Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017005

Video Nov 08, 1 59 37 PM Video Nov 28, 3 50 18 PM

Abstract: A geriatric Giant Schnauzer with recurrent/metastatic mast cell tumors was treated successfully with acupuncture for pain related to a ruptured cranial cruciate ligament, cervical myelopathy, and myofascial strain patterns. Despite success with pain management, treatment was discontinued due to the potential exacerbation of a mast cell tumor by dry needling.

History and Presentation: Ebony, an eleven year old, female spayed Giant Schnauzer, presented on November 7, 2017 for pain due to a left cranial cruciate ligament (CCL) rupture, which had been diagnosed on October 28, 2017 when she presented acutely lame. A tibial plateau leveling osteotomy (TPLO) and arthroscopy had been performed for a right CCL rupture in 2014, at which time Ebony had been diagnosed with a concurrent partial left CCL tear. Additionally, a mast cell tumor (MCT) had been diagnosed along her left lateral cervical/cranial shoulder region in September 2017. Recurrent high grade MCTs had been previously removed from her right triceps region in September 2017, April 2017, July 2016, and January 2016. The right prescapular lymph node was surgically excised in September 2017 due to mast cell metastasis. At presentation, Ebony was being treated with Palladia (90 mg PO Monday, Wednesday, and Friday), diphenhydramine (75 mg PO BID-TID), gabapentin (100 mg PO BID), omeprazole (20 mg PO SID), phenylpropanolamine (56 mg PO BID), and prednisone (20 mg PO SID).

Physical Examination and Clinical Assessments: Ebony was grade III/VI lame on her left rear limb on presentation. She was panting and tachycardic, with a heart rate of 180 beats per minutes and pale pink mucus membranes. Her owner reported that she had received Palladia earlier in the day, and the signs were consistent with the patient’s previous responses following administration of the drug. Otherwise, the patient was bright, alert and responsive. Multiple soft, subcutaneous masses were present, including a previously diagnosed mast cell tumor on her left caudal neck near the shoulder. Neurologically, she had a slow conscious proprioceptive (CP) reflex in her left rear limb; CP reflexes were normal in her other three limbs. She demonstrated a pronounced crossed extensor reflex in both rear limbs, with a more subtle crossed extensor reflex in her front limbs. Patellar reflexes were brisk bilaterally. Slight cranial drawer movement was appreciated in the left stifle. On myofascial exam, Ebony demonstrated heat and discomfort on palpation of her left stifle. Kyphosis was present in her lumbar spine, along with significant myofascial restriction and tenderness to palpation. Mild myofascial restriction was also present at her thoracolumbar junction. Significant tension was present in her cervical region, with her owner reporting decreased cervical range of motion at home, when questioned. Her head carriage appeared low when walking. Heat and tension were present bilaterally in the region of her supraspinatus and infraspinatus musculature. Tension was present in her hamstrings as well as her gastrocnemius muscles bilaterally. Trigger points were noted in her right latissimus dorsi musculature.

Medical Decision Making: In treating Ebony, it was essential to approach her pain at several levels. Central nervous system analgesia was incorporated by needling relevant spinal segments to provide opioid/neurotransmitter release and decrease wind up pain. Acupoints were chosen to balance the autonomic nervous system via long loop peripheral nerve reflexes. At the local level, trigger points and myofascial dysfunction were deactivated. Peripherally, acupoints were chosen both locally and remotely to affected areas to decrease inflammation and pain, as well as improve joint stabilization, cervical and joint range of motion, proprioception and circulation. Massage was also chosen to help with myofascial dysfunction and pain management. In addressing her neoplasia, acupoints were chosen that provided systemic immune stimulation by increasing circulated interferon, activating natural killer cells, and enhancing interleukin-2, among other effects. Massage was added for discomfort. To avoid exacerbating her neoplasia, laser therapy was avoided. Acupuncture points near the site of her current MCT were likewise avoided, with the closest needle being placed 8 cm from the tumor margin.

Differential Diagnoses:
” For left rear limb lameness, rule out CCL rupture, arteriovenous fistula/other vascular disease, tick borne/other infectious disease, neoplasia, degenerative joint disease, chronic inflammatory induced polyarthritis, hip dysplasia/other congenital disease, immune-mediated polyarthritis, trauma, endocrine neuropathy, myofascial pain syndrome, open
” For cervical spinal signs, rule out fibrocartilaginous embolism, diskospondylitis, nerve sheath tumor/other neoplasia, cervical myelopathy, autoimmune disease, cervical spondylomyelopathy/other congenital disease, steroid-responsive meningitis, trauma, hypokalemia/other endocrine disease, myofascial pain syndrome, open
” For thoracolumbar and lumber spinal pain, rule out fibrocartilaginous embolism, diskospondylitis, spinal cord neoplasia, degenerative disk disease, steroid-responsive meningitis, vertebral malformation/other congenital disease, autoimmune disease, trauma, endocrine neuropathy, secondary myofascial strain patterns, open
” Recurrent/metastatic mast cell tumor, diagnosed by an oncologist prior to presentation

Putative Diagnoses:
” Left cranial cruciate ligament rupture, diagnosed based on myofascial exam, orthopedic exam (cranial drawer movement), and previous history of partial CCL tear
” Cervical myelopathy, diagnosed via neurologic exam lesion localization and history
” Secondary myofascial strain patterns, diagnosed via myofascial exam and history
” Recurrent/metastatic mast cell tumor, diagnosed by an oncologist prior to presentation

Medical Acupuncture and Related Techniques: The initial acupuncture treatment for Ebony was performed on November 8, 2017. The following points were dry-needled with 0.16 mm x 30 mm coated Seirin needles for the listed indications:
” GV 14: Chosen for immunologic support and to address neck, back, and thoracic limb pain.
” GV 20: Chosen to promote relaxation and autonomic neuromodulation, as well as to address potential head pain secondary to trigger points.
” Bai Hui: Chosen to address lumbosacral pain as well as pelvic limb pain.
” Bladder (BL) 10 (bilateral): Chosen to address neck pain and restricted range of motion, back and shoulder pain, and muscle tension.
” BL 21 (right): Chosen to address local pain.
” BL 23 (bilateral): Chosen for pelvic analgesia and to address lumbar pain.
” BL 54 (bilateral): Chosen for local pain and hip pain.
” Stomach (ST) 34 (left): Chosen to address cranial stifle pain and instability.
” ST 36 (left): Chosen for immunologic support, cranial stifle pain and instability, as well as parasympathomimetic and antiinflammatory effects.
” Spleen (SP) 9 (left): Chosen to address cranial stifle pain and instability and to improve proprioceptive function.
” SP 10 (left): Chosen to address cranial stifle pain and instability.
” Large Intestine (LI) 4 (bilateral): Chosen for endorphin production, immunological support, and to address neck pain.
The following points were dry-needled using 0.20 mm x 30 mm coated Seirin needles:
” Governing Vessel (GV) 4: Chosen for pelvic analgesia and to address lumbar pain.
” BL 21 (left): Chosen to address local pain.
The second acupuncture treatment was performed on November 17, 2017. The following points were dry-needled using 0.20 mm x 30 mm coated Seirin needles for the listed indications:
” GV 4, GV 20, Bai Hui, BL 10 (bilateral), BL 21 (bilateral), BL 54 (bilateral), ST 34 (bilateral), ST 36 (bilateral), SP 9 (bilateral), and SP 10 (bilateral): Chosen for the same indications as on 11/8/17.
” BL 15 (bilateral) and BL 19 (bilateral): Chosen to address local pain.
” BL 27 (bilateral) and BL 28 (bilateral): Chosen to address lumbosacral and stifle pain.
” SP 6 (bilateral): Chosen for immunological support and pelvic analgesia, as well as to improve proprioceptive function and for somatovisceral reflex effects.
” Gallbladder (GB) 20 (bilateral): Chosen to address neck pain as well as local pain.
” GB 21 (right): o Chosen to address neck pain, restricted motion, and muscle tension bilaterally, as GB 21 on the left side was too close to the MCT to be safely approached.
” Small Intestine (SI) 11 (right): Chosen to address myofascial dysfunction and compensatory strain patterns.
” SI 12 (right): Chosen to address myofascial dysfunction and compensatory strain patterns.
” Local trigger points: Chosen to address myofascial dysfunction.
LI 4 was also dry-needled bilaterally at that time, using 0.16 mm x 30 mm coated Seirin needles, for the same indications as on 11/8/17. On both dates, acupuncture was followed by light massage using a combination of effleurage, skin rolling, and petrissage.

Video Dec 19, 8 01 20 PM  Video Dec 19, 8 01 08 PM

Outcomes and Discussions: Ebony demonstrated immediate improvement in comfort and lameness following her first acupuncture treatment, bearing greater weight on her left hind limb by the time she left the clinic. Following the treatment, the owner reported Ebony seemed brighter, with improved cervical range of motion and an overall easier gait. However, several hours after the treatment, the owner reported that the mast cell tumor had grown in size, only to shrink down again the next day. According to the owner, this was common on days the patient received Palladia. As the patient had received Palladia earlier on the day of treatment, the decision was made to proceed with a second treatment, but to schedule it for a different day so as to determine what effects, if any, the acupuncture had on the tumor. The decision was also made to avoid the point closest to the tumor, GV 14 at 8 cm away, during the second treatment. Ebony was assessed prior to her second treatment, and improvement was significant. The kyphosis and myofascial restriction in her thoracolumbar and lumbar spine were reduced, and her lumbar spine was less tender. Heat and tenderness were reduced in her left stifle. Her head carriage was less restricted, and there was a decrease in tension in her cervical region. Tension was still present in her infraspinatus and supraspinatus bilaterally. Acupuncture and massage were repeated, and again, Ebony seemed more comfortable following treatment, with continued overall decrease in tension and myofascial restriction. However, the owner again noted an increase in size in the mast cell tumor approximately four hours following her treatment. While the tumor shrunk again the day after, the decision was made to discontinue further acupuncture treatments in the event that mast cell degranulation due to dry needling had resulted in clinical exacerbation of the tumor. The owner was very pleased with the decrease in pain and increase in comfort/mobility following the acupuncture, even at several weeks post-treatment. Massage was discussed as an option for continued pain management, avoiding areas near the tumor margins. The case elucidated several points for learning. While the patient presented for a torn cruciate ligament, concurrent cervical spinal myelopathy and compensatory myofascial strain patterns were found to be significant contributors to Ebony’s pain overall, and underlined the importance of performing a complete myofascial exam on every patient. For the torn cruciate ligament, cervical spinal myelopathy, and the compensatory strain patterns, Ebony demonstrated marked improvements in both comfort and function immediately following acupuncture, confirming the efficacy of acupuncture in each of the conditions. However, Ebony’s response to dry needling also provided insight as to the pronounced effects mast cell stimulation at acupoints can have on mast cell tumors, and emphasized the need for monitoring in affected patients.

References:
— Lana, S.E. et al. 2006. The use of complementary and alternative therapies in dogs and cats with cancer. J Am Anim Hosp Assoc. 42: 361-365.
-Tekin, L. et al. 2013. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol. 32(3): 309-315.
-Wu, M.L. et al. 2015. Local cutaneous nerve terminal and mast cell responses to manual acupuncture in acupoint LI4 area of the rats. J Chem Neuroanat 68:14-21.
-Yao, W. et al. 2014. Mast cell-nerve cell interaction at acupoint: modeling mechanotransduction pathway induced by acupuncture. Int J Biol Sci. 10(5):511-9.


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