Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017015

Abstract: A 7 year old male neutered cat with a history of skin twitching, rolling, and rippling since adoption (about 1 year) presented for acupuncture treatment. His owner was told there was no treatment for these signs that were diagnosed as Feline Hyperesthesia Syndrome and the patient had a normal neurologic exam and was able to ambulate normally with a good quality of life. Myofascial exam revealed contracted muscle tissue and tight fascia in the shoulders, as well as tight fascia along the thoracic and lumbar spinal regions as well as lateral to the spine. He exhibited intermittent skin twitching before during and after examination. After his first acupuncture session, his tight muscles and fascia in the shoulder region were no longer present but the other tight fascia remained. His owner has not noted any change in the duration, frequency, or intensity of his clinical signs. Acupuncture presumably relieved his shoulder tension, but future therapies would ideally include laser therapy, medical pharmaceutical management such as gabapentin, and possibly electroacupuncture.

History and Presentation: Uncle Grandpa is an indoor/outdoor neutered male cat estimated to be around 7 years old adopted just under a year ago from a local shelter. He has been exhibiting signs of skin rippling, skin twitching, and intermittent licking of his caudal thoracic through lumbar spinal region since adoption. Per his owner, he ambulates normally, chases animals outdoors, and jumps onto tall furniture without incident. He seems to exhibit more skin twitching and rippling signs when the ceiling fans are on per his owner. He lives with a 2 year old neutered male greyhound and a young spayed female cat about 2 years of age and cohabitates well. More recently he has been chasing the other cat but gets along very well with the dog. He occasionally fights with neighbor cats outdoors. His history prior to adoption is unknown but he was overweight at adoption and has not lost any weight at a BCS of about 7/9. Uncle Grandpa has had no medical issues except mild periodontal disease and no known history of trauma or surgical procedures. He was not on any medications prior to treatment except for monthly Revolution.

Physical Examination and Clinical Assessments: BAR, eupneic, purring, sitting, standing, and walking during examination. Gait appears normal, placing is normal x 4 limbs; menace, palpebral reflexes and PLR are normal OU; normal mentation; anal tone and facial sensation WNL. Patient does not allow other neurologic testing. Abdominal palpation is difficult due to body habitus but not tense nor painful and no organomegaly or other abnormalities noted. Myofascial examination reveals sensitivity to even extremely light palpation of midthoracic spinal region down through sacral palpation with most reaction to thoraco-lumbar (TL) region and mid to caudal lumbar region. During palpation of these regions, reactions vary and include skin twitching and rolling, looking back at me, licking the air or his owner, or simply halting eating his food treats. At his first visit, his shoulder region revealed some symmetrical tight fascia at the lateral and dorsal shoulders. His fascia also palpated tight lateral to his spine from his TL region caudally. Taut bands were palpated bilaterally at lateral shoulders. Subsequent exams did not reveal any tightness at his shoulders nor any taut bands. Patient (pt) had, and continues to have, matted fur at caudal lumbar region, worse on the right side. At initial presentation he had a few small crusts, 2 on his dorsal cranium and one in ventrolateral neck region (attributed to cat fights outdoors). The rest of his integumentary exam was normal. There had been no labwork performed and his presumptive diagnosis has been feline hyperesthesia syndrome by his regular DVM with no treatment implementation. At my request, prior to treatment he had lateral and ventro-dorsal (VD) spinal radiographs taken which were included more of the chest and abdomen than requested but no boney or soft tissue abnormalities were noted.

Medical Decision Making: At Uncle Grandpa’s first visit, I wanted to work on his shoulders with some SI points or distal forelimb points but he was not conducive to needling there. I slowly started with GV14 for his shoulders as well as general homeostasis and continued with GV20 for homeostasis and calming. From there on, my point selection was based primarily on palpation and included inner bladder line points that were mildly reactive but not so reactive that he would not let me needle. Bai Hui was chosen for homeostasis as well as a consistent place in the caudal lumbar region that he would allow me to needle. The goal was to stimulate the local muscles and connective tissue to loosen the tight fascia and reset the stimuli causing his skin twitches. For the sites at which he did not allow needling and for general loosening of fascia, I performed skin rolling and massage before and after each session. Ideally, laser would have been use but I do not have access to one at this time.

Differential Diagnoses: Traumatic myopathy, neuropathy, or myofascial injury are highest on the list, but infectious damage or congenital abnormalities have not been ruled out. Diskospondylitis, despite the lack of progression of clinical signs and normal neurologic exam, would ideally be ruled out with MRI, as would IVDD (intervertebral disc disease). Degenerative causes are less likely than traumatic due to age but not ruled out. Allergic dermatitis despite normal integument has not been ruled out and food and atopy are higher on list than flea allergies. In a feline patient with these signs, metabolic is less likely than a canine in which endocrine causes should be explored, but ideally baseline bloodwork would be obtained to help assess metabolic etiologies. These are low on the list but have not been ruled out. Behavioral is less likely than it could be in other patients as it is not associated with any certain time of day, presence or absence of any resources, signs have not changed with any household change in dynamics, and examination reveals reaction to palpation.

Definitive (or Putative) Diagnosis: Highly suspect of myofascial dysfunction/hypersensitization resulting in the clinical signs summarized as feline hyperesthesia syndrome

Acupuncture Treatments:
• Acupuncture points selected 11/13/17
o BL 21 bilaterally with 0.14 x 15mm Seirin
o GV 14 with 0.16 x 30 mm Seirin
o GV 20 with 0.14 x 15 mm Seirin
o Bai Hui with 0.16 x 30 mm Seirin which he shook out immediately; then replaced a few minutes later with 0.14 x 15 mm Seirin
o Pt was twitchy and worked some needles out. The shortest duration was about 5 minutes, with the longest (GV 14) in for between 12 and 15 minutes.
• Acupuncture points selected 11/20/17 – all with Seirin 0.14 x 15mm
o BL 18 and BL 19 bilaterally
o GV 14 – patient shook out so it was replaced a few minutes later
o GV 20 attempted – first was a misfire (user error), and second attempt a few minutes later pt was too reactive
o Bai Hui
o Patient allowed them to stay in for about 15 minutes. I suspect they weren’t all in as long as I timed because his skin twitching behavior seems to work the needles out.
• Acupuncture points selected 11/27/17 – all with Seirin 0.14 x 15 mm
o BL 19 bilaterally but removed immediately due to reactiveness of patient
o BL 23 bilaterally
o Tender points along the inner bladder line lateral to L4 and L6 bilaterally
o GV 14
o GV 20 attempted but pt was too reactive
o Bai Hui
o Total treatment time was about 12 minutes before pt shook out needles, but Bai Hui was shaken out at about 7 minutes
• Needle selection: All of the bladder line points were chosen where there was some sensitivity on myofascial exam but not so much that the patient would not allow me to needle. GV 14, GV 20, and Bai Hui were chosen for calming and homeostasis. Other points were palpated but pt would not allow needling, especially distally.
• Methods of stimulation: dry needling and pre/post needling massage and skin rolling performed weekly for 3 sessions.
• Adjunct therapies: Pt was started on 2.5 mg/kg PO q12h gabapentin after the first session (owner implemented on 11/15/17 in the PM) and increased to 5 mg/kg PO q12h on 11/20/17 in the PM. Owner stopped administering it on her own around 12/4/17 but I suggested starting it again and trying for at least a month with the mention that we can play around with the dose as well as discuss adjunct medications. Weight loss was also recommended and transitioning pt to high protein low carbohydrate canned diet was discussed but the owner is unable to afford this option at the moment, but will decrease the amount of dry food fed by about 15-25% in the meantime.

Outcomes, Discussions, and References: After the first visit, I was no longer able to palpate any taut bands, nor the tight fascia in the shoulder and proximal pelvic limb regions. Clinically the owner did not note any change in the frequency or intensity of the skin twitching and rippling signs or his activity level. As I was unable to treat the taut bands directly, I cannot attribute their absence to acupuncture directly, but they could have been an indirect effect of acupuncture. As gabapentin was also started, it is possible the pt was jumping or ambulating differently post treatment as a result of the combination of gabapentin, acupuncture, and massage.
The patient ran away from us on 2 occasions making the likelihood of lost needles and ingestion more likely but we were able to convince him to come back before we lost sight of him by the offering of more treats.
Although I wasn’t able to place many needles in this patient, I learned very quickly how to adapt to a mobile, distracted, and very sensitive patient but moving with him and readjusting my plan several times throughout each session. After working with this patient I also have order some smaller needles, different brands, and some longer needles of the same diameter so that I can assess more easily how deep they are. Part of this case was a struggle for me as we had our weekly sessions and the owner had not seen any difference. However looking back through his files, I see now that his taught bands are no longer present, and that his adjunctive therapy of gabapentin may have been what allowed me to needle some more lumbar points at his third session.
Particularly for feline hyperesthesia syndrome, more information in many respects is needed. Ideally we would come to some sort of conclusion as to the etiology of these signs via diagnostics and a consensus statement, but in the absence of that, more integrative medical techniques should be researched and studied. There are a lot of suggestions in the available literature, and there are case reports, but examining the combination of laser, acupuncture, pharmaceuticals, massage, and other techniques should be explored further. There are still clinicians that tell clients there is no known cause and no treatment, which in my opinion, in unacceptable, as some of these patients are greatly affected by their pathology.

References:
1. Ciribassi, John. Understanding Behavior – Feline Hyperesthesia Syndrome. Compendium. 2009; Vol 31 (No 3); 116-121. http://www.vetfolio.com/behavior/understanding-behavior-feline-hyperesthesia-syndrome. Accessed December 11, 2017.
2. O’Leary, DJ. A swallowed needle in a cat treated for feline hyperaesthesia syndrome. Acupunct Med. 2015; 33: 336-337. doi: 10.1136/acupmed-2015-010807
3. Sharifi, D and Golezardy, H. Self mutilation in a traumatized cymric cat. Euro. J. Exp. Bio., 2014, 4(2):182-187. http://www.imedpub.com/articles/self-mutilation-in-a-traumatized-cymric-cat.pdf. Accessed December 11, 2017


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