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Flores JEM, Terrazas A, Lara Sagahon AV, Aleman M. Parasympathetic tone activity, heart rate, and grimace scale in conscious horses of 3 breeds before, during, and after nociceptive mechanical stimulation. J Vet Intern Med 2024. [PMID: 39150630 DOI: 10.1111/jvim.17174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 08/01/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Parasympathetic tone activity (PTA) in response to nociceptive stimulus in conscious non-sedated horses is unknown. OBJECTIVES Study PTA, heart rate (HR), and horse grimace scale (HGS) at rest and during mechanical nociceptive stimulation. ANIMALS Ninety healthy young adult horses (females, males): 30 each of Friesians, Quarter Horses, and Warmbloods. METHODS Prospective control study. The study consisted of habituation to equipment (Day 1), baseline recordings (Days 2 and 3), and nociceptive testing applying mild pressure to the metacarpus (Day 4). Parasympathetic tone, HR, and HGS were recorded simultaneously on Days 2 to 4. Each study lasted 30 minutes and was done in triplicate at 3 different time points per day. RESULTS Baseline PTA was not different among breeds. It decreased in Warmbloods and Quarter Horses during placement of the stimulus device without stimulation (P < .01). A significant decrease in PTA (P < .001) occurred during nociceptive stimulus (marked in Quarter Horses, intermediate in Warmbloods, and mild in Friesians). Heart rate and HGS increased significantly (P < .001) during the stimulus in all breeds but returned to baseline poststimulation. Friesians required higher pressure (P < .05) to elicit an aversive response to the stimulus. CONCLUSIONS Horses' PTA, HR, and HGS change in response to a mild mechanical nociceptive stimulus with Friesians showing less variation. Stress induced a decrease in PTA in Quarter Horses and Warmbloods but not in Friesians. Friesians appeared to be more tolerant to pain based on PTA, HR, and HGS findings compared with other breeds.
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Affiliation(s)
- Jorge Eduardo Mendoza Flores
- Department of Livestock Sciences, Faculty of Higher Studies, Cuautitlan, National Autonomous University of Mexico (UNAM), Mexico City, Mexico
- Doctorate in Animal Production and Health Sciences, National Autonomous University of Mexico (UNAM), Mexico City, Mexico
| | - Angelica Terrazas
- Department of Livestock Sciences, Faculty of Higher Studies, Cuautitlan, National Autonomous University of Mexico (UNAM), Mexico City, Mexico
| | - Alma V Lara Sagahon
- Department of Livestock Sciences, Faculty of Higher Studies, Cuautitlan, National Autonomous University of Mexico (UNAM), Mexico City, Mexico
| | - Monica Aleman
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, California, USA
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Pongrácz P, Dobos P. Behavioural differences and similarities between dog breeds: proposing an ecologically valid approach for canine behavioural research. Biol Rev Camb Philos Soc 2024. [PMID: 39101379 DOI: 10.1111/brv.13128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 08/06/2024]
Abstract
The behaviour of dogs holds great relevance for not only scientists from fundamental and applied research areas, but also due to the widespread roles of dogs in our societies as companions and working animals; their behaviour is also an important factor in animal and human welfare. A large proportion of dogs currently under human supervision belong to one of roughly 400 recognised breeds. Dog breeds can be characterised by distinctive, predictable and reproducible features, including some of their behavioural traits. To the scientist, the comparative analysis of the behaviour of dog breeds provides an opportunity for investigating an array of intriguing phenomena within an easily accessible model organism created from natural and human-driven evolutionary processes. There are many ways to design and conduct breed-related behavioural investigations, but such endeavours should always be based around biologically relevant research questions and lead to ecologically valid conclusions. In this review, we surveyed recent research efforts that included dog behaviour-related comparisons and applied a critical evaluation according to their methods of breed choice and the subsequent research design. Our aim was to assess whether these two fundamentally important components of experimental design provide a solid basis to reach valid conclusions. Based on 97 publications that fulfilled our selection criteria, we identified three primary methods used by researchers to select breeds for their investigations: (i) convenience sampling; (ii) hypothesis-driven, ancestry-based sampling; and (iii) hypothesis-driven, functional sampling. By using the SWOT (Strengths, Weaknesses, Opportunities, Threats) evaluation system, we highlight each of these techniques' merits and shortcomings. We identify when particular methods may be inherently unable to produce biologically meaningful results due to a mismatch between breed choice and the initial research goals. We hope that our evaluation will help researchers adopt best practices in experimental design regarding future dog breed comparisons.
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Affiliation(s)
- Péter Pongrácz
- Department of Ethology, ELTE Eötvös Loránd University, 1117 Pázmány Péter sétány 1/c, Budapest, Hungary
| | - Petra Dobos
- Department of Ethology, ELTE Eötvös Loránd University, 1117 Pázmány Péter sétány 1/c, Budapest, Hungary
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Caddiell RMP, Cunningham RM, White PA, Lascelles BDX, Gruen ME. Pain sensitivity differs between dog breeds but not in the way veterinarians believe. FRONTIERS IN PAIN RESEARCH 2023; 4:1165340. [PMID: 37435196 PMCID: PMC10332458 DOI: 10.3389/fpain.2023.1165340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Background Veterinarians hold distinct breed-specific pain sensitivity beliefs that differ from the general public but are highly consistent with one another. This is remarkable as there is no current scientific evidence for biological differences in pain sensitivity across dog breeds. Therefore, the present study evaluated whether pain sensitivity thresholds differ across a set of dog breeds and, if so, whether veterinarians' pain sensitivity ratings explain these differences or whether these ratings are attributed to behavioral characteristics. Methods Pain sensitivity thresholds [using quantitative sensory testing (QST) methods] and canine behaviors (using owner questionnaires and emotional reactivity tests) were prospectively measured across selected dog breeds. Adult, healthy dogs from 10 dog breeds/breed types were recruited, representing breeds subjectively rated by veterinarians as high (chihuahua, German shepherd, Maltese, Siberian husky), average (border collie, Boston terrier, Jack Russell terrier), or low (golden retriever, pitbull, Labrador retriever) pain sensitivity. A final sample of 149 dogs was included in statistical analyses. Results Veterinarians' pain sensitivity ratings provided a minimal explanation for pain sensitivity thresholds measured using QST in dogs; however, dog breeds did differ in their pain sensitivity thresholds across the QST methods evaluated. Breed differences were observed for some aspects of emotional reactivity tests; however, these behavioral differences did not explain the differences in pain sensitivity thresholds found. Veterinarians' pain sensitivity ratings were positively associated with dog approach scores for the disgruntled stranger test suggesting that the way dogs greet strangers may be a factor influencing veterinarians' ratings of pain sensitivity across dog breeds. Conclusions and clinical relevance Overall, these findings highlight a need to investigate biological mechanisms that may explain breed differences in pain sensitivity because this may inform pain management recommendations. Further, future research should focus on when and how these breed-specific pain sensitivity beliefs developed in veterinarians, as veterinarians' beliefs could impact the recognition and treatment of pain for canine patients.
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Affiliation(s)
- Rachel M. P. Caddiell
- Comparative Behavioral Research, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Translational Research in Pain, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Rachael M. Cunningham
- Comparative Behavioral Research, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Translational Research in Pain, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Philip A. White
- Department of Statistics, College of Physical and Mathematical Sciences, Brigham Young University, Provo, UT, United States
| | - B. Duncan X. Lascelles
- Translational Research in Pain, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Pain Research and Education Center, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Thurston Arthritis Centre, UNC School of Medicine, Chapel Hill, NC, United States
- Center for Translational Pain Research, Department of Anesthesiology, Duke University, Durham, NC, United States
| | - Margaret E. Gruen
- Comparative Behavioral Research, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Pain Research and Education Center, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
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Miller AL, Clarkson JM, Quigley C, Neville V, Krall C, Geijer-Simpson A, Flecknell PA, Leach MC. Evaluating Pain and Analgesia Effectiveness Following Routine Castration in Rabbits Using Behavior and Facial Expressions. Front Vet Sci 2022; 9:782486. [PMID: 35296059 PMCID: PMC8918579 DOI: 10.3389/fvets.2022.782486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/20/2022] [Indexed: 11/19/2022] Open
Abstract
Prevention of pain in rabbits is a priority for both welfare and validity of scientific data. We aimed to determine if the rabbit grimace scale (RbtGS) could be used as a viable, rapid assessment tool in two breeds of rabbit, Dutch belted (DB) and New Zealand white (NZW), following orchidectomy, as an adjunct to behavioral analysis. All animals received analgesia. Rabbits were filmed and their behavior was recorded at multiple time points pre- and post-orchidectomy. Observers then scored specific pain associated behaviors for analysis. Time matched footage was also scored using the rabbit grimace scale (RbtGS). Following surgery, rabbits showed significant increases in the duration spent displaying key pain associated behaviors at 1 and 5 h post-surgery. DB rabbits that received low dose meloxicam (0.2 mg/kg) showed significantly more pain behaviors at 1 and 5 h post-surgery compared to those administered a combination of higher dose meloxicam (0.6 mg/kg) and a lidocaine/bupivacaine local infusion. DB rabbits showed an increase in RbtGS score at both 1 and 5 h post-surgery. In the NZW rabbits, an increase in RbtGS score was only observed at 1 h post-surgery. Using behavioral analysis as the gold standard for comparison, the RbtGS was an effective means of determining when rabbits are painful following orchidectomy. Higher dose meloxicam (0.6 mg/kg) combined with local anesthetic was a more effective method of reducing pain, compared to lower dose meloxicam (0.2 mg/kg) alone.
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Affiliation(s)
- Amy L. Miller
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- *Correspondence: Amy L. Miller
| | - Jasmine M. Clarkson
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caroline Quigley
- Bioresearch and Veterinary Services, University of Edinburgh, Edinburgh, United Kingdom
| | - Vikki Neville
- Bristol Veterinary School, University of Bristol, Bristol, United Kingdom
| | - Caroline Krall
- Department of Molecular & Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Annika Geijer-Simpson
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul A. Flecknell
- Comparative Biology Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Matthew C. Leach
- School of Natural and Environmental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Evaluation of Quadratus Lumborum Block as Part of an Opioid-Free Anaesthesia for Canine Ovariohysterectomy. Animals (Basel) 2021; 11:ani11123424. [PMID: 34944201 PMCID: PMC8697988 DOI: 10.3390/ani11123424] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The aim of this study was to assess an anaesthetic protocol involving the quadratus lumborum block (QLB) for canine ovariohysterectomy. Ten healthy dogs were included. Anaesthetic protocol consisted of medetomidine and meloxicam, induction of anaesthesia with propofol and maintenance with sevoflurane in oxygen/medical air. The QLB was performed at the level of L1–L2 injecting 0.4 mL kg−1 of 0.25% bupivacaine/iohexol per side. Computed Tomography (CT) was performed before and after surgery. Fentanyl was administered as rescue analgesia during surgery. The Short Form of The Glasgow Composite Pain Scale and thermal threshold (TT) at the level of the humerus, T10, T13 and L3 were assessed before premedication and every hour postoperatively. Methadone was given as rescue analgesia when it was needed. CT images showed spreading of a median (range) of 3 (2–5) vertebrae, without differences between preoperative and postoperative images. One out of ten dogs needed intraoperative rescue analgesia. Pain score was less than 4/24 in all the animals until four hours after surgery. TT showed significative increase in all the areas tested apart from the elbow 30 min after the recovery. The QLB provides additional analgesia for canine ovariohysterectomy. Abstract Quadratus lumborum block (QLB) is used to provide analgesia for abdominal surgery in humans. The aim of this study was to assess an anaesthetic protocol involving the QLB for canine ovariohysterectomy. Ten dogs were included. Anaesthetic protocol consisted of premedication with IM medetomidine (20 μg kg−1) and SC meloxicam (0.1 mg kg−1), induction with propofol to effect, and maintenance with sevoflurane in oxygen/medical air. QLB was performed injecting 0.4 mL kg−1 of 0.25% bupivacaine/iohexol per side. Computed Tomography (CT) was performed before and after surgery. Fentanyl was administered as rescue analgesia during surgery. The Short Form of The Glasgow Composite Pain Scale and thermal threshold (TT) at the level of the elbow, T10, T13 and L3 were assessed before premedication and every hour postoperatively. Methadone was given as rescue analgesia postoperatively when pain score was >3. A Yuen’s test on trimmed means for dependent samples was used to analyse the data (p < 0.05). CT images showed spreading of the contrast/block for a median (range) of 3 (2–5) vertebrae, without differences between preoperative and postoperative images. One dog needed rescue analgesia during surgery. Pain score was less than 4/24 in all the animals during the first 4 h after surgery. TT showed a significant increased signal in all the areas tested, apart from the humerus, 30 min after surgery. The QLB may provide additional analgesia for canine ovariohysterectomy. Further studies are needed to assess the specific contribution of the QLB in abdominal analgesia.
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Iadarola MJ, Brown DC, Nahama A, Sapio MR, Mannes AJ. Pain Treatment in the Companion Canine Model to Validate Rodent Results and Incentivize the Transition to Human Clinical Trials. Front Pharmacol 2021; 12:705743. [PMID: 34421597 PMCID: PMC8375595 DOI: 10.3389/fphar.2021.705743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/14/2021] [Indexed: 12/14/2022] Open
Abstract
One of the biggest challenges for analgesic drug development is how to decide if a potential analgesic candidate will work in humans. What preclinical data are the most convincing, incentivizing and most predictive of success? Such a predicament is not unique to analgesics, and the pain field has certain advantages over drug development efforts in areas like neuropsychiatry where the etiological origins are either unknown or difficult to ascertain. For pain, the origin of the problem frequently is known, and the causative peripheral tissue insult might be observable. The main conundrum centers around evaluation of translational cell- and rodent-based results. While cell and rodent models are undeniably important first steps for screening, probing mechanism of action, and understanding factors of adsorption, distribution metabolism and excretion, two questions arise from such studies. First, are they reliable indicators of analgesic performance of a candidate drug in human acute and chronic pain? Second, what additional model systems might be capable of increasing translational confidence? We address this second question by assessing, primarily, the companion canine model, which can provide particularly strong predictive information for candidate analgesic agents in humans. This statement is mainly derived from our studies with resiniferatoxin (RTX) a potent TRPV1 agonist but also from protein therapeutics using a conjugate of Substance P and saporin. Our experience, to date, is that rodent models might be very well suited for acute pain translation, but companion canine models, and other large animal studies, can augment initial discovery research using rodent models for neuropathic or chronic pain. The larger animal models also provide strong translational predictive capacity for analgesic performance in humans, better predict dosing parameters for human trials and provide insight into behavior changes (bladder, bowel, mood, etc.) that are not readily assessed in laboratory animals. They are, however, not without problems that can be encountered with any experimental drug treatment or clinical trial. It also is important to recognize that pain treatment is a major veterinary concern and is an intrinsically worthwhile endeavor for animals as well as humans.
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Affiliation(s)
- Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, NIH, Bethesda, MD, United States
| | | | | | - Matthew R Sapio
- Department of Perioperative Medicine, Clinical Center, NIH, Bethesda, MD, United States
| | - Andrew J Mannes
- Department of Perioperative Medicine, Clinical Center, NIH, Bethesda, MD, United States
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Zibura AE, Salmon JH, Belda Lopez B, X Lascelles BD, Westermeyer HD. Glaucoma-associated pain results in mechanical sensitivity changes in dogs: A pilot study. Vet Ophthalmol 2020; 24 Suppl 1:116-124. [PMID: 32608141 DOI: 10.1111/vop.12800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To explore the effects of chronic, uncontrolled glaucoma on pressure sensitivity in dogs before and after enucleation of the painful globe. METHODS Client-owned dogs undergoing enucleation for chronic glaucoma with no other sources of pain were enrolled. Normal dogs of similar breeds and skull morphology were enrolled as controls. Craniofacial ratio (CFR) and relative palpebral fissure width (RPFW) were assessed in all patients. Serial mechanical quantitative sensory testing (QST) was performed the day before surgery, and 14, 30, 60, and 120 days after surgery. QST consisted of electronic Von Frey (eVF), and blunt algometry (BA) performed above and below the nonglaucomatous eye, the metacarpus, and metatarsus. Cochet-Bonnet esthesiometry (CB) was also performed on the remaining eye. RESULTS Twelve dogs (6 per group) were included. Compared to baseline values, sensitivity tended to decrease over time (increased thresholds) in treatment dogs while it stayed constant or increased slightly in control dogs. The difference in change from baseline sensitivity between control and treatment groups was significant at day 120 using BA at supraorbital (P = .0153), infraorbital (P = .0209), and metacarpal sites (P = .007) and overall (P = .0470). This divergence was also significant using CB (P = .0470) on the opposite cornea. As patient CFR and RPFWV increased, both eVF (P = .005-.023) and BA (P = .004-.041) increased. CONCLUSIONS Sensitivity to mechanical stimuli decreased both locally and at remote sites in dogs following enucleation for painful chronic glaucoma. Cranial conformation is associated with differences in sensitivity.
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Affiliation(s)
- Ashley E Zibura
- Comparative Ophthalmology, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Jacklyn H Salmon
- Comparative Ophthalmology, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - Beatriz Belda Lopez
- Small Animal Surgery, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.,Translational Research in Pain Program, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - B Duncan X Lascelles
- Small Animal Surgery, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.,Translational Research in Pain Program, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA.,Comparative Pain Research and Education Center, North Carolina State University, Raleigh, NC, USA
| | - Hans D Westermeyer
- Comparative Ophthalmology, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
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Essner A, Högberg H, Zetterberg L, Hellström K, Sjöström R, Gustås P. Investigating the Probability of Response Bias in Owner-Perceived Pain Assessment in Dogs With Osteoarthritis. Top Companion Anim Med 2020; 39:100407. [PMID: 32482283 DOI: 10.1016/j.tcam.2020.100407] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
Owners' ability to recognize signs of chronic pain in dogs undergoing pharmacologic and nonpharmacologic pain interventions during a period of physical rehabilitation is not known. This study aimed to compare dogs with and without chronic pain, and to assess the relationship between explanatory factors, including the probability of owners' response bias induced by pharmacologic and nonpharmacologic pain intervention, and chronic pain in dogs with osteoarthritis (OA). Seventy-one dogs with OA were included in this observational study. Owner-perceived pain interference was measured by Canine Brief Pain Inventory (CBPI) and owner-perceived pain behavior was assessed using Helsinki Chronic Pain Index. A dichotomous variable of Helsinki Chronic Pain Index was used in regression analysis to investigate the association between chronic pain and explanatory factors (body condition, anti-inflammatory medication, animal physiotherapy consultation once or more and owners' perception of pain interfering). Seventy-five percent of the dogs had ongoing anti-inflammatory medication, 51% of were overweight and 45% had a physiotherapy consultation. Higher levels of overt pain behaviors were reported in items addressing activities. Body condition, physiotherapy consultation and medication were not associated with chronic pain. Odds ratio (OR) and 95% confidence intervals of OR for the CBPI were 1.74 (1.23-2.47) and significantly associated with chronic pain. The adjusted OR of the CBPI did not differ from the crude OR. Owner-perceived pain behavior was not confounded by the dogs' medication. Results indicated that CBPI was not mediated by the medication. The CBPI pain interference score was not associated with response bias and may be used as clinical outcome measure of chronic pain and pain-related disability in dogs with OA along a period of physical rehabilitation comprising pharmacologic and nonpharmacologic pain interventions.
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Affiliation(s)
- Ann Essner
- Department of Neuroscience, Faculty of Physiotherapy, Uppsala University, Uppsala, Sweden; Evidensia Djurkliniken Gefle, Gävle, Sweden.
| | - Hans Högberg
- Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden
| | - Lena Zetterberg
- Department of Neuroscience, Faculty of Physiotherapy, Uppsala University, Uppsala, Sweden
| | - Karin Hellström
- Department of Neuroscience, Faculty of Physiotherapy, Uppsala University, Uppsala, Sweden
| | - Rita Sjöström
- Region Jämtland Härjedalen, Unit of Research Education & Development, Östersund, Sweden; Department of Community Medicine and Rehabilitation, Faculty of Physiotherapy, Umeå University, Umeå, Sweden
| | - Pia Gustås
- Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Husbandry, Swedish University of Agricultural Sciences, Uppsala, Sweden
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