Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4D2019009
Abstract
Medical acupuncture and electroacupuncture were used on a 14 year old male neutered Nigerian mix goat presenting for weight loss and suspected hindlimb discomfort. A total of three treatments were received over the course of three weeks. The importance of an appropriate treatment shelter was discovered due to an adverse reaction to poor weather conditions. The owner reported an increase in appetite post acupuncture treatment.
History of Present Illness and Chief Complaints
Kona is a 14 year old male neutered Nigerian mix goat. He is a pet goat that lives in a pasture with another 14 year old Nigerian mix and a 2 year old Alpine goat. The owner reports progressive weight loss with suspected hindlimb pain and stiffness. Kona does not receive any medications, is up to date on deworming and vaccinations. The owner is not interested in running additional diagnostic testing such as blood work or diagnostic imaging.
Physical Examination and Clinical Assessments
On gait analysis there was no obvious lameness observed. Kona appeared to have a thoracolumbar lordosis. Visually, hindlimb and spinal muscle atrophy can be appreciated. Kona is not handled on a daily basis therefore it was difficult to perform a thorough initial myofascial palpation. During the initial examination, there were non-painful muscular taught bands along the cervical spine bilaterally. Kona had bilateral stifle medial buttress and an increase in myofascial tension could be appreciate over the lumbar and sacral regions when the skin rolling technique was used.
On forelimb palpation, the pectoral muscles had non-painful muscular taught bands. Kona did not tolerate distal limb palpation. He does not appear to have any neurological deficits upon neurological examination.
Problem List:
1. Muscle atrophy
2. Weight loss
3. Cervical spine taught muscular bands 4. Thoracolumbar lordosis
5. Pectoral taught muscular bands
6. Bilateral medial buttress
Differential Diagnoses:
Muscle atrophy: Weight loss:
– Vascular: ischaemia
– Infectious: Caprine Arthritis Encephalitis
– Neoplastic: cancer cachexia
– Degenerative: osteoarthritis
– Iatrogenic: white muscle disease
– Congenital: angular limb deformity causing disuse atrophy
– Autoimmune: lupus erythematosus
– Traumatic: injury to peripheral nerves
– Endocrine: pituitary macroadenoma
– Myofascia: trigger point pathology causing disuse muscle atrophy. – Vascular: anaemia
– Infectious: Johne’s disease
– Neoplastic: cancer cachexia
– Degenerative: Scrapie
– Iatrogenic: nutritional deficiency
– Congenital: nephrogenic diabetes insipidus
– Autoimmune: pemphigus foliaceus
– Traumatic: traumatic injury (e.g. broken jaw) causing anorexia
– Endocrine: diabetes mellitus
– Myofascia: myofascial pain causing reduced appetite.
Putative Diagnosis: age related osteoarthritis and loss in body condition.
Based on the myofascial palpation and gait analysis, it is suspected that Kona has age related osteoarthritis with concurrent weight loss. However a full diagnostic work up has not been performed, therefore not all possible differentials can be definitively ruled out. The bloody supply to the peripheral vasculature, pulse quality and FAMACHA score appears to be within the normal limits. This helps to eliminate a vascular cause of muscle atrophy and weight loss. Kona is not exhibiting any thickening of the joint capsules and lives within a closed herd, reducing the likelihood of a Caprine Arthritis Encephalitis infection (1). The weight loss appears to be chronic and there is no evidence of diarrhoea in the pasture (1), thus ruling out Johne’s disease as a cause of the weight loss. Cancer cachexia cannot be ruled out due to the absence of more advanced diagnostic testing. A neoplastic process can explain both the muscle atrophy and weight loss seen.
As Kona is not exhibiting any neurological deficits, cutaneous hypersensitivity or pruritis, Scrapie is low on the list of differentials (1). A bilateral stifle medial buttress does exist, which is highly suggestive of osteoarthritis or degenerative joint disease. As clinical testing has not been performed, a nutritional deficiency cannot be ruled out as a cause of weight loss and muscle atrophy. Kona has free range of an unimproved pasture and is supplemented with finishing pellets. However, it is recommended that the owner provide a mineral supplement, as volcanic soils are known to be deficient in selenium (2).
A congenital cause such as an angular limb deformity would have been detected at birth. Kona does not present with these deformities and there has also been no history of polyuria or polydipsia thus also ruling out congenital diabetes insipidus. An autoimmune cause such as, lupus erythematosus and pemphigus foliaceus are also low on the differential list, as Kona is not exhibiting any skin lesions. Kona 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 or prehensile inability. A pituitary macroadenoma has only been reported in does (3) and Kona does not have a history of polyuria or polydipsia, which helps to rule out an endocrinopathy as a differential. It is highly possible that existing osteoarthritis is resulting in the development of myofascial pathology. A reduced appetite can also be associated with pain secondary to the osteoarthritis.
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 ST36 as Kona has a bilateral medial buttress. A forelimb shoulder point, GB21, was also selected. The autonomic nervous system (ANS) was neuromodulated via ST36 to relay somatic input into somato-autonomic convergence centres in the brain stem.
Medical Acupuncture and Other Techniques
Treatments were received once weekly. A total of three treatments were performed.
Treatment 1 – 21st May 2019
Acupuncture (5 minutes):
– GV14 (Seirin J type 0.20 x 30mm): a good test point to see how Kona would respond to needles. It was also chosen to target any neck pain
– GV20 (Seirin J type 0.20 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– Bai Hui (Seirin J type 0.25 x 30mm): CNS neuromodulation, lumbosacral/pelvic pain
– Bilateral BL26 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral BL27 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral ST36 (Seirin J type 0.25 x 30mm): for stifle dysfunction and for ANS neuromodulation.
The needles were left in place for about 5 minutes, before it began to rain. Kona became distressed due to the rain and treatment was ended.
Treatment 2 – 29th May 2019
Acupuncture (10 minutes):
– GV20 (Seirin J type 0.20 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– GV14 (Seirin J type 0.25 x 30mm): used for CNS neuromodulation and neck pain
– Bilateral BL 10 (Seirin J type 0.25 x 30mm): for cervical pain and tension
– Bilateral GB21 (Seirin J type 0.25 x 30mm): for any forelimb dysfunction and local tension
– Bai Hui (Seirin J type 0.20 x 30mm): CNS neuromodulation, lumbosacral/pelvic pain
– Bilateral BL26 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral BL27 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral ST36 (Seirin J type 0.25 x 30mm): for stifle dysfunction and for ANS neuromodulation.
Treatment #3 – 7th June 2019
Acupuncture (10 minutes):
– GV20 (Seirin J type 0.20 x 30mm): used for CNS neuromodulation, to help reduce any agitation of anxiety and to target any neck pain
– GV14 (Seirin J type 0.25 x 30mm): used for CNS neuromodulation and neck pain
– Bilateral BL 10 (Seirin J type 0.25 x 30mm): for cervical pain and tension
– Bilateral GB21 (Seirin J type 0.25 x 30mm): for any forelimb dysfunction and local tension
– Bai Hui (Seirin J type 0.20 x 30mm): CNS neuromodulation, lumbosacral/pelvic pain
– Bilateral BL26 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral BL27 (Seirin J type 0.25 x 30mm): CNS neuromodulation and lumbosacral pain
– Bilateral ST36 (Seirin J type 0.25 x 30mm): for stifle dysfunction and for ANS neuromodulation.
Electroacupuncture (5 minutes):
– Left BL19-BL23 (Seirin J type 0.25 x 30mm) using E-Stim II unit set on an intensity of 2 and frequency of 2: CNS neuromodulation, midthoracic to thoracolumbar local points
Discussion
As Kona is not handled on a regular basis, massage or acupressure were not utilised. This allowed Kona to be treated with as little handling as possible. Acupuncture was used in combination with electroacupuncture to help provide analgesia and relieve any myofascial tension. Kona was quite tolerant of acupuncture needle placement despite being rarely handled. During the first treatment session, the needles were left in place for about 5 minutes. This short duration is due to Kona becoming stressed as it began to rain during treatment. Escaping back to his house became his primary focus. During the second and third treatment the weather conditions were more favourable. More sites could be needled during the second treatment and needles were left in place for 10 minutes. Electroacupuncture at BL19-BL23 during the third treatment was chosen due to the mild thoracolumbar lordosis observed. This helps to relieve any myofascial tension via local points, it also provides analgesic affects as it acts directly on the spinal opioid receptors to induce the endogenous opioids and inhibit pain (4).
Kona had an adverse reaction to the rain which affecting the length of treatment. This highlights the importance of an appropriate shelter for large animals during acupuncture sessions. The shelter will provide a comfortable environment and reduce the amount of distractions that may hinder the length of any treatments. Another beneficial treatment option for Kona is photomedicine via laser therapy. This will provide a great “hands off” treatment approach. Laser therapy can cause alterations in both cellular physiology and neural activity leading to pain control, neuronal regeneration and tissue healing (5).
Outcomes
The owner reported that Kona’s appetite seems to be increasing. This was evident whilst trying to film the post treatment video, as all Kona wanted to do was graze. Kona will continue to receive regular acupuncture therapy in the hopes to further improve his level of comfort and quality of life.
References
1. Merck Manual: Veterinary Manual. 2019 Merck Sharp & Dohme Corp, Kenilworth, NJ, USA
2. National Academy of Sciences. Selenium in Nutrition: Revised Edition 1983. National Academies Press (US)
3. Pugh DG. Sheep and Goat Medicine: First Edition. 2002 Saunders USA
4. Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology 2014;120:482-503
5. Robinson N. Laser therapy treatment may be effective against TL IVDD. 2010 Veterinary Practice News.