Written by a CuraCore Veterinary Medical Acupuncture class graduate. Signed release obtained from client/author. 10D2018021
Abstract:
This case report describes an older horse with a history of sport and traumatic-related, chronic myofascial changes and discomfort. Acupuncture, electrostimulation, laser therapy, and massage were utilized to address the neck, back, and hip problems. Multimodal, integrative therapy dramatically improved the systemic, myofascial pathology and discomfort for this patient.
History:
Moose is an 18-year old, 1600 pound, Percheron-Thoroughbred gelding. The owner obtained Moose when he was eleven-years old. Moose performed as a jumper for 7 years, a dressage horse for 6 years, and is currently retired as a pleasure horse ridden three to four times per week. He has been ridden only with English saddles. Approximately four years ago Moose ran into a fence at full gallop resulting in a sacroiliac ligament injury in his right hip. The specific location of the injury and extent of damage was never diagnosed. Periodically Moose shows intermittent lameness involving his right hip and both tarsal joints especially when he is not exercised. His front limbs are sound. Every spring Moose colics which the owner treats using flunixin meglumine and short walks. Moose’s seasonal colic does not coincide with periods of lameness. Moose eats hay, Purina senior, and Smartpak Ultimate® joint supplement (glucosamine HCl, methylsulfonylmethane, and chondroitin sulfate). Although Moose is a gentleman of a horse, he can be aggressive and occasionally he will spar with other horses while on pasture.
Physical exam:
Moose is a very gentle horse and is exceptionally stoic. He demonstrates signs of discomfort by muscle twitches, flattening his ears, looking back, and trying to move away from me. He is very fit for his age with little to no signs of muscle loss. His gait exam showed a slight limp of his right rear leg demonstrated by decreased time of weight bearing compared to his left rear leg. There was also a mild decreased forward flexion in his right hip.
Myofascial exam:
There was significant bilateral tight bands (visible peaks and valleys) and discomfort spanning from cervical vertebrae one to the cervical-thoracic junction involving the rhomboid and cranial trapezius muscles especially on his right side. His sternocephalic and brachiocephalic muscles showed bilateral discomfort during myofascial palpation especially on his right side. There was an indentation of his right brachiocephalic muscle approximately half-way distal from his cranial neck region. The indentation was approximately ten centimeters across, painful, and was encircled with ropey myofascial tissue. Moose had several trigger points involving his left triceps muscles. There were bilateral tight bands and trigger points spanning his entire thoracic and lumbar back regions (inner and outer bladder channels) especially on his right side. He also demonstrated discomfort involving his right sacroiliac region. He showed good cervical range of motion, painful hip manipulation, painful thoracic and lumbar dorsal spinous process manipulation, and normal temporal-mandibular joint palpation. He had good range of motion of all four limbs and overall excellent muscle tone and structure.
Problem list:
1. Cervical (entire neck) myofascial changes and pain.
2. Thoracic and lumbar myofascial changes and pain.
3. Indentation of the right brachiocephalic muscle.
4. Sacroiliac and hip pain.
5. Slight abnormal gait involving his right rear limb.
6. Trigger points involving his left triceps muscles.
7. Seasonal colic.
Differential diagnosis of the cervical (entire neck) myofascial changes and pain.
Vascular: cardiovascular disease resulting in poor circulation, muscle weakness, and pain.
Infectious: viral or bacterial infection involving the cervical vertebrae or spinal cord.
Neoplastic: cancer or tumor involving the cervical vertebrae or spinal cord.
Degenerative: degenerative intervertebral disc and/or arthritic changes of his cervical vertebrae.
Iatrogenic/intoxication: multiple intra-muscular drug administrations over eighteen years results in myofascial and connective tissue scarring.
Congenital: abnormal cervical vertebral development resulting in chronic myofascial changes.
Autoimmune: autoimmune myositis seen as muscle pain.
Traumatic: traumatic event causing cervical bone and/or muscle injury.
Endocrine/metabolic: Ongoing, subclinical endocrinopathy demonstrated by muscle weakness and pain.
Myofascial: tight bands and trigger points involving the cervical regions including the muscles of the entire neck region.
Differential diagnosis of the thoracic and lumbar myofascial changes and pain.
Vascular: systemic vasculitis resulting in muscle pain and loss of function.
Infectious: viral or bacterial infection involving the thoracic and lumbar vertebrae or spinal cord.
Neoplastic: cancer or tumor involving the thoracic and/or lumbar vertebrae or spinal cord.
Degenerative: degenerative intervertebral disc and/or arthritic changes of his thoracic and/or lumbar vertebrae.
Iatrogenic/intoxication: moldy hay ingestion resulting in cellular damage of the skeletal muscles.
Congenital: abnormal thoracic or lumbar vertebral development resulting in chronic myofascial changes.
Autoimmune: Equine lupus erythematosus-like syndrome resulting in multiple organ dysfunction including the central nervous system (spinal cord).
Traumatic: chronic, reoccurring, low-grade trauma to the thoracic and lumbar back regions.
Endocrine/metabolic: Ongoing, subclinical endocrinopathy demonstrated by muscle weakness and pain.
Myofascial: extensive tight lines and trigger points along the entire thoracic and lumbar regions.
Putative/definitive diagnosis:
Moose is a perfect example of a retired, ex-athlete. For more than thirteen years Moose competed at a high level of performance which, over time, resulted in chronic arthritis and myofascial changes. For example, horses that compete in jumping competition can demonstrate sings of neck and tarsal pain later in life. Horses that are under saddle for years, especially involving high performance conditions, can eventually have thoracic and lumbar back pain with myofascial changes. Another possibility is poor saddle fit causing back problems; however, this is less likely because his owner is very knowledgeable and particular about saddles. In fact, Moose is actually in very good condition considering his size and the level of performance during his competitive years. Undoubtedly, Moose suffered a traumatic hip injury when he ran into the fence. Unfortunately, there was no definitive diagnosis as to exactly what he injured and to what extent. The myofascial changes in his triceps are related to strain-lines due to weight shifting from his right rear leg to his left front. His gait changes primarily signify an ongoing hip restriction with periodic pain. Moose’s back and neck myofascial changes and pain could be augmented by his hip injury and subsequent gait change. The indentation on his right brachiocephalic muscle is a common finding on horses. There several lay-terms for the abnormality such as the “pope thumbprint,” “prophet’s thumb mark, or “Jesus’s thumbprint.” The indentation is believed to be a birthmark due to a rear hoof lying against the neck muscle in utero. Other possible causes of these indentations include a long-term consequence of an old wound or muscle injury. Moose’s indentation had extensive myofascial changes and was painful. Considering his history of periodically sparring with other horses it is quite possible he received a blow or bite to the neck resulting in a chronic injury. Seasonal colic is not an unusual problem with horses. During the winter months Moose spends most of his time in his stall with less exercise and little to no access to grass. In the spring he is often outside in the pasture exercising and eating grass. The change with his exercise and diet routine results in changes with gut (colon) fermentation leading to a gas-related colic, which are usually not considered serious. Another possibility could be viscerosomatic or somatovisceral reflexes. Visceral diseases can result in somatic changes/pain, or vice-versa, due to reflexes involving shared spinal cord segments.
Integrated medical management:
Therapy 1 (3/20/2019): GV14 and Bai Hui (autonomic), BL10 bilateral (cervical, segmental neuromodulation) using Seirin 0.2 X 40mm needles. I wanted to introduce Moose to acupuncture needling; therefore, I limited therapy to four points. I performed myofascial and muscle petrissage, effleurage, and friction massage of the neck, thoracic, lumbar, and hip regions.
Therapy 2 (3/24/2019): The owner explained that Moose was much better and rode very well. It was obvious to her that he was more relaxed under saddle. Myofascial exam showed dramatic improvement of his cervical muscles with nearly all of the tight bands relieved bilaterally. There was still several areas of trigger points involving his brachiocephalic and rhomboid muscles, and the rest of his myofascial exam had not changed. GV14, Bai Hui, BL10 bilateral, TH16, LI16, SI11,12, BL 11-13, BL54, GB29, GB30 (segmental neuromodulation, myofascial) bilateral using Seirin 0.2 X 30 mm needles. SI9 bilateral (segmental crosstalk) using Hwato 0.3 X 25mm needles. I lasered the right neck area including the indentation using a MR4 ActiVet® class 1 laser with a setting of 1-250 Hz with alternating red and blue lights for 20 minutes (integrated).
Therapy 3 (3/25/2019): Myofascial exam improved especially along the neck bilaterally. The right sacroiliac area was less tense. The myofascial ropey tissue around the indentation was smaller and less painful. All needles used with this session were Seirin 0.25 X 30mm. GV14, Bai Hui, BL10-13, 17, 19, 23, 29, 54, TH14, 16, GB21, SI9, 11, 12, 16, and LI11 bilateral. Trigger points in muscles on both sides of the neck, right triceps, and dorsal-cervical areas were needled. Electrostimulation between SI16 and dorsal-cervical points using a Pantheon unit set at mixed frequency 94 to 100 hertz) at 4 milliamperes for 15 minutes. The myofascial tight ropey bands around the indentation on right neck area were needled.
3/26/2019: the owner rode Moose and reported that he had the softest fide she has experienced in a long time. His neck and hip are better, she is very happy because she believes he feels good under saddle. I suggested we continue weekly treatments for 3 weeks and then adjust from there (every-other week to once per month).
Outcome and discussion:
Moose is a typical, former athlete with typical, sport-related chronic inflammatory, myofascial, and pain problems. He could be compared to an ex-NFL football player twenty years after retirement. Because Moose’s owner is highly attuned to his well-being he is fit, well-muscled and has good overall structure. He gets plenty of the correct exercise and food. Moose does demonstrate a mild gait abnormality related to hip trauma; nonetheless, he has compensated well for what could have been a disastrous injury. I learned that even small treatments can result in dramatic changes. I wanted to slowly introduce Moose to needling and try something different, so I used only four acupuncture points and myofascial massage during his first session. The difference with Moose’s neck before and after his first therapy was night and day. He looked more comfortable, his neck was much less tense, and the visible peaks and valleys in the myofascia of his neck region were gone. As the therapy sessions intensified, more acupuncture points and other integrated modalities, his myofascial tissues improved globally. I am confident Moose will continue to respond positively to integrative medical therapy in the future.