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Acupuncture as adjunctive modality to treat symptoms of intervertebral disc disease in a beagle

Posted in Operations @ Aug 13th 2019 2:18pm - By Dr Alison Shen, BVSc (Hons) CVE (IVAS) Aussie Mobile Vet, Brisbane
Acupuncture as adjunctive modality to treat symptoms of Intervertebral Disc Disease in a Beagle

Case Study demonstrating how acupuncture can be successfully integrated into your veterinary practice.

Intervertebral Disc Disease (IVDD) in dogs is one of the common neurological conditions seen in practice [1].

It is caused by displacement of part of the intervertebral disc, often located in the thoracolumbar and cervical region, causing pain and neurological deficits. Most disc lesions (85%) occur in the thoracolumbar region (between T11-T12 and L2-L3) [2], with 50% of all disc lesions occurring at the thoracolumbar junction between T12-T13 and T13-L1 [3].

Treatment options include medical and/or surgical approaches. Regardless of the treatment performed, physical rehabilitation is an important part of the recovery process and acupuncture can play a role as an additional modality for pain relief and enhanced recuperation [4]. 

Disc displacement/ herniation is caused by disc degeneration and can be classified as Hansen Type I or Hansen Type II. Hansen Type I is typically seen in chondrodystrophic breeds [3, 5, 6]. Degenerative change in the discs of these breeds can begin as early as 8 months and continues until 2 years of age [7]. The peak incidence for at-risk breeds is between 4 and 6 years of age [8]. Normal collagen fibres in the nucleus pulposus (NP) are replaced with less elastic hyaline fibres which increase mechanical stress on the annulus fibrosus (AF) as intradisc pressure changes. The collagen fibres of the AF fail and degenerative NP is released into the neural canal. Disc material is extruded into the spinal cord causing haemorrhage, inflammation and oedema. 

Hansen Type II is usually seen in older large breed dogs 5-12 years of age. Fibrous collagen slowly increases in the NP, increasing pressure on the AF [4, 6]. As the AF bulges, it places pressure dorsally, compressing the spinal cord leading to a slow focal myelopathy. 

Acupuncture has been shown to be effective in the management of IVDD though its analgesic effect, preventing muscular atrophy, strengthening muscles, reducing spasticity and enhancing sensory awareness [9]. 

In particular, electroacupuncture (i) integrated with western medicine is effective in managing thoracolumbar IVDD [10]. The local and systemic effects of acupuncture are thought to be due to the release of neurotransmitters (endorphins, dynorphins, serotonin, norepinephrine, dopamine), an increase in blood circulation to regulate inflammation and growth factors, changes in cell signalling and reduction in hyperalgesia and allodynia in patients with chronic and neuropathic pain [11, 12, 10, 13]. 

Murphy’s Story

Murphy is a 10 ½ year old Beagle. Murphy had previously been diagnosed with IVDD in his cervical region at C5-C6 in July 2016. Decompression surgery (ventral slot) was performed and Murphy recovered well.

In January 2019 Murphy’s owner noticed that he was walking oddly with his hindquarters swinging “side-to-side”. On clinical exam there was slight ataxia in both hind limbs and slight lumbar pain on spinal palpation. He had normal CP and superficial pain in both hind limbs (HL) and tail.  There was significant panniculus reflex along his whole spine. He was unable to turn in a tight circle and was resistant to backing up. He was given a meloxicam injection and oral meloxicam to take home. 

Five days later Murphy was represented for HL pain and ataxia. He had not responded to meloxicam. During clinical examination there was no ataxia or proprioceptive deficits in the HL. HL reflexes were normal. There was marked pain on extension of both hips and pain response on the caudal thoracic area and at L1 to L3.

Differential Diagnosis:

  • IVDD (+/- osteoarthritis)
  • Hip Dysplasia (+/- osteoarthritis)

Radiographs:

  • Lateral and VD views of the thoracic and lumbar spine and hips:
  • Collapsed Intervertebral Disc space at T11-12 and spondylosis T12-T13.
  • Hips bilaterally thickened femoral necks (L>R) and osteophytic lipping on caudal acetabulum.

Initial Treatment

Murphy was diagnosed with suspected Grade 1-2 Thoracolumbar IVDD (T11-T12), Hansen Type I. It was recommended Murphy be confined and his movement restricted for 6 weeks. His referring vet prescribed gabapentin and to continue with meloxicam.

Two months later Murphy’s owner felt he was still in some pain and favouring hips and left HL despite the continued gabapentin and meloxicam treatment. There was pain on palpation of T11-T12 and the L-S junction. There was restricted extension of the left hip, and the quadriceps in both hind limbs were very tense. Mild kyphosis in the thoracolumbar area was noted. Acupuncture was recommended as a treatment option.

Treatment with acupuncture

Pain and ataxia (mainly LHL) – 6 weekly sessions of acupuncture – needle, laser (ii) and electroacupuncture.

Points selected: BL40, ST 36, Bai Hui (master point back and waist), BL 60 (“aspirin point”), BL54, GB 30, GB 29, BL 67 (ting), SP6 (damp), LI11 (wind-heat). Local bladder points corresponding with suspected IVDD lesion.

Needle – Bai Hui, BL 11, GB 30, BL 54, GB29

Local bladder points (T11-T13) – needle and electroacupuncture

Laser and electroacupuncture combination (TENS) BL40; ST 36; BL 60; BL 67, SP6, LI 11 – as the patient preferred to stand and not be tightly restrained during therapy, it was decided that a needle-less option would be more suitable for these areas with thinner skin and in the distal limb.

Needle and electroacupuncture - trigger points in Trapezius and Latissimus Dorsi muscle on right side and therapeutic ultrasound therapy.

 

How is Murphy doing today?

Murphy responded immediately after the first session and stopped gabapentin and meloxicam treatment from that point onwards. He had a complete resolution of clinical signs at the 4th week session.  He displays even weight bearing on both HL at rest, walks (slow and brisk), circling and the kyphosis has resolved.

He is currently on a weight loss plan and a pentosan polysulfate (Cartrophen, Biopharm) injection course.

It has been recommended that Murphy continue with regular acupuncture sessions (fortnightly- monthly) depending on recurrence of symptoms.

Conclusion

Murphy is an example of an older patient with a few orthopaedic problems, having previously had a hemilaminectomy in his cervical area, evidence of early arthritis in his hips and spondylosis T12-T13. It is common in these patients to have pain on palpation with muscular hypercontraction elsewhere, associated with an over-compensation for the weaker limb(s), back and muscle atrophy. Addressing this referred pain is just as important as treating the condition, to balance and strengthen all the muscles of the patient.

Acupuncture and its different modalities are very useful in addressing the pain associated with IVDD. Electroacupuncture can be used specifically to target muscles to prevent disuse atrophy as well reduce spasticity [9].

Laser and TENS acupuncture are viable options for patients that are adverse to needles, in patients that may be non compliant to sitting still for 20 minutes or in areas where needling is difficult.

Acupuncture is a useful additional treatment modality for rehabilitation and pain management of patients with intervertebral disc disease.

(a)   (b)                                

 (a) Seirin Acupuncture needles and Pointer Pulse (laser and TENS) and Therapeutic ultrasound 

(b) Intelect Vet (electrotherapy, laser and therapeutic ultrasound)

(i) Electroacupuncture involves application of a gentle electrical current to several acupuncture points to produce a more vigorous and prolonged stimulation to the needles. The electrical current can be applied to the acupuncture needles at either a high or low frequency, to produce different effects on systemic neuromodulation [10].

(ii) Laser (photobiostimulation), instead of a needle, is used to stimulate the acupuncture points [14].

References:

[1] D. Slatter, Textbook of Small Animal Surgery, 2nd ed., WB Saunders Co, 1993. 

[2] J. Coates, "Intervertebral Disk Disease," Veterinary Clinics of North America: Small Animal Practice, vol. 30, no. 1, pp. 77-110, 2000. 

[3] J. Joaquim, "Acupuncture for Treatment of Intervertebral Disc Disease," in WSAVA World Congress Proceedings, 2009. 

[4] D. Millis and D. Levine, Canine Rehabilitation and Physical Therapy, 2nd ed., Elsevier Inc, 2013. 

[5] M. Lorenz and J. Kornegay, Handbook of Veterinary Neurology, 4th ed., Saunders, an Imprint of Elsevier, 2004. 

[6] N. Jeffery, J. Levine, N. Olby and V. Stein, "Intervertebral Disc Degeneration in Dogs: Consequences, Diagnosis, Treatment and Future Directions," J Vet Intern Med, vol. 27, pp. 1318-1333, 2013. 

[7] J. Griffin IV, J. Levine and S. Kerwin, "Canine Thoracolumbar Intervertebral Disk Disease: Pathophysiology, Neurologic Examination, and Emergency Medical Therapy," Compendium of Continuing Education for Veterinarians, pp. E1-E13, March 2009. 

[8] J. Fingeroth and W. Thomas, Eds., Advances in Intervertebral Disc Disease in Dogs and Cats, John Wiley & Sons, Inc, 2015. 

[9] C. Zink and J. Van Dyke, Canine Sports Medicine and Rehabilitation, 2nd ed., John Wiley & Sons, 2018. 

[10] L. Fry, S. Neary, J. Sharrock and J. Rychel, "Acupuncture for Analgesia in Veterinary Medicine," Topics in Companion Animal Medicine, vol. 29, no. 2, pp. 35-42, 2014. 

[11] N. Silva, S. Luna, J. Joaquim, H. Coutinho and F. Possebon, "Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases," Canadian Veterinary Journal, vol. 58, no. 9, pp. 941-951, 2017. 

[12] Z. Zhao, "Neural Mechanism Underlying Acupuncture Analgesia," Prog Neurobiol, vol. 85, pp. 355-375, 2008. 

[13] S. Park, Y. Sunwoo, Y. Jung, W. Chang, M. Park, Y. Chung, L. Maeng, Y. Han, H. Shin, J. Lee and S. Lee, "Therapeutic Effects of Acupuncture through Enhancement of Functional Angiogenesis and Granulogenesis in Rat Wound Healing," Evid Based Complement Alternat Med, 2012. 

[14] D. Gross, "Topical Review: Introduction to Therapeutic Lasers in a Rehabilitation Setting," Topics in Companion Animal Medicine, vol. 29, no. 2, pp. 49-53, 2014.  

About Alison

Alison is a University of Sydney graduate (2005) and a small animal veterinarian in Brisbane. She completed her Certification in Veterinary Acupuncture though IVAS in 2008.

She currently runs a mobile vet business in Brisbane, Aussie Mobile Vet, focusing on acupuncture and rehabilitation therapies for small animals.

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