Why recognition – not diagnosis – is the missing step in chronic pain care
Dr. Findy Wills BVSc (Hons I) MSc Clinical Animal Behaviour
Introduction
Chronic pain in dogs is rarely a purely somatic condition. It is a primary driver of maladaptive behavioral change. While the nociceptive and neuropathic components of persistent pain are well understood clinically, their downstream effects on emotional processing, learned helplessness, and response inhibition are frequently overlooked.
Chronic pain doesn’t just cause limping or reluctance to jump; it fundamentally alters a dog’s affective state, lowering bite thresholds, increasing irritability, disrupting sleep architecture, and potentiating anxiety-based responses such as aggression, house-soiling, or compulsive behaviors.
Critically, these behavioral manifestations can persist even after adequate analgesia is established, as pain-induced neuroplasticity reshapes corticolimbic circuits governing fear and arousal.
For veterinarians, recognising this pain–behavior synergy is essential – not only to avoid misdiagnosing primary behavioral disorders but also to implement truly multimodal treatment. This post will explore the pathophysiological links between sustained nociception and behavioral pathology, offer practical frameworks for differentiating pain-driven behaviors from idiopathic conditions, and discuss how integrating behavioral monitoring into chronic pain management can improve long-term patient outcomes1,2.
Pain Is Expressed Through Behaviour – But Is Not Always Recognised
Pain is a sensory and emotional experience, defined by the individual experiencing it. As McCaffery (1989)3 states, “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” – and in animals, that experience is expressed through behaviour. When behaviour changes in a way that suggests discomfort, it is a signal for further veterinary investigation and treatment.
Although the World Small Animal Veterinary Association (WSAVA) guidelines4,5 emphasise behavioural signs as central to pain recognition, these can be overlooked, labelled as “behavioural problems,” or attributed to training, environment, or caregiver factors.
Compounding this, the absence of a gold standard for chronic pain measurement4,5 means clinicians often rely on medical diagnosis as a proxy for pain. However, many patients may lack overt orthopaedic findings, for example, and many behavioural indicators of pain can be quite subtle, or may be context-dependent.
The result is a recognition gap – where pain is experienced – but may not be identified, which can lead to ongoing welfare compromise without a clear pathway for patient support.
Behavioural Observation as a Recognition Tool for Chronic Pain
Recognition is how all diagnostic reasoning begins [6]. Just as a constellation of PU/PD, polyphagia, and weight loss raises suspicion of endocrinopathy, chronic pain presents as a similar pattern.
It is important to note, though, that we do not make a diagnosis of chronic pain from observation alone; but rather we are identifying clinical findings that are meaningful enough to prompt further investigation. Recognising patterns of behavioural change associated with chronic pain requires understanding of chronic pain as a medical condition.
Chronic pain is best understood as a biopsychosocial condition7, where biological, emotional, and social factors interact to shape how it is expressed. Accordingly, behavioural indicators of chronic pain emerge across these domains – through physical changes in the patient, emotional responses, and shifts in social interactions7,8.
So how does this translate into the consult room?
Behavioural signs of chronic pain often emerge in how the patient moves, responds, and relates to their environment and social bonds, and may include symptoms relating to physical discomfort, emotional changes, and relationship changes. Some examples of these behaviours are listed below:
Behaviour signs suggesting physical discomfort and body sensitivity include:
- Reduced tolerance to handling, grooming, or touch
- Chewing or licking body parts without clear dermatological causes
- Noise sensitivity
- Abnormal repetitive behaviours such as tail chasing, pica
- Frequent changes in sleep/resting positions
- Harness avoidance
- Hesitation with performing known cues such as heel, sit, lie down.
- Car travel difficulties due to balancing challenges
- Subtle gait changes, stiffness, hesitation, or asymmetry
- Shifting weight, offloading limbs, or difficulty with transitions (sit–stand, lie–rise)
- Reduced dorsal-ventral flexion
- Reduced fluidity of movement or “stop–start” patterns at a walk
Behaviour signs suggesting emotional changes associated with chronic pain include:
- Increased reactivity/confrontational behaviour towards people and/or dogs
- Avoidance behaviours (retreating, hiding, reluctance to engage)
- Separation-related behaviours (distress on departure, inability to settle alone)
- House soiling (especially if previously toilet trained)
- Resource guarding (food, objects, space, people)
- Reduced ability to learn or retain cues
- “Non-compliance” or “Demanding” behaviour that may reflect increased frustration and reduced capacity rather than choice
Behaviour signs suggesting relational changes associated with chronic pain include:
- Increased conflict and tension towards familiar people or known dogs
- Loss of confidence, feeling inadequate or “guilty” in management of the dog’s behaviour.
- Impact on caregiver’s daily functioning (sleep, work, social life, holiday care)
- Reduced enjoyment of the dog–owner relationship
- Escalation in attempts to control behaviour (e.g., more punishment or aversive tools used.)
Individually, these signs can be easy to rationalise, but when they occur together across domains, they form a pattern that should prompt consideration of chronic pain. Once recognised, the pathway often becomes familiar: further diagnostics where appropriate, pain treatment trials, multimodal care, and collaboration with allied professionals e.g., trainers, clinical animal behaviourists and animal physiotherapists.
However, it is important to recognise that not all patients with chronic pain will present with clear diagnostic confirmation at this stage. It is important to note, therefore, that the absence of a diagnosis does not mean the absence of pain. When behavioural indicators of pain persist despite not having a medical diagnosis, it is important to recognise that the animal is still communicating discomfort – and that deserves ongoing clinical consideration. In such cases, our role as veterinarians is not yet complete; it is a call for more time, information, and clinical exploration to support the patient in front of us.
Veterinarians are the most powerful advocates within a patient’s care team. We have the ability to recognise, diagnose, prescribe, and treat – but without the skill of recognising behavioural signs of chronic pain, our patients miss out on their strongest advocate.
Vet Education is excited to be working with Elevate Animal Physiotherapy and Let’s Talk Paws Veterinary Behaviour to bring you a special on-demand course – designed to support the whole veterinary team to confidently recognise the subtle behavioural and functional indicators of chronic pain, so you can act earlier, advocate more effectively, and change the trajectory of care for your patients.
References
Oliveira JT. Behavioral aspects of chronic pain syndromes. Arquivos de Neuro-Psiquiatria. 2000;58:360-5.
Mills DS, Demontigny-Bédard I, Gruen M, Klinck MP, McPeake KJ, Barcelos AM, Hewison L, Van Haevermaet H, Denenberg S, Hauser H, Koch C. Pain and problem behavior in cats and dogs. Animals. 2020 Feb;10(2):318.
Kwik J, De Keuster T, Bosmans T, Mottet J. Detection of maladaptive pain in dogs referred for behavioral complaints: challenges and opportunities. Frontiers in Behavioral Neuroscience. 2025 May 8;19:1569351.
McCaffery M, Beebe A. Pain: Clinical manual for nursing practice. 1989 Feb.
Monteiro BP, Lascelles BD, Murrell J, Robertson S, Steagall PV, Wright B. 2022 WSAVA guidelines for the recognition, assessment and treatment of pain. Journal of Small Animal Practice. 2023 Apr;64(4):177-254.
Sander AN, Storz S, Xenoulis PG, Heilmann RM. Assessment of acute and chronic pain in canine internal medicine—what is missing in our diagnostic toolbox? Frontiers in Veterinary Science. 2025 Nov 26;12:1614403.
Scott IA, Crock C. Diagnostic error: incidence, impacts, causes and preventive strategies. Medical Journal of Australia. 2020 Oct;213(7):302-5.
Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubiner H, Keefe FJ. Pain and emotion: a biopsychosocial review of recent research. Journal of clinical psychology. 2011 Sep;67(9):942-68.
