Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019002
Abstract: This case study summarizes multiple visit therapy on a 15-year-old neutered male Domestic Shorthair who suffers from decreased mobility, gastrointestinal signs, and previously resolved azotemia. The owner was quite reluctant to use steroids for gastrointestinal disease and previous azotemia preempted the use of NSAID medication. Mild improvement of intermittent anorexia was seen and moderate improvement in mobility was witnessed.
History of present illness and chief complaints: Snickers originally presented to my clinic on 2/22/18 with a history of acute anorexia and lethargy. In house blood chemistry revealed azotemia (BUN 61 ((16-37) & SDMA 36(0-14). IV fluids were instituted and the azotemia resolved after 48-72 hours. Upon rechecking blood work the following week, the azotemia remained improved (BUN 28 (16-37) & SDMA 14 (0-15). Over the next 6-8 months, he continued to do pretty well on a maintenance diet of Science Diet K/D except for a small amount of vomiting which transdermal metoclopramide seemed to mitigate. In early 2019, the owner noticed that Snickers had continued to eat less and was losing weight. His blood work showed no evidence of azotemia, normal thyroid levels and liver enzymes. His physical examination at the time, showed severe periodontal disease was present. After a lengthy discussion about the possibilities of dental disease versus gastrointestinal disease causing the weight loss and intermittent anorexia, the owner decided to go ahead with a dental cleaning but declined intestinal biopsies and feeding tube. The dental procedure involved surgical extractions of 107, 207, 307, and 407. After healing, his appetite improved somewhat but never to the level before early 2019. His weight declined but then stabilized. We revisited the possibility of gastrointestinal disease but the owner was reluctant to pursue biopsies or empirical steroid therapy. A trial of integrative therapy ensued.
Physical examination: When walking around the exam room, Snickers was moderately kyphotic in the T4-T8 region, lordotic in the T10-L3 region, and his hips were tucked beneath him. His hocks were dropped low to the ground when he walked as well. He had changes to his hair coat dorsally approximately from T10-L2 which corresponded to tenderness and sensitivity to light palpation of the epaxial muscles in that area. I found that he had taught bands in the L1-L2 region. Snickers had significant muscle mass atrophy over his hips, shoulders, and elbows that seemed affect all the muscles of the quadriceps group as well as the triceps, trapezius and deltoids muscles. Mild strain patterns were noted in the gluteus medius and tensor fascia latae bilaterally. It was also noted that his neurologic exam showed no conscious proprioception deficits and intact cranial nerve nerves. It was difficult to fully examine all the peripheral reflexes do to the temperament of the cat.
Problem List:
The following problems were identified for the patient. Gastrointestinal signs of intermittent anorexia, occasional loose stools, and weight loss. It was also noted that the patient had difficulty in his ambulation. He also had a previous history of azotemia, which currently appeared to be managed with Hills Science Diet K/D.
Differential Diagnosis:
Differentials for the gastrointestinal signs of intermittent anorexia and loose stools include FIP (feline infectious peritonitis), intestinal parasites, gastrointestinal lymphosarcoma, inflammatory bowel disease, gastrointestinal foreign body, chronic pancreatitis, or hyperthyroidism. Differentials for the patient’s orthopedic/ambulatory dysfunction include neoplastic disease such as metastasized lymphosarcoma or spinal neoplasia, degenerative myelopathy, autoimmune polyarthritis, spondylosis, osteoarthritis, or significant myofascial pain secondary to muscular atrophy from age and disuse.
Putative Diagnosis for top two problems:
Several differentials for gastrointestinal disease were eliminated due to the chronicity of the problem and the likelihood of increased morbidity in a shorter time frame for GI foreign body or FIP. Hyperthyroidism was ruled out with blood work (TT4 at 1.9 (0.8-4.7ug/dL). Gastrointestinal disease was further narrowed down to the possibilities of GI neoplasia (lymphosarcoma being the most likely), inflammatory bowel disease, or chronic pancreatitis. The remaining differentials were not determined to be definitively because of the lack of biopsies and pancreatic values on blood work (declined by the owner because of the cat’s age and not wanting to cause additional stress for him). Ambulatory dysfunction was narrowed to osteoarthritis, significant myofascial pain, or spondylosis. The other differentials were ruled out from physical examination, and the chronicity and static nature of the problem.
Medical decision making and integrative techniques used: I had two main goals when treating Snickers. The first was to try and get the most neuromodulation while choosing key points that could possibly help his gastrointestinal signs and his ambulatory issues. The second goal was to do my best in honoring the trust between the patient and myself and reading the mood he was in at each visit and trying to make his visit as enjoyable that I could. In addressing the gastrointestinal symptoms on his first visit of 5/29/19, I started with GV20 and GV14, and ST36 to help increase the parasympathetic input from the autonomic nervous system and decrease sympathetic tone. ST36 was also chosen the parasympathomimetic function that is accomplished through the long loop reflexes through the NTS (nucleus tractus solitarius). The more input that is stimulated from the parasympathetic nervous system, the more likely improved gastrointestinal function could occur. I also chose the following points bilaterally BL20 and BL21 (stomach shu) to try and stimulate the gastrointestinal tract through various local somatovisceral reflexes through the T4-L1 spinal nerve. I also placed needles in BL18 and BL19, as they seemed to correspond to local sensitivity of epaxial muscles (T10-T11). Photomedicine laser therapy was applied to the hips and spine between L1-L4 to assist in decreasing the inflammation that was noted in the taught bands in that region (K-Laser Cube 4:
1008 J /cm2) Light massage was direct pressure and gliding was applied over BL25 bilaterally to help stimulate gastrointestinal motility through local somatovisceral reflexes. On a second visit on 6/7/19, I repeated the previously mentioned points, but also added the kidney tiara (GV4, BL23, BL52, and GB25) for peripheral and central stimulation to his renal system giving the previous history to acute azotemia. I also placed needles in local hip points of GB29, GB30, GB 31, and BL54 bilaterally to help with orthopedic discomfort and myofascial strain patterns that were detected on the myofascial exam. Photomedicine laser therapy was also repeated at the previously listed dose. On the third visit on 6/17/19, I repeated on the previously mentioned points but also added BL60 for additional stimulation of the peripheral nervous system (both the Fibular and Tibial nerves) to assist Snickers in his ongoing orthopedic difficulties. A combination of red seirin (0.16 x 30 mm) and green seirin (0.12 x 15mm) needles when I performed dry needling. On his fourth visit, I repeated several of the previous listings but I also placed carbo needles (CB1 0.2 x 25mm) bilaterally at BL18 and BL25. I did electrostimulation at a mixed frequency (4Hz/100Hz for 10 minutes) on the right side. I tried to place micro-clips on the left side but he continued to move a lot so the right side was treated.
Outcomes, Insights, Discussion
Over the course of Snickers treatments, some measurable gains were noted in some areas while not as much in others. Orthopedically, his mobility improved, as did his general demeanor. The owner reported that she saw chase after a gopher after several treatments! He was also able to navigate up and down stairs, furniture, etc. as the treatments progressed. His gastrointestinal signs seemed to show very small improvements. His weight dropped initially between the first and second visits but then seemed to stabilize and maintain. His appetite was reported to increase slightly by the owner but then would be followed by periods of (hours to a day) of anorexia. He did experience less vomiting and less diarrhea during the treatment period. One adverse event was experience initially on 6/7/19 while placing a few red Seirin needles at BL18, BL19, and BL20, he seemed slightly uncomfortable and was moving around and shifting his weight on the exam table a lot. In noticing this change, I adjusted my needle size to a small gauge and placed dark green seirin needles instead (0.12 x 15mm) and the remainder of his dry needling went quite well. I would have tried light green (0.14 x 15 mm needles) if I had had them in stock but did not. In further visits, the tenderness in the epaxial muscles between T10-L2 improved as did the taut areas previously noted around his hips.
I learned several things from this case. It is vital to come into the session with a plan but be very adaptable while listening to what the patient is telling you and not forcing your “planned” treatment plan on the patient but rather approach as a partnership. I also learned that acupuncture could provide several benefits to patients when the owner wants to avoid chronic medication. The owner did not want to put Snickers on long-term prednisone or narcotics/opioids. Strong evidence has been found for acupuncture to be used as a complementary treatment for chronic pain that has been shown to decrease the usage of opioids (Lin, Yuan-Chi MD, MPH; Wan, Limeng BS; Jamison, Robert N. PhD, Using Integrative Medicine in Pain Management: An Evaluation of Current Evidence: Anesthesia & Analgesia. 125(6): 2081–2093, DEC 2017). Evidence has also been found to show that acupuncture can also be beneficial in gastrointestinal disease but it seems to be harder to get quantitative results. (Antonius Schneider, Konrad Streitberger, and Stefanie Joos, Acupuncture treatment in gastrointestinal diseases: A systematic review: World Journal of Gastroenterology. 2007 Jul 7; 13(25): 3417–3424. )
I gained insight that the orthopedic dysfunction seemed to have more rapid onset of improvement compared to improvement of gastrointestinal signs. This could be due to the fact that I was able to more directly stimulate local points in the hip and lumbar locations versus visceral areas being more difficult to directly stimulate. Acupuncture, photomedicine laser therapy, and massage are wonderful modalities to add to every day practice to help patients live their most rich and meaningful lives!