Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017017
Abstract: The following case report shows that acupuncture can be utilized as an important adjunct tool for treating acute neurologic conditions. The patient had an acute neurological insult and was treated with emergency medical supportive measures, but was also started on an acupuncture treatment regimen immediately. The patient was able to recover from being recumbent/unable to stand, to being supported in a sling, to currently being ridden lightly under saddle again. The outcome of this scenario could have been grave but due to the intensive treatment that this patient received, the patient recovered. Acupuncture was utilized in this case to encourage recovery of the nervous system, as well as treat myofascial discomfort associated with the initial injury and the recovery process.
History, Presentation: A 9 year old Thoroughbred gelding was found laterally recumbent in the morning, with multiple lacerations with local swelling around the orbits, abrasions to the hocks and knees, and unable to rise. There was evidence of struggle and the horse appeared exhausted. The horse was clinically normal at 9pm the previous night and had no previous symptoms of disease. The horse was regularly vaccinated for Rabies, Potomac Horse Fever, Eastern/Western Equine Encephalitis, Tetanus, Equine Influenza, Rhinopneumonitis, West Nile Virus (WNV) and Botulism, and was used as a pleasure riding horse.
The primary veterinarian was called out and the horse was treated initially for dehydration and the horse was presumed to have ‘tied up’ (exertional rhabdomyolysis) and was unable to rise due to exhaustion. Blood was drawn for a complete blood count and serum chemistry (CBC/Chem), and the horse received initial emergency medical treatment including Banamine (flunixin meglumine), methocarbamol, Solu-Delta Cortef (prednisolone sodium succinate), dexamethasone, 10 liters of intravenous fluids, and a dose of dimethyl sulfoxide (DMSO) in saline. The primary veterinarian gave instructions to try to get the horse up after an hour or so, and if the horse was unable to stand, he would need to be turned to alternate sides of lateral recumbency every 2-4 hours to prevent pressure sores and compressive peripheral nerve damage. At this time the horse was readily eating hay, and was allowed to eat and rest as he needed to regain strength.
By the evening, the horse was still unable to rise, despite multiple attempts, and concern was growing that the horse was not just ‘tied up’. At this time, the horse was started back on intravenous fluid therapy, and started on intravenous oxytetracycline for concern of possible Lyme disease. An Anderson sling and tripod was obtained from a local rescue and the horse was lifted to its feet. It was still unable to stand without support from the sling. Overnight, the horse had a seizure while in the sling.
The next day the horse was also started on oral Marquis (Ponazuril) for treatment of Equine Protozoal Myelitis (EPM) as a possible cause of disease. The sling was lowered for short periods of time to start encouraging the horse to start holding his own weight up without assistance. The horse was eating and drinking readily, and intravenous fluid therapy was discontinued, but other medical treatment (Banamine, dexamethasone, DMSO, oxytetracycline and Marquis) was continued. The primary veterinarian took blood and nasal swab samples for testing of EPM, Lyme disease and an IDEXX equine respiratory panel (Adenovirus, Influenza, Equine Herpesvirus type 1, 2, 4, 5, Rhinitis A and B virus, Streptococcus equi subspecies equi and zooepidemicus, S. Dysgalactiae supsp. equisimilis). The CBC/Chem that was drawn at presentation did not have significant changes except for a stress leukogram and mild elevation of creatine kinase. After 3 days in the sling, the horse had a suspected second seizure and toppled himself with the sling to the ground. At this time the horse was unhooked from the sling and after a short rest, was able to stand. Cervical spine radiographs were taken and no pathology was seen. Medical supportive treatment was continued and infectious disease tests came back negative, with the exception of the EPM titer which showed evidence of exposure to the causative organism, but not proof of active EPM disease. The patient never had a fever and had a good appetite during the entire ordeal.
Physical exam, clinical assessments: My first evaluation of the patient was after the initial medical treatment, while he was still recumbent. The exam revealed rigidity in the gluteal, semi-membranosus/tendinosus and lumbar longissimus dorsi and ileocostalis muscles. The horse also seemed to have decreased tone to the tail, but normal anal tone. Mentation and cranial nerves were normal. The horse appeared to have normal sensation to hind limbs. When the horse tried to rise, he was able to get his legs underneath him, but lacked the muscle strength and coordination to lift himself off the ground and stand.
When the patient was in the sling, he was very weak in the pelvic limbs, having significant weakness and conscious proprioceptive (CP) deficits to the hind limbs with the left being more severely affected. Once out of the sling, I was able to appreciate significant swelling on the neck bilaterally around the 5th cervical vertebrae (C5), some soft tissue swelling around the withers, swollen left pectoral muscle, and severe muscle tension throughout the shoulders, back and hind limbs (supra and infrascapular muscles, longissimus dorsi along thoraco-lumbar region, gluteal muscles, biceps femoris muscles, semi-membranosus/tendinosus and gastrocnemius muscles). Once out of the sling, the horse was very ataxic on the pelvic limbs showing a base-wide gait, toe dragging and mildly hypermetric gait of the pelvic limbs. He still had decreased CP, especially in the left hind limb, but was able to stand against a standing tail pull in both directions and back up without losing balance. About 4 days after initial injury, tail tone began to return and in the next few weeks the hind limb ataxia slowly waned. Over the following months, the horse’s strength, coordination and general condition improved significantly.
Medical Decision Making: The medical management of this case was done by the patient’s primary veterinarian. Both the central nervous system (seizures, loss of CP) and peripheral nervous system (muscle weakness) were affected in this case, and there was severe musculoskeletal/myofascial pathology. Acupuncture therapy was aimed at improving neurologic status (decreasing ataxia, improving CP, possibly preventing further seizure activity), regaining muscle strength, relieving pain and abnormal muscle tension/tonicity.
Differential Diagnoses: Differential diagnoses for this case included: Fibrocartilagenous embolism, brain or spinal cord embolism, cerebrovascular accident, EPM, neuroborreliosis, Equine herpesvirus, WNV, Equine Viral Encephalitis, Rabies, Tetanus, Botulism, bacterial meningio/encephalitis, myositis, polysaccharide storage myopathy (PSSM), exertional rhabdomyolysis, neurotoxin exposure, hepatic encephalopathy (+/- hyperammonemia), neoplasia of the brain and/or spinal cord, degenerative myelopathy, cauda equine syndrome, trauma to brain and/or spinal cord, skeletal trauma (limb, pelvic, or vertebral fracture), myofascial restriction causing nerve compression, myofascial strain.
Putative Diagnosis: Many of the infectious causes of the clinical signs were ruled out with testing. CBC/Chemistry results, the absence of fever, and the fact that appetite was maintained and no gastrointestinal symptoms were observed, helped to rule out most causes including hepatic disorder, toxin, and other encephalitides, though some of these were not directly tested for. The horse was rabies, tetanus and botulism vaccinated so these diseases are generally ruled out. Testing on spinal cord fluid may have been helpful in this case, but was not performed. Seeing rapid improvement of clinical signs allows ruling out of PSSM, neoplasia and degenerative diseases. The horse was never lame once he was able to stand on his own and no evidence of fracture was seen on cervical radiographs. The most likely cause of the clinical signs in this patient is severe trauma +/- embolism/cerebrovascular accident (brain +/- spinal cord), with possible involvement of EPM, and corresponding myofascial strain patterns.
Acupuncture treatments: The first acupuncture treatment was performed while the horse was unable to stand with the aim of relaxing severely tense/tonic muscles in the hind limbs and lumbo-sacral area. Dry-needling was done using 0.20mm x 30mm Seirin coated needles placed along the bladder line at BL21, BL23, BL25, BL26, BL27 (for local muscle tension), and BaiHui (major parasympathetic point – important to decrease sympathetic windup if seizures were present, and major point for hind limb disorders). Needles were also placed on the ‘up’ side of the horse (horse was in right lateral recumbency) at GB29 and GB39 (for muscle relaxation and pain relief of tense hind limb muscles and stimulation of sacral spinal, caudal gluteal and fibular nerves to help improve circulation, muscle recruitment and nerve conduction to help the patient stand). Electro-acupuncture (EAP) (3-channel Ito ES130) was used across BL26-BL27 and GB29-GB39 at a frequency of approximately 240Hz for 15 minutes. This frequency was used to try to induce a more immediate analgesia and muscle relaxation.
After the horse was standing in the sling, another treatment was performed that evening and again two days later with the same needle placements and EAP treatment, minus GB29 and GB39. Needles were additionally placed at GV-20 (for effects of anxiety relief and as a point used for cerebrovascular accidents and seizures by neuromodulation of the trigeminal and cranial cervical spinal nerves), BL40 bilaterally (as a major point for hind limb paresis/pain through stimulation of the Tibial nerve), and ting points on both hind limbs to try to improve CP via afferent sensory nerves.
Once the horse was out of the sling, the patient was treated twice over the following 3 weeks, and then received treatment approximately once a month for the next 3 months. The following was the treatment protocol: In general, Seirin 0.25mm x 30mm coated needles were used in all points except for ting points, where Carbo 0.20mm x 13mm uncoated needles were used. Needles were left in for 15-20 minutes, and EAP was performed across BL26-BL27 at 2.5Hz for 10 minutes at each session. Points used: GV20, GV14, BaiHui, GB21, LU1, LI16, BL10, BL11, BL12, BL13, BL21, BL25, BL26, BL27, BL29, BL40, BL54, ST36, GB29, GB30. (For the first 5 treatments, Seirin 0.3mm x 30mm needles occasionally had to be used at BL54, GB29, GB30 due to extreme muscle tension as thinner needles would not go through the skin.) These points were picked to address specific sites of muscle tension/pain in the lumbar spine, shoulders, pectorals and hind limbs, to try to reduce the swelling of the neck around C5, to increase parasympathetic tone to reduce risk of seizure activity, to try to stimulate the peripheral nervous system to improve CP and normal muscle recruitment in the pelvic limbs, and decrease ataxia/improve ambulation.
Physical therapy was also an important aspect of this horse’s recovery. Once the horse could safely be taken out of his pen, the owner worked with the horse almost daily for 3 months, gradually lengthening times of hand-walking, ground pole exercises to improve CP, arena turnout, and hill work to build strength and coordination.
Outcomes, discussion: Acupuncture can be an important adjunct modality in the treatment of neurological conditions. It has been shown to have effects on endogenous opioids which can help modulate pain, and may have ‘anti-seizure’ effects1. Acupuncture can also help aid in decreasing ongoing damage following neural ischemic injury2, and can improve sensory function in cases of paresis3. These effects are extremely relevant clinically in this case, as considerable neurological damage was evident based on observed clinical signs.
This case was dramatic and could have easily ended in euthanasia of the patient. It involved intensive medical care and strong commitment by the owner emotionally and financially. There was also considerable time and effort required for care and rehabilitation, which the owner and barn team took on without hesitation. This horse surprised everyone involved in his care, and despite a grave prognosis, responded exceedingly well to treatment.
Acupuncture was a beneficial part of this patient’s recovery. There were specific responses that occurred during and immediately after treatment sessions that showed acupuncture having a positive effect for this patient. For example, after the initial acupuncture session (when the horse was recumbent), the patient made an improved attempt to stand compared to attempts made earlier in the day. Additionally, when in the sling, the horse initially would stand with his left hind leg crossed under him resting on the lateral side of the hoof, and even when someone placed it correctly for him, was not able to stand on his hind legs for more than 10-15 minutes before becoming weak and needing sling support. Almost immediately after placing BL40 in the left hind leg (leg was crossed cranially and to the right of midline and was non-weight-bearing), the horse moved its leg into a normal standing position, and the horse then stood without sling support for over an hour (the longest it had stood since being placed in the sling). After another session, the patient went from having a limp tail prior to therapy, to then raising it up for defecation after acupuncture. These immediate effects were very encouraging to see, and showed me that even in emergent/acute situations, acupuncture may be utilized to great effect.
This case impressed upon me the profound effect acupuncture can have in neurological disease management and treatment. From my own previous clinical experience, a horse that is unable to stand on their own, and that has had seizure activity, has a grave prognosis. This horse, with intensive medical treatment and acupuncture therapy, coupled with consistent physical rehabilitation, has recovered. The patient still moves with a slightly base-wide gait in the hind limbs, but has been cleared by his primary veterinarian to return to work under saddle.
1 Chao1 Chao D, Shen X, Xia Y. From Acupuncture to Interaction between δ-Opioid Receptors and Na+ Channels: A Potential Pathway to Inhibit Epileptic Hyperexcitability. Evidence-based Complementary and Alternative Medicine : eCAM. 2013;2013:216016. doi:10.1155/2013/216016. 2 Shen Y, Li M, Wei R, Lou M. Effect of Acupuncture Therapy for Postponing Wallerian Degeneration of Cerebral Infarction as Shown by Diffusion Tensor Imaging. Journal of Alternative and Complementary Medicine. 2012;18(12):1154-1160. doi:10.1089/acm.2011.0493. 3 Yu H, Schröder S, Liu Y, et al. Hemiparesis after Operation of Astrocytoma Grade II in Adults: Effects of Acupuncture on Sensory-Motor Behavior and Quality of Life. Evidence-based Complementary and Alternative Medicine : eCAM. 2013;2013:859763. doi:10.1155/2013/859763.