Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018026

Abstract
RyLee, a 7 year 4-month-old, FS Dachshund was presented and treated for pain and discomfort related to intervertebral disc disease. Noted concerns were back pain, a hunched posture and loss of normal function of the hind limbs. Examination revealed ataxia, neurological deficits of the hind limbs and kyphosis and pain of the thoracolumbar spine. Acupuncture and Veterinary Orthopedic Manipulation (VOM) was initiated along with medical therapy of anti-inflammatories and pain medication. RyLee’s past surgical history includes a double mass removal for confirmed lipomas on her cranioventral chest and ventral abdomen in February 2018.
Summary
RyLee responded really well to acupuncture and VOM therapy targeting her pain and discomfort as well as neurological deficits to her hind limbs. Kyphosis of her thoracolumbar spine markedly improved, comfort markedly improved and ambulation, while it did not return to completely normal function, also showed great improvement. After initial improvement, an injury occurred leading to a return of her kyphosis, ataxia and hind limb neurological deficits. Acupuncture and VOM therapy was continued and improvement returned.

History Presentation (Chronologically):
RyLee was seen March 31 2018 for an injury leading to difficulty jumping up, not wanting to run, whimpering and not seeming herself.
Exam revealed hypertonicity of her hind limb musculature and a mild swelling dorsal to the right coxofemoral joint and gluteal musculature. RyLee exhibited normal ambulation at this time.
Medical therapy with Gabapentin and Meloxicam as well as rest and activity restriction (confined to leash walking for bathroom breaks and small bouts of controlled exercise) was instituted. Radiographs were deferred at that time.

RyLee presented again April 6, 2018 for difficulty moving around and acute, non-weight bearing lameness of the left hind limb.
Sedated radiographs of the abdomen, pelvis and hind limbs were obtained.
Radiologist interpretation revealed widespread, in-situ mineralized intervertebral discs indicative of intervertebral disc disease and impression of narrowed L3-L4 intervertebral foramen suggestive of intervertebral disc protrusion with spinal cord or nerve compression a likely cause for presenting complaint. No other radiographic abnormalities were identified.
Medical therapy and activity restriction were continued as RyLee was noted to have improved the next day when the radiograph interpretation was discussed. Advanced imaging (to include MRI, myelogram or CT) was discussed if clinical signs did not improve or worsened despite medical therapy.
RyLee continued to improve and lameness resolved.

July 24 video RyLee P

RyLee presented again on July 17, 2018 for return of lameness (favoring to dragging the right hind limb). Ramps had been placed around the home since her last injury and lifestyle changes to her activity had been made. She was receiving Cosequin and Meloxicam (started 7 days prior to exam). Interest in alternative therapies was expressed.
Myofascial exam: Heat was palpable over the thoracolumbar spine and thoracic inlet. Kyphosis of the thoracolumbar spine and pain with palpation of the epaxial musculature (mid-thorax to the cranial lumbar) was noted. Severe sensitivity with attempt to palpate the abdomen and with light touch over the flanks was exhibited. Hypertonicity of the Triceps and Biceps Brachii musculature was palpated bilaterally. Hypotonicity of the semimembranosus and semitendinosus muscles of the right hind limb was also appreciated. Her hind limbs would buckle underneath her as she walked.
Neurological exam: Ataxia of the hind limbs was appreciated with left sided plegia and right sided plegia to paralysis. Deep pain perception revealed a slow, but present response in the right hind limb and present, normal response in the left hind limb. Conscious proprioception was absent bilaterally in the hind limbs and present/normal in the forelimbs. Patellar reflex was hyperreflexic in the right hind limb and normal in the left hind limb.
Therapy was provided using Veterinary Orthopedic Manipulation (VOM), Gabapentin and continuation of Meloxicam with restricted activity, controlled small bouts of exercise and leash walking for toileting.
VOM therapy noted myofascial restrictions in the cervical, thoracic and thoracolumbar spine. Elevated body condition score was discussed and recommendations for decreased caloric intake/weight loss was provided. Acupuncture therapy was started 1 week after as time did not allow for it at initial appointment.

RyLee presented July 24, 2018 for her initial acupuncture session. She was noted to be moving better and more comfortable, but still dragging her back legs on occasion.
T: UTO HR:120 RR: 30 p/m <2 sec pain: 1 BCS 7/9
Physical examination: Deep pain perception in the right hind limb and kyphosis of the thoracolumbar spine was improved. Swelling previously noted over the right coxofemoral joint was improved.
Myofascial exam: Palpable heat and kyphosis of the thoracolumbar spine was present, but improved. Pain over palpation of the epaxial musculature was noted in the mid-thorax to cranial lumbar spine.
Neurological exam: Hind limb ataxia continued with left sided plegia and right sided plegia. Improvement was noted from the last visit (no further paralysis). The hindlimbs would abduct from the body during ambulation, where at her last visit they would buckle underneath her. RyLee was more stable than her previous visit during movement. Conscious proprioception was absent in the right hind limbs and severely delayed in the left hind limb.
Acupuncture was performed – GV20, GV14, Bai Hui, BL22(B), BL24(B), BL25(B), Hiwato jaji near Bai Hui, Hip Triad-R (BL54, GB29, GB30), BL36(R), Bafeng(R), KI1(R) and KI3(R).

August 3, 2018 – RyLee was presented for her second acupuncture therapy and was reported to be doing really good since her last acupuncture session. She is moving around better and they are noting a little foot dragging, but overall much more improved. They’re also noting that RyLee’s back is less hunched and she is wanting to play more.
Physical examination: RyLee is able to lift the hind feet with normal placement for 50% of the strides. When she became too excited the hind limbs would give out and buckle underneath her. The hind limbs continued to abduct from the body during ambulation. RyLee appears to have improved stability from her previous visit and is wagging her tail more rapidly.
Myofascial exam: Kyphosis and slight heat was palpable over thoracolumbar spine. Pain and discomfort with palpation of the epaxial musculature (mid-thorax to the cranial lumbar spine) remained.
Neurological exam: Ataxia of the hindlimbs is markedly improved. Deep pain perception is present in both hindlimbs. RyLee was very reactive to handling of both hind feet. Patellar reflexes were present normally in both hind limbs and conscious proprioception deficits were delayed bilaterally in the hindlimbs.
Acupuncture: GV20, GV14, Bai Hui, BL20-24(B), BL54(B), GB30(B), ST36(B), BL36(B) *Marked sensitivity with BL20-24 (primarily right side)

August 13, 2018 – RyLee presented for follow up and acupuncture session. She sustained an injury the week before when she jumped down from the seat of their truck onto the floor boards and was again acting painful, hunched and favoring to occasionally dragging her left hind limb.
T: UTO HR: 110 RR: 30 mm: p/m CRT: <2 sec pain score:1 BCS 7/9 Physical examination: Tense on abdominal palpation.
Myofascial exam: Heat continues to be palpable over the thoracolumbar spine. Kyphosis of the thoracolumbar spine and lateral curvature of the lumbar spine to the right was noted. Pain with palpation of the epaxial musculature (T10-L3) was observed. RyLee will swing her hind feet underneath her with internal rotation of the distal hind limbs during ambulation. She was exhibiting a short-strided gait and decreased range of motion (ROM) with coxofemoral flexion in the left hind.
Neurological exam: Mild hind limb ataxia and scuffing/dragging of the hind feet during ambulation was appreciated. Deep pain was present in the right hind limb and absent in the left hind limb. Patellar reflexes were present (hyporeflexic) in the left hind limb and normal in the right hind limb. Conscious proprioception was delayed in the right hind limb and absent in the left hind limb.
Acupuncture and VOM therapy were carried out.
Acupuncture-Seirin 0.16x30mm: GV20, GV14, Bai Hui, BL54(B), GB29(B), GB30(B).
Seirin 0.16x15mm: Placed, manipulated then removed as RyLee was getting anxious KI1(B), KI3(B).
Electroacupuncture using Asia Med Special+ (0.2x30mm) with two leads was focused at BL18-BL25(B).
VOM therapy was performed as well noting myofascial restrictions in the cervical, thoracolumbar and lumbosacral regions (AORA, AOLA, C1, C2, T10, T11, T12, T13, L1, L2, L3, RIS, LIS reads).
Additional diagnostics at this visit included bloodwork to monitor with NSAID use. Mild hemoconcentration was found with bloodwork being otherwise unremarkable.

Aug 21 video RyLee PSept 21 video RyLee P

August 21, 2018 – RyLee was seen for her acupuncture follow up and improvement was noted since her last visit. No new concerns were expressed. She was still receiving Gabapentin 100mg twice daily and Meloxicam once daily.
T: UTO HR: 110 RR: 30 mm: p/m, CRT: <2 sec pain: 1 BCS: 7/9 Myofascial exam: Heat remained palpable over the thoracolumbar spine and kyphosis of the thoracolumbar spine was improved, but remained present. The lateral curvature of the spine was resolved. Pain/discomfort with palpation of the epaxial musculature at T5-L3 and pain with tail jack was observed. Decreased ROM (range of motion) in the left hind limb was not noticeable today. Hypertonicity of the Semimembranosus and Semitendinosus muscles as well as the Gastrocnemius was appreciated bilaterally. Neurological exam: Mild ataxia is improved from the last visit. RyLee continues to swing her feet underneath her with internal rotation of the distal hind limbs during ambulation. Slight scuffing/dragging of the right hind foot > left hind foot is improved from the last visit. Patellar reflex is present and within normal limits in both hind limbs and conscious proprioception is delayed, but present in both hind limbs.
Acupuncture-Seirin 0.20x30mm: GV20, GV14, Bai Hui, BL54(B), GB29(B), BL36(B), BL18(B), BL19(B) Seirin0.16x15mm: Placed, manipulated then removed KI1(B), KI3(B)
Electroacupuncture using Seirin 0.20x30mm with two leads was focused at BL20-BL25(B), spanning the most prominent region of kyphosis.

September 21, 2018 – Acupuncture follow up (4 weeks from last session). RyLee is doing very well at home. She is no longer hunching her back, is moving almost normally and is happy and active. They are continuing to use her Gabapentin twice daily and her Metacam once daily as well as controlled activity and ramps around the home.
T: 101.4 F HR:114 RR: 36 mm: p/m CRT: <2 sec pain: 0-1 BCS 7/9
Myofascial exam: Kyphosis was resolved at this time and RyLee was ambulating with both feet directly underneath her. She had good pick up and placement of her hind feet, normal range of motion of her hind limbs and a good tail wag. Discomfort was noted with palpation along the outer Bladder line (T10-L3) and she was reactive with caudal abdominal palpation.
Neurological exam: Conscious proprioception is present and very slightly delayed in both hind limbs (best response thus far with her visits). Hind foot dragging and ataxia was not noted during examination.
Acupuncture: Seirin 0.20 x 30mm – GV 14, Bai Hui, GB 21 (B), BL 18 – BL23 (B), BL 54 (B), GB 29 (B)
Seirin 0.16 x 15mm – GV 20
*BL points BL 19 (L), BL 21 (L), BL 23 (L) and BL 22 (R) were initially difficult to remove. Seirin 0.16 x 30mm dry needles were placed in close approximation to these needles and gentle manipulation was used to remove each needle slowly as tissues lost grab and released. RyLee was very sensitive to removal.
Medication adjustment: A slow transition off of her daily medications is being started with reduction of the Gabapentin to once daily for 2-4 weeks, then pending response plan to continue to wean off the Gabapentin and over time see if we can reduce or discontinue the Metacam as well.
Recheck set for 4 weeks pending how she continues to do.

Treatment Plan:
The differential diagnosis for RyLee’s initial presentation included severe osteoarthritis or degenerative joint disease, spondylosis, intervertebral disc disease, open. Radiographic changes suggestive of intervertebral disc disease (IVDD) were found and a putative diagnosis of IVDD was made without more advanced imaging to confirm. Also taken into consideration was RyLee’s breed predisposition for IVDD, her clinical signs and neurological deficits seen often with a diagnosis of IVDD.
An acupuncture and integrative medicine plan was put together for RyLee to target specific aspects of the neurological system and areas of myofascial restriction.
Acupuncture points chosen specifically for their central nervous system effects were GV 20 and Bai Hui. Those points chosen to target the autonomic nervous system were GV 14 and ST 36. Peripheral points along the Bladder channel and Gall Bladder channel were used to further target nerve function, inflammation, pain and regions of myofascial restriction. KI 1 and KI 3, as well as BaFeng were used as distal peripheral points to aid with pain and restoration of nerve function to the hind limbs.
Dry needling was chosen for the majority of the points in RyLee’s acupuncture plan and tailored to each visit. Electroacupuncture was specifically used over the region of thoracolumbar kyphosis and radiographical changes consistent with IVDD. RyLee has had a total of 5 acupuncture treatments over 2 months and 2 VOM therapies. RyLee was initially seen weekly for 4 weeks, then she returned 1 month later for follow up (most current therapy). Her therapy is continuing based on her comfort and function as noted at home.
The Electroacupuncture unit used in RyLee’s therapy was model WQ-IOD1 multiple electronic acupunctoscope by M.E.D. Servi-systems Canada LTD. Treatments were with continuous frequency (setting 40-60), at 1.8-2.0 Intensity over 15-20 minutes.

Conclusion:
RyLee showed great improvement over time not only in her comfort and mobility but also in the reduction of medications and frequency of acupuncture sessions needed to maintain her comfort and mobility. Acupuncture, VOM therapy and pain and anti-inflammatory medications were instituted in RyLee’s treatment plan. Acupuncture, Gabapentin and Meloxicam aided with reduction in pain (via release of endogenous opioids, direct effects of Gabapentin and Meloxicam) and reduction of inflammation. Areas of myofascial restriction were targeted with both dry needling, electroacupuncture and VOM therapy. Dry needling was also used to target nerve stimulation (to aid with return of function in areas with neurological deficit) and protection (through reversing inflammation and inhibiting activation of microglia, thereby protecting neurons and oligodendrocytes)
Intervertebral disc disease and similar maladies occur frequently in our small animal patients. Acupuncture and related techniques, as noted above, can be used with good success to help manage the pain and discomfort of patients affected with these conditions as well as improve neurological function. Review of this case has shown how a multi-modal approach to the treatment of canine Intervertebral Disc Disease can result in a quicker return to function and comfort.

References:
1. Lee JH et al. “Systematic Review of Acupuncture for Neck and Lower Back Pain.” Clin J Pain, 2013; 29(2):172-185
2. Nuno et al. “Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases.” Can Vet J. 2017 Sep; 58(9): 941–951.
3. Joaquim et al. “Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits.” JAVMA. June 1, 2010. 236(11):1225-9


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