Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10S2018041
Abstract:
Chip is a 10 year old Dalmatian. He presented for acupuncture for chronic osteoarthritis. He was treated weekly for six weeks. We implemented massage, changed oral medications and adjusted lifestyle choices. We ultimately achieved improvement in quality of life and the owner plans to continue acupuncture as needed.
History and Presentation:
Chip is a 10 year old, male neutered Dalmatian. He presented on February 11, 2019 for an evaluation of suspected osteoarthritis. Per the owner, Chip has been intermittently lame on all four limbs for over a year. She has noticed worsening signs this past winter. The owner reports that Chip has the most difficulty in the mornings and evenings. Chip is active and goes on daily walks with the owner (roughly 2 miles/day) and will occasionally go to a local doggy day care and dog beach. Chip has been prescribed Rimadyl and Tramadol in the past. They owner uses it occasionally when she feels Chip is painful. In the past month Chip has had episodes of shaking and difficulty rising from bed in the morning. The owner notes a correlation with tremors and difficulty rising with having gone to doggy day care the day before. Chip has a history of chronic UTI’s and has seen a veterinary behaviorist for separation anxiety issues in the past. There are no other pertinent medical issues. Chip is prescribed Rimadyl (2.2. mg/kg PO BID); owner uses it sparingly. Chis is also prescribed Tramadol (4 mg/kg PO TID); owner uses it sparingly. Chip is also given a Dasuquin soft chew once daily. Chip is not taking any other medications or supplements. The owner does not wish to pursue blood work or digital radiographs to help support diagnosis.
Physical Examination and Clinical Assessment:
On physical examination, Chip is bright, alert and responsive. His TPR is normal. His BCS is 4/5. He has moderate dental tartar and gingivitis. Aside from his myofascial and orthopedic exam, he is clinically healthy. Myofascial palpation shows tightening of the cervical muscles on both the left and right side. Tightening of the bands is more severe on the right. He has full range of motion of his cervical spine, but shows some discomfort when extending the neck to the left. Muscle twitching is noted when palpating the thoracolumbar region of the spine. Chip shows signs of discomfort when palpating the lumbosacral regions of the spine. Normal ROM and no signs of pain during flexion and extension of the wrist and elbows of both forelimbs. Decreased ROM when extending both shoulders. Chip showed more signs of pain when extending the right shoulder when compared to the left. Bilateral decreased ROM with extension of his hips. Subtle muscle atrophy of the gluteals is noted. Examination of reflexes are normal. Chip is ambulatory in all four limbs. No neurologic abnormalities were noted, however I suspect that there are some mild peripheral neuropathies that need to be addressed. Gait evaluation revealed a short stride in all four limbs. The short strides are most noticeable in right forelimb and right hind limb.
Medical Decision Making:
Chip is a great dog with many different areas to treat; cervical tightness, shoulder pain (right), thoracolumbar pain, lumbosacral pain and hip pain. My first goal was to make Chip comfortable with needles. I planned to use points that would help relax Chip. My next goal was to address the owners’s primary concerns; trembling and difficult rising in the morning and getting comfortable at night. A part of my plan was to discuss lifestyle changes; changing neck lead to a chest harness and temporarily discontinuing the current doggy day care until we cold appropriately manage his pain. I then planned to work on some of the other problems I noted during the physical exam by implementing acupuncture and massage. I also planned on changing some of the prescription medications as well as the frequency of use by the owner. The owner and I worked on a diet change as well; with the shared goal of helping chip lose some weight and taking pressure off of arthritic joints.
Differential Diagnosis:
V (vascular): vascular disease, thromboembolism
I (infectious): tick born disease, discospondylitis (bacterial vs. fungal)
N (neoplastic): osteosarcoma, nerve sheath tumor, space occupying tumor placing pressure on peripheral spinal nerves
D (degenerative): Degenerative joint disease, osteoarthritis, intervertebral disc disease, degenerative myelopathy, spondylosis deformans
I (iatrogenic/intoxication): obesity, overuse at doggy day care
C (congenital): joint incongruity (hip dysplasia, elbow dysplasia, spinal deformity)
A (autoimmune): rheumatoid arthritis, immune mediated polyarthritis
T (trauma): repetitive injury from neck lead, traumatic injury at doggy day care
E (endocrine): hypoadrenocorticism
M (myofascial): disuse vs neurogenic atrophy, muscle tension from overuse
Definitive Diagnosis:
Chip’s TPR is normal, mucous membrane color is normal, behavior is normal and no history of recent issues or travel outside of the state or country. I believe Chip’s diagnosis is osteoarthritis in the hips and shoulders with myofascial restriction in his neck and back. I believe that his issues are degenerative in origin and exacerbated by either iatrogenic or traumatic causes.
Acupuncture Treatments:
Acupuncture treatments were performed once weekly for a total of six weeks. We used 0.16 x 30 mm sarin coated needles. Chip laid in lateral recumbency for all treatments. During each session I focused on the Bladder Line to address neuromodulation of the cervical, thoracic and sacral spinal nerves. I used the Small Intestine points more so on the right than on the left, as he demonstrated the most resistance in the right shoulder. Massage helped me find trigger points and acupuncture was used accordingly in these areas.
Treatment 1 –
GV 20, GV 14, BL 18, BL 19, BL 20, BL 54, GB 29, GB 30, SI 11, SI 12, massage and trigger point therapy was used in his neck
Treatment 2 –
GV 20, GV 14, BL 18, BL 19, BL 20, BL 54, GB 29, GB 30, SI 11, SI 12 massage and trigger point therapy was used in his neck
Treatment 3 –
GV 20, GV 14, BL 13, BL 15, BL 18, BL 19, BL 20, BL 28, GB 29, GB 30, massage and trigger point therapy was used in his neck
Treatment 4 –
GV 20, GV 14, BL 18, BL 19, BL 20, BL 21, BL 22, BL 23, LI 11, SI 11, SI 12 massage and trigger point therapy was used in his neck
Treatment 5 –
GV 20, GV 14, BL 13, BL 15, BL 18, BL 19, BL 20, BL 21, BL 22, BL 23, BL 54, GB 29, GB 30, massage and trigger point therapy was used in his neck
Treatment 6 –
GV 20, GV 14, BL 13, BL 15, BL 18, BL 19, BL 20, BL 21, GB 29, GB 30, SI 11, SI 12, massage and trigger point therapy was used in his neck
Outcomes, Discussions and References:
Chip’s most significant improvement was seen in the tension in his neck, which supports my diagnosis of myofascial restriction in this area. Chips owner switched to a chest harness on walks which I also believe contributed to the improvement seen. After the six week series of acupuncture treatments, I also noticed less reactivity of the trapezius and latissimus dorsi when palpating along his spine. Despite targeting the hips and gluteal muscles, the pain noted in Chips hips during orthopedic examination remained relatively unchanged. I believe that continued weight loss and use of laser therapy would help this problem. The owner was very satisfied with the results and has noticed improvement in his quality of life. She has not noticed any episodes of tremors a few weeks after starting acupuncture therapy. This is a long time client of mine and one of my favorite patients. His owner is adamant on not changing his lifestyle drastically and wants to continue his daily walks, trips to dog beach and occasional days at doggy day care. The human animal bond is important to maintain and I believe that acupuncture, combined with supportive care (chest harness, diet change and NSAIDs) has allowed my beloved patient and his owner to maintain the lifestyle they love and enjoy together.
Resources:
1. Mathews K, Kronen PW, Lascelles D, et al. (WSAVA) Guidelines for recognition, assessment and treatment of pain. J Small Anim Pract. 2014;55:10–68.
2. Hayashi AM, Matera JM, Pinto AC. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc. 2007;231:913–918.
3. Cho JH, Nam DH, Kim KT, Lee JH. Acupuncture with non-steroidal anti-inflammatory drugs (NSAIDs) versus acupuncture or NSAIDs alone for the treatment of chronic neck pain: An assessor-blinded randomised controlled pilot study. Acupunct Med. 2014;32:17–23.