Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019019
Abstract:
A total of three acupuncture treatments were performed on a 6-year old male castrated domestic shorthair (DSH) with a history of suspected inflammatory bowel disease (IBD), an intermittent right forelimb lameness and pain associated with the right elbow joint. Goals of acupuncture treatment were to reduce episodes of hyporexia and vomiting associated with gastrointestinal (GI) pathology, and to improve comfort of the right elbow joint as well as alleviate discomfort associated with compensatory gait patterns. After three consecutive weekly treatments of acupuncture in conjunction with manual massage and Gabapentin, the patient was noted to be significantly improved in terms of ambulation, overall comfort and GI well-being.
History and Presentation:
Mr. Kitty is a 6-year old male castrated DSH. He is kept indoors and shares his home with a 5-year old male castrated DSH and a 9-year old female spayed pit bull.
Mr. Kitty has a history of suspect IBD. In September of 2017, an abdominal exploratory surgery was performed following a 3-day history of vomiting, mixed bowel diarrhea and lethargy and several intestinal biopsies were performed. Histopathology of the biopsies was non-specific but no neoplastic cells or active infectious agents were noted, and treatment for suspect IBD was started. He is currently being treated with 1 milligram (mg) of oral Budesonide daily (every 24 hours), monthly subcutaneous injections of 25 micrograms (µg) vitamin B12, Maropitant 4-8 mg by mouth as needed, and a limited antigen diet (Hills feline Z/D). The patient is also regularly dewormed and is current on all vaccinations. Treatment has largely resolved the clinical signs but bouts of vomiting and hyporexia still occur approximately once monthly.
In October of 2018, Mr. Kitty’s guardian noticed that he was only bearing full weight on the left forelimb when walking down the stairs; his gait appeared normal when walking on flat ground. Two days later, she returned home to find that he had a grade II/IV right forelimb lameness. The next day, he presented to his primary veterinarian, where physical examination revealed a pain response on flexion of the right elbow joint. Mr. Kitty was prescribed 7 days of exercise restriction and 100 mg of Gabapentin up to three times daily as needed.
Mr. Kitty’s lameness initially resolved, but returned a few days after his restrictions were lifted. At this time, 3 cold laser treatments using a Class IV K-Laser were performed on three consecutive days; an additional treatment was performed the following week. The guardian reports that these four total cold laser treatments completely resolved his lameness for approximately 7 months, but within the past few weeks she has noted intermittent recurrence of the right forelimb lameness. Further diagnostics of the right forelimb (including radiographs) have not yet been performed. The owner’s goals are to improve the patient’s osteopathic pain and GI signs.
Physical Examination and Clinical Assessments:
Physical Examination:
General: (BCS) of 7/9 (overweight)
Skin: Mild bilateral hypotrichosis of lateral abdomen (recent abdominal ultrasound)
Eyes/Ears/Nose: Mild lenticular sclerosis in both eyes
Head/neck/throat: Symmetrical features with adequate musculature; see full exam below
Cardiovascular: No abnormalities are auscultated; pulses are strong and synchronous
Respiratory: There is normal rate and effort of respiration; no abnormalities auscultated
Dental: Permanent teeth; minimal dental calculus and moderate generalized gingivitis; comfortable on external palpation of the teeth
Gastrointestinal: No pain elicited on abdominal palpation; mildly thickened small intestine
Urinary: A small, soft and non-painful urinary bladder is palpated
Hemolymphatic: No abnormalities palpated
Musculoskeletal: Ambulatory x 4; abnormal gait (see below); symmetric musculature
Myofascial Palpation Evaluation:
Head: Normal facial features; no palpable myofascial abnormalities
Cervical region: Left-sided cervical range of motion (ROM) was mildly reduced. Several broad areas of bilateral myofascial restriction in the cervicothoracic region that palpated warmer than the surrounding tissue
Forelimbs: The right elbow joint was mildly thickened on the medial aspect as compared with the left elbow joint. ROM was found to be reduced in the right elbow joint, and the patient was resentful of gentle manipulation of this joint. Mild crepitus on flexion of the right elbow joint. Areas of moderate to severe myofascial restriction palpated in the carpal extensor muscles of the right antebrachium. All remaining joints are within normal limits.
Trunk: Tender to palpation of the right lateral thorax in the region of the latissimus dorsi muscle. Multiple trigger points palpated along the inner & outer Bladder Channel bilaterally
Hind limbs: No abnormalities found.
Neurologic Examination:
Mentation: Bright, alert and responsive; normal mentation
Gait/posture: Mild thoracolumbar lordosis. A very mild, grade I/IV lameness was noted in the right forelimb, especially prominent when descending stairs (steps down primarily with his left forelimb). The right forelimb is stiff in the swing phase of the gait. Mr. Kitty’s head moves upwards with weight bearing on the right forelimb.
Cranial nerves: No abnormalities are noted in relation to the cranial nerves.
Postural reactions: There is normal proprioceptive placement in all four limbs.
Reflexes: Myotatic reflexes could not be performed due to patient temperament. Flexor withdrawal reflexes and muscle mass/tone are normal in all limbs. The cutaneous trunci reflex is normal, and activated with gentle palpation of trigger points in the thoracolumbar and lumbosacral regions.
Pain/hyperesthesia: Possible hyperesthesia on left-sided cervical ROM as well as flexion of the right elbow joint and palpation of trigger points within the cervical, thoracolumbar and lumbosacral regions. Pain was also noted on gentle palpation of the latissimus dorsi muscle on the right lateral thorax.
Recent Labwork:
Blood work from 3/30/19 (Complete Blood Count, Chemistry Panel, SDMA, and thyroxine/T4) was within normal limits. Further diagnostics were declined at this time.
Problem List:
1. Overweight – BCS 7/9
2. Periodontal disease
3. Bilateral cervical myofascial restriction; pain elicited on left-sided ROM
4. Hyperesthesia of right latissimus dorsi muscle
5. Mild thoracolumbar lordosis
6. Grade I/IV right forelimb lameness; pain elicited on flexion of the right elbow joint
7. Multiple trigger points along the inner and outer Bladder Channel bilaterally
8. Intermittent vomiting, mixed bowel diarrhea & hyporexia with thickened small intestine
Differential Diagnoses:
1. Grade I/IV right forelimb lameness with hyperesthesia of the right elbow joint
a. Vascular: Vascular thrombus/Ischemic neuropathy
b. Infectious/Inflammatory: Septic arthritis, Osteomyelitis
c. Neoplastic: Osteosarcoma, Synovial cell sarcoma, Chondrosarcoma, Fibrosarcoma, Hemangiosarcoma, Lymphoma
d. Degenerative: Osteoarthritis, Elbow dysplasia
e. Iatrogenic/Intoxication: Nutritional osteopathy, Hypervitaminosis A
f. Congenital: Elbow joint incongruity
g. Autoimmune: Immune-mediated arthritis (Feline Progressive Polyarthritis, Systemic Lupus Erythematosus, etc.)
h. Traumatic: Fracture, Nerve damage
i. Endocrine/metabolic: Diabetic neuropathy
j. Myofascia: Compensatory changes secondary to gait abnormalities
2. Intermittent vomiting, diarrhea and hyporexia with mildly thickened small intestine
a. Vascular: Ischemic gastroenteropathy (example: foreign body, embolism)
b. Infectious/Inflammatory: IBD, Chronic pancreatitis, Parasitic enteropathy (helminths), Protozoal enteropathy (Tritrichomonas foetus), Viral enteropathy (coronavirus, FeLV, FIV), Bacterial enteritis (Salmonella, Campylobacter)
c. Neoplastic: Lymphoma, Adenocarcinoma
d. Degenerative: Chronic disease (renal, hepatic, pancreatic, etc.)
e. Iatrogenic/Intoxication: Partial gastric obstruction, Dietary indiscretion
f. Congenital: Sliding diaphragmatic hernia, hiatal hernia
g. Autoimmune: Food hypersensitivity
h. Traumatic: Traumatic diaphragmatic hernia
i. Endocrine/metabolic: Hyperthyroidism, Diabetes Mellitus, Renal failure
j. Myofascia: Increased sympathetic tone secondary to chronic myofascial restriction in the thoracolumbar and lumbosacral regions leading to altered GI mucosa
3. Cervical myofascial restriction and pain, hyperesthesia of the latissimus dorsi muscle on the right, and trigger points on the inner and outer Bladder Channel – suspected to be compensatory to the gait changes.
Putative/Definitive Diagnoses:
1. Right elbow osteoarthritis, possibly due to elbow dysplasia (other differentials considered less likely given clinical history, exam findings and available diagnostics)
2. Inflammatory Bowel Disease (other differentials considered less likely given chronicity, overweight body condition, physical exam, response to therapy and available diagnostics)
Medical Decision Making:
Possible differentials were discussed with the owner and additional diagnostics were recommended, including radiographs of the right elbow to rule out more serious causes of lameness. At this time, the owner declined further diagnostics and opted to continue symptomatic management of the patient’s clinical signs with the addition of acupuncture and manual massage. In lieu of a definitive diagnosis, acupuncture was instituted with the presumptive diagnoses of IBD and elbow osteoarthritis in mind. The owner was counseled to monitor for worsening of clinical signs and obtain further work-up if seen. Goals of acupuncture are to modify autonomic tone towards a more parasympathetic baseline to promote GI mucosal health and motility, promote immunomodulation and decrease osteopathic pain and wind-up associated with the patient’s elbow pathology.
Medical Acupuncture and Related Techniques:
VIDEO 1 6.4.2019 During Treatment 
Treatment #1 – June 4th, 2019:
Manual massage was performed before and after acupuncture treatment to loosen the myofascia and improve the patient’s comfort. Dry needling was then performed with Seirin J-Type red-handled (0.16mm x 30mm) coated needles and a tubed insertion. The following midline points were placed: GV20, GV14, GV4, Baihui. Bilateral points included: ST36, BL10, BL19, BL18, BL21, BL25, local trigger points in the cervical, thoracolumbar and lumbosacral regions.
VIDEO 3 6.11.2019 During Treatment
Treatment #2 – June 11th, 2019:
Treatment was the same as previous (manual massage and acupuncture), with the addition of the following bilateral points: SI11, SI12.
Treatment #3 – June 18th, 2019:
Treatment was the same as previous (manual massage and acupuncture), with the addition of Seirin J-Type blue handled (0.20 mm x 15mm) silicone coated needles with a tubed insertion and the following points: LU5, LI10, PC3 on right side
VIDEO 4 7.2.2019 Post-Treatment Video
Outcomes, Insights, Discussion:
Following just two acupuncture treatments in combination with daily Gabapentin, Mr. Kitty’s guardian reported significant improvement in mobility, especially evident when Mr. Kitty walked up and down stairs. Mr. Kitty began initiating play behaviors with his housemate cat for the first time in several years. After the third acupuncture treatment, Mr. Kitty was seen “bounding down the stairs,” something his guardian had not seen him ever do. Since the third acupuncture treatment, Mr. Kitty has had two additional treatments over the course of 2.5 months. While receiving acupuncture, manual massage and Gabapentin, Mr. Kitty has not had any episodes of hyporexia and vomiting. His appetite and energy level have been maintained. Mr. Kitty will receive acupuncture on an as-needed basis for the remainder of his life. Current treatments are about once per month.