Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2018041
History and Presentation: “Oakley” is a 12 year old male neutered Golden Retriever. His vaccines are up to date and he receives regular veterinary and dental care. He has been reported to be “getting stiff with age” and has some mild muscle wasting, and some intermittent front end lameness, diagnosed radiographically with elbow and carpal osteoarthritis (OA). More recently, he was diagnosed with a protein losing enteropathy of unknown origin, with vomiting. His muscle wasting rapidly increased, and was placed on prednisone (unknown dosage) which stabilized the muscle wasting and weight loss. He developed an intermittent tremor of his jaw and neck muscles, particularly when he became excited or was panting. This was the main presenting complaint for acupuncture. Oakley has received chiropractic and acupuncture care previously (records unavailable). He reportedly had a neutral response to treatments.
Physical Examination and Clinical Assessments:
Upon examination, Oakley was bright, alert and responsive. He exhibited a body condition score of 4/9. He ambulated well, down the hallway, with mild lameness of the LF today. Upon myofascial palpation, there was significant tenderness and restriction in the cervical neck bilaterally. Master muscles were also hypertonic, sore to palpation and smaller than would be expected. Significant myofascial restriction was also apparent over the head. Motion palpation of the spine revealed stiffness and tenderness of the caudal thoracic / lumbar area, with soreness of the epaxial musculature. Neurological examination was largely unremarkable, with a subjectively slightly slower response replacing the LF, however I could not rule out pain vs neurological deficit based on OA diagnosis.
Treatment #1 was performed as below.
Upon second visit, Oakley has gained significant muscle mass, and his gastrointestinal signs had resolved. He had not suffered another episode of jaw chattering or tremors since the first appointment.
Treatment #2 was performed as below. Laser therapy was included in the second treatment as described.
Upon third visit, Oakley has regained significant muscle mass. His owner reports his energy level has improved. His neck seemed markedly improved, with just mild ropiness palpated on the left side today. He showed delayed replacement of the RH today, with some hypotonicity in the right bicep femoris and right quadratic group.
Treatment #3 was performed as below.
Medical Decision Making
Initial treatment was targeted at the head/neck and lumbar area, not on the front end OA, as I believed that this was the primary issue during the first visit. I was concerned about the jaw chattering (which was not present until recently). Dental pain was ruled out, as Oakley receives regular dental exams and cleaning, and his rDVM has performed a dental cleaning and exam recently. Masticatory myositis was a possibility, but is usually not accompanied by chattering. Seizure was on the rule out list in my mind, as teeth chattering may indicate a focal seizure. I asked the owner if he was able to be gently “interrupted” when the episodes occur and she was unsure – this had not been attempted. The other big rule out in my mind was cervicogenic and myofascial pain. I wanted to focus on the cranial issues in the first treatment.
With the resolving of the presenting complaint on the second visit, I felt I was able to address more of the lameness concern. The laser therapy really appeared to offer relief of the cervical tension.
Plan: Going forward I will see Oakley monthly for comfort care. The initial complaint has been resolved, and my goal now is to maintain function of all of the limbs as optimally as possible by monitoring his muscle tone and placement ability, as well as ensuring his cervical restriction does not return.
V – Vasculitis leading to poor circulation to muscles
I – Infectious – could have infection enteropathy, although no fever or bloody diarrhea present, so less likely
N – Neoplasia could be present due to age / breed – possible gastric neoplastic activity
D – Degenerative – already diagnosed with OA. Lumbar OA as cause of the hind end deficit.
I – Iatrogenic / intoxication – possible cause of GI signs, but doesn’t explain lameness
C – Congenitial – unlikely at this time
A – Autoimmune – masticatory myositis could be likely
T – traumatic – unlikely at this time, although could explain head/neck symptoms
E – Endocrine / metabolic
Myofascial tie down of cranial and cervical myofascia
• Muscle hypertonicity as a result of repeated vomiting
• Dental pain/disease
• Biomechaniacal from front end OA compensation
• Focal seizure (jaw chattering)
• Masicatory myositis
Front end lameness – documented OA carpals and elbows
• Lumbar spinal OA (spondylosis)
• Biomechanical compensation from front end lameness
Definitive (or Putative) Diagnosis (or Diagnoses):
Myofascial tie down of the head and neck
OA of carpal and elbow joints bilaterally. OA of lumbar spine.
Treatment number 1 was performed with dry needles (uncoated Hwato 0.3mm x 30mm). As Oakley had previously been treated, I elected to try uncoated needles, to try and maximize my effect on the significant myofascial restriction I was noting. Needle placement was well tolerated, so uncoated needles were used throughout Oakley’s treatment. The needles were placed at the following locations:
GV 20 and GV14 – chosen as initial points for a calming effect, but additionally to attempt to alleviate some of the myofascial restriction in the head and neck. Attempting to affect trigeminal nerve, cranial cervical and cervicothoracic spinal nerves. Bai Hui was chosen next, to help with lumbosacral tenderness noted on palpation. These were well tolerated so BL10 was placed bilaterally, again to affect cranial cervical spinal nerves, and to help with cervical pain and tension. BL 22, 23 25 and 27 were placed bilaterally, and notable “needle grab” was seen particularly at BL23 and 25 bilaterally. Electrostimulation (E-stim) was utilized across BL 22 and BL27. A Pantheon unit was used, on mixed frequency mode (4Hz and 100Hz) for 10 minutes. Whilst the E-stim was in progress, needles were placed at TH17, 23 and ST6 bilaterally to stimulate/modulate the trigeminal and facial nerves, and attempt to alleviate some of the masseter tenderness palpated. The treatment was well tolerated and the myofascia was significantly more pliable after the treatment.
Treatment number 2 was performed with dry needles (uncoated Hwato 0.3mm x 30mm)
Much of the myofascial restriction noted on the first appointment was largely resolved. His posture was more upright, not “ducking” his head from cervical tension / pain. His lameness also appeared better. He was finished his prednisone at this time. He had gained significant weight and his presenting complaints at the second appointment. GV 20 and GV 14 were used as initial points, with Bai hui, again for calming and to affect cranial and cervical musculature. BL 22-25 and 27 were placed bilaterally with E-stim as described previously. Laser treatment was used. MLS Cutting edge laser (Dual frequency 808nm (continuous) and 905nm (pulsed)) was used. Point to point therapy was used, 4 sites down each side of the neck at 5 Joules/sq cm.
Treatment number three was performed largely as above, with the laser treatment repeated exactly, and GV 20, 14, Bai hui and BL22-25 and 27 stimulated with needles. E-stim was as described above. Additional sited treated this time were to target the RH delayed placement. BL36 and GB 30 were stimulated to target sciatic function, and ST36 was targeted to treat fibular nerve and also stimulate parasympathetics. Placement was dramatically improved after treatment.
Outcomes, Discussions, and References:
Oakley responded remarkably well to the initial treatment, with notable improvement right after the session. I was particularly happy that his head/neck/jaw issues resolved with one treatment, and no reported chattering occurred after the treatment. I believe that the chattering may have been a pain response to the immense cranial and cervical tie down, or focal seizure events. Due to the fact that the episodes resolved so quickly, I thought seizure less likely. Again, due to response and resolution, it makes more sense that the episodes were as a result of the vomiting and pain, possibly associated with the onset of the muscle wasting. The response may well have been so dramatic as the dog was treated with prednisone – if indeed there is an autoimmune or inflammatory component this would have helped the treatment.
The second and third visits I was able to focus more on the secondary complaints (OA and back soreness) which I do not believe to be particularly abnormal in a dog of this size and age. Oakley seems to gain comfort and mobility from his treatments, which is pleasing and encouraging. His owner reports that he once again is happy to chase a ball. I also was able to address the delayed replacement of the RH with stimulation of the lumbosacral plexus and associated nerves.
No adverse reaction to treatment was reported.
Discussion: Cervical and cranial myofascial pain:
One study showed a single acupuncture treatment was successful at reducing masticatory pain in humans. A single acupuncture session using large intestine 4 significantly reduced most myofascial pain endpoints when compared to sham acupuncture1. Dry needling of trigger points was also shown to improve pain and jaw opening. The application of dry needling into active trigger points in the masseter muscle induced significant increases in jaw opening when compared to the sham dry needling in patients with myofascial pain2. It is reasonable to think then, that Oakley responded appropriately in one session.
1. Fricton, J. R., Kroening, R., Haley, D., & Siegert, R. (1985). Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surgery, Oral Medicine, Oral Pathology, 60(6), 615–623. http://doi.org/https://doi.org/10.1016/0030-4220(85)90364-0
2. Fernandez-Carnero, J., La Touche, R., Ortega-Santiago, R., Galan-del-Rio, F., Pesquera, J., Ge, H.-Y., & Fernandez-de-Las-Penas, C. (2010). Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. Journal of Orofacial Pain, 24(1), 106–112.
Describe Your Medical Acupuncture Experience:
Medical Acupuncture has given me a very powerful tool to offer my patients. I enjoy the approach of examining the nervous system and nervous dysfunction, which has been a new path for me.