Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017045

Abstract:
“Lani” is a retired search and rescue dog who has been diagnosed with bilateral cranial cruciate injury and suspected lumbosacral disease and polyneuropathy. She receives weekly acupuncture, laser treatment, and underwater treadmill conditioning to promote stifle stability, relieve pain, and stimulate nerve regeneration and reduce inflammation in the lumbosacral region. Treatment have been successful for maintaining hind end mobility, alleviating pain, and reducing incontinence problems attributed to lumbosacral disease. I was involved with three of Lani’s acupuncture treatments while I was on the Mobile Equine Service rotation with the OSU clinician who performs large and small animal acupuncture.

History and Presentation: Lani is an 11 year old spayed female Labrador Retriever who receives weekly acupuncture treatments at the Oregon State University Veterinary Teaching Hospital for management of presumed lumbosacral disease and bilateral cruciate ligament injury.
Lani was diagnosed with a left CCL tear in September 2014, and a Tibial Plateau Leveling Osteotomy (TPLO) was performed. Subsequently, she sustained a partial tear to her right CCL, but was not a good surgical candidate at that time and this injury has been managed with underwater treadmill therapy, and laser therapy. In early 2016, Lani began to exhibit hind limb weakness and atrophy of the gluteal and hind leg muscles. Acupuncture treatments were initiated in April 2017, when Lani’s hind end neurologic deficits began to progress. She has received weekly acupuncture treatments since that time. Her owner reports that she has recently maintained improved bladder control, with no incidences of urinary incontinence in the last 6 weeks, however her hind end weakness continues to slowly decline.
Lani was also diagnosed with laryngeal paralysis, which was treated a left arytenoid lateralization surgery on 10/19/16. It is suspected that Lani’s hind end weakness may be partially due to Geriatric Onset Laryngeal Paralysis and Polyneuropathy syndrome.
I was involved with treatments for Lani on March 9th, 16th, and 23rd, 2018.

Physical Examination and Clinical Assessments:
On pre-acupuncture physical examinations, Lani consistently exhibits a stiff gait in the hind end, mild pelvic limb ataxia and proprioceptive deficits (spontaneous knuckling of the hind paws). I was unable to evaluate Lani’s gait thoroughly due to the short appointment times, however videos of Lani on the underwater treadmill provided by her owner show a decline over time in Lani’s neurologic and musculoskeletal function. She exhibits a pace gait in all the videos from 2013 and May 2017, which progresses by the November 2017 video to dyscoordination in rhythm between the front and hind limbs. This recent finding is suggestive of a cervical spinal lesion, but may also be due to severe weakness of the hind limbs and the suspected lumbosacral lesionl
All other physical examination parameters were within normal limits.

Medical Decision Making:
The goals for acupuncture of for Lani are to protect and promote neuroregeneration in the lumbosacral region of the spinal cord, to promote stifle stability, and to reduce pain and inflammation in the stifles and lumbosacral region. Needling is used to reduce myofascial restriction in the epaxial muscles caused by chronic pain and gait abnormality, and to

Differential Diagnoses:
Laryngeal paralysis (surgically treated with left arytenoid lateralization)
Lumbosacral disease (presumed)
Right cranial cruciate ligament partial tear
Left cranial cruciate ligament partial tear (surgically treated with left TPLO)
Bilateral stifle osteoarthritis
Suspected polyneuropathy related to GOLPP syndrome

Definitive and Putative Diagnosis (or Diagnoses):
Hind end weakness is believed to be largely due to lumbosacral stenosis, because the clinical signs (hind end weakness and proprioceptive deficits, bladder incontinence, pain to palpation of the lumbosacral region) are consistent. Imaging of the spinal column might confirm this diagnosis, however the owner declined further diagnostics as they would be unlikely to change the treatment plan. It is suspected that there may be a polyneuropathy component to the hindlimb weakness as polyneuropathy is known to occur with laryngeal paralysis in older Labrador dogs (GOLPP syndrome).
Stiff gait and lameness are likely associated with stifle osteoarthritis (diagnosed by radiology), cruciate injury, stifle instability, and fibrosis of the stifle joint capsule due to instability in the right stifle and post-surgical changes along with instability in the left stifle.

Acupuncture Treatments:
The same points were used for the three treatments which I was involved in. Points were chosen to promote stifle stability, spinal cord nerve conduction, and analgesia. Seirin needles (30 X 0.25 mm) were used for all points stimulated.

Dry needling:
Bai Hui – Chosen as a influential point for lumbosacral pain, pelvic limb pain, and neurologic dysfunction, all of which are present in this patient.
GV 3 and BL 23 bilaterally – To reduce myofascial tension in the epaxial muscles and relieve lumbar pain.
BL 40 (left) – Promotes stifle stability by stimulating the proprioceptors in the popliteus muscle. Stimulates the tibial nerve, and can be used to improve bladder control and hind limb weakness in lumbosacral stenosis patients.

Electroacupuncture:
BL 40 to ST 35 and KI 10 to GB 34 (right) – BL 40 provides stifle stability benefits outlined above. Electrical stimulation at 20 Hz was performed for 15 minutes at an amplitude just below the threshold to cause muscle twitching. Electrical stimulation across the stifle joint promotes bloodflow and provides analgesia. I would have chosen a lower frequency (2-4 Hz), however this frequency may still be low enough to provide long lasting analgesia by releasing enkephalins.
BL 25 to BL 25, BL 26 to BL 26, and BL 25 and BL 25 – Electrical stimulation was performed at 20 Hz for 5 minutes and 120 Hz for 10 minutes. Needling of these points may relieve muscle tension in the epaxial muscles caused by chronic pain in that region and compensation for stifle pain and instability. Electrical stimulation across the spinal cord is expected to promote neuronal regeneration and reduce inflammation of the spinal cord. High frequency electroacupuncture is expected to modulate pain at the spinal level and reduce spinal wind up. Low frequency stimulation is expected to provide longer lasting pain relief via enkephalin release. Stimulation in the region is also expected influence the innervation to the bladder by stimulating the somatic nerves that enter the dorsal root ganglion at the same level as the visceral nerves that innervate the bladder.

Outcomes, Discussions, and References:
The acupuncture treatments this patient receives seem to be partially attenuating symptoms of lumbosacral disease and polyneuropathy. If this were my case I would like to apply laser to the stifles and gluteal region as well as the lumbosacral region, with the goals of reducing pain and promoting peripheral nerve health and regeneration. GOLPP syndrome is characterized by axonal degeneration and loss of nerve fibers (Thieman et al. 2010). Laser therapy can promote nerve regeneration and pain resulting from neuropathy. Furthermore, laser therapy has been shown to reduce damage in rats with experimentally induced cranial cruciate injury (Bublitz et al., 2014) and can promote cartilage regeneration in rats with experimentally induced osteoarthritis (Santos, et al., 2014).

References:
Dos Santos, A, P Oliveira, K Fernandes, L Rhon, C Tim, F Vasilceac, N Antonio, A Renno. 2014. Effects of low-level laser therapy on cartilage repair in an experimental model of osteoarthritis. Photonics & Lasers in Medicine. 3(3)255-264.
Bublitz, C, C Medalha, P Oliveira, L Assis, L Milares, K Fernandes, C Tim, F Vasilceac, S Mattiello, A. Reno. 2014. Low-level laser therapy prevents degenerative morphological changes in an experimental model of anterior cruciate ligament transection in rats. Lasers in Medical Science. 29(5)1669-1678.
Thielman KM, DJ Krahwinkel, MH Sims, GD Shelton. 2010. Histopathological confirmation of polyneuropathy in 11 dogs with laryngeal paralysis. J Am Anim Hosp Assoc. 43(3):161-7.

Describe Your Medical Acupuncture Experience:
I appreciated the opportunity to work on this case with a veterinarian who is experienced in acupuncture. The attending clinician treats this patient on a weekly basis, and has a set of points that he routinely uses, in addition to points selected based on a traditional Chinese medicine examination. I was able to rationalize the points used from an anatomic and physiologic standpoint. If this were my own case, I would have preferred to perform a complete myofascial examination. I suspect that this patient would have myofascial restriction and trigger point pathology resulting from compensation for chronic lameness and ataxia as well as from mildly increased respiratory effort related to laryngeal paralysis. This case was interesting as there were several concurrent problems in this patient, and I was able to hear the results of acupuncture and laser therapy over a long period of time.


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