Cathy Madson, MA, CBCC-KA, CPDT-KA, Fear Free Certified interviews Margaret Gruen, DVM, MVPH, PhD, DACVB, Fear Free Certified


The relationship between pain and anxiety has gained the attention of researchers in recent years, with more studies looking at how the treatment of one affects the other. For dog owners, understanding the connection between their pet’s anxiety and possible pain can help them address both effectively, leading to a higher quality of life and a calmer state of mind.

I sat down with Dr. Margaret Gruen, Assistant Professor of Veterinary Behavioral Medicine at North Carolina State University College of Veterinary Medicine, and co-author of “Treatment of Canine Separation Anxiety Using a Pulsed Electromagnetic Field Device: A Pilot Study”, to talk about what pet owners should know when it comes to their pet’s pain and anxiety, what signs of pain to look for, and what treatment options are available.


Cathy: First off, what are the top issues about pain and anxiety that most pet owners aren’t aware of?


Dr. Gruen: One of the really important issues is that pain can make animals anxious, and not just because they’re protecting themselves. We often think about irritable aggression and that kind of behavior, but there’s no reason to think that pets wouldn’t have the same reaction that people have where you are anxious about things that will hurt. You might see increased anxiety around activities like jumping into the car, or other activities that used to be comfortable and easy and now are not.


It’s especially tough for dogs where there’s a lot of conflicts because they really want to do these things. They want to be with their owners, they want to please their owners. But even going up the stairs can become very painful and, as they become more unsteady, can be dangerous. I think that we see some anxiety there that is associated with that conflict.


And then there’s some evidence recently published by Daniel Mills about noise sensitivity and pain — musculoskeletal pain in particular. I think that that’s something that people would probably not be aware of either, that there may be this link between increased sensitivity to noise and musculoskeletal pain.


Cathy: Is that because they’re tensing up when they hear the noises and that’s what’s painful?


Dr. Gruen: I don’t think that we know yet, though that has been suggested. Dr. Mills put out a case series that showed us the correlation is there, but we actually don’t know which came first, the pain or the anxiety. In humans, there’s a lot of literature to suggest that there is a real relationship between anxiety and depression and chronic pain, and it’s not always clear which came first. That anxiety and depression can actually predispose to worse chronic pain. But also, chronic pain can cause anxiety and depression. It’s a somewhat vicious cycle and it is not clear that one is always before the other. More anxious dogs may be predisposed to chronic pain, but this is something we truly don’t know yet.


Cathy: You’ve mentioned musculoskeletal pain; what other kinds of pain are there for dogs in particular?


Dr. Gruen: Dogs can have soft tissue pain or visceral pain as well. Dogs who have IBD for example may have digestive pain that can be quite uncomfortable. We tend to think mostly of arthritis pain. But there are many other forms of pain.


Cathy: What’s happening in a dog’s brain when they’re anxious versus in pain or is it the same?


Dr. Gruen: The hippocampus and amygdala (parts of the brain) are certainly big players in sort of unpleasant emotions, but pain perception requires more conscious processing. To say that something is painful means that we have interpreted a stimulus as causing pain, and that’s a higher level of processing. There are definitely areas of the brain that are activated by both pain and by anxiety. There are definitely some parts of the amygdala, which is actually divided into several sections in itself, it’s a complicated little part of the brain. There are parts of the processing that become more amplified especially with chronic pain.

“The amygdala, long studied for its role in fear and anxiety, has a critical role in the emotional processing of pain. In acute pain conditions, activation of the amygdala can be pro- or anti-nociceptive [positively or negatively affecting the perception or sensation of pain], and the amygdala is critical for fear conditioning and stress-induced analgesia. However, in chronic pain conditions, sensitization and pain-related plasticity in the amygdala leads to a more consistently pro-nociceptive state, both in terms of sensory and emotional/affective pain.”

Neugebauer, V., et al., The amygdala and persistent pain. Neuroscientist, 2004. 10(3): p. 221-34.

Cathy: So, there are parts of the brain that are activated and feeding off of different sensations, which can then trigger that anxiety they’re seeing. Say a dog owner is noticing that their dog is becoming more anxious. Usually what I do as a trainer is recommend a visit to the vet. They need to double-check that nothing’s going on, especially if it’s sudden onset anxiety and there’s no obvious experience that they went through that triggered this anxiety. What kinds of things is a veterinarian going to ask the owner? How can a pet owner help the vet make a better diagnosis?


Dr. Gruen: We talk a lot about behavior diaries — you probably do, too. Being able to track what it means when an owner says their dog is anxious “all the time.” As they start to take notes, they can start to find out whether there is a temporal association. Do we see anxious behaviors more after eating? Or is it associated with times when they might be stiffer if it’s musculoskeletal pain, such as right after rest or when moving? So really having them keep track of that is helpful.


If they’re suspecting musculoskeletal pain of any kind, then a video of the dog doing standard activities, such as going up and downstairs, going on a walk, jumping up into the car can be very helpful. Those are things where you can see some subtle signs earlier and where you can pick up discomfort, especially musculoskeletal discomfort.


If there’s a sudden change in behavior, then you really want to be looking for any kind of pain component. And that doesn’t mean that the dog won’t also need to have their anxiety addressed. It just means that they probably won’t get as far in treating their anxiety if you don’t also address the pain.


Cathy: For people that have dogs who are more chronically anxious, they might have a harder time realizing that pain is a component. What are some of the smaller signs that most pet owners might not realize indicates pain, in body language in particular?


Dr. Gruen: Certainly any kind of body tensing when being touched or approached. The more bodyguarding types of behavior are really telling. And then I look for hesitation — hesitation to get back up, hesitation going up the stairs, hesitation in things that used to be easy. Even looking at hesitation to walk across surfaces that don’t have good, secure footing. That is one that we see a lot, a dog who is much more anxious and isn’t walking across areas to get to where their family is because they have to cross a big area of hardwood with no rugs. We can actually lower some dogs’ anxiety by just putting in better footing, like a yoga mat as a trial, or putting down some area rugs can help those dogs. They want to do it and be with their people, but they can’t get there without putting themselves through this potential slipping, falling, and discomfort.


Cathy: I can totally see why that would increase anxiety. It would make me anxious if I wanted to be with someone, but I can’t get there because it’s going to hurt me. Like having to walk across the ice to get there. That anticipation of discomfort increases anxiety.

Dr. Gruen: Right, so we think one reason why the anxious behaviors are being shown is that they want something so badly, but they know it’s going hurt.

Given that anxiety is often associated with cognitive dysfunction, it serves to reason that alleviation of anxiety would improve pain, cognitive function and quality of life amongst chronic pain patients.” – Gruen


Cathy: For the treatment of pain, especially in conjunction with anxiety, how do veterinary behaviorists approach it?


Dr. Gruen: The first thing to do is a trial for pain medication. Nonsteroidal medication can be helpful for many dogs, especially with musculoskeletal pain. So, a trial to see whether and how much of the anxiety is associated with discomfort is probably the best first step.


If you try to treat the anxiety without treating the pain, you won’t get as far. If you treat the pain and the anxiety remains, then you need to treat the anxiety too. Behavior logs come in handy for tracking treatment response. Maybe the dog will respond to just the pain medication and pain management. Some dogs are going to need both the treatment for pain as well as addressing the anxiety.


Cathy: And what if you have a pet owner come in and say they don’t necessarily want to start with prescriptions right away? Are there supplements that they can try?

Dr. Gruen: Yes, there’s evidence for Omega-3 fatty acid supplementation being helpful for pain. There’s also a lot of evidence that moderate exercise and weight management are very helpful, especially for dogs. So moderate exercise may be almost as good as a prescription and is a really important component of treating pain. It’s hard to get dogs who are uncomfortable to want to walk, and people tend to think, “Oh well, we’re not going to do that because the dog doesn’t like it.” But if you can get them to do a little bit, several times, and get them moving, it really helps. That’s true in people, too.


Cathy: Yes, definitely. And do you think that things like hydrotherapy or acupuncture could help pet owners who might not want to go straight to prescription?


Dr. Gruen: Yes. We always want to consider what recommendations are evidence-based, and there aren’t great studies available for those modalities. However, they may be helpful and are very unlikely to do harm. Especially hydrotherapy and physical therapy because those get them moving in a low-impact way.


I encourage people to figure out how to measure what they are looking for when they’re looking for improvement. This way there’s less risk of seeing improvement that isn’t actually there. What are the activities that they are going to look for to gauge improvement? This is where I think the video is amazingly helpful because we are all very subject to resetting our “normal” when behaviors change gradually. Video doesn’t allow you to do that. You can look back at the older video and think, “Oh, that’s what he looked like before — he looks so much better now.” Or maybe there isn’t much change, so maybe now it’s time to try a different approach.


Cathy: As a trainer, I’m curious as to what I can do to help anxious dogs in pain during my training sessions and day-to-day life. Are there certain things we should do or avoid doing during training?


Dr. Gruen: It goes without saying that we would avoid doing anything that makes the dog more anxious; we would avoid punishment or anything that has the potential to increase anxiety and conflict.


If we see more unwillingness from the dog to perform certain behaviors, just take a break to think about why the dog is hesitating. And if it’s something that has to do with pain or possible pain, then what could we do to help manage that, such as working in a different area that might make it easier for them? Can we do a different behavior instead? For example, if we’re doing, a “say please by sitting” behavior, can we do something besides sitting to say please, and ask them for behaviors that don’t elicit pain.


Cathy: Right. I always think of it as I’m going to look for what the dog naturally offers and seems comfortable with and look for any slowness of movement or hesitation and adjust as needed. Are there any tips or tricks for handling a dog or helping them move around that can make it less painful for a dog?


Dr. Gruen: It will depend on their level of pain and impairment. Sometimes a sling that goes underneath their abdomens to help lift them or support them can help. Or if there’s a way to break down what they’re being asked to do into smaller bits so they can do it themselves that’s also good. And making it very predictable for them.


Cathy: When you have a dog who’s suffering from both pain and anxiety, can tPEMF treatment like Assisi Animal Health’s Loop and Calmer Canine® be used for both of these things concurrently?


Dr. Gruen: Yes, I could see no reason why they wouldn’t be able to. Or use the Loop first and see if any anxiety is relieved just by decreasing the pain. I always try treating the pain first and then really looking at what kind of environmental management we can do to manage the pain. I think certainly that the Calmer Canine has potential in that field. We know that there’s increasing evidence that inflammation is a big player in behavior and particularly in anxiety and mood disorders. I think that Calmer Canine definitely has potential and we know that the Assisi Loop has a lot of great effects for treating pain.


Cathy: Anything else that you’d like pet owners to know?


Dr. Gruen: I like for pet owners to always give their dog the benefit of the doubt. If a dog stops doing a behavior that they used to do, or stops responding in the same way, taking a minute and thinking about: Why this is happening? What is different in the environment? Or what is different with my dog? Particularly for behaviors that a dog used to do and then isn’t doing. And not underestimating how difficult it is to learn when you’re anxious, that means we need to have compassion for those dogs. I think that’s really important.


Cathy: I love that point. And so much of that is just learning how to communicate and having that relationship. So, I think that’s just important because then pet owners can see things like pain or hesitation sooner if they’re in tune with their dog.


Dr. Gruen: Yes, for sure. The more that we understand what they’re doing, what their natural behaviors are and what they’re trying to tell us, the more we can see when they are in discomfort.