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Kschonek et al. Porcine Health Management (2025) 11:12 https://doi.org/10.1186/s40813-025-00421-0 REVIEW Open Access© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Porcine Health Management Part I: understanding pain in pigs basic knowledge about pain assessment, measures and therapyJulia Kschonek1*, Lara Twele2, Kathrin Deters3, Moana Miller4, Jennifer Reinmold3, Ilka Emmerich5, Isabel Hennig-Pauka3, Nicole Kemper4, Lothar Kreienbrock1, Michael Wendt6, Sabine Kästner7 and Elisabeth grosse Beilage3 Abstract Background Pigs can suffer from pain due to spontaneously occurring diseases, wounds, injuries, trauma, and physi-ological conditions such as the farrowing process; however, this pain is often neglected. To increase knowledge and awareness

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uries, trauma, and physi-ological conditions such as the farrowing process; however, this pain is often neglected. To increase knowledge and awareness about this phenomenon, the current article presents a scoping review of basic and new approaches for identifying, evaluating, and treating pain in pigs.Methods A scoping review was conducted with results from a search of the electronic database VetSearch and CABI. With regard to eligibility criteria, 49 out of 725 publications between 2015 and the end of March 2023 were included. The findings are narratively synthesized and reported orienting on the PRISMA ScR guideline.Results The results of this review showed that practitioners need to consider pain not only as a sign of a disease but also as a critical aspect of welfare. If both the symptoms of pain and the underlying reasons remain unassessed, the longevity and prosperity of pigs may be at risk. In this respect, veterinarians are obliged to know about intricacies of pain and pain mechanisms and to provide adequate treatment for their patients.Conclusion It is pivotal to increase knowledge about pain mechanisms, the reasons for heterogeneity in behav-ioural signs of pain, and methods for evaluating whether a pig is experiencing pain. This article will help practitioners update their knowledge of this topic and discuss the implications for everyday practice.Keywords Nociception, Inflammatory pain, Neuropathic pain, Clinical pain, Pain parameters, Pain therapy *Correspondence:Julia Kschonekjulia.dorothee.kschonek@tiho-hannover.de1 Institute for Biometry, Epidemiology and Information Processing (IBEI), University of Veterinary Medicine, Foundation, Hannover, Bünteweg 2, 30559 Hannover, Germany2 Clinic for Horses, University of Veterinary Medicine, Foundation,

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y of Veterinary Medicine, Foundation, Hannover, Bünteweg 2, 30559 Hannover, Germany2 Clinic for Horses, University of Veterinary Medicine, Foundation, Hannover, Bünteweg 9, 30559 Hannover, Germany3 Field Station for Epidemiology, University of Veterinary Medicine, Foundation, Hannover, Büscheler Str. 9, 49456 Bakum, Germany4 Institute for Animal Hygiene, Animal Welfare and Farm Animal Behavior, University of Veterinary Medicine, Foundation, Hannover, Bischofsholer Damm 15, 30173 Hannover, Germany5 Institute of Pharmacology, Pharmacy and Toxicology, Faculty of Veterinary Medicine, University Leipzig, An den Tierkliniken 39, 04103 Leipzig, Germany6 Clinic for Swine and Small Ruminants, Forensic Medicine and Ambulatory Service, University of Veterinary Medicine, Foundation, Hannover, Bischofsholer Damm 15, 30173 Hannover, Germany7 Clinic for Small Animals, University of Veterinary Medicine, Foundation, Hannover, Bünteweg 2, 30559 Hannover, Germany

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Page 2 of 18Kschonek et al. Porcine Health Management (2025) 11:12 IntroductionUntreated pain in animals is associated with suffering, distress and detrimental effects on physical and men-tal health and thus represents a welfare-related concern [1]. e causes and indicators of pain are less examined in pigs than in companion animals [2], and pain manage-ment in pigs is often disregarded in textbooks [3]. Indeed, pigs are still among the most neglected livestock species in terms of pain assessment and treatment [4]. Although some related studies have been published, the focus is often limited to certain topics. For example, publications examining pain assessment have focused on pain man-agement procedures (surgical castration, tail docking, teeth grinding, ear tagging or notching). Other studies have focused on pigs that are used as laboratory animals in translational medicine [5 11]. is is likely due to the critical discussion on the necessity of husbandry and laboratory procedures. However, despite being a serious welfare concern, pain caused by spontaneously occur-ring diseases or injuries including, wounds, trauma and physiological conditions like neuroma among pigs has been less well examined and reported [3, 11, 12]. e rea-son for this difference may be that pain directly induced by human intervention gains more attention than pain resulting from spontaneously occurring diseases or inju-ries. Another reason may be that veterinarians need to learn giving more consideration to pain management, as shown by a survey of veterinarians use of analgesics in livestock animals [13]. In general, it is the responsibility of a veterinarian to try to successfully alleviate pain in the animals under care [2]; however, achieving this goal can be complicated by difficulties

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y of a veterinarian to try to successfully alleviate pain in the animals under care [2]; however, achieving this goal can be complicated by difficulties associated with iden-tifying pain. e identification and grading of pain needs to be a necessary part of clinical examinations of individ-ual pigs. However, clinical examinations often focus on aetiological diagnoses, while the role or presence of dis-ease-related pain is not always of concern. Consequently, therapy often aims to resolve the cause of the disease and neglects to treat the related pain.For several reasons, it is important for a veterinary practitioner to be able to identify pain as an impor-tant symptom in pigs, thus enabling the veterinarians to choose an appropriate therapy and to monitor the effec-tiveness of the therapy. In the role of an advisor, for exam-ple, a veterinarian must support farmers in discharging their responsibility to protect their pigs from unnec-essary pain and suffering [14]. Moreover, severe pain, which cannot be effectively treated, is a common reason for euthanasia or emergency killing of a pig in practice. In this respect, thoroughly assessing the animal for the presence of possible pain states ensure that the correct approach is selected in jurisdictional terms, where emer-gency killing is defined as [ ] the killing of animals which are injured or have a disease associated with severe pain or suffering and where there is no other practical possibility to alleviate this pain or suffering [15].In summary, the identification and evaluation of pain in pigs is pivotal for ensuring the welfare and prosperity of pigs and for deciding about timely euthanasia in severe cases. To support these pivotal processes, this article summarizes the knowledge and understanding of

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d for deciding about timely euthanasia in severe cases. To support these pivotal processes, this article summarizes the knowledge and understanding of pain and related mechanisms. is article is a starting point for readers to become familiar with pain research and pain in pigs (Part I). Moreover, findings from the latest publications are presented to suggest how daily practice can benefit from findings in research. Building upon this review, another article addresses the state of knowledge on pain in specific, spontaneously occurring diseases and injuries in pigs (Part II).Method for the review e aim of this scoping review is to enhance the under-standing of pain and related mechanisms in pigs. In addi-tion to summarizing the basic literature on the subject, topics and new approaches to assess pain in pigs were examined in studies published between 2015 and the end of March 2023. is scoping review was conducted in accordance with the PRISMA-ScR reporting guideline [16]. e search database VetSearch (EBSCOhost Research Database) was used which includes the following data-bases: CAB Abstracts 1990-Present, Tierärztliche Hoch-schule Hannover Catalogue, CAB Abstracts, CAB Abstracts Archive, eBook Collection (EBSCOhost), ERIC, E-Journals, OpenDissertations, MEDLINE, and Global Health. us, studies from key publishers (such as Wiley, Springer, Wiley-Blackwell, Taylor & Francis, Else-vier, and MDPI Biomedical Central Ltd., Cambridge Uni-versity Press, among others) were included and addressed with the help of one single interface (one search mask). To control the search process and adhere to the journal requirements, we iterated the research steps in the Cabi Rxiv database in the English language.To find appropriate publications, two alternate search strings were

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s, we iterated the research steps in the Cabi Rxiv database in the English language.To find appropriate publications, two alternate search strings were used. Findings for the first search string are called version 1 (V1) for results of the search in VetSearch and version 3 (V3) for CABI Rxiv. Findings for the second search string are called version 2 (V2) for results of the search in VetSearch and version 4 (V4) for CABI Rxiv. e following search terms were used: ( pain ) in title (V1, V3) or keywords (V2, V4) AND in text ("pig" OR "pigs" OR "hog" OR "hogs" OR "porcine" OR "swine" OR "boars" OR "boar" OR "sow" OR "sows" OR "piglet" OR "piglets" OR "weaner" OR "weaners") AND in text ("noci-cept*" OR "hurt*" OR "suffer*" OR "damag*" OR in text

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Page 3 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 "injur*" OR "defect*" OR "harm" OR "sensation" OR "bur-den" OR "sensorium") AND NOT in text ( patients ).In brief, 715 publications were found. For the first screening step, the list of retrieved publications was assessed online (title, author, abstract) or downloaded and an overview of topics was generated, (the topics cor-respond to the chapters of the manuscript nociception, inflammation, therapy (non-husbandry interventions; husbandry interventions), neuropathic pain and assess-ment, other animals or topics). Papers were considered eligible if they were peer reviewed, accessible in either article or book (section) format and published between 2015 and March 2023. In the second screening step, a more detailed analysis was performed, and papers were assessed for the fit of addressing the principles of pain in pigs and pain in spontaneously occurring diseases and injuries. Papers were considered eligible after this step if they addressed one of the respective topics and presented results or reviews of clinical studies. Accordingly, papers were excluded if they focused too much on pain manage-ment procedures (e.g., docking, castration, ear notch-ing) or if pain or related concepts were only addressed as a buzzword. Moreover, papers were excluded if they elaborated mainly on the discourse, ethics or attitudes of people concerning the pain of pigs. In cases where no publication was found, papers were retrieved following a snowballing technique. As outlined before, commonly used papers, standard books and literature published before 2015 were also integrated. By help of this itera-tive screening process, 49 publications were collected for the search and review process. Additional metrics of the

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integrated. By help of this itera-tive screening process, 49 publications were collected for the search and review process. Additional metrics of the search can be seen in supplementary materials (Addi-tional file 1). For reporting, the most suitable paper was selected as the lead reference if several papers addressed the same aspect. To illustrate particular sections, addi-tional material is provided as pictures and video footage. e material is based on a study elaborating on timely euthanasia of pigs suffering from pain and distress on German farms [17].De nitions and (patho-)physiology of painResearch on pain has been conducted for centuries, and the definition of pain has evolved over time. In the fol-lowing, the most relevant definitions and perspectives on pain and pain mechanisms are presented together with a narrative report of findings from the review.Pain and nociception e International Association for the Study of Pain (IASP) is often cited both in human and veterinary medi-cine as the first reference to provide a definition of pain. Its latest and adapted version outlines that pain is [a]n unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or poten-tial tissue damage. ([18], Text Box 2). While the IASP explicitly addresses the pain experience of animals now, earlier definitions emphasized the focus on the animals response to pain: [pain] changes the animal s physi-ology and behaviour to reduce or avoid the damage, to reduce the likelihood of recurrence and to promote recovery ([19], p.266). A key aspect to bear in mind, in this respect, is that the inability to communicate the pain experience verbally does not negate the possibility that an individual is experiencing pain and requires

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is that the inability to communicate the pain experience verbally does not negate the possibility that an individual is experiencing pain and requires appropriate pain relief (cf. [18, 20, 21]). Because humans and verte-brates share similar neuroanatomical structures associ-ated with pain processing, painful events in humans are also very likely to occur in vertebrates [22]. In fact, the principle of analogy is often used to justify the use of animals, including pigs, in the study of human pain or to argue for considering pain in painful conditions [1, 5, 11, 12]. To date, numerous studies have proven this assump-tion and outlined a great set of shared physiological pain mechanisms, especially for pigs [23, 24].Moving from the definition of pain to the topic of pain mechanisms , however, requires defining the term noci-ception. Nociception describes the reception of stimuli by nerve cell endings, called nociceptors. It comprises a process by which the body encodes potentially or actually damaging stimuli and initiates a series of events required to transmit that information to the brain [25, 26]. Hence, the activation of nociceptors themselves does not neces-sarily result in pain [25, 27]. In contrast, pain perception arises through cortical processing and comprises emo-tional and perceptual (conscious) experiences [25]. In other words, nociception may not always lead to pain and other types of pain may occur without nociception (see an overview in Table 1).Types of pain are characterized by the different mech-anisms causing it (Table 1), but in clinical pain, they overlap and evolve over time. To facilitate reading, the following paragraphs are structured according to Table 1, as is common in the standard literature.Nociceptive painProcesses

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To facilitate reading, the following paragraphs are structured according to Table 1, as is common in the standard literature.Nociceptive painProcesses of nociceptionNociceptive pain is caused by the physiological activa-tion of peripheral high-threshold nociceptors. It plays an important role in the protection of the body from fur-ther injury by initiating reflex and avoidance responses [25]. Nociceptive pain can be induced by polymodal, peripheral sensory neurons (nociceptors) responding to noxious thermal, mechanical, or chemical stimuli. Nociceptors encode the quality and quantity (e.g., dura-tion, intensity, location) of noxious stimuli and transduce them into depolarizing action potentials (transduction).

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Page 4 of 18Kschonek et al. Porcine Health Management (2025) 11:12 Nociceptive impulses are then transmitted to the spi-nal cord by specialized afferent nociceptor fibres and Aδ- and C-fibres (transmission), [24, 27, 48]. e affer-ent nerve fibres enter the dorsal horn of the spinal cord. At that point, signal inhibition or amplification (modu-lation) occurs before the information is conveyed to the brainstem, thalamus, limbic system and cortex (projec-tion). Finally, complex processing of sensory nociceptive signals can result in the perception of pain [26]. ese processes are illustrated in Fig. 1.Importantly, the transmission of nociceptive pain must not be understood as rigid. It is subject to plasticity since modulation is a complex molecular process occurring at different levels of the central nervous system [49, 50]. Moreover, individual experience and factors, such as the type of initial fibre conduction, influence pain sensation. e initial pain, for example, is mediated by activation of thinly myelinated, fast-conducting Aδ fibres and can be perceived as brief, pricking and well-localized sensations eliciting protective responses (e.g., immediate motor withdrawal response). e subsequent pain is mediated by unmyelinated, slow-conducting C-fibres that account for long-lasting, burning and less well-localized pain [51, 52]. e second pain seems to initiate (long-term) behav-ioural responses to limit further injury [52].Anatomical location of nociceptive pain e anatomical location of tissue damage is associated with several typical characteristics, such as the experi-ence and expression of nociceptive pain. In this respect, nociceptive pain can be differentiated into superficial and deep somatic pain (skin, subcutis, muscles, joints, bones) Table 1

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ve pain. In this respect, nociceptive pain can be differentiated into superficial and deep somatic pain (skin, subcutis, muscles, joints, bones) Table 1 Types of pain, including the description and biological function [28]*Overview, some studies address several aspects; ** see [47] Pain typeNociceptive painIn ammatory painNeuropathic painDescriptionPain caused by physiological activation of peripheral high threshold nociceptors (subcatego-ries include somatic and visceral pain)Spontaneous and stimu-lus- dependent pain evoked by both low-and high-intensity stimuliSpontaneous pain caused by lesions or disease of the soma-tosensory nervous systemBiological functionAdaptive (physi-ological)Protection of the organism from injuryProtection by hypersensitivity during healing and repair Maladap-tive (patho-physiolog-ical)Persistent pain despite healing and absence of initial causes or trig-gers, may become a disease entity** on its ownNo protective function; may become a disease entity** on its ownReferences from the review*Pig as a model[24, 29]Pigs in the focus of the publica-tion[30 36]Pig as model[37 40]Pigs in the focus of the publica-tion[41, 42]Pig as a model[43, 44]Pigs in the focus of the publication[30, 31, 45, 46] Fig. 1 Schematic diagram of physiological nociceptive pathways by E. grosse Beilage (oriented on [3, 21])

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Page 5 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 and visceral pain (organs of the thoracic, abdominal, or pelvic cavities). Superficial somatic pain is initiated by the activation of nociceptors in the skin and mucous membranes, which are highly innervated. erefore, this type of pain is well localized. Deep somatic pain origi-nates from bones, muscles, joints, and connective tissues and is less well localized. Visceral pain originates from distension of hollow organs, mesenteric traction, ischae-mia, and endogenous inflammatory mediators [26]. It possesses exclusive characteristics concerning perception and perceived anatomical location: the liver, lung and kidney parenchyma, for example, are insensitive to pain, while the capsule of the liver and kidney and the parietal pleura possess nociceptors [53]. Visceral injury does not necessarily result in visceral pain (e.g., cutting the intes-tine), while distention or traction may cause pain without injuring the tissues [54]. Pain due to infections of the vis-cera, such as gastrointestinal disease, is commonly judged to be very painful for pigs [12, 55]. Hence, diagnosing the source of visceral pain might be challenging because the underlying pathology and the intensity of pain perceived by the individual animal are not necessarily closely cor-related [26]. Moreover, visceral pain is diffuse and poorly localized due to the sparse innervation of visceral organs and the spread of visceral afferents across several lami-nae as well as segments when terminating in the spinal cord, thereby inducing large receptive fields [49, 54]. Due to convergence of visceral and somatic nociceptive input in the spinal cord, visceral pain is often charac-terized as referred pain, meaning that pain is perceived adjacent

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eral and somatic nociceptive input in the spinal cord, visceral pain is often charac-terized as referred pain, meaning that pain is perceived adjacent to or at a distance from the noxious stimulus, typically at somatic sites (e.g., angina pectoris in humans leading to pain in the arm) [49, 54]. Finally, visceral pain can be accompanied by emotional (affective) and auto-nomic responses such as nausea, vomiting, sweating and changes in blood pressure and heart rate because of auto-nomic innervation of the visceral organs [53, 54].Duration of nociceptive pain e sensation of pain can be further differentiated into acute and chronic pain, depending on how long the sen-sation lasts. Acute pain (or adaptive pain) has a protec-tive function and is essential to the organism because it enables healing and tissue repair and thus the animal s wellbeing [56]. Chronic pain was arbitrarily defined as pain persisting or recurring for more than 3 months [57]. In addition to the time span, initiated alterations in pain pathways and induced changes in the nervous system are of particular concern. e latter may contribute to physiologic, metabolic, and immunologic alterations [25] and affect the quality of life of animals [58, 59]. Hence, chronic pain refers to maladaptive or pathological pain that has no protective effect and should not be regarded as a continuation of acute pain [60].In ammatory painInflammation is a physiological response of the body to noxious stimuli, including (surgical) trauma or infection [56, 61], that is intended to evoke protective behaviour to encourage healing. Inflammatory pain often accom-panies diseases and injuries and is accompanied by a set of well-defined pathophysiological characteristics. ere-fore, it is important to understand more about

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seases and injuries and is accompanied by a set of well-defined pathophysiological characteristics. ere-fore, it is important to understand more about its nature. A variety of proinflammatory agents and mediators (e.g., H+, prostaglandins, bradykinin, cytokines, nerve growth factor) are liberated following insult (see also paragraph biomarkers) and sensitize nociceptive fibres directly or indirectly [62, 63].Stimulation of nociceptors also leads to reverse (anti-dromic) activation of C-fibres and subsequent release of neuropeptides, notably substance P (SP) and calcitonin gene-related peptide (CGRP). ese peptides induce vasodilation, plasma extravasation, oedema, and fur-ther sensitization of nociceptors and thus contribute to neurogenic inflammation [64, 65]. It is well known that complex bidirectional neuroimmune interactions modu-late inflammation and pain [66]. In this context, nerve growth factor (NGF) was found to be an important sig-nalling molecule involved in mediating postoperative and osteoarthritic (OA) pain. Briefly, its interaction with the tropomyosin receptor kinase A receptor (TrkA) has been demonstrated to induce alterations in primary afferent nerve fibres and immune cells, sustaining and enhancing pronociceptive states [67]. Recently, anti-NGF monoclo-nal antibodies have been approved for the treatment of osteoarthritic pain in dogs [68] and cats [69].Most of the literature included in this review assessed inflammatory pain in pigs, with translational interest in inflammatory skin diseases in general [38]. Practition-ers can refer to these and other findings about cutaneous hyperalgesia (i.e., abnormally increased sensitivity to pain in response to a normally painful stimulus) due to UV-B irradiation [37, 40] when examining an

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algesia (i.e., abnormally increased sensitivity to pain in response to a normally painful stimulus) due to UV-B irradiation [37, 40] when examining an individual pig with impaired skin conditions or sunburn and the need to judge upon the pain state. While the depth of findings cannot be resumed at this location, behaviour appears to be a valid parameter for observing inflammatory pain and hyperalgesia following irradiation, at least in familiar or controlled environments [37].Neuropathic painNeuropathic pain is initiated by lesions of the somatosen-sory system [20, 28]. is pain may result from periph-eral or central nerve injury following acute events (e.g., amputation, spinal cord injury, freezing) or systemic or

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Page 6 of 18Kschonek et al. Porcine Health Management (2025) 11:12 local diseases (e.g., viral infection, neoplasia) [26, 61]. Following such damage, a cascade of neurochemical and neuroplastic changes and altered expression of ion chan-nels can lead to spontaneous painful sensations without an associated stimulus. Unlike inflammatory pain, which often subsides after the stimulus is eliminated, neuro-pathic pain can persist or become chronic [22]. Neuro-pathic pain can therefore be regarded as a maladaptive phenomenon leading to severe and long-term conse-quences for quality of life in humans [70] and animals [3].Sensitization and altered pain statesIn addition to the protective function of nociceptive pain, high-intensity and/or prolonged noxious stimuli can result in sensitization [26]. Sensitization of the noci-ceptive system can be longer lasting but is reversible and evokes protective processes to avoid further injury [71]. As described above, tissue injury and inflammation lib-erate a variety of mediators ( sensitizing soup ) [64], cre-ating an altered molecular environment that leads to a reduction in the activation threshold and an increase in the responsiveness of peripheral nociceptors [26, 64, 72]. is so-called peripheral sensitization is closely linked to the site of tissue damage [73].Intense, prolonged or repeated nociceptor input can trigger the excitability and pain transmission of neurons in central nociceptive pathways (i.e., the spinal cord and supraspinal structures) [22, 74]. Additionally, a reduc-tion in inhibitory pathways and the recruitment of sub-threshold synaptic inputs may lead to increased action potential output [71]. ese processes of pain facilitation and pain disinhibition may contribute to a state called central sensitization.

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eased action potential output [71]. ese processes of pain facilitation and pain disinhibition may contribute to a state called central sensitization. Consequently, central sensitization to nociceptive and innocuous stimuli is characterized by diffuse pain sensitivity and pain hypersensitivity. In contrast to peripheral sensitization, central sensitization is subject to changes in the properties of neurons in the central nervous system, meaning that painful sensations occur even after a stimulus is withdrawn [71]. Moreo-ver, inputs to dorsal horn neurons from the activation of low-threshold Aβ fibres, which normally convey innocu-ous tactile stimuli, may contribute to central sensitization [75]. All these phenomena emphasize the plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury [71]. It should be noted here that neuropathic pain and central sensitization are not synonymous since the latter is initiated by intense or prolonged nociceptive inputs, irrespective of the origin of pain (nociceptive, inflammatory, or even neuropathic) [72].Sharing some characteristics of central sensitiza-tion is the temporal summation of pain caused by repeated C-fibre stimulation or wind-up . It describes an increased pain sensation that is caused by repeated noxious stimuli [26]. Some of the mechanisms of wind-up are thought to be related to altered pain states [76]. Molecular factors that contribute to central sensitiza-tion include N-methyl-D-aspartate receptor (NMDA)-mediated signalling, disinhibition, and microglial activation, among others [56, 62]. Overall, peripheral and central sensitization may contribute to altered pain states such as hyperalgesia (i.e., an exaggerated and prolonged response to noxious stimuli)

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and central sensitization may contribute to altered pain states such as hyperalgesia (i.e., an exaggerated and prolonged response to noxious stimuli) and allodynia, a condition in which pain is caused by an innocuous stimulus (e.g., touching the skin) [22, 71].Clinical pain e above-mentioned categorization of pain types pro-vides a good overview and understanding of the com-plex topic of pain . Nonetheless, the clinical pain that practitioners encounter on a daily basis is usually a mix-ture of different pain types. is can be illustrated using the example of tail biting [77]. Following the initial insult, acute superficial somatic pain may be suspected. Over the course of time, due to the necrotizing puru-lent character of those lesions, inflammatory pain and possibly neurogenic inflammatory processes emerge. Depending on the degree of neural injury, neuropathic pain is likely to develop. Indeed, in an experimental study of pigs that underwent tail amputations, sensiti-zation and sustained alterations in peripheral sensitiv-ity resembling neuropathic pain were observed [31]. In fact, the transition from physiological to pathological pain conditions often occurs frequently. Pathological or maladaptive pain has no protective function [64]. is pain state is mostly persistent or recurring, even long after the traumatic event or illness subsides or if acute pain is inappropriately managed or untreated. is latter factor is especially important for practi-tioners. Even if the initial cause is absent, pain due to traumatic lesions may (re)occur over time. Initial ideas on how to assess and validate pain in amputated body parts in this regard may be inferred by studies elabo-rating on tail amputations [30, 31, 45, 46, see chapter nociception]. Another example is for

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ody parts in this regard may be inferred by studies elabo-rating on tail amputations [30, 31, 45, 46, see chapter nociception]. Another example is for practitioners who face chronically lame animals. Indicators such as the walking pattern (among others), as well as hints for diagnostic anaesthesia and evaluation protocols, may be derived from studies on neuropathic pain models [43, 44].Pain as a disease entityAlthough one incident can activate several pain types, the sensation of pain may also appear or be sustained

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Page 7 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 irrespective of the trigger, cause or healing process. Pain may be a self-standing disease entity in this respect, and pigs should be examined and treated for this diagnosis, similar to any other common swine disease.Pain as a disease entity in pigs includes both acute and chronic pain. Although it is difficult to diagnose pain in pigs (and treat different pain types with respect to avail-able medication), the consequences in terms of welfare and costs of neglected cases are high [58, 59]. If no pain alleviation is possible, pigs may even have to be eutha-nized with respect to the definition of mercy killing [15].In human medicine, discussions on how to diagnose and define pain as a disease entity are currently underway [47, 78]. Future studies on pain in pigs should elaborate on this topic as well, but in the first step, awareness of the need to document the diagnosis of pain as well as the appropriate treatment needs to be improved.Implications and outlookWhat further implications do the terms and definitions of pain and pain mechanisms have for everyday practice? One answer is that practitioners can apply the updated knowledge and re-evaluate individual cases. For example, when examining a pig with accidently amputated body parts such as a dew claw, a veterinarian should deter-mine whether common signs of chronic pain appear, as described in recent republications [30, 31, 45, 46, 79]. Another answer is that the updated knowledge leads to a change in perspective: rather than assuming that pain is not present in a pig, veterinarians should ask if enough evidence is present to reject the assumption that an indi-vidual pig is experiencing pain. According to recent pub-lications, individuals were

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enough evidence is present to reject the assumption that an indi-vidual pig is experiencing pain. According to recent pub-lications, individuals were asked whether a nonresponse to stimuli may be explained by the fact that the pig is distracted by examinations (cf. role of consciousness, [35]) or because it remembers previous routine visits and avoids being (painfully) re-examined (cf. role of habitua-tion, [34, 36, 80]). Moreover, if a pig scores lower on pain scales than expected, practitioners should consider how this state was experienced by humans or whether the pig may simply belong to a type less expressive of pain, just as there are different personalities and coping styles among humans [59, 81].In sum, incorporating the latest knowledge about terms and definitions of pain means that practitioners should focus on individual pigs and reconsider whether remote observation is needed or at least if additional time is needed to re-evaluate the first impression about individ-ual pain states.Furthermore, learning about the state of related research underlines how invaluable the perspective of pig veterinarians is for improving knowledge in the field. For example, few studies have examined pain due to gastrointestinal diseases and injuries [3, 82, 83] or urinary [84] and respiratory tract diseases [39]. Veterinarians who report field cases with the help of the above-defined terms will enhance the practice-research dialogue and refine the understanding of pain in pigs.Pain assessment in pigsAssessing pain in pigs requires knowing well about the typical behaviour of the species as well as the potential idiosyncrasies of the individual since pigs often tend to hide their pain [2, 85, 86]. e indicators relevant for pigs range from physiological to behavioural

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rasies of the individual since pigs often tend to hide their pain [2, 85, 86]. e indicators relevant for pigs range from physiological to behavioural aspects, and the latter is mostly used by practitioners [87]. Currently, no harmonized nomenclature or categorization of indicators has been established [3, 12]. While it is out of scope for this article to suggest a harmonized system, orienting to other fields shows that methods of pain assessment can differ according to the focus on spontaneous or evoked behaviour but also in terms of how the pain is scaled.Using a subjective verbal pain scale , for example, a practitioner describes the pain state with qualify-ing words such as moderate or severe pain. Using a categorical scoring systems , these words were associ-ated with numbers (mild, 1; moderate, 2; severe, 3), and a set of indicators was predefined for assessment (such as motion (movement behaviour, such as the movement to the feeder) or body condition (that can be affected by pain sensitivity). Once the scores are noted, they are weighted according to relevance for the species or dis-ease to calculate the sum and thus overall pain score of the assessment. Several further pain scales exist (visual analogue, numerical rating, simple descriptive or grimace scales), and they were developed to improve the reliabil-ity, validity and objectivity of measuring pain in animals [21].Concerning pain in pigs, similar efforts and discussions are underway [3, 12, 88]. For example, a recent study evaluated the value of behavioural pain scales for pigs. It was concluded that the overall evidence for the UPAPS (Unesp-Botucatu Pig Composite Acute Pain Scale) is strong and that the overall evidence for the PGS-B (Pig-let Grimace Scale-B) is moderate for assessing

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esp-Botucatu Pig Composite Acute Pain Scale) is strong and that the overall evidence for the PGS-B (Pig-let Grimace Scale-B) is moderate for assessing pain in cases of castration and tail docking, respectively [88]. e use of these scales among practitioners who assess pain induced by spontaneously occurring diseases and injuries has yet to be assessed. However, these scales rely on indicators such as attention given to the affected area, interactive behaviour, ear position, and orbital tightening (spontaneous behaviour), which are also major concerns for stable veterinarians. Hence, knowing about recent developments in pain scales and indicators is essential for ensuring the best evaluations of pain in pigs.

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Page 8 of 18Kschonek et al. Porcine Health Management (2025) 11:12 For pigs unfamiliar with typical pain behaviour, how-ever, the first step is to know and understand indicators before they can be detected in a pig. In this regard, the most common indicators of pain in pigs will be discussed and described with additional materials.Behavioural parameters e term behaviour summarizes the overall senso-motoric expression of an animal [89] and is classified as abnormal when it differs in pattern, frequency or context from the behaviour shown by most members of the spe-cies [90]. Behavioural changes associated with pain have mainly been deduced from spontaneously occurring behaviours arising or increasing in the context of pain-ful conditions induced by damaging management proce-dures [12]. Pain assessment based on behaviour analysis has the advantage that it is not invasive, does not require equipment or restraint, and can be assessed by remote observation [4]. Nonetheless, the evaluation of behaviour during a clinical examination might be confounded by pig-examiner interactions [12, 91].Behaviour, evaluated in terms of pain, consists of the expression of various indicators, describing how a pig is reacting to its environment, interacting with pen mates, and showing vocalization, muscle activities and changes in posture or locomotion. A set of clinical parameters, such as the amount of time spent time walking, rest-ing, sleeping, rooting, and interacting, as well as longer durations spent in an abnormal posture, walking with difficulty, and lying alone, have recently been validated to indicate pain after surgery [4]. Even though this fully validated scale for acute pain is based on longitudinal video analysis [4], it shows the general suitability of the parameters. To

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n though this fully validated scale for acute pain is based on longitudinal video analysis [4], it shows the general suitability of the parameters. To assess clinical signs of spontaneously occurring diseases and injuries, individuals of the same group or pen of unaffected pigs should serve as a refer-ence during an on-farm examination of individuals [81, 82]. A comparison of this level and an evaluation of a set of indicators will help to identify substantial differences from normal behaviour [4], but subtle changes may be overlooked.Several pain scales have been developed for various species and different purposes [4, 92 95], and as out-lined in [88], pain scores in pigs are already under way. Future research could explore whether these are help-ful tools for decision making about pain management in spontaneously occurring diseases or injuries or about pain treatment for veterinary practitioners. Moreover, it is important to consider and evaluate the behavioural changes known to be indicative of pain in pigs. e parameter attention summarizes how a pig responds to the environment, e.g., caretaker, examiner or noises from technical equipment. Unaffected pigs direct their attention towards any action. In affected pigs, reduced attention can range from listlessness (mild) to lethargic (severe) states [87]. However, restlessness can also indicate pain [96]. How pigs engage with their pen mates is called social interaction . Affected pigs exhibit self-separation [6, 87] by lying close to the wall or in corners and by reducing their encounters with other pigs. Indeed, social isolation may even be a more spe-cific indicator of pain than general interaction behaviour [82]. Defence in dominance-related interactions with pen mates is reduced among pigs

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ore spe-cific indicator of pain than general interaction behaviour [82]. Defence in dominance-related interactions with pen mates is reduced among pigs experiencing pain.Reduced feed intake is one of the most frequently used overall indicators for disease but cannot be considered valid pain indicators, as specificity is likely low and dif-ficult to evaluate in pigs fed ad libitum and housed in groups [87].Interpretation of vocalization as a pain response requires consideration, as some painful events induce vocalization, while other pain-related events suppress vocalization [3]. ere is clear evidence that vocalization is indicative of pain [3]. For example, technical analysis of individual vocalizations recorded from piglets showed that calls differed between various conditions (pain, cold and hunger) and could be detected with an accuracy rate of 81% [97]. In another study using multiparametric call analysis to classify vocalizations during castration pain, three call types were distinguishable (grunt, squeal, scream). In comparison, screams appeared to be pain related, as the piglets that were castrated without local anaesthesia produced almost twice as many screams as piglets that were castrated with anaesthesia. e screams during castration also became more extended and more powerful [98]. e total call energy, sound pressure level, peak-to peak pressure, maximum call frequency and temporal characteristics of the individual call can also be used as indicators of pain [99]. However, not every call represents pain; for example, inadequate handling may also provoke vocalization [100]. Hence, vocalizations must be examined in a particular context. For example, if a lame pig is screaming while walking without being moved forward, it is likely that the vocalization

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xamined in a particular context. For example, if a lame pig is screaming while walking without being moved forward, it is likely that the vocalization is an indi-cator of pain (Additional file 2).Teeth grinding (bruxism) is also indicative of pain [87]. Identification of this characteristic noise under on-farm conditions requires an experienced examiner, as teeth grinding is often drowned out by other environmental noise (Additional file 3).Tremor or trembling is a subtle indicator of pain. While shivering might be caused by low temperatures, tremors are limited to the skeletal muscles (Additional file 4) of a

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Page 9 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 part of the body and are considered to indicate pain [12, 87, 101].Tail posture can be used to indicate pain. Tail posture and motion are impaired in docked tails [102]. When tails are undocked or when only the tip is docked, a curled tail as well as a relaxed hanging or loosely wag-ging tail are associated with positive valence (emotional states) and high or low arousal, respectively. A constantly tucked, motionless tail indicates negative valence and low arousal, while a tail tucked in a sudden response to a threat is associated with negative valence and high arousal [102]. Tucked tails can be observed in cases of pain, sickness and fear. Tail tucking due to tail biting is often chronic and results in an almost permanently or frequently tucked tail [102, 103]. Tail wagging includes the side-to-side movement of the tail. Relaxed wagging (tail swinging) occurs during various social behaviours, locomotor and social play and locomotion. However, intense tail wagging in pigs with biting lesions can be a sign of distress, tail irritation, or pain and can occur in pigs that are victims of tail biting [102].Body posture also provides valuable information about pain in pigs [3]. Kneeling is a strong indicator of pain and is aimed at relieving painful parts of the body, e.g., lower parts of the forelegs, hind legs or abdomen (Addi-tional file 5 and Additional file 6). Tripping, i.e., the rapid change between burdening and not burdening a foot or leg, is also a response to pain and is indicative of pain in more than one foot or leg (Additional file 7). Stand-ing motionless with the head down might be caused by pain but also indicates suffering [12]. Postural change while sitting is indicative of pain, e.g.,

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ing motionless with the head down might be caused by pain but also indicates suffering [12]. Postural change while sitting is indicative of pain, e.g., when a pig is try-ing to unburden a hind leg by bending the spine to place the leg in an upper position (Additional file 8), pain may be reduced under pain treatment [42]. An arched spine while the pig is standing or moving is also a sign of pain located in the locomotor system or inner organs. Hud-dling, i.e., lying with at least three legs under the body or lying in a stiff position, is another sign of pain ([12], p.4).Lameness is a reduction in weight borne and expressed by carrying a foot, favouring a leg, or being unable to get up and move and it is an important indicator of pain in terms of severity [12]. Lame pigs exhibit asymmetrical weight bearing between legs, increased step frequency or stand time, tip-toe walking and altered stride length [104 106]. A previous study stated that locomotor dis-orders do not necessarily result in pain [3], as individu-als may be affected by a biomechanical abnormality [12]. In another publication, it was suggested that [ ] joint injuries may prevent normal movement of the joint, lead-ing to stiffness in gait , ([107], p.66) which may not be associated with pain. However, this statement may need to be interpreted with caution. In horses, osteoarthritis (OA) of the distal tarsal joints is a frequently diagnosed disorder causing lameness and is referred to as bone spavin . In general, medical and surgical treatments aim to accelerate fusion of the affected tarsal bones to provide pain relief [108]. However, even in horses undergoing surgical arthrodesis, the resolution of lameness took up to 12 months [108]. To the authors knowledge, there is no comparative

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n in horses undergoing surgical arthrodesis, the resolution of lameness took up to 12 months [108]. To the authors knowledge, there is no comparative literature on pigs. However, anatomical confirmation of the corresponding joints differs between horses and pigs.Grimace scales have been used to evaluate behavioural changes and the facial expressions of piglets, growers and sows induced by tissue damage or disease [109 113]. Facial expressions comprise a number of anatomically based actions, such as changes in the shape of the eyes, nose, cheeks, mouth and ears [114]. In piglets, orbital tightening might be an indicator of pain induced by cas-tration [109, 115]. is phenomenon is evaluated in the PGS-B grimace scale (among ear position, cheek tighten-ing, nose bulge), which has been shown to have a strong level of evidence [88]. However, the use of grimace scales for pain evaluation is not yet ready for use in practice, as it requires extensive video recording. Currently, research focusing on automated pain recognition based on deep learning models is of particular interest in numerous mammalian species [116 118]. Interestingly, a real-time facial recognition platform has been proposed for pigs and cows aiming to detect emotions [119]. In the future, we will show whether these systems have the potential to become reliable and valid tools in daily veterinary prac-tice for detecting painful conditions.Physiological parameters (biomarkers)In addition to behaviour, physiological parameters (Table 2) can indicate painful conditions in animals. Pain-ful stimuli lead to activation of the sympathetic nervous system and release of catecholamines, resulting in physi-cal reactions. ese include changes in cardiopulmonary parameters, as well as changes in skin temperature,

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lease of catecholamines, resulting in physi-cal reactions. ese include changes in cardiopulmonary parameters, as well as changes in skin temperature, pale mucous membranes, mydriasis, salivation, and decreased activity in the gastrointestinal and urinary systems [3, 120]. As nociceptive indicators, cardiovascular param-eters are often inconsistent and not pain specific, as they are influenced by many factors in addition to pain, such as stress; homeostatic mechanisms [121]; medi-cations; and the intensity, type, and location of noxious stimuli [122]. Elevated catecholamine concentrations, as well as glucose and lactate concentrations resulting from catecholamine-stimulated glycogen mobilization [123], have been detected in porcine blood as indicators of pain, although mostly in association with damaging manage-ment procedures such as piglet castration and tail dock-ing [3, 124].

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Page 10 of 18Kschonek et al. Porcine Health Management (2025) 11:12 Cortisol is the most commonly used blood parameter for assessing pain in pigs in experimental settings. Corti-sol is a steroid hormone produced by the adrenal gland in response to stress, and it can also increase in response to pain [125]. Studies have widely examined cortisol/adren-ocorticotropic hormone (ACTH) levels in blood plasma, serum and saliva in pigs in relation to pain [12]. Damag-ing management procedures aside, painful events such as intramuscular injections [126], lameness [127, 128], and rectal prolapse [127] were found to result in significantly elevated cortisol levels in blood or saliva. A more recent method of cortisol determination in pigs involves detec-tion in bristles. Findings showed that, compared with those in control groups, pigs suffering from chronic pain from tail biting or lameness during their lifetime had ele-vated cortisol levels in bristles [129], while avoiding any invasive, painful procedures in piglets resulted in lower cortisol levels at weaning age [130]. us, cortisol levels in bristles could be a suitable indicator of animal welfare.Additional biomarkers (included metabolic, immuno-logical, and inflammatory markers) have been identified as indicators of pain in pigs [124]. Most of these biomark-ers, however, were examined in experimental settings and have not been validated for pain assessment in individual pigs with naturally occurring diseases [3]. Overall, the determination of laboratory parameters has limited rel-evance for routine clinical pain assessment. ese param-eters do not always allow for a clear inference of pain, as some markers respond to both pain and stress [131] and show natural circadian variations in their concentration levels [132].

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ar inference of pain, as some markers respond to both pain and stress [131] and show natural circadian variations in their concentration levels [132]. Moreover, the delay in diagnosis does not allow for rapid on-farm decisions, which are essential in cases of severe, spontaneous disease in individual pigs.Other approaches to measure painAlthough several indicators have been mentioned and even more may be discussed in other reviews [3, 12], forthcoming and digitally assessed approaches need more attention. Electroencephalography (EEG), for example, provides a summation of electrical activity aris-ing from the cerebral cortex. Currently, the application of these methods is limited by the experimental setting [153 155].Infrared thermography (IRT) is a technique used to evaluate inflammatory conditions in pigs [156]. It is com-monly used in laboratory settings, but recent studies have used this technique under field conditions and found it to be very effective for the early identification and treatment of shoulder ulcers in sows [157].Another digital device for assessing pain sensitivity in pig skin and underlying tissues (e.g., osteoarthritis, syn-ovitis) is the hand-held pressure application measure-ment (PAM) device. is device enables the application of force and the monitoring/measurement of mechani-cal nociceptive thresholds. e approach is promising because of the need to constrain pigs during measure-ment, apply consistent stimuli (exertion of force per area) and gather objective and consistent evoked responses. [32, 34, 35, 158, 159].Table 2 Physiological parameters and biomarkersPhysiological parameters and biomarkers that have been used for pain identi cation in pigs (adapted from [124] with exemplary studies for each category). * In ammatory markers

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and biomarkers that have been used for pain identi cation in pigs (adapted from [124] with exemplary studies for each category). * In ammatory markers indicate the existence of an in ammatory state that may generate pain CategoryPhysiological parameter/biomarkerReferencesActivity of the autonomous nervous systemHeart rate/heart rate variabilityArterial blood pressureRespiratory rateTemperature (rectal, skin, eye)[127, 133 137]Hormonal concentrations in blood, saliva or urineAdrenal axis: ACTH, cortisol[138, 139]Sympathetic axis: adrenaline, noradrenaline, chromogranin a[140 142]Neuropeptides (substance p, beta-endorphin)[143, 144]Blood energetic metabolitesGlucoseFree fatty acidsLactate[82, 133, 139]Blood concentrations of inflammatory markers*Cytokines (interleukin-1, tumour necrosis factor-alpha)Acute phase proteins (serum amyloid a, c-reactive protein, haptoglobin, fibrinogen)[42, 77, 143, 145, 146]EnzymesCreatine kinaseSalivary α-amylaseTotal esterase activity and its components (lipase, cholinesterase etc.)[127, 146, 147, 148]PterinesNeopterineBiopterine[149, 150]Proto-Oncogenesc-Fos[151, 152]

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Page 11 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 In the future, practitioners may use and evaluate the role of cognitive tests (such as memory tests or spatial memory tasks) in the field. Especially for critics and as a complement to nociceptive measures, this approach will enhance the understanding of the affective-motivational dimension of pain (cf. [3, 12, 58, 160]).More commonly used in current practice is analgesic treatment (diagnostic anaesthesia), which is a tool for identifying pain in an individual pig. e ability of anal-gesic drugs (or anaesthetic techniques) to alleviate the effects of tissue damage is indicative of the presence of pain [3, 114]. e response to an analgesic treatment allows, to a certain degree, us to conclude that pain, but not every medicine, is potent for all kinds of pain [161]. Hence, the absence of pain reduction after treatment may indicate that the chosen pathway for relief failed instead of assuming that pain was generally absent [162].In summary, depending on the location and kind of injury or disease, practitioners can use and should com-bine a set of behavioural, physiological and digitally assisted approaches to elicit the pain state of an individ-ual pig.Pain therapy in pigsVeterinarians are responsible for providing the best pos-sible treatment. As outlined in the previous paragraphs, there is no doubt that pigs can sense pain. Hence, treat-ment will have to include pain alleviation, regardless of the challenges in clinical pain diagnosis. e list of avail-able drugs for treating pain in pigs is short, and pain is not a delimited indication. In this context, the following considerations will help generate a protocol for treating pain in pigs due to spontaneously occurring diseases and injuries.Among the

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t, the following considerations will help generate a protocol for treating pain in pigs due to spontaneously occurring diseases and injuries.Among the list of drugs for pigs, NSAIDs are com-monly used in porcine health management and should be selected given the indication, location, nociceptive path-way and agent of concern [161]. Most commonly, meloxi-cam and ketoprofen are used as anti-inflammatory and analgesic drugs for farm animals [87, 163]. NSAIDs act at the periphery by targeting specific molecules involved in nociception in sensory neurons [2], and some have central analgesic effects [161]. NSAIDs have been found to be effective at alleviating inflammation but not neu-ropathic pain [164]. Depending on the injury of concern, experiences and recommendations for using NSAIDs for pigs in cases of mastitis [87, 165], lameness [166], inci-sional insult [41] or shoulder ulcer [42] have also been published.Irrespective of the disease or injury, the half-life of a few hours for NSAIDs in pigs [167] requires the provision of more than one dose per day. Despite this limitation, the use of anti-inflammatory and analgesic agents is rated as the most effective method for reducing pain among ani-mals [87, 168], and many studies have proven its efficacy for treating pain in pigs [105, 169, 170]. However, most NSAIDs are licenced to control pyrexia (Table 3), and few studies have examined the effective dose of NSAIDs for other indications [41, 161, 167]. Hence, further collabo-ration between researchers and practitioners concerning common adverse effects on healing [42] or even long-term effects are needed [161, 171].In addition to NSAIDs, opioids can be successfully used to relieve (inflammatory) pain in model studies [38]. However, opioids are not licenced for

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71].In addition to NSAIDs, opioids can be successfully used to relieve (inflammatory) pain in model studies [38]. However, opioids are not licenced for general use in pigs [161]. In this respect, additional research is needed to broaden the range of potential drugs available for pigs, Table 3 Licenced NSAIDs and related drugs in GermanyAn example of licenced NSAIDs and related drugs in Germany for application in pigs (modi ed from VETIDATA, https:// vetid ata. de). For more information, refer to the search database of the European Medicines Agency (EMA, https:// www. ema. europa. eu/ en/ medic ines); max. maximum; P.O. Oral; IM Intramuscular; IV Intravenous; p8h every 8 h AgentDosage (mg/kg BW)Application (times a day)Application routeMaximum duration treatment (day)ReferencesAcetaminophen301 [24 h]P.O. (drinking water)5[172, 173]Acetylsalicylic acid305021P.O. (feed)P.O. (feed)35 10[174, 175]Flunixin2 2.21IM1 3[176, 177]Ketoprofen1.5 3.0/3.01 [24 h]/1P.O. (drinking water)/IV, IM1/1 (-3)[178 180]Meloxicam0.41IM1 (-2)[181 183]Metamizole15 50Once/3 [8 h]P.O./IM, IV1/As needed[184]Sodium salicylate351P.O. (drinking water)3 5[185]Tolfenamic acid2.0OnceIM1[186]

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Page 12 of 18Kschonek et al. Porcine Health Management (2025) 11:12 (see another discussion and overview with indications in [192]).Importantly, the failure to treat acute (perioperative) pain may promote the emergence of peripheral and cen-tral sensitization and maladaptive pain conditions [187]. Nevertheless, given the understanding of the mecha-nisms of the different pain types, it seems rational that the administration of NSAIDs alone may be inadequate if maladaptive or chronic pain conditions can be assumed. In terms of a multimodal analgesic approach (i.e., the use of 2 or more analgesics or techniques to target dif-ferent nociceptive pathways) [188], it would therefore be favourable to add adjunctive drugs to the therapy plan. Ketamine, an N-methyl-D-aspartate receptor (NMDA) antagonist, is administered at subanaesthetic doses and is known to modulate central sensitization and exert antihyperalgesic effects [187, 189]. However, ketamine is licenced for pigs for the purpose of injectable anaesthesia.Closely related to enhancing the knowledge about the use of drugs for pain alleviation, knowledge about pain intensity is needed to evaluate the effect of analgesics. For practitioners, these data are relevant for attenuat-ing the analgesic protocol. For example, a study found that the upper limit of mild pain scores and the diagnos-tic uncertainty zone overlap [190], indicating that pigs undergoing moderate pain should already receive analge-sia [4]. However, even if no data for diagnostic zones are available in practice, the results of this study recommend initiating pain therapy when pain is identified by behav-ioural changes and/or on the basis of a diagnostic evalu-ation. In the latter case, it is not absolutely necessary to prove pain in the individual before

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ral changes and/or on the basis of a diagnostic evalu-ation. In the latter case, it is not absolutely necessary to prove pain in the individual before starting the therapy. Pig veterinarians and farmers need to consider incorpo-rating the judicious use of analgesics into standard oper-ating procedures as a way of improving welfare [191]. In summary, monitoring the success of treatment is pivotal. Every practitioner should be aware that untreated or persistent pain can negatively affect health, welfare and quality of life. Nevertheless, in situations in which suffer-ing and pain cannot be addressed, euthanasia should be regarded as the only viable option [187].ConclusionKnowledge about the basic mechanisms, assessment and treatment of pain among pigs is needed to ensure that detrimental conditions among these animals are detected and alleviated in everyday practice. is article summa-rizes basic knowledge on this topic and invites readers to continue reading based on outlined references and topics. e paper provides guidance for practitioners based on the findings, details and intricacies of the latest research about pain in pigs. Limit of this article is that the search string included the term not and excluded the term patients .More research about pain is necessary to increase knowledge about the diseases and injuries that veterinar-ians observe when examining pigs. One way to increase this knowledge is to link assumptions in research back to basic principles that drive every detrimental condition. Another way is to invite practitioners to provide more informed and detailed reports about treatment proto-cols for painful conditions in pigs. In this way, practice-research dialogue will help to obtain more evidence about pain induced by spontaneously occurring

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or painful conditions in pigs. In this way, practice-research dialogue will help to obtain more evidence about pain induced by spontaneously occurring diseases and injuries in pigs.Short list for practitioners A pig that has been confirmed to be experiencing pain should receive adequate treatment Even a likely painful condition is enough reason to treat a pig for pain e fact that drugs are scarce, and pain identification is not easy does not justify leaving a pig suffering in a painful condition To identify pain among pigs, veterinarians and care-takers need deep knowledge about the basic princi-ples of pain mechanisms; this article can be used as a starting point for narrowing knowledge gaps and identifying articles for further reading Scales and scores for identifying pain in pigs exist but need further validation in clinical settings; moreover, the current knowledge is sufficiently valid to prevent unnecessary pain in pigsSupplementary InformationThe online version contains supplementary material available at https:// doi. org/ 10. 1186/ s40813- 025- 00421-0.Additional file 1. Metrics of the review. The table provides an overview of the search output and filter processes.Additional file 2: Vocalization. The video shows a lame pig screaming while walking. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted.Additional file 3: Teeth grinding. The video shows a pig teeth grinding under environmental noise. Permission to reuse the materials for the

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Page 13 of 18 Kschonek et al. Porcine Health Management (2025) 11:12 purpose of illustrating the signs and arguments of the authors in this article is granted.Additional file 4: Trembling. The video shows a pig with subtle trembling. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted. Additional file 5: Kneeling 1. The video shows a kneeling pig. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted.Additional file 6: Kneeling 2. The video shows a kneeling pig. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted.Additional file 7: Tipping. The video shows a tipping pig. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted.Additional file 8: Bending the spine. The picture shows a pig unburden a hind leg by bending the spine. Permission to reuse the materials for the purpose of illustrating the signs and arguments of the authors in this article is granted.AcknowledgementsNot applicable.Author contributionsJK designed, drafted, analysed, interpreted, revised, LT drafted, analysed, inter-preted, revised; KD revised, MM revised, JR drafted, revised, IE analysed, inter-preted, revised, IHP revised, NK revised, LK revised, MW revised, SK analysed, interpreted, revised, EGB designed, drafted, analysed, interpreted and revised.FundingOpen Access funding enabled and organized by Projekt DEAL. This work is financially funded by the German Federal Ministry of Food and Agriculture (BMEL) based on a decision of the Parliament of the Federal Republic of Germany,

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ncially funded by the German Federal Ministry of Food and Agriculture (BMEL) based on a decision of the Parliament of the Federal Republic of Germany, granted by the Federal Office for Agriculture and Food (BLE; grant number 28N-2 008-01 "CARE-PIG").Data availabilityNo datasets were generated or analysed during the current study.DeclarationsEthics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare no competing interests.Received: 8 February 2024 Accepted: 17 January 2025 References 1. Hellebrekers LJ. Pathophysiology of pain in animals and its conse-quence for analgesic therapy. In: Hellebrekers LJ, editor., Animal Pain. A Practice-Oriented Approach to an Effective Pain Control in Animals. Utrecht, The Netherlands: Van der Wees; 2000. pp. 11 16. 2. Vinuela-Fernandez I, Jones E, Welsh EM, Fleetwood-Walker SM. Pain mechanisms and their implication for the management of pain in farm and companion animals. Vet J. 2007;174(2):227 39. https:// doi. org/ 10. 1016/j. tvjl. 2007. 02. 002. 3. Herskin MS, Di Giminiani P. Ch. 11 - Pain in pigs: Characterisation, mechanisms and indicators. In: pinka M, editor. Advances in Pig Wel-fare: Woodhead Publishing; 2018. p. 325 55. 4. Luna SPL, de Araújo AL, da Nóbrega Neto PI, Brondani JT, de Oliveira FA, Azerêdo LMDS, et al. Validation of the UNESP-Botucatu pig composite acute pain scale (UPAPS). PLoS ONE. 2020;15(6):e0233552-e. https:// doi. org/ 10. 1371/ journ al. pone. 02335 52. 5. Marchant-Forde JN, Herskin MS. Ch. 16 - Pigs as laboratory animals. In: pinka M, editor. Advances in Pig Welfare: Woodhead Publishing; 2018. p. 445 75. 6. Prunier A, Tallet C, Sandercock DA. Evidence of pain in piglets subjected to invasisve management procedures. In:

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