Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018033
Abstract:
Toby, a 5-year-old Pitbull x Labrador mix breed male castrated dog, was presented for acupuncture due to episodic collapse and chronic allergies. Toby’s allergies have improved tremendously since starting acupuncture but he was also concurrently placed on Apoquel by his regular care veterinarian confounding the results. Toby has not been witnessed to have another episode of collapse since prior to starting acupuncture.
History and Presentation:
Toby is a 5-year-old Pitbull x Labrador mix breed, male castrated dog. He was rescued by his current owners at the age of 2 ½ years. He lives with a female spayed Pitbull and a neutered male cat. He came to his current owners with a history of inflammatory bowel disease and was on a special grain-free diet. On this grain-free diet Toby would still have weekly episodes of diarrhea lasting for 12-24 hours. These episodes of diarrhea were exacerbated by periods of excitement, such as people visiting or times of travel. Toby was put on a course of metronidazole and started on Hill’s dry W/D prescription dog food by his primary care veterinarian. He has been off metronidazole for over a year but continues to get the prescription diet. Toby only gets diarrhea when he gets into human food or other miscellaneous items. Toby has had two witnessed episodes of collapse within the last calendar year, approximately 5 months apart. The suspected seizure-like behaviors are sudden in onset and have been observed around meal time. Toby will paddle with all four legs, have his head and neck extended, and last only 1-2 minutes. The longest recovery time has been anywhere between 5-10 minutes after which Toby is perceived to be completely normal. Toby has seasonal allergies resulting in alopecia around his eyes, muzzle and flank. Other pertinent medical history includes a left sided systolic physiologic flow murmur heard on routine physical exam back in 2016, but since has not been auscultated during routine physical exams.
Physical Exam:
Attitude: bright, alert and responsive T: 101oF P: 120 R: 24 Weight: 53 lbs.
Physical exam revealed pronounced alopecia surrounding both eyes, across muzzle and bilaterally on his flank. Tenderness, inflammation and ceruminous debris in and surrounding both ears, the left more affected than the right. No evidence of hearing loss or trouble with balance.
Neurological: No cranial nerve deficits, no neurologic abnormalities.
The remainder of his physical exam was unremarkable.
Clinical Assessment:
Myofascial evaluation revealed restriction over the cranial cervical region especially on the left side. Any touch over cranium and upper cervical area results in Toby rolling into supine position. A tight band runs from the left occiput down along the cranial brachiocephalicus muscle. Tenderness of epaxial muscles ranging from anticlinal region through caudal lumbar. Quadricep muscles underdeveloped. Toby is a very high energy dog and human touch is one of the most stimulating things for him.
Problem List:
• Syncope vs. seizure
• Otitis externa
• Dermatitis
• Colitis
• Left sided, systolic physiologic flow heart murmur
Differential Diagnosis:
**differentials in italics are most probable
• Syncope vs. seizure
Syncope Seizure
Vascular Idiopathic decreased blood pressure, Cardiomyopathy, embolism, acute hemorrhage Vasculitis, hemorrhage within cranium
Infectious Pyelonephritis, cystitis, bronchitis Meningitis (toxoplasma, Neospora caninum)
Neoplastic Brain tumor, lung cancer (osteosarcoma), lymphoma in GI tract Brain tumor (meningioma, lymphoma)
Degenerative Chronic kidney disease Canine cognitive dysfunction
Iatrogenic Xylitol Idiopathic epilepsy, Brodifacoum
Congenital Portosystemic shunt, exercise induced collapse Chiari malformation
Autoimmune Inflammatory bowel disease, uveitis Encephalitis
Traumatic Proptosis Hit by car, skull fracture
Endocrine High vagal tone, Hyperadrenocorticism (Cushing’s disease), glaucoma Hypothyroid
Myofascial Myofascial restriction leading to irritation of the vagus nerve Myofascial restriction over head and base of skull leading to increased intracranial pressure
• Otitis externa
o Vascular: vasculitis
o Infectious: Malassezia dermatitis
o Neoplastic: Tumor of the ear (adenocarcinoma)
o Degenerative: anatomical changes of ear canal secondary to chronic ear infections or fluid build up
o Iatrogenic: secondary to surgical complications, fluid buildup from swimming
o Congenital: conformation of ear due to breed predilection
o Autoimmune: atopy
o Traumatic: ear hematoma
o Endocrine: hyperadrenocorticism
o Myofascial: restrictions surrounding ear resulting in irritation of facial and trigeminal nerves causing irritation of the surrounding tissue or the vestibulocochlear nerve causing irritation of the inner ear
Definitive Diagnosis:
At this time, a definitive diagnosis has not been made for Toby’s episodic collapse as the owners do not wish to pursue further diagnostics. Diagnostics that could be preformed to help distinguish between causes of syncopal episodes and seizures would be: bloodwork, radiographs of chest and abdomen, echocardiogram, Holter monitor, and magnetic resonance imaging (MRI) of cranium. The history of seeming to lose consciousness during these events suggests that seizures are most likely. Given Toby’s age, history and clinical exam idiopathic epilepsy is the most likely differential. In hopes of elucidating more information for the owners, they have been asked to video the next episode.
Toby’s otitis externa is most likely secondary to atopy and the conformation of his ears which leads to increased moisture and decreased drainage. Originally his otitis externa was spot treated with Mometamax when clinical signs were seen. Since recurrence was so common his regular care veterinarian decided to start Toby on a course of Apoquel.
Medical Decision Making:
Toby is a highly energetic dog and his first response to human touch is to roll onto his back. Taking this into consideration only several acupuncture needles were placed at a time and watched closely. Manual therapies or other stimulating touch methods were avoided to keep Toby as calm as possible. The first session’s acupuncture protocol was aimed at relaxation, increased parasympathetic tone and to help with some myofascial restriction. At each subsequent session, additional points were added to address Toby’s atopy, gastrointestinal sensitivity, potential blood pressure issues and left-sided otitis externa.
Medical Acupuncture and Related Techniques Used:
December 23, 2018 – dry needling
• Points used:
o Bilateral: BL 10, BL 27
o Unilateral/Midline: GV 20, GV 14, Bai Hui
December 31, 2018 – dry needling
• Points used:
o Bilateral: BL 10, 22, 23
o Unilateral/Midline: GV 20, GV 14, Bai Hui, right side only (laying in left lateral recumbency) BL 52, LI 11 and BL 17
January 25, 2019
• Points used:
o Bilateral: GB 20, BL 10, BL 23
o Unilateral/Midline: trigger point along Bladder channel at level of L5-6, GV 20, GV 14, Bai Hui, TH 21, SI 19, GB 2
Types of needles: 0.20 x 30 mm Seirin needles used for all acupuncture sessions
The points selected during Toby’s acupuncture sessions were aimed to help with parasympathetic tone (cranial: BL 10, GV 20 and sacral: Bai Hui, BL 27), immune modulation (LI 11, BL 52, GV 14) and otitis externa (TH 21, SI 19 and GB 2). Several acupuncture needles were placed in areas of myofascial dysfunction along thoracolumbar spine but were not the main focus of the treatments. Placement of a needle in GV 20 was always done first, after which Toby would lay down calmly during the session for approximately 20 minutes. The owner always carefully constrained Toby to ensure he wouldn’t roll onto his back unexpectedly.
Outcomes/Discussion:
Toby was started on Apoquel part way through his acupuncture series confounding the positive results seen with his atopy. Toby’s hair coat and alopecia cleared up significantly and his otitis externa was less evident. His owners reported that while he still had occasional debris and outward irritation of the left ear, the symptoms would not last as long nor be as severe as they had once been. The partial success of Toby’s otitis externa treatment was hard to decipher between acupuncture and Apoquel, however, the continued presence of myofascial dysfunction and tenderness in and around the left ear indicates acupuncture is still warranted. Toby outwardly appeared to have relief from TH 21, SI 19, GB 2 and BL 10, and would rest quietly, even with the stimulus of human touch.
Toby has not had another witnessed suspected seizure since prior to starting acupuncture. The results of this are also difficult to interpret as Toby went 5 months between the first two episodes. Treating Toby for this condition without a definitive diagnosis, either between syncope or seizure, made picking a protocol tricky. The owners were warned prior to the start of acupuncture that it was possible that Toby may experience another incident, which did not occur. The hope is that by dissipating Toby’s myofascial restrictions we can keep him free from his syncopal or seizure like incidents.
For this particular case, the learning points were less about the results of improving the conditions of the patient, but more about how to alter technique to fit each individual patient. Toby is certainly not the only dog that’s energy is amplified by human touch. By taking our time, both in the individual sessions and over the course of the three treatments outlined in this case report, we were able to accomplish a great deal. Acupuncture needles were placed initially to access the autonomic nervous system by increasing parasympathetic tone by using craniosacral points. Next points used were to address Toby’s health conditions and myofascial dysfunction. By tapping into the parasympathetic nervous system, Toby was calm for about 20 minutes, resulting in a more thorough and complete treatment than the owners ever anticipated. Luckily with each sequential session slightly more could be accomplished to address his issues, and other more relevant points could be used on him.
Charalmbous, M., Gomes, S., Papegeorgiou, S., Orioles, M. (2017) Epileptic Seizures Versus Syncope: Pathophysiology and Clinical Approach. Veterinary Evidence. Available at: https://www.veterinaryevidence.org/index.php/ve/article/view/58/136
Sanches-Araujo, M., Puchi, A. 1997; 22(3-4): 191-206 Acupuncture enhances the efficacy of antibiotics treatment for canine otitis crises. Acupuncture & Electro-therapeutics research. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9494627