Written by a Medical Acupuncture for Veterinarians course graduate.Signed release obtained from client/author. A2017024
A 15 year old Quarter Horse named “Dude” was examined for sudden onset of misbehaving on trail rides and dribbling of urine. He was diagnosed with sabulous cystitis and moderate back pain. The sabulous cystitis was treated with antibiotics, bladder lavage and acupuncture. Electroacupuncture was also used to treat pain in the thoracolumbar area of his back. Three acupuncture treatments were performed one week apart resulting in resolution of clinical signs. Dude will continue to get monthly maintenance acupuncture sessions to keep him pain free and ready continue his trail rides.
History and Presentation
Dude is a 15 year old, gray, Quarter Horse gelding. The current owner has had him in her care for a little over a year. His owner is a beginner and rides him only once or twice a month, usually just taking him on trail rides at a walk or trot. He is healthy with no major illnesses or lameness issues. Recently, the client has noticed Dude being more resistant on his trail rides. He will occasionally stop and refuse to move forward. The client has also noticed that he has been dribbling urine for a few weeks. He will often drop his penis to urinate and only urinate a small amount and grunt/strain while urinating.
Physical Examination and Clinical Assessments
1. Physical Examination: On initial examination, Dude was bright, alert and responsive. TPR and other physical exam findings were within normal limits (WNLs). BCS: 5/9. Oral examination revealed moderate to severe enamel points moderate rostral hooks. Limb palpation WNLs.
2. Soundness Evaluation, Flexions, Neurologic Examination: Dude was sound at a trot in hand. He was negative to flexion testing and Negative to hooftesters in all 4 limbs. Cranial nerves were all WNLs. No ataxia was noted with neurologic examination performed at the walk.
3. Myofascial Exam: Myofascial palpation revealed sensitivity over the TMJ bilaterally, worse on the left than the right. He had very good flexibility in his neck bilaterally. He was extremely sensitive to palpation of his back in his epaxial muscles bilaterally, especially in the area where the cantle/seat of the saddle sits. He also had some tightness and trigger points in his hamstring muscles and triceps bilaterally, worse on the left side than the right. Palpation of BL-28 was painful, causing him to drop his pelvis when pressed.
4. Further Diagnostics: I am not the primary care veterinarian in this case, so I recommended she discuss the urine dribbling with her regular veterinarian. The regular veterinarian performed a CBC/Chemistry, urinalysis, palpation per rectum, and ultrasound of the bladder. Bloodwork was WNLs and ultrasound revealed no abnormalities. Urinalysis was unremarkable except for the urine was very thick and cloudy. The client’s primary care veterinarian performed a dental float at my recommendation.
Differential and Definitive Diagnoses
Differential diagnoses for the urinary tract clinical signs included: urolithiasis, cystitis, and neurologic problem causing decreased innervation to the urinary bladder. After all of the diagnostics listed above, Dude was diagnosed with sabulous cystitis. Based on myofascial palpation, I also diagnosed him with moderate back pain, possibly from the saddle or the weight of an inexperienced rider.
Medical Decision Making
The treatment of the sabulous cystitis was decided on and performed by the client’s primary veterinarian. It included antibiotics (Trimethoprim Sulfa) and lavage of the bladder via catheterization. My goal with the acupuncture was to treat the sore back and trigger points that I detected on my myofascial examination and treat points associated with genitourinary disorders to help mitigate any visceral pain possibly associated with the sabulous cystitis.
Acupuncture has been used often to treat chronic back pain in horses. Dr. Martin and Dr. Klide demonstrated in their 1987 paper that stimulation of acupuncture points lead to the alleviation of signs in 13 out of 15 horses with chronic back pain, allowing them to continue to train and compete. Similarly, in another paper by the same authors published two years later, 37/45 horses with a history of chronic back pain were able to compete and train after stimulation of acupuncture points. In both papers, the treatments were performed one week apart, so I decided that is the spacing I would use for my treatments as well. Pain in my myofascial examination was mainly in the caudal thoracic and cranial lumbar area. I wanted to neuromodulate the mid thoracic, caural thoracic, thoracolumbar and mid lumbar spinal nerves with my acupuncture treatment for the back pain and relax tight muscles in that area. Acupuncture has also been used to treat visceral pain, as one would expect to find in a case of cystitis. In humans, a study by T. Alraek et. al in 2001. demonstrated women with recurrent urinary tract infections and cystitis reported an improvement in their clinical signs after treatment with acupuncture. More recently, the same researcher also found that treatment of adult women with acupuncture reduced the recurrence rate of urinary tract infections when compared to those who had not been treated. In this study they used a combination of points such as CV-3/CV-4 and BL-23/BL-28 and distal points such as KI-3, SP-6 and 9, ST-36, and LR-3. I hoped that the human research could translate to equine patients as well and I could incorporate some of these points in my treatment. Specifically, I was hoping to neuromodulate innervation to the bladder through S1 and S2 spinal nerves.
June 3rd-June 20th:
All acupuncture treatments were performed one week apart after a myofascial examination. GB-21 bilaterally, GV-14, and Bai Hui were used for their central effects. ST-7 was stimulated due to his TMJ pain and ST-36 for its immunomodulatory properties. Along his bladder line I placed needles in BL 18, 21, 23, 25 and 28 bilaterally and used electroacupuncture between BL 18-25. I did mixed mode with frequencies of 2Hz and 100Hz. This was for his back pain and BL-28 as the bladder back shu point. Trigger points in his triceps and gluteals were deactivated. 0.30mm x 40mm Serin needles were used for all points except for ST-7 and ST-36, where I used 0.16mm x 15mm Serin needles.
Outcomes, Discussions and References
I feel that the outcome in this case was very positive. The owner’s goal was to make Dude more comfortable and to continue riding him on trails. I told her to expect to do some maintenance acupuncture once a month. Research in the human field makes me feel that acupuncture may help decrease the relapse of cystitis. Similarly, by using acupuncture to stimulate innervation to his bladder, I treated a possible neurologic cause of the sabulous cystitis. Decreasing pain through the use of acupuncture likely sped up his recovery and could have made it easier for him to posture to urinate.
Dude’s poor behavior on the trails was due to pain and I was able to use acupuncture to treat it. There were no other changes in his environment or medication regime other than the acupuncture and we saw significant improvement in his demeanor. His myofascial examination improved each week, with him reacting less and less to palpation along his back. This was something I could definitively and visually demonstrate to his owner, which she was thrilled to see. Neuromodulation of the spinal nerves innervating the thoracolumbar area in conjunction with trigger point deactivation in epaxial musculature made helped Dude’s back pain leading to improved quality of life for him and his owner.
Alraek, Terje, et al. “Acupuncture Treatment in the Prevention of Uncomplicated Recurrent Lower Urinary Tract Infections in Adult Women.” American Journal of Public Health, vol. 92, no. 10, 2002, pp. 1609–1611.
Alraek, T., and A. Baerheim. “An Empty and Happy Feeling in the Bladder: Health Changes Experienced by Women after Acupuncture for Recurrent Cystitis.” Complementary Therapies in Medicine, vol. 9, no. 4, 2001, pp. 219–223.
Klide, AM, and BB Martin. “Methods of Stimulating Acupuncture Points for Treatment of Chronic Back Pain in Horses.” Journal of the American Veterinary Medical Association, vol. 195, no. 10, 1 Nov. 1989, pp. 1375–1379.
Martin, BB, and AM Klide. “Use of Acupuncture for the Treatment of Chronic Back Pain in Horses: Stimulation of Acupuncture Points with Saline Solution Injections.” Journal of the American Veterinary Medical Association, vol. 190, no. 9, 1 May 1987, pp. 1177–1180.
Robertson, Sheilah A., and L. Chris Sanchez. “Treatment of Visceral Pain in Horses.”Veterinary Clinics of North America: Equine Practice, vol. 26, no. 3, 2010, pp. 603–617.