Incompletely Managed Cases
In some cases, a primary complaint may be behavioral, but one or more of the signs may be related to pain. This is perhaps a less commonly recognized situation but no less important, as failure to recognize this can result in some aspects of the problem improving with a recognized behavior modification plan but the other aspects associated with pain appearing refractory to treatment. Indeed, from a diagnostic perspective, this feature of a case may be an indication to investigate this type of issue. If the pain aspect is not managed, not only does the patient suffer, but also the owners may be left frustrated at having got “so far but no further” with their management of the case, and indeed the case might even relapse as a result. These types of case are not well documented in the literature, but we describe a couple of illustrative case studies below. In the first case, the pain related sign may appear to be an integral part of the presenting syndrome (separation related problem), whereas in the second, the pain related issue seems initially to be a secondary issue of concern. In the third case, we highlight how a painful lesion may result in a behavior patient presenting as a potential relapse.
A 9-year-old male neutered Border Collie who had been in the owner’s home since 14 months of age presented with a 7 year history of being scared of jet planes as well as generalized anxiety that was exacerbated when he was left alone, and whilst many of the separation related signs could be controlled, there was a persistent problem related to destruction when left alone. The dog would dig through carpet and damage door frames, and thus the owner had taken up carpets in some parts of the home, kept him in a tiled room, and also tried to confine him to a crate when left alone. They found that neither giving the dog free access to the house nor crating made any difference to the frequency of destructiveness behavior. The case was referred by a veterinarian with an interest in behavior, because they were not making the expected progress. Treatments might be helpful for a short time, but the dog would soon relapse. The medication history for the problem included 9 months on selegiline, 1 month on propranolol and phenobarbitone, 2 years on clomipramine initially with alpha casozepine but subsequently replaced with alprazolam for 4 months, 2 months on paroxetine with a further 2 months on this medication combined with oxazepam. In the 3 months leading up to consultation, trazodone had been used in place of oxazepam, but it was agreed to start weaning the dog off all meds before the behavior clinic visit. Video assessment of the dog’s behavior showed that he would engage in relatively fixed, “compulsive-like”, short bouts of scratching behavior with one or the other forepaw after lying down. The dog had a varied history of suspected hindlimb injuries, including a cruciate tear, but of particular note was an injury to the left hock when the dog was about 2 years old. This was radiographed at the time, and since no bony damage was apparent, the condition was treated conservatively with non-steroidal anti-inflammatory drugs and rest. Upon clinical examination, the Achilles tendon appeared thickened but was not painful to touch. Initial behavioral advice consisted of continuing to wean the dog off all previous medications, with a view to introducing a combination of phenobarbitone and propranolol again, not only because this combination has been recommended for anxiety and especially noise fears with a strong autonomic component [51
], but also in case the digging behavior was seizure-related. The owner was advised to continue enhanced previous management recommendations at home and to provide the dog with a digging box (child’s sandpit with turf) with training aimed at encouraging redirection of the behavior towards it. The owner was also provided with a diary containing the identified eliciting contexts with which to monitor the behavior (as per King et al. [52
]) and encouraged to make regular video recordings when the dog was alone. After six months, the dog was generally doing well; he seemed more settled and less anxious, but the digging had not resolved. A radiograph of the left hock of the patient was then requested. This revealed extensive ossification of the Achilles tendon and spurs on the calcaneus. A course of meloxicam was therefore recommended with all other management remaining the same. After 1 month, the owner reported that the patient seemed more relaxed at home, and no digging was observed on any of the videos (several recordings had been made weekly, and some of these were 4+ h long). In humans, plantar fasciitis is a painful condition of the calcaneus characterized by stabbing pain when an individual starts an activity involving the foot [53
], and we suspect a similar condition was affecting this dog. Although it is normally a self-limiting condition in people, in this case, there was a clear pathology to explain its persistence. We suspect the foreleg digging was a form of redirected activity associated with discomfort following rest. Whilst the destructiveness was not the primary complaint of the owner, its resolution was critical to the owner’s perception of the complaint and also the dog’s well-being; indeed, we suspect that previous failure to resolve the pain may also account for the relapse given the relationship between anxiety and chronic pain [54
A 1-year-old male neutered Cockapoo belonging to first-time owners since he was 8 weeks old was presented for aggressive behavior over items. The dog was friendly with people and dogs when items were not involved. The dog had a history of being trained using reward focused methods, and the owners commented how he also did not seem to like to go for walks. The resource guarding behavior was successfully managed using standard behavior modification, but the reluctance to go for a walk did not improve. Further investigation of this issue revealed that the dog would back off and move away when the owner approached with the walking harness; he also appeared to be more generally avoidant of handling (the owners had come to the conclusion he was not very sociable, which they found disappointing). Despite this, the owners were still trying to walk the dog twice a day, but the dog was now stopping on walks (sitting down close to the home) on a variable basis; the problem was getting worse and more frequent in recent months. Sometimes he could be persuaded to walk using a food lure but not always; he would also now run away from the walking harness and snap, but there seemed to be less of a problem if they used a flat collar (the owners had previously been advised when he was a puppy that harnesses were better for dogs and thus had not wanted to change this). In the clinic, when he was taken out for a brief walk, his gait appeared stilted. The case was referred for further diagnostic work up, and in the interim, the owners were encouraged to use the collar for walking, to keep the walks short (15 min), and not to force him to walk but to make them up-beat. Upon veterinary examination, the veterinarian could find nothing on physical examination, but radiographs revealed marked bilateral hip dysplasia with joint laxity evident when the dog was anesthetized. The dog was then prescribed NSAIDs for 4–6 weeks. This enabled the owners to extend the walks to about 20 min each, and they used the garden more for exercise; however, there were still significant issues of aggression. Paracetamol was then added to the treatment, and some improvement in the target behaviors was seen, and the owner also noticed that the dog had begun to stretch his back legs occasionally. Gabapentin was then added, and a further marked improvement in the risk of aggressive incidents was evident alongside a further reduction in stopping on walks, although he was still occasionally avoidant. Over the course of the next few weeks, the owners continued to improve the management of the dog and were able to use the harness for walks.
In this case, the primary concern for the owner was their relationship with their dog, which was not what they thought it would be as novice owners. This was epitomized by the dog’s resource guarding behavior, which was the focus of their initial complaint. Although this resolved with a standard behavior modification program, the lack of enjoyment when trying to walk the dog meant the initial problem was not fully resolved due to the secondary issues being tolerated. Only once the first issue had been addressed did the significance of the secondary walking issue become apparent. The avoidance of the harness did not respond well to a desensitization and counterconditioning program until pain medication was used, and it took some time to find the combination for this particular subject. In our experience, this is not an uncommon finding, i.e., several combinations may be required, and the involvement of pain cannot be ruled out following a single negative result. The radiographic changes and the positive Ortolani test obviously helped to provide evidence for the general practitioner that the potential for pain needed to be pursued, but, in our experience, many cases may lack such evidence. Video footage can be invaluable, and it seems many dogs may inhibit or mask their behavior while stressed and thus show few signs in a short general practice veterinary appointment; by contrast, over the course of a much longer behavior consultation, more signs may be evident. For the general practitioner, one way around this problem is to ask the owner to video the dog at home so that the gait can be carefully evaluated.
A 4-year-old, 25 kg male neutered mixed breed dog was originally presented for attacking one of the other dogs in the house. Additional issues included aggression towards unfamiliar dogs, unfamiliar people, and general high arousal and hypervigilance. The patient was treated successfully for the interdog aggression and generalized anxiety with fluoxetine, management changes, and behavior modification protocols. The patient had been behaviorally stable for 6+ months until approximately a year later, when he presented with an apparent reoccurrence of his anxiety. No changes in household dynamics, medication, management, or behavior modification by the owner were noted. However, the owner now observed an increase in the frequency of the dog licking his lips, pupil dilation, heightened sensitivity to environmental noises (indoors and outdoors), and hypervigilance. The patient had not had a physical examination for about 10 months. Mild periodontal disease was reported at this time but no other findings, and the patient’s chart had a warning that he will bite if handled anywhere near his hind end. During the consultation, the patient was observed to be off-loading weight from the left rear limb while standing and to have a stilted/stiff hind limb gait. A 4 week NSAID (grapiprant) trial was recommended with all other treatments continued as previously prescribed. Four months later, the owner reported a decrease in hypervigilance and noise sensitivity, decreased intensity of responses to people and dogs on walks, and increased playfulness since starting NSAID treatment.
As illustrated by the case studies above, the importance of pain related behavioral changes may only become apparent after behavior modification for the primary complaint. Points to note in this regard are slow or lack of progress on certain signs within the complaint and frequent unexplained relapsing of certain signs. In some cases, the behavioral issue may be secondary to a medical one, and the owner may not be seeking help but is pleased when they see the behavioral problem resolve alongside the medical issue. An example of this from the IVBM was an account of a cat being treated for small cell lymphoma, whose owner commented how its pica disappeared as its medical treatment progressed. Another account related to a female spayed dachshund being treated for separation related problems alongside neck/back pain, whose nosing of the owner disappeared when the pain was managed. This might have been a form of care soliciting behavior associated with the discomfort. Perhaps the most common secondary sign that appears to resolve with the treatment of pain relates to various behaviors that, prior to the use of analgesia, were being interpreted by the owner as some form of stubbornness.
Dogs may show signs of pain when walking on very cold (e.g., ice or snow) surfaces, especially in countries with regular temperatures below −10 °C. These signs include: lifting or shaking a paw, unwillingness to walk (to move any limb), crouching or collapsing (all limbs flexed and the ventrum in contact with the ground), and vocalization (crying or whimpering). Central sensitization in relation to pain [55
] may be associated with hypersensitivity to cold [57
] or heat [59
] as well as to pressure (allodynia or hyperalgesia) [60
], and we speculate that this could be a sign of painful conditions (e.g., degenerative joint disease) in pet dogs; it may also be a performance-limiting factor in service dogs living in climates with temperature extremes (e.g., cold winters). A recent study showed somatosensory sensitivity to touch, heat, and cold in dogs affected with hip or stifle osteoarthritis at the affected joint as well as on the cranial tibial muscle and the dorsal metatarsus [55
]. Although the plantar surface of the foot was not tested, it seems reasonable to suggest, given our anecdotal observations, that hypersensitivity could extend to this region.
We have also seen numerous cases where the owners report what they think is a bizarre behavior related to the animal avoiding certain rooms in the house for no apparent reason; upon closer enquiry, it has become apparent that the nature of the flooring may be the source of this behavior (which is not the primary complaint). We hypothesize that the rooms may be avoided because the animal has difficulty coordinating its movement on certain types of surfaces that are slippery, leading to avoidance when the animal has pain, especially in the hips or the shoulders. A case study including this feature is given in the next section on the exacerbation of signs due to pain.