Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2019017
Abstract
A 26-year-old Quarter Horse mare was treated with dry needling techniques and massage one year after losing her eyesight bilaterally. The patient is sensitive to dry needling treatment and alterations were needed to ensure a successful treatment strategy. However, in spite of the changes and limited number of treatments, the patient has shown improvements in muscle tone and behavior in response to dry needling and massage.
History
Desi is a 26-year-old Quarter Horse mare presenting for blindness and discomfort associated with stall and round pen confinement. Desi was acquired by the owner at the age of 11. Initially, she was ridden for western pleasure, but the owner quickly noted this was not the best fit. Desi was then transitioned to a gymkhana horse and ridden in local shows for many years. More recently, as the owner’s life proceeded to get busier, Desi was not worked as often and spent most of her time in the pasture. Approximately 1.5 years ago Desi began losing her sight and owner noticed overall cloudiness of her eyes bilaterally. Although she had been treated by a veterinarian several times, Desi lost all sight except some mild shadows in the ventral field of her left eye. Owner does not know specific treatments at each veterinarian visit. Since losing her sight, Desi is kept in a box stall at night and during the day she is turned out in a round pen. Owner initially tried to allow her in the pasture with her two pasture mates, but unfortunately, she ran through the fence a couple times and it was no longer worth the risk of injury. Desi recently received intraocular steroid injections (owner does not know specific details) within the last 6 months. The injections markedly improved the amount of clear ocular discharge that occurred and was causing alopecia. She lost a moderate amount of weight over the past winter and it has been difficult for Desi to gain weight this year. She is due for dental floating this fall and owner has farrier perform regular hoof trims (every 6-8 weeks).
Physical exam
On physical exam, Desi appears very rigid when led out of her stall. She consistently walks with her head elevated and has moderate anxiety. Her BCS is 3/9 with noticeable mild muscle atrophy of longissimus, iliocostalis, and gluteal muscles. There is marked corneal edema and mild epiphora OU, suspect secondary to anterior uveitis bilaterally. There is no menace response OD but menace present OS from ventral direction only. Intraocular exam could not be performed due to marked corneal edema. Right hind limb exhibits mild shortening of stride length. During neurologic exam, there were no other deficits appreciated.
Myofascial examination revealed marked hypertonicity in the cervical muscles including the splenius, cervical rhomboideus, serratus, cranial trapezius, thoracic trapezius, and brachiocephalicus muscles. Additionally, there is tenderness to palpation of the cranial pectoral muscles and local trigger points found throughout all of these muscles. There is normal lateral and rotational bending of the spine and no pain was noted along Bladder lines. All limbs palpate normally, no pain noted in hindquarters or when stress is placed on sacroiliac joint. However, Desi was tense during initial exam and suspect some mild lameness of right pelvic limb but pain was not localized. Normal ventral flexion of cervical thoracic region noted.
Problem list
Loss of vision, Epiphora, Corneal edema
Myofascial restriction of cervical muscles
Weight Loss
Muscle atrophy
Differential diagnosis
Loss of Vision: Equine recurrent uveitis (Leptosporosis, Streptococcus, Borrelia burgdorferi, Equine influenza, Equine Herpes Type 1/3, Strangles), glaucoma, cataracts, trauma with secondary hemorrhage, optic neuritis, sinus cyst, tooth root abscess, hypertension leading to secondary retinal detachment, lens luxation, neoplasia (nerve sheath)
Cervical pain: Myofascial dysfunction secondary to vision loss, arthritis, subluxation, luxation, Borrelia burgdorferi, trauma, Vitamin E/Selenium deficiency, neoplasia, Equine Protozoal Myeloencephalitis, West Nile Virus, Encephalitis (Eastern/Western)
Diagnoses
Based on the history provided by the owner, I suspect Desi likely has equine recurrent uveitis and may have had mild episodes that occurred previously that went undiagnosed. The underlying cause is open but samples could be submitted to rule out infectious disease (although, Leptospirosis is often difficult to diagnose). Less likely to be trauma, tooth root abscess, or neoplasia leading to bilateral blindness. There has been no other evidence of systemic disease in the history and no neurologic deficits noted making other differentials less likely. Unfortunately, the prognosis for equine recurrent uveitis is poor and I do not expect Desi will regain any vision (Allbaugh, 2017).
Myofascial dysfunction secondary to vision loss is most likely due to overall tonicity of muscles and lack of evidence for systemic disease. She may have underlying arthritis, radiographs would be required to rule it out. Testing could be performed to assess Vitamin E and Selenium levels; however, I would expect more generalized muscles atrophy – it is specific to posterior chain muscles whereas cervical muscles are well developed. Lack of neurologic deficits makes encephalitis and other infectious diseases less likely.
Acupuncture decision making
My initial plan for treatment was to begin with parasympathetic points, GV14 and Bai Hui to determine how well Desi will tolerant acupuncture treatment. Initially, she responded well by lowering her head and licking/chewing. My initial plan was to target the hypertonic cervical muscles by beginning with BL10, BL11-BL13 bilaterally. The goal of this approach is to provide central and peripheral nervous system feedback. However, Desi is very sensitive and was moderately reactive to needle placement at BL10. I quickly changed my plan in order to allow Desi to get used to acupuncture in hopes of performing future treatments. Instead, I placed needles in BL26 and BL27 to use the central nervous system to provide feedback to iliocostalis and longissimus muscles and relieve tension cranially, near the trapezius muscle. Desi allowed treatment for about 15 mins and needles were removed. I recognized that Desi will need slow progression of treatments. A recent review article discusses the impact of trigger points and referred pain in cervical muscles, including the benefit of dry needling (Dommerholt et. al, 2017). My aim is to provide relief for Desi by releasing myofascial restrictions and decreasing sympathetic tone and input to her cervical muscles.
During the second treatment, I again began with parasympathetic points and moved again to the BL points that were previously tolerated. Desi was much calmer during the second treatment so I added two additional dry needles, BL16 bilaterally closer to the insertion of thoracic trapezius muscle. Prior to third treatment, myofascial palpation revealed significant improvement of tone in the thoracic trapezius muscle bilaterally. The same treatment protocol for dry needling was used in the third treatment. However, as Desi has become more comfortable with me she allowed effleurage and petrissage of bilateral cervical and pectoral muscles during acupuncture treatment. This allowed me to work on local trigger points in cervical region and pectorals muscles in additional to peripheral and central nervous system feedback provided by the dry needling techniques.
Treatment
All treatments were performed with dry needling Seirin Type J No.5(0.25x30mm). See images “Desi-Treatment1”, “Desi-Treatment2” for dry needling, “Desi-Treatment3” shows eye lesion, and “Desi-Treatment4” shows her enjoying the massage. Videos are saved as “Desi-Pre” for prior to treatment and “Desi-Post” after the third treatment.
Session one (15 mins):
GV14, Bai Hui
Bilateral: BL26, BL27
Session two (20 mins):
GV14, Bai Hui
Bilateral: BL24, BL26, BL16
Session three (20 mins):
GV14, Bai Hui
Bilateral: BL24, BL26, BL16
Effleurage and petrissage of all cervical muscles and cranial pectorals, specific attention given to any location trigger points.
Outcome/insight/discussion/references
Initially, I was naïve in the expectations that I had for this case. Upon hearing Desi’s story, I thought she wouldn’t have significant myofascial dysfunction since she is not ridden and spends most her time in a box stall or a round pen. I could not have been more wrong. Desi has marked tension and discomfort in her cervical and upper thoracic muscles due to constantly walking with her head held high in effort to try to see. Although she has somewhat adjusted to losing her vision, she faced a new set of challenges that led to different strain patterns on her muscles than I expected.
Upon initial examination and treatment, I realized Desi would be a patient where we have to work very slowly with her. I was concerned that we wouldn’t see any significant changes in the first three treatments. Again, I was wrong. By allowing her to set the tone and listening to her, I was able to scale down my initial plans and in return Desi responded positively. I saw significant changes in muscle tone in the thoracic trapezius muscle, after two treatments, and I used acupuncture points distal to the regions I had hoped to target. It shows me just how powerful the nervous system can be. The owner also reported changes in Desi’s behavior after the second and third treatment. Typically, when in the round-pen Desi will walk in circles for many portions of the day. The day after a treatment when the owner looked out the window to check on Desi, she had her head down and was grazing, much like she did before she lost her sight. I am so grateful to have something else I can offer to clients when our medications and western treatments fall short, I was able to provide some comfort for Desi that she has not had since losing her eyesight. My hope is that her increase in comfort level will reduce stress and improve digestion that may be leading to her weight loss over the last year, given her teeth are floated and there is not an underlying mechanical reason for her weight loss.
In the future, I plan to continue to use massage and dry needling for Desi. I hope to eventually be able to dry needle cervical muscles including BL10, LI16, LI17, LI18, SI 16, TH16, and BL11-BL13. Ideally, I would also like to treat her eye pain and inflammation using ST1, TH23, BL2, GB1 and ST36. Additionally, the Shu points can be used to stimulate digestion (BL21, BL 25, BL27) – some of which I have already used to target her weight loss. Alternatively, I think laser would be helpful for points where I am not able to use dry needling. Although using lasers around the eye is typically contraindicated, I am not sure it is in this case if my goal is to provide pain relief and reduce inflammation. I do not expect that Desi will regain her eyesight after the severity of inflammation that has occurred and due to the poor prognosis of equine recurrent uveitis.
Allbaugh RA. Equine recurrent uveitis: A review of clinical assessment and management. Equine Vet Educ. May 2017;29(5):279–288.
Dommerholt J, Finnegan M, Hooks T, Chou LW. A critical overview of the current myofascial pain literature – October 2017. J Bodyw Mov Ther. 2017 Oct;21(4):902-913. doi: 10.1016/j.jbmt.2017.08.002.