Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018059
Abstract: Acupuncture was utilized to improve appetite and mobility in a feline with a mandibular symphyseal separation and left scapulohumeral joint luxation secondary to unknown trauma.
History and Presentation:
Catman is a 5-year-old male neutered Siamese mix who presented to Emergency and Critical Care (ECC) service for evaluation of persistent anorexia and lameness following an unknown traumatic incident. He initially presented on 11/11/19. The evening prior to presentation, Catman did not return for dinner and the owners were unable to find him. They found him the next evening in lateral recumbency on the front yard. He was bleeding from his face and was unable to walk, so the owners rushed him in to the Emergency service for evaluation. On presentation (11/11/18), Catman was quiet and lethargic. He had instability of his mandibular symphysis with an avulsion of the gingiva of the cranioventral mandible. He had a fractured left maxillary canine and severe pain upon opening his mouth. There was dried crusted blood in and around both nares, on both thoracic limbs and along the right flank. No lacerations were noted. He had a grade 3/5 weight-bearing lameness left thoracic limb with pain on left shoulder palpation but no instability of joints. Focused Assessment with Sonography in Trauma (FAST) scan showed no thoracic or abdominal effusions. Thoracic radiographs showed historic metallic pieces consistent with gunshot but were otherwise normal. Catman was kept in hospital on fentanyl, Unasyn and intravenous (IV) fluid therapy. On day 2 hospitalization (11/12/19), Catman was briefly anesthetized for a closed left shoulder reduction and mandibular symphysis repair. He recovered well but remained anorexic throughout the rest of his stay. He was discharged on oral Cerenia, pantoprazole, mirtazapine, Clavamox and buprenorphine. By 11/15/18, Catman was still uninterested in food so an esophageal tube (E-tube) was placed. On 11/19/18, Catman was still anorexic and continued to limp at home
Physical Examination and Clinical Assessments:
On presentation, Catman was quiet, alert, responsive, and fractious. There were two integumentary sutures at the site of the symphyseal repair. There was mild discomfort upon opening the mouth. The esophageal tube was in place. Catman was trembling and sternally recumbent but would take a few steps when coaxed. He was ambulatory was on all four limbs but had a grade 3/5 left thoracic limb lameness. Myofascial pain was noted at his left shoulder, left proximal left thoracic limb and bilaterally on his thoracic dorsum. His segmental reflexes were intact and normal. There were no obvious cranial or spinal nerve deficits noted.
Differential Diagnoses:
- Anorexia: mandibular pain vs stress vs systemic disease
- Mandibular symphysis instability: vehicular trauma vs high-rise syndrome vs attacked by animal
- Left thoracic limb lameness: shoulder luxation vs myofascial pain vs other soft tissue injury
Definitive (or Putative) Diagnosis (or Diagnoses):
- Mandibular symphysis separation – observed on physical exam 11/11/18 and repaired on 11/12/18
- Anorexia – present since traumatic event on 11/11/18, E-tube placed on 11/15/18 and is currently in place
- Left shoulder luxation – palpated on physical exam 11/11/18 and reduced on 11/12/18
- Myofascial pain – palpated on myofascial exam on 11/18/18
Medical Decision Making:
The two major clinical signs to be addressed with acupuncture were Catman’s anorexia and his left shoulder pain. Catman’s anorexia had already been unsuccessfully addressed with pain medication, pantoprazole, Cerenia and mirtazapine. In cats especially, injury to olfactory nerves can facilitate anorexia since cats rely heavily on smell to eat. Pain and nausea as causes for Catman’s anorexia were already ruled out with medical management. Therefore, acupuncture to stimulate olfactory nerves was a plausible treatment. LI 20 is associated with regaining the senses of smell and taste, so it was a natural option. The area on his ventral mandible was still healing from the symphysis repair, so it was decided to forgo needle placement in that region. Medical management was also attempted to mitigate Catman’s lameness, however he was still limping and minimally ambulatory at home. Tightness and pain in the muscles adjacent to a joint are expected sequelae of luxation, so acupuncture was indicated to help decrease pain, improve comfort and promote healing of damaged joint tissues.
Acupuncture Treatments:
Needles were inserted into points: LI 20 (left only), GV 20, TH 14 (left only) and Bai Hui. All needles used were Seirin J-type 30 mm x 0.16 mm. Two identical treatments were performed on consecutive days.
Outcomes, Discussions, and References:
The owner’s primary concern was stimulating Catman’s appetite. The first needle placed was GV 20, utilized to promote relaxation for the acupuncture session as Catman was uncomfortable, nervous and fractious. He tolerated GV 20 well and after 3 minutes, a needle in GV 14 was attempted to be inserted. However, the E-tube wrap knocked out the needle as soon as Catman moved his head. Therefore, TH 14 on the left shoulder was selected as an appropriate shoulder point that would not interfere with the E-tube wrap. Bai Hui was utilized to help strengthen the hind end as Catman had not walked much in about 8 days. LI 20 was reserved for the final point as it is a very sensitive facial point. It was attempted to be inserted on both sides, however only the left side was tolerated. Approximately 10 minutes into the treatment, Catman began to relax in his owner’s lap and close his eyes. His trembling ceased. The needles remained for approximately 30 minutes. At the end of the treatment, the needles were removed and Catman was set down on the floor. He immediately began to walk around in the room without having to be coaxed, his lameness decreasing from 3/5 to 2/5. Catman was returned to his kennel and presented wet food (which he had previously refused). This time, he immediately ate a significant amount of the meal.
Describe Your Impressions of this Medical Acupuncture Experience:
Our medical team was concerned about progressive underlying disease since Catman did not respond to antiemetic or appetite stimulant therapy. Despite that, the owner was hoping for removal of the E-tube as soon as possible and was prepared to have any potential treatment performed to expedite that process. However, we advised against removal of the E-tube until Catman ate on his own. When acupuncture was offered to try and help with appetite stimulation, I was skeptical it would make a difference as I had never seen it used in person for that purpose, especially in an emergency room setting. However, acupuncture has been strongly supported to improve appetite in other cases such as with gastrointestinal cancers (1). Conversely, it has also been shown to suppress appetite in human patients with obesity using auricular points (2), though auricular points were also shown to have improved appetite in human patients with lung cancer (3). Auricular points were not used in this case, but they could potentially be used in future cases. The acupuncture point LI 20 was implicated in the restoration of olfactory senses in a human study with patients who had post-viral olfactory dysfunction (4). More research with this point is necessary in determining its usefulness for appetite stimulation in veterinary patients.
It was gratifying to see the rapid effect of appetite stimulation from only one treatment session, after which Catman ate very well and was more energetic, relaxed and willing to ambulate. The owner was thrilled and allowed me to perform one more identical treatment the following day. At that point, due to Catman’s marked improvement, the E-tube was removed. Until this point in time, my impression was that an emergency room setting is not the most appropriate place for acupuncture. However, in certain cases it is warranted, especially when more common first-line medical therapies fail. It would be helpful to both clients and patients for acupuncture to be integrated into emergency and critical care treatment plans and infrastructures, particularly when the clinician is certified in veterinary medical acupuncture and especially for invoicing, tasking and supply purposes.
References:
- Zhou J, Fang L, Wu WY, et al. The effect of acupuncture on chemotherapy-associated gastrointestinal symptoms in gastric cancer. Curr Oncol. 2017;24(1):e1–e5. doi:10.3747/co.24.3296
- Richards D, Marley J. Stimulation of auricular acupuncture points in weight loss. Aust Fam Physician. 1998 Jul;27 Suppl 2 S73-7. PMID: 9679359.
- Kasymjanova G, Grossman M, Tran T, et al. The potential role for acupuncture in treating symptoms in patients with lung cancer: an observational longitudinal study. Curr Oncol. 2013;20(3):152–157. doi:10.3747/co.20.1312
- Vent, J., Wang, D.-W., & Damm, M. (2010). Effects of traditional Chinese acupuncture in post-viral olfactory dysfunction. Otolaryngology–Head and Neck Surgery, 142(4), 505–509. https://doi.org/10.1016/j.otohns.2010.01.012