case report.2 lucie - bevas · 1 case report 2017 ‐ 2018 course belgium acupuncture used to treat...

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CASEREPORT

2017‐2018COURSE

Belgium

ACUPUNCTUREUSEDTOTREATACUTENON‐SEPTICKNEEARTHRITISINABERNESEMOUNTAINDOG

Lucie DEVEUGLE Bordeaux (33)

FRANCE +33.6.10.96.11.53

[email protected]

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TITLE Acupuncture was used to treat acute non-septic knee arthritis in a Bernese Mountain Dog. ABSTRACT Acupuncture therapy was used to treat acute non-septic knee arthritis in a Bernese Mountain Dog. A traumatic cause was suspected. Two dry needling sessions in a weekly interval were performed. The knee pain, the swollen and the lameness improved after the first treatment. A discreet pain especially after rest and a discomfort, when the knee was extended by force during manipulation, were still observed but disappeared after the second session. HISTORY Hikky, a 6,5 years old, male Bernese Mountain dog, 48 kg, was presented in November 2018 for an acute lameness of the right hind leg. He was in good health and ran every day in the yard. His owners noticed that he suddenly started to lame when he came back home after a day passed in the garden. Two days after, they came to the clinic for a consultation. Hikky obviously had pain on the right hind leg. He did not put down his leg and support on it. The knee was painful on the manipulation. The joint was a little bit swollen and warm. The drawer test was negative. First, a medical treatment of NSAIDs (Meloxicam 9mg q24) was given and Hikky had to rest for 10 days. After this time, despite the medication and the rest, Hikky was still lame and painful. He came back to the clinic and he was sedated to do X-rays. The drawer test was still negative and the joint swollen and warm. On knee X-rays (AP and lateral views, see below), signs of inflammation were seen. Hikky was referred to an orthopedic specialist. He recommended and practiced a knee arthroscopy, a joint puncture and a synovial membrane biopsy. A bacteriological analysis on the synovial membrane was sent and came back negative. The arthroscopy (see below) did not reveal any ligament or meniscal lesions. A rupture of the cruciate ligament was also rejected. The synovial fluid shown a high white blood cell count but no bacteria and the bacteriological analysis on the withdrawn synovial membrane was negative. A diagnosis of an acute non-septic knee arthritis was made. A traumatic origin was suspected. NSAID's and Chondroprotectors were prescribed and a more severe recommendation of rest was highly recommended (the rest was not well respected after the first consultation). After that, the owners of Hikky came back to the clinic and ask for an acupuncture treatment.

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CLINICALSIGNS/DIAGNOSIS–TCM(EASTERN) Hikky is a friendly dog adopted at the age of two months. He is peaceful at home and spends the day in the garden. He loves digging some holes in it and chasing cars. The knee pain and lameness started suddenly in November 2018. The symptoms worsened after long rest. The lameness and pain were described by the owners as severe and constant. He was still playful but shown hesitating movements. When he sat, he kept his right hind leg laterally. The knee pain seemed the same no matter weather conditions. He not often barked, only when cars go ahead the garden. His voice was loud. Hikky slept well and usually preferred hard bedding. He also preferred a cold, shady place to lie down. He is fed with commercial high-quality dry food. He loves to eat and does it very fast. He does not drink a lot, but when he is drinking, he drinks big amounts. His stool and urine consistency and rate are normal. Hikky is friendly and loves to be petted. He is a little bit agitated and nervous when an examination is performed but does not show any aggressivity. Hikky is robust, little bit overweighted, has a quite good coat quality and strong nails. Hikky is an Earth constitution1. On examination, Hikky's tongue appearance was red with a thin white coating. His pulse was rapid, superficial and strong and it was equal between the right and left legs. His Association Gall Bladder and Liver points were a little bit sensitive but not the Alarm Gall Bladder and Liver points. At the palpation of the right thigh, the cranial and lateral aspects of the biceps femoris muscle were tense. A hyperirritable locus (AhShi point) was present in the region of the GB 33 acupoint. A diagnosis of Heat Bi Syndrome2 with Excess pain3 and Qi Stagnation on the Gall Bladder Tendinomuscular Meridian was made based on the following findings :

– acute onset of the clinical symptoms – swelling and warm knee joint – severe and constant knee pain worsened with pressure – Ah‐Shi point on the Gall Bladder Meridian pathway – tenseness in the cranial and lateral aspects of the biceps femoris muscle – red tongue with thin white coating – rapid, superficial and strong pulse

CONVENTIONAL(WESTERN)TREATMENT Meloxicam (Metacam®) 9 mg q24 PO was previously prescribed before the first acupuncture session and stopped after the second acupunture session and was given for a duration of 3 weeks. Chondroprotectors; Glucosamine chlorhydrate 1g, Chondroitine sulfate 760 mg and Curcuma extract 100 mg (Seraquin®) q24 PO were added to the prescription after the orthopedic examinations for a month, just before the first acupuncture session.

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TCM(EASTERN)TREATMENT Principles: Heat Bi Syndrome4 :

– Clear Heat – Remove obstruction from the channel – Expel Wind, Resolve Damp – Invigorate the Channels

Excess Pain3 :

– Disperse the Stagnation – Invigorate the Channels – Eliminate the EPF – Treat any Liver Qi Stagnation

Acupuncture: Dry Needle Acupuncture Treatment using 0,20 mm x 15 mm copper wired handle, silicone-coated needles were placed at a depth of 5 mm, using an identical needle technique at all points. These needles remained in place for 10-15 minutes. The same needles and technique were utilized for each session. Points: GB41Zu Lin Qi

In the depression distal to the junction of the 4th and 5th metatarsal bones, on the lateral side of the tendon of the extensor digitorum longus muscle

Shu-Stream and Wood/Element point. Opening point for the Dai Mai, Coupled point for the Yang Wei Mai Distal point Clears Damp Heat and promotes the smooth flow of Liver Qi Useful for pain and stiffness in the hindlimb (especially the hip and stifle)5

LIV3Tai 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

Source, Shu-Stream and Earth Point Distal point Promotes flow of Liver Qi, extinguishes interior Wind, calms the mind and spasms6

TH5Waiguan

In the depression 2 CUN proximal to the carpus, on the cranial aspect of the interosseous space between the radius an ulna

Opening point for the Yang Wei Mai, Coupled point for the Dai Mai, Connecting (Luo) point Expels Wind Heat, removes obstructions of the channel7

GB33 In the depression just proximal to the Expels Wind, resolves Damp, removes

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Xi Yang Guan

lateral condyle and caudal to the lateral epicondyle of the femur. This point is found between the lateral epicondyle and the tendon of the biceps femoris muscle with the stifle flexed

obstructions from channel, relaxes sinews and benefits joints Local point/Ah‐Shi point Good point fort stifle stiffness, pain and swelling, especially on lateral aspect or involving the ligaments and tendons in that area8

PC3Qu Ze

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

He-Sea and Water point Clears Heat, cools and moves Blood, calms the Mind9

KneeEyesXIYANMedial XIYAN and Lateral XIYAN (ST35 Dubi)

In the depression distal to the patella, one point medial and one point lateral to the patellar ligament. Also referred to as the Lateral XIYAN (Lateral Eye of the Knee) or Dubi (Calf 's Nose). ST 35 and medial XIYAN together make up the traditional point, XIYAN

Local points, Expel Wind-Damp and stifle issues. Good points for stifle pain, especially when the pain is deep inside the joint and Painful Obstruction Syndrome (Bi Syndrome) of the knee10,11

Treatments: December3rd,2018: RightGB41 was selected first as a distal point to clear Damp Heat and to promote the smooth flow of Liver Qi. GB 41 is a Shu-Stream point and therefore it is helpful with Bi Syndromes to clear the pathogenic factors and alleviate pain5,12. RightTH5was chosen as distal point too. It is the Opening point for the YangWeiMai and the Coupled point for the DaiMai. TH5 has access to all the Yang channels making it one of the most effective points for expelling all pathogens from the Exterior, Wind, Cold, Heat, Summer-Heat and Damp. Moreover, TH5 via its connections with the Gall Bladder Channel, allows access to the sides of the body and the lower limbs. With its ability to expel pathogenic factors, TH5 can be used for pain of the limbs. TH5 combined with GB 41 has a better effect in treating the body from the head to toe7,12. Ah‐Shi pointnearGB33 was used as a local point to direct the flow of Qi and Blood to the affected area. GB 33 had the following properties : it expels Wind, resolves Damp, removes obstructions from channel, relaxes sinews and benefits joints . It is a good point for stifle stiffness, pain and swelling, especially on lateral aspect or involving ligaments and tendons in that area8. LeftPC3, front Yin point, was used in this case to have a balanced prescription13. This point clears Heat, cools and moves Blood and calms the Mind9. December10th,2018: The owners noted that, three days after the first acupuncture session, Hikky was more comfortable. He was less lame and putted some weight on his right hind leg. The lameness mostly appeared after a long rest. He sat back again in a normal way. On examination, his tongue was less red and his pulse still rapid but less superficial. The Ah‐Shi point was gone and the biceps femoris was softer to touch. The joint felt at a moderate temperature but still slightly swollen. The anti-inflammatory medication was stopped but chondroprotectors were still given for three weeks.

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The following acupuncture points were chosen to continue the treatment. RightLIV3. I decided to change GB 41 for LIV 3 because the Ah‐Shi point on the GB Meridian was gone and I wanted to have a more balanced prescription with a rear Yin point. It was used like GB 41 as a distal point to clear Heat. Furthermore, LIV 3 is a major point, it promotes flow of Liver Qi. It has a specific action in calming spasms, contractions and cramps of the muscles. It is a Shu-Stream point and so, has the property to alleviate pain and to clear pathogenic factors. It is also a Yuan-Source point that can be used for specific Bi problems as well as knee pain6. RightTH5was needled again for the reason mentioned above7,12. MedialXIYAN and LateralXIYAN (ST35) were needled as local points instead of the Ah‐Shi point because it was no tenser. These extra points are chosen to expel Wind, Damp and are used for stifle pain, especially when the pain is in the front of the stifle or deep inside the joint10,11. LeftPC3 was needled again for the reason mentioned above9. The symptoms have completely disappeared two or three days after the second session. Chondroprotectors were finally given for a month. Today, the lameness did not reappear so far. A diet prescription was recommended in order that Hikky lose some weight. DISCUSSION A 6,5 years old male Bernese Mountain Dog was presented with an acute knee pain and lameness, worsening with rest. The joint was swollen and warm to touch. The symptoms appeared suddenly after a day passed in the garden. A presumptive diagnosis of arthritis was established according to the acute onset of the symptoms, the palpation of a red and swollen knee joint, as well as the signs of inflammation on X-rays. An anti-inflammatory medication was prescribed based on NSAID's therapy (Meloxicam 9 mg q24) at the time of the first consultation but did not improve the symptoms, encouraging the realization of complementary examinations. Hikky was referred to an orthopedic specialist who performed an arthroscopy, a joint puncture revealing a high white blood cell count but no bacteria and a bacteriological analysis on the withdrawn synovial membrane. In the Western examination, Hikky was bright and alert and in good condition even if an overweight was noted. He could stand but walk without putting down the right hind leg. The clinical and neurological examinations did not reveal abnormality. The orthopedic examination revealed a right hind leg lameness. The right knee joint was a little bit swollen and warm on the palpation. An acute pain was noted when the knee joint was fully extended. The drawer test was negative. There was a tenseness in the lateral and cranial aspects of the biceps femoris. The other joints had normal range of motion. He did not have muscle atrophy. No Bloodwork was performed. AP and lateral views of the knee X-rays were done and revealed inflammation signs on the joint but no other lesions. Knee arthroscopy revealed only signs of inflammation on the joint. There were no ligament or meniscal lesions. Bacteriological analysis on the withdrawn synovial membrane was negative. A rupture of the cruciate ligament was rejected. From a Western point of view, a diagnosis of acute non-septic arthritis was made based on the results of the anamnesis, the orthopedic and complementary examinations. A traumatic origin was suspected according to Hikky's lifestyle.

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Hikky is a friendly dog adopted at the age of two months. He is peaceful at home and spends the day in the garden. He loves digging some holes in it and chasing cars. The knee pain and lameness started suddenly in November 2018. The symptoms worsened after long rest. The lameness and pain were described by the owners as severe and constant. He was still playful but shown hesitating movements. When he sat, he kept his right hind leg laterally. The knee pain seemed the same no matter weather conditions. He not often barked, only when cars go ahead the garden. His voice was loud. Hikky slept well and usually preferred hard bedding. He also preferred a cold, shady place to lie down. He is fed with commercial high-quality dry food. He loves to eat and does it very fast. He does not drink a lot, but when he is drinking, he drinks big amounts. His stool and urine consistency and rate are normal. Hikky is friendly and loves to be petted. He is a little bit agitated and nervous when an examination is performed but does not show any aggressivity. Hikky is robust, little bit overweighted, has a quite good coat quality and strong nails. Hikky is an Earth constitution1. On examination, Hikky's tongue appearance was red with a thin white coating. His pulse was rapid, superficial and strong and it was equal between the right and left legs. His Association Gall Bladder and Liver points were a little bit sensitive but not the Alarm Gall Bladder and Liver points. At the palpation of the right thigh, the cranial and lateral aspects of the biceps femoris muscle were tense. A hyperirritable locus (AhShi point) was present in the region of the GB 33 acupoint. A TCM diagnosis of Heat Bi Syndrome2 with Excess pain3 and Qi Stagnation on the Gall Bladder Tendinomuscular Meridian was made based on the following findings :

– acute onset of the clinical symptoms – swelling and warm joint – severe and constant knee pain worsened with pressure – Ah‐Shi point on the Gall Bladder Meridian pathway – tenseness in the cranial and lateral aspects of the biceps femoris muscle – red tongue with thin white coating – rapid, superficial and strong pulse

Indeed, in this case, the pain, the acute onset of the lameness oriented towards a Bi Syndrome. From a TCVM perspective, pain is Stagnation of Qi or Blood or a combination of both. It may affect one channel or many. It may be the result of trauma or an underlying imbalance in Yin and Yang that manifest as a musculoskeletal disease14. In this case, a trauma was suspected because of the sudden onset of the symptoms and the Hikky's lifestyle (overweight, all day passed in the yard running, digging holes and chasing some cars). A trauma injury is an Excess type of stagnation and can cause Qi and Blood Stagnation15. It is important to define the patient's type of stagnation. To make the difference between Qi or Blood Stagnation, we refer to different characteristics of pain as well as the time of attack, the nature, the tongue and the pulse. Hikky's pain occurred in daytime, his tongue was red and his pulse rapid, superficial and strong. So, Qi Stagnation was mostly suspected16. Pain can also be classified as either Excess (Shi) or Deficiency (Xu). This classification system compares the relative strenght of the WeiQi or ZhengQi or anti-pathogenic Qi to the amount of pathogenic factors. Patients with Excess Pain have healthy, strong levels of ZhengQi, but are overwhelmed with excess amounts of pathogenic factors in their environments. In this case, it's clearly an Excess type even if the overweight of Hikky might be a predisposing factor. Indeed, the acute onset, the fixed location, the severe, constant and worsening after rest

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characteristics of the pain consolidate this Excess type. Furthermore, the severe pain, worsened with pressure, the swollen joint and the feeling of warm in the knee area as well as the red tongue and rapid, superficial and strong pulse evoke a Heat Bi or Febrile Painful Obstruction (ReBi). Heat Bi can be caused by the invasion of Wind, Damp and Heat. It can also develop as a sequel of one of the previous three patterns2. Finally, following the work of Donald Kendall, OMD and Michelle Tilghman, DVM, CVA and their work about the muscles associated with each Sinew Channel, the Ah‐Shi sensation near GB 33, the tenseness of the cranial and lateral aspects of the biceps femoris and the painful forced extension of the stifle leave to think that the Gall Bladder Meridian is at least involved17. As discussed above, Hikky suffers from a Heat Bi Syndrome with Excess pain and Qi Stagnation on the Gall Bladder Tendinomuscular Meridian. To formulate the point prescription for Bi Syndrome, two fundamental principles should be followed when selecting acupuncture points. First, select and include distal points and points specific to the Bi Syndrome pattern. That is why GB 41 was selected first. GB 41 clears Damp Heat and promotes the smooth flow of Liver Qi. It should be kept in mind that in Bi Syndrome, one pathogenic factor may be more predominant but all three are usually present. Therefore, all pathogenic factors (Wind, Cold and Damp) must be expelled3. GB 41 is a Shu-Stream point and Shu-Stream points are extremely helpful with Bi Syndromes because it is where Qi “pours” into the channels, the flow of Qi increases and deepens within the channels. Shu-Stream points are where the external pathogenic factors are “transported” deeper into the channels and the Interior. Therefore, they help to clear them and alleviate pain18,19. The second fundamental principle for the point prescription for Bi Syndrome is to select points on Yang Channels. It is respected with GB 41, point along a Yang Channel and it is known more effective in moving Qi and Blood compared to Yin points, especially for the Yang Shu-Stream points20. Shu-Stream points expel also pathogenic factors from the Jing Luo, preventing the migration of the pathogenic factors into the Zang‐Fu Organs20. Another distal point was needled, TH 5 is the Opening point for the YangWeiMai and the Coupled point for the DaiMai. As the YangWeiMai travels from the rear limb at BL 63 to the head, it connects all six Yang channels and the Governing Vessel. Yang corresponds to the exterior portions of the body. As the Confluent/Opening point, TH 5 has access to all the Yang channels making it one of the most effective points for expelling all pathogens from the Exterior, Wind, Cold, Heat, Summer-Heat and Damp. Moreover, TH 5 via its connections with the Gall Bladder Channel, allows access not only to the sides of the head, but to the sides of the body and the lower limbs. With its ability to expel pathogenic factors, TH 5 can be used for pain of the limbs. Moreover, TH 5 combined with GB 41 has a better effect in treating the body from head to toe12. The third selected point is a local point. Local points “direct” the flow of Qi and Blood to the area. They support and focus the eliminating action of the distal points21. During the first session, it was the Ah‐Shi point near GB 33 that was needled. GB 33 had the following properties : it expels Wind, resolves Damp, removes obstructions from channel, relaxes sinews and benefits joints . It is a good point for stifle stiffness, pain and swelling, especially on lateral aspect or involving ligaments and tendons in that area8. I suspected to have similar effect needling near this acupoint. At the second session, the Ah‐Shi point was gone and that is why the extra points XIYAN (Medial and Lateral XIYAN or ST 35) were chosen instead. These points are both local points. They expel Wind, Damp and are used for stifle pain, especially when the pain is in the front of the stifle or deep inside the joint. Finally, in this case, PC 3, front Yin point, was used to have a balanced prescription13. It is also located on the elbow, same joint level that stifles (mirror effect). This point clears Heat, cools

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and moves Blood and calms the Mind. During the second session, to have a more balanced prescription and because the Ah‐Shi point on GB Meridian was gone, GB 41 was replaced by LIV 3. Moreover, LIV 3 promotes flow of Liver Qi, calms Mind and spasms. It is a Shu-Stream point and so, has the property to alleviate pain and to clear pathogenic factors. It is also a Yuan-Source point that can be used for specific Bi problems as well as knee pain. For Excess Patterns, like Hikky's case, the ideal treatment protocol is to place the distal points first (to disperse the stagnation), followed by the more proximal points (addressing the pattern issues)22. It is respected in these points selections. Acupuncture is useful in musculoskeletal disorders by creating segmental, circulatory, local humeral, systemic humeral and descending effects. Basically, the needle injury creates a local histamine release which stimulates nociceptors activating reflex arcs to the spinal cord to affect proprioception and spasm. The local release of histamine creates an increase in local circulation to aid in bringing anti-inflammatory agents and blood to resolve ischemic trigger points. The segmental and descending pathways also affect proprioception which can aid the body by increased use of the injured area and reducing prolonged guarding and spasm which may impair healing23. Scientifically,therearemanywaysinwhichacupuncturehasbeenshowntoinfluencethebody.Theeffectsofacupuncturecannotbeexplainedbyasinglemechanism.Acupuncturerepresentsaform of nerve stimulation. The needle insertion leads to micro‐trauma of the tissues. Theacupuncturemechanismsinregardtothenervoussystemcanbesubdividedinlocal(peripheral),segmental (spinal) and suprasegmental (supraspinal) mechanisms24. Local effects lead tovasodilatation and increase in blood flowwhichmay helpwith pain removal and to supporthealingmechanisms.Italsoleadstorelaxationofthemusclesandtissuesinthetreatedarea25.Inthesegmentalandsuprasegmentalmechanisms,acupuncturestimulatesnerveendingswhichinturn alters segmental and suprasegmental spinal pathways.This leads to changeswithin thebrainstem and the cortical regions and eventually affects the entire neural axis24. Themostimpressivesuprasegmentalmechanismisthereleaseofendogenousopioids26.ThelocalpointsIusedforthetreatment(Ah‐ShipointnearGB33,MedialandLateralXIYAN)ledtoasegmentalpainascendinginhibitoryresponsethroughtheGateControlMechanism.Thistypeofanalgesiaisproducedprimarilyonlylocallyandismoreintensethandistalnon‐segmentalneedling.Itusesthe local reactions of acupuncture.With the distal points (GB 41, LIV 3 and TH 5) a strongsupraspinalpain‐descendinginhibitoryresponseisactivatedtroughstimulationofAδfibresandsubsequent endogenous opioids release by stimulation of the midbrain and hypothalamuspituitary27.

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REFERENCES

1. Snijders, Albert. The 5 Constitutions. BEVAS Power Point Course Notes (2017) : 3. 2. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.14 –

15.15. 3. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.11. 4. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.24. 5. Schafer, Richard A. Getting Started in Small Animal Acupuncture : Acupuncture Points

and Meridians. IVAS Course Notes : Session 1 (2016) : 8.57. 6. Schafer, Richard A. Getting Started in Small Animal Acupuncture : Acupuncture Points






and Meridians. IVAS Course Notes : Session 1 (2016) : 8.12. 12. Delores T, Craig. Empirical Points. IVAS Course Notes : Session 1 (2016) : 30.10. 13. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.18. 14. Todd, Gregory. Acupuncture for Musculoskeletal Diseases. IVAS Course Notes : Session

3 (2016) : 24.2. 15. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.8. 16. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.10. 17. Boggie, Linda. Sinew Channels. IVAS Course Notes : Session 4 (2016) : 35.7. 18. Marsden's, Steven P. Points having Special Actions : Transporting, Entry and Exit,

source, Lower Uniting, Xi-Cleft, Connecting, Alarm, Extra, Influential, Four Seas, and Command Points. IVAS Course Notes : Session 1 (2016) : 6.11.

19. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.27. 20. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.29. 21. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.20. 22. Delores, Craig. Bi Syndrome or Bi Zheng. IVAS Course Notes : Session 2 (2016) : 15.28. 23. Todd, Gregory. Acupuncture for Musculoskeletal Diseases. IVAS Course Notes : Session

3 (2016) : 24.1. 24. Gutiérrez-Cepeda, L. Neurophysiology and Acupuncture. Pain and Neuropathology.

BEVAS Veterinary Acupuncture Hybrid Course (2017-2018) : 28-29. 25. Gutiérrez-Cepeda, L. Neurophysiology and Acupuncture. Pain and Neuropathology.



BEVAS Veterinary Acupuncture Hybrid Course (2017-2018) : 39-40.

case report.2 lucie - bevas · 1 case report 2017 ‐ 2018 course belgium acupuncture used to treat...

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