Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018027
Abstract:
“Teeka” a 6 year old, female spayed mixed breed dog presented with the primary complaint of chronic left hind lameness that worsens after mild exercise. She had a history of urinary incontinence and recurring urinary tract infections. On presentation she had a mild left hind lameness and a crossed extensor reflex of left hind. She had marked generalized atrophy of her left hind muscles and mild generalized atrophy of her right hind muscles. Acupuncture and laser treatments were performed to primarily treat the left hind lameness and crossed extensor reflex. Improvement was seen after the first treatment and the patient continued to improve over the course of four treatments.
History:
“Teeka” is a 6 year old, female spayed mixed breed dog that was rescued as a puppy. Three years ago she was hit by a vehicle on the highway and suffered a collapsed lung, complete fracture of her left radius and ulna, and a comminuted fracture of her left pelvis. Her left radius and ulna were surgically repaired by plating and a pin was placed in one of the left pelvic fractures while the remaining fractures were left unrepaired as they were non-weight bearing. During her recovery she developed diskospondylitis and urinary incontinence.
She recovered well from her injuries but has always been sore, especially on her left forelimb, after long runs. Her owner stated that approximately one year ago Teeka became acutely non-weight bearing on her left hindlimb after a day of playing off-leash. Her owner thought that the lameness was related to her previous accident and did not investigate the lameness. Since then, she has had intermittent left hind lameness.
Teeka has a history of urinary incontinence, urinary calculi and recurrent urinary tract infections. She is currently on Propalin for incontinence which has helped, but not resolved, her incontinence. Urinary calculi have been resolved with a prescribed urinary diet.
She has a history of reactivity, especially while on leash and will lunge at the end of her leash. To limit self injury to her neck when lunging and to provide her owner more control she is walked on a front attach harness instead of her collar.
Teeka Initial Consult Trot Teeka Initial Consult Walk
Physical Exam and Assessment:
On presentation Teeka was BAR and had a mild left hind lameness at the walk and trot. She had appropriate knuckling and withdrawal responses on all limbs, but had a crossed extensor reflex of her left hind. Her reflexes were normal on forelimbs and right hind. On the left hind, her patellar reflex was present but more pronounced than on the right. Her myofascial exam revealed restriction in the thoracolumbar, lumbar and lumbosacral regions. She had marked trigger points in her longissimus dorsi bilaterally at her thoracolumbar junction.
She had marked generalized atrophy of her left hind muscles and mild generalized atrophy of her right hind muscles, especially gluteal muscles and hamstrings. Medial buttress and tibial thrust were present in her left stifle suggesting previous stifle injury and instability. Her gluteal muscles, sartorius and hamstrings had trigger points on the left hind. There were sartorius and hamstring trigger points on her right hind.
On her forelimbs she had trigger points in her triceps and extensor carpi radialis bilaterally. The range of motion in her left carpus was significantly decreased due to radial and ulnar fracture repair. She also had trigger points in her left infraspinatus, supraspinatus and brachiocephalicus muscles likely due to compensation of decreased range of motion in carpus.
Problem List
Left hindlimb lameness
Crossed extensor reflex in left hindlimb
Urinary incontinence
Left forelimb lameness
Recurring urinary tract infections
Reactive
Differential Diagnoses:
Left hindlimb lameness
Vascular: Embolism
Infectious: Lyme disease – ruled out as Lyme disease is not in the area and she has not travelled
Neoplastic: Stifle joint neoplasia – unlikely due to lack of pain
Degenerative: Osteoarthritis
Iatrogenic: Overexertion off leash without proper conditioning
Congenital: Stifle joint instability
Autoimmune: Immune-mediated arthritis – ruled out as only 1 joint affected
Traumatic: Cranial-cruciate ligament injury
Endocrine: Diabetes mellitus leading to hindlimb weakness
Myofascial: Iliopsoas strain
Urinary Incontinence
Vascular: Mild spinal embolism – ruled out by MRI
Infectious: Diskospondylitis leading to nerve damage – diskospondylitis confirmed on MRI 3 years ago
Neoplastic: Spinal neoplasia – ruled out by MRI
Degenerative: Urethral sphincter incompetence
Iatrogenic: Damage to pelvic nerve during surgery to fix pelvic fracture
Congenital: Vaginal Stricture – unlikely as she did not have incontinence prior to accident.
Autoimmune: Compromised immune status leading to recurring urinary tract infections – ruled out due to no other signs of compromised immune status.
Traumatic: Trauma to pelvic nerve following hit by car
Endocrine: Diabetes insipidus leading to PU/PD – Ruled out as she does not have polydipsia
Myofascial: Fascial restriction in sacral region leading to pelvic nerve disfunction
Putative Diagnosis:
Left Hind Lameness – Previous stifle injury leading to osteoarthritis.
Urinary Incontinence – Pelvic nerve dysfunction due to hit by car or sacral fascial restriction
Medical decision making:
Treatments were tailored to address primarily the left hind lameness as that was the owners greatest concern. The left hind neurological dysfunction was addressed at the same time as addressing the left hind. Because of all the myofascial disturbance detected on exam the second treatment was scheduled 1 week after the first treatment. Following the first treatment there was considerable improvement so treatments were moved to every 2 weeks. Owner was interested in continuing acupuncture after the lameness resolved, so future treatments will focus on addressing the urinary incontinence. Cold laser treatments were performed with Class 1M super pulsed laser (MR4 ACTIVet).
Treatments & Rationale:
Treatment 1 (January 29, 2019):
Central nervous system (CNS): Bladder (BL) 10, 25, 27 bilaterally, Bai Hui, Governor vessel (GV) 14 & 20, Yintang. Laser unwind protocol (1,000 – 3,000 Hz BL line 2 minutes each side).
Peripheral nervous system (PNS): Left side only. BL 54, Gall Bladder (GB) 29 & 30.
Autonomic nervous system (ANS): Yintang, Bai Hui, GV 14 & 20, Stomach (ST) 36
Myofascial dysfunction: GB 29 & 30, BL 10. Laser 1,000 Hz for 2 minutes at carpi and hips bilaterally and left stifle.
Additional notes: Seirin 0.16 x 30 mm for ST 36, Seirin 0.16 x 15 mm for Yintang, Seirin 018 x 30 mm for remainder of needles.
Treatment 2 (February 5, 2019):
Central nervous system (CNS): BL 12, 21, 23 on left, BL 26, 27 bilaterally. Laser unwind protocol
Peripheral nervous system (PNS): Left side only. BL 40 & 60, Lung (LU) 1, Large intestine (LI) 11, ST 34& 36, Spleen (SP) 6 & 9, Kidney (KI) 3.
Autonomic nervous system (ANS): Yintang, Bai Hui, GV 14 & 20, ST 36
Myofascial dysfunction: LU 1, LI 15, BL 12, 21 & 23. Laser 1,000 Hz for 5 minutes total left carpus, hip and stifle. Laser 50 Hz for 5 minutes total left carpus and hip and stifle.
Additional notes: Seirin 0.16 x 15 mm for Yintang, Seirin 018 x 30 mm for remainder
Treatment 3 (February 12, 2019):
Central nervous system (CNS): Laser unwind protocol
Peripheral nervous system (PNS): Left side only ST 34, SP 9
Autonomic nervous system (ANS): Yintang, Bai Hui, GV 14 & 20
Myofascial dysfunction: Laser 1,000 Hz for 5 minutes total and 50 Hz for 5 minutes total left elbow, hock, hips and stifle. Massaged hamstrings and longissimus dorsi bilaterally
Additional notes: Seirin 0.16 x 15 mm for Yintang, Seirin 0.16 x 30 mm ST 34 & SP 9. Seirin 018 x 30 mm for GV 14 & 20. Different holder and did not want to sit still for acupuncture, therefore picked minimal points. Reactive to ST 36 today so did not place needle. Did not want carpi touched or lasered.
Treatment 4 (February 27, 2019):
Central nervous system (CNS): Laser unwind protocol. BL 26 & 27
Peripheral nervous system (PNS): Small Intestine (SI) 9, ST 36, SP 6 & 9,
Autonomic nervous system (ANS):, Bai Hui, GV 14 & 20, ST 36
Myofascial dysfunction: Laser 1,000-3,000 Hz for 2 minutes each stifle
Additional notes: Seirin 018 x 30 mm
Outcome and Discussion:
Due to the suspicion of stifle injury and instability multiple options were presented to the owner. Since there was already remodeling of the stifle surgery was not recommended and the owner would not have pursued surgery at that point regardless since the lameness was not that severe. Regular acupuncture and laser were strongly recommended and custom orthopedic bracing was recommended for times when she will have increased activity. At home PEMF therapy was also discussed for in between treatments. Owner was interested in custom bracing and PEMF therapy but did not purchase either due to financial constraints.
Following the first treatment there was significant improvement in Teeka’s comfort and lameness. The myofascial restriction appreciated on the first visit was present, but significantly decreased, especially in the thoracolumbar region. Myofascial restriction was still present in the sacral region. On her third treatment she was restless and did not want to sit still so only calming points and acupuncture points focusing on the stifle region were chosen. Choosing minimal points still had a large impact on her overall improvement and she was much more relaxed the following treatment.
References:
Saleki, M., Ahadi, T., Raxi, M., Raeisi G., Forough, B., Ali, M. (2013). Comparison of the effects of acupuncture and isometric exercises on symptom of knee osteoarthritis. International Journal of Preventive Medicine. 4(13): 73-77.
Zhang, L., Zeng Y.. Qi, J., Guan, T., Zhou, X., He, Y., Wang, G., Fu, S. (2017). Mechanism of Activating the Proprioceptive NT-3/TrkC Signalling Pathway by Reverse Intervention for the Anterior Cruciate Ligament-Hamstring Reflex Arc with Electroacupuncture. BioMed Research International. doi 10.1155/2018/6348764