Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S201900
Abstract:
Josie is a 10 year-old female spayed black labrador retriever. She has a history of mild separation anxiety, chronic gastrointestinal issues, ocular melanoma, cutaneous mast cell tumors, and chronic intermittent lameness, usually after vigorous exercise. She is mildly to moderately overweight. Her mobility and lameness issues improved significantly after four treatments with dry needling acupuncture and massage.
History and Presentation:
Her gastrointestinal issues are currently under control on a limited ingredient diet, her melanoma was treated with enucleation of her right eye, the mast cell tumors have been completely excised without evidence of recurrence or metastasis, but her lameness issues have been persistent, though they respond partially to intermittent non-steroidal anti-inflammatory (NSAID) therapy. Her anxiety has mostly resolved though she will rarely and unpredictably act destructively around the house, usually when food is not properly secured.
Her owners are retired and give her extensive daily exercise including several miles of walking and off leash playtime in a shallow creek. Josie will run non-stop, but the following days she can be stiff and painful, often refusing to walk or refusing to continue after a very brief walk. The main goal of therapy is to ease the discomfort using as few medications or invasive procedures as possible so as to not risk exacerbating her chronic digestive issues. A secondary goal will be to treat those digestive issues, though they are currently under control. Her recent blood work and lab results are unremarkable.
Physical Examination and Clinical Assessments Including Myofascial and Neurologic
Exams, June 1, 2019
Body Condition Score: 6/9, moderately muscled Appearance: Bright, alert, responsive
Temperature: 101.3 F Heart Rate: 120 beats/minute Respiratory Rate: 30 breaths/minute
Eyes – The right eye is enucleated. The left eye has heavy nuclear sclerosis but is otherwise normal.
Ears – The external and otoscopic examination is within normal limits.
Mouth/Throat – Mucous membranes are moist and pink. Capillary refill time is <2 secs. Incisors are worn. Mild dental calculus and very mild gingivitis are present.
Respiratory – There is no obvious nasal discharge. There is no cough elicited on palpation of the trachea. The auscultation of all lung fields is within normal limits.
Cardiovascular – The cardiac auscultation is within normal limits. There are no obvious murmurs or arrhythmias noted. The pulses are strong and synchronous.
Gastrointestinal – The abdominal palpation is non-painful with no obvious masses noted. The rectal exam reveals soft but formed stool with no obvious abnormalities.
Skin/Hair – There is no evidence of ectoparasites. The examination of the skin, hair coat, and nails are unremarkable.
Urogenital – The examination within normal limits for the age, gender, and size of the animal.
Hydration – The patient appears to be well hydrated.
Lymph Nodes – The peripheral lymph nodes are within normal limits.
Gait Analysis – The patient is ambulatory in all four limbs, but the stride is not smooth and has short stilted steps at a walk. The patient was unwilling to trot on video.
Nervous System – The patient is mentally appropriate. There are no obvious neurologic deficits noted. Her reflexes and conscious proprioception are normal.
Myofascial
– Head and Neck: The patient holds her head in a neutral to down position at a stand, walk and trot. She is able to raise her head when lured with treats but seems more comfortable orienting her whole body by sitting in order to lift her head rather than by manipulating her neck. She has taut bands over the omotransversarius muscles and along the cervical spinal segments.
– Spine – There are taut bands over the latissimus dorsi around the thoracolumbar spinal junction. Moderate muscle twitching was evident at this area with gentle pressure.
– Forelimbs – She is very well muscled over the forelimbs but with taut bands and excessive heat over the infraspinatus and supraspinatus muscles. There is moderate crepitus palpable over the elbow and carpi joints bilaterally. There is moderately reduced range of motion in the shoulder joint bilaterally. She holds her elbows slightly pronated while standing.
– Hindlimbs – She is weakly muscled for her size over the coxofemoral joint with notable atrophy in the superficial glutealis, semimembranosus and semitendinosus muscles. She has moderate crepitus and reduced range of motion over the coxofemoral and stifle joints.
Problem List and Differential Diagnosis for Top Two Problems:
1) Post-exercise pain and lameness; muscle wasting hind limbs
Vascular: Blood Flow Restriction to Affected Muscles; Stroke Infectious: Lyme Disease, Septic Arthritis
Neoplastic: Osteosarcoma, Osteochondroma Degenerative: Osteoarthritis
Iatrogenic: Nutritional Deficiencies Congenital: Hip Dysplasia
Autoimmune: Rheumatoid Arthritis Traumatic: Car Collision
Endocrine/Metabolic: Hypothyroidism, Cushing’s Disease Myofascial: Taut muscle bands; chronic shortening of quadricep group; overactive sympathetic tone
2) Gastrointestinal upset; intermittent
Vascular: Blood Flow Restriction to Gastrointestinal Tract; Stroke
Infectious: Clostridium Overgrowth, Giardia, Whipworms, Other Parasitism, Salmonella
Neoplastic: Lymphoma, Gastric Carcinoma Degenerative: Chronic Anxiety
Iatrogenic: Adverse Reaction to Medications, Nutritional Deficiency Congenital: Malformed Gastrointestinal Tract
Autoimmune: Irritable Bowel Disease (diet responsive); Food Intolerance Traumatic: Foreign Body Ingestion
Endocrine/Metabolic: Addison’s Disease, Exocrine Pancreatic Insufficiency Myofascial: Referred Pain From Pathologic Myofascia – Nerve Entrapment vs Other
Definitive Diagnosis
The clients were reluctant to pursue imaging and lab work at this time. Previous lab work has shown no significant abnormalities.
Post-exercise pain and lameness; muscle wasting hind limbs:
My top differential is osteoarthritis with secondary myofascial pathology. Josie is a stereotypical lab who will overexert herself playing in streams and catching balls. She has previously been significantly overweight, and the wear and tear on her joints, especially the stifles, is showing. She compensates well with powerful shoulders, but this has also created myofascial strain in the shoulders and neck.
Gastrointestinal upset; intermittent
My top differentials are irritable bowel disease (diet responsive) or food intolerance with contributions from myofascial referred pain. The patient has a history of getting into other foods and treats, which even in small quantities will give her weeks of colitis and diarrhea. When kept strictly to a limited ingredient diet (bison and sweet potato based) she can go without issues for months at a time. This response to treatment and non-progressive nature does not fit as well with the other differentials.
Medical Decision Making
Four treatments with dry needling acupuncture and massage (effleurage and petrissage) were conducted on four occasions between June 1 and June 22, 2019. Needle sizes utilized were Seirin 0.16-0.18x30mm and Carbo 0.18x25mm. I stimulated GV20, GV14, GV4, Bai Hui, ST34, ST36, spinal Bladder points (BL13-25), and local trigger points especially along the omotransversarius, supraspinatus, and infraspinatus muscles at various times during the treatments. These points were selected for patient tolerance, their ability to relax sympathetic tone (thereby reversing “wind up”), release endogenous opioids, and modulate myofascial restrictions. Exact treatment notes are available upon request.
Medical Acupuncture and Related Techniques Used
Only dry needle acupuncture and massage were utilized in this case. Laser therapy and electroacupuncture would certainly be useful if equipment is available, but this was not an option at the time of treatment. The owners have inspired the practice to purchase each of these modalities over the next few months.
Outcomes, Discussions, References
Josie improved substantially in her eagerness to walk following days of vigorous exercises. After the second treatment, she has had no instances of refusing to walk for the owners or dog walkers. The owners report she is more eager to go up and down stairs, climb on furniture, and move around the house between outings. Her gastrointestinal issues remain under control. The owners were very pleased with therapy and will continue acupuncture at decreasing frequency as long as her clinical signs remain under control. Electroacupuncture and laser therapy would be useful adjuncts to include in future treatments. Adequan injections were also discussed with the owners comfortable giving them at home.
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