ABSTRACT
Backpain may be primary, secondary, or as part of a generalised disorder. Depending on the cause, nature and duration, 70-90% of cases in horses and dogs respond to acupuncture (AP) therapy. In practice, it is difficult to make a specific diagnosis of the cause of backpain, especially in horses, due to the difficulty of routine X-ray and myelography. The general practitioner may be satisfied with clinical remission. In hospitalised dogs, AP is successful in treating post-operative pain and complications. It can be successful also in backpain which has not responded to surgery.
AP therapy is by stimulation of relevant reflex points in the skin and muscles. Points of tenderness to palpation are important. They are equivalent to human Trigger Points (TPs) or AHSHI points. Stimulation is given to the TPs, paravertebral (SHU) points, and points related to specific areas, organs or functions, e.g. local and distant points on meridians through affected areas.
AP points are located in dogs by transposition from human AP. Those in horses are located in the same way, with some adjustment for 18 ribs, 6 lumbar vertebrae and digital anatomy, or by reference to traditional horse AP texts. The choice of points to treat backpain in horses and dogs is similar to that outlined in humans (Paper 1). In animals, the position of PAIHUI is in the lumbo-sacral space, not on the head, as in humans. The combination of TPs, PAIHUI, BL23, 26, 30, 54, 60, GB30, 34, covers most backpain below the ribs, including radiating sciatic pain. The combination of TPs, BL13, 16, 21, TH15, SI 9 covers most thoracic backpain. The combination of TPs, GB20, 21, TH15, CO17, ST38 (or GB34) covers most neck pain. Other useful points are: PAIHUI (all problems below the ribs); BL11 (joints); BL23 (bones); BL16 (spinal column); GB34 (muscles).
Simple needling (for 20 minutes every 1-3 days in acute cases or every 3-7 days in chronic cases) is the classical method. Electro-needling is also used. Point injection is effective and faster.
Most responsive cases improve after 1-3 sessions but chronic cases may need 1-10+ sessions.
Other methods of point selection (Earpoints, Hoofpoints etc) and of stimul-ation (Dermojet, staples, implants, magnets, LASER, ultrasound etc) must be regarded as experimental at this time.
INTRODUCTION
Backpain may be primary (paravertebral muscle pain, thoracolumbar disc disease, vertebral, sacroiliac or arthrotic), secondary (referred from irritation of thoracic or abdominal organs), or as part of a generalised disorder (nutritional muscular dystrophy in deficiency of Vit E-Se; myositis in azoturia).
Animals used for competitive sports (racing, jumping, polo etc) or for active work (draught animals, hunting dogs etc) need to be physically fit. For top performance, they rely heavily on the musculo-skeletal system. In particular, they need full flexion and extension of the paravertebral musc-les for maximum stride and speed and to enable them to run around corners.
Owners request acupuncture (AP) for two main reasons: (a) the animal is visibly lame or some other signs of pain or stiffness (aggression, reluctance to be saddled, mounted or handled over the back; rigidity of the back; running wide on bends etc) are present or (b) the competitive performance has fallen off gradually or suddenly. In both cases, other forms of therapy usually have been tried without much success before AP is considered.
This paper deals with the clinical assessment and AP therapy of backpain in horses and dogs. It includes some examples of limb lameness, where this is associated with irritation of the vertebral nerves. Most of the data are from named experts but some of my own cases are included.
THE BASICS OF ANIMAL ACUPUNCTURE
Irritation of the thoracic or abdominal organs can refer pain to related skin and muscle segments, especially in the paravertebral area. This can establish Trigger Points (TPs), as detailed by Travell and Simons (1984) and in the TP Therapy Symposium (1981). Long after the visceral pain has gone, the TPs can remain active. Unless TPs in the thoraco-sacral muscles are 'removed' by AP or other physiotherapy, the function of the back muscles is impaired and performance is impaired. In human AP, the AHSHI point is defined as a point, usually in muscle, which is tender on palpation. AHSHI means Ouch! or Ah Yes! There are two kinds of AHSHI points: those from which palpation elicits only local tenderness and those which radiate pain to the problem area (the area in which the patient complains of pain). The latter type is the true TP of western medicine. In animals, however, it is not possible to distinguish between real TPs and AHSHI points which are just tender locally. In practice, this distinction is unnecessary- the tender point is the most important point in AP therapy and AHSHI points are taken to be TPs.
REFERRED PAIN: Hindlimb lameness is often due to pain referred from thoraco-lumbar or lumbo-sacral nerves, as in sciatica in humans. It may arise also in pain referred from abdominal viscera, such as in a painful kidney, ovary, uterus or colon. Forelimb lameness may arise in pain referred from cervical or upper thoracic nerves or from pain in thoracic organs (lung, pericardium, heart). Thus, neck- and back-pain often manifest as lameness in the fore- or hind- limb.
In human AP, the paravertebral SHU (reflex points for all major thoracic and abdominal organs) are located on the inner line of the bladder (BL) meridian as follows:
Lung (LU), Pericardium (HC), Heart (HE), Governor Vessel (VG), Diaphragm = BL13 to 17, in area T3 to T7 respectively; Liver (LI), Gallbladder (GB), Spleen-pancreas (SP), Stomach (ST) =BL18 to 21, in area T9 to T12 respectively; Triple Heater (TH), Kidney(KI), CHIHAISHU, COLON (CO), KUANYUANSHU = BL22 to 26, in area L1 to L5 respectively; Small intestine (SI), Bladder (BL), CHUNGLUSHU, PAIHUANSHU = BL27 to 30, in area S1 to S4 respectively. These points have diagnostic value (when tender). They help to identify the affected organ. They also have therapeutic value in treating the affectedorgan and local problems near the points. However, local muscle strain or trauma can also cause SHU point tenderness. Thus, SHU point tenderness need not always indicate disorders of the related organs. The outer line of paravertebral BL points (BL36 to 49) have similar functions to the related points on the inner line.
AP points are located in dogs by transposition from human AP. Janssens (1984) has prepared an atlas of the points in dogs. The points in horses are located in the same way, with some adjustment for 18 ribs, 6 lumbar vertebrae and digital anatomy, or by reference to traditional horse AP texts. Fuller details of animal AP (points, methods of therapy) are given elsewhere (Rogers 1987a, b).
ASSESSMENT OF HORSES AND DOGS BEFORE TREATMENT
A complete history is taken, together with any findings of previous investigations. In the clinical examination, attention is paid to any lesions or signs related to all major systems or functions. One tries to identify the primary problem(s) and the location(s) of pain.
It is essential to probe or palpate the muscles from head to tail, to locate any TPs. Particular attention is paid to the paravertebral muscles and the large muscles of the neck and limbs. The joints and tendons are also palpated. Animals with signs of pain, stiffness or lameness are seldom free of TPs. Their detection is indicated by an attempt to bite, kick, or avoid the palpation or by yielding to the pressure, or by vocalising.
TPs may occur almost anywhere in muscle. Scars may also act as TPs. TPs in the paravertebral area correspond with SHU points. For example, virus infection of the respiratory tract in horses can increase the fragility of capillaries and small bloodvessels. An affected horse may rupture small vessels in the lung or upper respiratory tract at full gallop, especially in a long race. Such horses are called Bleeders. The condition is a common cause of poor racing performance and often shows up as a sudden loss of speed on the run home. The condition may last for months or years. Most bleeders are tender to palpation of the reflex areas of the lung (BL13 and the area behind the posterior edge of the scapula). They may be tender also on the Diaphragm and Liver points (BL17, 18), which are related to haemorrhage and prothrombin (Fig. 15). As the saddle sits over those areas, such horses may resent being saddled, or may be troublesome when mounted. Horses with kidney or ovary problems may be touchy in the area L1 to L3 (BL22-24). The key reflex point for the ovary and kidney is BL23.
In mares and fillies, sporadic lameness (hindquarter, hunched or rigid back and, occasionally, forelimb lameness) which may be severe can arise due to referred pain from ovarian or uterine irritation. Check for TPs related to the ovary and uterus (see section 1.5 below).
Be careful to check for DIAGONAL relationships. Cain stresses that forelimb lameness is often accompanied by tenderness at contralateral lumbo-sacral or hind-limb points. Also, hindlimb lameness is sometimes associated with TPs on the contralateral side of the neck.
Be careful to check the paravertebral SHU points in relation to the location of limb pathology, for instance BL25 (lumbar 4-5, large intestine SHU) in medial forelimb lameness and BL21 (behind last rib, stomach SHU) in antero-lateral hindlimb lameness etc.
In all local problems (neck, shoulder, elbow, back, thoraco-lumbar, lumbo- sacral, hip, stifle, laminitis etc), the TPs must be found. They are recorded and clipped (in horses) as they are located. This helps rapid reassessment of the case on later visits. It also makes it easy for the handler to locate them for heavy massage or other physiotherapy (ultraound, LASER etc) between AP sessions.
CHOICE OF POINTS IN AP THERAPY
Rogers 1987 lists the methods of choosing points for the treatment of human backpain. Similar points and reasoning are used in animals. The points depend on the organs and parts involved. The most common combination of points is: all TPs, plus 1-2 LOCAL points (near the affected organ or part), plus 1-2 DISTANT points on meridians passing through, near or related to the affected parts. If an organ is thought to be involved, its SHU point is used, whether tender or not. To this can be added the MU (abdominal alarm) point.
In low-backpain patients, GB30, 34 and BL54, 60 are useful distant points. In animals, the lumbo-sacral space is called PAIHUI. (In humans, PAIHUI (VG20) is on the top of the head).
The combination of TPs, PAIHUI, BL23, 26, 30, 54, 60, GB30, 34, covers most backpain below the ribs, including radiating sciatic pain. The combination of TPs, BL13, 16, 21, TH15, SI 9 covers most thoracic backpain. The combination of TPs, GB20, 21, TH15, CO17, ST38 (or GB34) covers most neck pain.
Other useful points are:
PAIHUI (all problems below the ribs); BL11 (joints); BL16 (spinal column); CO 4 (forelimb & general effects); BL21, ST36 (hindlimb, appetite and general effects); ST44 (hindlimb); TH 5 (forelimb); GB34 (hindlimb, muscles, tendons, neck, shoulder and elbow); BL23 (lumbo- sacral and hindlimb; adrenal point, stress conditions; ovary/kidney/Vitamin D/para-
thyroid/bone point and general effects).
However, many point combinations are possible. Examples of these are given below and the locations are shown in attached figures.
METHODS USED IN AP THERAPY
Simple needling: In horses, special AP needles or hypodermic needles 19-26 gauge, 2-6 inches long are used. In dogs, human AP needles or hypodermic needles 26-30 gauge, 0.5-2 inches long are used. Sterile needles are inserted into the points. Cleansing of the skin before insertion of the needle is a cosmetic exercise unless the skin is wet or visibly dirty. The needles are left in situ for 20 minutes. Twirling and pecking of the needle is done every few minutes. Cases are treated at intervals of 1 - 2 days in acute or 3 - 7 days in chronic cases. Acute cases may require 1 to 3+ sessions to recovery. Chronic cases may need 1 to 10+ sessions.
Electroneedling: Needles are inserted as usual. Output leads from special electrostimulators are used to deliver electrical stimuli to the needles. Session length and intervals between sessions are as for simple needling. An advantage claimed for electro-AP is that it requires fewer sessions. This, however, is doubtful. Strong, painful needle manipulation is as good as electro-AP, but electro-AP leaves the operator free to talk, take notes etc. In cases of paralysis and in severe pain, electro-AP may be better than simple needling. White suggests electro-AP treatment every 12-24 hours in acute cases with severe pain or paralysis. Electro-AP is also the usual method used to obtain AP analgesia for surgery in animals.
Point injection: This is an effective, rapid and safe method in horses and dogs. It is very useful in busy practice. In horses, 1-5 ml is injected at each point; in dogs, .5-1.5 ml. The solution may be .5-1.0% procaine in saline, saline alone, saline-B12, Impletol, homoeopathic solutions etc. Choice of solution depends on practitioner preference- all methods are used. Point injection also allows the use of drug-therapy, when needed. The Dermojet (high-pressure skin injector) is also used.
Massage: It shortens recovery time if animal handlers are shown the techniques of massage. TPs and other important AP points can be marked or clipped. Massage for 2 minutes/point every 1-2 days between AP sessions is very useful. In the horse, I demonstrate massage by fist-pounding to the horse's tolerance. In the dog, I demonstrate deep massage with the thumbs (for spinal areas) or other methods for limb muscles.
Ultrasound: Standard equipment may be used. Different probes are available for diifferent parts- body surface, orifices etc. A contact jelly is essential. Output is .25-1.0 watts. Time 15-60 seconds/point. The method is painless and non-invasive but is not as well documented as the needling or injection methods.
LASER: Low power laser (1-5 mW) and higher power (5-10 mW) has been used in horses and dogs instead of needling. Three types are common: He-Ne (632 nm wavelength), infrared (902 nm) and diode lacers (not true laser light). Laser is painless and non-invasive but its penetration is shallow. It is not possible to assess laser effectiveness at this time.
Some users report excellent results (for instance Martin and Klide 1987) in backpain in the horse but others say the laser is not as good as needling. All agree that laser is excellent for local (superficial) problems, such as septic wounds, tendonitis, granulomas, ulcers, eye problems etc. It may be useful in Earpoint AP. However, at this time, Earpoint AP is also not as well documented as classical AP and TP therapy.
Implants: Skin staples, implant of sutures, platinum-, gold- or surgical beads or wire can be used to stimulate the AP points. Klide has used implants effectively to control epilepsy in dogs. Cain has used them to control nervousness in fillies. Others have used them in backpain and other conditions. They are very effective (implants around the acetabulum) in treating hip dysplasia in dogs. However, the method needs more documentation before acceptance as a routine procedure.