CASE REPORT
2011 – 2012 Course
Toronto, Ontario CANADA
Acupuncture as a Treatment for Hind Limb Weakness, Renal Insufficiency, and Constipation in a 16-year-old Domestic Shorthair Feline
Author: Dr. Erika Sullivan
Image 1: "Murphy"
Acupuncture as a Treatment for Hind Limb Weakness, Renal Insufficiency, and Constipation in a 16-year-old Domestic Shorthair Feline
Erika Sullivan, DVM
ABSTRACT
Acupuncture therapy was used to successfully treat hind limb weakness, ataxia, renal azotemia, and constipation in a sixteen-year-old domestic shorthair feline. A four-week course of dry needle acupuncture therapy was performed, including one session utilizing moxibustion, and one week utilizing aquapuncture. The patient demonstrated improvement in mobility, return of her normal appetite, improvement in the regularity of her bowel movements and overall improved strength in her hind limbs. The owner is encouraged by the progress made thus far and hopes to continue therapy until maximum results have been achieved and can be maintained on a regular basis.
HISTORY
The patient is a sixteen-year-old spayed female domestic shorthair feline named Murphy (Image 1). Murphy presented for an acupuncture consultation with a three-month history of hind limb weakness. Previous treatment included intermittent oral dosing of meloxicam and weekly Cartrophen® injections.
Two weeks prior to our initial consultation, Murphy presented to the hospital with progression of her hind limb weakness including ataxia, and constipation. At this time, bloodwork revealed mild azotemia, urinalysis revealed isosthenuria and pyuria, and a urine culture and sensitivity test had positive growth of Eschericia coli (E. coli) bacteria that was sensitive to all antibiotics. Intravenous fluids were administered in hospital for 48 hours, and 15 mg of oral enrofloxacin was initiated once daily for 14 days. Resolution of the pyruia and E. coli infection was confirmed by a repeat urine culture test, however Murphy’s hind limb weakness was unchanged and progressing. Her Blood Urea Nitrogen (BUN) level had returned to normal limits, however her Creatinine blood level remained mildly elevated. Radiographs of the caudal abdomen and pelvis were performed and revealed mild enlargement of the left kidney, a narrowed intervertebral disc space, periosteal reaction possibly indicating osteoarthritis at the lumbosacral joint, and normal feces in her distal colon. Feline Leukemia Virus and Feline Immunodeficiency Virus blood tests were negative. Murphy was started on 2 cc per os daily of Lactulose to soften her stool. The patient had no previous medical history of trauma or illness, until the progression of hind limb weakness and intermittent constipation was noted two to three months prior.
The owner felt that Murphy’s quality of life was poor due to her ambulatory difficulties, pain from falling down, and lack of regular defecation. The owner had discontinued meloxicam at the time of presentation, however was still giving lactulose. The owner was looking for renal-protective alternatives to treat Murphy’s hind end weakness and ataxia.
CLINICAL SIGNS/DIAGNOSTICS/DIAGNOSIS – CONVENTIONAL (WESTERN)
On presentation, Murphy was bright, alert, and responsive. She had a stiff posture, with muscle wasting along her thighs and back. Her caudal back was lowered towards the floor and her stifles were slightly flexed at rest. She required support to maintain alignment in gait, and without support her hind legs would stagger and collapse. Bilateral hind limb conscious proprioceptive deficits were present, but inconsistent; however she had positive withdrawal and pain reflexes. Murphy was very sensitive to touch over her caudal spine and coxofemoral joints, and an obvious pain response was elicited with gentle palpation. Murphy responded by falling in her hind end to the ground if palpated, while hissing and growling. Her anal tone was good. There was decreased range of motion in both hips and her tail carriage was low towards the ground. Firm, but not hard, feces of normal diameter were palpable in her distal colon. Her haircoat was unkempt in appearance and dry with dorsal dandruff. Her temperament was irritable. No pain was identified on abdominal palpation. Her body condition score was slightly high at 3.8 out of 5.
Blood results from one month prior revealed mild azotemia with a BUN of 14.6 mmol/L (5 – 13 mmol/L reference range) and a creatinine level of 271 umol/L (50 – 177 umol/L). Urine collected from the floor revealed pyuria, isosthenuria with a usg of 1.012, and culture tested positive for Escherichia coli bacteria >10*5 cfu/mL, which was sensitive to all antibiotics. Murphy was hospitalized and treatment consisting of intravenous fluids, antibiotics, and supportive care was delivered. Her bloodwork was repeated 48 hours later and her BUN level had returned to normal limits at 8.3 mmol/L, while her Creatinine level only improved to 220 umol/L. Radiographs of her caudal abdomen and pelvis revealed mild left renomegaly, narrowing at the L6 to L7 disc space, early spondylosis, and a periosteal reaction suggestive of early osteoarthritis at the lumbosacral joint. A normal volume of feces was present in her distal colon, with no evidence of megacolon (Image 2). Feline Leukemia Virus and Feline Immunodeficiency Virus blood tests were negative. An MRI (magnetic resonance image) was discussed to obtain a definitive diagnosis, and was declined by the client.
Based on the history, clinical signs, and physical examination, a presumptive Western diagnosis was progression of intervertebral disc disease at the lumbosacral joint or cauda equina syndrome, with chronic renal insufficiency. Spinal lymphoma could not have been ruled out completely without further testing including cytology or biopsy. An additional complication involving degenerative joint disease of the lumbosacral joint was considered. Murphy’s constipation was most likely due to dehydration, pain in posturing to defecate and/or a neurological weakness affecting the spinal nerves innervating the colon.
Murphy's Radiograph taken
two weeks prior to referral
for acupuncture.
CLINICAL SIGNS/DIAGNOSIS – TCM* (EASTERN) *TCM = Traditional Chinese Medicine
Murphy has historically been a quiet cat, usually aloof towards visitors and sometimes even the owner. She preferred to lie on warm soft surfaces, such as carpet or sofas, or in the sunshine when outdoors on the patio. She had difficulty rising and posturing to defecate, and her hind limb strength was worse after long periods of rest. In the past three months, she had started to defecate beside the litter box, and until recently no previous history of inappropriate defecation existed. Her feces were normal in appearance, but abnormal in frequency, occurring once every 24 to 72 hours. Her diet consisted of canned Friskies and dry commercial kibble ad libitum. There was a decrease in her appetite since the onset and progression of her symptoms.
Murphy was confident and reserved on initial presentation. Her eyes and expression were bright, while her haircoat was slightly unkempt and dry with dandruff dorsally, and small tufts of fur around her caudal lateral thighs. She was slightly overweight in appearance with a small pouch of excess adipose tissue hanging ventrally, typical of many overweight geriatric cats, and she had round lateral contours, and thin muscle-atrophied legs and hips. Murphy’s owner reported that she displayed symptoms of pain that was better with gentle touch or pressure applied to her hind end.
On exam, Murphy had difficulty getting up and walking. Her hind legs were weak and her gait staggered with inconsistent proprioceptive deficits. Murphy appeared sore as she attempted to stand and walk. Her pelvis and distal limbs were cold to touch, and her feces were firm, but not distended nor hard in her distal colon. The owner felt her lameness had been improving as the season was changing from winter into spring. Murphy’s tongue was pale and wet, with no coat. Her pulse was deep and weak. She was sensitive to palpation at BL 23. Palpation of her pelvis and lumbar spine resulted in aggression, and this coupled with discomfort while rising from a resting position, and the owner’s observation of an increase in sedentary behaviour, were interpreted as symptoms of pain.
The following table summarizes the clinical signs and differential diagnoses used to make a TCM diagnosis.
Clinical Signs Differential TCM Diagnosis
Dry haircoat Liver Blood Deficiency; Kidney Yin Deficiency
Reduced frequency of bowel Qi Deficiency; Bony Bi Syndrome; Kidney Yin
movements Deficiency
Muscle wasting/atrophy Bony Bi Syndrome, Wei Atrophy Syndrome
Early neurological deficits Qi Deficiency; Bony Bi Syndrome; Kidney Yin
Deficiency; Wei Atrophy Syndrome
Preference for sunshine Yang Deficiency or Yin Excess
– heat-seeking
Pale, wet tongue Qi Deficiency, Yang Deficiency, Yin Excess,
Blood Deficiency
Deep weak pulse Yang Deficiency, Cold Excess, Deficiency
syndrome
Weakness in the Hind Limbs Kidney, Qi, or Yang Deficiency
Sedentary Behaviour due to Qi Deficiency, Bony Bi Syndrome
Murphy had a weak pulse, and progressive symptoms that worsened suddenly in the winter season, which is consistent with a Deficiency, rather than an Excess1. Murphy’s pain appeared to be worse with palpation and pressure, better with movement and worse after rest, consistent with Excess Pain. The most common cause of Excess pain attributed to Murphy’s case included invasion of Wind, Cold or Damp in the channels2. Murphy had Kidney Yang Deficiency based on early neurological deficits, difficulty getting up and walking, coldness to her back and hind extremities, worsening during the winter season, a deep weak pulse, and a pale wet tongue3.
A diagnosis of Bony Bi Syndrome was given to Murphy. This diagnosis was based on the fact that a Deficiency pattern and symptoms of Cold including a slow weak pulse were present, and there was involvement of the Kidney Organ System, specifically Kidney Yang Deficiency. Murphy’s ability to walk and the quality of her gait worsened in cold weather. Murphy’s body around her pelvis and distal hind legs was cool to touch, and her tongue was wet and pale, while her pulse was deep and weak, supportive of a Deficiency in Kidney Yang and Bony Bi. Her decreased frequency of defecation was consistent with Qi deficiency. There was a lack of response to Western treatment with oral meloxicam and glycosaminoglycan injections. Murphy’s Eastern Diagnosis was Bony Bi Syndrome due to External Cold and underlying Kidney Yang Deficiency4.
CONVENTIONAL (WESTERN) TREATMENT
Three months prior to Murphy’s acupuncture referral she had been treated conventionally for progressive hindlimb weakness and pain. Murphy was prescribed oral meloxicam to be given consecutively for five days, and then intermittently every 24 hours “as needed” for symptomatic pain. Minimal, if any, improvement was noted. Following this, a series of four injections containing polysufated glycosaminoglycans were administered every seven days; however, Murphy’s symptoms continued to progress slowly over the next two months. Two weeks prior to Murphy’s acupuncture consultation she presented to the hospital with inappetance, dehydration, constipation, and an acute worsening of her pelvic weakness and pain when attempting to stand and walk. At this time, diagnostic bloodwork, urinalysis, and urine culture and sensitivity testing revealed azotemia, isosthenuria, and pyuria diagnosed as infectious pyelonephritis secondary to Escherichia coli bacteria. Murphy was admitted to the hospital at this time for 36 hours of continuous intravenous fluid therapy. A course of oral enrofloxacin dosed at 15 mg orally once daily for 10 days, and 2 cc per os of Lactulose therapy once every 24 hours was prescribed at the time of discharge. A follow-up urine culture and sensitivity test repeated two weeks after finishing enrofloxacin was negative, and repeat bloodwork demonstrated improvement in azotemia. However, Murphy’s hind end pain and difficulty walking progressed, which is when a referral for acupuncture was made. The only medication that Murphy continued after her trial in acupuncture therapy was 2 cc of lactulose given orally every 24 hours in an attempt to maintain the regularity of her bowel movements.
TCM (EASTERN) TREATMENT
The goals of acupuncture therapy were to support and tonify the Kidneys, eliminate painful obstructions, tonify Kidney Yang, tonify Qi, promote the circulation of Qi and Blood, unblock channels, support Source Qi, and dispel Damp Cold5.
A dry needle acupuncture technique was utilized using 0.22 mm (0.5 inch) x 13 mm (34 gauge) Jing Tang sterile acupuncture needles. The depth of needling varied between 0.1 and 5 mm. An even needling technique was used, except during the third session where a tonification technique was applied to the dorsal-placed needles. Needle retention time varied between 12 to 15 minutes per session. During the third session, moxibustion was performed. Moxibustion therapy offered active warming of the dorsal-placed dry acupuncture needles and was performed by burning smokeless Moxa sticks containing Artemis vulgaris or condensed Chinese Mugwort flower. Aquapuncture using 0.5 ml of sterile homeopathic Traumeel with Terumo syringes and 27 gauge needles was performed at the fourth treatment session.
The following table includes the complete list of points with their locations6.
Acupuncture Point
Chinese Translation Anatomic Location Indications
Bladder 11
Da-zhu 1.5 cun lateral to the caudal border of Influential Point for Bone
the spinous process of the first thoracic Increases Qi, nourishes
vertebra, midway from spinous process Blood, soothes sinews +
to the medial border of the scapula. eases pain. Good for bone,
neck, + shoulder problems.
Bladder 20
Pi-shu 1.5 cun lateral to the caudal border of Association Point for
the spinous process of the 12th thoracic Spleen. Dispels Damp,
vertebrae. Spleen Deficiency, used for
thoracolumbar IVDD.
Bladder 23
Shen-shu 1.5 cun lateral to the caudal border of the Association Point for Kidney.
spinous process of the 2nd lumbar Tonifies Kidney Yin + Qi
vertebrae. Deficiency, strengthens bones
marrow, benefits mind,
back + stifle. Good point for
TL disc disease, pelvic limb
weakness + incontinence.
Bladder 40
Wei-zhong Centre of the popliteal crease. Master Point Caudal Back and
Hip. He Sea Point. Clears heat,
cools Blood, removes
obstructions from the channel,
+ eliminates Blood stasis. Good
for problems with caudal back
stifles, + hind limb paralysis.
Bladder 60
Kun-lun On the lateral aspect of the hock Expels Wind, removes
area, in the middle of the webbed area obstructions from channel,
cranial to the calcaneal tendon, at the relaxes tendons, strengthens
level of the tip of the tuber calcanei caudal back + hock + alleviates
(calcanean tuber). swelling + pain throughout body.
Gall Bladder 25
Jing-men On the lateral side of the abdomen, on Alarm Point for the Kidneys.
the lower border of the free end of the Used for Kidney problems.
13th rib.
all Bladder 34
Yang-ling-quan In the depression cranial and Influential Point for Sinews.
distal to the head of the fibula. He-Sea point. Liver Qi
stagnation, tendon + ligament
disorders, pelvic limb lameness,
weakness or paresis or paralysis,
general pain relief, strengthens
caudal back + extremities.
Gall Bladder 39
Huan-tia 3 cun above the tip of lateral Influential Point for Marrow.
malleolus, in depression between Benefits Essence. Good for
the caudal border of the fibula + spinal cord problems, pain,
the tendons of peroneus longus + stiffness, + paralysis of hind
brevis muscles. limbs. Any Kidney Deficiency
problem.
Governing Vessel 3
Yao-yang-guan Largest deficiency point between Local Point strengthens caudal
the dorsal processes of L4 – L5, back + weakness or atrophy of
L5 – L6, or L6 – L7. rear legs.
Stomach 36
Hou-san-li 3 cun distal to ST-35, distal to tibial Master Point of Abdomen.
tuberosity + lateral to the cranial He-Sea Point. Important to
border of the tibia, in a depression tonight Qi + Blood. Good for
approximately in the middle of the general weakness, stifle pain,
cranial tibialis muscle. and hindlimb weakness.
Kidney 3
Tai-Xi In the depression cranial to the tuber Source Point. Shh-Stream point.
calcanei, at the midpoint of a line Tonifies kidneys, benefits
drawn from tip of medial mallelous kidney function, strenghtens
to the point of insertion of the common caudal back. Good for paralysis
calcanial tendon. of pelvic limb + caudal back pain.
SHEN-PENG
Kidney Shelf Equine classical point to Tonify
TCVM #7 In the depression 2 cun lateral to the Kidney + coxofemoral weakness
dorsal midline and 2 cun cranial to + pain.
SHEN-SHU.
SHEN-JIAO
Kidney Corner Equine classical point to Tonify
TCVM #71 In the depression 2 cun lateral to the Kidney + coxofemoral weakness
dorsal midline and 2 cun caudal to and pain.
SHEN-SHU.
Bai-Hui
Point of 100 Meetings In the depression on the Point where all Yang meridians
dorsal midline in the merge. Benefits local problems +
lumbosacral space. any problems in hindquarter, i.e.
musculoskeletal, neurological, and
gastrointestinal.
Liver 3
Tai-chong On the medial aspect of the second Source Point. Shu Stream Point.
toe, proximal to the Nourishes Liver Blood, promotes
metatarsophalangeal joint, midway flow of Liver Qi. Pelvic limb
between the dorsal and medial aspect paresis or paralysis. General
of the bone. painful conditions.
Spleen 6
San Yin Jiao 3 cun directly above the tip of the Master Point of Lower Abdomen
medial malleolus, on the caudal + Urogenital System. Dispels
border of the tibia, on the line drawn Dampness, tonifies Spleen,
from the medial mallelous to SP 9. nourishes Yin, invigorates Blood.
Acupuncture Session 1
The points chosen for the first treatment were BL 11, BL 23, BL 40, GB 34, GB 39, GV 3, ST 36, BL 60, and KI 3. BL 11 is the Influential Point for Bone, increases Qi, and nourishes Blood. BL 23 is an Association Point that tonifies Kidney Yin, strengthens Bone, Marrow, and benefits the caudal back and stifle. BL 40 is the Master Point of the caudal back and hips and eliminates Blood stasis. GB 34 is the Influential Point of the Sinews and nourishes weak tendons and ligaments, including pelvic limb lameness, and provides general pain relief. GB 39 is the Influential Point for Marrow, which is useful for spinal cord problems, hind limb paralysis, and any Deficiency problem. GV3 is a local point to strengthen the caudal back and legs, and tonify Yang. ST 36 is the Master Point for the gastrointestinal tract and abdomen, is an important point to tonify Qi and Blood, and was chosen to also support Murphy’s poor appetite on presentation. BL 60 is sometimes called the “Aspirin Point” as it is a useful point for hind leg analgesia and it may be needled through to KI 3, which was used to tonify Kidney Yang and reduce pain7.
Murphy was reluctant to accept her first treatment, as she was hissing, trying to jump off the treatment table, and growling. She had a weak deep pulse at the beginning of treatment that remained deep and was fuller by the end of treatment. Her tongue was pale pink with no coat. The owner was instructed to apply low-pressure massage to the muscles over the lumbar spine and pelvis in an attempt to increase temperature and blood circulation to affected regions. It was also suggested to lower the sides and increase the size of Murphy’s litter box, in order to facilitate easy manoeuvring within the box.
A follow-up call was performed 48 hours after her initial treatment. Murphy’s owner reported that she defecated almost immediately after treatment, and was much more mobile, able to rise from rest and that her appetite had also improved. A follow-up appointment was scheduled for seven days later, and Murphy’s owner was instructed to follow-up sooner if there were any signs of regression.
Acupuncture Session 2
Murphy was doing extremely well for the initial four days, however on day five after her initial treatment her hind end weakness, pain, and bowel movement frequency had started to deteriorate. The frequency of her bowel movements on any given day was normally every 36 hours; however, it had been just over 48 hours since she had last defecated on presentation. The feces were still firm, but not dehydrated or hard, without any blood or mucus or visible straining noted by the owner. Due to scheduling conflicts however, our follow-up appointment had been scheduled seven days following her initial consultation.
Murphy’s body weight remained stable and abdominal palpation revealed that feces were normal in her distal colon. She no longer had hind limb conscious proprioceptive deficits; however, her muscle atrophy and weakness when rising from rest were unchanged. Her gait was characterized by weakness, such that her tarsal joints lowered to the ground at rest, and abducted laterally when walking. She continued to seek heat, and her appetite had returned to normal. Her tongue was light pink, moist, and small such that the lateral edges were hidden within the confines of her teeth. Her pulse was choppy and deep. The quality of her haircoat had not improved, and she refused to take an omega fatty-acid supplement when given orally by the owner.
Due to the noted improvement following Murphy’s first treatment, most of the same prescribed points were repeated from session one, with a few additional points such as Shen Peng, Shen Shu, Shen Jiao, Bai Hui, and LIV 3; instead of GV 3 and ST 36. The Shen series (Shen Peng, Shen Shu, and Shen Jiao) are the equine classical points used to tonify Kidney and for coxofemoral weakness and pain. Bai Hui warms Kidney Yang and strengthens the back8. LIV 3 was added to nourish Liver Blood and promote the smooth flow of Qi9. Needles were retained for fifteen minutes.
The second acupuncture treatment was well-accepted by Murphy. This time she was relaxed, purring, and lying down during the entire treatment. Her pulse became smooth and her limbs were not as cool to touch. Murphy’s owner was instructed to start the recommended dose of Sasha’s Blend®, a nutritional supplement containing glycosaminoglycans and green lipid muscle, to be mixed with her food for joint health.
A follow-up 24 hours later revealed further improvement in Murphy’s symptoms. Her defecation became regular and effortless every 24 – 36 hours. Her gait and activity improved and her appetite remained good, although sometimes fussy with the Sasha’s Blend, and thus it was suggested to discontinue it if it interfered with eating. Due to scheduling conflicts, the next follow-up session was arranged twelve days later.
Acupuncture Session 3
The improvement in Murphy’s symptoms appeared to last almost eight days after her second treatment. The fur around her hips and perineum were becoming extremely matted as she was no longer grooming herself and disliked being touched in this area, suggesting sensitivity and pain. Spring season was arriving and Murphy’s owner noted an increased preference for warmth through sunshine. Her hind limbs were cool to touch, but not as cold as her previous appointment. Her appetite and the frequency of her bowel movements remained normal. Although she was still having an occasional bowel movement beside her litterbox, this occurred less often. This was attributed to pain involved with posturing to defecate and climbing into the box.
On examination, Murphy’s attitude and gait had improved significantly. She continued to have a narrow hind limb stance with slightly adducted tarsal joints, however there was improvement in her ability and willingness to walk around the clinic. Murphy lost a quarter of a kilogram of body weight, which was assumed to be a result of the owner changing her diet to high protein canned food, while restricting the dry kibble as was instructed. Her haircoat was unkempt with small tufts of fur around her perineum and pelvis. Her pulse was choppy and slower than the previous visit. Her tongue was a normal size and pale pink without any coat.
Dry needle acupuncture was performed at this session on the following points: BL 11, BL 23, Bai Hui, BL 40, GB 34, SP 6, KI 3, and BL 60. Due to Murphy’s continued cold intolerance, Moxibustion therapy was performed by burning smokeless Moxa sticks containing the Chinese Herb Artemisia vulgaris, and applying it to warm the dorsal-placed needle shafts. Moxibustion was included for tonification, to dispel Damp Cold as an External Pathogenic Factor, and for arthritic pain10. Spleen 6 was included for general tonification, to dispel Damp Stagnation, and to aid in the treatment of her pelvic limb disorder11. Bai Hui is a Classical point that was included to treat Yang Deficiency, lumbosacral disease and pelvic limb weakness12. A tonification technique was applied to the dorsal-placed needles.
Murphy remained calm and focused during her third treatment. Her pulse rate increased almost immediately and her extremities were warmer to touch. Murphy’s owner was instructed to continue the 2 cc per os of lactulose as her bowel movements were regular. A follow-up was scheduled the following week.
Murphy's third Acupuncture Session.
Heating the needles with moxa.
Acupuncture Session 4
Murphy presented for her fourth treatment with a reported 80% improvement in all symptoms since initiating acupuncture four weeks prior. With each successive treatment, Murphy’s positive response to acupuncture seemed to last a few days longer. At this time, bloodwork was repeated and revealed complete resolution of azotemia, as her creatinine was now normal at 171 mmol/L (50-177 mmol/L). Her appetite was healthy and she gained back the bodyweight she had previously lost. Murphy was seeking less heat since performing moxibustion; however, she did still occasionally lie in the sunshine. Murphy was alert and almost playful, as the owner reported that she attempted to catch a bird while outside.
On examination, Murphy’s gait and strength in rising and walking had further improved, such that her hocks no longer dropped with each step. Her tongue was full-bodied, pink colour, without any coat. Her pulse remained weak; however it was more superficial with a regular rate. Her haircoat remained unkempt around her hips and perineum, and Murphy’s attitude overall seemed more comfortable. Her distal extremities and ear tips were body temperature to touch.
Because of Murphy’s excellent response to therapy thus far, a combination of previously utilized points were chosen, however moxibustion therapy was not repeated and aquapuncture was performed instead. Aquapuncture using 0.25 ml per injection site of sterile injectable homeopathic Traumeel was performed at GB 25. Dry needle acupuncture was performed on the following points: BL 11, BL 23, Bai Hui, BL 40, GB 34, SP 6, KI 3, BL 60, and LIV 3. LIV 3 was repeated to nourish Liver Blood and promote the smooth flow of Qi13. Needles were retained for fifteen minutes. Aquapuncture was used to lengthen and strengthen the acupuncture treatment14.
Murphy was very relaxed during her fourth treatment. Her pulse rate increased, as did the strength and tone of her pulse following needle placement. A follow-up call was made three days following this session and Murphy’s owner reported a near perfect gait, a positive attitude, and regular bowel movements. It was agreed at this time that we would try monthly treatments and follow-up sooner if there were any return of symptoms.
DISCUSSION
Murphy, a 16-year-old spayed female Domestic Shorthair Feline, presented with a three month history of progressive hind limb weakness that was non-responsive to conventional medication, and which had suddenly worsened two weeks prior to presentation. In this time, Murphy had also experienced an episode of renal insufficiency characterized by azotemia, pyuria, dehydration, constipation, and inappetance, which was treated by hospitalization, intravenous fluids, and outpatient management including antibiotics and a stool softener. Murphy’s pyuria resolved two weeks following hospitalization and the azotemia improved; however, Murphy’s gait became progressively weak, ataxic, and painful. Radiographs revealed early lumbar spondylosis, ventral lumbosacral bone remodelling consistent with osteoarthritis, as well as left renomegaly. Viral blood testing for Feline Leukemia Virus and Feline Immunodeficiency Virus were negative. An acupuncture referral was made at this time. At the time of acupuncture therapy, Murphy had discontinued previously tried conventional medications such as meloxicam and glycosaminoglycan injections; however, the oral stool softener was continued as despite her bowel movements appearing normal, they were becoming less frequent.
Murphy’s gait revealed a narrow hind limb stance with adducted tarsal joints which lowered towards the ground and abducted when attempting to stand and walk. Her hind limbs lacked muscle tone and there was muscle wasting along her hips and lower spine. Early conscious proprioceptive deficits were present and pain was present along L2 – S3 on palpation. Murphy’s haircoat was unkempt and dry and her feces were palpably normal on abdominal palpation. Her blood creatinine level improved from previous levels, although was still mildly elevated in the face of persistent isosthenuria. Left renomegaly was palpable on abdominal palpation.
The presumed Western diagnosis was spondylosis, lumbosacral osteoarthritis, intervertebral disc disease, or cauda equina syndrome with possible concurrent degenerative joint disease and chronic renal insufficiency. Spinal Lymphoma could not be ruled out without further advanced diagnostic tests; however the client declined the option for referral. Murphy’s presentation appeared to be both a significant progression of her previous weakness, as well as a more acute spinal incident following an acute episode of azotemia, dehydration, and constipation. Months prior to acupuncture referral, Murphy had minimal to no response to the chronic use of oral meloxicam, or a series of weekly injections of glycosaminoglycans. Murphy’s more recent renal attack was not attributed to a drug side effect since she had discontinued all non-steroidal anti-inflammatory medications a few months prior. Lactulose stool softener given orally helped maintain consistent bowel movements for Murphy. The owner had difficulty medicating Murphy and was looking for alternatives that would improve her pain and mobility, while supporting her kidneys, and thus opted for a trial of acupuncture therapy.
On TCM exam, Murphy was reserved and confident. When it was warm outdoors, the owner reported that she preferred to lie in the sunshine. Murphy’s eyes looked old, her haircoat was dry along her dorsum, and she had a relaxed, deep, thready pulse. Her tongue was pale pink, normal size, moist, without any coat. Murphy resented palpation along her caudal spine showing sensitivity from L3 to S3 and overt pain upon extension of her hips. She had symmetric hind leg muscle atrophy, and caudal back weakness indicated by a hunched posture at rest, with difficulty rising from rest. Murphy had mild delayed proprioceptive reflexes and her tarsal joints were slightly adducted at rest.
Murphy’s case is typical of Bi Syndrome due to Kidney Yang deficiency. The presentation of lameness and stiffness falls into Bi Syndrome. The heat-seeking behaviour, cold rear extremities, weak pulse, and pale pink tongue indicate Kidney Yang deficiency. Her hind limb weakness, decrease in frequency of defecation, and wet tongue indicate Qi deficiency15. The Kidney is a Yin Zang Organ and is important for overall vigour because it is where Essence and Source Qi are stored16.
Murphy had sharp pain on extension of her hips and moderate sensitivity upon palpation of her caudal spine. Musculoskeletal diseases, known as Bi Syndrome in TCM, are the most common and responsive disorders treated with acupuncture. Bi refers to stiffness and blockage of circulation. Bi syndrome involves pain in muscles, tendons, bones, and joints as well as difficult movement of, or deformation of, these structures. Murphy’s spinal and pelvic radiographs likewise supported this. Murphy’s symptoms were influenced by the chronic invasion of Wind, Cold, and Damp, characteristic of seasonal and dietary influences at that time. Her pulse was deep and weak, further supportive of a Deficiency pattern. And although nine types of Bi Syndrome have been observed, Bony Bi is most similar to spondylosis and osteoarthritis, which was Murphy’s leading differential Western diagnosis. The exogenous pathogens Wind, Cold, and Damp occur after long-term exposure to windy, cold, and wet environments. The combination of Wind-Cold-Damp invades the body and blocks the Qi flow in the meridians and muscles, which leads to Bi Syndrome. As General Question (Su Wen) states in the Yellow Emperor’s Medical Classic, “invasion of a combination of three pathogens Wind-Cold-Damp causes Bi syndrome17.”
There are specific personality types in Five Element TCM theory. An Element type can reflect an animal’s strengths and weaknesses and influence health maintenance and imbalance. Individuals tend to have certain characteristics that can be explained by their elemental constitution. Murphy is a Water type. Water animals are timid and often hide when around strangers, and their “bark is bigger than their bite18”. Knowing Murphy’s constitution was important in determining how to help maintain her health, as these are factors that influence disease in any way: by improvement, aggravation, or other change. Since strong Cold weakens Water, this further supported that Murphy’s energetic root cause is a Process Imbalance in Kidney19.
The treatment goals were to eliminate painful obstructions, support and tonify Kidney, tonify Yang, improve mobility by moving stagnant Qi and Blood, stimulate Marrow, and utilize local points around the lumbosacrum20. Several points were initially chosen, each with a specific indication based on Murphy’s history and findings on examination. At the second treatment, most of the same prescribed points were repeated from Session 1, with a few additional points such as Shen Peng, Shen Shu, Shen Jiao, Bai Hui, and LIV 3; instead of GV 3 and ST 36. At the third treatment, moxibustion was included for geriatric tonification, to dispel Damp as an External Pathogenic Factor, and for arthritic pain21. Spleen 6 was also included for tonification, to dispel Damp stagnation, and to support her pelvic limb disorder22. A tonification technique was applied to the dorsal-placed needles during the third session only, whereas otherwise an even needling technique was used with needle retention time varying between 12 to 15 minutes. At the fourth treatment session, a combination of previously prescribed points was chosen, and aquapuncture utilizing homeopathic Traumeel at GB 25 was introduced using 27 gauge needles. All dry needle acupuncture sessions utilized 0.22 mm (0.5 inch) x 13 mm (34 gauge) Jing Tang sterile acupuncture needles, and the depth of needling varied between 0.25 and 5 mm.
In session one, treatment consisted of BL 11, BL 23, BL 40, GB 34, GB 39, GV 3, ST 36, BL 60 and KI 3. BL 11 is the Influential Point for Bone, increases Qi, and nourishes Blood. BL 23 is an Association Point that tonifies Kidney Yin, strengthens Bone, Marrow, and benefits the caudal back and stifle. BL 40 is the Master Point of the caudal back and hips and eliminates Blood stasis. GB 34 is the Influential Point of the Sinews and nourishes weak tendons and ligaments, including pelvic limb lameness, and provides general pain relief. GB 39 is the Influential Point for Marrow, which is useful for spinal cord problems, hind limb paralysis, and any Deficiency problem. GV3 is a local point to strengthen the caudal back and legs and tonify Yang. ST 36 is the Master Point for the gastrointestinal tract and abdomen, is an important point to tonify Qi and Blood, and was also chosen to support Murphy’s poor appetite on presentation. BL 60 is the “Aspirin Point” as it is useful point for analgesia and may be needled through to KI 3 which was used to tonify Kidney Yang23. Within 48 hours the owner reported that Murphy could get up easier from rest, was walking better, defecated, was more interested in food, and generally had a better attitude. A follow-up appointment was scheduled for seven days later.
Murphy’s positive results from her first treatment diminished after five days, and seven days later she returned for a second treatment. The frequency of her bowel movements was regularly every 36 hours, and it had been just over 48 hours since she had last defecated. She no longer had proprioceptive deficits; however her muscle atrophy and weakness to rise were unchanged. Her pulse was deep. Based on the moderate improvement noted after her initial session, most of the same points were repeated, with a few additional points; including, Shen Peng, Shen Shu, Shen Jiao, Bai Hui, and LIV 3; instead of GV 3 and ST 36. The Shen series (Shen Peng, Shen Shu, and Shen Jiao) are the equine classical points that tonify Kidney and are useful for coxofemoral weakness and pain. Bai Hui warms Kidney Yang and strengthens the back24. LIV 3 was added to nourish Liver Blood and promote the smooth flow of Qi25. Within 24 hours Murphy had improved, with regular effortless defecation every 24 – 36 hours, improved mobility, gait, and appetite. Due to scheduling conflicts, the next follow-up session was arranged twelve days later.
At the third session, Murphy’s owner reported that her improvement lasted eight days. Despite her improved ability to rise and overall gait, the fur around her hips and perineum were becoming more matted as she was no longer grooming herself, suggesting discomfort. Her hind limbs were cool to touch and she was still heat-seeking. Murphy had lost 0.25 of a kilogram of body weight, which was attributed to the owner changing her diet to high protein canned food. Her pulse was choppy and slower than previous visits. Her tongue was small and pale pink without any coat. Dry needle acupuncture was performed at this session on the following points: BL 11, BL 23, Bai Hui, BL 40, GB 34, SP 6, KI 3, and BL 60. Due to Murphy’s continued cold intolerance, moxibustion therapy was performed by burning smokeless Moxa sticks containing Artemisia vulgaris, and applying it to warm the shaft of the dorsal-placed needles. Moxibustion was included for geriatric tonification, to dispel Damp as an External Pathogenic Factor, and for arthritic pain26. Spleen 6 was included for generalized tonification, to dispel Damp stagnation, and to support treatment of her pelvic limb disorder27. A tonification technique was applied to the dorsal-placed needles. A follow-up was scheduled the following week.
Murphy presented for her fourth treatment with a reported 80% improvement since trying acupuncture four weeks prior. With each successive treatment, Murphy’s positive results from acupuncture lasted a few days longer. At this time bloodwork was performed and revealed resolution of azotemia, and her blood creatinine level was now normal at 171 mmol/L. Murphy had a normal appetite and gained back the bodyweight she previously lost. Murphy was alert and almost playful, and the owner reported she attempted to catch a bird while outside on the balcony. On examination, Murphy’s gait and strength in rising and walking had further improved, such that her hocks no longer dropped with each step. Her tongue was full, pink in colour, without any coat. Her pulse remained thin and slightly weak with a regular rate. Her haircoat remained unkempt around her hips and perineum; although overall she seemed more comfortable. Because of Murphy’s excellent response to acupuncture thus far, a combination of previously prescribed points were chosen. Although moxibustion therapy wasn’t repeated, aquapuncture with 0.25 ml per injection site of sterile injectable homeopathic Traumeel was performed at GB 25. Dry needle acupuncture was performed at this session on the following points: BL 11, BL 23, Bai Hui, BL 40, GB 34, SP 6, KI 3, BL 60, and LIV 3. LIV 3 was repeated to nourish Liver Blood and promote the smooth flow of Qi28. Needles were retained for fifteen minutes. Aquapuncture was used to lengthen and strengthen the acupuncture treatment29. Three days following this treatment Murphy’s owner reported a near perfect gait, a positive attitude, and regular bowel movements. It was agreed at this time that we would try monthly treatments and follow-up sooner if there was any return of symptoms.
Multiple indications for the points chosen were taken into account when prescribing Murphy’s acupuncture therapy. Murphy’s point prescription included: two Association points (BL 23 to tonify Kidney and move Essence within Yin organs along the spine; BL 20 to tonify Spleen Qi); three Influential Points (BL 11, GB 34 and GB 39, which are meeting points that strengthen the BL and GB channels and are the main Meridians along the caudal back); four Master Points (BL 40, ST 36, KI 6 and SP 6), two of which are He Sea Points (ST 36 and BL 40, both of which are strong movers of Qi and a last chance to pull out pathogenic influences)30; one Alarm point (GB 25, Alarm Point of the Kidney meridian to help diagnose and prescribe Kidney related problems)31; one Source point and Shu-stream point (Earth on the five element ko cycle) (KI 3 which distributes Source Qi from the Triple Heater and is effective for Yin channels, Kidney tonification, and can reach internal branches to pull out pathogens)32; two local points (GV 3 a local point that strengthens the caudal back and weakness or atrophy of the rear legs and BL 60 the “Aspirin point” for pain or paralysis of the pelvic limbs and tarsus)33; and a series of three Equine Traditional points (Shen Peng, Shen Shu and Shen Jiao to tonify Kidney and for coxofemoral weakness and pain)34 + 35.
Another factor involved with Murphy’s positive response to acupuncture was the timing of each treatment session, with respect to the TCM circadian clock of the 12 primary channels. Within these channels Qi and Blood circulate along each meridian in a specific order over the course of a 24-hour-period, with one channel dominating during its two-hour period. Murphy’s treatments were all performed at 6:45 pm, which is within the 5 p.m. to 7 p.m. time period to have optimal results on the Kidney meridian and organ systems36.
TCM does not place the same emphasis on specific agents or injury causing disease as Western medicine, and focuses instead on imbalanced interactions with both internal and external influences as causes of disease37. External pathogenic factors (EPF) are external influences that can invade and affect individuals in the context of their underlying problem or deficiency. As explained in the Yellow Emperor’s Medical Classic, “in the winter there may be arthalgia syndrome, but if the Yang Qi is in place, any seasonal problem can be averted”38. In Murphy’s case, Cold was both an external influence, as well as an internal factor. Cold in the winter acted as a Yin pathogenic factor and injured her Yang Qi, and due to its contractile nature caused stagnation of Qi and Blood in the channels39. Cold invasion into muscle resulted in stagnation of her Qi and Blood, creating congealing and contracture of muscle fibers and pain and aversion for Murphy when she was touched40. Cold also arouse internally in Murphy from a deficiency of Yang.
Huang Di asked, “In certain instances, chills and cold occur not because of exposure to external cold… It is also not because coldness exists naturally within the body. Rather, this coldness seems to be produced by the body. What is the cause of this?” Qi Bo replied, “Patients such as these primarily have Bi conditions and tend towards stagnation, with a deficiency of Yang. The Yin becomes relatively excess and causes cold.”41.
The pathologic condition affecting Murphy is Kidney Yang Deficiency with Bony Bi. This is an appropriate diagnosis based on her symptoms including difficulty in rising and walking, coldness in the extremities and a desire to seek heat, a pale pink tongue with a weak deep pulse, as well as her history of joint pain and renal insufficiency42. The Kidney Yang deficiency is the underlying cause and was treated, in addition to treating local points around affected joints. Acupuncture goals were to eliminate painful obstructions, dispel Damp Cold, tonify Qi, unblock channels, support original Qi, and promote circulation of Qi and Blood to the caudal back and hindlimbs to help her body heal43. Murphy responded immediately to acupuncture therapy and with each successive treatment seven to ten days later, a cumulative effect was observed. Murphy is currently enjoying life, walking without obvious discomfort, and enjoying spending time with her owner. Regular follow-up treatments were scheduled every four weeks after the forth session to monitor and maintain Murphy’s progressed state.
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