By Katherine Kramer, DVM, DAVBP (Canine/Feline), CVA, CVTP, Fear Free Certified

Felines have long been considered fascinating and formidable patients. Their ability to mask pain and disease can stymie even the seasoned veterinarian. The unique physiology and metabolism of the feline limit the medication options. Indeed, a cat that does not want to be medicated is certainly not going to be medicated. We have all laughed at the ‘trying to pill a cat’ jokes (mostly because they are true).

Fortunately, our admiration of the species has helped us adapt and evolve to better serve these mysterious creatures. The Feline Grimace Scale (FGS), the Feline Musculoskeletal Pain Index (FMPI), and multiple other pain scales, along with newer technology involving infrared imaging and wearable pain monitors, have helped clients and veterinary professionals better identify the subtle signs of pain. Recent studies have suggested non-steroidal anti-inflammatory drugs (NSAIDs) may not be so bad for cats after all, and mononuclear antibody injections stand to revolutionize the way we manage feline pain. Additionally, we have adapted to the inscrutable feline by using compounded transdermal and flavoured suspensions. Fear Free techniques have also helped in creating more receptive patients.

While we have new options for treating pain, we also know pain has many pathways and requires a multi-modal approach. Fortunately, there are many complementary options to allow for an integrative approach to pain management. What follows is a brief overview of some of the most common alternative modalities.

Cryotherapy and heat therapy

Simple techniques of applying cold or heat can be amazingly effective in reducing pain. Applying cold is most useful for acute injuries to induce vasoconstriction, thus reducing both swelling and further tissue damage. Nerve conduction velocity is also reduced.

Meanwhile, the application of heat is more effective for chronic pain, as it will induce vasodilation and improve circulation to the painful area. Heat can also soothe sore muscles and reduce pain signals by activating calcium channels. Many senior cats with chronic or degenerative conditions can benefit from heated beds and blankets. Clients should be cautioned, however, to take steps to avoid thermal burns.

Massage, reiki, and tui na

While the exact mechanism of pain relief is unknown, massage is reported to have many benefits, including improving circulation, strengthening immunity, and reducing pain. Multiple techniques exist and many cultures have systems of touch which have developed over thousands of years.

Tui na, a component of traditional Chinese medicine, involves a hands-on approach using specific hand movements. Another technique, reiki, is gaining ground in both human and veterinary medicine. This Japanese method involves light touch and can be soothing to both practitioner and patient. Many human nurses in palliative care and hospice wards have become reiki practitioners.

The power of touch should never be underestimated. Clients can be taught simple exercises that can be performed at home with very little risk. Massage can also be an excellent bonding activity between caretaker and pet. Courses for tui-na, reiki, and medical massage are available for veterinary professionals.

There are a few contraindications for massage. It should not be performed in patients with open wounds, fractures, coagulopathies, or undiagnosed pain.

Chiropractic/Spinal manipulation

Like massage, spinal manipulation, another manual therapy, has been practiced in many cultures for thousands of years. This modality is based on the theory that disease or pain originates due to the spine being misaligned, resulting in peripheral nerve impingement. The spine is adjusted to improve mechanical and neurologic function. Human studies suggest spinal manipulation reduces pain through spinal segmental mechanisms and is suspected to regulate the inflammatory response through a peripheral mechanism.

Modern veterinary chiropractic therapy is based on the work of Canadian-American chiropractor, D.D. Palmer, who began practicing the technique on animals in the early 20^th century. Allegedly, he began treating animals mainly to disprove claims of the placebo effect being responsible for any benefits humans experienced from chiropractic adjustments.

Today, multiple courses are available for veterinarians to achieve certifications in either spinal manipulation or chiropractic therapy. These courses, however, require significant time and financial investment.

Acupuncture

Multiple studies support the benefits of acupuncture. Needles placed in specific locations have been shown to stimulate the release of enkephalins, beta-endorphins, and endomorphins, while inhibiting the release of inflammatory cytokines. There is also evidence to suggest acupuncture can have a positive effect on neuroplasticity.

Most cats can be quite accepting of acupuncture, especially if performed at the animal’s home. Points can also be stimulated by acupressure or laser therapy for patients resistant to needles or electroacupuncture. Veterinary acupuncture courses are available based on either a Traditional Chinese Veterinary Medicine (TCVM) foundation or a science-based approach. Similar to chiropractic, achieving acupuncture certification requires considerable time and financial investment.

Shockwave therapy

Extracorporeal shockwave therapy (ESWT) uses focused high-energy sound waves to treat musculoskeletal disease. First developed for non-invasive lithotripsy, ESWT has rapidly gained ground due to its effect of stimulating both neovascularization and the release of growth factors. It is proposed ESWT also alters pain signalling through activation of the serotonergic system. Non-invasive and considered safe, human and canine studies have indicated ESWT to be helpful in reducing pain in a variety of musculoskeletal disorders.

ESWT machines can be quite costly. Older units typically required heavy sedation due to the loud noise and sensation, while newer units are quieter with shorter treatment times.

PBM

Photobiomodulation (PBM) or low-level laser therapy (LLLT) can offer an effective, non-invasive means of pain relief. Acting at the level of mitochondria, laser therapy has been shown to induce cell proliferation and stem cell differentiation, reduce pain and inflammation, and accelerate tissue repair.

PMB units are a sizable investment but are easy to operate. In this writer’s clinic, PMB sessions are performed by a veterinary technician or assistant.

Magnetic field therapy

The use of magnets for medical therapy dates back to ancient China. Working with the premise that illness is caused by a disturbance in the body’s natural electromagnetic energy, magnets are used to manipulate calcium and potassium ions to restore balance. Targeted electromagnetic field therapy generates a micro-current to stimulate the body’s natural healing abilities.

A wealth of human studies and an increasing number of companion animal studies indicate pulsed electromagnetic field (PEMF) therapy can effectively reduce pain. PEMF units can range in cost, depending on the size. Smaller devices can be used at home to provide non-invasive pain relief, though it is important to note PEMF units should not be used by clients with pacemakers.

HBOT

Hyperbaric oxygen therapy (HBOT) is gaining ground in both human and veterinary medicine for a variety of conditions, including inflammation and chronic pain. While research in veterinary patients is scarce, human studies appear promising. HBOT involves placing patients in a chamber to receive 100 per cent oxygen at greater than one atmosphere of pressure.

Increased oxygenation of the body has multiple effects, including:

• improving inflammation by decreasing inflammatory cytokine production and enhancing leukocyte phagocytosis;
• decreasing edema through vasoconstriction;
• inhibiting bacterial and fungal infections by increasing the production of super-oxides and increasing antibiotic efficacy;
• promoting angiogenesis and repair of damaged capillaries;
• mobilizing stem cells from bone marrow;
• promoting bone growth; and
• healing by increasing osteoclast and osteoblast production, proliferation, and activity.

While multiple veterinary hospitals in the United States offer hyperbaric therapy, in Canada, there is currently only one clinic (located in Richmond, B.C.) where this option is available.

HBOT is non-invasive but not without risk. A 2021 retrospective study found 3.5 per cent of dogs receiving hyperbaric therapy developed seizures which were associated with central nervous system (CNS) oxygen toxicity. Patients recovered when returned to normal oxygen and experienced no long-term adverse effects.

Homeopathy

Homeopathy remains the most criticized alternative modality for pain management, as science has not been able to determine a mechanism of action or obtain definite proof of its beneficial effects.

Whether explained by quantum physics or the placebo effect, homeopathy does, however, appear to be beneficial for some patients. Arnica, for example, can be helpful for generalized or soft tissue pain, while Rhus tox may benefit patients with arthritis, and Cantharis is shown to help relieve pain associated with cystitis.

Based on the premise of ‘like cures like,’ homeopathy utilizes minuscule amounts of natural ingredients to treat disease. Ingredients causing symptoms similar to the disease are used to prepare a treatment remedy. While remedies typically have very few side effects, the main criticism of this modality is clients may first opt for homeopathy, delaying conventional therapy.

Nutraceuticals

Natural supplements—such as glucosamine, chondroitin, green-lipped mussels, Boswellia, turmeric/curcumin, and omega-3 essential fatty acids—have shown to have some benefits in reducing inflammation and pain. Pentosan polyphosphate, in an injectable form, is commonly used off-label for cats with pain from arthritis or cystitis. Supplements are typically cost-effective and have few side effects but may have limited efficacy for cats that are resistant to taking oral products.

CBD

Though cannabis for pets remains experimental (and a legal quagmire), the field of veterinary cannabinoid medicine is flourishing. A growing number of companion animal studies, along with numerous anecdotal reports, support the use of cannabidiol (CBD) to relieve pain and inflammation.

Exploration of the endocannabinoid system (ECS), and now the endocannabinoidome, has led to a greater understanding of how CBD and other cannabinoids can reduce pain. Hemp (cannabis containing less than 0.3 per cent THC) is rich in phytocannabinoids, terpenes, and flavonoids that can interact and influence multiple receptors within the ECS, resulting in a variety of physiologic responses.

However, while companion animal cannabis research has exponentially increased in recent years, there have been few feline-specific studies. Published research explores:

• anti-tussive activity of some naturally occurring cannabinoids in anesthetized cats;
• localization and expression of cannabinoid receptors in the gingiva of healthy cats and cats with chronic gingivostomatitis;
• safety of escalating CBD doses;
• distribution of cannabinoid and pparα receptors in the skin of healthy cats and cats with hypersensitivity dermatitis; and
• a single-dose pharmacokinetics and safety assessment.

Though cannabinoid therapy can be quite effective, it is still somewhat controversial for several reasons. For one, dosing remains experimental. Safety issues with product quality are of particular concern since CBD pet products in Canada are, at this time, illegal and unregulated. While many painful cats appear to have responded to cannabis products, toxicity concerns remain regarding the use of terpene-rich formulas.

Conclusion

Recognizing and treating feline pain can be challenging. As such, cats have often forced veterinary professionals to ‘think outside of the box’ when it comes to their care. Fortunately, there are numerous alternative therapies available which can be extremely helpful. The combination of these therapies with conventional medicine offers an integrative approach which provides even more options for our feline patients.

Cats will surely continue to challenge and baffle veterinary professionals. They will, however, also continue to invoke our admiration and our devotion to keep them healthy and pain-free.

Katherine Kramer, DVM, DAVBP (Canine/Feline), CVA, CVTP, Fear Free Certified, is an integrative companion animal veterinarian practicing in Vancouver, B.C. She is a member of the Canadian Association of Veterinary Medicine, College of Veterinarians of British Columbia, International Veterinary Acupuncture Society, American Association of Feline Practitioners, and the International Veterinary Academy of Pain Management. She is a past director of the Canadian Association of Veterinary Cannabinoid Medicine. Dr. Kramer is also a co-editor/author of Cannabis Therapy in Veterinary Medicine, the first veterinary textbook in the field of veterinary cannabinoid medicine.

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