Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 10D2018042
Abstract:
A 17-year-old Paint mare presented with acute lameness of her right front foot, which progressed to both front feet over a 24-hour period. Laminitis was diagnosed, and the owners were willing to do anything possible without putting Bella in a stall. They agreed to a treatment plan that included laser therapy and acupuncture in addition to standard medical treatments. The mare was treated a total of 9 times over 11 weeks, and became very comfortable at a walk and trot by the end of treatment.
History and Presentation:
Bella is a 17-year-old Paint mare who has been with the same owner for over 10 years. Her right eye was removed years ago following an injury, and she has not been ridden for at least a year due to owner health issues. She lives in a dirt paddock with her son, and has a past history of a severe subsolar abscess a couple of years ago. On 3/4/19, I was called for an emergency exam on Bella for a suspected abscess. She seemed a little tender the day before, but on 3/4/19 she would barely move at all and the owner noticed her limping severely on her right front foot.
Physical Examination/Clinical Assessments
First General Physical Exam (3/4/19):
Bella’s physical examination was all within normal limits except for her body condition score/cresty neck score, heart rate, and musculoskeletal exam. She was overweight with a body condition score of 6.5/9 and a cresty neck score of 3/5. Her temperature was normal at 99*F, but her heart rate was mildly elevated at 60 bpm. Bella presented with a 4/5 lameness on her right front foot, but normal to slightly increased digital pulses and no response on hoof testers. No location to track an abscess was visible, although the foot felt warm. No edema was present. It was also not possible to really examine the left front foot because Bella almost fell down each time she was asked to put any weight on the right front. The left front digital pulses were barely palpable and the foot was not hot.
Second Physical Examination (3/5/19):
Today Bella’s palmar digital pulses were bilaterally bounding (increased), and she was so painful on both front feet that neither foot could be picked up without sedation and IV phenylbutazone, and then for only a few seconds at a time. A blood sample was pulled and submitted to the lab for ACTH and metabolic testing. Pads were bandaged onto her feet for comfort.
Bloodwork results (3/9/19):
An insulin value of 117 uIU without any grain intake beforehand was consistent with decompensated Equine Metabolic Syndrome. The ACTH value was 24 pg/mL, which is within the normal range and not consistent with Pituitary Pars Intermedia Dysfunction (Equine Cushing’s).
Radiograph interpretation (3/11/19):
The radiographs of each front foot showed rotation of the coffin bones. Shoes were placed accordingly during this appointment with the farrier present to examine the radiographs as well.
Bella Moving 3-14-19 Bella moving inside 3-14-19
Myofascial Palpation Evaluation (3/14/19) before first acupuncture session:
Diagnostic Acupuncture Exam (specific reactive points) – LU 1, PC 1, SI 9 (mild), BL 13 (mild), BL18a – BL 22, GB 29, and GB 30
Myofascial Exam (general areas of tension/pain) – The entire pectoral, hamstring, and gluteal muscles were very tight, as well as the muscles/fascia along the caudal cervical spine and the cranial aspect of the scapula (although there were no hyperreactive points in this area yet).
Balance – I was unable to pick up any of her feet for more than 1-2 seconds, including hind feet.
Cervical mobility – Bella’s cervical mobility seemed to be fairly good, but she did not want to weight one front leg more than the other so would not maintain flexion in either direction.
Withers – She was mildly reactive to palpation over the caudal withers.
Scapular mobility – This appeared to be fairly normal bilaterally, but my ability to test it was also very limited since Bella would not allow either front foot held up for long.
Shoulder (internal/external rotation) – I was unable to evaluate this.
Front limb stretch with neck lowering – I was unable to evaluate this.
Joint palpation/Range of motion – No joint effusion or altered range of motion detected.
Reactivity of paraspinal muscles – These were moderately reactive from T13 to L2.
Lumbosacral Spinal mobility – The spine itself was not painful to palpation, but its mobility felt limited by the very tight paraspinal muscles along the cranial lumbar spine.
Sacroiliac mobility and hindlimb circles – Both appeared normal, within the limits of minimal time.
Problems:
Bella’s problems were severe bilateral front foot pain with bilateral rotation of the coffin bone, mild tachycardia, and being overweight with a cresty neck. Bloodwork results also revealed elevated insulin levels (but for the purposes of the next section, this is not selected as a primary problem).
Differential Diagnoses
1. Acute bilateral front foot pain from laminitis
Vascular: Altered circulation to lamina (idiopathic or caused by any of the reasons listed below)
Infectious: Toxemia from systemic bacterial infection (colic vs. enteritis vs. other)
Neoplastic: Tumor causing Pituitary Pars Intermedia Dysfunction
Degenerative: Hindlimb degenerative joint disease causing excessive forelimb weight bearing
Iatrogenic/Intoxication: Poor hoof/farrier care vs. toxicity from Black Walnut exposure vs. other
Congenital: Poor hoof conformation vs. breed predisposition to insulin resistance
Autoimmune: Hypersensitivity to vaccination or other immune stimulation
Traumatic: Repeated concussion on hard ground vs. direct injury to the hoof
Endocrine/Metabolic: Equine Metabolic Syndrome
Myofascia: Musculoskeletal pain causing chronic psychologic or physiologic stress
2. Mild Tachycardia
Vascular: Dehydration vs. heart disease vs. obstructed gastrointestinal vasculature
Infectious: Hoof abscess vs. gastrointestinal infection
Neoplastic: Abdominal pain from internal lymphoma or other neoplasia
Degenerative: Pain from severe degenerative joint disease
Iatrogenic/Intoxication: Stressful situation (environmental changes vs. veterinarian appointment)
Congenital: Ventricular septal defect
Autoimmune: Immune-mediated sensitivity causing pain vs. recurrent airway obstruction
Traumatic: Pain vs. stress from an injury
Endocrine/Metabolic: Laminitis from equine metabolic syndrome
Myofascia: Exertional rhabdomyolysis vs. polysaccharide storage myopathy (PSSM)
Definitive/Putative Diagnoses
1. Acute bilateral front foot pain
Due to the radiographic images showing rotation of the coffin bone in both front feet, along with the blood test showing elevated insulin levels consistent with equine metabolic syndrome/insulin resistance, Bella’s diagnosis was fairly definitive as an acute case of forelimb laminitis secondary to equine metabolic syndrome.
2. Tachycardia
Due to the above diagnosis and Bella’s obviously high pain level, the tachycardia was putatively diagnosed as secondary to pain from laminitis. She never showed any issues with eating or defecating, and always maintained normal GI motility. She still had normal mucous membranes and capillary refill time, so was unlikely to have tachycardia secondary to dehydration. No other signs of injury, vasculitis, abdominal pain, heart disease, or PSSM were noted. A hoof abscess was a top differential for the first day when she appeared only lame on her right front foot, but was no longer consistent after the second exam, radiographs, and bloodwork.
Medical Decision Making
My primary treatment goals for Bella were to reduce the inflammation of the laminae, improve the comfort of the front feet, and address the compensatory pain throughout her body. I particularly wanted to get her comfortable as quickly as possible to reduce the amount of time she needed to spend on nonsteroidal anti-inflammatories, and subsequently reduce the associated risks (such as gastrointestinal ulcers). The additional motivation for complementary treatments was that Bella had never lived in a stall and would be extremely stressed and panicky if kept in a stall with sand or deep shavings. The footing outside was very poor during the wet spring, so we were battling a nonideal treatment environment aside from the shoeing and medication.
As for timing and frequency of treatments, I found a couple of papers using acupuncture and/or laser therapy that spaced treatments about one week apart. I felt that more frequent would be better at first, especially since I was not certain how aggressive to be with my needling and 10 days had already elapsed since the onset of acute clinical signs. I was able to perform approximately 2 treatments per week for the first 4 weeks. After that, the owners were fairly taxed on finances and time and Bella was significantly more comfortable, so we decided to end complementary therapies. I still had to come out for the next farrier appointment to sedate her, so I performed a final maintenance treatment at that time as well (12 weeks after the initial onset of signs).
Medical Acupuncture and Related Techniques Used
A total of 9 treatments were performed over 11 weeks, with the first 8 treatments taking place in the initial 4-week period. I used a combination of photomedicine, laser acupuncture, and dry needling for the treatments, using 0.20mm diameter by 30mm long Seirins and 0.25mm diameter by 40mm long Seirins (less frequently). I was nervous about placing needles near the coronary band at first, so I only used laser acupuncture and photomedicine in this area for the first two treatments. Then I began using needles for the ting points beginning with the 3rd treatment and noticed significant improvement in clinical signs after that treatment.
Acupuncture points were selected based on Medical Acupuncture and Integrative Neuromodulation techniques. Below are the acupuncture points I routinely used (via needle or laser) during Bella’s treatments:
Central Nervous System: BL 10 (cranial cervical spinal nerves, also an autonomic point), BL11 (cervicothoracic spinal nerves), BL 13 (midthoracic spinal nerves), BL18a – BL26 (mid-thoracic to caudal lumbar spinal nerves, several of these were selected each time based on the exam)
Peripheral Nervous System – Ting points (nervi vasorum originating from the median and ulnar nerves), BL 40 (tibial nerve), BL 60 (fibular and tibial nerves)
Autonomic Nervous System – GV 14 (cervicothoracic spinal nerves, also a CNS point), ST 36 (fibular nerve, also peripheral), Bai hui (mid- to caudal lumbar spinal nerves, also a CNS point)
Myofascial dysfunction – BL 40 (tibial nerve), LU 1 (cervicothoracic spinal nerves), PC 1 (cranial thoracic spinal nerves), GB 21 (spinal accessory nerve), GB 29 (sacral spinal nerves and caudal gluteal nerve), GB 30 (Sciatic nerve and caudal gluteal nerve), SI 9 (axillary and radial nerves)
These points worked together for neuromodulation of the front feet themselves (via the origins of the median and ulnar nerves from C8-T2, as well as peripherally at the ting points). Additionally, the treatments relieved pain in the areas of compensation where Bella was suffering. Finally, autonomic points were also selected to assist in regulation of Bella’s metabolism and assist her body in restoring homeostasis.
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 along the length of the spine (with special focus over the caudal cervical and cranial thoracic vertebrae, as well as along the cranial aspect of each scapula).
Bella moving1 5-27-19 Bella moving2 5-27-19
Outcomes, Insights, Discussions and References
The owners and I are fairly satisfied with Bella’s progress over the 4 months that I followed her case. While there was not much visible difference in Bella’s lameness during the first 2-3 treatments, I could still palpate releases in all of her muscles that were tight and painful. One of the papers I found only used laser therapy for laminitis treatment and got significant reductions in pain (Petermann 2011). Since I was nervous placing needles around the coronary band, I tried only using the laser for the ting points during first two treatments. However, I think that switching to using needles really made a big difference for Bella, because after her third treatment she went back into her pen, rolled for the first time since having laminitis, and then jumped up and trotted a bit. This showed much more comfort than she had exhibited prior! She also had not had any pain medications that day and was sore at the beginning of her treatment. Dr. Lancaster reports that it often takes 2-3 treatments to see results, and it was on the third treatment that I added the needles, so that is also a possible explanation for this dramatic improvement that day (Lancaster 2011).
One disadvantage that I think we faced in this treatment protocol is that I was not able to coordinate the first acupuncture appointment until over 1 week from the first day of clinical signs. I would be interested to have another case where treatment is started sooner, and see if that provides a quicker reduction in pain and digital pulses. However, a study in 2017 (Faramarzi) found a significant reduction in pain after hemo-acupuncture and dry needling for only 2 treatments, 1 week apart, in horses who had been suffering for months. Clearly each case is going to respond differently, but I am curious about the technique and reasoning for hemo-acupuncture or aqua-acupuncture (also used in this study). These techniques seem to be more accepted and utilized in Traditional Chinese Medicine, but the results described in that study were significantly quicker than what I was able to achieve, so I am curious about potentially trying those in the future. However, in summary, Bella was sound at the walk with imperceptible pulses after 3 months, and was trotting around her pen and abruptly stopping on her front feet without pain after 4 months.
References:
1. Faramarzi, Babak et. al., 2017. Response to acupuncture treatment in horses with chronic laminitis. The Canadian Veterinary Journal, 58(8): 823-827.
2. Lancaster, L., 2011. Medical acupuncture for equine laminitis. Journal of Equine Veterinary Science, 31(10): 64.
3. Petermann, Uwe, 2011. Comparison of pre- and post-treatment pain scores of twenty-one horses with laminitis treated with acupoint and topical low level impulse laser therapy. American Association of Traditional Chinese Veterinary Medicine, 6(1): 13-25.