De belles histoires

Belles histoires

Isolde - Acupuncture used to treat Acute Spinal Cord Injury following T3-T5 spinous processes and dorsal laminae Fractures with 4 out of 5 hind limbs Ataxia in a 24 year old Quarter Horse mare

L'histoire d'Isolde

Isolde est une jument grand poney Quarter Horse croisée née le 26 avril 1991 appartenant à la même famille depuis l'âge de 4 mois. Au cours de sa vie, Isolde s'est démarquée autant sur les circuits de chasseur/sauteur, de dressage et de concours complet dont elle a remporté maints championnats à la fois provinciaux et inter-provinciaux (Jeux Équestres du Québec) jusqu'en 2010 inclusivement. Par la suite, elle était cheval d'école pour débutants et intermédiaires jusqu'à ce que sa vie bascule...

Isolde
Isolde suite aux interventions en septembre 2017

Alors qu'elle sortait avec la même compagne d'extérieur depuis plusieurs mois et que tout se passait jusqu'alors normalement. Par un matin du 23 mars 2015, sa compagne plus dominante ayant été sortie par accident en premier, Isolde en entrant dans son enclos s'est vue chassée de celui-ci. Ancienne jument talentueuse et athlétique à l'obstacle, Isolde a esquivé avec succès sa compagne en sautant la barrière qui venait d'être refermée. Malheureusement, c'est à l'atterrissage sur la glace qu'elle a glissé et est tombée sur son côté droit. En se relevant, tout son arrière-main était faible et tremblait. L'employée m'a alors dépêchée sur les lieux pour prodiguer les premiers soins d'urgence. Étant donné la sévérité du cas et mon départ imminent le lendemain pour la dernière formation d'acupuncture en Oregon, Isolde a alors été transférée au Centre Hospitalier Universitaire Vétérinaire de Saint-Hyacinthe pour une prise en charge en mon absence. Un diagnostic d'ataxie proprioceptive (trouble neurologique) de grade 4/5 reliée à des fractures vertébrales de T3 et T5 dont au moins une fracture de la lame dorsale avec atteinte à la moelle épinière, est tombé. À mon retour une semaine après, comme ses symptômes étaient contrôlés, mais sans améliorations majeures médicalement et qu'aucun rapport de cas ne semblait rapporter de survie à ce type de trauma, l'euthanasie semblait la seule option puisque sa qualité de vie était sévèrement compromise. Cependant, due à l'énorme valeur sentimentale d'Isolde aux yeux de ses propriétaires qui voyaient encore ce désir de vivre en elle, Isolde fut transférée chez elle avec interventions assidues en électro-acupuncture (voir l'article ci-dessous en anglais).

Isolde est toujours retraitée, en santé et heureuse à ce jour. Elle ne fait pas physiquement ses 28 printemps ET personne ne pourrait savoir sans cette histoire que sa vie a passée si près d'être écourtée!


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ABSTRACT:

Acupuncture was used successfully to manage an acute spinal cord injury with 4 out of 5 hind limbs ataxia in a 24 year old Quarter Horse mare. Dry needle acupuncture therapy was used every other day for 4 treatments following the injury, then every three to six days as needed by patient's clinical signs for 4 months, to reduce spinal cord inflammation and proprioceptive deficits, along with lessening of Western medications. Electroacupuncture was introduced a month after the beginning of these dry needles acupuncture treatments. Her proprioceptive deficits gradually decreased from 4 to 1,5 out of 5 and allowed her to regain a good quality of life with ability to walk, trot and canter safely by herself in the paddock, in hands or on the lunge line.

HISTORY:

Isolde is a 24 year old Quarter Horse who suffered a bad fall on her right wither on March 23rd 2015. She was hospitalized at the closest Equine Hospital where they diagnosed 2 spinous processes fractures at T3 and T5 with at least one of them that probably involved the dorsal laminae and caused the acute spinal cord injury symptoms. Initially, she had 2 out of 5 hind limbs proprioceptive deficits. At the Hospital, on March 24th, she was started on 0,5mg per kilogram DMSO solution intravenously that was repeated to 1mg per kilogram on March 26th, 27th and 28th and she received Phenylbutazone 2g q 24h PO on March 23rd and 24th, 1g q 12h PO from March 25th to 31rd, then 1g q 24h from April 1st until she left the Hospital. On March 25th, Dexamethasone 20mg IV was given to her. On March 29th and 30th, she received Dexamethasone 10mg q 24h IV. Prednisolone 500mg q 24h PO was started on April 2nd. On March 26th, she was also introduced to vitamin E supplement 3000UI PO daily with her meals. In the following 48 hours of her hospitalization, on March 24th, her hind limbs ataxia increased to 4 out of 5 worst on the right. A week later, her ataxia started to stabilize to 3,5 out 5. She was discharged from the hospital on April 6th as her owners refused to have her euthanized as advised by the hospital medical staff.

The owners agreed to a course of TCVM treatment consisting of dry needles acupuncture every other day for a week and as needed by her clinical signs. Goals were to prevent secondary spinal cord damages, decrease her hind limbs deficits and increase her comfort while decreasing medications.

Isolde had a 4 year medical history of Cushing syndrome and laminitis crisis for which she received Pergolide 1,5mg q 24h PO since 2011. We also wanted to decrease her prednisolone medication as we were worried of laminitis recurrence which would encourage euthanasia. If possible, we were also hoping to decrease Phenylbutazone because of her age and stomach natural sensitivity.

WESTERN DIAGNOSIS:

April 6th, 2015

Isolde was slightly depressed. She had lost weight in the last couple of weeks to 7 out of 9 Body Condition Score (BCS) to now 5 out of 9 BCS. Her thoracic auscultation was normal, no cardiac or pulmonary abnormalities were elicited. She had 3 (almost 4) out of 5 hind limbs deficits worse on the left as her left hoof toe was severely dragging. Joints mobility were not tested due to her severe lack of balance and ataxia. She had moderate back tenderness to palpation from T16 to sacrum which worsened at L2-L3.

Interestingly, she has not laid down since her accident, while before she used to do it every night. It seemed as if she knew that she did not have the same physical capacity to lay down and get up since her accident.

EASTERN (TCVM) DIAGNOSIS:

April 6th, 2015

Despite Isolde looking happier to be home, she nonetheless still looked depressed as she was unable to move as well as before the accident. She looked like she understood something was going wrong in her body. Her hind limbs proprioceptive deficits, stiffness and weakness corresponded well with ''too weak to move''. The owner noted that Isolde's appetite was still very good and drinking was normal. Her stools and urine were normal as well. She had some problems posturing with unusual spread hind limbs, loss of balance and hind limbs trembling when urinating. She tended to keep her hind limbs under herself while resting. As she could not lay down, she did not have a good sleep. She sometimes seemed chilly and loved to stay in front of her window at noon time (sun rays). Blankets were used to keep her warm.

On examination, Isolde's tongue appeared pink and slightly wet. Her facial pulses were thin and deep, equals on both sides. Rapid meridians testing showed tenderness at LI 16 on the left, LI 17 on the right, GB 21, GB 39, BL 21 on the left, BL 23 on the right, Qi-Hai- Shu on the right and BL 54. Palpation of the epaxial muscles along the spine from T15 to L6 showed moderate tenderness and slight atrophy. Slightly warmer areas were noted over her withers and her lumbar vertebrae. Right hind limb patella ligaments hyperlaxity was also visualized with sort of upward fixation. Coronary band distension (excess) were noted at TH 1, SI 1 and BL 67 while deficiencies were noted at SP 1, LIV 1 and GB 44. All her hoof were equally warm.

A diagnosis of Trauma induced Wei Bi was made based on Isolde's traumatic history, her proprioceptive deficits, her right patella ligaments laxity and her muscles atrophy and weakness. She corresponded well to "too weak to move".

WESTERN TREATMENT:

Prednisolone 500mg q 24h PO was previously prescribed and, from April 6th, was continued every other day at the same dosage for an additional 10 days.

Phenylbutazone 500mg PO q 24h was recommended when needed only. Vitamin E 1500UI q 24h PO was continued for long term supplementation. Pergolide 1,5mg q 24h PO was continued as the last 4 years.

Isolde was only fed with 1st cut hay 1,5kg PO q6h to limit laminitis crisis risks. She was kept in her 10'x10' stall for another 10 days to facilitate bone callus formation, then was walked q 12h in the 30 meters stable alley for another 10 days to note her proprioceptive deficits evolution and to make her move a bit as it could have been detrimental to her wellbeing if she were to remain sedentary especially at her age. By the end of April 2015, she started to walk 2 minutes q 12h in the inside sand arena as daily physiotherapy. Every week, daily walks were increased by 5 minutes total a day. By the end of June, little hand trotting was added for 100 meters a day. By the end of July, she could go in daily turn outs with an old friend. She cantered quietly by herself for the first time on August 11th 2015.

EASTERN (TCMV) TREATMENT:

Principles:

Trauma induced Wei Bi: To move and nourish Blood, to relax the Sinews and to move Qi in affected channels.

Acupuncture:

Dry Needles Acupuncture Treatment using DLM Master singles 0,22mm X 0,25mm needles placed at a depth of 15 to 20mm using an even needle technique for all points. These needles remained in place for 15 minutes.

Isolde point d'acupuncture équin
Points, Locations Indications
LI 1, Shang-yang, Ting point On the dorsal aspect of the front foot, in the depression just proximal to the coronary band, approximately 1/3 the distance from the dorsal midline of the coronary band to the palmar border of the medial bulb of the heel. Distal point to remove obstruction of the channel. Local point for laminitis.
LI 10 left, Qian-san-li, Arm 3- Miles In the muscular groove between the extensor carpi radialis and the common digital extensor muscles of the forelimb, 2 cun distal to the transverse cubital crease. Qi and Blood tonic effect. Pain and atrophy.
LI 16 left, Ju-gu, Local point In the muscular groove between the cleidomastoideus portion of the brachiocephalicus and omotransversarius muscles just cranial to the subclavius muscle, ventral to the cervical vertebra column (C6-C7 approximatively). Disperses Blood locally, subdues ascending rebellious Qi and benefits the joints.
LI 17 right, Tian-ding, Local point In the muscular groove between the cleidomastoideus portion of the brachiocephalicus and omotransversarius muscles just cranial to the subclavius muscle, cranioventral to the cervical vertebra column (C5- C6 approximatively). Local problem.
ST 36, Hou-san-li, Leg 3-Miles, Master point for the abdomen and Gastrointestinal tract In the depression just lateral to the tibial crest, in the muscular groove between the tibialis cranialis and the long digital extensor muscles, 2 cun distal to the proximal edge of the tibial crest. Tonifies Qi and Blood. Stifles problems.
SP 6, San-yin-jiao, Master point of the caudal abdomen and urogenital areas In the depression 3 cun proximal to the most medial prominence of the medial malleolus of the tibia, just caudal to the caudal border of the tibia and dorsal to the combined heads of the deep digital flexor muscle: tibial caudalis and lateral digital flexor. Moves and nourishes Blood. Stops pain.
SI 1, Shao-ze, Ting point On the dorsal aspect of the front foot, in the depression just proximal to the coronary band, approximately 1/3 the distance from the dorsal midline of the coronary band to the palmar border of the lateral bulb of the heel. Distal point to remove obstruction of the channel. Local point for laminitis. Pain and stiffness in the neck.
SI 16, Tian-chuang, Local point In the depression of the caudodorsal border of the cleidomastoideus branch of the brachiocephalicus muscle in the ventral area of the 2nd and 3rd cervical vertebrae. Local point for upper neck tensions.
BL 11, Da Zhu, Influential point of the Bones In the depression just cranial to the craniodorsal border of the scapular cartilage, 1,5 cunlateral to the dorsal midline, over the cervical portion of the trapezius muscle. Increases Qi, nourishes Blood, soothes Sinews and eases pain.
BL 17, Ge-shu, Diaphragm Back-shu point and Influential point for Blood 3 cun lateral to the dorsal midline, in the 12th intercostal space, in the muscular groove between the longissimus thoracis and the iliocostalis thoracis muscles. Regulates and tonifies both Qi and Blood. Pacifies the Stomach.
BL 18, Gan-shu, Liver Back- shu point 3 cun lateral to the dorsal midline, in the 13th and 14th intercostal spaces, in the muscular grooves between the longissimus thoracis and iliocostalis thoracis muscles. Muscles and tendons problems.
BL 19, Dan-shu, Gallbladder Back-shu point 3 cun lateral to the dorsal midline, in the 15th intercostal space, in the muscular groove between the longissimus thoracis and iliocostalis thoracis muscles. Muscles and tendons problems.
BL 20, Pi-shu, Spleen Back-shu point 3 cun lateral to the dorsal midline, in the 17th intercostal space, in the muscular groove between the longissimus thoracis and the iliocostalis thoracis muscles. Benefits the Spleen function of raising Qi, dispels and transforms Dampness and nourishes the Blood.
BL 21, Guan Yuan Shu, Stomach Back-shu point In the depression 3 cun lateral to the dorsal midline, caudal to the 18th rib, between T18 and L1, in the muscular groove between the longissimus thoracis and the iliocostalis thoracis muscles. Regulates and tonifies Qi. Meridian hind limbs problem.
BL 23, Shen Shu, Kidney Back- shu point In the depression 3 cun lateral to the dorsal midline, between the spinous processes of L2-L3, in the muscular groove between the longissimus thoracis and the iliocostalis thoracis muscles. Strenghtens the Bones and Marrow, benefits the Mind and strenghtens the caudal back and stifle.
BL40, Wei Zhong, Master point of Lower Back and Hips In the depression at the midpoint of the transverse crease of the popliteal fossa, between the caudal division of the biceps femoris and semitendinosus muscles. Eliminates Blood stasis. Strenghtens caudal back. Hind limbs paralysis.
BL 60, Kun-lun, Jing-river ''Aspirin point'' On the lateral aspect of the hock area, in the middle of the webbed area cranial to the calcanean tendon, at the level of the tip of the tuber calcanei. Removes obstructions in the channel. Relaxes tendons, strengthens caudal back and hock and alleviates swelling and pain throughout the body. Weakness and paralysis of the hind limbs. Cervical stiffness.
KID 3, Tai-xi, Shu-stream point, Yan-source point On the medial aspect of the hock area, in the middle of the webbed area cranial to the calcaneal tendon, at the tip of the tuber calcanei. Tonifies the Kidneys. Cools Heat and strengthens caudal back. Paralysis of the hind limbs.
KID 10, Yin-gu, He-Sea point In the depression between the semitendinosus and the gracilis muscles at the level of the popliteal fossa. Tonifies Kidney Yin. Expels Dampness from the Lower Burner. Local stifles problems.
TH 1, Guan-chong, Ting point On the dorsal midline of the front foot, in the depression just proximal to the coronary band. Distal point to remove obstruction of the channel. Local point for laminitis. Invigorates Blood.
GB 21, Bo Zhong, Local point In the depression cranial to the cranial border of the subclavious muscle, dorsal to the dorsal border of the omotransversariusm muscle and dorsal to the 7th cervical vertebra. Relaxes sinews. Good point for the neck.
GB 34, Yang-ling-quan, Influential point for Sinews In the interosseous space between the tibia and fibula and between the long and lateral digital extensor muscle, cranio-distal to the head of the fibula. Strengthens the caudal back. Hind limbs pain and weakness.
GB 39, Xuan Zhong, Influential point of Marrow In the depression 3 cun proximal to the most lateral proeminence of the lateral malleolus of the tibia, caudal to the tibial border, cranial to the deep digital flexor muscle. Removes obstructions in the channel, especially in the neck. Spinal cord injury, hind limbs paralysis and pain/stiffness in the neck and hind limbs.
GB 44, Zu-qiao-yin, Ting point On the dorsolateral aspect of the rear foot, in the depression just proximal to the coronary band, approximately 1/3 the distance from the dorsal midline of the coronary band to the plantar border of the lateral bulb of the heel. Distal point to remove obstruction of the channel.
LIV 1, Da-dun, Ting point On the dorsomedial aspect of the rear foot, in the depression just proximal to the coronary band, approximately 1/3 the distance from the dorsal midline of the coronary band to the plantar border of the medial bulb of the heel. Distal point to remove obstruction of the channel.
GV 1, Hou-hai/Chang-qiang, Luo-connecting point for the GV channel On the midline, in the depression between the anus and the ventral tail base. Distal point for along the meridian. Sore back and spinal cord problems.
GV 4, Ming-men On the midline, in the depression between the dorsal spinous processes of the 2nd and 3rd lumbar vertebrae. Benefits the lumbar area and stifles and strengthens Original Qi.
GV 14, Da Zhui, Meeting point for all Yang channels and Sea of Qi point On the dorsal midline, in the depression between the dorsal processes of the 7th cervical and 1st thoracic vertebrae. Meeting point for all six Yang meridians of the forelimbs and regulates Nutritive and Defensive Qi. Cervical and Back problems.
Yao Bai Hui The depression in the dorsal midline in the lumbosacral space. Musculoskeletal and neurological hindquarter area problems.
CV 12, Zhong-wan, Alarm- Mu point for the Stomach, Influential point for Fu organs On the ventral midline, in the depression halfway between the xiphoid process and the umbilicus. Benefits Stomach and Spleen functions.
CV 17, Dan-zhong, Influential point for Qi On the ventral midline, in the depression at the level of the caudal border of the olecranon. Tonifies Qi. Resolves Phlegm.
Qi-Hai-Shu right, Association point for the Sea of Qi In the depression 3 cun lateral to the dorsal midline, in the 16th intercostal space, in the muscular groove between the longissimus thoracis and the iliocostalis thoracis muscles. Qi deficiency and general weakness.
Du Mai 1, Governing Vessel, Sea of Yang Opening SI 3 right: Proximal to the metacarpophalangeal joint, on the lateral side of the 5th metacarpal. Closing BL 62 left: In the depression just plantarodistal to the most lateral prominence of the lateral malleolus of the tibia. Strengthens the Spine and Kidney Qi and benefits the Spinal Cord. Controls and distributes Wei Qi to the Back and Head. Aids Qi circulation.

TREATMENTS:

April 6th 2015

GB 21 was used to relax the Sinews. GB 39 was used to strengthen her Marrow and to remove obstructions in the Gall bladder channel related to her spinal cord injury. BL 11 was used to nourish Blood, increase Qi, soothe the Sinews and ease pain. SI 1 and TH 1 were used as Ting points to drain the excesses in these channels. BL 21 on the left side was used as a local tender point, to tonify Qi and to help its meridian. BL23 on the right side was used to strengthen both Kidney and Qi, as well as strengthen the lower back and knees. BL40 is a Master point for the lower back and hips, and was used to move Blood and to help the hind limbs weakness and paresis. Qi-Hai-Shu on the right side was used as a local tender point and to supplement Qi deficiency. LI 16 on the left side was used to disperse local Blood stagnation and to benefit the joints. LI 17 on the right side was used as a local tender point. Yao Bai Hui was used to benefit the hindquarters musculoskeletal and neurological related conditions. Some other points could have been chosen as well, but I felt I should treat her progressively to avoid draining her and sending too many messages at the time especially for this first acupuncture treatment following that spinal cord injury.

April 8th, 2015

The owners and I noted a slight hind limbs paresis improvement since 2 days ago. Isolde looked more confident walking up the 3 meters from her stall to the alley with still not much proprioceptive deficit changes. Kind of intermittent upward fixation of Isolde's right patella became more evident following her stall rest. Her tongue was almost the same, but a little more wet while facial pulses were the same as two days ago. SP 1 still showed deficiency. BL 67 was now showing deficiency too. No temperature differences were noticed over her hooves. Isolde had tender points at GB 20, BL 20 on the right side and BL 21 on the left side. LI 10 on the left side was used for Qi and Blood tonic effects and for Isolde's pain and atrophy symptoms. GV 14 was used for her cervical and upper back symptoms. ST 36 on the right side was used to tonify Qi and Blood and to strengthen her right stifle symptoms. BL 20 was used on the right side as a local tender point and to tonify Blood. BL 21 on the left side was used again as a remnant local tender point, to tonify Qi and to help its meridian. Du Mai (SI 3 on the right side and BL 62 on the left side), Extraordinary Vessel, was used to strengthen deeply the Spine and Kidney Qi and to aid Qi circulation in her Spinal Cord. As she was stressing and panicking when I tried to needle GB 20, I decided to not treat this one to avoid an accident who could worsen her condition. Usually this point is related to a chiropractic issue, but it was too soon to treat it at this point of her rehabilitation.

April 10th, 2015

Isolde laid down the last two nights since her last treatment. This was the first time since the accident. The owners noted an improvement of her urination posture as her hind limbs narrowed and stabilized. At physical, no tongue, facial pulses or hooves temperature changes. Isolde was still sensitive at GB 20, BL 20 and BL 21. BL 23 sensitivity was popping out this time. Coronary band distensions were noted at LIV 1, GB 44, SI 1, TH 1 and LI 1 while deficiencies were noted at BL 67 and SP 1. Yao Bai Hui was used to benefit her hind end while GV 14 was used to improve her cervical and upper back pain and tonify Qi. As her tongue was still a little wet, CV 17 was used to resolve Phlegm in more as the Influential point for Qi. ST 36 on the right side was used to tonify Qi and Blood as much as tightening her right stifle. SP 6 on the left side was used to move and nourish Blood while reducing pain. SI 16 was used to relax her upper neck while GB 39 was used to strengthen her Marrow and to remove obstructions in the Gall bladder channel related to her spinal cord injury. LIV 1, GB 44, SI 1, TH 1 and LI 1 were used as Ting points to drain the excesses in these channels.

April 12th, 2015

Isolde laid down again during the last two nights. She was also observed backing up by herself in her stall which was new since her accident. The owners noted she was walking more and more in her stall and was seen resting on one hind limb at the time - signs she had a better balance. Weakness in her hind limbs musculature was noticeable due to her stall rest. She still had tender points at GB 20 and BL 23. Coronary band distensions were still palpable at TH 1, LI 1, SI 1, LIV 1 and GB 44. Tongue and facial pulses were normal. BL 11 was used to nourish Blood, increase Qi, soothe the Sinews and ease pain. BL23 was used to strengthen both Kidney and Qi, as well as strengthen the lower back and knees and as a local tender point. BL 17 was used to regulate and tonify both Qi and Blood. Also, as I was worried about her stomach with all the anti-inflammatory drugs she had received, I thought this point could also pacify her stomach. GV 4 was used to strengthen her lumbar and to tonify her Original Qi while GV 14 was used to improve her cervical and upper back pain and tonify Qi. KID 10 was used to tonify Kidney Yin and to strengthen her stifles, especially the right one. TH 1 and GB 44 were used as Ting points to drain the excesses in their channels.

End of April 2015:

Treatment schedule was now lengthened to every 5 to 7 days. She was seen on April 18th, 24th and 29th as needed by Isolde's clinical signs. Facial pulses and hooves temperatures were the same at each visit and tongue was always slightly wet. On April 18th, she was pretty stable, but she was still dragging her hind toes which were worse on the left. She was tender at BL 20 and 21 on the left side and at BL 23. Coronary distensions were at TH 1, SI 1, LI 1, LIV 1 and GB 44. Isolde was needled at LIV 1, LI 1, GB 44, Yao Bai Hui, GB 39 and BL 11 for the same reasons as in above treatments. I injected 2 cc by site of vitamin B 12 at BL 17 and BL 23 to extend the effects this time but for the same reasons as in above treatments. This time KI 3 was added to tonify the Kidneys, to cool the Heat, to benefit caudal back and paralysis of the hind limbs. GB 34 was used to strengthen the caudal back and help for hind limbs pain and weakness. CV 12 was added because she seemed to have some Stomach discomfort based on tenderness at BL 20 and 21. On April 24th, Isolde had improved as she could have more hind limbs strides without dragging her toes. Same facial pulses, tongue, hooves temperatures and coronary distensions as last time. She had tenderness at ST 10, BL 25, BL 54 and LI 16 all on the right side. I used LI 10, ST 36, SP 6, GB 39, GB 44, BL 11, BL 23, BL 40 and BL 67 for the same reasons as listed above. I added BL 18 and BL 19 to benefit her tendons and muscles as some discomfort was popping out in her right hip and stifle. Two days ago, on April 29th, she started 2 minutes hand walks in the inside sand arena 2 days ago. The owners said she was stable in her stalls but she seemed to have more proprioceptive deficits while walking. Facial pulses and hooves temperatures were the same as above. Tongue was slightly reddish and wet. Isolde had coronary excesses at LIV 1 and TH 1 while LU 1, LI 1, SI 1, BL 67 and SP 1 seemed deficient. She had tenderness at BL 18, BL 19, BL 20 and BL 21 on the left side, BL 25, BL 27, BL 54 and LI 16. LI 10, LI 16, ST 36 and SP 6 on the left side, BL 40 and GV 4 were needled for the same reasons given above. Du Mai was used again to stimulate Qi circulation and strengthen the Spine. GV 1 was used as a distal point along the meridian for her sore back and for her spinal cord issues. BL 60 was used to remove obstructions in the channel, to relax her tendons, to strengthen her caudal back and hock, to benefit her weakness and hind limbs paralysis and alleviates pain throughout the body as it was aggravated by a longer walk. BL 60 was not needled earlier because she was very sensitive and I did not want her to fall while kicking. Next treatment was scheduled in 4 days with electroacupuncture, if needed.

May to August 2015:

Isolde's clinical signs indicated to us when she should be seen and treated. Points were chosen following her physical exams and complaints and according to her states of mind. Electroacupuncture was started on May 7th as she had not improved much for the last 10 days. It helped her to start improving again. On May 15th, the ''Magnificent Seven'' were done as she started to have real intermittent upward fixation of patella. It resolved it, coupled with increasing walk length. Also, she had some aquapuncture points occasionally as needed from May 24th. She was seen on May 3rd, 7th, 11th, 15th, 18th, 20th, 24th, 28th and 31st, June 5th, 9th, 13th, 17th, 22nd and 28th, July 4th, 13th, 18th and 26th and then every week or every other week as needed from August to December. From January 2016 till now, she is mostly treated once a month and she lives a normal and happy retirement life with her old friend of 21 years - going outside during the day and sleeping inside at night.

DISCUSSION:

When I came to visit Isolde in April 2015, she was an old mare having undergone a severe wither spinal cord trauma with very low chances to recover due to her age, gravity of the symptoms and high risks of secondary spinal cord damages until the dorsal lamina fracture repaired. Owners were aware Isolde's life could end tragically as she would need to be euthanized in her stall were she to fall and unable to get up again; or if her condition worsened with a recurrence of a laminitis crisis. No other Western diagnosis and treatments were recommended by her internal medicine doctor. As Isolde was at high risk of laminitis, especially with her added prednisolone medication, and had increased organs secondary effects with corticosteroids and anti-inflammatory drugs mixed (both could decrease her quality of life), dosages reduction was also a priority. TCVM diagnosis and treatment was her last option. As she was undergoing Kidney Qi deficiency changes related to her ageing11, Isolde had already been treated successfully in acupuncture once a month, a year before her accident, so her owners agreed to try it again. Their only goal was to give her a good quality of life; they had no riding or work expectations. Isolde's TCVM exam in April 2015, post-traumatic, revealed that she was depressed and was not very responsive. She had trouble walking, moving around in her stall and posturing to pee as her hind end was very ataxic, stiff and weak. She had lost muscles mass because of the stall rest and suffered from hind limbs tendons and ligaments hyperlaxity. She was the perfect example of ''too weak to move'' caused by Trauma induced Wei Bi2. Liver Blood deficiency was involved in her whole locomotion pattern especially with patella's upward fixations while Spleen Qi deficiency was involved in her muscles wasting, lassitude and post-trauma loss of weight. Isolde's age also meant that her Kidney Qi was probably fragile and still deficient and was shown by her lethargy and weakness11. Her warmth-seeking behavior indicated some kind of Yang deficiencies as did her tongue wetness, her deep facial pulses and her hind limbs weakness. She had moderated tenderness and atrophy along the epaxial muscles from T15 to L6 and was slightly warmer over her wither and lumbar area related to her specific trauma locations. She had mild sensitivity on Bladder (BL 21 left, BL 23 right, Qi Hay Shu and BL 54), Gall Bladder (GB 21 and GB 39) and Large Intestines (LI 16 left and LI 17 right) meridians. TH 1, SI 1 and BL 67 were distended (excess) while SP 1, LIV 1 and GB 44 were deficient with normal hooves temperatures.

Using the Cooking Pot Model of Zang-Fu Physiology8, first treatment points, sensitivities and coronary band changes, here were the findings: the Lower Burner, Bladder and Triple Heater were over-working while Kidneys were deficient, in the Middle Burner, Gall Bladder was deficient while Small Intestines was over-working and, in the Upper Burner, Liver and Spleen were deficient. Vertebrae fractures seemed to have injured the Kidneys (deficiency) who stored fluids, ruled the bones and produced marrow. As their functions were not preserved, the Bladder ended full of fluids (Damp) while the Small Intestines seemed to continue its major role of providing the water that needed final purification to the Bladder. Then, Kidneys and Heart were not able to generate Source Qi and the whole cooking pot was damaged by a weak fire resulting in Heart Yang deficiency, a deficient Liver not able to distribute Qi and Blood to the extremities as usual, a deficient Gall Bladder not able to regulate movement of Yang to the surface and an excess Triple Heater regulating the descent of Yang into the interior. Triple Heater excess could have also been related to Isolde's Cushing syndrome history by its hormonal influence. With the Trauma circumstances, Qi and Blood stagnations were obviously involved.

In the Five Element Theory6, Liver and Kidneys share a Child - Mother relationship that supports and balances each other. Total amount of Qi available to the body is influenced by each form of existing Qi. If Kidney Qi, the Mother, is reduced by ageing and trauma, then it cannot nourish its Son, so the Liver Qi is decreased as well. Over time, Kidney Qi could become Kidney Yang deficiency leading to worsening of the ataxia, weakness, tendons and ligaments hyperlaxity and back pain.

Isolde's primary complaint was her acute Trauma induced Wei Bi, so the treatment emphasis was to move and nourish Blood, to relax the Sinews and to move Qi in affected channels to limit chronic organs and meridians dysfunctions. Doing so should help to relieve her clinical symptoms by improving her comfort, weakness and hind limbs ataxia. Due to Isolde low level of energy, it was important to avoid draining her with too many points. Before her trauma, she was not sensitive to distal limbs needling, but since she was pretty sensitive and tended to kick with not enough balance to make it. As it was risky for her condition, I decided to not use much of distal points until it was fairly safe for her. With that in mind, I chose Yao Bai Hui to tonify Yang and to benefit the hindquarters musculoskeletal and neurological related conditions. As the Bladder Meridian is useful for a variety of issues and it travels around Isolde's traumatic area - BL 11 as an Influential point for Bones who nourishes Blood and eases pain, BL 23 as strengthening both Kidneys and Qi, as well as the lower back and knees, BL 40 as a Master point for the lower back and hips and Qi-Hai-Shu as a supplement in Qi deficiency - they were all needled. Some Gall Bladder points were picked such as GB 21 to relax the Sinews and GB 39 to strengthen her Marrow and remove obstructions in the Gall bladder channel related to her spinal cord injury. As I was able to needle SI 1 and TH 1 without Isolde notices, they were picked as Ting points to drain the excesses in these channels. Indirectly by choosing those points, I was also tonifying the Kidney Yang which was also helping the Liver Blood deficiency2, .

While Isolde was undergoing stomach and kidneys possible corticosteroids and non- steroidian anti-inflammatory mixed side effects, I had this feeling it was decreasing her Kidneys and Stomach/Spleen Qi more, so I was hoping to decrease these drugs slowly. As her general attitude, comfort, ataxia and weakness started to improve slowly even after the first treatment, if it continued, this plan might be realistic. After only 2 treatments, she was able to lay down and get up again - a feat she had not done since her accident.

Like for every case treated with integrative medicines, one can wonder what would have been her outcome without acupuncture, but it is difficult to tell with certainty. Knowing how critical her condition was, combined with her past medical history that limited drugs use, I do not think she would be alive and enjoying her retirement as well as she is right now without her acupuncture treatments. Her hormonal sensitivity could not have supported to be only on drugs - that is a fact. As she needed something to control her pain until vertebrae fractures repaired themselves and avoid a second or third spinal cord injury10, without acupuncture, her quality of life would have probably decreased rapidly. When looking back to all Isolde's treatments, I realize how Isolde went through roller coasters improvements. The beauty with acupuncture is how we can adjust easily treatment plans depending of our findings and responses during the treatment. The key to the success of that special case was thanks to the owners' keen attention given to Isolde's condition which determined when she needed her treatments. Nevertheless and luckily, she could not have made it without her owner's financial determination as it was that kind of case that would not have improved enough with only a couple of treatments. Also, Isolde was the perfect patient to go through all of this because she had the intelligence to know what she could do or not - some horses become too stressed and do not understand what is happening and can get dangerous to themselves and to the people around them. Finally, everything for better or for worst was discussed with her owners before we began that trial which was important to me in prevention.

However, Isolde's case report can be analyzed through Eastern and Western Medical theories 3, 4, 9. When needling an acupuncture point locally, neurovasculoimmune regulatory response involve 1) cutaneous irritation and periphery vasodilatation, 2) nociceptive excitation and pain relief, 3) immune-stimulating mechanisms, 4) solubility needle-damaged products 5) tissue repair and wound-healing process and 6) inactivation of the inflammatory response by including 1) mast cells degranulation, 2) substance P and bradykinin axon cells release, 3) immune cells attraction, 4) aggregation and degradation of platelets and 5) heparin, histamine and cortisol release to reduce arachidonic acid formation. Releasing these coagulation, complement and histamine cascades tends to increase local blood flow and to relax surrounding tissues9. In spinal cord injury, alterations in vascular tone and integrity leads to ischemia and cells death especially in the grey matter that has more metabolic requirements. As hypoperfusion - reperfusion also brings oxygen-derived free radicals in circulation, the tricky part is to avoid these drastic blood flow changes while limiting necrotic and apoptotic cell death5, 12. This is why too many local needles in that case could have aggravated her. Although, choosing acupuncture points cranial and caudal to the fractures probably increased surrounding blood flow pathways without being too risky. BL 11, BL 17 and GV 14 were chosen also for these share and other fractures locations. Local acupuncture points involve segmental pain-ascending inhibitory effects known as the Gate Control Theory. Stimulation of mechanoreceptors by acupuncture needles has an effect on slow and fast pain fibers in the posterior horn of the spinal cord by inhibiting the passage of stronger pain signals while the stimulation of fast pain fibers also creates a strong morphine-type effect. Segmental points can be far or close to the stimulated area. Nevertheless, when inserting needles distally, strong spinal pain-descending inhibitory effects happen. By releasing endorphin, enkephalin, serotonin, norepinephrine and adrenocorticotrophic hormone from the periaqueductal grey matter, hypothalamus and pituitary gland, there is a central suppression of pain signals. Distal points like ST 36, BL 40 and BL 60 are good examples of this multimodal nerve transmission work. The internal organs acupuncture points effects, such as Association points, run through similar afferent nerves impulses between the point and the organ concerned.

In summary, acupuncture gave Isolde enough time to heal and allowed her to regain a good quality of life by increasing her mobility, proprioception and strength and reducing pain. The owners and myself were amazed at how she came back from that dramatic trauma even at her advanced age.

Dr Catherine Goulet DMV IPSAV
140, Rue du Quai Saint-Marc-sur-Richelieu, Québec J0L 2E0 CANADA
Cell phone: 514-806-2344
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