Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2019001
Abstract: Troy, a 14-year-old male, neutered Labrador Retriever presented for progressive generalized reduction in mobility, as well as urine and fecal incontinence. Troy had been on carprofen, Dasuquin joint supplement, and gabapentin to manage his pain and mobility. He had also started Proin for urinary incontinence, which had initially been effective, but had stopped controlling symptoms over the last 2 months. Integrative treatment was aimed at improving comfort and mobility, as well as urinary and fecal incontinence. Over the course of a month, Troy’s owner reported improvement in his attitude and activity levels, as well as improvement in his incontinence.
History and Presentation: Troy, a neutered male 14-year-old Labrador Retriever presented for progressive reduction in mobility and worsening of urinary and fecal incontinence. He had been treated for an episode of acute pain localized to the hips with carprofen and tramadol in January 2017. During his exam, it was also noted that he had some muscle atrophy in the pelvic limbs. Gabapentin was started in place of tramadol later that year to better manage his discomfort.
In addition to mobility concerns, Troy also presented for urine and fecal incontinence. He had been prescribed Proin in May 2018 after lab work to rule-out other causes for the urinary accidents. Until July 2019, he had responded well to the Proin twice to three times daily, but suddenly started having break-through urinary accidents in the house. His fecal incontinence started in April 2019.
Troy suffered from atopic dermatitis chronically. He was diagnosed with a Grade II/VI left-sided systolic heart murmur in November 2018 prior to a dental procedure to address a fractured tooth. No medication was started for the heart murmur. Because of his incontinence, Troy had been kept mostly outside during the day, which likely contributed to worsening of his allergy symptoms and skin disease.
Physical Exam: Troy presented with an abnormal gait, demonstrating a wide-base stance in the forelimb and appeared to have a left hind limb lameness. He had kyphosis along the lumbar back and was reluctant to demonstrate full range of motion in the neck or pick up his tail. On myofascial palpation, he was very tender around his elbows, especially on the right, laterally. He had multiple trigger points along neck and back as well as generalized muscle tension in the lumbar epaxial muscles. There was generalized muscle atrophy of the hind limbs and along the spine, and he appeared tender to palpation around his stifles and hips.
On neurologic exam, he demonstrated bilateral cross extensor reflexes in the hind limbs. His conscious proprioception appeared to be intact. Troy generally kept his tail down during visits, only raising it when stimulated along the lateral aspects. On radiographs, there was significant boney remodeling around both elbow joints and the right femoral head. He had spondylosis present on T12, T13, L1-L3, L6 and sacral vertebrae. The heart murmur that had previously been auscultated was still present as a grade II/VI left-sided systolic murmur.
Problem List: Heart murmur, hind limb lameness, upper motor-neuron disease, fecal and urinary incontinence, atopic dermatitis, osteoarthritis in elbows bilaterally, degenerative joint disease right hip.
Pre-treatment video 9-27 3 weeks into treatment
Differentials: Incontinence (fecal and urinary) – V – Fibrocartilaginous emboli I – Urinary tract infection, Osteoarthritis N – Transitional cell carcinoma D – Lumbosacral disease, Degenerative joint disease I – Prolonged urinary retention C – Ectopic ureters A – Diabetes mellitus T – Vertebral fracture, Intervertebral disc disease E – Renal disease M – Compression of the pudendal or pelvic nerves.
Hind limb lameness – V – Fibrocartilaginous emboli I – Lyme disease, osteoarthritis N – Osteosarcoma D – Degenerative joint disease I – Overuse C – Cauda equina syndrome secondary to vertebral dysgenesis A – Immune mediated polyarthritis T – Cranial cruciate ligament rupture E – Hyperadrenocorticism, hypothyroidism M – Myofascial restriction of muscles in left hindlimb; compensatory strain pattern
Putative/Definitive diagnosis: Radiographs demonstrated lumbosacral disease. Marked boney remodeling of the femoral head of the right hind limb and elbows supported the diagnosis of degenerative joint disease. The left hind limb lameness may be a result of compensatory myofascial strain and restriction as a result of arthritis in the right hip. The lumbosacral disease likely contributed to the urinary and fecal incontinence. Infectious, metabolic, and endocrine diseases were unlikely based on lab work
Medical Decision Making: My approach to acupuncture was based on the owner’s primary concerns for Troy’s comfort and overall quality of life in the household. His fecal and urinary incontinence had led to him being kept outdoors, which was a major change in lifestyle for Troy, and contributed to worsening of his skin disease.
Timing and frequency of sessions was based on availability of the owner. At least two sessions per week were performed. For each session, a thorough myofascial exam was performed to help identify trigger points in addition to points selected for their autonomic neuromodulation. There were many points for acupuncture I wanted to use locally for hip, stifle, and elbow pain, but Troy was quite reactive to needling on his distal limbs.
I focused on acupuncture points to help address his urinary and fecal incontinence. I also chose points along the Bladder line in the lumbosacral region, hoping to neuromodulate the nerves innervating the limbs since I could not needle specifically around the stifles. Electroacupuncture was employed two weeks into the treatment period, which allowed me to cover more area with fewer needles. This was helpful to reduce Troy’s overall reactivity. Photobiomodulation (low-level laser therapy) was also employed to treat problem areas that I could not treat with needling, like his elbows, stifles and more extensively along his back.
Medical Acupuncture and Related Techniques Used: A combination of dry needling, electroacupuncture, massage, and low-level laser therapy were used to treat Troy over the course of a month. Troy’s owner had already been utilizing low-level laser treatments on the hips and stifles sporadically, so we aimed to perform it at least twice weekly, on the days he received acupuncture. Some weeks he received it three to four times, incorporating his elbows into the treatment since we could not needle around the elbows at each session.
Dry needle acupuncture was the basis of treatment for Troy’s problems initially. During the first treatment, needling around the elbows was done at LU 5, PC 3, LI 10, and HT 3. ST 36 and 35 were also used, along with Spleen 6 locally for the stifle and for autonomic neuromodulation. Additional Bladder line points were selected based on their neuromodulation for anorectal and bladder disorders. These included BL23, 25, 35. Needling of GV4 and the variation of GVT at the proximal third of the lateral tail completed the first acupuncture session. Troy tolerated the treatment well with the Seirin J type 0.16 x 30mm needles
GV 20 was used to help relax and calm Troy during each session, and GV14 was used for sympathetic neuromodulation. In later sessions, Troy was too reactive to needle the elbow points, so low-level laser therapy was used as the primary modality to neuromodulate the elbows. In addition to BL23, 25, and 35, BL27 and 28 were added to all future acupuncture sessions. Trigger points in the dorsal and lateral neck and caudal thoracic epaxial muscles were dry-needled. Seirin J type needles were used. Initially a combination of 0.16 x 30mm, 0.18 x 30mm, and 0.2 x 30mm needles were used at these points. As Troy allowed, the larger needles, 0.2 x 30mm needles, were used primarily at these points.
When electroacupuncture was started, BL28 was connected to BL23 bilaterally to help stimulate the lumbosacral nerve segments associated with bladder function, hind limb stimulation, anorectal function, as well as manage pain in the lumbosacral region. When tolerated, ST36 and either BL54 or GB29 were used for electroacupuncture of the stifle and hip. The electroacupuncture unit used was the Pantheon 8c Pro on a mixed setting, alternating between two and 100 hertz. The amplitude tolerated was between one and two, and sessions lasted 15 to 20 minutes, using the milliampere channels.
The low-level laser unit used was the Companion Class IV laser unit. Pre-sets were used for treating each region. For all the regions treated, the settings were for a 40- to 60-pound dog of average body condition, short coat, light skin color, light coat color. For the hips, the pulse rate was continuous, the power was eight watts, the energy was 2,520 joules, and the total treatment time was six and a half minutes. For the stifles, a continuous pulse rate was used, the power was seven watts, the energy was 2,520 joules, and the total treatment time was six minutes bilaterally. For the elbows, a continuous wave was used for the pulse rate, the energy was seven watts, the energy was 1,680 joules, and the treatment time was four minutes bilaterally. For the lumbar spine, a continuous wave was used for the pulse rate, the energy was eight watts, the energy was 2,760 joules, and the treatment time was five minutes and 45 seconds. When treating lumbar back, the technician would extend the treatment area to include the thoracic spine as well.
Massage was also employed prior to, during, and after the acupuncture sessions. Effleurage was used primarily before and after the sessions. Petrissage was utilized over the neck, shoulders, and elbows during the acupuncture sessions. This was done to help relax Troy before and after his acupuncture sessions. Massage helped with identifying areas of tension or discomfort and gave us another modality to neuromodulate the limbs.
Last treatment video pre-tx 10-11 Last treatment video post-tx 10-11
Outcomes: After the first acupuncture session, Troy’s fecal and urinary incontinence improved. His owner noted an improvement in his mobility over the first week, with Troy trying to jump into the car again. Towards the end of the week he lost his footing and fell back on his hips, leading to a regression in his continence and a decline in comfort and mobility. His lumbar kyphosis became more pronounced and he began to tuck his hind end, maintaining bent stifles when standing.
About a week after Troy’s fall, the incontinence improved. With electroacupuncture, Troy’s owner reported he began interacting more with the family, moving with more ease, and showing interest in trying to get up on the owners’ beds. When excited, Troy would sometimes trot and even wag his tail, which he had not done for quite some time.
For the urinary and fecal incontinence, the improvement was likely related to the acupuncture treatment. Stimulation of sacral nerves one, two, and three via BL 27, 28 influences the somatic function of the external bladder sphincter and the anal sphincter as well as increasing pelvic floor stability. The lack of response to low-level laser therapy was likely due to the sporadic, inconsistent treatments, as well as the inability to directly stimulate the pudendal and pelvic nerves.
Troy’s fall would that have impacted his comfort as well as increased inflammation within the lumbosacral spine, affecting his fecal and urinary continence. Although managing activity had been discussed and the owner had experience with this, she admittedly allowed Troy to do more than was advised especially at the beginning of the acupuncture treatments. Low-level laser therapy had helped reduce the inflammation and pain for Troy. By increasing the frequency, we achieved clinical improvement in his mobility and comfort. Acupuncture also helped to reduce inflammation by reducing sympathetic tone in the body. Points like ST36 were used to help increase parasympathetic tone, helping to balance the autonomic nervous system. GV 20 was also chosen to neuromodulate the autonomic nervous system, reflexing with the vagus nerve, helping to calm Troy, but also influencing abdominal organ function.
Addendum: While lumbosacral disease may have been a source of discomfort and exacerbation of the urinary and fecal incontinence issues, upper motor neuron disease was the most likely underlying cause for the incontinence. A fibrocartilaginous embolus or intervertebral disc disease should have been considered for differentials of the upper motor neuron disease. A few thoracic BL points were used during Troy’s treatments and low-level laser was performed over the whole back, but it would have been helpful to include more thoracic BL points to account for upper motor neuron disease when the exact location of the lesion is unknown. It’s important to take inventory of all the exam findings and try to get a diagnosis in order to make an appropriate treatment plan.
References:
Bianco, G. (2019). Fascial neuromodulation: an emerging concept linking acupuncture, fasciology, osteopathy and neuroscience. European Journal of Translational Myology, 29(3), 195–201. https://doi.org/10.4081/ejtm.2019.8331
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Wu, J., Cheng, Y., Qin, Z., Liu, X., & Liu, Z. (2018). Effects of Electroacupuncture on Bladder and Bowel Function in Patients with Transverse Myelitis: A Prospective Observational Study. Acupuncture in Medicine, 36(4), 261–266. https://doi.org/10.1136/acupmed-2016-011225
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