Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2019016
Abstract:
Angular limb deformity (ALD) is a common condition in small breed dogs caused by either chondrodysplasia or premature closure of the ulnar growth plate. Patients with chondrodysplasia are also predisposed to intervertebral disc disease (IVDD). The patient in this case report is affected by both ALD and IVDD with secondary degenerative joint disease (DJD). He was treated with weekly acupuncture for a period of seven weeks with some setbacks, but significant improvement overall.
History and presentation:
Eddie, a sixteen year-old Jack Russell Terrier, presented with a history of intermittent left forelimb lameness for two years. The lameness had progressively gotten worse with more frequent occurrence and longer episodes. The lameness had been minimally responsive to trials of Galliprant, gabapentin, and tramadol. No traditional non-steroidal anti-inflammatories had been used due to a history of liver enzyme elevation. For the two months prior to presentation, Eddie had been more reluctant to go for walks, walking slower, and only able to walk about one quarter of the previous distance in the same amount of time. He had also started to collapse on his left forelimb two to three times during walks. Eddie was taking CBD oil daily which is the only treatment which had helped significantly. He was still getting tramadol occasionally as well.
Radiographs were taken of Eddie’s front limbs in February 2017 which showed evidence of significant degenerative joint disease affecting both of his elbow joints. These changes were thought to be secondary to his severe angular limb deformity.
Eddie had a history of liver disease with elevated alkaline phosphatase for four years and elevations in his other liver enzymes after a non-steroidal anti-inflammatory trial. He had also suffered episodes of pancreatitis in 2015 and 2016 which resolved with medical management.
In 2015 he had an episode of cervical pain which responded to medical management with Carprofen, tramadol, and methocarbamol.
Eddie also had a metal wire foreign body removed from the visceral fat that surrounds the hepatic blood vessels and bile duct in February of 2014.
Physical Exam/ Clinical Assessments:
Eddie’s body condition score was optimal with good overall muscle mass. He had mild periodontal disease and mild lenticular sclerosis bilaterally. His heart and lungs were normal on auscultation. Integument was normal except for multiple small sebaceous adenomas. There was mild hepatomegaly on abdominal palpation, but the abdomen was soft and non-painful. He had bilateral forelimb angular limb deformity with significant carpal valgus.
His gait analysis revealed an occasional upward head motion when he put weight on his left forelimb. He had a slightly stilted/ shuffling gait on his rear limbs as well, but no visible ataxia.
Eddie’s reflexes were difficult to test on his forelimbs due to his structure, but they appeared normal. He had mildly delayed conscious proprioception on the rear limbs. His patellar, sciatic, and withdrawal reflexes were all normal.
On myofascial examination, Eddie had tense bands on both sides of his neck and decreased range of motion on lateral flexion in both directions. There were trigger points in his cranial latissimus dorsi muscles bilaterally and tight bands in this left axilla on the medial aspect of the triceps muscle group. He was sensitive on palpation of his inner bladder line bilaterally from the 12th thoracic vertebrae to the 2nd lumbar vertebrae. His left semimembranosus and sartorius muscles were tense and sensitive to palpation. He had significant myofascial restriction in his dorsal thoracolumbar region with flattening of his haircoat and decreased mobility of his skin. He also had moderate thoracolumbar lordosis.
Problem List:
Chronic left forelimb lameness, bilateral forelimb angular limb deformity, thoracolumbar back pain, elevated liver enzyme.
Differential Diagnoses:
Chronic left forelimb lameness: radioulnar ischemic necrosis, Lyme disease, osteosarcoma, degenerative joint disease, elbow dysplasia, immune mediated polyarthritis, radial nerve injury, metabolic myopathy, nerve root signature from cervical IVDD, muscle strain/ sprain
Thoracolumbar back pain: Ischemic myelopathy, diskospondylitis, spinal nerve root tumor, degenerative intervertebral disc disease, DJD of facet joints, scoliosis, immune mediated meningoenchephalomyelitis, vertebral process fracture, epaxial muscle strain
Elevated liver enzymes: acquired portosystemic shunt, chronic active hepatitis, leptospirosis, hepatic lymphoma, liver cirrhosis, copper storage disease, NSAID toxicity, microvascular dysplasia, autoimmune hepatitis, trauma from previous removal of wire, hyperadrenocorticism, nodular regenerative hyperplasia.
Definitive/Putative Diagnoses:
Bilateral forelimb angular limb deformity, left forelimb lameness and collapse due to cervical IVDD, thoracolumbar IVDD, cause of chronically elevated liver enzymes is unknown.
Lyme disease was ruled out with negative test. Neoplasia is unlikely due to the radiographic changes being bilateral and the chronicity of the lameness. Immune mediated polyarthritis is ruled out as there is no joint effusion and the rear limbs aren’t affected. Radial nerve injury is ruled out as front limb reflexes are normal.
No further testing has been performed to obtain a differential diagnosis for the elevated liver enzymes. Hepatic lymphoma can be ruled out due to chronicity and lack of progression. The other differentials are still possible.
Medical Decision Making:
The goals of treatment were to decrease pain and myofascial restriction in the thoracolumbar region, improve use of the left forelimb, and address the liver disease when possible. The thoracolumbar region pain and dysfunction were addressed with central neuromodulation of the thoracolumbar spinal nerves using points along the Bladder line. Selection of the Bladder line points was based on sensitivity to palpation and location of myofascial restriction on the day of treatment.
Eddie had previously shown intolerance to treatments and restraint. He had a predisposition to bite when hurt or frightened. This made treatment with points on the limbs and cranial body undesirable. Initial treatments were focused on the sensitivity in the thoracolumbar region. Central points along the Governor Vessel and Bladder lines were used to address the forelimb lameness until tolerance to the procedure was established. As Eddie became accustomed to treatment and the frozen baby food, peripheral points were added to address the left forelimb lameness and tense bands in the neck. The liver disease was addressed mostly using the Liver Back Shu point (BL 18).
Medical acupuncture and related techniques:
Eddie was treated once per week for seven treatments using Seirin 0.16 x 30 mm needles unless specified otherwise. After most treatments, petrissage massage and skin rolling/ kneading was performed along the epaxial muscles and dorsal skin to enhance myofascial release. Electrostimulation was not used due to Eddie’s sensitivity and low threshold for being restrained.
The first treatment consisted of dry needling at the following points: GV 20, GV 14, and bilaterally at BL 20, BL 21, BL 22, and BL 23. Needles were placed for 20 minutes. Afterwards, massage was performed along the dorsal thorax and lumbar regions along with skin rolling to encourage myofascial release. The treatment was well tolerated.
For the second treatment, needles were placed at GV 20, GV 14, Bai Hui and bilaterally at BL 21, BL 22, BL 23, BL 40, and GB 30. Needles were in place for 20 minutes, then massage was performed.
Prior to the 3rd treatment, Eddie’s left forelimb collapse had worsened. For the 3rd treatment, needles were placed at GV 20, GV 14, Bai Hui, and bilaterally at BL 17, BL 18, BL 20, and BL 23. On the left side, LU 1, LI 11, SI 11, and SI 12 were also dry needled using Seirin 0.12 x 15 mm needles. Eddie was treated for 20 minutes followed by massage.
For the 4th treatment, needles were placed at GV 20, GV 14, Bai Hui, and bilaterally at BL 20, BL 21, BL 22, and BL 23. On the left side, LI 11 & SI 9 were dry needled using Seirin 0.12 x 15 mm needles. Two caudal cervical points on each side were placed as well. Eddie was treated for 20 minutes followed by massage.
Between the 4th and 5th treatments, Eddie had a significant setback after being bumped into repeatedly by a larger dog during a walk. He was very painful and slow moving. He was extremely sensitive to palpation of his back from his caudal thoracic to his caudal lumbar regions. He felt warmer than normal along both of his flanks and over his dorsal hips. He had vomited the previous night as well. Due to his sensitivity, he was not very tolerant of his 5th acupuncture treatment. Needles were placed at GV 20, GV 14, Bai Hui, and bilaterally at BL 18, BL 19, BL 20, BL 21 and BL 25. Seirin 0.12 x 15 mm needles were placed at ST 36 bilaterally as well. Needles were placed for 20 minutes. Eddie did not allow massage afterwards.
Eddie’s 6th treatment was better tolerated. Needles were placed at GV 14, Bai Hui, and bilaterally at BL 18, BL 20, BL 22, BL 23, BL 25, and GB 34. On the left side, LI 11 & GB 21 were dry needled using Seirin 0.12 x 15 mm needles. Two caudal cervical points on each side were placed as well due to tense bands. Eddie was treated for 20 minutes followed by massage.
By the 7th treatment, Eddies left forelimb lameness had improved. He still had mild back sensitivity. Needles were placed at GV 14 and bilaterally at BL 18, BL 21, BL 22, BL 23, and BL 52. Needles were placed for 20 minutes followed by massage.
Outcome/ Discussion:
Besides the setback between the 4th and 5th treatments, Eddie showed steady and significant improvement with acupuncture. He showed an increase in his ability and desire to move. His episodes of collapsing on his left forelimb resolved. He was also able to go back to walking his normal distance in a reasonable amount of time. He was reported to be much less tired following walks. The owner also stated that his left forelimb appeared slightly less rotated at rest.
I believe that the combination of acupuncture and massage resolved the restriction in Eddie’s dorsal thoracolumbar region allowing him to move more freely and comfortably. Resolution of the left forelimb collapse was likely due to neuromodulation of the caudal cervical region to cease the nerve root signature and related dysfunction.
From this case, I learned that even when there are glaringly obvious physical abnormalities and radiographic evidence of joint disease, those are not necessarily the cause of pain and dysfunction. With thorough myofascial exam, more significant sources of pain can be identified. Veterinary practitioners should be including myofascial exam during lameness and neurologic evaluations.
References:
Packer RMA, Hendricks A, Volk HA, Shihab NK, Burn CC (2013) How Long and Low Can You Go? Effect of Conformation on the Risk of Thoracolumbar Intervertebral Disc Extrusion in Domestic Dogs. PLoS ONE 8(7): e69650. doi:10.1371/journal.pone.0069650
Smolders, Lucas & Bergknut, Niklas & Grinwis, GC & Hagman, Ragnvi & Lagerstedt, Anne-Sofie & Hazewinkel, Herman & Tryfonidou, Marianna & Meij, Björn. (2012). Intervertebral disc degeneration in the dog. Part 2: Chondrodystrophic and non-chondrodystrophic breeds. Veterinary journal (London, England : 1997). 195. 10.1016/j.tvjl.2012.10.011.