Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019020
Abstract
Acupuncture using dry needling and massage were utilized to treat for signs of allergic dermatitis and degenerative joint disease associated with bilateral malformation of the coxofemoral joints in an 8 year old large mix breed dog. Three treatment sessions were performed on an every other week schedule. Improvements were observed in the patient’s overall energy, attitude and level of relaxation.
Signalment and History
Toby is an 8 year old neutered male Rottweiler mix who is a companion animal and a trained therapy dog. Toby was rescued from the shelter when he was approximately 5 years old and has a history of severe allergic dermatitis, suspected previous trauma and malunion of a fracture in his right tibia as well as bilateral malformation of his coxofemoral joint with resultant degenerative joint disease (DJD). In addition to his hindlimb mobility issues, Toby also has had intermittent lameness of his left forelimb with suspected shoulder pain after he jumped out of a slowly moving vehicle while tethered by a harness approximately 2 years ago.
He has received courses of non-steroidal anti-inflammatory (NSAID) and pain medications in the past using carprofen and gabapentin for episodes of lameness. He does not currently take medication other than his flea and heartworm preventative.
Toby has demonstrated signs of both food allergies as well as atopy and has been managed with hypoallergenic diet, Cytopoint injections and increased bathing frequency. His pruritus level was low at the time of his initial assessment, but progressed over the course of the next several weeks with moderate pruritus noted at the time of his final assessment and treatment.
Toby has had a gradual, progressive decline of his mobility in his hindlimbs. His owners note that he is less engaged in play with the other dog in the household and that he has a hard time maintaining traction on hardwood floors and tile; they have added runner carpets throughout the house.
Toby has not previously received acupuncture, but the owners have had other pets treated using acupuncture for mobility issues, cardiac disease and suspected intervertebral disc disease (IVDD). The owners generally feel that acupuncture was beneficial for these pets.
Physical Exam
Bright, alert, responsive; mucous membranes pink and moist; body condition score 6/9
Eyes: corneas and anterior chambers clear, minimal discharge or conjunctival hyperemia observed
Ears: minimal discharge or erythema observed on external exam
Nose: no discharge observed
Teeth: slight tartar and calculus
Heart and Lungs: no murmurs or arrhythmias ausculted; no crackles or wheezes ausculted; strong synchronous femoral pulses
Abdomen: minimal pain response on palpation; no masses or fluid distension palpated
Musculoskeletal: ambulatory in all four limbs; mild atrophy of muscles in hindlimbs; subtle thickening and deviation of proximal right tibia, good range of motion (ROM) in tarsi and stifles, moderate decrease in ROM permitted in hips; minimal changes to palpation and ROM testing in forelimbs, slightly stiff gait in right pelvic limb with occasional bunny hop
Neurological: mentation appears appropriate; strongly ambulatory with no ataxia observed; no conscious proprioception deficits appreciated
Integumentary: full clean coat
Myofascial: mild increased tension in cervical spinal muscles, moderate increased tension in iliopsoas bilaterally; moderate tension also noted in interscapular dorsal spinal muscles
Review of x-rays performed 1/18/2016 reveal boney remodeling with thickening and mild deviation of the diaphyseal region of the right tibia, moderate coxofemoral joint malformation and mild to moderate evidence of degenerative joint disease of the coxofemoral joints.
Assessment
1) Hindlimb lameness – differential diagnoses (ddx) bilateral malformation of coxofemoral joint with secondary DJD, neurologic (lumbosacral disease, IVDD, degenerative myelopathy, neoplasia), soft tissue injury (sprain/strain, tendonitis), myofascial disease, secondary to malformation of right crus, neoplasia, infectious, vascular
Primary consideration is given to malformation of the coxofemoral joints with secondary progressive DJD due to his physical exam findings, previous x-ray changes and lack of neurologic signs
2) History of pruritic dermatitis with recent flare- ddx atopy, flare of food allergies, secondary to pyoderma, flea allergies, parasitic, fungal, immune, secondary to endocrinopathy
Primary consideration is given to flare with signs of atopy due to controlled dietary intake and current use of flea prevention combined with lack of evidence of ectoparasites, infections or alopecia
3) Intermittent lameness left forelimb – ddx secondary to trauma following jumping out of moving vehicle (neurologic (neuritis, neuropraxia, cervical-thoracic myelopathy) soft tissue injury (sprain/strain, tendonitis, ligamentous injury), occult fracture), DJD, neoplasia, infectious
4) Radiographic evidence of bony remodeling right crus – ddx previous traumatic fracture with malunion, congenital malformation, neoplasia, infectious
Plan
Acupuncture and massage treatments were discussed with primary goals to treat for pain associated with hip dysplasia, degenerative joint disease and previous trauma as well as encourage improved tissue repair and proprioception (Wright 2019, Lane and Hill 2016). Potential for immune system support and palliation of signs of allergic dermatitis was also discussed. Treatment sessions were scheduled every 2 weeks for 4-6 sessions performed in the owner’s home. These modalities were selected due to patient’s high tolerance for handling for needling and limitations of equipment availability. Recommendations were made to recheck x-rays of spine, shoulders, hips and stifles, especially if acutely progressive signs noted. Ongoing supportive treatments and maintained activity level with walking and hiking were encouraged.
Technique
Acupuncture #1 (8/15/19)
Seirin needles used throughout treatment protocol using a dry needling technique. Massage of epaxial, iliopsoas and serratus ventralis muscles performed using effleurage and petrissage for added benefit of muscle relaxation, decreased inflammation, improved tissue repair and relief of myofascial restriction in areas not utilized for concurrent needling. Additional massage was performed in areas of needling following their removal.
GV 14 – 0.20 x 30 mm; selected as initial test point, CNS input for thoracic limb pain, immune system regulation
Bai Hui – 0.20 x 30 mm; selected for pelvic limb pain, potential lumbosacral pain
Right BL 54, GB 29, GB 30 – 0.20 x 30 mm; selected for hip pain, local point for biceps femoris
Right ST 36 – 16 x 15 mm; selected for immune support, anti-inflammatory effects, neuromodulation, pelvic limb motility issues and for potential stifle pain or pain associated with previous trauma
Patient intermittently attempted to roll onto back throughout session; used leg to bolster patient along spine to maintain in left lateral recumbency; a slight response was noted with needle placement (turned to look, shifted position) and with episodes of increased stimulation during session associated with a child who was present and when another family member came home during the treatment.
Needles were in place for approximately 15 minutes before either falling out with patient movement or when removed by doctor.
Acupuncture #2 (8/29/19)
GV 14 – 0.20 x 30 mm
GV 20 – 0.20 x 15 mm; added point for relaxation
BL 12, BL 14 x 2 – 0.20 x 30 mm; added points for local trigger points, agitation and anxiety
GV 3 – 0.20 x 30 mm; added for lumbar pain and additional central input
Bai Hui – 0.20 x 30 mm
Left BL 54, GB 29, GB 30 – 0.20 x 30 mm
Left ST 36 – 0.16 x 15 mm
Patient tolerated needle placement well and maintained in lateral recumbency with brief episode of patient attempting to roll onto back. Improved relaxation was achieved during this session.
Needles were in place for approximately 20 minutes before removed by doctor.
Acupuncture #3 (9/19/19)
Massage performed today limited to caudal dorsal epaxial muscles to avoid areas which triggered pruritic response.
GV 14 – 0.20 x 30 mm
GV 20 – 0.20 x 15 mm
BL 12, BL 14 x 2 – 0.20 x 30 mm
Bai Hui – 0.20 x 30 mm
Right BL 54, GB 29, GB 30 – 0.14 x 30 mm
Right ST 36 – 0.20 x 30 mm
Right ST 34 – 0.20 x 30 mm; added for anti-pruritic effects, local pain
Patient tolerated needle placement well and maintained in lateral recumbency. Attempted palpation and brief needling at left SP 10 for additional anti-pruritic effects and local stifle pain, however access to point limited by patient positioning and unable to maintain needle placement. Patient significantly more relaxed during this session and was falling asleep at the end of the treatment.
Needles were in place for approximately 20 minutes before removed by doctor.
Follow-up gait-lateral perspective Follow-up gait
Discussion
Toby’s level of relaxation achieved during treatment sessions noticeably improved throughout the therapy. Stimulation from the environment likely contributed to agitation during the first session, although, generally the home setting provided a calm setting and decreased arousal. Subsequent improvement in relaxation could be attributed to additional points added for calming effects, improved overall level of sympathetic input or patient acclimatization to the treatments.
His owner reports that Toby seemed to have increased energy and enthusiasm for play over the subsequent 24 hours following his first session and feel that his mobility has generally benefited from these treatments. His pruritus level was still moderately increased following his most recent treatment. High airborne allergies current in the environment were likely contributing to this flare of his signs. Subjectively, it is harder to determine what effect each component of his therapy is playing in controlling these signs of pruritus due the variable nature of atopy.
We have discussed continued acupuncture treatments for Toby and would also consider the addition of electroacupuncture, cold laser therapy and physical therapy as well as medications and supplements to help manage his signs of degenerative joint disease and allergic dermatitis. Non-steroidal anti-inflammatories, periodic injections with Cytopoint and polysulfated glycosaminoglycan, omega fatty acids, cannabidiol, curcumin and glucosamine and chondroitin may provide synergistic effects in our ongoing treatment of his signs.
References
Wright, Bonnie D. “Acupuncture for the treatment of animal pain.” Vet Clin North Anim Pract. Sept 2019.
Lane, David M. and Sarah A. Hill. “Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain.” Can Vet J. April 2016. 57 (4):407-14.