Can cat caregivers reliably assess acute pain in cats using the Feline Grimace Scale? A large bilingual global survey

Abstract

Objectives

This study aimed to investigate if cat caregivers could reliably assess acute pain using the Feline Grimace Scale (FGS), and if participant demographics could affect scores.

Methods

An online survey in English and Spanish was advertised by International Cat Care and other platforms (March–May 2021) using convenience sampling. Eligible participants were caregivers >18 years old and non-veterinary health professionals. Participants and a group of eight veterinarians scored 10 images of cats with different levels of pain. Data were analysed using linear models and intraclass correlation coefficient (ICC; α <0.05). Interpretation of the ICC was <0.2 = poor; 0.21–0.4 = reasonable; 0.41–0.60 = moderate; 0.61–0.80 = good; and 0.81–1.0 = very good.

Results

A total of 3039 responses were received with 1262 completed answers from 66 countries (86%, 11.1% and 2.9% identified as female, male or other, respectively). Scores for each action unit (AU; ear position, orbital tightening, muzzle tension, whiskers change and head position) and their sum (FGS score) were not significantly different between caregivers and veterinarians, except for muzzle (caregivers 0.9 ± 0.0; veterinarians 0.7 ± 0.1; P = 0.035). The ICC single (caregivers) was 0.65, 0.69, 0.58, 0.37, 0.38 and 0.65, respectively, for AU ears, eyes, muzzle, whiskers, head and sum of scores. Demographic variables did not affect FGS scores.

Conclusions and relevance

Total FGS scores had good reliability when used by cat caregivers, regardless of demographic variables, showing the potential applicability of the instrument to improve feline pain management and welfare worldwide.

Introduction

Cat caregivers consider their cats as family members and are concerned about their health and welfare, including pain management.^1–4 However, caregivers would agree that recognising pain is not easy in cats.^1,4 Indeed, identifying and quantifying pain in cats is notoriously difficult,^5,6 particularly for individuals not trained in animal pain-related behaviours. Cats, as solitary hunters, have a smaller repertoire of inter- and intra-species social communication and were domesticated much later than dogs, which normally communicate well with people and have similar social systems to humans.^7–9 These factors could delay pain recognition by cat caregivers until the clinical signs of pain become severe enough to prompt them to action, compromising the cat’s health and welfare. Educating cat caregivers about the importance of early pain detection, and equipping them with the necessary tools to do so, could significantly improve feline health and welfare and potentially increase veterinary consultations.

The Feline Grimace Scale (FGS) is a reliable method for acute pain assessment in cats that uses changes in facial expressions. ¹⁰ It includes five action units (AU): ear position, orbital tightening, muzzle tension, whiskers change and head position. Each AU is individually scored from 0 to 2, where 0 = AU is absent; 1 = moderate presence of AU or uncertainty over its presence or absence; and 2 = obvious presence of AU. The maximum possible score of the FGS is 10. Scores of 4 or higher (when all AUs are evaluated) suggest that the cat is in pain and requires the administration of analgesics. ¹⁰ The FGS has reported validity and reliability in different medical and surgical painful conditions,^10,11 using both image and real-time assessment. ¹² In a recent systematic review of grimace scales in non-human mammals, the FGS was found to have a high level of evidence for its measurement properties. ¹³

Preliminary data from our laboratory using a small cohort of participants indicated that cat caregivers can reliably use the FGS. ¹⁴ On two different occasions (1 week apart), five cat caregivers scored 100 images of cats with different degrees of pain using an online survey. Individual AU and total FGS scores were compared between cat caregivers and veterinarians. Inter- and intra-reliability of the total FGS scores of cat caregivers were good. ¹⁴ However, it remained unknown if these findings can be extrapolated to a large sample of cat caregivers from different geographical locations.

The aims of this study were to (1) investigate the ability of cat caregivers to reliably assess acute pain using the FGS in comparison with veterinarians through an online survey and (2) to evaluate whether demographic variables affect the ability of cat caregivers to use the FGS. The authors hypothesised that (1) cat caregivers of different genders, ages, countries and backgrounds would be able to reliably assess acute pain in cats using the FGS, and that (2) female cat caregivers would give higher total FGS scores than male ones; other demographic variables would not have an effect on total FGS scores.

Materials and methods

Ethical approval

The study involved human subjects and the protocol was approved by the ‘Comité d’éthique de la recherche en sciences et en santé (CERSES)’ of the Université de Montréal (#CERSES-21–007-D) and the ‘Human (Research) Ethical Review Committee (HERC)’ of the University of Edinburgh (#HERC_658_21). The research was performed in accordance with the Tri-Council Policy Statement ‘Ethical Conduct for Research Involving Humans’. All data obtained were in accordance with the Freedom of Information and Protection of Privacy Act. Informed consent was obtained from all participants prior to completing the survey. Participation was anonymous and voluntary, without any incentives offered; individuals could withdraw or review their responses before submitting their answers (see supplementary material). This study is reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).^15,16

Participant recruitment

A convenience sample was used with no limit to the number of participants. Eligible participants had to be over 18 years of age, have internet access and understand English or Spanish. They also had to care for (own) a cat presently or have done so in the past, and could not be a veterinary healthcare professional or veterinary student.

The survey was open and the link to the survey was available on the websites of International Cat Care (iCatCare; https://icatcare.org/) and the FGS (https://www.felinegrimacescale.com/). Social media posts (see supplementary material) were prepared in collaboration with iCatCare and distributed using the different platforms (eg, Facebook, Instagram, LinkedIn) of organisations such as iCatCare, the World Small Animal Veterinary Association, the International Veterinary Academy of Pain Management and the Federation of Companion Animal Veterinarian Associations, and the researchers’ personal social media. The survey was also advertised through a lay-language article published in the February 2021 issue of the magazine Your Cat. ¹⁷

Veterinarian recruitment

Ten veterinarians with at least 5 years of experience and working at the Faculty of Veterinary Medicine, Université de Montréal at the time of the study were invited to participate. A separate link to the same survey was provided to these individuals by email. The only demographic data collected from veterinarians was their gender and age group.

Online survey

The survey was available to cat caregivers from 15 March to 15 May 2021, and to veterinarians from 17 May to 27 May 2021. The survey was available via an online platform (SurveyMonkey) in English and Spanish (see supplementary material). Participants completed the survey in the following order: (1) preferred language; (2) completion of informed consent form; (3) confirmation that the FGS training manual (as previously published) ¹⁰ was consulted; (4) image scoring (one cat image per page); (5) demographic questions; and (6) final submission. The training manual could be consulted at any time during completion of the survey. All survey materials were developed in English, and subsequently translated to Spanish by a professional translator.

The survey included 10 facial images of cats with different degrees of pain. For each image, the participant was asked to score each of the five AUs from 0 to 2 (Figure 1). A response option ‘not possible to score’ was available for each AU. Participants were asked six demographic questions: gender (man, woman, other); age (18–30, 31–50, 51–70, >70 years); country of residence (dropdown menu); whether they had children (yes or no); whether they worked with health services (yes or no); and whether they were a cat breeder (yes or no). Each question also had a response option ‘Prefer not to answer’. The survey was estimated to take 20–30 mins to complete.

Figure 1.

Example of a facial image of a cat and response options available for cat caregivers completing an online survey containing 10 facial images of cats with different degrees of pain. Images were scored using the Feline Grimace Scale and the following instructions were provided: ‘For each image, please select the option you think is most appropriate for each action unit (AU). If an AU cannot be clearly seen, please select the option “Not possible to score”. You may refer to the training manual as many times as you wish’

Image selection

Facial images of cats collected from three clinical studies (study A, ¹⁰ study B ¹² and study C ¹¹ ) previously performed at our laboratory were included. Briefly, cats presenting with naturally occurring pain secondary to medical conditions (eg, pancreatitis) or surgery (eg, dental extractions and ovariohysterectomy) were filmed undisturbed in their cages and in the absence of any observers before and after surgery and/or before and after the administration of analgesia. Screenshots from these videos were captured by different observers using standardised methodology resulting in a large data set of facial images of cats that were used in studies A, ¹⁰ B ¹² and C. ¹¹ Ten good quality images that displayed cats with different degrees of pain (total FGS scores varying from 0 to 10) were selected for the present study.

Statistical analysis

Raw data were extracted from SurveyMonkey and imported into a Microsoft Excel file. Total FGS scores were calculated as the sum of all AUs divided by the maximum possible score based on the number of AUs (ie, ratio) scored for each image (not all AUs were scored every time).

Differences in scores for each AU and total FGS scores between cat caregivers and veterinarians were analysed using generalised linear mixed models. Scores were the dependent variables; status (veterinarian or cat caregiver) and cat images were the explanatory variables. Participants were added as a random factor. Inter-rater reliability of scores for each AU and total FGS scores were analysed using intraclass correlation coefficient (ICC). A two-way random effect, absolute agreement, single-rater model was used. Interpretation of ICC was as follows: <0.2 = poor; 0.21–0.4 = reasonable; 0.41–0.60 = moderate; 0.61–0.80 = good; and 0.81–1.0 = very good. ¹⁸ The effects of demographic variables on total FGS scores were analysed using linear mixed models. Scores were the dependent variable; all demographic variables were independent variables. P values <0.05 were considered to be statistically significant.

Results

A total of 3039 questionnaires were submitted; 1540 questionnaires had scores for at least one image, while 1499 were empty. Complete responses (ie, all 10 images and six demographic questions) were available for 1262 questionnaires, resulting in a completeness rate of 41.5%. Questionnaires with at least one scored image (n = 1540) were included in the generalised linear mixed model and ICC analyses. Complete questionnaires (n = 1262) were used for the linear mixed model analysis. Eight complete questionnaires were submitted by veterinarians.

Scores for each AU and total FGS scores were not significantly different between cat caregivers and veterinarians, except for muzzle tension (0.86 ± 0.01 for cat caregivers and 0.69 ± 0.09 for veterinarians; P = 0.035) (Table 1).

Table 1.

Feline Grimace Scale (FGS) scores from cat caregivers (n = 1540) and veterinarians (n = 8) who completed an online survey containing 10 facial images of cats with different degrees of pain

Action unit/total score	Respondent	Mean ± SD	P value
Ear position	Cat caregivers	0.81 ± 0.01	0.733
	Veterinarians	0.79 ± 0.09
Orbital tightening	Cat caregivers	0.84 ± 0.01	0.814
	Veterinarians	0.86 ± 0.10
Muzzle tension	Cat caregivers	0.86 ± 0.01	0.035
	Veterinarians	0.69 ± 0.09
Whiskers change	Cat caregivers	0.93 ± 0.01	0.811
	Veterinarians	0.95 ± 0.09
Head position	Cat caregivers	0.86 ± 0.01	0.653
	Veterinarians	0.82 ± 0.08
Total FGS score	Cat caregivers	0.43 ± 0.00	0.579
	Veterinarians	0.41 ± 0.04

P value refers to the comparison of FGS scores between cat caregivers and veterinarians

Inter-rater reliability for each group (cat caregivers and veterinarians) is shown in Table 2.

Table 2.

Inter-rater reliability of Feline Grimace Scale (FGS) scores among cat caregivers (n = 1540) and veterinarians (n = 8) who completed an online survey containing 10 facial images of cats with different degrees of pain

Action unit/total score	Respondent	ICCsingle (95% CI)	Interpretation
Ear position	Cat caregivers	0.65 (0.50–0.83)	Good
	Veterinarians	0.82 (0.69–0.93)	Very good
Orbital tightening	Cat caregivers	0.69 (0.54–0.86)	Good
	Veterinarians	0.90 (0.82–0.96)	Very good
Muzzle tension	Cat caregivers	0.58 (0.42–0.79)	Moderate
	Veterinarians	0.78 (0.62–0.91)	Good
Whiskers change	Cat caregivers	0.37 (0.24–0.62)	Reasonable
	Veterinarians	0.56 (0.36–0.79)	Moderate
Head position	Cat caregivers	0.38 (0.22–0.59)	Reasonable
	Veterinarians	0.50 (0.30–0.75)	Moderate
Total FGS score	Cat caregivers	0.65 (0.50–0.84)	Good
	Veterinarians	0.85 (0.73–0.94)	Very good

Data are reported as intraclass correlation coefficients for single measures (ICC)_single and 95% confidence intervals (CIs). Interpretation of ICC was as follows: <0.2 = poor; 0.21–0.4 = reasonable; 0.41–0.60 = moderate; 0.61–0.80 = good; 0.81–1.0 = very good ¹⁸

Demographic data for complete responses are shown in Table 3. Most respondents were middle-aged individuals that identified as females from Western countries and who answered the survey in English. Most respondents did not have children, were not healthcare workers and were not a cat breeder. Complete responses were available from 66 countries (Figure 2; Table 4). None of the demographic variables or their interactions had an effect on the total FGS score. Five female and three male veterinarians between 31 and 50 years of age completed the survey.

Table 3.

Demographic data and Feline Grimace Scale (FGS) scores of cat caregivers (n = 1262) who completed an online survey containing 10 facial images of cats with different degrees of pain

Demographic question	Response option, n (%)	Mean ± SD total FGS scores	P value
Gender	Man, 140 (11.1)	0.42 ± 0.01	0.233
	Woman, 1086 (86.0)	0.43 ± 0.00
	Other, 20 (1.6)	0.42 ± 0.02
	Prefer not to say, 16 (1.3)	0.41 ± 0.03
Age (years)	18–30, 271 (21.5)	0.43 ± 0.01	0.503
	31–50, 610 (48.3)	0.43 ± 0.00
	51–70, 335 (26.5)	0.43 ± 0.01
	>70, 39 (3.1)	0.45 ± 0.02
	Prefer not to say, 7 (0.6)	0.39 ± 0.05
Country of residence*	UK, 373 (29.6)	0.42 ± 0.09	0.626
	Spain, 218 (17.3)	0.42 ± 0.09
	USA, 181 (14.3)	0.44 ± 0.10
	Ireland, 54 (4.3)	0.44 ± 0.11
	Canada, 46 (3.6)	0.41 ± 0.09
	Brazil, 34 (2.7)	0.43 ± 0.11
	Germany, 25 (2.0)	0.44 ± 0.06
	Belgium, 24 (1.9)	0.39 ± 0.10
	Peru, 24 (1.9)	0.46 ± 0.10
	Uruguay, 24 (1.9)	0.49 ± 0.09
	Malaysia, 20 (1.6)	0.49 ± 0.12
Parent	Yes, 326 (25.8)	0.43 ± 0.01	0.386
	No, 911 (72.2)	0.43 ± 0.00
	Prefer not to say, 25 (2.0)	0.45 ± 0.02
Healthcare worker	Yes, 218 (17.3)	0.44 ± 0.01	0.601
	No, 1018 (80.7)	0.43 ± 0.00
	Prefer not to say, 26 (2.1)	0.44 ± 0.02
Cat breeder	Yes, 84 (6.7)	0.44 ± 0.01	0.917
	No, 1169 (92.6)	0.43 ± 0.00
	Prefer not to say, 9 (0.7)	0.42 ± 0.03
Language	English, 956 (75.8)	0.43 ± 0.00	0.587
	Spanish, 306 (24.2)	0.44 ± 0.01

P value refers to the comparison of mean total FGS scores among different response options for each demographic question

^*Only countries with at least 20 complete responses are reported in this table

Figure 2.

World map showing the geographical locations of 1262 cat caregivers who completed an online survey and scored 10 facial images of cats with different degrees of pain using the Feline Grimace Scale

Table 4.

Number of responses by country from 1262 cat caregivers who completed an online survey containing 10 facial images of cats in different degrees of naturally occurring pain

Country	Number of responses
UK	373
Spain	218
USA	181
Republic of Ireland	54
Canada	46
Brazil	34
Germany	25
Belgium, Peru, Uruguay	24
Malaysia	20
Colombia	19
Netherlands	18
Chile, Mexico	17
Australia	15
Argentina	12
France	8
Greece, Italy, Norway, Sweden	7
Finland, Poland, Portugal, Russia	6
Croatia, Singapore	5
Slovenia, South Africa	4
Austria, Denmark, Estonia, Guatemala, Israel, Japan, New Zealand, Philippines, Switzerland	3
Bulgaria, China, Czech Republic, Egypt, Luxembourg, Romania, Thailand, Turkey, Ukraine	2
Andorra, Armenia, Barbados, Bermuda, El Salvador, Eritrea, Grenada, Hong Kong, India, Indonesia, Lithuania, Malta, Puerto Rico, Serbia, Slovakia, United Arab Emirates, Venezuela, Vietnam	1

Discussion

This study investigated whether cat caregivers could reliably use the FGS for acute pain assessment in cats and if demographic variables would affect total FGS scores. Pain scores from cat caregivers and veterinarians were not significantly different for total FGS scores and individual AUs, with the exception of muzzle tension. Indeed, inter-rater reliability for cat caregivers was good or moderate for most AUs and total FGS scores. However, our second hypothesis was not corroborated as none of the demographics affected the total FGS scores. Overall, our results demonstrated that the FGS has wide potential applicability for assessing acute pain in cats by caregivers.

View rate (ratio of unique survey visitors divided by unique site visitors), participation rate (ratio of unique visitors who agreed to participate divided by unique first survey page visitors) and completion rate (ratio of users who finished the survey divided by users who agreed to participate), as defined by the CHERRIES guidelines,^15,16 could not be calculated in the present study because participation was anonymous. The number of unique site visitors was not available and only those surveys for which participants agreed to participate, viewed the survey and submitted their responses (whether complete or not) were considered. Completeness rate (how completely questionnaires were filled in) was 41.5%, and calculated as the number of complete responses divided by the number of submitted responses. The definitions of view, participation, completion, completeness and response rates are not uniform across the literature, making comparisons among studies difficult.^15,19,20 For example, recent internet-based surveys of cat caregivers did not define or report such rates, although the actual number of responses and global outreach observed here and in these surveys were comparable.^21,22 One survey investigating cat scratching behaviour obtained 4015 responses from 36 countries, ²² whereas another survey investigating cat ownership perception and caretaking behaviours in Australia obtained 1013 responses. ²¹ Both these surveys also used a convenience sample but were available for up to 4 months. It is possible that a larger number of responses could have been obtained if the present survey had been made available for longer than 2 months. In addition, the other surveys were based on multiple questions and did not require the same level of engagement as our survey, where cat caregivers had to read a training manual and undergo a ‘test/scoring’ type of activity, rather than simply reporting their opinions, practices or experiences.

A meta-analysis of internet-based surveys revealed that sample representativeness is much more important than response rates. ¹⁹ Responses from 66 countries demonstrates great geographical representativeness; nevertheless, our data were biased towards female individuals from Western countries. Female bias is a reality of internet-based research in medical and social sciences.^4,23,24 However, gender did not affect the total FGS scores in the present study (see discussion below).It is not clear how a Western cultural background may have had an impact on our results, especially when comparisons between scores from Western and non-Western countries were beyond the goals of this study. For example, non-Western nurses showed low empathic behaviours towards patient’s pain following coronary bypass surgery. ²⁵ Additionally, the level of education of the participants, as well as their understanding of feline/animal pain management was unknown, which could have resulted in additional response bias.Complete responses originated mostly from English- and Spanish-speaking countries, which is expected as the questionnaire was only available in these languages. It is difficult to know how the results of the study may have been affected if the survey was available in multiple languages, which would have allowed for the inclusion of non-English and non-Spanish speaking individuals. The survey still included a widespread global representation in countries where English and Spanish are not the primary language; however, these data are likely to represent individuals who are presumed to be at least bilingual and perhaps influenced by more than one culture.

With the increase in globalisation and multicultural societies, the question of how different races, cultures and ethnic groups perceive pain on themselves and other humans has been the subject of numerous studies and reviews highlighting the complexity of this issue.^26–29 Cultural influences become obvious when studies focus on facial expressions of different emotions. For example, in a recent study, Western and East Asian observers were asked to look at same-race facial animations of facial expressions of different emotions and to classify these as ‘pain’, ‘pleasure’ or ‘other’. It was found that similar face movements were considered by both cultures to categorise a facial expression as ‘pain’, whereas different face movements were considered to categorise a facial expression as ‘pleasure’. ³⁰ In a similar study involving Western white people and East Asians, observers were asked to categorise facial expressions of the six basic internal emotional states by Darwin (happy, surprise, fear, disgust, anger and sad). ³¹ Western white people categorised the six basic emotions considering a distinct set of facial muscles for each emotion, whereas East Asians showed considerable overlap on the set of facial muscles considered to categorise different emotions. ³¹ The authors highlighted the fact that facial expressions of emotion in humans are culture-specific. The issue becomes even more complicated when we think about cultural differences in the acceptance of animal sentience and speciesism and how this may influence the way each culture perceives the facial expressions of pain in different animal species.^32,33

Overall, the non-significant effects of demographic variables on FGS score in the present study demonstrate the wide applicability of the FGS to the general cat caregiver population, regardless of location and cultural background. Future research testing other instruments for feline pain assessment may contribute to the understanding of how demographics influence pain detection in cats, further contributing to feline health and welfare.

Mean scores for each AU and total FGS scores were not significantly different between cat caregivers and veterinarians, except for muzzle tension. These results are similar to our previous study in which five veterinarians and five cat caregivers evaluated 100 images of cats using the FGS. ¹⁴ In that study, agreement between groups for total FGS scores was very good, with minimal bias (−0.038 to −0.060) and narrow limits of agreement. ¹⁴ Similar to the present study, cat caregivers tended to give slightly higher scores than veterinarians, which might be protective of cats’ welfare if it prompts cat caregivers to look for veterinary care. Differences in scores for the AU muzzle tension are not surprising, based on previous studies.^10–12,14 Indeed, the ICC_single varied across different AUs and was higher for ear position and orbital tightening, and lower for muzzle and whiskers, showing the difficulty of scoring muzzle and whiskers than other AUs, regardless of experience in pain assessment.^10,11 For the AU head position, reasonable and moderate reliability were lower than previous studies for cat caregivers and veterinarians, respectively, and somewhat unexpected.^10,11,14 This could be related to the limited number of images and the specific images included in this survey. Another possible explanation is that observers participating in previous studies used a desktop computer, whereas, in this study, participants were free to complete the survey using either a desktop computer or a tablet/smartphone. It is possible that the use of different electronic devices may have disrupted visual assessments of AUs, including head position. Ultimately, total FGS scores are taken as the main outcome in the decision-making process to provide pain relief (ie, by veterinarians) or to consult a veterinarian (ie, cat caregivers). Hence, the practical relevance of differences in muzzle tension scores and slight differences in the specific observation of other AUs may be negligible in the majority of cases.

Demographics were found to have no significant effect on the total FGS score, demonstrating that cat caregivers give similar scores regardless of gender, age, country of residence, parental status or experience with healthcare or cat breeding. In a previous study involving five cat caregivers, female observers (n = 3) gave higher scores than male observers (n = 2). However, the small number of observers in that study makes comparisons difficult. Previous studies have shown that, when compared with male caregivers, female caregivers of small animals tend to be more concerned about animal pain and ensuring that analgesics will be used in their pets as needed.^1,3,4 Similarly, a survey of Norwegian dog caregivers found that women scored higher on ratings related to empathy and pain when compared with men. ³⁴ The lack of difference in scores between male and female participants in this study might indicate that cat caregivers perceive pain similarly, regardless of gender. Additionally, it is possible that the use of a validated tool with an available training manual, such as the FGS, eliminates differences related to pain scoring and gender.

This study has limitations, some of which have already been addressed. Convenience sampling using an online survey with specific recruitment criteria was used. This excluded cat caregivers without internet access, resulting in participant selection bias. ²⁰ Recruitment was carried out mainly via selected social media groups, which excluded people who were not part of these groups or do not use social media. It is possible that participants entered random answers to ‘try out’ the survey before quitting, or proceeded to score images without reading the training manual. Our online survey platform did not collect the ‘internet protocol’ (IP) address of individuals, which may identify a device on the internet or a local network. Therefore, anonymous participation meant some individuals could have submitted multiple responses. ²⁰ No formal training was given to cat caregivers besides the training manual, and it is not known how training would improve image scoring with the FGS. Any individual can now learn about the FGS and practise their skills using the FGS website (www.felinegrimacescale.com) or using the FGS app on Android or iOS devices. These tools may help with training and improve acute pain recognition in cats.

To our knowledge, this is the first study to demonstrate that cat caregivers worldwide are able to reliably identify and quantify acute pain in cats using a pain assessment tool. Pain in cats has been historically neglected; the lack of pain assessment is one of the main reasons for suboptimal analgesia in feline patients.^5,35 If cat caregivers can recognise pain in their cats, or realise that ‘something is wrong’, a significant increase in veterinary consultations could result in better feline health and welfare, and potential early disease diagnosis and better prognosis. Veterinarians may instruct cat caregivers to use the FGS when they suspect their cat is in pain and look for veterinary care when needed. Furthermore, cat caregivers can use the FGS at home, where cats are more relaxed than in a clinical setting, where pain assessment could be affected by the stress of transport and the veterinary visit. ⁵

Conclusions

Total FGS scores had good reliability when used by cat caregivers, regardless of demographics and background, indicating the potential applicability of the FGS to improve feline pain management and welfare worldwide.