Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018054
Abstract:
Poochie is a 13-year-old neutered male (MN) Tibetan Spaniel (14.4 lbs/6.55 kg) who was presented for acute vocalizing and chronic intermittent right front (RF) limb lameness.
Based upon physical exam, myofascial exam, radiographs, comprehensive bloodwork and a urinalysis, Poochie was found to have severe degenerative orthopedic changes to his glenohumeral joints bilaterally, severe kyphosis of his thoracolumbar spine, and early kidney disease. After three acupuncture treatments, Poochie was walking with a less stiff gait, had stopped vocalizing and decreased his frequency of inappropriate urination in the house.
History and Presentation:
Poochie is a 13yo MN Tibetan Spaniel who was originally presented in July 2017 to another doctor in my practice as the owners were beginning to notice a “wobble” when he walked and he was reluctant to use stairs. There was no previous history of prior trauma or veterinary care. At that time, baseline blood work (complete blood cell count (CBC), serum chemistry, canine pancreatic lipase (cPL), thyroid hormone (T4)) and urinalysis (UA) were performed and he was sent home with Rimadyl 12.5milligrams (mg) to be given by mouth (PO) every 12 hours (h). The only abnormality found on his bloodwork was a mild elevation in Symmetric DiMethylArginine (SDMA; 20 micrograms (ug)/deciliter (dL); normal = 0-14 ug/dL).
In September 2017, Poochie began receiving Tramadol 25-50mg PO every 8-12 hours and was managed well with Rimadyl and Tramadol with no concerns per the owner. In July 2018, Poochie was switched from Rimadyl to Galliprant 10mg PO every 24 hours and continued to receive tramadol every 8-12 hours. In August 2018, Poochie was presented for vocalizing, panting, pacing and right front limb lameness. Radiographs were declined at this time. The doctor treating Poochie at that time prescribed methocarbamol 125mg PO every 8 hours.
Poochie was not examined or evaluated until March 21st, 2019 when he was presented for incessant vocalizing, intermittent vomiting, hyporexia, and an extremely stiff gait with intermittent front limb lameness. He had not been regularly receiving pain medication and there was no knowledge of acute trauma.
At the time of presentation, Poochie was intermittently urinating inappropriately in the owner’s home. He was eating, drinking and his defecation habits were normal.
Physical Examination and Clinical Assessments:
Current medications: Galliprant 10 mg PO q24h, Tramadol 25 mg PO q8-12h, Methocarbamol 125 mg PO q12h.
Physical Examination: His body condition score was adequate (5-6/9). He was bright, alert and responsive; however, he was also incessantly vocalizing. He was less than 5% dehydrated.
Eyes, ears, nose, and throat: No discharge was noted in either eye. Both eyes had cataracts. The third eyelid gland of his right eye was prolapsed. There was no debris or malodor in his ears. He was not congested and had no nasal discharge.
Oral: He had Grade III/IV periodontal disease with mild gingivitis and moderate halitosis.
LN: No peripheral lymphadenopathy was palpable.
Cardiovascular: No murmurs or arrhythmias were noted and pulses were synchronous.
Respiratory: His lungs were clear in all fields; no wheezes or crackles were noted.
Musculoskeletal: Moderate to severe kyphosis of his thoracic and lumbar spine was noted. He had a stiff gait and his elbows were bowed and turned out laterally while walking. His hind paws were laterally turned out.
Myofascial: He exhibited muscle fasciculation and vocalizing on myofascial palpation of his cervical through cranial lumbar spine. He had taut ropy bands over his scapulae bilaterally as well as over the thoracolumbar junction and intermittently over the lumbosacral region.
Integument: He had a less than 1centimeter by 1centimeter alopecic cutaneous mass with mild ulceration over his lateral right shoulder.
Abdomen: His abdomen was tense but non-painful on palpation. There was no organomegaly, masses or other abnormalities noted on abdominal palpation.
Neurologic: He was mentally appropriate and no obvious cranial nerve deficits were noted. He did not have any proprioceptive deficits in any limb and he had positive withdrawal and cross-extensor reflexes in all of his limbs.
Urogenital: No abnormalities were noted grossly.
Problem List: Kyphosis (thoracolumbar spine), intermittent lameness on RF limb, pain and vocalizing
Options that were offered to the owner included: Radiographs (spine, shoulders, hips), senior panel blood work through IDEXX, acupuncture, Galliprant, Tramadol +/- Gabapentin, Methocarbamol, and referral to an orthopedist for magnetic resonance imaging (MRI). The owner elected radiographs, bloodwork, acupuncture, Galliprant, tramadol and methocarbamol.
Diagnostics & Results:
Radiographs – Radiographs show evidence of bilateral degenerative changes to both glenohumeral joints, moderate kyphosis of caudal thoracic and cranial lumbar spine and a possible mineralized disc between the twelfth and thirteenth thoracic vertebrae (T12-T13) as well as narrowed disc spaces within thoracic spine.
Senior panel IDEXX (CBC, serum chemistry, cPL, T4, UA) – All CBC values were within normal limits. Serum chemistry abnormalities included a mild elevation in SDMA, creatinine, blood urea nitrogen (BUN), aspartate aminotransferase (AST) and creatinine kinase. His cPL was mildly elevated. His urinalysis indicated mild isothenuria, a slightly acidic urine pH, mild proteinuria and a moderate amount of calcium oxalate crystals. All other values were within normal limits. These results indicate evidence of early kidney disease, mild pancreatitis and mild evidence of muscle inflammation.
Based on physical exam, radiographs and bloodwork changes, my plan included: beginning a prescription kidney diet (k/d), increasing availability to water in the home (such as fountains or a water dispenser), eliminating table scraps from the diet, beginning acupuncture one to two times weekly and consistently administering pain medications (methocarbamol, galliprant, tramadol), administering subcutaneous fluids and a subcutaneous cerenia injection, pursuing a urine culture with low colony count to rule out a urinary tract infection, and then rechecking bloodwork and a urinalysis in one to three months with a urine sample from the first urination of the morning.
Differential Diagnoses:
Degenerative joint disease (DJD), intervertebral disc disease (IVDD), neuropathy/myopathy
Definitive (or Putative) Diagnosis (or Diagnoses):
Based upon the myofascial exam, as well as radiographic findings, the patient has DJD of the glenohumeral joints bilaterally and moderate kyphosis of the thoracolumbar spine due to suspect IVDD and a mineralized disc between T12-T13. The patient also has early kidney disease and mild pancreatitis with a possible urinary tract infection.
Medical Decision Making:
When approaching these acupuncture treatments, my plan targeted central, peripheral and autonomic neuromodulation. Central points were placed along the bladder line in the cervical, thoracolumbar and lumbosacral spine. Peripheral points were placed more distally on the front and back limbs. Autonomic points included the kidney tiara and stomach 36 to treat mild kidney changes and local pain as well as inflammation.
Acupuncture Treatments:
Needles: MAC Ultra-Smooth S Type, Model 32G x 1.0″, Size 0.25 x 25mm
3/21/2019 Dry Needling, Points used (22): ST 36 bilaterally; SI 11, 12 bilaterally; GV 20, 14; BL 13, 14, 15, 16, 17, 18, 19 bilaterally
3/27/2019 Dry Needling, Points used (17): LI 11 (bilaterally); BL 11, 12, 13, 21, 23, 25 (bilaterally); GV 20, 14, Bai Hui
4/3/2019 Dry Needling, Points used (19): LI 11 (left side); ST 36 (left side); BL 11, 12, 13, 21, 23, 25, 52 (bilaterally); GV 20, 14, Bai Hui
Stomach (ST) 36: ST 36 was chosen to reduce inflammation related to degenerative joint changes as well as pancreatitis. ST 36 also aided in local pain relief within the stifle that may have been responsible for his laterally turned out hind limb stance as well as gastrointestinal upset that resulted in vomiting.
Small intestine (SI) 11 and 12: ST 11 and 12 were chosen because local trigger points were palpable in this region. As this myofascial region is critical to shoulder function, I was hoping to improve front limb ambulation and alleviate associated shoulder pain due to the degenerative changes evident in the shoulder joint via radiographs and palpable taut bands.
GV (Governor Vessel) 20, 14 and Bai Hui: Bai Hui was chosen due to its involvement in kidney health as Poochie had mildly elevated kidney values on bloodwork. In addition, Poochie was locally tender over the pelvic region on myofascial exam. GV 20 and 14 were chosen to ease anxiety and to function as “permission points” to allow Poochie to acclimate to the acupuncture treatments. In addition, GV 14 aids in management of thoracic limb pain, neck tension and inflammation.
Bladder (BL) points: The points along the bladder line were chosen to alleviate local trigger points in their respective regions.
Large intestine 11 (LI 11): This point was chosen for its anti-inflammatory modulation and to aid in management of local trigger points.
Outcomes, Discussions, and References:
Cellular apoptosis is a critical pathological change that occurs in intervertebral disc degeneration which can result in nerve root compression. Acupuncture has been recognized by the World Health Organization as an accepted treatment for pain as it improves blood circulation, reduces inflammation and aids in neuromodulation. During apoptosis, cells self-destruct1. Additionally, cysteine proteases called caspases modulate the apoptotic response as they become activated towards the end of the process. Caspases function within two major activating pathways: the mitochondria-mediated pathway and the fas-mediated pathway. According to Liao et al, electroacupuncture has been shown to suppress caspase activation and therefore inhibits cell death associated with disc degeneration via the mitochondria-mediated pathway1. Similarly, acupuncture point stimulation has also been demonstrated to inhibit intervertebral disc degeneration by resulting in modulation of the extracellular matrix collagen system2. Based on these research findings, acupuncture is a valuable treatment modality to help reduce pain, inflammation and cellular death associated with the degenerative changes evident in Poochie’s spine. Throughout his acupuncture treatments, his ambulation has improved and he appears more mobile through his spine when he walks. The owners report that he does not vocalize in pain at home and is able to run and jump. Although it is unlikely that acupuncture will ever reverse the cellular death and degeneration that has already occurred, it is likely that it can help to prevent future apoptotic changes and secondary pain and inflammation. For this reason, I would like to begin to use electroacupuncture for Poochie in the future.
Through the use of dry needling in conjunction with adequate pain medication, Poochie’s mobility improved throughout the acupuncture sessions. He became more mobile through his spine and his vocalization at home decreased. He even began to be able to trot, run and jump at home. His urinary accidents decreased in frequency and his appetite improved. This medical acupuncture experience taught me the importance of complementary modalities and illustrated how pain medication in conjunction with acupuncture can work together to enhance mobility in chronic degenerative disease.
1. Liao, Jun, Ke, Meigui, Xu, Teng, & Lin, Lili. (2012). Electroacupuncture inhibits apoptosis in annulus fibrosis cells through suppression of the mitochondria-dependent pathway in a rat model of cervical intervertebral disc degradation. Genetics and Molecular Biology, 35(3), 686-692. Epub July 13, 2012.https://dx.doi.org/10.1590/S1415-47572012005000046
2. Qinran Sun, Fangming Liu, Min Gao, Wenqing Wu, Weiju Liu, Cong Yin, Zhongshu Zhu, Lijin Zhang, Xiufang Ding, Yanping Guo, Hui Gong, Xuguo Sun, Daoping Zhang. (2019). Therapeutic evaluation of acupoint stimulation with needle-scapelon on rat model of degenerative cervical intervertebral discs. Biomedicine and Pharmacotherapy, 110, 677-684. https://doi.org/10.1016/j.biopha.2018.11.070.