Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019010
Abstract: “Rose” is a 7 month old kitten that presented with upper motor neuron (UMN) deficits of the rear legs and lower motor neuron (LMN) deficits to the bladder. She had been found abandoned in an apartment building and trauma was suspected. She has received 11weeks of acupuncture treatment and laser therapy. She is no longer painful, has regained control over defecation, has better control of her rear legs and her bladder control is improving.
History and Presentation: Rose is a 7 month old female spayed domestic short hair kitten that had been found abandoned in an apartment building hallway. She was taken to the local pound and then to a rescue. When found Rose was dragging her rear legs and was unable to urinate on her own. Her bladder was easily expressed and she passed stool as she walked.
Physical Exam and Clinical Assessment: On initial exam she had normal mentation and cranial nerve responses. Her patellar and sciatic reflexes were normal to hyperreflexic bilaterally. Conscious proprioception (CP) was difficult to assess, she did not allow knuckling of the feet. She had withdrawal response and a positive crossed extensor reflex bilaterally in the hind limbs. Her bladder was easily expressed. She held her tail low, could move her tail but did not have deep pain present. She had decreased perineal reflexes and decreased anal tone.
Myofascial exam revealed pain from T12-L5 and a significant panniculus response in this area. She had tight triceps brachii muscle (long head) and the cleidobrachialis muscle bilaterally. There was increased tone to the extensor muscles of her rear legs, keeping them in an extended position at rest. When trying to stand, her legs kicked repeatedly in a bicycle pedaling like motion. If placed in a standing position she could take a couple steps but would then lose her balance and fall to the side.
Radiographs were taken of the spine from the cervical region through the tail. There were no abnormalities of the spine. A Feline Leukemia and Feline Immunodeficiency Virus test was performed at the shelter and she was negative for both.
Problem List-Paresis of rear limbs, neurogenic bladder, and fecal incontinence.
Differential diagnosis– thromboembolism, toxoplasmosis, lymphoma of spinal cord, degenerative myelopathy, anti-cholinergic toxicity, cerebellar hypoplasia, trauma to the spine(a fall and/or tail pull).
Putative diagnosis- Tail pull injury and trauma to the spine are most likely causes of all three problems. Two lesions are suspected due to the UMN and LMN signs.
Medical Decision Making– The positive crossed extensor reflex pointed to UMN injury which would localize the lesion between T3-L3. This is consistent with the pain noted on exam. The LMN signs of the bladder would indicate lumbosacral or sacrococcygeal injury. Both these areas were targeted when treating.
The goal of treatment for Rose was to decrease pain, increase motor control to the rear legs, improve bladder function and improve fecal incontinence. Acupuncture points were chosen to specifically address pain and neurologic dysfunction. These are detailed in the following section.
The patient did not tolerate needling of the thoracolumbar area so laser therapy was added to treat the local pain and inflammation.
Bethanechol was prescribed at 5 mg twice daily to help with muscular tone of the bladder.
Medical Acupuncture and Related Techniques Used: Seirin 30 mm needles were used in all treatments. The diameter used is recorded with each treatment below.
Treatment 1(Day 1)- On the first visit a 0.14 needle was placed at GV14. This was done to see how she tolerated needling and to stimulate her immune system. There was significant skin and muscle twitching to the local area after placement of the needle.
Treatment 2(Day 6)- 0.12 needles were used to see if the smaller size was better tolerated. GV14, Bai Hui, BL13, 18, 23 and 28 were used. BL 13, 18 and 23 were used as local points in the area of pain noted on myofascial exam. BL23 also has benefits to the genitourinary systems as this is the area of the spine where the nerves to the kidney originate. BL28 is the Back Shu point of the bladder so it was used for its parasympathetic stimulation to the bladder. Bai Hui was used for its effects on the pelvic limbs by stimulating the nerves of the cauda equina. Bai Hui also has benefits to the pelvic organs.
Treatment 3(Day 9)-0.12 needles were placed at GV14, 20, Bai Hui, BL18, 23, 28. Bafeng were also attempted but not tolerated. GV20 was used for its autonomic calming effects. BL18 and 23 were not tolerated well.
Treatment 4(Day 12)- 0.12 needles were placed at GV14, 20, BL27, 28, Bai Hui, SP6, and KI3. SP6 and KI3 were only placed on the left leg due to positioning and tolerance of the patient. BL27 was utilized for its effects on the sacral nerve roots to help with the fecal and urinary incontinence. SP6 and KI3 were chosen as distal points for their neuromodulation of the tibial nerve to help with motor function and proprioception of the rear leg as well as the somatovisceral reflex with the bladder. Laser therapy was also started to treat the thoracolumbar spine that would not tolerate needling. A setting of 5 Watts, 815 Joules for a total of 3 minutes 24 seconds was used for all laser treatments. The laser therapy was well tolerated.
Treatment 5(Day 14)-0.14 needles were placed at GV20, GV14, Bai Hui, BL27, 28 and 0.12 needles placed at BL23, 25. These were not tolerated and removed quickly. Laser therapy on the thoracolumbar area was repeated. Bethanechol was started at 5 mg every 12 hours to help with tone to the bladder wall muscles.
Treatment 6(Day 20)- Rose is now in a foster home so is able to move around more than she was able to at the rescue. 0.14 needles were placed at GV20, 14, Bai Hui, BL27, 28, KI3(right), BL60(left). Laser therapy was repeated. BL60 was added as a distal point, that was accessible, to neuromodulate the fibular and tibial nerves to help with proprioception and motor control of the rear legs.
Treatment 7(Day 22)- 0.14 needles placed at GV20, 14, Bai Hui, KI3(left), SP6(left), BL60(right) and BL35. BL35 was used to stimulate the sacral spinal nerves to address the tail dysfunction and fecal incontinence. The acupuncture was short on this day due to Rose being very active and not settling down for treatment. Laser therapy was repeated.
Treatment 8(Day 27)- Foster reports that Rose is moving to the potty pad on her own where they express her bladder. 0.14 needles were placed at GV20, 14, Bai Hui, BL27, BL35, 40(right) and proximal tail points. BL40 was added in to help with the pelvic limb paresis as well as the reflex loop through the sacral region to help with the fecal and urinary incontinence. The proximal tail points were added to stimulate the nerves to the tail to help regain sensation. Rose is no longer showing discomfort on palpation of the thoracolumbar spine so laser therapy was discontinued.
Treatment 9(Day 30)- Foster reports that the urine leakage has decreased significantly and she is going to the potty pad to pass stool. On exam today Rose has normal anal tone. She also has significant scalding around the perineal area with skin irritation and sloughing. 0.14 needles were placed at GV14, 20, BL35, 60(left), KI3(right), ST36(left), proximal tail points. 0.16 needles were placed at Bai Hui, BL27, 28. ST36 was added for its anti-inflammatory effects, as well as it’s stimulation of the cranial tibial n. and fibular n. to aid with the pelvic limb dysfunction. She was also placed on clavamox drops and animax ointment is to be applied to the effected skin 2-3 times daily.
Treatment 10(Day 35)- Foster reports urine leakage has resolved and there was a one-time occurrence of Rose urinating on the potty pad by herself. Rose continues to defecate on or near the potty pad. Her skin is healing. 0.16 needles were placed at GV14, 20, Bai Hui, BL27, 28, 35 and 0.14 needles at BL60(right), ST36(right) and proximal tail points.
Treatment 11(Day42)- Foster states the Rose is using the potty pad at night. 0.18 needles placed at GV20, BaiHui, BL27, 28 and proximal tail points. 0.14 needles placed at GV14, BL35, ST36, KI3(left).
Treatment 12(Day49)-Foster reports that Rose is moving her tail more. She defecated near the potty pad. 0.18 needles were placed at GV20, Bai Hui, BL27(left), 35, ST36(left) and proximal tail points. 0.14 needles placed at BL60(left), KI3(left), SP6(left). Laser treatment of the perineal area was done to treat the urine scald. A setting of 1 Watt, 50 Joules for 1 minute 14 seconds was used.
Treatment 13(Day53)- Foster reports no changes- Rose defecates throughout the house and bladder still needs to be expressed. 0.18 needles placed at GV20, BaiHui, BL27, 28, 35(left), 60(left), ST36(left). 0.14 needles were placed at ST36(right), KI3(right), SP6(right). Laser on the perineal area was repeated. The affected area is decreasing in size.
Treatment 14(Day62)- Stability is much improved, the patellar reflexes are normal, crossed extensor reflex is difficult to assess because she is very active. Foster reports she is walking more than dragging herself at home. 0.2 needles placed at GV20, BaiHui, BL27, 28, 35(left), 60(left) and proximal tail points. 0.14 needles placed at ST36(left), KI3(right), Sp6(right). Laser therapy was repeated on the perineal area.
Outcomes, Discussions and References: Acupuncture following spinal cord injury has been shown to help manage motor and sensory dysfunction, pain, neurogenic bowel and bladder, as well as pressure ulcers, spasticity and osteoporosis (1). There is also increasing evidence that acupuncture therapy can decrease the oxidative damage and neural apoptosis in animals with spinal cord injury(2).
This patient has shown improvement in many of those areas. She is no longer painful in the thoracolumbar region. Her motor control of the rear limbs has improved. She can take several steps without falling to the side. Her ataxia has decreased and her rear limbs are no longer in extensor rigidity at rest. Her patellar reflexes are normal. She no longer has a positive crossed extensor reflex on the left but does on the right. She is regaining pain sensation and movement of her tail.
There have been improvements to her bowel and bladder control. She no longer leaks urine. Her anal sphincter tone has improved. Two weeks after her last treatment the foster reported that Rose has used the litter-box to pass urine and stool on her own several times. We have seen slow improvements with Rose and she hopefully will continue to improve given more time and treatment.
Many of the studies reviewed by Fan et al. utilized acupuncture points CV3 and CV4 as well as electroacupuncture. This patient did not tolerate those points and electroacupuncture was not an option. These would be additional things to work towards with this patient for an even better outcome.
This was my first acupuncture case so many of the things I learned had to do with technique. I learned to adjust to fit the patient and find new things to try if something was not tolerated. I switched to smaller needle size so the treatment was tolerated, but later increased the size for better placement and effect. Laser therapy was added to treat the area where she was too sensitive to tolerate needles. GV20 was added for its calming effect on the patient. Massage of the tail was used to help stimulate the muscles and nerves located in areas where needles were less tolerated. The patient developed a significant urine scald and sloughing of skin. The fosters were taught to be more diligent with cleaning and to use protective ointment to the affected skin.
References
(1) Qianqian Fan, Omer Cavus, Lize Xiong, Yun Xia. Spinal Cord Injury: How could acupuncture help? Journal of Acupuncture and Meridian Studies 2018:11(4):124-132.
(2) Zeng XH, Li QQ, Xu Q, Li F, Liu CZ. Acupuncture mechanism and redox equilibrium. Evid Based Complement Alternat Med 2014;2014, 482394.