Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10D2017045

Abstract:
“Chewy” is a therapy horse who has been treated for the past 3 years by Oregon State University’s Mobile Equine Service for Recurrent Airway Obstruction. Treatment has consisted of environmental management, acupuncture, and herbal supplements; however steroids were added to the treatment plan when these therapies were insufficient. Chewy’s respiratory signs are currently well controlled, and he receives weekly acupuncture treatments for maintenance. I was involved with three of Chewy’s acupuncture treatments while I was on the Mobile Equine Service rotation.

History and Presentation:
Chewy is a 10-year-old Saddlebred gelding who is seen weekly by the Oregon State University Mobile Equine Service for acupuncture treatments of Recurrent Airway Obstruction (RAO). He was diagnosed with RAO 3 years ago. The diagnosis was based on history and clinical signs, and the owner declined confirmation with bronchoalveolar lavage. Chewy has been managed since then with acupuncture and herbal supplements (Breathe Easy and Lilly combination) as well as environmental control including increased time outside and soaking of hay. These treatments were initially successful to eliminate clinical symptoms and Chewy has continued to be used for light riding. In early 2017, Chewy developed pneumonia characterized by wet lung sounds and severe lymphopenia. The pneumonia was successfully treated with a course of Trimethoprim Sulfamethoxazole. Shortly thereafter, he began to exhibit coughing, increased respiratory effort, and wheezing sounds on pulmonary auscultation, and was suspected to be have developed a relapse of RAO symptoms. These symptoms became severe enough to necessitate treatment with Dexamethasone. He remained on Dexamethasone until his symptoms resolved in mid-January 2018. He is currently tolerating light work without excessive respiratory effort or exercise intolerance.
Recently, Chewy has also exhibited front foot sensitivity with the farrier.
I was involved with treatments for Chewy on March 8th, 15th, and 22nd, 2018.

Physical Examination and Clinical Assessments:
Chewy’s physical examination parameters were within normal parameters on the three occasions that I examined him. Lung sounds were clear, and other indicators of RAO such as increased respiratory effort and heave lines in the abdomen were absent.
On the second examination that I was present for, sensitivity of LI 18 and PC 1 was present, indicating front hoof pain according to TMC philosophy. Sensitivity was also appreciated to the right of the caudal sacrum. At the third treatment, there were trigger points on both sides of the neck about 1/3 of the way from the head to the shoulder that were very sensitive to gentle palpation.

Medical Decision Making:
The goals for acupuncture therapy for Chewy are to reduce inflammation in the lungs by promoting appropriate regulation of the immune system, and to reduce myofascial tension and spinal wind up related to increased respiratory effort. Coronary band points were also chosen to promote blood flow to the hoof and modulate hoof pain.

Differential Diagnoses:
History of coughing and exercise intolerance:
Primary lung disease (RAO, pneumonia)
Primary cardiac disease (left sided congestive heart failure)
Upper airway disease
Myofacial, skeletal, or neurologic causes of exercise intolerance

Foot pain:
Sole softening caused by muddy paddock footing and bruising
Navicular disease
Laminitis
Hoof abscess

Definitive and Putative Diagnosis:
History of respiratory signs: RAO was diagnosed based on the character of lung sounds and the resolution of signs with environmental management and standard RAO treatments.
Front hoof pain: Diagnostic work up of hoof pain was declined by the owner and acupuncture points were selected for analgesia of the distal front limbs.

Acupuncture Treatments:
Dry needling was performed with 40 X 0.3 Hwato needles except for the coronary band points which were needled with 15 X 0.2 mm Jing Tang needles.
GB 21 – Permission point
LU 1 – Reduce T1 to T4 spinal wind up and myofascial restriction in the cranial epaxial and intercostal muscles.
BL 13 and BL 42 – Reduce T1 to T4 spinal wind up and myofascial restriction in the cranial epaxial and intercostal muscles.
GV 14 – Immune modulation and autonomic regulation.
KI 27 – Chosen by my attending clinician as a TCM point for respiratory disease. This point may also contribute to reduction of T1 to T4 spinal wind up related to increased respiratory effort.
CV 17 – Chosen by my attending clinician as a TCM point for respiratory disease. This point may alleviate myofascial restriction in the intercostal muscles caused by abdominal breathing related to increased respiratory effort. Even though respiratory effort is not appreciably increased, there may be residual myofascial restriction persisting from his recent flare up of RAO, or there may be mildly increased effort that is not noticeable.
LU 11 and LI 1– These are local points for foot pain, and they stimulate the nervi vasorum of the coronary venous plexus. Stimulation of the coronary plexus is expected to promote blood flow and lymphatic drainage in the distal limb, and to promote autonomic modulation.
LI 11 and ST 36 – These points were added at the third treatment as immune regulatory points, to reduce inflammation in the lungs and protect against infection.
Local points: On the second treatment, a needle was placed in the sensitive region to the right of the caudal sacrum on the second treatment. At the third treatment, a needle was placed in each of the two neck trigger points.

Outcomes, Discussions, and References:
Several autonomic modulating points were used in Chewy’s treatment. Bronchospasm in RAO patients is suspected to be caused by enhanced cholinergic tone caused by inflammatory mediators (Robinson et al., 1995), so acupuncture points that help to restore sympathetic/parasympathetic balance are expected to relieve RAO symptoms. When effective, acupuncture is a preferred alternative to the sympathomimetics typically prescribed to regulate the autonomic nervous system of RAO horses, as it does not have undesirable side effects that beta agonists have. Points were also chosen to reduce myofascial restriction caused by excessive effort of the abdominal and intercostal muscles and the resulting spinal wind up.

Immune modulating points were chosen to reduce allergic reaction in the lungs, and to promote immunity against infection of the lungs secondary to inflammation and a weakened primary immune defense (mucocilliary elevator and mucosal barrier).

Katsuya et al. used a similar set of points to those used for Chewy to demonstrate that acupuncture therapy can reduce inflammation in the lungs of rats with experimentally induced lesions. Their protocol used ST 36 and SP 6 in addition to several of the points we used for Chewy. I added ST 36 and LI 11 to the treatment plan on the third treatment, when I was given more liberty to make decisions. I would have liked to acupuncture SP 6 as well, however Chewy did not seem amenable to a second hind limb point on that day.

References:
Katsuya, EM, MA de Castro, CR Carneiro, Y Yamamura, VL Silveira. Acupuncture reduces immune mediated pulmonary inflammatory lesions induced in rats. Forsch Komplementmed. 2009. 16(6):413-6.
Robinson, NE, FJ Derksen, MA Olszewski, et al. The pathogenesis of chronic obstructive pulmonary disease of horses. Br Vet J. 1995; 152: 283-306.

Describe Your Medical Acupuncture Experience:
I appreciated the opportunity to work on this case with a veterinarian who is experienced in acupuncture. The attending clinician treats this patient on a weekly basis and has a set of points that he routinely uses, in addition to points selected based on a traditional Chinese medicine examination. I was able to rationalize the points used from an anatomic and physiologic standpoint. If this were my own case, I would have preferred to perform a complete myofascial examination and select a few more immune modulating points. Overall, I appreciated the guidance and the opportunity to research this case, as acupuncture for immunologic dysfunction cases is less intuitive to me than for chronic pain and lameness cases.


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