Written by a Medical Acupuncture for Veterinarians course graduate.    Signed release obtained from client/author.  4370

Abstract:

Mocha, a 6.8 kg 10-year-old female spayed Rat Terrier, was presented for severe cervical pain.  After failing initial medical treatments consisting of carprofen, methocarbamol, and gabapentin, acupuncture was used to alleviate her pain and neurologic symptoms. These points included local cervical points, autonomic points, as well as points dictated by myofascial examination. To date, she has remained pain free.

History and Presentation:

Mocha is a 10-year-old 6.8 kg female spayed Rat Terrier.  She has had a long history of atopic dermatitis that is been controlled by cyclosporin as well as oclacitinib. She previously traumatized the 5th digit of her left hind foot while chewing at her skin. This has caused the digit to grow abnormally small and lateral displaced. She was last seen for her preventative care on 4/20/17.  During that examination, she had a mild otitis externa, pododermatitis of the hind feet, and bilateral luxating patellas (R II/IV and L III/IV).  Her blood work revealed an increased alkaline phosphatase 579 (23-212), low phosphorous 2.2 (2.5-6.8), and a stress leukogram with mild leukocytosis characterized by a mature neutrophilia and monocytosis.  This change was attributed to her anxiety that she has upon coming to veterinary hospitals.

On 5/9, she presented for a lameness that consisted of difficulty walking of 3 days duration.  The client noted that it seemed to be a right hind and right forelimb lameness.  She would also yelp while being picked up. A colleague saw her on this visit and found her to be tense on extension of the neck with right fore and hind limb lameness.  Mocha also trembled in pain throughout the examination.  Radiographs were taken of her cervical and thoracolumbar spine, which did not reveal any overt bony lesions, but renal opacities (presumed to be stones) were identified in both kidneys.  She was started on 12.5 mg of carprofen every 12 hours for 14 days, 125 mg methocarbamol every 12 hours for 5 days, and gabapentin 100 mg every 12 hours for 14 days.

Physical Examination, Clinical Assessments, and Treatments:
On 5/12, I took over care of Mocha as my colleague who saw her previously was not present that day. Mocha’s heart rate was 150 beats per minute. Her respiratory rate was 55 respirations per minute (panting) and she would not allow temperature. Thoracic auscultation was unremarkable as was abdominal palpation. Her skin had areas of mild erythema associated with her chronic atopic dermatitis. The previous findings remained stable during the next several visits. She was not walking and was crying out in pain when trying to walk. Using Colorado State University Canine Acute Pain Scale, Mocha was a 4 out of 4. She was having a hard time using her left forelimb. She had tense, painful cervical muscles along with mild thoracic and lumbar pain with several areas of ropey muscle along the lumbar spine. No overt pain was noted in any limb. She had decreased placing responses on the left forelimb but was ambulatory on all four limbs with normal reflexes. No overt cranial nerve deficits were noted. Given the breed, acute nature of the problem, and clinical signs, the top differential was intervertebral disc disease with myofascial pain in the epaxial muscles. Acupuncture as a treatment modality was discussed, but the client chose to continue the previous medical treatments, add additional pain management and performing effleurage massage of the neck and back at home. Referral to Texas A&M University College of Veterinary Medicine for advanced imaging to confirm the diagnosis was recommended, but the client declined. Mocha was maintained on the previously prescribed carprofen and gabapentin. Additionally, the client, who is a veterinarian, was to give 0.1 mg of buprenorphine subcutaneously every 8 hours for pain for 3 days.

During a recheck examination on 5/19, the client noted Mocha did well while she was receiving the buprenorphine injections, but the pain returned after that treatment stopped. She was crying out while lying still and refused to move. During the examination, she was found to have painful, tight neck muscles and was unwilling to move her head. Her triceps were painful bilaterally. She had decreased proprioception on the left forelimb, hyperesthesia of the right forelimb, and normal reflexes in all four limbs with normal placing in the hind legs. Her pain score was a 4 out of 4 on this visit. Referral to a neurologist was offered and declined again. Acupuncture was again discussed and the client elected to start acupuncture during this visit.  Dry needling was performed with Serine J 0.16 x 30 mm needles at points Governor Vessel (GV) 20 and 14; Bladder (BL) 10; cervical points bilaterally at Cervical (C) 4, 5, and 6; Gallbladder (GB) 20 on the left; Lung (LU) 1 bilaterally; and Small Intestine (SI) 9 bilaterally. Medical management with carprofen and gabapentin was continued with the addition of 7.5 mg of amitriptyline orally every 12 hours for neuropathic pain.

During a recheck examination on 5/24, the client noted a 70% improvement since the last visit.  Mocha was significantly happier and more active at home with more energy. Upon examination, she was moving her neck better but still resisted dorsoflexion. Her left forelimb had improved proprioception (with delayed side hopping but normal wheelbarrowing and backward dancing), mild triceps pain bilaterally, and the right forelimb hyperesthesia was improved. The pet was not significantly painful on thoracic or lumbar spine during this visit and the hind legs showed no neurologic deficits or pain. Her pain score was 2 out of 4 on this visit. Dry needling treatments were performed with DBC Spring 10 0.2 x 30 mm needles. Points included GV 20 and 14; BL 10; cervical spinal nerve points at C4, C5, C6, and C7; GB 20; LU 1; SI 9 (all bilaterally); and Large Intestine (LI) 4 on the left.  Medical management with carprofen, gabapentin, and amitriptyline were continued.

During a recheck examination on 5/26, the client noted continued improvement in pain.  Proprioception was now normal on the left forelimb and no hyperesthesia was noted on the right forelimb. The pet’s pain was significantly improved with some tightness and discomfort noted at C5, 6, and 7 vertebral areas. The pet was walking around the room much better and moving her neck better. The triceps did not show pain during this visit, but there was pain noted in the infra- and supraspinatus muscles bilaterally.  Her pain score on this visit was a 2 out of 4. Acupuncture dry needling was performed using DBC Spring 10 0.2 x 30 mm needles. The following points were used: GV 20 and 14; GB 20; BL 10 and 11; cervical spinal points at C3, 4, 5, 6, and 7; SI 9, 11, and 12; and LU 1 all bilaterally; and LI 4 on the left (the right was attempted but the patient would not allow). Medical management as previously was continued.

During a recheck examination on 6/1, the client noted an 85% improvement from the beginning of treatment. The pet was moving the neck better and with less pain than the previous visit.  Mocha did not have any evidence of proprioceptive deficits or weakness. The hyperesthesia of the right front limb was resolved. She had a pain score of 1 out of 4. Acupuncture dry needling treatment was performed using DBC Spring 10 0.2 x 30 mm needles. The points included GV 20 and 14; left LI 4; LU 1 bilaterally; BL 10 and 11; Triple Heater (TH) 10; GB 21; cervical spinal points of C3, 4, 5, 6, and 7; and SI 9, 11, and 12. Medical management with carprofen, gabapentin, and amitriptyline was continued. About 20 min after the treatment, the pet cried out in pain while walking around the room. No overt source of pain was found after this. She also cried out once on the way home but was completely normal the next morning.

During a recheck examination on 6/8, the client noted that the pet was continuing to improve.  The pet had a few tender points: one on the left at the C5-6 spinal region and one bilaterally at C6-7 spinal region. Mild cranial lumbar pain was elicited. She had a pain score of 1 out of 4.  Acupuncture dry needling was performed using DBC Spring 10 0.2 x 30mm needles. Points included GV 20, 14, and 4; Bui Hui; left LI 4 bilaterally; LU 1; SI 9, 11, and 12; TH 10; GB 21; cervical spinal points C3, 4, 5, 6, and 7; and BL 10, 11, 12, 22, 23, and 25.

Medical Decision Making:

Due to the unknown cause of the initial pain, Mocha was started on carprofen and gabapentin, but due to the lack of control of pain, amitriptyline was added to block an additional pain pathway. If this and acupuncture had not controlled her pain, amantadine would have been added as an NDMA antagonist. I do not believe tramadol it is very efficacious except for its serotonin effects. As such, amitriptyline was added instead of tramadol.

From an acupuncture stand point: insertion of needles into points with higher tightly packed connective tissue triggers mechanical stimuli. This ascends to the dorsal tracts of the spinal cord causing activation of the supraspinal and higher centers that are involved in pain processing.  This leads to modulation of noradrenaline and 5-hydroxytryptamine (HT) signaling system, mu-opioid receptor activation, and production of related neurotrophins that enhance inhibition of nociception on the spinal afferents. There is also stimulation of C-fibers that activate the diffuse noxious inhibitory control in the spinal cord. This augments inhibitory control of nociception and modulates higher processing of pain. With repeated treatments, neuroplasticity develops in the dorsal horn of the spine which alleviates nociceptive signals from the target site of treatment on a long term basis1.

A Cochran Database review by Trinh et al (3) revealed that acupuncture is effective at relieving pain in humans with cervical disease.

Differential Diagnoses:

Intervertebral disk disease(IVDD), neoplasia, vascular disease, severe trigger point pathology, discospondylitis.

Definitive (or Putative) Diagnosis (or Diagnoses):

Suspected Intervertebral disk disease plus trigger points of cervical, triceps, infraspinatus and supraspinatus muscles.

Acupuncture Treatments:

The acupuncture treatments listed above were chosen based on myofascial examination for each visit along with trying to reduce anxiety in this pet. All treatments were dry needling.  Points were chosen to reduce local pain as well as to affect the autonomic nervous system by increasing parasympathetic and decreasing sympathetic drivers in the body. GV 20, 14 and 4, Bui Hui and LI 4 were chosen to affect the autonomic nervous system. LU 1 was chosen to decrease probable tension in the pectoral region as it was difficult to determine if pain was present due to the degree of cervical pain. SI points were chosen to decrease triceps pain and trigger points within the suprascapular nerve regions. Gallbladder points were chosen to affect local discomfort when the pet would tolerate needling them. The various bladder points were chosen due to both local and distant sights of neuromodulation. The cervical points were chosen to both reduce local pain as well as to deactivate any trigger points within.

Outcomes, Discussions, and References:

Following initiation of acupuncture in Mocha, she showed significant improvement in her pain score. She also showed significant recovery of neurologic function. Medical management was continued for Mocha based on her initial pain scores. The points at each treatment were individualized for each visit and included autonomic, local, and distal sites. It was chosen to more heavily concentrate on local sites in the beginning as this is what Mocha would tolerate.  Ideally, more distal sites would have been added to further neuromodulate Mocha’s pain as described by Liu et al (2), immune system for atopy, and her autonomic system for her anxiety.

Following Mocha’s session on 6/1 she seemed to have two episodes of increased pain which were unexplained at the time. It is unclear if this was due to other trigger points that were not initially identified or other complications such as neuritis secondary to needle trauma, additional disc protrusion, or thrombus.

Following the 6/8 visit, Mocha’s owner felt that her pain was well controlled so they stopped bringing her to the hospital for acupuncture treatments. We have continued medical management of her pain. To date of the writing of this case report, Mocha continues to be much happier and ambulating well at home.

I have learned from this case that pets will have up and downs during treatment and that each visit should be tailored to their specific needs. Mocha would not allow some distal sites both due to hyperesthesia but also due to her long history of not allowing much handling of her feet.  During treatment, she also had great reduction in her anxiety of being in the hospital and during many would lay calmly on the table.  Both reduction of pain and anxiety have great benefits for in hospital treatments of a wide range of pets.

There are limited references for canines with cervical disease and acupuncture and many for humans. I have included one from each topic below.

  1. Leung, L. (2012). Neurophysiological Basis of Acupuncture-Induced Analgesia An Updated Review. Journal of Acupuncture and Meridian Studies, 5(6), 261-270.
  2. Liu CM, Chang CF, Lin CT. (2016, Sept 30). Retrospective Study on the Clinical Effects of Acupuncture on Cervical Neurological Diseases in Dogs. Journal of Veterinary Science, 17(3), 337-345.
  3. Trinh K, Graham N, Irnich D, et al. WITHDRAWN: Acupuncture for neck Cochrane Database Syst Rev. 2016 Nov 17;11:CD004870.

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