For Allied Professionals: Is it Behaviour or Pain? Understanding the link, and summarising the benefits of the Cooperative Care approach.

Many dogs are labelled as ‘difficult’ or ‘stubborn’ in the clinical environment are likely to be experiencing pain which is attributing to their behaviour. Recognising the connection between behaviour and pain is an essential skill for the Animal MSK Practitioner. Behavioural signs are often missed by owners which cause them to escalate; however, a behaviour change is often the first clinical sign of discomfort.

A dog in pain will likely show avoidance behaviours, refuse food rewards, and may resort to aggression. Chronic pain can result in a long-term behavioural change in patients if it goes missed and untreated.  These behavioural responses are commonly misinterpreted for poor training or fearfulness, and are likely to affect your assessment outcomes, as well as treatment outcomes.

Nociceptive input from tissue damage will affect the emotional state of the animal; the effect of this will be variable depending on if the patient is experiencing acute or chronic pain. Chronic pain is not thought to be related with healing and patients experiencing chronic pain can have acute flare-ups. Acute pain is typically ‘easier’ to treat; therapy focuses on treating the underlying cause of the pain as opposed to ‘undoing’ long-term pathological changes in patients with chronic pain.

Patients with chronic pain can develop central sensitisation which can heighten their sensitivity to pain and may present with behavioural signs that appear un-related to movement.

The link between behaviour and pain is critical for a MSK practitioner. We require patients to tolerate our touch for performance of manual therapies and willingly engage in exercises as part of therapeutic exercise programmes. When these behavioural signs of pain are missed, we will see a reduction in ‘compliance’ to treatment and an increased fear of the clinical environment. All of which is likely to result in poor therapeutic outcomes for the patient, threaten the patient’s welfare, and may cause a risk to the safety of the practitioner if the patient turns to aggression.

As a practitioner, it is important to be aware of subtle behavioural signs of pain and attend relevant CPD to enhance our skills. Cooperative care training is also a valuable tool to encourage patient participation and willingness. One example of the cooperative care approach that can prove useful for your treatment sessions includes a patient voluntarily standing for laser treatment which is likely to reduce the time taken, especially useful for those practitioners who use a Class III laser.

‘Non-compliance’ in veterinary practice is often a representation of a protective strategy which is aimed to protect the patient from anticipated pain. For example, a patient with cruciate ligament pathology may be avoiding limb manipulation by moving away from the practitioner or guarding the limb. The patient is anticipating pain from the palpation assessment and so is implementing a protective strategy. This represents communication from the patient, rather than resistance and ‘non-compliance’. The practitioner should adjust their handling technique and ensure that the patient’s pain is adequately managed, which may involve referral to the patient’s primary care vet for assessment of their pain medication regime.

In recognising and mitigating against behavioural signs of pain and taking a cooperative care approach, there will be a multitude of rehabilitative benefits. The process is likely to be a lot less stressful for the patient and therefore their welfare. The practitioner-patient bond is also likely to be improved from an increased trust and engagement level, having a significant impact on practitioner safety.

As a Veterinary Physiotherapist, a key part of my role is collaborating with vets and behaviourists, as well as educating owners to recognise pain-related behaviour. Working as a multi-disciplinary team creates optimal therapeutic outcomes for patients and puts our patient’s physical and emotional welfare at the forefront.