Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2018016

Abstract

Kaz is a 9 year old Bavarian Warmblood gelding that presented for soreness and difficulty performing high level movements. Kaz also has a history of recurrent colic episodes. After monthly acupuncture, electroacupuncture, and laser therapy, Kaz is moving and performing better than he ever has and has experienced fewer colic episodes.

History and Presentation

Kaz is an upper level dressage horse that presented for general soreness and reluctance to “use” his back end and step under himself. This difficulty began during heavy training prior to his regional competition in the fall of 2018. Kaz also has a propensity to play hard and occasionally injure himself during turnout. He was obviously painful to the touch in his left lumbar region, so the owner treated him by massaging Surpass (topical non steroidal anti-inflammatory) to the lumbar muscles and using the Assisi Loop in the affected region right before the horse show. Kaz did not perform well at the show and his owner elected not to take him to the national competition the following month. The client had her primary care veterinarian examine Kaz for pain. Kaz was diagnosed by his primary care veterinarian with sacroiliac disease and referral to the university veterinary hospital for steroid injection of his right sacroiliac joint was advised. The client instead decided to pursue acupuncture therapy first. Additionally, Kaz has a tendency to colic after returning home from horse shows. He was diagnosed with gastric ulcers via endoscopy in June 2018 and treated with one month of omeprazole, but has continued to have flare ups of colic where he is uncomfortable, sweating, and goes off feed. These episodes are treated with Sucralfate and tend to resolve quickly.

Kaz before

Initial Physical Examination and Clinical Assessments

On physical exam on 11/8/2018, Kaz was very tense, tight, and reactive in his mid to caudal lumbar paraspinal muscles on the left side. When lateral flexion/rotation of the lumbar spine was attempted he stepped away in avoidance. He was also reactive to palpation of his right sacroiliac joint, but to a lesser extent compared to his lumbar musculature. He had some tight bands palpated in his left triceps muscle. He seemed to flex his left hind limb during the cranial phase at the walk slightly less than the right, but was tracking up evenly and appeared to be evenly weigh bearing. No neurologic abnormalities were noted.

Problem List

Lumbar back pain, sacroiliac pain, tight bands in lumbar epaxial muscles, tight bands in the left triceps, gastric ulcers, recurrent colic

Differential Diagnosis

Back Pain: Muscle fatigue, myofascial dysfunction, polysaccharide storage myopathy (PSSM), intervertebral arthritis, hind gut ulceration, gas pain, overriding dorsal spinous processes (kissing spine), sacroiliac disease, degenerative joint disease of the hocks or stifles

Recurrent Colic: Gastric ulcers, hind gut ulcers, gas colic, spasmodic colic, impaction colic, enteritis, myofascial dysfunction

Definitive Diagnosis

Gastric Ulceration with occasional spasmodic colic and Myofascial Dysfunction of Lumbar Spine

Medical Decision Making

During our first acupuncture session, a minimal number and a smaller gauge of needle was used to assess Kaz’s response to treatment.  GV 14 and Bai Hui were the first points placed on all acupuncture sessions to increase parasympathetic tone and help to relax him. Laser therapy was utilized to help relax tense muscles and increase the cellular ATP and healing, as the back pain he was presenting with was suspected to be caused by overtraining just prior to his big competition. Needles were placed along the bladder line (BL 21 or 22-25) in the tense lumbar region to directly treat trigger points by disrupting the spasming muscles and thereby causing the body to repair those local muscle bundles. These needles also stimulated the thoracolumbar and midlumbar spinal nerves to neuromodulate local pain, as well as address digestive issues. BL 25 is a commonly used point to treat intestinal pain. BL 27 was used to stimulate the SI sacral nerve and treat sacral pain.

Based on Kaz’s myofascial exam at each appointment, point selection varied to treat the tight muscle bands or trigger points palpated directly. Needle size was increased in subsequent sessions as Kaz tolerated it, and because when electroacupuncture was added to his protocol and the larger needles tended to stay in more reliably. ST 36 was added to Kaz’s treatment plan for its neuromodulatory effects on the gastrointestinal system, to modulate inflammation, and also because stifle pain was also considered as a differential diagnosis.

On Kaz’s 1/2/19 treatment, Kaz was more painful in his sacroiliac joint than previously, so BL 28 and 29 were added to neuromodulate the S2 and S3 spinal nerves. BL 40 was added to neuromodulate the tibial nerve and treat potential stifle/pelvic limb pain. GB 29 was used to treat a local trigger point. Electroacupuncture was used during this session (1/2/19) on a low frequency to decrease lumbar pain and to cause greater stimulation of the points selected. Low frequency was chosen as it to release endogenous opioids and one of the treatment goals was to decrease pain.

Medical Acupuncture and Related Techniques

11/8/2018: Points used: GV 14, GV 4, Bai Hui, BL 22, BL 23, BL 24, BL 25, BL 27 bilaterally and a trigger point in right gluteal muscle using Seirin 0.20mm x 30mm needles. Needles were left in for 20 minutes and stimulated every 5 minutes. Laser therapy was delivered to paralumbar spinal muscles after acupuncture at 8W for 1500 joules.

12/3/2018: On myofascial exam, Kaz was tense in his lumbar spinal muscles, moreso on the right than the left (which is opposite compared to his previous exam). He had tight bands palpated cranial to both scapulae.

Points used: GV 14, GB 21, Bai Hui, trigger points left triceps, left GB 29, left BL 54, BL 21, BL 22, BL 23, BL 24, ST 36 using Seirin 0.25mmx30mm needles. Needles were left in place for 20 minutes and stimulated every 5 minutes.

1/2/2019: Kaz was tender to palpation of his right sacroiliac joint with tight epaxial muscles along his right lumbar spine and right gluteal muscles. He was more painful on this exam than the previous exam in 12/18.

Points used: GV 14, GB 21, Bai Hui, BL 40, BL 21, BL 22, BL 23, BL 24, BL 25, BL 26, right BL 28 and 29, trigger points near BL 54 and GB 29, and ST 36 using Seirin 0.25mm and 0.20mm x 30mm needles.

2/4/2019: Tight muscles were palpated along the mid to caudal lumbar spine bilaterally, but moreso on the right lumbar epaxial muscles and right gluteal muscles. Overall, the tightness of his lumbar muscles has improved. Tight bands of muscle were palpated cranial to the left scapula and within the right pectoral muscles.

Points used: GV 14, LI 16, Bai Hui, BL 11, BL 13, BL 21, BL 22, BL 23, BL 24, BL 25, trigger point in L tricep, right BL 54, right LU 1, ST 36 using Seirin 0.20mm x 30mm needles. Electroacupuncture was performed on low frequency (2Hz) for 10 minutes. Attempted to run current from BL 21-25 on each side but needles were pulled out so electroacupunture was performed from BL 22-24 on each side. Lead 1 was connected along the right side of the bladder channel and Lead 2 was spanning along the left side of the bladder channel. Smaller gauge needles were used this session only because I ran out of the 0.25mm Seirin needles.

Kaz after

Outcomes, Discussion

Kaz is a dressage horse whose body is constantly in work–learning and practicing new movements. Each myofascial exam revealed new or different areas of tension or soreness, likely a caused by a combination of muscle soreness/fatigue, underlying soundness concerns, and compensation. In order to continue his progression “up the levels” it is important to keep him feeling his best. Acupuncture has proven valuable in Kaz’s health and training program. He has been able to continue a consistent training program without set backs and needing days off to recover from soreness issues. There has been a notable decrease in the number of Kaz’s colic episodes and his need for Sucralfate treatments, though he has not been traveling to shows over the winter which can also reduce his stress and ulcer issues. Because each of Kaz’s myofascial exams varied so much (such as his lumbar soreness switching from left to right and his sacroiliac pain coming and going), this really shows the importance of taking the time to perform a thorough myofascial exam at each appointment as this can help to guide and change the points selected from session to session. It is difficult to remember to keep looking at the whole picture. At each session I was initially focused on Kaz’s back pain and tight muscles, and had to remind myself to treat the whole horse, including making sure I was having a positive impact on his gut health as well. For Kaz, a lot of the points that neuromodulate areas where he was tender also corresponded to points that would positively affect his gut health as well.

References

  1. Zhen Ci Yan Jiu. [Effects of transcutaneous electrical acupoint stimulation of “Zusanli” (ST 36) on gastric mucosal injury in exercise stress-induced gastric ulcer rats]. 2013 Jun;38(3):181-5.
  2. Dunkel B, et al. A pilot study of the effects of acupuncture treatment on objective and subjective gait parameters in horses. Vet Anaesth Analg. 2017 Jan;44(1):154-162.
  3. Xie H, Colahan P, Ott EA. Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. J Am Vet Med Assoc. 2005 Jul 15;227(2):281-6.
  1. Klide AM, Martin BB Jr. Methods of stimulating acupuncture points for treatment of chronic back pain in horses. J Am Vet Med Assoc. 1989 Nov 15;195(10):1375-9.

 


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