Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017012

Abstract:
A four year old female spayed dog presented for acupuncture to address orthopedic and musculoskeletal consequences of a physical injury to the left carpus, sustained as a puppy. She is in apparently good health and was not showing signs of lameness at the time of presentation. On initial physical exam she was extremely guarded in her left forelimb and had tightness in her paraspinal muscles bilaterally as well as the contralateral supporting tissues of the scapula. She has thus far been treated with dry needle acupuncture therapy and massage. She has shown progress in flexibility, tolerance of handling of her feet, and comfort with firm massage and dry needling. She continues to not show signs of lameness.

History and Presentation:
Luna is a four year old female spayed Chihuahua mix who sustained a physeal fracture of her left forelimb as a puppy prior to adoption. Consequently she developed valgus and anterior bowing of that limb. She has not shown any signs of lameness thus far, however her owners are concerned that the abnormal stress she places on that limb will over time cause arthritis, pain, or chronic muscle strain. Luna has no other medical history. She is generally a shy and fearful dog, and does not like having her feet touched. She lives in a farm house, where she regularly runs up stairs, jumps off the porch, and plays with large breed dogs who also live in the house (labs, huskies).

Physical Examination and Clinical Assessments:
7.22.17
TPR: T 101.2, P 120, R 38, Doppler BP 128mmHg systolic, wt 2.3kg
BCS: 5/9
Hydration: Normal
EENT: no oculonasal discharge, ears clean AU. Moderate dental disease.
Cardiovascular System: No murmur or arrhythmia noted, pulses strong/synchronous.
Abdomen: Soft nonpainful abdomen on palpation, no masses/organomegaly appreciated
Respiratory: Lungs clear bilaterally, normal RR/RE.
Lymph Nodes: no peripheral lymphadenopathy
UG: unremarkable
Musculoskeletal: Patient is ambulating normally on all 4 limbs with no appreciable lameness. Valgus and anterior bowing of left forelimb at carpus. Tries to bite if feet are touched. Taught bands/trigger points and myofascial restrictions palpated in area of paraspinal muscles along thoracic and caudal cervical vertebrae (BL13 – BL22). Resistance to flexion/extension of right shoulder and flexion of right carpus. Could not evaluate left carpal ROM due to patient temperament / tolerance.
Neurologic: alert/appropriate mentation. Motor intact x4, CNN wnl. No ataxia.
Integument: No significant abnormalities noted.
Fundic Exam: Normal.
Rectal Exam: Not performed.

Assessment
Problem List
1. Left carpal valgus and anterior bowing
2. Myofascial restriction / tight muscle bands paraspinally along caudal cervical and thoracic vertebrae
3. Limited ROM right shoulder, right carpus (could not evaluate left carpus)
4. Shy/fearful
5. Moderate dental disease

Medical Decision Making:  Based on Luna’s history of trauma early in life and the clearly observable musculoskeletal consequences, I expected to find compensatory changes in the right forelimb as well as on her back. She is also a fearful dog who is generally not tolerant/trustful of very much handling, and is especially difficult to manipulate beyond petting her or picking her up. Therefore, my plan was to start with massage (used this to free myofascial restriction as I found it, and also to palpate more deeply) to earn her trust, and then eventually I moved into dry needling in areas where I expected her to be least painful or sensitive. I started with calming points (bai hui and GV 20) and avoided areas around her forelimbs and cranial spine. As she became more comfortable with me and the sessions, I began to incorporate more points around her shoulders and paraspinal region. I conducted weekly sessions for 9 weeks.

Differential Diagnoses:
1. Based on the pattern of musculoskeletal abnormalities that I found on physical exam, I believe that Luna’s historical injury to her left carpus has caused growth defect in that limb, which has led her to compensate for her abnormal orthopedic conformation by carrying her weight asymmetrically on her forelimbs.

2. Within her left forelimb, I believe she is also unevenly stressing the muscles and joints in that limb. With all of these compensatory changes, she is more vulnerable to arthritic and potentially degenerative changes in her orthopedic/musculoskeletal system over time. Even given her young age, could very possibly have early osteoarthritis at this time given her abnormal weight bearing on that joint.

3. The limited ROM in right should and carpus may be due to early arthritis vs muscle tightness vs soft tissue inflammation.

Radiographs of both forelimbs are recommended to assess for arthritis and more completely characterize nature of left carpal deformity.

Definitive (or Putative) Diagnosis (or Diagnoses):  Based on physical exam, musculoskeletal palpation, and history, Luna has previously been diagnosed with left carpal valgus and anterior bowing; I concur with that evaluation. Based on the pattern of left limb growth it is likely that she sustained a distal ulnar fracture prior to full growth. Myofascial restrictions and trigger points are consistent with compensatory response to orthopedic malformation and altered weight bearing in left forelimb.

Acupuncture Treatments:
My treatment plan was as follows:
– All dry needling. I have an electroacupuncture unit but Luna was so skittish and hypervigilant that I opted to do just dry needling with her, using Seirin 16mm J-type needles.
– Adjunct: massage for myofascial release
– Points used and why:
o GV20, Bai Hui – calming points, away from areas of primary trigger points / myofascial restriction
o GV14 – calming point, thoracic limb pain, also first foray into area that seemed most sensitive
o SI11, SI12 – myofascial restriction in shoulders, restricted ROM in right shoulder, trigger points
o LU1 – reduced shoulder mobility
o ST36 – wanted to try a point in the hind end to take her attention away from the front. Also immune boosting like LI11, GV14 (nice bonus!). It’s also a point I wanted more practice with.
o BL13, BL15 – Myofascial restriction, trigger points. Also BL15 for anxiety.
o BL18, BL21 – Myofascial restriction, trigger points
o HT 3 – Medial elbow pain, emotional stress. Also incorporated because I was trying to work my way down her limbs.

Itinerary of each visit:
1 (7.22.17). Introduce myself. Met with Luna and her mom, sitting on a bed, and chatted with mom while we petted Luna. I used this visit to discover where Luna did and did not tolerate being touched (for example, would growl and pull her left forelimb away when it was lightly petted). I incorporated some mild massage along the back, focusing on the lower back where I predicted she would not be painful. She tolerated that well, but did not fully relax at any point.
2 (7.29.17). Started with massage and working towards release of myofascial restrictions. Introduced GV20 and Bai Hui with Seirin 16mm needles.
3 (8.6.17). Repeated visit 2. Tried to massage down forelimbs after placing GV20 and Bai Hui but Luna did not tolerate this.
4 (8.19.17). Started with massage. GV20, Bai Hui, GV14, SI11 (SI12 attempted but not tolerated)
5 (8.26.17). Started with massage. GV20, Bai Hui, GV14, SI11, SI12, LU1, ST36, BL13, BL15
6 (9.2.17). Started with massage. GV20, Bai Hui, GV14, SI11, SI12, LU1, ST36, BL 13, BL15
7 (9.9.17). Started with massage. GV20, Bai Hui, GV14, SI11, SI12, LU1, LI11 (R only), BL 13, BL15
8 (9.16.17). Started with massage. GV20, Bai Hui, GV14, SI11, SI12, LU1, LI11 (R only), ST36, BL 13, BL 18, BL 21
9 (9.24.17). Started with massage. GV20, Bai Hui, GV14, SI11, SI12, LU1, LI11 (R and L), ST36, BL 13, BL 18, BL 21, HT 3 (R). Attempted points further distal on forelimbs but Luna did not tolerate this.

Outcomes, Discussions, and References:
Qualitative
Luna tolerated massage very well (once she decided the human performing it was not a threat). When I started to use a bit more pressure along her shoulders and paraspinally, she would often glance sideways at me to tell me she was not enjoying it anymore. When she did that, I would move to another area and use lighter pressure (essentially going back to just petting her). Each day we did this, she would tolerate longer massages, with more myofascial work, and in more sensitive places. For example, on the fourth session she allowed me to spend several minutes on her left shoulder area, which she had not tolerated before. Part of this was trust, I think, and part of it was physical progress in loosening her up over time with needling and massage. As for needling, Luna did not care at all about the first two points I used (bai hui and GV 20) – I snuck them in during massage. When I introduced SI11 she noticed it but tolerated it (this followed massage and placement of GV20 and bai hui), however when I tried for SI12 (first on the right side), she nipped at me and we stopped. I think this was a combination of pain and behavioral/anxiety. The next session I did the same things, but had needles ready in my hands and moved quickly and smoothly from SI11 to SI12, still petting her in circles as I moved my hand, and Luna was OK with that (although still watching me closely). She did seem to visibly relax during each session, and never seemed to mind once the needles were in.

Luna had myofascial restrictions, trigger points, and guarded parts of her body that you can detect on physical exam. However, she is not clearly lame while she moves, nor are there any actions she seems resistant to doing. So, it was difficult to evaluate progress on that front. My assessment of progress was by how much she would allow me to do, and how tight she felt under my fingers during massage. In the course of our nine sessions, I feel that she has become much more relaxed and tolerant of handling; I interpret this to mean that her comfort level has improved.

Quantitative
My quantitative metric for progress was how many acupuncture points/needles she would allow me to put in. Since Luna is such a sensitive and fearful girl, I think this is an accurate way to assess how comfortable v painful she is. At almost every sequential session, I was able to incorporate at least one additional point.

What was learned
I learned a lot about how to introduce acupuncture to a painful and fearful dog. Earning her trust through petting and massage was a hugely helpful tool. I also feel that I had a chance to see the “calming points” in action during every single session, and I found myself relying a lot on their influence on Luna as well. I also learned that patience is a huge virtue, and that I could get farther with my treatments if I spent a lot of time “just” petting and massaging between needle placements if Luna was starting to get worried about what I was doing.

Through research and reading about acupuncture applications, I also learned more about several topics interesting to me:
1. Combining acupuncture and manual therapy has been shown to provide immediate improvement in comfort and mobility in dogs with musculoskeletal pain
a. D. Lane and S. Hill, 2016. Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain. Canadian Veterinary Journal 57(4): 407-414.
i. Used traditional Chinese acupuncture in conjunction with “manual therapy” (massage, manipulations, mobilizations, stretching), and showed that dogs receiving this treatment were able to perform tasks that were previously difficult, compared to dogs receiving no treatment
2. An older study recounted how acupuncture increases circulation to areas of the body affected by musculoskeletal disorders, as well as decreases inflammation and provides analgesia. This is something we talked about in our class in May, however I believe that with Luna I had a chance to see this in action. She was subjectively more comfortable with massage and palpation with each additional acupuncture session.
a. Schoen AM, 1992. Acupuncture for musculoskeletal disorders. Problems in Veterinary Medicine 4(1): 88-97.
3. There is still some conflicting evidence in the human world (where there are more studies to be found) regarding the efficacy of acupuncture in osteoarthritis. However, it is difficult to compare across studies as the metrics used to measure success vary, as do the experimental designs. There seems to be a general consensus that it does not do harm.
a. Bennell K, Buchbinder R, and R Hinman, 2015. Physical therapies in the management of osteoarthritis: current state of the evidence. Current Opinions in Rheumatology 27(3): 304-11.
4. Looking forward to when I introduce electroacupuncture to Luna’s regimen, there are studies that show prolonged analgesia following electroacupuncture when compared to butorphanol (especially post-operatively). Additionally, in human studies there is evidence of electro-acupuncture positively benefitting people with stifle osteoarthritis, both in terms of comfort and function.
a. Chen N, Wang J, Mucelli A, Zhang X, Wang C. 2017. Electro-acupuncture is beneficial for knee osteoarthritis: The evidence from meta-analysis of randomized controlled trials. American Journal of Chinese Medicine 45(5): 965-985.
b. Groppetti D, Pecile AM, Sacerdote P, Bronzo V, G Ravasio. 2011. Effectiveness of electroacupuncture analgesia compared with opioid administration in a dog model: a pilot study. British Journal of Anaesthesia 107(4): 612-8.


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