Have we really ruled out pain?
Are you convinced your horse has pain somewhere but can’t seem to find it? Maybe this is showing up as a change in behaviour or performance. Perhaps you have done the standard “back, tack and teeth” check, which has returned nothing but the behaviour is happening and you’re not sure where to go next. You might have gone much further than this and done extensive diagnostics that have still returned few findings. Or you might be treating or managing a known painful condition such as an injury found during investigations, or perhaps a chronic condition, laminitis, or gastric ulcers. How do you know whether you have found the underlying cause, whether pain relief is working, when you might need to alter your management and when the pain has gone away?
I’ll start with defining pain. The definition given by the International Association for the Study of Pain (IASP) is “An unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Importantly, the definition of pain includes the fact that it is inherently an emotional experience, and this is important because emotional states affect how adverse the experience of pain is. At the same time, pain impacts on emotional state. I had some questions at the recent free virtual Q&A call about the relationship between spookiness and pain and part of my answer was that behaviour is always indicative of an underlying need. In terms of spookiness the horse is worried for their safety in that situation, and that might be because there is actual pain, a memory of it, or the potential for it. Unraveling this requires giving the horse the benefit of the doubt. I won’t go deep into pain physiology here, but it’s also useful to keep in mind that pain can occur in the absence of actual tissue damage. There are various pain states that can arise that don’t require the presence of tissue damage and are just as real to the being experiencing them. Also, lesions found on physical examination or imaging can have varying significance in terms of their contributions towards the painful state.
Just as physical, mental and emotional wellbeing are all inextricably linked, so are pain, posture, movement and behaviour. Herein lies the first principle I bring to answering the question of “Have we really ruled out pain?”, which is the first of the three pillars of my overall approach that I call Attuned Assessment. This involves making lots of observations, initially without attaching any meaning to those observations (because this can colour what you subsequently notice). This is easier said than done but is hugely valuable. Watching the horse’s behaviour, posture and movement at liberty, in-hand and under saddle at a standstill and at all gaits and manoeuvres, sometimes using varying equipment, may be necessary to gather enough information to answer the question. We need to slow down during this process to really notice. Many people say “Wouldn’t it be easier if they could just tell us” and they can! They will show us if we are open to it. Initially these observations are hands-off, but physically examining the horse hands-on is also all-important. The attuned assessment part of this is letting the horse communicate with you during it - noticing subtle changes that can give away painful areas and worries and showing them that you have noticed their response, which is likely to give them cause to show you more. Repeating these observations and giving enough time is paramount.
Once we have compiled our observations, we can start interpreting them, noticing links and patterns, and thinking about what they might mean. We then need to use a logical approach to clinical problem solving to arrive at a list of differential diagnoses (this is a list of possible conditions that might be causing the signs) and start ruling them out one by one. This may require diagnostic tests such as nerve blocks, imaging or blood tests. Sometimes we might decide on a therapeutic trial instead, for example pain relief and rest for a certain period of time, or rehabilitation work. Response to treatment is an important part of the diagnostic process too. The attuned assessment is ongoing as part of evaluating the success of the intervention.
I think a really important part of “Have we really ruled out pain?” is to just keep asking that question and questions in general. I have identified many deep roots of health and wellbeing during my time as a vet that fall into four categories (Husbandry for Happiness, Movement Medicine, Cultivating Comfort, and Communication, Compassion and Consent). Identifying these has come from looking deeper and asking why and how the situation has arisen - for example yes the horse has a suspensory ligament injury, but why and how did that come about? Is there something we need to fundamentally change about this horse’s lifestyle, posture, movement, training, you name it, to resolve this once and for all?
If you have enlisted the help of a professional and they believe pain has been ruled out but the horse’s demeanour, behaviour, posture or movement still makes you concerned that there might be pain there, dig deeper. At the same time as being kind to your horse professionals (everyone is on their own journey and we don’t emerge from our training knowing everything there is to know), be a bit sceptical of pronouncements that don’t seem to fit with the overall picture. And ensure assessments are not cursory, they need to be thorough and deeply questioning. The only real way to answer the question “Have we really ruled out pain?” is to keep asking it! It should be normal for a horse to be engaged, alert, relaxed and willing and able to participate in their life with us humans. If this is not the case, pain could be one reason why.
