Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017043

Abstract
This case deals with Della, an 11 year old spayed female boxer with a previous history of stifle injury who has been very slow to get up over the last few years. She has been living with pain in her stifles and generalized back discomfort, which has resulted in decreased mobility and decreased ability to perform activities she used to do regularly. The owner mostly feels Della has been generally painful and hoped that acupuncture along with oral anti-inflammatories and pain meds could improve her quality of life.
After four sessions of acupuncture, there has been a noticeable improvement in Della’s mobility and willingness to get up without significant coaxing. Acupuncture sessions were performed once weekly, and the improvement in mobility seemed to last around 5 to 6 days each time. After acupuncture for 1 month, the most notable change observed by the owner was Della’s ability to jump on the couch again.

Della prior to acup at clinic

History
Della is an 11 year old spayed female, boxer with a body condition of 3/5. In 2009, as a 3 year old, Della ruptured her left ACL and had an extra capsular repair performed 3 months after diagnosis. Della has also had several tumors removed in 2006, 2012, 2015, and 2017. Of the tumors, one was diagnosed as a mast cell tumor in 2015. Della spends most of her time in the owner’s house and does not perform any rigorous activities. The owner first started noticing generalized discomfort and a decrease in mobility in 2015.

Physical Exam

HR: 120 bpm, RR: 60 bpm, CRT: < 2 sec, MM: pink/moist, Hydration: adequate, Temp: 102.5
Upon physical exam, Della was observed walking with a bilaterally stiff, wide-based hindlimb gait and mild lumbar kyphosis. Lenticular sclerosis was found in both eyes. She had severe medial buttress formation on the left stifle as well as moderate right stifle joint thickening. Her lumbar spine was warm to the touch, and myofascial tightening and restrictions were observed in the thoracolumbar, mid lumbar, and lumbosacral regions. There were tight ropey bands palpable in the semimembranosus and semitendinosus muscles in both hind limbs. On examination, there were very mild bilateral proprioceptive deficits present in both hindlimbs and normal proprioception was present in the forelimbs. There was mild decreased range of motion in the neck laterally to either side. The hair coat was thinning over the dorsum of the trunk and abdomen. Muscle atrophy was observed and palpated in both hindlimbs. Radiographic images provided show significant spondylosis deformans of the thoracolumbar spine, lumbar spine, and lumbosacral junction. In addition, Elbows were bilaterally thickened on palpation.

Medical Decision Making
Knowing the previous history of mast cell tumor(s), I did not pursue laser therapy. As Della was a relatively calm patient anyway, I still had in mind to neuromodulate the parasympathetic nervous system first to see how receptive she would be for acupuncture. I wanted to begin with GV20, GV14, and BaiHui to accentuate parasympathetic effects. Having seen radiographic images showing the severity of spondylosis deformans in the spine, I wanted to focus on the bladder channels beginning at BL11 and moving caudally towards BL60 to provide an array of effects on local tension and pain along the thoracolumbar, lumbar, and lumbosacral regions. I wanted the distal bladder points to neuromodulation pelvic limb pain. I wanted to use Bafeng and Baxie points to distally stimulate the peripheral neurologic pathways and spinal segments. I also had in mind to use points of ST36 involving the fibular nerve to increase communication distally up to the spine and brain, stimulating vagal neuromodulation. I also wanted to use LI10 and LI11 for elbow pain via the radial nerve.

Differential Diagnosis
My differential list included:
Hypothyroidism Rickettsial Disease Myasthenia Gravis
Spondylosis Deformans Polyarthritis/Osteoarthritis Congenital Anomaly
Osteosarcoma/Mast Cell Tumor Myofascial restrictions Encephalitis
FCE Heartworms/Heart disease Hypoglycemia
Hyperadrenocorticism Hypoadrenocorticism Vestibular Disease
Intervertebral Disc Disease

Definitive Diagnosis
Osteoarthritis of elbows and stifles
Spondylosis Deformans of Spine at L7-S1, L1-L7, T5-T6, T7-T8, T8-T9, T9-T10, T10-T11, T11-T12, T12-T13, and T13-L1
Myofascial tightening/compression over longissimus dorsi and iliocostalis muscles especially in the thoracolumbar and lumbar regions. Diagnosis made by myofascial exam and response to acupuncture over bladder line points on the back.
Intervertebral Disc Disease In region of T3-L3

Acupuncture Treatment with Dry Needling
• In order to increase vagal tone, I used BL10, Bai Hui, GV14, GV20, and ST36.
• Bai Hui also used for lumbosacral pain, pelvic limb pain and weakness due to its central location over cauda equina
• GV14 to accentuate parasympathetic effects due to its large amount of intersecting myofascia and for thoracic limb pain
• GV20 to decrease sympathetic tone by autonomic crosstalk with vagus
• Bafeng and Baxie points to stimulate thoracic (Baxie) and pelvic (Bafeng) neuropraxia distally to the main source of pain and for manus and pedal discomfort
• LU1 for local shoulder pain
• LU5 for local elbow pain
• LI4 for autonomic neuromodulation through nervi vasorum
• LI10 and LI11 and LI14 to regulated autonomics, taking down sympathetic tone and accentuating parasympathetic effects.
• ST36 to accentuate parasympathetic effects and its anti-inflammatory effects for stifle pain. This is important as it reaches the brainstem and NTS
• BL10 for vagal neuromodulation by connections to the NTS
• BL 10 and BL11 and BL12 and BL14 for shoulder pain.
• BL 18 and BL19 for mid-thoracic neuromodulation and pain
• BL 20 for caudal thoracic neuromodulation and pain
• BL 21, BL22, BL23 for thoracolumbar spinal neuromodulation and pain
• BL 40 for pelvic limb pain, paresis, and stifle pain
• GB29 for sciatic neuropraxia and GB 30 for cranial gluteal and local tender points
• BL 54 for sciatic nerve pain
• Huatuo Jiaji points and GV4

All applicable bilateral points were used when possible by patient positioning and comfort.

Needles used were Seirin J Type. Bafeng and Baxie points were needled with 30mm 0.16 diameter Seirin J needle. All other points were needled with 30 mm 0.2 diameter Seirin J needle.

Outcomes
Della handled acupuncture very well and continues to improve with continued therapy. The owner was very happy with the results. She was pleased with the way that Della seems much more comfortable in her daily activities. Her ability to rise from a sitting position was much faster and the owner was especially pleased to see Della jump up on the couch for the first time in years. Videos taken after seven days of acupuncture treatment show significant coaxing was needed to get Della up from a sternal or sitting position, alerting the owner to return for another session. Della was also being maintained with NSAIDs and Gabapentin, but the owner especially notes an increase in comfort level when acupuncture was added to the regimen.


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