Written by a Medical Acupuncture for Veterinarians course graduate. Author’s name available upon request. Signed release obtained from client/author/4906.
A 14 year old, 10 kg, male, neutered Pomeranian X with hypoadrenocorticism and a history of bilateral cranial cruciate tears presented with osteoarthritis in all four limbs. Acupuncture treatments included systemic, regional, and local dry needling techniques, including trigger point therapy. His family reported improved mobility and increased energy levels as a result of acupuncture treatments. At home massage and range of motion exercises augmented these results. In addition, frequent, in-depth exams allowed time for the dog’s complex medical concerns to be appropriately addressed and his medication regimen to be optimized.
History & Presentation. Siko is a 14 year old, 10 kg, male, neutered, Pomeranian X who presented 11/13/2015 for chronic pain. Siko is an Addisonian with bilateral cranial cruciate ligament tears, one surgically repaired. His family reports he is stiff on rising and has limited range of motion, with radiographically diagnosed osteoarthritis in the front and hind limbs.
He passes soft, unformed stools, vomits weekly, and has morning inappetance. He consistently has high liver enzymes on bloodwork and elevated serum calcium levels. Siko takes 0.4 mg of fludrocortisone once daily and 1.25 mg of prednisone once daily for hypoadrenocorticism.
Physical Examination & Clinical Assessments. On physical examination Siko was quiet, alert, and responsive with a body condition score of 6/10. Physical examination revealed multiple soft subcutaneous masses, mild dental disease, a tense abdomen, and a grade III/VI systolic murmur.
On orthopedic examination Siko had a stiff gait, especially the left hind limb. He had moderate, diffuse, bilateral, hindlimb muscle atrophy. Medial buttressing was palpable on both stifles. Range of motion examination was avoided, to minimize stress. There was palpable warmth over the thoracolumbar junction. GB 25 and LI 10 were very sensitive to gentle palpation bilaterally.
Acupuncture Treatment & Medical Decision Making. Acupuncture points chosen for the first treatment included Yin Tang, LI 10 – R, ST 36 – L, BL 22 – R, L, GB 41 – L, and TH 14 – R (R= right side; L= left side). Dry needling was performed with silicon coated needles. 0.20 x 30 mm needles were used on the back; 0.16 x 15 mm needles were used on the forehead and limbs. Needle retention time was approximately 15 minutes. Response to treatment was exceptional. His person reported he was extremely energetic the next two days, so much so that he seemed sore afterwards. Treatments continued weekly for two more weeks, then every other week.
Outcomes & Follow-up. In February 2016 Siko’s family brought recent bloodwork to his acupuncture appointment. Despite previous requests, this was the first time records were provided. Alkaline phosphatase and gamma-glutamyl transferase were extremely elevated. Abdominal ultrasound was recommended, to rule out gall bladder disease. His regular veterinarian offered a trial of ursodiol and gastrointestinal signs immediately, dramatically improved. Medications and nutrition were adjusted, including replacement of fludricortisone with monthly desoxycorticosterone pivalate injections plus oral physiologic dose prednisolone.
With Siko’s newfound energy he again experienced overuse injury. On 4/13/2016 he was acutely non-weight bearing on the left pelvic limb. His regular veterinarian prescribed a course of tramadol. Siko was sensitive at LI 10 and had palpable trigger points in the triceps bilaterally and the left semimembranosus muscle. Trigger point therapy was added to his acupuncture treatments with good success. He arrived three legged lame and left weight bearing on all four limbs. Treatments continued weekly, with needle retention times of 15-25 minutes.
An example of a point protocol from April 25, 2016 was: GV 20, GV 14, SI 9- R, triceps trigger points bilaterally, BL 25, Bl 40- L, KI 3- L, ST 36- R (R= right side; L= left side). 0.16 x 15 mm silicone coated needles were used. Further additions to therapy included home stretches, massage, and passive range of motion exercises and Adequan injections. Siko’s family reports that his comfort and quality of life consistently improve as treatments continue. His regular veterinarian reports liver values have decreased dramatically, calcium is normal for the first time in his adult life, and electrolytes are more stable than they have been in years.
Table 1. Acupuncture Point Selection
|Systemic||Central: calming, homeostasis, anti-inflammatory, analgesia||Yin Tang, ST 36, GV 20, GV14|
|Regional||Somatovisceral*, regional innervation^, analgesia||LI 10^, BL 22*, BL 25*, BL 40^|
|Local||Myofascial trigger point therapy#, proprioception**, local analgesia||GB 41, TH 14, SI 9, triceps#, KI 3, ST 36, LI 10, BL 40**|
Discussion. Injuries often result in guarding of affected areas and weight shifting. Resultant compensatory postures result in myofascial strain patterns and palpable trigger points. Dry needling of myofascial trigger points can provide direct pain relief and improve return to function, even if structural abnormalities cannot be corrected (Shah et al. 2015).
Acupuncture improves chronic pain conditions via neuromodulation; stimulation of acupuncture points promotes homeostasis, analgesia, and normal nerve conduction (Egorova et al. 2015, Robinson 2012). Acupuncture has direct effects on local nerve signaling pathways, spinal reflexes, the autonomic nervous system, and the central nervous system. It also indirectly affects the nervous system via myofascial interactions and can influence local circulation. Local effects of the needle on collagen, connective tissue, nerves, vessels, may activate mechanoreceptors, nociceptors, vasodilators, and with deep placement, muscle spindles (Robinson 2012).
Long loop pathways stimulated by particular acupuncture points (i.e. ST 36) act centrally to mediate autonomic tone and/or dampen inflammation (Robinson 2012). In conditions of chronic physical stress which lead to heightened sympathetic tone acupuncture can have neutralizing effects by promoting parasympathetic balance (Leong 2012). Regional effects mediated via spinal reflexes include somatovisceral and viscerosomatic feedback, which can improve organ function and reduce associated somatic pain (Bowsher 1998). Chronic pain perpetuates due to a vicious cycle of signal amplification. Acupuncture treatment can interrupt this cycle and promote return to normal neural connectivity (Egorova et al. 2015, Leong 2012).
This case demonstrated an array of internal medical and musculoskeletal complexities, and showed how acupuncture can help improve quality of life for a geriatric patient. It also demonstrated a need for caution, as improvement may lead to overexertion injury. In addition, this case showed the benefits of frequent appointments for a complex patient. Every time Siko came for acupuncture there was a discussion of his medications and clinical signs, allowing for personalized adjustments to his care.
Bowsher, D., Mechanisms of Acupuncture, Medical Acupuncture: A Western Scientific Approach, Eds. Jacqueline Filshie and Adrian White, Churchill Livingstone London, 1998, Chapter 6, pp.69-82.
Egorova, N., Gollub, R.L., Kong, J., “Repeated verum but not placebo acupuncture normalizes connectivity in brain regions dysregulated in chronic pain” NeuroImage: Clinical 9 (2015) 430–435
Leong, L., “Neurophysiological Basis of Acupuncture-induced Analgesia – An Updated Review”, J Acupunct Meridian Stud 2012; 5(6):261-70.
Robinson, N.G., “One Medicine, One Acupuncture”, Animals 2012, 2, 395-414; doi:10.3390/ani2030395
Shah J.P., Thaker N., Heimur J., Aredo J.V., Sikdar S., & Gerber L. “Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective”, PM R. 2015 July ; 7(7): 746–761, doi:10.1016/j.pmrj.2015.01.024.