Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019008
Abstract
The goal was to alleviate arthritic pain and urinary incontinence in a 13 year old Jack Russell terrier with possible early Cushing’s disease, aka hyperadrenocorticism, using acupuncture, cold laser therapy and massage. The patient was seen every 2 weeks for ongoing treatment. At each visit I would use the 3 above mentioned techniques, focusing on the affected elbow, trigger points, points for the adrenal glands, the bladder, and urinary incontinence. Success of therapy was measured by number of urinary accidents over the 2 week period and a more subjective assessment of limping. The owner reported that the left forelimb lameness did not improve substantially but the urinary incontinence drastically improved.
History
Maverick is a 13 year old, male, neutered, long haired Jack Russell terrier that has been with the same owner since he was a puppy. He lives with 3 other Jack Russells and one rat terrier. He has a mild chronic limp of 4 years on the left front limb with no known trauma. He has a tremble in his hind limbs that the owner says has been there for at least 3 years and is known to be present in his blood lines. He eats well and interacts well with the other dogs in the house. The owner reports increasing water consumption and urinary incontinence since November of 2018. The incontinence occurs mostly at night while he is sleeping. He has also been more restless and waking the owner up at least once a night. Maverick is the half-brother of a Jack Russell that suffered from diagnosed Cushing’s disease and had many side effects from the trilostane treatment. The owner suspects Cushing’s disease in Maverick but does not want to pursue diagnosis or treatment with trilostane. The owner gives 25 mg of carprofen once daily as needed and is giving Si Miao San ¼ tsp twice daily. Maverick has been receiving cold laser treatments every 2 weeks for the last year for lameness and trigger points but they have not seemed to affect the more recent urinary incontinence. The acupuncture treatments were added in May of 2019.
Physical Exam and Clinical Assessments
Maverick is bright, alert and responsive. He easily jumps the 2 foot rise into the mobile veterinary van. There is nuclear sclerosis in both eyes. Both ears are clear and his nose is cool and moist. The heart rate is rhythmic and femoral and dorsal pedal pulses are strong. Lung sounds are clear and capillary refill time is 1 sec. Temperature is normal. The skin and coat are healthy and free of any sign of licking such as porphyrin staining or lick granulomas. There is an intermittent tremble in both hind legs. Orthopedic exam reveals decreased range of motion in the left elbow on extension and flexion. There are no significant findings on the neurological exam. Conscious proprioception and the crossed extensor reflexes are within normal limits. The myofascial exam reveals tight muscles of the caudal cervical neck bilaterally, atrophy of the muscles of the left shoulder and scapula and tension in the supraspinatus, infraspinatus, biceps and triceps of the right forelimb. Although no tension in the lumbar spine is palpated, the dog does not like to be petted there and will get up and move. He seems especially sensitive at the thoracolumbar junction. Blood work shows an elevated alkaline phosphatase at 210 IU/L (ref 5-131 IU/L) with renal values well within normal limits. Urinalysis shows a dilute urine with a specific gravity of 1.005, no blood, no white blood cells, no glucose, and a quiet sediment. On lameness evaluation, there is a mild left forelimb limp, slight lumbar kyphosis, and the head is held low.
Problem List
o Urinary incontinence
o Left front lameness
o Hind limb tremble
Urinary Incontinence
o Vascular: Hypertension
o Infectious: Urinary tract infection
o Neoplastic: Transitional cell carcinoma
o Degenerative: Intervertebral disk disease
o Iatrogenic: Prednisone use
o Congenital: Ectopic ureters
o Autoimmune: Lupus
o Traumatic: Spinal trauma affecting bladder sphincter
o Endocrine: Hyperadrenocorticism
o Myofascial: Muscle spasms of the pelvic muscles
Left Elbow Lameness
o Vascular: Thrombus
o Infectious: Joint sepsis
o Neoplastic: Osteosarcoma
o Degenerative: Degenerative joint disease
o Iatrogenic: Cartilage damage from use of enrofloxacin as a puppy
o Congenital: Ununited anconeal process (UAP)
o Autoimmune: Immune-mediated polyarthritis
o Traumatic: Fracture
o Endocrine/Metabolic: Diabetic neuropathy
o Myofascial: Injury or strain on any muscle of the forelimb
Definitive Diagnoses
Given Maverick’s lab results and genetic history, the urinary incontinence is most likely due to degenerative disease or an early form of hyperadrenocorticism. Infection has been ruled out, there is no sign of neoplasia in the sediment, no sign of neurological disorder, no autoimmune disorder, no trauma and no apparent muscular/soft tissue disorder. Congenital has been ruled out because the incontinence started late in life and iatrogenic is unlikely because he became incontinent before the use of the NSAIDs or herbs. There is no history of surgeries, trauma or steroid use.
The forelimb lameness has been an ongoing issue that has not gotten worse or better. This rules out vascular, infectious, neoplastic, and autoimmune. This could easily be a degenerative arthritis that may or may not have started with trauma or a congenital malformation such as UAP. Myofascial disease is most likely present and complicating the arthritis.
Medical Decision Making
On myofascial exam, Maverick had decreased ROM in the left elbow, tight bands of tissue in the cranial aspect of the trapezius muscle more so on the right side and tension over the right scapula. The sensitivity at the thoracolumbar junction was thought to be related to adrenal dysfunction. The objective was to treat the left arthritic elbow, relieve tension in the cervical spinal area and the compensating right forelimb, and improve bladder control. Due to time constraints, treatments were set for every 2 weeks. The plan consisted of using dry needling, photobiomodulation, massage, and possibly electroacupuncture if the needling was well tolerated. For autonomic and calming effects, the points GV 20, GV 14 and Bai Hui were selected. For incontinence, the points BL 27, BL 28, and KI 3 were selected. BL 22 was planned as a point to address the adrenal glands. For the elbow lameness, points LI 11, LU 5, PC 3, HT 3, SI 8 and TH 10 were elected to encircle the joint.
Medical Acupuncture and Related Techniques Used
In the first acupuncture attempt, Maverick was a very active patient. Despite the use of red Seirin 0.16 mm needles, he did not appreciate the needling. The first needle placed was at GV 20 which did not stay in long as he circled and rolled. Further needling became very difficult but a GV14 and BL 27 were placed without discomfort. Cold laser was performed with a SpectraVet 3B Zeus unit using a continuous wave 500 mw, 810 nm deep probe. The left elbow was treated at the above mentioned points for roughly 10 seconds at each point. The spine, starting at the tail base and ending with the cranial cervical neck, was treated in multiple spots for roughly 20 seconds each. The laser was also used on KI 3 for roughly 10 seconds on each leg. After 10 minutes, the few needles were removed and massage, consisting mostly of petrissage was performed along the cervical and thoracic spine and proximal forelimbs. Effleurage was performed on the lumbar spine. The patient collapsed blissfully during massage
The second, third and fourth treatments went more smoothly. The GV 20 needle was omitted to allow for head scratching during treatment. The patient welcomed GV 14, BL 22, BL 27, BL 28 and Bai Hui. KI 3 was tolerated but needling around the L elbow was not. The treatment with the cold laser and massage as described above was repeated.
Post Treatment 2 Post Treatment 1 Post Treatment Bliss
Discussion and Conclusion
At the second acupuncture treatment, the owner reported that Maverick had only had 2 urinary accidents in the 2 weeks since the last treatment. One was the day after acupuncture and the next was 13 days post treatment and the night before his second treatment. The owner reported at the third treatment that the dog had 1 accident at day 10 following the second treatment. At the fourth treatment, the owner reported no accidents and stated that the dog is sleeping through the night. The owner reported no noticeable change in the left forelimb lameness but that Maverick seemed less painful overall and was moving and jumping better as he normally did with cold laser treatments alone.
Although many attempts were made, Maverick did not appreciate the needling of his forelimb despite the size of needle used. It would have been interesting to see if dry needling and electroacupuncture of the forelimb would have had an effect. Although disappointing to see no change in lameness, this is a chronic problem that does not appear to be worsening and is much less of an issue than the urinary incontinence and middle-of-the-night awakenings.
I have been treating Maverick with cold laser for the past year and have seen how it helps his trigger points and stiffness. However as a new student of acupuncture, I was thrilled with the effect acupuncture and aculaser had on Maverick’s urinary incontinence. The owner, who was about to start Maverick on phenylpropanolamine, was also very pleased since the cold laser alone was not affecting the incontinence. In my recent research, I found that adding ST 36 may be useful for further autonomic control of the adrenal glands.
I have learned that it is important to remain mentally flexible. The patient may not tolerate what was done at the previous treatment or they may tolerate more. I found it is important not to get “stuck” in one specific treatment mode. I am relieved with how well Maverick tolerates the acupuncture. As I have continued to work with Maverick, I find that some days we do less and some days we do more. He will remain my patient and I will continue to treat him within his comfort zone.
Citations
Katpatin AS, Tomasic M, Beech J, Meadows C, Boston RC, Mayhew PD, Powers MY, Smith GK. Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronic elbow joint arthritis. J Am Vet Med Assoc. 2006 May 1;228(9):1350-4
Lin JH, Su HL, Chang SH, Sheien YS, Wu LS. Treatment of iatrogenic Cushing’s syndrome in dogs with electroacupuncture stimulation of Stomach 36. Am J Chin Med. 1991;19(1):9-15
Sun, Zhang X, Cao T, Song Y. Treatment of urinary incontinence after total hysterectomy with acupuncture: A case report. Medicine (Baltimore). 2019 May;98(20):e15687. Doi: 10.1097/MD.0000000000015687.