Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2016001

PreTxPostSx CCLtear1

CCLtear1

Abstract
9 year old spayed female mixed breed dog was presented with intermittent non weight bearing left hindlimb lameness at 1 month post TPLO surgery. The patient was treated with myofascial massage and dry needle acupuncture for associated pain and tension, as well as signs consistent with anxiety and possible depression. Outcome includes reduced muscle tension, reduced signs of anxiety/depression, and improved gait. While presurgical rehabilitation would have been ideal, results indicate that without pre-surgical rehabilitation, even the most simple and affordable manual therapies may cause notable improvement within a relatively short time frame.

History and Presentation
9 year old spayed female mixed breed dog presented for support in ongoing recovery one month post left TPLO surgery, with intermittent non weight bearing left hindlimb lameness and pain. The patient had signs indicative of cranial cruciate rupture (cranial drawer, meniscal click, joint pain and effusion) after acute trauma one month prior to her surgery. Complete tear of the ligament as well as medial meniscal tear and moderate osteoarthritis/DJD was later confirmed in radiographs and surgery. Surgery included left mini medial arthrotomy, left medial menisectomy, and left TPLO. Prior to surgery, the patient did not receive any manual therapy or rehabilitation. The patient did receive carprofen and tramadol along with restricted activity (short leashed walks). Blood work had previously been within normal limits, but at the time of surgery, after a one month regimen of daily carprofen, a mild elevation in ALT was noted (129, reference range 10-125). No other signs of liver issues were noted. Carprofen was discontinued after one week post surgery. Post operative cryotherapy and PROM exercises were provided at home, as well as limited leashed walks according to typical discharge instructions for post TPLO patients. While post surgical radiographs confirmed good alignment and implant placement, the patient remained non weight bearing in the affected limb with any gait faster than a restricted slow walk. Owners had noted patient anxiety (pacing, licking lips, following closely around the home) since the death of her canine housemate which was sudden, violent, and witnessed by the patient, and which occurred only one day prior to the patient’s acute stifle injury. Owners also noted depressed behavior after these combined incidents, though it is unclear if the depressed behavior is secondary to grief, pain or sedation secondary to tramadol.

Physical Examination and Clinical Assessments
Vital parameters were within normal limits. Patient was bright, alert and anxious, with significant off loading of the left hindlimb (places approximately 10% weight) when standing. Intermittent completely non weight bearing lameness of the same limb when ambulating was noted. When slowly walked, patient was able to place weight but continued to demonstrate lameness of this limb with associated compensatory patterns. No signs of neurological
deficits or of icterus/heptatobiliary illness, nor other issues. Incision site was healing well with no complications. Remainder of basic exam was unremarkable, however a detailed myofascial palpation revealed adhesions and pain at the T-L junction, throughout the lumbar spine region, tension and trigger points at the hamstring groups as well as significant tension and fasciculation at the popliteal mm. of both hind limbs. Palpation of quadriceps/iliopsoas regions of both hind limbs also revealed some tension. Forelimbs and scapula were not as problematic, with only mild tension (right more than left) which resolved with initial massage.

Medical Decision Making
Goals were to reduce muscle tension, fascial adhesions, and address the compensatory patterns such as right hind  limb issues, in an effort to help prevent similar loss of joint integrity in the right stifle. Goals also included treatment which both accommodated and addressed patient anxiety via neuromodulation of the parasympathetic system, and by limiting treatment to avoid over stimulating or overwhelming the patient. Treatment plan included homework for the client such as gentle massage, and patient rest with controlled, focused activity including slow, limited and leashed walks in order to employ both agonist and antagonist muscle groups. Prior to dry needling, myofascial palpation and massage was performed not only to assess, but also to reduce anxiety and facilitate myofascial release. It was accompanied by music therapy (calm, measured, classical music was played at low volume), and aromatherapy (subtle use of essential oil of lavender) to further relax the patient. For overall anxiety, GV 14, 20 and Bai Hui were used as the initial points in an effort to help calm the patient via parasympathetic stimulation, with Bai Hui also employed to address the hindlimb problems and lumbar region tension via local stimulation and communication with spinal segments. BL 23 was chosen for it’s local intramuscular stimulation and it’s established treatment of low back pain (1). LR 8 was manually stimulated via acupressure for somatovisceral neuromodulation, to address the previous mild elevation in ALT. ST 36 was employed with the goal of overall parasympathetic stimulation, as well as stifle-specific local effects. This point as well as local points ST 34, SP 9, 10, BL 40 were all stimulated with the goal to provide local effects, including proprioceptive feedback after the patient’s menisectomy. BL 40 was also chosen due to it’s effect via local intramuscular stimulation to reduce tension at the popliteal muscles. Overall the intention was neuromodulation, via stimulation of mechanoreceptors/Golgi tendons and peripheral/somatic afferent nerves.This in turn may result in reduced muscle spasms, increased local circulation, and the promotion of crosstalk between peripheral nerves and spinal segments, with proprioceptive benefits to an area with reduced proprioceptive ability due to menisectomy. Nutritional supplementation (eg glucosamine chondroitin) was also initiated due to known OA.

Acupuncture Treatment
Myofascial massage was performed with aromatherapy and music therapy. Massage included gentle, passive touch,effluerage, compression, skin rolling, friction, and trigger point therapy and lasted 30 to 40 minutes. Dry needlingfollowed using Seirin (0.16 and 0.2 x 0.30 mm) needles for time periods ranging 5 to 15 minutes and adjusted basedon patient tolerance. Visits lasted 1+ hours and included slow, calm assessment and treatment due to the fact that rushing may have resulted in missed signs of pathology as well as increased patient tension and anxiety. Initial points were: GV 14, 20, then Bai Hui. The following points were then added as patient tolerated : ST 34, 36; SP 9,10, BL 40 bilaterally, as well as local treatment of trigger points informed by myofascial palpation. Treatment plan included client homework (gentle massage, controlled exercise). Frequency included three visits, every other day, for the first week of treatment. It was followed by weekly ongoing treatment based on client availability.

Final

Final1

Outcomes: Discussions and References
While at first the patient’s lumbar and T-L tension was generalized, by the second treatment, palpable muscle tension was improved and fascial tissue adhesion had mostly resolved. More specific localization to the level of L5 was appreciable. This may be secondary to myofascial dysfunction from compensatory patterns associated with stifle injury or secondary to unknown underlying spinal pathology (eg DJD, IVDD, etc). Regardless of the underlying cause, the use of BL 23 point for low back pain is likely to be helpful through neuromodulation, with a local effect via intramuscular stimulation (1). Popliteal, hamstring group, and quadriceps tension was more notable in the opposing right hind limb by as early as the second treatment, which is likely indicative of compensatory pathology. Trigger points were treated with massage and dry needling, treating pain by stimulating cutaneous and subcutaneous A delta fibers (2). Increased comfort and gait improvement was notable even after the initial treatment. A faster patient response to therapy during treatment itself was also noted at progressive visits. By the second treatment, resolution of trigger point tension and muscle fasciculation was noted within 5 minutes of massage verses 30 minutes. If available, laser would be a useful tool for local muscle treatment via photo biomodulation. The equipment was unavailable in this particular case. Electroacupuncture (EA) may provide more potent analgesia than manual acupuncture (3). In an effort to accommodate limited but improving patient receptivity, EA was held and treatment remained focused on gentle, detailed myofascial massage as well as simple dry needling. The patient relaxed as trust was developed, but remained generally prone to anxiety. Future treatments may include EA and laser. The death of a long time canine companion was likely disturbing and, at the very least, disruptive of long term household patterns for this patient. Combined with the discomfort and limited activity associated with stifle injury, it is not surprising some anxiety and depressed behaviors were noted at home. The depressed behavior may be due to pain, and/or grieving, or may have been sedation secondary to tramadol (which had been discontinued by presentation). Acupuncture provides an option for adjunctive post operative pain management without the sedative side effects of medications (4). Increased liver enzymes may have been secondary to carprofen and this, too, may be avoided by employing acupuncture and massage without these unwanted side effects (4). Outcome of treatment included reduced signs of anxiety/depression. At initial visit patient reacted anxiously, but these signs reduced by the second treatment and still further by the end of first week of therapy. At home, she was reportedly more eager to engage and more inclined to get up and go outside. Goals remain to help protect patient’s right hind limb from a similar cruciate rupture, reduce progression of known osteoarthritis, and control myofascial compensation patterns. Lessons learned include a noticeable reduction in patient anxiety after the use of acupuncture points associated with stimulating the parasympathetic system. Furthermore, this parasympathetic stimulation and local neuromodulation resulted in improved pain control as demonstrated by reduced trigger point pathology and improved gait. Perhaps the most important lesson from this case has been the significance of even the simplest of treatments. Expensive equipment or a complex number of points is not required to elicit marked improvement in a relatively short time frame. Continued assessments are planned, including 12 week post operative imaging to assess bone healing and blood work to survey liver enzymes. Due to the lack of clinical signs for hepatopathy and only very mild elevation in ALT, normal reference values are anticipated. However, should ALT remain elevated, further work up and treatment may be indicated.

References
1. Kwoming, James C. Neuroanatomical basis of acupuncture treatment for some common illnesses. Acupunct Med
2009; 27(2): 61-64
2. Filshie & White. Medical Acupuncture: A Western Scientific Approach. Churchill. Livingstone. London. 1998
3. Leung, L. Neurophysiological basis of acupuncture-induced analgesia – an updated review. J acupunct Meridian
Stud 2012; 5(6): 261-270
4. Sun Y1, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic
review of randomized controlled trials. Br J Anaesth. 2008 Aug;101(2):151-60


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