Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019016
Abstract
Sophie was treated for right hip and stifle osteoarthritis, spay urinary incontinence, and adverse effects (inappetence and vomiting) from medical treatments for these conditions. She received a series of acupuncture and medical massage treatments at one to three week intervals. The adverse effects and urinary incontinence resolved within the first three treatments. Pain, pelvic limb function, and gluteal and quadriceps femoris muscle mass improved throughout the treatment series, but require ongoing treatments for maintenance.
History of Present Illness and Chief Complaints
Sophie, a 12-year-old, spayed female Boxer, presented in April 2019 for urinary incontinence and pain in the hindquarters. Her owner reported that Sophie had slipped on the ice last winter, injuring her right pelvic limb. Additionally, her owner reported that Sophie had injured her back when she was one year old, but her owner could not recall the details of the injury, and previous records were not available for review. Lastly, Sophie had experienced a recent loss of muscle mass in the right hind leg and gluteal region. Sophie was being given Heartgard Plus, Bravecto, meloxicam, tramadol, levothyroxine, and Chinese herbs, but her owners did not feel that the medications were helping the problems (other than her hypothyroidism, which was controlled on 0.3 mg levothyroxine every 12 hours).
Physical Examination and Clinical Assessments
Sophie had myofascial pain over the sacrum. The perineal fur was wet from urine leakage, and small wet spots were present wherever Sophie sat during the exam. The quadriceps femoris muscles were mildly smaller in the right pelvic limb than in the left; however, her owner reported that both thighs were smaller than they used to be. Sophie was slow to sit and rise on her pelvic limbs. When standing, Sophie’s pelvic limbs were placed caudal to the level of the pelvis, with the hips more extended than normal, and the stifles more flexed than normal. Crepitus was present in the right stifle. Both pelvic limbs had normal range of motion (ROM). No conscious proprioceptive (CP) deficits were present in any of the limbs. Patellar, cranial tibial, and sciatic reflexes were all normal. Crossed extensor reflexes were not present. Cranial nerves were also normal. A urinalysis was unremarkable. Sophie was prescribed Rimadyl (carprofen) at 50 mg by mouth every 12 hours for presumptive osteoarthritis of the pelvis (lumbosacral/sacroiliac) and right stifle. She was prescribed Incurin (estriol) at 1 mg by mouth every 24 hours for urinary incontinence. The meloxicam, tramadol, and Chinese herbs were discontinued.
After about one month, Sophie’s owner reported that Sophie seemed more comfortable, but that she was still having urinary incontinence overnight. Her Incurin dose was increased to 2 mg every 24 hours. Two weeks later, Sophie presented for her first acupuncture treatment. Her owners carried her in, as she was too lethargic to walk. She had lost two pounds, and was experiencing vomiting and inappetence. She was no longer having incontinence issues, but she was now drinking a lot. In addition, her pain level had increased to the point where she refused to go for walks, paced around the house, and had difficulty sleeping. Her quadriceps femoris and gluteal muscles had undergone further atrophy since the previous exam. Myofascial restriction was present at the thoracolumbar (TL) junction, lumbosacral (LS) junction, and over the sacrum. Severe cutaneous trunci twitching was elicited during lumbar palpation. ROM was normal in the thoracic limbs. Extension of the right hip was decreased compared to the left. The right stifle was tender on palpation and had medial buttress. Her neurologic exam was unremarkable and similar to the previous exam other than the lethargy. Videos of her gait could not be acquired, as she was too tired to stand or walk.
Problem List
The problem list included pelvic limb lameness, pelvic limb weakness, pain (despite medication), TL and LS myofascial restriction, gluteal and quadriceps muscle atrophy, urinary incontinence (improved on medication), inappetence, vomiting, and polydipsia.
Differential Diagnoses
Pelvic Limb Lameness/Weakness
Vascular: fibrocartilaginous embolism (FCE).
Infectious/Inflammatory: tick paralysis, acute idiopathic polyradiculoneuritis, botulism.
Neoplastic: osteosarcoma, peripheral nerve sheath tumor, spinal cord tumor, urinary
bladder and urethral neoplasia, thyroid carcinoma.
Degenerative: osteoarthritis, degenerative joint disease, degenerative myelopathy, cranial
cruciate ligament rupture, intervertebral disk disease, lumbosacral syndrome.
Iatrogenic/Intoxication: adverse drug effect, rodenticide, marijuana, ethylene glycol.
Congenital: hip dysplasia.
Autoimmune: myasthenia gravis, systemic lupus erythematosus.
Traumatic: spinal cord injury, peripheral nerve trauma, soft tissue trauma, fracture.
Endocrine/Metabolic: hypothyroidism, hyperadrenocorticism, hypoadrenocorticism,
nutritional secondary hyperparathyroidism.
Myofascia: compensatory myofascial strain, cicatricial restrictions/fibrosis.
Urinary Incontinence
Vascular: cerebrovascular accident, fibrocartilaginous embolism.
Infectious/Inflammatory: cystitis, pyelonephritis, tick paralysis, urolithiasis.
Neoplastic: urinary bladder or urethral neoplasia.
Degenerative: lumbosacral syndrome, osteoarthritis, canine cognitive dysfunction,
degenerative myelopathy, intervertebral disk disease, detrusor atony.
Iatrogenic/Intoxication: NSAIDs, alcohol, bromethalin, marijuana.
Congenital: ectopic ureter.
Autoimmune: dysautonomia, myasthenia gravis.
Traumatic: urinary bladder or ureteral trauma, spinal cord injury, peripheral nerve
trauma.
Endocrine/Metabolic: spay incontinence, chronic kidney disease, diabetes mellitus,
diabetes insipidus, hyperadrenocorticism, hypoadrenocorticism, hyperparathyroidism.
Myofascia: viscerosomatic reflex, somatovisceral reflex.
Putative/Definitive Diagnoses
Sophie’s putative diagnoses were osteoarthritis of the right hip and stifle (likely secondary to previous hip trauma and cranial cruciate ligament rupture) and spay incontinence.
For pelvic limb lameness, infectious/inflammatory and autoimmune causes were ruled out due to lack of exposure and supportive systemic signs. No known exposure to toxins had occurred. A CBC, chemistry panel, and TT4 run by the previous veterinarian on 12/12/18 were all within normal limits, making endocrine/metabolic differentials less likely. Sophie’s hypothyroidism was controlled on her current levothyroxine dosage. Vascular, neoplastic, degenerative, congenital, traumatic, and myofascial differentials could not be completely ruled out. Degenerative myelopathy was the most concerning differential given Sophie’s signalment and clinical signs, and will continue to be monitored for in the future.
For urinary incontinence, vascular differentials were ruled out due to lack of other symptoms. Infectious causes were ruled out based on urinalysis results and lack of exposure. Toxic causes were ruled out since symptoms preceded the use of medications and no other toxin exposures had occurred. Ectopic ureters could not be definitively ruled out without imaging studies, but since symptoms had not been lifelong, this differential was unlikely to be the cause. Supportive signs of autoimmune diseases were not present. Endocrine/metabolic causes other than spay incontinence were not supported by previous blood work. Neoplastic, degenerative, traumatic, and myofascial causes could not be completely ruled out.
Medical Decision Making
The owners’ goals for treatment were to decrease the Rimadyl and Incurin dosages due to adverse effects, improve mobility, and control pain. The acupuncture approach was designed to include central, peripheral, autonomic, and myofascial points to achieve these goals. Sophie’s appetite was stimulated through central and autonomic points. Her osteoarthritic pain and muscle atrophy were treated with central, peripheral, autonomic, and myofascial points. Her urinary incontinence was treated through central (Shu/Mu) points. Myofascial dysfunction resulting from both problems was treated with central and myofascial points.
Medical Acupuncture and Related Techniques Used
Treatment 1 (5/17/19): Nausea, inappetence, and stress were treated with the autonomic points GV 20, GV 14, ST 36 (right [R] side only), and PC 6. These points were selected to elicit neuromodulation through trigeminovagal reflexes, the rostral ventrolateral medulla, and the nucleus tractus solitarius. TL junction myofascial dysfunction was treated with BL 21, BL 22, and BL 23. LS junction myofascial dysfunction and urinary incontinence were treated with Bai Hui, BL 27, BL 28, and CV 3. Right coxofemoral and stifle pain and dysfunction were treated with GB 29, GB 30, ST 34 (R), ST 36 (R), SP 9 (R), and SP 10 (R). All points were dry-needled with 0.16 x 25 mm Millennia needles. The owner was taught to massage the LS and hip regions at home.
Treatment 2 (5/23/19): Sophie’s sleeping, eating, nausea, and urinary incontinence were improved. Her mobility was better, but her pelvic limbs were still sliding caudally when standing. The myofascia was more relaxed at the TL junction, but was still restricted at T10 and the sacrum. Autonomic neuromodulation was elicited with GV 20, GV 14, ST 36, and PC 6. Myofascial dysfunction was treated with BL 18, Bai Hui, BL 27, and BL 28. Pelvic limb pain and dysfunction were treated with Bai Hui, GB 29, GB 30, BL 54, ST 34, ST 36, SP 9, and SP 10. All points were dry-needled with 0.16 x 25 mm Millennia needles.
Treatment 3 (5/30/19): Sophie’s appetite was voracious, and her energy and comfort levels seemed excellent according to her owner. Her stifles would flex when she was standing for long periods. Her gluteal and quadriceps femoris muscle mass was improving. Her TL myofascia was significantly more mobile, but the sacral myofascia continued to exhibit dysfunction. No incontinence episodes had occurred over the past week. The treatment focus therefore shifted to the pelvic limbs and sacral myofascial dysfunction. GV 20, GV 14, Bai Hui, BL 27, BL 28, BL 54, GB 29, GB 30, and ST 36 were dry-needled with 0.16 x 25 mm Millennia needles. The owner was advised to return in two weeks.
Treatment 4 (6/14/19): Sophie’s urinary incontinence remained controlled. Her pelvic limb strength and stamina had improved. Her gluteal and quadriceps muscles continued to regain mass and tone. Trigger points and myofascial dysfunction were present in the trapezius and rhomboideus muscles between the scapulae, at the TL junction, and at L5. GV 20, GV 14, Bai Hui, BL 13, BL 23, BL 25, BL 27, BL 28, BL 54, GB 29, and GB 30 were dry-needled with 0.16 x 25 mm Millennia needles.
Treatment 5 (7/5/19): Sophie’s incontinence continued to remain controlled, so her owner elected to discontinue the Incurin. Sophie stood with her pelvic limbs squarely under her hips. Massage of the quadriceps femoris muscles elicited extension of both legs. Myofascial mobility and gluteal muscle mass had continued to improve. GV 20, GV 14, cervical trigger points, BL 18, Bai Hui, BL 54, GB 29, GB 30, ST 34, ST 36, BL 60, and the middle Bafeng point on each pes was dry-needled with 0.18 x 30 mm Seirin needles. BL 60 and Bafeng points were added to integrate proprioception and motor control. The treatment interval was maintained at 3 weeks.
Treatment 6 (7/26/19): Sophie’s urinary incontinence remained controlled without Incurin. Her mobility was improved, but her owner had noticed pelvic limb weakness recurring over the past week. Myofascial dysfunction was present in the lateral neck, T5-T13, and the lumbar region. Sophie stood with her pelvic limbs placed caudal to the level of her hips. The third and fourth digit claws of both pelvic limbs had mild scuffing and were worn shorter than the second and fifth digit claws. The pelvic limbs were not lifted as high as the thoracic limbs when ambulating, and intermittent pelvic limb ataxia was present. GV 20, GV 14, BL 10, BL 15, BL 18, BL 22, BL 23, BL 25, Bai Hui, BL 54, GB 29, GB 30, ST 34, ST 36, and BL 40 were dry-needled with 0.20 x 30 mm Seirin needles. Full-body effleurage and petrissage were performed post-acupuncture to further treat the myofascial dysfunction. Fulling and compression of the back and pelvic limbs, followed by full-body effleurage completed the treatment. The three-week treatment interval was maintained.
Treatment 7 (8/16/19): Sophie’s mobility continued to be excellent. She had gone on a 2.5-mile walk the day before her appointment. Myofascial dysfunction was present in a ring from the caudal scapulae to the sternum bilaterally. The muscles at L5 were tender to palpation. Sophie stood with her pelvic limbs placed below her hips, but massage of the quadriceps femoris still elicited bilateral pelvic limb extension. GV 20, GV 14, Bai Hui, BL 25, BL 27, BL 54, GB 29, GB 30, SP 9, ST 36, BL 40, and BL 60 were dry-needled with 0.20 x 30 mm Seirin needles. SI 9, BL 13, BL 14, and BL 15 were also added to treat the myofascial dysfunction in the scapular region, which was likely due to the long walk the day before the treatment. Full-body effleurage and petrissage were performed following acupuncture. Treatment was recommended in three weeks.
Outcomes, Insights, Discussion, and References
Sophie’s inappetence and nausea resolved after her initial acupuncture treatments, both due to direct neuromodulation and somatovisceral reflexes, and due to the ability to control her osteoarthritis and urinary incontinence with lower dosages of the medications that were causing adverse effects. Sophie’s gluteal and quadriceps femoris muscles have regained some of their lost mass and strength, and her mobility has continued to improve from one treatment to the next. Owner-reported visual analog scale pain ratings for Sophie have decreased from 8-10 prior to treatment to 2 at the seventh treatment.
Management of osteoarthritis and urinary incontinence in Western veterinary medicine relies heavily on pharmaceuticals, many of which can produce severe adverse effects. This case demonstrates that acupuncture and medical massage can be utilized as part of a multimodal approach to the treatment of these conditions to help minimize the adverse effects of pharmaceuticals.
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