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).