Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2018053
Abstract: Scooter is an 18 year old gelding who was being managed for chronic bilateral forelimb laminitis. He was managed on anti-inflammatories and Gabapentin with waxing and waning comfort levels. Scooter’s owner expressed interest in acupuncture treatments as an additional pain management modality.
On initial examination, Scooter was moderately uncomfortable in both front feet. On myofascial exam, Scooter’s main trigger points were along his thoracolumbar musculature and caudal neck. Points in these regions along with heel points were the focus of his treatments. Scooter had a total of 5 acupuncture treatments. His back and neck pain improved with acupuncture treatments and he was discharged from the hospital. His acupuncture treatments were not continued at home due to financial constraint. Scooter was, unfortunately, euthanized a couple months later due to uncontrolled pain from his laminitis.
History and Presentation:
Scooter is an 18 year old Quarter Horse gelding who was being managed for bilateral chronic forelimb laminitis. He originally presented in July 2018 for an acute laminitic episode. Radiographs of both front feet revealed evidence of chronic laminitis with moderate coffin bone rotation (approximately 12 degrees in both front feet). Scooter was diagnosed with Equine Metabolic Syndrome with severe hyperinsulinemia at that time. Scooter was hospitalized for aggressive medical management. His EMS was being managed with diet changes (low carbohydrate hay and grain), levothyroxine and Metaboleeze. His pain was being managed with NSAIDs (Flunixin) twice daily and Gabapentin three times daily.
His comfort waxed and waned throughout his hospitalization. He would go through 4-5 day periods of greatly improved comfort followed by 1-2 days of moderate discomfort when his NSAID doses were decreased. In late July, his pain was moderately improved and he was placed in front shoes. His comfort level drastically declined and he was placed back in his Soft Ride Boots. In August, his owner expressed interest in acupuncture as an additional pain management modality since his pain control was not consistent on his current medications.
Physical Examination and Clinical Assessments:
On August 17th, Scooter presented for his initial acupuncture treatment. His physical examination revealed normal vital signs. His digital pulses were moderately increased in both front limbs with the right being slightly worse than the left. He was moderately uncomfortable on both front feet particularly when asked to move in circles. His myofascial exam revealed moderate trigger points along his caudal neck and thoracolumbar epaxial muscles. He also had focal trigger points at LI 17, LI 18 and ST 10.
Differential Diagnoses:
Foot Pain:
– Laminitis (traumatic or metabolic associated)
– Trauma (fracture, soft tissue injury such as ligament or tendon injury)
– Arthritis
– White line disease
– Conformational abnormalities (thin soles, sheared heals, club feet, etc)
– Bone cysts
– Septic joint(s)
Wind up pain in back and neck due to compensation from foot pain
Definitive (or Putative) Diagnosis (or Diagnoses):
Chronic bilateral forelimb laminitis with moderate rotation
Medical Decision Making:
The plan discussed with the owner was to do dry needling with focus on foot points and focal trigger points along Scooter’s back and caudal neck. Electrostimulation would be used along the back and neck points if tolerated.
Acupuncture Treatments:
The plan was to do acupuncture treatments every 3 days for one week, then once weekly for a month and then once monthly if financially feasible.
8/17- Neck points: LI17, LI 18, ST 10, Forelimb points: SI9, GB 21, Feet points: PC9 and Qian ti men, Back points: BL 19, 21, 23, 25, 27, 28 and Bai Hui
8/20- Neck points: LI17, LI 18, ST 10, and local caudal neck points, Forelimb points: SI9, GB 21, Feet points: PC9, KI 1 and Qian ti men, Back points: BL 21, 23, 25, 27, 28 and Bai Hui
8/23- Neck points: LI17, LI 18, ST 10, GV 20 (relaxation), Forelimb points: SI9, GB 21, Feet points: PC9 and Qian ti men, Back points: BL 19, 21, 23, 25, 27, 28 and Bai Hui
8/29- Neck points: LI17, LI 18, ST 10, GV 20, Forelimb points: SI9, GB 21, Feet points: PC9 and Qian ti men, Back points: BL 19, 21, 23, 25, 27, 28 and Bai Hui
9/6- Neck points: LI17, LI 18, ST 10, Forelimb points: SI9, GB 21, Feet points: PC9 and Qian ti men, Back points: BL 19, 21, 23, 25, 27, 28, 33, 40 and Bai Hui
The neck and back points were selected due to sensitivity on myofascial exam. PC9 and Qian ti men were used in all four feet as local points for the pain associated with laminitis. Dry needling was used in all of the points. Electrostimulation was used mostly along the bladder points and local caudal neck points.
Needles used: Foot points and GV 20- Seirin 0.16 x 30mm, all other points- Seirin 0.25 x 40mm
Electrostimulation: ITO Es-130 with Strength setting at 3-4 for 15minutes.
Outcomes, Discussions, and References:
Scooter was discharged from the hospital after his fifth acupuncture treatment due to his improvement in comfort levels and financial constraints. His overall comfort was the best it had been since presentation. He was significantly less sensitive to palpation of his back and neck after his acupuncture treatments. His digital pulses improved and his foot comfort also improved greatly.
Laminitis is one of the most common ailments managed by equine veterinarians. While it is one of the most researched topics in equine veterinary medicine, the treatment standards have not changed drastically. Acupuncture may provide additional pain modulation and circulatory modulation for management of this debilitating disease. This case taught me the importance of the myofascial exam and to view my patient as a whole. It is easy to focus on the main problem at hand, but the subsequent discomfort in Scooter’s back and neck from compensation was not something I was expecting. Scooter was, unfortunately, euthanized a couple months after his acupuncture treatment due to worsening comfort levels.
A study done by Faramarzi, et al on response to acupuncture treatment in horses with chronic laminitis showed an improvement in lameness score by an average of 1 grade. Acupuncture increases opiod peptide secretion, oxytocin concentration and activation of serotonin receptors which can help with pain modulation. It is speculated that acupuncture may increase local nitric oxide synthase activity which is important for local circulation. Since laminitis is associated with decrease perfusion, ischemia and necrosis of the lamina, this increase in circulation may help prevent further lamellar damage.
*Faramarzi, B., D. Lee, K. May, et al. 2017. Response to acupuncture treatment in horses with chronic laminitis. Canadian Veterinary Journal. 58(8):823-827.