Written by a Medical Acupuncture for Veterinarians course graduate.  Signed release obtained from client/author. 10S2017012

Abstract
An 8 ½ year old, male, neutered German Shepherd presented for progressive hind limb weakness. His condition deteriorated on carprofen and gabapentin. His genetic test for degenerative myelopathy was negative. There was mineralized material above L2-L3 and a narrowing of T11-T12 on radiograph. Acupuncture was instituted at 3 to 7 day intervals for 5 sessions, then biweekly. His gait and weakness steadily improved and after 3 sessions he was climbing stairs. The most dramatic improvement was noted after electroacupuncture was added on his 6th session. This case study demonstrates that acupuncture and electroacupuncture are effective treatment modalities in cases of hind limb weakness secondary to upper motor neuron disease.

History Presentation
Oz, an 8 ½ year old, 97 lb, male, neutered German Shepherd was adopted by his owners at 2 years of age when he did not succeed in the Seeing Eye guide dog program. He presented for routine examination and vaccination on October 24, 2017. Several weeks prior to presentation he cried suddenly and stopped short during a run. His owners reported at least 3 prior episodes of hind limb lameness that was presumed to be recurring Lyme disease. These symptoms would improve with antibiotics and pain medication.

Physical Examination and Clinical Assessments
On October 24, 2017, Oz’s physical exam was normal with the exception of his musculoskeletal and nervous system. Discomfort was apparent as a dramatic flinch on gentle palpation of his mid-thoracic and lumbar spine. There was banding of his epaxial muscles in this region as well as kyphosis. Oz did not display discomfort on deep myofascial palpation of his neck, front or hind legs. His stifles and hips were normal and non-painful on palpation. He demonstrated hind limb ataxia and decreased hind limb conscious proprioceptive reflexes. He was not amenable to a patellar reflex or crossed extensor response test during this visit.
His blood chemistry, CBC and T4 were normal. His Lyme C6 antibody and genetic test for degenerative myelopathy were negative.
Oz’s radiograph showed a suspected narrowing at T11-T12 and a mineralized opacity superimposed over the spinal canal at L2-L3. The radiologist identified this as mineralized disc material and also stated that this can be asymptomatic in dogs and an incidental finding. Further imaging such as CT, MRI or myelogram were recommended. His owners chose not to pursue these diagnostics.
Acupuncture, physical therapy and laser therapy were discussed and recommended. Oz was placed on carprofen 2.3 mg/kg BID and gabapentin 6.8mg/kg BID while his diagnostics were pending and his owners considered their options. He presented for acupuncture four weeks from his initial presentation. On 11/15/17 his condition had deteriorated and he could barely stand from a sitting position. He would pull himself up with difficulty using momentum and his front legs. He could not climb stairs. He was still painful on palpation of his thoracolumbar region. Oz had exaggerated patellar reflexes and a positive crossed extensor reflex in both hindlimbs.

Medical Decision Making
Acupuncture treatment plan
1) Due to overlap of spinal nerve and sympathetic innervation of the spinal cord, acupuncture points proximal and distal to the site of injury in the thoracolumbar region were chosen. This neuromodulation of the central nervous system (CNS) would decrease pain and facilitation and promote circulation and healing. (1)
2) Mixed low and high frequency electroacupuncture (EA) at sites proximal and distal to areas of discomfort was administered to provide both immediate spinal segmental and long term systemic analgesia. (2,3)
3) Acupuncture points along peripheral nerve pathways from the lumbosacral spine to the distal hind limbs were chosen to provide somatic afferent stimulation, reinforcing and supporting communication with the CNS. Stimulating peripheral nerves with acupuncture would also help decrease further deterioration of the nerve cell bodies within the injured spinal cord. (4,5)
4) Acupuncture points in areas with high autonomic neural traffic, nervi vasorum, and connectivity to autonomic nervous centers in the brain were chosen. This neuromodulation would decrease heightened sympathetic tone induced from chronic pain and inflammation. (1, 6)
5) Dry needling and massaging trigger points and compensatory tight and sensitive muscles would alleviate myofascial compression and strain contributing to discomfort and poor circulation. (7)
Oz’s treatments were scheduled once to twice weekly as the owner’s schedule allowed. Laser and physical therapy a nearby facility were also recommended but declined. Oz would continue carprofen if his owners appreciated added benefit.

Differential Diagnosis
Intervertebral Disc Disease (IVDD) (local compression of spinal cord)
Vascular Accident of Spinal Cord (thromboembolic disease)
Discospondylitis
Vertebral Instability (congenital or acquired)
Fibrocartilaginous Emboli
Degenerative Myelopathy (in addition to back pain or with compensatory back pain)
Neoplasia
Toxoplasmosis / Neospora
Hip Dysplasia (in addition to upper motor neuron disease)

Putative Diagnosis

Degenerative myelopathy was ruled out with a negative genetic test. Hip dysplasia was unlikely since his hips were not painful on exam and The Seeing Eye had documentation of a good Penn Hip score on Oz when he was over 1 year of age.
Oz’s radiographs did not support a diagnosis of discospondylitis or show malformed or traumatized vertebrae that would lead to vertebral instability. Infectious disease such as toxoplasmosis and neospora were less likely due to very low risk of exposure.
Radiographic evidence of mineralized disc material in the spinal canal at L2-L3 and narrowing of T11-T12 as well as pain in this region made IVDD with spinal cord compression the most likely diagnosis. Thromboembolism, fibrocartilaginous emboli and neoplasia could not be ruled out without further imaging.

Acupuncture Treatments

11/15/17: First session: Needles- Seirin 0.16 and 0.2x30mm needles for LR2 and Bafeng points.
Seirin 0.2x30mm needles for all other points. 30 minute session
GV14 – This point was selected due to its proximity to sympathetic nerves emerging from the spinal cord on their way cervical sympathetic ganglia. Neuromodulation here decreases sympathetic overstimulation from chronic pain and inflammation and promotes autonomic homeostasis. Also, stimulation of the cervicothoracic spinal nerves at this site provide analgesia to his neck and upper back, as these areas are receiving excess compensatory strain.
ST 36 (right) -Neuromodulation here contributes to autonomic homeostasis by way of connectivity with the nucleus tractus solitarius and reinforces communication with the CNS via somatic afferent stimulation of the fibular nerve, branching from the sciatic nerve. Only the right point was used due to his positioning in the exam room. In later sessions both left and right ST36 points were accessible and used.
BL 17, 18, 19, 21, 23, 24 (left and right) – These points were selected based on the location of discomfort on gentle palpation of the paraspinal musculature and presence of banding of the epaxial muscles on palpation. These points extended proximal and distal to his areas of pain.
Bai Hui and BL 27, 28 (left and right) – These points were selected to stimulate lumbar spinal nerves (Bai Hui) and sacral nerves (BL27, 28) reinforcing communication with the more proximal spinal cord.
BL 36, BL 39, BL 60 (right) – BL 36 and 39 were selected to reinforce communication with the CNS via somatic afferent stimulation of the sciatic nerve and common fibular nerve respectively. BL 60 was also chosen for somatic afferent stimulation via the tibial and fibular nerve. These points were chosen on his right side only due to his left lateral recumbency in the exam room. In later sessions both left and right points were used.
LR 2 (left and right) and Bafeng points (left and right). These points were selected to reinforce communication with the central nervous system via neuromodulation near the deep fibular nerve and digital nerves respectively.
Gentle massage of his thoracolumbar musculature was performed after his needles were removed.

11/22/17, 11/25/17, 11/29/17, 12/6/17 and 12/18/17 : Needles: Seirin 0.2 x 20mm for LR2 and Bafeng points.
Hwato 0.2 x 25mm needles for all other points. 30 minute sessions with a gentle massage of thoracolumbar epaxial muscles after each session.
The same points as the first session were used with additional points chosen based on accessibility (his posture and positioning in the exam room) and amenability to treatment.
Additional points: (ST 36, BL 36, BL 39 and BL 60 left side in addition to right)
BL 54, GB 30 (left and right)- These points were selected due to their association with the sciatic nerve to support communication with the CNS.
BL35 and GVt3 (left and right) – These points were selected to send somatic afferent stimulation to the spinal cord via the sacral nerves, reinforcing neural communication.
12/7/17: Carprofen was discontinued.
12/18/17: 6th session. Bafeng and LR2 points were discontinued due to sensitivity. Fifteen minutes of EA was added from BL17-BL21 (proximal and distal to area of discomfort) at the start of the session and while remaining needles were placed. This would provide both general endorphin based analgesia (low frequency) and non-opioid dependent, faster onset analgesia (high frequency). A Pantheon unit was used with mixed frequency settings at 2Hz/100Hz. A l.5 amplitude setting was well tolerated.

Outcome and Discussion

Oz’s gait and ability to stand from a sitting position were evaluated at each visit. His owners stated that he was dragging his hind legs less and was more energetic within 24 hours of his first treatment, but this response only lasted a few days. On his second visit he was still scuffing his hind feet, but could stand from a sit without assistance. By his third session he could climb 3-5 stairs without assistance and was able to climb on the sofa at home. On each visit Oz was able to stand up faster and with less effort. He lifted his feet more when walking and less ataxia was noted. His owner reported that his most dramatic and sustained improvement was after his EA session. He began climbing stairs regularly at home and his conscious proprioceptive reflexes in his hind legs improved. Oz will continue maintenance EA monthly.
Oz’s severe hind limb paresis improved quickly with acupuncture, but his sustained and continued improvement required repeat treatment at regular intervals. His immediate response to acupuncture could be attributed to analgesia from endogenous endorphin release. (8,9) His gradual and sustained improvement with regular acupuncture treatment could be attributed to the anti-inflammatory effects of acupuncture which promote healing and decrease scarring. (5,10,11, 12, 13)
EA provided a more dramatic response and would have been employed earlier in his treatment had it been available (the unit took several weeks to arrive). Laser and physical therapy would likely have facilitated Oz’s recovery but his owners did not want to pursue these treatments at a referral center.
Based on his history, Oz may have had a previous spinal cord injury that was exacerbated a few weeks prior to presentation. His condition deteriorated on carprofen and gabapentin. He began to improve when acupuncture was instituted and continues to improve with electroacupuncture as his sole therapy.
Oz’s return of hind limb function with the use of acupuncture weeks after spinal cord injury demonstrates that acupuncture is a valid and effective therapy for spinal cord injury regardless of delayed or poor response to other treatment.

References
1 Robinson, Narda G. Interactive Medical Acupuncture Anatomy. Jackson:Teton NewMedia, 2016
2 Han, Ji-Sheng. “Acupuncture: Neuropeptide Release Produced by Electrical Stimulation of Different Frequencies.” Trends in Neuroscience (2003); 26; 17-22.
3 Han, Ji-Sheng. “Acupuncture and Endorphins.” Neuroscience Letters (2004):May6;361(1-3)258-61.
4 He, Guan-heng, Rua, Jing-wen, Zeng, Yuan-shan, Zhou, Xin, Zhou, Guang-hui. “Improvement in Acupoint Selection for Acupuncture of Nerves Surrounding the Injury Site: Electroacupuncture with Governor Vessel with Local Meridian Acupoints.” Neural Regeneration Research. (2015): Jan;10(1);128-135.
5 Choi, Doo C., Lee, Jee Y., Moon, Youn j., Kim, Shin W., Oh, Tae H., Une Tae Y.. “Acupuncture-Mediated Inhibition of Inflammation Facilitates Significant Functional Recovery after Spinal Cord Injury”. Neurobiology of Disease. (2010):,39;272-282.
6 Li Q, Shi G, Xu Q, Wang J, Liu C, Wang L. “Acupuncture Effect and Central Autonomic Regulation.” Evidence-Based Complementary and Alternative Medicine. (2013): doi: 10.1155/2013/267959.
7 Chou LW, Kao MJ, Lin JG. “Probable Mechanisms of Needling Therapies for Myofascial Pain Control”. Evidence-Based Complementary and Alternative-Medicine. (2012): doi: 10.1155/2012/705327.
8 Zhang R., Lao L, Ren K, Berman B. “Mechanisms of Acupuncture-Electroacupuncture on Persistent Pain”. Anesthesiology. (2014):Feb;120(2): 482-503.
9 Zhang G, Yu C, Lee W, Lao L, Ren K, Berman B. “Involvement of Peripheral Opioid Mechanisms in Electroacupuncture Analgesia.” Explore: The Journal of Science and Healing. (NY) (2005): Sept;1(5):365-71.
10 Dorsher P, McIntosh P. “Acupuncture’s Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature. “Evidence Based Complimentary Alternative Medicine.” (2011): doi: 10.1093/ecam/nep010.
11 Liu H, Quian XY, An JX, Liu CC, Jiang YD, Cope D, Williams J. “Analgesic Effects and Neuropathology Changes of Electroacupuncture on Curing a Rat Model of Brachial Plexus Neuralgia Induced by Cobra Venom.” Pain Physician. (2016): 19:E435-E448 ISSN 1250-1149.
12 Liu F, Zou Y, Liu J, Wang T. “Electro-acupuncture Treatment Improves Neurological Function Associated with Downregulation of PDGF and Inhibition of Astrogliosis in Rats with Spinal Cord Transection.” Journal of Molecular Neuroscience. (2013): Oct:51(2):629-635.
13 Lee J, Choi D, Oh Tae, Yune T. ” Analgesic Effect of Acupuncture is Mediated via Inhibition of JNK Activation in Astrocytes after Spinal Cord Injury.’ PLoS One. (2013): Sept 9 doi: 10.137/journal.pon


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