Written by a CuraCore Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4S2018028
ABSTRACT: A 13-year-old, intact male, golden retriever, Randy, presented with a chronic history of decreased mobility that had recently worsened. Although dry needling was the only type of acupuncture (AP) and/or physical medicine modality utilized during the once weekly, four weeks of treatment … the patient’s ambulation (function) significantly improved after only two weeks and continued to improve throughout the duration. By the end of only four weeks, a moderate increase in muscle mass (form) had occurred. Lastly, neuropathic, inflammatory and myofascial pain states were controlled.
HISTORY AND PRESENTATION: Randy had a one-year history requiring the owner’s assistance to get in/out of back seat of their sport utility vehicle (SUV), while also demonstrating hesitation and difficulty using the stairs twice daily (morning and bedtime) in the house. Acutely for the past two weeks, Randy progressed to becoming splay-legged in the hindlimbs, upon getting up from laying down on tile floor with a prolonged, obvious struggling effort and no longer would use the stairs without the owner’s help. Although having a one-year history of chronic renal disease, he was not demonstrating any of its metabolic symptoms, such as vomiting, diarrhea and/or hyporexia/anorexia, and Randy’s primary polyuria with secondary polydipsia as well as any previous weight loss had been static for several months. Randy was on a grocery store bought commercial diet and had been taking daily 1000mg of generic omega 3 fatty acids for the past year for osteoarthritis. The senior owner of Randy was concerned that his mobility issue would progress to the point that he could no longer get up off the floor and/or go up and down the stairs in the house, even with the owner’s assistance.
For seven days before his first AP treatment, during which Randy started receiving gabapentin 300mg (~12mg/kg) BID PO, and after only 24 hours of a self-limiting, lethargic acclimation period to the new medication, the owner noticed Rocky using the stairs more on his own and his activity level had increased above his low baseline activity that had been noted for the past year, which confirms neuropathic pain.
As seen in VIDEO 1, the patient initially demonstrated exercise intolerance and a moderate decrease in neuromuscular function, as well as severe pain during only a 50 meters short walk. More specifically, VIDEO 1 showed sarcopenia (BCS 2/9), pelvic limb ataxia with intermittent bilateral hind paw ‘knuckling,’ mild plantar walking, a moderate ‘head bob’ left forelimb lameness, a mild hypo-metric hindlimb gait, thoracolumbar (TL) kyphosis with a persistent resistance and intolerance to only a single short walk, indicating pain as also seen from the patient’s painful facial expression. Although the muscle atrophy appeared predominantly in the caudal half of the dog overall from a far, was actually generalized, axial and appendicular, moderate to severe skeletal muscle atrophy upon physical exam.
PHYSICAL EXAMINATION: Even though tacky mucous membranes were noted, the color was normal pink, with a normal capillary refill time and overall hydration was considered adequate. Panting throughout the exam, with a normal pulse character and rhythm, the pulse rate was deemed to be elevated at 150b/minute and remained at this elevated rate during and after the day’s treatment. No abdominal pain upon palpation was noted but mild generalized allodynia was present. After only two weeks of AP treatments (three treatments), the pulse rate decreased to a normal, nonpainful rate for a dog this size, at ~120b/minute.
Cranial nerve reflexes were WNL, but marked bilateral temporal mm atrophy was present. Bilateral cervical lateral flexion tests (via following treats) were WNL. Forelimb reflexes were WNL. Pelvic limb reflexes demonstrated bilateral equivocal positives to both conscious proprioception (CP) tests, as well as bilateral crossed extensor reflex tests, therefore making highly possible a T3-L3 myelopathy. Pudendal reflexes were WNL. Bilateral forelimb elbows had moderate boney proliferation with painful crepitus, with bilateral biceps and triceps mm tightening/contracture (i.e., compensatory dysfunction). T11-L3 (at TL kyphosis) paraspinal allodynic pain was found during palpation of surrounding soft tissue. Bilateral latissimus dorsi mm contracture/tightening was also present. Nonpainful crepitus of right hip extension was noted, with both knees palpating with moderate boney proliferation and equivocal effusion, and the quadriceps mm had tightening/ contracture with atrophy, and the hamstring muscles had diffuse atrophy. Brachiocephalic and trapezius mm on both sides of the neck had taught bands (i.e., compensatory contracture). Based on watching the dog rise from recumbency and/or sitting, by shifting weight to his forelimbs and then using them to do a ‘pull up,’ it was presumed these compensatory hypertrophy muscles of neck, triceps, biceps and latissimus dorsi, were a result of the nervous system over firing to help compensate for difficulty getting up from a lying or sitting position due to mild paraparesis and chronic multifocal osteoarthritis.
Differential diagnoses consisted of chronic inflammatory/degenerative/painful orthopedic disease with disuse muscular atrophy (myofascial dysfunction) causing decreased muscular proprioception and therefore decreased CP, chronic painful TL spinal cord disease due to degeneration/inflammation also causing decreased CP, chronic hypertrophy of respective compensatory muscles (myofascial dysfunction), chronic neuropathic (maladaptive sensitization) central (at dorsal horn of spinal cord) and peripheral (e.g., inflammatory, myofascial and maladaptive sensitization) pain syndromes, chronic metabolic dysfunction of synovial joint fluids due to chronic inflammatory environment and stable kidney metabolic dysfunction (also a possible additional cause of sarcopenia beyond severe aging and/or disuse muscle atrophy as the two main causes).
PUTATIVE DIAGNOSIS: Given all the aforementioned findings, a tentative diagnosis consisted of multifocal osteoarthritis of appendicular (elbows and stifles) and axial (e.g., TL spine) skeletons, chronic thoracolumbar intervertebral disc disease type 2 (with likely TL myelopathy with ambulatory, mild neurological pelvic limb deficits), peripheral and central sensitization maladaptive pain syndromes and sarcopenia from high geriatric age, myofascial dysfunction and/or chronic renal disease.
TREATMENT PLAN: was prioritized based on owner’s goals to improve quality of life with pain management of inflammatory and neuropathic maladaptive pain states and to prevent further progression of worsening mobility to protracted recumbency, where the senior owner could no longer help, resulting in humane euthanasia. Acupuncture dry needling was started due to multiple, positive multiple neuromuscular physiological effects that include the following: decrease inflammation directly (e.g., by increasing circulation with anti-inflammatory cytokines)1 and indirectly (e.g., one proposed mechanism is via autonomic neuromodulation towards sympathetic inhibition and parasympathetic stimulation, with subsequent inflammatory pain analgesia,1,11 provide endogenous opioid analgesia,2,6,11,12 reversal of the central and peripheral sensitization pain syndromes,3,5,6,7,8,12 and restore neuromuscular and myofascial function (s) by recruitment of local stem cells4 and/or increasing circulation for regenerative properties of neuromuscular tissue (and/or decreasing further neuromuscular degeneration), allowing for enhancement of proprioceptive and ambulatory functions.5
A recommendation was given to put out a non-slip traction mat on the lower tile floor and stairs with extra bedding and to continue the gabapentin at the same dose. NSAIDs were not given due to renal disease.
Additionally, if more therapeutic efficacy (i.e., more stimulation needed for more neuromodulation) would be needed from the acupuncture treatment, Electroacupuncture (EA) via a Pantheon machine could be used in the future, as long as necessary minimal needle size of 0.2gauge was regularly tolerated by the patient at relative connection points of the spine, thoracic limbs and/or pelvic limbs. Set to a mixed signal at two frequencies of 2 and 100hz for 20 minutes, the mixed EA would facilitate increased neuromodulation (i.e., increased AP analgesia) via different endogenous opioid pathways predominantly as well as other neurotransmitters (e.g., serotonin, norepinephrine, dopamine and acetylcholine).6,13,14Specifically at 2hz, met-enkephalins and beta-endorphins (i.e., endogenous opioids that are mu agonists) were predominantly produced, but the higher frequency 100hz produced the endogenous opioid dynorphin (a Kappa opioid agonist) and the aforementioned serotonin, noradrenergic neurotransmitters.6,13,14 In addition to the EA, therapeutic LASER could have also been used as an anti-inflammatory for analgesia and/or to facilitate tissue healing (all of which, via photo biomodulation improves tissue form and function).9,13
ACUPUNCTURE: The AP treatment plan consisted of once weekly dry needling treatments for four weeks. After the first treatment with 0.16gauge (30mm) Seirin (coated) needles into listed points and in left lateral recumbency, it was noted that Randy preferred to be a typical golden retriever, as he would remain sitting with his head in the owner’s lap throughout the remaining four treatments which easy allowed for bilateral peripheral points (although bilateral cross talk with peripheral nerves does occur through neurologic contralateral reflex pathways). Moreover, Randy readily accepted the larger 0.2 gauge (30mm) Seirin needles for all future treatments as well as the deqi always being performed to attract fibroblasts for added therapeutic effect (i.e., increased neuromodulation).10,13
All AP visits began with multimodal, central nervous system and automatic nervous system neuromodulation points, GV14, Bai Hui, GV20, Yin Tang. These points always allowed for patient relaxation by neuromodulating the autonomic state to that of a more parasympathetic tone, via reflex arcs through the spinal cord projecting to the brain, specifically the rostral ventrolateral medulla, with subsequent vagal nerve neuromodulation output.1,12 This increased parasympathetic tone and/or decreased sympathetic tone, besides alleviating mental stress, also has an anti-inflammatory effect on the body.1,12,13 Both GV20 and Yin Tang utilized somatic afferent stimulation via the trigeminal nerve in order to produce the trigeminal vagal reflex neuromodulation. Additionally, because both GV14 and Bai Hui are located in the brachial plexus and lumbosacral plexus respectively, both of which are large intumescences, central sensitization neuromodulation of each relative segmental spinal level, as well as peripheral sensitization neuromodulation with their respective peripheral nerves of thoracic and pelvic limbs respectively, likely also occurred.
The next two points, bilateral BL10, was not only used for neuromodulation of the autonomic system (via cranial cervical spinal nerves’ somatic afferent stimulation reflex arc onto the Vagus nerve to project to the nucleus tractus solitarus within the medulla oblongata of the brainstem) but both peripheral and centrally via two different mechanisms of neuromodulation (peripherally via proximal spinal accessory (CNX1) nerve to the trapezius mm and centrally via cranial cervical spinal nerves to the paraspinal cranial cervical muscles). Additionally, bilateral GB21 was also used as a distal peripheral point for CNX1- trapezius mm neuromodulation for compensatory dysfunction.
The following ‘inner bladder line’ points were utilized bilaterally for positive peripheral effects ( on form and function) on the various epaxial muscles (e.g., longissimus and iliocostalis mm) and thoracolumbar fascia via their relative cervicothoracic (BL11,12), cranial thoracic (BL13,15), mid-thoracic (BL17,18,19) caudal thoracic (BL20), thoracolumbar (BL21,22,23) (BL23 also has autonomic regulation and possible renal neuromodulation), and mid-lumbar (BL25) spinal nerves as well these ‘inner bladder points’ acting on central sensitization neuromodulation of the spinal cord at each relative spinal segmental level at the dorsal horn via somatic afferent AP stimulation. Also, because ‘outer bladder line’ points (bilateral BL52,54) have similar adjacent neuroanatomy, they were added for additional, similar neuromodulation efficacy.
Distal points with peripheral neuromodulation of flexors/extensor myofascia located on either thoracic (via radial, musculocutaneous, median and/or ulnar nn) and/or pelvic limbs (via cranial gluteal, femoral and/or sciatic nn (and its branches, fibular and tibial nn), were used with priority to ease of access while sitting and/or patient tolerance (hip triad points BL54, GB29,30), as well as those points with dual functions (i.e., points also having autonomic neuromodulation were preferably chosen). These ‘two for one’ points in the thoracic limb were the following: LI4, LI11, LU7, HT7 and PC6, and for the pelvic limb were the following: ST36, BL60, KI3, SP6 and LR 3.11,12,13
Certain subjective qualitative feedback from the owner throughout the case was limited due to a language barrier, which precluded accurate pain scoring via the Modified Visual Analog Pain Scale. However, there were obvious improvements noted after only several weeks of the treatment, of which highly satisfied the owner (e.g., getting in/out of the car and/or getting up/ down the stairs without any human help whatsoever). A recommendation was made to help Randy in and out of the SUV regardless to prevent future flareups from microtrauma. Randy preferred seated position facilitated more needles being inserted bilaterally, then that of lateral recumbency, that could have allowed for more efficacy since not relying solely on cross talk between reflex arcs of contralateral sides.
OUTCOMES, DISCUSSION: Although quantitative feedback was unfortunately absent in this case due to resource limitations (e.g., lack of objective serial weights due to lack of scale), the before VIDEO 1 (time zero, before any AP) and after VIDEO 2 (at 4 weeks, immediately after 5th AP treatment) treatment videos easily show marked improvement in neuromuscular form (much less mm. atrophy) and function (e.g., ~90% resolved pelvic limb ataxia and plantar walking) and the various pain states (e.g., resolved exercise intolerance, hypo-metric gait, rising with much less difficulty, and a moderate decrease in ‘head bobbing’ forelimb lameness). Furthermore, serial exams would also no longer demonstrate allodynia, and all previous compensatory myofascial changes had returned to a more relaxed musculoskeletal tissue state. When providing effective palliative care, it’s always important to recall that all of these physiological states (form, function and pain) are all interdependent.
AP uses somatic afferent stimulation which allows peripheral, central and autonomic neuromodulation of both form and function as well as analgesia.1,13 Remote peripheral limb needle placement/treatment follows their respective neurovascular myofascial tracts (“channels”) and modulates the form/function relative to its neuroanatomical location. Muscular conscious proprioception is pathologically decreased in disuse atrophy at the myotendinous junction, where the Golgi tendons are decreased in number due to the myofascial dysfunction, which worsens the progressive cycle of various musculoskeletal and neurologic diseases and pain states. If available, swimming, underwater treadmill and/or other forms of physical therapy/rehabilitation would have also proved helpful in this case to further restore both form and function of musculoskeletal and neurological tissues.
The positive response to gabapentin (e.g., patient started using the stairs again on his own and had yet to have AP) confirmed the presence of maladaptive pain with likely both peripheral (e.g., upregulation of inflammatory receptors) and central (e.g., wind up of NMDA pain receptors at the dorsal horn of the spinal cord) sensitization pathways. Outside of pharmacology, AP has been the only proven physical modality to reverse chronic wind up (neuropathic) pain.3,6,7,8,13 Given the patient’s two problems of both neurological and musculoskeletal chronic nonreversible progressive diseases, it was recommended that Randy stay on gabapentin indefinitely (with likelihood of increasing the dose and/or frequency over time) and that a maintenance regimen AP treatment plan be continued for life at once to twice monthly intervals, while increasing back to once weekly AP treatments at the first sign of any relapse in response (and/or adding EA at any time).
Although the author has limited experience with myofascial palpation, the before and after changes were easily palpable due to the marked reversal of muscle atrophy and relaxation of compensatory muscles via generalized myofascial neuromodulation, with dry needling AP as the only physical form of treatment. On the other hand, this initial severe muscle atrophy may have precluded the author from palpating any of the myofascial trigger points that were likely present and/or because of being inexperienced in the necessary gentle touch palpation. Ultimately the amount of anabolic (regenerative, therefore increasing form and function) effect on muscle tissue (even the temporalis mm at that) was very impressive.
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