Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10L2018010

Abstract: A 10-year-old Stationbred gelding was referred for evaluation and treatment with acupuncture for ongoing brachiocephalic muscle pain, diffuse bilateral epaxial muscle pain and bilateral sacroiliac pain. The horse was treated with acupuncture, electro acupuncture and adjunctive treatments including stretches, rest and controlled exercise, weight reduction and Equissage. Acupuncture treatments were performed approximately weekly and are ongoing at time of report writing. Electro acupuncture in particular was noted by the client to improve comfort and demeanour of the horse, however has not fully resolved clinical signs at this stage. Acupuncture is being continued in conjunction with conventional therapy at the time of report writing.

History and Presentation: A 10 year old Stationbred gelding initially presented to a referral institute for a gait abnormality and recent behaviour changes. He was purchased 6 months previously by his teenaged owner for pleasure riding and low-level competition. Prior to purchase he was utilized by the Riding for the Disabled organization, and his only known prior health concern was severe pneumonia several years earlier from which he fully recovered. The behaviour changes consisted of not quite being himself, and walking with his head down frequently, as well as some twitching of his neck muscles, especially when touched. He was up to date with vaccinations, last shod 2 weeks prior, and recent fecal showed no eggs. The horse was kept on pasture year round, and supplemented with a ration balancer and daily hay. On evaluation by a colleague, the gelding was mildly overweight and was found to have pain localized to the lumbosacral region as well as bilateral sacroiliac pain on palpation. Both stifles had a mild degree of effusion present. A bilateral forelimb lameness was evident and a hind limb lameness was also suspected though not fully worked up at that time. Additionally, diffuse bilateral back pain was diagnosed. A recent saddle fitting had suggested his saddle fit poorly, and a new one had been ordered. The horse was discharged with pain medications consisting of low dose phenylbutazone and gabapentin, both to be administered by mouth twice daily for 7 days. Revisit two weeks later with the aim of further localizing lameness: improved thoracic back muscle palpation with limited pain reaction. No improvement was noted in the back musculature over the lumbar and sacroiliac regions. The right side was noted to be most reactive. Stifle effusions remained. Forelimb assessment found a grade 3/5 lameness in both front limbs, as well as long toes, low heels and shoes that were deemed to be inappropriately fitted. 2-view front feet radiographs were obtained and shoeing recommendations were made in order to correct the palmar angle of the coffin bones over the next 2-3 shoeing cycles. Further hind limb lameness localization was delayed until shoeing was addressed. Further recommendations included feed restriction, hand walking but no riding, carrot stretches and daily hot towel rubs to help relax his back musculature.

Revisit 2 months later: Significant pain response on palpation of brachiocephalic muscles bilaterally as well as lumbar epaxial muscles bilaterally. Stifle effusion persisted and was classified as moderate in the left stifle and mild in the right stifle. Gait evaluation found grade 2/5 right front limb lameness, 1/5 left front limb lameness, 3/5 left hind limbs lameness. Flexion tests showed mildly positive on both upper and lower limb flexion on both hind limbs. There was a 70% improvement in left hind limb lameness following intra-articular anaesthesia with mepivacaine injected into the left medial femorotibial joint, lateral femorotibial joint and the femoropatellar joint. Left stifle radiographs identified a mild bony change on the tibial condyle underlying the medial
meniscus. Stifle ultrasound was to be performed at a later visit due to intra-articular injection having been performed this day. During this visit Pavlova received an Equissage treatment for his epaxial musculature. Revisit another 2 weeks later and first acupuncture assessment (14 December 2018): Ultrasound by surgeon revealed a lesion of the medial cranial meniscotibial ligament of the left stifle. Bilateral brachiocephalic pain was reportedly improved, as was epaxial muscle palpation. Sacroiliac pain was reportedly unchanged. Front limb lameness had improved with shoeing. The surgeon assessed him to be 3/5 lame on the left hind on a straight line, as well as on the lunge in both directions. Acupuncture was recommended to see if it would help back pain and sacroiliac pain, with the possibility of steroid injections in the sacroiliac joints if no significant improvement occurred.

Physical Examination and Clinical Assessments including myofascial palpation evaluation and neurological examination: 

Assessment by myself on 14 December 2019: Patient was bright, alert and responsive. Vital signs were within normal limits with a temperature of 100 °F, heart rate of 40 beats per minute and respiratory rate of 16 breaths per minute. Basic physical examination was unremarkable with exception of several superficial sunburn lesions on his pink muzzle. The gelding was overweight with a body condition score of 6/9 and a weight of 603 kg.

Gait evaluation at walk and trot found a 3/5 lameness of the left hind limb, which was present both in a straight line as well as circling in both directions. Myofascial palpation found a number of abnormalities. There was bilateral brachiocephalic muscle pain, especially in the region where LI 18 is located, although this was reported to be much improved with the implementation of corrective shoeing of both front hooves. No atrophy of neck musculature was seen. Palpation of the epaxial muscles (longissimus and iliocostalis mm) found diffuse pain from the caudal aspect of the withers, extending caudally and including the lumbar region. The horse showed appropriate lateral flexion of the neck in both directions but appeared somewhat reluctant to fully ventroflex his cervical spine. Stimulation of dorsal spinal nerves was not tested, as he was already quite uncomfortable on back palpation. Lateral movement of the vertebral column appeared slightly diminished in the thoracolumbar region. Palpation over the sacroiliac joints elicited a pain response bilaterally, though slightly more so on the left side. The left stifle had presence of mild effusion though no pain on palpation. Slight muscle atrophy was observed bilaterally over the longissimus muscles and the gluteal musculature, resulting in a slightly pronounced tuber sacrale. A pain response was also observed with downwards pressure applied to the tuber coxae and was very slightly more pronounced on the left compared to the right, most likely related to sacroiliac pain. Neurologic evaluation did not find any neurological deficits in gait assessment or cranial nerves.

Problem List
-Overweight -Sunburn on muzzle -Hind limb lameness -Left stifle lameness -Bilateral sacroiliac pain -Left stifle effusion -Bilateral brachiocephalic muscle pain (likely secondary to thoracic limb pain) -Diffuse back pain (Epaxial musculature, predominantly longissimus muscle)

Pavlova Video 1

Differential Diagnoses for top two problems
Hind limb lameness – Stifle injury causing ligament damage -Stifle osteoarthritis – Previous sacroiliac injury causing damage to ligaments/hyaline cartilage – Trauma -Cruciate tear (unlikely) *Note* EPM does not exist in this country
Diffuse back pain (epaxial muscle pain) -Poor saddle fit (evaluation by qualified saddle fitter also recommended) -Secondary to hind limb gait abnormality -Secondary to previous forelimb lameness – Kissing spinous process (not ruled out) – Diseases such as immune mediated myositis or vasculitis (considered unlikely) -Infiltrative sarcoma/lymphosarcoma- considered extremely unlikely -Trauma

Definitive (or putative) diagnosis (or diagnoses): A lesion in the medial cranial meniscotibial ligament of the left stifle was definitively diagnosed by u/s. Bilateral sacroiliac injury was strongly suspected based on localization of pain by palpation. Back pain was strongly suspected to be secondary to gait abnormality in fore and hind limbs, rather than a primary condition itself although improper saddle fit had likely contributed mildly. Trauma had not been witnessed but could not be ruled out as an initiating factor.

Medical Decision Making: Full assessment of the patient in conjunction with the surgeon who has been managing the case indicated that acupuncture was likely to be of benefit in treating some of the patients various conditions, in conjunction with continued western medicine. The main focus of acupuncture treatment was on the muscular pain of the brachiocephalic mm and the epaxial muscles, as well as the sacroiliac joint pain. The stifle lesion was not a primary target of the acupuncture sessions, with rest being most likely to assist this; however, distal acupuncture points were chosen to include the stifle as well. Due to multiple conditions, further western treatments were delayed to assess the outcome of acupuncture. Ideally, the surgeon was planning to inject corticosteroids into the sacroiliac joint, however the horse would be recommended to be worked after that, and this was not feasible due to the stifle injury.

Medical Acupuncture and Related Techniques Used: The horse was treated with acupuncture weekly for eight treatments. Treatment is on-going at the time of report writing. The initial treatments were performed with no electrical stimulation as my unit had been ordered, but had not yet arrived. Additional therapy included prolonged rest, with restricted turnout and no riding, some gently hand walking, and hot towel rubs over the back muscles. “Carrot stretches” were utilized to encourage the horse to gently stretch its neck downwards, and to each side, with the aim of helping to release some of the muscle tension and restriction in the brachiocephalic muscles, and the epaxial muscles. An Equissage machine was also used intermittently to help with the back pain- a vibrating machine that sits over the caudal withers/back region. The horse was also placed onto a strict diet, with the aim of losing 50 kg over the next 2-3 months, which will help reduce stress on muscles and joints in addition to numerous other health benefits. A variety of acupuncture points were used over 8 treatments, depending on the assessment of the horse at that appointment. So, not all of the following points were used at every single appointment.

Initially the horse was treated using Purple Seirin needles, 0.25mm by 30mm, however he was quite reactive to these. He responded much better to use of light blue Seirin needles, 0.20mm by 30mm so these were used for future appointments, with exception of Bai Hui where a brown Seirin 0.30mm by 40mm was used each time. When Electrical stimulation was performed, an ITO unit was used to deliver 4Hz, on intensity 2-3, with leads approximately BL13-BL 21 and BL 23 to BL 27 or BL 54. Electrical stimulation was applied for 5-10 minutes. Points used at varying times for treatment included the inner bladder line along the border of the longissimus muscle (BL 13, BL 15, BL 16, BL 18 (both), BL 21, BL 23, BL 25, BL 26, BL 27, BL 28). These points were utilized for back pain, and have local effects on the muscle as well as via spinal nerves innervating it. Bladder points have varying sympathetic/parasympathetic input depending on the level of the spinal cord. The more caudal points (BL 27, BL 28, BL 29) are also useful for sacroiliac pain.

Additional points used on the Bladder meridian (on the left side only) included BL 40 as a master point and distal point, as well as BL 36 and BL 54. Bai Hui was used for parasympathetic calming effect, as well as being a convergence center for numerous nerves in the lumbosacral region. GB 21 was used as a point for saddle pain, as well as for thoracic limb dysfunction and for general parasympathetic calming effect. For neck pain/brachiocephalic pain, points used included ST 10, LI 16, LI 17, LI 18, TH 15, SI 16.

Outcome and Discussion: Due to excellent client compliance, the horse had weekly weigh-ins at the time of acupuncture treatment and had lost 53 kg by the time of report writing. Following eight acupuncture treatments at weekly intervals, the brachiocephalic muscle pain was completely resolved (in conjunction with corrective shoeing). Epaxial muscle pain was significantly improved, with minimal to no pain response on back palpation. Stifle lameness remained unchanged and sacroiliac pain fluctuated between weeks. Sacroiliac pain also changed from left to right as to which side was most painful. At the time of writing, sacroiliac corticosteroid injections were likely to be performed. The owners observed the horse to be more comfortable after the electrostimulation was added to the protocol. He had been quite dull the day after travelling, and needed phenylbutazone, however once E-Stim was used, phenylbutazone was no longer needed. During one acupuncture session when the patient was quite fidgety and moving a lot due to flies, muscular contraction caused bending of a needle at BL16, making it difficult to remove. Placement of a number of needles encircling this needle, allowed the bent needle to be removed a few minutes later. Use of wider diameter needles, or application of fly spray prior to treatment may have reduced the likelihood of this occurring. This horse may also have benefited from use of laser therapy, however finances have precluded the purchase of one at this time, thus this modality was not an option. This was an interesting case to see how nicely the brachiocephalic muscles responded to acupuncture and therapeutic shoeing, and really highlighted some of the learning points from the practical course, regarding painful locations on the brachiocephalic muscle correlating with presence of a forelimb lameness.

Pavlova Video 2

References
Xie, H., Colahan, P., Ott, A.E. 2005. Evaluation of electro acupuncture treatment of horses with signs of thoracolumbar pain. Journal of the American Veterinary Medical Association. July 15;227(2):281-6. Ridgeway, K. 1999. Acupuncture as a treatment modality for back problems. Veterinary Clinics of North America: Equine Practice. April;15(1):211-221.
Martin, B.B Jr., Klide, A.M. 1987. Treatment of chronic back pain in horses. Stimulation of acupuncture points with a low powered infrared laser. Veterinary surgery, Jan-Feb;16(1):106-110.


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