Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018042
Abstract:
A 7-year-old male neutered dachshund presented with bilateral hindlimb paralysis. The owners’ finances were very limited, so they agreed to a treatment series of laser therapy and acupuncture instead of surgery. The dog was treated a total of 14 times over 7 weeks, and regained full neurologic function of his hind legs by the end of treatment.
History and Presentation:
Bennie is a 7-year-old neutered male dachshund who presented to Allbrick Veterinary Clinic on 10/26/18. The owners have had him since he was a puppy. He has stairs up to the bed at home, stairs in the house, and chairs and couches that he routinely jumps on/off of. The past few weeks, he had been whining to get on the bed, and the owner was not sure whether he was jumping onto the furniture as much. However, he was still going up/down the stairs fine, jumping onto the furniture sometimes, running around outside and generally acting normally.
On 10/23, the owner got home to find Bennie unable to stand or walk (could not stand up on his hind legs). Bennie is usually free in the house during the day, so the owner has no idea what specifically happened while he was at work. He took Bennie to the emergency clinic that night, but declined radiographs or other diagnostics due to cost. The emergency clinic performed one laser treatment, then sent him home with information about intervertebral disc disease (IVDD) and with gabapentin, prednisone, and methocarbamol.
Bennie drank very little on 10/24 and stopped drinking on 10/25. He would eat special treats on 10/24, but also stopped eating the night of 10/25. The owners brought Bennie into Allbrick on 10/26 because Bennie was not eating, drinking, or moving. He was acting very dull and like he had “shut down or given up,” and the owners wanted advice on whether euthanasia should be considered. At the very least, they wanted suggestions for supportive care.
Physical Examination/Clinical Assessments
General Physical Exam (10/26/18):
Bennie’s physical examination was all within normal limits except for his body condition score, his oral exam, and his neurologic/musculoskeletal exam (see next section). He was obese with a body condition score of 8 out of 9. His mucous membranes were pink and fairly moist with a capillary refill time less than 2 seconds. He had mild to moderate dental tartar and gingivitis, and moderate gingival recession over both upper canines. He also had significant gingival recession over his right upper carnassial tooth, with a palpable swelling over that tooth. Bennie’s bladder did not palpate excessively full or distended, and he passed a normal stool on the table after the exam.
Myofascial Palpation Evaluation and Neurologic Examination (10/26 – 10/27/18) – this exam was done briefly in the exam room with the clients, and more thoroughly before treatment on 10/27.
Cranial nerves: All cranial nerves appeared to be functioning normally (normal pupillary light reflex, normal sensation throughout his face, intact menace response bilaterally, able to track movement with his eyes, and no strabismus or spontaneous nystagmus present).
Thoracic limbs: He had normal proprioceptive placement and withdrawal reflexes of both front feet. He was extremely uncomfortable and panicky when we attempted to lay him on his side, so his biceps and triceps reflexes could not be evaluated. A crossed extensor reflex was also not evaluated due to his behavior.
Panniculus reflex: This reflex was absent caudal to the 11th thoracic vertebrae.
Pelvic limbs: The withdrawal and proprioceptive placement of both hind limbs were absent. However, both limbs withdrew partially when needles were placed in the Bafeng points. He was conscious of the left, but not the right, Bafeng needles. Patellar reflexes were not evaluated at this time due to patient behavior. Deep pain was not tested, since Bennie was able to respond to Bafeng needles. A crossed extensor reflex could not be evaluated since there was no withdrawal reflex.
Motion assessment: The patient dragged both hind legs in a sitting-type position if he was scared enough to move away, but he would not move toward anything during the exams. He also minimized the movement of his neck in both directions (mostly following his environment with his eyes), but could flex it around to look behind him in both directions if he was worried enough.
Perineal Reflex – His perineal reflex was intact.
Bennie CPs Oct29th18 Bennie moving Oct29th18
Problems:
Bennie’s problems were bilateral pelvic limb paralysis, anorexia and adipsia, obesity, and dental disease with gingival recession over both upper canines and a small soft-tissue swelling over his right upper carnassial tooth (probable tooth root infection).
Differential Diagnoses
1. Bilateral pelvic limb paralysis
Vascular: Fibrocartilagenous embolism (FCE)
Infectious: Myelitis (Lyme disease vs. Toxoplasma gondii vs. Neospora caninum vs. canine
distemper virus vs. sepsis vs. fungal disease)
Neoplastic: Spinal tumor vs. brain tumor
Degenerative: Degenerative joint disease vs. IVDD Hansen type I vs. type II
Iatrogenic/Intoxication: Early toxic polyneuropathy/tick paralysis
Congenital: Hemivertebrae vs. spina bifida
Autoimmune: Degenerative myelopathy
Traumatic: Fell off the furniture or collided with one of the other dogs during play
Endocrine/Metabolic: Pathologic spinal fracture secondary to hypocalcemia
Myofascia: Myofascial restriction over the spinal cord and/or peripheral nerves causing compression and dysfunction/paralysis
2. Anorexia and adipsia – The complete differential list is quite extensive, and includes any systemic illness, source of pain, organ/metabolic/nerve dysfunction, psychological reason (stress/dietary preference/etc.), toxicity/medications, gastrointestinal disease (primary or secondary, any cause of nausea), or a mechanical or environmental issue. The following list provides sample differentials for the “VINDICATE the Myofascia” schematic:
Vascular: Heart disease vs. disseminated intravascular coagulation
Infectious: Bacterial/viral/protozoal systemic disease vs. infected tooth/dental disease
Neoplastic: Metastatic disease that causes organ dysfunction vs. gastrointestinal neoplasms vs. pain secondary to neoplastic process
Degenerative: Intervertebral disc disease vs. degenerative joint disease
Iatrogenic/Intoxication: New stressors vs. sedating medication (gabapentin)
Congenital: Portosystemic shunt vs. hiatal hernia
Autoimmune: Masticatory muscle myositis vs. immune-mediated hemolytic anemia
Traumatic: Pain from trauma causing a decreased appetite vs. foreign body trauma to the gastrointestinal system
Endocrine/Metabolic: Hypothyroidism vs. diabetes mellitus vs. hypoadrenocorticism
Myofascia: Myofascial restriction causing pain vs. restriction over acupuncture points with
impact on nerves related to gastrointestinal motility (such as Stomach 36)
Putative Diagnoses
1. IVDD Hansen type 1 causing bilateral hindlimb paralysis
Bennie was mentally normal, lived indoors mostly, was up to date on vaccinations, had no prior history of back issues when he was younger, and had an unremarkable physical exam (aside from his paralysis and infected tooth). Due to these factors, the infectious, congenital, metabolic, and intoxication causes were considered unlikely. FCE was also unlikely since he was very painful, and he was a little younger than expected for significant neoplasia (although it could not be ruled out without further diagnostics). Due to an acute neurologic decline, degenerative myelopathy was also less likely (although not ruled out). Since the owners declined further diagnostics and Bennie’s age/breed/history/clinical signs were most consistent with IVDD (Hansen type I), a putative diagnosis was made (and the patient was treated accordingly).
2. Anorexia and adipsia secondary to extreme pain
As described above, there was no reason to suspect any other systemic disease process that might also cause anorexia and adipsia. These signs correlated with the patient’s paralytic signs and resolved after two laser treatments and one acupuncture treatment, supporting a putative diagnosis of pain resulting in the anorexia and adipsia.
Medical Decision Making
My two primary treatment goals for Bennie were to stabilize him at home (if he would eat and drink normally, then his owners could give him time to recover) and to eventually regain as much neurologic function to his hind legs as possible. For stabilization, I insisted the owners leave him at the clinic for an acupuncture treatment and two laser treatments as soon as possible. This reduced his pain enough that he began eating and drinking again.
Then, based upon advice from more experienced veterinarians (especially Dr. Timothy Walker), I developed a plan with the owner that involved me doing acupuncture/laser/massage house-calls almost daily for the first week, and then slowly spreading them out over the following 6-8 weeks. The importance of these frequent treatments was to get Bennie comfortable enough to be weaned off steroids (allowing faster healing), provide frequent input to his nervous system, and support the owners through resting him and doing basic physical therapy exercises.
Medical Acupuncture and Related Techniques Used
A total of 14 treatments were performed over 7 weeks, with 6 treatments performed in the first 8 days and then the remaining 8 treatments gradually spread out. I used a combination of photomedicine, laser acupuncture, dry needling with 0.16mm diameter by 30mm long Seirins, and a single treatment of electroacupuncture with 0.2mm by 25mm Carbo needles. I gradually transitioned to using mostly laser/laser acupuncture with Bennie as he became more reactive to needles. I used manual massage (primarily effleurage and direct pressure, with some digital circles) in limited amounts as well. My massage focused on the sore muscles in the cranial part of the body, but I encouraged the owner to do effleurage multiple times per day on the hindlimbs.
I selected acupuncture points based on the Medical Acupuncture and Integrative Neuromodulation techniques. Below are the acupuncture points routinely used (via needle or laser):
Central Nervous System: BL 10 (cranial cervical spinal nerves, also acted as an autonomic point),
BL 17-23 (mid-thoracic to thoracolumbar spinal nerves), Bai hui (mid- to caudal lumbar spinal nerves, also acted as an autonomic point)
Peripheral Nervous System – BL 40 (tibial nerve), BL 60 (fibular and tibial nerves), GB 30 (sciatic nerve), KI 3 (tibial nerve), KI 1 (tibial nerve), Bafeng (digital nerves)
Autonomic Nervous System – GV 14 (cervicothoracic spinal nerves, also a CNS point), GV 20 (trigeminal nerve and cranial cervical spinal nerves), ST 36 (fibular nerve, also a peripheral point)
Myofascial dysfunction – SI 9 (axillary and radial nerves), trigger points in the triceps brachii and
latissimus dorsi muscles, and massage of the forelimbs and neck
These points worked together to stimulate nerve recovery from the spinal nerves down to the digits. The autonomic points calmed him during his treatments and reduced the sympathetic tone he was experiencing, especially while his pain was more severe. Finally, I focused my myofascial support on his front legs and neck, which were exhibiting significant compensatory pain.
Laser acupuncture was performed with the MR4 ACTIVet Cordless Super Pulsed Laser at 50Hz for 1 minute per point. Each session began with a 5-minute photomedicine treatment (using the same laser) to calm the patient. For calming and pain reduction, 1000Hz was used for the first few treatments, then 1000-3000Hz. In the second week of treatment, when Bennie was more comfortable, I added a 2-minute 1-250Hz treatment over T9-L2 to stimulate more tissue healing.
The Pantheon Electrostimulator 4pro unit was on backorder when I started treatment. It was only available and tolerated by the patient for a single treatment (the 9th one) on 11/14/19. For that treatment, I ran a lead from BL 17b (along the bladder meridian, caudal to T8) to BL21 bilaterally for 12 minutes. The Pantheon was set to the dense-disperse mode at 100hz.
Bennie walking Nov10th18 Bennie trotting Nov27th18 Bennie moving Dec15th18 Bennie CPs Dec15th18
Outcomes, Insights, Discussions and References
The owners and I are very satisfied with the outcome of this treatment series. Bennie is happier and more active now than he was for at least a year before his injury. He is able to walk up and down the stairs again, wags his tail vigorously, and has regained conscious proprioception of both hind feet (although the right hind is still slightly delayed). Bennie’s recovery can be directly attributed to the acupuncture/laser therapy, since 3 days of pain medications did not help his movement or anorexia/adipsia. After one treatment, he began eating and drinking, and was able to use his left hindleg a little by the next day. He finished all medications 10 days into treatment with acupuncture/laser, but continued making huge improvements afterward and did not require further medication to maintain comfort. Bennie did have a brief worsening of his pain (with no decline in neurologic function) 3 weeks into the series. This is likely due to insufficient rest as Bennie was feeling better, and may have been averted if I was more assertive about my recommendations.
Through this case, I learned some basic principles of rehabilitation, the importance of rest during recovery, and especially gained comfort using laser acupuncture for very nervous or reactive patients. While reading the large volume of research supporting acupuncture for IVDD and other neurologic disorders (summarized in the 2018 review article by Roynard et al.), I found it interesting that some studies date back to the 1980s with good results, and yet acupuncture was not mentioned during my neurology course or clinical rotation in veterinary school. Bennie responded so well with dry needling and laser, that I am now a strong advocate for nonsurgical management.
On a separate topic, there is a study by Joaquim et al. where 79% of dogs with Grade 4 neurologic signs (similar to Bennie) recovered with only electroacupuncture. The time to resume normal activity was over two months in that study, much longer than the couple of weeks it took Bennie. I believe the high frequency of treatments and the addition of laser therapy accelerated Bennie’s recovery, but I look forward to more cases and fine tuning my treatment protocol.
References:
1. Joaquim, Jean G. F. et. al., 2010. Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. Journal of the American Veterinary Medical Association, 236(11): 1225-1229.
2. Roynard, Patrick et.al., 2018. Acupuncture for small animal neurologic disorders. Veterinary
Clinics: Small Animal Practice, 48(1): 201-219.