Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018014
Sage, a 10-year-old spayed female canine Ridgeback mix, presents with intermittent left hind limb weakness of approximately 2 years and occasional lameness of the right front limb which started in early 2018. Symptoms improve with laser (photobiomodulation) therapy from Veterinarian as needed, rest and controlled walks. Owner interested in acupuncture and requested further treatment options for Sage regarding the left hind limb.
Sage was treated in 5 sessions from June 3 to June 21, 2018 with myofascial exam, massage, acupuncture and laser therapy. At the time of treatments, no lameness or discomfort noted in the right front limb. Treatment was concentrated on the left hind limb, hip and back. Pre-acupuncture videos showed limited weigh bearing of left hind limb and using both hind limbs per stair as she walked. During the 5 sessions, Sage used one foot per stair more frequently and walked more evenly on her hind limbs and was sturdier during bowel movements. She stood without shaking of the left hind limb and did not try to cut her walks short. The results were accomplished by acupuncture, massage and laser therapy.
History and Presentation:
Sage, canine, spayed female, Ridgeback mix, date of birth 08/11/2007, 75 pounds.
Sage was diagnosed with Hepatic Microvascular Dysplasia in 2009. She is routinely monitored with annual exams and bloodwork. In 2014 she had a partial tear of her cranial cruciate ligament of the right stifle. Surgery was performed and she recovered without complications with rehabilitation and laser therapy. Then she had a tumor removal and splenectomy in January 2017. A large 7-pound benign tumor attached to the spleen was removed in an emergency surgery. Follow up ultrasound at 9 months post op was performed and no concerns were noted. At the same time of the splenectomy a benign melanoma was removed from the roof of her mouth which has extended dorsal to the bridge of the nose. There appears to be no complications at this time from the nasal tumor.
She is on a diet of Royal Canine Hepatic and medications consist of Denamarin 2 tablets SID (once a day dosing), Dasuquin chewable large breed 1 tablet BID (twice daily dosing). Sage also takes Standard Process Supplements of Renafood 1 tablet BID, Hetapropin 1 tablet BID, Livaplex 1 tablet BID and Catalyn 2 tablets BID, all prescribed by her Veterinarian at Evergreen Family Veterinary Hospital.
Sage presents with intermittent left hind limb weakness of approximately 2 years. This is presented as difficulty getting up from a down position, shaking of the limb, shifting weight to right hind leg and when walking stairs.
A partial tear of the left cruciate is the working diagnosis. There is very little muscle atrophy of the left hind limb in comparison to the right hind limb. Patient does enjoy walks and does not appear to be in pain but does have discomfort evident by favoring of the left hind limb. She has a good attitude, eats and drinks normal.
Physical Examination and Clinical Assessments:
The neurological exam revealed normal patellar reflexes, good awareness of proprioception, no cross-extensor reflexes and good range of motion of the hip and stifles. Cranial drawer cautiously performed and was minimal for the left stifle. Her tail is easily able to thump and show her happy personality.
The myofascial exam shows well developed muscle tone of her dorsum, hips and hind limbs. There does not appear to be restriction in the neck or shoulders. The skin is easily manipulated from the fascia, easily rolled and does not show discomfort to Sage from the thorax to sacrum. No warm areas are felt through the torso. The left hind limb at the biceps femoris muscle shows a slight indentation proximal to the joint line more prominent than the right. No pain elicited at this location. Both hind legs were examined for fascial restriction. The left stifle did have warmth felt from the medial aspect which was not found on the right stifle.
Definitive or Putative Diagnosis:
The diagnosis of degenerate joint disease caused by cruciate tear was made by the presentation and evaluation of Sage. She is able to walk with minimal discomfort, very little muscle atrophy, a history of TPLO (tibial plateau leveling osteotomy) of the right stifle and according to the American College of Veterinary Surgeons (AVCS) it is common for 50% of cases to have a tear occur in the opposite stifle. The diagnosis of a partial tear of left stifle cruciate ligament is made upon history, physical exam, and the amount of discomfort Sage shows when walking and standing. Radiographs have not been taken.
A partial tear of a stifle ligament, partial tear of meniscus, sciatic nerve restriction, bone or soft tissue neoplasia and inflammatory joint disease.
Medical Decision Making:
The acupuncture approach was focused on her continued intermittent discomfort of the left hind leg. The plan is to concentrate on her lumbosacral spine segments which feed to her hind limb. I will concentrate on neuromodulation from the spinal cord to the peripheral segments which stimulate the muscles to ambulate the leg, assuring the musculature stays strong and functions appropriate.
Dry needling, laser (photobiomodulation) and massage was performed on Sage over the 5 treatment periods.
The first treatment 6/3/18, was focusing on the myofascial exam and her comfort with dry needling. First focusing from the head to tail then the limbs. Sage did not show any trigger points or restriction until the left hind limb. There was warmth on the medial aspect of the left stifle and minimal tight hamstrings. Acupuncture started with GV14, GV20, and BaiHui, focusing on relaxation. Then on the left hip with BL54, GB29, GB30. These points were chosen to target any hip discomfort due to the shifting of her weight from the left onto the right hind. The sciatic helps extend the hip joint, flex or extend stifle joints and extend the hock joint. By targeting the sciatic nerve of the biceps femoris, quadratus femoris, gemelli, the innervation will keep the limb stimulated by muscular innervation. The GB29 targets the cranial gluteal which targets the middle and deep gluteal and tensor fascia lata of the limb. This assists in extending and stabilizing the stifle joint. The stifle was difficult to approach from the medial aspect where the warmth occurred, so due to her comfort I stayed on the lateral aspect with ST34 and ST36 to focus on the stifle for stifle pain and instability. Femoral nerve at L4-L5 extends to the iliopsoas which will protract pelvic limb and the quadriceps femoris extends the stifle. These needle placements seemed to be enough for Sage for the first-time acupuncture. Massage of the limb was not performed after removal of the needles for she walked away. She did go for a short walk after treatment and used one foot per stair.
The second appointment 6/5/18, BL36 was added for hamstring muscle tension. She appeared tight in the biceps femoris, semitendinosus and semimembranosus muscles. The Bladder point was added to the previous session points.
The third session 6/10/18, all the same points were used as previous sessions but added, BL23, BL52 these for where chosen for their origination from the spinal cord which branches to the limb. Then GB31, GB33, GB39, these were to target the stifle. Fifteen minutes of laser focused on the left hind stifle and lumbosacral area.
The fourth session 6/12/18, Sage was sensitive to needle insertion so less seemed to be more. GV14, GV20 for relaxation and then GB29, GB30, GB31, GB33, GB39 to target the stifle of the left hind limb. Since Sage was not relaxed, these points did not stay in for long so laser treatment was initiated for 15 minutes 5Hz to lumbosacral and left hind limb and massage from L1 to tail and both hind limbs. There was relaxation of the hamstring muscles after acupuncture and massage compared to prior to this 4th session.
Prior to the fifth session, Sage walked down some steps which she used one foot per stair, however on the way up the stairs she returned to using two hind feet per stair. The fifth session on 6/21/18 Sage was mildly anxious. After an initial massage period she seemed to relax and acupuncture was performed using GV14, GB29, GB30, GB31, and GB39. The hamstring muscles were tense. Massage was continued during acupuncture of the hamstrings and the needles continued to be withdrawing from the muscle tension. Laser was performed 5Hz to the lumbosacral area and down the left hind limb for 10 minutes.
Needles and laser (photobiomodulation):
Seirin J type with guide tube 0.16 red 30mm needles
TQ Solo by Multi Radiance Medical Laser used 5Hz low level laser for deep chronic pain
Outcomes, Discussions and Refences:
After the first session, Sage walked down each stair with one foot on each landing. After the fourth session the owner took Sage for a walk and she commented that she seemed to have better range of motion on the walk. By the end of the fifth session, the owner commented on her ability to stand equally weight bearing while she had a bowel movement. Her quality of life appears to be improved upon by acupuncture, massage and laser.
Long term goals for Sage are to return to climbing stairs with normal limb placement, continued equal range of motion of all limbs on walks and prevent muscle wasting.
For a first-time acupuncture patient, I wanted her to enjoy feel comfortable and enjoy the procedure. This type of presentation is commonly seen in a clinical practice. Degenerative joint disease occurs in many breeds and progresses with more complications for the patient as they age. Acupuncture is a great noninvasive option for clients. I also recommended to Sages owner to continue massage therapy in between appointments, concentrating on both hind limbs hamstring muscles as well as the lumbosacral region. Sage is to continue controlled walks to maintain her muscle mass and keep arthritis at bay.
Concern for adverse events would be entering the joint capsule, damaging the sciatic nerve or stimulating a trigger point which causes the animal discomfort and unable to relax. The points chosen for Sage were safe and effective for now. If she develops complications down the road these points will be adjusted to what Sage needs at the time.
This addendum is to the original report dated June 30, 2018, and to the follow up dated August 4, 2018. This addendum dated August 21, 2018 shall replace the previous two reports diagnosis of degenerative joint disease to the diagnosis of caudal cervical myelopathy, likely caused by disc protrusion. This definitive diagnosis explains the hindlimb gait which appeared as joint disease, the neck discomfort with thickening and reduced range of motion as well as an asynchronous gait. It can be further diagnosed to location by MRI or radiographs but not necessary. Sage has shown improvement through acupuncture and photobiomodulation. This diagnosis explains the most recent videos taken of Sage showing a marked improvement after adding cervical acupuncture points and owner massage to the neck and back in between sessions. Restricted, controlled walks with acupuncture, massage and laser are helping Sage from flare ups of the vertebral column. Sage is unable to add anti-inflammatories due to her liver abnormalities so these options discussed are best.
ACVS.org, Cranial Cruciate Ligament Disease
Au, Jennifer DVM, DACVS, DACVSMR, CCRT Charleston Veterinary Referral Center, Charleston South Carolina, Rehabilitation Therapy: Sciatic Nerve Injury. Clinicians Brief, 2016 September