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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/4936.

Rollie 2016-05-03, 4 21 07 PM (1)

Abstract
Rollie presented with suspected IVDD near his T­L junction causing complete paraparesis. The family had decided on euthanasia prior to their appointment with me. After much discussion, they agreed to treatment with acupuncture and cold laser. Rollie had three combined acupuncture and cold laser treatments within seven days. By his third appointment, he was walking and able to urinate with normal leg lifting posture. He remained moderately ataxic with decreased proprioception and delayed withdrawal reflexes. The recommendation was to continue acupuncture weekly for further healing and improved neurological function. Unfortunately, Rollie’s family was unable to bring him in for further treatment.

History and Presentation
On April 25th, 2016, Rollie, an 11-year-old neutered male Bichon x Shih Tzu, presented after hours to a neighboring practice for being hunched over and not walking normally. The owners did not see him fall; no history of trauma. Their exam findings included grade II periodontal disease, lenticular sclerosis, sore with palpation of TL junction and ataxia. He was crossing his hind feet over, swaying and had difficulty walking in circles. His panniculus reflex and proprioception of his hind legs were described as delayed. He urinated at the clinic without posturing but appeared aware of urination. He was diagnosed with suspected IVDD and sent home with tramadol, Metacam, and instructions for strict cage rest for several weeks. A recheck was recommended in two weeks to look for improvement or progression. Advanced imaging would be recommended if he was deteriorating with potential for surgery. On April 28th, 2016, Rollie presented to me for worsening of his condition. He was non-ambulatory in his hind limbs. He had been urinating in his bed and had not had a bowel movement since before April 25. Prior to his current condition, he was otherwise healthy.

Physical Examination & Clinical Assessments
On April 28, he was bright, alert, and responsive. He was non-ambulatory on his hindlimbs with no conscious proprioception or motor function. He had delayed withdrawal reflexes and positive cross extensor reflex on his left hind. His patellar and knuckling reflexes were absent. Deep pain was present, he was wagging his tail and had good anal tone. He was painful with palpation from T-11 through L-2. IVDD Hansen’s type I disc extrusion was suspected near his T­L junction. His clinical condition was complete paraparesis with deep pain perception. His physical exam was otherwise unremarkable.

Myofascial exam showed moderate tension in his triceps and pectoral muscles. He had twitching with palpation of T­L and lumbar spine, and taut muscle bands along his lumbar iliocostalis and longissimus muscles.

Medical Decision Making
Finances were a concern for this family and neither radiographs, advanced imaging nor surgery were an option. They elected euthanasia due to concern for Rollie’s quality of life and financial constraints. I recommended acupuncture and cold laser because of their high success for managing pain, returning ambulation and normal voiding in patients suffering from IVDD. After much discussion, the family agreed to try three treatments to start. I discussed although he may never fully recover neurologically, my goals were for him to be pain free, ambulate, and urinate and defecate on his own. My acupuncture points were chosen with these goals in mind. Cold laser was performed following each treatment from T-1 through L-7 for analgesia, axonal regeneration and prevention of motor neuron degeneration. Laser and acupuncture together were used for their influence on release of nerve growth factor, neurotophins and other reparative substances in the spinal cord and peripheral nerves following neurotrauma.

Acupuncture Treatment
April 28: BL 19, 20, 27, 28, K-I3 BL-60 R, SP-6 L, Bai Hui, GB-30 R, ST-36, Bafeng

April 29: Bai Hui, BL 27, 28, BL-54, GB-29, GB-30, Bafeng, ST-36, KI-1, KI-3 BL-60 L, SP-6 R

May 3: BL 19, 20, 27, 28, GV 20, 14, Bai Hui, ST-36, SP-6, Bafeng, KI-1 L, GB-21, SI-11

All treatments included electro­acupuncture ST-36 to Bafeng (12­18 mins) and cold laser treatment. Dry needling was done along the inner bladder line above and below his injury for analgesia and in his sacral spine for genitourinary input. Electro­acupuncture from ST-36 to bafeng was performed for somatic afferent stimulation of his paretic hind limbs. Hip triads (GB 29, 30, BL-54) were chosen for sciatic nerve dysfunction. Additional distal points KI 1 and 3, BL-60, SP-6 were chosen for their relationship to the tibial nerve to promote normal voiding as well as stimulation of his paretic hind limbs. Rollie showed some anxiety during his treatment which seemed to improve with dry needling of GV-20. In addition, GB-21, SI-11 and GV-14 were chosen for local muscle tension and myofascial dysfunction in his forelimbs. ST-36 was chosen as an important immune modulating point with somatic afferent stimulation reaching the nucleus tractus solitarius of the brainstem.

Outcome and Discussion
On presentation, Rollie’s condition was non-ambulatory paraparesis with deep pain perception. Following three combined acupuncture and cold laser treatments Rollie showed remarkable improvement. He was able to stand and walk unassisted. His withdrawal responses were almost normal with no cross extension. His knuckling reflexes and proprioception remained mildly decreased. His patellar reflexes were mildly increased following treatments. Significant improvement in his neurological exam and ability to ambulate was noted upon starting treatment; before treatment he had been steadily declining. Following the 1st treatment, while demonstrating how to assist him walking with a sling, Rollie passed stool in clinic for the first time in several days. This response was attributed to the positive impact of acupuncture on gastrointestinal motility. Following the second treatment he regained the ability to ambulate and was able to urinate unassisted, lifting his leg. By his third treatment Rollie was walking, comfortable and urinating/defecating without any trouble. His gait was ataxic with some crossing over of his hind legs. On myofascial exam, the twitching resolved in his T­L spine and the taut muscle bands in his lumbar iliocostalis and longissimus muscles improved. Tension and trigger points persisted in his pectoral and triceps muscles. Phone call updates revealed continued improvement with only mild dragging of his back feet and rare crossing of his hind legs. The family was overjoyed with the outcome and he had no adverse reactions. The benefits Rollie received from acupuncture and cold laser matches the findings of Hayashi et al. (2007) and Joaquim et al. (2010) as successful in the treatment of IVDD.

The lesson learned from Rollie’s case is the success of acupuncture treatment for IVDD and paresis. Prior to presentation the family was distraught having come to the conclusion that euthanasia was the only option because they could not afford surgery. The clinical implications of acupuncture in the successful treatment of IVDD are that fewer animals would be euthanized due to the severity of their neurological deficits when families cannot afford decompressive surgery. More research on the benefit of physical medicine for dogs with IVDD will continue to support the use of these modalities rather than only presenting cage rest or surgery as options as was initially done with Rollie. Importantly, Joaquim et al. (2010) found treatment with electro­acupuncture resulted in higher clinical success than decompressive surgery in dogs with severe neurological deficits for >48 hours. These findings make it clear that we as veterinarians should be recommending acupuncture as the mainstay treatment for IVDD whether or not surgery is an option.

References:
Acupuncture needles used: Mixed 0.18 x 30mm and 0.2 x 30mm seirin

Electro­acupuncture done using Ito ES­130 device. Settings used ranged from 1­1.5Hz at an output level of b/w 4­6. The voltage current range from the device is 0­36mA. Needles used for electro­acupuncture were 0.2 x 30mm seirin.

Cold laser was done using a Class IIIB device. The multi probe was used on 4 points along his dorsal midline spine from T1­L7, power 60mW, Time 1:30min /site.

Hayashi AM, JM Matera and AC Fonseca Pinto, 2007. Evaluation of electroacupuncture treatment for thoracolumbar disc disease in dogs. J Am Vet Med Assoc, 231: 913­918.

Joachim JG, SP Luna, JT Brodani, SR Torelli, SC Rahal et al., 2010. Comparison of decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long­standing severe neurological deficits. J Am Vet Med Assoc, 236: 1225­1229.