Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019014
Abstract: This study will evaluate the effectiveness of integrative medicine on a patient who had plateaued and was regressing with traditional veterinary medical protocols. Fabio was first evaluated on January 2019 with bilateral hind limb weakness. He had delayed proprioception and withdrawal reflexes and regressed to absent right hind limb proprioception, withdrawal and deep pain reflexes by May of 2019. A 7-week course of dry needle, electrical stim, laser and medical massage was employed and by the end of the treatment course he is now able flex and to extend his right hip and stifle to walk, has a withdrawal reflex and can navigate uneven terrain. His owner notes that he has gone from dragging his right hind limb to walking approximately 450 feet a day.
History: Fabio is 12.6 year old male intact, 7# Pomeranian. He was adopted in January 2019 and was presented to our clinic with severe dental disease and hind limb weakness. A dental was performed 1/15/2019 with numerous extractions and Fabio was placed on antibiotics and gabapentin. His owner felt that his hind limb weakness was becoming more pronounced and radiographs were performed on 2/14/2019 the following findings were documented:
1. Severe bridging spondylosis and vertebral disc narrowing at the T12-13, T13-L2 and L4-L6.
2. Bilateral shallow acetabulums
3. Right femoral head flattening and femoral neck thickening.
An orthopedic review recommended a MRI to evaluate the neurological impact of these findings. His owner was unable to comply due to financial constraints and Fabio was placed on Meloxicam 0.1mg/kg PO SID, glucosamine and omega 3 fatty acids. The owner thought like he felt better but that he was not improving in strength. On 3/5/2019 Fabio started a series of 6 bilateral laser treatments utilizing a class IV Companion laser employing a protocol that toggles between 810nm and 980nm. The following treatment areas were selected.
Lumbar (Watt (W) =4, Time (T) = 5.37 min and Total Joules (TJ) =1080) and the stifle (W=4, T=5.37 min, TJ=1080) with the last treatment on 3/26/2019. Post laser evaluation revealed that he regained some improvement in mobility and strength. This was verified with his owner, and at that time he wanted to wait on further treatments. By 5/1/2019 he suffered severe regression in the right hind limb. His neurological evaluation revealed that proprioception, withdrawal and deep pain reflexes were absent, and he had significant atrophy of all the right hind limb musculature. Integrative medial modalities were introduced 5/21/2019.
The physical examination performed on 5/21/2019 was unremarkable except for his neurological and myofascial evaluation. The neurologic exam revealed that Fabio had right hind limb paresis with no withdrawal or crossed extension reflexes nor proprioception and delayed withdrawal reflex and proprioception on his left hind limb. His myofascial evaluation revealed major atrophy of all muscle groups in the right hind limb. There is significant myofascial restriction and kyphosis at the thoracolumbar region and all cranial thoracic, cervical and shoulder muscles groups were taunt. Trigger points were not detected, but with his small size and my inexperience I am sure they have to exist. In addition his triceps bilaterally, were 3 times the size of a normal dog of his size.
Given his neurologic and myofascial exam findings, Fabio has monoparesis of the right hind limb with lower motor neuron (LMN) dysfunction. This is a chronic progressive disease process with a suspected unilateral spinal cord lesion involving the L4-S3 segments. Possible rule outs for hemi or monoparesis are as follows:
Vascular: Fibrocartilaginous embolism, Aortic thromboembolism. Both are acute and non-progressive.
Infectious/Inflammatory: Distemper myelitis, granulomatous meningoencephalomyelitis, and immune meningoencephalomyelitis. All differentials are chronic and progressive and would need further diagnostics to rule out.
Neoplasia: Primary, lymphoreticular, skeletal, metastatic. All are chronic and progressive – radiographs are non-supportive for skeletal neoplasia. Cat Scan (CT) or magnetic resonance imaging (MRI) would be required to differentiate a definitive diagnosis.
Degenerative: Degenerative myelopathy, degenerative lumbosacral stenosis and neuropathies, are all possible differentials that are chronic and progressive. However, radiographs though supportive are not definitive and diagnosis could only be determined by CT, MRI or Myelography.
Iatrogenic/ Intoxication: Motor neuropathies are chronic progressive. Toxic: Aminoglycides are acute progressive. Heavy metals, organophosphates and industrial toxins are chronic progressive, though he has no known exposure.
Congenital: Hydrocephalus- Usually diagnosed at 2 -3months of age. Globoid cell leukodystrophy usually causes bilateral signs with ataxia and progressive para paresis. Spinal dysraphism, hemivertebra and spinal bifida are congenital differentials but, radiographs are not supportive.
Autoimmune: Immune meningoencephalomyelitis. This is a chronic progressive disease process. Further diagnostics are required to definitively rule it out.
Traumatic: Hemorrhagic myelomalacia, intervertebral disc rupture and luxation’s are highly likely differential, as the children from his previous home carried Fabio by his hind legs.
Endocrine: Hypothyroid –Is a chronic progress disease causing generalized weakness. A Free T4 could rule it out.
Most likely R/O: Type II disc disease, degenerative myelopathy, degenerative lumbosacral stenosis, and neuropathies. Diagnosis could only be determined by CT, MRI or Myelography.
Plan:
Gait analysis: We were unable to obtain any footage in the hospital or outside as Fabio would not move for us. All the video submitted are curtesy of his dad. From the footage you can see kyphosis and right hind limb paresis along with an unsynchronized gait. Since Fabio has a monoparesis significantly affecting the Sciatic n, Femoral n, Fibular n, and the Tibial n on the right side. The following acupuncture points support the neuromodulation of those nerves as well as the peripheral points to support parasympathetic stimulation.
Acupuncture: 5/21/2019
Dry needle using Seirin J15 Coated 0.14 X 15mm
CV14, CV20
Yin Tang
BL 25 bilateral, BL28, and BL54 right side
Bai Hui
GB29, GB30, right side
ST36 right side
Bafeng right tarsus
KI 1
Massage using passive hands touch, effleurage and compression on the thoracolumbar and hind limbs, and petrissage was incorporated to the cranial thoracic, cervical and shoulders of the forelimb.
Laser: Class IV utilizing 810nm – 980nm
WT =<10
Body condition = average Treatment areas
Hair coat length = long Lumbar and Stifle
Hair coat color = light W=4 per site
Skin color = light T=5.37 minutes per site
Protocol = Arthritis TJ=1080 per site
*Fabio has a positive withdrawal reflex on the right side after the treatment.
Treatment changes: 5/28/2019, 6/4/2019 and 6/11/2019.
The following additional dry needle points were added to the protocol established on 5/21/2019: GB31, BL39 and BL40 to further support the neuromodulation of the Sciatic n, Femoral n, Common fibular n and the Tibial n.
10 Video June 12th
Treatment changes: 6/18/2019 and 6/25/2019.
Acupuncture:
Dry needle using Seirin J15 Coated 0.14 X 15mm
CV14, CV20
Yin Tang
BL 25 left side and BL54 right side
Bai Hui
ST36 right side
Bafeng right tarsus
KI1
Electroacupuncture using Carbo non coated metal needles 0.20 X 0.25mm. Utilizing a mixed setting of 2Hz and 100Hz for 10 minutes on the following points:
BL25 – BL28
GB29 – GB31
GB30 – BL40
Massage using passive hands touch, effleurage and compression on the thoracolumbar and hind limbs, and petrissage was incorporated to the cranial thoracic, cervical and shoulders of the forelimb.
Laser: Class IV
WT =<10
Body condition = average Treatment Area’s
Hair coat length = long Lumbar and Stifle
Hair coat color = light W=4 per site
Skin color = light T=5.37 minutes per site
Protocol = Arthritis TJ=1080 per site
12 Negotiating varible terrain height
After completing a 6-week Integrative medicine protocol of dry needle and electroacupuncture combined with photomedicine and massage, Fabio has regained his ability to walk. He still has an asynchronous gait and if he attempts to move too quickly he will stumble. He has regained muscle strength and proportion in his right hind limb compared to that of his left hind limb. His right hind limb withdrawal reflex is not consistent and he still has no proprioception. Over all, his owner is very pleased with his progress and has committed to 11 more weeks of integrative medicine modalities. Incorporation of the following points is being implemented into his electroacupuncture protocol: BL23-BL28 bilateral. (Media list 13) This is the first time his dad ever witnessed him standing to scratch his shirt.
13 1st time ever standing to scratch july 1
References
1. Robinson, N.G. (2017) CuraCore Medical Acupuncture for Veterinarians – Canine Point Mini Manual
2. Oliver, J,E. Jr. &Lorenz, M.D. (1993) Handbook of Veterinary Neurology – Second addition
3. Horowitz A. & Berg R. (2007) Anatomy of the Dog – Fifth, revised edition
4. Acupuncture’s Effects in Treating the Sequelae of Acute and
Chronic Spinal Cord Injuries: A Review of Allopathic and
Traditional Chinese Medicine Literature
Evidence-Based Complementary and Alternative Medicine
Volume 2011, Article ID 428108, 8 pages
doi:10.1093/ecam/nep010
Jacksonville, Florida: Hindawi Publishing Corporation
5. Bilateral Effects of 6 Weeks’ Unilateral Acupuncture and
Electroacupuncture on Ankle Dorsiflexors Muscle Strength:
Arch Phys Med Rehabil 2012; 93:50-5.
Tianjin, China: Department of Health and Exercise Science, Tianjin University of Sport