Hello everybody, a very warm welcome to this session about pain and behaviour. I'm primarily gonna be talking about case studies, but in order to illustrate various points, to try and help you identify which behaviour cases may actually be being influenced by pain. This is one of my favourite topics because a huge proportion of my cases I send back to my referring vets for pain relief trials and so on.
And so what I really want to aim to do with this session is to help you spot those things before referring cases on, or put you in a good position to be able to work effectively with behaviourists that are sending things back to you so that you have a good understanding of what might be going on. So this is just a summary of what we're going to include today. We're going to look at what we might be trying to spot in a behavioural presentation that means it's not just a straightforward behaviour case and that there might be something underlying involving medical issues that's affecting that behavioural presentation.
We're gonna look at how we might identify whether pain is an underlying factor. We're also gonna look at why this actually matters and how pain can influence a behaviour modification programme and how it can affect behaviour. We're gonna very briefly touch on working with anxious and fearful patients who are experiencing pain.
And we'll also talk about how to work with non-veterinary behaviourists in terms of, What each person's role is and how you can help each other out to work together as a team. So this is what it is not. There are so many amazing lectures that detail all the pathophysiology of chronic pain and everything else.
That's not my role. This is entirely related to the behaviour side of things. If you want to know more, this book is absolutely awesome.
I would definitely recommend it. It's, it's a, a really good, intense book about chronic pain. So there you go.
So, what we're gonna talk about today, I, do you know, I, I could have talked all day on this topic, and so I've had to be really self-controlled in terms of the cases that I've put into my presentation. As you can see from this slide, there are a huge number of medical conditions that can influence behaviour. Not just in terms of pain, but in terms of all sorts of presentations.
In terms of pain, the most common things that I see are gastrointestinal issues, as in the, the guts are actually uncomfortable, dermatology in terms of being itchy and irritable, and, the skin being uncomfortable, and musculoskeletal pain. So, today, all of the cases I've chosen are actually musculoskeletal pain because I didn't have time to include all the others. But don't forget that there are a huge number of other medical conditions to be considering.
So, all of the general principles that I'm talking about in terms of how, Musculoskeletal pain may affect a behavioural presentation are relevant to identifying any kind of medical condition that might be underlying a behavioural presentation in terms of the the general themes to look for. So don't always assume that musculoskeletal pain is the answer because it could be something else. So why does pain actually matter in terms of behaviour?
Obviously we've got the negative impact on welfare, which we're all fully aware of, but in relation to behaviour cases, what are we, why do we care so much about trying to identify pain? You may have come across this Yerkes Dodson graph before. This is in relation to learning in terms of, if you are at this end of the curve and your arousal level is very low, you aren't going to learn very much.
So if you're half asleep, falling asleep in a lecture as a student, you're not going to take in much of the information. And so as we go up this curve, the ability to learn is increasing as the arousal level of the animal or the human is increasing. But actually we then get to a point where we've reached that peak and optimal performance in terms of our brains working really well.
So a little bit of arousal and stress is actually very useful for learning. If we tip over and we go into this higher level of arousal, either because we're too overexcited or because we're too worried, this can impair performance. It interferes with memory and learning.
And how is this relevant to pain? Well, if you are painful, if you've got really itchy skin or your guts are sore or you've got a sore back, all of those things are going to influence your arousal level and interfere with your performance and your ability to learn. So we need to make sure that our patients are in this optimal state of arousal for learning.
If they're experiencing behaviour problems and we're trying to teach them something new to, to cope with whatever they're struggling with, they're going to struggle. If they are, even if they've just got a low grade ongoing pain that's interfering with their ability to learn and concentrate. We also have the issue of associative learning, which we'll talk a bit more about in a moment, .
If, if a painful experience is associated with another experience, so for example, we will all have come across, dogs who've had painful ear infections, and after visiting the vet they become really scared of coming to the vet. That is due to associative learning. They've associated the pain they are experiencing in their ears with that experience of being at the veterinary surgery.
And again, with, with all aspects of learning in terms of trying to work with, say, a dog who's reactive to other dogs, if we've got pain linked into all of that, it's going to make it very difficult to unlearn things if they've actually made an association that a certain context predicts pain. So we need to make sure we're fully addressing pain in order to make our behaviour modification programme effective. We also have significant risks to clients' compliance if we don't address underlying pain.
If we design a behaviour modification programme and we tell the client, this is what you need to do, this is gonna help your dog and resolve the problems, and they don't have any success. And they don't understand why they're not having success. And actually, the reason is because we haven't addressed some underlying pain.
The client is going to lose faith in that, that strategy working, and they may either just give up and think, well, we, we can't solve this problem, this, we just need to rehome our dog because we can't cope, or they may even go as far as euthanasia, depending on how significant and severe the problems are. They may also go and look at alternative methods for training, and this is a real concern in the current climate. There are unfortunately a lot of, what we call balanced trainers, on the internet who are advising clients to use some quite horrible aversive methods, which, if actually an animal is experiencing pain, that is even more of a welfare concern than than using those horrible aversive methods in a dog that's not experiencing pain.
So, We need to be really cautious about our clients having a really good understanding and making sure that they are able to implement our advice. And if we give them advice that that doesn't address the pain, they're not going to, to have success. So it's crucial that we're educating them, finding pain, understanding why that's affecting behaviour and why it matters to the behaviour modification programme, and then explaining all of that to our clients so that they understand fully the situation for their individual animal.
So, this is, just a slide to explain about classical conditioning. And what I normally use this image for in my behaviour lectures is actually to explain, how animals can learn positive associations between two things, and that makes the world a more Predictive, a predictive place for them so that they understand what's going on and what's likely to happen next. And this is happening all the time during normal daily life.
This isn't something that's an active training session. It's happening to all of us and every animal throughout the day, every day, all the time. So in this case, we've got the harness predicting a walk, and actually, Wilma really loves going for a walk.
And so for her, the harness it has associated with walking and is a nice thing, and the harness it is something nice. If, however, Wilma was experiencing pain on a walk, we could see this associative learning happening the the in a detrimental way. So she might learn the harness predicts a walk, and that causes her to feel some musculoskeletal pain.
So she then starts to avoid the harness instead of getting excited when it comes out. And I see this a lot with my patients that the, the, one of the alarm bells for me is if an owner says, You know, I ask them, what's your what's your dog's response to getting the lead and harness out. If that dog isn't getting excited about going for a walk, that worries me because they should be enjoying their walk.
It may be purely behavioural. It may be that they're just really anxious out and about. They might be scared of traffic or scared of what other things they're going to encounter, but it may be that they're experiencing pain and they're avoiding the, the, the queue that has told them some pain is going to happen.
Another situation where I often see this is with trying to move dogs off sofas, especially in the evenings. It seems to be higher risk in the evening, perhaps when they've been active all day and they're a bit more sore by bedtime, that an owner trying to move the dog off the sofa could predict pain, and this could cause the dog to then show defensive aggression. So when they see the owner approaching, they may start to grumble under their breath or snarl at them, and so on, because actually they don't want to move because they know it's going to hurt them.
So, when we're looking at solving behaviour problems, we want to do the opposite of this. We want to do what's called counter-conditioning. So, currently, if you've got an animal, who is reacting to a stimulus in a negative way, so we might have a dog who's worried about people, or worried about dogs, or scared of noises, and so on, And they are then feeling a negative emotion, they might be feeling fear or anxiety or frustration.
That leads them to show an undesirable behaviour. And the general theme of our management, our behaviour modification programme is to use management to avoid this line of, learning happening, because every time this happens, every time a dog barks at a dog to make it go away because it's scared of it. So it's showing that undesirable response that is being reinforced, and a really key factor is managing their ability to practise those behaviours so that we can teach them something new.
And then the in terms of teaching them something new, this is, there are obviously loads of different potential strategies, but the commonest thing that I'm using is counter-conditioning. So what I would be doing for a dog who is scared of sounds or other dogs, I would be trying to pair that scary thing with something really good, and that depends on the individual dog and the context of what's going to be appropriate. It may be toys, play, food, social interactions, something that makes the dog feel happy.
And I want to expose them. To this scary or frustrating situation, at a low enough intensity that they don't feel all these negative emotions, we want to keep it at a low intensity, so we might have a dog really far away, we might have a really quiet noise and so on, and we pair that with the really nice thing. So that those scary things start to actually predict pleasure.
And that's what this red arrow here is. So we need to do multiple pairings, and eventually the, the thing the dog used to be worried about will become a pleasurable thing, and they'll, you know, spot a, a person in the distance and think, oh, hooray, I'm gonna get some cheese now. I love seeing people.
So that is what we're trying to do. So what happens if we've got pain involved in this situation? We're going to struggle, this actually, let me just go back to this slide.
If we've got pain in here, we are going to struggle to do this training if we aren't managing the pain. And actually, this is an example with my puppy, who's now 5 months old. She was feeling car sick, when we first got her, and her harness, when we were taking her out for walks, started to predict her going in the car.
And this predicted sickness. So she then started to avoid the harness. So I'm just gonna show you this little video clip of her that we've done to try and help her to like the harness, just to demonstrate what this counter-conditioning is.
I don't need the sound on cos actually you can. See she's avoiding the harness. So what I'm doing is bringing the harness out onto view and you can see she's moved away.
So I actually brought that a bit too close to her, but I've thrown her a treat anyway, cos what I want her to do is learn that every time she sees the harness, she's gonna get a treat. And then I'm going to not put it closer to her this time so that she's starting to build that positive association, and you'll see by the end of this video. She's actually looking like she's expecting and anticipating a treat when the harness comes out.
You can see she's pricking her ears up and thinking, Oh, do I get a treat? That harness came out again. Ooh, where's my treat?
So this is what we're doing, we're altering her perception, so instead of feeling scared of it and it predicting car sickness, it's instead predicting yummy treats. So that's, that's the aim of what we're trying to do. However, if we do this and she's still feeling sick in the car and we still expose her to that discomfort, or we still expose a dog to any kind of pain they're experiencing, we're not going to be able to build this association up.
So this is a photo of her a few weeks ago when before we'd done any harness training with her when she was still feeling sick, and you can see she's leaning back. She really doesn't want to get in the car. This is her in the hall looking all apprehensive, not wanting to even go out the front door because the car predicts that sickness.
See, that training that we're trying to do to help her love her harness is going to be completely undone if we continue to take her in the car, and the harness continues to predict that horrible feeling of car sickness for her. And it's exactly the same with pain of any kind, that our, our training programme just simply won't be effective if we continue to, cause that problem for them. So this is why it's really crucial from a behaviour and learning point of view to be addressing and identifying any underlying pain.
So, I said at the beginning, I send a lot of cases back to to my referring vets, and this is absolutely no criticism of my referring vets. I will talk a bit more at the end about the difference between a normal clinic consultation with a vet compared to with a behaviourist. It is very difficult to spot these things in a normal 10 minute appointment.
So this is by no means a criticism of you guys, and this is why this presentation I'm aiming to just help you spot some really easy red flags that you can spot in a quick appointment. So out of my last 80 cases that I've seen, these are the proportions that I've had where pain has been involved, . And as I say, all of these have been referred on, on vet referral.
They've all had a relatively recent examination by a vet and a, and a consultation. So, these are ones that are being missed for one reason or another, and I end up sending them back. I would strongly recommend you look up this paper by, Daniel Mills and colleagues.
This is a free access paper, so you can, have a good read of that, and it just, again, explains exactly what I see in my case load that, a variation between 3 and 80% of cases are involving some kind of painful condition in in the people that they have in the in the case load they've assessed. And as with my caseload, it is normally musculoskeletal gastrointestinal or dermatological. I actually find that with a lot of the dermatological cases, when they're initially referred to me, I say, well, you need to sort the skin out first.
And actually, I then have an email from the owner saying, oh, my dog's actually totally fine. I don't need to see you anymore, because once the skin is sorted, they actually haven't needed a, a behaviour, consultation. That's, that's not necessarily the case for everybody because there will still be the risk that there are some learned behaviours going on.
But I think with skin conditions, they can perhaps be less chronic because owners are looking for help a lot more quickly. If there's a very obvious dermatological lesion or very obvious pruritus, they're perhaps seeking help more quickly than they might with a chronic musculoskeletal or gastrointestinal disorder. So it's really important, this all this italics is quoted from this paper, and, it says, really, clinicians ought to err on the side of caution, where there is a suspicion that a patient could be in pain, Carefully evaluate the patient's response to an analgesia, analgesia trial, even if specific lesion cannot be identified.
And that is going to be a a recurrent theme throughout my talk today. So how can we recognise medical involvement? I've, I've put in red the, the, the really key ones that you need to remember, .
But in general, I'm asking, does this fit with what I expect? Does this make sense in terms of learning and behaviour, or does it not make sense? Are there things we can't explain.
So for example, if Harvey and Beth have always loved playing together, and then suddenly Harvey decides, oh, I don't like playing with Beth anymore, and there's no obvious reason why, I'd be thinking, well, hmm, pain. Why would he change his mind about this thing that he's always done? .
So, we want to be looking in part about whether a behaviour change is sudden or gradual, but actually, I would link that into whether there are any obvious triggers or, or obvious, developmental period changes. So, for example, I do see a lot of dogs where a change may appear to be quite sudden, but it's in fact them just growing up. So social maturity can be an explanation for why their behaviour has changed relatively suddenly.
So for example, we might see a dog who is really submissive and appeasing with visitors or with other dogs, and as they reach adolescence, they actually start to bark and growl and lunge at those, things. And, and that is simply a behaviour change due to them growing up. So that might appear quite sudden, but in fact it's got an explanation for it.
. In terms of whether it's more gradual, we might see, for example, that a dog might start off by only reacting to some dogs, but over time, because of the learning that's going on, or because a a painful condition is becoming worse over time, that might generalise into something more significant and frequent. So again, we're, we're linking, whether it's sudden or gradual, with the entire picture of what else might be explaining it. Have we got any obvious clinical signs of a problem?
You know, I see a lot of colleagues who actually, my behaviourist colleagues, sorry, who aren't vets who are getting cases referred to them, where there are clear signs of a problem, but the vet has decided to refer the case anyway, because they don't think that that problem is linked to behaviour. So, You know, there may even be a diagnosis of, for example, hip dysplasia, but they say, well, actually it, that's nothing to do with the behaviour. I would totally disagree with that.
We always need to be thinking if there is an identified medical condition, that is very likely to be influencing behaviour in some way. We want to look at, normal maintenance behaviours. I would say that's often more common in older animals in terms of self-care, but the poor appetite thing can be a, a real significant factor for dogs who are experiencing pain.
I've actually, in the last two weeks, I've had 3 clients where poor appetite has definitely been an indication of musculoskeletal pain. And on the days when the dog is feeling fine, the appetite is fine. So, don't dismiss a poor appetite as just a dog being fussy.
It may well actually mean something. Is it out of the range of normal expected behaviour for that individual animal? So we'll see that more as we go through the case studies.
Would this animal normally show aggression in that context, or was this very out of the blue that he's just bitten a visitor who bent over to stroke him in his bed? We need to be thinking about what we would expect from that animal normally, and has that changed. We want to be making sure that we've got some triggers that are clearly identifiable, or if we've got a trigger, is it consistently causing that problem?
So we might see a dog who's reactive to other dogs when out walking. They're barking and lunging and growling at other dogs, but 9 out of 10 dogs they walk past, they don't care about, and Unless there's something very specific about the context, so for example, they might only react if a dog appears suddenly around a corner. They might only react to black Labradors because they had a bad experience with the black Labrador ones.
So there may be something that initially appears inconsistent, but on further questioning, it isn't. That if there is an inconsistency or a lack of triggers identified, one of the classic ones for this, I would say, is sound sensitivity. I see a lot of dogs referred to me for sound sensitivity, where actually there are a lot of loud sounds that they don't care about.
There are also sometimes on walks, they will just stop for no apparent reason, and the owner is assuming the dogs heard a sound because their dog has obviously got massively better hearing than them. And they, they assume it's sound related when actually the dog is stopping for another reason, and it's nearly always musculoskeletal pain. We want to look at the predictability, which I've just actually kind of touched on as I've been talking about the triggers, .
If a dog is purely experiencing a behaviour problem, I would expect that given all things equal, you put them in the same context, that behaviour should be predictable, and they should always respond in the same way, in the same context, provided everything else is the same. We also see a lot where they may have been referred to a behaviourist, but they're not responding as we expect them to. And then we would be going back to look, oh, well, why aren't they responding?
Provided they've had an appropriate diagnosis by an appropriately qualified and experienced behaviourist, which is not always the case, because unfortunately, this profession is not regulated. I A lot of clients where they've already seen 2 or 3 other people who've given them inappropriate advice. So we need to be checking that before assuming that the animal hasn't responded well.
Check that they've got a good plan in place, the appropriate diagnosis. The owner has been compliant about implementing that correct advice, and it's still not working. Then there'd be alarm bells, oh, let's look for a reason for this.
So let's just quickly talk about Barney. Barney is a patient who was . Referred to me because he had bitten one of the children in the household when he was a year old, and the reason he'd been seized was because she'd gone to hospital for some stitches.
It was a very minor wound, but she had gone to hospital. And so social services and the police were notified and the dog was seized. He had no previous behavioural concerns.
He was unfortunately in kennels for 3 months, and when he came home, he really quite struggled because he had been in social isolation for 3 months, not being walked, not being interacted with, not seeing the world. And this was a really, really sad case, because actually, poor Barney had quite significant hip dysplasia. The reason he had bitten the child was because she had jumped on his back when he was lying resting at the top of the stairs, and he didn't realise she was even there.
It was a really unfortunate incident, and actually the rest of the time he had a really beautiful relationship with this child, but he then became scared about her because every time he saw her, he was anticipating pain. So it would have been impossible in his case to rebuild that relationship with the daughter whilst he was still experiencing pain. It was absolutely crucial that we addressed that hip problem.
And really sad that this wasn't recognised before he was seized by the police because it could have been a very different long-term prognosis for, for the family and the dog. So that's just an example. Here's another example.
This is, Dave, who, he again, he was actually very lucky dog because his, his veterinary practise had a vet nurse who was doing some minor behaviour work despite not being appropriately qualified. And she had actually recommended euthanasia of this dog based on a bite incident where the female owner was hospitalised. So this is another thing where we need to be getting history.
The only reason the female owner was hospitalised was because she couldn't take antibiotic tablets and had to have IV antibiotics. She, it, the bite itself was not actually severe. It was because of the tetanus risk and her needing IV antibiotics, so.
When you, when an owner says they've been to hospital, please do ask for further questions about the severity of the incident. In Dave's case, he again had been a really, really lovely dog, and his behaviour changed. Well, I saw him when he was 2 years 9 months old, so he was already an adult dog.
This was totally out of character for him, and that is what should have sparked some alarm bells, . He had also started to be aggressive to various other people and dogs, which again was very out of character for him. So we should have immediately been thinking, gosh, there's, there's something going on with this dog.
Why is his personality suddenly so different? He was also very unpredictable, which was another big clue. So what alerted me in these two cases with Barney, again, it was both of these, it was out of character for what their normal temperament and behaviour would be.
It was a relatively sudden change. So actually with Barney, I forgot to say as well about walking, he started to jump up and bite at his owner's arms when they were out walking, which he'd never done before. He also started to react to traffic, which he hadn't really bothered with.
And interestingly, when we went out for a walk together, that got worse the longer he was out, so. I suspect that was because his pain was getting worse, and he was, I don't know, he, he was particularly reactive with vans, transit vans, and I don't know if because they were louder, that was causing him more discomfort when they were driving past him because of the noise. He'd also been reported as being defensive around grooming his hind legs.
The groomer had actually advised the owner to go to the vet. The owner had gone to the vet, but unfortunately the dog was not very conducive to being handled because he was painful. And rather than assuming that was pain, they had just assumed that the dog was scared of the vet, and they hadn't actually fully investigated that.
So again there were alarm bells here, and, and the owners had been alerted to there being a problem before the poor daughter was bitten. And if that had been recognised as an issue early on, we could have avoided that whole problem. We also actually can see from the video I showed you of him that his confirmation was pretty poor, and we could have been guessing that there was very likely to be something going on.
So in his case, he was diagnosed with hip dysplasia. We managed him with, a non-steroidal and gabapentin. Unfortunately, his behaviour did deteriorate whenever we tried to reduce that.
He, because of the kenneling and the, a lot of undesirable learning that had gone on before he was referred to me, we did end up having to do quite a lot of intensive behaviour work with him. Which actually I feel like if actually that alarm bell with the grooming had triggered some investigations early on, we may well have been able to avoid all of that happening in the first place, which is really sad. .
In terms of Dave, the little spaniel, so one of the really significant things for me was this snapping at people visiting, and the, the pub waiter. So his owners regularly took him to the pub from when he was a puppy, and he really liked them. It was a local pub.
They weren't going to lots of different unfamiliar pubs. It was a local pub to them that they regularly went to, and all the waiters knew him, and they used to come over and give him a biscuit, and he used to really enjoy them. So it was very out of character and unusual for him to snap at this waiter.
His behaviour was really unpredictable as well. He suddenly started to be a bit grumpy towards dogs, and he had really heavy contact with dogs. He was used as a working dog at a shoot, so he regularly was interacting with other dogs.
And there was an incident where he grumbled and snapped at a dog who came to him when he was resting after a shoot. Which again, he would never have normally done. So that's really clear alarm bells.
He was diagnosed with luxating patellia and he actually sadly already had some arthritis. And he again, similar to Barney, if, if we try to reduce his pain relief, his behaviour deteriorates again. The difference being in his case that it was entirely down to pain, and once his pain was managed, we actually didn't need to do any training with him at all, which was really nice, a really good outcome for him in terms of not having to do all that training, but really sad that such a young dog is requiring ongoing pain relief.
So how do we identify pain other than these behavioural red flags that we need to look for? In both Barney and, and Dave's cases, there were very obvious things on clinical examination which were identified after I'd been and, and said this isn't a neat behaviour thing. But very often there won't be any abnormalities found on clinical examination, and we often will do a pain relief trial.
I also work very closely with veterinary physiotherapists. Just beware of the variable qualifications. This is a bit like behaviour in that there are a lot of people who've just done quite a short course and then call themselves physiotherapists, and that's, not ideal when we're looking at complex cases.
So I always use an ACPAT registered physio because they've got human degree, a human degree level training, plus additional animal training. And, they are very thorough and know what they're doing. So, in terms of imaging, I'm, I'm in two minds sometimes about whether to image.
Sometimes it can be really helpful if we've identified pain through a pain relief trial and we're very suspicious of it on clinical examination or behavioural red flags, or the physio has perhaps recommended it. It can be very helpful in terms of long term management and deciding what we need to do. It may assist with our prognosis, and explaining to the owners what, what we need to do in the long term.
And it may also assist with client compliance if we find something, because if they then agree, oh yeah, gosh, this dog's got hip dysplasia, we know there's something painful going on, so we know to believe what our vet and our behaviourist are telling us and, and long-term management is going to be required. However, if nothing is found, which is unfortunately quite common, it can be detrimental to compliance because that could make an owner think, oh well, there's nothing on the X-ray, so he's not got pain, so why is he being so grumpy? You know, if that's actually a dog who's like this little chap here who's sometimes aggressive around resting places, if the owners think, well, he hasn't got any pain because his X-rays looked all right, he's just being stubborn and awkward, and they start treating him in a different way rather than respecting that actually he saw, that could be really detrimental to compliance, and it could escalate a problem quite significantly.
So, believe what the dog says is what I have put. And believe the dog, don't believe the ear. Age, don't believe the neurologist, don't believe the orthopaedic surgeon.
Believe the dog. If the dog is saying they are sore, like this guy and this guy, so this is actually my little dog, this fluffy guy. The reason he's lying like this with his back stretched out and his back end raised, is actually because he's got a sore back.
He has problems with his lower back, and he lies like this when he's overdone it, and it's a, it's a really clear signal to me that we need to do something with him. So, any signs like this of posture are really important to take into account. He's taking weight off the saw bit and making himself feel more comfortable.
And this is exactly the same with this little guy. So, the reason I've put two photos of him is because a lot of dogs may just lie like that as, as a relaxed thing. And you need to see that it is a consistent situation.
So, this dog is always taking the pressure off of one. Side and on to the other side, and he consistently sits like this all the time. He is capable of doing a square sit.
If you get a treat out and ask him to sit for a treat, he's perfectly capable of sitting square, but when he's choosing to rest, he's always taking the weight off one side, and that to me is a big alarm bell that he saw. So in terms of a pain relief trial, this is another thing that I think really requires some clarification because I see a lot of cases where a vet may have prescribed 2 or 4 weeks of a non-steroidal, and they say, oh, we've done a pain trial, but there's still this problem, so we're referring on to you. When I'm doing a pain relief trial, I do a minimum of 12 weeks, which I know sounds a really long time, and I do apologise to owners that it needs to be this long, but it is really, really needed.
In terms of the, the pathological, I can't speak, pathological changes that are going on in the nervous system. It can take that full 12 weeks for medication to make a difference. So I always use a combination of gabapentin and a non-steroidal, provided we can use a non-steroidal.
If there were any, gastrointestinal issues, then I might use something like paracetamol instead, but I, I would always try to use an NSAID. And if they're struggling with one, I would try switching to a different one to see if, if we can find one that suits them. Gabapentin, I tend to start at a 5 mg per kg twice a day for about 5 days, and then increase to 10 milligrammes per kilogramme twice a day.
Ideally, it ought to be every 8 hours, but I find with a lot of my clients, that's actually quite difficult for them to, to manage in terms of giving the medication. And most of my patients do show a benefit on doing it twice a day. And, so I don't worry too much about 3 times a day.
Remember that gabapentin must be weaned off gradually if after this 12 week period you can't just stop it suddenly. This image I've included, we've, I've got a video of this dog later, so hold this picture in your mind because this is a dog who is now on a pain relief trial and is able to go to sleep, and it is really lovely. So, whilst we're doing this pain relief trial, I always get owners to keep a diary, and if they can keep notes, it is so helpful because every day is different in terms of exercise, or whether there's been a visitor or whether they got upset by the postman coming, and so on.
So, I like them to keep a detailed diary if they are able to. But for compliance purposes, I always say to people, the only bit that's absolutely essential is a daily score at the end of the day. So at bedtime, score your dog out of 1010 is the worst your dog's ever been.
It's been a really difficult day and you've really struggled, and 0 is like this one where the dog's been asleep and all's been relaxing and easy. And over that 12 week period, it doesn't matter if there are daily fluctuations, because what we're looking for is that by week 12, or hopefully earlier than that, maybe by week 5 or 6, we're starting to see a reduction in those general scores. And that will tell us that, yeah, pain is there and, and we're doing something helpful with these medi these drugs.
So, let's talk about some cases. I will try to get through all of these. I, we'll see how we get on for time, cause we've already, I've already been talking for ages.
So, Victor, is a 5 year old male castrated cocker spaniel cross poodle. When he was a few months old, he got quite upset by some gunshots going off, literally just the other side of a hedge from where he was walking with his male owner. And since then, he's been really upset by sounds, and he hides between his owner's legs and becomes really, really clingy.
His owner has been trying to do counter-conditioning. He has had some success, but not as successful as he hoped it could be. And he's also started to recently generalise.
So this is a dog who goes off with his owners in their motorhome, and they travel to Europe, and he's done that ever since he was a puppy, . On a recent trip abroad, they were travelling on a bus with him, and he, they actually had to get off the bus because he was so traumatised about the hissing of the doors on the bus, and this was a new thing. He's never struggled with that sort of thing before.
It used to be quite specific to things that sounded like gunshots, so, bird scarers, gunshots, the bangs of fireworks, and so on, but he has now started to generalise and become much, much more sensitive to these sounds. He's also reacting to sounds really far in the distance when he's out walking, which he didn't used to do. So around a year before I saw him, he started to bark at some other dogs, but only when he's on his lead, and he becomes very aroused and has accidentally bitten his owner a few times during these incidents, and that was what actually prompted the referral, because the, the male owner had been bitten by him and, and that had really unnerved them.
He doesn't do it with every dog, with some dogs, he's totally fine. And he's still fine off lead with other dogs. So in terms of what makes us think there's something medical going on with this dog, the sound sensitivity absolutely makes sense.
He had a really scary incident when he was little and that totally makes sense that he became scared of sounds. What doesn't make sense is there's absolutely no trigger for his change in behaviour towards other dogs. He was 4 years old.
He's an adult dog. He's suddenly started behaving differently around other dogs, and it's an unpredictable thing. Sometimes he's fine and sometimes he isn't.
The counterconditioning with sounds, the owners had been doing this in a really sensible way, but they hadn't been as successful as you would expect them to be, given what they were doing. And he's also had this completely unexplained escalation in his sound sensitivity. There was no further aversive incident that made sense as to why this has recently, just in the last year or so, got worse.
So I'm immediately thinking this is not a straightforward behaviour thing. There, there must be something painful going on. So let's have a look at these videos.
This is him. He, he's heard a sound on this one. We don't actually need this.
You can see how he walks between the owner's legs. So this is something he's always done since that incident with the gunshots when he was only a few months old. So this is not new, but it has recently escalated and he's become more sensitive.
This is him seeing another dog in an alleyway where you would think if he's reactive to other dogs, that is a really difficult situation for a dog. He's in a narrow space. He's got a dog coming straight on towards him, and yet he's actually not reacted at all.
This is him really not coping with another interaction, so you can see he's. Really struggling with this, becoming extremely aroused. This is the kind of arousal level where he becomes at risk of accidentally biting the owners.
He hasn't deliberately turned round and directed bites at them. He's just, he's just, sorry, I just didn't mean to run that again. He's just caught them by mistake because he's barking so frantically when they've been trying to move him out the way he's like, caught them on the back of their legs and so on.
So, none of this makes sense in terms of just straightforward learning. And so I immediately sent him to my veterinary physiotherapist that I work with and also got some gait analysis videos. I just want you to look at this video.
You can see. He's very obviously lame in this. And what's really interesting is this was really coming and going.
I'll just play that again for you. You can see how lame he is, but actually, most of the time, he's totally fine. So he will be like that literally just for a few strides every now and then, and the rest of the time he looks OK.
But when I got his owners to do some gait analysis, gait analysis videos for me, there were some very obvious things that were there when I'm looking in slow motion. So, The physiotherapist found that he did have some discomfort around his lumbosacral spine and his right hip. And so based on her findings of abnormalities, we decided to X-ray him, and he has got hip dysplasia, and he's already got some, arthritic changes.
And what was really, useful of this referring vet was to say that although the changes were mild, she unfortunately did say that we wouldn't normally expect behaviour to be affected at this level, but she did identify that small changes can cause more pain to some dogs than others. Well, this dog was very, very clearly a dog that was experiencing pain, and I think that, although this perhaps only looks mild on the x-ray, I think from this video you can see it is very obviously not mild in terms of the severity of the lameness that is occurring intermittently. So what did we do for Victor?
We started him on a pain relief trial because there was absolutely no point in doing this training to counterdition him to sounds and other dogs if actually he was going to be continuing to experience pain. So he started pain relief straight away. We started some management for his reactions with dogs, but we did actually also start counterconditioning straight away.
And he's now amazingly, doing, doing brilliantly with other dogs. I only saw him, he's actually still within this 12 week pain relief trial. And he now only reacts to other dogs if there's a sudden unexpected appearance, so a dog comes around the corner suddenly or, or whatever, or if another dog is threatening him, in which case he's quite justified to defend himself.
So we are now actually weaning him off the pain relief because he's been working with my physiotherapist. And he's been doing lots of exercises and his owners are fully aware that he is going to have a long-term requirement to maintain that, those physio exercises and have intermittent pain relief when he flares up. But he's, he's shown an excellent response which he would not have shown had we not addressed the pain.
So what about Violet? Violet is a 4 year old female livestock guarding breed. She was imported when she was 5 months old, collected from the transporter's vehicle, which is a very common scenario with these foreign imports.
This was actually during the COVID pandemic, and so she also experienced some ongoing lockdown restrictions. She used to live with an older male dog, and he died when she was 2 1/2. So when she was 3, she started to bark at unfamiliar people.
She'd always been apprehensive of interacting, which didn't matter because actually the older male dog was very sociable, so everyone used to say hi to him and kind of ignore Violet and give her the space she needed. 6 months after he died, she started to actually bark at people. And at home, I'll just show you these videos.
This is her barking at other dogs. You can see she's, really reactive on her lead with other dogs. But actually, when she's off lead, she's, she's OK.
So that, that's her reacting to other dogs. And this is her reaction to someone arriving at the door, and one of the owners is chatting on the doorstep with the person, and you'll see her going up the stairs to get away. So she's, she's barking to try and make the person go away.
The person's not going, so she's showing avoidance. She's, she's taking herself away up to the top of the stairs where she feels safe, and then she continues to bark at them, saying, Please go away, get out of my house. I'm scared of you.
So, . In her case, what do we see that makes sense? So she very likely had inappropriate social and environmental experience as a, as a street puppy.
So a lot of this makes sense. It's, she also had a traumatic journey to the UK. She's had lockdown restrictions.
Her breed, she's a livestock guarding breed. She's been bred to be wary of the unfamiliar and to show territorial behaviour. The loss of the other dog in the household could have been significant, but actually she was already used to walking without him and so on, because he was very elderly and she'd been going out for walks without him for quite some time.
And the change in her behaviour happened 6 months after he had died. So what doesn't fit in terms of her behaviour? Why has she changed from avoidance to barking?
What, what's caused that to happen in a four year old dog? It doesn't make sense. And she's also started to stop on walks for no clear reason.
So, in terms of her behaviour modification plan, again, management to avoid practising those undesirable responses, so they're not being reinforced. Dangerous Dogs Act advice in terms of her barking and landing at people. I asked them to keep a diary.
We also really needed to get some weight off her. You could see in the video, she's quite overweight, so if she has got an orthopaedic problem, that really matters. But also, she wasn't that food motivated, so trying to do training was difficult.
They had tried giving her treats when, when visitors came and so on, but she just wasn't motivated enough by food. So getting her down to a trimmer weight was, in part because we needed to, to increase her motivation to work for food. Her gait analysis, I won't show you those because actually you could see her really struggling trying to get up the stairs in that previous video.
And we, we put her on an analgesia trial. She's massively improved on walks, she's much better. In visitors, she's still tricky.
So we are now, adding in some psychoactive medication so that we're better able to do some counterconditioning training with visitors and also in terms of settle training. So another thing that dogs who are in pain are going to struggle with is getting them to settle on a mat, and that's one of the things I want to do. She's never probably going to feel that safe with visitors.
So what we want to do is to teach her to just settle on her bed in another room so that she doesn't have to interact with them and be present with them if she doesn't want to be. But teaching a dog who's uncomfortable to lie on a mat for half an hour or an hour while some visitors there is going to be really difficult because she needs to be comfortable enough to be able to settle. So that's her.
I'm whizzing through these, cause I want to give you, several different behavioural presentations that, that show pain so that you can, get a good gist of how different they can all be. But they've all got those same underlying themes. So Ophelia is a cocker spaniel cross toy poodle.
She's 1.5. She has a very long list of behaviour problems, as you can see.
The main one that the owners were really struggling was this very actively seeking out and consuming non-food items, both at home and on walks. She'd been to the vet multiple times to have a vomiting injection because of eating things she shouldn't. But she's also got loads of other high arousal and annoying attention-seeking behaviours, which she's a very difficult dog to live with.
So behaviour that makes sense for her, she's a cocker spaniel. She is going to have difficulty settling. She's going to be highly aroused.
She's gonna be really excited out on walks. I see a lot of cocker spaniels that steal and resource guard. This is mainly because they just are so motivated to pick things up, and then very often their owners behave in an inappropriate way, and they trigger resource guarding because of getting into confrontation with their dog.
And the key with those is actually to teach them a retrieval really early on. Every cocker spaniel puppy that comes for a first vaccination should be advised to the owners should be advised to teach them a retrieval and a, and a drop cue really early on and not get into confrontation. So all of those behavioural things actually just make sense with her being a cocker spaniel, as does the attention seeking stuff in terms of her just needing a really high degree of physical and mental enrichment.
These owners had also unfortunately reinforced behaviours a lot which they hadn't realised. They thought they were doing the right thing. They thought they were ignoring her and so on, but actually whilst I was there, their idea of ignoring was actually not ignoring, and they had reinforced things a lot.
So there's loads that make sense. They'd also seen previous behaviourists and dog trainers and so on, and either been given inappropriate advice or they hadn't implemented it appropriately. So there was a lot that made sense, and she is going to be an ongoing behaviour case that requires a lot of support.
However, there were things that didn't make sense for her. The degree of motivation to actively seek and consume non-food items didn't make sense to me. So a lot of animals, a lot of dogs will consume non-food items as part of a resource guarding presentation.
If they don't want to show defensive aggressive behaviour, they will often swallow an item in order to maintain possession of it. However, that didn't fit with the history that we were seeing with these clients, and she was just so, so motivated to seek stuff out that that also, the severity of that didn't make sense in terms of behaviour. The inconsistency in settling, so sometimes she would actually settle fine and sometimes she wouldn't.
All of her problem behaviours seemed to have some degree of inconsistency with good days and bad days. So I was suspicious that although there was a lot of, definitely purely behavioural stuff going on in this case, there was probably some pain as well. And what we were thinking about in this case was, could it be hormonal?
The owner was worried that whether she'd been spayed at the right time, whether spaying had played a role. In fact, it hadn't, that all looked fine. Gastrointestinal disease, she had had some problems early on with some gastrointestinal problems, but that was not ongoing, but that could have had some historic learning influence.
. She was on a very high protein diet, so her normal diet was not that high protein, but the, the owners were using loads of very high protein chews and treats in order to, manage the situation. So we did reduce her protein, level to, to see if, if she responded with that. Muzzling was an absolutely essential because on walks, the problem was the owners were so distressed about the idea of her eating something and having to take her to the vet's to be sick again, that they were unfortunately causing a problem in terms of making items seem even more valuable to the dog.
So it was crucial that we muzzled her so the owners could actually effectively ignore that behaviour because the dog couldn't get hold of anything. We also did a lot of training exercises. This is all still ongoing.
I'm actually seeing her for a follow-up next week. So she, lots of training exercises, which she is perfectly capable of responding to if the owners have appropriate guidance about how to, to do that. So, she historically used to, they, they had to restrict her from the room when they were doing washing because she would just dive in and steal socks and all sorts from the washing machine or from the laundry basket.
She has now learned to wait on her bed whilst they're doing the washing machine, which is awesome. I did refer her back for a musculoskeletal assessment by the referring vet because on gait analysis videos, I was very suspicious there was something wrong with her hind legs. Unfortunately, that wasn't done, but she was, oops, she was referred to the physiotherapist, based on, on my findings, and this is what has been found so far, but she's, she's going to be assessed again in a couple of weeks' time.
So she, she does have some clear problems, and we are about to start a pain relief trial with her. It's unclear at this stage whether she may also need some psychoactive medication, because we need to see what the pain is doing before we can decide whether she might need some additional medication. And in this case, owner education was a really, really important element to, to helping Ophelia.
So. Let's just quickly look at Peter cos we're running out of time. He is a 3 year old miniature poodle course golden retriever.
Aggressive owners, aggressive responses to everybody, basically who handles him in an unpredictable fashion. And this is what his owner said, This is an extract from my report, based on what the owner had told me, that he varies in, how likely he is to respond. You go through periods of around 2 weeks every 4 to 5 weeks, where they have to be more careful, and he seems a bit subdued and taking himself away.
So I asked them to send me various videos. I did do, I did a video consultation for these guys initially, but I have subsequently done home visits. As you can see in this video.
They're just putting the harness on, but he is not fully weight bearing on his left hind in this video, and he's also slipping on the slippery floor. So that rang some alarm bells, as well as this unpredictability and inconsistency. So, I, again, I asked for gait analysis videos.
I, we did a pain trial. The physiotherapist actually recommended that we do imaging because of the findings that she was seeing. Can Considerable, interestingly, on that video, it was his left hind that he wasn't fully weight bearing, but what the physio found was actually more on his right hind.
And on my gait analysis videos, I thought it was both. So he went for a CT scan, and this is what was found, compression of the caudal quier and thickening of the right left L7 spinal nerve. .
Unfortunately, we've had some significant compliance issues in this case because the neurologist has, very unhelpfully said that, the aggressive behaviour is probably nothing to do with these really significant CT scan findings. So this is where I say again, believe the dog, but also do believe the imaging, and perhaps take with a pinch of salt what the referral neurologist. Saying, because we need to remember that the vast majority of, of vets don't have behavioural training and don't understand how pain can influence behaviour.
So, please listen to the dog, and please listen to your behaviourist that you're working with. This is a dog who I am going back to see for a follow-up, even though I've told them that we really, really need to address the pain, and me going back is just probably going to result in me telling them that again. But they're insistent that I, I go back for a followup to address this primary behaviour problem.
So we shall see what happens. Right, this is the golden retriever who I showed you fast asleep whilst on pain, and you can see this is her before her pain trial. She was really, really hard work to live with.
So she was 12 months old when she was referred to me, and her behaviour problems started to become significant about 4 months before I saw her. She was really struggling to settle, pacing around, mouthing at the owners, suddenly jumping across the room at them. Like sometimes the the female owner might just be standing cooking dinner and the dog would fly across the room and grab her and bite her hard enough to make bruises, mostly grabbing clothing, but also grabbing arms.
She also was biting at the lead and arms out on walks, . But only ever if she'd been out walking for a while. So when she first went for a walk, she was fine, but after she'd been out for sort of 1520 minutes or so, she would start to bite at Leeds and arms.
She also was reluctant to re-enter the house by the front or back doors. She was doing a lot of chewing. They'd had to lift all the, rugs up from the floor.
They'd had to not ever give her a bed to, to lie on because she would chew it and consume it. She was also a bit unsettled by novelty, and the owner was struggling with meal feeding because they were using so many treats to to try and train her. She was also unable to jump into the car, and the owner was having to pick her up to put her in the car, but she was, objecting to this and, and mouthing and biting at them.
So in this one's case, we've got behaviour that makes sense. Young dog with high energy, she also was chewing, she was, you know, she, the chewing started when she was an adolescent and, and, and getting her adult teeth and needing to build up jaw strength. There was a lot of accidental reinforcement by the owners.
The meal feeding was, again, a lot of that was related to, to owner behaviour, rather than to the dog. The being unsettled by novelty was explained, but she had been hospitalised as a puppy and did miss out on quite a lot of socialisation and habituation opportunities. The stuff that didn't make sense was, why if the biting at the, the arms and lead, why is she only doing that after she's been out on a walk for a while?
That suggests something's changing while she's out, i.e., she was getting more painful.
There was no clear trigger for her suddenly jumping across the room and biting at the owner. No clear trigger for her change in behaviour around doorways. She used to quite happily come in and out.
They had very slippery floors, and actually it turned out that she didn't want to come back in because of slipping on the floor. She was consuming non-food items. She couldn't jump into the car, you know, she should be capable of that.
And she didn't like being picked up because it was uncomfortable. So again, she went for a CT scan, diagnosed with hip dysplasia, I'm rushing through now, because the, one of the things I really wanted to say with her, which also was relevant to Victor, is that the pain was massively aggravated after having a GA and being manipulated for, The imaging and in Petra's case, it was so bad that I actually, I had a video call with the owner for about an hour where she was just in absolute tears because things had got so much worse after the CT scan that she was really, really struggling. So she was on a lot of pain relief, and we also started her on fluoxetine because she was so anxious because of the pain, .
So, actually, now, a year and a half later, she's lost lots of weight, she can go to training classes, and she's, the dog walker now actually enjoys walking her rather than it being really hard work. Everything is looking good, but she is a dog that's gonna require long-term management. So very quickly, painful and fearful patients.
There are a lot of really good webinars out there about dealing with fearful patients. I strongly recommend you look at the resources related to that. The Dogs Trust have some really good resources, and.
In terms of pain, really, my, my key thing was to, to just say be really cautious of exacerbating underlying pain when you're handling because that's the, the main thing we need to be really careful of with these patients. If they're too fearful to examine when they're awake, we are likely to need to sedate them, and that is at risk of making pain worse. So just be aware of that.
And very speedy bit through working with non-veterinary behaviourists. So this, this is where I wanted to just highlight that I, this is not in any way a criticism of vets in general practise in terms of identifying pain, because in a veterinary clinic appointment, we've got about 10 or 15 minutes, and we're seeing the dog in what's very often a stressful environment for them. So they may already be tense and, or they may be inhibited, and we may not be able to do a thorough clinical examination because of that.
We also may not have time to get that really thorough history. Compared to what I do and what a, a non-veterinary animal behaviourist does, is it usually a two hour home visit. I'm looking at video footage.
I've got a really detailed questionnaire. I'm observing the animal in more than one environment. So there's, there's a lot more information to, to gather because I've got so much more time with these people.
In terms of appropriate referral, please, please make sure you are referring appropriately to people who know what they're doing, because this is still unregulated. The RCVS is currently in discussions with the profession and with themselves about what to do, and there may, I hope, be a change in the near future. But for now, make sure you are checking the accreditation of the people you are referring to, and also check what methods they are using in terms of whether they are reward-based or whether they are using any aversive methods.
If a behaviourist comes back to you and says, actually, this behaviour presentation doesn't fit, please trust them and believe them and work with them. I have a lot of colleagues who find it very frustrating that they go back to vets and vets say, no, I didn't find anything on clinical examination. They refuse to do pain relief trials.
They refuse to believe that the behaviourist is seeing something. So please, please respect your clinical animal behaviourist if they come back to you. And it's really important we work together as, as a team for these patients.
The, Fellowship of Animal behaviour clinicians has some really brilliant resources. I would strongly recommend you look on there for, there's a they've got a section of veterinary resources. This is just a summary of the difference between what a, a clinical animal behaviourist versus a veterinary behaviourist can help with.
. And in terms of psychoactive medication, we haven't got time to discuss that at length, but the key point I wanted to make here is that we must rule out pain before deciding to put dogs on psychoactive medication. One very sad case that I saw about a year ago was a dog who'd been on fluoxetine for 3 years for a supposed sound phobia and anxiety. And actually the poor dog had elbow dysplasia and hip dysplasia, which was not being properly managed.
So the fluoxetine had done absolutely nothing and the dog had been in pain for a very long time. So we need to be really cautious, to, to, to ensure that we've, we've addressed any underlying medical factors. If you have a clinical animal behaviourist who, and a general practise vet who are unable to make decisions about medication, there are veterinary behaviours such as myself and others who will offer remote services to assist in that, in.
In terms of just a support system for making decisions about whether medical conditions may be involved, whether there are further investigations that would be a good idea, and advising on psychoactive medication as well. There's a list of, of people who offer that service on the FAC website. So, a super quick summary, cos I've gone over time like I always do, always look for pain.
A, a brief behavioural history can give those clues. Look for unpredictability, look for whether it's expected for that individual dog, look for the triggers, look for the explanations, look for whether they've already seen an appropriately qualified professional, but they're not responding as they ought to be. Work really effectively with your clinical animal behaviourist.
It, we are part of a team and we really have to work together with these patients. And if you're unsure, do involve a veterinary behaviourist. And most importantly, believe what the dog is telling you.
If you don't find anything on clinical examination or imaging, but the dog is telling you from its behaviour that there's something going on, please believe them. Thank you. I hope you have found that helpful, sorry for running over time.
I, I, I really hope you've enjoyed the presentation and it, it's given you some useful things for your day to day life. Bye.