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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/4949.

 

Abstract
Joy, a 21-year-old PercheronX mare, was presented for chronic lameness following a traumatic motor vehicle accident with injuries to her neck, thoracolumbar region, and left hindlimb. Physical examination and diagnostics revealed painful soft tissue with the most significant discomfort located in the left middle gluteal muscle. Acupuncture, electrical stimulation, and trigger point muscle therapy were performed on the affected areas over a two-month period. Improved lameness score, decreased reactivity on myofascial palpation exam, and return to normal comfort was noted over the course of treatment, allowing the patient to return to riding work. It is expected this case will require ongoing monitoring and/or follow-up treatments.

History & Presentation
Joy was injured in a motor vehicle accident in October 2015 when the trailer was hit from the left side by a truck. Initial examination by the referring DVM at the time of the accident revealed left hindlimb lameness, swelling over the left tuber coxae, and left abdominal body wall. Joy was standing with her neck held in a ventral-flexed guarded stance. Pain was elicited on palpation of the entire neck, withers, back, left stifle, and left tuber coxae. Radiographs of both stifles, tarsal joints, and tuber coxae revealed no significant abnormalities. Treatment for Joy from November 2015 until February 2016 had included oral phenylbutazone, rest with paddock/pasture exercise, and daily hand walking. Prior to the accident, there was no relevant medical history of illness or lameness other than Joy was extremely needle phobic during veterinary exams. Joy’s primary use is pleasure and drill team riding.

Physical Examination and Clinical Assessments
Initial physical examination on 24-Feb-2016 revealed TPR, cardiac, respiratory, and GIT findings to be within normal limits. Myofascial palpation examination (MPE) revealed pain on palpation of the neck, thoracolumbar, and dorsal pelvic musculature, with the most painful areas located over the left middle gluteal muscle. There was gross visual enlargement of the left middle gluteal with palpable areas of extremely firm tense muscle bands. Specific acupuncture points sensitive to palpation included: LEFT (BL-10, LI-18, LI-17, BL 21-23, BL 25-28, Bai Hui, BL-54, GB 29-30, BL 39-40) and RIGHT (BL-10, LI-18, LI-17, BL 21-23).

Lameness examination revealed left hind 3/5 lameness at all gaits. Flexion tests of the distal LH limb and tarsus did not worsen the lameness. Flexion of the LH stifle and forward extension stretching both worsened lameness. There was intermittent toe-dragging of the LH limb at all gaits. Limb proprioception tests (ground poles forwards and backwards, pivots, tight circles, dorsal foot re- positioning) were normal for all limbs. Neck range of motion (voluntary treat-stretches) showed normal right lateral flexion, normal ventroflexion, and reduced willingness for left lateral flexion.Previous radiographs by the rDVM showed no significant abnormalities of the cervical vertebrae, LH tuber coxae, LH stifle, or LH tarsus. A primary diagnosis of myositis of the left middle gluteal and bilateral lumbar epaxial musculature was made.

Medical Decision Making
Approximately 3 months had passed since the initial accident injury. During this time there was very little specific therapy directed at the injury locations. Stall confinement with a small outdoor paddock had allowed for only limited self exercise along with occasional hand walking by the owner. While initial radiographs at the time of the accident were normal, the elapsed time of 90 days may have allowed abnormalities to be evident. After discussions with the owner it was decided to pursue soft tissue therapy via acupuncture vs. further diagnostics. Goals of neuromodulation were to reduce afferent pain signals from the cervical spine (cranialcervical, midcervical, and cervicothoracic nerves) and lumbosacral region (mid/caudal lumbar, and cranial sacral nerves). Increased rehabilitation exercise would be included pending response to treatment.

Acupuncture Treatment
Acupuncture treatment protocols were performed.

Date of procedure: 14-Mar: dry needling
Acupuncture treatment protocol: LEFT – BL-10, LI-18, LI-17, GB-21, BL 21-23, BL 25-27, Bai Hui, BL-54, GB-29, GB-30, BL 39-40 RIGHT – BL-10, LI-18, GB-21, BL 21-23

Date of procedure: 17-Mar: dry needling, E-stim
Acupuncture treatment protocol: LEFT – LI-17, GB-21, BL-23, BL 25-29, Bai Hui, BL-54, GB-29, GB-30, BL-40 RIGHT – LI-17, LI-18, GB-21, BL-23

Date of procedure: 05-Apr: dry needling, E-stim
Acupuncture treatment protocol: LEFT – LI-17, LI-16, BL 23-27, GB-27, GB-29, GB-30, BL-54, left middle gluteal trigger points RIGHT – BL 21-26

Date of procedure: 08-Apr: dry needling, E-stim
Acupuncture treatment protocol: LEFT – BL 23-27, GB-27, GB-29, GB-30, BL-54, left middle gluteal trigger points

Date of procedure: 11-Apr: dry needling, E-stim
Acupuncture treatment protocol: LEFT – BL 23-27, GB-27, GB-29, BL-54, left middle gluteal trigger points

Date of procedure: 16-Apr: dry needling, E-stim
Acupuncture treatment protocol: LEFT – BL 23-26, GB-27, GB-29, BL-54

Treatment points were selected based on areas of pain on the MPE. A combination of initial dry needling (~20min, Seirin 0.20-0.25mm/30mm needles) and mixed mode electrical stimulation (~20min, Pantheon 5/100Hz) were used per treatment session. The tension of the left middle gluteal was identified as the most significant source of pain on all examinations. Methocarbamol was also administered 05-Apr to 09-Apr following physical and MPE.

Outcomes
Follow-up examination on 04-May-2016 showed a lameness score of 0/5 on the LH limb at all gaits on hard and soft surfaces. MPE revealed no painful reactions over the cervical, lumbar, or sacral regions. Deep firm palpation of the LH middle gluteal muscle revealed no pain reaction, and taught muscle bands were absent. Joy was cleared for return to riding with a detailed walk/trot/ longe/riding schedule in place for six weeks. At the time of this report, there continues to be improved comfort with rehabilitation. It is expected this case will require follow-up monitoring and treatment. The only adverse event during the course of treatment was the development of more widespread muscle stiffness in the 17-Mar to 05-Apr interval. This represented an extended period between acupuncture visits along with an increase in rehabilitation exercise. A five-day course of methocarbamol administered at this time likely contributed to healing response, and may have confounded evaluation of acupuncture as the only modality providing benefit to the patient.

Discussion
This case provides an example of chronic muscle tension and pain being treated and alleviated with acupuncture. Initial cervical pain and right-side lumbar pain were alleviated with the first two-three treatment sessions. Gradual but consistent response was observed in relief of the LH middle gluteal muscle tension and pain. Reduction in pain response on the MPE throughout the treatment period, reduction in tense bands and trigger points of the LH middle gluteal, and improved AAEP lameness score were evidence of therapeutic response. This case also illustrates an extremely needle-phobic horse showing rapid acceptance of acupuncture treatment. Quiet resting, eating, and alternating hind-limb resting was observed thought the treatment sessions.

In retrospective critique of this case, additional acupuncture points may have been included to improve healing time. Continued right side BL23-27 points would have given additional afferent stimulation to the affected spinal cord segments L2-S1 affecting the injured left gluteal. Left and right BL-40 points may have given improved response as master caudal back points. Finally, huatuojiaji points may have reduced lumbar tension in this case, although the the temperament of the patient may have precluded these points from being included.

References
Ridgway, K. Diagnosis and Treatment of Equine Musculoskeletal Pain. The Role of the Complementary Modalities: Acupuncture and Chiropractic, in Proceedings. Am Assoc Equine Pract 2005; 51:403-408.

Haussler, K. Equine Chiropractic: General Principles and Clinical Applications, in Proceedings. Am Assoc Equine Pract 2000; 46:84-93.

 

What did I learn
This was a great case to see a vet-phobic and needle-phobic horse respond positively to acupuncture. Over several years, Joy has been extremely difficult for routine procedures such as vaccinations and medical treatments. However, very soon into the treatment sessions there was no resistance whatsoever to the MPE or needling. Bau Hui needling and the initial 30 second of E-stim were the only times for proceeding cautiously. Also, the relief of muscle tension happened more rapidly than I would have expected given the severity and duration of the injury.

 

Implications for clinical practice
This case provides a good example for a common scenario in everyday clinical practice. Often horses on rest or rehab have reduced activity and increased small-area resting time. While this may benefit the original injury, there may be muscle tension and trigger points built up in the postural resting muscles from a prolonged resting stance or movement. Ensuring these distant muscles and trigger points receive therapy should be standard protocol for rehabilitation programs.