Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4L2018024
Abstract: Case report of multi limb lameness that was no longer responsive to joint injections. Reactivity was found in the cervical region, thoracolumbar region and addressed with a combination of acupuncture and electro acupuncture. Results were more significantly appreciated by the rider but mild improvements were seen in lameness score on multiple legs.
History and Presentation:
Toni is a 12 year old Dutch Warmblood chestnut gelding. He is housed in a stall at night with 6+ hours of paddock turn out each day. His owners goal for him is to be able to flat him comfortably and jump small fences (2 feet and under). He has shown up to the 1.3m classes in the local shows. He has a history of right front (RF) lameness and right hind (RH) lameness. He had an exploratory laparotomy in 2014 for right dorsal displacement and then bilateral stifle arthroscopy in 2015 where a medial femoral condyle lesion was identified bilaterally (left worse than right) and debrided. Surgery was followed up with a series of IRAP interleukin 1 receptor antagonist protein) injections and his hind end lameness issues seemed to be maintained with regular 6 months – 1 year interval injections. He was diagnosed with bilateral proximal interphalangeal joint arthritis managed by steroid injections. Toni has also been diagnosed with mild caudal cervical facet joint arthritis in 2014 which up to this point has not been treated. Toni is no longer responding to joint injections as well as before over the last year. His soundness has been a challenge to maintain. Due to the increase in persistent lameness despite joint injection treatment patient presented for acupuncture evaluation and treatment. He had received acupuncture several years ago by his previous veterinarian for back pain.
Physical Examination and Clinical Assessments:
On exam patient is bright, alert and responsive. His heart rate is 40 bpm, respiratory rate is 16 bpm and temperature is 99.5F. His body condition score is 5/9 and he appears adequately muscled.
In motion exam patient is 3/5 (3 out of 5) right front lame, worse going to the right on hard ground. There is a mild intermittent 1/5 LF lame to the left on hard ground. When evaluating his hind end he is a 2/5 right hind with him carrying his right hind asymmetrically underneath himself compared to the left hind. When walked in a tight figure 8 he is a mild grade 1 ataxic and drifts his hind legs outwards slightly longer than normal. He also stops with an unusual stance and does not straighten and correct his hoof placement very quickly. No ataxia is noted in the front limbs although owner reports he does trip in the front end more than previous horses she has ridden.
Flexion tests: RF – 2/3 distal limb flexion. LF – 1/3 distal limb flexion; negative carpal flexions bilaterally. Hind limb flexions: RH – 2/3 caudal extension flexion, and mild positive flexions 1/3 to LH stifle and bilateral upper limb flexions.
Myofascial palpation: Patient is mildly reactive over his left TMJ and in the region of ST 7. Facial symmetry is equal, and CN responses are appropriate.
Left side: Patient is reactive along the caudal cervical bladder meridian especially over LI 15 and 16. Patient is moderately reactive over BL 21-25. On pelvic slide can elicit a very small amount of movement and then patient braces against the movement when elicited from the left side. He is reactive through his hamstrings and gluteal muscles on the left hind. On motion palpation of the left front patient has reduced flexibility on internal and external rotation of the shoulder/elbow and decreased range of motion (ROM) of the scapula. With left hind circles patient will slightly tip pelvis to the left but circles are stiff and it is difficult to keep him relaxed into them.
Right side: Patient is non reactive over right TMJ. He is mildly reactive over BL 10, and LI 18 (which fits with prominent RF lameness). He is mildly reactive through the caudal cervical region and into BL 11 and 13. He is symmetrical in back reactivity with BL 21-25 being reactive, as well as a little bit through his gluteal region. RF motion and RH motion palpation similar to left side in stiffness and circle ability. No pelvic slide elicited on the right side.
On back flicks there is no hypersensitization found indicating patient is not in windup. Patient was initially very stiff to lateral fish wiggle but relaxed into it and seemed to enjoy it.
Patient was happy to flex the cranial cervical spine but when reached about C5 level there was decreased ROM to the right and left with slightly less flexion obtained to the right.
Patient was unable to gator with either leg fully. He could stretch his neck down or his front leg forward alone but when combined was very resistant (concern for C6/7 – T1 facet arthritis).
Dorsal spinal flexion was adequate through thoracic region but decreased in the lumbar region and patient did not enjoy thoracic and lumbar spinal rotation but had good ROM.
Differential Diagnoses: Cervical facet joint arthritis or disease, bilateral distal forelimb arthritis and hind limb lameness with concurrent compensatory muscle tension, OCD lesion, less likely but cannot exclude EPM for ataxia.
Definitive (or Putative) Diagnosis (or Diagnoses): Caudal cervical facet joint arthritis based on radiographs performed by previous veterinary, Bilateral Proximal interphalangeal joint osteoarthritis.
Medical Decision Making: Due to the horses history of lameness and increasing lack of response to joint injections the goal of his acupuncture treatment was to improve overall comfort level and make him rideable again for light riding. Due to the findings on the myofascial exam the key areas for treatment were: caudal neck, thoracolumbar back, pelvis region and RH leg. The forelimb lameness was treated with steroid injections into the pastern joints 5 days prior to my myofascial evaluation. Due to the chronic nature of the horses discomfort I decided to perform 3 acupuncture treatments 1 week apart initially to try and stimulate relaxation and have a strong neuromodulatory effect. The goal was to release muscle tension in the lumbar and SI region to hopefully increase pelvic slide. Focusing on neuromodulation in the caudal neck was aimed to help with the cervical facet joint arthritis to make the horse more comfortable but also to hopefully resolve some of the multi limb lameness that may be originating from his neck rather than a local pain source.
Acupuncture Treatments: (All needles were Seirin needles)
Treatment #1 – Goal: evaluate response to acupuncture and work on neck stiffness, scapular ROM and general hind end lameness.
Bau hui, GV 14 using brown seirin needles (0.3mm x 30mm) to start connecting the front and the hind end of the horse and provide some autonomic neuromodulation. All remaining needles were purple (0.25 mm x 30 or 40 mm)
Bilateral: GB 21, LI 16, LI 17 – first needles to evaluate how patient would be with acupuncture, as calming points, and treatment of caudal cervical facet arthritis. BL 11 and 13 – to improve his restricted scapular motion. BL 21, 23, 25, 27, 29 were selected based on reactivity over the lumbar and sacral region and decreased pelvic slide.
On his right side LI 18 was very reactive so a dry needle was placed there as well as the hip triad (BL 54, GB 29, 30) on his right side due to his right hind lameness and complete lack of pelvic motion on the right side.
Treatment #2: Goal – introduce electrical stimulation to help increase effectiveness of acupuncture on cervical neck pain and back pain.
ST 10, LI 18, LI 17, LI 16, GB 21(0.25 mmx30mm)-cervical facet arthritis, initial calming points
BL 11, BL 13, SI 11/12 (0.25 mm x 30 mm)- help release scapular restriction
GV 14, Bau Hui, (0.3 mmx30mm)-Autonomic nervous system modulation, front/hind lameness
ST 36 (0.25 mm x 30 mm)- autonomic NS modulation, as well as hind end pain.
BL 21, 23, 25, 27, 29 (0.25 x 40 mm) – back soreness
BL 54, GB 29, GB 30 (0.25 mm x 40 mm) – RH lameness
E stim on continuous frequency 25 hz for 10 minutes from LI 18 → LI 16 for caudal cervical arthritis (pain and inflammation control) as well as from BL 23→ BL 27 to target pelvic region and local back pain.
Treatment # 3: Goal – continue to improve neck ROM, scapular ROM and pelvic slide. After re-evaluation patient has increased Scapular ROM compared to first exam but still slightly restricted. He has almost normal pelvic slide on the left, but still very minimal movement on the right side.
Treatment was the same points and needle selection as treatment #2 with the addition of LU 11 and LU 7 (very superficially) bilaterally to try and stimulate blood flow and see if it would improve his front end lameness. LU 7 also works as the master point for the head and neck to see if it would supplement local cervical treatment. For these points 0.2mm x 30mm blue needles were used and needles were placed very superficially.
Outcomes, Discussions, and References:
The goal of the treatment plan was to improve overall comfort and soundness as patient had both hind end and front end lameness issues. After the second treatment owner felt that Toni no longer wanted to swap leads behind in the canter like he had been prior to his acupuncture treatments. She also noticed he no longer held his head as rigid and fixed in place to the right at the trot. On evaluation of him on a lunge line after 3 treatments he still had a mild 1/5 LF lameness but seemed more intermittent. His hind end lameness was a 1/5 RH which is an improvement from previous exams. He tracked straighter and held more natural flexion in the circle to be lighter on the lunge line.
The improvements seen in his neck comfort and his gait were not as drastic as the owners’ perceived improvements under saddle. Toni always was more lame with a rider on his back and the difference she felt was much greater than I appreciated on my exam. He went from a horse she was concerned to even ride, to a horse she felt comfortable working for 30 minutes. Multi limb lameness can be related to cervical facet arthritis in some cases (Ricardi & Dyson, 1993 and Pasteur, C. W, 2016). By addressing the cervical region in this case one of the components of the forelimb lameness was improved. The joint injections prior to the acupuncture treatments improved the local arthritis component so that together there was a significant improvement in front limb lameness. Cervical disease can also contribute to hind end lameness and the hind end lameness can be the root cause of the back pain and lack of pelvic mobility seen. Electrical acupuncture has been shown to decrease thoracolumbar pain for up to two weeks according to Xie et all, and in this case Toni’s back reactivity and pain were decreased on each consecutive exam. In this case by working on the cervical region as well as focusing on the right hind and the compensatory back strain patterns there was visible improvement in the right hind lameness, and the ease with which \Toni could maintain his canter stride to the left. In this case neuromodulating both the cervical region and the thoracolumbar region of the spine enabled more free movement and flow both up front and behind in the trot and canter.
In hind sight this may have been the case to have done multiple treatments at a shorter interval than 1 week. A 4 day interval may have been a better interval for pain modulation when treating arthritis and then after the initial 3 treatments try to space them at lengthening intervals. In this case a 1 week interval was the most realistic to obtain. Also looking at the case utilizing an increased number of distal limb points (ex. Ting points) for the focal issues would have been interesting to try and may have provided some added benefit. Some of his 2 lameness grade improvement in front end lameness was most likely combined with the previous joint injections he received, however his baseline lameness after the acupuncture treatment was the soundest he had been in a year even after having received the same injections 6 months previously.