Development and psychometric validation of pain scales in feline osteoarthritis

L’arthrose féline est détectable sur radiographie, surtout chez l’animal âgé. La rareté antérieure du diagnostic clinique s’explique par ses signes subtils et facilement attribués à d’autres maladies gériatriques ou au processus normal de vieillissement. Ces signes répondent néanmoins au traitement analgésique. Le but de ce projet de recherche était de développer et valider deux grilles de douleur arthrosique (Montreal Instruments for Cat Arthritis Testing), une pour les propriétaires de chats [MI-CAT(C)], et une pour les vétérinaires [MI-CAT(V)]. Le développement était fondé sur une revue de la littérature, notre expertise clinique en douleur et en comportement félin, et un sondage de propriétaires de chats arthrosiques. Des experts internes et externes ont confirmé la validité de contenu des grilles. Ensuite, une étude pilote sur chats de laboratoire a permis une évaluation préliminaire de leur fiabilité et validité. Dans le cadre d’un essai clinique chez des chats arthrosiques, la grille pour propriétaires MI-CAT(C) discriminait les groupes placebo et meloxicam, et ses changements de score corrélaient avec l’activité motrice et l’âge, soutenant sa validité. La grille était généralement facile à comprendre, appuyant de façon préliminaire sa validité de face (l’acceptabilité) et son interprétation. La mesure de fiabilité intra- et inter-observateur préconisait l’évaluation par le propriétaire principal vs. un(e) propriétaire secondaire. La grille MI-CAT(C) était homogène, sans redondance, selon l’évaluation préliminaire de la consistance interne. Une seconde évaluation de la grille vétérinaire MI-CAT(V) a été menée chez des chats de laboratoire (avec ou sans arthrose naturelle). L’évaluation de la fiabilité intra- et inter-observateur démontrait une courbe d’apprentissage pour le nouvel utilisateur de la grille. Seules les sous-catégories Gait (démarche) et Posture (allure) avaient une tendance (non-significative) à détecter le statut arthrosique; la palpation et la manipulation des articulations n’avait aucune sensibilité du même genre. Gait et Posture corrélaient avec une mesure objective, la force verticale d’appui au sol. Une analyse vidéo a ensuite été faite pour améliorer la sensibilité de la grille MI-CAT(V) à l’arthrose. La grille révisée a été soumise à des étapes successives de validation et de raffinement, via trois études thérapeutiques (utilisant la gabapentine, le tramadol, et le meloxicam sous forme orale transmuqueuse par vaporisateur). Sa fiabilité intra- et inter-observateur, et l’évaluation préliminaire de la consistance interne étaient bonnes à excellentes, et elle fut capable de détecter le statut arthrosique. Cependant, elle ne détecta pas les effets thérapeutiques démontrés par d’autres mesures objectives. Des recherches ultérieures devront confirmer que la grille pour propriétaires MI-CAT(C) distingue le statut arthrosique, et évaluer sa réponse, vs. placébo, à d’autres traitements que le meloxicam. La grille vétérinaire MI-CAT(V) requerra une confirmation de sa fiabilité et validité chez des chats de propriétaires ; elle nécessitera encore des raffinements pour détecter les effets de traitement. L’établissement de seuils (p. ex. : distinction arthrosique/non-arthrosique, différence minimale significative) pour les deux grilles est conseillé pour faciliter leur utilisation clinique, ainsi qu’une évaluation de leur faisabilité et utilité clinique, ainsi qu’une réévaluation de leur structure interne et de leur compréhension.Radiographic signs of osteoarthritis are prevalent in cats, becoming more common with age. Historically, the rate of diagnosis has tended to be low, suggesting that signs are subtle and/or tend to be attributed to normal age-related changes or to other geriatric diseases. However, cats with osteoarthritis display signs that are responsive to analgesic treatment. This project aimed to develop and validate rating scales for detection and measurement of feline osteoarthritis pain and related disability (the Montreal Instruments for Cat Arthritis Testing). Two such scales, one for use by caretakers/owners [MI-CAT(C)], and one for use by veterinarians [MI-CAT(V)], were developed based on a review of the literature, expert opinion, and a survey study of owners of cats with a diagnosis of osteoarthritis. The content validity (via expert review) was excellent for both scales. A pilot study in a colony of laboratory cats with naturally-occurring osteoarthritis evaluated reliability and ability to detect osteoarthritis status, for both scales; preliminary revisions were made based on the results. The MI-CAT(C) owner scale subsequently underwent validation in a clinical trial of meloxicam in client-owned osteoarthritic cats. Evidence for validity included the ability to distinguish placebo from active treatment, and correlations with objectively measured activity and age. Owners found most scale items clear/easy to understand, preliminarily supporting comprehensibility and face validity (acceptability). Evaluation of intra- and inter-rater reliability suggested that secondary owners varied substantially in their ability to complete the scale, compared to primary owners. A preliminary assessment of internal consistency reliability supported homogeneity, without redundancy, of the scale. The MI-CAT(V) veterinary scale was evaluated in a study of laboratory cats with and without naturally-occurring osteoarthritis. Intra- and inter-rater reliability assessments suggested that a naïve user’s ability to use the scale was influenced by experience with it. The scale was unable to distinguish osteoarthritic and non-osteoarthritic cats, but the subcategories Gait and Posture were somewhat promising based on a non-significant tendency to detect osteoarthritis status, and correlations with an objective measure of osteoarthritis pain, peak vertical force. Palpation of the limbs did not detect osteoarthritis status. A video analysis was performed to increase MI-CAT(V) scale sensitivity to osteoarthritis. Subsequent evaluation and refinements based on three therapeutic trials (involving gabapentin, tramadol, and oral transmucosal meloxicam treatments) in laboratory cats with and without naturally-occurring osteoarthritis resulted in good to excellent intra- and inter-rater reliability, and ability to detect osteoarthritis status. Preliminary evidence supported scale internal consistency. Therapeutic response detected by objective outcome measures was not demonstrable using the scale. It is recommended that the MI-CAT(C) owner scale be evaluated for ability to distinguish osteoarthritic from non-osteoarthritic cats. The MI-CAT(V) veterinary scale requires testing in client-owned cats, and potentially further refinements to permit detection of treatment effects, if it is to be used as more than a disease screening tool. Both scales require additional investigation of internal structure and comprehensibility, and determination of cut-points to guide clinical use (e.g., minimally important difference, and thresholds for classification of cats as osteoarthritic vs. non-osteoarthritic), and evaluation of their feasibility and clinical utility

Decision making and welfare assessment in canine osteoarthritis

Little has previously been described about how or why owners, veterinary nurses or veterinary surgeons make decisions about pets under their care. The Animal Welfare Act (2006) and the Royal College of Veterinary Surgeons’ oath should ensure the health and welfare of pets in the United Kingdom (UK) is the central focus of those decisions. The aim of this thesis was to characterise the nature and basis of decisions made about the treatment and welfare of osteoarthritic dogs by owners, veterinary surgeons and veterinary nurses. Three studies were performed. Firstly, two rapid reviews identified and appraised the outcome measures used in the peer-reviewed literature to assess canine quality of life and canine osteoarthritis. Secondly, thirty-two interviews were performed with owners of dogs with osteoarthritis and five focus groups were performed with veterinary surgeons and veterinary nurses who manage osteoarthritic dogs. Thematic analysis performed on transcripts of those interviews and focus groups identified key themes. Thirdly, a prospective study was performed to test a novel home monitoring outcome measure for use by owners of osteoarthritic dogs, developed using data gathered in the previous studies. The first study found outcomes assessed in the peer-reviewed literature focus predominantly on physical health. Those assessments are frequently unvalidated, may be subject to bias and neglect other aspects of the dogs’ welfare impacted by osteoarthritis and its management. The second study identified four important themes in the interviews and focus group data in relation to decision making. Most owners were highly motivated to make good decisions about their dogs’ welfare. However, many barriers to dog-focused decisions were recognised including: incorrect prior knowledge; ineffective veterinary consultations, in part due to different language used by owners and veterinary surgeons; the lack of available, relevant evidence on which to base decisions; an inability to reliably interpret canine behaviour; and risk aversion. A wide range of impacts of canine osteoarthritis on the welfare of the dogs, their owners and the veterinary professionals caring for those dogs were described. The third study identified several significant deficits in existing outcome measures designed for owners to assess their osteoarthritic dogs. Dogs with osteoarthritis may have day-to-day variations in their physical health and demeanour and owners appear to assess a complex mix of inputs to, and indicators of, their dogs’ welfare when decision making. More work is needed to develop outcome measures that are relevant to owners and more accurately reflect all aspects of canine welfare. This thesis is the first in-depth body of work using evidence synthesis and qualitative methods to characterise how decisions are made about osteoarthritic dogs under veterinary care. Most decisions about osteoarthritic dogs are made by owners using unvalidated assessments with little veterinary guidance. Valid, relevant and practical outcome measures are needed to collect information on which decisions can be based. Evidence does not exist to guide the majority of decisions made; the evidence that does exist appears to be poorly disseminated, particularly amongst owners. Relevant evidence must be created through well designed clinical trials to support those decisions then widely disseminated. Veterinary consultations are not always effective in making decisions focused on the best interests of osteoarthritic dogs, particularly in relation to their welfare; differences in language and perspectives may play a significant part in this. Future work in this field should involve collaboration between owners, veterinary professionals in general and specialist practice, animal welfare scientists and experts in dog behaviour. Methodological approaches taken and conclusions drawn from this thesis may be relevant to many other veterinary diseases

Decision making and welfare assessment in canine osteoarthritis

Little has previously been described about how or why owners, veterinary nurses or veterinary surgeons make decisions about pets under their care. The Animal Welfare Act (2006) and the Royal College of Veterinary Surgeons’ oath should ensure the health and welfare of pets in the United Kingdom (UK) is the central focus of those decisions. The aim of this thesis was to characterise the nature and basis of decisions made about the treatment and welfare of osteoarthritic dogs by owners, veterinary surgeons and veterinary nurses. Three studies were performed. Firstly, two rapid reviews identified and appraised the outcome measures used in the peer-reviewed literature to assess canine quality of life and canine osteoarthritis. Secondly, thirty-two interviews were performed with owners of dogs with osteoarthritis and five focus groups were performed with veterinary surgeons and veterinary nurses who manage osteoarthritic dogs. Thematic analysis performed on transcripts of those interviews and focus groups identified key themes. Thirdly, a prospective study was performed to test a novel home monitoring outcome measure for use by owners of osteoarthritic dogs, developed using data gathered in the previous studies. The first study found outcomes assessed in the peer-reviewed literature focus predominantly on physical health. Those assessments are frequently unvalidated, may be subject to bias and neglect other aspects of the dogs’ welfare impacted by osteoarthritis and its management. The second study identified four important themes in the interviews and focus group data in relation to decision making. Most owners were highly motivated to make good decisions about their dogs’ welfare. However, many barriers to dog-focused decisions were recognised including: incorrect prior knowledge; ineffective veterinary consultations, in part due to different language used by owners and veterinary surgeons; the lack of available, relevant evidence on which to base decisions; an inability to reliably interpret canine behaviour; and risk aversion. A wide range of impacts of canine osteoarthritis on the welfare of the dogs, their owners and the veterinary professionals caring for those dogs were described. The third study identified several significant deficits in existing outcome measures designed for owners to assess their osteoarthritic dogs. Dogs with osteoarthritis may have day-to-day variations in their physical health and demeanour and owners appear to assess a complex mix of inputs to, and indicators of, their dogs’ welfare when decision making. More work is needed to develop outcome measures that are relevant to owners and more accurately reflect all aspects of canine welfare. This thesis is the first in-depth body of work using evidence synthesis and qualitative methods to characterise how decisions are made about osteoarthritic dogs under veterinary care. Most decisions about osteoarthritic dogs are made by owners using unvalidated assessments with little veterinary guidance. Valid, relevant and practical outcome measures are needed to collect information on which decisions can be based. Evidence does not exist to guide the majority of decisions made; the evidence that does exist appears to be poorly disseminated, particularly amongst owners. Relevant evidence must be created through well designed clinical trials to support those decisions then widely disseminated. Veterinary consultations are not always effective in making decisions focused on the best interests of osteoarthritic dogs, particularly in relation to their welfare; differences in language and perspectives may play a significant part in this. Future work in this field should involve collaboration between owners, veterinary professionals in general and specialist practice, animal welfare scientists and experts in dog behaviour. Methodological approaches taken and conclusions drawn from this thesis may be relevant to many other veterinary diseases