Written by a Medical Acupuncture for Veterinarians course graduate. Signed release obtained from client/author. 10S2017009
Abstract: “Giovanna” is a 10.5 year old cat who has been diagnosed with progressive chronic renal insufficiency, constipation, lumbosacral spondylosis, eosinophilic keratitis in both eyes, and has had surgery on her right cranial cruciate ligament due to injury.She has received all conventional western medical treatments for her ailments. She was treated with acupuncture to help with pain in her lumbosacral area that was not well controlled on medications, as well as to help her chronic constipation and hoping to slow deterioration of her kidneys if able. She underwent a series of acupuncture treatments and has become a much more mobile and happy cat. She is able to move up and down stairs easily and engages with her family now. Her renal values did not decrease but rather steadily increased despite treatments, but clinically she is doing extremely well.
History and Presentation: Giovanna is a female spayed calico domestic short haired cat. She has been diagnosed with chronic kidney disease(CKD), chronic constipation, lumbosacral spondylosis, bilateral recurrent eosinophilic keratitis, and has suffered a tear to her right cranial cruciate ligament which was repaired in 2013. She had an initial episode of constipation in 2012 and this has become more frequent in the last 2 years. Her keratitis is currently not problematic, and occurs with times of stress in the past, and responds to medications rapidly. After her CCL surgery in 2013, she initially did well and did not require any medications except glucosamine. In 2014 she began to have pain in her rear right limb, so after bloodwork was performed and was normal, was started on meloxicam low dose and Adequan. Her bloodwork remained stable and she did well with this adjustment. In June of 2016 her creatinine began to slowly climb and meloxicam was discontinued. She was then placed on gabapentin, renal food, and eventually benazepril as her values continued to slowly increase. Her owner administered subcutaneous fluids once per week as well. In January of 2017 her constipation worsened and she was placed on regular lactulose. In late fall of 2017 her creatinine began to climb more rapidly and she was not feeling as well overall. She was not very mobile, sat at her food dish all day. Her fluids were increased to twice weekly. She started acupuncture in November 2017.
Physical Exam and Clinical Assessments: Giovanna was re-examined just before starting her acupuncture treatments. She had a normal heart rate, respiratory rate, temperature, with body condition score of 4/5, and was painful in her lumbosacral spine from L2-S1 region, most notably over her lumbosacral spinal musculature. No pain was notable in her neck or forelimbs and no trigger points were found there. She had mild kyphosis in the area of T11-L5 as well. She had small trigger points in her right and left lateral quadriceps muscles. She ambulates well with no notable lameness. Abdomen was soft, chest ausculted normally. Blood pressure was not performed at this exam as done prior. Radiographs were performed showing significant spondylosis of lumbosacral area. Bloodwork was repeated and creatinine, BUN, SDMA, and amylase were more elevated. Her Hct, RBC, and potassium were decreased compared to past values. She had mild reluctance to fully extend her right hind limb as well, but no noted crepitus or visible lameness. Her complete neurologic exam was normal.
Medical Decision Making: Giovanna was currently on conventional western medical therapy for her various ailments, but our hope was to improve her pain management and provide more mobility, improve her constipation, and possibly slow the progression of her renal disease with acupuncture and physical medicine. We did not change any of her current therapies. Points chosen involved those to decrease stress/ anxiety, regulate parasympathetic responses to decrease inflammation, improve blood flow to her kidneys and improved constipation through viscerosomatic influences, as well as improve pain in spine and associated musculature and myofascia through local and distal channel points. I also planned to perform massage in conjunction, and laser if she did not tolerate points well.
Renal disease: We had a series of bloodwork results each year supportive of progressive renal disease (CRI) and had ruled out neoplasia due to time frame. We could not rule out toxic causes such as meloxicam or other unknown toxin. Other possibilities would be autoimmune, pyelonephritis, congenital and traumatic causes. Congenital was unlikely due to age of onset and traumatic was unlikely as cat spent life indoor and had no known trauma there. Pyelonephritis was ruled out with a normal urinalysis. We did not perform tests to rule out autoimmune and owner did not elect ultrasound exam during treatment course.
Constipation: Possible causes included mild dehydration due to progressive renal disease, pain due to lumbosacral spondylosis, loss or neurologic function to colon, viscerosomatic response to pain in lumbosacral area. We combated dehydration with subcutaneous fluids, added lactulose to diet to soften stools, and treated pain which improved her constipation and helped support a possible multifactorial cause. She had no neurologic deficits in her anus, tail, rear limbs making neurologic loss less likely.
Lumbosacral /Spinal pain: Causes could include intervertebral disc disease(IVDD), fibrocartilaginous emboli (FCE), fracture or trauma, referred pain from previous cruciate injury, myofascial restriction, and arthritis. Radiographs ruled out a fracture and confirmed lumbosacral spondylosis. Her physical exam confirmed associated myofascial pain in the associated areas. She did not receive MRI to rule out FCE or IVDD per owner decision.
Definitive (Putative) Diagnosis: Chronic renal insufficiency was highly suspected per progression of her disease and test results. She had progressed into Stage 2 disease in a very short time so wanted to target this area in hopes of slowing her disease as able. Constipation was assumed due to both lumbosacral pain and mild dehydration due to lab and radiograph results. Lumbosacral spondylosis was confirmed on radiographs. Myofacial pain/tightness/restriction was noted on physical exam likely due to above radiographic changes and previous surgery causing gait adjustment and compensatory strain.
Acupuncture Treatments: Giovanna received eight acupuncture treatments at twice weekly intervals. We decreased to weekly sessions which is ongoing. She missed three weeks of treatments during the holidays due to family illness. Her first four treatments were followed by laser over lumbosacral spine. Our laser machine is a Companion brand with 960/810 nm and the preset setting brought up 5 minutes at 5 watts power. We decreased the power to 3 watts over 3-5 minutes over her entire spine because she became agitated each time with the higher wattage and did much better at 3 watt setting. We found over time that she did better without the laser altogether, so it was discontinued.
Points chosen: GV20 was chosen for calming effect/vagal interactions and parasympathetic regulation to improve blood flow and decrease inflammation. GV14 was chosen for above reasons as well as some local effects and distal effects from cervicothoracic nerves as Giovanna would not allow forelimb points to be needled. GV4,GB25,BL23, BL 52, KI were chosen for their viscerosomatic reflex effects on the kidneys, local effects on the lumbar spine and distal effects on rear limbs(KI).Bai Hui was chosen for its local effects on lumbosacral spine and sciatic area. BL 27 and BL28 were chosen for their viscerosomatic reflex effects for constipation, spinal pain, and rear limb pain. Occasionally she would allow BL 25 for viscerosomatic and local effects, as well as ST36 for appetite regulation, any associated nausea, and parasympathetic regulation as well as local effects on stifles. She would not allow other distal limb points or trigger point needling so used medical massage there as well as on forelimbs and to assist with constipation based on the textbook Canine Clinical Medical Massage, by N. Robinson and S. Sheets.
Needles used were No. 1(0.16)Seirin red 15mm. She would not allow much manipulation/stimulation of needles once in place so EA was not considered for her. The laser did not seem helpful for her, although I have seen great results in other patients.
Outcomes, Discussions, and References:
Giovanna responded well to each acupuncture session. Her owner noted a nearly immediate improvement in mobility, being able to run up the stairs and play with toys, which she had not done in many months. Four weeks into treatment she chose to stand on her rear limbs to play with a toy without any coaxing. She no longer sat at her food dish all day and became much more interactive with family. As sessions progressed, her spinal sensitivity decreased significantly. She did not have any episodes of constipation or keratitis. Unfortunately her renal values did not decrease over the study period although her bloodwork was performed after a 3 week lapse in acupuncture treatments due to owner illness. Her blood pressure was rechecked and she had become hypertensive at this time and was started on medication. I could not find any referenced cases that acupuncture treatment had worsened renal values either in the animal or human literature. After questioning the owner re any changes in her environment, it was found that the owner did start diffusing Doterra essential oils in her home at the same time we started acupuncture, which can be potentially toxic if ingested. I am otherwise assuming that the renal climb was due to the development of hypertension and normal progression of CKD. Giovanna accepted her treatments well and her owners are very happy with her progress. There seems to be very little research in the feline world associated with renal disease, and this seems to be a wonderful area of further research, especially considering that renal disease in the most common feline disease in aging cats.
The effects of acupuncture and medical massage are well documented for constipation. An article by T. Zhang et al , “Efficacy of acupuncture for chronic constipation: a systematic review” from 2013 and another by A.G. Klauser et al, “Body acupuncture: effect on colonic function in chronic constipation” from 1993, as well as numerous others demonstrate very good results in managing constipation with acupuncture in humans.
Articles to discuss renal effects are harder to find. One by J.S. Yu “Acupuncture on renal function in patients with chronic kidney disease: a single-blinded, randomized, preliminary controlled study” from 2017 did demonstrate a reduction in creatinine levels in a large number of participants and there are other studies discussing the effects of controlling nausea and other clinical signs associated with progressive renal disease.
There are numerous studies that support pain control in the spine with acupuncture, most of which deal with spinal trauma. One such article by N. Robinson “Why the standards of care for spinal cord injuries are changing” from 2016 discusses how acupuncture reduces inflammation and improves blood supply thereby helping to reduce pain. Although Giovanna did not have spinal cord trauma, she is still suffering from effects of pain in that area.