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Acupuncture for Neurological Disorders. It matters not whether medicine is new or old, it only matters that it is applied for the benefit of the patient. Neurologic Assessment. Is it a neurologic disease? Seizures Intention tremor CN deficits Head tilt Nystagmus CP deficits Dysmetria

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acupuncture for neurological disorders

Acupuncture for Neurological Disorders

It matters not whether medicine is new or old, it only matters that it is applied for the benefit of the patient.

neurologic assessment
Neurologic Assessment
  • Is it a neurologic disease?
    • Seizures
    • Intention tremor
    • CN deficits
      • Head tilt
      • Nystagmus
    • CP deficits
    • Dysmetria
    • Paralysis
minimum database
CBC

Chemistry

Bile acids

Cholinesterase

Urinalysis

Chest and abdominal radiographs

Abdominal ultrasound

Heartworm test

Fecal

Minimum Database
ancillary neurologic tests
Electrodiagnostics

EEG

EMG

BAER

CSF tap & analysis

Cells & protein

Pressure

Cholinesterase

Titers

Radiographs

Skull & spinal films

Myelography

CT scan

MRI

Muscle Analysis

Enzymes

2M antibody

Anti-ACH receptor antibody

Biopsy

Ancillary Neurologic Tests
when all else fails
When all else fails…

Look at the patient!!!

outcome of neurologic assessment
Localization of Lesion

D

A

M

N

N

I

I

I

T

T

V

Outcome of Neurologic Assessment
  • Def (Qi, Yin, Blood)
  • Jing Def
  • Def (Qi, Yin, Blood, Yang)
  • Def (Qi, Yin, Blood)
  • Stagnation (Blood)
  • Jing Def/Excess or Def
  • Phlegm Fire
  • Phlegm Fire
  • Trauma
  • Excess or Def
  • Wind Phlegm

O

slide7
Plan
  • Differential Dx
    • ?
  • Diagnostic Approach
    • ?
  • Treatment
    • ?
  • Problem List
    • ?

P

seizures in small animals
Seizures in Small Animals
  • It is estimated that the overall incidence of seizure disorders in dogs and cats is around 1%
  • In pure breed dogs, this incidence may increase to 15-20%, due to the presence of inherited, primary epilepsy in those breeds
lesion localization in seizures
Lesion Localization in Seizures
  • Cerebral Cortex
  • Diencephalon
    • Thalamus
    • Hypothalamus
  • Mesencephalon
seizure diagnoses
Seizure Diagnoses

Probably Symptomatic Epilepsy

Symptomatic Epilepsy

seizure diagnosis
Minimum Database

Abnormal in Reactive Epilepsy

CSF tap & analysis

Abnormal in Active Secondary Epilepsy

CT or MRI Scan

Abnormal in Active Secondary Epilepsy

EEG

Abnormal in Secondary Epilepsy

Seizure Diagnosis
  • All test are normal in Primary Epilepsy
seizures and signalment
Seizures and Signalment
  • Primary Epilepsy- purebred dogs 1-3 years of age
  • Secondary Epilepsy- any age but especially under 6 months and over 3 years
seizures tcm
Seizures- -TCM
  • Represent various aspects of the Liver (Wood) system
  • Excess (3 types)
  • Deficiency (3 types)
seizures tcm1
Excess

Wind-Phlegm

Tongue pale & greasy

Pulse wiry & slippery

Phlegm-Fire

Tongue red & greasy

Pulse rapid, wiry & slippery

Blood Stagnation

Tongue & Pulse like Wind-Phlegm

History of head trauma

Deficiency

Liver Blood Def.

Tongue pale & dry

Pulse weak & thready

Liver & Kidney Yin Def.

Tongue red & dry

Pulse weak & thready

Kidney Jing Def.

Tongue pale or red & dry

Pulse weak & thready

< 1 year of age

Seizures- -TCM
seizures tcm2
Excess

Wind-Phlegm

expel phlegm, extinguish the wind, open the orifice and stabilize the seizures

Ding Xian Wan

Phlegm-Fire

clear the liver, drain the heat, transform phlegm and open the orifices

Di Tan Tang and Long Dan Xie Gan Tang

Blood Stagnation

expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood

Ding Xian Wan and Tao Hong Si Wu San

Deficiency

Liver Blood Def.

tonify Qi and Blood and quiet the wind

Bu Xue Xi Feng San or Di Tan Tang plus Rehmannia 8

Liver & Kidney Yin Def.

nourish Yin and extinguish wind

Yang Yin Xi Feng San or Di Tan Tang and Left Side Replenished (Zuo Gui Wan) or Tian Ma Gou Teng plus

Kidney Jing Def.

extinguish the wind and astringe or nourish the kidney jing

Di Tan Tang and Epimedium Powder

Seizures- -TCM
epilepsy tcm
Epilepsy -- TCM
  • Internal heat leading to generation of wind
  • Clear wind & heat and calm the Shen
  • Points
    • Constitutional points
    • Clear wind & heat
      • GB20, LI4, LI11, GV14, LIV3
    • Calm the shen
      • PC6, HT7
    • Local points
      • GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1, ST40
  • TCM Herbals
    • Di Tan Tang (TCM phenobarbital)
    • Specific herbs for excesses or deficiencies present
ear staple
Ear Staple
  • Shen Men
    • Center of the ear
    • Staple or point AP can help control 50% of refractor epilepsy cases
    • Fold ear over & find center on inside
acepromazine in an shen
Acepromazine in An Shen
  • An Shen
    • Half way around the back of the ear
    • Aim toward the opposite base of lips
    • Inject 0.1-1 mg diluted with saline to 0.5-6ml
basic antioxidants
Vitamin E 10 IU/lb daily

Vitamin C 5-10 mg/lb twice a day

Selenium 2 µg/lb daily

Beta carotene 250 IU/lb daily

B Complex 2mg/kg twice a day

Vitamin E 100-400 IU daily

Vitamin C 100-250 mg twice a day

Selenium 50 µg daily

Vitamin A 1000-5000 IU daily

B Complex 10 mg twice a day

Basic Antioxidants

Dogs

Cats

additional considerations
Probably safe parasite control

Interceptor

Frontline Top Spot

Revolution

Should avoid

Heartgard

Proheart 6

Program

Sentinel

Frontline Spray

Advantage

Advantix

Additional Considerations
additional considerations1
Diet

Low-carbohydrate food

Supplements

Ginkgo biloba

2-4 mg/kg q8-12h

Ginkoba or Publix brand

Tofu or Lecithin

20 mg/kg daily

Acetylcysteine

25 mg/kg q8h qod

Additional Considerations
meningoencephalomyelitis
Meningoencephalomyelitis
  • Infectious Diseases
    • Species Specific
  • Steroid Response ME (SRME)
  • Necrotizing Vasculitis (SRMA)
  • Necrotizing ME (NME)
  • Granulomatous ME (GME)
meningoencephalomyelitis1
Meningoencephalomyelitis
  • Pain to paresis to plegia
  • Dx with CSF tap
  • Spinal radiographs normal
  • Myelography normal (might be contraindicated)
csf tap
CSF Tap
  • Collection site for seizures is at the cisterna magnum.
  • Allows analysis for cells, protein and pressure.
  • Cytology and titers for infectious organisms can be obtained.
meningoencephalomyelitis3
CSF Analysis

may be normal or show increased pressure, protein and/or cells.

CSF Titers

species specific tests

many must be paired with serum titers.

Meningoencephalomyelitis

CSF cytology form a dog exhibiting

a mixed reaction withneutrophils,

lymphocytesand macrophages.

meningoencephalomyelitis4
Meningoencephalomyelitis
  • Infection
    • virus
    • rickettsia
    • protozoa
    • fungus
    • bacteria
  • Inflammation
    • GME
    • NME
    • SRME
    • SRMA
slide31
Can be:

peracute

acute & progressive

chronic

In brainstem, tends to be a multifocal inflammatory disorder

Responds temporarily to steroids.

GME

Patient with GME presenting with

vertical nystagmus, long tract signs,

and circling with incoordination.

slide32
GME

GME histologically causes multifocal meningoencephalitis due to proliferation

ofreticulohistiocytic cells.Lesions also showmultinucleated giant cells.

treatment of me
Depends upon whether infectious or inflammatory

Prednisolone

Find minimum daily dose and then used 2 times MDD QOD

Primor (activated sulfadimethoxine)

15 mg/kg BID

Doxycycline

5-10 mg/kg QD

Herbal Support

Bromelain/Curcumin

2.5/5 mg/kg TID

Treatment of ME
menigoencephalomyelitis
Menigoencephalomyelitis
  • Wind-Phlegm
    • expel phlegm, extinguish the wind, open the orifice and stabilize the seizures
    • Ding Xian Wan
  • Phlegm-Fire
    • clear the liver, drain the heat, transform phlegm and open the orifices
    • Di Tan Tang and Long Dan Xie Gan Tan
vestibular disease
Vestibular Disease
  • Cardinal Signs
    • Head Tilt
    • Nystagmus
      • Horizontal
      • Rotatory
      • Vertical
      • Positional
    • Circling (tight)
    • Imbalance & Incoordination
vestibular disease1
Vestibular Disease

Vestibular Disease

8th Nerve,

7th Nerve &

Horner’s Syndrome

8th Nerve only

Anything Else

Idiopathic V.D.

Inner Ear Disease

Central V.D.

Brainstem V.D.

Cerebellar Disease

idiopathic vestibular disease
Idiopathic Vestibular Disease
  • Acute Onset of Vestibular Signs
    • Head tilt
    • Horizontal or Rotatory nystagmus with fast-phase away from head tilt
    • Nothing else
  • Can Be Very Severe
  • Acute, regressive disease
idiopathic vestibular disease tcm
Idiopathic Vestibular Disease -- TCM
  • Wind (heat) invasion
  • Clear wind & heat and calm the Shen
  • Points
    • Constitutional points
    • Clear wind & heat
      • GB20, LI4, LI11, GV14
    • Calm Shen
      • PC6, HT7, GV17, GV20, GV21
    • Local points
      • TH17, TH18, TH21, SI19, GB2, Er jian, An shen
inner ear disease
Inner Ear Disease
  • 8th Nerve Signs
  • 7th Nerve Signs
    • ear & lip droop
    • lack of palpebral reflex
    • nose turn
    • nostril flaring
  • Horner’s Syndrome
horner s syndrome
Horner’s Syndrome
  • Small Animals
    • Ptosis
    • Myosis
    • Enophthalmos
  • Large Animals
    • Facial sweating (horse)
    • Lack of muzzle sweating (cow)
inner ear disease1
Inner Ear Disease
  • Most cases are secondary to bacterial infection (otitis media & interna)
    • extension from otitis externa
    • pharyngitis with extension up the Eustachian tube
    • hematogenous spread
ear polyps in cats
Ear Polyps in Cats
  • Benign growth in the external ear canal which causes signs by extension.
  • Can also be pharyngeal mass which grows into middle ear via the Eustachian tube.
ear polyps in cats1
Ear Polyps in Cats
  • Treatment is surgical removal.
  • Damage can be permanent, if pressure necrosis has destroyed the inner ear structure.
inner ear disease tcm
Inner Ear Disease -- TCM
  • Invasion of external pathogen leading to wind, heat, damp.
  • Heat boils the fluids leading to the accumulation of phlegm.
  • Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.
inner ear disease tcm1
Inner Ear Disease -- TCM
  • Points
    • Constitutional points
    • Clear wind & heat
      • GB20, LI4, LI11, GV14
    • Calm the shen
      • PC6, HT7, GV17, GV20, GV21
    • Eliminate damp
      • SP9
    • Activate Qi & blood
      • ST36, ST40, Xin shu
    • Local points
      • TH17, TH18, TH21, SI19, GB2, Er jian, An shen
central vestibular disease
Central Vestibular Disease
  • Postural Changes
    • CP Deficit
    • Dysmetria
  • Reflex Changes
    • hyperactive reflexes
    • crossed-extensor reflexes
    • Babinski’s sign

Conscious proprioceptive deficit

may be on the same or opposite side

of the lesion.

central vestibular disease1
Central Vestibular Disease
  • CSF Analysis
    • may be normal or show increased pressure, protein and/or cells.
  • CSF Titers
    • species specific tests
    • many must be paired with serum titers.

CSF cytology form a dog exhibiting

a mixed reaction withneutrophils,

lymphocytesand macrophages.

central vestibular disease2
Central Vestibular Disease
  • Inflammatory or Infectious Diseases
    • canine distemper
    • toxoplasmosis and neosporiosis
    • fungal
    • rickettsial
    • GME
    • SRME
central vestibular disease3
Central Vestibular Disease
  • Trauma or Vascular
    • remember dogs don’t get atherosclerosis !
  • Neoplasia
    • meningiomas
    • choroid plexus papillomas
    • oligodendrogliomas
    • astrocytomas
    • metastatic neoplasia
central vestibular disease4
Central Vestibular Disease

MRI of Cerebellar Meningioma

central vestibular disease5
Central Vestibular Disease
  • Infectious Diseases
    • FIP
    • FeLV
    • toxoplasmosis
    • cryptococcosis
  • Trauma
  • Metabolic
    • thiamine deficiency
  • Toxicity
    • organophosphates
  • Neoplasia
    • meningiomas
central vestibular disease tcm
Central Vestibular Disease -- TCM
  • Can be wind, heat-damp or wind cold based upon the causative factor involved.
  • Points
    • Constitutional
    • 8 Principle
    • Zang-Fu
ivd tcm diagnosis
IVD- -TCM Diagnosis
  • Represents a “bi” syndrome often accompanied by “wei” syndrome
  • Under domain of KID (bones) & LIV (joints & free flow of qi & blood)
ivd tcm patterns
Excess types

Wind-Cold-Damp

Blood stagnation

Deficient types

Yang deficiency

Yin deficiency

Yin & Yyang deficiency

IVD- - TCM Patterns
fibrocartilagenous emboli
Fibrocartilagenous Emboli
  • Vascular occlusion from IVD material
    • IVD herniates into the venous sinus or the vertebral body
    • the venous sinuses have no valves
    • increased pressure forces material into spinal cord
slide58
FCE
  • Generally affects a radicular penetrating branch which leads to a quadrant (wedge) of infarction
  • Many will improve with time
ivd wind cold damp
Acute invasion of external pathogen leading to stagnation (cold slows blood flow which is worsened by accumulation of damp)

Tongue

Greasy

Pulse

Slow & soft

Rx principle

Dispel W-C-D, activate blood & relieve stagnation

TCM herbal

Xiao Huo Luo Dan

Acupuncture

Hua-tuo-jia-ji, BL23, BL67, GB39, GV1, & GV14

IVD- -Wind-Cold-Damp
acute spinal cord injury
Acute Spinal Cord Injury
  • Damage affects the vascular supply leading to ischemia
  • The ischemia leads to lactic acidosis and lipid peroxidation which furthers the injury
pathology of spinal injury
Pathology of Spinal Injury
  • Within 5 minutes there are petechiations in the grey matter
  • Progresses to complete hemorrhagic necrosis of the grey matter by 4 hours
pathology of spinal injury1
Pathology of Spinal Injury
  • From 4-24 hours there is progressive local extension to involve the white matter.
  • If force is great enough, then progresses up & down spinal cord
treatment of acute spi
Treatment of Acute SPI
  • Antioxidant steroids (Solu Medral or Solu Delta Cortef)
    • 30mg/kg
    • 15mg/kg every 8 hours for 24-48 hours
  • Surgical correction

Acupuncture needle in

wei jian (tip of tail)

intervertebral disc disease chondrodystrophic dogs
Intervertebral Disc Disease:chondrodystrophic dogs
  • Collagen fibers of the nucleus pulposus metamorphs into hyalin cartilage
  • IVD looses elasticity and leads to damage of annulus fibrosus
ivd chondrodystrophy
IVD- -chondrodystrophy
  • Annulus ruptures extruding degenerate nuclear material into the neural canal
  • This leads to pain, paresis or paralysis
ivd pain only
IVD- -Pain Only
  • Cage Rest for 30 days or 3 weeks after patient becomes clinically normal.
  • Acupuncture
  • Oral steroids and diazepam only under supervision
ivd paresis
IVD- -Paresis
  • Hospitalize
    • Prednisolone (2 mg/kg divided 2-3 times a day)
    • Misoprostol 3-4 µg/kg twice a day
    • Diazepam 0.25-0.5 mg/kg TID
  • Should improve in first 5-7 days
ivd paralysis with deep pain
IVD- -Paralysis with Deep Pain
  • Emergency
    • Give Solu Medral or Solu Delta Cortef 30 mg/kg
    • Refer
  • May observe for 24 hours to see if dramatic improvement
    • If none, Emergency
ivd paralysis no deep pain
IVD- -Paralysis No Deep Pain
  • Emergency
    • Give 30 mg/kg Solu Medral or Solu Delta Cortef
    • Refer
  • 75% respond in first 24 hours
  • 50% in first 72 hours
  • 25% after that
integrative therapy of ivd disease
Acute IVD Disease is a surgical emergency

Even with no deep pain there is a 75% chance of success within the 1st 24 hours & 50% chance in the 1st 72 hours

After 72 hours with no deep pain, the chances are no different

Chronic IVD Disease may respond poorly to surgery

Integrative Therapy of IVD Disease
hemilaminectomy
Hemilaminectomy
  • The thinned lamina is further removed and the laminectomy expanded with rongeurs exposing the spinal cord
  • The area is probed for the problem

IVD material

slide73
After surgery, healing is needed

Physical therapy

Passive movements

Massage

Standing exercises

Hydrotherapy

Walking

Acupuncture

Control pain

Stimulate nerves

Magnet therapy

North pole magnet stimulates nerve regeneration

Healing touch

IVD
ivd diet
Basic antioxidants

Vitamin E, vitamin C, vitamin B complex, selenium, beta carotene

Anti-inflammatory membrane stabilizers

Omega-3-fatty acids, gamma linolenic acid, coenzyme Q-10

Lecithin to help support myelination

Herbal medications to help immune system

Astragalus, cordyceps mushroom, garlic

Dietary cartilage

IVD- -Diet
ivd prevention
IVD- -Prevention
  • Diet & weight control
    • Low carbohydrate diet
    • Basic antioxidants
  • Chiropractic care
  • Massage
  • Exercise
slide77
Hans
  • Routine radiographs showed a narrowed IVD space at T11-12 with a cloudy IV foramen
  • Incidentally there was calcification of T13-L1
ivd blood stagnation
Most common type in chondrodystrophic dogs

KID Jing deficiency leads to failure to nourish LIV leads to joint problems & stagnation

Tongue

Purple

Pulse

Wiry or Fast

Rx Principle

Activate blood, dissipate stagnation and resolve stasis

TCM herbal

Da huo luo dan (Double P formula #2)

Acupuncture

Hua-tuo-jia-ji, BL23, BL11, GB39, GV14, Wei jian, GV6, GV1, & LIV3

IVD- -Blood Stagnation
cervical spondylomyelopathy
Cervical Spondylomyelopathy
  • Young Great Danes and older Doberman Pinchers
    • Young dogs is due to misarticulation and spondylolithesis
    • Older dogs is due to IVD disease and ligamentous hypertrophy
ls stenosis cardinal signs
LS Stenosis- -Cardinal Signs
  • LS Back Pain
    • pain on palpation at LS junction
    • pain on raising the tail head
  • Diminished tail movement
  • Urinary and Fecal continency problems
ls stenosis diagnosis
LS Stenosis- -Diagnosis
  • EMG
    • fibrillation potentials and positive sharp waves caudal to LS junction, distal limb and tail
  • Imaging techniques
    • CT Scan
    • MRI Scan
ivd yang deficient
Old age leads to KID deficiency

General weakness & cold back

Tongue

Pale & wet (swollen with teeth marks)

Pulse

Deep & weak

Rx principle

Nourish Yang & warm KID

TCM herbal

Sang ji sheng san (lorathus powder)

Chronic IVD

IVD- -Yang Deficient
ivd yin deficiency
Chronic illness or old age consumes KID Yin

Weakness in back worse at night

Tongue

Red & dry

Pulse

Deep, thready & weak

Rx principle

Nourish Yin & tonify KID

TCM herbal

Di gu pi san

Chronic IVD

IVD- -Yin Deficiency
discospondylitis
Discospondylitis
  • Infection of the intervertebral space
  • Common causes
    • Staph. aureus
    • Strep. sp.
    • Corynebactrium
  • Signs
    • Pain (can be extreme)
    • Ataxia to plegia
discospondylitis1
Discospondylitis
  • Diagnosis can be made on plain radiographs
    • May initially be normal, until 2-3 weeks of incubation
  • Find organism via
    • Blood culture
    • Urine culture
discospondylitis2
Discospondylitis
  • Also consider
    • Nocardia or other fungal cause (aspergillosis)
    • Brucella canis
    • Spirocerca lupi
  • Treatment (6-8 wk)
    • Cephalosporins
    • Sulfa drugs
moose
Moose
  • 9 year old M/C Labrador
  • HBC 4 months ago
    • Recovered
  • Chronic, progressive paresis over 2 weeks
moose surgical observation
Moose- -Surgical Observation

Abnormal articular process at T12

Epidural mass

moose cytology
Moose- -Cytology
  • Impression smears from both the articular process and the epidural mass revealed PMN with intracellular bacteria
moose post op
Moose- -Post OP
  • Antibiotics
    • Sulfadimethoxine (Primor) 15 mg/kg q12h
    • Cephalexin 22 mg/kg every 8 hours
    • Use for 6-8 weeks
ivd yin yang def
Aging leads to KID Yang & Yin deficiency

decreases resistance & allows low grade infection to start

Tongue

Pink or pale

Pulse

Deep & weak

Rx Principle

Nourish Yin & tonify KID

TCM herbal

Double P #1 (hindquarter formula)

Very chronic

IVD- -Yin & Yang Def.
conclusions
Conclusions
  • Acupuncture can help treat or control a number of neurologic diseases
  • Point selection depends upon the constitution of the animal and the nature and location of the disease
  • Patience is still a virtue with neurologic conditions