Practicing Fear Free is about preventing fear, anxiety and stress (FAS), making the veterinary experience positive, and calmly and safely managing pets that are fearful or anxious. Studies clearly demonstrate the negative impact of FAS on the physical and emotional wellbeing of our patients, and on the delivery of veterinary health care.

1.  The stress response is a normal adaptive mechanism. In fact, the initial stressor may be immune enhancing when it is acute, precedes the challenge and there is a return to homeostasis. However, when the stressor is intense, persists or follows a challenge to the immune system, the immune response is suppressed, wound healing and recovery may be delayed, susceptibility to infection is increased, and both fear and pain responses are heightened and intensified. Following veterinary visits most cats are stressed on returning home, sometimes for days.^1,2

2.  Stress during veterinary visits in cats and dogs impacts on both physiological measures and laboratory findings including a stress leukogram in response to corticosteroids, a more acute response to noradrenaline and adrenaline, increased blood pressure, heart rate, temperature and respiratory rate (panting in dogs) and glucose in cats.^3,4

3.  FAS negatively impact the delivery of veterinary care. As many as 58% of cat owners and 38% of dog owners report their pets hate going to the veterinarian, and 38% of cat owners and 26% of dog owners are stressed thinking about it. Pet owners report that they would visit the veterinarian more frequently if it wasn’t so stressful.⁵

Practicing Fear Free

Fear free is about making positive associations and ensuring positive outcomes from travel to clinic and home again; gentle control to prevent and manage emerging stress; identifying potential stressors to prevent and avoid what might be negative; reading and recognizing signs of FAS; keeping an emotional record to guide current and future visits; and responding to signs of FAS by stopping, modifying and/or medicating. Use of an FAS scale provides a mechanism for continuous monitoring to immediately stop and modify plans should FAS escalate.

Preventing FAS

a. Putting the treat into treatment—accentuate the positive.

Make positive associations by pairing highly valued treats (and toys or play) from carrier to travel, through all aspects of the veterinary visit (reception, examination room, handling/procedures, equipment, hospitalization) and home again. Repeatedly offering small morsels or continuous delivery will increase the frequency of reward, help to keep the pets focus, and aid in ongoing monitoring. Ceasing to take treats or play can be a barometer of fear.

b. Gentle control—How to comfortably and safely position the pet for veterinary care.

Monitor the pet’s body language and determine the approach, location (where the pet prefers), and handling (what the pet prefers) that keeps the pet comfortable and secure, and proceed calmly and positively using motivating treats (or play or petting) to distract, and make positive associations, while continually assessing level of stress and insuring safety.

c. Touch gradient

Begin gentle physical contact with what the patient most readily accepts and maintain contact while moving gradually to more stressful parts of the body or more unpleasant procedures. While handling tolerance and pain sensitivity vary between individuals, for most dogs the shoulders and neck are most accepted with feet, face, ears and tail the least. Temperature, injections, and blood collection are the most stressful procedures.⁶ Cats generally prefer between the ears, cheeks and chin and are most resistant of the belly and caudal.⁵ Injections, temperature and blood collection are most stressful.

d. Considerate approach

Approach and interact with the pet in a way that is calm and non-confrontational. Consider all of the senses to maintain a calm, positive atmosphere and attitude, while identifying and avoiding social (veterinary staff, owners, other animals) and environmental (auditory, visual, odor, surfaces) stimuli that might be fear or anxiety evoking. Allow cats to come out of their carrier on their own or examine in carrier with the top removed. Cats may be least stressed facing their owners. Avoid reaching or moving quickly. Approach dogs from the side. Pheromones and classical or species modified music may help to calm and facilitate handling. Having the owner remain with the pet reduces FAS for most pets, provides a secure base, avoids separation distress and can help to calm and reward.

e. Emotional record—Read, recognize and record.

Veterinarians, staff and pet owners must observe, read and recognize body postures and facial expressions that indicate the pets emotional state from relaxed to increasing levels and intensity of fear and anxiety. Provide education and resources. While most owners can identify obvious signs of FAS (fight, flight, soiling), they are poorly able to recognize subtle signs. Record what are stressors (dislikes) and what works (likes) in an emotional record to plan and guide future visits.

f. Home care

Provide guidance for travel and reintroduction into the home (environment, people, other pets) taking into consideration the pet, the procedures, and the environment. Recommend pheromones and medications if indicated for fear, anxiety, nausea, intestinal upset or pain.

The Fearful Patient

If the pet stops taking treats or signs of FAS begin to escalate, then stop, review and revise either to a) make modifications to be able to resume calmly and positively, b) to avoid some or all of the procedures that are not immediately necessary to reschedule for a later visit with a modified approach, or c) to use medication immediately, prior to a future visit, or both.

1. Stop, review, revise and resume.

If the pet stops taking treats or FAS escalates then stop, give the pet a chance to habituate, and identify what caused the increase in fear (visual, auditory, odor, tactile). By modifying the handling (gentle control), avoiding negatives (considerate approach), using more motivating treats and proceeding more slowly (gradient of touch), fear might be reduced to be able to positively proceed. Products such as towels, blankets, muzzles and head halters might provide safer control, although it is best if these are familiar and positively conditioned in advance. Use sufficient and appropriate pain medication before any procedure that might be uncomfortable or painful.

2. Stop, review, reschedule and revise.

If the pet continues to display moderate to marked FAS, consider whether to reschedule with a new plan of action or to use medication to complete the procedures on the same day. Determine whether some or all of the procedures can be postponed in order to implement strategies to achieve future successful visits, including modifications to the scheduling (to avoid negative outcomes), location (where the pet might prefer), environment (to make more pleasant and avoid unpleasant), gentle control, maximizing positives (fasting, favored treats or toys), pre-conditioning to products that might help to calm or improve safety and pre-medication.

Pet owners can work with staff, trainers and resources that can guide the pet through desensitization and counterconditioning in advance of future visits based on the needs of the pet, the procedures, and the abilities and limitations of the owners and pets. Identify each stimulus that evokes fear to eliminate and avoid what might be negative and desensitize and counter-condition to make them positive including, carrier, travel, veterinary facility, personnel, products (e.g., muzzles or head halters), instruments, and body regions and handling and procedures (ears, eyes, injections) with a goal of effectively treating or to be able to administer sedation. Pre-visit nutraceuticals and pharmaceuticals should be dispensed where needed.

Training of cues that are predictive of interactions and reward training of focused and relaxed behaviors can also provide a foundation for communicating, achieving desirable outcomes, calming, distracting, maintaining focus, and rewarding throughout the visit including touch (targeting), chin rest (with focus), and relaxing on a “bed” or “mat”.

Additional Resources

• www.fearfreepets.com
• www.fearfreehappyhomes.com
• Howell A, Feyrecilde M. Cooperative Veterinary Care. Wiley-Blackwell, 2018.
• Yin S. Low-Stress Handling, Restraint and Behavior Modification in Dogs and Cats. CattleDog Publishing 2009.

References

1.  Volk JO, Thomas JG, Colleran EJ, et al. Executive summary of phase 3 of the Bayer veterinary care usage study. J Am Vet Med Assoc. 2014;244:709–802.

2.  Mariti C, Bowen J, Campa S, et al. Guardians’ perception of cats’ welfare and behavior regarding veterinary visits. J Appl Anim Welf Sci. 2016;19:375–384.

3.  Bragg RF, Bennett JS, Cummings A, et al. Evaluations of the effects of hospital stress on physiologic variables in dogs. J Am Vet Med Assoc. 2015;246:212–215.

4.  Quimby JM, Smith ML, Lunn KF. Evaluation of the effects of hospital visit stress on physiologic parameters in the cat. J Fel Med Surg. 2011;13:733–737.

5.  Volk JO, Felsted KE, Thomas JG, et al. Executive summary of the Bayer veterinary care usage study. J Am Vet Med Assoc. 2011;238:1275–1282.

6.  Mariti C, Pierantoni L, Sighieri C, et al. Guardians’ perceptions of dogs’ welfare and behaviors related to visiting the veterinary clinic. J Appl Welf Sci. 2017;20:24–33.