Written by a Medical Acupuncture for Veterinarians course graduate.Signed release obtained from client/author. 10S2017042
Thor, an 11-year old outdoor lab, has a history of IVDD with increasing lameness and fecal incontinence over the last three years. Since Thor’s owners live in a very rural town with no veterinary acupuncturists in the area, the owners elected to board Thor for a week to receive daily acupuncture. Thor’s lameness improved during the week of treatment and owners noticed marked improvement in energy level over the following 3-4 weeks. Fecal incontinence did not improve during the treatment week, though owners reported decreased frequency during the first week Thor returned home. During the treatment week, Thor was also weaned off prednisone and tramadol that he had been receiving intermittently over the last few years. Boarding with pulse acupuncture treatment may be a good option for treating lameness in dogs with IVDD in rural areas that cannot receive more regular treatments.
History and Presentation:
Thor, an 11-year old, male, neutered, black lab mix, has a history of moderate to severe four limb lameness with intermittent fecal incontinence since May 2015. In May 2015, Thor presented for acute onset cervical pain, lethargy, and mild forelimb lameness. Cervical and spinal radiographs revealed mild ventral spondylosis deformans L2-L4 and moderate articular process joint enlargement and irregularity at C3-C7. Cervical MRI showed cervical vertebral spondylomyelopathy C5-C6 with mild canal stenosis and cord compression due to articular process joint hypertrophy and mild disc degeneration C6-C7 with no evidence of compression. Thor has been medically managed with 300mg (8mg/kg) gabapentin BID, 100mg (2.7mg/kg) tramadol BID, and 20mg (0.54mg/kg) prednisone SID and 20mg famotidine SID. Thor lives outdoors in a rural area, 1.5 hours from available acupuncture treatment, so it was elected to board Thor for one week to receive daily acupuncture treatment. Since one month after Thor’s initial workup at LSU SVM, he has not had any exercise restriction and frequently takes long, off leash walks with owners despite lameness. Owners reported that they have seen Thor defecate without posturing on concrete while walking to the grass about once per week. Though consistently ambulatory x4, Thor’s lameness has slowly increased over the last three years, with a sudden increase six months prior to acupuncture treatment after an incident where Thor suddenly yelped and appeared to be in an extreme amount of pain for a few minutes. Thor is up to date on vaccines, flea, tick, and heartworm prevention. Thor is free fed a mixture of Purina Adult and Science diet j/d. He has lost about 10 lbs since his initial diagnosis and has a current BCS of 4/9.
Physical Examination and Clinical Assessments:
Thor presented QAR with normal mentation, but low energy. Body weight is 82lbs/37kg and BCS is 4/9. No ocular or nasal discharge observed. Mild ceruminous debris observed AU and mild dental tartar present with worn incisors. Mucous membranes are pink and moist and capillary refill time is <2sec. Femoral pulses are strong and synchronous and no arrhythmias or murmurs were auscultated. Normal bronchovesicular sounds bilaterally with normal respiratory rate and no crackles or wheezes auscultated. All lymph nodes palpate smooth and symmetrical with no lymphadenomegaly. Abdomen is soft and non-painful with no masses or fluid wave appreciated. Clear, clean coat is free of ectoparasites. Right hind medial and caudal gluteal muscles have moderate atrophy. Patella reflex is hyperreflexive bilaterally. Extensor carpi radialis reflex is increased on the right side, normal on the left. Bilateral, severe medial buttress and crepitus present with mild left cranial tibial thrust and drawer movement. Left triceps and infraspinatus muscles are sensitive with myofascial restriction and trigger points. Left thorax has severe myofascial restriction, especially T2-T5. Mild muscle spasms in left triceps and quadriceps muscles. Multiple trigger points with myofascial restriction in mid left cervical region. Right supraspinatus is hypertrophied with painful trigger points dorsally. T13-L3 dorsal spine is sensitive with palpable increased heat and multiple trigger points bilaterally. Myofascial restriction is present T13-S1. Right cranial tibialis is hypertrophied on the right. Thor’s left elbow and both stifles appear to have increased lateral laxity at the walk. Thor also generally holds his head ventrally with head bobbing dorsally with placement of his left forelimb. Thor shows no neck pain when head is turned laterally, dorsally, and ventrally and Thor does not react to spinal palpation. Thor has mild kyphosis and has a moderately shortened stride. Fecal incontinence was observed 4 times during the week, with no improvement during the week with continued treatment. Urine was observed to be discolored and malodorous and urinalysis revealed a UTI that was treated starting on the 6th day of treatment and antibiotics were continued after the owner returned home. Thor has been given prednisone since August, 2016 with no recent bloodwork. CBC/Chem was performed on day 3 of treatment with no significant abnormalities observed. Predisone and tramadol were tapered throughout the week with no tramadol and prednisone administration by day 6 of treatment. Gabapentin was continued at previously prescribed dose.
Medical Decision Making:
Thor appears to have severe bilateral hindlimb instability originating from suspect degenerative or partially torn cruciate ligaments. Additionally, left forelimb lameness, likely originating from his left elbow, has caused compensation with the right forelimb and hindlimbs creating myofascial restriction and multiple trigger points from the dorsal mid thorax caudally. Cervical MRI revealed multiple cervical issues three years prior, though currently there are only a few mild trigger points along the neck and the majority of the discomfort is now likely originating further caudal. The intermittent fecal incontinence is likely due to IVDD that is suspected to be between T13 and L3 as there is sensitivity, heat, and myofascial restriction in that area. Targets for treatment include trigger points along the bladder lines, stifle pain, cervicothoracic pain, fecal incontinence and overall pain control with parasympathetic activation and modulation. Massage for myofascial and trigger point release along the dorsum and limbs, but especially from T2-T5 along the inner bladder line will also be used, depending on the patient’s position and accessibility of the points. Due to owner’s inability to return for repeat or routine treatments, it was elected to perform daily acupuncture treatments for 7 days while dog is boarding.
IVDD, cervical vertebral spondylomyelopathy, Malignant Peripheral Nerve Sheath Tumor, brachial plexus avulsion, peripheral nerve trauma, spondylosis deformans, articular process joint osteoarthrosis, torn or degenerative cranial cruciate ligaments bilaterally, left elbow dysplasia, UTI,
Definitive (or Putative) Diagnosis (or Diagnoses):
Previous MRI and radiographs revealed cervical vertebral spondylomyelopathy, spondylosis deformans, articular process joint osteoarthrosis. Left elbow dysplasia and torn or degenerative cranial cruciate ligaments bilaterally are suspected based on physical exam findings. UTI was diagnosed with urinalysis and culture/sensitivity. IVDD is suspected based on clinical history and sudden, severe pain observed by owner six months prior.
Dry needling was performed every 24 hours for 7 days with Seiren 0.20x30mm J-type acupuncture needles. Between 30 and 40 points were chosen per treatment depending on patients positioning and response to treatment. Due to patient compliance, Thor was rotated between left and right lateral each day of treatment. Each treatment began with myofascial palpation, effleurage, skin rolling and trigger point massage. GV20 was first placed to relax the patient and for autonomic neuromodulation, increasing parasympathetic tone in a patient with chronic pain and in turn, chronically increased sympathetic tone. GV14 was then placed for cervicothoracic pain and Bai Hui was used for lumbosacral pain. GV14 and Bai Hui also increase parasympathetic tone and were used at the start of treatment to relax the patient. To increase stifle strength and stability and decrease associated pain and inflammation, SP9, SP10, ST34, and ST36 were used. BL27, BL28, BL39, and GV1 was used to reduce fecal incontinence. Fecal incontinence was also targeted with KI3, while also activating BL 60 for spinal pain. Cervicothoracic pain was modulated with SI3, BL10, and trigger points throughout the dorsal neck and thorax. LI10, LI11, and BL11 was used to target the left elbow pain. Gluteal muscle atropy was treated with BL54 and GB 30 to modulate any potential sciatic nerve dysfunction. Lastly, many dorsal trigger points along the bladder line were chosen, especially BL 12-15 and BL 21-24. After needles were removed, myofascia was again palpated and patient was assessed at the walk.
Outcomes, Discussions, and References:
Acupuncture was chosen for pain modulation because of the relatively few side effects compared to NSAID’s and prednisone. Acupuncture has been shown to reduce pain and increase quality of life in dogs with neuromuscular and musculoskeletal disease. , Acupuncture works by activating nerve fibers near the needle to modulate local pain by increasing local blood flow and moderate mechanoreceptors, muscle spindles, golgi tendon organs, underlying fascia, and the nervi vasorum. Thor’s energy steadily increased throughout the week of acupuncture treatment, rest, cessation of tramadol and prednisone, and treatment of his UTI. The hind limb instability appeared to improve rapidly, which caused the forelimb pain to become more apparent initially. Towards the end of the week, both fore and hindlimbs appeared more stable and Thor walked significantly faster with his head held in a normal position. At the end of treatment, Thor’s head bobbing was still present, but his stride length increased. The mild kyphosis was no longer present post treatment. Owners reported that Thor had increased energy at home at one week and one month later. However, a video of Thor walking taken by the owners one month later showed a return to shortened stride, increased head bobbing, and bilateral increased stifle and left elbow laxity similar to pre-treatment. Owners reported that Thor’s increase in energy has led to increased exercise during walks around owner’s property. It is unclear if the increase in energy is due to the acupuncture treatment, UTI treatment, discontinuation of the tramadol and prednisone, or due to one week of restricted exercise or most likely a combination of these factors. Thor’s fecal incontinence remained consistent throughout the treatment week and owners reported a mild decreased in the number of observed defecations without posturing during the first week post treatment. At the one month recheck owners reported similar rates of fecal incontinence as pre-treatment.
Pulse, clustered acupuncture treatment with boarding may be a useful tool in the future for Thor and other clients who cannot routinely visit a rehab or acupuncture facility. Thor would likely also benefit from laser therapy, electroacupuncture, and water treadmill.
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