Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017003

Abstract:
Coco, a senior female spayed  Wirehaired Pointing Griffon, presented for evaluation and treatment of suspected hind limb pain and arthritis, with the goal of pursuing acupuncture as an additional modality for pain control and maintaining mobility, and possibly to help reduce age-related constant panting. She showed improvement in her mobility most notably when navigating stairs, mild reduction in her panting, and seemed to relax and even fall asleep in response to dry needling and massage.

History and Presentation:
Coco, a 13 year old female spayed  Wirehaired Pointing Griffon, presented for evaluation and treatment of pain associated with her hind end that was beginning to affect her mobility and level of activity at home. She also had been panting more frequently to the point it almost seemed constant, even when at rest.
Her discomfort was first noted over 2 years ago, but has been slowly progressive to the current point where she can no longer jump into the truck and tires quickly when out hunting with her owner. Her owner reports she occasionally slips and falls down stairs and seems more hesitant to use stairs in general. She has been a bird hunting dog her entire life, and was spayed later in life after having a litter. Her hips and stifles have been evaluated twice, initially before being bred, and more recently when her owner began to notice her slowed gait and increased panting. Both evaluations showed no signs of degenerative joint changes or hip dysplasia. Her increased panting was first noted about a year ago, and chest radiographs were also obtained to assess for possible cardiopulmonary causes of her increased panting and showed no abnormalities. Coco is kept on year-round heartworm prevention and year-round flea and tick prevention.
Her current medications and supplements include 150 mg carprofen given by mouth every 24 hours, and one Dasuquin Advanced chewable for Large Dogs given once daily.
Her medical history includes a Caesarian section and spay performed in 2009, and dental cleanings and evaluations involving oral surgery to remove teeth in 2011 and 2014. There has been no known injury or trauma to the affected joints, and no history of respiratory illness.

Physical Examination and Clinical Assessments:
Her physical exam showed a body condition score of 4 out of 5, a calculus index of 1 out of 4, and numerous subcutaneous masses over her chest and abdomen. She had mildly increased bronchovesicular sounds in all lung fields consistent with age-related changes. She panted throughout the exam, despite no exertion. Her gait was noted to be “choppy” in nature in her hind limbs, with lumbar spinal region kyphosis. Complete blood count and chemistry screening was most recently performed in August 2016, and only mild elevation of alkaline phosphatase was seen. Her 2017 annual heartworm and tick-borne disease screening was negative for heartworm, Lyme, Anaplasma, and Ehrlichia.
Her neurologic exam showed normal mentation, normal conscious proprioceptive placement in all four limbs, normal patellar, biceps, and triceps reflexes bilaterally, and no crossed extensor reflex bilaterally. Her withdrawal reflex was normal in all four limbs.
Myofascial palpation showed increased heat and tension in her hips and quadriceps muscles, more pronounced in the right hind than in the left. Her triceps muscles were very tense bilaterally. She tensed and began lip-smacking with palpation around her stifles, more pronounced with the right stifle. She showed evidence of lumbar epaxial musculature tenderness to light palpation on both sides of her spine, with taut bands along her right thoracolumbar epaxial region, causing muscle fasciculation toward her right fore limb.

Medical Decision Making:
Coco appeared to have no neurologic deficits, and her changes in gait and activity appeared to be related to musculoskeletal pain associated with both of her hips and stifles. My goal with treatment was to have a multimodal approach to her pain control and inflammation reduction, using both physical medicine modalities including dry needling and massage, and non-steroidal anti-inflammatory medication. For autonomic neuromodulation, I planned on using points to stimulate parasympathetic drive since her pain has increased sympathetic drive in general. For central nervous system neuromodulation, I planned on using points near the main nerve supplying the affected joint, namely the sciatic nerve near its point of origin, and peripheral points around the painful joint itself, including hip and stifle points. Also, I planned on needling local trigger points and taut muscle bands in her triceps, quadriceps, and lumbar epaxial musculature, and using the Back Shu and Front Mu points for her lungs to see if we could neuromodulate any somatovisceral or viscerosomatic pain.

Differential Diagnoses:
Vascular – Reduced blood flow to hind limb musculature, such as a thromboembolism
Inflammatory/Infectious – Septic arthritis, Lyme arthritis, osteomyelitis, discospondylitis
Neoplasia – Osteosarcoma, chondrosarcoma
Degenerative – Degenerative joint disease in her hips and stifles
Iatrogenic/Intoxication – Pain from subluxation from positioning for radiographs, plant-related toxicity
Congenital – Undiagnosed hip dysplasia
Autoimmune – Immune-mediated polyarthritis
Trauma – Cranial cruciate ligament tear, pes anserinus tendonitis
Endocrine – Hyperadrenocorticism
Myofascia – Myofascial restriction around origin of sciatic nerve

Definitive (or Putative) Diagnosis (or Diagnoses):
Based on the absence of neurologic deficits and examination findings including pain associated with her hips and stifles, and no evidence of degenerative joint changes on her radiographs, I diagnosed osteoarthritis affecting her hips and stifles. She also had musculoskeletal pain around her lumbar spine, resulting in compensatory over-exertion of her triceps muscles due to shifting of her weight to her fore limbs. Her increased panting was likely due to the combination of decreased lung compliance that has come from advanced age, possible somatovisceral pain, and also response to increased sympathetic drive from the pain.

Acupuncture Treatments:
Channel abbreviations used below include Governor Vessel (GV), Stomach (ST), Bladder (BL), Gallbladder (GB), and Lung (LU).
December 7: GV14, Bai Hui, ST34, ST36, BL13, BL54, GB29. Dry needling was performed using Seirin J-type 0.2 millimeter (mm) width by 30 mm length needles at all points. She would not hold still and resented needling of GV20 and triceps trigger points.
December 14: GV14, Bai Hui, ST34, ST36 left side only (She reacted painfully on right side on needle insertion), BL13, LU1, BL54, GB29, GB30, BL19 on right side (trigger point). I massaged her triceps muscles bilaterally, as she was too sensitive to allow needling. All dry needling was done with Seirin J-Type needles, 0.2 mm diameter and 30 mm in length.
December 19: GV14, Bai Hui, ST34, BL13, BL54, LU1, GB29, GB30. I massaged her triceps and thoracolumbar epaxial musculature. All needling was done with Seirin J-type 0.2 mm by 30 mm length needles.
January 4: GV14, Bai Hui, BL13, LU1, GB29, GB30, BL 54. I massaged her triceps, medial thigh musculature, and hamstrings. I used less points because she was initially nervous, but relaxed after needles were inserted. All points were needled with Seirin J-type 0.2 mm by 30 mm length needles.
GV14 and Bai Hui were chosen for “introduction” points to see how Coco would react to needling, and to help achieve better balance of her parasympathetic versus sympathetic drive. The stomach channel points were chosen for local anti-inflammatory effects, analgesia related to her stifles, and again overall parasympathetic stimulation (ST36). The hip triad points (BL54, GB29, GB30) were chosen for hip analgesia and neuromodulation of the sciatic and cranial gluteal nerves. BL13 and LU1 were chosen as the Lung Shu and Mu points to try to reduce the frequent panting.

Outcomes, Discussions, and References:
Coco responded well to dry needling and massage, but did not show quite as much improvement in her overall comfort as I had hoped. Her owner described her as subjectively doing better with handling stairs and her gait in general, and her panting became less pronounced. Since our clinic does not own equipment to objectively assess her gait such as a force plate, no objective measures were tracked. Her improvement can be attributed to the acupuncture treatments, as there were no changes in medications, supplements, or her activity throughout the case study treatment time. The only adverse event experienced was when I attempted to needle ST36 on her right hind limb during her second treatment. This caused her to jump up from lying down in a very relaxed state, and she did not calm her back to the same level of relaxation at that treatment.
I learned to start with a treatment plan based on the combination of a thorough general exam, neurologic exam, and myofascial exam, and then adjust to what Coco was comfortable with and what she seemed to respond to in the best manner. I also learned I won’t always be able to needle or treat every point I would like to, but instead need to choose those that would be the most clinically important, such as points that treat both locally and have the desired autonomic or central nervous system effects I am going for. The combination of dry needling and massage worked for relief of Coco’s musculoskeletal pain, which is supported by a recent article in the Canadian Veterinary Journal by Lane et al1.

Works cited
1. Lane, David M., Hill, Sarah A. “Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain.” Canadian Veterinary Journal. vol. 57, 2016, pp. 407-414.


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