Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2019004
Abstract: Zoey is a geriatric boxer mix with chronic right hindlimb lameness for the past six years. Her lameness never completely resolved with non-steroidal anti-inflammatories, joint supplements and rest and proceeded to get worse as she aged. A series of acupuncture and photobiomodulation sessions were started this fall in which her mobility began to improve after a few treatments.
History and Presentation: Zoey is a 10-year-old spayed female Boxer mix with a history of chronic lameness. In April 2013, Zoey was chased by the neighbor’s dog where she fell in the driveway and started limping on her right hind leg. At that time her veterinarian suspected a right cranial cruciate ligament tear. She was treated with Rimadyl for several months and placed on exercise restriction; no radiographs were performed at that time. In August of that year, her owner reported she was still sore and was intermittently giving her Rimadyl when she felt like she needed it. At that visit, her veterinarian then switched her to Metacam and recommended a joint supplement, Phycox, along with continued rest. Zoey seemed to improve in her owner’s eyes but at her yearly wellness exam in June 2015 she was noted to have bilateral medial buttress in both her stifles along with continued tenderness in her right hip and stifle. Her owner was only administering Metacam at half her daily dose and allowed Zoey to gain over ten pounds. Zoey continued to have lameness flare ups over the next few years along with occasional allergies and ear infections. Her owner would refill Metacam as needed but would not give it to her on a regular basis and had discontinued Phycox. At her most recent physical exam it was discussed trying acupuncture and photobiomodulation for her lameness as her owner did not want to pursue surgery, additional diagnostics, or referral.
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Physical Examination and Clinical Assessments: On physical exam, Zoey was noted to have a BCS of 7.5/9. She had moderate dental tartar and several missing incisors. Her eyes had mild lenticular sclerosis and left ear had a mild amount of black pruritic otic debris from a previously diagnosed otic yeast infection. She had a few previously diagnosed lipomas on her sternum along with a few dermal papillomas on her face. Her neurologic exam was unremarkable; no delayed conscious proprioception, extensor withdrawal reflexes, or ataxia were seen. Patellar reflexes were also normal. Bilateral lumbar muscular hypertrophy was noted along with pronounced bilateral medial buttress in both stifles. Cranial drawers could not be elicited in Zoey without sedation. On myofascial palpation, Zoey had several changes. She had multiple taut bands in her dorsal cervical muscles along with taut bands in bilateral biceps, triceps and pectoral muscles which is suspected compensatory changes from her hindlimb pain. She also had a weight bearing lameness in her right front leg. There was myofascial restriction from L1-L7 and in her bilateral quadriceps muscles. There was kyphosis noted around L5-L6. She had decreased range of motion in her right coxofermoral joint and bilateral stifles with notable weightbearing lameness in both hindlimbs. When sitting, she would sit with both her hindlimbs abducted at the pelvis and could not get comfortable in the exam room.
Problem List: Stage 3 dental disease, left ear infection, multiple lipomas, bilateral lenticular sclerosis, right front lameness, right rear lameness, left rear lameness, lumbar and quadriceps myofascial restriction
Differential List for Top Two Problems:
| Right Front Lameness | Right Rear Lameness | ||
| Vascular | Septic Arthritis | Vascular | Septic Arthritis |
| Infectious/Inflammatory | Lyme Disease | Infectious/Inflammatory | Lyme Disease |
| Neoplastic | Osteosarcoma | Neoplastic | Osteosarcoma |
| Degenerative | Degenerative Joint Disease | Degenerative | Degenerative Joint Disease |
| Iatrogenic/Intoxication | Overuse | Iatrogenic/Intoxication | Overuse |
| Congenital | Elbow Dysplasia | Congenital | Hip Dysplasia |
| Autoimmune | Immune-Mediated Polyarthritis | Autoimmune | Immune-Mediated Polyarthritis |
| Traumatic | Biceps Tendon Strain | Traumatic | Iliopsoas strain |
| Endocrine/Metabolic | Hypothyroidism | Endocrine/Metabolic | Hypothyroidism |
| Myofascia | Myofascial Restriction | Myofascia | Myofascial Restriction |
Putative Diagnosis: For the right front lameness, the putative diagnosis is a compensatory biceps tendon strain, degenerative joint disease, hypothyroidism and/or myofascial restriction. Septic arthritis seems unlikely due to the duration of the lameness and the fact that she’s afebrile. Lyme disease is less likely as she was tested in 2013 and has since been on a Seresto collar but it cannot be completely ruled out. Osteosarcoma is also less likely due to the duration of lameness and there were not any palpable bony masses but cannot be ruled out without radiographs. Overuse injury is a possibility but there is no history of overexertion, running or hard play since she mostly lays on the couch all day. Elbow dysplasia is not likely due to the onset of the lameness being much later in life. Immune-mediated polyarthritis is less likely since there is no palpable effusion in her joints, no fever and no lymphadenopathy. Hypothyroidism is a possibility due to her age and weight gain; senior bloodwork should be performed if owner will consent. Myofascial restriction could be a contributing factor to her lameness as well. For the right rear lameness, the putative diagnosis is iliopsoas strain, degenerative joint disease, hypothyroidism and/or myofascial restriction. Septic arthritis is unlikely due to the duration and the fact she is afebrile. Lyme disease is less likely since she has been on Seresto and tested negative a few years ago but it cannot be completely ruled out. Degenerative joint disease is a possibility due to her age and chronicity of lameness. Overuse is a possibility but unlikely since she has no history of overexertion and does not get routine exercise. Hip dysplasia is less likely due to the onset of lameness, but radiographs have not been performed to completely rule it out. Immune-mediated polyarthritis is less likely since there is no palpable effusion and no systemic clinical signs such as fever. Iliopsoas strain is possible since there is a history of trauma when she was a young adult dog which has not resolved. Hypothyroidism cannot be rule out since she is older and has a history of weight gain; bloodwork is recommended but owner did not want to pursue. Myofascial restriction could also be contributing to her cause of lameness.
Medical Decision Making: When Zoey was examined, a multitude of problems were noticed and unfortunately no additional diagnostics such as vector-borne screening, senior bloodwork, or radiographs were performed due to financial limitations. Zoey had not been on any medications or supplements recently. She was prescribed meloxicam and Dasuquin daily to help get her more comfortable while starting her integrative medicine. It was recommended to start with a series of acupuncture treatments in combination with photobiomodulation for each treatment session. Zoey was treated on week one, two and four with both acupuncture and photobiomodulation. Originally Zoey was scheduled to receive treatment once a week consecutively for three sessions but there was an early winter snowstorm which resulted in her owner needing to reschedule her last session. Point selection was targeted to obtain the most neuromodulation possible with the least number of needles since Zoey tends to have anxiety at the clinic. For her treatment plan, the central and autonomic points were needled first, followed by peripheral if tolerated, and finished with photobiomodulation for the areas that acupuncture was not well received. For most treatments, Zoey would let the needles stay in about five minutes on average before she would move or shake them out but tolerated the laser therapy treatments in their entirety.
Medical Acupuncture and Related Techniques: For the first treatment session, the treatment goal was to not overdo it while also getting the most neuromodulation possible since Zoey was very anxious. To start, a Seirin 0.16×15 at GV20 was placed as a central and autonomic point for agitation. Then, a Seirin 0.2×30 at GV 14 was placed as a central and autonomic point for cervical and thoracic limb pain. Next, a Seirin 0.2 x30 at BaiHui was placed as a central and autonomic point for pelvic limb pain. A series of Seirin 0.2×30 at BL23 and BL22 were placed as central points for lumbar pain. Since she was tolerating treatment well, a few cervical points with Seirin 0.2×30 in some of the taut band trigger points were placed. The last point selected was a left ST36 using Seirin 0.2×30 as a peripheral and autonomic point for stifle pain. Ideally a right ST 36 would have been placed as well but Zoey would not tolerate sitting or standing long enough to make this point accessible. At this point, Zoey was getting restless, so no additional needles were placed. The needles were left in for approximately five to ten minutes. After the needles were removed, the therapeutic laser was for additional anti-inflammatory effects and pain relief in the areas of myofascial restriction and pain with which Zoey would not allow acupuncture. A Companion Animal Health CTX-IQ laser with a contact head was used for her treatments. Photobiomodulation was applied to the lumbar spine 5:00 minutes, 12 Watts, 3600 Joules; bilateral stifles 5:00 minutes, 12Watts, 3600 Joules; and bilateral hips 5:04 minutes, 12 Watts, 3648 Joules. At the end of Zoey’s first session, massage of her cervical, lumbar, and quadricep muscles were performed to relax the taut muscle bands and myofascial restriction that had developed over the years. For her second, Zoey had less kyphosis in her L5 region but still had a noticeable haircoat change in her lumbar spine and quadriceps muscles. The second treatment was very similar to the first treatment but BL13, BL14, BL15 were added to get additional central points for the compensatory thoracic limb lameness. The needles were changed from Seirin 0.2×30 to Carbo 0.2×25 to get better tissue grab allowing the needles to stay in longer if Zoey moved which worked well. For the last treatment, the second session’s treatment was repeated but BL40 was added as a peripheral point for pelvic limb pain. This peripheral point was selected because Zoey did not tolerate ST36 for very long in any of the treatments but tolerated BL40 well.
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Discussion and Outcome: Acupuncture and photobiomodulation have made an improvement in Zoey’s pain and has improved her quality of life. Following the first treatment, her owner reported that Zoey was trying to jump on the bed again, playing with her housemates, and chasing the neighbors dogs up and down the fence which she had not done in many years. On her exam, it was noted she was less kyphotic and seemed more comfortable during her treatment. After her second session, her owner reported she was playing with her housemates even more and getting out her toys. At her last appointment, Zoey’s kyphosis was less noticeable, and she was less anxious and very comfortable during her treatment. While she still had some myofascial restriction especially in her lumbar region, it was less pronounced. The goal for Zoey would be to continue doing treatments and focus more on her bilateral stifle pain if she will tolerate the needles being placed in those areas. The acupuncture, photobiomodulation, and massage helped release some of the myofascial restriction in her cervical and cranial lumbar spine allowing her to ambulate better and with less pain. Adding the laser therapy also helped penetrate the deeper tissues in areas such as her stifles and caudal lumbar spine that she would not allow to be needled. Following her last session her owner was inquiring about continuing treatments due to the improvement she has seen with just acupuncture, photobiomodulation, and massage. Her owner had not been giving her meloxicam or Dasuquin as previously discussed, nor does it seem like she will. What was learned from this case was to not assume a hindlimb lameness is always a cruciate tear and that frequently there are compensatory biomechanical changes resulting from an injury. It has been known that Zoey had a chronic right hindlimb lameness for many years but looking more closely, she was lame and/or painful on most aspects of her body. By performing acupuncture, photobiomodulation, and massage these types of patients with chronic pain can be provided some immediate relief without having to take routine medication and risk metabolic changes. With more treatment sessions and getting Zoey started on Dasuquin and physical therapy the goal is to get her even more comfortable. If the owner would allow for additional testing a senior profile and vector screening would be beneficial to rule out hypothyroidism and Lyme disease. Hopefully her owner will schedule her additional appointments now that she has noticed the improvements at home.
References:
Lane, D. M., & Hill, S. A. (2016). Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain. The Canadian veterinary journal = La revue veterinaire canadienne, 57(4), 407–414.
Weight, B.D. (2019). Acupuncture for the treatment of animal pain. The Veterinary clinics of North America. Small animal practice. 49(6), 1029-1039.