Top 5 Signs that May Indicate Chronic Pain

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A pain score is considered the fourth vital sign of a patient evaluation after temperature, pulse, and respiration rate,1 and pain should be assessed at each veterinary visit. Behavior observations are the most accurate method of pain evaluation,1 but because veterinary patients are nonverbal and may not behave the same way in the practice as they do at home,2 the veterinary team will need to rely on the client’s history and focus questions on behavior changes to recognize and assess pain.

Many clients do not realize their pet’s behavior changes are linked to pain. (See Common Painful Conditions.) Following are the top 5 signs that may indicate a patient is suffering from chronic pain. 

Common Painful Conditions3

  • Cancer pain, especially osteosarcoma or other bone metastases
  • Chronic periodontal disease
  • Degenerative joint disease
  • Feline lymphocytic plasmacytic stomatitis  
  • Idiopathic feline lower urinary tract disease
  • Inflammatory bowel disease
  • Intervertebral disk disease
  • Otitis externa
  • Pancreatitis

1 Decreased Activity & Exercise Intolerance 

Clients may notice that their dog does not want to go on long walks or goes with less enthusiasm than he or she used to, or that their dog or cat is lying around more than usual. 

 Clients often will misinterpret this slowing down as a normal aging process, so it is important to let them know these changes could be caused by a medical condition that warrants a practice visit. Ask these kinds of questions: 

  • Has your pet been more or less active lately?
  • Are the distance, speed, and number of walks the same as usual?

2 Changes in Daily Living Activities

Ask clients if they have noticed any changes in their pet’s routine activities. The important point is whether the pet has stopped doing anything he or she used to do. Ask about these activities: 

  • Has the amount of grooming decreased? (particularly for cats)
  • Is your pet no longer jumping into the car or onto furniture?
  • Is your pet reluctant or refusing to go up and down stairs?
  • Has getting up become more challenging for your pet?
  • Does your pet no longer routinely stretch after getting up? 
  • Is your pet interacting less with you and/or other pets? 

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3 Inappropriate Elimination

Dogs and cats eliminate inappropriately for many reasons. Discerning behavior problems from medical conditions is important because if a behavioral issue is not treated properly, the owner’s frustration may cause him or her to choose early euthanasia for the pet.

  • Dogs and cats may defecate and/or urinate in the house because they hurt too much to walk to their favorite elimination spot, to squeeze through the dog or cat door, or to navigate the steps or entrance.
  • Dogs may defecate as they walk because they have painful hind-end conditions that do not allow them to posture normally.
  • Cats may start eliminating outside the litter box because they have a painful orthopedic condition that makes climbing into the litter box too difficult.

Ask these kinds of questions:

  • Does your pet posture normally to urinate and defecate?
  • Have your pet’s elimination habits changed? Is your cat eliminating outside the litter box? or Is your dog urinating and/or defecating inappropriately? 

4 Lameness 

Clients may note their pet is:

  • Walking with a different gait 
  • Favoring one limb (ie, lifting one or several limbs)
  • Unable to stand in one place for a long time
  • Appearing to walk on eggs
  • Shifting weight to one side or from front to back when standing

Any of these changes could be caused by joint pain. Ask the client:

  • Have you noticed your pet favoring or lifting one or several limbs while sitting or standing?
  • Did you notice a gait change such as skipping or hopping?
  • Have you noticed a change in posture such as stiffness or hunching over when your pet is standing?

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5 Aggression 

Some pets in pain may try to protect a painful body part by growling, snapping at, or biting other pets or humans when they are approached or petted, another sign that clients may mistake for a behavior issue. Questioning should be along these lines:

  • Is your pet growling, snapping, or biting when someone approaches a certain body region?
  • Is your pet unusually aggressive when playing with other pets?


Detecting chronic pain in dogs and cats is challenging, but asking the client questions with the right focus can help the veterinary team recognize areas of concern. Clients will not necessarily associate their pet’s behavior problems with chronic pain; therefore, because the veterinary team is qualified to recognize and assess patient pain, they need to educate clients to note the signs and contact the practice. (See Pain Scales.) Pain treatment will enhance patient quality of life and strengthen the veterinarian–client–patient relationship.  

Pain Scales

Several pain scales developed for dogs have been validated,4,5 but scales for cats, though available, have not yet been validated. Using pain scales decreases any veterinarian subjectivity and bias when judging treatment outcome, and using the same scale each time is recommended for consistency and familiarity with its limitations. Feline and canine pain scales are not interchangeable because they are based on the species’ inherent behaviors. 

The client should complete the questionnaires at the start of therapy and at intervals during treatment according to the veterinarian’s judgment.

Here are some of the pain scales available. 



1Educating clients that their pet’s behavior problems may be related to chronic pain is paramount because clients may consider it bad behavior, become frustrated, and even consider euthanasia.

2Be sure veterinary team members know that asking questions that focus on the patient’s behavior changes can help assess the pain that could be causing these changes.

References and author information Show
  1. Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. J Feline Med Surg. 2015;17(3):251-272.
  2. Epstein ME. Assessing chronic pain in dogs. Today’s Veterinary Practice. 2013;3(5):32-35.
  3. Epstein ME. Managing chronic pain in dogs and cats, part 3: management of nonosteoarthritic conditions. Today’s Veterinary Practice. 2014;4(6):40-44.
  4. Hielm-Björkman AK, Rita H, Tulamo RM. Psychometric testing of the Helsinki Chronic Pain Index by completion of a questionnaire in Finnish by owners of dogs with chronic signs of pain caused by osteoarthritis. Am J Vet Res. 2009;70(6):727-734.
  5. Merola I, Mills DS. Behavioural signs of pain in cats: an expert consensus. PLoS One. 2016;11(2):e0150040.

Caroline Goulard

DVM, CCRT, CVA, CVPP Paws on the Go, Laguna Woods, CA

Caroline Goulard, DVM, CCRT, CVA, CVPP, opened Paws on the Go, a practice dedicated to physical rehabilitation, acupuncture, and noninvasive pain management for small animals, in 2013. An athlete, she has suffered from several sports injuries and benefited from physical therapy, acupuncture, osteopathy, and chiropractic and massage therapy, which inspired her to bring the same therapies to pets. She earned her veterinary degree from Montreal University in Canada in 1988 and was certified in veterinary acupuncture in 2006, canine rehabilitation therapy in 2010, and as a veterinary pain practitioner in 2012. 

FUN FACT: In 2008, Caroline participated in the pro division at the World 24 Hours of Adrenalin, a solo 24-hour mountain bike race. These days, she likes spending time with her turtle, 4 cats, 1 dog, and her husband, and working in her large fruit and herb garden.

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