Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 3D2019004
ABSTRACT:
Bilateral forelimb flexor tendon contracture secondary to severe anemia and emaciation leading to debilitation in a 7-year-old female Nubian/Saanen cross breed goat. Treatment modalities included warm compress, passive range of motion (pROM), therapeutic ultrasound, acupuncture, splinting, and rehabilitation exercises. Initially, patient ambulation was accomplished bilateral on the dorsum of the carpi of the thoracic limbs with pelvic limb compensation. After 5 weeks, ambulation was accomplished unassisted with normal anatomic range of motion in the thoracic and pelvic limbs. Final discharged from hospitalization was 07/12/2019.
HISTORY OF PRESENT ILLNESS AND CHIEF COMPLAINT(S):
Emmy presented on May 30, 2019 with a presenting complaint of severe emaciation and an inability to stand or ambulate properly. Emmy was surrendered to Barn Sanctuary with a 1-year-old wether goat and immediately brought to the hospital. Emmy successfully kidded in 2012, 2013, and 2015-2017 at her previous farm. Her previous farm housed approximately 40 other goats in various states of health. In mid-March 2019, Emmy became weak and was treated with over the counter medications and nutritional supplements.
PHYSICAL EXAMINATION AND CLINICAL ASSESSMENTS:
05/30/2019: On initial presentation physical exam findings included: Temperature: 101.8◦F; Pulse: 90 bpm; Respirations: 36 brpm; Body Condition: 1/5; Mucosal Membranes/Capillary Refill Time: pale pink/<2 seconds, FAffa MAlan CHArt (FAMACHA) score: 5.
Emmy exhibited severe generalized emaciation, labored breathing, and an inability to ambulate due to bilateral forelimb contractions at the carpi. All of Emmy’s hooves were grossly overgrown further compromising her ability to ambulate. Examination and diagnostic testing revealed a lice infestation with gastrointestinal and respiratory parasitism, and severe non-regenerative anemia. Neurologic examination was within normal limits with the exception of ambulation. Infrequent ambulation attempts occurred only on dorsum of carpi bilaterally. Upon further evaluation, Emmy had contracted bilateral distal forelimb flexor tendons.
06/03/2019: Myofascial exam findings included a limited examination of distal limbs due to contracture of fetlocks bilaterally and patient tolerance. Severe generalized muscle atrophy and significant bilateral fetlock contracture was appreciated. The right fetlock was moderately more resistant to extension. Bilaterally caudolateral neck, triceps brachii, and vastus lateralis demonstrated warmth. Due to the severe amount of muscle atrophy, palpation of muscles and trigger points proved extremely difficult. Tight bands were palpated bilaterally in lateral triceps brachii, significantly worse on the right. Skin exhibited generalized tight adherence to underlying muscle.
PROBLEM LIST:
1. Anemia (nonregenerative, normocytic, normochromic)-severe emaciation indicating serous atrophy of bone marrow fat leading to non-regeneration of red blood cells: resolved after blood transfusion on 05/30/2019, supportive care, and increased nutrition during hospitalization. (Initial packed cell volume (PCV)=10%, Discharge PCV=24%)
2. Ambulation bilaterally on dorsum of carpi: resolved with supportive care, increased nutrition, physical therapy modalities, and acupuncture treatments by discharge 07/12/2019.
3. Labored breathing with increased lung sounds-attributed to lungworm parasitism
4. Marked elevation in lactate levels-poor perfusion secondary to anemia: resolved at time of discharge 07/12/2019.
5. Mild leukocytosis, moderate segmented neutrophilia, moderate lymphopenia-stress leukogram and/or active inflammation: resolved at time of discharge 07/12/2019.
6. Mildly increased urea nitrogen, mildly decreased creatinine, mild hypocalcemia, mild hypophosphatemia, mild hypomagnesemia, mild hypoalbuminemia, moderate hyperglycemia, moderate decrease in cholesterol-attributed to malnutrition/emaciation: resolved at time of discharge 07/12/2019.
7. Respiratory parasitism-Protostrongylids (lungworm): resolved with Fenbendazole treatment from 05/31-06/16/2019.
8. Gastrointestinal parasitism (trichostrongyles-5175 eggs/gram and coccidia-11700 eggs/gram): resolved with Fenbendazole treatment from 05/31-06/16/2019.
9. Ectoparasitism-sheep body louse-Bovicola ovis: resolved with bathing, shearing, and permethrin topical treatment on 06/05/2019 and 06/07/2019.
10. Overgrown hooves: resolved with trimming on presentation and periodic maintenance during hospitalization.
DIFFERENTIAL DIAGNOSES Top Two Problems:
1. Generalized atrophy and emaciation leading to serous atrophy of bone marrow fat leading to severe anemia
• V(ascular): Parasitic thrombosis
• I(nfectious): Mycobacterium avium subspecies paratuberculosis: tested with negative results or Haemonchus contortus or Coccidiosis
• N(eoplastic): Caprine alimentary lymphoma
• D(egenerative): Degenerative joint disease resulting in diminished ability to ambulate to food source
• I(atrogenic, intoxication): Copper toxicity or decreased appetite from abomasum ulceration from non-steroidal anti-inflammatory therapy
• C(ongential): Border Disease viral infection in-utero resulting in persistent infection
• A(utoimmune): Immune mediated hemolytic anemia
• T(raumatic): Dental trauma impairing ability to eat, neurogenic atrophy
• E(ndocrine, metabolic): Copper, Selenium, Vitamin E deficiency, or malnutrition due to neglect or poor food quality (protein deficient)
• M(yofascia): Pain attributed to myofascial components resulting in diminished ability to ambulate to food source
2. Inability to ambulate properly, specifically contracted bilateral forelimb flexor tendons:
• V(ascular): Parasitic thrombosis or another vascular compromise/impingement leading to tendon degeneration
• I(nfectious): Caprine arthritis encephalitis virus: tested with negative results
• N(eoplastic): Synovial sarcoma, myeloma, or malignant lymphoma
• D(egenerative): Degenerative joint disease
• I(atrogenic, intoxication): Over-trimming of hooves creating painful ambulation
• C(ongential): β-mannosidosis or congenital contracted flexor tendons due to limited fetal movement or toxins in-utero
• A(utoimmune): Rheumatoid arthritis
• T(raumatic): Neurogenic atrophy or heterotopic ossification post-trauma
• E(ndocrine, metabolic): Copper, Selenium, or Vitamin E deficiency, or malnutrition
• M(yofascia): Pain attributed to myofascial components resulting immobility
DEFINITIVE DIAGNOSES:
Due to history, physical exam findings, clinical presentation of signs, diagnostic laboratory findings, and response to treatment, Emmy’s generalized muscle atrophy and subsequent anemia is attributed to malnutrition secondary to poor quality food, neglect, or inability to ambulate to the food source. It is most likely that the bilateral carpus flexor tendon contracture occurred as a result of weakness secondary to malnutrition compounded by prolonged immobilization culminating in reduced flexibility.
MEDICAL DECISION MAKING: Acupuncture treatments in chart 06/06/2019-07/12/2019
Points used Reasoning behind point selection Method Frequency
GV20 Relaxation, anxiety reduction, peripheral stimulation Dry needling Once daily until discharge
Bai Hui Masterpoint of hind end, autonomic neuromodulation, balance point between mostly forelimb focused treatments Dry needling Once daily until discharge
SI9 (bilaterally) Axillary and radial nerve stimulation-shoulder and forelimb pain Dry needling Once daily until discharge
SI11 & SI12 (bilaterally) Suprascapular nerve stimulation-shoulder stabilization, strength, range of motion Dry needling Once daily until discharge
LI4 (bilaterally) Nervi vasorum-peripheral stimulation
Autonomic neuromodulation
Recover function of thoracic limb Dry needling Once daily until discharge
LI10 & LI11 (bilaterally) Radial nerve stimulation Dry needling Once daily until discharge
TH14 (bilaterally) Suprascapular nerve and axillary nerve stimulation Dry needling Once daily until discharge
ST 36 (bilaterally) Autonomic neuromodulation and regulation Dry needling Once daily until discharge
MEDICAL ACUPUNCTURE AND RELATED TECHNIQUES USED:
• 06/03-07/12/19 Warm compress and pROM modalities initiated to facilitate tendon relaxation. These modalities continued until discharge approximately 4 times daily.
• 06/03-07/12/19 Therapeutic massage with myofascial skin rolls implemented twice daily over entire body to facilitate increased circulation to the tissues and provide relaxation.
• 06/03-07/12/19 FitPaws peanut (large blue smooth sided) utilized for active and passive range of motion stretches 4 times daily. Patient also stood supported by the peanut for increasing amounts of time to increase flexibility and weight bearing on limbs and joints.
• 06/04-07/12/19 Therapeutic ultrasound was used once daily at 0.5 Watts on the equine superficial carpus tendon setting for 5 minutes per area over the right triceps brachii and bilaterally over fetlock, radius and ulnas. Therapeutic ultrasound was utilized to apply deep heat to the tendons, muscles, and ligaments to facilitate healing through increased circulation to tissues.
• 06/04-06/22/19 Mobility cart utilized to support patient initially during standing which evolved into ambulation with patient’s increase in strength. The mobility cart was utilized during all acupuncture treatments to facilitate ease of access to desired point locations and eliminate patient’s opportunity to ingest needles.
• 06/05/19 Initial acupuncture treatment: GV20 (cranial and caudal to horn stump), Bai Hui
o Seirin J #1-tubed (0.16) x 30mm for 5 minutes for general relaxation and assessment of patient tolerance of dry needle treatments. After 06/06/19, Seirin J #3-tubed (0.20) x 30mm needles were used for 5 to 10 minutes as tolerated.
• 06/22-07/02/19 Splint placed on right forelimb carpus and fetlock to assist in walking during the day; the splint was removed at night. On 07/02/19- splint removed at all times and patient ambulated completely without assistance.
10 Emmy ambulating in cart 20190615
9 Emmy standing unsupported to eat 20190613
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OUTCOMES, INSIGHTS, DISCUSSION:
Emmy’s case provided an excellent opportunity for adjunctive acupuncture therapy. However, as an initial case study for a student, evaluating the benefit from acupuncture alone becomes obscured by the other modalities utilized. Due to her emaciated state and muscle atrophy, finding enough muscle mass to needle safely was challenging. As such, I was unable to use points that I thought would be beneficial, such as Bladder points for referred spinal compensatory pain. Further follow-up on Emmy’s progress and continued acupuncture therapy after discharge would have been ideal, however, as a student I am no longer on the Large Animal Service rotation to observe her continued treatment plan.
REFERENCES:
Kiser, K. Patti & Lohr, V. Christiane. “Lymphoma Classification in goats”. Veterinary Pathology 2017, Vol. 54(4) 611-619.
Miller, D. L., Smith, N. B., Bailey, M. R., Czarnota, G. J., Hynynen, K. , Makin, I. R. “Overview of Therapeutic Ultrasound Applications and Safety Considerations”. Journal of Ultrasound in Medicine 2012, 31: 623-634. doi:10.7863/jum.2012.31.4.623.