Acupuncture used to Treat Frustration and Pain after OCD Surgery on Stifle

By:

Sanna Immonen

Finland

cimmonen@gmail.com

ABSTRACT

Acupuncture treatment was succesfully used to alleviate frustration derived from the restricted exercise after osteochondrosis dissecans surgery in a Borzoi. Dry needle acupuncture therapy was used as weekly sessions altogether three times. After every treatment owner reported reduced signs of frustration. Lameness didn´t improve in this time and the owner stopped the treatments. One week after the last treatment the owner informed that the dog was finally sound.

HISTORY

A one year old bitch Borzoi was presented for an acupuncture treatment with a history of 10 months of lameness of the right hind leg. Originally the dog had hurt its leg when 3 months old when three dogs collided together. As a 4 month old the dog was diagnosed with OCD on the medial condyle of right femur and recommended surgery as soon as possible.

Dog was operated as 8 month old and the cartilage piece was removed. Dog has been on gabapentin, intermittent meloxicam and restricted excercise since the OCD diagnosis. After surgery dog had physiotherapy and later visits at dog masseuse, but dog was still lame 4,5 months after the surgery.

CLINICAL SIGNS – WESTERN

At the first presentation the dog was still lame on right hind leg. Less muscles on the right leg and the leg often placed on outer rotation, but no swellings or other joint abnormalities found. On clinical examination the dog had fractured upper right third incisive. No other abnormal findings.

CLINICAL SIGNS – TCM

Degree of the lameness varies over time but the dog is never totally sound. Owner reported many signs of frustration. Dog barks inside, seems quite frustrated and wakes the owner early in the morning with restless walking.

Right hind leg rotates outwards and has less muscle compared to the left leg. The dog also stands most of the time with scoliotic curve with the right side being the concave side.

Tongue seems very short in the mouth even the dog is panting and the tongue colour is little purplish.

Both Shu- and Mu-points of Gallbladder were sensitive. Liver and Stomach had only Back Shu-points sensitive. GB 27 and ST 30 were both bilateraly sensitive. Endoscopy scars on the right knee were also examined, but there was no sensitivity found.

Pulse diagnosis was not done.

DIAGNOSIS – TCM

Diagnosis of Qi Stagnation of Gallbladder and Liver was done based on sensitive Shu- and Mu-points, sensitive GB 27 and hip area and obvious frustration certainly compromising the Liver functions of moving Qi1 and further on increasing the pain16.

Second diagnosis of Kidney Jing Deficiency was also made based on the bone and tooth problems starting at very young age2.

CONVENTIONAL TREATMENT

The owner continued with the gabapentin treatment concurrently with the acupuncture treatments, but no meloxicam was given during the acupuncture treatment period.

TCM TREATMENT

Dry needling was used during all sessions. In first session silicon coated Korean type needles were used and rest of the sessions were done with metal Shen Long needles, both 0,2 mm x 15 mm. Needle retention time was about 10 to 20 min.

First session treatment

On the first session the treatment principle was to relieve pain in the hind end and move Qi stagnation to also help with the pain and lameness but also alleviate the frustration.16

Gallbladder was my main target, so GB 34 was chosen it being also the Influential point for Sinews.3 GB 34 also benefits the Liver function of patency of the flow of Qi, strengthens the caudal back and extremeties, helps with hindlimb pain and weakness and is local point for stifle problems.3 GB 34 was treated in left side so as the healthier leg because the dog showed obvious ah-shi -reaction in the left side but not on the right.

LIV 3 was put to right hind leg because it promotes flow of Liver Qi, calms Mind and alleviates spasms.4 I thought it was important to support the movement of Qi, both for relieving the pain and also because of the serious frustration that this young dog was suffering with the restricted exercise. Liver and Gallbladder points also work effectively together supporting each other.5

Following the ballanced method, I chose Triple Heater and Heart points in front. Triple Heater works in the same energetic level (Shao Yang) with the Gallbladder6 and was therefore supporting the Gallbladder-treatment. TH 14 on right side was chosen to balance the points from the hind legs and this point is at the same joint level as the hips.19 Because the dog was very sensitive on the hip area, I didn´t want to use local needles there, especially on the first treatment so I chose the same level from the front. From the Heart Channel I chose HT 7 to balance the treatment and most importantly to calm the Shen.7

First session results

After first treatment the owner reported that the dog seemed less frustrated and barking less inside the house. There was no significant improvement noticed on the lameness by the owner or by me before the second session.

Second session examination, diagnosis and treatment

On the second time Gallbladder Shu- and Mu-points were still sensitive, but the hip area locally was not so sore anymore. Muscle triggers near the spine at level of BL 22 and BL 23 was also found. Based on the TCM-examination the diagnosis of Stagnation of Gallbladder and Liver stayed the same.

In the second session the points on hind legs were the same GB 34 and LIV 3 as in the first session, but this time I chose to concentrate more on Liver and so I changed the front meridians to Large Intestine and Lung.

LI 4 was chosen because it promotes calming, alleviates spasms and pain, activates Qi8 and with Liv 3 (the 4 Gates) it´s good for soreness in all joints of the extremities4.

LU 5 was chosen for the Yin front point because it relaxes the Sinews9, is at the same joint level with stifles19 and it balances the Liver -treatment.

Muscle triggers were treated locally. I felt that the triggers were located inside the first Bladder-line so they most propably were Hua Tua Jia Ji -points. They were treated bilateraly at the level between the 1st and 2nd lumbar vertebra and on the left side at the level between the 2nd and the 3rd lumbar vertebra.

Second session results

After second treatment the owner reported that the dog had started sleeping better. It didn´t wake up the owners as early as it had done before. Previously the dog started nervous walking around the house really early. On the leash walks owner had noted the dog having some new, strange movement on the right hind leg. I supposed that the dog started to use the leg more, but the tendons and ligaments were propably little weak with the lack of use. This strange movement disappeared in few days. The lameness was still quite the same.

Third session examination, diagnosis and treatment

On the third session TCM-examination there was no sensitive MU- or Shu-points found. There were still triggers bilateraly at BL 21 and on BL 22 on the left side and some sensitivity at GB 27 bilateraly. Because the evident stagnation of the Liver ja Gallbladder had started to resolve, the treatment was targeted at the underlying Kidney Jing deficiency. The main goals for the treatment was to Tonify the Kidney, treat the hind end, the stifle locally and to calm the Shen.

KI 3 was selected as the Source point of the Kidney to tonify the Kidneys and strengthen the caudal back.10 KI 3 was needled trough to reach the Bl 60 at the same time to remove obstructions from the Bladder channel11 as the dog had the triggers on the inner Bladder line and to relaxe tendons and alleviate pain.

BL 40 was used in the righ hind leg as a local point for the stifle and because it´s the Master point for the Caudal Back and Hip region12, which were the problem areas of this dog. BL 40 also removes obstructions from the Bladder channel12 so as to enhance the actions of the BL 60 on the other side.

LI 10 was chosen to balance the Kidney treatment. LI 10 regulates and tonifies Qi and Blood13 and is located at the same joint level with the stifle19.

PC 3 was selected because it moves Blood, calms the Mind14 and is located at the same joint level with stifle19, balancing the Kidney treatment.

BL 11 was used bilaterally as a Influental point for Bone15, because of all the bone and tooth problems that the dog had. BL 11 also soothes Sinews and eases pain15, which was ideal for this case.

In addition to the acupuncture treatment on the third visit, I recommended that maybe this dog would benefit from the chiropractic treatment because the dog seemed so crooked and had been lame for such a long time.

Acupuncture points used

Location

Indications

GB 34, Yang Ling Quan

In the depression cranial and distal to the head of the fibula.

Influential point for Sinews, benefits the Liver function of patency of the flow of Qi, strengthens the caudal back and extremeties, hindlimb pain and weakness, stifle problems.3

LIV 3, Tai Chong

In the depression on the dorsum of the rear foot, between the 2nd and 3rd metatarsal bones, at the level of the junction of their heads and shaft, just proximal to their associated metatarsophalangeal joints.

Promotes flow of Liver Qi, calms Mind and spasms.4

HT 7, Shen Men

In the depression on the transverse crease of the carpal joint, lateral to flexor carpi ulnaris and superficial digital flexor tendons.

Calms the Shen, clears the channels.7

TH 14, Jian Liao

In the depression caudodistal to the acromion, on the caudal margin of the acromial head of the deltoideus m.

Shao Yang -level with Gb and on the same joint level with hips.6, 19

LI 4, He-Gu

In the depression between the 1st and 2ndmetacarpal bones, approximately in the middle of the 2nd metacarpal bone on the radial side.

Promotes calming, alleviates spasms and pain, activates Qi, with LIV 3 (the 4 Gates) good for soreness in all joints of the extremities8, balancing Liver treatment24.

LU 5, Chi Ze

In the depression on the transverse cubital crease, just lateral to the tendon of the biceps brachii m.

Relaxes the Sinews9, same joint level with stifles, 19 balancing Liver treatment24.

KI 3, Tai Xi

In the depression cranial to the

tuber calcanei, at approximately

the midpoint of a line drawn from

the tip of the medial malleolus to

the point of insertion of the

common calcanean tendon.

Source point, tonifies the Kidneys, strengthens the caudal back.10

BL 40, Wei Zhong

In the depression of the popliteal fossa at the midpoint of the transverse crease, in the division of the biceps femoris and the semitendinosus mm.

Master point for the Caudal Back and Hip region, removes obstructions from the channel and helps also stifle locally.12

BL 60, Kun Lun

In the depression cranial to the tuber calcanei, at approximately the midpoint of a line drawn from the tip of the lateral malleolus to the point of insertion of the common calcanean tendon.

Removes obstructions from the channel, relaxes tendons, alleviates pain.11

LI 10, Qian-San-Li

In the depression in the muscular groove between the extensor carpi radialis and the common digital extensor mm. of the forelimb, 2 cun distal to the transverse cubital crease.

Regulates and tonifies Qi and Blood13, same joint level with knees, 19 balancing Ki treatment.

PC 3, Qu Ze

In the depression on the transverse cubital crease, medial to the tendon of the biceps brachii (elbow flexed).

Moves Blood, calms the Mind14, same joint level with knees, 19 balancing Ki treatment24.

Hua Tuo Jia Ji

between 1st and 2nd and 2nd and 3rd lumbar vertebras

1 cun lateral to the mimidline, in the intercostal or intervertebral spaces of the spine, from the 1st thoracic vertebra to the last lumbar vertabra.

Locally for muscle triggers.

BL 11, Da Shu

In the depression 1.5 cun lateral to the caudal border of the spinous process of the first

thoracic vertebra, mid-way from the spinous process to the medial border of the scapula.

Influental point for Bone, soothes Sinews and eases pain15.

DISCUSSION

A one year old bitch Borzoi was presented for an acupuncture treatment with a history of 10 months of lameness of the right hind leg. Originally the dog had hurt its leg as a 3 month old puppy. As a 4 month old the dog was diagnosed with OCD on the medial condyle of right femur and recommended surgery in another veterinary clinic. Dog was operated as 8 month old and the cartilage piece was removed. Dog had been on gabapentin, intermittent meloxicam and restricted excercise since the OCD diagnosis. After surgery dog had physiotherapy and later it was treated dy dog masseuse, but dog continued to be still lame 4,5 months after the surgery.

In the examination the dog was lame on right hind leg, had less muscles on the right leg and the leg was often placed on outer rotation. No swellings or other palpable joint abnormalities were found. The dog was also standing most of the time with scoliotic curve with the concave side on the right. On clinical examination the dog had fractured upper right third incisive. The dog was barking inside, seemed frustrated and woke the owner very early in the morning with restless walking. The pain getting worse after long rest is a sign of stagnation getting even worse while the dog is resting.17 In TCM-examination tongue seemed very short and the tongue colour was purplish indicating stagnation20. Both Shu- and Mu-points of Gallbladder were sensitive in first and second session and the dog was sensitive around the hip area on both sides and especially in Gallbladder-meridian. Endoscopy scars on the right stifle were not sensitive and there was no sensitivity found locally in stifles.

Diagnosis of Qi Stagnation of Gallbladder and Liver was done on the first and second visit. Purple tongue indicated the stagnation20 which was ofcourse evident by the pain also. Gallbladder Shu- and Mu-points, Gb 27 and hip area were also sensitive indicating that the main meridian involved was Gallbladder. I added Liver also because in the first session the Liver Shu-point was also sensitive and that obvious frustration was certainly compromising the Liver functions of moving Qi1,16. The pain and frustration had been going on such a long time that I was convinced that Liver had a essential part in this situation. Second diagnosis of Kidney Jing Deficiency was made based on the bone and tooth problems starting at very young age.2 Also in the examination Kidney Shu- and Mu-points were not at all reactive, like there was nothing in there, supporting the idea of deficiency state in the Kidneys. However I felt it was more relevant for this dog to treat the pain causing problem first and concentrate on the underlying deficiency later18 when the dog would be more comfortable.

The dog was under gabapentin treatment concurrently with the acupuncture treatments, but the owner felt no need for meloxicam during this period of time.

On the first and second session the treatment principle was to relieve pain on the hip area and hind legs and move Qi stagnation to help with the pain and lameness but also alleviate the frustration.16 GB 34 and LIV 3 was chosen in the first and second session. GB 34 being the Influential point for Sinews.3 GB 34 also benefits the Liver function of patency of the flow of Qi, strengthens the caudal back and extremeties, helps with hindlimb pain and weakness and is local point for stifle problems.3 GB 34 was treated first time in left side because the dog showed obvious ah-shi -reaction in the left side but not on the right. Probably the ”better” leg was more strained with overuse and therefore showing the ah-shi -reaction.

LIV 3 was chosen because it promotes the smooth flow of Liver Qi, calms the Mind and alleviates spasms.4 I thought it was important to support the movement of Qi, both for relieving the pain and also because of the serious frustration that this young dog was suffering with the restricted exercise. Liver and Gallbladder points also work effectively together supporting each other while Liver moves the Qi more in the inside and Gallbladder more in the outside of the boby.5

Following the ballanced method24, I chose Triple Heater and Heart points in front. Triple Heater works in the same energetic level (Shao Yang) with the Gallbladder6 and was therefore supporting the Gallbladder-treatment. TH 14 was chosen because it is at the same joint level as the hips.19 Because the dog was very sensitive on the hip area, I didn´t want to use local needles there, especially on the first treatment so I chose the same level from the front. From the Heart Channel I chose HT 7 to balance the treatment24 and most importantly to calm the Shen.7

On the second time Gallbladder Shu- and Mu-points were still sensitive, but the hip area locally was not so sore anymore. Muscle triggers near the spine at level of BL 22 and BL 23 was also found. In the second session the points on hind legs were the same GB 34 and LIV 3 as in the first session, but this time I chose to concentrate more on Liver and so I changed the front meridians to Large Intestine and Lung. GB 34 and LIV 3 were placed in opposite legs than in the first treatment because the dog didn´t have an oppinion on which leg to use so I changed the sides.

LI 4 was chosen because it promotes calming, alleviates spasms and pain and activates Qi.8 With LIV 3, LI 4 forms ”the 4 Gates” and it´s good for soreness in all joints of the extremities.4 Even though I used them only unilateral in this case. LU 5 was chosen for the Yin front point because it relaxes the Sinews9, is at the same joint level with stifles19 and it balances the Liver -treatment24.

Muscle triggers were treated locally with dry needling21. They were treated bilateraly at the level between the 1st and 2nd lumbar vertebra and on the left side at the level between the 2nd and the 3rd lumbar vertebra.

Diagnosis staying the same after first treatment confused me a little. Somehow I expected to find something more different, but thinking about it afterwards it´s understandable that after such a long course of trouble and lameness it´s not going to recover that quickly.

On the third session TCM-examination there was no sensitive MU- or Shu-points found, only triggers bilateraly at BL 21 and on BL 22 on the left side and some sensitivity at GB 27 bilateraly. Because the stagnation of the Liver ja Gallbladder resolving, the treatment was targeted at the underlying Kidney Jing deficiency. The main goals for the treatment was to Tonify the Kidney, which had propably caused all the trouble in the first place. Keep supporting the hind end and to calm the Shen, because the dog was still lame and on restricted exercise.

KI 3 was selected as the Source point of the Kidney to tonify the Kidneys and strengthen the caudal back.10 KI 3 was needled trough to the BL 60 at the same time to remove obstructions from the Bladder channel as the dog had the triggers on the inner Bladder line and to relax tendons and alleviate pain.11

BL 40 was used in the righ hind leg as a local point for the stifle and because it´s the Master point for the Caudal Back and Hip region12, which were the problem areas of this dog. BL 40 also removes obstructions from the Bladder channel12 so as to enhance the actions of the BL 60 on the other side. I hoped that it would help to resolve the triggers in the back if I used Bladder meridian on both sides, both points removing obstructions because the earlier local treatment wasn´t sufficient.

LI 10 was chosen to balance the Kidney treatment24. LI 10 regulates and tonifies Qi and Blood13 and in the elbow area it is located at the same joint level with the stifle19. In general I thought it´s usefull to tonify Qi and Blood in any deficiency to get better nourishment of the tissues and better function of the organs.

PC 3 was selected because it moves Blood, calms the Mind14 and is located at the same joint level with stifles,19 balancing the Kidney treatment.

BL 11 was used bilaterally as a Influental point for Bone,15 because of all the bone and tooth problems that the dog had. BL 11 also soothes Sinews and eases pain,15 which was ideal for this case. I also reasoned that with all the pain in the hind end dog must have put more weight to the front, which had caused the dog to be quite stiff in the front part and this point could help locally with that.

During the treatment period we got some nice reduction in the frustration behaviours of the dog. After the first treatment the owner reported less barking inside the house. After second session the owner told that the dog had started to sleep better and didn´t wake up the owners as early as it did before. Unfortunately we didn´t get any proper improvement of the lameness during this time. The owner canceled the fourth session and wanted to have a brake with acupuncture despite the couraging results with the emotional side. One week after the last treatment the owner reported that the dog was finally sound and she had stopped the gababentin medication.

It was quite unfortunate that we didn´t get better pain management results in this period of time but I also doupt that it wouldn´t have been even realistic to wait such a miracle. The dog had been suffering pain for such a long time and using it´s body in unbalanced way. I informed the owner that after such a chronic problem it would be expected that the recovery will take longer time also and that we can´t asses the efficacy of the acupuncture in this case after only three sessions of treatment.23

Obviously the dog was in need of other solutions when it was still lame after surgery and normal pain medications. Also thinking about other surgery patients, acupuncture has lot to give. With acupuncture treatment one can release both physical and emotional stress, activate anti-inflammatory mechanisms, accelerate soft tissue healing and treat the pain.22

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