Equine

Assessing pain in horses

In Practice: first published as 10.1136/inp.k4781 on 29 November 2018. Downloaded from http://inpractice.bmj.com/ on 1 December 2018 by guest. Protected by copyright.
Karina Bech Gleerup

Pain management is important for optimal convalescence and is imperative for good
horse welfare. Some veterinary procedures inevitably cause moderate to severe pain
and some performance problems are the result of undiagnosed painful conditions.
Recognising pain may pose a greater challenge than successfully alleviating it because it
is an individual emotional experience. Recent research has found that behavioural traits
are the most informative clinical sign when assessing pain in horses, which makes pain
evaluation dependant on the observational skills of the veterinarian and the patient’s
owner. This article describes the pain process and how to evaluate behavioural changes
that are associated with pain in horses.
Karina Bech Gleerup
qualified from the
University of Copenhagen, Protective mechanism of pain
Denmark, in 2007 and way; these structures are known to induce a different
spent a few years in Acute pain is a protective mechanism. People with emotional, biological and psychological pain experience
practice before returning congenital insensitivity to pain experience repeated in people (Sessle 2002).
self-inflicted injuries (Zhang and others 2016). The
to the university to
normal response to tissue damage is for a patient to: Visceral pain
complete her PhD on pain
Escape from the danger causing the pain, resulting in Visceral pain originates from visceral structures in the
evaluation in horses and ■■
a withdrawal reflex, and, frequently in horses, a flight abdomen, pelvis and thorax. Visceral nociceptive prop-
cattle. She worked as an
attempt; erties are less well described than somatic nociception,
assistant professor at the
but ischaemia, distension of hollow organs, traction of
University of Copenhagen ■■ Protect the injured body part;
the mesentery, endogenous chemicals (eg, inflammatory
until April 2018. She ■■ Rest, for recovery and regeneration. products) and acidosis activate visceral nociceptors; they
now works as a locum are not activated by cutting or burning, unlike somatic
practitioner in Denmark. Furthermore, the painful stimulus impacts on the memo- nociceptors. Furthermore, visceral pain is poorly local-
ry to ensure that an individual avoids a similar injury in the ised and may be felt in places distant to the pathology;
future. Therefore, pain is essential for maintaining bodily this is known as referred pain (Wesselmann and Lai 1997,
integrity – it is a well-developed mechanism for surviving Strigo and others 2002). An example of this is the well-
acute injury (Woolf 2010). known phenomenon of unrideable mares that have uter-
ine tract inflammation (Christoffersen and others 2007).
The path from a physical insult to a conscious perception
of a noxious stimulus is complicated. First, the noxious Neuropathic pain
insult activates nociceptors, which are specialised orga- While acute pain obviously serves a biological function,
nelles of the primary afferent nerve fibres that react only the role of chronic pain is less obvious. Pain is plastic,
to noxious stimuli. They are found in nerves in the skin, which means that the signal-transducing neurons can
subcutis, periosteum, muscles, tendons, synovial linings, upregulate their ability to process noxious stimuli. If a
subchondral bone and serosa surfaces; the walls of hol- horse that is in pain is left untreated, the result can be an
low organs; the pulp of teeth; the cornea, and so on. There increased magnitude of pain with peripheral or central
are no nociceptors in the parenchyma of the liver, lung, sensitisation. This may evoke areas of allodynia, where
kidney or brain.

After initial activation of the nociceptors, the noxious stim-

ulus is transmitted to specialised pain-signalling neurons
in the dorsal horn of the spinal cord, where the signal is
modulated before proceeding to the central nervous sys-
tem (CNS). In the CNS the stimulus causes the conscious
perception of pain and initiates a descending modulation
of the pain signal (Basbaum and others 2009).

There are three types of pain:

■■ Somatic pain;
■■ Visceral pain;
Fig 1: This horse experienced severe allodynia around the
■■ Neuropathic pain. girth and on the shoulders, which could be demonstrated
by touching the area where the rider’s legs would usually
Somatic pain be (as indicated). This induced extreme skin twitching
(the blurred part of the figure in the shoulder area) and, if
Somatic pain arises from somatic structures such as persistent, would cause the animal’s whole body to shake.
the skin, periosteum, ligaments and synovium. Orofacial The owner thought the horse was just sensitive or ticklish
doi: 10.1136/inp.k4781 structures are also somatic but have a different pain path- and did not consider this to be abnormal behaviour

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2007). Horses with a low degree of hoof pain often need

Box 1: Systematic pain evaluation sedation for farriery, but if corrective shoeing relieves the
pain there is no need for sedation (Mansmann and others

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Always start by looking at the patient from a distance, to get a chance to observe its 2011).
behaviour before it is aware that the veterinarian has arrived.
Neuropathic pain is often unresponsive to traditional
n Where is the horse located? Is it at the front or back of the stall?
analgesics such as non-steroidal anti-inflammatory
n Is the horse aware of its surroundings or occupied with feeding? Is the horse drugs (NSAIDs), so it is important to consider alternative
inactive? analgesic regimens for these patients. However, it is best
n Evaluate the animal’s posture. Is there equal weightbearing on all four legs and to avoid neuropathic pain states wherever possible by
is the top line nice and smooth? Are the abdominal muscles tense? What is the treating acute pain when it occurs (Love 2009).
level of the head: is it at or below the withers (sign of pain), or above the withers
(normal)?
n Are there any signs of excessive behaviour such as pacing, pawing, head shaking, Systematic pain evaluation
and so on? Changes in behaviour occur as a result of the physiologi-
n Evaluate the facial expression (see Box 2) cal response to pain, as mentioned above. Therefore, a
n Move towards the horse (or ask the owner to) and observe whether it also knowledge of pain physiology can help to improve equine
approaches readily or hesitates welfare and treatment success, resulting in a safer work-
n Offer some food. Some horses have a reduced appetite as a sign of pain ing environment. A horse in pain experiences fear and
stress, making it want to escape or, if that is not possi-
ble, fight, which can be challenging for a practitioner who
is trying to examine an acute wound. In such cases it is
Box 2: Evaluation of the equine pain face important to be familiar with pain physiology and know
that although the patient will be experiencing pain from
n Face: Look at the horse and evaluate the face as a whole – is it tense or relaxed? the wound, a much larger area will have increased sen-
n Ears: Are the ears positioned lower on the head than normal, with an increased sitivity to palpation due to the inflammatory process. This
distance between the base? is why some horses may react to palpation well before the
n Eyes: Do the eyes have a tense stare or a withdrawn appearance? Do the muscles actual wound is touched.
around the eyes appear tense? Does the eyebrow have an angular shape?
n Nostrils: Is there mediolateral dilation of the nostrils during inspiration? The When evaluating behavioural signs of pain it is impor-
nostrils do not have to be dilated (this is often only seen during inspiration) tant to have basic knowledge of normal horse behaviour
n Lips: Are the lips pressed together? (Gleerup and Lindegaard 2016). This can act as a bench-
n Visible muscles: Do the visible muscles on the side of the face look tense? mark for a practitioner who has not seen the patient
before, even though each horse is different and pain is an
The equine pain face is useful for detecting low- to moderate-degree pain, individual experience. The first step to better pain recog-
especially when there are no other obvious pain behaviours. nition is the systematic observation of a horse each time
it is approached (Box 1). Important information can be
obtained by pausing briefly to watch an undisturbed ani-
mal in the stable before initiating a clinical examination.
a non-painful stimulus is perceived as being painful; for
example, during tacking up (Fig 1). Allodynia can cause Attention, activity and ‘gross pain
performance problems such as kicking in response to behaviour’
the rider pressing the legs towards the flanks, bolting or A glance from a distance is very useful to determine the
refusing to move forward, and may co-exist with stereo- position of the patient in its stall and its awareness of its
typical behaviour (Fureix and others 2010, Hothersall and surroundings (Fig 2a). Horses in pain tend to place them-
Casey 2012, Jonckheer-Sheehy and others 2012). Chronic selves at the back of the stall (Fig 2b) (Pritchett and others
laminitis in horses has a neuropathic component that may 2003) and when outside in the paddock they tend to keep
cause an animal to feel constant pain (Jones and others their distance from other animals – they simply become

(a) (b)

Fig 2: (a) Stopping briefly in the doorway of a stable and observing the patient at a distance may provide valuable
information. The animal in the first stall on the left was not at the stall door and was observed to be standing at the back
of its stall and showing no interest in its surroundings. The horse had undergone surgery during the night and was in pain.
After analgesic treatment, the animal became alert and moved to the door, taking note of its environment. (b) This horse
was suffering from acute laminitis and lying down at the far end of its stall in a sandbox. It was wearing cooling bandages
to reduce the pain as much as possible, as well as receiving analgesia

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(a) (b)

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(c)

Fig 3: (a) Horse rolling vigorously in its stall, indicating

abdominal pain. (b) Horse experiencing severe pain in the
left forelimb, with abnormal weight distribution and the
gross pain behaviour of head shaking. (c) Horse in severe
pain displaying the gross pain behaviour of chewing.
The chewing was also a stereotypy for this horse. As
often seen, this stereotypy had increased magnitude and
frequency during the painful event

less social and less attentive towards their surroundings with colic might kick towards its abdomen, or an animal
(Dodds and others 2017). This reduced attention com- might focus on a specific area. ‘Looking to the flanks’ is
plies with the physiological reaction to pain: quiescence probably the most well-recognised example of this type
facilitating recovery. of behaviour in horses with colic (Fig 4a), but it can also
manifest as looking at a painful leg/joint, and nudging
Although the general activity level decreases when or biting a painful area (Fig 4b) in other cases. Licking or
horses are in pain, moderate to severe pain may mani- rubbing near a painful area may soothe pain by segmen-
fest as restless walking or other ‘gross pain behaviour’. tal inhibition, where signals from one part of the body can
This is normal horse behaviour – for example, rolling help reduce pain in another part.
(Fig 3a), pawing, head shaking (Fig 3b), chewing (Fig 3c)
and flehmening – that is performed with an increased fre- Posture
quency or intensity, just like stereotypies. Postural changes that occur with pain are most evident
in undisturbed animals. Horses in pain often keep their
Horses may also display pain-specific behaviours that are heads lower than usual and may lie down more often
directed towards the painful area; for example, a horse or for longer periods than usual. They may also take on
abnormal postures to avoid or reduce the stimulation of
painful areas, as seen with lame animals resting a lame
(a) leg (Fig 5a), or avoid painful positions when working or
grazing (Fig 5b). Horses may also show postural changes
like ‘back arch’ or the less obvious ‘pinched’ abdomen
with tension of the abdominal muscles (Fig 5c). This is
frequently seen in horses that have colic, but can also be
apparent in horses with orthopaedic pain, where postural
changes may be caused by a less obvious change in weight
distribution. Weight shifting is an important sign of pain;
healthy horses will square up, possibly rest on a hindlimb
and should only shift weight occasionally. More frequent
shifting or the shifting of weight on the front limbs indi-
cates pain (Gleerup and Lindegaard 2016). Weight shifting
(b) in horses with colic may be an expression of restlessness
due to pain, but in cases of severe colic, weight shifting
due to pain from early stage laminitis should be ruled out.

Facial expressions
People are gifted with a specialised neural apparatus for
attending to and processing facial expressions, which ena-
bles reliable and objective measurement of pain in their
fellow humans. Research into the facial expressions of
pain in horses has suggested this enables people to dis-
tinguish between horses that are in pain and those that are
pain free (Dalla Costa and others 2014, Gleerup and others
2015, van Loon and van Dierendonck 2015). This bears out
Fig 4: (a) Horse with colic looking at its flank. the commonly held veterinary opinion that at least mod-
(b) Horse looking towards its painful right hindlimb that
erate to severe pain in horses can be detected through
had undergone surgery. This behaviour is sometimes
interpreted as the patient disliking the bandage, which observation. However, there are still great challenges with
can be the case, but very often horses will only pay this. As systematic pain evaluation helps to improve pain
attention to a bandage if the leg is painful recognition, a systematic approach to facial expressions

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(a) (b)

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Fig 5: (a) Horse with severe pain in the left carpal joint
(c)
has reduced the load on this limb as much as possible by
resting the left forelimb and placing the other three legs
closer towards the centre of the body. (b) When grazing,
this horse would place its forelimbs as shown, with the
hindlimbs tugged under a little. The horse did not take a
normal step forward but would move the right forelimb
a short distance and then place the left forelimb in front
again. (c) This horse is in pain after colic surgery. The
positioning of the limbs are abnormal (forelimbs forwards
and hindlimbs backwards) and the abdominal muscles are
very tense, forming a tension line

would benefit the early detection of pain. Wathan and oth- the side of the head; strained, dilated or changed nostril
ers (2015) described facial expressions in horses using a shape; and tension in the lips and chin (Fig 6).
systematic anatomically based approach (EquiFACS); the
same group also found that horses communicate with Three articles have described the facial expressions of
peers through facial expressions and that they are capable pain in horses and, despite differing approaches, they all
of distinguishing between happy and angry faces in people describe common features for horses in pain (Dalla Costa
(Wathan and others 2016). This suggests that facial expres- and others 2014, Gleerup and others 2015, Van Loon and oth-
sions constitute an important communication tool when ers 2015). Box 2 describes the equine pain face (Gleerup and
working with horses – both as a sender and as a receiver. others 2015). Facial expressions are best evaluated when
the horse is undisturbed, unless the animal has severe pain,
Areas of interest when looking at facial expressions of in which case the pain face is visible continuously.
pain are the moveable parts: ears, eyes, lower facial
muscles, nostrils and muzzle (Fig 6). The ears are very Interaction
moveable and can take several positions in relation to After observing the patient from a distance for a short
pain. They will be lower than usual or further back, moving while, evaluation of the response to interaction can be
asymmetrically and responding less to the surroundings. helpful. Horses in pain tend to be less responsive to people
The eyes show tension in the surrounding muscles and and tend to stay away from the stall door, but horses with
the eyelids may be more closed or open than usual. Pain mild to moderate pain may increasingly seek contact with
also results in a withdrawn or tense stare, with less focus familiar people (Gleerup and others 2015). Whether this
on the environment. The last area of interest is the lower contact is to seek assistance in uncertain, but Mejdell and
face comprising the nostrils, muzzle and the muscles others (2016) showed that horses are capable of seeking
connected to these structures. The overall impression assistance through symbols. The horses in this study were
here is of increased tension in the mimetic muscles on trained to show their preference for wearing a blanket.

(a) (b) (c)

Fig 6: (a) Relaxed facial equine expression. (b) Tense expression due to pain. The position of the ears has changed, there is tension above the eye, the
muscles on the side of the head are tense, the lips are tense and the nostrils have changed shape. (c) Horse in pain with a tense expression and changes
as described in (b). Pictures (a) and (b) from Gleerup and others 2015

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(a)

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(b) (c)

Fig 7: (a) Normal view of the teaching herd of the large animal hospital, University of Copenhagen, at pasture, with the
animals standing together enjoying the morning sun. (b) The white horse (free from pain) that was lying down got up to
greet people who approached the field. (c) Horse standing alone in the middle of the paddock and unresponsive to people
approaching. The posture of the horse indicates severe pain from lymphangitis in the left hindlimb. The alternative weight
distribution (ie, all hoofs placed closer to the centre) takes as much weight bearing out of the painful leg as possible

Aggression The Equine Pain Scale (Table 1) (Gleerup and Lindegaard

A horse with chronic pain may become aggressive as it can- 2016) is a pain scale based on all the pain scales pub-
not get away from the pain (Fureix and others 2010). If there lished before 2015 and can be used for all types pain,
are areas of allodynia, an owner may unknowingly provoke as several pain behaviours were included in pain scales
pain repeatedly whenever handling their horse. Aggression for both orthopaedic and visceral as well as postsurgi-
is frequently the result of an undiagnosed painful condition cal pain. Pain evaluation using the Equine Pain Scale can
but is rarely associated with pain by owners as it is often be performed in one to two minutes, so this appears to a
considered to be a behavioural problem. The behaviour of very practical pain scale for use in practice (Gleerup and
horses that are in pain due to chronic hoof pathology has Lindegaard 2016).
been described in terms of defensive actions, such as mov-
ing away, rearing, backing or being fearful, or in terms of
offensive/aggressive behaviours such as biting, kicking or
Analgesic testing
tail lashing, when they are being attended by the farrier. Analgesic testing is routinely used in equine practice to
localise lameness. Systemic analgesic testing, where a
Self-mutilation, expressed as self-biting, stomping and kick- horse is treated systemically with an analgesic (NSAID,
ing, rubbing and lunging into objects, may also be an indica- opioid or similar) to determine whether a problem is
tor of pain. Self-mutilating horses whose pain is relieved will potentially pain related, can also be used to recognise
usually return to normal behaviour (McDonnell 2008). pain. Systemic analgesic testing is useful in cases involv-
ing poor performance or riding problems, where a thor-
ough investigation has resulted in no diagnosis. For such
Pain scoring scales animals, training under analgesic treatment might assist
The gold standard for behavioural analysis is prolonged in evaluating whether the poor performance or riding
periods of observation, which is very time consuming problem is pain related. If the specific unwanted behav-
and requires specialists in equine behaviour (McDonnell iour is reduced or eliminated while the horse is being
2005) so is not possible in an equine clinic. Comprehensive treated, an undiagnosed painful condition is most likely
pain scoring scales for visceral pain (van Loon and oth- to be the cause of the behaviour. If the unwanted behav-
ers 2010), head pain (van Loon and van Dierendonck 2017), iour recurs after the treatment has finished, the positive
colic pain, postsurgical pain (Graubner and others 2011) result is confirmed. This is a relatively cheap and easy
and orthopaedic pain (Bussières and others 2008) have diagnostic tool; however, it is extremely important not to
been developed for hospital use and are reported to take rely on a negative result (ie, the horse does not improve).
approximately eight to 15 minutes to perform, but this is While analgesic testing has an excellent specificity for
also not very practical in equine practice. More recent improvement, it has a poor sensitivity. A horse may not
pain scoring scales have combined the evaluation of facial improve with treatment simply because the chosen anal-
expressions with more traditional pain indicators (van gesic is not efficient for the specific type of pain in ques-
Loon and van Dierendonck 2015, Gleerup and Lindegaard tion or there was insufficient dosing and/or the duration
2016), resulting in a promising tool for veterinarians. of the test was too short.

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Table 1: Equine Pain Scale

Score

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Behaviour category 0 1 2 3 4
Pain face No pain face Pain face present Intense pain face
Gross pain behaviour* None Occasional Continuous
Activity Exploring, attention No movement Restless Depressed
towards surroundings
or resting
Location in the stall At the door watching the Standing in the middle, Standing in the middle Standing in the middle
environment facing the door facing the sides facing the back or
standing at the back
Posture/weight bearing Normal posture and Foot in intermittent Pinched (groove between Continuously taking foot No weight bearing.
normal weight bearing contact with the ground/ the abdominal muscles off the ground and trying Abnormal weight
occasional shift in weight is visible) to replace it distribution
Head position Foraging, below Level with the withers Below the withers
withers or higher than
the withers
Attention towards Does not pay attention Pays brief attention to Biting, nudging or
the painful area to the painful area the painful area (eg, flank looking at the painful
watching) area (eg, flank watching)
Interactive behaviour Looks at the observer or Looks at the observer Does not look at the Does not move, not
moves to the observer but does not move observer or moves away reacting/introverted
when approached to avoid contact
Response to food Takes food with no Looks at food No response to food
hesitation
* Gross pain behaviour includes all readily visible behaviours; for example, excessive head movements (vertical/lateral), flehmening, kicking, pawing, rolling, tail
swishing, mouth playing, stretching, etc. Table reproduced with permission from Gleerup and Lindegaard (2016)

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preferences. Applied Animal Behaviour Science 184, 66-73 results in neurogenic plasma extravasation in the skin. Pain 73,
PRITCHETT, L. C., ULIBARRI, C., ROBERTS, M. C., SCHNEIDER, 309-317
R. K. & SELLON, D. C. (2003) Identification of potential WOOLF, C. J. (2010) What is this thing called pain? Journal of
physiological and behavioral indicators of postoperative pain Clinical Investigation 120, 3742-3744
in horses after exploratory celiotomy for colic. Applied Animal ZHANG, S., MALIK SHARIF, S., CHEN, Y. C., VALENTE, E. M.,
Behaviour Science 80, 31-43 AHMED, M., SHERIDAN, E. & OTHERS (2016) Clinical features
SESSLE, B. J. (2002) Recent insights into brainstem mecha- for diagnosis and management of patients with PRDM12 con-
nisms underlying craniofacial pain. Journal of Dental Education genital insensitivity to pain. Journal of Medical Genetics 53,
66, 108-112 533-535

Self-assessment Self Assessment: Assessing pain in horses

quizzes
1. What is gross pain behaviour? 3. Pain can be evaluated in horses by . . .
In Practice has
a. Normal horse behaviours, a. Different pain evaluation methods must be
partnered with BMJ
performed with increased intensity used when evaluating different pain types
OnExamination to host
or frequency by a horse in pain (colic, orthopaedic pain, head pain etc)
the self-assessment
quizzes provided b. Abnormal but specific behaviours, only b. Horses do not display pain behaviours
with each clinical performed when the horse is in pain c. Many of the same pain behaviours are
article. These can be c. Abnormal but specific behaviours, only seen in both orthopaedic and colic pain
completed online and performed when the horse is in extreme pain d. Cannot be performed by the owner
found at the end of d. Pain behaviours related to colic pain only
the online version of 4. The Equine Pain Face . . .
each article at www. 2. Do horses become more or less social with a. Describes changes in the mimic
inpractice.bmj.com people during painful events? of horses with face pain
a. Horses always become less social with people b. Describes changes in facial expression
because they will seek rest and recovery on horses with mild to severe pain
b. Horses always become more social with people c. Describes the mimic of horses with severe pain
because they perform displacement behaviours d. Describes all changes in facial
c. Horses most often become less social expression on horses
but some horses with mild to moderate
pain may also become more social
d. Horses do not change their social
behaviours while in pain
Answers: a, c, c, b

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