Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018026
Abstract:
A dog experiencing night time anxiety and restlessness, as well as occasional left thoracic limb and right pelvic limb lameness presented for acupuncture to alleviate these clinical signs. Previous med-ical management provided short term, inadequate relief of her clinical signs. She was treated with acupuncture during three sessions over the course of three months. Her clinical signs resolved with one treatment and returned when sessions were more than 6 weeks apart.
History:
Rory is an 11 year old spayed female Siberian Husky dog. She was adopted by her owner when she was 4 years old and her medical history prior to that is unknown. 3 years ago, Rory had a lipoma surgically excised from an area just distolateral to her left elbow. Over the past year, the owner has noticed that Rory is occasionally not bearing any weight on her right pelvic limb when descending a full flight of stairs. Rory also has a 1 – 2 year history of mild limping on her right pelvic limb, as well as left thoracic limb after rigorous activity. The owner also notes that in the last year, she has stopped extending her front limbs forward to stretch as she used to do frequently. In addition to limping, the owner’s primary complaint is that Rory has become very restless in the evening and will wake up in the middle of the night to pant and pace around the room. These episodes have occurred 3 – 5 times per week for the last 6 months and will last for several hours. Rory was prescribed medications by her primary care veterinarian 3 months ago to address these issues. If Rory was very active that day or if she seems restless, the owner administers 300 mg gabapentin and 50 mg carprofen orally. The owner notes that Rory only shows mild improvement in her limping and restlessness when given these medications.
Physical Examination & Clinical Assessments:
Rory is approximately 22 kgs and has a body condition score of 5/9. Her mentation is bright, alert, and responsive and she can be skittish to fast movements and is resistant to gentle touch and handling of her limbs. She has an open slab fracture of her upper left carnassial premolar. The remainder of her physical exam is unremarkable. At her most recent visit to her primary care veterinarian two weeks prior to our first session, she had a complete blood count, chemistry, urinalysis, thyroid panel, heartworm test, and tick borne disease panel performed, which all showed no significant ab-normalities.
On her myofascial evaluation, her triceps brachii muscles were thickened and firm bilaterally. Her right triceps brachii muscle was especially sensitive on palpation. She was tender to palpation on the proximal half of her left extensor carpi radialis and common digital extensor muscles. She had very firm, ropy bands in her dorsolateral neck bilaterally. Compared to the right side, she had mild muscle atrophy of the muscles controlling and supporting her left shoulder (omotransversarius, deltoid, supraspinatus and infraspinatus). She readily picked up her front left limb when standing and was more hesitant to pick up her right front limb. She had multiple trigger points in her left la-tissimus doors muscle and throughout her longissimus dorsi and iliocostalis muscles bilaterally. Trigger points in her epaxial muscles were most sensitive in the lumbar region. She did not tolerate thorough palpation of her pelvic limbs and subtle changes in musculature could not be appreciated due to her thick fur. On brief palpation, her right stifle felt moderately thickened in comparison to the left stifle. Rory showed no abnormalities or deficits on her neurologic assessment. She did not tolerate being placed in lateral recumbency for a crossed extensor evaluation. No overt lameness was observed at a walk or trot initially. After about 10 minutes, she would occasionally very lightly drag her right pelvic nails on the concrete. While walking, the forward extension of her left front limb is decreased compared to her right thoracic limb.
Problem List:
Based on Rory’s history and physical exam, her problem list can be narrowed down to the following: Restlessness and anxiety at night, pain and muscle tension in her neck to thoracic limb region, lameness on her right pelvic limb, and and open fracture of the upper left premolar.
Differential & Putative Diagnoses:
Differential diagnoses for night time anxiety include vasculitis, meningitis, hypothalamic tumor, canine cognitive dysfunction, noise disruptions, traumatic brain injury, hyperadrenocorticism, and myofascial pain syndrome. In Rory’s case, canine cognitive dysfunction and myofascial pain syndrome are the most likely definitive diagnoses for night time restlessness. She would likely have other clinical signs, such as progressive fever, general malaise, neurologic signs and possibly lab abnormalities with vasculitis, meningitis, hypothalamic tumor, traumatic brain injury, and hyperadrenocorticism. Noise disruptions can not be completely ruled out. However, the owner reports no recent changes to her environment and has not noticed noise disruptions herself.
Differential diagnoses for pain and muscle tension in her neck to thoracic limb region include vasculitis, chronic ehrlichiosis, chronic borreliosis, fibrosarcoma, degenerative myelopathy, degenerative joint disease, overexertion, scarring at mass removal surgical site, elbow dysplasia, immune mediated polyarthritis, blunt force trauma, diabetic neuropathy, and myofasciitis due to compensa-tion for left thoracic limb lameness (i,e. myofascial pain syndrome). It is expected that she would have other clinical signs, such as fever, lymphadenopathy, joint edema, and malaise if vasculitis, chronic tick borne disease, and immune mediated polyarthritis were present. Normal lab results recently also rule out diabetes, ehrlichiosis, and borreliosis. Imaging would be needed to rule out el-bow dysplasia. Although there are no palpable masses, fibrosarcoma can not be completely ruled out. However, Rory’s clinical signs (limping on her left thoracic limb) started at least one year ago. If fibrosarcoma were the cause, a palpable mass would likely be apparent by now. There is no known history of blunt force trauma since the owner has had her. No lab tests have been per-formed to test for degenerative myelopathy, but she is not experiencing progressive pelvic limb ataxia, so this is unlikely. Myofascial pain syndrome, scarring at the surgical site, degenerative joint disease, and overexertion are the most likely definitive diagnoses for pain and muscle tension in her neck and thoracic limb region.
Medical Decision Making:
As Rory can be fairly skittish and resents palpation to her limbs, her treatment was somewhat limited by what she would reasonably allow. I created a plan that starts each session with parasympathetic balancing points to help promote calmness, as well as gauge her response to needling. Based on my palpation that day, I planned to focus on trigger points in her neck, shoulders, back, and hips. Additionally, I chose points along her spinal nerve roots that would effect changes distally since she did not allow palpation or needling of her distal limbs. So I planned to needle along the C6 – T1 spinal nerve roots to promote function of her suprascapular, subscapular, axillary, musculocutaneous, radial, medial, ulnar, and thoracodorsal nerves bilaterally.
Treatments:
Dry needling was performed on Rory during three sessions, which took place on 10/28/18, 11/18/18, and 1/6/19. All points were needled using Seirin J type 0.16 x 30 mm acupuncture nee-dles. During each session, GV 14, GV 20, and Bai Hui were the first points placed. GV 14 was chosen to address local pain, as well as to assess her response to needling that day. GV 20 was chosen to address anxiety and agitation, which may also play a role in her night time restlessness. Bai Hui was chosen as a central point to address pelvic limb pain and to assess her response to needling in her hind end. During her first session, I focused mainly on her shoulders and neck. I chose to needle GB 21 and local trigger points to release myofascial tension in that area. Similarly, I chose to needle BL 10, BL 11, BL 12, and BL 13 since there were trigger points at or around these points. I manually twisted each needle until I felt a muscle grab and left the needles in for 20 minutes. During the second session, I needled the same points described above, and added GB 29, GB 30, BL 54, and ST 36 on the right side to address right pelvic limb pain. I also added in BL 22, BL 23, and BL25 as there were trigger points at these spots. During the third session, Rory was significantly more skittish than previous meetings and more sensitive to gentle touch all over. I re-peated dry needling at the same points around the neck and shoulders. I also added in BL 21 and BL 22 since there were trigger points at these spots. The owner also reported that Rory experienced a decreased appetite in the last week, so BL 21 was also chosen to help with appetite stimulation.
Outcomes:
After the first session of acupuncture, the owner reported that Rory completely stopped panting and pacing at night and seemed to be able to sleep throughout the night. The owner also stated that she was able to stop giving her gabapentin and carprofen, since she was giving these medications mostly to help her sleep through the night. She noticed mild left thoracic limb and right pelvic limb lameness if she was especially active, but notes that the duration of lameness is shorter than before. The owner reported that Rory’s night time restlessness did not return until around 12/28/18, approximately 6 weeks after the second session. Her clinical signs completely resolved again after receiving her third acupuncture treatment on 1/6/19 and her appetite returned to normal.
Discussion:
The rapid resolution of Rory’s clinical signs after receiving acupuncture is very supportive of how acupuncture can effectively relieve myofascial tension to provide pain relief throughout her body and decreasing overall anxiety. The deactivation of trigger points is safe, rapid, effective technique to provide relief of pain caused by myofascial tension (1). This was done by releasing contracted muscle fibers, promoting the release of endogenous opioids, and regulating her parasympathetic system (2). Even though I was limited by my patient’s low tolerance to handling, tailoring my approach to what she comfortably allowed still provided fantastic results that increased the quality of life for her and her owner. This case emphasized the importance of using proximal points to achieve results distally.
References:
1.) Desai, Mehul J., et al. “Myofascial Pain Syndrome: A Treatment Review.” Pain and Therapy, vol. 2, no. 1, 2013, pp. 21–36., doi:10.1007/s40122-013-0006-y.
2.) Dunning, James, et al. “Dry Needling: a Literature Review with Implications for Clinical Practice Guidelines.” Physical Therapy Reviews, vol. 19, no. 4, 2014, pp. 252–265., doi:10.1179/108331913×13844245102034.