Introduction

Intervertebral disc disease (IVDD) is commonly seen in dogs in veterinary practice. The clinical signs of IVDD are back or neck pain, trouble walking, lameness, trouble urinating, paresis and/or paralysis. The most common types of thoracolumbar IVDD are caused by herniation of the nucleus pulposus into the spinal canal (Hansen type I) and protrusion of the intervertebral disc into the spinal canal, with the dorsal annulus still covering the disc material (Hansen type II). Acupuncture and rehabilitation can be effective at returning dogs to an ambulatory state and return of normal function, when used alone or in combination with Western medicine and surgery, for both types of IVDD. Several studies have shown promising effects of using electroacupuncture at treating IVDD in dogs and rat models. This presentation explains the Traditional Chinese Veterinary Medicine (TCVM) etiology and effective treatment modalities, which include physical rehabilitation used in IVDD cases.

TCVM Etiology and Pathophysiology in IVDD

The nervous system is related to the Kidney (bones and spinal cord), the Liver (joints and smooth flow of Qi and blood), and the Spleen (muscle strength). IVDD are often also considered as a Bi syndrome and are usually accompanied by a Wei (weakness) syndrome. There are 2 Excess Patterns and 3 Deficiency Patterns that are associated with various forms of IVDD. The Excess conditions are invasion of WindColdDamp and QiBlood stagnation, which are often associated with acute trauma in chondrodystrophic dogs (Type I). The Deficiency Patterns, often associated with chronic, Type II IVDD in nonchondrodystrophic breeds, include Qi/Yang Deficiency, Yin Deficiency and combined YinQi Deficiency.¹

TCVM Treatment for IVDD

1.  Acupuncture
Acupuncture has been proven to be an effective therapy for IVDD.^2-8 A general acupuncture treatment plan for a patient with IVDD is as follows:

a.  Dry needle: GV-20, Liu-feng, BL-60, KID-3, SP-10, LIV- 3, BL-40, ST-41, GV-1

b.  Electroacupuncture: (20–40 Hz for 10 minutes, 80–120 Hz for 10 minutes, 200 Hz for 10 minutes) at the following pairs of acupoints:

i.  GV-14 to Bai-hui or GV-1

ii.  Left BL-11 to right Shen-shu

iii.  Right BL-11 to left Shen-shu

iv.  Hua-tuo-jia-ji at or proximal and distal to the suspected or diagnosed disc space, bilateral

v.  ST-36 to GB-34, or ST-36/GB-34 bilateral

vi.  KID-1 to BL point proximal to IVDD lesion, or KID- 1/Liu-feng, bilateral

c.  Aqua-acupuncture (vitamin B12) at Hua-tuo-jia-ji at or proximal and distal to the suspected or diagnosed disc space, KID-1, BL-40, LIV-3, LI-4, Liu-feng

d.  Hemo-acupuncture: use acupuncture needle or 24G hypodermic needle to puncture Jing-well points on the affected limbs and Wei-jian acupoint and get a few drops of blood.

2.  Scalp acupuncture

a.  Motor area: A line starts at GV-22 and extends cranial and ventral to TH-23 on the lateral eyebrow

i.  GV-22: In the small triangular area formed by the ridges of the frontal crest

ii.  TH-23: In the depression on the rim of the orbit at the end of the eyebrow where it extended to the lateral canthus

b.  Sensory area: Starts at GV 20 and extends cranial and ventral to Nao-shu

i.  GV-20: On the dorsal midline on a line drawn from the tips of the ears level with the ear canals

ii.  Nao-shu: Over the temporalis muscles 1/3 the way along a line from the cranial ear base to the lateral canthus

c.  Long insertion methods: use 32–38G acupuncture needle (½” for small dogs and cats; 1” for big dogs) to penetrate subcutaneously the entire motor line (from GV-22 through TH-23) and sensory line (from GV-20 through Nao-shu). Rotate, lift and thrust, or electrically stimulate the needles every 2–3 minutes.

3.  Herbal medicine
General herbal dosage for dogs is 0.5 g per 10–20 lb body weight BID for 2 to 4 months, and then as needed.

a.  Da Huo Luo Dan or Double P II (Da Hua Luo Dan modification) is the primary herbal medicine used to treat IVDD. It may cause loose stool in some cases. It can be used as long as the gut is able to tolerate it. Do not give if patient is sensitive to herbal medications or is prone to diarrhea.

b.  Add Bu Yang Huan Wu for Qi or Yang Deficiency (rear weakness, pale and wet tongue, and deep/weak pulse). Better tolerated than Double P II, so can use instead of Double P II if animal is prone to diarrhea.

c.  Add Di Gu Pi San for Yin Deficiency (cool-seeking, or rear weakness, red/dry tongue, and fast/thin pulse).

d.  Add Hindquarter Formula for Qi and Yin Deficiency (cool-seeking, rear weakness, red or pale tongue, and fast/weak pulse).

e.  Add Stasis Breaker if a tumor or mass is present in the spinal cord.

f.  Add Jie Gu San for fractures of the vertebra.

Physical Rehabilitation for General Practitioners

In conservative cases of acute and recurrent thoracolumbar disk disease, it is important to perform minimal intervention and avoid motions that might risk further herniation of disk material for one month or longer. Patients with cervical or thoracolumbar disk disease are more likely to have proprioceptive and motor deficits, requiring greater attention to balancing and strengthening activities.

1.  General exercise:

a.  Gentle massage of musculature in the cervical, forelimb, paraspinal, and hindlimb for 10–20 minutes to warm up the muscles or to relieve muscle tensions, BID–TID.

b.  PROM with bicycling movements all joints of affected limbs, 10–15 reps, BID–TID.

2.  Proprioception and balancing training:

a.  Assisted Standing with abdominal support (e.g., sling, physioball beneath abdomen, standing in water level to the greater trochanter) as needed on a stable, high-traction surface; gradually decreasing support as the patient was able to stand better.

b.  Weight Shift (weight bearing, balance): Stand behind the dog with the hands placed on either side of the pelvis to support the dog for rear limb weight shift (place on the chest for front limb weight shift). With the limbs in a square standing position, the dog is gently pushed in one direction, and then the other in a slow, rhythmic fashion. Gently push 10–15 times, BID–TID. Make sure this is done on a surface with good traction with the four legs underneath the dog in a normal standing position.

c.  Challenged Standing (improves weight bearing, balance/proprioception): Have the dog stand on any irregular surface such as couch cushions, foam, trampoline, etc. While standing, can provide gentle pushing to challenge balance, but not too much to lose balance. Repeat 5–10 times during each session, BID–TID.

d.  Figure Eights (balance, spinal ROM, weight shifting): Walk the dog on an outline of the number ‘eight’ on the ground. Start with SLOW speed and BIG Eights. Watch the weight-shifting and weight-bearing carefully. Repeat 5–10 times during each session, BID–TID.

e.  Weave Poles (core strengthening/range of motion): Place the cones or bottles close enough together that the dog has to bend its spine sufficiently during the exercise. This distance is typically slightly less than the body length of the dog. Lead the dog carefully through the cones so that the head, neck, and body flex as the poles are negotiated. Repeat 5–10 times during each session, BID–TID.

f.  Obstacle Course (balance/proprioception): Place various objects in a hallway or in a line and slowly walk the dog over the obstacles on a short leash. Obstacles can be pillows, cushions, rolled towels, PVC pipes, broom handles, air mattresses, steps, dog beds, etc. Repeat 5–10 times during each session, BID–TID.

3.  Strengthening (typically 4 or more weeks postoperatively):

a.  Sit to Stand (rear leg strength/ROM): Using a treat or other cue, the dog is placed in a square sitting position. She is then allowed to push up to a standing position. Be certain that the dog sits and stands squarely and symmetrically. Placing an affected leg against a wall or having the dog sit in a corner helps to encourage symmetrical sitting and standing. Repeat this motion 5–10 times during each session, BID–TID. Give only as much support as needed to help encourage the dog to use its muscles

b.  Stair Climbing (ROM/strengthen legs/core): Begin with wide, low stairs; avoid open stairs. Gradually increase number and steepness of stairs. Initially, walk dog upstairs 5 steps, and downstairs 5 steps. Repeat 3–5 times, SID–BID. Gradually increase the steps up to 10 each time.

c.  Cryotherapy at lesion site as needed for 20 min after exercise.

* Caution: Choose only 2–4 exercises per session. Other exercises may be performed as part of a home exercise program. Doing all exercises may result in lameness and pain early in the program.

Outcome Measurement

Using a 0–5 grading scale to evaluate clinical neurological signs of IVDD (Table 1), it can be a valuable tool to help choose the mode of treatment, determine the prognosis, and assess the success of treatment.⁹ For the most optimum recovery, it is best to use TCVM with decompressive surgery for cases with grades 4 and 5. IVDD with Grades 1 to 3 may be successfully treated with TCVM alone.^2-8

Table 1. Neurological grading scale in canine intervertebral disc disease

A 2010 study evaluated the effectiveness of acupuncture in comparison to decompressive surgery, and a combination of both surgery and acupuncture, in forty dogs that had long standing clinical signs of IVDD (>48 hours). The dogs were re-graded six months after onset of clinical signs, and were considered a success if they returned to ambulation (i.e., they decreased from grades 4/5 to grades 1/2). This research demonstrated that electroacupuncture had a greater success (79% or 15/19 dogs) than did decompressive surgery alone (40% or 4/10 dogs). Dogs that had both decompressive surgery and electroacupuncture had an intermediate response (72% or 8/11).² This study indicates that the duration of clinical signs prior to treatment appears be an important factor in determining if decompressive surgery will benefit the patient. Therefore if the clinical signs of IVDD have persisted for over 48 hours, and the animal is a grade 5 for a prolonged amount of time, electroacupuncture is the treatment that shows the most benefit to these patients. In addition, if the client is unable to afford surgery, TCVM may be the only potentially effective treatment option.²

Summary

Intervertebral disc disease is commonly seen in small animal clinics. Traditional Chinese Veterinary Medicine (TCVM), including acupuncture, food therapy and herbal medicine, can be an effective singular therapy, or part of integrated therapy with Western medicine and surgery, based on a grading scale of clinical signs and type of IVDD.

References

1.  Huisheng Xie. Chinese Veterinary Herbal Handbook. 2nd edition. Chi Institute of Chinese Medicine. 2008: page 6.

2.  Joaquim JG, et al. Comparison of decompression surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervetebral disc disease with long-standing severe neurologic deficits. J Am Vet Med Assoc. 2010;236:1225–1229.

3.  Hayashi AM, Matera JM, Fonseca Pinto AC. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disc disease in dogs. J Am Vet Med Assoc. 2007;231:913–918.

4.  Hayashi AM, Matera JM, da Silva TS, Pinto AC, Cortopassi SR. Electroacupuncture and Chinese herbs for treatment of cervical intervertebral disc disease in a dog. J Vet Sci. 2007;8:95–98.

5.  Janssens LA, Rogers PA. Acupuncture versus surgery in canine thoracolumbar disc disease. Vet Rec. 1989;124:283.

6.  Janssens LA. Acupuncture for the treatment of thoracolumbar and cervical disc disease in the dog. Probl Vet Med. 1992;4:107–116.

7.  Lai A, Chow DH, Siu WS, Holmes AD, Tang FH, Leung MC. Effects of electroacupuncture on a degenerated intervertebral disc using an in vivo rat-tail model. Proc Inst Mech Eng [H]. 2008;222:241–248.

8.  Lubbe AM. Auriculotherapy in canine thoracolumbar disc disease. J S Afr Vet Assoc. 1990;61:187.

9.  Björn Meij. Cervical and thoracolumbar disc disease: diagnosis and treatment. In: The proceedings of 30th World Congress of the World Small Animal Veterinary Association (WSAVA), May 11–14, 2005, Mexico City, Mexico.

10.  Laitinen OM, Puerto DA. Surgical decompression in dogs with thoracolumbar intervertebral disc disease and loss of deep pain perception: a retrospective study of 46 cases. Acta Vet Scand. 2005;46(2):79–85.

11.  Millis D, Levine D. Canine Rehabilitation and Physical Therapy. 2nd edition. Saunders, 2014. VitalBook file.