Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2019009
Abstract
Medical acupuncture and manual therapy techniques were used on an 8 year old male neutered Pit bull mix presenting left hindlimb lameness. A total of three treatments were received over the course of three weeks. The importance of a multimodal treatment approach was discovered due to an initial adverse reaction to needle placement at ST36. The owner reported an improvement with the left hindlimb lameness and believes that Machavelli is able to last longer during exercise and play.
History of Present Illness and Chief Complaints
Machavelli is an 8 year old male neutered Pit bull mix. He had a right extracapsular repair performed in August 2018. He then represented in March 2019 with a one week history of a grade 2/5 left hindlimb lameness. Sedated radiographs of the left stifle were performed. Stifle joint effusion and osteophyte formation of the patella were noted. There was no obvious dysplasia of the coxofemoral joints on radiographs. On sedated palpation, a cranial drawer was not appreciated. A complete blood count, biochemistry and electrolytes were performed with the results being unremarkable. Machavelli was treated with a two week course of carprofen. It was recommended that he rest, with leash walks only for 7 days.
On presentation for initial myofascial palpation on May 5th 2019, the owners’ primary concerns were that Machavelli is still favoring the left hindlimb and he cannot jump into or out of the bed and car. The owner notices that Machavelli will wake up stiff and sore. She is happy to report that there is no apparent right hindlimb lameness post surgical correction. The owner takes Machavelli on 20 minute leash walks daily. Current medications include a variety of joint supplementations that contain chondroitin and glucosamine. Products being used consist of; hip and joint chews, mobility bites and hemp and hip. The owner has also self-prescribed milk thistle and dandelion supplementation.
Physical Examination and Clinical Assessments
On gait analysis a grade 2/5 left hindlimb lameness and a grade 1/5 right forelimb lameness was observed. Machavelli has a lowered head carriage at the walk, as well as a thoracic and lumbosacral kyphosis. Visually, forelimb muscle hypertrophy and hindlimb muscle atrophy can be appreciated. The left hindlimb muscle atrophy is more severe than the right hindlimb.
On myofascial palpation, there were non-painful muscular taught bands along the cervical spine bilaterally. Apparent pain was evident at the thoracolumbar spine from T10-L2. Trigger point pathology and tenderness to palpation was present along the quadriceps and hamstring muscle groups. The iliotibial bands were tight and tender to palpation, with the left hindlimb being worse than the right. Machavelli also exhibited pain to palpation of GB30 as he sat when acupressure was applied. Increased myofascial tension over the lumbar and sacral regions was appreciated when the skin rolling technique was used along the spine. On forelimb palpation, the pectoral muscles had non-painful muscular taught bands. Machavelli does not appear to have any neurological deficits upon neurological examination.
Problem List:
1. Grade 2/5 left hindlimb lameness
2. Hindlimb muscle atrophy
3. Taught muscular bands along the cervical spine
4. Thoracic spine kyphosis
5. Lumbosacral kyphosis
6. Forelimb muscle hypertrophy
7. Grade 1/5 right forelimb lameness
Differential Diagnoses:
Grade 2/5 left hindlimb lameness: Hindlimb muscle atrophy:
– Vascular: peripheral vascular disease causing impaired blood flow
– Infectious: canine neural angiostrongylosis
– Neoplastic: osteosarcoma
– Degenerative: degenerative myelopathy
– Iatrogenic: post surgical compensatory lameness
– Congenital: medial luxating patella
– Autoimmune: myasthenia gravis
– Traumatic: cruciate disease
– Endocrine: diabetes mellitus
– Myofascia: trigger point pathology of the hindlimb musculature.
– Vascular: ischaemia
– Inflammatory: polymyositis
– Neoplastic: cancer cachaexia
– Degenerative: fibrotic myopathy
– Iatrogenic: post surgical quadriceps contracture
– Congenital: muscular dystrophy
– Autoimmune: lupus erythematosus
– Traumatic: traumatic injury to peripheral nerves
– Endocrine: hyperadrenocorticoism
– Myofascia: trigger point pathology causing disuse muscle atrophy.
Definitive Diagnosis: cruciate disease with secondary myofascial trigger point pathology.
Based on the diagnostic testing, myofascial palpation and gait analysis, it is suspected that a partial cranial cruciate ligament tear of the caudolateral band has occurred. This has lead to trigger point pathology of the hindlimb musculature, or myofascial pain syndrome (1) causing discomfort, disuse atrophy and the lameness observed. The blood supply to the peripheral vasculature appears to be within the normal limits, eliminating a vascular cause of the lameness. Machavelli is not exhibiting any neurological symptoms putting canine neural angiostrongylosis lower on the deferential diagnosis list. Polymyositis does not appear to be the cause of the lameness as depression, lethargy and weight loss have not been exhibited. Polymyositis is also commonly associated with an immune-mediated disorder (2). The presence of neoplastic processes such as an osteosarcoma was not evident on diagnostic imaging. It is unlikely that Machavelli is exhibiting signs of cancer cachexia or lupus erythematosus, as the muscle atrophy is limited to the hind-limbs. As the lameness does not appear to be progressive, this rules out degenerative and fibrotic myelopathy.
It is possible that the left hindlimb was over compensating for the right post extra-capsular repair, resulting in the cruciate injury and myofascial pathology. Post surgical quadriceps contracture can explain the muscle atrophy in the right hindlimb. There does not appear to be any congenital deformities such as a medial luxating patella or muscular dystrophy. A medial luxating patella in a larger breed dog is less commonly congenital and is usually associated with a traumatic event. Muscular dystrophy is usually detected around one to three months of age (2) and does not appear to be the cause of atrophy in this case. An autoimmune cause such as myasthenia gravis is also low on the differential list as there are no other symptoms being exhibited such as; exercise induced weakness or regurgitation secondary to megaoesophagus (2). Machavelli’s recent blood work rules out an endocrinopathy as a possible cause of the lameness and muscle atrophy. Machavelli does not appear to have any sensory or motor neurological symptoms and the owner does not report any traumatic incident that may have caused peripheral nerve damage.
Medical Decision Making
The medical acupuncture and integrative neuromodulation approach was used to formulate a treatment rationale. The central nervous system (CNS) was neuromodulated by targeting the spinal segment origins of the peripheral nerves receiving the treatment. The Governor Vessel channel was used as a brain based target to try and help reduce any agitation or anxiety. The peripheral nervous system (PNS) was neuromodulated by choosing points around the stifles as Machavelli had a previous right extracapsular repair and is showing signs of left cruciate disease. Points were also selected around the coxofemoral joint. The autonomic nervous system (ANS) was neuromodulated via ST36 to relay somatic input into somato-autonomic convergence centres in the brain stem. The myofascial dysfunction was addressed using medical massage, as taut bands were present in the cervical region and along the iliotibial bands.
Medical Acupuncture and Other Techniques
Treatments were received once weekly. A total of three treatments were performed.
Treatment 1 – 5th May 2019
Acupuncture (8 minutes):
– GV14 (Seirin J type 0.20 x 30mm): a good test point to see how Machavelli would respond to needles. It was also chosen to target any neck pain
– GV20 (Seirin J type 0.16 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– Bilateral BL10 (Seirin J type 0.20 x 30mm): for cervical pain and tension
– Bilateral BL19 and BL25 (Seirin J type 0.20 x 30mm): mid thoracic – mid lumbar local points
– Left GB29 and GB30 (Seirin J type 0.20 x 30mm): to target any hip problems
– Left ST34 (Seirin J type 0.16 x 30mm): for stifle dysfunction and for PNS neuromodulation
– Left ST36 (Seirin J type 0.16 x 30mm): for stifle dysfunction and for ANS neuromodulation.
Machavelli turned to bite during the placement of ST36. At this point all needles were removed and treatment was ended. Machavelli became fearful and started shivering and would not allow any post acupuncture manual therapy.
Treatment 2 – 15th May 2019
Acupuncture (10 minutes):
– GV20 (Seirin J type 0.16 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– GV14 (Seirin J type 0.20 x 30mm): used for CNS neuromodulation and neck pain
– Bilateral BL 10 (Seirin J type 0.20 x 30mm): for cervical pain and tension
– Bilateral BL20 (Seirin J type 0.20 x 30mm): caudal thoracic local point
– Bai Hui (Seirin J type 0.20 x 30mm): CNS neuromodulation, lumbosacral/pelvic pain
Electroacupuncture (5 minutes):
– Left BL26-27 (Seirin J type 0.20 x 30mm) using E-Stim II unit set on an intensity of 2 and frequency of 2: CNS neuromodulation and lumbosacral pain
Acupressure (5 minutes):
– Left ST34 and ST36: acupressure was used for these sites due to Machavelli’s extreme sensitivity during the first treatment.
Manual therapy (5 minutes):
– Effleurage technique used on the left iliotibial band: used for local taught bands
Treatment #3 – 22nd May 2019
Acupuncture (15 minutes):
– GV20 (Seirin J type 0.16 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– GV14 (Seirin J type 0.20 x 30mm): used for CNS neuromodulation and neck pain
– Bilateral BL 10 (Seirin J type 0.20 x 30mm): for cervical pain and tension
– Bai Hui (Seirin J type 0.20 x 30mm): CNS neuromodulation, lumbosacral/pelvic limb pain
– Left BL54 (Seirin J type 0.20 x 30mm): for hip and gluteal pain
– Left ST34 (Seirin J type 0.20 x 30mm): for stifle dysfunction and for PNS neuromodulation
– Left ST36 (Seirin J type 0.16 x 30mm): for stifle dysfunction and for ANS neuromodulation
Electroacupuncture (10 minutes):
– Left BL20-BL22 (Seirin J type 0.20 x 30mm) using E-Stim II unit set on an intensity of 2 and frequency of 2: CNS neuromodulation, caudothoracic to thoracolumbar local points
– Left GB29-GB30 (Seirin J type 0.20 x 30mm): to target any hip problems
Manual therapy (5 minutes):
– Effleurage technique used on the left iliotibial band, ST36 and cervical area: used for local taught bands and to relieve myofascial tension.
Discussion
Acupuncture was used in combination with medical massage to help provide analgesia and relieve myofascial tension. Machavelli was very tolerant of acupuncture needle placement until the placement of ST36 where he turned to bite. During the second treatment, manual therapy and acupressure were used on the iliotibial band, ST34 and ST36. It has been shown that manual therapy such as massage can improve circulation, relax muscular tension and settle the nervous system (3). Using acupressure in these areas can also help to desensitize the patient to touch. Electroacupuncture at BL26-BL27 during the second treatment would also have provided analgesic effects, as it acts directly on the spinal opioid receptors to induce the endogenous opioids and inhibit pain (4). These endogenous opioids help to desensitize peripheral nociceptors and decrease proinflammtory cytokines at peripheral sites (4). By the third treatment, an acupuncture needle could be placed in ST36 without a response. This shows that Machavelli was very painful and sensitive within the cranial tibialis and that the first treatment protocol may have been too aggressive.
Acupuncture was also beneficial for myofascial pain in Machavelli’s case. A lowered head carriage can be associated with taut muscular bands within the cervical region. The only regional neck points used during all three treatments were BL10 bilaterally. With this treatment alone, the owner was able to notice an improvement. BL10 may have provided treatment to myofascial trigger points as well as local effects though increasing nutritive blood flow and releasing neuropeptides (5). This results in an analgesic effect via the inhibition of the nociceptive path way and by local effects on the myofascial trigger points (5).
As Machavelli had an adverse reaction to needles during his first treatment, this highlights the importance of a multimodal treatment protocol for successful results and patient comfort. This case has also highlighted the importance of the myofascial palpation to detect sensitive and painful areas. It would have been beneficial to begin with acupressure and manual therapy around the stifle, to help desensitise and initially treat the patient. It was fortunate that Machavelli had a great disposition, as another patient may not have tolerated repeat acupuncture treatments.
Outcomes
The owner reported that Machavelli was beginning to show improvements after two treatments. It was noticed that he was able to walk for a longer period of time and that his head carriage had improved. Machavelli will continue to receive regular acupuncture therapy in the hopes to further improve his level of comfort and quality of life.
References
1. Desai MJ, Saini V, Saini S. Myofascial pain syndrom: a treatment review. Pain Therapy. 2013;2:21-36.
2. Merck Manual: Veterinary Manual. 2019 Merck Sharp & Dohme Corp, Kenilworth, NJ, USA
3. Gray RA. The use of massage therapy in palliative care. Complementary Therapies in Nursing & Midwifery. 2000;6:77-82.
4. Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology 2014;120:482-503
5. White A. Western medical acupuncture” a definition. Acupuncture Medicine. 2009;27;1:33-35