Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018035
Abstract:
Sockett, a 7yr 4mo domestic shorthair cat presented for treatment of chronic kidney disease with a history of feline asthma and hyperesthesia. He has numerous congenital abnormalities including phthisical globes and bilateral cryptorchidism. An integrative approach was elected with acupuncture, laser therapy, and manual therapies as well as traditional western medicine. His renal disease stabilized. Asthma flare-ups decreased in frequency and severity, and he experienced reduced sensitivity with less reliance on analgesics.
History and Presentation:
Sockett is 7-year 4-month-old male intact domestic shorthair cat. He is nonvisual with phthisical globes at birth and a bilateral enucleation performed at maturity. Due to complications under anesthesia at the time of enucleation, abdominal surgery for castration was not entertained by the owner and he remains an intact male despite bilateral cryptorchidism. He was diagnosed with feline asthma at 4 years old and uses an albuterol inhaler as needed, approximately once weekly. Feline hyperesthesia syndrome of unknown cause was diagnosed at 5 years old and while clinical signs wax and wane the disease does not appear to have progressed. He receives gabapentin as needed to manage his symptoms. Mild barbering of the proximal tail was noted during the initial exam. In September 2018, he was diagnosed with an acute kidney injury which has led to chronic kidney disease (CKD).
The owner is concerned for his overall welfare and most recent diagnosis of CKD. While the owner is unable to afford advanced diagnostics, she heard acupuncture may help slow the onset of CKD, improve his appetite and generally improve his quality of life.
Physical Examination and Clinical Assessments:
A gradual, progressive hyporexia has been noted over the past couple months. On initial presentation, the patient was bright, alert and responsive. Bilaterally absent globes were consistent with previously reported bilateral enucleation. His gait was slightly slow and stilted initially, but he was quick to explore his surroundings and his gait improved with familiarity. Overall, he was very confident and adjusted rapidly to his surroundings. His abdomen was comfortable on palpation and the renal margins were slightly small and irregular. Auscultation of the heart and lungs was unremarkable. Mild barbering of the proximal tail was noted. Mild to moderate skin twitching noted with gentle palpation of the caudothoracic paraspinals caudally to the tail base. Numerous ropey bands noted bilaterally at the lateral cervical regions. No proprioceptive deficits or other neurologic disease noted. Azotemia has been progressive from creatinine (creat) of 3.2 and blood urea nitrogen (BUN) of 109 in September of 2018 to a creat of 4.7, BUN of 67 in November of 2018.
Problem List:
1) Azotemia – differential diagnosis: congenital disease, ischemia, cystic/urethral calculi, pyelonephritis, renal lymphoma, secondary to diet, polycystic kidney disease, renal amyloidosis, immune mediated disease, other
2) Intermittent excessive grooming/pain – differential diagnosis: neurologic etiology (intervertebral disc disease, allodynia, focal seizure activity), musculoskeletal etiology (arthritis, myopathy), dermatologic etiology (allergic dermatitis, ectoparasites), behavioral etiology (anxiety, displacement behavior, other)
3) Hyporexia
4) Pain on palpation of paraspinals
5) Ropey bands in the cervical region
6) Intermittent stiff, stilted gait (suspect secondary to novel environment)
7) Historic feline asthma
8) Bilateral cryptorchid, intact
9) Non-visual with previous enucleation
Diagnoses:
1) Chronic kidney disease (CKD), IRIS stage 3, non-proteinuric, normotensive
2) Feline hyperesthesia syndrome
3) Feline asthma
4) Bilateral cryptorchid, intact male
5) Non-visual with previous bilateral enucleation
Medical Decision Making:
The three primary problems that were addressed using medical acupuncture were chronic kidney disease, hyperesthesia and feline asthma. The renal disease was addressed using the kidney tiara (Governor Vessel 4, Bladder 23 and Gallbladder 25) as well as thoracolumbar and cranial lumbar regions to counter wind up. Stomach (ST) 36 and Kidney (KI) 3 were also included in later treatments due to efficacy in treating surgically induced renal disease in rats [1].
Hyperesthesia was addressed primarily with manual massage and skin rolling as well as laser. Sensitivity was too great and needles smaller than 0.16mm were not available.
Feline asthma was addressed using acupuncture at Governor Vessel 14, Bladder 13 and Lung 1. As well as points of sensitivity between thoracic spinal segments one through four.
Medical Acupuncture and Related Techniques Utilized:
The goal of integrative therapy was to delay the progression of CKD. The underlying cause was never identified, but reducing inflammation, improving perfusion and maintaining appropriate autonomic regulation of the kidneys were of primary concern. Additionally, the patient’s previously diagnosed feline hyperesthesia syndrome may be related either to an underlying neurologic condition or related directly to his renal dysfunction, either of which would respond favorably to acupuncture and integrative therapy.
Acupuncture, laser therapy and gentle massage were utilized with Sockett. All feline exam rooms were equipped with a Feliway diffuser and calming aroma therapy scents (citrus, lavender and peppermint) were selected throughout Sockett’s treatment. He has been reinforced with rewards-based training methods (primarily food treats) and was offered Hill’s k/d canned or Royal Canin Renal Support canned when calmly resting in preparation and during treatment. He was also lured into place for laser therapy. Additionally, Sockett responds well to petting of the head and face, but became agitated with petting/manual manipulation caudal to the mid thoracic region.
Acupuncture is a novel therapy for Sockett, and with a known history of hyperesthesia (of unknown etiology) Serin 0.16mm silicone coated needles were selected for treatment.
He responded well to Governor Vessel (GV) 14, but was moderately sensitive to Bai Hui. Bladder (BL) 10 was needled bilaterally and well received. The kidney tiara was attempted with
GV 4 being moderately sensitive to needling and BL 23 markedly sensitive. Gallbladder (GB) 25 was well tolerated. Large Intestine (LI) 11 was utilized as an anti-inflammatory point and mildly sensitive. BL 13 was utilized in treatment for his asthma and well tolerated. BL 27 was chosen due to palpable sensitivity and was poorly tolerated.
The acupuncture points chosen for continued therapy were adjusted to accommodate patient comfort and were primarily focused on the cranial third of the body and extremities. Well tolerated points were continued (GV 14, BL10, LI 11, GB 25) as well as novel points including: GV 20, pericardium (PC) 6, spleen (SP) 6, KI 3, ST 36, LU 1 and LI 4. This treatment did not induce patient discomfort.
Given Sockett’s occasional dramatic response to needling (for example: BL 27), concerns for an underlying neurologic condition causing his hyperesthesia arose. Gentle acupressure, skin rolling, manual manipulation of the soft tissues and laser therapy were utilized during subsequent treatments. The owner was taught gentle skin rolling and massage techniques to utilize at home with the goal of releasing subcutaneous connective tissue potentially causing patient discomfort.
Laser therapy was utilized during treatments when available. The risk of use on cryptorchid testicles that are prone to neoplasia was discussed. A prior focused assessment with sonography in trauma (FAST) ultrasound was performed without evidence of current neoplasia. A Cutting Edge Class IV laser was utilized on 3.99J/cm2 setting over the lumbar and thoracic spine and kidneys. Electroacupuncture was never utilized due to sensitivity to needling in general and the patient’s activity during treatment.
It should be noted that since initial diagnoses of acute on chronic kidney disease in September 2018, Sockett has been receiving traditional western treatments including a canned renal diet, subcutaneous fluids and recently a phosphorus binder meal supplement.
Outcome and Discussion:
The evening and day following the initial treatment, the owner reported that Sockett was more active and vocal than he had been in years. He has continued to have a good appetite since starting treatment.
Traditional western medicine with subcutaneous fluids, phosphorus binders and a renal diet were utilized simultaneously with acupuncture. This created a major setback due to an episode of fluid overload secondary to aggressive subcutaneous fluid administration. Furosemide therapy and hospitalization with supplemental oxygen were necessary and caused a temporary acute kidney injury (creat of 9.9, BUN of 224) with resultant progressive azotemia (creat of 6.9, BUN of 110). Additionally, patient distress, and financial strain on the owner should be considered.
Feline asthma flare ups decreased in frequency with rescue albuterol administered monthly or every other month since starting treatment. Hyperesthesia remains a concern and will likely need long term treatment and management. It remains unknown if Sockett’s chronic marked wind up in the caudothoracic and lumbar region is related to the recently developed CKD [2]. He is responding well to laser therapy, gentle massage and skin rolling and has become more tolerant to body petting. He continues to intermittently barber his tail base, but with less frequency and severity. Gabapentin use was reduced and only utilized during episodes of skin rippling.
References:
1) Paterno J, C, Bergamaschi C, T, Campos R, R, Higa E, M, S, Soares M, F, Schor N, Freire A, O, Teixeira V, P, C: Electroacupuncture and Moxibustion Decrease Renal Sympathetic Nerve Activity and Retard Progression of Renal Disease in Rats. Kidney Blood Press Res 2012;35:355-364. doi: 10.1159/000336095
2) Batle, P. A., Rusbridge, C., Nuttall, T., Heath, S., & Marioni-Henry, K. (2019). Feline hyperaesthesia syndrome with self-trauma to the tail: retrospective study of seven cases and proposal for an integrated multidisciplinary diagnostic approach. Journal of Feline Medicine and Surgery, 21(2), 178–185. https://doi.org/10.1177/1098612X18764246
Please find attached photos and videos. Please note he was very difficult to photograph during treatment since he was inclined to explore when not actively entertained.
1) Sockett Pre-Treatment
2) Sockett Receiving Acupuncture
3) Post Acu Treatment
4) Helping with Office Work
5) Post Treatment Play
6) Sockett’s Moral Support Team
7) Hanna Wachtel
8) Curacore Release