Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017006
History Presentation: “Cobalt” is a 10y10m year old spayed female Bernese mountain dog. She presented to me for an annual physical examination/wellness assessment on May 10, 2017. At that time, her owner noted that she was having trouble getting up and down from the furniture, and that she felt Cobalt was generally slowing down. Cobalt has a long history of joint disease. At the age of 18m (April 2008) she had arthroscopic surgery on her left elbow for Osteochondrosis Dissecans (OCD). She recovered from her procedure without complications, and sought care from a local rehabilitation specialist for acupuncture, water treadmill therapy, and manual therapy (chiropractic care). In January 2014, she experienced a right cranial cruciate ligament (CCL) tear, which was successfully repaired in September of that same year, using a Tibial Tuberosity Advancement (TTA). Pre-, peri- and post- operatively, Cobalt received laser therapy, acupuncture, and manual therapy (chiropractic care). At the time of her annual examination she was not taking any nutraceuticals or pharmaceuticals, nor receiving any form of integrative/alternative care.
Physical Examination and Clinical Assessments: At presentation, Cobalt was very BAR. Her BCS was 3.5/5. All vitals and organ systems were within normal limits except for Musculoskeletal and Neurological. Cobalt has muscle wasting of her hind hips, quadriceps and hamstrings on the right side. She also has muscle wasting of her left supra- and infra-spinatus muscles and her left triceps muscle. She has marked bony changes and crepitus around the left elbow and medial buttressing of the right stifle. She resisted extension of both hips but more so on her right side. She had normal proprioceptive reflexes but slight wearing of the nails on the medial digits of her right hind. She had normal patellar and withdrawal reflexes. No other neuro- or musculoskeletal abnormalities were noted.
Medical Decision Making: At the time of presentation, Cobalt was not taking any supplements or medications. She has historically taken a non-steroidal anti-inflammatory medication (NSAID) Meloxicam (Metacam®) with success. I felt it was important to combine both pharmaceutical and integrative care to manage Cobalt’s musculoskeletal discomfort. Given her history of two orthopedic surgeries and the findings of her clinical examination, I prescribed a 40mg/kg dose of EPA1,2,daily Metacam at a 40kg dose (based on her lean body weight), and 200mg of gabapentin twice daily (with plans to adjust dose as needed)3. Her owner was interested in pursuing acupuncture treatment, and we decided to try weekly sessions of acupuncture and gentle massage to improve her gait and level of discomfort. I planned to start our sessions with just a few needles to help her adjust to her acupuncture treatments. I knew that I wanted to treat her from a CPA approach – central, peripheral and autonomic nervous systems, as well as her local myofascial pain. I felt I would achieve this via acupuncture therapy, focusing on both local/peripheral points, and points that would stimulate the central nervous system.
Diagnoses: Multi-joint osteoarthritis (OA) with acute on chronic/dysfunctional and neuropathic pain with local regions of myofascial discomfort. Other differentials would include bony or soft tissue neoplasia.
Definitive Diagnoses: Based on her previous medical history (left elbow dysplasia and surgical correction in 2010; right cranial cruciate ligament rupture and TTA in 2016) and current clinical signs, my differential diagnosis of multi-joint degenerative joint disease (DJD) was most probable. Cobalt’s’ owner declined any current radiographs for confirmation.
Acupuncture Treatments: Since her first treatment on May 31, 2017, she has been coming for treatments every 2-3 weeks, and at the time of the writing of this report we have performed 5 treatments. Treatment #1 – GV20, GV14, GB33, Bai Hui, GB 29 and ST 36. I wanted to start with these points to induce calm (GV20), help stimulate the autonomic nervous system (GV14, ST 36), and hit some local points for pain/arthritis (GB 33, GB29, ST 36). I also wanted to minimize the number of points placed to see how well she reacted to dry needles. During needle placement I gave some gentle massage over some trigger points in her triceps bilaterally. Treatment#2 – GV14, GV20, GB 30, ST34, ST 36. At treatment #2 she was experiencing some mild lameness in her right hind, so I wanted to focus a bit more on local points. Treatment #3 – GV14, GV20, GB29, GB 30, BL 60, ST 36, LI 11 and PC6. Her right hind lameness had improved with her previous acupuncture treatment, so I added some more local points in addition to the autonomic point PC 6. Treatment #4 – GV 14, GV 20, LU5, LI11, ST 36, SI 11/12, Bai Hui, TH 10 and GB 30. At her fourth treatment, I found her to have some trigger points along her right triceps, right supra- and infra-spinatus muscles, and some resistance to flexion of her right elbow, so I added SI 11/12 to help treat these dysfunctions, as well as the addition of TH10 to help with her triceps. Treatment #5 – GV 14, GV 20, LI 11/12, ST 36, GB 29, GB 30, ST 36. At her fifth treatment, she was very comfortable, so I repeated a few local points that she responded well to during previous sessions.
Outcomes, Discussions, and References: Owners find that she feels much better after her treatments. She is driving from out of town, otherwise she would pursue weekly therapy. She adjusted to dry needle very well. She has been my longest ongoing case to date and I am learning quickly that sometimes less is more. I initially focused on hind end points as I felt more comfortable placing needles away from her front end, but at her third treatment I started treating her forelimb lameness and she responded very well with no reaction to the dry needle placement.