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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. A2017014

This case report summarizes the treatment of a 12 year old QH gelding named Sage due to head shaking during riding and routine dental flomuscular tension/trigger points related to pain of unknown etiology in cranial cervical spine. Treatment consisted of a series of three dry needling treatments with Serin needles (0.30 x 50.0 mm), each 7 days apart. I started the first treatment with relatively few needles and kept adding more points as the treatments progressed. The owner noted increased mobility and comfort level within 72 hours, and reported improvement every following treatment. Strengthening and passive ROM exercises were implemented by owner at home, but patient received no other pain medications.

History and Presentation:
Sage, a 12- year-old QH gelding, was presented to Beaverhet Veterinary Clinic in June 2017 for head tossing during riding and routine dental float procedure, making the procedure nearly impossible, as reported by owner. Sage’s clinical signs had persisted all year and worsened recently, so that the owners, who use Sage and their other 6 horses for pleasure and trail riding in Montana, had not been riding him for 3 months. The owners use a regular snaffle bit as well as a regular western saddle. Sage shares his pasture with the herd of 6 horses. The owner of the clinic, Dr. Ben Abbey, had previously noted pain on palpation of TMJ and cranial cervical spine and referred the case to me.

Physical Examination and Clinical Assessments:
On physical exam, Sage was BAR, with physical exam parameters within normal limits. physical exam was unremarkable (vital signs: T 99.9 F, pulse 30 bpm, respiration 12 bpm). No lameness was noted. No abnormalities were noted on brief neurologic examination. Myofascial palpation revealed trigger points in around atlanto-occipital junction, caudally along the cervical spine, over withers, and multiple areas of tenderness along thoracolumbar back as well, as well as on TMJ palpation bilaterally. Passive ROM during circling of hind limbs was decreased bilaterally. Overall, Sage appeared a bit stiff, with decreased ROM laterally of neck as well. Head shaking was minimal during the exam unless provoked with bilateral pressure application over TMJ region.

Medical Decision Making:
Although I noted multiple areas of tenderness on myofascial palpation, I did not feel that pharmacologic intervention ( such as a muscle relaxant and/or anti-inflammatory dose of steroids such as methocarbamol and flunixin meglumine or phenylbutazone) was indicated at the time because his clinical signs were mild to moderate: There was no lameness, no swelling, no acute pain, rather chronic muscle soreness and trigger points due to potential misalignment at atlanto-occipital junction. Surgical intervention did not seem indicated at the time, although I cautioned the owner, that if Sage did not improve, head/cervical/thoracic spinal radiographs may need to be taken in order to rule out osseus fragments, kissing spine, or a form of spinal cord compression. At this time, I decided that acupuncture as a neuromodulation tool along with controlled, moderate, regular exercise (daily hand walking along with multiple passive ROM and strengthening exercises I showed the owner) may help control Sage’s pain, increasing his flexibility, mobility, and help return him to normal function.

Differential Diagnoses:
While radiographs were not taken at this time (although I offered with the reservation that my spinal radiographs may not be very good with my limited expertise and the portable x-ray machine), actual boney involvement, such as osseous fragment causing pain in the cranial cervical area, kissing spines, or mild spinal cord compression (from, for instance, a tumor) could not be completely ruled out at this time. I cautioned the owner that if Sage did no improve with exercises and acupuncture, that imaging of the spine may have to be performed to find the exact etiology of his clinical signs (vertical head shaking). Multiple other causes for head shaking exist: external triggers (such as dust, insects, or allergies, bright sunlight), ear mites, middle ear infections, TMJ problems, Temporo mandibular osteopathy, guttural pouch empyema/infections, ocular disease, dental disease, Some of these (especially external) triggers can affect/tickle the trigeminal nerve, causing a sot of neuropathic pain, and making the horse feel itchy in the snout and thus cause head shaking, as Dr. Loving reports in “Head shaking, Triggers and Treatment” in The Horse, 2009. Sometimes, horses may begin head shaking due to any number of these etiologies, and then continue head shaking even if the underlying problem has resolved, head shaking as a habit. Any of the etiologies, even if resolved, then may cause myofascial tenderness, trigger points, decreased flexibility, and unwillingness to perform.

Definitive (or Putative) Diagnosis (or Diagnoses):
In Sage’s case, ocular, dental, and otic disease was ruled out during physical and dental exam. Guttural pouch disease was not likely, although nasopharyngeal and guttural pouch endoscopy was not performed. Any external triggers may have lead to his head shaking, and actual spinal disease could also not be ruled out. Radiographs or more advanced imaging techniques would be needed in order to rule out spinal pathology. Although the cause of head shaking may not be determined, my hope was to at least help alleviate Sage’s pain with help of acupuncture. Direct or indirect muscle pain that perpetuated the head shaking served as my most suspicious differential.

Acupuncture Treatments:
Acupuncture treatments consisted of 3 dry needling sessions, 1 week apart.
Week 1: wanted to increase parasympathetic stimulation to create muscle relaxation, then stimulate some relevant spinal nerves as well as touch on some regional tender points but avoid the most tender area itself, not wanting to create an aversion.
• Bai Hui ( good balancing point, parasympathetic stimulation, and balances with more cranial points, as well as local tender points)
• Li 16 (calming, local point)
• GB 21 (local tension, thoracic limb pain)
• BL 21 (TL pain, local tenderness)
• GV 14 (head and neck pain)
• GV 20 (head shaking, poll pain, cervical pain)
• BL 25, 26, 27 (LS pain, local trigger points)
• TH 14, 15 (shoulder pain)
Week 2: Building on previous treatment, working more towards neuromodulation and trigger point release at more discrete local points. Added more head-shaking specific points.
I also added joint mobilization exercises (hind leg circles, flick tests, neck passive ROM) for the owner to employ at home at least SID.
• Added:
o BL 10, plus local cervical points (cervical points, headache, head shaking, pain near poll, upper cervical region)
o ST 10 (head shaking, poll pain, cervical pain)
o TH 16 (neck pain)
o GB 2
o local bladder points/ trigger points
o SI 11,12 (for myofascial dysfunction, especially trigger points related to shoulder)
o SI 16 (cranial neck pain)
o LU1 (local pain, reduced shoulder mobility)
Week 3: used points tolerated well previously but also added in more needles along the bladder line
Added Topline Strenghthening and Flexibility exercises for owner to do at home: Belly lifts, tickling heave line, tail stretches.
• same treatment as Week 2
• Added: Da Feng Men (calming point)
• more local points along the bladder line

Outcomes, Discussions, and References:
Sage responded very well to his acupuncture treatments. During his first treatment, he relaxed, and while I made sure to not make big promises, the owner was very pleased with the outcome. She noted, within about 72 hours post treatment, more calmness and less head shaking in Sage while he was in his pen. After his second treatment, during which he was also relaxed, I had shown the owner exercises (as described above), to help with Sage’s flexibility and strength, which seemed to improve Sage’s overall comfort level immensely. The owners began ponying Sage behind their other horse on short rides, with decreased reported head shaking. She was very conscientious about introducing Sage to exercise gently and gradually. They noted improved relaxation and less head shaking following each treatment. Following the third week treatment, Sage was ridden bareback (see photo), and seemed to keep his head much lower and more comfortably. The owners unfortunately are no longer in my area of service, but they keep in touch periodically, and while Sage still occasionally head shakes, he seems much happier and more comfortable and can be ridden bareback with bit now. They also scheduled an appointment with a chiropractor to help bring Sage back to hopefully full function soon.