Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017056
Abstract: This case report follows the treatment of a bulldog with severe, long standing hind limb paresis. He was treated with acupuncture, electroacupuncture, home exercises/physical therapy and home massage. These treatments led to functional improvements in the patient in a short amount of time.
History: Gus is a 6 year old, neutered male English Bulldog. He presented on May 4, 2016 for progressing ataxia in the pelvic limbs. On physical exam (PE), he was ambulatory but paraparetic with marked proprioceptive ataxia in both hind limbs (scuffed both hind paws, crossed both hind limbs significantly, occasionally walked on the dorsum of the paws). Conscious proprioception (CP) placement of paws was normal in the thoracic limbs, decreased in the right pelvic limb, decreased to absent in the left pelvic limb. He had increased patellar reflexes bilaterally. He had pain on palpation of the thoracolumbar (T/L) spine. He also had crepitus on range of motion in both stifles. Radiographs of the thoracic and lumbar spine, stifles, pelvis and coxofemoral joints were performed. These showed multiple hemivertebrae with kyphosis in the caudal thoracic spine, narrowed caudal thoracic disc spaces, including T13-L1, bridging spondylosis deformans ventrally from T10-T12, moderate lumbosacral (L/S) spondylosis deformans, sacral and coccygeal vertebral malformations, shallow acetabula with mildly subluxated femoral heads but no secondary degenerative bony changes, mild osteoarthritis (OA) and effusion or soft tissue thickening in both stifle joints. Gus was referred to a neurologist who confirmed a diagnosis of T3-L3 myelopathy, with possibly an L4-S3 myelopathy. The owners did not elect to pursue advanced imaging, surgery or physical therapy at that time. Gus was started on gabapentin for pain control. His ataxia continued to progress and he has been in a wheelchair for approximately 6 months.
Physical Exam and Clinical Assessments: On May 13, 2017 Gus was non-ambulatory in his pelvic limbs. When assisted, he was capable of slight pelvic limb movement. He could stand unassisted for only a couple seconds before collapsing onto one hip. CP was absent in both hind limbs. Withdrawal was present in both hind limbs, but delayed in the left hind. He had a normal to increased patellar reflex in the right hind, I was unable to elicit a reflex in the left hind. He had control of his bladder and bowels and had normal anal tone. He was reactive/painful on gentle palpation of the T/L junction area of his spine. Gus has hypertrophy of his neck, chest, shoulder and forelimb muscles with tense muscles and some trigger points in these areas (especially the pectoral, caudal trapezius, rhomboideus, latissimus, supraspinatus and triceps muscles).
Differential (Ddx)/Definitive Diagnoses: T3-L3 myelopathy, with the most likely localization being T10-L1. Ddx include intervertebral disc disease (IVDD), congenital malformations of the vertebrae (these two are the most likely Ddx), neoplasia, infectious inflammatory disease, non-infectious inflammatory disease.
Possible L4-S3 myelopathy, especially left side. Same Ddx as above.
Bilateral hip dysplasia. Bilateral stifle OA.
Medical Decision Making: Treating the caudal thoracic to cranial lumbar and the caudal lumbar to sacral area inner bladder line points will be important for pain control and to stimulate nerve signal transmission from these spinal segments to the brain and to the pelvic limbs. Distal points that correspond to the sciatic and femoral nerves and their branches will help facilitate nerve signal transmission. I will include points to balance the autonomic nervous system, provide immune system stimulation and hopefully relax the patient during the treatments. I will use points to treat the compensatory strain patterns and trigger points. I will treat coxofemoral and stifle points–this is important as he‘ll need to be as comfortable as possible to use his hind limbs again. Home exercises, physical therapy (PT) and massage will also be important for strengthening and to retrain normal hind limb ambulation. We added oral carprofen for pain control.
Acupuncture Treatments: Gus was treated once weekly for 4 weeks. Dry Needling: Central Nervous System Points: Inner BL line points–BL 17-25, BL 27-28; Peripheral Nervous System Points: BL 54, GB 30, BL 40, ST 34, ST 36, GB 33, GB 34, BL 60/KI 3, LR 3, Bafeng; Autonomic Nervous System Points: GV 20, GV 14, Bai Hui, ST 36, LR 3 (I attempted to do LI 4 but Gus would not tolerate it); Myofascial/Musculoskeletal Points: BL 10, cervical spinal nerve points, BL 13-15, GB 21, SI 12, BL 54/GB 29/GB 30, BL 40/ST 34/ST 36/GB 33/GB 34, tense muscles/trigger points. Electroacupuncture: BL 18 to BL 23 or 25, BL 23 or 25 to BL 27 or 28, Bafeng to ST 36, LR 3 or GB 34. Home Exercises/PT/Massage: Client was shown how to do assisted standing and walking with a harness, balance/core strengthening exercises, brisk stimulation of caudal thighs and tail base to elicit hind limb movement, assisted sitting to a correct, stifles flexed position, range of motion of hind limbs, and gentle massage of compensatory strain areas. They try to do a variety of these exercises for about 5-10 minutes twice a day.
Outcomes/Discussion: Gus is now able to rise and stand unassisted long enough to eat his meals and to urinate/defecate. He can ambulate a few correct steps with both hind limbs but fatigues quickly–he’ll continue to walk, but incorrectly (hind limbs out behind him, walks on dorsum of left hind paw). The clients feel he is happier and more comfortable since starting acupuncture. They notice the greatest difference in his comfort level and ability to ambulate correctly the first 2 days after an acupuncture session. They plan to continue weekly treatments until Gus is stronger and able to use his hind limbs correctly for more sustained periods. Gus was anxious about acupuncture initially, but has become much more relaxed and seems to actually enjoy the sessions now. This case has shown me what an amazing difference acupuncture can make in a patient’s, and the client’s, lives! I was worried we wouldn’t get a response in the short amount of time required for my case report (given how long Gus has been in a wheelchair), but we have. The clients are thankful and it has been an extremely rewarding experience for me. Acupuncture has renewed my excitement about veterinary medicine. Thank you!
References: Ching Ming Liu, G. Reed Holyoak, Chung Tien Lin: Acupuncture combined with Chinese herbs for the treatment in hemivertebral French bulldogs with emergent paraparesis; J Tradit Complement Med, October 2016;6(4):409-412.
Joaquim et al: Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with IVDD with long-standing severe neurologic deficits; J Am Vet Med Assoc, June 2010;236(11):1225-9