E

RE

ER
PE

IE W

LEADING EDGE

Recognition and Treatment

of Pain in Horses
By Debra C. Sellon, DVM, PhD, DACVIM
Editors Note:

Horses have not seen the great strides in pain management that have been witnessed for dogs and cats. However,
recent research on analgesics has demonstrated similar benefits for equine patients. Dr. Sellon shares this information with us in this months Leading Edge.Marie Rosenthal, MS, Executive Editor
In recent years, there have been tremendous
advances in recognizing and treating pain in human and
veterinary patients. Demonstration of the broad benefits
of pain management to the overall health and well-being
of a patient has led to widespread inclusion of pain assessment as a fourth vital sign in human, canine, and feline
patients. However, these advances in pain management
have often failed to translate into a similar increased
understanding of pain management in horses. Research
conducted during the past decade is starting to reverse
this trend, with new evidence of the benefits of effective
analgesic strategies for the overall health and well-being
of equine patients.

What Is Pain?
We experience pain daily. It serves as a warning system
of impending tissue damage; without it, survival would be
difficult. After surgery or trauma, pain compels a patient to
limit mobility to facilitate tissue repair and return to
health. However, uncontrolled pain has severe physiologic
consequences that can impair healing, prolong recovery,
and increase postsurgical morbidity and mortality.
The International Association for the Study of Pain
has proposed the following definition of pain: Pain is an
unpleasant sensory and emotional experience associated

with actual or potential tissue damage or described in

terms of such damage. It goes on to state that the
inability to communicate in no way negates the possibility that an individual is experiencing pain and is in need
of appropriate pain-relieving treatment.
These statements imply that pain has both physical
and emotional consequences and individuals may
respond physically and emotionally in vastly different
ways, even when experiencing identical painful stimuli.
Responses are modulated by genetic and environmental
influences so that individuals respond differently when
provoked with identical painful stimuli. The individual
variability in response to a painful stimulus makes it difficult to prescribe one-size-fits-all analgesic regimens
for specific health care scenariosa consideration that is
even more problematic for caretakers of a nonverbal
species that cannot articulate the severity and significance of a pain response.

How Can We Tell When a Horse Is

Experiencing Pain?
There are probably few veterinarians or horse owners who doubt that horses can feel pain. Some painful
stimuli, such as acute severe abdominal pain or lameness,
evoke profound and easily recognizable behavioral signs.

Leading Edge is published by Veterinary Forum in partnership with Morris Animal Foundation. The column highlights the cutting-edge work and insights of leading veterinary researchers who are working with
the Foundation. For each column published, Veterinary Forum is making a donation to the Foundation in
support of its important research programs. Studies funded by Morris Animal Foundation have led to new
diagnostic, surgical, treatment, and prevention techniques, some of which are now the standards in animal
health care. For more information, visit the Foundations website at www.MorrisAnimalFoundation.org.

44

Veterinary Forum

www.ForumVet.com

October 2006

Table 1

RE

LEADING EDGE

ER
PE

IE W

Numeric Rating Scale of Behavior of Horses after Abdominal Surgerya

Behavior Category

Gross pain behaviorsb

None

Occasional

Continuous

Head position

Above withers

At withers

Below withers

Ear position

Forward, frequent
movement

Location in stall

At door watching
environment

Standing in middle,
facing stall door

Spontaneous locomotion

Moves freely

Occasional steps

No movement

Response to an open door

Moves toward door

Looks at door

No response

Response to approach

Moves toward
observer, ears forward

Looks at observer,
ears forward

Lifting feet

Freely lifts feet

when asked

Lifts feet after mild

encouragement

Extremely unwilling
to lift feet

Response to grain

Moves toward door

and reaches for grain

Looks at door

No response

Slightly back,
little movement
Standing in middle,
facing sides of stall

Moves away
from observer

Standing in middle,
facing back of stall

Does not move,

ears back

a Total behavior score is calculated as the sum of scores in each behavior category. Postural score is calculated as the sum of scores in the cate-

gories of gross pain behaviors, head position, ear position, location in stall, and spontaneous locomotion. Socialization score is calculated as the
sum of scores in the categories of response to an open door, response to approach, lifting feet, and response to grain.
bGross pain behaviors include pawing, sweating, looking at the flank, curling the upper lip, and lying down/standing up repeatedly.
From Pritchett LC, Ulibarri C, Roberts MC, et al: Identification of potential physiological and behavioral indicators of postoperative pain in horses
after exploratory celiotomy for colic. Appl Animal Behav Sci 80:30 43, 2001; with permission.

Recognition of more subtle behavioral signs of pain is

more difficult, often leading to a wide disparity in perceived severity of pain among veterinarians who are
assessing the same patient.
Lack of Consensus

Specific behavioral changes in response to painful

stimuli vary widely among species and often are not easily defined. The lack of consensus regarding the presence
and severity of pain after castration was demonstrated in
an article and resultant series of letters to the editor in
Veterinary Record in 2001.14 A similar lack of consensus
is obvious among equine veterinarians in the United
States. When asked to rank the severity of pain experi-

October 2006

enced after routine castration on a scale of 0 (no pain) to

10 (worst possible pain), veterinarians provided answers
that varied from 1 to 9.a
If behavioral signs referable to abdominal pain or
recent trauma are excluded, veterinarians in the United
Kingdom cited an increase in heart rate and change in a
horses demeanor as the major criteria used to assess
pain.5 Although an increase in heart rate is widely held
to be an indicator of pain in animals, studies of postoperative pain in small animals, horses, and laboratory animals have failed to support this belief. The variety of
other factors that can influence heart rate (e.g., hydraaSellon

DC, Unpublished data, Washington State University College of Veterinary Medicine, Pullman, 2005.

www.ForumVet.com

Veterinary Forum

45

RE

LEADING EDGE

ER
PE

IE W

types of instruments with some success.

However, as with VAS, Holton and coTable 2
workers6 found that individual observers
were quite consistent in the use of NRSs
Behavior
Posture
Socialization
Time
Group
Score
Score
Score
but interobserver reproducibility was
poor.
Day 1
Control
20.6
12.1
8.6
Recent work by Sellon and coworkTreatment
17.0
10.2
6.0
ers7 funded by Morris Animal Foundation
describes behavioral changes observed in
At discharge
Control
11.9
6.8
5.1
horses after abdominal surgery. In this
Treatment
11.9
6.4
5.5
randomized, blinded, placebo-controlled
a Scores were obtained using the NRS described in Table 1. Trained observers evaluated
trial, all horses received flunixin meglueach horse every 4 hours for 24 hours after surgery and on the day of discharge from the
hospital. The scores at each point during the first 24 hours were averaged for each horse to
mine at 0.1 mg/kg IV q12h before and
arrive at a Day 1 score for that horse. The mean of the Day 1 scores for all horses in each
after surgery. Treated horses also received
group is shown in this table. Treated horses received flunixin meglumine and CRI butorbutorphanol tartrate at 0.013 mg/kg/hr as
phanol as described in the text. Control horses received only flunixin meglumine. Adapted
from Sellon DC, Roberts MC, Blikslager AT, et al: Effects of continuous rate intravenous
a continuous-rate infusion (CRI).
infusion of butorphanol on physiologic and outcome variables in horses after celiotomy.
An NRS assessing direct postural
J Vet Intern Med 18:555563, 2004; with permission.
observations (e.g., head height, ear position, location in stall, spontaneous locomotor activity) and social interactions with caregivers (e.g.,
tion status, sepsis, arrhythmia, anxiety, fear), especially
response to humans, lifting a foot, response to grain) was
after surgery or a traumatic event, render heart rate unreevaluated (Table 1).8 Horses receiving CRI butorphanol had
liable as a sole indicator of pain in most clinical settings.
significantly more normal total behavior, postural behavior,
and socialization response scores in the first 24 hours after
Using Behavior Assessment Instruments
abdominal surgery compared with control horses receiving
Pain assessment in small children and animals may
flunixin only (Table 2 and Figure 1). Treated horses had a
be attempted by using a variety of subjective behavior
more normal head and neck position, were more interested
assessment instruments. The most simple of these are the
in their environment, and responded more appropriately to
visual analog scale (VAS) and the simple descriptive
social interactions, including the entrance of a handler into
scale. The VAS requires an observer to score the severity
the stall and the offering of food. Of importance, there was
of pain in a patient on a range of 0 (no pain) to 10 or 100
no significant difference in heart rate among groups of
(worst possible pain). The advantage of this type of
horses at any period before or after surgery.
instrument is its simplicity and internal consistency with
In 2003, Price and coworkers9 analyzed data from
a single observer. However, the agreement among
video recordings of horses before and after arthroscopic
untrained observers is often poor, making it difficult to
surgery to identify behaviors suggestive of postoperative
determine trends in the degree of pain that is being monpain. The behavior of six horses after undergoing arthroitored by multiple caregivers. The simple descriptive
scopic surgery and that of six normal, healthy horses
scale requires an observer to score pain severity as one of
were compared using time budgets derived from analysis
a few levels of severity (e.g., mild, moderate, severe).
of continuous video recordings. There was a wide variaNumeric rating scales (NRSs) for assessing pain are
tion in individual responses, and the effect of general
more complicated than the VAS or simple descriptive
anesthesia on postoperative behavior was not assessed.
scales and may provide a more sensitive technique for
The behaviors that differed the most in postoperative
assessing pain if appropriately validated before use. Sevhorses compared with control behavior included indicaeral types of NRSs have been devised in the assessment
tors of restlessness, locomotion, and positioning in the
of pain in dogs. Most of these assign a numeric value to
stall. Horses that had undergone surgery spent less time
a variety of defined behaviors, and the sum of the indieating, less time at the front of the stall, and more time
vidual values is defined as the pain score for that patient.
exhibiting abnormal behaviors (e.g., posture, locomotion,
A number of studies of small animal pain have used these

Numeric Rating Behavior Scores of Horses

after Receiving Butorphanol or Flunixina

46

Veterinary Forum

www.ForumVet.com

October 2006

RE

LEADING EDGE

ER
PE

IE W

500
Butorphanol

450
6

Saline

400
Cortisol (mmol/L)

Weight Loss (% Body Weight)

4
*

350
*
300

250
200
150

100
Treatment

Control

Figure 1. Change in body weight among treatment (butorphanol) and

control (saline) horses from the time of abdominal surgery until discharge from the hospital. Treatment horses received flunixin meglumine and CRI butorphanol for 24 hours after surgery. Control horses
received flunixin meglumine only. Asterisk indicates significant difference between treatment and control horses (P = 0.05). Adapted from
Sellon DC, Roberts MC, Blikslager AT, et al: Effects of continuous rate
intravenous infusion of butorphanol on physiologic and outcome variables in horses after celiotomy. J Vet Intern Med 18:555563, 2001;
with permission.

oral behavior). These behaviors were more apparent in

review of videotapes than in direct behavioral observation
for a limited time. The researchers concluded that evaluation of activity over time may be more useful in assessing
pain than short-term direct behavioral observations. As
with other studies, there was no significant difference in
heart rate among groups of horses.

Does Pain Have Physiologic Consequences?

Pain and Overall Health

Much of our knowledge of the role that pain plays in

overall health and healing after injury or illness is derived
from investigations into the importance of postoperative
pain in the recuperative process after surgical interventions. Pain responses are an important part of an overall
neurohumoral stress response to surgery that is also influenced by anxiety, fluid loss, hemorrhage, endotoxemia,
fear or anxiety, and infection.
The stress response induces neural, endocrine,
immune, hematologic, and metabolic changes that are
intended to restore homeostasis in the patient. Sympathetic activation triggers increases in the heart rate and
blood pressure and inhibits gastrointestinal motility.
Alterations in cortisol, insulin, glucagon, and other stress

October 2006

20

40
Time (hr)

60

80

Figure 2. Plasma cortisol concentrations (mean SE) of treatment

(butorphanol) and control (saline) horses after abdominal surgery.
Asterisk indicates significant differences between treatment and control groups (P < 0.05). Adapted from Sellon DC, Roberts MC, Blikslager AT, et al: Effects of continuous rate intravenous infusion of
butorphanol on physiologic and outcome variables in horses after
celiotomy. J Vet Intern Med 18:555563, 2001; with permission.

hormones lead to a catabolic state characterized by

hyperglycemia, lipolysis, and protein catabolism and the
resultant weight loss and impaired wound healing.
Humoral and cellular immunity are inhibited during
the surgical stress response because of sympathetic stimulation, increased cortisol release, and endogenous opioid activity. The beneficial effects of decreasing the
postsurgical stress response through the provision of adequate postoperative analgesia have been extensively documented in humans. These benefits include improved
wound healing, fewer cardiopulmonary complications
(e.g., myocardial infarct, thromboembolism), decreased
risk of developing gastrointestinal ileus, decreased hypercoagulability, fewer postoperative infections, less weight
loss, and shortened hospital stays.
Pain and the Effect of Analgesia

Few studies in horses have assessed the physiologic

responses to analgesic medication or the effect that analgesia may have on the speed and quality of recovery after
trauma or surgery. In the 2004 study by Sellon and
coworkers described above,7 horses receiving CRI butorphanol in addition to intermittent intravenous flunixin
meglumine had significantly lower plasma cortisol concentrations, lost less body weight, and were discharged

www.ForumVet.com

Veterinary Forum

47

RE

LEADING EDGE

ER
PE

IE W

more rapidly than were horses receiving flunixin meglumine only (Figures 1 and 2). These findings are consistent with reports of hastened recovery after abdominal
surgery in humans who received adequate postoperative
analgesia. Additional equine studies are needed to determine analgesic protocols for horses that can maximize
postoperative recovery and minimize pain-associated
morbidity.

New Approaches in Horses

In the past few years, descriptions of novel
approaches to equine pain management have appeared
with increasing frequency in the veterinary literature.
These approaches include administration of morphine or
detomidine by epidural catheter; transcutaneous administration of drugs such as fentanyl and lidocaine; CRI of
drugs, including ketamine, lidocaine, detomidine, and
butorphanol; and preliminary descriptions of the use of
novel analgesic agents, such as gabapentin derivatives or
selective cyclooxygenase-2 inhibitors.
In the past, equine veterinarians probably erred on the
side of caution and used minimal analgesia for their
patientsoften for very good reasons. Concerns about

adverse drug reactions, expense, and the labor involved

with the administration and monitoring of drugs, failure to
recognize subtle behavioral signs of pain, and reliance on
heart rate as an indicator of pain have contributed to underrecognition and probably undertreatment of pain in horses.
The rapid expansion of knowledge related to pain
management in humans and small animal veterinary
patients along with the shift in the role of horses in society from agricultural commodity to companion animal
clearly indicate that times are changing. In the future,
equine veterinarians will be held accountable by their
conscience and their clients to provide a pain management plan that is optimized for each patient. To accomplish this, much additional study is needed to identify
behavioral indicators of pain in horses and to enhance an
understanding of the risks and benefits associated with
specific analgesic protocols in specific clinical settings.

Reviewer Comment
This article succinctly reviews the definition of pain,
impact of pain on homeostasis, difficulties associated
with identifying pain in animals, and recent work that
has advanced the ability of veterinarians to identify
and address pain in horses. The author also gives historical perspective to the reasons pain management
has traditionally been inadequate in horses.
References
1. Capner C: Castration of horses and analgesia. Vet Rec 149:252, 2001.
2. Flecknell PA, Raptopoulous D, Gasthuys F, et al: Castration of horses
and analgesia. Vet Rec 149:159160, 2001.
3. Harris R: Castration of horses and analgesia. Vet Rec 149:279280,
2001.
4. Jones R: Castration of horses and analgesia. Vet Rec 149:252, 2001.
5. Price J, Marques JM, Welsh EM, et al: Pilot epidemiological study of
attitudes towards pain in horses. Vet Rec 151:570575, 2002.
6. Holton LL, Scott EM, Nolan AM, et al: Comparison of three methods used for assessment of pain in dogs. JAVMA 212:6166, 1998.
7. Sellon DC, Roberts MC, Blikslager AT, et al: Effects of continuous
rate intravenous infusion of butorphanol on physiologic and outcome
variables in horses after celiotomy. J Vet Intern Med 18:555563, 2004.
8. Pritchett LC, Ulibarri C, Roberts MC, et al: Identification of potential physiological and behavioral indicators of postoperative pain in
horses after exploratory celiotomy for colic. Appl Anim Behav Sci
80:31 43, 2003.
9. Price J, Catriona S, Welsh EM, et al: Preliminary evaluation of a
behaviour-based system for assessment of post-operative pain in
horses following arthroscopic surgery. Vet Anaesth Analgesia
30:124137, 2003.
Dr. Sellon is Professor of Equine Medicine in the Department of Veterinary Clinical Sciences at Washington State University College of Veterinary Medicine in Pullman.

48

Veterinary Forum

October 2006