Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017007
Abstract: Scarlett is a 3 year old mix breed dog who was diagnosed with hip dysplasia at 8 months old. She had been medically managed on glucosamine/chondroitin and fish oil. Her owner recently noticed her posture has changed to become more kyphotic. She was interested in other methods of treatment to manage Scarlett’s suspected pain and elected to move forward with acupuncture treatments. Scarlett returned for several treatments of acupuncture twice weekly for 3 weeks and the owner reports that she has an increased energy level and her posture has become more normal in appearance but not completely improved.
History and Presentation: Scarlett is a 3 year old mix breed dog who presents for physical exam and acupuncture. Scarlett was adopted as a puppy. At 8 months old Scarlett was non-weight bearing on her left hind limb. Radiographs were performed at this time and moderate to severe hip dysplasia with bilateral mild osteoarthritic changes were detected. Scarlett was placed on rimadyl for 1 week and her symptoms subsided. Since then the owner had placed her on Dasequin and Welactin. Scarlett has been doing well but she does slow down on longer runs or hikes. More recently the owner noticed that Scarlett appeared more kyphotic than normal and is concerned she may be in pain. The owner elected to try acupuncture before further work-up.
Physical Examination and Clinical Assessments:
Eyes: Menace intact OU. No ocular discharge.
Ears: Minimal ceruminous debris AU.
Oral cavity: MM pink, moist, CRT <2 seconds. No significant periodontal disease visualized.
Integ: Healthy skin and coat.
LN: No peripheral lymphadenopathy.
Resp: Eupneic. Normal bronchovesicular sounds in all fields. No crackles or wheezes.
CV: Grade III/VI left apical systolic mumur. Strong, synchronous, symmetric femoral pulses.
Abd: Soft, non-painful. No masses, organomegaly, or ascites palpable.
Rectal: Adequate anal tone, no masses or pain palpable, scant soft brown feces in colon. Anal glands moderate in size, easily expressed brown liquid.
U/G: No discharge.
M/S: Ambulatory x 4 with no lameness noted. BCS 5/9. Moderately kyphotic posture. Reluctance to extend hips bilaterally,
Neuro: Bright, alert, responsive. Normal mentation, cranial nerves intact. No postural deficits. Moderate thoraco-lumbar and distal lumbar pain palpated , full cervical range of motion.
Hydration: Adequate hydration, <5% dehydrated.
Musculoskeletal palpation: Taught bands detected in the cervical region, thoracolumbar region, lumbosacral region. Pain elicited on palpation of T13-S1.
Medical Decision Making: For Scarlett, we only had dry needling available but had laser or electroacupuncture been available, we may have added those in. We wanted at least 3 treatments over 3 weeks to start and the owner was open to more so we decided on 2 treatments weekly for 3 weeks for a total of 6 treatments. A thorough myofascial exam was conducted and light massage was also used to begin treatments. Light massage was also used after each treatment to help loosen muscles and relieve any lingering tension. It was decided the focus would be the cervical region, back and pelvis, in particular the bladder line with a few additional points. These points are used often with issues involving the muscles following the spine (epaxials), as well as hips/pelvic area where Scarlett seemed to have most of her discomfort. With these points, we hoped to loosen muscle fibers (fascial release), increase blood flow and decrease local inflammation which would therefore decrease pain for Scarlett.
Differential Diagnoses: Scarlett was already diagnosed with hip dysplasia with some arthritis but she most likely also has some associated muscular back pain based on her myofascial exam. This may be contributing to her appearance and she may have some other secondary skeletal changes which would need further diagnostics. She may also have some cervical muscular discomfort either associated with her painful pelvis or as a separate entity, potentially due to the use of her gentle leader harness. The cervical and back tightness could also potentially disc related but is considered less likely at this point.
Definitive (or Putative) Diagnosis (or Diagnoses): Hip dysplasia with associated arthritis and muscle trigger points of the cervical and lumbar regions. This is based on previous radiographs and myofascial exam.
Acupuncture Treatments: For Scarlett, we only had dry needling available but had laser or electroacupuncture been available, we may have added those in. We wanted at least 3 treatments over 3 weeks to start and the owner was open to more so we decided on 2 treatments weekly for 3 weeks for a total of 6 treatments. A thorough myofascial exam was conducted and light massage was also used to begin with. To start, GV 20 (governor vessel) was activated using red Seirin (0.16 x 30mm) for all treatment sessions. This was to help Scarlett relax before continuing. This seemed to help her quiet down. DBC spring needles (0.18 x 30mm) were used for all other points. Bladder 10 was used for cervical tension as well as BL 11. These activate cranial cervical and cervicothoracic spinal nerves. These needles were turned to activate connective tissue until tension was felt. GV 14 was also used to aid in neck and back pain and activates the cervicothoracic spinal nerve. GB (gallbladder) 21 was used for local cervical pain and activates the spinal accessory nerve. These needles were also turned until tension was felt to help alleviate cervical muscle tightening. Bladder lines 18,19, 20, 21 and 22 were activated bilaterally for possible local pain/discomfort. BL 23 was used for lumbar and pelvic pain. These activate caudal thoracic and thoracolumbar spinal nerves. BL 27 and 28 were also used for potential local pain and activate S1 and S2 spinal nerves. BL 35 was used for any sacral pain and activates the sacral spinal nerve. BL 52 was activated for lumbar and pelvic pain and is associated with the thoracolumbar spinal nerve. BL 54 was used for any hip and gluteal pain and involves the sciatic nerve. GB 29, 30 and 31 were also used for hip issues by activating cranial gluteal, sciatic and femoral nerves. Bai Hui point was used for lumbosacral pain and activates the mid to caudal lumbar spinal nerves. Most of these points were used for all 6 treatments as Scarlett tolerated needling well. The first couple sessions lasted about 15-20 minutes and were prolonged to 35 minutes as the sessions continued and Scarlett got used to needling. It was noted she had less and less cervical tension as sessions progressed and needles in this area did not need to be left in as long as previous.
Outcomes, Discussions, and References: The needling appeared to really help with muscle banding and tension points. Scarlett’s cervical tension loosened as treatment progressed both at each treatment and in the long term. As the sessions progressed, less time was needed for the needles in this area. The winding of the collagen fibers allowed for relaxation of the muscles. The same can be said for the tight bands of muscle of her epaxials but the muscle relaxation took longer and the banding seemed more intense than the cervical region which would fit with her on going arthritis and hip dysplasia. The hip/pelvic points were attempted to be left in the longest at each session so she could get as much benefit as possible. Although Scarlett still is stiff on hip extension (expected with arthritis), she does feel more loose in her back muscles and back end in general and appears to have less of a kyphotic appearance. Owner also states she has more energy on walks and is able to walk for longer distances although still seems painful if pushing it too much. Releasing muscle tension over all by winding collagen fibers and increasing blood flow seems to aid Scarlett in her hip dysplasia pain as they are most likely secondary to this. Although the arthritis and hip dysplasia will not improve, it does seem we can make her more comfortable by getting ahead of the chronic secondary pain she gets from muscle banding and tension points and this may help slow the progression of her current diseases. Good myofascial exam is important for proper needle placement and plan as well as examining results of acupuncture. Massage was also used for muscle relaxation, before and/or after treatment.
This treatment plan showed that irreversible diseases can still be helped by treating chronic pain and that acupuncture does have a role in this as well as massage. There is a wide range of effects and these are patient dependent but it may be a good alternative, especially if owners or pets cannot/do not want to use medications or they are already on max amount of medications. In this case, the owner wanted to attempt other means than medication at this time.
References for this treatment plan include DVM360: Acupuncture is Pinteresting, but is there any point? (Kathryn Primm, 2016), Skeptical about Veterinary Acupuncture? Get Current. (Janice Huntingford, 2016), Acupuncture: The Science Behind the Practice (Nancy Scanlan, 2008), JAVMA: Owner assessment of chronic pain intensity and results of gait analysis of dogs with hip dysplasia treated with acupuncture (Teixeira et al, 2016), Curacore Canine Point Mini Manual.