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Written by a Medical Acupuncture for Veterinarians course graduate.  Author’s name available upon request.  Signed release obtained from Client/Author/4961.

Abstract:

Maggie’s primary issues are lumbosacral (LS) disease and a chronic left supraspinatous and biceps tendinopathy.  Maggie responds well to her acupuncture sessions. However, Maggie’s severe LS crises tend to respond better with acupuncture in conjunction with laser therapy and, if indicated, epidural steroid injections.

History/Presentation:

Maggie, 14 yr. FS German Shepherd. Initial thoracic limb (TL) lameness, LS intervertebral disc disease (IVDD) and possible osteoarthritis (OA) appeared in July 2012. In May 2013, was diagnosed with bilateral carpal hyperextension, received first LS steroid epidural, and underwent physiotherapy (PT). In 2015, she began acupuncture treatments at monthly intervals.  In March 2016, Maggie had a second LS steroid epidural injection.  In May 2016, Maggie underwent a diagnostic musculoskeletal ultrasound for bilateral shoulders, which revealed atrophy and calcification of her L supraspinatous and biceps tendons. An injection of autologous concentrated platelets (ACP) was performed into the L supraspinatous and biceps, followed by another period of PT.  December 2016: Third LS injection and degenerative myelopathy blood test (results: DM carrier). Maggie has an additional history of bilateral pannus that was successfully treated with ocular drops. She lives in a multi-floor apartment with stairs and slippery tile. Maggie has begun falling down the stairs at night and tripping/slipping on the tile with increased regularity.

Physical Examination/Clinical Assessments:

Mild slope to the hind end at a stance and during ambulation. Shuffling gait to the pelvic limbs with mild ataxia.  Slow to rise from laying to standing. Orthopedic exam: Sore for palpation of T8, T9, T13, L6, L7 spinous processes and LS junction. Decreased shoulder extension with mild discomfort for supraspinatous stretch. Decreased range of motion in carpal flexion and decreased motion of accessory carpal bones bilaterally. Decreased flexion of all digits in the thoracic limbs.  Musculoskeletal exam: Myofascial strain pattern from mid-thoracic spine to LS region. Triggers in epaxial muscles, at insertion region of latissimus and along thoracic vertebrae. Significant muscle atrophy of L supraspinatous and infraspinatous muscles. Neuro: Absent CP in R pelvic limb (PL), delayed in L PL. Intact withdrawals bilaterally. Crossed extensor response present in both hind limbs. Thoracic limb neuro exam is WNL. Cranial nerves WNL.

Radiographs: most recent (December 2016) reveal bridging spondylosis at LS, L6-7, L5-6, L2-3, L2-1, T13-L1, T12-13, T9-10, T8-9, T6-7, T5-6. Old radiographs (2012) reveal lesser spondylosis at some of these regions, as well as mild bilateral elbow OA, mild mineralization of R supraspinatous and significant mineralization of L supraspinatous tendons.

Medical Decision Making:

The acupuncture approach was based on providing comfort for Maggie’s back pain and to target her hind limb weakness and neuropraxia. Neuromodulation focused on targeting the hind limb peripheral nerve regions well as the LS region due to the collection of nerves in this region, mainly to increase nerve communication and for the somatic afferent stimulation of the associated spinal structures. Fascial stimulation and trigger point release was desired for her sore and reactive paraspinals.  Additional homeostatic effects were hoped for, to help with inflammation, stimulate autonomic system and interact with receptors for pain control.

Acupuncture Treatments:

Needle size and type was based on Maggie’s previous tolerance of acupuncture, her body size, and exam findings. Non-coated needles were used for better tissue engagement for trigger point deactivation. Desire to use E-stim also influenced needle size and E-stim on a dense-disperse setting was used for a broader signal that the nervous system couldn’t get accustomed to and for the hind limb neuropraxia.

Bladder points: thoracic and lumbar discomfort, myofascial strain pattern and related triggers points and needle placement included the area of discomfort as well as the areas cranial and caudal.  BL 27 and 28: sacral region discomfort. SI12: supraspinatous muscle tension and injury. LU9: carpal discomfort and as a distal point along the forelimb. LI-11: distal limb point, for trigger points, and for its anti-inflammatory effect.  TH14: shoulder discomfort and its association with the suprascapular nerve. GB21: regional muscle tension associated with the supraspinatous tendinopathy. ST 36: distal limb point, for its neuromuscular role in pelvic limb dysfunction, and for anti-inflammatory properties (Maggie wasn’t a huge fan of Bafeng points, so this was our distal limb point at most times). Bai Hui- for its association with the LS region, LS plexus and lumbosacral pain, as well as pelvic limb weakness. GV14: stimulate cervicothoracic nerve for back pain and for TL limb pain related to shoulder injury, as well as its autonomic effects. Bafeng: distal point on affected limbs and for peripheral nerve stimulation. Local trigger points were chosen to release tight fascia and help with nerve communication in hind limbs.

9/29/16: C&G 0.22 x 25mm x 26 needles -GV14, Bai hui, BL 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, ST36, SI12, LU9, LI11, L TH14; Mixed E-stim (4, 100Hz) from BL14 to BL20 bilaterally, and from BL23 to BL27 bilaterally

11/8/16: C&G 0.22 x 25 mm x 23 needles – GV14, b-ST36, Bai hui b-GB21, L SI12, BL15 BL21 BL25, BL27, BL27, BL28, b-LU1, paraspinal trigger points, LI15 (L); Mixed E stim (4, 100 Hz) BL25 to BL28 bilaterally, SI-12 to LU1 on Left

12/1/16:C&G 0.22 x 25 mm x 25 needles – GV14, BL15, BL17, BL20, BL21, BL22, BL25, BL27, BL28, BL19, GB21, L SI12, Bai hui; Mixed E stim 4, 100 Hz at BL15 to BL20 and BL21 to BL27

12/10/16:C&G 0.20 x 25 mm x 28 needles – GV14, b-BL 18, 19, 20, 21, 22, 23, 25, 27, 28, Bai Hui, R Bafeng, triggers points in lumbar paraspinals; Mixed E-stim (4, 100 Hz) from BL 18 to 23 and 25 to 27 bilaterally; Laser 3b, 5J/cm2 LS, thoracic and lumbar paraspinals

Outcomes:

Maggie was more comfortable after acupuncture with less paraspinal reactivity and triggers points. Her comfort lasts for approximately 3-4 weeks. She could rise to stand with more ease and was slipping less at home. Throughout treatments, Maggie discomfort increased due to more falls at home and she eventually needed additional treatments to help with her pain, such as the addition of laser therapy and a third LS injection.  Maggie now responds best to the combination of acupuncture and laser therapy. I have learned that dogs often respond better to multi-modal pain control (supported by Hayashi et al) and that I need to be able to constantly adjust my protocols based on the presentation of the animal that day. Dogs with either lumbosacral stenosis and/or IVDD can be successfully medically managed with acupuncture, as well as multi-modal pain management.

 

References:

Levine, JM, Levine GJ, Johnson SI, Kerwin SC, Hettlich BF, Fosgate GT. Evaluation of the success of medical management for presumptive thoracolumbar intervertebral disk herniation in dogs. Vet Surg. 2007; 36: 482-491.

Janssens, LA. Trigger points in 48 dogs with myofascial pain syndromes. Vet Surg. 1991; 20,4, 274-278.

DeDecker S, Wawrzenski LA, Volk HA. Clinical signs and outcome of dogs treated medically for degenerative lumbosacral stenosis: 98 cases (2004-2012). JAVMA 2014; 245, 4, 408-413. (ONLY REST AND MEDS).

Levine GJ, Levine JM, Walker MA, Pool RR, Fosgate GT. Evaluation of the association between spondylosis deformans and clinical signs of intervertebral disc disease in dogs: 172 cases (1999-2000). JAVMA 2006; 228, 96-100.

Hayashi AM, Matera JM, Pinto ACBDCF. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. JAVMA 2007; 231, 913-918.

Joaquim JGF, Luna SPL, Brondani JT, Torelli SR, Rahal SC, Freitas FDP. Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. JAVMA 2010; 236, 1225-1229.