“BEFORE” photo
“AFTER” Photo
Case Report by Mihaela Mocanu, DVM, cVMA.
February 2024
VIDEO CLIP OF COACHING SESSION.
[Update, November 2024 from Dr. Mocanu: “Thanks to you Tank (the dog we did the massage on) is muzzle free and happier than ever. We are forever grateful!” (See photo of Tank without wire basket muzzle)]
Abstract: Tank, a 9.5-year-old Pitbull Mix, presented with a history of pituitary macroadenoma, Cushing’s disease, bilateral biceps tendinopathy, left cranial cruciate ligament (CCL) tear with history of Tibial Plateau Level Osteotomy (TPLO), and trilostane-induced seizures. Despite undergoing laser therapy and water treadmill sessions, Tank’s myofascial examination revealed significant restrictions and tender points. Acupuncture was introduced as part of the treatment regimen, resulting in improved tolerance to myofascial manipulation and enhanced mobility.
History: Tank, a 9.5-year-old Pitbull Mix, presented with a history of pituitary macroadenoma, Cushing’s disease, bilateral biceps tendinopathy, left CCL tear with TPLO, and medication-induced seizures following trilostane administration. Current medications include fluoxetine, gabapentin, Keppra, and carprofen. Tank has been receiving laser therapy and water treadmill sessions prior to acupuncture initiation. He is also scheduled to receive intra-articular injections with the surgeon.
Physical Evaluation: Tank presented as bright, alert, and responsive (BAR) with ambulation on all four limbs. Heart and lung sounds were within normal limits. Abdominal palpation was unremarkable. All palpable lymph nodes were within normal limits on initial examination. On observation, Tank is wearing a metal basket muzzle due to previously diagnosed aggression in a medical environment. Tank has not been aggressive in a very long time but has been trained to wear the muzzle whenever outside of the home. He is holding his head low with a noticeable lordosis in the thoracolumbar area and kyphosis in the lumbo-sacral area. On myofascial evaluation, Tank exhibited multiple taut bands, tension, and restrictions in the neck, pectoral area, and limbs. Neurological assessment revealed normal cranial nerve reflexes, with mildly decreased conscious proprioception noted in the left hind limb and right front limb.
Problem List:
- Pituitary macroadenoma
- Cushing’s disease
- Bilateral biceps tendinopathy
- Left CCL tear with TPLO surgery previously performed
- Medication-induced seizures (trilostane)
- Myofascial restrictions and tender points worse in the neck and pectoral area but really, noted throughout the entire body
- Secondary muscle atrophy
Differential Diagnosis: Possible differentials included vascular abnormalities (thrombosis, vasculitis), infectious diseases (Lyme disease, discospondylitis ), neoplasia, degenerative conditions (osteoarthritis, degenerative joint disease), iatrogenic effects (previous TPLO surgery), autoimmune disorders (immune mediated polyarthritis), traumatic injuries (post-TPLO overcompensation, previous trauma), and endocrine-related body conformation changes due to Cushing’s disease.
Presumptive Diagnosis: Myofascial pain and dysfunction secondary to Tank’s underlying medical conditions, including pituitary macroadenoma, Cushing’s disease, bilateral biceps tendinopathy, and previous orthopedic surgeries.
Medical Decision-Making: The primary goals for neuromodulation and myofascial engagement included reducing pain, improving mobility posture, and enhancing overall comfort for Tank. Acupuncture sessions were tailored to address specific myofascial restrictions and tender points, with a gradual increase in treatment intensity based on Tank’s response and tolerance.
Medical Acupuncture Specifics: For each session, Tank received dry needling using Seirin needles, targeting central, peripheral, and autonomic points. Tank started with receiving every other day laser therapy (arthritis settings) to both shoulders, neck and hind limbs. These were targeted at decreasing inflammation and increasing blood supply. We added acupuncture to target a larger area of Myofascial tissue restriction (including cervical spine, thoracic and lumbar spine, stifle area, bilateral scapula and humerus) and decrease sympathetic tone, increase parasympathetic effects and improve circulation. The treatments were performed twice a week.
Session 1: Dry needling for 10-15 minutes using 0.16 x 30mm Seirin needles.
- Central
- GV14, GV 20, BaiHui – increase parasympathetic tone, stimulates endogenous pain modulation pathways in brain stem and spinal cord.
- BL 10, 11, 12, 13 – cervical and thoracic segments
- BL 20, 21, 22, 23 – spinal segments T12-L2
- Peripheral
- SI 11 and SI 12 – chosen to help with suprascapular nerve – patient reacted to these points and showed discomfort.
- Autonomic
- LI 4
- Myofascial
- Focused on neck area and trigger points, massage added as well.
Session 2: Discussed reactions to previous session with owner and elected to gain more trust first with Tank. For this session we chose to focus on massage of the neck and pectoral area. Patient reacted very well to this treatment, was relaxed and showed great improvement with posture. Also, discussed with owner to possibly remove muzzle to decrease tension in the neck area.
Session 3: Owner had been working at home with patient, continuing massage of the neck and pectoral area. We discontinued the use of the muzzle and patient did very well with just owner restraining gently. Patient was also diagnosed prior to this visit with lymphoma so discontinued laser therapy.
Point selection added:
- Central
- GV14, GV 20, BaiHui – increase parasympathetic tone, stimulates endogenous pain modulation pathways in brain stem and spinal cord.
- BL 10, 11, 12, 13 – cervical and thoracic segments
- BL 20, 21, 22, 23 – spinal segments T12-L2
- Peripheral
- LI 11, TH 10, LU 5 (stimulate the radial nerve)
- SI 11 – avoided SI 12 that caused discomfort at previous visit.
- Autonomic
- LI 4
- Myofascial
- Focused on neck area and trigger points, massage added as well.
Outcomes and Discussion: Tank’s response to acupuncture treatment demonstrated improved tolerance, mobility, and overall comfort. The integration of acupuncture into Tank’s multimodal treatment regimen contributed to managing his complex medical conditions and enhancing his quality of life. Adjunctive therapies were to continue the gabapentin and at home massage. Follow-up acupuncture appointments would be conducted twice a week.
References & Source Material
- Itoh, K., Saito, S., Sahara, S., Naitoh, Y., Imai, K., & Kitakoji, H. (2014). Randomized trial of trigger point acupuncture treatment for chronic shoulder pain: A preliminary study. Journal of Acupuncture and Meridian Studies, 7(2), 59–64. doi: 10.1016/j.jams.2013.02.002
- Robinson, N. G. (2016). Interactive Medical Acupuncture Anatomy. Jackson, WY: Teton NewMedia. doi:10.1201/b20729
- Srbely, J., Dickey, J., Lee, D., & Lowerison, M. (2010). Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. Journal of Rehabilitation Medicine, 42(5), 463–468. doi:10.2340/16501977-0535