Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018045
Abstract
A ten year-old female spayed German Shepherd dog by the name of “Sonja” presented for persistent lameness of the right hindlimb and right forelimb, as well as weakness in the hind-limbs. The patient was treated with a combination of traditional medications, medical acupuncture, and medical massage. Over the course of six weeks, Sonja received five acupuncture treatments which resulted in increased quality of life, better mobility, and improved stamina.
History and Presentation
The patient, “Sonja,” is a 10-year-old female spayed German Shepherd dog with a history of chronic lameness of right forelimb and right hindlimb, dermatologic issues requiring medicated bathing and routine ear treatment, and anxiety. Sonja has had previous severe gastrointestinal reactions related to non-steroidal anti-inflammatory use. Radiographs of the coxofemoral joints, right stifle, and right elbow were performed in August 2017 at the time of an unrelated dermal mass removal. Radiographs showed significant right stifle effusion with osteophyte and enthesophyte proliferation, left acetabular roughening and mild osteophyte proliferation on left femoral head and neck, and right elbow osteophyte proliferation on radial head, anconeal process, and medial and lateral humeral epicondyles. Osteoarthritis and alternatives to NSAIDs were discussed with owners at that time and they elected to pursue treatment modalities outside of our clinic. Sonja was taken for underwater treadmill therapy at a different facility in an attempt to build muscle and make her more comfortable in the long term. These sessions were terminated in the fall of 2018 due to Sonja’s reluctance to get in the underwater treadmill. No records were provided for treatment sessions at the other facility.
At a recent appointment, Sonja was diagnosed with allergic moist dermatitis and otitis externa in her left ear, a possible complication of underwater treadmill therapy and incomplete drying. This led to further discussion of additional modalities with which to make the patient comfortable in regards to osteoarthritis, including gabapentin, tramadol, grapiprant, as well as acupuncture and laser therapy. Owners elected to treat skin condition and ears, as well as begin gabapentin and pursue acupuncture at this time. At time of initial acupuncture assessment and treatments, Sonja was receiving gabapentin (8.8mg/kg dosage twice daily), terbinafine (22mg/kg dosage once daily), in addition to owner supplementation of glucosamine, T-relief tablets (arnica), and turmeric of undisclosed origin and amount.
Physical Exam
Sonja presented bright, alert, and responsive, with a body condition score 7/9. Her ears were clear, with mildly hyperemic pinna noted. Sonja was noted to have a grade 4/5 lameness on the right forelimb and mild weakness noted in both hindlimbs. Right stifle showed medial buttress and stifle thickening was noted, though no cranial drawer sign elicited at time of exam. Sonja had decreased range of motion in both coxofemoral joints.
On neurologic exam, Sonja was ambulatory in all four limbs with a narrow-based stance of her hindlimbs and mild hindlimb paresis noted. Upon walking, slight scuffing of the hind paws was noted on the forward swing phase of the gait. Forelimb conscious proprioception was normal at time of initial assessment. Left hindlimb conscious proprioception was normal, while right hindlimb conscious proprioception was slightly delayed. Forelimb and hindlimb spinal reflexes were intact, with no crossed extensor or Babinski reflex noted in any limb. Anal tone and perineal reflex were intact, with no pain elicited on dorsoflexion of patient’s tail.
Myofascial palpation examination was performed, beginning over the patient’s face and head and working caudally. Tension was noted in the right masseter muscle, bilaterally at the level of Bladder 10, and throughout the right cervical musculature. The right thoracic limb contained tension in the biceps brachii. Paraspinal heat, sensitivity, and tension were palpable at the level of the thoracolumbar junction. The pelvic limbs displayed tension in both hamstring muscle groups. No pertinent myofascial findings were noted in the abdominal wall and intercostal musculature.
Problem List
1. Right forelimb lameness
2. Right hindlimb lameness
3. Pelvic limb weakness
4. Atopy
5. Generalized anxiety
Differential Diagnoses
1. Right forelimb lameness
a. Vascular – ischemic myositis
b. Infectious – fungal osteomyelitis, rickettsial polyarthropathy
c. Neoplastic – osteosarcoma, chondrosarcoma
d. Degenerative – osteoarthritis
e. Iatrogenic – fluoroquinolone-induced cartilage damage
f. Congenital – elbow dysplasia, ununited anconeal process
g. Autoimmune – immune-mediated polyarthritis
h. Traumatic – fracture, dislocation
i. Metabolic – nutritional deficiencies
j. Myofascial – radial nerve entrapment, trigger points within thoracic limb musculature
2. Right hindlimb lameness
a. Vascular – fibrocartilaginous embolism
b. Infectious – fungal osteomyelitis, rickettsial polyarthropathy
c. Neoplastic – osteosarcoma, chondrosarcoma
d. Degenerative – osteoarthritis, degenerative myelopathy
e. Iatrogenic – fluoroquinolone-induced cartilage damage
f. Congenital – hip dysplasia
g. Autoimmune – immune-mediated polyarthritis
h. Traumatic – fracture, cranial cruciate ligament damage
i. Metabolic – nutritional deficiencies
j. Myofascial – trigger point pathology in hamstrings or quadriceps
Definitive Diagnoses
Osteoarthritis is the putative diagnosis of the right elbow, right stifle, and left coxofemoral joint based on previously described radiographic evidence and current examination findings. There is no evidence of osteomyelitis, neoplasia, fracture, or dislocation on radiographs. Patient’s history does not support fluoroquinolone use or nutritional deficiencies. Laboratory results do not support rickettsial disease or immune-mediated conditions. Physical exam findings indicate trigger points consistent with lameness, but do not support generalized myositis or nerve entrapment.
Medical Decision Making
Sonja’s treatment protocol consisted of both acupuncture weekly and medical massage therapy. Based on the physical exam, radiographs, neurologic exam, and myofascial exam, I elected to focus neuromodulation on the right elbow, right stifle, left coxofemoral joint, and associated spinal cord segments, along with strain patterns noted on myofascial exam as tolerated. I went into each appointment with “goal” points and allowed her comfort and positioning designate which points were placed. At her first appointment, I utilized points I felt were important, yet limited my number of needles to allow for a positive experience. The following treatments utilized more needles, though depending on Sonja’s positioning, not all areas were able to be treated at any one time, therefore each local area was targeted on different treatment days. I was able to place Bladder points associated with desired spinal cord segments at each treatment.
Medical Acupuncture and Related Techniques Performed
Sonja received five acupuncture treatments, focusing on central, peripheral, and autonomic nervous system, and myofascial palpation findings at each visit. The first four treatments were performed each a week apart and the fifth treatment performed two weeks after the fourth. Each treatment performed was limited to dry needling and medical massage. Electroacupuncture was unavailable.
1. SEIRIN needles, 0.16mm in diameter, 30mm in length were used for Sonja’s first treatment. A total of 13 points were used to keep the patient’s experience brief and positive.
a. Autonomic and central nervous system points – Bai Hui, GV 14, GV 20, LI 4 (left) and ST 36 (both left and right)
b. Peripheral nervous system points to left coxofemoral joint – BL 54, GB 29, GB 30.
c. Peripheral nervous system points to right elbow – LI 10, LI 11
d. Peripheral nervous system points to right stifle – ST 36, ST 34
e. Myofascial strain pattern points – SI 11, SI 12 (right)
2. SEIRIN needles, 0.20mm in diameter, 30mm in length were used for Sonja’s following treatments. Points varied between the treatments based on patient positioning and patience for treatment at that particular session.
a. Autonomic nervous system points – GV 20, GV 14, Bai Hui, ST 36 (bilaterally), and frequently LI 4 (bilaterally)
b. Central nervous system points – BL 11, BL 12, BL 13, BL 14 (right) to influence spinal cord segments associated with the right elbow; BL 23, BL25, BL 27, BL 28 (bilaterally) to influence spinal cord segments associated with pelvic limbs.
c. Peripheral nervous system points associated with left coxofemoral joint – BL 54, GB 29, GB 30 (left).
d. Peripheral nervous system points associated with right stifle – SP 9, SP 10, ST 34, ST 36, BL 40 (right).
e. Peripheral nervous system points associated with right elbow – LI 4, LI 10, LI 11, LU 5, HT 3, PC 3 (right)
f. Myofascial trigger points – BL 10 (bilaterally) for palpable cervical tension, BL 19, BL 20, BL 21 (bilaterally) for sensitivity and heat over thoracolumbar epaxials
g. Additional points and their influences used included LU 7 and BL 40, bilaterally. Placement of LU 7 was performed due to patient’s dermatitis problems. In addition to providing local influence to the stifle, BL 40 also contributed the added benefit of influencing proprioception and balance in the patient’s hindlimbs.
h. Medical massage therapy focused on the paraspinal muscles of the caudal thoracic and cranial lumbar region was also pursued during each session, after the removal of acupuncture needles. Effleurage and petrissage techniques were performed and demonstrated to the owners, with the instructions to perform massage at home each evening as Sonja was resting.
Outcomes and Discussion
Sonja became more comfortable and less anxious over the course of her treatment, particularly when weekly treatments were administered. Owners reported that following each treatment the patient would become tired and sore for a period of 24 hours. After the initial 24 hours, the owners perceived Sonja’s attitude much improved, she moved with greater ease and fewer stumbling episodes and was more willing to move readily about the home to be with her family. In observing her gait following four treatments, she ambulated more easily, had fewer observed instances of stumbling on her right forelimb, and was able to lay and rise more quickly with less discomfort. In addition, on follow up myofascial palpation, Sonja had less cervical muscular tension following her series of weekly treatments. At Sonja’s most recent visit, her thoracolumbar epaxials were notably less sensitive than at previous visits.
Sonja’s treatments have led to greater comfort and relief for her. While no treatment will achieve complete pain relief for her osteoarthritis, acupuncture has made a difference in her quality of life. She is receiving other medications and supplements to help with her pain and inflammation, however, these medications were used prior to acupuncture treatments with no considerable changes to the patient’s gait, stiffness, and mobility. Sonja’s owners report that underwater treadmill therapy made a difference in her comfort in the past, but when she became non-compliant they discontinued therapy. According to her owner, acupuncture has a better impact on Sonja’s comfort and mobility, without the added stressors of anxiety, non-compliance, and moist dermatitis.
Medical massage also contributed to Sonja’s comfort in between sessions. I performed massage techniques on her epaxials at each session and her owners were diligent about nightly massage with her at home. Sonja both enjoyed and benefitted from massage, likely extending the amount of time she was comfortable between treatments.
Sonja’s case taught me that even the most anxious of patients can become very accepting and even eager for acupuncture treatments. After two treatments, she began to run into our physical therapy room and wait patiently on the mats where she receives her treatments. This experience also taught me that patients with chronic, long term pain can respond favorably to treatments, even when pharmaceuticals and other techniques have made only a small difference in the past.
For the future, I would like to see how electroacupuncture impacts Sonja in her treatments, particularly along the spinal segments related to the right thoracic and right pelvic limbs. It was not used in her treatments as I have had a difficult time convincing our clinic to purchase a device. I also believe Sonja would benefit from long term weekly treatments, rather than waiting two weeks between treatments. She tends to become slow and more painful about day 10 post-treatment, rather than being comfortable the entire time between treatments. I hope to continue her regular treatments to keep her comfortable and less anxious throughout the remainder of her life.
References
Zhang Q., Yue J., Golianu B., Sun Z., Lu Y. (2017 Dec). “Updated systematic review and meta-analysis of acupuncture for chronic knee pain.” Acupuncture in medicine: Journal of the British Medical Acupuncture Society, Vol. 35(6), pg 392-403. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29117967.
Manyanga T., Froese M., Zarychanski R.,Abou-Setta A., Friesen C., Tennenhouse M., Shay B. (2014 Aug 23). “Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis.” BMC Complementary and Alternative Medicine, Vol. 14. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158087/