Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 4D2018021

Abstract: “Hershey” presented to me for evaluation of a right pelvic limb lameness of an unknown origin. Prior work-up, including distal limb nerve blocks and radiographs were unremarkable. Hershey had a total of three acupuncture treatments performed at intervals of 2-3 weeks between treatments. Unfortunately, clinical improvement was not overtly appreciated by the owners. Hershey was noted to be playing in the pasture between the second and third treatments, and he was clinically lamer for several days after this event according to the owners. Even though overt improvements were not noticed by the owners, I felt that Hershey was ambulating more normally, was able to lift and adduct the right pelvic limb more than prior to treatment, and was less reactive on myofascial exam.

History and Presentation: “Hershey” is a 20 year old male castrated Quarter Horse that presented for evaluation for an undiagnosed right pelvic limb lameness that has been present since the current owners purchased him 8 years ago. Hershey was born in Kentucky and was started undersaddle in Western style riding. He was transported to Alaska as a three year old, and was used for jumping. A more detailed prior history is not known by the current owners. At 12 years old, he passed a pre-purchase exam and was sold to the current owners. Shortly after purchase it was noted that he was inconsistently lame in the right pelvic limb with exercise. He was also diagnosed with having a benign rectal mass and a large, healed laceration on his tongue. Radiographs and nerve blocks were performed on the right pelvic limb to the level of the hock joints, and were both apparently unremarkable. Hershey was unresponsive to steroidal hock joint injections in the right hock. A further work-up was not pursued due to financial and location constraints. Hershey also did not have a notable response with chiropractic treatment. Hershey currently gets ridden lightly around once weekly, and gets pasture turn out daily. When not in pasture, he is housed in a walk out stall connected to a smaller paddock. He is on Firocoxib ½ tab 57mg orally once daily chronically, and becomes lamer when he does not receive this dose. Hershey’s lameness seems to respond best to regular light activity with turnout, and his lameness will become worse when he is confined or when he is exercised more heavily. He gets regular corrective shoeing and veterinary maintenance. Hershey is noted to be a high anxiety horse and can be unpredictable under saddle. He is primarily fed imported timothy hay and grass when turned out in pasture, and does receive a multivitamin supplement.

Hershey first treatment video #1

Physical Examination and Clinical Assessments: Hershey was found to be bright, alert and responsive, and had a normal temperature, pulse, and respiration. He was at a body condition score of 6/9. Thoracic auscultation was within normal limits. Hershey was found to be lame at the walk in the right pelvic limb, but appeared to be sore on all 4 limbs at the trot on hard ground. The right stifle joint was found to be thickened and moderately effusive, and was tender with palpation. The right tibiotarsal joint palpated to be mildly effusive for the first 2 treatments, but was moderately effusive on the final treatment after an injury while being in pasture. There was mild-moderate muscle atrophy of the right pelvic limb, most notable in the hamstrings muscle group. Hershey was unable to pick up his right pelvic limb more than an inch on initial evaluation, and had great difficulty with adducting the right pelvic limb. When turning to the left, he crossed his right hind behind the left hind rather than in front, and is unable to cross beyond midline. He is able to cross over normally in the left pelvic limb.

Neurological examination: Neuroopthamalic and cranial nerve exams were within normal limits. Tighter circles to both the right and left directions seemed to neurologically be normal, but turning to the left revealed ambulatory deficits as described above. Hershey seemed to be neurologically normal walking on varied terrain, including up and down a small incline and backing up. Tail pull testing and walking with a raised head did not reveal neurological abnormalities. It was noted that during some walk/ trot transitions that Hershey would scuff his right pelvic limb hoof, and mild wearing on the dorsal aspect of the right pelvic limb hoof was noted. Distal limb sensation palpated to be within normal limits. Righting reflexes could not be properly assessed as the right pelvic limb could not be lifted up more than an inch, but were normal for all other limbs. No proprioceptive deficits were appreciated during malpositioning and during ambulation.

Myofascial and mobilization exams: Generalized myofascial restriction and multiple trigger points found in the cranial to middle cervical spinal regions (right side had more notable trigger points compared with the left). Hershey seemed to have symmetric range of motion in the cervical spine with each direction, and the Gator test was within normal limits (WNL). The thoracic limb exam revealed slightly reduced bilateral dorsal and caudal scapular motion, but otherwise was WNL. The middle to caudal thoracic spine was sensitive to palpation, was more reactive to vertebral flicks in the caudal thoracic spine on the right side, and was noted to have reduced rotational movement bilaterally (I felt that left rotation was lesser than right, even though both were reduced). The pelvic rock test and SI tests were symmetric bilaterally. Gentle lateral tail flexion testing with concurrent spinal manipulation revealed less lateral mobility/was less tolerated in the right lumbar spine when compared with the left side. Pelvic limb flexion testing and toe circles were not attempted due to Hershey’s markedly reduced ability to lift the right hind pelvic limb. The right quadriceps and adductor groups were hypertonic and well developed, and had multiple trigger points noted on the right side. Hamstrings groups were atrophied and hypotonic on the right side. There was mild-moderate generalized right sided hind end muscle atrophy when compared with the left side.

Differential Diagnoses: Right pelvic limb pain: fibrocartilaginous embolism, vascular myelopathy/ ischemia, Borrelia burgdorferi, ehrlichiosis, discospondylitis/ vertebral osteomyelitis, osteoma, osteosarcoma, degenerative joint disease, compressive myelopathy, fibrotic myopathy, spondylosis, intervertebral disc disease, Vitamin D/ fluoride toxicosis, polymyositis, polyarthritis, stress fracture/ subluxations, hyperparathyroidism, exertional myelopathy, degenerative joint disease (DJD), osteochondrosis dessicans lesions, meniscal injury/ disease, collateral ligament (or other pelvic limb ligament) disease, patellar ligament disease, patellar fracture, upward fixation of the patella, enthesiopathy, bursitis/ tendinitis, soft tissue injury/ disease (such as a chronic deep digital flexor tendon issue), caudal heel pain, kissing spine, compressive pain/ discomfort/referred pain from the benign rectal mass.

Definitive (or Putative) Diagnosis (or Diagnoses): Unfortunately, radiographs and/ or advanced imaging were not allowed due to financial constraints. Based on my physical, neurological, orthopedic, and myofascial exams, in addition to the previous history of unremarkable radiographs of the right pelvic distal limb (radiographs were taken from the hock joints to the distal limb), no improvement after nerve blocks above the level of the hock joints, and no improvements with hock steroidal joint injections, my top differentials are: degenerative joint disease of the right stifle, hock joints, or coxofemoral joint, meniscal/ cruciate injury or disease. Orthopedic disease is expected over a neurological issue. I suspect that such debilitating pathologies have occurred gradually over the years with disuse/ misuse of the right pelvic limb. Also behaviorally, Hershey is not expected to lift his right pelvic limb, as he will try to kick the handler in the process of this, likely due to pain partially but also due to the fact that he is never expected to perform this motion. A differential for not lifting his right hind hoof normally could be related to training.

Medical Decision Making: The medical acupuncture and integrative neuromodulation (MAIN) technique was used to arrive at my treatment rationales. My main goals with Hershey were to alleviate pain and muscle tension, improve autonomic dysregulation, and help with emotional and immune support. Therefore, my focus of treatment was not just on the needle to tissue interface, but also with intension on influencing the central, peripheral, and autonomic nervous systems in addition to the myofascia.

Acupuncture Treatments: The same acupuncture point approach was used for each treatment, and sometimes Hershey would tolerate the placement of extra acupuncture needles. Additional points were used will be stated treatment to treatment. A total of 3 treatments were performed, and intervals between treatments were between 14-21 days in length. Needle selection: Seirin J type coated 0.16mm-0.25mm were used depending on the treatment and location (wanted to make earlier treatments or very stimulating points less stressful with smaller gauge needles, but found that it was more difficult to advance 0.16mm needles if there were large muscular bands or trigger points). I used various needle lengths between 15mm-40mm depending on the location, desired depth, and coat length. For example, if BL 60 was being used, generally a shorter needle length was used, where if GB 29 was chosen, a longer needle was used due wanting to deactivate deeper trigger points (ex: deep gluteal muscle) and also concern that the needle may get pulled deeper into the tissue (I wanted to avoid getting the needle inserted near the plastic hub/needle interface, as this is the weakest part of the needle). Unfortunately, only dry needling and manual therapy were used for this study as my clinic does not currently have access to laser or an electrostimulator, which could be assets with future treatments on Hershey (if tolerated). Treatment length varied from 10-15 minutes in length, depending on how Hershey was tolerating the treatment. Manual therapy, such as massage (manual and with a vibrator), skin rolling, stretching, and passive range of motion exercises, were performed following each dry needling session for an additional 10-15 minutes. Hershey in general had high anxiety for his treatments and exams, and did not have great ground manners. He unfortunately had all 3 treatments performed just prior to feeding times for owner convenience, which made it more difficult behaviorally for him to relax. The most success with relaxation was noted if he was pet/ massaged during the treatment and allowed to chew on his lead rope than if he was ignored or fed treats. Hershey was typically excellent for needle placement, but would often become increasingly agitated with boredom or with anticipating his dinner. The treatment length for the 1 and 3rd treatments were shorter than the 2nd treatment because of this. Hershey seemed to be the most reactive to treatment on the final treatment. This is suspected due to a reported re-injury noted by the owners while he was playing in the field. I suspect that he was more painful prior to this treatment, and therefore, was more agitated during the treatment.
Treatment #1: Used GV 14, Bai Hui, and GB 21 bilaterally as initial points hoping to get Hershey to relax. GV 14 was selected due to its effects with relaxation, thoracic limb pain, cervical muscle tension, and immune regulation. Bai Hui was selected for its impact with autonomic dysregulation, pelvic limb dysfunction, and lumbosacral (LS) pain. GB 21 was applied bilaterally to help with neck and shoulder tension and thoracic limb dysfunction, in addition to it being a generally well tolerated point. A few minutes were allowed to pass, and no relaxation effect was visually appreciated. I proceeded with additional points, as he seemed to be tolerating the treatment well otherwise. Hip triad points (GB 29 and 30, BL 54) were applied bilaterally to help with hip and gluteal pain, and sciatic pain and dysfunction. BL 23 was chosen bilaterally for local pain, TL dysfunction, pelvic limb pain, and lumbar pain. BL 40 was selected to help with pelvic limb pain and stifle pain. An unnamed cervical trigger point in the omotransversarius muscle group on the right side was selected to help treat local pain. The treatment was discontinued at the 10 minute mark due to Hershey becoming agitated. The vibrator was used primarily on the gluteal and paralumbar spinal regions as tolerated and manual massage was performed mostly on the hamstrings/ adductor groups.
Treatment #2: Treatment approach was similar to treatment #1, except Hershey allowed several additional points to be performed today. BL 10 was chosen bilaterally for its impact on the central nervous system, and for cervical and thoracic limb pain. ST 36 was chosen bilaterally to help counter sympathetic overactivation with acute and chronic pain, help with immune and inflammatory problems, and pelvic limb pain. SP 9 was chosen on the right side only to help with stifle pain primarily (since he has limited mobility in this limb, I felt it was a safe choice), but also may help alleviate genital/ rectal pain (I was concerned with possible anorectal discomfort from his benign mass). BL 36 was chosen on the right side only due to local discomfort on palpation, and to help treat hamstrings muscle tension/ restrictions and sciatic neuralgia. BL 60 was chosen last on the right side only to help alleviate lower back and chronic neck pain (this needle was only in place for 1-2 minutes prior to falling out). Hershey tolerated a treatment length close to 15 minutes this session.
Treatment #3: Treatment approach was more similar to treatment one, involving all of treatment one’s points except the unnamed right cervical trigger point (could not palpate this today). Hershey was seen by the owners to be playing out in the field approximately 5 days prior to this treatment, where he turned very suddenly and became more lame on the right pelvic limb. More effusion was noted by the owners in the right hock joints, particularly the tibiotarsal joint. Hershey was more sensitive today with the distal limb points and became agitated more quickly.

Hershey final treatment video #4

Outcomes, Discussions, and References: I feel that Hershey did respond well to his acupuncture therapy, even if the owners did not appreciate much improvement. Ambulation and postural changes throughout treatment are noted both in the images and videos provided. Hershey is much better able to ambulate with the right hind limb, particularly with lateral movements and flexion. With the final treatment, Hershey was able to flex the right hoof off the ground by about 6 inches; which is a marked improvement from the previous 1 inch. He was also physically able to laterally cross the right hind in front of the left hind, which previously he was not able to perform. Ambulation seems to be more free and fluid, even though an obvious lameness in the right pelvic limb is still apparent at the walk. Myofascial pathology palpated to have improved throughout the course of treatment. Hershey’s demeanor for handling and treatments did not seem to change much during treatments. Acupuncture was the only extra modality that was added into Hershey’s regime above his normal management, and mobility improvements were appreciated throughout his treatment course. I am convinced that acupuncture was the primary influential factor to improve Hershey’s comfort and mobility. I have learned a great deal from this case. Hershey was overall tolerant of needle placement, but was overall a high energy horse that was very excitable. I needed to adjust my acupuncture approach each time depending on his mental status, myofascial exam, and concurrent issues (worsening lameness in the right pelvic limb).
References:

1. Robinson, N. G. DO, DVM, MS, FAAMA. (2016). Integrative Medical Acupuncture Anatomy. Jackson, WY: Teton NewMedia.

2. Robinson, N. G. DO, DVM, MS, FAAMA. (2015). Medical Acupuncture for Veterinarians: Equine Point Mini-Manual. OneHealth SIM Inc.


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