Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 04S2018002
History and Presentation:
Maddie Berkley is an 11 year old, female spayed, tri-colored Beagle. She has a several year history of gait change in the rear limbs and occasional limping in the right front limb. However, during this current presentation, Maddie had an acute incident over the weekend. She has been worse this week because she rough housed with a housemate dog and tripped on some steps. Her ambulation was slower going upstairs and she appeared more lethargic. Her owner also thought her back appeared abnormally arched.
Her past, relevant history includes a cystotomy in 2015 to remove struvite bladder stones causing a urethral blockage. They introduced a new baby into their home three months ago, which seemed to increase her level of anxiety. She lives with two other dogs, another Beagle and a mixed breed dog. She has had some food aggression demonstrated around her other canine housemates, in which they are all fed separately now. Her current medications include carprofen 37.5mg q12h, gabapentin 100mg q12h, fluoxetine 20mg q24h, Adequan injections monthly, omega 3 fatty acid supplement, and Dasuquin daily.
Physical Examination and Clinical Assessments Examination:
Physical Examination and Clinical Assessments:
Myofascial examination: There is tenderness to palpation and taut bands in the right biceps region, patient disliked palpation of this region; there is tenderness in the TL junction with muscle twitching with light palpation; the right nails appear slightly longer than the left nails on the front limbs; back limb toenails are all short. There is mild kyphosis at the TL junction. The fascia is also very tight in the TL junction region.
Neurologic examination: Cranial nerves are within normal limits. Patient is bright, alert, and mentally appropriate. She ambulated on all four limbs with no paresis noted. No proprioceptive deficits are noted. There is discomfort, muscle twitching and showing discomfort in facial expression, when palpating the thoracolumbar junction. Patellar and gastrocnemius, and cranial tibial reflexes appear within normal limits. She does appear to have a slight crossed extensor reflex in the rear limbs. There is normal tail tone and anal tone. Musculature appears symmetrical.
Two view radiographs of shoulders and cervical-lumbar spine: There is mineralization between L1-L2, L2-L3, and L3-L4 and moderate remodeling of the head of the humerus bilaterally. No cardiomegaly noted. No abnormalities in the lung fields.
CBC/Chem/HWT/T4: There are mild increases in her liver function tests.
Remodeling of the head of the right and left humerus, taut bands in the right biceps muscle is most likely suspected a change consistent with osteoarthritis and secondary, compensatory changes. The kyphosis, tenderness to palpation, and crossed extensor reflex is consistent with a lesion in the T3-L3 region, most suspicious for an disc impingement and some degree of degenerative joint disease, but cannot definitely rule out FCE, vascular lesion, soft tissue injury, or early beginning of neoplasia. In regards to her hepatopathy, we have trended these values for years and she has had previous, unremarkable, abdominal ultrasounds and aspirates, with the diagnosis of canine vacuolar hepatopathy.
My working problem list for Maddie includes suspected spinal cord impingement with some degree of degenerative joint disease localized to the T3-L3 region, osteoarthritis in the shoulders, and canine vacuolar hepatopathy. These diagnoses were derived based on neurologic and myofascial exams, blood work, and diagnostic imaging to confirm.
Medical Decision Making/Treatment plan:
MAIN technique approach: Myofascial examination and massage, dry needling acupuncture, e-stimulation, and laser therapy are all incorporated in Maddie’s pain management. Massage (during my exam and by the owner), is to help patient quality of life, increase blood flow, release tension and trigger points, and help muscle strength. Acupuncture is utilized to aid in neuromodulation the pain pathways, increase blood flow, and alleviate strain patterns and trigger points. Laser is incorporated for treatment of the thoracolumbar, thoracic and caudal cervical spine/interscapular region, and right biceps region. The goals of laser are to decrease the tension in the muscles, reduce inflammation, and help with pain control, especially in regions that are more tender on palpation, where acupuncture/e-stimulation is more difficult. Electrostimulation provides additional reinforcement of neuromodulation and pain control.
Acupuncture needles used were Seirin J type needles 0.16 x 30mm coated needles, Seirin J type needles 0.20 x 30mm coated needles, and Carbo 0.20 x 25mm needles uncoated. Dry needling was utilized along with electrostimulation.
Acupuncture points chosen were GV 20, GV 14, BL 13-15 bilaterally, BL 21-23 bilaterally, Bai Hui, and one needle in the taut band of the right biceps muscle.
GV 20 and GV 14 were used as first time needling points for calming/test points and also neuromodulation of the cranial cervical spinal nerves and cervicothoracic spine. Bai Hui was added as an autonomic nervous system point and mid-caudal lumbar spinal nerve neuromodulation. BL 13-15 were used to help address any tension in the shoulders and distally (cranial thoracic spinal nerves), the biceps muscle, primarily on the right side. BL 21-23 were chosen to help neuromodulate the thoracolumbar spinal nerves and help local pain and trigger points in the epaxial muscles of the bladder line in the TL region. In the end, I was able to place a single needle in the taught band in the right biceps muscle to help decrease the tension and increase blood flow to this region.
Electrostimulation: This technique was added to the third and fourth integrative pain management sessions. A Pantheon Research Electrostimulator 4c Pro was utilized at the acupuncture points BL 23 and BL 25, bilaterally, with Carbo 0.20 x 25mm needles uncoated needles. The settings were on mixed. Continuous mode was at 4 ad Mixed mode was at 100. The duration of electrostimulation was approximately 10 minutes for both sessions.
Laser therapy: A Companion Class 4 laser was utilized at the following regions with correlating settings and duration:
Right biceps and shoulder region: CW / 15W / Time: 41 seconds / 817.5J
Caudal cervical region: CW / 15W / Time: 1.3 minutes / 1762.5J
thoracolumbar region: CW / 15W / Time: 1.3 minutes / 1762.5J
Medication management: At this time, Maddie’s medication management consists of carprofen 37.5mg q12h, gabapentin 100mg q12h, fluoxetine 20mg q24h, Adequan injections monthly, omega 3 fatty acid supplement, and Dasuquin daily.
Outcomes, Discussions, and References:
Assessment and discussion:
Her owner has noticed that she has had a lot more energy, she seems to have an easier time from sit/lay to stand position, and her mobility has improved. When she used to just trot in the backyard, she will now to sprints to play with the other dogs.
As we continued to do more acupuncture therapies, Maddie appeared more relaxed in our environment. On her myofascial examination, she is much more comfortable in the palpation of her biceps regions, specifically on her right side. The first time we did our exam, she gave me a warning nip with just gentle pressure. Now she allows massage of that region and tolerates needling of trigger points present. The slight ataxic sway in her rear limbs remains. She has less tension in the myofascia of her lumbar back.
Maddie has had a total of 4 visits so far. For her dry needling, we initially started with primarily Seirin J type needles 0.16 x 30mm needles and a few Seirin J type needles 0.20 x 30mm needles on her first visit. As she has tolerated and enjoyed her acupuncture, we primarily use Seirin J type needles 0.20 x 30mm needles and Carbo 0.20 x 25mm uncoated needles.
Her laser protocol has remained the same. She appears comfortable during her treatment, does not show any discomfort, and is relaxed.
We added in the electrostimulation starting at her 3rd acupuncture treatment, primarily because I had to wait for my machine to arrive. She was very tolerant of this in addition to her dry needling. The owner felt that she had the most improvement with the addition of the electrostimulation, and described her as “a wild maniac” in terms of the increase in mobility due to her comfort and decreased tension.
I have demonstrated to the owner simple, light pressure massage that she can do just to help relieve the tension and trigger points in Maddie’s shoulders, neck, and lumbosacral region. I do not have much experience with canine massage, but basically reiterated the basic techniques learned in the course (primarily effleurage and skin rolling). I also stressed keeping her active, but promoting consistent, walks to keep her muscles active, the muscle mass present, and to help with osteoarthritis.
The only adverse event we encountered was we gave her canned food as her treat during her first acupuncture/laser session, which resulted in loose stools for the next 24 hours. It was reversed with time and probiotics, but that was less than ideal. We switched to homemade frozen pumpkin/chicken/apple puree popsiclces that her owner made.
Our tentative plan going forward is to decrease her NSAID in half and assess her quality of life and comfort level. Ultimately, the goal will be to decrease her oral prescriptions to the smallest, effective dose possible. We will start to increase the duration of time between treatments, starting with every 2 weeks, and if doing well, once monthly for maintenance. If she ever has a setback or acute injury, we will adjust and do more frequent treatments. I will most likely continue with the combination of multi-modal, integrative pain treatments (massage, dry needling, electrostimulation, and laser therapy).