Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018023
Abstract: Sasha is a 14 year old pygmy goat that has been dealing with arthritis in both her front limbs for 4 years. She has been on meloxicam for 4 years that has been progressively worsening. Her owner (Richard Gulvin, my father) wanted to pursue acupuncture and other medical modalities to increase Sasha’s quality of life. Acupuncture, Laser therapy, Gabapentin, and Adequan were all added to Sasha’s treatment and resulted in a substantial increase to her quality of life with mild benefit in her walking pattern.
History: Sasha is a 14 year old black pygmy goat that lives in a horse barn and has been a companion to miniature horses since she was 2 months old. She was living with two other goats, both which were the same age and have been deceased for 2 and 3 years. Sasha has had a stiff gait and arthritis since she was 9 years old. She has not been tested for Caprine Arthritis Encephalitis (CAE), and has no other clinical signs. As she has been getting older her arthritis has been getting much worse, to the point that now she doesn’t move around the barn much and when she does she hobbles on her front legs. She seems to be more painful on extremely cold days in the winter, and on extremely hot days in the summer. Her quality of life seems to be decreasing, but not enough to the point where euthanasia is warranted. She still eats her food, chews her cud, and follows the barn hands around the barn during chores. She also enjoys breaking out of the barn during chores and eating grass around the barn. She is offered 1 pound goat feed twice a day and free choice grass hay with a bucket of fresh water at all times. She is eating and drinking very well.
Current medications: 30 mg Meloxicam PO SID
Physical Examination and Assessment:
My first assessment of Sasha was performed on 10/26/2018. While walking Sasha’s front carpal joints are in a bent position and she is moving very stiffly. She seems more lame on the right front than on the left front, but both front limbs are very painful while walking, this is apparent because she has a head bob with both front limbs. Weight is being shifted onto the hind limbs to relieve the weight from being on the front limbs. Sasha is also walking with severe kyphosis along her lumbar region suggesting that she has some lumbar pain.
Myofascial palpation revealed pain along the cranial aspect of the right scapula. She showed pain upon superficial palpation of the right thoracic fascia, also present on the left, but not as severe of a reaction as seen on the right. Upon deeper palpation, Sasha was extremely painful to muscle palpation cranial to the scapula and in the caudal cervical region. There were multiple trigger points caudal to the scapula bilaterally. Gluteal muscles were very tight upon palpation, and Sasha was not willing to allow complete palpation.
Limited Neurological examination revealed normal cranial nerves and no neurologic abnormalities.
Problem List:
• Severe elbow arthritis bilaterally
• Lumbosacral muscle pain
• Cervical muscle pain
• Gluteal muscle pain
• Trigger points of several muscles.
Differential Diagnosis: Differential diagnoses of elbow arthritis in Sasha can include: degenerative or infectious causes. Differential diagnoses of lumbosacral, cervical, and gluteal pain in Sasha can include: trauma and degeneration.
Definitive Diagnosis: The elbow arthritis is likely a degenerative process. Goats can get arthritis secondary to an infectious process, called CAE. Since Sasha has had this arthritis for several years and has no neurological signs, this is unlikely, but she should ultimately be tested to rule this out. The muscle pain that can be seen along the dorsal aspect of Sasha’s body is from the trauma that is occurring due to the way she is moving her body. Since Sasha is walking differently and laying down more, she is causing trauma to these muscles – the main reason for this trauma is from over-use and over-exertion. These muscles are doing more work than they are meant to be doing and that is causing trigger points, muscle stiffness, muscle contraction, and even tearing of the muscle fibers. These all cause the pain that she is experiencing.
10 26 18 sasha walking 10 26 18 sasha walking 2
Medical Decision Making: Sasha seems to be experiencing severe windup pain from the overload that her muscles are experiencing due to the way in which she walks because of her arthritis pain. She is painful in the elbow, the suspected location of the arthritis radiographs have not been performed to confirm), but the pain she is most sensitive to is the muscles along the cervical, lumbar, sacral, and gluteal regions. Knowing how she is offloading this weight, if I can relieve some of the tension and help these over-stressed muscles heal, I should be able to make her much more comfortable. I can also neuromodulate the nerves that innervate these muscles so that the windup pain that is being experienced by these nerves can lessen. This may take several treatments to notice a big difference in the way Sasha walks, but we can monitor how tense and painful she is throughout the process. Sasha would benefit from dry needling, electroacupuncture with the current going through the elbow, and laser to help the muscle cells heal.
Medical acupuncture and Related Techniques Used:
First treatment: 10/26/2018.
– Red needles: 0.16 x 30mm
– 15 needles placed
o Bilaterally: SI 11, SI 12, BL 11, BL 13, BL 15, BL 18, BL 19,
o BaiHui
– Laser 50hz for 5 minutes along the lumbar area.
– Laser 50hz for 2 minutes each elbow.
– Manual therapy – firm pressure and manipulation of the trigger points and sore muscles. Patient loved this!
Second treatment: 11/12/2018.
– Carbos 0.18 x 25mm needles
– 20 needles placed before patient lost patience.
o Bilaterally: SI 11, SI 12, BL 11, BL 13, BL 15, BL 18, BL 19, BL 20, BL 21, BL 22
– Laser 50hz for 5 minutes along the lumbar area.
– Laser 50hz for 2 minutes each elbow.
– Manual therapy – firm pressure and rubbing motion of the trigger points and sore muscles.
Third Treatment: 11/20/2018.
– Carbos 0.18 x 25mm needles
– 25 needles placed. Patient was very calm
o Bilaterally: SI 11, SI 12, BL 10, BL 11, BL 12, BL 13, BL 15, BL 18, BL 19, BL 20, BL 21, BL 22,
o BaiHui
– Laser 50hz for 5 minutes along the lumbar area.
– Laser 50hz for 2 minutes each elbow.
– Manual therapy – firm pressure and manipulation of the trigger points and sore muscles.
Fourth Treatment: 12/30/2018.
– Carbos 0.18 x 25mm needles
– 17 needles placed.
o Bilaterally: SI 11, SI 12, BL 10, BL 11, BL 13, BL 15, BL 18, BL 21
o BaiHui
– Laser 50hz for 5 minutes along the lumbar area.
– Laser 50hz for 2 minutes each elbow.
– Manual therapy – firm pressure and manipulation of the trigger points and sore muscles
Outcome/Discussion: Sasha’s muscles are VERY tight and she has a lot of windup neuropathic pain. She loosens up after acupuncture, laser, and manual therapy. Although there is more movement of the myofascia, she still has significant stiffness and the myofascia is not moving as much as I would like. She would very much benefit from electroacupuncture, but I cannot afford the unit at this time. Sasha walks with a little more speed and less buckling at her knees, but she is still gimping and holding her legs up. She is much more active and is more interested in leaving the barn than she has been the past few months. I have added gabapentin to her medications to help with some of the neuropathic pain that she is experiencing. I also added adequan once a week for 2 months then once every 6 weeks and fish oil in her food once a day. She is tolerating these new medications well and is more comfortable while taking them (if she misses a day or a dose of adequan then she becomes much more uncomfortable). Overall, Sasha has had a positive, beneficial, response to the therapies that I have been performing on her. She will continue to receive monthly acupuncture and laser treatments to see if we can keep decreasing her neuropathic pain and loosen the myofascia and muscles. She is a happy little goat right now and has a good quality of life. Rick will ultimately decide to euthanize her when we stop seeing improvement.
I learned a lot through this case about neuropathic windup pain and how muscles respond to weight shifting due to lameness for such a long period of time. It was great experience to see the benefit and how much more comfortable she became with so few treatments. I would eventually love to see how electroacupuncture could help her. Clinically, I think it is very important for clinicians to understand the neuropathic pain pathway and how chronic, severe pain can cause de-sensitization so just the smallest amount of stimuli can cause an exaggerated pain response. According to a paper written by Edwin de Vrij called Acupuncture and Pain Relief, acupuncture provides analgesia at the level of the spinal cord, brain, nerves, and receptors. Acupuncture does this through the activation of opoid receptors in the brain and spinal cord. The somatic afferent fibers that are activated can then cause a sympathetic reflex to that area that results in an increase in blood flow. The increase in blood flow helps remove the nociceptive substances that were brought to the area by the insult that is now causing pain. This, ultimately, is how acupuncture helps reduce pain. A review article written by J. Kong explains how acupuncture has proven to be an effective intervention to help treat chronic pain in humans. This paper also explains how electroacupuncture helps release endorphins, which helps calm and relax the recipient.
Sources:
1. Acupuncture and Pain Relief. Edwin de Vrij. UMC Groningen. 16-07-2010.
2. Understanding Central Mehanisms of Acupuncture Analgesia Using Dynamic Quantitative Sensory Testing: A Review. J. Kong, R. Schnyer, K. Johnson, and S. Mackey. Evidence based complementary and alternative medicine. Volume 2013. 3/29/2013.