Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. A2017060

ABSTRACT
A ten-year-old male neutered Rhodesian Ridgeback was treated utilizing acupuncture techniques for a chronic two year history of muscle tremors affecting his left and right pelvic limbs. There are multiple recorded causes of idiopathic myotonia in otherwise healthy canine patients with no known successful treatments1. After three treatments, the patient showed marked improvement with minimal to no reported tremors within two to three weeks between treatments. This provides positive evidence that acupuncture and electrical stimulation may be used in combination to provide symptomatic relief of canine myotonia of unknown cause.

HISTORY
A ten-year-old male castrated Rhodesian Ridgeback (Sooner) presented after an approximate two-year history of tremors effecting the muscles of the pelvic limbs with the right reportedly more severely affected than the left. Sooner was adopted by his family as puppy from a breeder and has lived primarily in Wyoming. His only medical issues include a tail amputation that occurred 5 years prior due to ‘happy tail’ as well as bilateral aural hematomas that were surgically repaired. Sooner has been a very active dog until recently when the family implemented exercise restrictions when they noted that increased activity worsened his muscle fasciculations. This is commonly reported with cases of myotonia2.

PHYSICAL EXAMINATION AND CLINICAL ASSESSMENT
On presentation, Sooner was BAR, with good BCS and vital signs within normal limits. Musculoskeletal examination revealed Sooner to have very well developed, symmetrical muscling possibly secondary to muscle hyperactivity. Neurological examination and routine bloodwork showed no abnormalities. Normal lab work and physical examinations are generally standard when diagnosing idiopathic myotonic disease3.
On the initial visit, Sooner’s tremoring was constant and effected all muscles associated with the left and right upper thighs particularly the right biceps femoris mm. Tremors were non-painful and caused dependent shaking of the distal crus and metatarsi as muscles quickly contracted and relaxed (see SoonerVideo1). Fasciculations occurred only during weight bearing (standing and walking) and ceased when non-weight bearing (sitting or lying down).

SoonerVideo1
MEDICAL DECISION MAKING/DIFFERENTIAL DIAGNOSIS/PUTATIVE DIAGNOSIS
Similar conditions of muscular trembling have been described including congenital and acquired myokymia and neuromytonia. Research with congenital myotonia in Jack Russell terriers has identified an autosomal mutation of the CLCN1 gene encoding the skeletal muscle voltage-dependent chloride channel, ClC-14. With a defect in this channel, membrane repolarization following muscle contraction is decreased resulting in hyperexcitability5.
Compared to Sooner, this condition causes more severe clinical signs affecting musculature at all times including weight bearing and non-weight bearing. However, if Sooner’s tremors were associated with a similar neuropathy or dysfunction at the neuromuscular junction or sarcolemma itself we hypothesized that acupuncture may return the cycle of overactive

ACUPUNCTURE TREATMENT
With myopathy affecting muscles of the upper pelvic limbs, a plan was made to stimulate neuroanatomic points along the spinal cord as targeted stimulation of nerves associated with the upper pelvic limb. These specifically included the sciatic, common fibular, tibial, femoral, cranial gluteal, deep fibular and S1 and S2 spinal nerves. Stimulation of these nerves utilizing dry needling and electrical stimulation attempted to return erratic nervous activation of associated muscle groups to a normal level.
Sooner was treated for three sessions lasting between 20-30 minutes two weeks apart with acupuncture points including GV14, GV20, GB29, GB30, GB31, GB33, GB34, BL10, BL21, BL23, BL27, BL28, BL36, BL39, BL40, BL54, LR2, ST36 and Bai Hui. The first treatment utilized smaller 0.16 x 30mm Seirin needles and the second and third treatments used larger needles 0.20 x 30mm Seirin needles to allow Sooner to acclimate to the needling more slowly. Electrical stimulation using a Pantheon electrostimulator unit was implemented during the third treatment attached on the left and right side between BL28 and GB31 on mixed setting between level two and three.
Sooner tolerated his treatments very well. During the first session, Sooner’s muscle tremors were constant throughout his session (see SoonerVideo2). However, fasciculations were notably improved during the second and third treatments but upon placement of a needle at ST36 tremors of the associated hind limb were temporarily ‘activated’.

SoonerVideo2
OUTCOMES/DISCUSSIONS
Following Sooner’s first treatment, the family described a notable improvement in his clinical signs at home. Even with return to normal activity level, Sooner’s tremors remained very well controlled. Acupuncture treatments were put on hold upon completion of the three sessions and his clinical signs reportedly returned within three to four weeks. The shaking was of equal if not worse in intensity.
I suspect that stimulation of the affected muscles and associated nervous pathways in this case with dry needling and E-Stim greatly improved the patient’s clinical signs by reducing muscular hyperactivity. Whether or not worsening of signs upon completion of acupuncture sessions was related to Sooner’s condition or a result of acupuncture is difficult to determine. This condition will likely not be ‘cured’ by acupuncture but relief of signs can allow patients to return to normal activity level which can be very rewarding for their families. As most myotonic conditions reportedly worsen over time, acupuncture may also play an important role in allowing affected animals to maintain normal activity for as long as possible.

ADDITIONAL DISCUSSION
The medical acupuncture experience for this case was excellent. It was an important reminder to keep in mind the anatomy and innervation affected leading to the patient’s clinical signs. Improvement in clinical signs were seen within 24 hours after treatment which was gratifying to myself as well as my clients. Similar cases that I have experienced in the past (geriatric patients with degenerative musculoskeletal disorders) have caused frustration to myself and owners particularly when definitive diagnoses are difficult without advanced diagnostics. This has made medical management difficult as well as often unsuccessful.
The incorporation of acupuncture into my practice has been an excellent option for patients showing limited response with medical management alone and for clients seeking alternative therapies for their pets. Additionally, the process of medical decision in acupuncture reminds me to evaluate patients from multiple perspectives when determining diagnoses and treatments.

1 Vite CH: Myotonia and disorders of altered muscle cell membrane excitability. Vet Clin North Am Small Anim Pract 2002 Vol 32 (1) pp. 169-187.
2 Beale BS, Langley-Hobbs S, Trout NJ: Diseases of muscles and tendons. In Morgan RV (Ed). Handbook of Small Animal Practice, 5th ed. Elsevier Saunders, St. Louis 2008.
3 Vite CH: Myotonia and disorders of altered muscle cell membrane excitability. Vet Clin North Am Small Anim Pract 2002 Vol 32 (1) pp. 169-187. 4 Lobetti RG: Myotonia congenita in a Jack Russell terrier. J S Afr Vet Assoc 2009 Vol 80 (2) pp. 106-7.
5 Aromataris EC, Rychkov GY: C1C-1 chloride channel: Matching its properties to a role in skeletal muscle. Clin Exp Pharmacology Physiol 2006 Nov (11) pp. 1118-23.
muscle contraction to homeostasis. Without electromyography or muscle biopsy histopathology, the cause of Sooner’s myopathy can only be classified as idiopathic but acupuncture could be utilized to improve clinical signs.

 


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