Pain in plain sight: Recognizing chronic pain in the exam room

Cats and dogs experience pain in many forms, from the obvious discomfort of acute injuries or surgery to the persistent, more challenging symptoms to identify of chronic conditions such as osteoarthritis. Pain may also result from injury, inflammation, or musculoskeletal disease. As veterinary professionals, it is our responsibility to help caregivers and clinical teams recognize these symptoms, differentiate normal behavior from pain-driven behaviors, and implement timely interventions that improve welfare, mobility, and quality of life.

Chronic pain affects more than comfort. It can interfere with eating, elimination, drinking, grooming, mobility, and social interactions, disrupt gastrointestinal function, delay wound healing, increase infection risk, elevate cardiovascular parameters, and contribute to anxiety, fear, fatigue, or depression. Unrecognized pain can also strain the human-animal bond and increase stress and compassion fatigue among veterinary teams.

Exam considerations

Observation begins before handling. How a patient enters the room, moves, or rises from a resting position can reveal compensatory movements, asymmetry, or reluctance to jump, climb, or turn. A critical thinking approach to handling, including utilizing feline-friendly, fear-fear, and low stress handling techniques is essential because fear, stress, and adrenaline can temporarily suppress an animal’s perception of pain, masking discomfort. For example, a dog that was limping at home may not exhibit that symptom once in the exam room. This highlights the importance of observing the patient’s baseline behavior in the home environment and gathering caregiver input to accurately identify chronic pain.

Fear Free techniques such as using a touch gradient allow clinicians to identify sensitive areas, tailor handling, and enhance diagnostic accuracy. Gentle palpation of joints, muscles, and the spine, combined with careful evaluation of range of motion, can uncover discomfort that might be missed in a cursory exam. Pain scoring tools, including the Glasgow CMPS, Feline Grimace Scale, and Colorado State Pain Scales, provide consistency and structure.

A touch gradient is a term used to describe how to touch our canine and feline patients to minimize fear and stress during veterinary procedures. It emphasizes continuous hands-on contact, acclimating to touch intensity, identifying sensitive areas, and considering individual patient needs. Handling begins with the least sensitive areas and progresses to more sensitive regions. For example, a patient with a severely inflamed ear would have that area examined last. This approach minimizes stress, prevents fear escalation, and allows observation of body language changes that indicate discomfort before procedures like injections or blood draws.¹

Stress complicates pain recognition. Anxiety or prior negative experiences may suppress pain behaviors, making pain symptoms harder to detect. Even with low-stress techniques, many patients arrive anxious, making continuous observation critical. Behavior remains the most reliable indicator of pain.² Small shifts in posture, movement, facial expression, and coat condition frequently reveal discomfort and provide valuable diagnostic information.

Behavior speaks louder than vitals

The 2022 AAHA/AAFP (now known as the Feline Veterinary Medical Association) Pain Management Guidelines emphasize that behavior is the most reliable indicator of pain.²

Common signs of chronic pain noted during exams:

• Altered posture: hunched, “statue-like,” or stiff stance
• Reluctance to rise, sit, lie down, jump, or climb
• Stiff, deliberate, or shortened movements
• Tail changes: tucked, awkward, or low carriage
• Facial tension or grimacing: muzzle tension, squinted eyes, whiskers pulled back or straight, ears rotated back, lowered head
• Restlessness, pacing, or panting at rest
• Avoidance or defensive behaviors when touched and/or approached
• Increased or localized muscle tension; skin rippling or twitching
• Head turns, displacement behaviors, or shifting weight
• Escalating fear or anxiety: lip licking, whale eye, dilated pupils, freezing
• Vocalizations: growling, hissing, yelping, meowing
• Sudden changes in demeanor when specific areas are palpated
• Odd coat patterns: rippling, clumping, directional changes, mats, rough patches, overgrooming
• Can exhibit aggressive behavior, both defensive and offensive, with handling

Caregiver input: The missing piece

Caregiver observations are invaluable, as many chronic pain signs are most apparent at home. Caregivers can identify baselines and detect changes from baseline in daily activities, such as jumping, grooming, greeting, or play. Open-ended questions encourage detailed feedback. Below are examples of open-ended questions.

Maintenance of normal behaviors

“Walk me through a typical day for your pet, what activities do they still enjoy?”

“How is your pet interacting with family members, other pets, and their environment?”

Loss of normal behaviors

“What changes have you noticed in how your pet moves, jumps, climbs, or rests?”

“Are there activities your pet used to do that they’ve stopped, if so, which ones?”

“What changes have you noticed in eating, drinking, or grooming routines?”

Development of new behaviors

“What new or unusual behaviors have you noticed?”

“When was the last time your pet increased anxiety, irritability, or avoidance?”

“How are the interactions between them and the other animals and people in the home?”

“What behaviors, if any, concern you or cause you stress?”

Video recordings of pets at home can provide valuable insight into gait, movement, and behavior that may be masked in clinic visits.

Helping pets adapt at home

Chronic pain management is more than medication. Environmental modifications can reduce strain and improve quality of life, such as:

• Low-sided litter boxes or multiple locations for cats
• Ramps, stairs, or non-slip surfaces
• Elevated food and water bowls
• Orthopedic bedding
• Nightlights for older pets with vision or mobility challenges
• Framing these adaptations as “quality of life tools” helps caregivers see them as proactive support.

Educating caregivers

Caregiver education improves chronic pain detection and promotes early intervention. Effective strategies include:

• Sharing videos of pets walking, eliminating, and engaging in favorite activities.
• Providing handouts, blogs, or social media posts highlighting signs. ^3,4
• Demonstrating cooperative care medication techniques. ^3,4
• Setting expectations for reassessment and adjustment of multimodal pain plans
• Discussing benefits and side effects of medications.

Reassessment: A continuous process

Chronic pain management is ongoing:

• Establish a baseline for mobility, behavior, and daily function as well as a pain score
• Use ongoing reassessment through video, diaries, pain scores, and caregiver reports
• Employ multimodal interventions (pharmacologic therapy, rehab, acupuncture, environmental support)
• Regularly adjust care plans as conditions progress

Chronic pain is not subtle once we educate ourselves and foster caregiver understanding and engagement. Animals constantly communicate discomfort through behavior and body language; we simply need to observe and interpret it. By assessing body language throughout the exam and actively involving caregivers in recognizing and managing pain, veterinary professionals can uncover discomfort that might otherwise remain hidden. This collaborative approach not only enables earlier recognition and more effective pain management but also promotes caregiver compliance and ultimately improves the quality of life for the animals entrusted to our care.

References

1. Fear Free. Fear Free Pets. Fear Free Pets. https://fearfreepets.com
2. Gruen, M. E., Hellyer, P. W., & Rodan, I. (2022). 2022 AAHA Pain Management Guidelines for Dogs and Cats. Journal of the American Animal Hospital Association, 58(2), 55–76. https://doi.org/10.5326/JAAHA-MS-7292
3. Kucera, T. Chirrups and Chatter. Accessed September 24, 2025. https://chirrupsandchatter.com
4. Kucera, T. [@chirrupsandchatter]. Instagram profile. Accessed September 24, 2025. https://www.instagram.com/chirrupsandchatter/