Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018044
Abstract
This report details treatment a 15 year old male neutered Labrador Retriever presented for a 3-4 year history of gradually progressive pelvic limb weakness and ataxia. Euthanasia had been considered due to progressive decline in mobility and sequelae of his condition. Through one month of acupuncture treatment, proprioceptive deficits were partially restored, mobility and contact time with his owner were improved, and chronic wounds secondary to ataxia nearly resolved.
History and Clinical Presentation
Jackson was a 15 year old male neutered Labrador Retriever presented for further treatment of pelvic limb weakness and ataxia. Jackson experienced gradually progressive pelvic limb weakness over the past approximately 3 years. This resulted in chronic scuffing and subsequent wound formation on the dorsal aspects of the pes, and was likely a contributor to frequent fecal accidents in the house. Concurrent disease included laryngeal paralysis, urinary incontinence responsive to phenylpropanolamine, and stage 1 chronic kidney disease. The concurrent neurologic impairments (pelvic limb weakness, laryngeal paralysis, and possibly urethral sphincter mechanism incompetence), suggest a multifocal neurologic condition such as geriatric onset laryngeal paralysis polyneuropathy (GOLPP). Jackson was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and glucosamine/chondroitin supplements over the past year for coxofemoral and back pain. Leading up to acupuncture therapy, Jackson’s weakness and discomfort began to cause impairment in his quality of life, including chronically infected wounds on his feet, inability to posture for eliminations without assistance, and decreased mobility and contact time with his owner. Euthanasia had been discussed, but Jackson maintained a healthy appetite and lively attitude, and his owner sought alternatives that may give him improved quality of life in his remaining time with her.
Physical Examination and Clinical Assessments
On initial presentation Nov 1, 2018, vital parameters were normal. He appeared bright, alert, and responsive, and eyes, ears, and oral cavity were unremarkable for the patient’s age. Breathing was loud and stertorous, especially when excited, and other than referred upper airway noises, lung auscultation was clear. No murmurs nor asynchronous or weak pulses were appreciated. His abdomen was soft and compliant with no masses on palpation. He was ambulatory on all four limbs, but experienced significant difficulty rising on the pelvic limbs and scuffed the pelvic limb feet on approximately 75% of steps. Mild discomfort was appreciated on extension of both hips. Moderate elbow thickening was palpable bilaterally. The patient experienced intermittent lameness of the left thoracic limb throughout the treatment period. The patient occasionally collapsed on the hind end when walking and posturing for eliminations, and required sling support often for these activities. Hind end collapse would occur with mild pressure on the lumbar and sacral spine. He had moderate muscle wasting of the semimembranosus and semitendinosus muscles, epaxials, and biceps brachii muscles, with hypertrophy of the triceps and gastrocnemius muscles bilaterally. Taut bands were present within the triceps, dorsal cervical musculature, and along the latissimus dorsi. The neck was held low at rest and experienced moderate discomfort on right and left flexion. The tail was held low but had sufficient tone. There were two, approximate 1.5cm ulcerated, thickened lesions on the dorsal aspect of both pes. Conscious proprioception (CP) was absent on the pelvic limbs and moderately delayed on the thoracic limbs. Crossed extensor reflex was absent on the left thoracic limbs and present on the remaining three limbs. Spinal reflexes (biceps, triceps, patellar, gastrocnemius, and withdrawal) were appropriate. Most recent labwork 7/6/18 showed Stage 1 chronic kidney disease and mild anemia. Abdominal radiographs on 9/23/18 and 11/29/18 revealed progressive bridging spondylosis and near complete collapse of the disc spaces L7-S1 and T12-T13 disc spaces, bridging spondylosis at L1-L2-L3 and less severe spondylosis at L3-4, L6-7, C7-T1, and T11-T12. The coxofemoral and stifle joints had mild degenerative changes, and mild osteophyte formation was present at the glenohumeral joints.
Problem list
● Pelvic limb weakness
● Neck pain
● Intermittent left thoracic limb lameness
● Coxofemoral pain
● Laryngeal paralysis ● Occasional fecal incontinence
● Recurrent traumatic ulcerations on pes
● Suspected cognitive dysfunction
● Early chronic kidney disease
● Mild anemia
Differential Diagnoses and Putative Diagnosis for Top Two Problems
1. Pelvic limb weakness: Geriatric onset laryngeal paralysis polyneuropathy (GOLPP), intervertebral disc disease (IVDD), degenerative joint disease (DJD). Less likely differentials include metabolic disease (hypothyroidism, diabetes mellitus, Cushing’s disease), cervical vertebral instability (“Wobbler’s”), immune-mediated disease (myasthenia gravis, immune-mediated polyarthropathy, degenerative myelopathy), thromboembolism/fibrocartilaginous embolism (FCE), neoplasia, and infectious disease (toxoplasmosis, canine distemper virus).
Given the chronicity of the disease process, lab work values, and physical exam findings, infectious, metabolic, immune-mediated causes, neoplasia, and Wobbler’s were considered unlikely. Advanced imaging would be required for definitive diagnosis of IVDD, but at least some degree of myelopathy related to spinal pathology was expected given radiographic findings. Considering the multiple concurrent neurologic impairments (laryngeal paralysis, urinary and fecal incontinence, proprioceptive deficits) and signalment of the patient, all typical of the disease process [1], GOLPP was considered a main contributor to Jackson’s clinical signs. However, a multifactorial process was strongly suspected.
2. Neck pain: IVDD, DJD, and myofascial pain secondary to primary neuropathy and abnormal gait were considered the most likely differentials for neck pain. Other differentials included cervical vertebral instability/”Wobblers”, and immune-mediated or infectious processes.
Considering radiographic findings of the shoulder, multifocal sites of vertebral spondylosis, and abnormal gait and physical exam findings, this discomfort was likely multifactorial and involved a combination of muscle strain, degenerative joint disease, and possibly IVDD. Advanced imaging would be needed to further classify the severity of each process. It should be considered that the intermittent left thoracic limb lameness could have been related to neuropathy involving the cervical spine, relaying a root signature to the thoracic limb.
Medical Decision Making
Acupuncture was pursued in Jackson’s case as traditional therapies had possible significant adverse effects on his health and quality of life. Additional analgesics (tramadol and gabapentin) had caused profound sedation in the past, even at low doses. Alternative NSAID therapy (carprofen and grapiprant) were not clinically effective, and meloxicam dose was not increased for risk of exacerbating his renal disease. Advanced imaging and potential surgical intervention were not pursued by the other due to his increased surgical risk related to laryngeal paralysis. Jackson was also frequently boarded at the hospital, and was very compliant and food-motivated, making him a good candidate for treatment sessions. Overall, acupuncture offered many potential benefits to treat nerve restriction, and reduce pain and sympathetic activity within a wide margin of safety.
Medical Acupuncture and Related Techniques Used
Treatment #1, Day 1
Dry needle: Seiren 0.16mm/30mm – GV20, Bai Hui, GB29, GB30, BL54, BL25, ST34 & 36, Bafeng
Treatment #2, Day 6
Dry needle: Seiren 0.2mm/30mm – GV 20, Bai Hui, BL54, GB29, GB30, ST34 & 36, Bafeng
Massaged latissimus dorsi, carpal extensors, and pelvic limb muscles
Treatment #3, Day 12
Dry needle: Carbo 0.2mm/25mm – GV20, BaiHui, BL27&28, BL54, GB29, GB30, ST 34 & 36, Left Bafeng and Baxie, BL 22, 23, & 25
Massaged Latissimus dorsi, epaxial, and pelvic limb muscles
Treatment #4, Day 15
Dry needle: Seiren 0.16mm/30mm – Right Bafeng, ST 36 & 34, gastrocnemius taut bands, BL54, GB 29, 30, GV 20, right Baxie
Hwato 0.2mm/25mm – SI 11,12, GV 14
Exercises: backwards walking, side stepping, up/down stairs.
Treatment #5, Day 20
Dry needle: Seiren 0.16mm/30mm – Bai Hui, BL 28, BL 35, BL 54, BL 52, Bafeng
Electroacupuncture (EA): Seiren 0.2mm/30mm – BL 25-27, Mixed Freq 2/100Hz, 10min
Treatment #6, Day 22
Dry needling: Seiren 0.16mm/30mm – SI11, SI12
EA: Carbo 0.2mm/25mm – BL 23-25, BL 54-ST36 mixed stimulation 2/100Hz, 10min
Massaged taut bands of triceps and right latissimus dorsi
Treatment #7, Day 28
Dry needling: Seiren 0.16/30mm – BL 23, 24, 27, 28, Bafeng, BaiHui
Massaged tender thoracic limb extensors and taut bands on epaxials
Outcomes, Discussions, and References
Following Jackson’s first acupuncture treatment on day one, concentrating on lumbar, hip, and parasympathetic neuromodulation, strength was improved and he no longer collapsed with pressure on the spine. Day six treatment involved a slightly larger gauge needle, focused on sacral, hip, and pro-parasympathetic points, and layered in massage of taut bands in the pelvic limb, epaxials, and thorax. His owner called the hospital, unprompted, to relay her satisfaction in response three days later. She found that he was scuffing his pelvic limbs less, able to handle uneven terrain better, and his back appeared to be held higher and more aligned with his front end. On day 12, CP was delayed, but no longer absent, in the left pelvic limb. Crossed extensor response was now negative in this limb. Treatment on this day consisted of non-coated needles, and additional lumbar spinal points were added along the inner bladder line. Following this treatment, the owner reported less splaying of the pelvic limbs on slick surfaces, and that friends unaware of his acupuncture treatment began to comment on his improved mobility. She also observed 1-2 days of soreness following treatment before observing the positive effects. At treatment day 15, Jackson had developed sensation (retracting foot) upon placement of right Bafeng points. He continued to have good stability with pressure on his lumbar and sacral spine, and the chronic wounds on his dorsal pes were beginning to heal. Day 15 treatment concentrated on neuromodulation of the neck and thoracic limbs, and parasympathomimetic points, and was less aggressive due to the owner’s reported soreness. Strengthening exercises and focused massage exercises were also provided to Jackson’s owner to continue at home. Prior to treatment on day 20, the owner reported that Jackson had nipped at her during massage, a behaviour that was very uncharacteristic for him. This was the first sign of behavioural change that may have suggested cognitive impairment. On day 20, electroacupuncture of lumbar paraspinal points was introduced. Jackson had improved comfort and range of motion in his neck at day 22. Treatment this day consisted of neuromodulation of the neck and thoracic limbs, and electroacupuncture of points affecting the lumbar and sacral spine. During Jackson’s subsequent boarding period, he was observed to be less bright, and experienced a rapid decline in ambulation. His owner decided to pick him up early from boarding, as his mobility often rebounds at home, where he is constantly active by following her owner around the house. Mobility was severely impaired, and euthanasia was considered. However, Jackson suddenly rebounded to the point that the owner had difficulty keeping up with him. Jackson remained detached and possibly confused at home, getting “stuck” against walls and seemingly unaware of his surroundings. He was brought in for a final treatment on Day 28. At this time, conscious proprioception was present in the thoracic limbs and were only moderately delayed in the hind. His previously regained strength in the hind end had regressed, and his attitude was noticeably more detached and distant. Due to his acutely progressive weakness and decline in awareness at home in the following days, Jackson’s owner elected humane euthanasia. Upon his passing, his owner expressed great gratitude in the quality of life and dignity that acupuncture provided him over his final month of life.
In summary, acupuncture provided significant improvement in proprioception and strength, likely via its anti-inflammatory and analgesic effects [2] on the spinal cord and peripheral nerves. This modality was of particular importance with Jackson, as only a conservative dose of non-steroidal anti-inflammatory medication could be tolerated due to his concurrent renal disease, and he was severely sedate with even subtherapeutic doses of oral analgesics. The improvement in strength and ambulation resulted in improvement in chronic traumatic wounds on his feet, eliminating the need for systemic antibiotics. Most importantly, as has been reported in literature [3], Jackson’s quality of life and contact time with his owner improved with acupuncture.
References
1. 1. Acquired idiopathic laryngeal paralysis as a prominent feature of generalised neuromuscular disease in 39 dogs N.D. Jeffery, BVSc, PhD, CertSAO, DSAS(ST), DipECVN, DipECVS, FRCVS, C. E. Talbot, MA, VetMB, MRCVS, P. M. Smith, BSc, BVM&S, PhD, MRCVS, N. J. Bacon, MA, VetMB, CertVR, CertSAS, DipECVS, MRCVS. The Veterinary Record, January 7, 2006
2. 2. Veterinary Acupuncture. Schoen et al. Seminars in Veterinary Medicine and Surgery (small animal) Vol 1. Number 3 (August). 1986: pp 224-229.
3. 3. Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal disease. Nuno E.O.F. Silva, Stelio P.L. Luna, Jean G.F. Joaquim, Heloisa D. Coutinho, and Fábio S. Possebon. The Canadian Veterinary Journal.