Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019013
Abstract:
A four-year-old castrated male Pitbull presented for evaluation of right forelimb discomfort and mild lameness, only partially responsive to non-steroidal anti-inflammatory therapy. Following acupuncture and massage, his discomfort improved and he has been maintained off of routine oral analgesics.
History and Presentation:
A four-year-old castrated male Pitbull presented for evaluation of right forelimb discomfort associated with intermittent lameness. Signs were noted six months prior to his current presentation; at that time, he had begun to vocalize when attempting to jump on and off the furniture and favored his right forelimb slightly when walking. He was examined by a Diplomate of the American College of Veterinary Surgeons (DACVS); a specific joint localization was not reached, aside from right forelimb discomfort. A course of rest and non-steroidal anti-inflammatory (NSAID) therapy was recommended, with follow-up for imaging to be considered.
Signs improved with conservative medical therapy, with only intermittent episodes of vocalization when jumping over the next several months. However, at the time of his current presentation, he had again begun to consistently display mild right forelimb lameness and vocalization when attempting to jump on and off the furniture. NSAID therapy was again implemented on a routine basis with only mild improvement in clinical signs observed.
Prior medical history included parvoviral enteritis, an episode of severe heatstroke, and allergic skin disease. Routine heartworm, intestinal parasite, and flea/tick prevention were the only medications being administered other than the NSAID.
Physical Examination and Clinical Assessment:
On presentation, vital parameters were normal and cardiopulmonary auscultation and abdominal palpation were unremarkable. His skin was mildly erythematous with a thin hair coat. No other abnormalities were noted on general physical examination.
Neurologic examination was unremarkable, with intact cranial nerve reflexes, normal conscious proprioception assessment and intact spinal reflexes. No pain was elicited on spinal or cervical palpation and cervical range of motion (ROM) was normal.
The patient vocalized and displayed decreased ROM on right shoulder flexion. No other long bone or joint pain was identified on the remainder of his orthopedic examination. The DACVS who had previously evaluated him repeated the examination and concurred with localization to the right shoulder. Radiographs were declined; CT was also discussed and similarly declined.
Gait analysis revealed a very mild right forelimb lameness and a slightly choppy pelvic limb gait. Taut bands in the rhomboids and dorsal cervical region were identified on myofascial palpation.
Pre Treatments_1 Pre Treatments_2
Problem List:
-Right shoulder pain with taut bands in the rhomboids and dorsal cervical region
-Mildly erythematous skin with history of allergy
Differential Diagnoses:
-Problem 1: Right Shoulder Pain
Vascular: thromboembolic event
Infectious/Inflammatory: inflammatory myositis
Neoplastic: rhabdomyosarcoma
Degenerative: degenerative myelopathy
Iatrogenic/Intoxication: excessive palpation/manipulation exacerbating discomfort
Congenital: OCD lesion in shoulder
Autoimmune: IMPA localized to the shoulder joint
Traumatic: jumping on/off furniture leading to muscle strain
Endocrine/Metabolic: rhabdomyolysis
Myofascia: chronic trigger points leading to pain
-Problem 2: Erythematous Skin with History of Allergy
Vascular: vasculitis
Infectious/Inflammatory: demodex, sarcoptes, fleas; atopy/allergy
Neoplastic: mast cell degranulation and associated systemic response
Degenerative: necrolytic dermatitis
Iatrogenic/Intoxication: cutaneous drug reaction
Congenital: none that would lead to such mild signs
Autoimmune: pemphigus (although lesions are not characteristic)
Traumatic: burns
Endocrine/Metabolic: hyperadrenocorticism
Myofascia: necrotizing fasciitis (although signs are so mild that this is highly unlikely)
Putative Diagnosis:
The putative diagnosis for the right shoulder pain was soft tissue injury related to repetitive activity, with likely some contribution from chronic trigger points. High levels of activity (wrestling with housemate, jumping from the furniture) were common for this patient and the potential for soft tissue injury was high. He was a very heavily muscled dog over his cervical region and cranial thorax, with trigger point development also thought likely to play a role. The remaining differentials all were expected to have led to more severe clinical signs—with the exception of an OCD lesion, which could not be fully ruled out without imaging.
The putative diagnosis for the mildly erythematous skin was atopy/allergy. Prior dermatologic evaluation had ruled out the presence of secondary infections and the relatively mild nature of signs largely excluded the other differentials. This was not his presenting complaint, but was considered as an adjunct problem that acupuncture may have the ability to modulate.
Medical Decision Making:
Acupuncture and massage were elected to begin therapy. Points were selected based upon the MAIN approach to acupuncture (specific points and rationale detailed below in each treatment).
Medical Acupuncture and Related Techniques Used:
Treatment One:
GV 14, 20 (chosen for central/autonomic input)
BL 13, 14, 15 (chosen for central input)
Cervical spinal points (chosen for myofascial input)
SI 9, 11, 12 (chosen for peripheral input)
ST 36 (chosen for its immunomodulatory input to aid in dermatologic condition)
The first treatment utilized red Seirin (0.16×30) needles. They remained in place for 10 minutes before the patient was intolerant of further therapy. Massage was utilized over the taut bands in the cervical musculature.
Treatment Two (one week later):
Physical examination at this visit revealed less discomfort on right shoulder flexion and improved range of motion in this joint. Taut bands through the cervical musculature persisted.
GV 14 (chosen for central/autonomic input)
BL 11, 13 (chosen for central input)
SI 9, 11, 12 (chosen for peripheral input)
TH 14 (chosen for peripheral input)
GB 21 (chosen for peripheral input)
ST 36 (chosen for its autonomic/immunomodulatory input to aid in dermatologic condition)
The second treatment utilized blue Seirin (0.20x30cm) needles. They remained in place for 20 minutes. Massage was intended, but the patient was overly excited and did not want to remain still for further manipulation so massage was not pursued.
Treatment Three (six days after second treatment):
Physical examination revealed no pain on right shoulder flexion and good range of motion through the joint. The taut bands in the cervical musculature and rhomboids were relatively mild on palpation.
GV 14, 20 (chosen for central/autonomic input)
BL 12, 13,14 (chosen for central input)
SI 9, 11, 12 (chosen for peripheral input)
GB 21 (chosen for peripheral input)
Bai Hui (chosen for autonomic input)
ST 36 (chosen for its autonomic/immunomodulatory input to aid in dermatologic condition)
The third treatment again utilized blue Seirin (0.20x30cm) needles. They remained in place for 25 minutes. Massage was also utilized over the taut bands.
Post All Treatments_1 Post All Treatments_2 Post All Treatments_3 Post All Treatments_4
Outcomes and Discussion:
After the first treatment, the patient was comfortable at home for the first three days. His NSAIDs were not used and his activity was not restricted. By the fourth day following treatment, he seemed reluctant to jump onto the furniture and mild intermittent lameness recurred. His NSAIDs were restarted and he remained comfortable.
His physical examination findings at the second evaluation revealed less right shoulder discomfort; he was more tolerant of needle placement and a lengthier treatment duration. Immediately after treatment, the taut bands were improved in character and he remained comfortable at home throughout the full week following treatment, with NSAID therapy given only after extended activity. Lameness did not recur.
At the third evaluation, he had remained comfortable at home and pain was not elicited on examination. He was quite tolerant of both needle placement and massage at this visit and the mild taut bands that were appreciated resolved. Gait analysis after this treatment did not show any lameness—although in comparison to video obtained from the initial presentation, his gait was not remarkably altered. He continues to follow up for intermittent acupuncture as his owner’s schedule permits and has not required routine NSAID administration.
No changes were noted in his mildly erythematous skin with these treatments, however, this was not his primary presenting complaint and thereby not the main focus of therapy. The literature does, however, suggest a potential role for acupuncture in management of dermatologic illness.1
Although this patient’s signs were mild, he did show some convincing signs of a positive response to acupuncture and massage therapy throughout his treatments. Prior to presentation, he was receiving routine NSAID therapy; following treatment, he was able to remain largely untreated with NSAIDs with limited clinical signs. Electroacupuncture and laser would likely have been ideal to employ as adjunct therapies to the standard acupuncture and massage, however, access to these modalities was unfortunately not available.
Due to the mild nature of his signs, a dramatic response to acupuncture was not necessarily achieved (not a “miracle” improvement), however, he was able to be maintained largely off of NSAIDs, which was considered a treatment success. Acupuncture certainly has a role in pain control and particularly for those patients with mild pain and who may be sensitive to NSAIDs, may be an excellent modality to help minimize the need for oral analgesics. The literature also suggests a specific role for acupuncture in the management of shoulder pain, with electroacupuncture and motion style acupuncture suggested as modalities with potential benefit.2,3 Continued intermittent therapy for maintenance for this patient would have been ideal, however, his owner’s schedule has not allowed for routine follow-up—although at last conversation one month after the third treatment, the patient was reportedly doing well at home.
References
1. van den Berg Wolf M, Burgoon T. Acupuncture and cutaneous medicine: is it effective? Medical Acupuncture. 2017. 29(5): 269-275.
2. Lo GX et al. The effect of electroacupuncture merged with rehabilitation for frozen shoulder syndrome: A single-blind randomized sham-acupuncture controlled study. Journal of the Formosan Medical Association. Accepted March 2019; article in press.
3. Shi MY et al. Motion style acupuncture therapy for shoulder pain: a randomized controlled trial. Journal of Pain Research. 2018. 11: 2039-2050.