Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017010
Dio has severe hip dysplasia and paralysis of the rear limbs since July of last year. He was not tolerating the medications he was being given to help him not be painful. The goals for my treatment for him were to see if I could help his paralysis and decrease his pain levels. I was also hoping to help with his incontinence too. In treating him, we were able to get him to only need his Meloxicam, which he tolerates very well. He was comfortable enough to play again and his attitude improved as he became less painful. His paralysis did not go away but he was able to haul himself up a few times and seems to feel his feet better. His incontinence improved but never has gone away.
History and Presentation:
5/7/2017 – Dio is a 12-year-old Labrador retriever mix. He was last weighed on 4/8/17 and was 66 pounds. He first presented to me on 5/7/17 for hind limb paralysis, and bilateral hip dysplasia. He also was diagnosed with a rectal adenocarcinoma via cytology on 2/07/14. His owner did not pursue surgery for the mass, and it appears to be stable at this time. His hip dysplasia was diagnosed on radiographs on 3/20/14, see attached radiographs. He has been on a combination of Meloxicam, Gabapentin and Tramadol since being diagnosed with his hip dysplasia in 2014. As he, either gets diarrhea or seems sleepy on the medications, his owner does not give him the medications at the same time, or every day. In late July 2016, his owner came home from a trip and found him down in the back end and unable to get up on his own. She got him a help-em-up harness, and when she lifted him with that he could walk on his own as long as he was stabilized. But thinking back, she can remember him falling hard in the back when laying down for 6 months prior to that. She took him into her veterinarian on 8/25/16 for a wound on his side where he was licking a lot. Her veterinarian noted decreased conscious proprioception in both rear legs, and bilateral muscle atrophy in the rear legs. No new radiographs were taken at that time as his owner was not going to pursue surgery due to the anal mass previously diagnosed. He is unable to get his rear feet under him but if he is positioned right he can push himself up. If he sits down, then his rear legs hyperextend in front of him. Right now, he is on Meloxicam 7.5 mg ½ tablet every 24 hours unless he gets diarrhea then they switch to Gabapentin 100mg 1 capsule every 12 hours. They cannot give the two together because he gets looser stool, and leaks urine as he drinks more water. He has become urinary incontinent especially when he is excited or anxious. He is also more likely to have fecal incontinence if he gets very excited, and has not gone out for the day yet. He has always been a very anxious dog. His favorite thing to do is to sit at a glass window or door and repetitively lick at it, which he would do for hours if his owner lets him. He is also the protector of the house, and having the paralysis has increased his anxiety because he is unable to do his job. He is helped by the other dog in the house, who has taken on telling him there are people at the door and that he is needed there. His owner thinks the paralysis was worse when it first started because he will walk sometimes when helped up with the harness now, though he still cannot get up on his own and is likely to just use his front legs and drag his back end after him.
5/14/2017 – He is using his front end to get up more than pushing with his back end. Owner thinks the last two days were harder for him, and he was stiffer in the rear end with crossing his back legs more. When trying to turn a tight circle, he cannot without falling over, whereas earlier in the week was able to do this ok without falling over. But he does seem to be trying to do more things on his own this week, up until the last two days. Getting Gabapentin Every 12 hours only, no Meloxicam because he got diarrhea and needed Flagyl after eating so much of the Chicken last time. His Diarrhea has resolved but with getting the Gabapentin more is more urinary incontinent. A good change is that he does not seem to be as afraid of the tile this week.
5/21/2017 – He did not get as much of a boost this last week, on moving, but more comfortable and wagging more and wanting to play more. Seemed this time that by Wednesday the effects were wearing off, and he was not liking the tile as much or pulling himself up. His appetite has been a little down this week, though it has also been hotter this week. One of his baby sitters came over and mentioned that he looks better and happier than she has seen in a while and she has not seen him trying to walk this much in a long time. He did really well with the Baby Food over the week, no diarrhea.
5/28/17 – He is placing his feet better, doing more180 degree pivots and not immediately falling over. He is not liking having his feet wiped now, and he will shift weight to the rear to try to stop you from picking up his feet to wipe them. Now only on the Meloxicam- walking more but not able to get up on his own nor is he trying this week. His incontinence is better now, not leaking while walking him across the deck now in the past 4-5 days. He has been play bowing this week, which is new.
Physical Examination and Clinical Assessments:
5/7/2017 – He had normal Range of Motion (ROM) in his neck no restrictions following a cookie in every direction. Both front legs had normal conscious proprioception (CPs) and reflexes present. They also had normal ROM. Pelvic limbs had bilaterally decreased ROM of the hips and crepitus when moving them, but normal ROM of the remaining joints. CPs are absent in the pelvic limbs, with hyperreflexia and a pronounced crossed extensor reflex. The right stifle clicked when moving it, but was not swollen or hot when palpated. He does still have some voluntary control of his rear limbs and wags his tail well, but there is decreased anal tone noted.
Left front limb infra and supraspinatus muscle had trigger points whereas the right front was the supraspinatus and the triceps that were reactive. Muscle atrophy started at T11 in the paraspinal muscles and continues back to the pelvic limbs which are severely muscle atrophied and flabby. Trigger points along the bladder lines especially in the T/L junction area. Sensitivity to palpation of his hips and pelvis also existed.
5/14/2017 – In the L6-L7 area there are tight bands paraspinal bilaterally, where as in the L5 area it is more the right side tight. He is not as stressed today either about me being there, and not doing the heavy panting he was doing before. Negative CPs noted, but stronger when standing and he can walk in a circle around the owner with only some support from the help-em-up harness. Normal PROM of all but his hips which have great flexion but decreased extension. Hips less sensitive today to palpation though.
5/21/2017 – Right front SI 12 bands noted, Bilateral taught bands felt in the L5 area. He seems to be controlling his sits a little better and moving the rear limbs with some support more fluidly than previously, though still no CPs present and hyper-reflexive in the rear.
5/28/2017 – Cervical bilateral taught bands, and SI 12 left and right taught bands noted. Also T11-T13 taught bands felt. He still has exaggerated reflexes in the rear and crossed extensor with no CPs in the rear limbs.
Medical Decision Making:
Points I wanted and why:
GV 20, GV 14, ST 36 for autonomic influences and anti-inflammatory properties and GV 20 for anxiety too.
SI 11 and 12 bilaterally for the trigger points
ST 34 for stifle pain
Bai Hui for pelvic pain and autonomic influence
Bafeng for the paralysis
SP 6 for voiding dysfunction and to stimulate the tibial nerve
SP 9 and 10 for Stifle pain and to stimulate the tibial nerve
LR 3 for anxiety and to stimulate the deep fibular nerve
GV 2- for anal dysfunction and GV 4 – for lumbar pain and genitourinary dysfuntion
BL 20, BL 21, BL 22, BL 23, BL 25, BL 27 and 28 – for trigger points and to stimulate the associated spinal segments to try to help the paralysis
BL 40 – pelvic limb pain
KI 3 – for Tibial nerve stimulation and for urinary voiding problems
BL 54, GB 29 and 30- hip triad for the hip dysplasia pain
5/14/17 – GV 20, GV 14, ST 36, BL 10, BL 18, 20,20,22,23,25,27,28, Bai Hui, Bafeng, GB 29 and 30, BL 54, SP 6 – see previous
5/21/2017 – GV 20, GV14, ST 36, Bai Hui, SP 6, SI 12, BL 20, BL 18, GV4, BL 23, BL 25, BL 27, BL 28, GB 29, GB 30, GB 39, BL 54, Bafeng, KI 3, PC 6 – see previous
5/28/2017 – Cervical Spinal points (for trigger points) , SI 12, GV 20, GV 14, Bai Hui, ST 36, SP 6, Bafeng, BL 10, BL 20, BL 21, BL 23, BL 25, BL 27, BL 28, BL 54, GB 29, GB 30, KI 3 – see previous
Rear Limb Paralysis – R/O Inter-vertebral disc disease, neoplasia, trauma
Hip Dysplasia with advanced degenerative joint disease – see radiographs
Anxiety- his licking at the window and nervous behavior around all but his family
Intermittent Enteritis – R/O anxiety, medication (iatrogenic), IBD, neoplasia
Incontinence – R/O iatrogenic from the medications, kidney disease, neurologic
Definitive (or Putative) Diagnosis (or Diagnoses):
Rear limb paralysis and muscle atrophy were found through the physical exam.
Anxiety was seen by watching his behavior.
Severe Hip dysplasia with DJD bilaterally was noted on radiographs and I felt the crepitus on my physical exam.
Dietary and Medication induced Enteritis were noted when he was given too many medications together in his history, and after feeding him too much chicken the first time I treated him.
Incontinence both neurologic in origin and medication induced were noted when on certain medications. The neurologic part was noted when he just leaked as he walked across the deck.
Dry needling with 0.20 Serrin 30 mm for about 10 minutes but some came out before the 10 minutes were up
Got: GV 20, GV 14, BL 20 bilateral, BL 21 bilateral muscles caught and held the needles, BL 23 bilateral, BL 25 bilateral, BL 27 and 28 bilateral, Left rear limb: BL 54, GB 29 and 30, ST 36- sensitive, SP 6 and 2 Bafeng points, Right Rear limb: SP 6, 2 bafeng points, BL 54, GB 29 and 30
Dry needling 0.20 Serrin 30 mm for 20 minutes
Added in Electroacupuncture 5 minutes BL 18-25 Mixed 4Hz and 100 Hz
Bilateral: BL 10, BL 18, BL 19, BL 21- which both sides grabbed the needles, BL 23, BL 25, BL 27, BL 28, BL 54, GB 29, GB 30, SP 6- felt the needle on the right, ST 36, Bafeng- 2 spots
GV 20, GV 14, Bai Hui
Dry needling 0.20 Serrin 30 mm for 20 minutes though due to speed I put them in some were in for 40 minutes. Electro BL 18 to 25 for 15 minutes
Got points: Bilateral BL 15, BL 18, BL 20, BL 23,BL 25, BL 27, BL28, BL 54, GB 29, GB 30, GB 39, SP 6, ST 36, KI 3, PC6, SI 12, Bafeng all 4 points
GV 14, GV 20, Bai Hui
Dry Needling 0.20 mm, by 30 mm Serrin for 20 minute Put all needles in in 16 minutes so some in total of 36 minutes
Electro acupuncture10 minutes BL 19 to 25 Mixed 4 and 100 Hz
Bilateral: BL 19, BL 20, BL 21, BL 23, BL 25, BL 27, BL 28, BL 54, GB 29, GB 30, SP 6, ST 36, KI 3, SI 12 Bafeng, cervical spinal points
GV 14, GV 20, Bai Hui
Outcomes, Discussions, and References: The overall outcome of doing acupuncture was that we were able to decrease the amount and number of medications that Dio was receiving to help keep him comfortable, thus decreasing his diarrhea episodes and incontinence incidents. He also seemed overall less anxious, which I believe is a combination of the points I used and having an almost two-hour session with his Mom and I, where he gets all of the attention and chicken baby food. He is also moving more fluidly and walking more once he is gotten up, which is directly related to the decrease in pain level that the acupuncture has given him. “The acupuncture of today employs filiform needles that directly engage connective tissue and collagen fibers, altering the cytoarchitecture of fibroblasts and tugging on somatic afferent nerve fibers in the vicinity. Sequelae of needle stimulation include local cytokine changes, neural receptor activation, blood flow changes and action potentials transmitted to the spinal cord and brain. Central nervous system changes reflect generalized neuromodulation and modified neuroendocrine regulation.” From Laser vs Acupuncture and Massage by Narda Robinson
The paralysis has not resolved though. ” As the leading choice for neurologic recovery, acupuncture (somatic afferent nerve stimulation) wins again as the most studied and best understood of all complementary and alternative medical techniques. Neuroanatomically designed needling protocols address neurophysiologic dysfunction peripherally, autonomically and centrally. After a medical acupuncturist identifies the locus of the lesion, she selects stimulation methods shown to repair nerve tissue at the site of damage and facilitate communication throughout the neural network.” From Acupuncture for Neurologic Recovery by Narda Robinson. The only adverse event was when we gave him too much real chicken the first time, and he got pretty severe diarrhea from that. He has responded really well to the needles and not had any weird reactions to them or the electro-acupuncture. “A 2009 review by the Mayo Clinic’s Dorsher and McIntosh pointed to the accelerated improvements made possible on multiple measures with acupuncture. Indeed, they indicated that one study showed a “much larger effect of electroacupuncture on ultimate neurologic recovery from acute SCI than any pharmacologic intervention to date.” From Evidence Points to Acupuncture for Disk Disease by Narda Robinson.
I did not add in laser because I do not have a portable one, and he has the history of cancer in his anal gland and I did not want to risk causing him any issues with that.