?
Some people think pain is okay. I had a woman tell me the other day, to my face - and she's an educated woman - that she had to take her dog off of pain meds because he was running around too much. And I said, "What you're telling me is that you would rather that he be painful and less active than pain-free and active." She said, "Yes." And I said, "That's not a medical problem. That's a behavioral problem. That's where we put the leash on, take him for walks, and we have lots of things to deal with." I told her that it's not fair to use pain as a restraint device.
How do you talk to pet owners who haven't yet embraced the idea that pain is bad?
We talk about the physiological problems with pain and what it does to the brain and what it does to the rest of the body, and what compensation pain is all about. We deal with a ton of compensation pain. For instance, a dog comes in with a chronic tear to its cruciate ligament and for a variety of reasons the owners have elected not to do surgery. The owners look at me like I'm crazy when I'm palpating up around the neck and shoulders and front legs of the dog and they're like, "No. No, doc. it's back here." And I tell them, "I understand it's back there, but feel this up here. Your dog has been shifting her weight forward for so long. Now she's got a problem in her shoulder and her elbow. It's all connected. Pain just travels through the body."
So when you talk about the depth of what the certification brought to your practice, the simple acknowledgment that "Pain is bad" is a big part of that piece.
Yes. Absolutely. It's acknowledging the pain, recognizing that it is bad, learning how to assess it, and learning how to prevent it. We want all our patients walking out of here looking as good as possible. Because we know they will heal better and it will be less stressful on their family.
Dr. Erin Troy is the owner of Muller Veterinary Hospital and The Canine Rehabilitation Center in Walnut Creek, California. Watch for Part 2 of this series where she'll tell us about the cases she used to get her IVAPM certification. She will talk more about integrated pain management with the Assisi Loop as a part of the treatment protocol.
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