Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018055
Abstract: Dolly, an 18-year-old spayed female domestic short-hair cat that was presented for acupuncture in June 2018. Dolly was treated with acupuncture to aid in treatment of suspect osteoarthritis, chronic kidney disease, and cognitive dysfunction of unknown origin. Though Dolly’s comfort and mobility improved with therapy, her cognitive status declined. She began to have generalized seizures and was humanely euthanized.
History and Presentation: Dolly, an 18-year-old spayed female domestic short-hair cat, was presented on 6/14/2018 for acupuncture. She had a history of trauma to the base of her tail in 2008, chronic kidney disease diagnosed in 2016, and untreated suspected hyperthyroidism. Dolly’s therapies included gabapentin, subcutaneous fluid administration, potassium supplementation, mirtazapine, and a diet high in omega-3 fatty acids. In May of 2018, Dolly’s kidney disease appeared to be stable with a creatinine of 2.14 mg/dL. A total T4 measured at that time was elevated at 5.4 ug/dL; treatment with methimazole was discussed and declined. Recently, Dolly’s owners felt that she had periods of time where she was “not there.” She also seemed more uncomfortable and had not been jumping onto chairs as she had in the past. The owner’s priority was increasing comfort and mobility as well as improving cognitive function.
Physical Examination and Clinical Assessments: On initial evaluation, Dolly was bright, alert, and responsive. Cranial nerve exam and fundic exam were normal. Conscious proprioception and placing appeared normal and no ataxia was noted. Generalized moderate muscle atrophy was present, but was more pronounced in the hind limbs and over the lumbar spine. At a walk both hind limbs appeared stiff, but was more pronounced in the right. There was also a weight-bearing right forelimb lameness. Tail carriage was subjectively low and the tail appeared to have limited mobility. There was a taut band on the right side of the neck that was tender to palpation, crepitus and thickening of both stifles, tenderness to palpation of the hips and gluteal muscles as well as taut adductor muscles, tenderness on palpation of the inner and outer bladder line in the mid to caudal lumbar region, and myofascial restriction in the lumbar and sacral region.
Medical Decision Making: As the patient did not tolerate being held or touching or manipulation of her limbs well in general, central points were chosen for treatment. Weekly treatments were recommended, though the patient’s attitude and agitation during some sessions limited the needles that could be placed. Points along the bladder line in the lumbar and sacral region were chosen to neuromodulate pain signals coming from the peripheral nerves of the hind limb at the level of the origin at the spinal cord, help release myofascial restriction, and to impact sympathetic tone to the kidneys. Governor vessel points were chosen to help regulate sympathetic tone to the kidneys as well as to impact cerebral blood flow and to aid in relief of cervicothoracic pain. ST36, when tolerated, was included for its parasympathomimetic effects on gastrointestinal motility and immune modulation as well as for regional pain control and effects on proprioception. Therapy with a class IV laser was also discussed and declined due to finances.
Differential Diagnoses: Dolly was previously diagnosed with chronic kidney disease and is suspected to have hyperthyroidism based on total T4 measurement. Based on gait and orthopedic exam as well as strain patterns, I suspect that she had osteoarthritis of the hips and stifles. Her low tail carriage may be due to myofascial restriction and nerve impingement or may be a result of her past trauma. Differentials for Dolly’s cognitive changes include vascular accident or stroke, toxoplasmosis, intracranial neoplasia, cognitive dysfunction syndrome, pain secondary to joint disease past trauma, and head trauma.
Definitive (or Putative) Diagnosis (or Diagnoses): Chronic kidney disease, hyperthyroidism, presumed osteoarthritis of stifles and hips (based on orthopedic examination), tail dysfunction from myofascial restriction of nerves, open for cognitive changes.
Acupuncture Treatments: Coated Seirin 0.16 x 30mm needles were used in each treatment. Needles were placed, stimulated, and left in for 5-20 minutes as tolerated by the patient. Massage of the lumbar region and hind limb muscles followed each treatment. GV20 was chosen for calming effects and effects on cerebral blood flow. GV14 was chosen for its parasympathetic effects and stimulation of cervicothoracic nerves to relieve forelimb and neck pain. GV4, BL23, and BL52 were utilized to help regulate sympathetic tone to the kidneys as well as stimulation of lumbar spinal nerves and relief of myofascial restriction. BL25, BL27, and BL28 were used to relieve LS pain and to help relieve myofascial restriction. GB29, GB30, and BL54 were chosen to help treat hip pain.
6/14/18: GV20, GV14, Bai Hui, GV4, BL 23 (LR), BL52 (LR), BL25 (LR), BL28 (LR), ST36 (R), GVT/3 (LR).
6/20/18: GV20, GV14, Bai Hui, GV4, BL23 (LR), BL25 (LR), BL27 (R), BL42 (LR), ST36(L), GVT/3 (LR).
6/27/18: GV20, GV14, Bai Hui, GV4, BL25 (LR), BL28 (LR), BL52 (LR), GB29(R), GB30(R), GB54(R), ST36(R), GVT/3(R)
7/21/18: GV20, GV14, Bai Hui, BL23 (LR), BL52(LR), GVT/3(R)
7/25/18: GV20, GV14, Bai Hui, BL54 (R), GB29(R), GVT/3(R)
Outcomes, Discussions, and References: Over the course of treatment, Dolly’s hind limb and tail comfort and mobility appeared to improve. Her owners reported that she seemed more stable on slippery surfaces. After three treatments, her owners discontinued her gabapentin and saw no noticeable change. Though Dolly responded well to acupuncture, the addition of laser therapy would likely have increased her comfort and complimented the effects of acupuncture through local vasodilation, modulation of inflammatory mediators, and increased cell turnover. Given Dolly’s resistance to manipulation of touching of her limbs, laser treatment would also have provided a “hands off” modality for treatment of her stifles.
Symptoms of cognitive dysfunction syndrome in cats include restlessness, irritability, house soiling, decreased grooming, and decreased ability to learn. These symptoms can also be indicative of physical discomfort. Though Dolly’s improved comfort and ease of motion unfortunately did not accompany an improvement in mental status, myofascial dysfunction and pain should be considered as a contributor or cause of perceived cognitive dysfunction in aging pets.
Dolly was my first feline acupuncture patient, and she taught me a lot about the handling and placement of needles in cats. Given the cognitive changes seen in her case, I considered electroacupuncture as it has been shown to improve cognitive changes in mice and rats with Alzheimer’s disease, but I hesitated because of the unknown etiology of her mentation changes as well as her predilection to move and dislodge needles during her sessions. More recently, I came across an abstract discussing improvement of learning and spatial awareness in mice with Alzheimer’s; unfortunately, the only point my protocol had in common with the researcher’s was ST36. The comparison of electroacupuncture and acupuncture in regards to cognitive dysfunction may be a useful area of study as not all patient are good candidates for electroacupuncture and not all practitioners have an electroacupuncture unit.
Kan BH, Yu JC, Zhao L, Zhao J, Li Z, Suo YR, Han JX. Acupuncture improved dendritic structure and spatial learning and memory ability of Alzheimer’s disease mice. Neural Regen Res. 2018 Aug;13(8):1390-1395.
Wang Y, Kong L, Li W, Zhang K, Shen F, Want Y, Zhou H, Sun G. Effects and mechanisms of different frequencies of electroacupuncture for learning and memory ability of Alzheimer’s rats. Zhongguo Zhen Jiu. 2017 Jun 12;37(6):629-636.