Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019005
ABSTRACT:
“Avatar” is a 14 year old, Arabian, gelding with a known history of progressive degenerative joint disease of his left front pastern joint. He presented on exam with a grade 2/5 left forelimb lameness, bilateral neck soreness, and decreased rotational bending at the level of his thoracolumbar and lumbar spinal segments. Three dry needling treatments were performed with the selected acupuncture points: GB 21, LI 16, LI 17, SI 12, SI 11, TH 14, LI 15, LI 11, and PC 6 (Seirin 0.25 x 30mm needles). Treatments were performed 7 days apart and response to therapy revealed improved willingness to trot in-hand and under saddle, less pain on palpation of his left forelimb, and less resistance to internal rotation of the left forelimb and cervical spinal segments from his initial exam. A grade 2/5 left forelimb lameness remained after the treatments; however due to the chronicity of degenerative joint disease and the mild improvements, continued acupuncture therapy is recommended.
HISTORY:
“Avatar” is a 14 year old, Arabian, gelding presenting for a left forelimb lameness. He has been shown successfully in hunter pleasure for most of his life and his current owner acquired him in 2014. Radiographs performed in 2014 revealed: left front pastern joint roughening and collapsing of the joint space medially, left hind fetlock showed two plantar process fragment, left hind stifle showed a medial femoral condylar cyst, right hind revealed a calcification in the area of medical meniscus, right hind showed lateral trochlea ridge osteochondrosis dissecans (OCD) and suspected medial malleolus OCD. He has a history of a left tuber coxae fracture of unknown cause. Until January 2018, Avatar did not have any evidence of lameness. His most recent radiographic findings in 2018 revealed an increase in the left forelimb pastern joint roughening. Therefore, Avatar had corticosteroid joint injections which included left and right coffin joints and ankles (forelimbs). The January 2018 joint injections resolved his left front lameness. His last joint injections were given June 2018 as Avatar experienced lameness again; however, there was decreased effectiveness of the injections performed at that time and it was decided to retire him from showing in July 2018.
The owner’s goal is to keep him comfortable. Avatar is ridden lightly 2-3 times per week and is otherwise turned out on pasture during the day and lives in a stall at night. Avatar had his teeth floated in January 2019 and is up to date on vaccinations. His current medication includes Previcox (Firocoxib) 56mg by mouth every 24 hours. His hoof care includes an aluminum shoe on all four hooves and he is reset every 6-8 weeks. He has no past injuries aside from the tuber coxa fracture (unknown cause) or surgeries.
PHYSICAL EXAMINATION AND CLINICAL ASSESSMENT:
Avatar’s eyes, heart, and lungs are all within normal limits. He was grade 2/5 lame on his left front limb. His left pastern joint was moderately thicker than his right front. Both hind fetlocks were mildly distended. He is slightly toed in on his front forelimbs, the left is worse than the right hoof. His neurologic exam was unremarkable.
Myofascial exam:
Myofascial palpation exam revealed on the left neck: a trigger point on the dorsal aspect of the brachiocephalicus muscle (cranial third of the neck), 2 inch taught band in the middle of the splenius muscle, trigger point on the dorsal aspect of the splenius muscle (cranial portion), 2 and trigger points in the cervical portion of the trapezius muscle. On the right neck: a 3 inch taut band in the middle of the cervical part of the trapezius muscle, 2 trigger points on the dorsal aspect of the brachiocephalicus muscle (cranial third of the neck) and a 2 inch taut band just distal to these trigger points on the dorsal aspect of the brachiocephalicus muscle.
Avatar had mild pain on palpation of his temporomandibular joint palpation bilaterally. He had bilateral myofascial restriction of his cervicothoracic and thoracolumbar areas. He had mild pain on compression of his medial heel bilaterally. On palpation of the distal tendons along the metacarpus, mild pain noted bilaterally (superficial digital flexor tendon vs. deep digital flexor tendon vs. suspensory ligament). On internal rotation of the left forelimb there was moderate resistance. Right hindlimb revealed mild resistance on medial to lateral rotation.
Rotational bending showed mild restriction at the level of the left thoracolumbar area and the right thoracolumbar and lumbar areas. High velocity stimulation of the paraspinal nerves and muscles and movement of the spinal facets showed mild pain along the right thoracolumbar and right thoracolumbar and lumbar areas.
Avatar had moderate resistance of the left cervical spinal segments of C5-C6 and C4-C5 and resistance of the right cervical spinal segments of C1-C2 and C2-C3. He had mild resistance of caudal cervical mobility and protraction of his right forelimb. The remainder of the myofascial physical exam was within normal limits.
PROBLEM LIST:
1. Grade 2/5 left forelimb lameness
2. Taut bands/trigger points (bilaterally) on neck
3. Severe osteoarthritis of the left pastern joint
4. Two plantar process fragments of the left hindlimb
5. Medial condylar femoral cyst of the left hindlimb
6. Calcification in the area of the medial meniscus of the right hindlimb
7. Lateral trochlea ridge osteochondrosis dissecans (OCD) of the right hindlimb
8. Suspected medial malleolus OCD of the right hindlimb
9. Left tuber coxae fracture
10. Mild temporomandibular pain bilaterally
11. Bilateral myofascial restriction of his cervicothoracic area and thoracolumbar area
12. Mild pain bilaterally of distal tendons along the metacarpus, mild pain noted bilaterally
13. Moderate resistance of internal rotation of the left forelimb
14. Right hindlimb revealed mild resistance on medial to lateral rotation
15. Mild restriction at the level of the left thoracolumbar area and the right thoracolumbar and lumbar areas on rotational bending
16. High velocity stimulation of paraspinal nerves and muscles and movement of the spinal facets showed mild pain along the right thoracolumbar and right thoracolumbar and lumbar areas
17. Moderate resistance of the left cervical spinal segments of C5-C6 and C4-C5 and resistance of the right cervical spinal segments of C1-C2 and C2-C3
18. Mild resistance of caudal cervical mobility and protraction of his right forelimb
19. Left forelimb mildly toed in
DIFFERENTIAL DIAGNOSES:
1. Left forelimb lameness
a. Degenerative joint disease/osteoarthritis of pastern joint (vs. coffin joint vs. fetlock joint) is most likely given radiographic evidence
b. Connective tissue injury (suspensory ligament vs. superficial digital flexor tendon vs. other) may be attributing to lameness
c. Developmental issue of toed-in conformation contributing to lameness causing more weight to bear on the outside of the hoof
d. Trauma causing an acute flare of osteoarthritis (tripping in paddock, etc.)
2. Bilateral neck soreness (resistance)/taut bands in neck
a. Myofascial restriction secondary to compensation of left forelimb lameness
b. Muscle soreness secondary to neck collection during exercise
PUTATIVE DIAGNOSIS / MEDICAL DECISION MAKING
Severe degenerative joint disease of the pastern joint was confirmed on radiographs in 2018. The bilateral neck soreness is likely secondary to the compensation of the lameness as well as neck collection when ridden. Due to the clinical evidence of the patient’s forelimb lameness and bilateral neck soreness, these were the initial issues to treat. Three acupuncture treatments were performed 7 days apart and the therapy was based on the myofascial palpation exam, gait evaluation, and history of severe degenerative joint disease. A myofascial palpation was performed prior to each treatment to reassess the patient.
MEDICAL ACUPUNCTURE AND RELATED TECHNIQUES:
Treatments – Dry Needling
Acupuncture points selected for the three treatments:
GB 21, LI 16, LI 17 (bilateral)
SI 12, SI 11, TH 14, LI 15, LI 11, PC 6 (left side)
The bilateral neck points were first placed and selected as autonomic points and their aid with parasympathetic stimulation. Additionally, Avatar exhibited neck soreness on palpation, these points would also act as local pain relief and deactivating trigger points.
The following points: SI 12, SI 11, TH 14, LI 15, LI 11, and PC 6 were selected due to Avatar’s left forelimb lameness. The supraspinatus and infraspinatus muscles as well as the suprascapular nerve were targeted due to secondary shoulder discomfort from the lameness. Referred pain from the lameness at the level of the elbow and radial nerve were also targeted. The median nerve was supported as well.
Method of stimulation was dry needling using Seirin 0.25 x 30mm needles for all three treatments. Based on the patient’s response, the three treatments lasted 20 minutes, 25 minutes, and 18 minutes respectively.
DISCUSSION:
After three dry needling acupuncture treatments, the patient showed more willingness to trot in-hand and under saddle and had less resistance to internal rotation of the left forelimb and cervical spinal segments from his initial exam (mild improvement). Avatar still had a grade 2/5 left forelimb lameness after three treatments. There were no adverse events during the three treatments.
For clinical practice, I would utilize other needle types for future treatments. Seirins will be used for my initial acupuncture treatment, but I plan to use Carbo CB1 uncoated 0.20 x 25mm/0.25 x 25mm needles for subsequent equine treatments and as the patient tolerates. After needle manipulation, the silicone coating on the Seirins would yield an initial muscle grab and twitch response (De qi) but within 3-5 minutes after initial placement, the needles would slide out with only a small portion remaining within the muscle (they were replaced throughout the treatments). While the objective of this case study was to evaluate the left forelimb lameness, Avatar’s future treatments will include BL channel points due to the resistance in rotational bending and adding SI 9 for additional support of his thoracic limb pain. I would readjust my LI 15 and TH 14 to be more craniodorsal and caudodorsal to the greater tubercle of the humerus and provide more trigger point deactivation along his neck (not necessarily using specific points). Additionally, this patient would benefit from laser therapy and electroacupuncture to reinforce neuromodulation, but it was not available at the time.
Acupuncture should be considered in patients with osteoarthritis as there are statistically significant reductions in pain intensity, improved functional mobility, and improved health related quality of life in human patients. Due to the chronicity of pain associated with osteoarthritis, the presence of inflammation, and established nociceptive pathways, it may require a threshold dose or duration of therapy before there is clinical effect. Since there has been sustained nociceptive input secondary to osteoarthritis, it can have large effects on the central nervous system and cause pathologic neuroplastic changes, thus recommended guidelines entail 10 acupuncture treatments on average for these patients. Continued care is recommended in Avatar’s osteoarthritis case, as there were mild improvements of mobility and decreased pain on palpation of the pastern joint after three dry needling treatments. However, due to the chronic nature of his disease, more acupuncture treatments are warranted.
References:
Manyanga, T., Froese, M., Zarychanski, R., Abou-Setta, A., Friesen, C., Tennenhouse, M., & Shay, B. L. (2014). Pain management with acupuncture in osteoarthritis: A systematic review and meta-analysis. BMC Complementary and Alternative Medicine,14(1). doi:10.1186/1472-6882-14-312
Tu, J. (2019). Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: Statistical analysis plan for a randomized controlled trial. Trials. doi:10.21203/rs.2.475/v1
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