Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018033
Abstract:
Hideaway’s High Fidelity (HiFi) is a 10-year-old Connemara x Thoroughbred mare used for lower level eventing and pure dressage through second level. HiFi was presented for acupuncture due to chronic back pain, failure to develop top line muscling despite training, bucking, bruxism and inflammation of the left front metacarpophalangeal joint. Over the course of several acupuncture treatments HiFi has shown signs of decreased back pain, increased muscling along her topline and less of the unwanted behavior owner was concerned about.
History and Presentation:
Hideaway’s High Fidelity, a 10-year-old Connemara x Thoroughbred mare was presented for acupuncture for the chief complaint of chronic back pain, bruxism and intermittent bucking. The bucking is often associated with landing from a jump or when asked for more complex lateral work. In work, the owner and trainer have noted difficulty with straightness as a result from perceived stiffness when tracking to the left and weakness in the right hind and failure to develop proper top line muscling. At the canter the mare often props or travels with the hind limbs together instead of the typical fluid 3 beat stride. On occasion the mare will buckle over the left front metacarpophalangeal joint resulting in occasional soft tissue swelling on the dorsal aspect of the joint. Lastly, mare exhibits signs of anxiety manifested as bruxism and unwillingness to stand still during grooming, tacking and while under saddle. Several years ago, HiFi had suspected cranial nuchal bursitis that resolved without treatment. Other relevant historical issues are an old suspensory core lesion in her right front and white line disease in both front hooves. HiFi has been owned by the same owner her entire life.
Physical Exam:
Attitude: bright, alert and responsive T: 100oF P: 40 bpm R: 12 bpm
Musculoskeletal: No joint effusion. Body condition score 5/9. Decreased muscle development in cranial thoracic epaxial musculature. Mild kyphosis in lumbar region, L3-4 most pronounced. Callous formation on medial aspect of right front fetlock from chronic interference. Resented having high head carriage during neurologic evaluation.
Neurological: No cranial nerves deficits, no neurologic abnormalities.
The remainder of the physical exam was unremarkable.
Front Trot Dec 2018 Front Walk Dec 2018
Clinical Assessment:
Voluntary neuromuscular system evaluated by asking HiFi to lift each individual limb displaying delayed response in front end, particularly the right front. Her spinal temperature was increased starting at the thoracolumbar junction and continuing caudally over sacrum. The dorsal spinal nerve root reactivity was reduced from T13-16. Lateral flexion decreased through lumbar spinal segment, more so on the right side.
Myofascial examination showed restriction over mid-cervical region and taut bands in deltoids of both shoulders. There was decreased muscle mass and myofascial restriction present along entire topline. The underdeveloped muscles were most pronounced in the cranial thoracic region from T8-14. Myofascial restriction was found over the gluteal muscle groups bilaterally.
Problem List:
• Back pain – extending from cranial thorax through sacrum. Manifests as anxious behavior/unwillingness to work, tension under saddle affecting movement in all 3 gaits and in lateral work, bucking and alterations in biomechanical movement.
• Capsulitis of dorsal left front metacarpophalangeal joint (fetlock joint)
Differential Diagnosis (top 2 problems):
• Back pain
o Vascular: venous congestion of spinal veins, subdural hematoma, compression of spinal arteries
o Infectious: discospondylitis, meningitis, Lyme disease
o Neoplastic: osteosarcoma
o Degenerative: over-riding dorsal spinous processes (kissing spines), spondylosis, facet syndrome, supraspinous ligament desmitis, supraspinous bursitis
o Iatrogenic: saddle fit, rider imbalance, improper hoof balance
o Congenital: lumbarization or sacralization, fused vertebra
o Autoimmune: immune mediated myositis
o Traumatic: undiagnosed pelvic fracture, vertebral fracture
o Endocrine: gastric ulcers, nutritional myopathy or equine motor neuron disease
o Myofascial: tension of extensors and flexors of the spinal column
• Capsulitis of dorsal left front metacarpophalangeal joint
o Vascular: hematoma
o Infectious: infectious synovitis
o Neoplastic: fibrosarcoma, lymphosarcoma, squamous cell carcinoma, liposarcoma
o Degenerative: synovitis, extensor tendon desmitis
o Iatrogenic: improper wrapping/boot placement
o Congenital: conformation resulting in stress to dorsum of fetlock
o Autoimmune: idiopathic immune-mediate polysynovitis
o Traumatic: chip fracture
o Endocrine: pituitary pars intermedia dysfunction (PPID)
o Myofascial: restriction of myofascial along neck and forelimb leading to altered flight and placement of limb
Definitive Diagnosis:
Owner declined further diagnostics of the back which would include radiographs, ultrasonography and specialized bloodwork and/or biopsies to help define a diagnosis. The most likely conditions HiFi presents with are degenerative (facet syndrome, over-riding dorsal spinous processes and spondylosis), iatrogenic (saddle fit, rider imbalance) or myofascial dysfunction. Her short-backed conformation makes over-riding dorsal spinous processes a likely diagnosis for her discomfort. The hair loss present on her back is associated with wear and contact from the saddle. The owner has worked extensively with a saddle fitter to try and prevent saddle fit issues but it could be contributing to the pain. Facet syndrome or spondylosis could both be contributing to the pain seen through her back, but without further diagnostics it is difficult to say definitively. The mare clearly exhibits myofascial restriction through epaxial musculature and extending caudally over hind quarters.
The other differentials are less likely since the mare has never presented with a fever (infectious), has no history of trauma (fractures), no neurologic deficits (vascular compromise), and does not have any other symptoms (autoimmune, endocrine, neoplastic). Without further diagnostics it is impossible to definitely rule these differentials out, but they are less likely to be the inciting cause.
Radiographs of both front fetlock joints revealed no underlying osseous changes. Due to no history of direct trauma, the soft tissue nature of the swelling and the fact that it is intermittent helps to rule out differentials such as infectious, vascular, autoimmune, neoplastic, and traumatic. Endocrine is highly unlikely as this is not a typical sequela of PPID or a common cause of synovitis in equine patients. The specific dorsal location of the swelling on the fetlock rules out a generalized synovitis as this would include the dorsopalmar pouches of the fetlock joint.
Medical Decision Making:
HiFi had never received acupuncture prior to this assessment so the initial approach was to avoid placing needles into areas of clear myofascial restriction/tenderness and to keep the sessions relaxing with increased parasympathetic tone. LI 16 and Bai Hui are well tolerated point in equine patients and she was not reactive over these areas so the sessions were always started there. Then the combination of the myofascial restriction, tenderness, under-developed top-line musculature and history of back pain led to focus along the Bladder channel. Acupuncture needles were place cranially along the Bladder channel, starting at BL 13 and as far caudally as BL 30 in an attempt to maximize the neuromodulation of the channel. Care was taken to never place a needle in the areas of discomfort, but to bookend those areas instead. HiFi is very sensitive over her legs so the decision was made to avoid needling those areas, in the hope of continued treatments being an option. Mix-mode electroacupuncture was not introduced until the second visit, with the desire to again away from increased sympathetic tone.
Medical Acupuncture and Related Techniques Used:
December 18, 2018 – dry needling
• Points used:
o Bilateral: LI 16, GB 21, BL 13, 14, 19, 25, 28, 54 and GB 29
o Unilateral: right side – BL 21; left side – BL 20 and 23; midline – Bai Hui
• Types of needles: 0.20 x 30 mm Seirin
December 27, 2018 – dry needling and electroacupuncture
• Points used:
o Bilateral: LI 16, BL 13, 19, 24, 25, 27, 54, GB 29, 30
o Unilateral: right side – trigger point latissimus dorsi; left side – BL 28, midline – Bai Hui, Da Feng Men
• Types of needles: 0.20 x 30 mm Seirin, 0.30 x 40 mm Seirin and 0.18 x 25 mm Carbo
• Electroacupuncture – Pantheon research, mixed mode 2 Hz & 100 Hz just past output 1, approximately 5 minutes per side
February 7, 2019 – dry needling and electroacupuncture
• Points used:
o Bilateral: LI 16, BL 13, 19, 25, 28, 29, 30, 54
o Unilateral: midline – GV 4, Bai Hui, trigger point caudal to dorsal spinous process of L5
• Types of needles: 0.20 mm x 30 mm Seirin
• Electroacupuncture – Pantheon research, mixed mode 2 Hz & 100 Hz just past output 1, 5 minutes per side
Dry-needling was the method chosen for HiFi’s initial acupuncture session. In an attempt to keep her sympathetic tone low, different modalities were not attempted as she is a very sensitive horse. Manual therapy was attempted briefly but the mare became more agitated even with effleurage, so a less-is-more approach was taken with her. Needle types were experimented with over her hind end, in attempt to create a more robust response over the restriction in her hind quarters but results were not satisfying. The second and third visits included mixed mode electroacupuncture from BL 19 to BL 24 bilaterally. Mixed mode was chosen for it’s short- and long-term effects.
Trot Side View Feb 2019 Walk side view Feb 2019 Trot Feb 2019 Walk Feb 2019
Outcomes/Discussion:
HiFi’s back pain was helped substantially with acupuncture. The mare improved through the muscling of her topline, has decreased sensitivity along her back and has been showing less of the anxious behavior during known trigger events. The muscling in her topline has been changed most significantly from approximately T8-13, which is also the area off most concern for the owner. The spots associated with the saddle rubs, as seen in the pictures, actually show signs of new hair growth which is hard to appreciate in the still photos taken. Under saddle the mare has been more willing and supple during lateral work, exhibiting less tension and has not bucked. HiFi has not been jumped since starting acupuncture due to weather and footing related problems. The suppleness of her myofascial has improved significantly, having originally started off with very firmly adhered myofascia but now it is loose and supple, most pronounced over her caudal thoracic and gluteal region. HiFi has been ridden in the same equipment and has had no medical changes since the acupuncture was initiated. HiFi’s acupuncture did not happen as often as originally hoped both due to financial and timing constraints for the owner, however, despite not happening as planned, the horse has made vast improvements and the owner is happy with the results.
Pain in the equine back is a significant issue veterinarians face on a daily basis. The profound effect several treatments of acupuncture had on HiFi is very enlightening. Acupuncture is currently not considered a standard therapy when discussing what to do with horses who are exhibiting unwanted pain behaviors or lameness. Therapies utilized commonly by veterinarians include but are not excluded to: shockwave therapy, mesotherapy, facet injections, sacroiliac joint injections and intertransverse injections. Many of these modalities need sedation or aggressive restraint techniques that may be otherwise avoided. We need to strive to accurately diagnose and neuromodulate pain within the equine back. Having the ability to better evaluate, quantify and understand equine back pain would make every veterinarian a better diagnostician and ultimately would help horses.
Riccio, B., Fraschetto, C., Villanueva, J., Cantatore, F. and Bertuglia, A. (2018). Two Multicenter Surveys on Equine Back-Pain 10 Years a Part. Frontiers in Veterinary Medicine. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115529/ [Accessed 4 Jan. 2019].
Martin, B., Klide, AM. (1987). Treatment of chronic back pain in horses. Stimulation of acupuncture points with a low powered infrared laser. Vet Surg. Available at: https://www.ncbi.nlm.nih.gov/pubmed/2976547