In experimental studies acupuncture appears to have a modulating effect on immune function. This may be via endorphin release and similar to the effects of exercise.
Atopy and pruritus in general causes such significant suffering in dogs (especially) that it would be useful to know whether acupuncture can really have an effect on this condition and if so, what proportion of patients may respond and how quickly?
In my pain clinic population I do not see cases that are presented with atopy as the primary complaint, but some patients being treated for chronic pain have concurrent atopy. Patients that appear to respond to acupuncture in terms of pain relief do not always respond in terms of relief from their atopy, but sometimes they do. Recently, at my clinic in Stirling (Broadleys Veterinary Hospital) I started treatment of a little dog who has been suffering with atopy for years and is still suffering despite autogenous vaccine. This year she has been particularly affected and has licked the hair off both carpi (must make a note to do before and after photos!) – the attached photo shows where the previously areas are starting to grow back. Over four weeks, the owner has observed a gradual but significant reduction in her licking. We are now starting to reduce the frequency of her treatment.
It is my intention to treat a series of these cases to get an impression of whether further study is warranted.
Any comments positive or negative from colleagues in general practice would be appreciated.
One of the most common questions asked by both vets and owners is whether there is any merit in treating degenerative myelopathies with acupuncture.
These are distressing conditions not least because the patient usually appears healthy, bright and active but gradually loses control over its hindlegs and is eventually unable to walk and sometimes incontinent.
From what we understand about these diseases and about acupuncture it is unlikely that acupuncture will have a direct positive effect on these conditions, but there are other aspects to consider.
These diseases are often complicated by concurrent problems such as chronic disc prolapse and degenerative joint disease, both of which are also common in the breeds affected. Additionally, dogs affected with CDRM and related conditions commonly have pain in the caudal back muscles because these are the ones trying to stabilize the hindquarters as the animal gets up and moves about.
Therefore, it is not surprising that there are reports of improvements when these patients are treated with acupuncture.
It is also recognized that these conditions may “plateau” for long periods and if this period coincides with when acupuncture is started it will appear that the treatment has arrested the progress of the disease.
In conclusion, it is worth examining these patients for sources of pain and treating these. It is not unusual to see improvements after acupuncture, but it is vital to keep emphasizing to owners that, as far as is understood, the disease will progress regardless of our intervention and the best we can do is keep the patient comfortable as it does so and perhaps maintain its mobility for longer if we can remove or reduce sources of pain.
A Texel ram is treated for secondary muscular lumbar pain, gluteal pain and stifle pain after injury and cruciate rupture. The photo above shows needles in trigger points along the inner bladder line, over GB30 and a needle in ST36; there is also one in BL54/40 out of sight. The wool was parted and the skin visualised to be clinically clean before inserting 40 x 0.25mm Seirin needles to a depth of between 20 to 25mm.
Holstein Friesian cow being treated segmentally for the pain of mastitis and pain associated with a septic joint. In this case the sacral area was swabbed and cleaned and more local areas avoided because they were too difficult to clean and the risks involved with needling outweighed any possible benefit. The needles used were 50 x 0.30mm Seirin needles with guide tube. Needling direction was down towards the sacrum in a very poorly muscled animal.
All this talk of sharks for some reason reminded me of a cartoon some of you may remember from the Foundation Course (I know there were lots) of the “organic acupuncture” and the patient speared by numerous swordfish. The cartoon was used to illustrate the point that one of the difficulties with acupuncture research is that acupuncture is not the same the world over, or even between practitioners taught in the same way. There is no specific “dose” of acupuncture as there is a dose of aspirin or meloxicam, and different techniques may even be almost unrecognizable as acupuncture (“laser” acupuncture, swordfish acupuncture). This means that unless acupuncture is defined for a given study and, further than this, what techniques were used (“robust” needling, electroacupuncture, superficial needling) judging the study or report, and being able to repeat its effects, will be impossible.
But how does this relate to practical, clinical acupuncture? It is just that it is worth remembering the factors that contribute to the “dose” of acupuncture a patient receives. Firstly, the patient is a factor –whether they are a “good responder” or not (I defined this in a recent blog). A few needles, placed moderately deeply and stimulated a couple of times may turn out to be a big dose for a good responder who may be worse initially before improving dramatically. For most normal responders such an approach would probably have little or no effect. Then there is what the acupuncturist does with the needles – depth of placement; diameter of needles; the use of “lift and thrust” movements to stimulate; targeting of myofascial trigger points; the addition of electrical stimulation. Additionally, our veterinary patients tend to move about much more than do human patients, thus stimulating the points further as the needle tips alter position.
There may be other, subtler factors: if the clinician is a good responder themselves or very sensitive to the needles (i.e. feels a lot when the needles are inserted) it seems possible that they may be more likely to “under dose” their patients by using finer needles, fewer needles and less stimulation, because of, perhaps misplaced, empathetic feelings. Those who feel very little from needle insertion may have a tendency to take a more robust approach to needling.
All these considerations and judgements are part of what makes acupuncture so fascinating. Many of the positive studies of acupuncture use electroacupuncture as the stimulus, ie a potent stimulation, but so called “sham” (or what would look like rather feeble needling) acupuncture for migraines may be superior to standard treatment.
So it is worth remembering all this if your patients are not responding in the way you think they ought to, and examine the aspects of your technique that contribute to the dose of acupuncture delivered.
Oh, yes, and that the swordfish bit was a joke…
Allodynia and hyperalgesia – may be signs of central sensitisation…
Although the terms “wind up” and central sensitisation are often used synonymously, although they are not strictly equivalent. Wind up will occur in response to any painful stimulus and would normally resolve over time. Central sensitisation can be thought of as wind up that has not wound down and represents a chronic pain state.
In practical terms central sensitisation may be identified in our patients by the presence of allodynia and, to a lesser extent hyperalgesia. Allodynia refers to when a normally non-noxious stimulus (touch for example) is perceived as pain. Hyperalgesia is an exaggerated response to a painful stimulus, and is therefore rather harder to be certain about.
Allodynia will be missed if the examination of the patient involves immediate firm palpation, such as grasping a limb and manipulating the joint – all the examiner will discern is pain, although it will not necessarily correlate with the movement of the joint and may therefore be confusing.
A light touch over the whole patient prior to deeper palpation will reveal suferficial allodynia by a sharp or shrinking movement away from the touch, fasiculations and tremor, as well as other more obvious pain responses.
Needling an area of superficial allodynia will generally be resented and is likely to make the pain condition worse. If the area is localized, then the following approaches can be tried:
In practice, those patients who just seem to get worse with acupuncture and do not improve may have central sensitisation, and their pain condition should be reviewed with this in mind.
Last week I wrote about sighthounds and lurchers possibly being ‘good acupuncture responders’.
The words we use to describe how patients react and respond to acupuncture become easily muddled and it is probably not important except when we try to explain how our interactions with patients should vary.
Good responder: these patients show a good clinical response to acupuncture, usually with just manual acupuncture. It appears that needle placement does not always have to be so precise (i.e. where the pain is) and they respond quickly, often dramatically well, and stay free of signs for weeks if not months. These patients will often become very sedated with the needling, but this is not necessarily the case. It may be easy to “over treat” these patients and make them worse, sometimes markedly so. These patients will usually improve after worsening and so it is often taken as a good sign, but if the patient is much worse then the treatment should be modified (less stimulation, less time, finer needles) and if they continue to be worse after every treatment then the possibility that they may have an altered pain state (central sensitization, disorders of central processing) should be considered.
Sensitive patients: often the term sensitive is used synonymously with “good responder”, but a patient who is sensitive to acupuncture would more usually mean sensitive to the insertion of the needles, in that they appear to find insertion aversive, even when trigger points are not being directly needled. It is important to make the distinction between patients who find the insertion uncomfortable because of their current pain state (allodynia or hyperalgesia – see next week’s blog) and those who will always find it uncomfortable.
There does not appear to be any correlation between sensitivity and response – some sensitive patients respond well, others not at all. Just because a patient finds needling uncomfortable does not mean that they do not need a more potent stimulus, e.g. with electroacupuncture. For these patients the use of fine needles, such as 0.16mm diameter, will allow them not only to have an acupuncture treatment but also to receive electroacupuncture should they need it (although this is more fiddly, it is possible with the more modern machines with light clips).
Strong reactors: these patients are more readily identifiable in the human population and experience profound alterations in the way they feel during or after an acupuncture treatment. These reactors could include the relatively rare “cathartic” reactions where patients laugh or weep uncontrollably and without knowing why they are doing so. More often they will feel profoundly sedated or euphoric. The sedative response is the one that is most easily identifiable in our animal patients. Whilst strong reactors are often good responders there does not always appear to be a direct correlation and the absence of a strong reaction does not mean that the acupuncture will be ineffective.
A seven year old MN Lurcher presented with left carpal arthritis, previous ventral slot C6-C7 and a suspicion of problems with C2-C3 and C4-C5 on MRI. He was on meloxicam, tramadol and gabapentin, but was still restricted in exercise and could not run without becoming profoundly lame, painful and having to rest subsequently for weeks at a time.
Significant trigger points were found in cranial trapezius bilaterally, left infraspinatus and triceps, and right lower lumbar longissimus at L4-L5. Less painful trigger points were found in the right infraspinatus and triceps and in thoracic longissimus.
He had difficulties getting up and lying down and could not raise his front legs sufficient to put his feet on the windowsill or give a paw.
Five treatments were performed targeting painful areas with 0.16mm diameter needles, and following the treatment he began exercising normally and came off all medication. To date he has been free from pain from two months with no further acupuncture.
An eight year old MN Lurcher presented with IBD and bilateral carpal arthritis. He was on 2mg/kg carprofen. Restricted exercise was necessary but made him dull and depressed, and normal exercise resulted in him becoming very lame.
He had trigger points in his right cranial trapezius, rhomboids and caudal trapezius bilaterally and infraspinatus and triceps on the left. He growled consistently on palpation of these. He was also reluctant to fully laterally flex his neck to the right (he habitually would circle and spin to the right).
He had a number of habits that would exacerbate his carpal pain eg bouncing and spinning.
Six treatments over eight weeks (this included an episode of acute neck pain resulting in yelping/screaming) of the painful areas with 0.16mm diameter needles (associated with profound sedation) resulted in the patient being pain free and able to exercise normally for four months without any further acupuncture.
A five year old MN Lurcher presented with episodic neck pain and spasm of the left temporalis muscle, associated with irritability and aggression to people and other dogs. Treatment with tramadol, NSAIDs and gabapentin appeared to be helpful in reducing the frequency of episodes but not the intensity when they occurred.
Examination revealed restriction of lateral neck flexion to the right, and a significantly painful trigger point in left cranial trapezius and in left temporalis.
Four treatments of the main trigger points with 0.16mm diameter needles resulted in resolution of the episodes and behaviour, with no relapse three months later.
We all have had cases like these – what appears to be different here is the relatively minimal treatment (fine needles, minimal stimulation, relatively few treatments) with a resolution of significant suffering for weeks and months without the need for further treatment.
Is the explanation that these appear to be primarily myofascial problems and therefore more amenable to the “miracle cure”? Possibly, except that two of the dogs (and possibly all of three) have existing underlying pathology and have resumed the levels of exercise, including repetitive behaviours and episodes of intense exercise that previously caused pain and lameness without ill effect.
(On the other side of the picture we appear to be seeing increasing numbers of lurchers and sighthounds with what would appear to be central pain processing problems: shifting pain, sometimes swellings, muscle pain, lameness but no pathology on MRI, radiography, muscle biopsy, EMG, joint taps, CSF; these appear to be relatively insensitive to acupuncture).