Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017022

Abstract:
The purpose of this report and treatment series was to assess response to acupuncture for hindlimb degenerative changes, and, as a secondary goal, upper respiratory infections (URI). Additionally, how to make the environment more acceptable for acupuncture for a nervous feline and to optimize the point choices that he would tolerate a longer session with more impactful points was addressed.

Outcome:

Hindlimb lameness showed improvement, as noted by change in jumping habits demonstrated by less hesitation and higher heights, reduction in self-barbering, and increased comfort in certain positions. No significant change in resolution of URI symptoms when compared to baseline, but improved toleration of treatment was noted.

History:
Larry is a 10-year-old neutered male Maine Coon who presented for evaluation of hindlimb lameness which has been progressing over the last two years. Owners note that he preferably lays on his left side. He is not able or willing to jump as high vertical distances as he once did. Additionally, he hesitates more prior to any jump. Most recently, he has begun barbering the hair on his pelvic limbs, which is a different pattern than seen with atopy that he has historically experienced. His activity level is decreasing with time as owner notes less enthusiasm over his favorite toys. He is still using the litterbox but has stopped covering his feces over the last three years. He is not on any supplements or medications for his orthopedic issues.
Larry was adopted as a young adult following a short stint as a free-roaming cat. He is an only cat in the household and is now strictly indoors. His medical history includes anaphylactic reaction to feline leukemia virus vaccination. He has a II-III/VI parasternal cardiac murmur first noted at four years of age, stable since first detected. Recent cardiac echocardiography showed early hypertrophic cardiomyopathy; medications are not indicated at this point. He has a history of a subcutaneous fibrosarcoma on his ventral thorax that was completely excised but with poor margins. Larry also suffers from chronic upper respiratory infections, primarily manifesting as sneezing and mild ocular discharge. Finally, Larry has atopy, demonstrated by generalized pruritus. This is currently controlled by a limited ingredient diet and chlorpheniramine daily. Recent bloodwork shows no abnormalities. Radiographs showed mild degenerative changes of bilateral hips but no other significant abnormalities.

PHYSICAL EXAMINIATION AND CLINICAL ASSESSMENTS:
Heart Rate: 180 beats per minutes, Respiratory rate: 50 breaths per minutes Bright, alert, responsive. He spent a little time in a cage in the kennel area of the clinic prior to the acupuncture session unfortunately which made him a little more resistant to handling versus normal.
Mucous membranes: Pink, moist; Oral exam: Several missing teeth. 304 has intrinsic pink staining that was first noted at this exam (previous dental 6/2017).
Eyes: Mild serous discharge OU. Ears: Free of debris and odor. Nares: Mild nasal discharge right nostril. Normal airflow through both.
Cardiovascular: Grade 3/6 parasternal murmur. Pulses strong and synchronous.
Abdomen: Tense but non-painful. Integument: thin hair coat along caudomedial aspect of bilateral pelvic limbs.
Musculoskeletal: Mild sarcopenia over epaxials and pelvic limbs. Resistance to range of motion of hips on bilateral pelvic limbs with left hind worse than right hind. Left hock is slightly dropped relative to right. Neurologic exam: Hyperesthesia noted at L3-L5. Left pelvic limb placement is delayed. Spinal reflexes and remainder of neurologic exam are within normal limits.

Myofascial exam: Myofascial restriction noted along lumbar spine, left more predominant than right. Mild restriction noted in caudal neck.
Neuro: Slightly delayed placement on left hind limb. Good facial symmetry. Normal pupillary light reflex/menace. Hind limbs patellar reflex within normal limits. Tibial reflex done at next visit (due to Larry’s attitude) and this is normal.
Ambulation in the room: Walks slinked as expected for cat in an unfamiliar environment. At home, owner notes no overt lameness. Hesitation is seen when attempting to jump on counters in room.

MEDICAL DECISION MAKING:
The primary concerns for Larry were his orthopedic issues. My approach was to focus on first calming points, then to focus on his orthopedic issues. Points that helped with orthopedic issues as well as helped with holistic immune-function (given his atopy and chronic respiratory issues) were my primary focus. I hoped to reduce the myofascial restriction of his pelvic limbs to allow better mobility.

Diagnoses: Chronic degenerative change was my primary differential. This fits with the radiographic findings of hip dysplasia with degenerative joint disease.

Acupuncture Treatments:
Treatment 1: Serin J-type needles for all points. Initial treatment was attempted with 0.16×30 needles, however, he tolerated 0.14 x 30 needles much better. Larry was unfortunately becoming a little anxious following the physical exam and neurologic exam, so this first session was limited to assessing his response to needling.
Points – All stimulated via acupuncture.
 GV 14: evaluate response to needling, support respiratory system, immune system support
 GV 20 – used for autonomic neuromodulation effects
 GV 4 – Lumbar pain modulation.
BL-54, GB-29, GB-30 – Hip triad treatment (just left side)
 Bai Hui – Pain, neurologic function.
This was all he would tolerate today. He twitched and attempted to remove the needles.
Treatment 2: Serin J-type needles for all points – 0.14 x 30. Larry had a mild upper respiratory infection (URI) flare-up. Points – All simulated via acupuncture. All bilateral if not GV/CV or if noted otherwise
 GV 14 – Evaluate response to needling, support respiratory system as well as boosting immune
 GV 20 –Used for autonomic neuromodulation effects
 GV 4 – Lumbar pain modulation.
 BL-54, GB-29, GB-30 – Hip triad treatment.
 LI 20 – Attempted but Larry would not tolerate needling in this area. Would be great for his
URI. He did tolerate acupressure, so this was applied.
 BL 10, BL 12, BL 13 – Used for URI.
 ST 36 – Boost immune system as well as pelvic limb.
 BL 21-23, BL 25, 36 – Lumbar spinal pain.
 Local trigger points were also stimulated along lumbar spine.
 Bai Hui – Pain, neurologic function.
Treatment 3: Serin J-type needles for all points – 0.14 x 30; 0.16 x 30. Larry was much less reactive to needling and settled right in to enjoy his treatment. Consequently, I increased the needle size to 0.16×30 His URI has improved so the focus was more on his pelvic limbs. Points – All simulated via acupuncture. All bilateral if not GV/CV or if noted otherwise
 GV 1 – Support respiratory system as well as boosting immune
 GV 20 – Used for autonomic neuromodulation effects
 GV 4 – Lumbar pain modulation.
 Bai Hui – Pain, neurologic function
 BL-54, GB-29, GB-30 – Hip triad treatment
 GB 31 – Neurologic dysfunction Left side only.
 ST 36 – Boost immune system as well as pelvic limb.
 BL 21-23, BL 25, 36 – Lumbar spinal pain.
 BL 15 – Support cardiac function.
 Local trigger points were also stimulated along lumbar spine and on left thoracic limb
 LU 7 – Attempted but Larry did not tolerate.
Between session 3 & 4, Larry underwent an anesthetic procedure for extraction of 3 teeth. Unfortunately, I was traveling during his procedure. If I had been available, it would have been a great opportunity to stimulate LI 20, ST 2, LU-7, LI-4 both for dental pain and URI issues.
Treatment 4: Serin J-type needles for all points – 0.14 x 30 on GV points and Bai Hui; 0.16 x 30 for treatment points. Given a bit more time elapsing between the sessions, Larry was a bit more reactive to needling today so it was an abbreviated session.
 GV 14 – Support respiratory system as well as boosting immune
 GV 20 – Autonomic neuromodulation effects.
 GV 4 – Lumbar pain modulation.
 Bai Hui – Pelvic limb pain.
 BL-54, GB-29, GB-30 – Bilateral today.
 BL 21-23, BL 25, 36 – Lumbar spinal pain.
 Local trigger points were also stimulated along lumbar spine.
Treatment 5: Serin J-type needles for all points – 0.14 x 30 on GV points and Bai Hui; 0.16 x 30 for treatment points. Owner notes that Larry is more confident in jumping and the barbering has reduced. She also purchased a heatedbed for him.
Physical Exam:
Heart Rate: 160 beats per minutes, Respiratory rate: 30 breaths per minutes Quiet, alert, responsive. Mucous membranes: Pink, moist Oral exam: Several missing teeth. Incision from extractions healing well. Integument: Hair growing from previous self-trauma. Musculoskeletal: Mild sarcopenia over epaxials and pelvic limbs. Decreased hip range of motion (ROM) of bilateral pelvic limbs, however, less reaction to palpation and manipulation than at
pre-acupuncture visit. Walks slinked as expected for cat. However, he jumps willing and without hesitation onto the counters. Remainder of physical exam stable from first session.
 GV 14 – Support respiratory system as well as boosting immune system.
 GV 20 – Autonomic neuromodulation effects.
 GV 4 – Lumbar pain modulation.
 Bai Hui – Lumbar pain.
 BL-54, GB-29, GB-30 – Hip triad treatment for hip pain.
 GB 31 – Neurologic dysfunction Left side only.
 ST 36 – Boost immune system as well as pelvic limb.
 BL 21-23, BL 25, 36 – Lumbar spinal pain.
 Local trigger points were also stimulated along lumbar spine – 5 needles placed.

Conclusions:
Larry demonstrated improvement in his pelvic limb pain. His placement deficit remained but did seem subjectively improved. Since the only other change was the heated bed, it can be inferred that the bulk of improvement was due to acupuncture. The owner noted improved jumping ability with less hesitation and greater heights. She also noted less self-mutilation of the pelvic limbs. Additionally, in the first session, Larry appeared guarded on his left side. Following the first session and the perceived benefit, he favored needling of his left hip joint. His upper respiratory infection did not seem to improve quicker than baseline. However, I do believe the fact that he did not tolerate needling of numerous respiratory points contributed to his lack of response. At his next flare, I will try again or implement owner massaging acupressure points. If laser is available at that point, we will implement that. His cardiac issues remained stable, but this was not a focus of his therapy given he has very mild changes at this point. His allergic dermatitis did not flare during the treatment period. However, at his next seasonal flare, acupuncture will be added to his treatments to assess the response to this. Given Larry’s variable accepting of acupuncture, he would have benefited from a more quiet/stable environment (we could not control for barking dogs, people speaking, etc.). Additionally, I believe he would have benefited significantly from laser therapy and massage in addition to the acupuncture. However, I did not have access to a laser at the time of his therapies. Once this is an option, we will pursue this treatment for him. Electrotherapy has helped in other causes for similar issues. This will be a future treatment option for him if we can control the environment to allow him to stay calm long enough to tolerate a treatment.

Larry presented primarily for his hindlimb orthopedic issues due to his decreased jumping ability and intermittent fur-barbering. We briefly delved into his respiratory issues but did not address his allergic dermatitis. In future sessions, we will work on overall health for his immune system and his pruritus/allergic issues to see if we can reduce his dosage of chlorpheniramine. Additionally, continued support of his hindlimb changes as well as introduction of a more holistic approach including supplements and rehabilitation exercises will help improve function. Overall, he demonstrated improvement noted by his owner in orthopedic issues and will continue to receive maintenance acupuncture at minimum.

References:
Hardie, E. Management of osteoarthritis in cats, Veterinary Clinics of North America: Small Animal Practice, 24,
1997, 945–953.
Hardie, E., Roe, S., Martin, F. Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases
(1974–1997), Journal of the American Veterinary Medical Association, 220, 2002, 628–632.
Shelly, H. Feline osteoarthritis: signs, diagnosis and management, The Veterinary Nurse, 2013 4:4, 220-226.


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