IVDD in a 3-Year-Old Dachshund

Dominique Matthews, DVM, cVMA

ABSTRACT

A young Dachshund presented with acute rear limb paralysis and loss of voluntary motor function of urination. A putative diagnosis of acute disc herniation secondary to chronic intervertebral disc disease (IVDD) was made following physical examination and spinal radiographs. After careful consideration, surgical intervention was declined in the pursuit of medical management and alternative therapies including, but not limited to acupuncture, electrical stimulation, cold laser therapy, and targeted pulsed electromagnetic therapy. Within one month, significant improvements in rear limb mobility were noted in addition to regained control of bladder function and improved quality of life.

HISTORY AND CHIEF COMPLAINTS:
Maggie, a 3-year 8-month-old female spayed Dachshund, first presented on the evening of November 11, 2021 with chief complaints of abnormal breathing, mild lethargy, and slow movements which had all started within the previous 48 hours. Maggie had taken a 12-hour car ride with her owners on the 9th. Maggie’s odd behaviors started that evening with trembling and slight lethargy, which her owners contributed to possible anxiety related to the long trip. On the morning of the 10th, she had a small amount of mucous in her otherwise normal bowel movement, but did not have any new problems. She continued trembling and being mildly lethargic. By the afternoon of the 11th, Maggie had seemed to be moving in slow motion, which was extremely out of character for her normally energetic self and she was reportedly ‘gasping for air’. When Maggie was picked up, she seemed very stiff and tense and her ‘gasping’ intensified so her owners presented her immediately.

On physical examination, Maggie was ambulating normally with all four limbs with no ataxia or proprioceptive deficits, but was found to be holding her neck outstretched and stiff with slow shallow breathing. There was no identifiable nasal foreign material and her heart and lung auscultations were within normal limits. The clinician noted some pain on palpation of Maggie’s thoracic spine, ranked as a 2/4 on Colorado State University’s Canine Acute Pain Scale. There were no other abnormal physical exam findings aside from stage 1 periodontal disease and a severe overbite. Primary rule outs were intervertebral disc disease (IVDD) versus nasal discomfort. Due to the lack of neurological signs, Maggie was treated conservatively. Maggie’s thoracic spine received a cold laser treatment and she was prescribed strict rest along with a short tapering course of prednisone and methocarbamol.

Maggie subsequently presented on the morning of the 12th with additional chief complaints of inability to use her rear limbs and leaking urine. The ability to use her rear limbs was lost around 10 PM on the evening of the 11th.  On the morning of the 12th, a puddle of urine was found where Maggie was lying overnight and Maggie would leak urine whenever she was picked up. Maggie still presented with her neck outstretched and shallow breathing.

Maggie had no history of previous trauma, IVDD, or significant falls to explain her presenting clinical signs. There were no diet changes and there was no exposure to toxins. She had maintained her appetite and did not have any coughing, sneezing, vomiting, or diarrhea. She had a long history of characteristically being exuberant and active with a lot of jumping onto and off of furniture, repeatedly bouncing on her rear limbs at dinnertime, and being active in the yard with the other three family Dachshunds. Maggie did not have any history of complications related to IVDD nor had any previous surgeries aside from her spay as a puppy. She was otherwise considered to be a healthy adult pet, not taking any medications or supplements.

PHYSICAL EXAMINATION AND CLINICAL ASSESSMENT:

On examination, Maggie was found to be quiet, alert, and responsive and of normal body condition with normal vital signs. She was lacking all voluntary motor function in her rear limbs with thoracolumbar kyphosis and warmth. She continued to sit holding her neck outstretched as previously noted the night before. Her pain score was again noted to be 2/4 with thoracolumbar palpation. She was unable to use her rear limbs to walk (dragging rear limbs) nor was she able to support weight when her rear limbs were placed in a normal standing position. Bilateral rear limb muscles were generally toned. Proprioception was completely lost in both rear limbs as were placing and postural reactions. Her panniculus reflex was lost around T13-L1 bilaterally and she was lacking a perineal reflex. She had a slight response to deep pain when pinching toes on the left rear limb, evidenced simply by slight exacerbation of neck outstretching (no vocalization or withdrawal), but questionable deep pain in the right rear limb. She maintained normal ambulation, muscle tone, and reflexes of her forelimbs and she allowed complete range of motion of her neck with no notable discomfort. Her tail was limp and there was no obvious voluntary motor control of her tail. Her urinary bladder palpated of normal shape and size, but was rather flaccid leading to expulsion of urine with the application of light manual pressure. She would occasionally dribble small amounts of urine when dragging her rear along the floor, but would not constantly leak urine.

Radiographs of the cervical, thoracic, lumbar, and sacral spine were obtained. Radiologist interpretation revealed multiple areas of moderately narrowed intervertebral discs (T10-11 and T12-13) suspect secondary to chronic intervertebral disc disease. There was a poorly marginated angular mineral opacity superimposed with the spinal canal dorsal to the mid body of T13 that may have represented extruded disc material versus summation of vertebral features. Additionally, there were multifocal mild to marked well-defined mineralization of the cervical, thoracic, and lumbar intervertebral discs in situ, worse in the lumbar spine. The urinary bladder was noted to be moderately distended displacing the colon dorsally and the small intestine cranially. No other radiographic abnormalities were identified. Given the reported myelopathy and described radiographic findings, intervertebral disc extrusion was suspected and most likely to have occurred at T12-13.

PROBLEM LIST:

Acute Paraplegia (T3-L3 Lesion)

Loss of Panniculus Reflex @ T13-L1 (T3-L3 Lesion)

Loss of Withdrawal Reflexes in Pelvic Limbs (L6-S1 Lesion)

Urinary Incontinence (S1-S3 Lesion)

Loss of Perineal Reflex (S1-S3 Lesion)

Loss of Tail Tone & Mobility (S1-S3 Lesion)

DIFFERENTIAL DIAGNOSES:

Acute Paraplegia:

V – Vascular – Fibrocartilaginous Embolism
I – Infectious – Discospondylitis (bacterial vs fungal – Staphylococcus, Streptococcus, Brucella, Escherichia coli vs Aspergillus vs Blastomyces vs Histoplasma vs Coccidioides)
N – Neoplastic – Spinal Cord Neoplasia (extramedullary vs intramedullary – peripheral nerve sheath tumor, meningioma, lymphoma, fibrosarcoma, osteosarcoma, multiple myeloma)
D – Degenerative – Intervertebral Disc Disease, Lumbosacral Stenosis, Spondylosis Deformans
I – Iatrogenic/intoxication – Tick Paralysis, Botulism
C – Congenital – Atlantoaxial Instability, Chiari-Like Malformation with Syringomyelia
A – Autoimmune – Meningoencephalitis (granulomatous vs necrotizing vs idiopathic eosinophilic)
T – Traumatic – Intervertebral Disc Disease, Vertebral Fracture, Luxation/Subluxation

E – Endocrine/metabolic – Degenerative Myelopathy, Diabetic Neuropathy, Hypothyroidism

Urinary Incontinence:

V – Vascular – Fibrocartilaginous Embolism
I – Infectious – Discospondylitis, Cystitis, Myelitis (Distemper vs fungal vs bacterial)
N – Neoplastic – Spinal Cord Neoplasia (extramedullary vs intramedullary – peripheral nerve sheath tumor, meningioma, lymphoma, fibrosarcoma, osteosarcoma, multiple myeloma), Bladder Neoplasia, Prostatic Neoplasia
D – Degenerative – Intervertebral Disc Disease, Lumbosacral Stenosis, Senescence (age-related degeneration)
I – Iatrogenic/intoxication – Marijuana Toxicosis, Prednisone, Dysautonomia, Ureterovaginal Fistula
C – Congenital – Ectopic Ureter, Patent Urachus
A – Autoimmune – Meningoencephalitis (granulomatous vs necrotizing vs idiopathic eosinophilic)
T – Traumatic – Intervertebral Disc Disease, Vertebral Fracture (causing traumatic spinal cord injury), Luxation/Subluxation

E – Endocrine/metabolic – Diabetes Mellitus, Cushing’s, Kidney Disease, Hypothyroidism, Urethral Sphincter Mechanism Incompetence, Testosterone Deficiency, Obesity

PUTATIVE DIAGNOSES:

With Maggie’s signalment, acute history supportive of pain, the host of neurological deficits found on physical examination, and the radiographic findings related to her spine, a putative diagnosis of Hansen Type I intervertebral disc disease was made with confidence. Chondrodystrophic breeds, particularly Dachshunds, have an increased predisposition to IVDD in comparison to other differential diagnoses listed above. Both the fact that she is a chondrodystrophic breed and also of a young age, combined with the radiographic finding of numerous locations of intervertebral disc mineralization and physical exam findings (TL pain and kyphosis), help to classify her disc disease as Hansen Type I as opposed to Hansen Type II which is generally more common in larger older breed dogs.

Maggie’s signalment and radiographs alone can discount the majority of other differential diagnoses. For example, there was no evidence of vertebral neoplasia, vertebral fractures or luxations, or congenital anatomic abnormalities related to the vertebral column on radiographs. Although neoplastic processes within the spinal cord itself cannot be completely ruled out without more advanced diagnostics (CT/MRI), her youth makes neoplasia a less likely diagnosis. And although fibrocartilanginous embolism (FCE) and degenerative myelopathy (DM) cannot be definitively ruled out either, FCE & DM are more common ailments of large breed dogs and are rare in small breed dogs.

Maggie was also lacking multiple presenting clinical signs and appropriate history that would be necessary for diagnosis of many other differentials such as meningoencephalitis (not experiencing any seizures, mentation changes, blindness, cranial nerve deficits, cervical pain, fever, etc.), botulism (no history of toxin ingestion, no cranial nerve deficits), or tick paralysis (no history of recent tick exposure, lacking progress to flaccid tetraplegia). Other differential diagnoses, including infectious etiologies and endocrine/metabolic etiologies, would require additional diagnostics to definitively rule out. Nevertheless, the supporting evidence for Hansen Type I IVDD was overwhelming in Maggie’s case.

Maggie’s primary problem, acute paraplegia and accompanying loss of panniculus around T13-L1, and her radiographic findings supported a primary lesion location at T12-13 leading to a T3-L3 neuropathy (TL IVDD). It is suspected, based on neurological deficits (loss of perineal reflex and tail tone) and a urinary bladder falling into the lower motor neuron (LMN) category, that Maggie may have also had some nerve impingement or damage in the sacral spinal segments between S1-3.

MEDICAL DECISION MAKING:

Diagnostic and treatment options considered for putative IVDD included advanced imaging modalities (CT/MRI/Myelography) with pursuit of surgical intervention versus conservative management with strict rest, pharmaceuticals (prednisone and gabapentin), nutraceuticals (Adequan – polysulfated glycosaminoglycan injections) and alternative therapies (acupuncture, electrical stimulation, cold laser therapy, and targeted pulsed electromagnetic therapy). After careful consideration of risks and prognosis associated with either option, conservative management was elected. This decision resulted largely from the fact that Maggie had numerous areas of concern for future disc herniations, no guarantee for good recovery of mobility post-operatively, and the acute presentation of her clinical signs, combined with the finding of deep pain perception (although slight – Maggie was deemed to be a very stoic dog!).

MEDICAL ACUPUNCTURE AND RELATED TECHNIQUES:

Treatment was initiated during Maggie’s visit on the 12th of November. It was recommended to treat Maggie with a tapering course of prednisone for anti-inflammatory purposes in addition to a two-week course of gabapentin to address neuropathic pain (see details below). Supplementation with Adequan was initiated and recommended for lifelong use. Maggie’s owners purchased an Assisi Loop for at home use to be administered on a tapered schedule (see details below). Acupuncture was recommended once weekly with cold laser therapy recommended three times weekly for two weeks, then decreased to twice weekly for 3 weeks. Treatment duration lasted 7 weeks. A total of 8 weekly acupuncture/cold laser/tPEMF treatments were completed (an additional acupuncture treatment was given during the first week of treatment) with one to two additional cold laser treatments per week (7 additional laser treatments, for a total of 15 laser treatments).

Acupuncture Points over Maggie’s dorsum were selected primarily based on the area of kyphosis, which correlated with radiographic problem areas. BL18-23 addressed the area of kyphosis cranially to caudally for effects central nervous system. BL25 was added during some sessions to address midlumbar pain. BL27 and BL28 were also added to address dysfunction correlated with the S1-S2 spinal segments. GV14 & Bai Hui were commonly used to help balance the treatment and to address the central & autonomic nervous systems. Peripheral points used included BL60, BL35, and Bafeng. Seirin 0.20x30mm needles were used to treat BL18-23 (bilateral), GV14, and Bai Hui. Seirin 0.16x15mm were used to treat BL27, BL28, BL35 and BL60 (bilaterally), and Bafeng (bilateral). Cold laser therapy and tPEMF were applied to Maggie’s thoracic, lumbar, and sacral spine during each acupuncture session. Details of each treatment are provided in table 1 (Medical Acupuncture and Related Techniques).

OUTCOME:
Maggie showed significant improvement in mobility and function of her rear limbs, tail, and urinary control by the end of her treatments. Her initial two acupuncture treatments did not result in any notable increase in mobility or function, but her dorsum was significantly more comfortable once acupuncture was added to her treatment plan; medications alone were not controlling her pain or discomfort. Maggie began to regain mobility after her third acupuncture treatment, two and a half weeks after initial presentation. Her overall mobility, comfort, spirit, and quality of life continued to improve with subsequent treatments comprised of cold laser therapy, acupuncture, and electrical stimulation.

DISCUSSION:

This case study demonstrates the benefits that can be obtained from acupuncture (and electroacupuncture), cold laser therapy, and tPEMF for the treatment of a rather complicated case of IVDD. Acupuncture is thought to be largely responsible for the success of this case by aiding in the control of central and peripheral pain during the acute phase and enhancing natural healing mechanisms through its effects on the neuroendocrine system and its regulation of inflammation. Over the years, there has been a multitude of research validating the positive effects resulting from treatment with acupuncture in both humans and animals. Among veterinary studies, there have been repeated cases establishing the host of benefits in treating neurological disorders, least of which is IVDD. Maggie is yet another case example supporting that a multi-modal treatment approach of canine IVDD can result in a similar, if not quicker, return to function and comfort than with surgical intervention. Overall, acupuncture and related therapies resulted in decreased pain, improved motor and neurological function, and increased quality of life. Maggie’s owners were thrilled with the outcome.

References:

  1. Hayashi AM, Matera JM, Pinto AC. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc. 2007;231:913–918.
  2. Joaquim JGF, Brondani JT, Luna SPL, Torelli SR, Rahal CR, Freitas FP. Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. J Am Vet Med Assoc. 2010;236:1225–1229.
  3. Nuno et al. Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases. Can Vet J. 2017 Sep; 58(9): 941–951.
  1. 26. Still J. Analgesic effects of acupuncture in thoracolumbar disc disease in dogs. J Small Anim Pract. 1989;30:298–301.

 

TABLE 1: MEDICAL ACUPUNCTURE AND RELATED TECHNIQUES:

Nutraceuticals Instituted on 11/12/2021:

  • Adequan 100mg/mL – administer 0.30 mL SQ twice weekly for 1 month, then once weekly for 1 month, then every other week for 1 month, then once monthly long-term.
  • Assisi Loop (tPEMF) 2.0 20cm Manual – use over TL & LS spine three times daily for 2 weeks, then twice daily for 2 weeks, then once daily for 2 weeks, then as needed

Pharmaceuticals Instituted on 11/12/2021:

  • Prednisone 5mg: 1 tablet by mouth twice daily for 10 days then once daily for 7 days then every other day for 3 doses
  • Gabapentin 100mg: 1 capsule by mouth every 8-12 hours as needed for pain for 14 days

Cutting Edge MLS (Multiwave Locked System) Therapeutic Laser Settings: IVDD setting, point mode. Photoype: black. Total Joules: 225.389. Dose: 3.99 J/cm2. 18 Hz. 75% Intensity. Lasered directly over the paravertebral muscles of thoracic, lumbar, and sacral segments (T10 caudally, bilaterally).

Jing Mei (JM-2A) Electro-Acupuncture Stimulator Settings: Intensity: 2, Frequency: 2 (x10), Time: 20 minutes

Treatment #1, November 12, 2021:

Cryotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), GV14, Bai Hui

Electrical Stimulation: BL18-23 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Maggie 11 12 First Treatment with Electroacupuncture and Assisi Loop

Maggie’s Inability to Walk (MOVIE)

Treatment #2, November 13, 2021:

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), GV14, Bai Hui

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Progress: Maggie was visibly more comfortable with more movement of her thoracic limbs and neck. She displayed a notable increase in deep pain sensation on the left side with a mild deep pain response on the right side. Remains paraplegic with limp tail and continues to lack voluntary control of urinations.

Treatment #3, November 15, 2021:

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Progress: No notable changes in comfort or mobility from previous visit. Maggie remains paraplegic with limp tail and continues to lack voluntary control of urinations. Maggie developed diarrhea, suspect secondary to treatment with prednisone. Pro-Pectalin was prescribed to remedy.

Treatment #4, November 17, 2021:
Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Progress: No notable changes in comfort or mobility from previous visit. Maggie’s diarrhea is improving with the Pro-Pectalin.

Treatment #5, November 18, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: HWATO 0.20x30mm: BL18-24 (bilateral), GV14, Bai Hui,

Acupuncture: Seirin 0.16x15mm: BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-24 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Maggie 11 18a Second Treatment with Electroacupuncture and Assisi Loop

Progress: No notable changes in comfort or mobility from previous visit. Maggie remains paraplegic with limp tail and continues to lack voluntary control of urinations.

Additional Recommendation: Start passive range of motion exercises on all 4 limbs and matchstick exercises on bilateral rear limbs at home. Owners purchased a stroller with securing straps to take Maggie on walks in an attempt to lift her spirits.

Side Note: Maggie did not seem to tolerate the HWATO needles as well as the Seirin needles, so subsequent acupuncture treatments will be performed with Seirin needles.

Treatment #6, November 19, 2021:

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Progress: No notable changes in comfort or mobility from previous visit. Maggie remains paraplegic with limp tail and continues to lack voluntary control of urinations.

Treatment #7, November 22, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), BL25 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-25 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Progress: No notable changes in comfort or mobility from previous visit. Maggie remains paraplegic with limp tail and continues to lack voluntary control of urinations.

Additional Recommendation: Continue passive range of motion exercises on all 4 limbs and matchstick exercises on bilateral rear limbs at home. Owners report Maggie enjoys the stroller, but wants to sniff around. Gave owners a donated wheelchair from a previous patient of similar size for use in the yard at home.

Treatment #8, November 30, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), BL25 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-25 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Maggie 11 30 Third Treatment with Electroacupuncture and Assisi Loop

Maggie 11 30a Third Treatment with Electroacupuncture and Assisi Loop

Progress: Maggie is able to hold her rear limbs under her when placed in standing position and she is able to utilize them to walk, however she is ataxic in the rear limbs and knuckles bilaterally. Her rear limbs will buckle underneath her if she loses balance. There is notably improved proprioception bilaterally (still delayed) and slight perineal reflex present (ventral to anus). Her tail remains generally limp, but has occasional slight movements. She continues to lack voluntary control of urinations (still leaking) and her urine is malodorous. Owner reports Maggie licking her vulva frequently at home. Owner reports she has regained some of her personality and her spirits are improved (barking more and tearing around the yard in the wheelchair).

Additional Recommendation: Continue passive range of motion exercises on all 4 limbs and matchstick exercises on bilateral rear limbs at home. Amoxicillin 50 mg/mL initiated – 2 mL by mouth twice daily for 14 days.

Side Note: Gabapentin was discontinued on 11/27/2021.

Treatment #9, December 7, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), BL25 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-25 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Progress: Maggie is able to stand on her own and consistently hold her rear limbs under her. She remains ataxic when walking and crosses her rear limbs underneath her, however she is no longer knuckling. Proprioception has normalized bilaterally and perineal reflexes are present circumferentially. She is able to wag her tail. Owner reports no urinary accidents in the home or urine leaking in general over the past week, however Maggie ends up in a sitting position when attempting to defecate. Owner reports it has been more difficult to perform PROM and matchstick exercises with Maggie because she wants to walk around on her own.

Additional Recommendation: Continue passive range of motion exercises on all 4 limbs and matchstick exercises on bilateral rear limbs at home. OK to start taking Maggie on short controlled leash walks. Emphasized stairs, jumping, and playing are permanently off limits.

Side Note: Prednisone discontinued.

Treatment #10, December 10, 2021:

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Treatment #11, December 16, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), BL25 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-25 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Progress: Maggie’s mobility continues to improve. She remains ataxic when walking, but is no longer seen constantly crossing her rear limbs underneath her. Crossing of the rear limbs remains when attempting turns. Mobility of her tail continues to improve. Owner reports no fecal or urinary accidents in the home over the past week, however Maggie ends up in a sitting position when attempting to defecate. Owner reports it has been more difficult to perform PROM and matchstick exercises with Maggie because she wants to walk around on her own.

Additional Recommendation: Continue passive range of motion exercises on all 4 limbs and matchstick exercises on bilateral rear limbs at home, if Maggie will allow. Initiate gentle swaying exercises while Maggie is eating.

Side Note: Prednisone discontinued.

Treatment #12, December 21, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-23 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Progress: Maggie’s mobility continues to improve and she is moving more quickly. She remains ataxic when walking, but to a lesser degree. Occasional crossing of the rear limbs occurs. The nails of digits 3 & 4 on bilateral rear limbs are significantly worn, but not bleeding. When Maggie attempts to walk quickly, her rear limbs cannot keep up with her forelimbs and she knuckles/scuffs her rear digits. When walking at a controlled pace, there is no scuffing. She is wagging her tail more frequently. Maggie’s TL epaxial musculature palpated tender today.

Additional Recommendation: Continue matchstick and swaying exercises. Initiate sidestepping, if able. Galliprant initiated for anti-inflammatory effects: 10 mg by mouth once daily.

Treatment #13, December 22, 2021:

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Treatment #14, December 27, 2021:

Thermotherapy: thoracic, lumbar, and sacral spine x 5 minutes

Acupuncture: Seirin 0.20x30mm: BL18-23 (bilateral), GV14, Bai Hui

Acupuncture: Seirin 0.16x15mm: BL27 (bilateral), BL28 (bilateral), BL60 (bilateral), BL35 (bilateral), Bafeng (bilateral)

Electrical Stimulation: BL18-23 (bilateral) x 20 minutes

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

Assisi Loop (tPEMF): TL spine (15 minute cycle) & LS spine (15 minute cycle)

Maggie Can Walk Again (MOVIE)

Progress: Maggie’s mobility continues to improve. She remains ataxic in both rear limbs. The nails of digits 3 & 4 on bilateral rear limbs remain worn due to knuckling/scuffing of her rear digits when attempting to walk at a fast pace. She continues to have good tail mobility. Maggie’s TL epaxial musculature did not palpate tender.

Additional Recommendation: Continue matchstick, swaying, and sidestepping exercises.

Treatment #15, December 29, 2021:

Cold Laser Therapy: thoracic, lumbar, and sacral spine on IVDD setting

**Therapy to be continued in the owner’s home state of NJ.**