Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018037
Abstract:
The following case report discusses the use of veterinary medical acupuncture in combination with cold laser and massage therapy for the treatment of osteoarthritis and upper motor neuron disease in a 10 year old spayed female Alaskan Malamute. The treatment protocol was based off referral history, physical examination, neurologic examination and myofascial palpation findings. A combination of dry needling, massage and phototherapy was used and a drastic improvement was seen in the myofascial and neurologic examination as well as an improved quality of life reported by the owner.
History and presentation:
The patient, a 10 year old, 51 kg spayed female Alaskan Malamute, was presented on referral for progressive hind limb weakness, stiff rear legs and intermittent falling when she shook her head. The owner reported no change in appetite, urination or defecation but reported that the patient’s activity level had slowly declined over the course of the last year. The owner adopted the patient from a shelter approximately eight years ago so a full medical history is unknown other than an ovariohysterectomy prior to adoption. She has no known history of illness, injury or procedures other than a left aural hematoma and spinal and stifle osteoarthritis since her adoption. This patient was not on any medication or treatment plans at the time of her referral. Further diagnostics were discussed including radiographs, blood work and advanced imaging but were ultimately declined.
Examination and Assessment:
Physical examination identified mild dental disease, a semi-firm, semi-movable 5 cm x 3 cm growth over the right caudal ventral thorax which the patient was not reactive to, muscle atrophy of the rear limbs bilaterally as well as the epaxial muscles from T11-S1, fibrosis of the left ear pinna, and medial buttress of the stifles bilaterally. Neurologic examination revealed positive crossed extensor reflex bilaterally in the rear limbs, delayed conscious proprioception bilaterally in the rear limbs and a hyperreflexic patellar tendon reflex bilaterally. Myofascial palpation identified restriction in the cervical region most prominently in the sternocephalicus and brachiocephalicus muscles, prominent ropey bands in the triceps brachii muscle, various trigger points throughout the latissimus dorsi muscles bilaterally, myofascial restriction throughout the epaxial muscles most prominent from T11-S1, hypertonic quadricep and hamstring muscles bilaterally with myofascial restriction and ropey bands throughout and myofascial restriction and hypertonia of the adductor muscles bilaterally. The patient was reactive to palpation of the lumbar spine, sacrum and hips bilaterally. She had difficulty rising from sitting to standing. When standing, the patient had a flattened hair coat over the caudal dorsum, kyphosis of the lumbar spine and an abducted stance bilaterally in the rear limbs. Gait analysis identified decreased flexion and extension of the hips bilaterally, decreased flexion of the stifle bilaterally, shortened gait in the rear legs, kyphosis of the lumbar spine, low head carriage, abduction and circumduction of the rear limbs and a tucked tail with decreased motion. Based on the physical, neurologic and myofascial examination the problem list for this patient included; neurologic deficits consistent with upper motor neuron disease, muscle atrophy, myofascial restriction, pain in the lumbar spine, sacrum and hips, suspect chronically torn cranial cruciate ligaments bilaterally, body wall mass over the thorax and dental disease.
Differential Diagnosis and Definitive/Putative Diagnosis:
Differentials for the patient’s upper motor neuron disease in order of decreasing likeliness include; spinal arthritis (definitively diagnosed by referring veterinarian), spinal cord/spinal neoplasia (osteosarcoma, myeloma, meningioma, hemangiosarcoma, lymohoma, chondrosarcoma, fibrosarcoma, astrocytoma), un-witnessed trauma, intervertebral disk disease, embolism/thrombus, meningitis
The definitive diagnosis for the upper motor neuron disease based on history and examination is (bridging) spondylosis deformans.
Differentials for the patient’s muscle atrophy in order of decreasing likeliness include; disuse atrophy, neoplasia (lymphoma, splenic, hepatic, etc.), metabolic disease (chronic kidney disease, hyperadrenocorticism, hypothyroidism, diabetes mellitus, protein losing enteropathy/nephropathy), malabsorption, malnutritional, parasites.
The putative diagnosis for the muscle atrophy is disuse atrophy from chronic osteoarthritis and myofascial restriction.
The examination and history make the remainder of the differentials less likely for both conditions however they cannot be ruled out without further workup.
Medical Decision Making/Treatment Plan:
Outcome goals for the patient were discussed with the owner and included reducing falls, improving muscle weakness, decreasing pain and improving quality of life. Moving towards the goals of the owner would require providing analgesia, decreasing myofascial restriction and improving nervous system conduction. Due to the neurologic deficits and degree of myofascial restriction and osteoarthritis dry needling, massage and phototherapy using the cold laser were elected for the treatment protocol. The possibility of neoplasia and the contraindication associated with laser and acupuncture at the level of the neoplasia were discussed with the owner and the associated risks were accepted.
Treatments:
The patient received treatment every seven days for three weeks and treatments will continue as needed as the owner sees fit based on deterioration and recurrence of clinical signs. Dry needling, massage and phototherapy were used at each visit. The dry needling protocol is listed below (Fig 1.1). Massage therapy was started after needles had all been placed and focused primarily on the adductors, hamstrings and quadriceps. Cold laser therapy was focused on the lumbar spine, sacrum and hips bilaterally. Electrotherapy was not used for this patient due to anxious behavior and concern that she would develop a negative association if it was instituted before she was ready. Drastic improvements in patient compliance as well as movement towards the owner’s goals were seen with each treatment.
Fig 1.1
Needles Autonomic Points Local Points Spinal
Points Peripheral
Points Response
1 Seirin
0.20 x 0.30 GV20, GV14, Bai Hui Local trigger points (shoulder, triceps), BL20, 21, 22, 23, 25, 27, 28, 54, GB29, 30 BL20, 21, 22, 23, 25, 27, 28 Bafeng Patient was anxious and wanted to walk around through the entire treatment. Mildly reactive to the hip triad with no reaction to Bafeng points. Owner reported no falls for the entire week following treatment and jumped out of the truck for the first time in six months when they arrived home.
2 Seirin
0.23 x 0.30
Carbo
0.20 x 0.25 GV20, GV14, Bai Hui Local trigger points (shoulder, triceps), BL20, 21, 22, 23, 25, 27, 28, 54, GB29, 30 BL10, 20, 21, 22, 23, 25, 27, 28 Bafeng Patient was less anxious but still wandering throughout treatment. Mildly reactive to hip triad, slight withdrawal to Bafeng points. Owner reported that patient was trotting around the farm again. No falls were reported.
3 Seirin
0.23 x 0.30
Carbo
0.20 x 0.25 GV20, GV14, Bai Hui, ST36 Local trigger points (shoulder, triceps), BL20, 21, 22, 23, 25, 27, 28, 54, GB29, 30, ST36, ST34, SP9 BL10, 20, 21, 22, 23, 25, 27, 28, ST36 Patient laid down for the majority of her treatment. Bafeng was not placed due to reactivity of patient.
Outcomes and Discussion:
After three treatments the owner saw drastic improvement in the patient’s pain level and quality of life at home. As early as the first treatment her falling subsided and she was more eager to jump into and out of the vehicle. She was able to rise easier from a sitting position and was trotting around the farm after the second treatment. The patient’s crossed extensor reflex is still present however conscious proprioception is drastically improved as well as less hypertonic patellar reflexes. No pain response is elicited on palpation of the epaxial muscles, sacral area, hips or stifles and overall mobility appears improved. Throughout the course of treatment no other medications or treatments were initiated. The patient has had no complications arise since treatment was initiated. The protocol designed for this patient was strongly focused on decreasing pain, improving neurologic conduction and relieving myofascial restriction which has been subjectively achieved based on improved clinical signs, improved quality of life and satisfaction of the owner. Initiating electroacupuncture in the future should provide the patient with increased analgesia and overall nervous system balance. Medical acupuncture combined with laser and massage therapy provided this patient relief without surgical intervention or the administration of medication and is an option to be considered for patients suffering from chronic osteoarthritis and upper motor neuron disease.
References:
Liu, CM, Chang, FC, Lin, CT. 2016. “Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs.” Journal of Veterinary Science 17(3): 337-345.
Shmalberg, J., Memon, MA. 2015. “A retrospective analysis of 5,195 patient treatment session in an integrative veterinary medicine service: patient characteristics, presenting complains, and therapeutic interventions”. Veterinary Medicine International .
Silva, NEOF., Luna, SPL, Joaquim, JGF, Coutinho, HD, Possebon, FS. 2017. “Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases”. The Canadian Veterinary Journal 58(9): 941-951.
Um, SW, Kim, MS, Lim, JH, Kim, SY, Seo, KM, Nam, TC. 2005. “Thermographic Evaluation for the Efficacy of Acupuncture on Induced Chronic Arthritis in the Dog.” Journal of Veterinary Medical Science. 67(12): 1283-1284.