Written by a Medical Acupuncture for Veterinarians course graduate. Author’s name available upon request. Signed release obtained from client/author. 10S2017004
ABSTRACT
Speedy is a 9 year old MN greyhound that presented for ambulatory paresis of the right
hind limb and knuckling the right hind paw. The paresis occurred acutely after slipping
on a hardwood floor and landing on the right side of the hip. Three acupuncture
sessions were performed over three weeks with emphasis on re-establishing nerve
communication between the extensors of the right hind paw and the central nervous
system and improving mobility and strength of the right hind limb. After three
treatments Speedy began to consistently extend the right paw while walking and was
able to appropriately flex and extend the joints of the limb.
HISTORY AND PRESENTATION
“Speedy”, a 9 year old castrated male greyhound, was presented to our hospital
on 11/1/2017. The presenting complaint was a right hind limb “lameness” noticed the
previous day. When a trick-or-treater rang the doorbell Speedy, eager to greet her,
slipped on a hardwood floor and landed firmly on his right hip. After the incident, the
owner noted that Speedy was dragging his right hind limb. Speedy was otherwise
thought to be a very healthy dog with no history of lameness or other medical issues.
He was not on any medications when the incident occurred. The owner stated that
despite his advanced years Speedy still had lots of energy and that his eating and
bathroom habits were like clockwork. Speedy was adopted seven years ago from a
racing track where he was considered a poor performer; ignoring the track’s curves, he
often ran in a straight line. The owner was not aware of any medical history prior to his
adoption. The owner stated that since the incident Speedy was having trouble getting around the
house. She did not feel that the dragging of the right hind limb had changed
significantly since it first appeared. Speedy skipped his Halloween dinner but ate well
the morning before presentation. His water intake decreased slightly as well.
The owner felt that Speedy was painful; reacting strongly to touch around the lumbar
spine and right hip.
PHYSICAL EXAMINATION AND CLINICAL ASSESSMENTS
On initial presentation 11/1 Speedy was seen by Dr. Folkers. He was bright, alert, and
responsive with a body condition score of 4 out of 9. The heart and lungs auscultated
normally and the mucous membranes were pink and moist. Tension and muscle
fasciculations were noted on gentle palpation of the thoracolumbar spine. Speedy had
a severe CP deficit of the right hind limb and was not able to correct his right hind paw
when it was placed in a dorsal position. Panniculus response was normal. Patellar
ligament reflexes and cross extensor reflex were not performed. Radiographs of the
thoracolumbar spine and pelvis/coxofemoral joints were discussed with the owner
however were declined at that time. Differential diagnoses at that time were trauma
induced neuropathy, IVDD, fibrocartilaginous emboli, and neoplasia. Dr. Folkers
suspected that the lesion was present at the level of L2-L4 as Speedy was most
sensitive on palpation of this area. Speedy was started on prednisone (10 mg BID hours
for 5 days, then tapering dose), gabapentin (200 mg PO BID), and methocarbamol (500
mg PO q8-12 hours) and sent home with instructions for strict cage rest. Consultation
for acupuncture was scheduled the following day.
On presentation for acupuncture 11/2 Speedy was unchanged per the owner. No
improvement in Speedy’s ability to place the right hind foot had been noted. However,
Speedy was eating well and did seem less painful. Speedy was BAR and appeared
comfortable however severe muscle tension and sensitivity to palpation was
appreciated from the level of T13 to L5. Speedy was also sensitive to palpation of the
right hind limb however this did not appear to be specific to any area. Mild muscle
atrophy of the right hamstring muscles was noted. Speedy had intact withdrawal reflex
in the right hind but this was slightly decreased. Speedy was not able to correct the
right rear paw when flipped to the dorsal aspect. Crossed extensor reflex was not
present and patellar ligament reflexes were within normal limits bilaterally. Cranial
nerve exam was within normal limits. While ambulating Speedy dragged this right hind
paw consistently. Radiographs to assess the spine and rule out a bony mass were
recommended. The owner decided to perform these at Speedy’s follow up acupuncture
visit to decrease stress during his initial treatment.
MEDICAL DECISION MAKING
Given the suspected location of the lesion at L2-L4 and findings on acupuncture exam
there were several goals for treatment:
1. Resolution of muscle pain and inflammation in the L2-L4 region (and the
thoracolumbar region in general) while increasing blood flow and stimulating
return of the tissue to homeostasis
a. Points used for this purpose were BL 21-25. BL 24 was included in this
which I interpreted as being lateral to the caudal border of the spinous
process of the 3rd lumbar vertebra.
2. Stimulate nerves responsible for flexion of the right hind paw
a. Points used for this purpose were KI3, BL 60, LR 3, KI 1 (not really in the
area of the extensors but a good point to stimulate nerve function of the
paw) and the BaFeng points
3. Resolve tension in the right biceps femoris and hamstring muscles as well as
combat muscle atrophy in these groups as much as possible
a. Points used for this purpose were BL54 (added benefit of effects on the
sciatic nerve to promote paw extension indirectly), ST 34, BL 36, and BL
39
4. Resolution of neck pain and tension
a. Points used for this purpose include BL10 and GV14
5. Reduce anxiety and improve quality of life
a. Points used for this purpose include GV 20, GV 14, and Bai Hui
6. Focus on the CPA methodology
a. Central points used included GV 20, GV 14, and Bai Hui. These points
were also included as autonomic points. BL 21-25 could also be included
as central points due to their proximity to the spinal cord. Speedy was
very sensitive at ST 36 so this point was not used as an autonomic point.
b. Peripheral points included the remainder of the points
DIFFERENTIAL DIAGNOSES:
V: Fibrocartilaginous emboli, vascular event
I: Discospondylitis
N: Neoplasia affecting the spine and/or spinal cord
D: Acute exacerbation of spondylosis or osteoarthritis affecting the coxofemoral joint
and/or intervertebral joints
I: Macadamia nut toxicity
C: Cauda equina syndrome, malformation of vertebrae, coxofemoral or lumbosacral
joint malformation
A: Autoimmune polyarthropathy, Immune mediated polyarthritis
T: Trauma, nerve impingement or direct nerve trauma
E: Prothrombotic condition such as Cushing’s disease or chronic renal disease
Myofascia: Muscle tension and pain, soft tissue injury such as tendinitis or strain/sprain
PUTATIVE DIAGNOSIS
At this time we are working with a tentative diagnosis of nerve damage secondary to
trauma, which may be exacerbated by degenerative discs in the thoracic and lumbar
spine. Speedy had no known history of exposure to macadamia nuts. IVDD as well as
a vascular event cannot be ruled out without additional imaging which was declined.
Owner declined blood work to investigate a metabolic cause. A general health profile
consisting of CBC, Comprehensive, and Urinalysis performed 7/2017 was
unremarkable. No evidence of neoplasia or discospondylitis were seen on radiographs.
ACUPUNCTURE TREATMENTS
Initial acupuncture session 11/2 (See medical decision making section above for
rationale of points used):
BL10, left side only
GV20/14
BL20-25 bilaterally
Bai Hui
BL54 right
ST 34 right
KI3/BL 60 right
LR 3 right
Ba Feng right
30mm 0.16 Seirin needles used for all points.
No electrical stimulation or laser therapy was performed. Radiographs of the abdomen,
thorax, and right hind limb as well as the pelvis were recommended; Speedy lost
approximately 3 pounds from his previous visit and I did not feel comfortable performing
laser therapy without investigating the possibility of neoplasia. Radiographs were
scheduled for 11/11 with Dr. Folkers.
Acupuncture session 11/5:
The owner reported that while Speedy was still knuckling the right hind foot he was
beginning to place the foot appropriately every few steps. He had a great appetite and
the owner did not feel that he was painful. On physical exam the muscle tension
associated with the neck was greatly improved as well as the muscle tension over the
spinespine. Mild muscle tension over the lumbar spine remained. Withdrawal reflex on the
right hind was improved approximately 20%. Speedy had developed a dermal wound
on the right foot from dragging the paw. He placed the right hind paw appropriately
about 30% of the time while ambulating.
Acupuncture session:
BL 10 bilaterally
GV20/14
BL 20-25 bilaterally
Bai Hui
ST 34 right
ST 36 bilaterally
LR3 right
KI1 right
Ba Feng right
30mm 0.20 Seirin needles used for all points.
Electrical stimulation:
BL54-ST34 and KI3/lateral Ba Feng point at a mixed setting using 5/25 Hz for 10
minutes. Our e-stim machine is the Pantheon 8c.pro.
Laser therapy: None
Recommendations: Went over PROM exercises with O and how to massage lumbar
spine. O to continue with Gabapentin, Prednisone, and Methocarbamol and recheck in
one week for next acupuncture session. Discussed placement of bootie to protect the
dermal wound and prescribed topical zymox.
On 11/8/17 Speedy was seen for recheck exam with Dr. Folkers. A 40% improvement
in mobility was reported. Radiographs of the spine, abdomen, and thorax were not
performed at that time.
Acupuncture session 11/9/17:
The owner states that Speedy’s ability to appropriately place the right hind paw is
continuing to improve. Muscle tension associated with thoracolumbar spine and neck
has resolved at this point. The right paw is dragged about every other step while
walking which is greatly improved from previous acupuncture exam. There is significant
muscle atrophy of the right hamstring muscles. Speedy had much more control of right
hind limb in general at this time . No changes to withdrawal reflexes were noted in this
exam. Conscious proprioception of the right right hind paw continues to be delayed but
Speedy is able to correct the paw after a short 2-3 second delay.
Acupuncture session:
BL10 bilaterally red
GV20/14 red
BL 20-25 bilaterally red
Bai Hui
BL54 right blue
ST34 right blue
ST36 right blue
KI3/BL 60 right blue
LR 3
KI1 right blue
Ba Feng right blue
red= 0.16 30mm Seirin
blue= 0.20 30mm Seirin
ELECTRICAL STIMULATION:
BL54-ST34, ST26-BL60 and BL60/Ba Feng mixed setting 5/25 Hz for 15 minutes
LASER THERAPY:
No laser therapy was performed. Owner also reported that Speedy is losing weight and
muscle mass despite great appetite. Discussed that this could be due to decreased
activity and neurogenic muscle wasting but I would still like to perform radiographs of
the thoracolumbar spine, abdomen, and thorax to ensure no mass is present, this was
scheduled for 11/11.
Speedy Bruun video 11.9
OUTCOME, DISCUSSIONS, and REFERENCES:
Qualitative:
Speedy’s ability to walk without dragging the right hind paw greatly increased over the
course of treatment but there is still ample room for improvement. During treatment
Speedy developed a dermal wound on the right hind 3rd digit which become infected
and required Clindamycin (300 mg PO BID for 10 days) and a series of dry bandages
for protection. However, the owner feels that Speedy is able to get around well enough
to enjoy his regular routine and does not seem to be in any pain. Speedy is very much
a family dog and is content to simply be around his people. He still goes on short walks
around the neighborhood but we have yet to find a good way to protect his paw from
further wounds as he pulls off socks and booties placed to protect it.
Quantitative:
After the initial acupuncture session Speedy regained the ability to extend the paw.
After the second session he was properly placing the paw every 4th to 5th step while
walking, and this increased to proper placement every 3rd step after the third
acupuncture session. Speedy’s neck and lumbar pain also greatly improved by the
second treatment and appeared to have resolved by the third. Muscle atrophy of the
right hind limb was also subjectively improved at the third acupuncture exam although
goniometry was not performed.
This case was a great introduction to handling lameness. Speedy was very sensitive to
insertion of needles using the tube and I’ve found that the majority of my patients prefer
tubeless insertion so he was a great opportunity to become more comfortable with this.
I also discovered the importance of proactively managing any trauma secondary to a
lameness as I had to deal with the complications of dermal infection. I have also started
using GV20, GV14 and Bai Hui as a starting point for most of my patients due to their
calming effects, which is a technique I learned while working with Speedy.
REFERENCES:
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