Written by a Medical Acupuncture for Veterinarians course graduate. Author’s name available upon request. Signed release obtained from client/author. 4377
Abstract: Orbit Ryggs is a neurotic, impossibly handsome, male, castrated 11-year-old Australian Shepherd for whom complementary medicine – and acupuncture in particular – was clearly indicated based on diffuse myofascial disease/restriction, pain, neurological deficits and lateralized left pelvic limb muscle atrophy. Outcome of ongoing treatments has been excellent thus far!
History: No coughing, sneezing, vomiting, diarrhea; up-to-date on vaccines (historical hypersensitivity to rabies vaccine, consider titers from now on). Patient receives carprofen (75 mg BID) & Dasquin (bottle recommendation SID) daily. no other medications or travel history. Eating well, diet: Blue Buffalo Senior kibble. No excessive or inadequate water intake, no history of seizures, syncope or other health concerns.
Presentation: Progressive hindlimb paresis, culminating in an episode of collapse at the top of staircase followed by transient inability to get up, crying/pain/anxiety in early June 2017.
Physical Exam & Clinical Assessments: Patient is BAR and very friendly with BCS of 6/9. Moderate nuclear sclerosis OU, mild epiphoral staining with no blepharospasm or obvious ocular disease. Hyperkeratosis of nasal planum, progressing to mild ulceration over right nare. Oligodontia (majority of maxillary molars absent) with moderate dental calculus present on remaining teeth, especially over buccal aspect of maxillary canines & maxillary 4th premolars. Peripheral lymph nodes all wnl upon palpation. Mild hepatosplenomegaly, abdomen soft and compliant, no obvious pain or masses. Auscultation wnl, no murmurs/arrhythmias, patient is eupneic with normal bronchovesicular sounds along all fields. Musculoskeletal: mild medial buttressing of stifles with no palpable effusion, tibial thrust & cranial drawer absent in awake patient. Patient resists coxofemoral extension at 45 degrees bilaterally. No significant Ortolani sign bilaterally but patient very tense upon manipulation of pelvic limbs and coxofemoral joints in particular. Neurological:Mentation wnl, cranial nerves intact, only peripheral deficit noted was inconsistent slow-to-correct CP deficit in left rear limb.
Myofascial Examination: Marked and asymmetrical atrophy of left pelvic limb musculature. Compensatory, bilateral triceps contracture (especially right front limb), and hypertrophy and myofascial dysfunction of right pelvic limb. Diffuse dorsal epaxial myofascial disease (tension, taut bands & trigger points) extending from occiput to sacrum. Bilaterally symmetrical, firm nodules consistent with large trigger points/neurovascular bundles/myotendinous bulge at the insertions of serratus anterior muscles. Moderate to marked tension, taut bands throughout entirety of dorsum/epaxial musculature/longissimus & iliocostalis muscles, from occiput to sacrum, left side more significantly affected than the right. With mild progressing into moderate pressure, for a patient who has required a muzzle for physical exams in the past, reasonable to assume that current medication protocol is adequate in terms of analgesia. Severe tension/partial contracture/taut bands and trigger points in both triceps, especially the right side. Very amenable to massage/warming and incremental stretches
Differential Diagnoses: Coxofemoral +/- stifle osteoarthritis; generalized rear limb ambulatory paresis – multifocal osteoarthritis +/- neurological component (type I intervertebral disk disease vs mass vs degenerative myelopathy vs peripheral neuropathy); lateralized (to left) pelvic limb muscular atrophy: rule out disuse > neurogenic, myopathy Mild/inconsistent CP deficit in left rear limb – r/o muscular weakness vs true neurologic origin ((lateralized type I intervertebral disk disease vs mass vs degenerative myelopathy vs peripheral neuropathy).
Putative Diagnoses: bilateral coxofemoral osteoarthritis, pelvic limb muscular atrophy. No formal diagnostics (imaging) performed thus diagnoses are not definitive but certainly fit with patient presentation and progression.
Acupuncture Treatments: Bladder line (BL), Gallbladder (GB), Small Intestine (SI), Governors Vessel (GV), Large Intestine (LI) and Triple Heater (TH) were primary channels utilized. Bladder line (especially inner) was mainstay of treatment, based more on palpation and the detection of trigger points and taut bands than anatomical landmarks for established point locations. All treatments were performed using 30 mm long Seirin J-15 coated acupuncture needles. Over the course of 5 treatments, acupuncture needle diameter was gradually increased from 0.16 up to 0.3 cc and the number of points/needles used also gradually increased based on patient’s patience, tolerance and efficacy of dietary distraction. Hip triad was utilized in every session, especially over left hip: BL 54, GB 29 and GB 30. SI 9 and trigger points were targeted in triceps bilaterally. Shoulder points were added: SI 12 & 11, LI 15 & TH 14. Treatment sessions always began with autonomic points: GV20, GV 14, Bai Hui
Outcomes, Discussions & References: Although slow and steady, patient improvement was undeniable in terms of mobility, strength, endurance and overall quality of life. Over a relatively short period of time, changes in muscle mass were not appreciable but presumed given increased length and duration of walks, etc. Unfortunately, patient has not lost a significant amount of weight which is both encouraging (illustrating that treatment interventions played a major role in improvements) and discouraging (considering how much more improvement is possible with weight loss). I was particularly impressed by the impact and utility of tricep muscle treatments. Although it makes sense for these muscles to be replete with myofascial disease due to shifting of weight from the pelvic limbs to the forelimbs, the inevitable influence of egocentric vantage points and the relative rarity of tricep myofascial disease in bipeds culminated in a profound impact of the importance of treating the triceps in quadripeds, especially those with pelvic limb disease and the subsequent shifting of weight to the forelimbs where triceps must take on the brunt of that weight.
Describe Your Medical Acupuncture Experience: Prior to starting this course, aside from cursory discussions with colleagues, I had no experience with medical acupuncture. I have slowly introduced this modality to my protocols since and have been extremely pleased and motivated with the results.
Describe Your Related Medical Experience: I have been a veterinarian since 2003 and completed a rotating small animal internship in 2004. I worked as an emergency clinician for the first 5 years of my career and then transitioned to almost exclusively soft tissue surgery and end-of-life care for the last decade.
Describe your feelings about this case: Although it took a few sessions, I was delighted to see the dramatic benefits of dry needling – for instance, my patient was running and ascending steep stairs without hesitation once the needles were out (necessitating that access to the stairs be prevented in later sessions!). Hearing encouraging and enthusiastic updates from the clients/owners was second only to my patient’s decreased pain and limitations, and increased mobility and quality of life with regard to satisfaction with acupuncture and massage treatments.
How has acupuncture changed your practice: Though I do my best to avoid superlatives, nothing has had a greater impact on my career – on my role as a veterinarian – than medical acupuncture. It has changed my approach to physical examination, surgery, knowledge of anatomy (making me a better if more reluctant surgeon) and the recommendations and the treatments that I offer my patients. I am dumbfounded that myofascial examination was not even mentioned in veterinary school! The sheer amount of information and simultaneous therapy using nothing more than my hands ensure that I – and the way that I practice veterinary medicine and surgery – shall never be the same.