Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017017
Abstract: In the following clinical case, acupuncture was used in an attempt to manage pain and increase mobility in a canine patient that was diagnosed with hip dysplasia. In this case, surgical correction was not feasible due to financial constraints, and the owner’s goal was to improve the patient’s comfort level on a day-to-day basis, as well as minimize the need for medication to manage symptoms. The patient was showing signs of discomfort prior to treatment, and after 3 acupuncture sessions, had significant improvement in mobility both as reported by the owner, and on clinical exam observations.
History and presentation: A 4 year old, spayed, female German Shepherd was presented for acupuncture therapy after being diagnosed with hip dysplasia by her primary veterinarian. The owner had adopted the dog approximately 6 months prior to presentation. The previous owner had been giving the patient an oral joint supplement (Glucosamine and Chondroitin Sulfate) for approximately one year, and this was continued by the current owner. The current owner noticed the patient showing clinical signs of discomfort including occasional limping (owner was unsure which hind limb) and reluctance to jump. The owner reported that the patient would regularly stand with her hind legs very close together, would have an irregular hind limb gait when running and playing with other dogs (the owner described it as landing and pushing with both hind legs almost simultaneously instead of a normal 2-beats of the hind limbs), and was reluctant to jump up on furniture (couch, bed). There had been no known major medical problems or any surgical history except for ovariohysterectomy (at unknown age, but prior to current owner adopting pet). The patient was presented to the primary veterinarian for exam. There was no history of generalized disease such as fever, malaise or inappetance. The patient had recently had a Lyme snap ELISA test done (Idexx 4dx), which was negative, was receiving Proheart injections every 6 months for heartworm prevention and was receiving a flea/tick medication monthly. The primary veterinarian examined the pet and determined pelvic radiographs were indicated. The radiographs showed marked femoral neck thickening, decreased acetabular coverage of the femoral head, increased sclerosis of the acetabulum, irregular contour to the femoral head, and osteophyte formation on the cranial portion of the acetabulum (osteophyte formation was especially apparent in the right coxofemoral joint). The primary veterinarian diagnosed hip dysplasia with significant osteoarthritic changes, and recommended continuing the joint supplement, and prescribed Rimadyl (carprofen, non-steroidal anti-inflammatory drug (NSAID)). At this time, the owner wanted to try acupuncture for the patient as well to see if it would help the patient’s comfort and improve clinical signs.
Physical exam and clinical assessments: On initial presentation, the patient was bright and energetic. The owner reported she had not yet started the Rimadyl that was prescribed by the primary veterinarian. There was no overt limping seen when patient was walking, but the patient did move with a stilted gait in the pelvic limbs and stood with hind limbs close together. The patient appeared neurologically appropriate, with no ataxia or conscious proprioceptive deficits of any limbs noted during ambulation. On palpation, the pet had tension and response to palpation of the triceps muscles and cranial portion of the latissimus dorsi muscles bilaterally. She had sensitivity to palpation over the caudal-thoracic and lumbar (T13-L6 region) longissimus dorsi muscles/fascia, and had tension and response to palpation of the semi-membranosus, semi-tendinosus and biceps femoris muscles bilaterally. A brief palpation of the stifles and manipulation for evidence of joint instability was performed and no evidence of
effusion or instability was found. Limb palpation and manipulation was limited due to patient sensitivity of being handled/touched on the limbs/paws. The patient did allow a brief check for hind limb conscious proprioception, which was normal, and with help from the owner we were able to get the patient to lay with hindlimbs in left lateral recumbency and check for a crossed-extensor reflex, which was normal (no evidence of neurologic disease present). The owner brought a copy of the radiographs, and they showed significant osteoarthritic changes to the coxofemoral joints, supporting the diagnosis of hip dysplasia.
Medical decision making: Since the primary veterinarian had started medical management, my treatment focused on acupuncture. Acupuncture treatment was aimed at relieving muscle tension and strain patterns that were found on myofascial palpation exam, promoting analgesia for the patient’s musculoskeletal condition, while keeping both patient and handlers safe due to patient’s temperament and sensitivity. Points were chosen that would allow and encourage the patient’s acceptance of needles, adding treatment points effecting the central, peripheral and autonomic nervous systems where possible, and working toward points that would help relax specific tense muscles.
Differential Diagnoses: Initial differential diagnoses included: Vascular abnormalities to pelvic limb such as Legg-Perthes syndrome, septic vs. non-septic synovitis or arthritis, Lyme disease, other infectious diseases effecting the musculoskeletal system, osteosarcoma or other musculoskeletal neoplasia, degenerative osteoarthritis, degenerative neuropathy, hip dysplasia, osteochondritis dessicans, cruciate disease, immune-mediated arthritis, myositis, neuritis, trauma to growth plates when young, recent trauma exacerbating another condition, myofascial disorder as either primary disorder or secondary to primary disease.
Definitive diagnosis: Based on history, radiologic findings from the primary veterinarian, lack of fever or generalized pain/symptoms, no significant muscle loss, negative Lyme test (with history of regular tick preventative administration), and exam and palpation findings, most of the differential diagnoses were ruled out. The patient was determined to have hip dysplasia with coxofemoral osteoarthritis and myofascial strain patterns resulting from this disease.
Medical acupuncture and related techniques: The patient received one acupuncture treatment per week for a total of 3 weeks. Treatment consisted of dry-needling acupuncture points, with one electro-acupuncture treatment in the third treatment session. The first treatment was performed using Seirin 0.16mm x 30mm needles due to patient sensitivity. I wanted to make sure the patient had a positive experience and so opted for a smaller diameter, coated needle to facilitate this. Initial points used included GV20-a good initial point to gauge the patient’s response to needle placement, as well as having effects to help reduce agitation/anxiety. GV14 was selected to begin to address the strain patterns in the latissimus dorsi and triceps muscles through the cervicothoracic nerves, and BaiHui was chosen as a major point for hind limb and lumbosacral pain, beginning to address the lumbar and hindlimb strain pattern due to hip pathology, as well as increasing parasympathetic tone which can aid in muscle relaxation. The patient tolerated these points well. Points were added to address thoraco-lumbar myofascial tension, including BL21, BL23, BL25 as these effect the caudal thoracic, thoraco-lumbar and midlumbar spinal nerves that effect the paraspinal muscles in these areas. At this time, BL40 and GB30 were attempted to help more specifically address the muscle tension in the semi-membranosus/tendinosus muscles
and the biceps femoris via neuromodulation of the tibial and sciatic nerves. The patient allowed BL40 to be placed bilaterally, but was very sensitive to GB30 and so at this point the needle was placed and then immediately removed on the right side only. Other common ‘hip points’ (GB29, BL54) were not attempted at this time due to patient sensitivity, and no other needles were placed so that the patient did not have a bad association with the treatment. Needles were left in place for 15 minutes and then were removed.
The second treatment was performed using 0.18mm x 30 seirin needles at GV20, GV14, BaiHui, BL21, BL23, BL25, BL40, and needles left in place for 15 minutes. The larger needle was selected in hopes of better tissue grip because the patient was very excited/wiggly during the second and third appointments. At the second and third treatments, the patient allowed 0.16mm x 30mm Seirin needles to be placed at GB30, GB29 and GB54 bilaterally, left in place for 10 minutes (these needles were placed on one side, left in place, removed, and then repeated on the other side). These points were chosen to help relieve pain and tension in the hips, semi-membranosus/tendinosus and biceps femoris muscles. Though gluteal muscle tension/pain was not appreciated on exam, GB29 (in addition to BaiHui) was utilized to help support normal function of these muscles since they can be effected by gait disturbances due to hind limb pathology. At the third treatment, the patient tolerated placement of 0.20mm x 30mm Seirin needles at BL21, BL23, and BL25 which allowed electroacupuncture to be utilized. Electrical stimulation was placed bilaterally from BL21-BL25 at a setting of 2.5Hz on a 3-channel Ito ES-130, for 7 minutes. This frequency was chosen to provide longer-term analgesia to the patient since this was to be her last treatment for an unknown period of time. During the last treatment, the patient also tolerated needle placement just dorsal to TH10 bilaterally to help relieve local triceps trigger point discomfort. Seirin 0.16mm x 30mm needles were used at these points, and left in for 15 minutes.
Outcomes, Discussion: This patient responded very well to acupuncture and did show improvement of clinical signs as a result of acupuncture treatments. Though the patient was prescribed Rimadyl, the owner did not administer it before or during the acupuncture treatment period. I did not suggest nor encourage withholding the NSAID medication from the patient, but this did allow for a well-controlled scenario to see if the acupuncture itself was of measurable benefit. This patient showed observable improvement after only the first treatment. The owner noted that after the first treatment, the patient started jumping up onto the bed regularly, where as she had been reluctant to jump previously. After the second and third treatments, the owner reported that the patient started playing harder (more energetic, running with more force, not stopping as often for sitting breaks) with other pets. The owner did report that the patient still stood with hind limbs close together, but was enthusiastic about the other improvements that were observed. During follow-up exams (after the first treatment), the most significant change was that the patient became less sensitive to palpation over the hind limbs. The fact that the patient would not allow placement of ‘hip points’ at the first treatment due to extreme sensitivity, but then was receptive to placement (and retention) of needles at these points in the subsequent treatments shows that the acupuncture was decreasing sensitivity in the hind limbs.
This case is a great example of how acupuncture can be used to help with pain management in a commonly-seen orthopedic disease in dogs. Hip dysplasia and hip osteoarthritis effects many pets and can become debilitating especially in the later stages of the disease. Current treatments
include medical management with chondroprotectives1 and varying pain medications, and surgical treatments such as total hip replacement, pelvic osteotomy or salvage procedures such as femoral head ostectomy. Emerging therapies include denervation of the hip joint capsule2 or stem-cell injections3 but these may still involve invasive procedures. Commonly used pain medications (NSAIDS specifically) have significant side effects such and liver or renal impairment and gastrointestinal upset or bleeding4, and surgical repair comes with risks of anesthesia, infection, associated pain from the procedure, as well as significant cost to owners.
Acupuncture can be utilized in these patients to help ease pain, improve mobility, and possibly decrease or delay the need for medications5 or surgical intervention. This case showed me the positive effect that acupuncture can have in treatment of musculoskeletal disease. Due to the severity of this patient’s arthritis (as evidenced by radiologic findings and clinical signs), I was unsure about the degree of effect or improvement that this patient would have. This patient was also highly sensitive and initially I was not confident that I would even be able to place any needles for treatment. However, with the owner’s help and some peanut-butter-filled Kongs, we were able to keep the patient pre-occupied and still long enough to receive effective treatments. Not only did this case show me the powerful effect of acupuncture for treatment of this musculoskeletal condition, but it also taught me that it is important to try to utilize this modality in almost any patient, as they may be more receptive to the treatment than you would expect.
1 Bhathal A., Spryszak M., Louizos C., Frankel G.. Glucosamine and chondroitin use in canines for osteoarthritis: A review. Open Veterinary Journal. 2017;7(1):36-49. doi:10.4314/ovj.v7i1.6.
2 Sienkiewicz W, Dudek A, Czaja K, Janeczek M, Chro ´szcz A, Kaleczyc J. Efficacy of lateral- versus medial-approach hip joint capsule denervation as surgical treatmentsof the hip joint pain; a neuronaltract tracing study in the sheep. PLoS ONE . 2018: 13(1):e0190052.https://doi.org/ 10.1371/journal.pone.0190052
3 Marx C., Silveira M. D., Selbach I, et al., Acupoint Injection of Autologous Stromal Vascular Fraction and Allogeneic Adipose-Derived Stem Cells to Treat Hip Dysplasia in Dogs, Stem Cells International, vol. 2014, Article ID 391274, 6 pages, 2014. doi:10.1155/2014/391274
4 Rimadyl™ Medication Information Insert. https://vetlabel.com/lib/vet/meds/rimadyl-1/ 5 Silva N. E. O. F., Luna S. P. L., Joaquim J. G. F., Coutinho H. D., & Possebon F. S.. Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases. The Canadian Veterinary Journal, 2017: 58(9), 941–951.