Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017029

Abstract:
Caprise is an 11 year old female spayed Golden Retriever mix who presented to the clinic for difficulty rising and ataxia in the rear limbs. After examination and diagnostics she was diagnosed with arthritis of the lumbar spine and being overweight. Intervertebral Disc Disease was suspected as well but a definitive diagnosis was not made. Caprise was managed with a weight loss protocol, oral analgesics, joint supplementation, and weekly treatments of acupuncture and laser therapy for 6 weeks. Caprise improved dramatically after treatment and had an improved gait, better pain control, and resolvement of neurological deficits in her rear limbs.

History Presentation:
Caprise presented to the clinic on March 28, 2017 as a new patient. She has no history of trauma or surgeries. The chief complaint was trouble with mobility that has been off and on for 6 months. She was having the most difficulty getting up and she seemed sore once she was up and walking. Caprise also had anxiety towards strangers (especially men) and has long nails that previously could not be trimmed without a sedative. Caprise lives a sedentary life indoors. She is not currently on any medications (including heartworm and flea/tick preventatives) and eats 2 cups of Pedigree healthy weight once a day. She was vaccinated for rabies and distemper/parvo about 3 years ago. She is eating/drinking normally. No vomiting/diarrhea/coughing/sneezing.

Caprise Before Getting Up Caprise Before Walking
Physical Examination and Clinical Assessments:
T- 100.6 F
P- 100 bpm
R- 40 breaths/min
General: BAR, BCS: 7/9
MM: Pink and Moist, CRT<2 sec
EENT: No ocular or nasal discharge, mild wax AU, mild to moderate tartar
LN: Palpate WNL
H/L: no murmurs or arrhythmias ausculted, femoral pulses strong and synchronous, lung fields
clear
Abdomen: soft and non-painful with no palpable masses
Integumentary: severely matted fur with seborrhea sicca; 1 cm fleshy (wart-like) dermal mass on top of head and near base of right ear; urine odor on fur; severely long nails
MS/Myofascial exam: tight pectorals; tight bands on dorsal cervical region; tender to palpation of dorsal lumbar region with tight bands palpated; resists extension of hips (not fully extended); severe difficulty rising; mild to moderate muscle atrophy of rear limbs; short-strided gait in rear limbs; difficulty with ambulation in front limbs – short, stiff gait (maybe due to very long nails?); kyphosis of thoracolumbar region; hocks slightly dropped
Neuro: Normal ROM of cervical spine when following treat; normal CPs in front limbs; slow CP in left rear, absent CP in right rear; normal patellar reflexes, negative cross extensor in rear limbs; difficulty with hopping
Rectal: Normal anal tone, normal feces in colon, anal glands mildly full, no blood noted
CBC – wnl
Chem- Glu 66 (70-143) likely from blood sitting on counter prior to being sent to lab
Phos 1.9 (2.5- 6.8) r/o myopathy, poor diet, hypothyroidism, other
ALKP 483 (23-212) r/o bone disease, liver disease, cushing’s, other
HWT 4dx – negative
Radiographs (spine, pelvis, stifles) – arthritis of cranial lumbar spine; effusion in both stifles but no evidence of arthritis; normal pelvis

Medical Decision Making:
Caprise was initially seen by another associate at the clinic. Her owners had financial constraints so initially declined acupuncture and laser treatments. She was started on oral analgesics (galliprant and gabapentin) and mild improvement was seen. Caprise was on the pain medications for two weeks prior to presentation for acupuncture and laser (“before” video submitted was while she was on pain medication). My initial treatment was a more aggressive weight loss plan. Caprise was transitioned from Pedigree Healthy Weight to a prescription weight loss food with added glucosamine and chondroitin sulfate (Hill’s Science Diet Metabolic + Mobility). Keeping patients at a lean body weight will decrease the load on the joints and contribute to an overall healthier status. Caprise was also enrolled in a 6 week acupuncture + laser + massage package at no charge for this case study. She came to the clinic once a week and was dropped off for the day to help with scheduling conflicts. Acupuncture was chosen as a treatment option to help with neuromodulation of the central and peripheral nervous systems, relieve myofascial trigger points, and help decrease inflammatory mediators. Laser treatment was chosen to help decrease inflammation and help with muscular cellular recovery. Massage was chosen to help relieve tight muscular bands and help with muscle flexibility. Prior to treatments Caprise was completely shaved of her thick mats. She was bathed and her nails were trimmed and nail/toe grips were placed to help with her footing on hardwood surfaces which is in her home. In the past Caprise was described as getting anxious/aggressive withtreatments such as nail trims but by going slow, using treats, and being calm Caprise accepted all her treatments without any signs of aggression.

Differential Diagnosis:
Osteoarthritis
Intervertebral Disc Disease
Hip Dysplasia
Neoplasia (spinal cord, bone, other)
Fibrocartilagenous embolism
Trauma
Meningiomyelitis
Myelomalacia
Lumbosacral stenosis
Discosponydlitis
Fracture
Degenerative Myelopathy
Muscle strain/soft tissue injury
Diabetes mellitus, neuropathy

Definitive Diagnosis:
Osteoarthritis, Lumbar Spine – this diagnosis was confirmed by radiographic review of the spine, pelvis and stifles. IVDD was suspected but not confirmed by radiographs and further imaging was not pursued. Caprise was still treated for probable IVDD.
Additional diagnoses:
Overweight
Periodontal Disease, grade 2
Dermal masses – suspect dermal papillomas

Acupuncture Treatments:
GV20 – calming point used for relaxation GV14 – homeostatic point, used for neck and back pain, BaiHui – homeostatic point, pelvic limb pain and neurological dysfunction, L-S pain ST36 – autonomic point helps with immune and inflammatory issues, pelvic limb dysfunction, stifle pain BL10 – cervical pain/tension, local trigger points BL20-BL25 – local points to help with pain along lumbar spine, also targeted trigger points along this line Hip Triad (GB29, GB30, BL54) – hip and gluteal pain BL60/KI3 – pelvic limb pain These points were selected to address Caprise’s musculoskeletal pain (mainly neck and cranial lumbar back) and neurologic dysfunction (mainly rear limbs). Caprise tolerated acupuncture very well and all points were placed at each visit. Caprise preferred to lay on a bed on one side of her hips. Due to this the following points were not done bilaterally but one side at each visit,
alternating sides every visit: Hip Triad (GB29, GB30, BL4), ST36, BL60/KI3. These points were dry needled once a week for 6 weeks. They were left in place for about 20 minutes. For the first two visits, red Sierins (0.16 mm x 30 mm, coated) were used to ease Caprise into acupuncture. The rest of the treatments were done using yellow Sierins (0.18 mm x 30 mm, coated). For the last two sessions electroacupuncture was added to the session. An ITO acupuncture stimulator device was used on points along her bladder line near BL20-25 (exact placement depended on tight bands palpated during the myofascial exam that day). Leads were placed at the most cranial lumbar points and the most caudal lumbar points. It was set on low frequency (2 Hz) for 10 minutes then increased to a higher frequency (100 Hz) for 10 minutes. This was to elicit a varying response from the nervous system (ie- different endorphins released). After acupuncture was performed, a class IV laser treatment was performed along with massage. The laser was set to 8 Watts and was performed from the cervical region along the spine to the sacrum. This was done for 8 minutes while massaging Caprise’s neck and back during treatment. Then an additional 4 minutes was added to continue lasering at 8 Watts along the hips.

Caprise After
Outcomes, Discussions, and References:
Caprise made marked improvement with her ability to get up from a laying down position and to ambulate more normally. Since only mild improvement was seen after being on analgesics for a couple weeks, I believe the significant changes seen after starting acupuncture and laser is a testament to its effectiveness. I believe it was this multi-modal approach which made Caprise benefit the most. Caprise’s owner were warned that she may be sore the day of acupuncture. This was reported after the first day of treatment but otherwise was not noted by the owner after that. One challenge Caprise had was losing weight. Despite being on the prescription food, Caprise only lost 3 lbs in 6 weeks (from 89 lbs to 86 lbs). After discussing her home care with the owner it was revealed that Caprise was not taken for walks at home or given any exercise. This was discussed with the owner and a better home exercise plan was put into place. From this I learned to have better communication regarding home care requirements. From this case study and
course I have learned not only that acupuncture is effective but it is safe and can be used for a wide range of uses.

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556488/


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