Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017034
Abstract: Greta is a 14 year, 4 month old female spayed Catahoula, who presented for a quality of life discussion due to severe chronic progressive elbow arthritis, anxiety and urinary incontinence. Neuromodulation protocol consisting of: acupuncture – dry needling and electrostimulation (E-Stim), laser therapy, pain medication, trigger point therapy and massage were instituted. Rehabilitation and hydrotherapy were also recommended, but due to time and financial constraints, currently not being implemented.
Greta responded favorably, however did show some transient worsening in lameness following use of E-stim. She is now able go on walks and rise unassisted. Owners are no longer using medication for urinary incontinence, and have noted a significant decrease in her anxiety level and excessive panting. Currently, Greta is being seen on a weekly basis, with the hope to begin to spread out time between sessions.
History and Presentation: Greta is a 14 year, 4 month old female spayed Catahoula, who presented on 7/21/17, for a quality of life discussion due to severe issues ambulating secondary to chronic progressive elbow. Owners reported she not only has difficulty walking, particularly associated with her forelimbs, but now cannot rise unassisted. Her owners also have noted excessive panting and inability to settle, mild urinary incontinence and increasing anxiety. She was adopted in 2007, and prior to this adoption owners have very little history.
• 10/2008- first notation of LFL lameness- no diagnostics done; responded to rest and NSAIDs
• 7/2009- presented for RHL lameness- no diagnostics done responded to rest, NSAIDs and Tramadol
• 3/2012- First notation of decrease ROM and thickening in left elbow
• 11/2013- First notation of decreased ROM in hips and hindlimb muscle atrophy – started on daily glucosamine, and intermittent carprofen
• starting in 2015 (no specific date noted)- Patient was needing daily carprofen twice daily
• 12/2015- Patient was prescribed Tramadol- discontinued due to increased anxiety
• 7/2016- Platelet rich plasma injections (PRP) – bilateral elbows; showed significant improvement, but short lived
• 9/2016- Second round of PRP injections
• 10/2016- Started showing signs of incontinence and placed on Proin and additional analgesic amantadine
• 4/2017- Owner began questioning quality of life
• 7/2017- First time I examined Greta
• 7/27/17- First acupuncture appointment
• Gabapentin 200mg TWICE daily (every 12 hours)
• Carprofen – 50mg TWICE daily (every 12 hours)
• Amantadine 100 mg ONCE daily (every 24 hours)
Physical Examination and Clinical Assessments: Wt: 61.1 pounds = 27.7kg, T: 100.7, P: 90, R: panting, BCS: 4/9, PAIN: 2-3/4
ATTITUDE: Bright, alert, and responsive; EARS: AU: no ceruminous debris, no stenosis or erythema; EYES: OU: No episcleral injection, epiphora or aqueous flare. LS OU; NOSE/THROAT: No nasal discharge; LUNGS/TRACHEA: Clear bronchovesicular sounds in all quadrants, no crackles or wheezes noted, slight increase in upper airway noise; HEART/CARDIOVASCULAR: No murmur or arrhythmia. Femoral pulse strong and synchronous; LYMPH NODES: Mandibular, prescapular and popliteal WNL; HYDRATION: Normal; MUCOUS MEMBRANES: Pink and moist. CRT <2; MOUTH/TEETH/GUMS/TONGUE: Severe calculus, moderate gingivitis ; GI/ABDOMINAL PALPATION: Soft and comfortable. No masses, mild cranial organomegaly due to rounded liver margins; URINARY/REPRODUCTIVE: Normal conformation; NERVOUS SYSTEM: Normal mentation, no ataxia, hyperreflexive patellar reflexes bilaterally with cross extensor present, SKIN/HAIRCOAT/NAILS: Full haircoat, minimal shedding, multiple S/c masses ; PAIN SCORE: 2/4; RECTAL: moderate discomfort with palpation of the pelvic floor; GAIT (https://www.dropbox.com/sh/u5n7do3ww92lbp1/AAAQrhpIboUb_4GaE3e1MwbKa?dl=0) NEUROMYOFASCIAL EXAM: Generalized assessment and gait- Needs to helped up with harness assistance and unable to stand for longer than 20-30 seconds. Mildly kyphotic stance. Stiff stiled gait with wide-based pelvic limb stance. Grade 2/5 weight-bearing L- thoracic lameness. Muscle atrophy of the supra and infraspinatus bilaterally. Moderate thickening of the left metacarpals and thickened elbow bilaterally. Decreased range of motion (ROM) of elbows with callus formation on both, resistant to full extension of shoulders bilaterally. Pain detected on lateral palpation of left elbow with trigger points in triceps and tension along extensors. Pain in right elbow was more medially with tension in flexors. Discomfort and trigger points on paraspinal palpation from mid-thoracic through lumbar spine but most pronounced T-L junction and cranial lumbar region. Trigger points also noted in pectorals. Good ROM in stifles bilaterally, decreased extension of hips bilaterally with right worse than left, and bilaterally thickened metatarsals with decrease ROM.
Medical Decision Making: Greta’s left elbow discomfort was mostly lateral, whereas the right elbow pain was mostly medial, therefore local points would vary on each limb. Local elbow points associated with the radial, median and ulnar nerves would also need to be selected to target the peripheral nervous system. Caudal cervical and cranial thoracic spinal points bilaterally would provide connection into the central nervous system, as well as help with the associated wind-up from chronic elbow OA. Autonomic points – both sympathetic and parasympathetic would be particularly beneficial in this case assisting with anxiety and urinary incontinence. Bilateral dysfunction severely altered her gait causing her to extend and strain her neck while walking; as such, myofascial points would be chosen based on exam to alleviate the subsequent strain pattern in her neck, and paraspinal muscles.
Differential Diagnoses: Severe osteoarthritis of elbows significantly worse on the left with suspect concurrent radial neuropathy. Secondary tension in the latissimus dorsi and myofascial attachments in the lumbosacrum leading to lower back pain. Suspect sciatic neuralgia on right side leading to weakness when rising also contributing to urinary incontinence.
Definitive (or Putative) Diagnosis (or Diagnoses): Radiographic evidence of osteoarthritis in elbows bilaterally and strong suspect OA at insertion of attachment of the right iliopsoas.
Number of Sessions: 10 sessions thus far beginning 7/27/17 and ongoing. Frequency- every 3-4 days for 3 treatments, then weekly.
GV 20 (parasympathetic), GV 14, Bai Hui
BL 10, 11-13, 18-25 (central nervous system/ spinal cord)
L- Thoracic limb- TH 10, LI 4 (peripheral nervous system- radial nerve), LI 11 (extensor trigger points), LI 10, SI 11, SI 12, GB 21, trigger points in triceps
R- Thoracic limb- HT 3, LU5 (local points for medial elbow pain)
L- Pelvic limb- SP 6 (master point of urogenital system) , KI 3 (for urinary incontinence)
R- Pelvic limb- BL 54, GB 30 (peripheral nervous system-sciatic nerve), GB 29 ST 36 (parasympathetic point)
Session 2: Points as above and added: Cervical spinal points bilaterally, LR 3, KI 1, BL 35 on RHL and BL60/KI 3 on LHL Also added in laser therapy on the left elbow
Session 3; Points as above and E- stim from LI 11- HT 3 on the left elbow, Laser therapy on right hip
Outcomes, Discussions, and References:
In Greta’s case, our goal was always to improve her quality of life. We were never going to cure her OA, but we could deal with the secondary issues arising from her chronic disease. She was also experiencing side effects associated with her pharmaceutical protocol, therefore by using acupuncture, we were able to inhibit pain via stimulation of endogenous opioids leading to the desensitization of peripheral nociceptors (Chen et al., 2014). Zhang (2014) noted that the use of electroacupuncture was successful at alleviating inflammatory and neuropathic pain more effectively by activating chemicals through peripheral, spinal, and supraspinal mechanisms. However in Greta’s case, the owner noted increased lameness 24 hours following E-stim. As such, requested that this modality not be used in future sessions. He did however note the most astounding response when using the K-laser, likely due to its ability to reduce pain, inflammation and edema (Hashmi et al., 2010) as well as increasing circulation and improving motor function in dealing with peripheral nerve injury (Larkin et al, 2012). Being able to take Greta off her medication for incontinence was never an ultimate goal, but a surprising benefit, showing how all of her problems were related. After the 3rd session, I also noted a marked improvement in the number of trigger points detected on exam. Qualitatively, Greta was subjectively less anxious, no longer panting or having trouble settling at home. She was also able to get up on her own for the first time in months and able to go on walks which were her favorite activity.