Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018032
Case report: Kana – 13 year old spayed female domestic shorthair with recent pelvic limb lameness and a 9 year history of intermittent chronic coughing responds favorably to acupuncture treatments
Abstract:
Kana is a domestic shorthair feline with a 9 year history of idiopathic bronchial disease. She presented with an acute onset of pelvic limb lameness, primarily affecting her right hindlimb. Using scientific integrative medicine; including acupuncture, photomedicine and manual therapy, Kana experienced significant improvement in her mobility and relief from her respiratory clinical symptoms.
History of Present Illness and Chief Complaints:
Iolakana Kana Bear (Kana) is a spayed female domestic shorthair who is approximately 13 years of age. She resides in a home which includes 5 other cats, and the occasional foster cat. She was found as a stray in 2009. At the time she was found she did not have a tail, it is uncertain if she was born this way, although no evidence of trauma or damage to her tail is evident.
Kana has a history of intermittently coughing, which began in June 2010. This coughing has continued throughout the last 9 years, with worsening of episodes in the fall and spring. The cough was presumed to be feline bronchial asthma, based on repeated physical examinations and thoracic radiographs. Past treatments consisted of prednisolone for one to two weeks and terbutaline, when needed.
Kana presented to the clinic in December 2018, with an acute onset of pelvic limb lameness, primarily favoring the right pelvic limb. There was no known trauma, although her owners noted that she was chased by a cat she resides with around the time of her lameness. She was treated with Buprenorphine 0.06 mg given two to three times daily and showed mild to moderate improvement. Gabapentin was added to provide additional pain relief, 50 mg two to three times daily, but quickly resulted in diarrhea and was subsequently discontinued. She also received three treatments with a class IV laser and showed mild improvement. It was at this time that I became involved with Kana’s treatment and care.
Physical examination and Clinical Assessments:
Kana maintains her weight close to 11 pounds. She has a body condition score of 6/9. She has a small amount of iris atrophy. She is affected by tooth resorption, with one upper premolar demonstrating root exposure, granulation tissue and sensitivity. Her heart auscultates within normal limits, with a rate of 120 beats per minute, normal rhythm and no murmur. Her lung sounds are clear, with no audible crackles or wheezing and no increased respiratory rate or effort.
She has an observable lameness in the clinic, tucking her pelvic limbs in a hunched posture and visibly bearing less weight when placing her right pelvic limb on the floor. Her neurologic exam was fairly unremarkable with no deficiencies observed, appropriate placement of each limb, and normal reflexes. A reliable crossed extensor reflex was difficult to ascertain and would occur unreliably with gentle stimulation. This was in part due to Kana’s reluctance to be positioned for an accurate assessment. She has decent musculature, with no obvious asymmetry. Her myofascial evaluation was most impressive, with muscle fasciculations occurring along her right epaxial and biceps femoris muscles when gently palpated. In addition, myofascial bands were palpable along her epaxial muscles from her thoracolumbar junction to her sacrum. Her forelimbs are well muscled and slightly tense over her supraspinatous and infraspinatous bilaterally.
A total health profile included a chemistry, complete blood count, urinalysis, and proBNP. Her urine concentration was decreased at 1.021, the remaining profile was unremarkable. Radiographs reveal a bronchointerstitial lung field. Spondylosis deformans is visible from the the 11th thoracic vertebra to her sacrum.
Problem List:
1. Intermittent chronic cough, year round but seasonally worse in spring and fall
2. Acute onset of pelvic limb weakness, right hindlimb lameness
Differential Diagnosis:
Intermittent Cough-
● Heart disease
● Heartworm infection
● Primary lung tumor or metastatic disease
● Age related chronic airway disease, idiopathic bronchial disease
● History of anesthesia causing tracheal irritation or aspiration pneumonia
● Redundant tracheal membrane
● Immune mediated or allergic airway disease
● History of blunt force or trauma to chest
● Obesity
● Myofascial restriction in thorax secondary to spondylosis in the thoracolumbar region
Pelvic limb lameness-
● Thrombus
● Undetected abscess over pelvis
● Vaccine associated sarcoma
● Degenerative disc disease, degenerative joint disease
● History of recent injections to the right pelvic limb or medications that can cause sedation and weakness
● Cauda equina syndrome, absence of tail
● Systemic lupus erythematosus
● Recent attack by other resident cats in household
● Hyperadrenocorticism causing muscle wasting and weakness
● Myofascial restriction along the thoracolumbar epaxial muscles with subsequent fasciculations with gentle palpation
Putative/Definitive Diagnoses:
1. Idiopathic bronchial disease: This is based on the chronic intermittent episodes of coughing. They first occurred when Kana’s owner moved from Baltimore to Annapolis, Maryland. Coughing episodes also follow a seasonal trend when environmental allergens are worse in the area
2. Spondylosis deformans and trauma to lower back: Although spondylosis deformans is a degenerative process, Kana’s owners reported seeing another cat in the household chasing her around the house close to the time of her acute lameness. This resulted in tension and spasms in her epaxial and quadricep muscles.
Medical Decision Making:
Determining Kana’s treatment plan was initially a result of her myofascial examination. She had considerably tight myofascial bands parallel to her spine, was tender to palpation in this region and had pronounced muscle fasciculations when the area was stimulated. The initial goal was to address specific trigger points identified with palpation. This was done using acupuncture and photomedicine to the specific areas with myofascial bands and restriction, as well as massage after these treatments. I also felt it was important to consider her 9 year history of chronic intermittent coughing. Doing so, the back shu and front mu lung points were stimulated with acupuncture and photomedicine. Acupuncture points that provide additional neuromodulatory benefits aimed at decreasing stress and inflammation were also used during her treatments.
Medical Acupuncture and Related Techniques Used:
The goals for Kana’s first treatment was to determine how well she accepted acupuncture, establish a relationship with her, and focus on the palpable areas of myofascial restriction. The acupuncture points consisted of Bai Hui, GV 14, GV 20, BL 13, GB 30 and myofascial trigger points, primarily beside Kana’s lumbar spine and right coxofemoral joint. In total 19 acupuncture needles were used all Seirin 30 mm x 0.16 mm. While her needles were in place phototherapy using a class IV laser was utilized over each acupuncture needle at 2 watt for 4 seconds. After all of the acupuncture needles were removed, her thoracolumbar region was treated using photomedicine, class IV laser using predetermined settings for the lumbar spine (5 watts, 2 minutes and 30 seconds, 600 joules) and hips (2.5 watts, 3 minutes and 30 seconds, 420 joules). Manual therapy was then briefly applied using both effleurage and petrissage over the thoracolumbar spine.
Kana’s second treatment followed a similar structure to her first, she accepted acupuncture very well, and I was able to expand the treatment points used. The acupuncture points consisted of Bai Hui, GV 14, BL 14, GB 29, GB 30, SI 11, SI 12, BL 20, BL 21, BL 22, BL 23 as well as additional myofascial trigger points. The Bladder channel points were to assist with Kana’s occasional history of stress related colitis and dilute urine concentration. A total of 25 acupuncture needles were used, Seirin 30 mm x 0.16 mm and Seirin 30 mm x 0.20 mm. Photomedicine was also utilized in the same protocol as the first treatment.
Kana’s third treatment focused equally on her back pain and bronchial disease. She proved to be very accepting to her acupuncture treatments and responded so well that there were few trigger points identified. The goal was also to focus on neuromodulatory points. The acupuncture points consisted of Bai Hui, GV 20, GV 14, BL 13, LU 1, BL 23, LI 4, ST 36, GB 30 and two myofascial trigger points located at BL 19. A total of sixteen Seirin 30 mm x 0.16 needles were used, as Kana appeared a little more sensitive to the Seirin 30 mm x 0.2 needles during her second treatment. No photomedicine was utilized in this treatment and effleurage was performed after the needles were removed.
Outcomes, Insights, Discussion:
Kana responded very well to her acupuncture treatments. After her first treatment the longitudinal myofascial banding that coursed parallel to her lumbar spine relaxed. The video submitted demonstrates the degree of fasciculations present along her epaxial muscles, not only with gentle palpation, but also with insertion of the acupuncture needles. By her second treatment, only one trigger point had a brief spastic response when the acupuncture needle was inserted. The myofascial bands were no longer apparent and the trigger points found were markedly less dramatic. At this time we decreased her buprenorphine to be given only as needed. Her owner mentioned that Kana’s activity at home also improved, she was more playful around the home once again. The elapsed time between Kana’s second and third treatment was three weeks. During this time, Kana experienced an episode of coughing and her owner initiated a course of prednisolone; 2.5 mg daily for 5 days, then 2.5 mg every other day for 3 treatments. With this information, her treatment was focused equally on her chronic respiratory disease and her acute and recent lameness. I instructed her owner to discontinue the prednisolone and notify me if any coughing was observed. Her owner reported that no additional coughing episodes occurred that warranted medication, but Kana did cough briefly after episodes of excitement from activity when running around her home. Kana also demonstrated minimal lameness after her second treatment. She was given one dose of buprenorphine in the interval between her second and third treatment, and no medication since the third treatment.
This was a very rewarding case and Kana’s owner is very happy with the results. At this time, Kana has not needed any additional oral medication. I have continued to examine Kana and have treated her using acupuncture since. She has continued to have very few trigger points so I have focused more on neuromodulation points and points associated with her respiratory disease.
This case demonstrates the use of acupuncture, photomedicine and manual therapy for both chronic and acute conditions. Kana responded immediately and it was very rewarding when I reevaluated her for the second treatment and found very few trigger points. “Feline asthma, allergic bronchitis, and respiratory diseases have all been treated successfully with acupuncture” (2). The use of acupuncture, photomedicine and massage has eliminated Kana’s need for additional medications at this time. “Essentially anything that is considered a painful or inflammatory condition can benefit from laser therapy. Some examples of common conditions that have responded to laser therapy are asthma in cats, pancreatitis, urinary tract disease, acute and chronic skin conditions, and acute and chronic musculoskeletal disorders” (3). This multimodal and noninvasive approach avoids side effects associated with oral medications, improves the bond with her owner, and eliminates the expense and inconvenience of using a controlled substance like buprenorphine. As we move into spring, which can be especially challenging for Kana, my goal is to manage her bronchial disease using acupuncture and photomedicine, in the hopes of avoiding oral medications.
References
1. Mitchell D. Improve Your Treatment Outcomes With Veterinary Acupuncture. Western Veterinary Conference Proceedings, 2012.
2. Johnson J. Role of Laser Therapy in Pain Management. Pacific Veterinary Conference Proceedings, 2016.
3. Littlle S, Baral R. The Cat: Clinical Medicine and Management. Elsevier Saunders. 2012. pp866-875.