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Written by a Medial Acupuncture for Veterinarians course graduate.  Author’s name available upon request.  Signed release obtained from client/author/4972.

Abstract:

Brief description of the case:  A 2 year old mixed breed ewe presented for a left lateral recumbency of 96 hours duration. She had been found cast outside (mean temperature 12 F on that day). The ewe was approximately 115 days pregnant on presentation. She had been initially treated by her owner with parenteral flunixin meglumine, procaine penicillin G and oral electrolyte drenches. Upon presentation infectious and metabolic etiologies were eliminated as differentials and diagnosis was a traumatic event and soft tissue damage to the left coxofemoral region. Acupuncture, electrical stimulation, restricted exercise, physical therapy and non-steroidal drug administration were utilized as therapies over an 11 day period prior to discharge. Acupuncture points focused on Bai Hui, GB 29, GB 30, BL 31, BL 36, BL 37, BL 38, and ST 32 and were utilized q 48 hours. Electrical stimulation was utilized q 48 hours. Hobbles were applied to limit excessive movement of the left pelvic limb. The ewe was hand walked in a deeply bedded sand arena as a form of physical therapy.

Brief summary of the results:  While initially laterally recumbent on the left side the ewe improved dramatically after the first two treatments. Once ambulatory she progressed rapidly to a higher physical therapy work load. While the use of acupuncture in pregnant patients is controversial, care was taken to avoid any of the “forbidden points”, and ultrasound at reception and prior to discharge identified two fetuses with normal heart rates and appearance. Five days after discharge the owner reports that the ewe is continuing to ambulate well, and the use of the rear limb is almost at a normal function.

History/presentation:

A two year old mixed breed ewe, presented to ISU Food Animal Medicine left laterally recumbent yet responsive. The owner notices her laterally recumbent 4 days prior to presentation. She had been unresponsive to penicillin q 12 hour, flunixin q 12 hour, and electrolyte drenches q 8 hour. The ewe was from a flock of approximately 120 ewes that the producer uses to produce 4H and club lambs for show. She was current on a clostridium perfringens types C and D and tetanus toxoid, and is routinely dewormed with ivermectin. The ewe has had no previous medical issues, and the flock’s history is fairly unremarkable with the exception of a storm of chlamydial abortions 2 years prior.

Physical Examination and Clinical Assessments:

On initial presentation to the ISU FACH the ewe was non-ambulatory, but responsive to stimuli. Vital parameters were a temperature of 101.2 F; pulse of 120 beats per minute; and a respiratory rate of 50 breaths per minute. Her rumen was slightly hypomotile with 1 moderately strong rumen contraction per minute. Mucous membranes were slightly pink and moist, and the ewe’s lungs auscultated normal bronchovesicular sounds. On neurological examination the ewe had delayed menace response and direct PLR OS but had normal reflexes OD. Muscle atrophy was appreciated over the left hip, and weakness was noted on later abduction and adduction of the pelvic limbs. Additionally an abdominal ultrasound was performed and two viable fetuses were noted.

Medical Decision Making:

Initial differentials included an infectious etiology (such as listeriosis), trauma, and metabolic issues (such as hypocalcemia, pregnancy toxemia, hypoglycemia, polioencephalomalacia). Point of care bloodwork yielded normal ionized calcium, serum electrolytes, glucose and ketone levels. The next diagnostic step was a CSF tap. CSF cytology and analysis yielded: 86% macrophages, 10% neutrophils, 4% lymphocytes. The macrophages appeared activated and occasionally contain phagocytized erythrocytes or blue-green pigment consistent with melanin and/or hemosiderin. Etiologic agents are not observed. CSF protein was slightly elevated (57.7, normal: 29-42). Based on the presence of hemosiderin and lack of an infectious changes to the CSF trauma to the coxofemoral region was diagnosed.

Meloxicam was administered PO q 24 at a 1 mg/kg dose as an anti-inflammatory. Additionally procaine penicillin G was administered IM q 12 at 22000 units/kg. Thiamine was also administered SC q 8-12 at a dose of 10 mg/kg. PPG and thiamine were gradually discontinued over the next 2-3 days. Initially hobbles were utilized to prevent excessive abduction of the pelvic limbs. The ewe was also confined to a small stall with assisted standings q 2-4 hours.

Acupuncture Treatment:

Myofascial examination yielded responses at BL-31, GB-29, GB-30, ST-31, ST-32, BL-54, BL-37, and BL-38. BaiHui was also treated with the other points on the first day with “J type” number 3 Seirin needles. On day 2 palpation of ST-32 and ST 31 were markedly less reactive. For the second treatment BL-31 was avoided due to proximity to BL-32 and the ewe’s pregnancy status. On the second treatment electro acupuncture was also utilized. Acupuncture was utilized in the manner of the second treatment every 48 hours until discharge for a total of 5 treatments. At the time of the last treatment reaction could only be elicited from BL-36 and BL-34.

Adjunct therapies utilized included hobbles (to prevent INSERT SMART WORD HERE), Meloxicam (NSAID), stall confinement, haltered walking, and haltered walking in a deeply-bedded sand arena. The sand walking was used as a physical therapy measure and serpentine patterns, tight turns and figure eights were utilized to strengthen the hip region.

Outcomes, Discussions, and References:

With the ewe being in her third trimester care was taken to avoid the forbidden points of LI4, SP6, GB21, BL32, CV4, SP6, BL60 and BL67. While considered safe in normal pregnancies, there are references both for[1] and against[2] the use of these points in pregnant patients, the clinician elected to avoid these points entirely as to not risk the pregnancy. The meloxicam used in this patient was used in a permissible extra-label fashion, and the pharmacokinetics of this drug favor dosing in this manner for sheep[3]. Side effects are rare, but include abomasal ulcerations. As such this patient was monitored q 48 hours via a fecal occult blood test. The ewe was followed up with 5 and 9 days post hospitalization and was doing well, with a normal appetite, while being confined to a small stall in a barn.

References:

  1. Carr DJ. The safety of obstetric acupuncture: forbidden points revisited. Acupuncture in Medicine. 2015:acupmed-2015-010936.
  2. Betts D, Budd S. Forbidden acupuncture points in pregnancy: historical wisdom? Acupuncture in Medicine. 2011:acupmed3814.
  3. Stock ML, Coetzee JF, KuKanich B, Smith BI. Pharmacokinetics of intravenously and orally administered meloxicam in sheep. American journal of veterinary research. 2013;74(5):779-83.