Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018039
Abstract
A previously healthy thirteen-year-old dog with no known trauma or prior disease experienced an acute onset of tetraplegia. Physical exam revealed absent proprioception in all limbs, questionable deep pain sensation in the forelimbs, deep pain sensation present in the hind limbs and inability to bear weight. The patient required assistance to stay in sternal recumbency as he would naturally want to fall to his side. A definitive diagnosis could not be determined from diagnostics performed by the referring veterinarian but from clinical signs the lesion was localized to the cervical spine. Laser therapy and electroacupuncture were instituted once weekly starting nine days after onset of clinical signs. Within the first week, the patient began to show signs of improved balance and strength. After three and a half weeks the patient began taking several steps forward on his own. By four and half weeks he was walking unassisted. It can be concluded that electroacupuncture and laser therapy were vital in this patient’s recovery.
History
A thirteen-year-old neutered male miniature dachshund weighing 5.3kg presented to the Holistic Veterinary Center for acupuncture therapy and related techniques on December 29th, 2018. On December 20th, 2018, the owner reported that he was running to his food bowl and fell over. He did not cry out in pain but was not able to bear any weight in his limbs. The owner took him to his regular veterinarian (rDVM) who induced vomiting due to concern for potential toxicity, but only his dog food was recovered upon emesis. A complete blood count was unremarkable and a blood chemistry panel showed mildly elevated alkaline phosphatase of 230 IU/L (20-156) and moderately elevated gamma-glutamyl transferase of 16 IU/L (1-9). IV fluids supplemented with B vitamins and 50% dextrose, 1000mg ampicillin and 20mg famotidine were administered at 35mL/hr for twenty-four hours. The patient was given 2mg of Dexamethasone sodium phosphate prior to release. No improvement in mobility was noted but the patient was able to urinate and
defecate normally and did exhibit any signs of pain. A few hours after release, the owner reported that the dog had a thirty-second seizure-like episode in which he was thrashing his head around. He recovered quickly from the episode but the following day he had another thirty-second episode followed by three fifteen-second episodes a day and a half later. Since the initial episodes of seizure-like behavior the owner reported no further episodes. The patient has had no major health issues prior.
Physical Assessment and Medical Decision-making
The general physical exam was unremarkable. A myofascial examination revealed no pain, no taut bands and no areas of myofascial restriction. The cervical spinal range of motion was evaluated using a treat and asking the pet to move the head up, down, left and right. The range of motion was deemed appropriate. The neurological examination showed the patient was bright, alert and responsive with normal cranial nerve function. Conscious proprioception was absent in all limbs and he was unable to do any visual or tactile placing. Deep pain sensation was questionable in the forelimbs and present in the hind limbs. Withdrawal reflexes were absent in the forelimbs but normal in the hind limbs. There was no pain on palpation of the entire spine. The patient would naturally fall into lateral recumbency and could not weight bear or stand without assistance. Even with assistance, normal weight bearing could not be achieved.
The problem list was then created to include two main symptoms – tetraparesis and seizure-like episodes.
The differential diagnoses for the patient’s tetraparesis included but were not limited to fibrocartilaginous embolism, toxoplasmosis, meningioma, intervertebral disk disease, atlanto-axial subluxation, or autoimmune meningitis. Trauma was deemed unlikely due to the patient’s history. The differential diagnoses for the patient’s seizure-like episodes included but were not limited to cerebral infarction, toxoplasmosis, meningioma, lissencephaly, bromethalin ingestion, autoimmune meningitis, or liver disease.
A cervical lesion or injury was suspected as the primary etiology of the patient’s tetraparesis, a fibrocartilagenous embolism being deemed most likely. Due to the resolution of the seizure-like activity and normal mentation, the seizure behavior was suspected to be either stress induced or related to ischemic injury to the brain from compression of the cervical spinal cord secondary to the suspect embolism. Therefore, the author chose to focus treatments on the cervical region. Laser therapy was utilized to help reduce any swelling or inflammation on the spinal cord and increase healing of any injury that may have occurred. The owner was advised that it would be
used with caution as a neoplastic cause could not be ruled out but was not suspected due to the acute onset of symptoms. Electroacupuncture was also selected to help improve blood supply, regeneration and neuronal recruitment of the spinal cord and associated nerves in hopes of improving motor function, as has been demonstrated in previous research (Dai-xun Jiang et al.).
The owner was informed that although some resources state that seizures can be a contraindication for the use of electroacupuncture, there is much more research to support its benefit in the use of many causes of seizures (Kang et al.).
Treatments
The patient underwent four treatment sessions. Each treatment consisted of laser therapy from C1 to C7 with a class IV Cutting Edge laser at a frequency of 18Hz for a treatment period of two and half minutes at 100% intensity and 50% duty cycle (75.097J, 3.99J/cm2). The patient then received electroacupuncture with 20x13ga Vinco ® Microclean acupuncture needles and a Cefco Accuall Model 91-10 electroacupuncture unit. The specific acupuncture points and electroacupuncture settings are detailed below. For the first treatment, the following acupuncture points were used: GV 20, GV 14, BL 10, cervical spinal nerve points from C1-C7, Bai Hui (BH) plus two points on either side of BH, Baxie, Bafeng, BL 40. The acupuncture points were chosen for the following reasons. GV 20 was chosen for its autonomic nervous system input via convergence of the trigeminal nerve with the vagal nerve in the nucleus tractus solitarius to help calm the patient and for its anti-seizure properties. It was also chosen for its peripheral nervous system input via stimulation of the cranial cervical spinal nerves. GV 14 was chosen for its anti-seizure properties as well as a local point for the neck and thoracic limbs. BL 10 was used for peripheral input via cranial cervical spinal nerves and as a regional point for the neck. It was also used to provide central nervous system input via trigeminocervical reflexes. Cervical spinal nerve points from C1-C7 were used as regional points
and for the peripheral input via the cervical spinal nerves. BH plus two points on either side were chosen for their peripheral nervous system input to the hind limbs via the mid to caudal lumbar spinal nerves and for their central input via convergence of the spinal nerves with the nucleus tractus solitarius. Baxie and Bafeng points were used for peripheral input via stimulation to the digital nerves to help improve proprioception of the front and hind limbs. BL 40 was used to provide peripheral input via stimulation of the tibial nerve to encourage motor function of the hind limbs. Electroacupuncture was applied to the cervical spinal nerve points C1-C7 at a frequency
alternating from 2-4Hz on dense disperse mode for 5min followed by a frequency alternating from 80-120Hz on dense disperse mode for 5min. The intensity was slowly turned up until muscle twitching was observed, then turned slightly down to maintain patient comfort. Dense disperse mode was chosen with these frequencies to provide maximal endogenous opioid release, to help reduce any inflammation, to improve blood supply and neuronal recovery as well as to prevent the body from adapting to the effects. For the second treatment, the following acupuncture points were used: GV 20, GV 14, BL 10, cervical spinal nerve points C1-C7, BL 15, BL 18, BL 20, BH plus two points on either side of BH, Baxie, BL 40, BL 60, KID 1. A few acupuncture points were added this session for the following reasons. BL 15, BL 18 and BL 20 were used to treat local trigger points. BL 60 was used to provide peripheral input via stimulation of the fibular and tibial nerves to encourage motor function of the hind limbs. KI 1 was used for its peripheral input to the hind limbs via stimulation of the tibial nerve to enhance proprioception. Baxie points were attempted but due to the return of much of the patient’s sensation in the forelimbs, he would flick his feet upon needle insertion, causing the needles to be dislodged. Electroacupuncture was applied to the cervical spinal nerve points C1-C7 bilaterally at a frequency alternating from 2-4Hz on dense disperse mode for 5min
followed by a frequency alternating from 80-120Hz on dense disperse mode for 5min. The owner had asked about adding an anti-inflammatory and gabapentin, not because she felt the patient was painful, but because she wanted to do anything that could help speed up his recovery. The author therefore elected to add carprofen 4.7mg/kg once daily and gabapentin 4.7mg/kg two to three
times daily. For the third treatment, the following acupuncture points were used: GV 20, GV 14, BL 10, cervical spinal nerve points C1-C7, BH plus two points on either side of BH, BL 40, BL 60. Due to the return of much of the patient’s sensation in the hind limbs, he was too reactive to place Baxie and KI 1 points – he would flick his feet upon needle insertion, causing the needles to be dislodged. Electroacupuncture was applied to the cervical spinal nerve points C1-C7 bilaterally at a frequency alternating from 2-4Hz on dense disperse mode for 5min followed by a frequency alternating from 80-120Hz on dense disperse mode for 5min. At this point, the owner had discontinued the carprofen and was only giving gabapentin 4.7mg/kg twice daily. For the fourth treatment, the following acupuncture points were used: GV 20, GV 14, BL 10, cervical spinal nerve points C1-C7, BH plus two points on either side of BH, BL 40, BL 60. The
patient was very agitated and could not settle this session so electroacupuncture was not used. The owner was no longer giving gabapentin at this point.
Results and Discussion
The patient showed consistent and dramatic improvement within a four-week period of time. At the second visit, one week after his first treatment, the patient was starting to prop himself up on his front legs and could hold himself up for about five seconds at a time before falling over. He also began spontaneously moving his hind limbs, although in uncoordinated paddling movements. After two treatments, the patient was able to sit in sternal recumbency without falling over. He was able to propel himself forward in one movement but would then fall over. After three treatments, the patient was able to make several coordinated steps forward. If he fell over, he would be able to
right himself back into sternal recumbency within three to five seconds. After four treatments, the patient was ambulating with mild ataxia, occasionally falling to his side but rapidly righting himself within one second. The owner reported no adverse effects and none were found on physical exam and follow up. The patient received no other treatments during this time period aside from one week of an anti inflammatory and two weeks of gabapentin. Therefore, the author concludes that the electroacupuncture and laser treatments played a significant role in the patient’s rapid improvement in mobility. There is very little scientific literature regarding the use of acupuncture and electroacupuncture for the treatment of cervical spinal diseases in dogs. This case demonstrates the potential for these
modalities to provide significant and rapid improvement in mobility. For many years surgery has been believed to be the best treatment for most cases of acute paresis and paralysis. However, perhaps more considerations should be given to utilizing less invasive modalities. More research will need to be done to determine ideal protocols and to compare specific outcomes of patients with cervical spinal cord disease undergoing surgery versus more conservative management with acupuncture and electroacupuncture.
References
1. Ayne Murata Hayashi, et al. (2007). Electro-acupuncture and Chinese herbs for treatment of cervical intervertebral disk disease in a dog. Journal of Veterinary Science, 8(1), 95-98.
2. Ching Ming Liu, Fang Chia Chang, and Chung Tien Lin. (2016). Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs. Journal of VeterinaryScience, 17(3), 337-345.
3. Dai-xun Jiang, et al. (2015). Electroacupuncture improves microcirculation and neuronal morphology in the spinal cord of a rat model of intervertebral disc extrusion. Neural Regeneration Research, 10(2), 237-243.
4. Jing Fei, et al. (2019). Electroacupuncture promotes peripheral nerve regeneration after facial nerve crush injury and upregulates the expression of glial cell-derived neurotrophic factor. Neural Regeneration Research, 14(4), 673-682.
5. Joaquim et al. (2010). Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing neurological deficits. Journal of the American Veterinary Medical Association, 236(11), 1225-1229.
6. Xuezhi Kang, Xueyong Shen, and Ying Xia. (2013). Electroacupuncture-induced attenuation of experimental epilepsy: a comparative evaluation of acupoints and stimulation parameters. Evidence-Based Complementary and Alternative Medicine, 2013, Article ID 149612, 10 pages https://doi.org/10.1155/2013/149612