Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2019024
Abstract: “Edith,” a 6 year old female Saanen presented for evaluation after conventional therapies had not helped with full recovery from meningeal worm infection. On initial presentation, “Edith” was unable to rise without assistance and was unable to stand for prolonged periods without the help of a sling. The patient was treated with acupuncture, laser therapy and underwater treadmill sessions and can now rise and ambulate independently.
History and Presentation: “Edith” is a 6 year old female Saanen that was born and raised on the owner’s farm with no history of previous illnesses and is maintained on yearly vaccinations of CD&T and rabies. The patient lives in a closed herd of five other goats on ¼ acre pasture with access to a run-in shed.
In July of 2019, the owner states that she found “Edith” acutely down in the pasture but was still bright, alert and eating/drinking. The owner’s veterinarian diagnosed the patient with meningeal worm and prescribed ivermectin, fenbendazole, and a tapering dose of dexamethasone. The owner states that the patient minimally improved and would require assistance rising and standing. The owner moved “Edith” to her own stall in her horse barn for closer monitoring and rehabilitation where she would frequently lift the patient, slinging her hind end and performing range of motion exercises. The patient would occasionally be found standing on her own but required help the majority of the time. Despite having free access to an individual pasture, “Edith” wouldn’t go out to graze even with coaxing. The owner explored other therapies, such as acupuncture, as she felt “Edith’s” quality of life was poor and wanted to increase her chance of recovery.
Physical Examination and Clinical Assessment: On presentation, the patient was bright and alert, despite being unable to rise from a sternal laying position. The patient was euhydrated, FAMACHA score 1/5, normal heart and respiratory rates and no abnormalities found on chest auscultation or lymph node palpation. The patient appeared to be moderately underweight with a body condition score of 3/9. The patient was in an appropriately bedded, clean stall and did not show any evidence of pressure sores. The owner reported that the patient eagerly eats grain and hay and will drink when the bucket is within reach. The patient was currently receiving ½ of a phenylbutazone tablet once daily.
The majority of the myofascial exam was performed with the patient in sternal recumbency. The cranial nerve exam was within normal limits with no deficiencies noted. There was a severe pain response elicited on palpation of the neck bilaterally. There was marked muscle wasting along the spine (epaxial muscles) and both hind limbs. There was heat appreciated in the caudal lumbar spine (L4-L6). The patient was not cooperative for a standing myofascial exam but it could be determined that withdrawal reflexes were normal in all four limbs and the cutaneous truni reflex became mildly depressed caudal to L3. There was kyphosis and her hind legs were tucked underneath her.
Problem List:
1. Unable to rise/stand unassisted
2. Neck pain
3. Lumbar back pain
4. Abnormal gait
Differential diagnosis:
Unable to rise/stand unassisted
• Vascular – thromboembolism
• Infectious/Inflammatory – meningeal worm
• Neoplastic – spinal tumor
• Degenerative – muscle wasting/weakness secondary to Johne’s
• Iatrogenic/Intoxication – kidney disease secondary to repeated NSAID administration
• Congenital – limb deformity
• Autoimmune – immune-mediated polyarthritis
• Traumatic – spinal damage
• Endocrine/Metabolic – selenium deficiency
• Myofascia – severe epaxial muscle wasting/degeneration
Neck pain
• Vascular – thromboembolism
• Infectious/Inflammatory – CAE
• Neoplastic – spinal tumor
• Degenerative – degenerative joint disease (cervical vertebrae arthritis)
• Iatrogenic/Intoxication – neck pain secondary to injections (intramuscular dexamethasone)
• Congenital – cervical neck deformity
• Autoimmune – immune-mediated polyarthritis
• Traumatic – injury from pasture mate
• Endocrine/Metabolic – ketosis
• Myofascia – trapezius muscle pain
Medical Decision Making: The patient was refractory to most of the initial examination, which the owner believes is secondary to the repeated injections of ivermectin and dexamethasone required during initial treatment. It was decided to do minimal treatments on “Edith” during the first visit and to target a few specific, effective acupuncture points and use laser therapy as a less invasive method. It was recommended to start the patient on gabapentin to help with additional pain control. Once the patient was more receptive to treatments, acupuncture and laser therapy would be used in conjunction to help stimulate muscles and nerves weakened by the meningeal worm as well as managing neck and back pain that has developed as a compensatory injury due to prolonged periods of recumbency and altered stance/gait. The owner also agreed to transport the patient into the clinic for underwater treadmill therapy in an effort to help improve muscle mass and coordination.
Medical Acupuncture and Related Techniques: All needles used for acupuncture were Seirin J-type 0.16 mm x 30 mm.
08/08/2019 – BL23, BL25 bilaterally, Bai Hui, and GV3 for lumbar back pain. GB21 and BL10 were attempted for neck/shoulder pain but the patient was extremely reactive and painful. The MLS laser therapy system (class IV laser) was used on chronic pain setting over entire left and right side of neck. Instructed the owner to begin gentle neck massages and performing range of motion exercises of the neck using treats/grain.
(The above points and laser treatments were repeated every 4-5 days for a total of three treatments to help the patient become accustomed to therapies.)
08/29/2019 – The patient was much more responsive to treatment so more points were attempted and there was a positive response, the patient relaxed and began chewing her cud during treatment. GV20 was used for overall relaxation. BL23-25 bilaterally, BL27-28 bilaterally, Bai Hui, and GV3-4 for lumbar back pain. GB30-31 were used bilaterally to help stimulate neurologic function in the hind legs. The patient would only tolerate GB21 for neck pain.
09/05/2019 – This session was performed in-clinic for the underwater treadmill. The patient was moderately aggravated after the car ride and the stress of being in the clinic. GV20 was used for relaxation. BL23-25 bilaterally, BL27-28 bilaterally, Bai Hui, and GV3-4 for lumbar back pain. GB30-31 were used bilaterally to help stimulate neurologic function in the hind legs. The patient would not tolerate any neck points. (See video of “Edith” ambulating almost completely normal once submerged in water on the underwater treadmill.)
Outcomes, Insights, and Discussions: After the initial series of minimal treatments and the owner beginning additional rehabilitation techniques at home, “Edith” became more comfortable and independent. The owner would find her standing more frequently (although there were still times where the patient required assistance) and the patient was exhibiting more signs of an improved attitude such as bleating when the owner entered the barn and having a more voracious appetite. On the 08/29 visit, it was apparent that the patient was substantially more comfortable and receptive to acupuncture. There was significantly less reaction to the myofascial exam of the neck compared to the initial visit and the patient remained standing independently during the entire visit (previous visits were frequently done with the patient in sternal recumbency).
“Edith’s” case was a valuable lesson in the beginning of my acupuncture career. It is easy to become overzealous with new treatments and protocols in order to hasten recovery but it was important to remain patient with allowing “Edith” to become comfortable with treatments and not causing any more stress or discomfort. The owner elected to continue with acupuncture and laser treatments on “Edith” every other week. “Edith” is now able to rise independently, ambulates frequently, and has gained appropriate weight and muscle mass (see Photo 3). While “Edith” still has minor difficulties ambulating, the owner is pleased with results and is still diligently working with rehab techniques at home.
References:
Li-Li Cheng, Ming-Xing Ding, Cheng Xiong, Min-Yan Zhou, Zheng-Ying Qiu, and Qiong Wang, “Effects of Electroacupuncture of Different Frequencies on the Release Profile of Endogenous Opioid Peptides in the Central Nerve System of Goats,” Evidence-Based Complementary and Alternative Medicine, vol. 2012, Article ID 476457, 9 pages, 2012.
Jezie A A, Jessica M C. “Surgical Analgesia, Physiological Responses and Cortisol Levelin Goats Subjected to Exploratory Laparotomy under Distal Paravertebral Nerve Block, Conventional Needle Acupuncture and Aquapuncture.” Dairy and Vet Sci J. 2018; 5(3): 555664