Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017057

Abstract:
This case report summarizes the treatment of an 14 year-old MN Brussels Griffon named Buddy. Buddy has multiple concurrent disease states including diabetes mellitus, cataracts, pancreatic insufficiency, deafness, neuropathy (generalized), acid reflux, and spondylosis. He also is resistant to examination and needs to be muzzled while in the clinical environment. Because of the complexity of the case and low tolerance level of the patient (short fuse), fewer needles were used and the points were selected carefully in order to maximize the beneficial effects of the experience. Buddy received a total of three dry needling sessions with Seirin No. 1 acupuncture needles with tubes (0.16 X 30mm). Each session was approximately two weeks apart. Buddy’s owner has reported that he seems more comfortable at home, particularly right after acupuncture sessions. Buddy has even been observed playing, which he has not done for some time.

History and Presentation:
Buddy, a 14 year-old MN Brussels Griffon, presented to Banfield Pet Hospital for acupuncture. As stated above, Buddy has multiple disease states (diabetes mellitus, cataracts, pancreatic insufficiency, deafness, generalized neuropathy, acid reflux, spondylosis) and the owner elected to begin acupuncture as a multi-modal addition to Buddy’s current treatment regimen. Buddy’s medications/therapies include insulin (3.75 units BID), pancreatic enzymes (1 tsp BID), carprofen (12.5 mg BID), glucosamine/chondroitin (.25 tablet BID), diclofenac (1 drop Q24), artificial tears (1 drop BID), famotidine(12.5 mg BID) and vitamin B injections (0.25 ml Q 6 weeks). He is also on a prescription diet – Royal Canin Glycobalance. Buddy was first diagnosed with diabetes in 2012, EPI in 2013, cataracts and acid reflux in 2014, and spondylosis in 2017. His hearing loss has been gradual, with complete loss noted at the beginning of 2017.

Physical Examination and Clinical Assessments:
On presentation, Buddy was bright, alert and responsive. His vitals were WNL and his pulses were strong and consistent. Myofascial palpation revealed guarding and trigger points along the bladder line in the cervical and thoracolumbar regions of the spine. Buddy walks with a stilted gait, although it is difficult to discern if this is secondary to discomfort or if it is due to lack of spatial awareness from blindness. No neurologic or proprioceptive deficits were noted, although Buddy is very resistant to examination and a thorough clinical picture is difficult to obtain.
Radiographs were taken of Buddy’s spine in July of 2017 and revealed spondylosis at T12-T13 and L1-L2. Buddy’s most recent blood work was performed in July of 2017 and revealed elevated cholesterol (432), phosphorus (7), BUN (31), and globulins (4.9). Buddy’s glucose at that time was WNL (90).

Medical Decision Making:
This case provided a particularly interesting challenge due to the fact that the patient has multiple concurrent disease states and is prone to aggression and difficult to examine. As stated previously, fewer needles were used and the points were selected carefully in order to maximize the beneficial effects of the experience. The same treatment protocol was used for each of the three sessions with minor variations. This decision was made based on the positive results observed beginning with the first session. It was also clear beginning with the first session that Buddy would only tolerate certain points. The main focus of the acupuncture treatment was neuromodulation of musculoskeletal pain and tension. I did my best to select points that would also influence diseased organ systems (pancreas, etc).

Differential diagnoses:
In terms of Buddy’s spondylosis, differentials include intervertebral disc disease and degenerative joint disease. Buddy’s most recent radiographs did not show overt evidence of these processes, but without more advanced imaging (CT/MRI) it is not possible to rule them out.
Buddy’s diabetes has been well diagnosed in the past and is responsive to insulin treatment. We can definitively conclude that Buddy has diabetes mellitus. His exocrine pancreatic insufficiency diagnosis is also well established. However, both of these diseases involve the pancreas and immune system dysfunction. Although there is not overt evidence on blood work, it is not possible to rule out other pancreatic disease (chronic pancreatitis) or other autoimmune diseases.
Many of Buddy’s diagnoses are sequelae to his primary diagnosis of diabetes mellitus. These sequelae include cataracts and neuropathy. As with spondylosis and DM, these have also been previously diagnosed. Differential diagnoses include arthritis/degenerative joint disease. A definitive diagnosis of cataracts can be made with a thorough physical exam.

Definitive (or Putative) Diagnosis (or Diagnoses):
Buddy’s definitive diagnoses have been historically well established. These diagnoses were made based on physical examination, diagnostics (blood work and radiographs), and response to treatment.

Acupuncture Treatments:
Acupuncture treatments consisted of 3 dry needling sessions. The sessions were 2 weeks apart. The decision was made to perform acupuncture using dry needling alone based on logistics. I do not have access to electro-acupuncture or laser at this time.
Week 1: The main goals of the first treatment were to decrease stress and anxiety and to make the patient as comfortable as possible. The treatment protocol was formulated with this priority in mind in order to establish a positive experience for the patient.
● Bai Hui – Stimulates the parasympathetic nervous system to aid in calming – an appropriate first point for a patient that is resistant to examination. Also used to treat local back pain (spondylosis) and neurologic dysfunction (neuropathy).
● GV-20 – Helps to decrease agitation. May also help to address local neurologic dysfunction.
● BL-17 – Local trigger point
● BL-20 – Local trigger point. Also used to address digestive problems (EPI).
● BL-21 – Local trigger point. Shu point for the stomach to aid in acid reflux.
● BL-23 – Local trigger point. Also used to address lumbar pain (spondylosis).

Week 2: When designing this session, I chose to maintain the priority of patient comfort and calming. I used the points described above with the exception of BL-17 and BL-21. This decision was made based on my myofascial palpation – local trigger points were no longer present. The patient was slightly more compliant during this session and I was able to add some distal limb points. The following points were added:
● BL-18 – Local trigger point.
● BL-40 – Used to help treat the patient’s diabetic neuropathy
● KI-7 – Can help with lower back pain and neuropathy/numbness in the distal limbs

Week 3: During this session, my patient’s compliance was low. The therapeutic design was created with this in mind and fewer needles were used. The justification behind each point was consistent with previous treatments. The following points were targeted:
● GV-20
● Bai-hui
● BL-17
● BL-21
● BL-23

Outcomes, Discussions, and References
Buddy’s owner has reported that Buddy seems more comfortable, particularly right after acupuncture sessions. While Buddy has chronic, incurable diseases, acupuncture provides a complementary therapy to his current treatment regimen. Buddy will require insulin and pancreatic enzymes for the rest of his life. At this point, he will also continue to receive anti-inflammatories. For this patient, the goal is not to discontinue western therapies, but rather to use a multi-modal approach to ensure that the patient is as comfortable and well controlled as possible.
At this point it is difficult to quantify the response to treatment in a scientific manner. I look forward to being able to observe marked, noteworthy improvements in this patient.
No adverse effects have been observed in response to treatment.


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