Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017021

Abstract:
Henry is a 3 year old male castrated Bernese Mountain Dog who was diagnosed with bilateral fragmented medial coronoid processes at approximately 1 year of age. At the time of presentation, Henry exhibited bilateral elbow pain and lameness, as well as myofascial pain and dysfunction in the forelimbs and epaxial muscles. Acupuncture treatment was used to address the myofascial dysfunction and support Henry’s body as it attempted to compensate for the elbow pain. After treatment, the myofascial pain had markedly resolved.

History and Presentation:
“Henry” is a 3 year old male castrated Bernese Mountain Dog. Henry presented with intermittent, bilateral forelimb lameness at less than one year of age. He also displayed weakness of the hind limbs and diffuse muscle atrophy. At approximately 1 year of age, Henry had a CT study performed of all four limbs. The only abnormality identified by the CT was mild, bilateral fragmented medial coronoid process. Surgery was not pursued in this case. Medical management was recommended including physical rehabilitation, maintaining lean body condition, an oral joint supplement, fish oil, and NSAIDs as needed.
The owner chose not to continue with physical rehabilitation because Henry was uncooperative with the prescribed exercises. Additionally, Henry has been diagnosed with food allergies and thus cannot receive the oral supplements. At this time, Henry is able to comfortably perform daily activities including short walks, but he becomes lame in both front limbs after more strenuous exercise. The owner reports that Henry’s elbows crack when he gets up from lying down for long periods of time. The owner’s goal for acupuncture treatment is to improve Henry’s comfort level and maintain his comfort and mobility for as long as possible.

Physical Examination and Clinical Assessments:
Henry is a bright, alert, and energetic dog. Physical exam showed BCS of 4/9, poor muscle development diffusely, few small patches of erythema on the ventrum, mild erythema of the ears, and mild erythema and crusting of the paws. Henry is under the care of a dermatologist for his skin lesions. Neurologic exam including postural reactions was within normal limits. Other than the musculoskeletal abnormalities listed below, the rest of the physical exam was unremarkable.
Henry displays a number of conformational and musculoskeletal abnormalities. As mentioned above, he has very poor muscling throughout his entire body. The muscles of both limbs are very underdeveloped for a dog of his size, and the epaxial muscles are also noticeably underdeveloped. Henry also displays generalized weakness; for example, the owner reports that he has always needed assistance to get onto the bed or into the car.
Henry’s front limbs have a very upright conformation, with a very straight angulation of the distal limb. He has mildly decreased range of motion in both carpi. He resists elbow flexion and palpation and has moderately decreased range of motion of both elbows. He walks with a stilted gait in the front limbs, taking short steps and circumducting the limbs rather than flexing them. The rear limbs have a tarsal valgus and sickle hocked conformation. He also displays weakness of the rear limbs. His back is mildly kyphotic in the thoracolumbar region. The neck is non-painful and has excellent range of motion in all directions.
Myofascial palpation revealed soreness along the inner bladder lines of the epaxial muscles on both sides of Henry’s back in the thoracolumbar region. Trigger points were identified bilaterally in the long head of the triceps near the attachment to the olecranon. Tight bands were palpated in the supraspinatus and infraspinatus muscles.

Medical Decision Making:
My first treatment goal was to address the myofascial discomfort that I detected in Henry’s epaxial muscles, triceps, and supra- and infraspinatus muscles. I believe that this discomfort was an appropriate initial target because of the discomfort on palpation and the high likelihood of success with treatment. I also chose points that would target the elbow directly. To accomplish this I chose points that would target the ulnar nerve and the spinal segments that supply the forelimbs.

Differential Diagnoses:
1. Fragmented medial coronoid process
2. Congenital conformation defects
3. Osteoarthritis – particularly of the elbow joint, but also other joints
4. Cervical neuropathy – Wobbler’s syndrome, IVDD
5. Nutrition related muscle atrophy
6. Disuse muscle atrophy

Definitive (or Putative) Diagnosis (or Diagnoses):
The CT study confirmed the presence of fragmented coronoid processes. Although recent radiographs are not available, based on the progression of this disease and the clinical presentation, it can be inferred that there is also significant osteoarthritis of the elbow joint. Due to his conformation, osteoarthritis is also likely to be currently present or develop in the future in other joints as well. The myofascial pain is believed to be secondary to protection of the painful joints.
Inflammatory and infectious causes were not considered because of the duration of these signs (over 2 years). Cervical neurologic disease was considered less likely due to the lack of neck pain, the excellent range of motion of the neck, and the lack of neurologic deficits on neurologic exam.
The generalized muscle development was attributed to nutritional causes – Henry eats a vegetarian diet due to his food allergies, and he is also calorie restricted in order to maintain lean body condition. Additionally, he is not a very active dog, which contributes to the lack of muscle development.

Acupuncture Treatments:
Treatments were performed approximately every two weeks; there have been three treatments to date with plans to continue
Needles Used:
• Seirin J-Type needles 0.16 x 30mm
• Seirin J-Type needles 0.20 x 30mm
Points Selected:
• GV 20
o chosen for calming and relaxation effects
• GV 14
o chosen to address thoracic limb pain and weakness
• Bai Hui
o chosen to address pelvic limb weakness
• Bilateral BL 11, 12, 13, 14
o chosen to target the cervicothoracic spinal nerves that innervate the thoracic limbs
• Bilateral BL 18, 20, 22, 23, 25
o chosen to target local pain palpated in this region
• Bilateral SI 11, SI 12
o chosen to address the tight bands and atrophy identified in the supraspinatus and infraspinatus muscles
• Bilateral SI 9
o chosen to address generalized thoracic limb pain and local triceps tension
• Bilateral HT 3
o chosen to address elbow pain and for neuromodulation of the ulnar nerve
• Bilateral LI 10
o chosen for elbow pain and neuromodulation of the radial nerve with the goal od addressing triceps tension and trigger points
• Also used dry needling directly in the triceps trigger points
Electroacupuncutre:
• Used bilaterally from BL 18-23 to address the local myofascial pain
o Frequency of 2 was used for approximately 10 minutes
o Using ITO ES-130
o This area was chosen as the initial target of electrostimulation because Henry was most reactive to myofascial palpation at this site
• At this time, Henry’s patience for acupuncture sessions is limited. In future sessions, I would like to use electroacupuncture to target the elbows and triceps muscles

Outcomes, Discussions, and References:
Henry responded well to acupuncture treatment. He struggled with relaxing and holding still for extended periods of time, so sessions were kept relatively short to accommodate his needs. The myofascial abnormalities were demonstrably improved after a single session – the bladder line was less reactive to palpation and the triceps trigger points had noticeably relaxed. At subsequent sessions, these areas remained improved in comparison to the initial exam.
At this point in the treatment, Henry’s elbow abnormalities remain unchanged. Based on the severity and chronicity of his osteoarthritis, I am not confident that acupuncture, or any other treatment, will be able to mitigate his elbow pain. However, I believe that acupuncture treatments have already, and will continue to, improve his overall comfort and quality of life. In their 2009 study, Bockstahler et al. examined compensation patterns in dogs affected by elbow osteoarthritis. They found the most notable compensation to be an increased load bearing on the contralateral hind limb, and they also hypothesized that vertebral spine dysfunction could occur secondary to elbow osteoarthritis or other forelimb lameness. Acupuncture can be used in Henry’s case to abate the myofascial dysfunction that occurs in his forelimb and back secondary to his elbow pain, as well as to support his hind limbs as they bear an increase load due to his forelimb lameness. I suspect Henry’s back takes more of the compensatory brunt than his hindlimbs due to the hindlimb weakness and conformational abnormalities. Strengthening his hindlimbs should be another treatment goal moving forward.
A 2006 study by Kapatkin et al. examined the affect of electroacupuncture on force plate analysis of dogs with confirmed elbow osteoarthritis. The study did not find any affect on the force plate readings. However, 8 of 9 owners in the study were able to successfully identify when their dog received electroacupuncture treatment versus a sham treatment. This supports the idea that acupuncture can help these dogs feel better and enjoy an increased quality of life, even if their primary problem remains. I also believe acupuncture can help support Henry as he ages, as he is likely to develop osteoarthritis in additional joints due to his size, conformation, and compensatory patterns.
Moving forward, Henry will continue to be maintained with regular acupuncture treatments and NSAIDs as needed, particularly for days when he has more activity and exercise than normal. Additionally, I recommended Adequan as an option for joint support that would not aggravate his food allergies.

References:
Bockstahler, Barbara A., et al. “Compensatory Load Redistribution in Naturally Occurring Osteoarthritis of the Elbow Joint and Induced Weight-Bearing Lameness of the Forelimbs Compared with Clinically Sound Dogs.” The Veterinary Journal, vol. 180, no. 2, 2009, pp. 202–212., doi:10.1016/j.tvjl.2007.12.025.
Kapatkin, Amy S., et al. “Effects of Electrostimulated Acupuncture on Ground Reaction Forces and Pain Scores in Dogs with Chronic Elbow Joint Arthritis.” Journal of the American Veterinary Medical Association, vol. 228, no. 9, 2006, pp. 1350–1354., doi:10.2460/javma.228.9.1350.


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