Case Report: Acupuncture and Massage for Hip Dysplasia (Medical Acupuncture for Veterinarians Grad)

Christene Olschewski, DVM, cVMA

Medical Acupuncture for Veterinarians Course Graduate

Title: Use of acupuncture and massage to treat hip dysplasia with secondary osteoarthritis and copper storage disease in a 12-year-old Labrador Golden Retriever Mix

Abstract: A senior dog presented with decreased mobility associated with hip dysplasia and secondary osteoarthritis, and chronic hepatopathy due to copper storage disease. Three treatments were performed using massage and acupuncture. The patient showed improved mobility and comfort, increased interaction with the younger housemate, and return of her younger personality traits.

History of Presenting Illness and Chief Complaints: A 12-year-old female spayed Labrador golden retriever mix presented for progressive decrease in mobility. At one and a half years old the patient was denied official training as a therapy canine due to PennHIP evaluation indicating increased laxity in both hips and suspected hip dysplasia in the left hip. The patient had difficulty getting onto the owner’s bed and required owner assistance and a bench at the foot of the bed. When sleeping in bed with the owners, she would growl or bark when they moved, even if she was not directly being touched, followed by her getting off of the bed. The patient had become sensitive to any touch around her hips. The winter season had produced a lot of snow and the patient’s back legs trembled after maneuvering through the snow. After her examination and first treatment X-rays were taken by her primary veterinarian at the time of anesthesia for dental work which showed arthritic changes in the left shoulder, bilateral hip dysplasia with secondary remodeling and osteoarthritis with the left hip worse than the right hip. She was taking Cosequin as a glucosamine supplement and Duralactin Microlactin to reduce inflammation. The patient had a chronic mildly elevated alanine aminotransferase. A liver biopsy taken at the time of her spay diagnosed copper storage disease, being managed with a prescription liver diet and a liver supplement.

Physical Exam and Clinical Assessments: The patient was examined in her home. She was very nervous and hesitant to allow a full examination but her owners reported better response than typical in a veterinary clinic setting. She was bright, alert, responsive, well hydrated, and overweight. Abnormalities included bilateral mild lenticular sclerosis, mild to moderate periodontal disease, and several soft moveable subcutaneous tumors of various sizes.

• Haircoat observation: The owners reported that the patient’s hair had always been coarser along her thoracic through sacral spine. There was a change in the direction of hair within the following areas: dorsolateral and lateral neck, craniolateral and caudodorsal to her scapulae, dorsally and laterally along her mid thorax, and dorsally over her sacrum.  Her toenails were short from the owners regularly using a Dremel.
• Gait examination: Lameness was found in all limbs with hindlimbs more prominent than front limbs, with left hind greater than the right hind, left front greater than the right front limb. She had decreased flexion of the stifles with the right hind more than the left hind, seen as a straight and stiff appearance to the stifles. She had decreased flexion of her hips with left hind more than right hind, her hips swayed to advance her hind limbs, and she shuffled her hind feet causing bilateral shorter stride length. There was limited shoulder extension bilaterally causing shorter stride length. While walking she off loaded the left front more quickly than the right, seen as a quicker step on the left front, and had an intermittent head bob with placement of the right front limb. She had normal passive range of motion in her elbows and carpi. Her tail remained down at all times and when walking moved tightly side to side more often toward the right, and was held toward the inside leg when turning. She stood and sat with the left front limb placed more cranial. She preferred to lay with her right hip tucked under her body, her thorax and front limbs sternal.
• Myofascial examination: The patient had taut ropy bands within her dorsal and lateral neck. Trigger points were found in the infraspinatus and triceps muscle bellies. Her proximal scapulae were close together and she had decreased movement of the scapulae around her thoracic wall. She had paraspinal myofascial spasms with dorsal spinal palpation from her thorax through her sacrum. The entire adductor muscle belly was taught bilaterally in the hindlimbs. She attempted to bite with palpation of her right hind proximal thigh.
• Neurologic assessment: The patient appeared neurologically normal with normal cranial nerves, withdrawal reflexes, and proprioceptive placement. She had negative crossed extensor reflexes.
• Laboratory findings: The complete blood cell count and total thyroid hormone were within normal limits. The single abnormality on the chemistry panel was an elevated alanine aminotransferase 191 (12-118 IU/L).

Problem List: Decreased mobility, chronic alanine aminotransferase elevation with liver biopsy diagnosis of copper storage disease, overweight, multiple subcutaneous tumors, periodontal disease which was considered resolved after the initial visit due to professional periodontal treatment.

Differential Diagnosis for Decreased Mobility: Vascular – ischemic neuropathy, fibrocartilaginous emboli; Infectious/inflammatory – osteoarthritis, tendinitis, osteomyelitis, discospondylitis, tick born polyarthritis, myositis, neuritis; Neoplastic – osteosarcoma, central nervous system lymphoma, synovial cell sarcoma; Degenerative – osteoarthritis, hip dysplasia, neuropathy, osteoporosis; Iatrogenic/intoxication – disuse atrophy, nutritional osteopathy; Congenital – hip dysplasia, dyschondroplasia; Autoimmune – immune-mediated osteoarthritis, myasthenia gravis; Traumatic – old or recent injury to muscle, tendon, ligament, joint, or nerve; Endocrine/Metabolic – liver disease, Cushing’s disease associated pseudomyotonia; Myofascia – compensatory change secondary to chronic pain, muscular dystrophy, fibrotic myopathy

Differential Diagnosis for Chronic Alanine Aminotransferase Elevation: Vascular – hepatic microvascular dysplasia, hemolysis; Infectious/inflammatory – hepatitis, gastroenteritis, periodontitis, leptospirosis; Neoplastic – hepatocellular carcinoma. Metastatic lymphoma, mast cell tumor or osteosarcoma; Degenerative – hepatocellular death, cirrhosis, muscular dystrophy, ischemic myopathy; Iatrogenic/intoxication – supplement administration, aspirin or acetaminophen ingestion; Congenital – portosystemic liver shunt, hepatic microvascular dysplasia; Autoimmune – immune-mediated hemolytic anemia; Traumatic – liver damage related to movement such as falling, severe muscle injury; Endocrine/Metabolic – copper storage disease, pancreatitis, hepatic lipidosis, cholelithiasis or cholestasis; Myofascia – muscular dystrophy, ischemic myopathy

Definitive Diagnoses: X-ray diagnosis of hip dysplasia and osteoarthritis with the left hip more severe than the right hip, and osteoarthritis in the left shoulder. Examination revealed compensatory myofascial changes related to her structural disease. Chronic elevation in alanine aminotransferase with biopsy diagnosis of copper storage disease.

Medical Decision Making and Treatments:

• January 21, 2023: Treatment began with effleurage massage along the patient’s spine from cervical through lumbosacral, and down her front limbs to address myofascial strain patterns and help relax the patient. She rotated from side to side with any attempt at massage around her hips or lower on her hindlimbs. Overall, she enjoyed the massage more on the left side of her body compared to the right side. The patient was nervous at the site of new objects such as the needles and was fed her dinner meal one kibble at a time by the owner and was allowed to move about as she pleased. The first point placed was GV 14 to test her response to needle placement and to provide autonomic neuromodulation to innervation of the head and neck to address her myofascial strain pattern within her neck and front limbs. GV 20 was chosen to assist with calming and for its strong parasympathomimetic input, BL 11 for local tension between scapula and for central cervicothoracic spinal nerve stimulation, BL 13 for local tension between scapula and central cranial thoracic spinal nerve stimulation, BL 17 for central midthoracic spinal nerve stimulation, BL 18 for peripheral liver support and central mid thoracic spinal nerve stimulation, BL 23 for lumbar and pelvic pain and central thoracolumbar spinal nerve stimulation, BL 25 for central lumbar spinal nerve, BL 27 for sacroiliac dysfunction and sacral spinal nerve stimulation, Bai Hui for hind limb discomfort, ST 36 for hind limb dysfunction and parasympathomimetic effects due to its long loop reflexes. The patient moved away from palpation around both hips preventing needle placement at BL 54, GB 29 and GB 30 for hip and gluteal pain and sciatic nerve dysfunction. Needles were left in place while she fell asleep, and they were removed 30 minutes later when she awakened.
• January 29, 2023: The patient had anesthesia the previous day for periodontal cleaning. She had been anxious and intermittently vocal throughout the evening and had diarrhea. Her treatment was focused on calming through effleurage massage of her face, neck and along her spine. Acupuncture included calming through GV 20, liver and digestive support through BL 18, BL 19, BL 20, BL 21, BL 25, ST 36. Bai Hui was used to target hindlimb discomfort, GV 14 was used as an autonomic point and for myofascial strain. Needles were left in place while she fell asleep, and they were removed 45 minutes later when she awakened, effleurage was repeated.
• February 5, 2023: Treatment began with effleurage and petrissage massage of the patient’s neck, front limbs, spine, and she allowed the addition of her hindlimbs. Points selected: GV 20, GV 14, BL 11, BL 13, BL 18, BL 23, BL 27, Bai Hui, ST 36. She allowed the addition of GV 2 for a point near her tail and BL 54 for hip discomfort. Treatment concluded with effleurage. Needles were left in place while she fell asleep, and they were removed 35 minutes later when she arose.

Outcomes and Discussions: After the first session, the patient had a larger than normal formed bowel movement with easier placement of her hindlimbs, she slept the entire night instead of waking up her owner multiple times, and she was willing to interact with the younger dog in the house over the following few days. After the second session, the patient was more relaxed, slept comfortably the entire night, and her digestive symptoms resolved. Her owner was pleased that she was starting to see the patient’s younger sassy personality return, willingness to jump onto the couch for TV time and onto the bed at night, minimal growling in response to owner movement when sleeping, and continued engagement with the younger dog. By the third session, the patient appeared more relaxed in her movements, her skin was more loose appreciated through skin rolling, her haircoat changes were minimizing, and she allowed handling of her hindlimbs. Several days after the treatment her owner reported the patient was able to move easier and faster, including the use of stairs. The patient’s positive response of decreased pain and improved mobility was solely related to the massage and acupuncture treatments as her owners did not want to perform anything additional because they were curious to see what her response would be to minimal treatment. The owners have decided to continue treatment with addition of laser therapy for her spine, shoulders, and hips to decrease pain and inflammation, improve blood flow, and allow treatment of areas where she would not allow acupuncture. Additional paraspinal, hind limb and front limb points will be added as the patient allows to address pain and myofascial strain patterns.

Due to the patient’s anxious behavior and discomfort, I was concerned about her willingness to allow handling and needling, and therefore focused on targeting minimal points. I chose the Carbo 0.2 x 40mm needles because her owners wanted her to be able to get up and move as she pleased during treatment and I wanted her needles to be more likely to stay in place. I chose the longer length for easy owner visualization within her areas of longer hair. Overall, I felt this plan worked well for this patient as she did get up and move a lot and roll from side to side, and only had a single needle fall out during each treatment. Each visit I was happy to see her relax and fully fall asleep after needle placement, and hear positive owner observations following treatment. This patient had a positive response to acupuncture and massage. I am looking forward to seeing her response to continued treatment.

References:

1. Robinson, Narda G. Medical Acupuncture for Veterinarians Canine Point Mini-Manual. Curacore Integrative Medicine and Education Center. 2021.
2. Merck Veterinary Manual merckvetmanual.com. Accessed 07 Feb 2023.
3. DuralactinÒ (MicrolactinÒ) Technical Monograph. https://duralactin.wpenginepowered.com/wp-content/uploads/2020/06/Duralactin-Tech-Monograph-2019.pdf. Accessed 14 Feb 2023.
4. Teixeira, Lívia R, et al. “Owner assessment of chronic pain intensity and results of gait analysis of dogs with hip dysplasia treated with acupuncture.” Journal of the American Veterinary Medical Association. November 2016;249(9):1031-1039.