Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018038
Abstract
Bear is a 12-year-old mixed breed dog who is experiencing progressive hind end paresis and muscle loss. After four integrative treatments, he shows improved endurance while hiking with his owner but still exhibits significant myofascial restriction and muscle loss in the hind end.
History
Bear is a 12-year-old neutered male mixed large breed dog. He broke his left femur in 2007 and had an open reduction with a plate. He was diagnosed with inflammatory bowel disease (via endoscopy and mucosal biopsy) and treated with a course of steroids and three months of prescription veterinary dog food in March of 2017, with no recurrence of GI symptoms. He is an active dog who enjoys hiking, swimming, and playing in the snow. Over the last several years, Bear’s owner has noticed a decrease in muscle mass in his hind end and has noticed that he struggles more going up and down stairs and while hiking than he used to. Bear’s regular veterinarian has performed laser therapy and he has had several rehabilitative workouts on the underwater treadmill there.
Presentation
Bear presents for worsening hind end weakness and muscle atrophy.
Physical Examination & Clinical Assessments
On physical examination, Bear is bright, alert, and responsive. He has mild lordosis when standing still, which improves at the walk and the trot. While standing Bear shifts weight frequently between hind limbs to balance himself, particularly on a surface with less traction such as hardwood or smooth concrete. At the walk, his hind limbs abduct as the swing forward, and exhibit decreased flexion in the stifle and tarsal joints. His toenails in the rear are short and appear to undergo regular wear, likely from “scuffing” of foot as limb is protracted. These gait abnormalities are pronounced at the trot.
Myofascial Palpation Evaluation
On palpation, Bear has decreased muscle mass in temporalis muscle bilaterally. There are tight bands of muscle tissue and trigger points bilaterally at the location of BL 10, as well as ventrally on the neck throughout the sternocephalicus muscle. Range of motion of the cervical spine is decreased laterally as well as ventrally and dorsally (although it was not forced to the point of pain). Bear’s entire thoracolumbar spine has decreased lateral range of motion, and the iliocostalis and longissimus muscles are very restricted and sensitive upon palpation, particularly in the T13-L3 area. In the hindquarters,
Bear has significant atrophy of the gluteal muscles bilaterally. The biceps femoris muscle is tight diffusely on both sides, and there is mild atrophy of the hamstring muscle group.
Neurologic Examination
Cranial nerve function was assessed and determined to be within normal limits. As mentioned above, standing and ambulatory paresis of the hind limbs is present, indicating mild to moderate ataxia. This ataxia worsens when ascending and descending stairs, and Bear does not consistently clear a pole placed on the ground with his hind feet when walked over it. Postural reactions (placement) were performed to assess proprioceptive deficits in the fore- and hindlimbs. Forelimb postural reactions were within normal limits. In the hind end, conscious proprioception was delayed bilaterally, more in the right hind than the left hind. Flexor (withdrawal) reflex is within normal limits in all four limbs. Patellar and cranial tibial myotatic reflexes were assessed and found to be mildly increased in both hind limbs, indicating the likelihood of upper motor neuron disease within the cervical spine. Tail and anal tone were within normal limits
Problem List
Hind limb paresis and ataxia
Muscle atrophy
Inflammatory bowel disease (not currently active)
Myofascial restriction and pain within the neck musculature
Myofascial restriction and pain within the thoracolumbar spine
Differential Diagnoses for Top Two Problems (VINDICATE)
1. Hind limb paresis and ataxia
Vascular- ischemic myelopathy within the spinal cord
Infectious- canine distemper virus acts on spinal cord, causing segmental myelopathy. This is unlikely because Bear is 12 years old, fully vaccinated, and does not exhibit multi-segmental deficits nor myoclonus. Toxoplasmosis could also be ruled out.
Neoplastic-extramedullary mass (either benign or malignant) causing ischemic myelopathy. This could originate from the vertebral bodies (eg, osteosarcoma) or the spinal cord (eg, meningioma or nerve sheath tumor). Diagnostic imaging will help to rule neoplasia in or out.
Degenerative- degenerative myelopathy causes progressive paresis and muscle atrophy of the hind limbs.
Additionally, degenerative joint disease and osteoarthritis of the vertebral facets causes inflammation which contributes to intervertebral disk disease and often results in a compressive myelopathy of the spinal cord involving upper motor neurons within the spinal cord. Degenerative (osteoarthritic) changes are also highly likely within the stifles and tarsi of an active 12 year old dog. Bear may have bridging spondylosis of the thoracolumbar spine, which decreases range of motion and can lead to local myofascial restriction and pain.
Iatrogenic/Intoxication- Bear received a course of steroids (prednisone) for Inflammatory Bowel Disease in the spring of 2017, at which time he also lost significant weight (including muscle mass) particularly in his hind end which has not returned fully since stopping the prednisone. This likely contributes to the paresis but is not responsible for neurologic signs such as ataxia and conscious proprioception deficits.
Congenital- it is thought that degenerative myelopathy may have a genetic basis and causes progressive hind end paresis and ataxia.
Autoimmune- autoimmune polyarthritis could cause inflammation, pain, and thus weakness of a number of joints including those in the hind end.
Traumatic- it is possible that Bear sustained damage to his spinal column as a young dog when he fell 10 feet off a bridge, breaking his left femur contributing to degenerative changes such as intervertebral disk disease and osteoarthritis.
Endocrine/Metabolic- Addison’s Disease (rare cases), Diabetic neuropathy or hypothyroidism may cause muscle wasting and paresis which may be particularly apparent in the hind end.
2. Myofascial restriction and pain within the thoracolumbar spine
Vascular- ischemic myelopathy within the spinal cord
Infectious- canine distemper virus acts on spinal cord, causing segmental myelopathy. This is unlikely because Bear is 12 years old, fully vaccinated, and does not exhibit multi-segmental deficits nor myoclonus. Toxoplasmosis could also be ruled out.
Neoplastic-extramedullary mass (either benign or malignant) causing ischemic myelopathy. This could originate from the vertebral bodies (eg, osteosarcoma) or the spinal cord (eg, meningioma or nerve sheath tumor). Diagnostic imaging will help to rule neoplasia in or out. Additionally, osteosarcoma of the vertebral bodies would cause significant musculoskeletal pain.
Degenerative- intervertebral disk disease, osteoarthritis of the vertebral facets, and compressive myelopathy of the spinal cord in the thoracolumbar region (T3-L3) would cause not only myofascial restriction and pain within this region, but also paresis and ataxia of the hind limbs.
Iatrogenic/intoxication- if Bear’s rehabilitation or other activity is pushed too hard, he may become painful in the thoracolumbar spine due to age and his long-back conformation.
Congenital-hemivertebra can cause significant pain and restriction locally
Autoimmune- autoimmune polyarthritis
Traumatic-Bear is an active dog, and even one small slip on the ice during the winter or jumping into the river during the summer can cause a chain reaction leading to local pain and restriction in the thoracolumbar spine.
Endocrine/Metabolic-Diabetic neuropathy, hypothyroidism
Definitive (or Putative) Diagnosis (or Diagnoses)
Intervertebral Disk Disease within the thoracolumbar spine, causing compressive myelopathy of the spinal cord.
Medical Decision Making
Because Bear is very sensitive to palpation and needling in his hind end (likely due to hyperesthesia), I chose to begin each treatment with a gentle massage to relax him and warm his muscles. I first addressed the myofascial restriction in his cervical spine because that is likely where pathology contributing to his hind end paresis exists. From there, I worked my way down his back along the Bladder line to his hind end where I indirectly addressed the painful trigger points using primarily massage and some smaller needles (Red Sierin).
Diagnostic imaging of Bear’s cervical spine would provide a better understanding of any pathology responsible for his clinical neurologic signs and help to rule out neoplasia. From there, a rehabilitation plan including stretching, strengthening, underwater treadmill, laser, acupuncture, and massage can be fine-tuned to maximize his comfort, athletic ability and activity level. His inflammatory bowel disease appears to stay under control on his current diet, and his weight should be monitored closely so that he does not gain too much (this will be best for his joints and overall health).
Medical Acupuncture and Related Techniques Used (Dry Needling, Electroacupuncture, Manual Therapy, Photomedicine, Etc)
.20 mm Sierin needles were used to perform acupuncture at the following points: GV20, GV14, Bai Hui, BL21, BL23, BL25, BL27, LU1.
.22 mm, 1-inch Sierin needles were used to perform acupuncture at the following points: ST 36, PC6, LR3
Outcomes and Discussion
After four integrative treatments, Bear appears to move more comfortably throughout his thoracolumbar spine, and his conscious proprioception has stabilized and possibly even improved slightly (right hind postural placing reaction not as long). The muscle atrophy and myofascial restriction within his lumbosacral spine is still present, and he remains highly reactive to needles being placed there. Laser and massage therapy would be very beneficial to loosen this area prior to dry needling in the future. Due to prevalent and progressive presumed degenerative joint and intervertebral disk disease, it is imperative that Bear continue treatments to support his musculoskeletal system and address areas of myofascial restriction, imbalance and pain. Patients with advanced degenerative joint disease benefit from consistent, light to moderate exercise which should be monitored carefully by a veterinarian. He would also benefit from rehabilitation exercises to increase core strength, hind limb strength, proprioception and joint range of motion.
Bear will also benefit from continued underwater treadmill sessions and regular laser therapy. As his comfort with acupuncture continues to increase, electroacupuncture across the Bladder channel in the thoracolumbar area may further improve the response to dry needling in this area.
References:
Smith, Mary O. Neurological Examination for the Busy Practitioner. AAHA Press, 2002. Lakewood, CO.
Sellon, Rance K. The Immune-mediated Basis of Endocrine Diseases. World Small Animal Veterinary Association World Congress Proceedings, 2007. www.vin.com
Relevant media:
IMG_2063.mov Bear before treatment
IMG_2064.mov Bear before treatment
IMG_2260.mov Bear after treatment, including ascending staircase
IMG_2266.mov Bear after treatment
IMG_2263.jpg Bear receiving treatment
IMG_2264.jpg Bear receiving treatment
IMG_2265.jpg Bear relaxing in his bed during treatment; he preferred some time on his own after I put in the first group of needles, before being ready for more.