Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017022

Abstract:
Liyah, an estimated 4 year old FS Boxer, presented for severe disuse atrophy of her right hind limb after a surgically corrected femoral fracture. After multiple acupuncture treatments, physical therapy exercises and gentle massage, her range of motion (ROM) is improving and she is consistently bearing weight and using her leg.

History and Presentation:
Liyah, an estimated 4 year old FS Boxer, was found hanging from a fence by her right hind leg and brought into the clinic about one week later. On presentation, she was emaciated and unable to bear weight on her RH. They diagnosed her with a femoral fracture and recommended surgical correction. She was relinquished to Happy Landings Rescue due to money constraint and became a SAST (Saving Animals in Shelters by Teaching) case at CSU. Her femoral fracture was corrected on July 26th and she was adopted by a family in Littleton, CO. She presented to me on August 14th for a physical exam and routine care. At this time, the owner was concerned about the continued disuse of her right hind leg.

Physical Examination and Clinical Assessments:
T: 101.6, P: 120, R: panting
BAR, anxious, BCS 3/9, mm pink & moist, CRT <2
EENT: clear, no discharge; CV: normal rate and rhythm, no murmur, strong femoral pulses; Resp: eupneic, normal bronchovesicular sounds; Int: healthy skin and haircoat, incision on the lateral aspect of her RH leg (healing); oral exam: normal boxer dentition, no dental calculus or gingivitis; Abd palpation WNL; Pln WNL; Neuro: normal mentation, CPs normal in all four limbs, withdrawal present in RH, patellar reflex normal in RH ; MS: severe atrophy RH (most notably semimembranosus and semitendinosus, gluteal muscles, and biceps femoris), toe touching but not consistent use of her RH leg, limited ROM RH with resistance to flexion of both hip and stifle, tight muscle bands palpated in right gastrocnemius, bilateral latissimus and triceps muscles, possible back pain during spinal palpation. Normal ROM in LH.

Medical Decision Making:
Based on the severe atrophy noted in Liyah’s right hind leg, my goal with acupuncture was to help control pain through neuromodulation, stimulate additional blood supply and healing to the muscles, and address the compensatory pain. In addition, physical therapy exercises were started to help with range of motion and core stability.

Differential Diagnoses:
1- low body condition (3/9)
r/o malnutrition vs systemic illness
Likely due to malnutrition because of history and bloodwork prior to anesthesia was unremarkable.
2- generalized, severe muscle atrophy with limited ROM of RH.
r/o chronic injury and disuse vs nerve injury
Likely due to chronic injury and disuse because the reflexes and neurologic assessment was normal.
3- possible back pain
r/o compensatory pain vs trauma from original injury
Likely due to pain from shifting full body weight forward while compensating for a fractured leg. Radiographs, while not directly focused on the spine, didn’t show evidence of narrowed disk space or other trauma.

Definitive Diagnosis: Surgically corrected femoral fracture with disuse atrophy of right hind leg and compensatory pain in back and other limbs.

Acupuncture Treatments:
August 16th: At home session due to Liyah’s anxiety at the hospital. Unknown acupuncture history but likely first treatment. Needle type (Seirin J 0.18 x 30mm) selected for this reason. I started with GV 14 & GV 20 for relaxation and to see how she would handle the dry needling. I then moved to Bai Hui to help neuromodulate pelvic limb pain. BL 21, 22, & 23 for thoracolumbar spinal pain. And the hip triad (GB 29, GB 30, and BL 54) for sciatic nerve activation and hip range of motion. She handled all theses points well. After the acupuncture session, gentle massage over her forearms and back were performed.

August 30: According to Liyah’s owner, she did very well after the first acupuncture session. They continued to work on ROM exercises and controlled movement (sit and down) during the two weeks. She is beginning to regularly use her right hind leg while walking but still holds it up while standing in place. This session included all the points from the first session but also focused on the trigger points in her latissimus muscles, plus BL 15 & BL 13 for trigger point deactivation.

September 13: Liyah continues to improve. The muscles in her right hind leg have continued to develop and strengthen. She is using her leg during controlled leash walks and her ROM has improved. In addition to the points mentioned above, ST 34 and ST 36 were added to the acupuncture treatment for additional femoral nerve activation. Needle type Seirin J 0.20 x 30 mm was used and well tolerated.

Liyah is scheduled to have one more acupuncture treatment next week. Electroacupuncture will be considered now that she is tolerating the 0.20 size needle.

Outcomes, Discussions and References:
Acupuncture in combination with physical therapy and analgesics help with pain and improve quality of life1, especially in musculoskeletal cases. The combination of acupuncture, physical therapy, and massage have improved Liyah’s range of motion of her right stifle and hip and she has strengthened her muscles. She is able to fully extend each joint and flexion has greatly improved. Her muscle mass has subjectively increased (sadly, measurements not taken). Liyah is also able to go on longer walks without fatigue. This case reemphasized two important points for me. First, I believe if acupuncture and physical therapy were maintained throughout her healing process, her recovery wouldn’t have been so prolonged and the muscle atrophy not so drastic. Second, evaluation and treatment of the whole dog is essential for a positive outcome. Without a thorough physical exam, her compensatory pain would not have been recognized and treated. This could have also prolonged recovery and healing.

1- NEOF, S. et al. “Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases”. Can Vet J. 2017 Sep; 58(9):941-951
2- Lane, DM, et al. “Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain.” Can Vet J. 2016 Apr;57(4):407-14.


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