Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018050
Abstract: Chevy is a young dog who lost the ability to jump into his owner’s car and was always painful after playing. The owner wanted to see him enjoy himself more and didn’t want to have to lift him into the car each time because he is a large dog. Acupuncture proved to be very successful for him, but he requires weekly maintenance treatment.
History and Presentation: Chevy is a 3.5 yr. old M/I, 110 lb. Great Dane mix. He has a several year history of pain after playing and not wanting to jump in the car (Jeep). The owner cannot pin point a specific traumatic event, but does note that he was a very active puppy and played a lot with their older puppy. Physical exam at the time was within normal limits. Radiographs of the pelvis (VD) and knees (lateral) were taken and reviewed by a radiologist in 2016 and were found to be within normal limits as well. The owner’s concern has been that he is developing arthritis. We radiographed again and did not see evidence for this, so we pursued acupuncture of surrounding musculature and tense myofascia. We focused our treatment on lumbar spine, the iliopsoas, quadriceps, stifles and gluteal muscles. Acupuncture showed very positive improvement within 24 hours of the first treatment, so the owner opted to continue treatment. The owner and her husband found that Chevy was actually playing for a long time the day after and did not suffer any resultant pain as he did previously (videos included). He has also been jumping into the car more often than not, which has been helpful for the owner due to his large size (video included). Owner has been working on Chevy’s weight loss with little success.
Physical Examination and Clinical Assessments:
Bright, alert and responsive with a body condition score (BCS) of 4/5.
Chevy has a history of gastroenteritis related to food sensitivities. He is currently maintained on Hill’s I/D. He was not having any gastrointestinal problems the days he received treatment.
Restricted range of motion during extension of hind limbs, especially the right side.
Tender musculature at lumbar spine and around stifles.
Physical exam was otherwise within normal limits.
Differential Diagnoses:
V – Vascular: deep vein thrombus
I – Infection or inflammation: early osteoarthritis
N – Neoplasm: tumor in spinal canal
D – Drugs/toxins, degenerative processes: degenerative myelopathy, Cervical Spondylomyelopathy
I – Iatrogenic, idiopathic: restricted mobility from kenneling at home
C – Congenital/inherited, developmental: hip dysplasia
A – Autoimmune, allergic, anatomic defects: hip dysplasia, immune mediated polyarthropathy (neither supported by radiology)
T – Trauma: muscle strain, specifically iliopsoas strain
E – Endocrine/metabolic, exposures (environmental, occupational): overweight body condition
Definitive (or Putative) Diagnosis (or Diagnoses): Muscle strain in iliopsoas (right>left) primarily, but also quadriceps (right > left), thoraco-lumbar epaxial muscles.
Medical Decision Making: Treatment was aimed at increasing range of motion so that he could return to playing and jumping in his car. I also took into account his owner’s perception of where he was painful. She was convinced that there was early hip osteoarthritis, so we initially spent a considerable amount of time needling the coxo-femoral joint region. In the end, it was careful myofascial examination that revealed that the real source of pain was the iliopsoas and surrounding musculature. We started to focus on just these regions and found that he was doing very well. The longer treatments were not necessary in this patient when the treatment was focused on areas of pain found after careful palpation.
Needles used for treatments: Seirin 0.20 mm diameter, 30 mm length, Carbo 0.22 mm diameter, 30 mm length
July 13, 20 Treatments
Myofascial exam revealed tenderness along the quadriceps, groin, and lumbar musculature. At the time I suspected coxofemoral pain due to loss of range of motion. He was very resistant to having his legs extended backwards. I later realized that the iliopsoas was the main problem.
Initiation Points:
GV 20: To help relieve anxiety
Bai Hui: General point to neuromodulate pelvic limb pain
Hip/Gluteal Points:
BL 54: Part of hip triad to target hip and gluteal pain. Neuromodulate possible sciatic nerve pain.
GB 29: Part of hip triad to target general hip pain. Neuromodulates cranial gluteal nerves.
GB 30: Part of hip triad to target hip and gluteal pain. May also neuromodulate possible sciatic nerve pain and dysfunction
GB 31: Neuromodulates the femoral and sciatic nerves to treat hip and pelvic pain and neurologic dysfunction.
Local trigger points along bladder line of lumbar spine.
Acupuncture was followed by massage.
July 26 Treatment
A myofascial exam and physical exam were performed. Our main concerns:
1) Chevy has had about 4 lbs of weight gain. His hip points were already difficult to palpate, so we discussed initiating some weight loss.
2) At the end of last week’s treatment (July 20), we watched Chevy repeat the sitting and standing motion. My concern at that appointment was that along with loss of range of motion in the coxofemoral joint, he is likely experiencing some knee pain as well. He does not like to flex his knees or kick his legs back and this may be contributing to his resistance to jump in the car. Being a large breed dog, knee pain is a common complaint and warrants treatment.
Initiation Points:
GV 20: To help relieve anxiety
Bai Hui: General point to neuromodulate pelvic limb pain
Hip/Gluteal Points:
BL 54: Part of hip triad to target hip and gluteal pain. Neuromodulate possible sciatic nerve pain.
GB 29: Part of hip triad to target general hip pain. Neuromodulates cranial gluteal nerves.
GB 30: Part of hip triad to target hip and gluteal pain. May also neuromodulate possible sciatic nerve pain and dysfunction
GB 31: Neuromodulates the femoral and sciatic nerves to treat hip and pelvic pain and neurologic dysfunction.
Local trigger points along bladder line of lumbar spine.
Stifle Points:
GB 33: Targets lateral stifle proximal to joint. Neuromodulates the fibular nerve to treat pain, arthritis and edema. Chevy does not have evidence of arthritis and edema, but is resistant to full flexion of the knees.
GB 34: On the lateral stifle region in the depression cranial and distal to the fibular head. Neuromodulates the fibular nerve to treat stifle pain. It also targets musculotendinous pain or tension, which is now appearing to be a problem in Chevy’s case. This point is also known to treat lateral pelvic limb or hip discomfort, so is a great point to treat Chevy’s entire pelvic limbs.
GB 39: On lateral side of distal pelvic limb. Approximately 3 cun proximal to the lateral malleolus in the depression between the caudal border of the fibula and the tendons of the peroneus longus and brevis muscle. This was a difficult point to needle due to the shallow musculature. However, Chevy tolerated this well and provides point stimulation critical to his mobility problems. This point is known to neuromodulate the fibular n to reduce pelvic limb pain, improve movement and stiffness problems.
ST 34: On the lateral side of stifle region, 2 cun proximal to the patella in the vastus laterals m, opposite SP 10. This point is known to neuromodulate the femoral N to treat stifle pain, instability and dysfunction. Chevy is not known to have femoral nerve injury, but this point would be useful for this problem if encountered.
ST 36: On the lateral stifle region, 2 cun distal to the tibial plateau, 1 cun lateral to the tibial crest in the belly of the cranial tibialis m. This point is known to neuromodulate the fibular nerve to treat stifle pain and pelvic limb dysfunction. Chevy has a history of severe GI sensitivity, so this point is useful for its known benefit of neuromodulating GI problems and motility issues.
ST 40: This point is on the lateral side, midway between the lateral malleolus and stifle joint, between the cranial tibialis and long digital extensor muscle. This point was chosen to treat the distal limb and to help further modulate the GI tract.
SP 9: Just distal to the medial tibial condyle. This point neuromodulates the saphenous and tibial nerves. It is a point useful for stifle pain. This point was chosen to treat stifle pain.
SP 10: On the medial side of this thigh in the vastus medialis muscle, 2 cun above the craniomedial border of the patella. This point was chosen to treat stifle pain as it neuromodulates the femoral nerve. Chevy has occasional pruritus from his allergies and this point can be helpful for pruritus and erythematous skin.
Electro-acupuncture was performed using E-Stim II machine.
1) Between GB 29 and GB 30 for 10 minutes at an intensity of 6 mA for both channels with a frequency of approximately 5 Hz.
2) Between ST 34 and GB 34 for 10 minutes at an intensity of 6 mA for both channels with a frequency of approximately 5 Hz.
Acupuncture treatment was followed by 5 minutes of massage using mainly effleurage with petrissage where tolerated.
August 2 Treatment
Myofascial exam: Sensitivity, though not overt pain, in lumbar musculature at the thoraco-lumbar junction region. Stifles continue to be mostly non-painful on exam, but there is noticeable weight shifting when sitting. He is jumping into the car now, though not every time. Iliopsoas is tender to palpation. Brief treatment due to time contraints.
Initiation Points:
GV 20: To help relieve anxiety
Bai Hui: General point to neuromodulate pelvic limb pain
Hip/Gluteal Points:
BL 54: Part of hip triad to target hip and gluteal pain. Neuromodulate possible sciatic nerve pain.
GB 29: Part of hip triad to target general hip pain. Neuromodulates cranial gluteal nerves.
GB 30: Part of hip triad to target hip and gluteal pain. May also neuromodulate possible sciatic nerve pain and dysfunction
GB 31: Neuromodulates the femoral and sciatic nerves to treat hip and pelvic pain and neurologic dysfunction.
Local trigger points were palpated and treated along bladder line and along iliopsoas.
Electroacupuncture was performed using E-Stim II machine. Between GB 29 and GB 30 for 5 minutes at an intensity of 6 mA for both channels with a frequency of approximately 5 Hz.
Massage was done to all treated areas at the completion of treatment.
August 9, 16, 23, 30, September 6, 13
Myofascial exam showed less pain in lumbar spine, iliopsoas and quadriceps. Acupuncture points from the July 20 session were repeated
September 20, 24 Needles used:
Trigger point needling to right iliopsoas with electroacupuncture (6 mA for both channels with a frequency of approximately 5 Hz) was performed in short sessions for maintenance.
Outcomes, Discussions, and References:
Chevy is much less painful and enjoying a life with greater range of motion with his weekly acupuncture treatments. I have been encouraging the owner to massage his greatest areas of tension starting from the lumbar spine, through the iliopsoas, quadriceps and gluteal. I have also convinced her that he should not be caged all day as this may have contributed to loss of range of motion after the initial strain. He was previously being kenneled from 8-10 hours a day. She purchased a large orthopedic pillow for him, and he now has a spare bedroom to himself while she is gone.
Reference: Robinson, Narda G. Medical Acupuncture for Veterinarians. Fort Collins, CO. Curacore Integrative Medicine & Education Center.
Describe Your Impressions of this Medical Acupuncture Experience:
This was initially a frustrating experience as my palpation skills needed to be fine tuned to assess the problems this dog was experiencing. I was confused why his hind limb range of motion was so restricted even though his orthopedic evaluation was normal. I needed to get away from my old way of thinking and realize that the musculature and myofascial needed to be more carefully examined. My treatment, fortunately, was working well, but I only realized after a few sessions and exams that it was the iliopsoas that was painful in this dog and causing most of the range of motion problems, especially in the right limb. In hindsight, this makes sense because he is a large, active dog and this pain started relatively young with no orthopedic changes. I have now decided for our current therapy to only treat the iliopsoas and associated painful lumbar points and add on other points as needed based on our exam. He has done well with this treatment protocol for the last two weeks. The last video of him jumping into his owner’s blue Jeep is after the most recent focused treatment.