Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019001
Abstract:
The case study is based on the treatment of Bruno Chandhok, a 12 years old Irish Setter, neutered male, with a chronic neurologic deficit which presented itself in the form of knuckling and his being unstable on the hind legs and gradually worsened with time. A combination of dry needling, light emitting diode (LED) therapy and massage therapy is being used. He is walking more confidently without knuckling indicating regained nerve supply to the back legs.
History and Presentation:
Bruno was presented with arthritis around February, 2017. I kept him pain free and mobile using electrical stimulation with electrode pads for his hind legs and general trigger point release type of massage. The physiotherapy sessions were stopped sometime mid March 2019 when he had to be hospitalised for other medical conditions.
On 2nd April, 2019 he was in pain and was not able to stand without support. He would knuckle even while walking with support. The physiotherapy therapy sessions were resumed which helped control the pain and kept him more comfortable.
He also has a mass in his lung. The radiograph shows a space occupying lesion. No other diagnostic tests such as a biopsy were run at the primary vet clinic. . He has spondylosis with fusion at L2 and L3 vertebrae. He suffered from frequent acid reflux and constipation. Abscess formations occur randomly on the body.
Physical Examination and Clinical Assessments:
Body Condition Score (BCS) is 3/5. He weighs 48.5 lbs which has been his constant weight for the last one year.
Neurologic examination: Crossed extensor reflex was present in the right hind leg but was absent on both front legs and left hind leg. Withdrawal reflex was present on the left hind leg. Conscious proprioception (CP) was delayed on both hind legs and was present on both front legs. Triceps and biceps reflexes, both were present on the front legs. Patellar and sciatic reflexes were present bilaterally on hind legs. Anal tone was present.
Orthopaedic examination: Cookie stretches were performed for checking range of motion of the neck. He had marked restriction when his head moved towards the right. Elbow crepitus was noted bilaterally. There was no pain on bony palpation. Range of motion ended with a bony feel at most joints. It was painful on rotation of the hips. Ortolani wasn’t performed. Cranial drawer test and tibial thrust test were both negative bilaterally.
Myofascial examination: On the dorsal neck tight bands were palpated along the cleidobrachialis muscles. Both the left and right half of the dorsal midline was painful to touch. Left lateral neck muscle was atrophied. There were tight but atrophied muscles on the right side of the neck. Triceps muscles were tight and really thick band like bilaterally. The left pectoralis muscle was tight otherwise most muscles are atrophied throughout his body. Taut band was felt on the right latissimus dorsi muscle. There was warmth along the spine palpated between T3 to T6 dorsal spinal processes and tightness in the trapezius muscles. The distance between the scapular dorsal borders was very less. It was painful to touch around the paraspinal muscles of L2 to L4 lateral spinal processes and around the hip sockets. Atrophy was noticed in most hind leg muscles.
Gait analysis: Head was slightly depressed from the point of cervico-thoracic junction. Head bob was noticed on placement of front right leg on to the ground. There was abduction of the left elbow which was noticeably rotated outwards. While walking he needed support from the rear end. He was severely emaciated and had muscle atrophy almost as a general pattern around the thorax and both hind legs. Knuckling was noticed on both hind legs, left being more prominent, taking a longer time to get back in normal position as he walked. He circumducts the left hind leg and if not knuckling drags both his hind legs. With the spine there was slight lordosis as the caudal thoracic spine started almost at level T9-T10 vertebrae. He wagged his tail but usually it was placed below spine level. Gait was asynchronous.
Problem List:
1. Arthritis of the elbows, knees and hip joints
2. Spondylosis leading to complete fusion at L2- L3 vertebrae and knuckling of hind legs.
3. Mass in the lungs.
4. Right sided neck restriction
5. CP deficit bilaterally in the hind legs
6. Crossed extensor positive on the right hind leg only
7. Thickened cleidobrachialis muscle bands on the dorsal neck, muscle atrophy on lateral neck bilaterally noted
8. Thoracic kyphosis and warmth felt around the-T 5 region, with tightness in the trapezius muscles
9. Bilaterally tight triceps and left pectoralis muscle tight.
10. Trigger point in the right latissimus dorsi muscle.
11. Sensitive to touch around the L 4-L 5 region.
12. Sensitive to touch around the hips and generalized muscle atrophy of the hind legs.
13. Acid refluxalmost daily and constipation every second day.
Note: the highlighted problems are my top two issues that I would VINDICATE the Myofascia for
Differential Diagnoses for the above points:
V – Fibrocartilaginous embolism (FCE)
I – Staphylococcus infection/abscess in the spine
N -The mass in the lung may be putting pressure on the spine, may have metastasized
D -Caudal cervical myelopathy and lumbar spondylosis, and arthritis in the joints
I -Ingestion of chocolate or rat poison can cause neurologic signs and symptoms
C -Degenerative myelopathy (DM)
A -Myositis
T – Getting pulled on leash walks by the neck / having spinal concussion due to a sudden fall
E – Pituitary macroadenomas
the
M – cleidobrachialis muscle was bilaterally tight and sore, triceps muscles were bilaterally tight, left pectoralis muscle was sore and painful. There were tight bands in the right latissimus dorsi muscles. There was soreness around the paraspinal muscles of the lumbar region more around the longissimus muscle and gluteal muscle atrophy.
Putative Diagnosis:
There are no granulomas internally. The abscesses have been superficial and have been treated. The mass in the lung is the same size and in the same location as per radiographic evidence. No episode of paralysis or paresis so very less possibility of it being an FCE. The reflexes are normal and terminal kick of the hind leg is absent, only CPs are delayed thus ruling out DM. However no DNA testing has been carried out for the same. He has lost muscle mass gradually since his lung mass was diagnosed. He has been at a constant weight and appetite for some time now and is not generally painful on touch throughout his skull or body. Thus I would rule out myositis. There is no history of a fall leading to spinal concussion reported, and he doesn’t ever wear a collar, only a body harness. No severe neurologic signs such as circling, head pressing, excessive salivation etc that would accompany chocolate/rat poisoning and pituitary macroadenomas. But he does have an asynchronous gait with painful and tight neck muscles with definitive ankylosed L2-L3 vertebrae and CP deficits. Thus I would diagnose his condition to primarily be caudal cervical myelopathy with age related degenerative changes.
Medical Decision Making:
He had fallen severely ill post his electro-acupuncture sessions done at another practice. Thus only dry needling will be used for the central, peripheral, autonomic and local points. Keeping his history of the lung mass in mind I have opted not to use laser therapy and instead I have opted for LED therapy along his dorsal neck, antebrachium, para-lumbar spine and hips. He would definitely benefit with massage in all the sore and tight muscle areas allowing myofascial release and trigger point release as well as in improving general circulation. Thus the above three modalities (marked in bold) have been focused on through his treatments.
Medical Acupuncture and Related Techniques Used:
I began treatment on 8th May, 2019 and have been doing two sessions a week with each session comprising of:
a) Dry needling on GV20 to relax him, GV14 for neck and thoracic limb pain, BL13 for the lungs, BL14, BL15 for the heart, Bai Hui for lumbosacral pain, BL18 for the liver problems, BL25 for intestinal pain and distension, BL27, BL28 for sacroiliac dysfunction, BL23 for lumbar and pelvic pain, GB29, GB30, BL54 as the hip triad along with GB31 for hip and pelvic limb pain, ST36 as an autonomic point for immunity and general gastro-intestinal motility, LR3 for anxiety and distant point for cervical pain [1], Bafeng for the digital extensors of both hind legs. Local points used were at trigger point at long head of right triceps muscle and latissimus dorsi muscle.
I started my first session with Lhasa OMS Seirin J Type 0.2*30 mm silicon coated acupuncture needles. However he became very restless and I was able to place the needles only in GV20, BL13, BL14, BL15, Bai Hui, BL25, trigger point in the latissimus dorsi muscle. GV20 was left in the longest for about 15 minutes. The others were taken out in a time range of 10-12 minutes.
From the second session onwards I switched to Lhasa OMS Seirin J type 0.16*30mm silicon coated acupuncture needles. He has been accepting the needles in all the points since then. The needles are being removed at 20 minute mark [2] in each of the sessions.
b) LumaSoothe brand LED with deep tissue (DT) setting is then used for a minute each on L4 to L5 region for pain relief, LR3 for relieving his anxiety, dorsal neck and triceps bilaterally to release the tightness, ST36 bilaterally and around the hips bilaterally. This has 32 infrared 940nm LEDs and 8 green 520nm LEDs.
c) The sessions are ended with a 10 minutes massage using the methods of effleurage and skin rolling, for increasing general blood circulation and myofascial release.
Outcomes and Discussions:
The feedback post the first session was that he had become more active and was walking a lot more instead of lying down all the time. He had become more vocal and was barking more often and clearly. The acid reflux episodes had also stopped and his appetite had improved.
Examination before beginning the second session showed that the trigger point noted at the right latissimus dorsi muscle was absent. Dorsal neck muscle restrictions and tightness was markedly softer but not flaccid.
Improvement shown in gait analysis post the second session was that he held his head slightly elevated from the point of cervico-thoracic junction. Knuckling was less prominent. He was taking cleaner turns without falling and without help and was dragging his feet much less.
Before the third session the long head of the right head of the triceps showed a very angry looking trigger point (video). Dorsal neck muscles felt softer.
Having completed ten sessions, now there are no trigger points in the triceps muscles though they are still tight. The pectoralis muscles are soft and not painful or tight. The CP on the left hind leg has markedly improved and knuckling is almost absent. He is steadier on all four feet and is able to stand and eat his meals without a fall. The trapezius muscle has become soft and distance between the scapular shoulder blades is much more making his posture in the front more relaxed. He is doing better with each passing session. Acid reflux has completely stopped.
References:
[1] Ching Ming Liu, Fang Chia Chang, Chung Tien Lin. Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs. J Vet Sci. 2016 Sep; 17(3): 337–345. Published online 2016 Sep 20. doi: 10.4142/jvs.2016.17.3.337
[2] James Dunning, Raymond Butts, Firas Mourad, Ian Young, Sean Flannagan, Thomas Perreault. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug; 19(4): 252–265. doi: 10.1179/108331913X13844245102034