Behavioural treatment plan for young golden retriever with chronic pain

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Estimated reading time: 7 minutes

Subedited by Dr Phil Tucak

Chronic musculoskeletal pain is much more prevalent than we realise. In referral behaviour practice, up to approximately 70-85% of the patients we see are in some form of discomfort requiring treatment.4 Pain is one of the major differentials of problems such as anti-social behaviour, excessive barking and owner-directed aggression.5

Beliefs such as pain being ‘an effective immobiliser’ are harmful and outdated. Pain can become maladaptive and is experienced more intensely with anxiety.2,3 Use of measures such as the Glasgow Pain Scale will increase the awareness of pain, lead to effective treatment and improve patient quality of life.

Mae is a two-year-six-month-old, 27kg female-spayed golden retriever with a streak of mischief. Mae presented to the referral behaviour practice for barking, coprophagia, humping her brother Murphy, and clingy behaviour towards her guardian. In her history it was also noted that Mae would ‘bunny hop’ when running, was slow to get on furniture and always required assistance getting into the car. Fluoxetine (1.1 mg/kg) had already been prescribed by her regular veterinarian and minimal changes noted. It was confirmed that Mae had been getting her Fluoxetine as prescribed, for a period longer than 12 weeks. 

During the initial behavioural home consult, it was noted that Mae settled quickly on her bed but would frequently adjust and reposition. On further examination, she had a short, stiff gait in her hind limbs with significantly reduced range of motion and pain on extension of the hip joints bilaterally. Mae’s body condition was 7/9, with a muscle condition score of 5/9. Palpation of the paralumbar and sacral region caused Mae to flinch, pull away, spin around and roll over, consistent with pain response.

Based on the examination and her history of barking, a presumptive diagnosis of chronic pain was made. Referral for assessment of hip dysplasia was indicated and accepted by Mae’s guardians, as successful treatment of any chronic pain would be necessary to help rule in or out differentials and potential comorbidities such as generalised anxiety, situational anxiety, separation related distress and noise sensitivity/hyperacusis.

Mae was weaned off the Fluoxetine, and commenced Amitriptyline (Endep, tapered up to 1.8 mg/kg, twice daily), preferred for the potential improvement in maladaptive nociceptor activity through immunomodulation and neurotrophic effect.6 A multi-modal analgesia plan (Gabapentin 11.1 mg/kg twice daily, Paracetamol 13.88 mg/kg twice daily and Meloxicam 0.1 mg/kg once daily) was also implemented, and Mae returned to her regular vet for radiographs under sedation. It was also recommended that Mae’s family discuss with their regular veterinarian a course of Cartrophen, healthy weight loss and using Antinol or other joint supplements as a multi-modal approach to managing joint pain.2

chronic musculoskeletal pain in a dog

Once Mae’s radiographs had been obtained, she was referred to a speciality centre for hip dysplasia assessment, and the Meloxicam/Paracetamol treatment had been ceased. Mae remained on Amitriptyline BID, Gabapentin BID, Zylkene SID and Antinol SID for her assessment—Mae’s condition had improved with treatment, although the changes were gradual and difficult to appreciate, and Mae’s guardian was not able to appreciate these changes until later in Mae’s journey. 

Her examination was reported to have no gait or postural abnormalities, good range of motion of the hips with nil pain described. She did have mild bilateral muscle atrophy of the thigh compared to her forelimbs. It was noted that Mae had obvious radiographic changes consistent with hip dysplasia. The specialist recommended tapering and withdrawing all medication and maintaining Mae on a therapeutic joint diet. Mae’s family then moved interstate.

After moving interstate and reassessing, Mae’s guardians noticed a deterioration in her behaviour as the medications were withdrawn. Mae was unsettled, unable to remain in one place overnight, and displayed inconsistent sleep patterns. Her barking frequency, intensity and duration increased. Mae would go from rest (even in the middle of the night) to suddenly barking at an 8/10 intensity. If Murphy started barking, Mae would hump him with huffing lips, whale eye, tense facial features etc.

Mae’s intense attachment to her family returned, becoming ‘velcro’, not coping being left alone, or separated from Murphy. If Murphy had to go to the vet or was separated by a door, Mae would become very distressed—pacing, panting, staring out the window and whining until Murphy returned. Examination by the author was consistent with anxiety and pain with minimal body movement for arousal levels initially, short gait in the hindlimbs, pain on palpation and manipulation of the hip with reduced range of motion. Mae’s body condition score and muscle condition score were 5/9. A diagnosis of chronic pain, generalised anxiety and separation anxiety was made. 

Mae’s guardians requested she return to treatment with Amitriptyline and multimodal analgesia. Mae began Cartrophen and Glucosamine (Synovan) 3.3 mg/kg subcutaneously once weekly for 4 weeks, Gabapentin 11.1 mg/kg twice daily and Amitriptyline (Endep) 0.5 mg/kg twice daily. 

A follow-up assessment was conducted six weeks later, and it was noted by the guardian that there had been approximately 30% improvement in the frequency, intensity and duration of problematic behaviours. Amitriptyline was increased to 0.9 mg/kg BID, Grapiprant (Galliprant) 2 mg/kg once daily and Bedinvetmab (Beransa) 20mg subcutaneously once monthly was commenced. Physiotherapy was also recommended and sought out. 

A further assessment after another six weeks showed Mae’s sleep quality improved significantly, she could rise quicker, she was more settled in herself, and she had stopped having episodes of ‘barking out of nowhere’. Her physical examination demonstrated markedly reduced pain response to palpation and improved range of movement.

Mae has demonstrated marked improvement in her behaviour when treated with a combination of anxiolytics as well as multimodal analgesic therapies. Adequate analgesia is essential for successful treatment of mental health conditions such as generalised anxiety and separation anxiety.1,7


References

1. Brioschi, F. A., Di Cesare, F., Gioeni, D., Rabbogliatti, V., Ferrari, F., D’urso, E. S., Amari, M., & Ravasio, G. (2020). Oral transmucosal cannabidiol oil formulation as part of a multimodal analgesic regimen: Effects on pain relief and quality of life improvement in dogs affected by spontaneous osteoarthritis. Animals, 10(9), 1–14. https://doi.org/10.3390/ani10091505
2. Burley, C. V., Casey, A.-N., Jones, M. D., Wright, K. E., & Parmenter, B. J. (2023). Nonpharmacological approaches for pain and symptoms of depression in people with osteoarthritis: systematic review and meta-analyses. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-41709-x 3. Chen, T., Wang, J., Wang, Y. Q., & Chu, Y. X. (2022). Current Understanding of the Neural Circuitry in the Comorbidity of Chronic Pain and Anxiety. In Neural Plasticity (Vol. 2022). Hindawi Limited. https://doi.org/10.1155/2022/4217593
4. Mills, D. S., Demontigny-Bédard, I., Gruen, M., Klinck, M. P., McPeake, K. J., Barcelos, A. M., Hewison, L., Van Haevermaet, H., Denenberg, S., Hauser, H., Koch, C., Ballantyne, K., Wilson, C., Mathkari, C. V., Pounder, J., Garcia, E., Darder, P., Fatjó, J., & Levine, E. (2020). Pain and problem behavior in cats and dogs. Animals, 10(2). https://doi.org/10.3390/ani10020318
5.
Overall, K. (2013). Manual of Clinical Behavioral Medicine for Dogs and Cats – E-Book by Karen Overall – Books on Google Play. Elsevier Health Sciences.
6. Royds, J., Cassidy, H., Conroy, M. J., Dunne, M. R., Lysaght, J., & McCrory, C. (2021). Examination and characterisation of the effect of amitriptyline therapy for chronic neuropathic pain on neuropeptide and proteomic constituents of human cerebrospinal fluid. Brain, Behavior, and Immunity – Health, 10. https://doi.org/10.1016/j.bbih.2020.100184
7. Testa, B., Reid, J., Scott, M. E., Murison, P. J., & Bell, A. M. (2021). The short form of the Glasgow composite measure pain scale in post-operative analgesia studies in dogs: a scoping review. Frontiers in Veterinary Science, 8, 751949.


Dr Channy McGowan BSVc MANZCVS (Behaviour) Elite CCFP

chronic musculoskeletal pain in a dog

Calm Pet Vet

Dr Channy McGowan (she/they) has over a decade of experience in metropolitan clinical practice and behaviour consulting, including a leadership role in an International Society of Feline Medicine-accredited hospital.

Among their many accomplishments, Dr Channy led the groundbreaking ‘Take Your Cat To The Vet’ initiative in 2020-2021 while working with Royal Canin. They also represented Royal Canin ANZ, hosting a global podcast advocating for inclusion and diversity within the greater Mars business.

In 2022, Dr Channy took on a pivotal role as treasurer and sponsorship officer at Australian Rainbow Vets and Allies (ARVA), helping the organisation incorporate and pave the way for positive change. Through ARVA, they played a key role in organising the first-ever Inclusion and Diversity conference for veterinarians in the southern hemisphere, ‘The 2023 Veterinary Kaleidoscope Summit’. Dr Channy is now vice-president of The Veterinary Kaleidoscope.

Dr Channy also founded The Calm Pet Vet, a venture dedicated to educating veterinary professionals and pet owners about Fear Free handling. Dr Channy has earned an Elite Fear Free Certification and Fear Free Coach status, presenting at multiple conferences, clinics and webinars, highlighting their dedication to creating a stress-free environment for our beloved furry friends.

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