Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018051
Abstract:
An 11 year old Beagle presented for acupuncture for chronic osteoarthritis and suspect intervertebral disc disease. Over an almost three month period of weekly to every other week acupuncture treatment the patient had significant improvement in myofascial exam and quality of life parameters as assessed by the veterinarian and owner. The addition of laser therapy, electroacupuncture, and massage was utilized to achieve the results.
History and Presentation:
Roxy, an 11 year old female spayed Beagle, presented to the Veterinary Hospital on Monday May 21st, 2018 for a pain management evaluation. For the last year Roxy has been intermittently lame (all limbs, not consistent) and has been having difficulty rising and sitting. She is still active but does not jump on and off the furniture anymore and mainly lays on a dog bed on the floor. Roxy has periods of panting and vocalizing, mainly during activity, and has intermittent tremors of her head and neck which mainly seem to occur when the owner misses a day or two of Rimadyl. When walking at home her back legs do give out sometimes, especially when trying to walk up stairs. She has a history of dental disease and some skin issues that she has had for years. Roxy’s current medication is Rimadyl at a 2.2mg/kg dose by mouth every 12 hours. The owner was not interested in pursuing any further diagnostics or adding in any other drugs and was just interested in seeing if physical medicine could help Roxy.
Physical Examination and Clinical Assessment:
On physical examination Roxy was bright, alert, and responsive, panting, and moderately anxious. She had an approximately 4x3cm patch of scabbing over her left flank with mild flaking and multiple subcutaneous and dermal masses throughout her body. Myofascial palpation revealed stiffness throughout the cervical musculature with taught bands, severe tensing/twitching and vocalization with gentle palpation of the epaxial musculature over the thoracolumbar and sacral regions, and discomfort/vocalization with gentle palpation of the lumbosacral spine. There was thickening and crepitus in the elbows and stifles bilaterally with decreased range of motion as well as crepitus and vocalization with hip extension. Neurologic exam and gait evaluation revealed a stiff, short strided gait in all four limbs, reluctance to turn especially to right (see video). From a laying position she had difficulty rising and was very reluctant to lie back down. Patellar reflexes were normal to slightly increased and all other reflexes were assessed to be normal.
Medical Decision Making:
For my acupuncture treatment I wanted to be sure that I was addressing Roxy from a few different angles. My plan was to first use points that would be relaxing and decrease Roxy’s anxiety. After that I wanted to address her significant myofascial tenseness in her neck and back. To help ease the tension I planned to utilize laser therapy prior to acupuncture as well as adding in electroacupuncture to help stimulate the nervous system and increase the intensity of the treatment. Once Roxy became more comfortable with the needles I planned to start to work on points to address the hips, stifles, and elbows as well.
Differential and Definitive Diagnosis
Based on my problem list including the stiff gait, crepitus, myofascial tenseness, and vocalization with palpation, my differential diagnoses included:
V (vascular): Thromboembolic disease, peripheral vascular disease
I (infectious): Bacterial (meningitis), viral disease
N (neoplastic): Lymphoma, sarcoma
D (degenerative): Osteoarthritis, joint disease, neurologic disease (degenerative myelopathy, intervertebral disc disease)
I (iatrogenic/intoxication): Neck leads, rough handling
C (congenital): Hip dysplasia, elbow dysplasia
A (autoimmune): Allergies
T (traumatic): Past trauma
E (endocrine): Hypoadrenocorticism, diabetes mellitus
M (myofascial): Muscular tension, disuse
My definitive diagnosis for Roxy was severe osteoarthritis of the neck, spine, hips, elbows, and stifles as well as suspect intervertebral disc disease in her thoracolumbar and lumbosacral spine.
Acupuncture Treatments:
Treatment #1:
Physical exam above. Treatment with Serein 0.16mm needles for GV 20, 14, Bai Hui, BL 10-14, 18-23, 27-28, and sensitive cervical points bilaterally. Roxy was slightly antsy during the treatment but tolerated the needles well once in place.
Treatment #2 (May 27th, 2018):
Physical exam revealed mild improvement over thoracolumbar epaxial and cervical musculature but was otherwise unchanged. Acupuncture treatment with Serein 0.16mm needles for GV 20, 14, Bai Hui, BL 10-13, 18-23, 25, ST 36, and sensitive cervical points bilaterally. Roxy tolerated needles very well with frozen baby food. After removing needles finished treatment with dry needling of a trigger point over the left thoracic epaxial musculature with some improvement.
Treatment #3 (June 11th, 2018):
Physical exam revealed more improvement with cervical musculature tenseness but otherwise unchanged. Acupuncture treatment with Serein 0.16 and 0.2mm needles for GV 20, 14, Bai Hui, BL 10-13, 18-25, and sensitive cervical points bilaterally. ST 34 and 36 on left. Dry needled various trigger points over latissimus dorsi and epaxial musculature with some improvement. Roxy tolerated needles very well with frozen baby food.
Treatment #4 (June 18th, 2018):
Physical exam remained unchanged from previous visit. Acupuncture treatment with Serein 0.2mm needles for GV 20, 14, Bai Hui, BL 10, 18-23, and sensitive cervical points. Added electroacupuncture from BL 18-23 on left side which was tolerated well at a mixed frequency (2/100). Tried electroacupuncture on right side but Roxy would not tolerate. She did very well with the needles in place while enjoying frozen baby food. Epaxial musculature sensitivity decreased significantly after treatment during massage.
Treatment #5 (June 24th, 2018):
Physical exam remained unchanged from previous visit. Acupuncture treatment with Serein 0.2mm needles for GV 20, 14, Bai Hui, BL 10, 18-23, sensitive cervical points, and ST 36 bilaterally. Electroacupuncture from BL 10 to caudal cervical points and BL 18 to 23 bilaterally with mixed frequency (2/100) was tolerated very well with frozen baby food. Finished treatment with massage.
Treatment #6 (July 1st, 2018):
Physical examination revealed significant reduction in sensitivity over cervical and epaxial musculature but more sensitivity over stifles and hips especially on right side. Acupuncture treatment with Serein 0.2mm needles for GV 20, 14, 4, Bai Hui, BL 10, 18-23, and sensitive cervical points bilaterally. ST 36, BL 54, GB 29, 30 on right side. Electroacupuncture with mixed frequency (2/100) from BL 18 to 23 on left and BL 18 to 54 on right. Tolerated needles with frozen baby food but was sensitive on right side. Finished with massage.
Treatment #7 (July 9th, 2018):
Physical exam revealed sensitivity over both stifles but otherwise unchanged from previous visit. Used class 4 MLS laser with chronic pain setting over epaxial musculature and stifles. Acupuncture treatment with Serein 0.2mm needles for GV 20, 14, 4, Bai Hui, sensitive cervical points, BL 10, 18-23, 54, GB 29, 30, ST 34, 36, and SP 9, 10 bilaterally. Electroacupuncture with mixed frequency (2/100) from BL 20 to GB 29 and from BL 10 to caudal cervical point bilaterally. Roxy tolerated needles very well with frozen baby food. Finished with massage.
Treatment #8 (July 29th, 2018)
Physical exam revealed less sensitivity in stiles but otherwise unchanged from previous visit. Used class 4 MLS laser with chronic pain setting over epaxial musculature, hips, and stifles. Acupuncture treatment with Serein 0.2mm needles for GV 20, 14, 4, Bai Hui, sensitive cervical points, BL 10, 11-14, 18-23, 27-28, 54, GB 29, 30, ST 36, and PC 6 bilaterally. Roxy tolerated needles very well with frozen baby food. Finished with massage.
Outcomes, Discussions, and References:
Around treatment #4 the owner was reporting improvement in Roxy with more comfort in rising and sitting but the twitching of the head and neck and other clinical signs continued. At treatment #7 the owner reported that Roxy seemed much more comfortable at home walking and that her back legs were not giving out as much. At treatment #8 the owner said that Roxy’s quality of life had improved significantly and that she was having much less difficulty getting up and moving around, slipping less, and that her neck and head twitching had decreased significantly. At this point we decided to decrease the frequency of Roxy’s acupuncture treatments to every 3-6 weeks as needed for follow up care.
This was my first acupuncture case and it taught me a large amount. First, frozen baby food is a fantastic way to keep patients distracted and tolerate treatments better (see treatment picture). Second, addition of laser therapy allows ease of needle placement in very sensitive locations. Third, electroacupuncture leads to significant increase in speed of response/relaxation with sever myofascial tightness. Fourth, the reward of improving the quality of life of a dog and giving the owner hope for more time with their loved one is priceless.
This case increased my confidence and application of acupuncture in my daily practice. It has helped to give me ideas for clinical research in dogs with severe osteoarthritis to study the improvement with the addition of physical medicine alone.
Current literature is supportive of positive outcomes of acupuncture with dogs with musculoskeletal issues. In a study by Land and Hill (2015) acupuncture was shown to significantly improve quality of life standards including play behavior, walking, trotting, jumping, descending stairs, and ease of rising and stiffness after rest in dogs with musculoskeletal pain. The dogs in this study were either given acupuncture or let rest in a cage and the owners were blinded to the treatments. A similar study by Teixeira et al (2016) found owner improved assessments of lameness and pain score decreased with addition of acupuncture in dogs with hip dysplasia. This study compared dogs treated with Rimadyl or acupuncture and found similar improvement in both groups. Silva et al (2017) showed that pain scores and quality of life assessment was improved with addition of acupuncture in dogs with neurologic and musculoskeletal disease.
A study by Rose et al (2017) reviewed studies that have evaluated the use of acupuncture in companion animals (dogs, cats, and horses). They found that the most common subjects in trials were dogs and the most common indication for use was musculoskeletal pain. Rose et al (2017) highlighted the need for high-quality randomized controlled trials for veterinary patients.
References:
1. Lane, DM and Hill SA. Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain. Can Vet J 2016; 57: 407-414.
2. Rose WJ, sergeant JM, Hanna WJB, Kelton D, Wolfe DM, Wisener LV. A scoping review of the evidence for efficacy of acupuncture in companion animals. Anim Health Res Rev 2017; 18(2): 177-185.
3. Silva N, Luna S, Joaquim J, Coutinho H, Possebon F. Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases. Can Vet J 2017; 58: 941-951.
4. Teixeira LR, Luna SP, Matsubara LM, Capua MLB, Santos BPCR, Mesquita LR, Faria LG, Agostinho FS, Hielm-Bjorkman A. Owner assessment of chronic pain intensity and results of gait analysis of dogs with hip dysplasia treated with acupuncture. JAVMA 2016; 249(9): 1031-1039.