Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018028
History:
“Chrome” a 5 year old off the track thoroughbred gelding presented for poor body condition, marked muscle atrophy on the left side of his body and inability to hold his hind legs up to have his hooves handled. He was purchased 3 weeks prior to presentation and when he arrived at his current owner’s facility he was dull, markedly underweight, and had severe pastern dermatitis (“scratches”) on all 4 distal limbs causing swelling and discomfort. He was treated for pastern dermatitis topically with chlorhexidine scrub and antibacterial/antifungal topical ointment and systemic antibiotics (sulfamethoxazole/trimethoprim) by another veterinarian. Owner had been offering him free choice hay and senior feed supplement for weight gain.
His previous owner contributed his poor body condition and muscle atrophy to being left in the pasture with limited shelter during a period of cold, snowy weather where he was fed only poor quality hay. There was no mention of an accident or injury that may have caused left sided muscle atrophy.
Physical Exam and Assessment:
On presentation the patient was a body condition score (BCS) of 3/5 with marked muscle atrophy and myofascial restriction of the epaxial muscles and gluteal muscles on the left. His epaxial and gluteal muscles on the right were tense with multiple trigger points (most evident in thoracolumbar region) and appeared overdeveloped for his body condition. There were trigger points in his gluteal muscles, hamstrings and trapezius bilaterally. He was reactive to palpation of ST 7 bilaterally and did not like the remainder of his face being touched. Mild pastern dermatitis with no associated swelling was present on all 4 distal limbs.
Cervical bending, truncal rotation, lateral bending and dorsal nerve root ganglion tests were within normal limits bilaterally. He had decreased cranial ventroflexion to the right, which may have been behavioural, or due to pain and myofascial restriction. He was non-reactive to lumbar pull, tuber sacrale pinch and sacroiliac flexion. When he picked up his hindlimbs he had an exaggerated, spastic movement and was unable to hold his hindlimbs 2 inches above the ground to test hind limb circles. On dynamic exam he showed no spastic movements in his hindlimbs forwards or backwards, but had a mild (Gr II/V) left hind lameness.
Chrome Oct 31 
Chrome Oct 31 Circle 
Problem List and Differential Diagnoses:
The two most prominent problems were generalized left muscle atrophy and the spastic movements when asked to pick up hindlimbs. Other problems noted were the tense overdeveloped musculature on the right, poor body condition score and pastern dermatitis.
Many of the differential diagnoses for the two most prominent problems were the same: post anesthesia myositis (vascular), equine protozoal myelopathy (EPM, Sarcocystis spp.), malnutrition (iatrogenic), equine polysaccharide storage myopathy (PSSM, congenital), immune mediated myositis due to Streptococcal spp. (immune), and pars pituitary intermedia dysfunction (PPID, endocrine). Other differential diagnoses for left sided truncal and gluteal muscle atrophy include: Myofascial restriction in left withers and gluteal muscles causing nerve entrapment and subsequent atrophy, nerve injury causing neurogenic atrophy, and equine shivers (degenerative). Other differential diagnosis for spastic movement of hindlimbs include: equine motor neuron disease (EMND, degenerative), fibrotic myopathy (traumatic), and myofascial restriction following castration.
Putative Diagnosis: Myofascial restriction throughout left truncal and hindlimb muscles causing disuse atrophy of associated muscles and compensatory hypertrophy of the right truncal and hindlimb muscles. Myofascial restriction suspected to be due to trauma, exacerbated by uneven riding and malnutrition.
Canada does not have Sarcocystis spp., ruling out EPM. Equine shivers and PSSM were unlikely due to breed. There was no history of recent anesthesia or Streptococcal spp. infection making post anesthesia myositis and immune mediated myositis unlikely. Fibrotic Myopathy, PPID and EMND were ruled out as the rest of the clinical signs were inconsistent.
Medical decision making:
Treatment focused on resolving myofascial restriction bilaterally and stimulating the nervous system on the left side of his body to improve his muscling and comfort. Treatments were weekly for the first 2 months due to the severity and chronicity of the patient’s condition. Acupuncture, photomedicine and manual therapy were used to achieve maximum neuromodulation and myofascial release. Due to patient’s reactivity to acupuncture, each treatment was modified based on exam and temperament to include the least amount of needles possible. Seirin needles (0.25 mm x 40 mm) were used for all acupuncture treatments unless otherwise stated. Cold laser treatments were performed with Class 1M super pulsed laser (MR4 ACTIVet). Electroacupuncture (E-stim) treatments performed with AS SUPER 4 digital (schwa-medico Menschliche Medizin).
Treatments & Rationale:
Treatment 1 (October 31, 2018):
Central nervous system (CNS): Bladder (BL) 11, BL 13, BL 26, BL 27 bilaterally, Bai Hui. BL 19 on right side. Laser 1,000 Hz for 5 minutes along BL line (Unwind Method).
Peripheral nervous system (PNS): Large Intestine (LI) 16 (cervicothoracic spinal nn.)
Autonomic nervous system (ANS): Bai Hui
Myofascial dysfunction: BL 11, BL 13, BL 26, BL 27 bilaterally, Bai Hui. BL 19 on right side. Laser 1,000 Hz 2 minutes at BL 11 to remove stuck needle.
Additional notes: 0.20 mm gauge Seirin used because of patient unfamiliarity and his reactivity to palpation. Patient became agitated with BL 19 and was violently reactive to all needles previously placed so all needles were removed immediately.
Treatment 2 (November 7, 2018):
CNS: BL 11-13, BL 21-27, Bai Hui. BL 23-27 were chosen to stimulate the lumbosacral nerves and encourage proper muscle activity in the hind limbs
PNS: BL 54 (cranial gluteal n. and sciatic nerve dysfunction), Gall Bladder (GB) 29 (sacral spinal nn. and caudal gluteal n.), GB 30 (sciatic n. and caudal gluteal n.), SI 11 and SI 12 (suprascapular n.), LI 16, and ST 36 (fibular n.)
ANS: Bau Hui & ST 36
Myofascial dysfunction: BL 11-13, BL 21-27, Small Intestine (SI) 11 and SI 12
Additional Notes: No needles were placed to provide positive experience for the patient. Laser acupuncture (1,000 Hz for 1 minute) was used to stimulate acupuncture points.
Treatment 3 (November 14, 2018):
CNS: BL 13, BL 26 and BL 27 bilaterally. Laser Unwind Method
PNS: LI 16 and ST 36 bilaterally. BL 54, GB 29 and GB 30 on left only
ANS: ST 36. Laser acupuncture 1,000 Hz for 1 minute at Bai Hui
Myofascial dysfunction: BL 13, BL 26 and BL 27 bilaterally, BL 54, GB 29 and GB 30 on left only. Massage therapy to left gluteal muscles.
Additional notes: To keep the patient calm and under threshold, only 5 needles were placed at a time and were only in place for 5 minutes.
Treatment 4 (November 21, 2018):
Needles were left in for 15 minutes and only 5 needles were placed at a time.
CNS: BL 26, BL 27 bilaterally, Bai Hui. Laser Unwind Method
PNS: ST 31 (femoral n), BL 54, GB 29 and GB 30
ANS: Bai Hui
Myofascial dysfunction: ST 31. Right iliocostalis trigger point at approximately BL 52. Laser 1,000-3,000 Hz hips and hind limb muscles for 5 minutes each side. Massage as before.
Treatment 5 (November 28, 2018):
CNS: Bai Hui, BL 26 and BL 27 not tolerated. Laser Unwind Method
PNS: SP 9 on left 0.16 mm x 15 mm Seirin. 1-250 Hz for 2 minutes on LH atrophied muscles to stimulate of cranial gluteal n., caudal gluteal n. and sciatic n.
ANS: Bai Hui, attempted ST 36 but he kicked
Myofascial dysfunction: Lasered gelding scar 50 Hz for 2 minutes, 1-250 Hz for 2 minutes on LH atrophied muscles, 1,000 Hz for 1 minutes on hocks, stifles and hips bilaterally for improved range of motion (ROM). Massage as before.
Treatment 6 (December 5, 2018):
CNS: BL 26 and BL 27. Laser Unwind Method
PNS: 1-250 Hz for 2 minutes on left hind atrophied muscles to stimulate cranial gluteal n., caudal gluteal n. and sciatic n.
Myofascial dysfunction: Massage and laser therapy same as previous treatments.
Additional Notes: No specific acupuncture points were chosen to directly target PNS or ANS due to patient’s low tolerance for needling. Needles removed after 20 minutes.
Treatment 7 (December 12, 2018):
CNS: Laser Unwind Method
PNS: MR4 ACTIVet Sweeney Protocol was performed with 1,000 Hz for 2 minutes and 50 Hz for 5 minutes on left hind atrophied muscles to stimulate and promote regeneration of cranial gluteal n., caudal gluteal n. and sciatic n.. 1-250 Hz for 2 minutes was applied to the RH gluteal region to minimize compensatory pain and muscle overdevelopment.
Myofascial dysfunction: Sweeney Protocol left hind gluteals. 50 Hz for 2 minutes followed by 1,000 Hz for 1 minutes on hocks, stifles and hips bilaterally for improved range of motion (ROM). Massage therapy applied to left gluteal muscles.
Additional Notes: Reactive to the anticipation of needles, so laser treatment and manual therapy were used without acupuncture.
Treatment 8 (January 2, 2019):
CNS: BL 26 bilaterally, Bai Hui and BL 27 on left. Laser Unwind Method
PNS: MR4 ACTIVet Sweeney Protocol was performed same as December 12 treatment.
ANS: Bai Hui
Myofascial dysfunction: E-stim from BL 27 to scar tissue along BL line at approximately BL 54 (Alternating between 2 Hz, 210 us for 3 seconds and 100 Hz 120 us for 3 sec) at 0.2 mA for 10 minutes. Laser and massage therapy the same as previous.
Treatment 9 (January 16, 2019):
CNS: BL 26 and 27 bilaterally, Bai Hui, BL 29 and 30 on left. Laser Unwind Method
PNS: MR4 ACTIVet Sweeney Protocol was performed same as previous treatment.
Myofascial dysfunction: E-stim from BL 29 to BL 30 (Alternating between 2 Hz, 210 us for 3 seconds and 100 Hz 120 us for 3 sec) at 0.2 mA for 18 minutes. Laser and massage therapy the same as previous treatment.
Additional Notes: Able to leave needles in for 40 minutes.
Treatment 10 (January 30, 2019):
CNS: BL 26 and 27 on left and Bai Hui. Laser Unwind Method
PNS: MR4 ACTIVet Sweeney Protocol was performed same as previous treatment.
ANS: Bai Hui
Myofascial dysfunction: E-stim from BL 26- scar tissue at approximately BL 54 (Alternating between 2 Hz, 210 us for 3 seconds and 100 Hz 120 us for 3 sec) at 0.2 mA for 5 minutes. Trigger point at approx. GB 29. Laser and massage therapy the same as previous treatment.
Additional Notes: Able to leave needles in for 30 minutes after removing e-stim.
Chrome Jan 30 trot Chrome Jan 30 walk
Outcome and Discussion:
Each week following there was a noticeable difference in the patient’s muscling and ability to pick up and hold the hindlimbs. Improvements were more pronounced following acupuncture, laser and manual therapy than when no acupuncture needles were used. The mild left hind lameness resolved after the first treatment. The left epaxial muscle atrophy and the overdevelopment of the right epaxial and gluteal muscles was resolved at treatment 5 and the left hind atrophy was significantly improved. After treatment 7 he was able to circle both hindlimbs and the owner was encouraged to increase the intensity of his exercise program to include more ground pole work and cavalletti’s. After the addition of e-stim at treatment 8 the muscle development in his left hind significantly improved at each subsequent visit, which was also likely due in part to his increase in exercise. After treatment 9 he had all 4 hooves trimmed without having any issues holding up his hindlimbs.
His violent reaction to needling was an adverse event that could have been prevented by watching body language even closer, placing fewer needles and avoiding needling the more painful regions on the first visit. From that reaction the Animal Health Technician and I learned that we both needed to watch the animals body language very closely and communicate with each other about any changes, even if they appear minor. I also learned many techniques to minimize reactivity in my equine patients including: laser with the unwind method before placing needles to relax patients, massaging the muscles before and after needling, tapping the skin before placing needles, and placing minimal needles.
This case highlights the effectiveness of medical acupuncture, cold laser therapy and myofascial release in improving muscling and gait abnormalities. This offers an advantage over exercise and change in nutrition alone which is generally recommended to treat muscle atrophy.
References:
Su, Z., Hu, L., Cheng, J., Klein, J., Hassounah, F., Cai, H., Li, M., Wang, H., & Wang, X. (2016). Acupuncture plus low-frequency electrical stimulation (Acu-LFES) attenuates denervation-induced muscle atrophy. J. Appl Physiol 120, 426-436. doi:10.1152/japplphysiol.00175.2015
Onda, A., Jiao, Q., Nagano, Y., Akimoto, T., Miyamoto, T., Minamisawa, S. & Fukubayashi, T. (2011). Acupuncture ameliorated skeletal muscle atrophy induced by hindlimb suspension in mice. Biochemical and Biophysical Research Communications, 410. 434-439. doi:10.1016/j.bbrc.2011.05.152