Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017010

Abstract: Buddy, a 4 year-old castrated male mixed breed canine, presented for acupuncture after bilateral TPLO surgeries (the most recent performed approximately 1 month prior to presentation). Additional history includes dermatologic issues that seem to be controlled with diet and possible hip restriction or pain. After Buddy’s gait evaluation, physical exam, and myofascial palpation, my main goal was improving healing for the most recently operated stifle by increasing blood flow and healing factors and relieving tension in compensatory limbs such as the right stifle and the front limbs. I also wanted to focus on treating the hips too as this could also be contributing to the perceived lameness. Overall, Buddy responded well to the acupuncture treatments. The owner reported less shaking in the hind limbs, better passive range of motion in the compensatory limb, and better treadmill sessions at home.

Signalment: 4-year-old castrated male mixed breed canine

History and Presentation:
In February 2016, Buddy presented for mild effusion palpated within the right stifle joint. Mild to moderate muscle atrophy, positive cranial drawer and positive tibial trust were noted. Radiographic findings included mild right stifle osteoarthritis. Buddy was taken to surgery for a right tibial plateau leveling osteotomy (TPLO) on 2/17/17. Upon evaluation of the right stifle joint it was determined that Buddy had a complete tear of his cranial cruciate ligament. Remnants of the torn ligament were removed. The medial meniscus appeared normal and was left intact. There were no complications during the surgery and Buddy recovered from anesthesia uneventfully.

Incisional infection was noted in February 2017 due to licking and antibiotics were changed. At the 8 week recheck, rehabilitation exercises included range of motion, sit-to-stand exercises, cavaletti rails and obstacle course. At the 11 week recheck, rehabilitation exercises included the previous exercises, dancing and mat walking.

Buddy also has a history of allergies and Staphylococcus pyoderma infections. In an appointment in July 2017, there were noted multiple 1-3 mm epidermal collarettes along the dorsum, a 5 mm epidermal collarette along the right cranial stifle, erythema on the plantar surface of the left hind digit 2, right tarsus, and right carpus, and seborrhea sicca along the dorsum. Buddy was given a subcutaneous injection of Cytopoint (an antibody that targets cytokines responsible for itching related to atopic dermatitis for 4-8 weeks). He was also put on Welactin and Cephalexin. Oatmeal baths were recommended for his seborrhea and Buddy’s diet was switched to Hill’s z/d. Since then, improvement has been noted with his skin issues. However, the z/d diet has made him constipated at times.

In November 2017, Buddy was evaluated. There was some resistance to abduction and extension of both hips, with the left slightly more affected than the right. On observation of Buddy’s gait at a walk, shorter strides were noted on the left pelvic limb, which could be indicative of left pelvic hip arthritis. There was no evidence of effusion at the left stifle. There was evidence of subjective muscle atrophy on the left rear limb. Acupuncture was performed for any hip discomfort and potential cranial cruciate ligament disease in the left rear limb.

Buddy became lame around late November 2017 while running freely on the farm. After another week, the owner heard Buddy cry out in pain. After this, Buddy seemed painful and was non-weight bearing on the left hindlimb. On orthopedic exam, cranial drawer was present in all degrees of flexion and extension on the left side. Tibial thrust was also present on the left side. At this time, the right hind limb was noted to be stable. Radiographs showed evidence of left cranial cruciate ligament injury with secondary osteoarthritis. A left tibial plateau leveling osteotomy (TPLO) was performed on 12/20/17. The cranial cruciate ligament was noted to be fully torn but the menisci were intact.

Home care instructions for both TPLO procedures included:
” Strict cage rest for the next 8 weeks. Buddy could be walked outside on a leash and sling for up to 5 to 10 minutes 3-4 times per day for the first 4 weeks. After that 4 weeks, leash walks of increasing length of 5 minutes for the following 6 weeks were permitted.
” Passive range of motion was recommended to be performed 3-4 times a day.
” Cold compresses were recommended for the first two days after surgery. Warm packs were recommended after the first two days.

Physical Exam and Clinical Assessments:
1/21/18
” Gait Evaluation: mild weight-bearing left hindlimb lameness. Walks with shortened stride and swaying hips which could indicate some hip discomfort. Seemed to walk with hips more underneath his pelvis and some internal rotation was noted.
” Mentation: BAR, very excited
” No abnormalities noted on physical exam
” Conformation: forelimb carpal valgus
” Myofascial palpation: some tension noted in forelimbs specifically. No other areas of tenderness palpated

1/28/18
” Gait Evaluation: mild weight-bearing lameness on left hind. Some inward rotation of the hips still noted.
” Myofascial palpation: some tension noted in shoulders, hips and lower lumbar region

2/5/18: same as 1/28

Medical Decision Making:
” Central points: BL25, BL27 and other epaxial points that innervate nerves of the stifle joint.
” Peripheral points: stifle-specific points such as ST36, ST34, SP10, SP9, BL60; hip-specific points such as GB29, GB30, BL50
” Autonomic points: GV20, GV14, ST36, Bai Hui
” Myofascial points: compensatory points on right stifle and forelimbs

Problem List:
” Mild left hind lameness and other gait abnormalities (internal rotation of hindlimb and somewhat stilted gait) that may indicate coxofemoral pathology
” Previous history of dermatologic issues – seem resolved at this time

Definitive Diagnosis:
” Healing bilateral TPLO – left (~1 month) and right (~11 months)
” Radiographs of coxofemoral joint would be helpful in determining presence of osteoarthritis but suspect some amount arthritis based on gait, previous exam findings and some stiffness during passive range of motion

Acupuncture Treatments:
” 1/21/18: My goal this session was to focus more on patient comfort as this was the first treatment I had done with him. Hence, I focused more on compensatory strain on the right hindlimb and forelimbs (specifically in the shoulder area).
o Relaxation Points: GV20, GV14, Bai Hui
o Shoulder Points: SI11 and SI12 – bilateral due to compensatory tension
o ST34, SP10, SP9 – right stifle (Note: ST36 was too tender for needle insertion)
o BL60
o Hip triad- GB29, GB30, BL50
o Bladder line points on epaxial muscles associated with nerves innervating the left and right hindlimbs
” 1/28/18: My goal this session was to focus more on the left stifle (the most recent TPLO) in addition to compensatory strain as done previously
o Relaxation Points: GV20, GV14, Bai Hui
o Shoulder tension points around SI11
o ST34, ST36, SP10, SP9 – left stifle
o ST36, SP9 – right stifle
o BL60- bilateral
o Hip triad – GB29, GB30, BL50
o Bladder line points on epaxial muscles associated with nerves innervating the left and right hindlimbs
” 2/5/18: similar treatment as 1/28
o ST 36 seemed tender on both stifles
o Buddy seemed more hesitant on right leg (first TPLO performed)

Needles, Electroacupuncture, Laser:
” 1/21- 0.16 mm needles used; were not very sturdy when being inserted so may try another needle at next treatment
o Would also consider laser therapy for increased blood flow and healing to surgery site
o Electroacupuncture or TENS would be helpful to cross the stifle joint especially on the most recent TPLO site
” 1/29- 0.20 mm needles used; seemed to stay in much better and patient did not seem phased. I have mostly been using 30mm needles. Would consider 15mm for some of the stifle points where needle does not seem to have as much grab
o Would also consider laser therapy and electroacupuncture as mentioned before

Outcomes:
” Post-treatment 1/21- Owner reports that Buddy seemed relaxed and sleepy afterwards. Owner has been doing treadmills session and gradually increasing in time. Did well on the treadmill afterwards. Owner thinks he may have done better with his stretches on the left hindlimb that I focused more of the treatments on.
” Post-treatment 1/28, 2/5- Tolerated remaining treatments well. Owner reported relaxation after treatment and maybe increased flexibility but seems comfortable overall

Other Comments and References:
” After researching through the CuraCore Curriculum, some of the points that I used may also have some benefit for dermatologic issues.
” I would recommend to determining the underlying cause of the allergies first whether atopic or food-related and potentially supplement indicated therapy with some acupuncture.
” Points recommended include: LI11, HT3, ST34 and SP10 (these last two points were used in Buddy’s treatment)

References: Below are just a few articles that support various modalities for Buddy’s main orthopedic issues (stifle OA/CCL repair and potential hip OA)

Assis, L., et al (2016). “Aerobic exercise training and low-level laser therapy modulate
inflammatory response and degenerative process in an experimental model or knee
osteoarthritis in rats.” Osteoarthritis and Cartilage, 24(1), 169-177.
Rakel, B.A., et al (2014). “Transcutaneous electrical nerve stimulation for the control of pain
during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled
trial.” Pain 155(12), 2599-2611.
Teixeira, Lívia R., et al. “Owner assessment of chronic pain intensity and results of gait analysis
of dogs with hip dysplasia treated with acupuncture.” Journal of the American Veterinary
Medical Association, vol. 249, no. 9, 2016, pp. 1031-1039.
Zeng, Jie, et al. “Electroacupuncture relieves neuropathic pain via upregulation of glutamate
transporters in the spinal cord of rats.” Neuroscience Letters, vol. 620, 2016, pp. 38-42.


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