Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018022
Abstract:
An 11-year-old spayed female German Shepherd dog presented with asymmetrical, slowly progressive paresis of the hind limbs, worse in the left. A putative diagnosis of degenerative myelopathy was assigned and she was treated with acupuncture, electroacupuncture, and laser therapy to provide analgesia, release myofascial tension, and improve blood supply to the spinal cord and painful compensatory musculoskeletal structures in order to enhance her quality of life. Mild to moderate improvement in comfort was noted over the course of treatment described in this case report and notable retention of muscle mass and lack of decline expected with this disease was facilitated by multimodal therapy.
History and Presentation:
Twist, an 11-year-old spayed female German Shepherd dog was originally presented in October 2018 for inconsistent mild weakness of the hind end, worse in the left hind limb. A history of acute pain was not concurrent. This development was not unexpected to her owner due to her breed predisposition and homozygous positive testing for the superoxide dismutase-1 (SOD-1) allele in June 2018. Since initial signs were observed she has progressively become weaker in the hind limbs, and in December 2018 she lost complete motor function in the rear limbs. She currently retains voluntary motor function of urination and defecation. Her current owner has cared for her for the last 8 months, and prior to that she has lived a life both outdoor and indoor with another member of the family. Prior to her change of care/ownership she was fed a RAW diet, but is now maintained on a grain-free Hill’s Science Diet food due to suspected allergic dermatitis which appears under control. She is also currently administered supplements including vitamin E, N-acetylcysteine, and aminocaproic acid. She historically was administered carprofen and meloxicam, but is not currently on any non-steroidal anti-inflammatory drug (NSAID) therapy. In October 2018, when the signs were first noted, rehabilitation exercises (including underwater treadmill exercise), massage, and at-home laser therapy was initiated. Recent baseline lab work (CBC, serum biochemistry, urinalysis) was within normal limits.
Current concerns of the owner include suspected pain or discomfort getting up onto the bed (where previously there did not seem to be any pain), poor water consumption and occasional vomiting. Her goals for Twist are to maintain a good quality of life for as long as reasonably possible based on her attitude, motor function of her hind and front limbs, and motor function of her urination and defecation processes. Twist had received electroacupuncture at some time in her past, however all that was known was that she “did not like it” and had needed to be sedated.
Physical Examination and Clinical Assessments:
On physical examination, Twist was bright, alert and responsive to the environment. She had a normal heart rate (88 beats/min), rectal temperature (100.8 F), was panting and mildly anxious. She was in good body condition (BCS 4.5/9) with a healthy, shiny hair-coat, bright clear eyes and ears, no-halitosis, and only mild tarter build up on her teeth. There was no lymphadenopathy, and no abnormal structures identified on abdominal palpation. She was fairly self-ambulatory, but unassisted would drag her rear limbs behind her to the side. With mild assistance using her full-body harness she would utilize her hind-limbs to walk but the left hind limb would frequently become caught behind her right hind limb and she clearly demonstrated proprioceptive deficits in both hind limbs.
The neurologic examination revealed normal mentation and cranial nerve examination. Voluntary cervical orthogonal flexion (bilaterally, extension, flexion) was free and willing. A knuckling test revealed conscious proprioceptive deficits in both hind limbs, but was normal in the front limbs. Withdrawal was present in the front limbs but was slow in the hind, and she had positive crossed extensor reflex in both hind limbs. Bicipital reflex was normal bilaterally in the front limbs, but decreased from both patellar tendons. She had anal and tail tone, of moderate strength, and still had mild motor function of her tail, which she would use for balance on occasion. Sensation and nociception was intact to her hind paws, and she had a small (approximately 5mm) superficial skin abrasion over the 3rd inter-phalangeal joint of the left hind foot which caused a recognition response when examined. Rubber toe-nail caps were present on each of her hind toe-nails. Based on the neurologic examination the lesion was localized to T3-L3 spinal cord.
Myofascial examination revealed a strain pattern that began in her cervical region characterized by two taught ropey bands bilaterally, and extended through her infraspinatus m. bilaterally, triceps brachii mm., pectoral musculature, and common digital flexor mm. In addition, she had skin restriction at T8-T9, and was repeatedly tense and would provide a subtle response (looking, licking, cessation of panting) when palpating over the T12-L2 region of the spine, along the Bladder line. Hair coat changes and palpable increased skin warmth was also noted in this location. There was mild bilateral muscle atrophy of her right and left semitendinosis and semimembranosis muscles, as well as her biceps femoris mm. The adductors of her medial thigh, including her gracilis m. were also tight and ropey. On the right hind limb there was a strain pattern that extended from the vastus lateralis m. (biceps femoris m.) and sartorius m. to the cranial tibial m. Based on the duration of clinical disease it was surprising the muscle atrophy was not more severe.
Problem List:
Historical and current problems include the loss of motor function of her rear limbs and a neurologic lesion that localizes to T3-L3 spinal segments. There was also discomfort noted by the owner to move to favorite places in the house, along with myofascial palpation abnormalities that localize to the neck, thoracic limbs, thoracolumbar region, and hind limb strain patterns with mild muscle atrophy of her hind limbs. She had a small skin lesion on her left hind foot that appeared to become aggravated when scraped. Additionally, she was noted to have decreased water consumption, and intermittent vomiting at home.
Differential Diagnosis (Ddx):
1) Loss of motor function and a neurologic lesion that localizes to T3-L3 include intervertebral disk disease (IVDD), central nervous system (CNS) infection or abscess, trauma, spinal cysts, neoplasia, fibrocartilaginous embolism (FCE), and degenerative myelopathy (DM). The secondary strain patterns identified in her cervical region and thoracic limbs, and muscle atrophy and strain patterns of the hind limbs, and skin abrasion are presumed to be secondary to the loss of use/motor function of the hind limbs and resultant way of ambulating.
2) Ddx for vomiting can be multifactorial but includes gastritis, indiscriminate eating, foreign body bowel obstruction, CNS lesion, water and electrolyte imbalance, gastrointestinal neoplasm, medication administration, and inflammatory bowel disease. On further investigation later in her visits, we learn that occasionally Twist picks up and eats a stick from outside that tends to correlate with a vomit episode, and since no change in her defecation frequency or volume had been noted, she had normal lab work, and otherwise a bright attitude, this occasional vomiting was attributed to indiscriminate stick consumption unless further clinical changes occur.
3) Decreased water consumption could be due to a systemic disease, causing malaise and lethargy reducing movement and drive to drink. Additionally, general musculoskeletal pain may cause discomfort such that she chooses to not ambulate to the water dish. A normal recent baseline lab work showed no evidence of renal or metabolic disorders that would explain decreased water intake, nor did it indicate that she was dehydrated, suggesting that perhaps she was in actuality obtaining water from somewhere.
Definitive (or Putative) Diagnosis:
Despite the general frequency of intervertebral disk disease in the canine population, a putative diagnosis of DM was made. This working diagnosis was made based on her signalment, the positive SOD-1 genetic testing, the slow progressive onset, and most notably the absence of significant pain. Progressive asymmetric pelvic limb paresis and lack of paraspinal hyperalgesia and common clinical features of DM1. However, pelvic limb hyporeflexia, as seen with this case, is a less common characteristic of DM and suggests nerve root involvement (degenerative radiculomyelopathy)2. Nevertheless, it was recognized that other differentials were possible and neurodiagnostic techniques such as cerebrospinal fluid analysis, myelography, computed tomography, and magnetic resonance imaging would be indicated to rule these in or out. However, these diagnostics were discussed and declined by the owner.
Medical Decision-Making:
DM is an inherited neurologic disorder of dogs similar to amyotrophic lateral sclerosis (Lou Gehrig’s disease) in humans, and as such also has no cure, and no drug therapy has been shown to slow the progression. Therefore, the treatment goal for Twist is to manage the secondary effects of the disease and maintain a good quality of life. The key to achieving this is to start with early therapy to maintain muscle tone, increase neuromuscular function via peripheral nerve stimulation, stimulate spinal nerve branches within the region where the neurologic lesion was localized, but also to neuromodulate the autonomic nervous system to decrease oxidative damage to the degenerating myelinated fibers. Significant myofascial dysfunction was also noted on initial and follow up examinations, and will be treated directly with local points to release muscle spasms, and myofascial tension3.
The predisposition for DM to initiate in the thoracic region of the spinal cord may be due to the lower percentage of radicular artery contributions and smaller diameter of blood vessels in comparison with other spinal cord segments and this may lead to neural tissue damage from oxidative stress (exposure to reactive oxygen radicals) as a result of the mutation of the SOD-1 enzyme. Consequently, the use of photobiomodulation (low-level-light-therapy) to increase blood flow to this region (T3-L3), and to body regions with myofascial restrictions, will augment acupuncture therapy4,5.
Acupuncture Treatments and Related Techniques:
Each acupuncture session started with CNS points (Bai Hui and GV14), which promoted some relaxation. Following this each appointment included a myofascial exam, effleurage, and closed with skin rolling. After approximately 3-5 minutes, the remainder of the needles were placed, which did on occasion cause stimulation of certain points. Due to her history of requiring sedation, electroacupuncture was not initiated until the third session. Treatments were performed approximately once a week and concurrently, she continued to attend her Rehab appointments on a weekly basis.
Treatment #1, 2/14) All dry needle (Seirin 0.16mm x 30mm). CNS: GV14, Bai Hui, GVT, BL20(bilat), BL21(bilat), BL22(bilat), BL26(bilat), BL27(bilat), BL54(left) PNS: Bafeng (bilat; Seirin 0.16mm x 15mm), GB29(left), GB30(left) ANS: ST36(left), PC6(bilat, very short time) MYO: cervical spine tight bands, 1 pt bilat; approx. ST34(left) tight band
Comments: Due to reported history of requiring sedation and natural anxiety, I started the first session with only a few points, and extra massage as she enjoyed this, but she still frequently got up and down during the session. Laser therapy (class 1M) over the thoracic spinal segments.
Treatment #2, 2/21) All dry needle (Seirin 0.16mm x 30mm). CNS: GV14, Bai Hui, GVT, BL10(bilat), BL20(bilat), BL21(bilat), BL22(bilat), BL23(bilat), BL26(bilat), BL27(bilat), BL54(right) PNS: Bafeng (bilat; Seirin 0.16mm x 15mm), GB29(right), GB30(right), BL40(right), BL60(right) ANS: ST36(right), PC6(bilat, very short time) MYO: cervical spine tight bands, 1 pt bilat; SI9(bilat), latissimus dorsi tight band (bilat), LU1(bilat)
Comments: Slightly less anxiety this time, strain patterns similar on myofascial exam. Owner reports less evidence of discomfort at home, will be getting fit for a cart. Laser not available for this appointment – owner will do at home.
Treatment #3, 2/25) All dry needle (Seirin 0.20 x 30mm). CNS: GV14, Bai Hui, GVT, GV20, BL10(bilat), BL21(bilat), BL22(bilat), BL23(bilat), BL26(bilat), BL27(bilat), BL54(left) PNS: Bafeng (bilat; Seirin 0.16mm x 15mm), GB29(left), GB30(left) ANS: ST36(left) MYO: cervical spine tight bands, 1 pt bilat; latissimus dorsi tight band (bilat), LU1(bilat)
Comments: Much more relaxed – just myself and owner, spent most time laying down. Has been wearing cart for walks at home and doing well. No further report of vomiting, has been drinking much better.
Treatment #4, 3/8) (Seirin 0.20 x 30mm) CNS: GV14, Bai Hui, GVT, GV20, BL10(bilat), BL18(bilat), BL19(bilat), BL21(bilat), BL22(bilat), BL23(bilat), BL26(bilat), BL27(bilat), BL54(right) PNS: Bafeng (bilat; Seirin 0.16mm x 15mm), GB29(right), GB30(right), BL60(right), KI3(left) ANS: ST36(right) MYO: cervical spine tight bands, 1 pt bilat; SI9(bilat) in tight band
Comments: Attempted electroacupuncture (EAP) this session over a palpably sore location in the region of BL18, BL19, bilateral ipsilateral pattern Pantheon mixed 2Hz/100Hz for 10 minutes. Tolerated EAP very well.
Treatment #5, 3/15) (Seirin 0.20 x 30mm) CNS: GV14, Bai Hui, GVT, GV20, BL10(bilat), BL20(bilat), BL21(bilat), BL22(bilat), BL23(bilat), BL28(bilat), BL54(left) PNS: Bafeng (bilat; Seirin 0.16mm x 15mm), GB29(left), GB30(left), BL40(left) ANS: ST36(left) MYO: cervical spine tight bands, 1 pt bilat; SI9(bilat) in tight band
Comments: Used EAP successfully BL20-23(bilat, ipsilaterally) Pantheon 4Hz/100Hz 10 min. Used laser therapy over adductors on inner thigh, thoracic spinal segments, and cervical region. Patient was very compliant and relaxed. She now has rubber socks she wears when in the cart to minimize toe-scuffing.
Treatment #6, 3/22) (Seirin 0.20 x 30mm) CNS: GV14, Bai Hui, GVT, GV20, BL10(bilat), BL18(bilat), BL20(bilat), BL21(bilat), BL22(bilat), BL23(bilat), BL28(bilat), BL54(right) PNS: Bafeng (bilat; Hwato 0.16mm x 10mm), GB29(right), GB30(right), BL40(right) ANS: ST36(right) MYO: cervical spine tight bands, 1 pt bilat; SI9(bilat) in tight band, ST34(right) tight band
Comments: Used EAP successfully BL18-23(bilat, ipsilaterally), and BL54-GB30(right) Pantheon 4Hz/100Hz 10 min. Used laser therapy over adductors on inner thigh, thoracic spinal segments, and cervical region. She continues to have tail and anal tone and uses her tail for balance.
At home care: Owner was instructed on how to do passive range of motion exercises with her at home, and also had her own laser which she performed 2-3 times per week in addition to her rehab and acupuncture appointments.
Outcomes, Discussion:
This is an interesting case for me because of the reflection that my therapy is not intended to cure her but improve her quality of life, which is amazingly rewarding and different than many of the other expectations that my job has previously required me to do. My hopes and expectations are different and my conversations with the owner are focused on Twist’s daily life, happiness and comfort. It brings me joy to see her happy face each time she comes in, despite knowing that her time with us is limited to some degree. At the time of the writing of this she continues to do well, despite the slow progression of her disease, and her appointments will be ongoing until she says her time is done. It surprises me each time I see her, how little atrophy is occurring in her hind end, which I believe is a product of all that is done for her to maintain that muscle mass.
References:
1) Averill Dr Jr. Degenerative myelopathy in the aging German Shepherd dog: Clinical and pathologic findings. J Am Vet Med Assoc 1973;162:1045-1051.
2) Griffiths IR, Duncan ID. Chronic degenerative radiculomyelopathy in the dog. J Small Anim Pract 1975;16:461-471.
3) Kline KL. Complementary and alternative medicine for neurologic disorders. Clin Tech Sm Anim Prac 2002;17(1):25-33.
4) Gross DM. Laser therapy and multimodal performance maintenance. Laser Therapy in Veterinary Medicine: Photobiomodulation. 1st Ed. Etd. Reigel, R,Godbold, Jr.JC. 2017 JohnWiley&Sons, Inc. Pgs 267-275
5) Kathmann I, Cizinauskas S, Doherr MG, Steffen F, Jaggy A. Daily controlled physiotherapy increases survival time in dogs with suspected degenerative myelopathy. 2006;20(4):927-932.