Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2018058
Abstract
Clara is a 16 year old Labrador retriever who presented for difficulty moving. The owners had moved about 6 months prior and since coming to the new house she had not used the stairs. After receiving acupuncture and massage treatments she is now getting up and lying down more easily, does not slip or hop as much, has improved cross extensor reflexes in the pelvic limbs and her owner has also noticed decreased anxiety levels. She sleeps more soundly, paces less at night and she will now use the stairs.
History & Presentation
Clara is a 16 year old, spayed female, black Labrador retriever. She had previously been diagnosed with Canine Cognitive Dysfunction and her owner has noticed she seems more anxious and paces, especially at night. She has difficulty walking at times, slips frequently and will not use the stairs. Her owner gives her NSAIDs on the days she seems painful.
Other history that was noted; Clara had her tail amputated about 8 years ago because of an un-healing wound and she does urinate in the house sometimes. About a year and a half ago she was attacked by bees and went into severe shock. She did recover, but her owner says the incident aged her very quickly and since then she has had more difficulty moving around. According to her owner prior to the bee incident she was an active dog who had only “a little arthritis”. The owners had recently moved to a new house and Clara will not use the stairs.
Physical Examination & Clinical Assessments
At her first appointment Clara’s heart and respiration rate were both normal. She is thin, approximately 4/9. Her coat was clean, but dull. When ambulating she appeared to be stiff in all four limbs and neck. Her thoracic and pelvic limb conscious proprioception was delayed, and cross extensor reflexes are weak in the pelvic limb, but normal in the thoracic limb. When ambulating she will often slip and when standing her legs will sometimes start to slide out from underneath her.
Myofascial exam revealed tender areas along the cervical vertebrae and neck. Tight bands in the deltoids, supraspinatus and infraspinatus. Tenderness to palpation in the mid-thoracic and lumbar areas. Palpation of the pelvic limbs revealed tight quadriceps and hamstring muscles. She felt tight and stiff over most of her body and acted uncomfortable during the exam. Her skin did not slide around or move easily over the shoulders, lumbar back and hip area.
Differential Diagnoses
Vascular – anemia causing weakness, possibly due to neoplasia, Infectious – Lyme disease or other tick borne disease, Neoplastic – osteosarcoma, hemangiosarcoma, Degenerative – degenerative joint disease, osteoarthritis, Iatrogenic/intoxication – polyarthritis, Congenital – elbow or hip dysplasia, Autoimmune – rheumatoid arthritis, Traumatic – cranial cruciate ligament tear, Endocrine/metabolic – endocrine myopathy, Myofascial – multiple trigger points and myopathy in the thoracic and pelvic limbs, and thoracic lumbar muscles
After discussion and review of the case with Dr. Robinson, it was noted that I had not included any neurologic issues in my differential list. Neurologic compromise is playing a definite part in Clara’s dysfunction and difficulties ambulating. I would add compressive cervical spinal disease to the list of differentials, as well as, degenerative peripheral neuropathy of the nerves supplying the thoracic and pelvic limbs. Clara does loosen up and move better after walking around and stretching for a few minutes, which is why I initially gravitated towards orthopedic issues, but neurologic disease processes are present and should not have been overlooked.
Definitive Diagnosis
Osteoarthritis, degenerative joint disease, compressive cervical spinal disease, muscle dysfunction due to trigger point pathology in the thoracic and pelvic limbs.
I ruled out anemia or other vascular issues because of normal heart sounds and rate, normal mucous membrane color, and normal respiration rate. Lyme disease is common in our area and I would have liked to test for this if the owner had approved, but there had been no history of tick bites, swollen joints, fever or lameness that comes and goes. The joints were not tender, and no heat or fluid was felt on palpation making polyarthritis or rheumatoid arthritis less likely. The owner described this issue as long term and not a sudden or intermittent lameness that you would see with a cranial cruciate tear. The owner also noted that as a young dog Clara had no issues moving or lameness ruling out congenital elbow or hip dysplasia. No bloodwork was done, so I was not able to definitively rule out an endocrine myopathy, this would remain low on my list of differentials.
Medical Decision Making
The problems that I wanted to address with Clara’s treatment were myofascial dysfunction and pain of the cervical area, thoracic and pelvic limbs, as well as the anxiety and pacing that was most likely due to Canine Cognitive Dysfunction (CCD), but also could have been due to pain and discomfort. I planned to use dry needling and massage for pain relief and neuromodulation. I wanted to use a combination of points to stimulate the central, peripheral, autonomic nervous system and work on relieving trigger points. I also wanted to use massage to help “loosen” the skin back up in areas where it felt adhered to the body.
Medical Acupuncture and Related Techniques
Seirin .16 30mm, Seirin .16 15mm, and Seirin .14 15mm needles were used in Clara’s acupuncture treatments. Clara has been receiving treatments every 3 to 4 weeks. We are currently working on starting bi-weekly treatments.
Clara’s treatment plans always started with massage and the points GV14 and Bai Hui to stimulate the central nervous system. She would struggle to relax and so by starting the treatments this way every time was a signal to her about what we were going to do and made her more comfortable. GV14 also was chosen to help with neck pain, back pain and thoracic limb pain and weakness. Bai Hui was used for lumbar and pelvic limb pain.
01/02/19 – Began with massage of the neck and pelvic limb, GV14 and Bai Hui. BL27 and BL28 (bilateral) to stimulate S1 and S2 nerves and help with hip and pelvic limb pain. BL60 (left) to stimulate the fibular and tibial nerves and help with pain. Bafeng points (bilateral) to stimulate digital nerves and help improve proprioception. LI11 (left) for elbow pain and stimulation of the autonomic nervous system. Massage of the shoulder, forelimb and neck trigger points.
01/24/19 – Massage of the neck and lumbar areas. Acupuncture included GV14, Bai Hui, BL27 (bilateral) and BL28 (bilateral). Additional points used at this treatment ST34 (right) to stimulate the femoral nerve and trigger points in the pelvic limb, BL54 (right) to stimulate the sciatic nerve and provide pain relief to the hips and gluteal muscles, BL40 (right) for tibial nerve stimulation and trigger points in the hamstring area, BL23 (bilateral) because she was tender in this area, BL 15 (bilateral) due to trigger points in this area. I also used ST36 in this treatment for autonomic stimulation, but she was very tender at this point so the needle only was in for a minute or so.
02/14/2019 – I wanted to try and focus more on Clara’s front end this treatment if she would allow it. Started with massage of the neck, deltoids, biceps brachii & triceps. Acupuncture of GV14 and Bai Hui for central nervous stimulation and pain relief in the lumbar and cervical areas. BL28 (bilateral) for stimulation of S2 nerves, hip & pelvic limb pain. GB31 (right) was treated because it was tender on palpation, BL54 (right) for hip pain, ST36 (bilateral) for autonomic nervous system stimulation, BL14 (right) was tender on palpation, GV20 to help relax and relieve tension, BL10(right) tender to palpation and to treat neck pain, LI11 (right) autonomic nervous system stimulation, Bafeng & Baxie to stimulate digital nerves in the pelvic and thoracic limbs. I also treated a trigger point in the long head of the triceps on the right side and one at SI11 (right). This was the first time she allowed me to use multiple points in the neck, shoulders and thoracic limb.
Outcomes, Discussion and References
After her first treatment Clara began using the stairs, seemed to have reduced anxiety, and less pacing. Her owner says that she sleeps better at night following her treatments and seems more content. Clara still slips but gets up from lying down much easier and will use the stairs. Besides the NSAIDs she was on previously, acupuncture is the only other treatment that she is receiving. I am very curious as to whether the bee sting incident is what led to the overall body pain and myofascial issues that Clara has.
Designing Clara’s treatments has been a challenge, because she will only tolerate needles for about 10 minutes before she wants to get up and walk away. I have had to pick points that she seems more tolerant of and focus on using massage for other areas that are tense and need work. If I could use laser therapy on her I would love to try it. I have noticed she is very tense in her thoracic limbs and cervical areas, and she is not as tolerant of me needling in these places. Over the first month of acupuncture treatments we have had improvement in her pelvic limb and lumbar pain. I have used massage in these areas and am hoping as we get further into the treatments she will allow for more dry needling in the thoracic and cervical areas, as well as electroacupuncture in some areas. My hope is with more frequent treatments we can continue to provide her with pain relief and improve her quality of life.
The videos of Clara moving were taken in her home. Rugs were recommended to help with slipping and allow her to move more easily in areas of the house that she frequently uses.