Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018026
Abstract:
A pony with a history of recurrent laminitis and now experiencing general malaise, low head carriage, and front limb lameness was treated with dry needling during three sessions. Treatment focused mainly on trigger point deactivation. Her overall demeanor, neck flexibility, and gait improved with each acupuncture treatment.
History:
Tinkerbell is a 19 year old Welsh Arabian mare. Her owner acquired her in July 2016 and prior to that, she was used as an English lesson show pony. She is now a companion for an adult gelding quarterhorse and is not being worked or ridden. The owner’s primary complaints are that she seems stiff in all four legs, as well as her neck, which the noticed in September 2018. The owner also noted that, in the past, she usually rested with her weight on the left pelvic limb, with her right leg slightly lifted. In the last month, she noticed that Tinkerbell has been resting with her weight on her right pelvic limb. Tinkerbell was diagnosed with laminitis in September 2012, May 2017, and October 2017. She was treated medically each time and recovered over the course of 4 – 8 weeks. The owner notes that since she acquired her, she has always tested positive on hoof testers despite showing no signs of lameness. She was diagnosed with Cushing’s and insulin resistance in May 2017. Her current diet is Wellsolve LS with free choice hay and occasional supplemental flax seed and she is not given any treats that are high in sugar. Her medications include 1 mg of pergolide daily, Quiescence, and is treated with 400 mg hydroxyzine daily in the spring and summer for allergies. She is no longer taking levothyroxine since she was averse to eating her grain with the medication mixed in and has managed well without it.
Physical Examination & Clinical Assessments:
Tinkerbell weighs approximately 700 – 750 pounds and has a body condition score of 5/9. She is quiet, alert, and responsive. Her general physical exam revealed no significant abnormalities. On examination of her hooves, there were no palpable digital pulses, and no heat or pain on palpation. On her most recent exam with her primary care veterinarian, she tested positive on hoof testers on her front heels bilaterally. At a walk, she takes short, stiff strides on both thoracic limbs and has a low head carriage. On her myofascial examination, she was unwilling to extend her head cranioventrally to the ground and had very firm, ropy bands of muscle throughout her neck bilaterally. Her skin over the right side of her neck feels cool and firm to the touch and it was immobile over the underlying fascia. There were numerous reactive points and ropy bands throughout her deltoid, serratus ventralis and brachiocephalicus muscles bilaterally and numerous trigger points through-out her left latissimus dorsi muscle. She showed more hesitation in picking up her right thoracic limb than her left thoracic limb and was resistant to lateral rotation of both thoracic limbs. She was resistant to lateral movement of her mid-thoracic vertebrae and was resistant to palpation over her gluteal muscles. She did not allow either of her pelvic limbs to be picked up, kicked her left pelvic limb and sunk under light pressure of her left gluteal muscles. She showed no abnormalities on a neurologic exam. Her most recent blood panel was run in September 2018, including a complete blood cell count, chemistry, and tick borne disease panel showed no significant abnormalities.
Problem List & Differential Diagnoses:
Based on Tinkerbell’s history and physical exam, her problem list can be narrowed down to neck pain, thoracic limb pain, and left pelvic limb pain. General malaise and low energy are likely sec-ondary to the pain she’s experiencing. Thoracic limb pain and neck pain have many overlapping differential diagnoses, including vasculitis, borreliosis, anaplasmosis, Potomac Horse Fever, lym-phosarcoma, intervertebral disc disease, poor saddle fitting, cervical vertebral malformation, im-mune mediated myositis, vertebral fracture, polysaccharide storage myopathy, osteochondrosis, and myofasciitis due to compensating for recurrent laminitis.
Putative Diagnoses:
Since there is no ataxia present, cervical vertebral malformation can be ruled out. Vasculitis, borreliosis, anaplasmosis, Potomac Horse Fever, and immune mediated myositis are unlikely since her most recent lab results were all normal and she does not have a fever. There are no palpable masses and the affected area is fairly widespread, so lymphosarcoma is unlikely, but can not be completely ruled out. Tinkerbell is no longer used for riding so saddle fitting is not an issue. Although she is not currently exhibiting signs of laminitis, it’s likely that she has myofascial pain from compensating for recurrent, bilateral thoracic limb laminitis. Intervertebral disc disease, osteochondrosis, and vertebral fracture can not be ruled out without imaging, but if present, they can all contribute to myofascial pain in that area. Although Tinkerbell does not fit the typical signalment and presentation of polysaccharide storage myopathy, this can not be completely ruled out without a muscle biopsy.
Medical Decision Making:
My treatment plan for Tinkerbell focused on deactivation of trigger points mainly in her neck, shoulders, and a few points in her gluteal muscles as she would allow. She did not allow needling of her distal limbs, so I also focused on choosing points near spinal segments that can have beneficial effects distally. To neuromodulate the axillary, musculocutaneous, median, and ulnar nerves, I chose points around nerve roots originating from the 7th, 8th, and 9th cervical vertebrae. Similarly, I chose points around nerve roots originating from the lumbar and sacral vertebral bodies to neuromodulate the sciatic, femoral, cranial gluteal, fibular, and tibial nerves.
Treatments:
Dry needling treatments took place during three sessions on 11/18/18, 12/30/18, and 2/25/19. Seirin J Type 0.25 x 30 mm acupuncture needles were used for all points. At each session, LI 16, GV 20 and Bai Hui were placed first to assess Tinkerbell’s tolerance to needling and to promote calm-ness by down regulating sympathetic tone. She has tight, ropy bands around LI 16, LI 17, and LI 18 so needles were placed at these points and redirected and twisted multiple times to release the trigger points. Trigger point deactivation techniques were also performed at numerous points throughout her cervical serratus ventralis and deltoid muscle bilaterally, as well as her left longissimus dorsi muscle. Mid-thoracic points along the inner Bladder line (i.e. BL 13 through BL 18) were also needled to relieve pain in this area, which may have been due to the thick band of connective tissue running from the latissimus dorsi to the vertebral bodies. In addition to Bai Hui, other pelvic points included GB 29, BL 54, and GB 30 as there were multiple, very sensitive trigger points in these areas. Tinkerbell did not tolerate trigger point deactivation techniques at these points. Needles remained inserted for 20 minutes at each session.
Outcomes:
Tinkerbell’s owner noted that she was quite sedate immediately after each session, but was very active by the following day. When she was turned out onto pasture in the morning following an acupuncture session, she ran around for several minutes, bucked, and her head and neck carriage were higher. The owner also noted that she was resting again on her left hind leg, as she used to do in the past. The owner noticed immediate improvement in her overall energy level and did not experience any adverse effects. The positive effects lasted for 2 – 4 weeks after each session, at which point she would gradually return to having a stiff gait, low head and neck carriage, and refused to trot or run.
Discussion:
Tinkerbell’s overall comfort level and demeanor improved greatly after acupuncture therapy, with-out having to add in additional medications. Directly addressing a significant cause of her pain (myofascial tension) allowed her to return to a more active lifestyle, which is crucial for her overall physical and mental health, especially given her history of Cushing’s and insulin resistance. Deactivating these trigger points allows for more adequate blood flow, nerve transmission, and muscle movement in those areas. The analgesic effect of acupuncture has been largely attributed to promoting the release of endogenous opiates (1) and acupuncture has been shown to significantly decrease signs of lameness in horses (2). This case provided a great opportunity to expand my knowledge and techniques of trigger point deactivation and tailoring my approach to an individual patient. I look forward to continue working with Tinkerbell in helping her remain pain free. We are also planning future sessions to work on immunomodulating points to provide relief of pruritus that she typically experiences in warmer weather.
References:
1.) Chou, Li-Wei, et al. “Probable Mechanisms of Needling Therapies for Myofascial Pain Con-trol.” Evidence-Based Complementary and Alternative Medicine, vol. 2012, 2012, pp. 1–11., doi:10.1155/2012/705327.
2.) Dunkel, Bettina, et al. “A Pilot Study of the Effects of Acupuncture Treatment on Objective and Subjective Gait Parameters in Horses.” Veterinary Anaesthesia and Analgesia, vol. 44, no. 1, 2017, pp. 154–162., doi:10.1111/vaa.12373.