Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 3S2019001
Abstract: Ollie is being treated for severe degenerative joint disease of the stifles secondary to grade 4 luxating patellas bilaterally and bilateral partial tears of the cranial cruciate ligaments. He has thus far been treated with four acupuncture sessions and the owner plans to continue on with these treatments every 1-2 weeks as it has helped him to have less pain and increase his play scores and quality of life. He has extended the length of walks he will go on and has begun initiating play with his owner and housemate which he was not doing at all before.
Ollie is a 5 year old castrated male English Bulldog. Ollie is new to his current owner, she has only had him for 2 months. He previously belonged to a friend and was then shuffled around to several other owners after his owner passed away. His most recent home was not caring for him and he was not receiving any care for his issues. The only history we have was that he was diagnosed with grade 1 luxating patellas around 1 year of age. Owner was aware he had some problems with his knees when she got him. Since being in the care of his new owner he has been seen at a local specialty hospital by an orthopedist for potential surgical intervention to correct his issues. She was told they would only be able to correct his knees to a grade 2, so she is not sure she wants to spend $10,000 to only get a mediocre result. He is currently taking 50 mg Rimadyl once or twice daily. He is on fish oil (unknown mg) and Dasequin daily. She has Tylenol with codeine to use on really bad days. He doesn’t take this often. He also receives 50 mg Benadryl three times daily for seasonal allergies. This seems to do a decent job most of the time. Owner states he can only go on walks for 5 minutes before he has to sit down or be carried back. He will play with his housemate but only while lying on his back, he doesn’t initiate the play, only reciprocates. We do not have any radiographs available for viewing. He is going to be seeking consult with UT and MSU to get second and third opinions on options for his knees. His UT consult is scheduled for May 11, 2019. The orthopedist did recommend acupuncture as an option for long term pain control and I volunteered my services upon hearing his plight.
Our first visit was on April 27, 2019.
We started his visit with observation of his gait. Left to walk on his own he will only walk for a few steps and wants to sit. On leash, he will follow the owner for longer distances. There is pronounced kyphosis of his caudal spine, stilted gait in both rear legs, limited flexion of the stifles, narrow stance of both rear feet, hocks turned inwards, lateral bowing of stifle region, and a very pronounced hip sway while walking, has a faster phase on the right side with this sway and a bit of a hip drop, the feet shuffle and don’t clear the ground as much as the front legs do. When he sits he will sit with the legs straight out. The front legs did show some bowing out of the elbows but this can be normal for the breed. On physical exam he is bright, alert and responsive. He has good head movement and no signs of neck pain. There was surprisingly no pain elicited with palpation along his back despite the pronounced kyphosis, no taut bands were found and he didn’t resist palpation of the back. He did not appreciate his stifles being examined so I didn’t push the issue here. They are severely thickened from medial to lateral and there is so much scar tissue I can’t palpate where his stifle is. Owner reports it to be permanently medially luxated per the specialist with no ability to be moved to a normal position due to excessive scarring present. I did feel some crepitus in the right knee with the minimal flexion that I did. I did not get to do the left as I stopped after the right and making him agitated even with as gentle as I was being. I did find mild tibial thrust in both legs. His hamstrings are atrophied and feel flaccid, quadriceps are still well developed. There was some roping in the quads and lateral shoulders but wasn’t painful for him when palpated. His skin is a little red on his face and in his ears from his allergies. He shows mild dental calculus as well. His conscious proprioception was normal in all limbs, crossed extensor was normal, I could not locate the patella so could not test the patellar reflex as tendon was also hard to locate. I tried where I thought it should be, but he was not pleased with me using the neuro hammer so I stopped. He is the nicest dog but is very sensitive when you get near those knees for obvious reasons. All other body systems were within normal limits. His weight looks excellent and owner is very aware of keeping him lean.
Problems list: painful stifles (bilateral grade 4 luxating patellas, bilateral cranial cruciate rupture, degenerative joint disease of the stifles), red skin and eyes, dental calculus
Differential diagnosis for stifle pain: V-blood clots, I-Lyme disease, N-osteosarcoma, D-arthritis, I-abuse from previous owner, C-luxating patellas, A-rheumatoid arthritis, T-cranial cruciate rupture, E-Cushing’s leading to cruciate rupture.
Differential diagnosis for red skin and eyes: V-bleeding disorder, I-pyoderma/conjunctivitis, N-cutaneous lymphoma, D-unknown, I-using perfumes in the home, C-atopy, A-lupus, T-pet rubbing face on objects, E-hypothyroid
Diagnosis: bilateral grade IV luxating patellas, bilateral partial cranial cruciate rupture, degenerative joint disease and seasonal allergies (atopy). The stifle problems have been diagnosed on exam and consultation with a specialist as congenital and traumatic causes with secondary changes. There has been no signs of bleeding disorders, infectious causes, cancer or autoimmune conditions to lead to other diagnoses. Pet’s red face and eyes have responded well to Benadryl administration thus supporting a diagnosis of seasonal allergies.
I focused my acupuncture approach on relieving stifle pain using points known for this and pelvic limb pain in general and calming the immune system to deal with his allergies. I avoided points that were directly around the stifle due to the abnormal anatomy and fear of accidentally entering the joint space. I followed all acupuncture sessions with therapeutic massage to relieve taut bands I found on the day of therapy. I did not have access to a laser or an electroacupuncture unit, so this was not an option.
First therapy session March 27, 2019
All points were treated bilaterally except for midline points and left in place for 15 minutes on each side. Dry needling only.
GV 20- Seiran 16 mm x 15 mm –used as a calming point
ST 34- Seiran 20 mm x 30 mm- used as a point for stifle pain
ST 36- Seiran 20 mm x 30 mm- used as a point for stifle pain and also for immune problems
GB 33- Seiran 20 mm x 30 mm- used as a point for pain of the stifle
SP 6- Seiran 16 mm x 15 mm- used as a distal point as I couldn’t access SP 9 with patient positioning
BL 36- Seiran 20 mm x 30 mm- used as a point to neuromodulate the hamstrings
BL 39- Seiran 16 mm x 15 mm- used as a point for pelvic limb pain
BL 60- Seiran 16 mm x 15 mm- used as a point for pelvic limb pain
Bai Hui- Seiran 20 mm x 30 mm- used for lumbosacral pain targeting the kyphosis though no pain was palpated here, also for pelvic limb pain
BL 23- Seiran 20 mm x 30 mm- used as a back point and also for potential lumbar pain with the kyphosis
BL 28- Seiran 20 mm x 30 mm- used as a back point
Followed acupuncture with massage of the quadriceps, shoulders and back with skin rolling and petrissage. He enjoyed this very much. Showed owner how to do this at home.
Treatment went very well, he slept during part of it. Owner reports the following morning he was pretty sore from his first treatment and he had started to drink bowls and bowls of water and urinate all over the house which is very out of character for him. This subsided within 24 hours with no therapy and I decided to not use BL 23 again as in TCVM this can be a water release point. I also removed SP 6 since it can also be used for urinary issues.
Second therapy session April 8th, 2019.
Owner doesn’t note much change at home after the first session. Physical exam was very similar to prior week with the exception of shoulders being less ropey than before. He had a few days of GI upset about 48 hours prior to out session. Getting more aggressive this week with bigger needles and adding more points.
All points were treated bilaterally except for midline points and left in place for 15 minutes on each side. Dry needling only.
GV 20- Seiran 16 mm x 30 mm –used as a calming point
ST 34- Seiran 16 mm x 30 mm- used as a point for stifle pain
ST 36- Seiran 16 mm x 30 mm- used as a point for stifle pain and also for immune problems
GB 33- Seiran 16 mm x 30 mm- used as a point for pain of the stifle
SP 9- Seiran 16 mm x 15 mm- used as a point for stifle pain- rolled towel up between feet so could get to it this week
SP 10- Seiran 16 mm x 15 mm- used as a point for stifle pain
BL 36- Seiran 16 mm x 30 mm- used as a point to neuromodulate the hamstrings
GB 39- Seiran 16 mm x 15 mm- used as a point for pelvic limb pain, movement problems and stiffness
GB 34- Seiran 16 mm x 15 mm-used as a point for stifle pain
BL 40- Seiran 16 mm x 15 mm- used for pelvic limb pain
BL 60- Seiran 16 mm x 15 mm- used as a point for pelvic limb pain
BL 25- Seiran 16 mm x 30 mm- used as a back point to neuromodulate along the spinal cord
BL 28- Seiran 16 mm x 30 mm- used as a back point to neuromodulate along the spinal cord
BL 27- Seiran 16 mm x 30 mm- used as a back point to neuromodulate along the spinal cord
BL 10- Seiran 16 mm x 30 mm- used as a neck point to neuromodulate along the spinal cord
BL 20 and 21- Seiran 16 mm x 30 mm- used as a back point to neuromodulate along the spinal cord and also to treat recent GI upset
Acupuncture followed with massage. Massaged quads, shoulders and hip flexor region with skin rolling and petrissage.
Spoke to owner one day following treatment and she says he is feeling really good. He was able to go on a 15 minute walk where he normally tires after only 5 minutes. He is initiating play with his housemate which he never does. He is also playing standing which he also never does. He usually rolls to his back and wrestles this way. He is playing standing and jumping around throwing his back side into his housemate. No excessive thirst or urination after changing points up this week.
Third therapy session April 14, 2019. Same therapy plan used on April 8, 2019 with same points and needle selections.
Physical exam on April 14 was much the same as April 8. His eyes are red this week though. Still shows no back or neck pain but mild roping in shoulders and hip flexor region persists. I am always surprised with how normal his myofascial palpation exam is based on the changes I see in his gait. He has continued to be more feisty and playful at home this week.
Fourth therapy session April 28, 2019. We had a week off due to my being sick, so was 2 weeks between treatments. Owner notes he is slowing down the last few days and his allergies are really acting up, so 2 weeks appears to be too long between therapy sessions. Physical exam and myofascial palpation continues to be the same week to week. I don’t see much change in his exam, but he has more pep in his step and owner notes improvement at home as well. Still shows mild roping in shoulders with no pain, back palpates normally, kyphosis continues in the caudal lumbar spine. Knee mobility looks the same but he has very chronic, permanent scarring present so I don’t expect much change in the mechanics of his gait as those problems are structural and can’t be overcome without surgery.
I used all the same points as treatments 2 and 3 and the same needles as well. I did add in a few points this week though to see if I could get more response.
Bai Hui- Seiran 16 mm x 30 mm
GV 4- used as a cranial spinal point to neuromodulate signals coming from the rear legs
GV 14- spinal point used for pelvic limb pain.
We finished up with massage of the shoulders, back and rear legs including hip flexors to work out the ropiness, tight muscles and for general comfort and well being. I used both skin rolling and petrissage.
Outcome:
Ollie’s overall success has been measured by his activity level, playfulness, and ability to go on longer walks. I don’t have any quantitative values to measure here. Owner is very in tune to this dog, so she notices everything. She notices improvements in his willingness to play with his housemate, wrestling standing up where was only laying before, throwing his rear end into his housemate during play and being willing to go on longer walks that ever before. His gait is much more peppy though the abnormalities noted in his gait remain due to the structural changes that are present. Even if he feels good, there is permanent scarring that prevents him from having a normal gait and proper use of his knees. His allergies have responded some weeks, but not so much other weeks, so this result has not been as consistent as I would like but spring time in Tennessee is very hard on allergy sufferers and with the very wet last few months we have had, pollen counts are through the roof. There have been no changes to his medications or lifestyle since he has been treated with acupuncture, so any positive change is a direct result of his acupuncture. He has done really well and we are both pleased with his progress. Owner wants to continue his therapy. Massage I am sure helped to work out some stiffness as well, but these sessions were pretty quick as the acupuncture sessions were taking a long time to get all the points in and then the wait time. He was a very good boy, but he was ready to get up and go after an hour. I tried to get faster but it was just a lot of points and I gave him a little break between each one. The only complication was the first week with the excessive drinking and urination. So, it was either a coincidence or removing BL 23 and SP 6 from his therapy plan corrected the problem. I had never heard of these symptoms being a potential complication, so no way I could have predicted that would occur to try and avoid this complication. It only lasted about 24 hours and didn’t recur after subsequent therapy sessions, so either it was some kind of bad timing it happened in the first place or removing those 2 points helped prevent it from happening again. Owner was very understanding and not upset and was in fact fascinated my acupuncture was powerful enough to have caused such a thing.
References:
Holt A. Systematic review of patellar luxation in dogs. 2017. Honors theses.
Ness M, Abercromby R, May C, Turner B, Carmichael S. A survey of orthopaedic conditions in small animal veterinary practice in Britain. Vet Comp Orthopaed. 1996:9(2):6-15.
Roush JK. Canine patellar luxation. Vet Clin North Am Small Anim Pract. 1993:23(4):855-68.