Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4L2019006
Abstract:
Keara, a 13 year old, Connemara pony mare presented for primary complaints of back stiffness, coughing, and possible hind end soreness and/or lameness. Three acupuncture treatments were performed over the course of 4 weeks during which the myofascial restriction of the neck and back, hamstring muscle trigger points, and respiratory issues were primarily targeted. Keara’s owner was also instructed on how to perform beneficial exercises in between treatments. Overall, Keara’s problems of myofascial restriction and sore hamstring muscle trigger points improved most in between the first and second treatments.
History and Presentation:
-Keara, a 13 year old, Connemara pony mare, presented on 5/29/19 for chief complaints of owner perceived focal back soreness centered at the thoracic spine just caudal to the withers and at the lumbar spine; as well as, neck stiffness. Keara is currently being ridden twice a week on trails and in the arena doing low-level dressage work.
-Approximately three years ago, Keara was lame in her left hind limb and her veterinarian injected the left stifle joint which appeared to improve Keara’s lameness. The stifle has not been injected since as Keara has not appeared overtly lame on the limb.
-Keara also has a history of sidebone (ossification of the collateral cartilages) in her left front hoof. Her owner does not believe this impacts Kiara’s soundness.
-Intermittently throughout the day, Keara will cough which her owner attributes to possible allergies to the hay. Several years ago, Keara’s owner was concerned that she may be developing heaves, but a veterinarian examined Keara and did not find any evidence for this condition.
Physical Exam:
HR: 40 bpm RR: 12 bpm Temp: 99.8
General: Bright, alert, responsive; mucous membranes pink and CRT < 2 sec
Lungs: eupneic, normal respiratory sounds auscultated; did cough several times while walking
Cardiovascular: normal heart rate and sinus rhythm heard on auscultation, normal membrane perfusion
GI: normal borborygmi present in all four quadrants
Neuro Exam:
Cranial Nerves: WNL, Proprioception: WNL, Mentation: WNL Gait: no neurological deficits observed
Acupuncture/Myofascial Exam:
Walking/Trotting: Overt lameness was not observed but the patient has an interesting gait as the left hind consistently crosses midline during cranial phase of stride while trotting
Skin/Hair: No areas of increased or decreased temperature palpated; hair coat normal; no areas of thin/broken hairs or abnormally growing hair
Fascia: Myofascial restriction was detected at cranial aspect of neck bilaterally and along the back at the level of the withers and lumber spine
Left Forelimb:
The scapula had moderately decreased vertical motion when lifted manually. All other structures and joints were within normal limits upon palpation and mobilization with the only abnormality being ossification of collateral cartilage. Caudal cervical motion could not be evaluated due to the patient’s behavior.
Right Forelimb:
The scapula had moderately decreased vertical motion when manually lifted. All other structures and joints were within normal limits upon palpation and mobilization. Caudal cervical motion
could not be evaluated due to the patient’s behavior.
Left Hindlimb:
Mild joint effusion was palpated in the medial femorotibial and femoropatellar joints. All other structures and joints were within normal limits on palpation and mobilization.
When the left hind limb was lifted and circles were performed with the limb underneath the body, the circles felt mild-moderately rigid and the tilt of the pelvis was decreased. This likely indicated sacro-iliac joint pain. When circles were performed with the limb extended behind the body, the circles were moderately rigid, and Keara reacted by putting the limb down. This likely indicated soreness of the iliopsoas muscle.
Right Hindlimb:
All structures and joints were within normal limits upon palpation and mobilization.
When the right hind limb was lifted and circles were performed with the limb underneath the body, the circles felt moderately rigid and decreased pelvic tilt was observed. This likely indicated sacro-iliac joint pain. When circles were performed with the limb extended behind the body, the circles were moderately rigid, and Keara placed her foot down. This likely indicated soreness of the iliopsoas muscle.
Back:
Palpation along dorsum: Keara was reactive to palpation from base of withers (T10) to about T13. Lateral movement of the withers and back were within normal limits.
Keara would not perform a sternal lift but I believe this to be due to not being reactive to cue for sternal lift rather than inability to perform the sternal lift.
Lumbosacral: good motion in LS junction when LS was mobilized
Left SI and right SI: good motion when dorsal ventral tuber coxae mobilization was performed but hind limb circles were abnormal which contradicts this finding.
Head/Neck:
The left temporomandibular joint (TMJ) was moderately reactive to palpation. The right TMJ was mildly reactive to palpation. Keara was resistant to lateral bending of her neck bilaterally,
but I believe this was more due to behavior than to musculoskeletal restriction as Keara was becoming very stubborn and uncooperative as the exam went on which is consistent with her personality. Stiffness resulting from a problem in the cervical vertebrae and neck musculature could not be ruled out though.
Problem List:
-TMJ discomfort bilaterally; myofascial restriction at the cervical neck, withers, and lumbar spine; poor scapular vertical mobility bilaterally; rigid hind limb circles bilaterally; mild left stifle effusion; coughing during exam
Differential Diagnoses:
Problem 1: Myofascial Restriction and Pain at Caudal Withers
V: local vascular compression due to poor fitting saddle I: Clostridial Myositis N: I can’t come up with a neoplastic cause but another N could be nutritional and Vitamin E/selenium deficiency could work for this D: osteoarthritis of thoracic vertebrae facet joints I: ionophore toxicity C: vertebral malformation A: Immune-mediated myositis T: kicked by another horse E/M: electrolyte (sodium, potassium, chloride, magnesium, calcium) deficiencies M: An ill-fitting saddle or the manner in which the rider sits could lead to compression of the nerves in the myofascial which then leads to pain and myofascial restriction.
Problem 2: Intermittent Cough
V: Left sided heart failure I: allergies to hay N: primary pulmonary neoplasia D: degenerative mitral valve disease I: Fumonisin toxicity C: tracheal malformation A: Recurrent Airway Obstruction T: kick to the neck leading to damage to the recurrent laryngeal nerve and subsequent laryngeal hemiplegia and aspiration E/M: I am unable to come up with an endocrine or metabolic cause M: myofascial restriction at the level of the larynx intermittently impacting swallowing leading to aspiration and coughing
Putative/Differential Diagnoses:
Myofascial restriction and pain at the caudal withers was likely due to saddle fit and the way the rider sits in the saddle since the area of restrictions are underneath where the saddle sits. Linda did mention that she is slightly unbalanced when she rides which could contribute to this.
Coughing was likely due to allergies to the dust or spores in the hay since lung auscultation was within normal limits and recovery from exercise was appropriate. In June in New York, most of the hay is from the season before causing it to be very dusty.
Medical Decision Making:
-Based on the exam findings, treatment of musculoskeletal system in areas of myofascial restriction with acupuncture was decided upon as it was not believed that Keara was experiencing a medical condition that required traditional medical intervention. Keara has a very strong personality was very uptight on presentation. Based on this observation and her owner’s input, it was decided to use a lesser number of needles during the first treatment in order to be cautious due to her personality and behavior. It was likely that is uptight personality also led to some of the myofascial restriction that she was experiencing. Three sessions were decided upon as Keara’s owner’s work schedule was about to change and she would no longer be able to fit treatments into her schedule.
Session One (all points were performed bilaterally, Seirin 0.20X30mm needles were used)
GB21, LI 16, LI 17: used as initial points in acupuncture treatment as most horses respond well to these points and they seem to reduce anxiety
TH 16, SI 16: used for myofascial restriction and tension relief in the muscles (splenius m. and brachiocephalicus m.) over which they are located
BL 11, 12, 13: utilized for Keara’s decreased scapular vertical range of motion as well as myofascial restriction around the withers and muscle tension (rhomboideus m., trapezius m., longissimus thoracis m., and iliocostalis m.); since BL 13 is the Lung Shu point, this also was impacting the respiratory system for the coughing.
Bai Hui: utilized for parasympathetic innervation and to reduce anxiety
BL 26, 27: utilized for sacroiliac joint discomfort as Keara had difficulty with hind limb circles during examination
Session 2: (all points were performed bilaterally, Seirin 0.20X30mm needles were used except for Bai Hui, BL 26, and 27 where Seirein .30X60mm were used)
GB21, LI 16, LI 17
TH 16, SI 16
BL 11, 12, 13, 14, 15 (decided to add in BL 14 and 15 to better address restriction at the withers)
Bai Hui, BL, 26,27
ST 36: used for parasympathetic innervation and reduction in anxiety
LU 1: utilized in order to impact respiratory system since it is the Lung Mu point
ST 7: used for TMJ discomfort (Keara did not tolerate the needle on the right side, so it was removed)
TH 15: used for Keara’s decreased vertical scapular range of motion
BL 40: utilized for trigger point just dorsal to BL 40 in hamstring muscle group
Session 3: (all points were performed bilaterally, Seirin 0.20X30mm needles were used except for Bai Hui, BL 26, and 27 where Seirein .30X60mm were used)
GB21, LI 16, LI 17
BL 11, 12, 13, 14, 15, 16:
Bai Hui, BL 26, 27:
LU 1
ST 36
BL 36,37,39,40: utilized for trigger point just dorsal to BL 40 in hamstring muscle group (Keara was very sore in the left hamstrings upon palpation, so I decided to add additional points in)
Outcomes/Discussion:
At the start of the acupuncture treatments, I was a somewhat cautious with Keara as she is very impatient and pushy, and I was afraid that she may not tolerate acupuncture well. I tried to treat as few points as possible due to her personality and behavior. Overall, I feel that she enjoyed the acupuncture somewhat but would tell me when she had enough. She was a hard patient to work with as I feel that her personality made it hard to read and understand if she was really reacting to something during the exam phase or if she just didn’t want to do something because she is stubborn. It was very helpful to have her owner present to help me since she knows Keara much better than I do.
In terms of improvement of the problems listed above, I believe that the most improvement occurred after the second treatment. Her owner, Linda, described to me that after this treatment, Keara felt great under saddle as she was much more even, and her canter was very smooth. She also observed that Keara could regulate her pace and control her body better.
From a myofascial standpoint, I feel that I did noticed the most difference in the myofascial exam between the first and second treatments which were one week apart. I believe that her scapulas lifted better as well as she was not as back sore as previously. The second and third treatments were two weeks apart due to a scheduling conflict and I think this led not seeing much of an improvement in between treatments.
Between the 1st and 2nd treatments, Linda also performed exercises that I taught her such as sternal lifts, carrot stretches, and hind limb circles. She did these several times between treatments and I think these exercises also contributed to the success of the first two treatments. She was not able to perform these exercises in between the 2nd and 3rd treatments so I think this also led to less of an improvement between these treatments.
Unfortunately, due to both Linda and I starting new jobs, we could not continue with Keara’s treatments. Linda was very impressed by the acupuncture so I hope she will find another practitioner to treat Keara who will be able to accommodate her new work schedule.
My Acupuncture Experience:
I really enjoyed doing acupuncture on Keara even though she was difficult to work with at times. I think that being a newly graduated vet does make things more difficult since I am not great at lameness exams yet but I feel that the myofascial exam and dynamic acupuncture exam that I learned at the MAV were very helpful and allowed me to assess Keara appropriately. Not having a lot of experience working up an acupuncture case also added challenge to this case, and I feel that more case workups at the MAV would have been more helpful so that students could gain more experience while instructors were present.
References:
I used the CuraCore Equine Point Mini-Manual and the course notes.