Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019011
Abstract: Tudy was presented June 6, 2019 for examination of chronic lameness and pain. She has undergone 12 weeks of weekly acupuncture and 2-3 times weekly treatment with class IV laser therapy. With the addition of these complimentary disciplines we were able to reduce the medications that were causing Tudy to be sedated in order to keep her comfortable.
History: Tudy is a 15 year old spayed female Border Terrier weighing 19 pounds. She was first presented with a chronic history of back pain and lameness most frequently noted on her right thoracic limb. Always an active terrier, she is frequently digging aggressively and chasing her housemate (a 4 year old Border Terrier named Tiva) as well as playing tug of war type games. According to the owner she has had multiple radiographs demonstrating significant degenerative joint disease of her hips and back as well as collapsed disc spaces between the 1st and 2nd lumbar vertebrae and the 2nd and 3rd lumbar vertebrae. She stopped jumping up on the furniture and going up stairs over the past couple of years.
Physical Examination and Clinical Assessment: On initial presentation for acupuncture she was found to have a grade 2/4 lameness of her right thoracic limb. Mild kyphosis was noted from caudal thoracic to cranial lumbar spine. Taut bands were palpable in her infraspinatus muscle (m), sternocephalicus m, and gluteus maximus m bilaterally. She was sensitive on palpation lateral to the 10th thoracic through the 2nd lumbar spinous processes. Weakness was demonstrated in both rear legs with pain noted in the supporting muscles, tendons, and fascia around both hips. No neurologic deficits were noted on exam. Her medications included Galliprant 10 milligrams (mg) once daily, tramadol 25mg every 8 to 12 hours, and gabapentin 25mg every 12 to 24 hours. Her owner complained of over sedation due to the amount of medications required to keep her comfortable.
Problems:
*Degenerative joint disease (DJD) of coxofemoral joints bilaterally
*Back pain
*Off-loading of right thoracic limb
*Sedation related to medications used to moderate pain
*Nuclear sclerosis
*Stage 2/4 dental disease- heavy tartar, moderate gingivitis with gingival recession
Differential Diagnosis:
Hip pain:
1. Avascular necrosis
2. Lyme disease, Ehrlichia disease, septic arthritis
3. Osteosarcoma
4. Dysplasia
5. Exercise induced tenosynovitis
6. Intervertebral Disc Disease
7. Immune mediated arthritis or polyarthritis
8. Previous fracture or soft tissue tear
9. Hyperadrenalcorticism causing excess weight injury to joints over time
10. Impingement or other injury of sciatic nerve, contraction or injury of caudal thoracic and lumbosacral muscles, iliopsoas m injury, pes anserine injury
Right Thoracic Limb Lameness:
1. Thrombolic disease
2. Lyme disease, Ehrlichia disease, septic arthritis
3. Osteosarcoma, osteochondrosis
4. Elbow dysplasia
5. Exercise induced tenosynovitis
6. Congenital joint luxation (shoulder or elbow)
7. Immune mediated arthritis or polyarthritis
8. Previous fracture or soft tissue injury
9. Hyperadrenalcorticism causing excess weight injury
10. Impingement of cervical nerves, contraction or injury of cervical or dorsal thoracic muscles innervating and supporting the thoracic limb
Diagnosis: Chronic osteoarthrits due to degenerative joint disease of hips, right shoulder, and elbow. Myofascial disease secondary to compensatory changes. Due to the chronic mid to late life onset of clinical signs and slow progression of disease, the neoplastic, immune mediated and acute injury causes are not likely. Many of the congenital, traumatic, or infectious causes may have contributed to the current status.
Medical Decisions: Tudy has been undergoing medical therapy for her clinical pain with Gabapentin and non-steroidal anti-inflammatory medications. According to her owners she is excessively sedated by this combination and her quality of life is not sufficient. For this reason the owners have elected to include complimentary techniques. I chose to add acupuncture, photobiomodulation, and massage in combination.
Treatment: The acupuncture sites selected include Governor Vessel (GV)14 to improve relaxation, autonomic regulation, and acceptance of other treatment (LeLaCruz, 2006, as cited in Robinson, 2016) . Bladder (BL)13, BL14, BL15, BL17, BL18, BL19, BL20, BL21, BL25 bilaterally were selected in different combinations determined by palpation at the time of each treatment. BL54, Gallbladder (GB)29, GB30 and Stomach (ST)36 were treated alternating left or right side for each treatment. ST36 was selected for its autonomic regulating properties (Michukami, Kamiya, Kawada, et al,2006, as cited in Robinson, 2016) . Small Intestine (SI)11 and SI12 on the right side were selected for treatment due to palpation of taut bands locally. Seirin coated needles were selected for use. Initially 0.16 X 15mm size were used then she was gradually introduced to 0.2 X 30mm needles as she became more relaxed at each session. I started her on weekly sessions. After 3 acupuncture treatments I discussed the possibility of reducing the sessions to every 2 weeks but the owner felt that she was continuing to improve with the weekly treatments so the weekly treatments have been continued. During the time that the acupuncture needles are in place I perform gentle circular massage of her sternocephalicus m and trapezius m bilaterally. After 12-15 min of dry needling the needles are removed and effleurage massage over her dorsum and shoulders is performed. After the short use of these massage techniques Tudy undergoes class IV laser therapy with Companion Therapy Laser Class 4 (980/810nm, 15W, CW). The right carpal region is treated for 2.4 minutes at 3 watts to deliver 381 joules. The dorsal lumbar region is treated for 3.2 minutes at 6 watts to deliver 948 joules. The hip region is treated for 4.5 minutes at 5 watts to deliver 1080 joules. These laser treatments have been repeated 2 to 3 times weekly. The plan going forward is to repeat the laser treatments weekly and the acupuncture treatments every 2 weeks.
Discussion: After the first 2 weeks of complimentary medical treatment we were able to discontinue the gabapentin. The reduction of pain is most obvious in her willingness to venture up the steps and play again in the back yard per the owners. On physical exam she has greatly reduced sensitivity on palpation along thoracolumbar spine and decreased lameness on her right thoracic limb. The ability to reduce Tudy’s pain level and increase her function while reducing her use of sedating drugs has been tremendously beneficial for her quality of life. Her owners were very close to electing euthanasia for her and are now extremely happy with her comfort and activity level at home.