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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.

Abstract

Acupuncture was used on a 10-year-old Pitbull Terrier with osteoarthritis to decrease myofascial strain and muscle trigger points from compensatory strain patterns and for neuromodulation to decrease chronic pain and normalize ambulation. After three weeks of once weekly acupuncture treatment sessions preceded by a brief massage, the patient exhibited improved comfort and quality of movement based on evaluation using a lameness grading scale, subjectively decreased medial elbow effusion, decreased myofascial restriction, and a marked decrease in hyperirritable skeletal muscle and muscle shortening (trigger points).

History Presentation

Zoey presented for acupuncture treatment for acute on chronic osteoarthritis (OA) pain.  Zoey historically has had corrective surgery for bilateral elbow dysplasia with bilateral ulnectomies and fragmented coronoid processes removed (at three years of age), as well as bilateral TPLO surgeries for Cranial Cruciate Ligament injury (at one and two years of age).

Zoey does not exhibit overt signs of lameness during the summer season while she has access to once-twice daily swimming sessions, with limited concussive exercise.  She consistently scores a grade 1/5 lameness (barely detectable lameness) during swimming season with no other therapies, but resumes a grade 3/5 lameness (moderate lameness observed at a walk and trot with obvious off-weighting of the limb while standing) when her activity is limited to land exercise such as on and off leash walks without any other therapeutic exercises or modalities implemented.  On presentation Zoey had not had been swimming for two-three weeks, and had become increasingly lame in a short amount of time.  Her osteoarthritis medical management consists of Gabapentin (8mg/kg PO BID), daily Phycox HA joint supplements, fish oil (870mg EPA 570mg DHA), and Purina’s Joint Mobility diet.  Tramadol is also used occasionally when greater patient discomfort is appreciated.

Physical Examination and Clinical Assessments

On initial presentation, Zoey was bright alert and responsive, body condition score of 4/9, with physical exam parameters within normal limits aside from the myofascial and musculoskeletal exam.  Myofascial examination revealed trigger points and hypertonic muscles along the dorsal cervical area, long head of the triceps and teres major bilaterally, m. rhomboideus, m. brachiocephalicus and m. serratus ventralis bilaterally, forelimb extensor muscles, and mild reaction to palpation along the paraspinal muscles (tight palpable muscle bands along the thoracic spine).  The superficial pectoral muscles, m. semimembranosus, and m. sartorius were markedly taught bilaterally, and myofascial restriction was appreciated over m. latissimus dorsi and superficial pectoral muscles.  On musculoskeletal examination there was mild lordosis from approximately T-6 through T-11, marked bilateral decrease in elbow range of motion with severe resistance to passive range of motion (PROM), moderate to severe effusion palpated on the medial aspect of the left elbow and mild effusion on the medial aspect of the right elbow, enlarged elbows (left greater than right), normal carpal and digit PROM, mild-moderate medial buttress of both stifles (right greater than left), and decreased stifle PROM bilaterally with no meniscal clicks or pain elicited.  On gait evaluation there was a mild to moderate head bob appreciated (worse at a trot than walk) with a grade 3/5 left forelimb lameness, and at the canter the patient held her head and tail to the right while trying to off-weight the left forelimb.

Medical Decision Making

Acupuncture points chosen for Zoey’s acupuncture treatment targeted local trigger points, myofascial strain patterns, spinal segments, innervation paths to the affected joints (elbows and stifles), and needle placement proximal and distal to the affected joints (1).  This treatment plan considered local tissue benefits of tissue matrix deformation (decrease trigger points, myofascial release, increased blood flow/nutrients/oxygenation, local inflammatory mediator stimulation) as well as more central affects and benefits (neuromodulation affecting neurotransmitters in the brainstem and spinal cord and input to the autonomic nervous system to decrease pain and inflammation).

Acupuncture Treatment

Acupuncture Points (all done bilaterally where applicable): SI-3, BL-10, BL-11, GV-14

Rational: Cervicothoracic pain/trigger points due to compensatory gate/ Local effect/ Cervicothoracic spinal nn. influence

Acupuncture Points (all done bilaterally where applicable): BL-17 to BL-21

Rational: Myofascial strain pattern/trigger points/Local effect/Mid and Caudal thoracic spinal nn. influence

Acupuncture Points (all done bilaterally where applicable): TH-10, GB-21, trigger point in long head of triceps and m. teres major

Rational: Local effects/tissue matrix deformation

Acupuncture Points (all done bilaterally where applicable): LU-5, LI-10, LI-11

Rational: Lateral elbow pain/ Local effect/Radial n. influence

Acupuncture Points (all done bilaterally where applicable): ST-34, ST-35, ST-36, GB-33, GB-34, BL-40

Rational: Stifle pain/Local effect/Femoral n. influence on all but ST-36/BL-40/GB points that have innervation influence from branches of the Sciatic N. that innervates hamstrings)

Acupuncture Points (all done bilaterally where applicable): BL-36

Rational: Hamstring mm. tension

Needles used: Seirin J type (0.18) x 30mm
Acupuncture technique: Dry needling

Patient Position: Sternal
Additional modality: Therapeutic massage prior to needling at each session (petrissage, effleurage, skin rolling)

Frequency: One acupuncture session once weekly for three weeks, next session will be based on patient’s pain/lameness status

Outcome

Owner reported mildly improved ambulation on leash walk approximately two days post first acupuncture session.  The second session revealed less severe muscle tightness and trigger points, with elbow effusion and resistance to elbow flexion relatively the same, subjectively measured as a grade 2/5 lameness (subtle but obvious lameness at walk and trot with mild off-weighting of left forelimb while standing).  The third session revealed mild-moderate trigger points, less hypertonic/reactive muscles and myofascial restriction, subjectively moderate decrease in elbow effusion, and less resistance on elbow flexion.  After the third session, the owner reported markedly improved longer leash walks, most often appearing to be a grade 1/5 lameness (unless pushed too far), with the dog also performing more frequent and deeper plow bows from which she more easily recovered.  Next session will be scheduled when the patient appears to be less comfortable or shows increased lameness.  The goal is to gradually increase the time span between sessions, after more aggressively treating her (treatment frequency and needle number) initially, for a more profound improvement in her comfort and mobility at the start of treatment (2).

Discussion

Due to Zoey’s multifactorial OA/joint disease and many compensatory musculoskeletal and myofascial issues, point selection was attempted to be narrowed down, with the goal being to target spinal nerve segments/peripheral nerves that could be influenced for neuromodulation and large trigger points/myofascial strain patterns as well while trying to choose points that would allow all needles to be placed at once without moving the patient.  The patient had been needled in the past, has been a positive responder to acupuncture historically, and appears to enjoy her acupuncture sessions; some patients may not tolerate the large quantity of points used.  Other points considered but not used: SP-9, SP-10, BL-40 for stifle (due to patient positioning), HT-3 for elbow (patient was sensitive and positioning was difficult).  The massage prior to acupuncture provided initial relaxation, as well as some degree of myofascial, circulation, and neuromodulatory benefits, with the acupuncture treatment providing greater local tissue deformation and neuromodulatory input for chronic OA.

More objective outcome measures would be ideal, such as goniometry, force plate analysis (kinetics), kinematic analysis, and gulick assessment of muscle mass overtime would be an interesting factor to assess as well.  This case shows how acupuncture in clinical practice can be successfully used as part of a multimodal approach for medical management of canine osteoarthritis for analgesia and mobility rehabilitation (3).  Acupuncture can lead to more normalized weight bearing and comfortable ambulation in patients afflicted with OA due to the modulation of inflammation and pain, and the local effects on tight hyperirritable muscle and restricted myofascia, ultimately improving the overall quality of life of affected canines.

References:

1. MAV 2016 course material

2. Macpherson, H., Maschino, A. C., Lewith, G., Foster, N. E., Witt, C., & Vickers, A. J. (2013). Characteristics of Acupuncture Treatment Associated with Outcome: An Individual Patient Meta-Analysis of 17,922 Patients with Chronic Pain in Randomised Controlled Trials. PLoS ONE, 8(10).

3. Oh, J. H., Bai, S. J., Cho, Z., Han, H. C., Min, S. S., Shim, I., . . . Lee, B. H. (2006). Pain-Relieving Effects Of Acupuncture And Electroacupuncture In An Animal Model Of Arthritic Pain. International Journal of Neuroscience, 116(10), 1139-1156.