Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018017

ABSTRACT
King Charles Cavalier Spaniel (KCCS) with intermittent mild lameness of hind end presented for additional, non-pharmacological, sources of decreasing discomfort and prolonging progression of joint changes to improve long term quality of life. After three sessions, owner reported that pet is more playful, weight loss program is achieving results, and periods of lameness have decreased.

HISTORY PRESENTATION
A one-year-six-month-old male, castrated, KCCS originally presented for chronic worsening of mild intermittent lameness of the right pelvic limb in June 2018; owner reported no apparent cause of lameness. Pet has two other KCCS siblings (both younger) and two cats at home that he plays with. Other physical activity consists of routine play and occasional walks; no working, training, etc, in history. Patient is fed Hill’s Science diet adult formula and had been feed the small breed puppy formula until 1 year old. No history of surgery other than routine castration at 6 months old.

PHYSICAL EXAMINATION AND CLINICAL ASSESSMENTS
Temperature, pulse, respiratory were within normal limits for signalment. Pet had a body condition score of 7/9. Grade 2/5 lameness on pelvic limbs. Routine blood work held no significant findings besides mildly decreased platelets (blood smear showed very large platelets) which can be attributed to patient’s breed. Neurological examination showed no significant abnormalities. Orthopedic examination noted medially luxating patella bilaterally; pain on extension of the coxofemoral joints, worse on the left. Myofascial palpation revealed very tight muscles of the superficial gluteal, vastus lateralis, vastus medialis, and gastrocnemius muscles. Radiographs reported mild to moderate laxity of the coxofemoral joints.

DIFFERENTIAL DIAGNOSIS
• Bilateral medial luxating patella
• Cruciate disease
• Early onset arthritis
• Hip dysplasia
• Nerve entrapment
• Hip dislocation / subluxation

DEFINITIVE DIAGNOSIS
Grade two out of four medial patella luxation bilaterally; when examined the patella could be luxated with pressure and would remain out of place until manual replacement (Putnam).
Hip subluxation; based on radiographs, physical examination, and joint movement, hips were determined not to be completely dislocated but did have abnormal positioning and movement that could not be permanently corrected without orthopedic surgery.
Ruled out:
Cruciate disease; injury ruled out at this time due to negative cranial drawer / tibial thrust, no soft tissue swelling apparent caudal to patellar fat pad; however, owner informed that laxity in these soft tissues might not be appreciated at this time and could develop further.
Early onset arthritis: no boney changes could be visualized on radiographs at this time, clear evidence of normal cartilage apparent in all joint visible on radiographs
Nerve entrapment: no deficits revealed during neurological exam.

MEDICAL DECISION MAKING
Recommended acupuncture for neuromodulation of tissues influencing coxofemoral and stifle joints. This would be accomplished via stimulating the local nerves (sciatic n., cranial gluteal n., femoral n., etc) to influence mechanoreceptors and nociceptors that can lead to effects on the central nervous system to provide analgesia, decreased inflammation, and promote healthy muscle growth of these areas being treated (Robinson).
Patient was started on daily joint supplements of glucosamine, chondroitin, and omega fatty acids. A weight loss program was also recommended.
Treatments were recommended weekly and / or during periods of lameness / increased discomfort.


ACUPUNCTURE TREATMENTS
Patient receiving therapeutic laser treatments at another facility.
Session 1: Dry needling of the following points:
• Left Spleen (SP) 10 using Seirin 0.16 x 30 mm – stimulate the femoral nerve to promote analgesia and neurmodulation to the vastus medialis m. to help support the stifle
• Left Stomach (ST) 34 using Seirin 0.16 x 30 mm – stimulate femoral n. to promote analgesia and neuromodulation of vastus lateralis m to promote joint stability
• Bladder (BL) 14 using Seirin 0.16 x 30 mm – neuromodulate sympathetic tone to promote relaxation
• Left Gall bladder (GB) 29 using Seirin 0.16 x 30 mm – stimulate cranial gluteal n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left GB 30 using Seirin 0.16 x 30 mm – stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left BL 54 using Seirin 0.16 x 30 mm — stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• BaiHui using Seirin 0.16 x 30 mm – neuromodulate sympathetic tone to promote relaxation
Session 2: Dry needling of the following points:
• Bai hui using Seirin 0.20 x 30 mm – neuromodulate sympathetic tone to promote relaxation
• Left ST 34 using Seirin 0.20 x 30 mm – stimulate femoral n. to promote analgesia and neuromodulation of vastus lateralis m to promote joint stability
• Left ST 36 using Seirin 0.20 x 30 mm – stimulate fibular n. to promote analgesia and neuromodulation of vastus lateralis m to promote joint stability, neuromodulation of parasympathetic system to decrease inflammation
• Left GB 29 using Seirin 0.20 x 30 mm – stimulate cranial gluteal n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left GB 30 using Seirin 0.20 x 30 mm – stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left BL 54 using Seirin 0.20 x 30 mm — stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Pet became mildly agitated after stifle points placed therefore no further needles were placed.
Session 3: Dry needling of the following points:
• Bai hui using Seirin 0.20 x 30 mm – neuromodulate sympathetic tone to promote relaxation
• Yintang using Seirin 0.20 x 30 mm – neuromodulate sympathetic tone to promote relaxation
• Left ST 34 using Seirin 0.16 x 30 mm – stimulate femoral n. to promote analgesia and neuromodulation of vastus lateralis m to promote joint stability; used a smaller size needle during this visit due to pet’s agitation with this location at last treatment area
• Left ST 36 using Seirin 0.16 x 30 mm – stimulate fibular n. to promote analgesia and neuromodulation of vastus lateralis m to promote joint stability, neuromodulation of parasympathetic system to decrease inflammation; used a smaller size needle during this visit due to pet’s agitation with this location at last treatment area
• Bilateral SP 9 using Seirin 0.16 x 30 mm – stimulate the saphenous n. and tibial n. to provide analgesia and neuromodulation to medial distal muscles of the pelvic limb; used a smaller size needle during this visit due to pet’s agitation with this location at last treatment area
• Left SP 10 using Seirin 0.16 x 30 mm — stimulate the femoral nerve to promote analgesia and neurmodulation to the vastus medialis m. to help support the stifle; used a smaller size needle during this visit due to pet’s agitation with this location at last treatment area
• Left GB 29 using Seirin 0.20 x 30 mm – stimulate cranial gluteal n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left GB 30 using Seirin 0.20 x 30 mm – stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability
• Left BL 54 using Seirin 0.20 x 30 mm — stimulate sciatic n. to promote analgesia and neuromodulate of gluteus mm. for hip stability

OUTCOMES and DISCUSSIONS
Owner reported that after each session pet experience mild lethargy for the rest of the day which was attributed to normal effects of acupuncture treatments. Owner reported that in the days to weeks following treatments, pet was more active, playful and incidences of mild lameness decreased from once a week to once every few weeks; duration of lameness decreased from lasting a week or more to lasting a few days.
Serial examinations during treatment (which lasted over course of 3 months) showed decreased resistance of pain during flexion and extension of coxofemoral joints, no pain on flexion or extension of stifle joints, when presented with lameness was decreased at a grade 1/5. Pet also decreased weight by 3 pounds – attributed hopefully to pet’s willingness to play more as owner admitted had not been strict on calorie restriction.
Overall, these three treatments of dry needling (with conjunction of laser therapy at the other facility and joint supplements at home) appeared to cause the pet’s discomfort to decrease as well as improved his short-term quality of life.
The majority of animals diagnosed with patella luxation occurs around six months of age (Nunamaker). Long term study with continued treatment might be useful to determine whether early treatment of patellar luxation in young animals may decrease the progression of this ailment and thus decrease the need for not only pharmacologic pain management (nsaids, opioids) but also eventually decrease the need for surgical intervention in the later years.

REFFERENCES
Nunamaker, David. “Patellar Luxation” in History of Small Animal Orthopaedics, chapter 81 <cal.vet.upenn.edu/projects/saortho/chapter_81/81mast.htm>
Putnam: Patellar Luxation in the Dog. Master’s thesis, University of Guelph, 1968.
Robinson, Narda: One Medicine, One Acupuncture. Animals.2012, 2, 395-414.


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