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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/4991.

Abstract:

OBEJECTIVE: To evaluate pain management in a dog with a left stifle injury treated with acupuncture, Metacam and Tramadol.

PROCEDURE: Acupuncture was performed using dry needling technique approximately every two weeks with a total of three sessions to date 12/29/2016. A myofascial evaluation was performed before and after each session.

RESULTS: Client assessments revealed that outcomes of the three sessions helped with overall pain management in addition to the use of Metacam and Tramadol. After the second session the client discontinued the Metacam.

CONCLUSIONS: Acupuncture in addition to multimodal pain medications (Metacam and Tramadol) reduced the degree of subjectively evaluated lameness and acupuncture was associated with a decrease in the need to use Metacam.

Abbreviations:

BAR bright alert responsive                                       TPR temperature pulse respiration

BCS body condition score                                          WNL within normal limits

PLR pupillary light response                                      CP central proprioception

L left side                                                                    R right side

TTA tibial tuberosity advancement                            CBC complete blood count

History and Presentation:

5 year old male neutered Pit-bull presented for chronic (several weeks) left hind intermittent weight bearing lameness on 12/29/2016. There was no history of present illness and no past surgical history. The pet is said to have injured himself by running up and down the stairs of a town house apartment after which he exhibited lameness. After ~3-4 weeks, he presented to the Veterinary Hospital for evaluation.

Physical Examination and Clinical Assessments:

On presentation pet was BAR with a normal TPR and BCS of 6/9.

Exam Findings: Eyes/Ears/Nose/Teeth: External ocular and otic exam WNL, minimal calculus; Lymph nodes: WNL; Heart and Lungs: No murmurs, lungs clear

Abdomen: Soft non-painful; Dermatologic: Generalized pruritus, thinning of hair over caudal thighs; Urogenital: neutered male; Neurological exam: PLRs WNL, normal menace response, CPs WNL (all four limbs); Musculoskeletal: Intermittent weight bearing left pelvic limb lameness when walking and trotting; toe touching on left hind; mild tibial thrust elicited and left stifle was warm and painful to the touch; mild soft tissue swelling noted around left stifle; mild pain on palpation of lumbo-sacral junction; Myofascial palpation: Severe tension over both shoulders due to weight shifting, tight gastrocnemius (L,R); tension and trigger points over antebrachium and triceps (L,R); Pain on palpation of L stifle with soft tissue swelling around it.

CBC, Chemistry and Urinalysis – unremarkable and WNL

Radiographs: Not performed on the date of presentation due to financial constraints. Only performed 2-3 weeks after medical management with Metacam and Tramadol and restricted activity.

Radiographic assessment: moderate amount of L stifle effusion; no obvious lytic lesions; tibia is slightly cranially displaced; osteophytic changes over cranial tibia.

Clinical recommendations made:  TTA surgery versus Rehabilitation/Acupuncture

Medications started: Apoquel, Metacam and Tramadol 

Medical Decision Making:

The client declined surgery and referral for rehabilitation due to financial constraints. The client opted for multimodal pain management in addition to acupuncture offered.

Acupuncture Treatment: Three acupuncture sessions were performed to date (1/25/2017) using Serin 0.20 x30mm and 0.25 x 30mm and dry needling technique.

Treatment #1 (12/29/16) 1

Problems: Tension over left and R shoulder region due to weight shifting; tight gastrocnemius; ropy tension over antebrachium and triceps (L, R); Sensitivity on palpation of L pelvic limb stifle

Points: LI4, LI 10; SI11BL10, 11,12,13,14,15 (L, R); BL22, 23,25 (R); BL27, 28 (L); BL54, GB29, GB30 (L); BL 60 (R); GV14, GV20; BaiHui; Bafeng (L)

Reason for point selection: Pain over shoulder, L stifle, triceps and gastrocnemius 1,2.

Recommendations: Continue Metacam and Tramadol; Acupuncture in 1 week; Strongly recommend rehab exercises;

Treatment #2 (1/14/17) 1

Problems: More anxious at this visit; Myofascial restriction over dorsolateral neck, scapulae latissimus dorsi (L, R); paraspinal trigger points over lumbar spine; taut gastrocnemius (L)

Points:  GV 14;BaiHui; HT3; LR3; GV20; C6, 7 ventral cervical spinal points; LI4; ST34, 36 (L); BL10, 13,14,15,21,22,23(L, R); BL 36 (L); BL 27,28 (R); BL54, GB29, GB30 (L); Bafeng (L, R)

Reason for point selection: Anxiety, tension over neck/shoulders and lower back1,2.

Recommendations: Continue Metacam & Tramadol; Acupuncture in 1-2 weeks

Treatment #3 (1/25/17) 1

Problems: Decreased myofascial restrict over lumbar spine compared to first session. Taut bands over triceps and shoulders (L,R); Taut gastrocnemius (R)

Points: GV 14,20;BaiHui; LI4; ST34, 36(R); SI11, 12(L); BL13, 14,15,21,22,23(L, R); BL52 (L, R); BL54 (L, R); BL 60 (R); GB29, 30 (L); Bafeng

Reason for point selection: Tension over triceps/shoulders, caudal thighs/gastrocnemius1, 2.

Recommendations:  Continue Tramadol, recommend restarting Metacam as needed; Rehab/swimming to increase muscle mass over L hind; Acupuncture every 2-4 weeks.

Outcomes and Discussion:

The client noticed an overall increase in comfort and weight bearing ability of the patient.  On clinical examination at the third session (when compared to the first acupuncture visit), it was noted that pet had a decreased amount of myofascial trigger points over dorsolateral shoulders, neck and spine and was more comfortable and relaxed during the treatment. The client had run out of Metacam after her second treatment and had chosen to discontinue it (due to financial constraints). In addition pet seemed comfortable and was responding well to acupuncture sessions.

As far as adverse events noted, the pet was more tired after acupuncture treatments (rule out long car ride versus effects of acupuncture treatment), however slept better.

This case is a classic example of how surgery on the affected limb does not have to be performed immediately (unless medically deemed appropriate) and acupuncture can act as an adjunct to conventional pain medication.  Acupuncture via neuromodulation has demonstrated muscle pain relief and anti-inflammatory effects thereby reducing the amount of non-steroidal medication necessary for pain management 3,4. In addition acupuncture has demonstrated that it can relieve muscle tension and stiffness3,4. Thus acupuncture has proved to be beneficial in this case for pain management.

References:

  1. Medical Acupuncture for Veterinarians, Canine Point Mini-Manual. onehealthsim.org
  2. Robinson NG. How Acupuncture Works–Without the Mumbo Jumbo. Western Veterinary Conference 2006.
  3. Schoen AM. Veterinary Acupuncture Therapy for Musculoskeletal Conditions. 65th Convention of the Canadian Veterinary Medical Association, 2013

4.   Kaplan G. Efficacy of acupuncture in the treatment of osteoarthritis and musculoskeletal pain. NIH Consensus Development