Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2019024
Abstract: “ZaZA,” a 14 year old FS SiameseX presented for evaluation of abnormal gait and change in behavior at home. “ZaZa” had her left forelimb amputated as a kitten and has a history of paralysis in her hind-end due to unknown causes. Myofascial examination of the patient showed cervical neck pain, back pain, and neurologic deficits in the right pelvic limb. After 4 weekly sessions of acupuncture and laser therapy, the owner reports a significant improvement in mobility and increased socialization.
History and Presentation: “ZaZa” is an approximately 14 year old spayed female Siamese cross that was found as a stray when she was a young adult in 2010. Previous veterinary records note that she was unable to use her left front leg at that time, but do not describe exam findings or radiographs. The owner states that the patient had her left front leg amputated without complication. The patient has a history of chronic gastrointestinal upset (occasional vomiting and diarrhea) which responds to hypoallergenic diet and steroids (oral prednisolone). Recent comprehensive blood work in December 2018 did not show any abnormalities and the patient is FeLV/FIV/HWT negative. The owner states that “ZaZa” is typically a very social, interactive cat and has no notable behavioral vices such as biting, inappropriate elimination or otherwise.
“ZaZa” has had two previous episodes of musculoskeletal dysfunction. In July of 2017, the owner states that the patient became unsteady in the hind end. Previous veterinary records indicate the patient was standing with a hunched posture but no pain noted and radiographs of the spine do not show any abnormalities. The patient was treated with prednisolone and gabapentin and the owner states that the patient improved, but never completely returned to normal. Two months later, in September of 2017, the patient was noted to be stumbling and falling over her right front leg, at which point veterinary records indicate that “ZaZa” had pain in her right stifle. Radiographs of the stifle are noted to be normal and the patient was treated with rimadyl and methocarbamol. Owner states that the patient moderately improved with therapy but her ability to normally ambulate waxes and wanes.
The owner states that “ZaZa” is currently unable to walk more than 2-3 paces without falling and uses walls and other furniture to help balance herself while moving around the house. The patient has also begun to isolate herself, often sleeping in unoccupied rooms and is no longer eager to jump onto couches and beds. The owner would like to help improve the patient’s mobility as well as help control any potential pain the patient is experiencing.
Physical Examination and Clinical Assessment: On presentation, the patient is extremely bright, interactive, and mentally appropriate. The patient is euhydrated with a normal heart and respiratory rate and no abnormalities found on chest auscultation or abdominal and lymph node palpation. The owner notes no changes in eating, drinking or litter box habits. The patient receives daily Cosequin chews and is current on flea/tick prevention.
The patient exhibits moderate kyphosis, a wide-based stance in the hind end and is unable to walk a substantial distance without falling over (see Video 1). A complete gait analysis is difficult to perform due to the patient’s inability to consistently ambulate. It is difficult to discern if the patient’s dysfunction is due to ataxia or restrictive motion due to pain. The left scapula is still present after the forelimb amputation with severe muscle atrophy of the infra- and supraspinatus muscles and severe prominence of the scapular spine. The patient had taut muscle bands in the trapezius muscles lateral to the cervical vertebrae (right side is more tender to palpation than the left). The patient exhibits a pedal reflex every time the neck is palpated and the owner reports the patient has done this for many years. There was no resistance noted on passive range of motion exercises of the neck. There is moderate heat appreciated on spinal palpation extending from T13-L4. The patient is resistant to caudal extension of the right hip but no obvious trigger points appreciated.
The cranial nerve exam is within normal limits with no deficiencies noted. Hopping test performed on the right front limb showed an inability for the patient to properly place the limb. The cutaneous trunci reflex was normal bilaterally, withdrawal reflex present in all three limbs, and patellar reflex was normal in both hind limbs. Conscious proprioception was delayed in only the right hind limb.
The owner declined further diagnostics such as bloodwork or radiographs due to previous tests showing no abnormalities.
Problem List:
1. Inability to ambulate
2. Neurologic deficits to right hind limb
3. Kyphosis
4. Cervical neck pain
5. Thoracolumbar pain
Differential diagnosis:
Inability to ambulate
• Vascular – fibrocartilaginous embolus
• Infectious/Inflammatory – calicivirus polyarthropathy
• Neoplastic – osteosarcoma
• Degenerative – degenerative joint disease (DJD)
• Iatrogenic/Intoxication – previous medical therapies (NSAID vs steroids) causing weakness due to kidney disease
• Congenital – hydrocephalus
• Autoimmune – immune-mediated polyarthritis
• Traumatic – hit by car
• Endocrine/Metabolic – DKA
• Myofascia – pain in epaxial muscles
Neurologic deficits to right hind limb
• Vascular – saddle thrombus
• Infectious/Inflammatory – toxoplasmosis
• Neoplastic – spinal cord tumor
• Degenerative – degenerative joint disease (osteoarthritis in hip)
• Iatrogenic/Intoxication – rat poison ingestion (bromethalin)
• Congenital – limb malformation
• Autoimmune – immune-mediated polyarthritis
• Traumatic – falling injury
• Endocrine/Metabolic – diabetic neuropathy
• Myofascia – nerve entrapment
Medical Decision Making: The main goal of treatment was to improve “ZaZa’s” quality of life by increasing mobility and decreasing pain. Her cervical neck and thoraco-lumbar back pain is likely a secondary compensatory injury from a chronic altered gait. It was discussed with the owner that managing “ZaZa” with acupuncture and laser therapy to decrease pain will consequentially lead to increased mobility.
Medical Acupuncture and Related Techniques: All needles used for acupuncture were Seirin J-type 0.12 mm x 15 mm.
08/05/2019 – “ZaZa” was extremely amendable to acupuncture and laser therapy treatment, with the exception of neck points which elicited a strong pedal reflex. GV20 was used for relaxation. GV14 was used for neck and right front limb pain. SI11 and SI12 were used on the right side to help with maintaining muscle control for movement of the right front leg. Bladder points were used along the dorsum to correspond with trigger points and heat – BL21, BL23, BL25, BL27, BL28 bilaterally. BaiHui was used for overall pelvic pain. ST36 and bafeng were used on the right hind to help with neurologic dysfunction. The MLS laser therapy system was used on a chronic pain setting along the left and right neck.
08/19/2019 – The owner reported that “ZaZa” had a substantial improvement in mobility and was found spending more time in rooms occupied by the family (owner noted “ZaZa” started to improve 24 hours after first treatment). The previous points were repeated, as well as LI15 and TH15 were placed bilaterally for neck pain as P was significantly less reactive to myofascial palpation of the neck. The MLS laser therapy system was used on a chronic pain setting along the left and right neck.
09/02/2019 – The owner reported that “ZaZa” is 75% improved with mobility and is becoming increasingly social. The same points that were used on 08/19 visit were repeated. The MLS laser therapy system was used on a chronic pain setting along the left and right neck.
Outcomes, Insights, and Discussions: “ZaZa” was a rewarding case because the results affected the patient’s overall quality of life in such a positive manner. The owner reported that after the three sessions, “ZaZa” had returned to normal socialization behaviors and continued to become more agile. After the initial 4 weekly sessions, “ZaZa” has continued to return monthly for acupuncture sessions and has remained comfortable and mobile.
The laser was extremely beneficial to helping control the pain that “ZaZa” was experiencing in her neck. Initially, “ZaZa” was extremely reactive to any type of palpation of her neck and the laser allowed to decrease inflammation and associated pain without requiring contact.
Taylor, P. M., & Robertson, S. A. (2004). Pain management in cats—past, present and future. Part 1. The cat is unique. Journal of Feline Medicine and Surgery, 6(5), 313–320.
Choi, K. H., & Hill, S. A. (2009). Acupuncture treatment for feline multifocal intervertebral disc disease. Journal of Feline Medicine and Surgery, 11(8), 706–710.