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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/4979.

Abstract:

Blue is a feline hind limb amputee who subsequently developed phantom limb pain. His pain manifested as growling and biting at his stump. The pain started 3 weeks after amputation and resolved almost completely after the first acupuncture treatment.

History/Presentation:

Blue is a 2 year old male neutered domestic shorthaired cat. He was a stray, found in July of 2016 and diagnosed with Feline Leukemia Virus. Prior to being adopted, he had a large open wound over the left hock. Radiographs confirmed the local infection had caused a local osteomyelitis. Antibiotics were administered for 2 months and radiographs repeated. The suspected osteomyelitis continued to spread despite antibiotic therapy. At this point in time, he was still painful, becoming less mobile and somewhat lethargic. Surgical biopsies and culture/sensitivity were offered but declined. The owner wanted to take the least expensive and shortest approach to resolution possible. Immunosuppression from leukemia virus and the infection being difficult to control was a valid concern as well. Hind limb amputation (via coxofemoral luxation) was elected as the therapy of choice for Blue and performed on 9/8/16. Blue was sent home the following day on onsior and buprenorphine.  About 3 weeks post amputation, he started growling and biting his stump. Prior to surgery, phantom limb pain had been discussed as a possible outcome to amputation and that acupuncture would be a good modality to control this pain. The owner called right away to set up an appointment when she noticed these signs.

Physical Examination and Clinical Assessments:

On physical examination, he was tender on light palpation of the stump but neurologically normal in the right hind limb. Proprioception was assessed by placement testing (allowing him to reach for the exam table when his remaining limb was placed at the edge of the table) and found to be normal.  Withdraw reflex and crossed extensor reflex were normal. Peripheral reflexes were tested routinely with sciatic, patellar, and cranial tibial reflexes (all were normal). Ambulation was normal. On myofascial palpation, he had trigger points along his dorsum (especially near the forelimbs), in his triceps, near the surgery site, and in the caudal lumbar epaxial muscles.

Medical Decision Making:

Dry needling was tolerated extremely well by Blue and was the primary source of treatment.  Laser therapy was initiated in his treatment protocol on the fourth treatment. He was rather painful at several locations at that time and dry needling was not tolerated. I think the increased sensitivity was due to too long of a time period between treatments. More frequent treatments were recommended moving forward.

Acupuncture Treatment:

Treatments were recommended once weekly for 3-4 weeks, then every other week, and eventually decreasing to monthly treatments. Three weeks lapsed between the 3rd and 4th treatment and he was not quite as tolerant of needles at that time, so treatments were continued every other week. Unless otherwise indicated, the points listed below were all treated with dry needling.  The first 2 treatments were performed prior to the clinical intensive. The first on October 7, 2016 and the second on October 14, 2016. These first 2 treatments were identical. After attending the clinical intensive I altered my approach slightly to incorporate some of my newly acquired methods/knowledge.

For the first 2 treatments, GV 20 was the first point placed for relaxation and to determine how he would respond to dry needling. (After the clinical intensive I changed the first point to GV 14 since this point seems to be more relaxing than GV 20 for most. However, Blue didn’t seem to mind either point.) Inner bladder line points were chosen based on myofascial palpation and trigger point pathology. The points chosen and treated were as follows: BL 25, 27, and 28.  The sciatic and cranial gluteal nerves traveling to the pelvic limb arise near spinal cord segments (L6-S1) (1), which are close to the trigger points palpated at the corresponding bladder points.  I also attempted to target points on the contralateral limb that encompassed innervation of surgically severed nerves in the missing limb. These points will also provide additional feedback to appropriate spinal cord segments. GB29 was chosen to stimulate the cranial gluteal nerve. GB 30 and BL 54 was chosen for sciatic nerve stimulation.  ST 34, ST 35, and SP 10 were chosen for more proximal stimulation of the femoral nerve.  KI 3 and BL 60 were simultaneously stimulated using one needle to communicate with tibial and fibular nerves (distal branches of the sciatic nerve).  SP 9 was chosen to reinforce the tibial nerve and the saphenous nerve (branch of the femoral nerve).  ST 36 and BL 40 were chosen for tibial nerve stimulation, and BL 39 for the common fibular nerve. Bafeng points were chosen distally to stimulate digital nerves, as a comprehensive approach.

The next 2 treatments were on November 4, 2016 (treatment 3) and November 29, 2016 (treatment 4). As a result of attending the clinical intensive, I was able to improve upon my myofascial palpation skills. So, the next treatments incorporated all of the points listed above in the first 2 treatments, plus the addition of the following points. GV 14 was the first point and added to both treatments 3 and 4 for relaxation (for reasons previously discussed).  BaiHui communicates with mid to caudal lumbar spinal nerves and chosen (for treatments 3 and 4) because the pelvic limb nerves originate from the spinal cord nearby.  Trigger points were palpated at BL 10, 13, and 21 so dry needling of these points was performed during treatment 3.  It makes sense that some myofascial strain was detected in the neck and shoulder region a couple months after surgery since his gait has been altered.  However, BL 10 and 13 were a bit too painful to dry needle during treatment 4, so laser therapy was performed instead. A Class IV companion animal laser was used, settings at 3.5W and 448J for 2 min 40 sec.  The laser was applied over dorsal and lateral cervical region and between the shoulder blades.  The trigger point at BL 21 was not apparent at the 4th treatment, but instead one was present at BL 18. Dry needles were tolerated well in this region and were used to stimulate these points.  Three trigger points were also palpated near the surgery site during treatment 3 and two trigger points in the same region during treatment 4, all were treated with dry needling.  Normal anatomy at the surgery site was interrupted due to amputation, so precise labeling of the location of these points proved difficult.

Outcomes and Discussions:

Upon critical review, I think he responded well because I was rather comprehensive from a neuroanatomy stand point.  However, I could have added more trigger point pathology to my point rationale during the first two treatments.  This was a skill that was improved upon at the clinical intensive during the course of this treatment protocol (between treatments 2 and 3).  Furthermore, after learning more about my laser unit, I could have also used the acupuncture setting to laser specifically at BL 10 and 13 instead of using the laser over an entire region.

In humans, phantom limb pain has been described to peak at 1 month and 1 year after surgery (2).  In an attempt to avoid this second peak, I have recommended that we continue monthly treatments for 18 months to avoid a second peak in his pain around 1 year post surgery.  The increase in neck pain at the 4th treatment could be due to compensatory myofascial strain secondary to changes in his gait.  So, the current recommendation is acupuncture every other week to avoid myofascial strain from his altered gait, unrelated to phantom limb pain.

References:

  1. Evans, HE. Miller’s Anatomy of the Dog, 4th 2013.
  2. Schley MT, Wilms P, Toepfner S, et al. Painful and nonpainful phantom and stump sensations in acute traumatic amputees.The Journal of Trauma. 2008;65(4):858–864. [PubMed]