Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2018021
Abstract:
This case report describes a dog that suffered a tarsal injury with subsequent surgical correction, rehabilitation, and recovery. The report also discusses an unknown injury to the dog’s lumbar back region resulting in mild neurological pathology, myofascial changes, skin damage, and chronic pain. Acupuncture, electrostimulation and laser therapy was used to address the tarsal joint and back injuries.
History:
Reese Gillette is a 3 year-old, spayed female, mixed breed dog. She was adopted when she was eight months old from the island of St Kitts. The owner requested acupuncture for Reese due to a recent surgery on her left tarsal joint. On August 9, 2018 Reese was seen due to an acute tarsal injury that occurred approximately twenty minutes prior to presentation. On August 10, 2019 Reese had surgery on her left tarsal joint to stabilize the short medial and lateral collateral ligaments. Post-operatively Reese underwent soft bandaging and three months of rehabilitation. On November 7, 2018 Reese’s left tarsus was examined and found to be completely healed without any post-operative complications. The only concern reported by the owner was that Reese would hold her left rear leg extended when she squatted to urinate in order to shift weight away from her left tarsal joint. The owner also reported that Reese is a picky eater and she has a tendency to vomit with certain foods. Subsequently, Reese is on a strict diet consisting of Hill’s Sensitive Skin and Stomach which she tolerates well. Reese is current on her vaccinations and internal/external parasite control including heartworm prophylactic treatment.
Physical exam:
Reese is a healthy, 20 kg, mixed-breed dog. She is very gentle, kind, and attentive; however, shed tends to be somewhat skittish. Abdominal palpation revealed some tenseness around the cranial to mid-abdominal area, but not specific. There was a large scar involving the majority of her lumbar back (picture one). The scar extended from lumbar vertebrae #2 (L2) to the lumbosacral junction, but was especially evident between L2 and L5 on her left side, and laterally beyond the internal bladder line. The owner informed me that Reese had the scar when she was adopted, but at the time it was much larger (picture two). The owner did not know the exact cause of Reese’s injury; however, dogs with chemical burns are common on St. Kitts. When the scarred area was lightly palpated/caressed Reese turned her head and lick her lips which, according to the owner, was her normal response. There was also a surgical scar on the medial side of Reese’s left tarsal joint. A gait exam revealed a mild decrease in forward motion of the left hind limb resulting in a slightly abnormal cadence between the pelvic limbs (videos one, two, and three). A neurological exam revealed crossed extensor reflexes involving both left hind limbs, most noticeable on her left side. Reese subjectively had an increased left myotatic patellar reflex; however, her right myotatic patellar reflex was normal. The remaining neurological and physical exams were normal.
Myofascial exam:
Trigger points (taught bands) were found bilaterally involving the infraspinatus muscles especially on her right side. Trigger points were found bilateral involving multiple areas along the lumbar back especially between L3 and L5. Myofascial exam of the scarred area revealed tension and discomfort bilaterally of the longissimus dorsi and iliocostalis muscles extending from L1 to the lumbosacral junction, most noticeable on her left side. When the lumbar area was examined Reese would lick her lips, turn her head to look at her back, and try to move away. Gentle palpation of the lumbar dorsal spinous processes showed a difference in muscle thickness between the left and right para-spinal muscles. There appeared to be loss of both skin and muscle on the left side of her vertebral column. The left muscle girth was subjectively smaller than the right and the skin was thinner/scarred. Myofascial exam of the hind limbs revealed mild atrophy of the left superficial and middles gluteal muscles as well as stiffness and tenderness involving her left tarsal joint. The remaining myofascial exam was insignificant.
Objective data:
Pre-operative CBC and chemistries, was normal (8/10/2019). Radiographs of the left tarsus showed no fractures. There were no radiographs of her back.
Reese Gait 3 Reese Gait 2 Reese Gait 1
Problem list:
1. Tarsal injury and surgery.
2. History of vomiting and stomach problems.
3. Slight abnormal gait of her left hind limb.
4. Myofascial changes, discomfort, and scarring involving her lumbar back.
5. Crossed-extensor reflexes of her hind limbs especially on her left side.
6. Myofascial changes involving her infraspinatus muscles.
7. Loss of skin and muscle involving her lumbar back especially on her left side.
Differential diagnosis of the scarring and myofascial changes involving her lumbar back.
Vascular: vasculitis related to injury and/or infection resulting in muscle and/or skin damage.
Infectious: infection of the lumbar muscles and skin related to injury of unknown cause.
Neoplastic: cancer involving the spinal cord such as lymphoma.
Degenerative: degenerative disc disease of the distal thoracic or lumbar intervertebral disks.
Iatrogenic/intoxication: Second and third degree burn across her lumbar back resulting in tissue damage and dermal scarring.
Congenital: abnormal development/number of lumbar vertebrae.
Autoimmune: muscle and/or dermal autoimmune disease resulting in muscle and skin damage.
Traumatic: trauma to the lumbar back area resulted in second and third degree cutaneous burns, muscle damage, and tissue loss.
Endocrine/metabolic: inadequate nutrition resulted in abnormal bone/muscle growth.
Myofascial: discomfort and trigger points involving her lumbar back.
Differential diagnosis of the crossed
Vascular: vascular accident of the spinal cord distal to thoracic vertebrae #3 (T3).
Infectious: viral or bacterial infection of the spinal cord and/or lumbar vertebrae.
Neoplastic: tumor in the spinal cord distal to T3.
Degenerative: degenerative disc disease involving distal thoracic or lumbar intervertebral disk.
Iatrogenic/intoxication: ingested toxin resulting in neurological damage to spinal cord.
Congenital: abnormal development/number of thoracic and/or lumbar vertebrae resulting in abnormalities of the spinal cord.
Autoimmune: autoimmune inflammation of the spinal cord distal to T3.
Traumatic: trauma to the lumbar back causing spinal cord injury.
Endocrine/metabolic: inadequate food resulting in poor neurological development of the spinal cord.
Myofascial: discomfort and trigger points involving her lumbar back.
Putative/definitive diagnosis:
Reese suffered a traumatic injury to her back resulting in a mild spinal cord injury distal to T3 with significant, scarring, tissue atrophy, and loss of the lumbar muscles and skin. The damaged area was most noticeable on her left side. The spinal cord trauma did not cause significant neurological deficits of her pelvic limbs; however, it did result in chronic spinal cord damage manifested as crossed-extensor reflexes. The myofascial changes within her infraspinatus muscles were related to weight shifting onto her forelimbs from chronic pain originating from her lumbar back and/or left tarsus. The traumatic injury to her lumbar back may have contributed to her stomach problems via a somato-visceral, segmental reflex.
Integrated medical management:
I consulted with a neurology resident and he concluded because Reese’s neurological abnormalities were minor, and Reese showed little to no changes in her gait, urination or defecation, further investigation of her spinal injury was not yet indicated.
Unless stated otherwise, all needling treatments used Serin, 0.2 X 30mm needles for 10 to 20 minutes. All laser therapy sessions utilized a MR4 ActiVet® class 1 laser with a setting of 1-250 Hz with alternating red and blue lights for 10 to 20 minutes.
Therapy 1 (2/25/19): GV20 and GV14 (autonomic), Bai Hui (autonomic, neuromodulation/central input) were needled to introduce Reese to acupuncture. Reese responded remarkably well by becoming recumbent, and relaxed.
Therapy 2 (2/26/19): Similar myofascial exam. GV14 (autonomic) and Bai Hui (autonomic, neuromodulation/central input) were needled producing similar calming and relaxing effects. Points GB31, BL60, KI3, GB40, and Bafeng 3-4, 4-5 (segmental, central input) were needled to address discomfort and/or functional disorder related to her tarsal injury and surgery.
Therapy 3 (2/28/19): The owner reported that Reese was squatting to urinate using both rear limbs symmetrically with equal weight distribution. Myofascial palpation was similar. Points GV14 and Bai Hui (autonomic, neuromodulation/central input) SI11 bilateral (myofascial), BL25 and approximately 3 cun caudal to BL52 bilateral (segmental, myofascial) were needled to address her lumbar injury. I chose to stay away from the proximal, inner BL channel due to the possibility of making her scar bleed. Laser therapy was performed along the lumbar scar and trigger point areas. I explained to the owner that Reese could signs of regression i.e. increased lameness and/or discomfort, after acupuncture. If that occurred, I told the owner not to worry because usually that type of response is transient.
Exam 4 (3/1/19): The owner reported the Reese did not have signs of regression. Myofascial exam showed improvement of infraspinatus muscles bilateral and taught bands involving the lumbar back. Trigger points and taught bands at thoracolumbar junction bilateral were present. Acupuncture points included GV14, Bai Hui, SI11, BL49 and BL50 bilateral and focal, myofascial release (thoracolumbar trigger points). Needles used were Hwato 0.2 X 30 mm for fifteen minutes. Laser was performed along the lumbar back area. Again, Reese responded to acupuncture and laser therapy by lying down and relaxing. Post myofascial exam showed marked improvement of trigger points and taught bands at thoracolumbar junction bilateral.
Exam 5 (3/4/2019): Owner had not noticed any problems or changes. Myofascial exam showed that although there were still some trigger points along T13 to L5, the entire lumbar region had greatly improved and Reese showed less adversity to touch and palpation. Both infraspinatus muscles palpated normal. Remaining myofascial exam was normal. Acupuncture points GV14, Bai Hui, ST36, BL60, BL62 (left tarsal joint), BL17, BL23, BL26 (bilateral) were needled. Electrostimulation was done between BL23 and BL26 bilateral utilizing two channels on a Pantheon unit set at mixed frequency (4 to 100 hertz) at 2 milliamperes for ten minutes. Laser therapy of the lumbar back regions.
Outcome and discussion:
Crossed extensor reflexes are an indication of upper motor neuron (spinal cord) pathology most often related to a chronic condition. Reese’s forelimb neurological exam was normal; therefore, the spinal injury occurred distal to the cranial intumescence (T2) but proximal to L3. Based on Reese’s physical and myofascial exams there was evidence that she may have suffered a traumatic injury to her lumbar region resulting in dermal, muscular, and spinal damage. The lumbar injury was manifested by mild, upper motor neuron damage (crossed extensor reflexes), myofascial changes involving her longissimus dorsi muscles (bilateral), skin damage and scarring, and discomfort. Although Reese seemed to have adjusted well to her back injury and knee surgery, she demonstrated signs of weight shifting from her pelvic to her front limbs manifested by myofascial changes involving the infraspinatus muscles bilaterally. It is possible that Reese’s gastric dysfunction may be due to somato-visceral, segmental crosstalk occurring in her lumbar spine related to her lumbar injury. I decided to treat Reese’s tarsal injury and surgical recovery at the owner’s request and because there was a mild decrease in range of motion and stiffness of the joint. However, I elected to concentrate more emphasis on her lumbar back due to obvious myofascial changes and her undeniable demonstration of pain during palpation. Reese consistently responded to acupuncture and laser therapy from being nervous and skittish to quiet and relaxed. Throughout the sessions involving electrostimulation she napped during the treatment. The relaxing effects of acupuncture on Reese was due to long-loop reflexes with a subsequent decrease in sympathetic tone peripherally (muscle relaxation) and centrally (sedation, relaxation). Although Reese responded to integrative medical therapy by becoming calm and relaxed she would tolerate a limited number of needles for a limited amount of time. Undoubtedly Reese would benefit from continued acupuncture, electrostimulation, and laser therapy. Even though her upper motor neuron changes were not serious, continued acupuncture and electro-therapy to produce segmental cross-talk and neuromodulation will help reduce the possibility of further neurodegeneration. Reese was showing early signs of myofascial strain lines involving her forelimbs indicated by changes in her infraspinatus muscles Future therapy sessions with Reese will include addressing her neck and forelimb muscles of extension. I recommended that we continue therapy twice a week for at least 4 weeks and then make adjustments as needed. I also recommended a radiograph of her back sometime in the future.
What I learned:
The take-home message from this case was to avoid having a narrow-minded approach toward differential diagnoses. Reese at first appeared to be a straight-forward, post-surgical case for integrated therapy; however, it was soon evident there were bigger problems. I learned that our patients irrefutably tell us where they hurt. Myofascial palpation and close observation is the key to understanding their communication. Lastly, I am amazed at how our veterinary patients respond to integrative medical therapy. It is rewarding for me to see them become calm and relaxed without relying on pharmaceutical intervention.