Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4365
Abstract: Prissy is a 29-year-old Appaloosa mare that presented with chronic, severe bilateral carpal arthritis. She was initially a grade 4/5 lame in both forelimbs and could not stand unload either thoracic limb even for long enough to clean her hooves. Acupuncture treatments utilizing dry needling were performed over a 4-month period. Prissy is now maintained with acupuncture treatments every 3 weeks; she is no longer lame at the walk on most days and is able to hold both feet up during farrier visits with no sedation.
History and Presentation: Prissy is a 29-year-old Appaloosa mare that presented for lameness of both front limbs beginning in September 2016. The owner had started oral glucosamine/MSM supplementation, Back on Track support boots, and padded shoes. Radiographs at this time showed large osteophyte formation on palmar aspect of the right carpal joint as well as bilateral periosteal reaction and moderate joint effusion. Both carpi were injected with 10 mg triamcinolone and 1 ml HA and Prissy was started on firocoxib 56 mg once daily. Prissy lives in a box stall at night with free turnout in the yard during the day but starting in December spent more time lying down in the stall and struggled when attempting to stand. She was switched from firocoxib to phenylbutazone 1 g twice daily and shockwave treatment every 3 weeks was initiated but resulted in only moderate improvement.
Physical Examination and Clinical Assessments: At presentation in February 2017, Prissy had normal vital parameters and a body condition score of 4/9. She was lame at the walk on both hard and soft surfaces and would occasionally trip on either forelimb. She was unwilling unweight either front limb for longer than a few seconds and required sedation with 150 mg xylazine and 1 mg butorphanol for farrier visits. Moderate bilateral carpal effusion was also present. Prissy had taut muscle bands in the supraspinatous and infraspinatous muscles, restricted myofascia over cervical and thoracic spine, and tense ventral abdominal muscles. She resented myofascial palpation distal to the shoulder joint of either thoracic limb.
Medical Decision Making: A multi-modal approach to treatment was continued for Prissy’s arthritis. The owner desired to return Prissy to firocoxib due to the increased safety for long-term administration, so phenylbutazone was discontinued. Due to the chronicity of Prissy’s arthritis, much of the acupuncture treatments were directed towards secondary muscle tension and dysfunction as a result of compensatory weight bearing. During initial treatments, fewer points were needled as Prissy became agitated by overstimulation of her sore thoracic limbs. The owners instead performed massage every other day during the first month of treatment.
Differential Diagnoses: Differential diagnoses for lameness with carpal effusion include carpal osteoarthritis; less likely immune-mediated poly-arthritis, septic arthritis, or chip fracture
Definitive (or Putative) Diagnosis (or Diagnoses): Carpal osteoarthritis with bilateral periosteal reaction and large osteophyte on palmar aspect of right metacarpal III diagnosed by radiographs
Treatment 1 and 2- 2/11/17 and 2/20/17: dry needle GV 14; bilateral LI 16, ST 10, BL 11, BL 13, BL 23. Prissy was unwilling to allow needling of points on her shoulders or thoracic limbs so points in the neck and bladder line were selected for initial treatments. Prissy’s owner was instructed to perform light acupressure of LI 11, SI 9, TH 14 and massage over the infraspinatous m. and supraspinatous m. all of which Prissy enjoyed.
Treatment 3 and 4- 3/11/2017 and 4/1/17: dry needle GV 14; bilateral LI 10, LI 15, LI 16, LI 17, ST 10, BL 11, BL 13, BL 23, TH 14, TH 15, PC 1, PC 6. Prissy was very relaxed during these treatments compared to the first treatment and would lick/chew especially when needling LI 10, TH 14 and BL 11.
Treatment 5 and 6- 5/1/17 and 5/22/17: dry needle GV 14, Bai Hui; bilateral LI 11, LI 15, LI 16, BL 11, BL 13, BL 21, BL 23, TH 10, TH 14, TH 15, PC 6, ST 10, 36, local trigger points in brachiocephalic m, infraspinatous m, extensor muscles of forelimb.
Outcomes, Discussions, and References: Over the course of 6 weeks, Prissy’s lameness improved to where she was only mildly lame at the walk and she was able to unweight each limb for long enough for the farrier to trim and then apply her shoes without sedation. I believe the massage techniques Prissy’s owner did in between acupuncture treatments helped Prissy as much if not more than the acupuncture itself. After massage she was significantly more comfortable with needling of LI 10, PC 6, TH 14. Massage reduces nerve windup and muscle tension as published by Diego et al. in the Journal of Neuroscience, which due to the chronicity of Prissy’s carpal pain resulted in severe nerve pain.