Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017004
Abstract: An 18-year-old American Quarter Horse (AQH) was evaluated for subtle lameness and discomfort. Mild contralateral limb lameness was detected with the lameness not apparently originating from foot or leg conditions. Diagnostic acupuncture and myofascial evaluation revealed caudal cervical and sacroiliac dysfunction. The therapeutic modalities of electroacupuncture (EA), myofascial release, and photobiomodulation were used in six treatments over two months. The treatments were completed along the Large Intestinal (LI) line of the neck and the inner Bladder (BL) line of the lumbosacral region. The use of all three modalities in conjunction, led to a resolution of clinical signs. Client perception of original complaint also indicated resolution. Client and veterinarian satisfaction in acupuncture as a diagnostic and therapeutic element of equine care was apparent and will aid in improved future equine wellness and health.
History and Presentation: Jewel, an 18-year-old, 550 kg, buckskin, AQH mare, was presented on May 6, 2017 for initial evaluation. The presenting complaint was for reluctance to extend the right forelimb or to remain balanced on three legs while the farrier worked on the right forelimb the previous week. Previously, the farrier had no difficulty trimming or shoeing Jewel. Jewel was dewormed in March and vaccinated for Eastern and Western Equine Encephalitis Viruses, West Nile Virus, Influenza, Rhinopneumonitis, and Streptococcus Equi in the summer of 2016. The only remarkable history was an incident the previous summer when the owner was bucked off after Jewel was asked to transition into a lope.
Physical Exam: On examination, Jewel was found to be alert, responsive, afebrile, have a body condition score of five 6n a nine-point scale (5/9), bilateral dental points and hooks, an elevated right tuber sacrale, and reluctance to flex the caudal neck to the left and the right. Neurologic exam was insignificant. On lameness exam, there was a grade two out of five (2/5) left forelimb lameness and a two out of five (2/5) right hindlimb lameness. Joint flexion and extension were unremarkable, except for bilateral reluctance to extend the hips. Diagnostic acupuncture and myofascial exam (DAPE) findings indicated discomfort when pressure was applied to both Stomach (ST) 7 acupuncture points concurrently, but elicited no discomfort when each point was palpated individually. A positive drop of the lumbosacral region, approximately 10-12 cm, was produced by applying positive pressure medially (squeezing) to both tuber sacralae simultaneously. Myofascial discomfort (trigger-points) was palpated along both brachiocephalicus muscles, at the LI points 16, 17, 18 and ST 10. Trigger-points were also located at the longissimus muscles at the level of BL 25, 16, 27, and 28. All other parameters were within normal limits. Further diagnostics, such as radiography and ultrasonography, were unavailable, thus not performed.
Differential and Putative Diagnoses: The differential diagnoses were based on the history, geography, and complete (including routine, lameness, neurologic, and DAPE) examination findings. They included degenerative joint disease (DJD) of the cervical vertebrae, DJD of the lumbosacral vertebrae, DJD of the sacroiliac (SI) joints, myofascial trauma and dysfunction of the cervical musculature, myofascial trauma and dysfunction of the lumbosacral musculature, Borreliosis, caudal cervical instability, and fractures of the ilia or vertebrae. Since further diagnostics were not performed, the presumptive diagnoses of sacroiliac dysfunction and cervical myofascial dysfunction were made. These diagnoses were made based on the myofascial examination findings, the lack of an elevated temperature, lack of neurologic dysfunction, and low level of pain and discomfort, all of which helped to rule out the other differential diagnoses.
Medical Decision Making: The initial neuromodulation approach for Jewel was based on the DAPE findings as well as the routine acupuncture points for anxiety and parasympathetic tone. Points were selected on the brachiocephalicus and the lumbar and sacral longissimus muscles. These points were chosen to release the trigger-points by affecting the muscle spindle fibers. Stimulation of the local nerves causing a reflex arc to the spinal column artd helping to alleviate pain at the local nerve and spinal nerve level were also of importance in selecting the desired points. The acupuncture points affected both pain and dysfunction at the cervical spinal nerves, brachiocephalicus muscles, longissimus muscles, mid and caudal lumbar spinal nerves, and the sacral spinal nerves.
Acupuncture Treatments: The initial acupuncture plan included the use of myofascial release along both brachiocephalicus muscles, both lumbosacral longissimus muscles, and both cranial superficial gluteal muscles. Photobiomodulation was also incorporated into the plan using a Class lM Superpulse device with 905nm, 860nm, and 660nm wavelengths fluctuating between 1000 and 3000 Hz. The therapeutic l ser was used at the tuber sa’ crale, at each visit, to try to directly influence the SI joint and reduce pain and inflammation by targeting local cells and the local nerves. Dry needling only was initiated on the first visit until it was determined how Jewel would tolerate the procedure, the needles were removed after 20 minutes. The initial points were Bai hui; Gallbladder (GB) 21; LI 16, 17, 18; BL 25, 26, 27, and 28. These points were selected to influence the parasympathetic pathways, and the pathways contributing to cervical and sacroiliac pain, dysfunction, and local trigger-points. The initial frequency of treatments was set at once weekly for four treatments, followed by every two weeks for two treatments, and then as needed based .on the owner’s observations. The second, and subsequent treatments, utilized EA using the Pantheon device in a mixed mode utilizing 4 and 100 Hz for 20 minutes. Each treatment was modified based on a brief DAPE evaluation at each visit. The initial points were consistently used on each visit. On the second through the sixth visits, EA was used bilaterally from LI 16 to 18, and from BL25 to 28. Additional points at those visits included BL 10, 18a, 18b, 21, 23, Triple Heater (TH) 15, 16, and ST 10 based upon trigger-points being palpated.
Outcome: Evaluation at the second visit indicated positive responses to the previous treatment. Cervical flexion was essentially normal to the left and approximately 80% of normal flexion to the right side. When palpating bilateral ST 7 concurrently, the results were negative at this and each subsequent visit. Firm tuber sacrale palpation was still positive, but the degree of drop had diminished from 10-12 cm to 3-5 cm. At the third evaluation, hip extension and neck flexion were within normal ranges; they would remain within normal ranges at each visit. At the fifth visit on June 10, 2017, all clinical signs, and lameness, were absent and tuber sacrale palpation was negative. At the June 25, 2017 visit, the owner stated that Jewel appeared back to normal and stated that the farrier had commented on how much better she acted for shoeing. Maintenance evaluations and treatments were set at monthly intervals.
This case highlighted the importance of the diagnostic acupuncture and myofascial exam. Without them, I would not have picked up the subtle myofascial dysfunction that led to the lameness at hand. I would, instead, have proceeded to multiple joint blocks and finally would have referred Jewel to the university clinicians for further work-up. The treatment of chronic pain by neuromodulation without consistently using pharmaceuticals was also made app?rent. This case allowed me to incorporate acupuncture into my equine exam and treatment practices, which have made me a better clinician and equine advocate. It did not supplant what I knew, but enhanced it. With the increased diagnosis of sacroiliac disease, I believe that this case would make a good stepping point for research into the use of acupuncture as an adjunct therapy. I wish I had the ability to make a concrete diagnosis for the case. It would have made a greater impact to the validity of the case.