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A case-control study for this topic seems to be quite hard to find. In theory, it also does not make sense to have a case-control study for this topic because it would likely require a study that is setup to see how acupuncture affects patients with and without osteoarthritis. I do not see why someone would search out acupuncture for themselves or their animal if they were not experiencing some sort of pain at all.

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Cross Sectional Study: Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain

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Cross Sectional Study: Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain

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In this study 47 client owned dogs with naturally occurring lameness were subjected to “blind treatment” and then asked to complete questionnaires based on their dogs comfort and mobility. 21 different breeds were examined for this study. Clients did not not know the treatment schedule of their dog. Dogs participating in the study were given instructions that are to be routinely followed when receiving manual therapy and acupuncture. The dogs were split into 2 groups: A and B. During the first two appointments group A dogs were cage rested for thirty minutes and then returned to owners with no treatment. During the same time period group B dogs received a thirty minute examination and treatment. The treatment was reversed between the two groups for weeks 3 and 4. Outcomes were measured using a Likert scale in the initial form. Instead they settled on a VAS format which allowed owners to place a point on a range of 0 to 100 on the scale. Improvement in movement (all except moving upstairs) were noticed in dogs after the first treatment. However, there was not a significant improvement after the second treatment.

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Language: English | French

Abstract

Despite the rise in popularity of both acupuncture and manual therapy in veterinary medicine, and the increasing number of Canadian veterinarians practising these techniques, there is little research demonstrating their effectiveness. In this repeated measures, therapeutic trial, 47 client-owned dogs with naturally occurring lameness were assessed for clinical response to treatment. Owners were blinded to the treatment schedule and completed questionnaires to assess their dogs' comfort and mobility. Comparison between pre- and post-treatment results demonstrated that combined acupuncture and manual therapy provides immediate short-term improvement in comfort and mobility, as demonstrated by owner observed changes in play behavior ( P = 0.015), walking ( P < 0.001), trotting ( P = 0.002), jumping ( P < 0.001), descending stairs ( P = 0.003), rising from a lying position ( P < 0.001), and reduced stiffness after rest ( P < 0.001) or following exercise ( P < 0.001). Mood and attitude also improved, but did not attain statistical significance.

Résumé

Efficacité de l'acupuncture et de la thérapie manuelle combinées par rapport à l'absence de traitement pour la douleur musculo-squelettique canine. Malgré la croissance de la popularité de l'acupuncture et de la thérapie manuelle en médecine vétérinaire et le nombre grandissant de vétérinaires canadiens qui pratiquent ces techniques, il existe peu de recherche démontrant leur efficacité. Dans cet essai thérapeutique à mesures répétées, 47 chiens appartenant à des clients atteints de boiterie naturelle ont été évalués pour leur réponse clinique au traitement. Les propriétaires n'ont pas été informés du calendrier de traitement et ils ont rempli des questionnaires afin d'évaluer le confort et la mobilité de leurs chiens. La comparaison entre les résultats avant et après le traitement ont démontré que l'acupuncture et la thérapie manuelle combinées offraient une amélioration immédiate à court terme pour le confort et la mobilité, comme le démontrent les observations faites par les propriétaires pour le comportement de jeu ( P = 0,015), la marche ( P < 0,001), le galop ( P = 0,002), le saut ( P < 0,001), la descente d'escaliers ( P= 0,003), le lever d'une position couchée ( P < 0,001) et une raideur réduite après le repos ( P < 0,001) ou après de l'exercice ( P < 0,001). L'humeur et l'attitude se sont aussi améliorées, mais sans atteindre une importance statistique.

(Traduit par Isabelle Vallières)

Introduction

The demand for manual therapy and acupuncture medicine is increasing among dog owners, as is the number of Canadian veterinarians graduating from programs that teach these skills. The recently established specialty of veterinary sports medicine and rehabilitation routinely employs both these techniques to address musculoskeletal disorders. There are veterinarians who perform manual therapy concurrently with acupuncture as part of their regular practice when treating musculoskeletal pain. Many, including the primary author of this paper, do so because they believe that the combination of these 2 modalities yields better results than they see with either therapy alone.

Despite this rise in popularity and common acceptance of these techniques, the effectiveness of acupuncture in addressing musculoskeletal pain in dogs has only been superficially examined ( 1- 6). The authors could find no research publications regarding the effectiveness of manual therapy in dogs, and only few papers examining the effectiveness of combined acupuncture and manual therapy (CAMT), all of which were from human medicine ( 7- 10).

Manual therapy is an umbrella term for therapeutic techniques involving the "hands on" movement of joints and stretching of muscles. It can be divided into the broad categories of manipulations, mobilizations, and stretching or massage. The International Federation of Orthopaedic Manipulative Physical Therapists defines manipulations as "a passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit with the intent to restore optimal motion, function, and/or to reduce pain." Similarly, they define mobilizations as a "therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes." Although physiotherapists and chiropractors can each perform manipulations and mobilizations, manipulation techniques are predominantly performed by chiropractors ( 11).

Traditional Chinese Medicine acupuncture involves the stimulation of specific anatomic locations known as acupuncture points with an irritant, often a thin needle. Alternatively, needles can be placed in palpable regions of hyperirritable skeletal muscle. This latter technique is known as myofascial trigger point dry needling or intramuscular stimulation ( 12).

Other techniques employed by veterinary acupuncture practitioners include aquapuncture, the injection of fluid into acupuncture or myofascial trigger points ( 12, 13), and electro-acupuncture, which involves running electric current between 2 or more needles ( 10, 14).

Many studies on the effectiveness of manual therapy have been done in humans ( 15- 20). The underlying mechanism of manual therapy is unclear, with many suggesting that the originally proposed mechanistic model should be replaced with a neurophysiological one ( 21, 22). Although meta-analytic review demonstrates a positive benefit to manual therapy, a common criticism is that more randomized controlled studies are needed, and that designing a study in which the patients are blinded is difficult to achieve ( 15- 20).

Side-by-side comparison of the effectiveness of mobilizations versus manipulations have found that overall the 2 techniques have similar efficacy ( 23, 24).

Meta-analyses of acupuncture research also found that it is effective in treating chronic lower back pain in humans, but there is inadequate evidence to evaluate its effectiveness in acute back pain ( 25). There are concerns that there is a lack of evidence stemming from quality research, particularly blinded research ( 20, 26, 27).

The purpose of this experiment was to determine if the combination of manual therapy and acupuncture is an effective treatment for improving comfort or mobility in dogs. We hypothesized that the combined therapies will result in increased comfort and mobility as assessed by owner-completed questionnaires. In order to maximize clinical relevance, the experiment was designed to mimic typical patient presentation and appointment structure.

Materials and methods

Sample

Owners of dogs with "painful or restricted movement" were invited, via Facebook, television, and newspaper interviews, to visit a website providing information about the study. Specific information about the duration of the study, the nature of the treatment involved, and the costs/benefits to participants were provided on the website, and individuals were requested to complete a short questionnaire about the dog's signalment, presenting complaints, and answer 12 validated questions about behavior and comfort ( 28- 31). A summary of the presenting complaints taken from the online application form, and key examination findings that were later analyzed statistically, are detailed in . In order to mimic the wide variety of patient presentations, few limitations were placed on applicants: dogs needed to be ambulatory, could not have been previously diagnosed with an irreversible progressive neurologic condition, and must have difficulty in performing at least 1 of the activities identified on the application form. Patients with ongoing pain-modifying prescriptions were eligible to participate as long as they were on a regular daily schedule that did not vary during the data collection period.

Table 1

Presenting complaint

Incidence

Historic findings

Incidence

Diagnostic findings

Incidence

Due to scheduling constraints, a maximum of 59 participants could be accepted into the study. Because this research was occurring concurrently with a project on the relationship between urinary incontinence and lower back pain, 14 dogs with a history of urinary incontinence were preferentially included in this study. Statistical comparisons were conducted between the incontinent dogs and the rest of our sample, and there was no discernible difference between the groups on any relevant variables. The incontinent dogs were therefore included in the main sample, and will not be discussed further. The remaining 45 of 68 eligible applicants were randomly chosen by having a young child select from a shuffled array of face down application forms.

At the beginning of the first appointment, owners signed a consent form for participation in the research, as is required by the Canadian Council on Animal Care in science.

Study design

A repeated measures design was selected to minimize the number of required participants, and to evaluate improvements as a function of treatment relative to each dog's presenting baseline. Starting the day of the orientation appointment, enrolled dogs were placed on a restricted exercise regimen to mimic the instructions that are routinely given following a manual therapy and acupuncture treatment. By instructing owners to initiate exercise restriction a minimum of 2 wk prior to the first treatment rather than immediately following treatment, we were able to control for this variable by standardizing the experience of all participating dogs. Exercise restriction instructions consisted of not allowing any galloping, jumping a distance greater than 1 body length, exercising more than 75% of the amount that would normally result in fatigue (e.g., if a 1-hour walk would result in noticeable fatigue by the end of the walk, or flare in lameness the following day, then walks were to be restricted to 45 min or less), and no aggressive playing. Exercise restriction remained constant throughout the experiment for all dogs.

To enhance the "blinding" of dog owners, the experiment was designed with a double crossover format, meaning that during the first 2 appointments used in the analysis, group A dogs rested in a cage for 30 min with no treatment before being returned to the owner, and group B dogs received a 30-minute examination and treatment. For the third and fourth appointments, group A dogs received a 30-minute examination and treatment (identical in format to that received by group B) and group B dogs rested in a cage. Treatment consisted of CAMT personalized for each dog's examination findings.

All dogs, regardless of their group allocation, were seen 14 d prior to the first treatment, for the first treatment, 6 d later at the time of the second treatment, and 8 d following the second treatment (). The appointment schedule was filled to accommodate participant availability, and then appointments that started at the top of the hour were assigned to group A, and appointments that started on the half hour were assigned group B. Each participant's allocation to group A or B remained the same for the remainder of the experiment.

Table 2

Orientation appointment
Day 0
(28 days before Treatment 1 for Group A, 14 days before Treatment 1 for Group B)

Orientation appointment
Initiation of exercise restriction program
Visit: Pre-treatment 1

Orientation appointment
Initiation of exercise restriction program
Visit: Pre-treatment 1

Prior to the commencement of each appointment, to confirm that there had been no deviation from the instructions given during the orientation appointment, owners were specifically asked if their dogs had changed their medication schedule in any way, and what activities their dogs had engaged in the previous week. Owners were separated from their dogs and blinded to the treatment schedule. To reduce any placebo effect, owners were informed of the existence of sham appointments but knew nothing further about the treatment schedule, except that their dogs would receive at least 1 treatment. Questionnaires were completed prior to the start of each appointment.

Outcome measures

The 12 questions selected as dependent variables for this research project had all been assessed previously and found to be repeatable and reliable ( 28- 31). However, in their original form, many of these questions employed a Likert-type response scale. Critics of Likert scales have suggested that the data provided by them is ordinal and not interval, which can limit the statistical analysis that can be applied ( 32). Visual analogue scales (VAS), which consist of a 10-cm line with the same anchors as a Likert scale, and onto which the participant is instructed to mark an "X" over the location that bests corresponds with their answer, allow for more nuanced responses, as well as providing interval data for subsequent analysis ( 32). For this study, a VAS format was employed. Scores were obtained by measuring along the line (in mm) to the point indicated by owners (range: 0 to 100). Items from the survey are listed in . Owners completed this questionnaire during the orientation appointment, and before the start of each subsequent appointment.

Table 3

All statistics were calculated using SPSS (version 21; 2012 © IBM, Armonk, New York, USA).

Statistical model

Data relating to vocalization showed poor internal consistency (i.e., inclusion of this variable reduced Cronbach's alpha values for the overall measure) with the other survey items. Follow-up questions were posed to the owners in an attempt to learn more about their responses, and it was determined that in many cases, vocalizations that were unlikely to be related to comfort level (e.g., barking to be let outside) had been factored into the owners' survey responses. For that reason, survey results relating to vocalization were excluded from further analysis.

Prior to testing the hypothesis, responses to survey items were compared across scheduling groups at each of the 4 time intervals of interest for this study, using independent samples t-tests, and no significant differences emerged. Data were therefore collapsed across scheduling groups for all subsequent analyses.

The cases comprising complete data were examined using repeated measures analysis of variance (ANOVA) of owners' ratings of 11 aspects of their dogs' behavior at 4 points in time (Pre-treatment 1, Treatment 1, Treatment 2, Post-treatment 1), with paired comparison follow-up tests for clarification. Although a multivariate model was originally planned, multiple univariate models were run to avoid excluding cases on the basis of small amounts of missing data. Missing data points did not follow any systematic pattern within the sample as a whole. Although most assumptions (normality, sample size) were met for all analyses, as is commonly the case in repeated measures analyses, the assumption of sphericity was violated. These violations were dealt with by interpreting Greenhouse-Geisser corrected values for all ANOVA models.

Results

Sample description

Forty-seven of 59 dogs remained eligible at the end of the data collection period. Of those, 21 were spayed females, 24 neutered males, and 2 were intact males. The average age was 9.65 y [standard deviation (SD) = 3.30 y; range: 2.5 to 14 y]. The average female age was 7.95 y (SD = 3.13 y; range: 2.5 to 14 y), which is significantly younger than the average male age of 11.02 y (SD = 2.79 y; range: 5.5 to 14 y), t (45) = 3.54, P = 0.001 (2-tailed).

There were 21 breeds: 13 of the subjects were mixed breed, 10 were Labrador retrievers, 3 German shepherds, and the remaining purebreds were represented by only 1 or 2 individuals. The average patient weighed 26.23 kg (SD = 12.31 kg; range: 5.5 to 44.3 kg). There were no significant differences in dog weight by gender: females averaged 22.62 kg (SD = 12.09 kg; range: 5.5 to 41.9 kg) and males averaged 29.14 kg (SD = 11.92 kg; range: 6.3 to 44.3 kg).

A total of 11 dogs which failed to attend any of the scheduled appointments were excluded from the experiment. Data from a single patient whose owner abruptly stopped a daily anti-inflammatory prescription were also excluded.

Hypothesis tests

Repeated measures ANOVAs for each survey item revealed significant differences for 9 of the 11 outcome measures (all but mood and attitude) (). Post-hoc paired comparisons were then conducted to determine which schedule intervals were significantly different from one another (). Except for difficulty with moving upstairs, differences were observed between responses provided immediately prior to the first treatment (Treatment 1) and responses provided 8 d after the second treatment (Post-treatment 1) for variables that produced a significant ANOVA result. The difference associated with scores at these time intervals for the upstairs variable failed to achieve significance once corrections for multiple comparisons were applied, but the trend was similar (i.e., comparison of pre-treatment and post-treatment scores was in the same direction and approached conventional levels of significance). Further, for trotting, jumping, rising, stiffness after rest, and stiffness after exercise items, significant differences between baseline (Pre-treatment 1) and scores taken immediately before the second treatment (Treatment 2) were significantly different. For trotting, jumping, moving downstairs, rising, stiffness after rest, and stiffness after exercise, significant differences were observed between baseline (Pre-treatment 1) and 8 d after the second treatment (Post-treatment 1). Walking, trotting, jumping, rising, stiffness after rest and stiffness after exercise showed significant change between the first and second treatment. Finally, no significant differences were observed between Pre-treatment 1 and the first treatment (the period over which exercise restriction alone had been imposed), or between Treatment 2 and Post-treatment 1.

Table 4

Table 5

Additional analyses

Although the main hypothesis did not suggest that treatment would be differentially effective for dogs with different presenting complaints, we explored the possibility by means of re-rerunning the repeated measures ANOVA model using each dog's history and diagnostic variables () as between group factors. Dogs were grouped as either having or not having specific problems, which created substantial variation in the sizes of groups to be compared. To avoid spurious results, only diagnostic variables that produced sub-samples of 12 or more (25% or more of the total sample) were examined. Specifically, history of single leg lameness, a diagnosis of elbow degenerative joint disease, shoulder muscle pain, iliopsoas pain, and an assymetrically positioned/hypomobile pelvis met our criterion for evaluation of comparison of groups with and without the presenting problem (). Of these, only a history of single leg lameness produced a significant result when included in the model [i.e., a 2 (presence/absence of presenting problem) × 4 (appointment) mixed-model ANOVA for each of the survey items]. In all cases, owner responses to the survey items were of equivalent or greater magnitude when the dogs had a history of single leg lameness than responses from owners of dogs without such a history. The general pattern of improvement over the course of treatment was the same as for the repeated measures ANOVAs reported, though the pattern of significant paired comparison analyses within the groups with and without a history of lameness was not as consistent. The pattern of significant differences in the paired comparisons should be interpreted with some caution, however, given the smaller group sizes. No history × appointment interaction was observed in any of the mixed model ANOVAs. These results are summarized in and .

Table 6

Table 7

Discussion

The purpose of this experiment was to determine if a combination of acupuncture and manual therapy could produce measurable improvement in the comfort and mobility of canine patients, as indicated by changes in blinded owner survey responses. From the initiation of the exercise modification program until immediately before the first treatment, none of the measured parameters showed statistically significant improvement. When the survey results of group A and group B during this period were compared, there was no statistical difference between them. This indicated that patients showed no statistically significant improvement in response to exercise restriction alone, regardless of whether they received 14 or 28 d of restricted exercise. However, 6 d after a single CAMT appointment (immediately before Treatment 2), significant improvement was seen in the dogs' ability to walk, trot, jump, and rise from a lying position. Furthermore, the owners observed less stiffness after long rests or following exercise.

When the survey results from immediately before the first CAMT appointment are compared to those 8 d after the second CAMT appointment, patients showed significant increase in play behavior, and their ability to walk, trot, jump, descend stairs, and rise from a lying position. They also experienced less stiffness after rest or following exercise. Although improvements were also seen in mood, attitude, and ability to negotiate upstairs movement, these changes were not statistically significant. This pattern of findings suggests that any improvement due solely to exercise restriction was not sufficient to produce significantly better ratings of measured parameters by owners, as there were no significant differences between questionnaire responses collected at the initiation of the modified exercise program and those collected just before the first treatment. Furthermore, the differences between ratings collected immediately before the first treatment and 8 d following the second treatment suggest that the treatment was a causal factor in the improvements seen. The trend in the data is most clearly observed when the variables are compared visually ().

Based on the parameters listed in , no contra-indications for CAMT referral were found, nor were any parameters deemed more likely to respond to treatment. It would appear that the patient's individual response to treatment will ultimately determine the value of CAMT for each case. Based on these findings, if CAMT is going to help a given patient, it is reasonable to expect demonstrable improvement with just 2 treatments.

Dogs that presented with a history of a single leg lameness were given significantly higher survey item values by their owners at all 4 time points, relative to other dogs. This indicates that owners perceived that dogs with a single leg lameness were, on average, less debilitated than dogs without single leg lameness as a presenting complaint. It should be noted that dogs with a single leg lameness were no more or less likely to respond to CAMT than dogs that presented without this complaint.

Although the exercise restriction program was controlled for, was determined to not result in any significant improvement on its own, and was found not to be a cause for the clinical improvement following CAMT treatment, all patients were put on an exercise restriction program as part of the experimental design. Further research is required to determine the benefits of CAMT in the absence of an exercise restriction program.

Although this study demonstrated short-term benefit to CAMT lasting at least 8 d after the last treatment, further research is required to determine how long the benefits of CAMT are likely to last before additional treatments are required, if at all. A further limitation of this study is that it only sought to measure the effects of combined acupuncture and manual therapy, and made no attempt to isolate the benefits of either modality alone. As a result, no conclusions can be made about whether the observed benefits are solely due to 1 of the 2 modalities, or whether they reflect contributions from each, or perhaps even a synergistic response.

The purpose of this research was to determine whether CAMT has a therapeutic benefit relative to no treatment at all. Further research is required to determine if the benefits of CAMT are equal to those of other more established therapies such as pharmaceutical prescriptions. Further research would also be required to see if different practitioners produce the same clinical response. There is value in having future research projects include gait analysis equipment, such as a force plate or pressure mat in their methodology as this would allow for objective measures of gait quality following CAMT.

This experiment lacked an adequate sample size to perform a double crossover analysis but the design lends itself well to becoming a double crossover format for subsequent analyses. A larger sample size and a few additional variables would also allow for regression analysis to determine if dogs with certain presenting complaints, examination findings, or signalment variables, are more or less likely to respond to CAMT.

In summary, there appears to be good support for the hypothesis that 1 or 2 sessions of CAMT provides immediate short-term improvement in dogs' comfort and mobility, as demonstrated by owner observed changes in play behavior, walking, trotting, jumping, descending stairs, rising from a lying position, and stiffness after rest or following exercise. This is the first paper to examine combined acupuncture and manual therapy in dogs. Veterinarians now have more information on which to form an evidence-based opinion on the value of CAMT. Because the owners were unaware of their dog's treatment schedule and knew that not all appointments included treatment, this research was able to achieve a level of blinding that is difficult for human medical research to match. CVJ

Footnotes

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ( gro.vmca-amvc@nothguorbh) for additional copies or permission to use this material elsewhere.

This research was privately funded.

References

12. Wall R. Myofascial pain syndrome in dogs. In: Egger CM, Love L, Doherty T, editors. Pain Management in Veterinary Practise. 1st ed. Ames, Iowa: Blackwell Publishing; 2014. pp. 161-170. [ Google Scholar]

21. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14:531-538. [[ PMC free article] [ PubMed] Google Scholar]

23. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: Clinical outcomes from the UCLA neck-pain study. Am J Public Health. 2002;92:1634-1641. [[ PMC free article] [ PubMed] Google Scholar]

# data[].attributes.attachment_link.title
Effectiveness of combined acupuncture and manual therapy relative to no treatment for canine musculoskeletal pain

# data[].attributes.attachment_link.description
Language: English | French Despite the rise in popularity of both acupuncture and manual therapy in veterinary medicine, and the increasing number of Canadian veterinarians practising these techniques, there is little research demonstrating their effectiveness. In this repeated measures, therapeutic trial, 47 client-owned dogs with naturally occurring lameness were assessed for clinical response to treatment.

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Randomized controlled trials: The effect of acupuncture treatments on gait outcome measures- A randomized double blinded placebo- Controlled study on 16 dogs suffering from osteoarthritis due to hip dysplasia

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Randomized controlled trials: The effect of acupuncture treatments on gait outcome measures- A randomized double blinded placebo- Controlled study on 16 dogs suffering from osteoarthritis due to hip dysplasia

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This randomized control study tests the effects of dry needle acupuncture treatment on dogs suffering from hip dysplasia and osteoarthritis. The purpose of the study was to see if acupuncture treatment influenced locomotion of dogs with osteoarthritis.  In conclusion, although no statistically significant changes were detected, the results indicate that dry needle acupuncture treatment might have had an influence on the locomotion of the dogs in the acupuncture group by slightly reducing hind limb lameness.

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Animal trials & in vitro studies: Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronic elbow joint arthritis

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Animal trials & in vitro studies: Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronic elbow joint arthritis

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This is a clinical trial involving nine dogs that were treated for chronic elbow joint osteoarthritis secondary to elbow joint dysplasia. The treatment was in three phases between electrostimulated acupuncture (ESA), a sham treatment, and no treatment, over the course of three weeks along with routine gait analysis and pain scoring. Owners were double-blinded yet noticed improvement in their dogs when in the ESA treatment phase. However, treatment overall did not seem to have a significant effect on ground reaction forces for any limb (severity of lameness or pain).

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May 1, 2006, Vol. 228, No. 9, Pages 1350-1354

Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104-6010. (Kapatkin, Mayhew, Powers, Smith); Department of Clinical Studies-New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA 19348. (Tomasic, Beech, Boston); Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210. (Meadows)

Dr. Kapatkin's present address is the Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA 95616.

Dr. Powers' present address is the Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA 99164.

Dr. Tomasic's present address is 91 Encantado Loop, Santa Fe, NM 87505.

Dr. Meadows' present address is Schering Plough Animal Health, 556 Morris Ave, Summit, NJ 07901.

Supported by Ms. Kindy French, Washington, DC.

Presented in part at the 29th Annual Conference of the Veterinary Orthopedic Society, The Canyons, Utah, March 2002.

Address correspondence to Dr. Kapatkin.

Objective -To determine whether use of electrostimuluated acupuncture (ESA) would result in significant improvements in ground reaction forces and lameness scores in dogs with chronic elbow joint osteoarthritis secondary to elbow joint dysplasia.

Design -Randomized, controlled, crossover clinical trial.

Animals -9 dogs with chronic forelimb lameness and radiographic evidence of elbow joint osteoarthritis.

Procedures -All dogs had a 3-week control acclimation period during which gait analysis was performed weekly. Dogs then received ESA once weekly for 3 weeks followed by a sham treatment once weekly for 3 weeks or received the sham treatment followed by ESA. Gait analysis was repeated prior to each treatment, and owners were asked to provide pain scores by use of a visual analog scale method.

Results -Treatment (control, acupuncture, or sham) did not have a significant effect on ground reaction forces for any limb. Owners of 8 of the 9 dogs were able to correctly guess the time period when ESA was delivered.

Conclusions and Clinical Relevance -Results suggested that ESA did not have any significant effects on severity of lameness, as determined by measurement of ground reaction forces, or severity of pain, as determined by visual analog scale pain scores, in dogs with chronic elbow joint osteoarthritis secondary to elbow joint dysplasia.

Dorothy CiminoBrownDVM, MSCE, DACYS Raymond C.BostonPhD John T.FarrarMD, PhD. (2010) Use of an activity monitor to detect response to treatment in dogs with osteoarthritis. Journal of the American Veterinary Medical Association 237:1, 66-70.
Online publication date: 1-Jul-2010.

AnninaLaimDr med vet AndréJaggyDr med vet, PhD FranckForterreDr med vet Marcus G.DoherrDr med vet, PhD GinaAeschbacherDr med vet OlivierGlardonDr med vet. (2009) Effects of adjunct electroacupuncture on severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease. Journal of the American Veterinary Medical Association 234:9, 1141-1146.
Online publication date: 1-May-2009.

(2006) Letters to the Editor. Journal of the American Veterinary Medical Association 229:2, 204-207.
Online publication date: 15-Jul-2006.

(2006) Letters to the Editor. Journal of the American Veterinary Medical Association 229:1, 26-29.
Online publication date: 3-Jul-2006.

# data[].attributes.attachment_link.title
Effects of electrostimulated acupuncture on ground reaction forces and pain scores in dogs with chronic elbow joint arthritis

# data[].attributes.attachment_link.description
May 1, 2006, Vol. 228, No. 9, Pages 1350-1354 Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104-6010. (Kapatkin, Mayhew, Powers, Smith); Department of Clinical Studies-New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA 19348.

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Cohort Study: Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases

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Cohort Study: Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases

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The purpose of this prospective cohort study was to investigate the effects of acupuncture alone or combined with analgesics in chronic pain and quality of life by owners The study found that the use of acupuncture alone or in combination with analgesics reduced pain and improved quality of life in dogs with neurological and musculoskeletal diseases.

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Introduction

Although the assessment and management of acute pain in animals has advanced considerably, chronic pain is still underestimated and, therefore, undertreated, because the diagnosis is complex and treatment is limited ( 1). Validated tools have been developed for evaluation of acute ( 2) and chronic pain ( 3- 6), and although acute pain is well-evaluated by veterinarians ( 2), the owner is more apt to identify chronic pain based on changes in the pet's attitude and behavior ( 7). Assessment of quality of life is important to measure treatment efficacy in chronic cases ( 3, 7). Chronic pain and quality of life have been assessed by validated questionnaires in dogs with joint diseases ( 4, 6, 8), cancer ( 3), spinal cord injuries ( 9), and quality of life in general ( 7).

Due to the complex multi-dimension of chronic pain and the limitation of pharmacological treatment, acupuncture (AP) may be a good option in a multimodal approach ( 10, 11). Meta-analyses of high-quality, randomized and well-controlled studies demonstrated that the analgesic effect of AP was better than sham AP or no treatment in 29 clinical studies with nearly 18 000 human patients with osteoarthritis (OA) and chronic headache and shoulder, back, and neck pain ( 12). Another meta-analysis including 14 studies with about 4000 human patients with OA of the knee showed that AP provided better pain relief than sham AP or standard care treatment ( 13).

Acupuncture is a traditional Eastern medicine therapy performed by introducing needles in acupoints. This technique embraces several clinical applications due to its wide mechanism of action involving the neuroendocrine system ( 14). Several techniques may be used alone or in combination to stimulate the acupoints, such as single needle, electroacupuncture (EA), laserpuncture (LASER), and ozone therapy. Electroacupuncture is the most used technique for relieving central and peripheral pain, as it combines mechanical and electrical effects ( 14). Laserpuncture involves the use of laser in acupoints ( 15) and is recommended for animals that do not tolerate needling. Ozone therapy is used in acupoints (ozonepuncture) or by intra-rectal insufflation ( 16).

There are few high-quality veterinary medical studies that have evaluated the effects of AP in treating pain and improving quality of life in dogs. Gold implants in acupoints reduced pain scores by 65% in dogs with hip dysplasia and improved mobility and decreased pain signals in 83% of these animals ( 17). Recovery of ambulation and deep pain sensation was faster in dogs with thoracolumbar intervertebral disk disease (IVDD) treated with EA, combined with standard medical treatment, such as corticosteroids and/or opioids, than with conventional treatment alone ( 10). Electroacupuncture was more effective (79%) than delayed decompressive surgery (40%), as measured by return of ambulation and decreased neurologic deficits, in dogs with grades IV and V thoracolumbar IVDD ( 11).

Based on the hypothesis that AP reduces pain and improves the dog's quality of life either when used alone or in combination with conventional and adjuvant analgesia, and that dogs affected by musculoskeletal diseases would improve faster than dogs with neurological diseases, the aim of this study was to evaluate the efficacy of AP and related techniques alone or in combination with analgesics in chronic pain and quality of life of dogs with neurological and musculoskeletal diseases, using pre-validated scales answered by owners.

Materials and methods

Animals

This prospective study involved dogs with 2 main causes of chronic pain: neurological ( n = 145) and musculoskeletal ( n = 36) diseases. The selection of animals was based on physical, neurological, and orthopedic examination and complementary diagnostics: radiography, computed tomography, magnetic resonance imaging (MRI), electroneuromyography, and clinical pathology tests. Intervertebral disk disease (IVDD) and non-compressive myelopathy were diagnosed by MRI and compressive myelopathy and trauma by radiographic image. All musculoskeletal diseases were diagnosed by radiography. According to these assessments, each clinical case was classified and included in the main types of specific conditions of neurological or musculoskeletal diseases which are discriminated in the results ().

Initially all animals were subjected to once-weekly sessions of AP, for about 20 min and the maximum trial period was 24 wk. Once the animals improved, the AP sessions were conducted every other week. Sucess of treatment was analyzed by comparing data before, during, and after the proposed therapy. The dogs were discharged when treatment was successful before 24 wk. Cancer patients were excluded, as well as animals with comorbidities or when treatments were modified since the first assessment carried out before any treatment at the beginning of the study.

This study was approved by the Institutional Ethical Committee on Animal Use for Research (protocol number 150/2014). The owners were informed about the study and signed a consent form.

Evaluation

Dog owners answered at each treatment session, every wk or at least every other wk, 2 validated questionnaires, the HCPI ( 8) and health-related quality of life scale for dogs with signs of pain secondary to cancer (QLA) ( 3) and the VAS for pain and locomotion ( 5). The HCPI is a multifactorial and descriptive questionnaire to assess chronic pain in dogs and consists of 11 questions, with a minimum score of 0 and a maximum score of 44, representing maximum intensity of chronic pain ( 8). The QLA consists of 12 questions; "0" and "36" are considered the worst and best quality of life, respectively ( 3). The VAS is a line of 100 mm length; for pain (VASpain) or locomotion (VASloc), "zero" is the best and "100" is the worst possible condition ( 5). The HCPI was translated to the native language of the owners and was in process of validation during the study; QLA was already validated in the native language of owners.

Successful treatment was based on a composite score of ≤ 22 in the HCPI, which corresponds to 50% of the total score, ≥ 24 for QLA, which is the score empirically indicative of good quality of life (66% of the total score) and ≤ 33 mm for both VAS, which is a score empirically used for intervention analgesia in acute pain. Success was considered for each individual scale; therefore, some cases were included as success in one scale but not in another. All baselines scores were taken at the first AP session before the begining of treatment. Dogs that had baseline scores below the success cut-off scores for HCPI, QLA, and VAS and worsened after treatment were classified as treatment failures or unsuccessful and were included in the analysis. Dogs that were already scored as success at the beginning of treatment and remained as such, were not included in the survival curves.

Treatment

Animals were treated as follows: alternative medicine (ALG, n = 50), which included AP and related techniques [EA, LASER and ozone and/or less frequently pharmacopuncture (injection of microdoses of drugs into acupoints) or moxibustion (the stimulation of an acupoint by burning a cylinder of moxa placed close to the acupoint)] and alternative medicine associated with conventional analgesics and adjuvant analgesics (AAG, n = 131). In this group, analgesics [nonsteroidal (NSAIDs) and steroidal (SAIDs) anti-inflammatory drugs, opioids, amitriptyline, amantadine, gabapentin] and adjuvant analgesics [nutraceuticals, transcutaneous electrical nerve stimulation (TENS), magnetic and antalgic physical therapy] were used alone or in combination, and the protocols were discontinued or modified according to the individual clinical response.

Animals that were not under treatment before or were not treated with analgesics or adjuvant analgesics after the beginning of AP, were included in the ALG group. Animals that were under any treatment before or were treated with analgesics or adjuvant analgesics after the beginning of AP were included in the AAG group. In most animals of the AAG group, the use of analgesics, especially NSAIDs and SAIDs, was already in progress. When the clinical condition improved after the AAG treatment, drugs were discontinued, AP was continued but the dogs remained in the same group (AAG).

Statistical analysis

Non-parametric data were analyzed by Wilcoxon test to compare the scores of each scale and type of disease (neurological versus musculoskeletal) before and after the onset of treatments. Kaplan-Meier curves were used to evaluate the percentage of success during AAG and ALG treatments. The dogs were only discharged when treatment was successful before 24 wk. Differences were considered significant when P < 0.05.

Results

We selected 181 of 254 evaluated animals based on the inclusion and exclusion criteria. Demographic data included: 61% female and 39% male dogs; 29% crossbred, 16% dachshund, 9% poodle, 8% Labrador, 3% Rottweiller, and 35% other breeds; 8% were < 1-year-old, 55% between 1- and 10-years-old, and 37% > 10-years-old; 31% were < 10 kg, 43% weighed between 10 and 25 kg, and 26% weighed > 25 kg.

Statistical power of all analyses was > 95%. In about 15% of the cases it was not always the same owner who filled out the questionnaires from 1 session to another. The distribution of each specific type of neurological and musculoskeletal disease is expressed in .

The frequency of use of different techniques associated with AP to treat neurological and musculoskeletal cases is described in . From the dogs that received EA, 6% also received laser and ozone in acupoints.

The AAG treatment was predominant in both neurological and musculoskeletal cases ().

Scale evaluation

Before treatments all animals scored outside the success range in at least 1 of the scales and most dogs scored outside the success score range for all 4 scales. At the beginning of treatment, there was no difference between ALG and AAG for HCPI, QLA, and VASloc, when both neurological and musculoskeletal disorders were grouped ( n = 181) () or in neurological patients only ( n = 145) (). Success was achieved in QLA and VASloc at the end of both treatments, with no difference between them; however, HCPI scores were lower in ALG than in AAG ( P = 0.01).

The initial VASpain scores for the AAG group were higher than the scores for the ALG group in all animals () and in neurological patients (). VASpain scores were reduced in both groups at the end of the trial.

There was no difference between groups for QLA and both VAS scores in musculoskeletal patients ( n = 36), at the beginning and at the end of the trial period. These scores were reduced after both treatments (). Initial HCPI scores for the ALG group were lower than for the AAG group ( P = 0.01), with no difference between groups at the end of treatment. The HCPI scores were reduced in both groups ().

Survival curves

According to the analysis of Kaplan-Meier curves, at the end of 24 wk, success was achieved in 79%, 84%, 78% and 78% of animals suffering from neurological and musculoskeletal diseases combined (submitted to both treatments), according to HCPI, QLA and both VAS, respectively ().

Dogs with musculoskeletal diseases improved faster than those with neurological diseases according to HCPI and VASloc scores ( P = 0.003 and P = 0.045, respectively) (). Although there was no difference for QLA and VASpain scores between the 2 types of diseases, QLA scores also improved faster in dogs with musculoskeletal disorders ().

There was no difference between treatments when both diseases were grouped or when each disease was analyzed separately (-).

Discussion

Acupuncture and related techniques or the combination of AP and other analgesic modalities reduce chronic pain and improve quality of life in dogs suffering from neurological and musculoskeletal diseases ( 10, 11, 17). Conditions such as spinal cord injuries and hip-joint arthritis usually show moderate clinical benefits after conventional or surgical treatment ( 10, 11, 18).

The analgesic effect produced by AP and related techniques in this study has been previously shown in both acute ( 16, 19, 20) and chronic pain ( 10, 11, 17, 21). Possible local and systemic mechanisms behind the AP effect are based on the release of several neurotransmitters (such as endorphins, enkephalins, dynorphins, serotonin, norepinephrine, dopamine, and acetyl-choline), changes in cell signaling, modulation of the N-methyl-D-aspartate receptor and reduction of hyperalgesia and allodynia in patients suffering from chronic and neuropathic pain. These mechanisms have been reviewed elsewhere ( 22, 23). Acupuncture also regulates inflammation processes and growth factors by increasing blood circulation in affected areas ( 24).

Electroacupunture is the most common AP-related technique used for analgesia in previous studies ( 10, 11, 18) and here. This technique combines the mechanical effect of the needle and electrical stimulation. The quality and intensity of the hypoalgesic effect depends on the choice of acupoints and frequency of electrical stimulation used, which determine the class of neuropeptides released in the central nervous system ( 18).

When OA is considered specifically, AP reduces metalloproteinases and increases their tissue inhibitors, suggesting a chondroprotective effect in rats ( 25). The combination of other techniques with AP in the ALG group also likely contributed to the analgesic effect observed here. Both laserpuncture ( 15) and intra-rectal ozone insufflation and ozoniopuncture ( 16) were effective in avoiding or minimizing postoperative pain in dogs undergoing ovariohysterectomy. Ozone therapy has anti-inflammatory and analgesic properties, and by promoting a very short acting oxidative stress, stimulates the endogenous defence mechanisms and mediates an immune response ( 16).

In this study, the treatment with AP (ALG) or AP combined with analgesics (AAG) was chosen according to specific requirements of each case and, therefore, there were no defined criteria by which to assign animals to each group and it is not possible to make any comparison about efficacy between these different treatments. This is a limitation of the study as one would expect that other analgesic regimes were included in AAG, because animals were suffering more intense pain, as shown by the greater pre-treatment VAS pain scores in the AAG group. The inclusion of analgesics could contribute to a better and quicker recovery in this group. However, according to all assessed instruments, both treatments improved neurological and musculoskeletal signs. There is some controversy regarding the benefit of combining AP and conventional medicine. A previous report suggested that the use of NSAIDs and SAIDs combined with AP, provided better results than the use of AP alone in dogs with thoracolumbar IVDD ( 26). However, in our study, the neurological patients treated with AP only showed a better recovery compared to those in which AP was combined with conventional medicine but this result may be biased by different disease severity between groups. In humans suffering from chronic low back pain, AP was more effective for pain relief and functional improvement compared with no treatment or AP associated with conventional therapy ( 27).

Our results suggest, like previous ones, that when used alone or in combination with analgesics or adjuvant analgesics, AP is a relevant conservative treatment to alleviate pain and improve quality of life in dogs with neurological and/or musculoskeletal diseases. The use of a multimodal therapeutic approach may reduce doses of conventional analgesics and therefore their adverse effects ( 14).

Although AP and related techniques (ALG) produced similar results to the combination of AP with conventional analgesics (AAG) when success curves of the neurological diseases were compared, in contrast, especially for HCPI, musculoskeletal patients showed a better outcome after AP associated with other analgesic modalities, as reported in some human OA studies ( 28).

Previous studies reported that both AP and carprofen reduced pain in dogs with hip dysplasia, but only AP maintained the effect for 2 wk after the end of treatment ( 29). Other types of local stimulation, such as gold implant, without the need for weekly AP sessions, reduced pain for of up to 2 y in dogs with hip dysplasia ( 17). In humans AP was more effective than NSAID to treat carpal tunnel syndrome ( 30), thus it is important to highlight the additional value of this technique to minimize chronic pain. Our study included a wide range of diseases and analgesics, strengthening the importance of a multimodal treatment in dogs with chronic pain.

Osteoarthritis can cause hyperalgesia and evolve into neuropathic pain, given the fact that, for example, 80% of afferent neurons in the knee joint are nociceptors ( 31). Therefore use of analgesic adjuvants, such as gabapentin and amitriptyline may be required, combined with AP, as in this study, because treatment with NSAID or SAID is limited ( 1).

The promising results of the association of AP with conventional medicine strengthen the concept that AP may be used in addition to conventional therapy to treat chronic pain. Medicine should be integrative, wherein all possible therapies should be used to improve the patient's condition.

Animals with musculoskeletal diseases achieved better results for HCPI and VASloc than those with neurological disorders. This may be biased by the fact that some dogs with neurological problems were suffering from mild to moderate OA, which may have hindered their recovery. In contrast, musculoskeletal cases were exclusively orthopedic, with no neurological deficits.

There is no validated test to assess outcome in canine neurological diseases. The HCPI has only been validated for OA, and not for neurological cases; however, it was necessary to use the same scales to compare both neurological and musculoskeletal diseases. Since most of the HCPI assessment involves locomotion, which is also compromised in neurological cases, the authors considered that this instrument might be used for the neurological cases as well in this study.

Although the QLA questionnaire was designed for dogs with cancer-related pain, we considered it useful to evaluate the quality of life in dogs with neurological and musculoskeletal diseases in this study, as by the time the study was started, to our knowledge, there was no other tool to assess quality of life in dogs ( 3). A new tool to assess quality of life in various diseases was published after the beginning of this study ( 7).

A study investigating reliability and validity of VAS to measure chronic pain in dogs with OA ( 5) concluded that there was a significant correlation between the VAS score and the quality-of-life scale and HCPI scores. Use of VAS was valid and reliable, but face validity was only observed once the owners perceived that pain had abated and returned after initiating and withdrawing NSAID treatment, respectively. Considering that VAS is a poor pain assessment tool for untrained owners ( 5), we included 2 other validated questionnaires in the study.

This study had some limitations. For ethical reasons a placebo was not included as a negative control group, once the owner had requested AP to treat their pet. However a previous study showed that the analgesic effect of inserting needles into sham points was not significant ( 19). A temporal and/or placebo improvement effect cannot be disregarded, but HCPI has been validated to compensate for this effect ( 8). In a recent blinded controlled study from our group comparing AP versus carprofen versus placebo to treat hip dysplasia in dogs, by using the same measurement tools, the placebo effect was negligible ( 29).

Another limiting factor was the difficulty that some owners felt in interpreting some questions, but the owners were not given any guidance on how to complete the questionnaires. In about 15% cases it was not always the same owner who filled out the questionnaires from one session to another, but as questionnaires were filled every week or every other week, this would reduce a possible variation of the overall results based on evaluation by different owners.

As we used patients from the routine practice, some variables could not be controlled. A limitation, inherent to any clinical experiment, is the heterogeneity of the population and epidemiological data, with different severity of diseases and associations among them. Therefore the authors did not use the same treatment protocol or same acupoints and treatments were adjusted individually according to the specific need of each animal.

We conclude that, when used alone or combined with analgesics, AP and related techniques reduced pain and improved quality of life in dogs with neurological and musculoskeletal diseases. Dogs with musculoskeletal disorders had a better improvement in chronic pain and locomotion than those with neurological disorders. The clinical relevance of our findings is that AP is an important conservative therapeutic tool to be included in the multimodal treatment protocols of neurological and musculoskeletal diseases in dogs.

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Effect of acupuncture on pain and quality of life in canine neurological and musculoskeletal diseases

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This prospective study investigated the effects of acupuncture alone or combined with analgesics in chronic pain and quality of life assessed by owners for up to 24 weeks in 181 dogs with neurological and musculoskeletal diseases. The scores before and ...

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2 case reports summarize how acupuncture was helpful in pain management. The first is an osteoarthritis case, and the second being a painful neurologic disease case. The osteoarthritis case reported a 13 year old Weimaraner that suffered from severe osteoarthritis in multiple joints (inc. elbows) that greatly improved and urinary incontinence that completely resolved after 3 treatments of acupuncture.

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Successful pain management encompasses pharmacologic and nonpharmacologic interventions. This is especially true for chronic, neuropathic, or persistent pain. ¹ While pharmacologic options remain the mainstays, nonpharmacologic interventions are an important part of a comprehensive pain management plan.

Acupuncture is a safe, nonpharmacologic intervention with minimal adverse effects that most animals tolerate well. 2,3 It has become more accepted for pain relief in veterinary medicine. In fact, the pain management guidelines published by the American Animal Hospital Association, American Association of Feline Practitioners, and World Small Animal Veterinary Association endorse acupuncture as a safe adjunct treatment for pain management in dogs and cats that should be strongly considered as a part of a multimodal pain management regimen. 4,5

Acupuncture can be used independently or integrated into conventional analgesia protocols. It has significant analgesic effects on inflammatory, neuropathic, cancer, and visceral pain states. ⁶ It can help ease acute pain from neuromusculoskeletal injuries and surgery, as well as chronic spinal and osteoarthritic pain. Veterinary clinical trials also provide evidence for its effectiveness. 2,7-20

HOW DOES ACUPUNCTURE WORK?

Acupuncture is the stimulation of certain points on the body that correspond to neurovascular bundles, blood plexuses, sites of nerve branching, and motor endplate zones ( TABLE 1). ²¹ Recent evidence suggests that the effects of acupuncture are likely mediated by the nervous system at peripheral, spinal, and supraspinal levels. 6,22 Neurophysiologic effects of analgesia in response to acupoint stimulation include release of endogenous opioids and neurotransmitters (e.g., endorphin/endomorphin, enkephalin, 5-hydroxytryptamine), activation of the descending pain inhibitory pathway, and inhibition of inflammatory mediators (e.g., cyclooxygenase-2, interleukin-1β, interleukin-6). 6,22 Acupuncture also causes micro-trauma and vasodilation to improve local circulation and catalyze healing. ²³ Recent evidence suggests inhibition of microglial activation by acupuncture may play a key role in neuropathic pain diseases. ²⁴

CLINICAL EFFICACY

In 1 noncontrolled study, acupuncture alone or combined with analgesics reduced chronic pain and improved quality of life in dogs with neurologic and musculoskeletal diseases. ⁸ Results were similar for acupuncture plus manual therapy in dogs with musculoskeletal pain; the authors found immediate short-term improvement in comfort level and mobility compared with before treatment. ⁹

In 2 controlled studies in dogs with hip dysplasia, a gold bead implanted at acupoints significantly reduced osteoarthritic pain. 10,11 A 2-year follow-up study revealed that gold-bead acupuncture provided long-term pain relief, an effect not observed in dogs receiving placebo. ¹²

In another controlled study, neither acupuncture nor carprofen significantly differed from placebo on gait analysis of dogs with hip dysplasia, but only acupuncture was associated with a decrease in validated chronic pain scores. 13 A controlled, blinded study in dogs undergoing hemilaminectomy found significantly lower postoperative pain scores in the acupuncture than the control group. ¹⁴

Two studies showed that among cats undergoing ovariohysterectomy, the need for rescue analgesia after surgery was lower in the acupuncture than the control group. 15,16 Similar results were found in dogs undergoing mastectomy. ¹⁷

In horses, 2 controlled studies found acupuncture was effective in treating back pain. 18,19 A recent study showed horses with chronic laminitis were improved by acupuncture after receiving 2 acupuncture treatments 1 week apart. ²⁰

METHODS OF STIMULATION

Acupoints can be stimulated by dry needle (DN), electroacupuncture (EA), aqua-acupuncture (AQ), laser acupuncture (LA), moxibustion, and material implantation ( FIGURE 1). 2,7 Each method traditionally serves a different purpose. DN involves the insertion of fine, sterile needles into acupoints. These needles vary in size (28- to 36-gauge) and length (0.25 to 1.5 inches). The needles are typically left in place for approximately 10 to 30 minutes.

In EA, acupoints are stimulated by applying electricity through needles for 10 to 30 minutes. EA has more profound and prolonged analgesic effects than other techniques. ⁶ It is useful for neuralgia, nervous system injury, and persistent pain. 6,7 Low-frequency EA (2 to 10 Hz) produces longer-lasting alleviation of inflammatory pain and inhibits nerve injury-related allodynia/hyperalgesia more potently than do higher frequencies (100 Hz). ⁶

With AA, 0.1 to 0.5 mL of sterile fluid (e.g., saline, vitamin B12) is injected into acupoints. It is commonly used after DN or EA to prolong the effect of acupoint stimulation.

LA, the modern practice of stimulating acupoints using low-level energy of wavelengths (630 to 960 nm), may provide anti-inflammatory and antinociceptive effects. ¹⁵

HOW IS ACUPUNCTURE INTEGRATED?

Veterinarians who have received formal training can incorporate acupuncture into conventional practice settings. Basic or advanced veterinary acupuncture courses are available at the Chi Institute of Traditional Chinese Veterinary Medicine, or through the International Veterinary Acupuncture Society.

Before acupuncture, underlying pain or medical conditions are always diagnosed as part of conventional care. Once standard treatment measures are underway, acupuncture can be used as an integrative modality to reduce acute or chronic pain. For outpatients, it can be offered at the clinic, once or twice a week. For inpatients, it can be performed in the hospital, once a day before discharge. Practices that do not offer acupuncture can refer patients to veterinarians with CVA (certified veterinary acupuncturist) credentials.

Veterinarians who perform acupuncture must obtain informed consent beforehand. The discussion of acupuncture in the context of conventional medicine must focus not only on the efficacy of acupuncture but also expectations and potential adverse effects. A multimodal approach with acupuncture may allow for a reduction in dose of conventional analgesics and therefore a decrease in their adverse effects. ⁶ For patients that are resistant to pain medications or cannot tolerate their side effects, acupuncture can be a reasonable alternative treatment.

As with any therapy, not every patient responds to acupuncture; therefore, realistic expectations need to be set for clients. The author often requires clients to commit to sessions once or twice a week for at least 4 to 6 treatments, especially for chronic conditions. Although many patients may not need even 4 treatments to experience benefits, shorter durations and lower intensities of treatment may result in suboptimal outcomes. Acupuncture has both immediate and cumulative analgesic effects following repeated treatments. ²⁵

SAFETY AND CONTRAINDICATIONS

Acupuncture is safe when performed correctly by licensed veterinarians certified in veterinary acupuncture. Common minor adverse effects after acupuncture include tiredness, increased water intake, soreness, muscle spasm, and minor bleeding, which typically resolve quickly. 2,3 Other rare complications include infection, dermatitis, and broken needle fragments. Acupuncture needles should not be placed on infected or inflamed skin, open wounds, or sites of tumor and fractures; around the abdomen of a pregnant animal; or in specific points that may contribute to premature parturition (i.e., ST-36, SP-6, BL-40, BL-60, and BL-67). ² Deep needle insertion into acupoints around the lung fields (e.g., SP-21, LIV-13, LIV-14, GB-24, BL-12 to BL-19) is contraindicated. Acupuncture should be used cautiously or avoided in patients with clotting abnormalities. Do not apply EA across the thorax area (heart position) in animals with heart disease or pacemakers. ² Be cautious when using acupoints around the eyes.

CASE EXAMPLES

Case 1: Chronic Pain Associated With Polyarticular Osteoarthritis

A 13-year-old female spayed Weimaraner had osteoarthritis in multiple joints (elbows, carpi, hips, and stifles) and back pain. Despite the combination of firocoxib, gabapentin, tramadol, and glucosamine-chondroitin, her pain was worsening and her mobility was deteriorating. She developed urinary incontinence and was awoken more often during the night.

An internist suggested acupuncture as a last resort before euthanasia. The dog received acupuncture twice weekly for 4 weeks initially, then every 2 to 4 weeks. After 3 treatments, the dog could rise up and walk without assistance and sleep normally. Her urination incontinence was resolved after 6 treatments. She continued to receive acupuncture monthly for pain management. She died at home at age 16.

Her acupuncture treatment consisted of the following:

1. DN: GV-20, TH-5, SI-9, GB-34, BL-40, LIV-3, Bai-hui

2. EA: LI-4 to LI-11, ST-36 to ST-41, BL-11 bilaterally, BL-23 to Shen-shu (crossing), BL-54 bilaterally; 2 to 20 Hz for 20 minutes

3. AA: TH-4, LU-5, LI-10, SI-9, BL-23, BL-54, ST-36, BL-39, KID-3; 0.1 to 0.2 mL per acupoint

Case 2: Pain and Neurologic Deficits Associated With Meningoencephalitis of Unknown Cause

A 4-year-old male neutered Yorkshire terrier was diagnosed with meningoencephalitis of unknown cause at the cervical region. He had nonambulatory tetraparesis with severe cervical pain and was hospitalized. He received IV fluids, immunosuppressive doses of dexamethasone, fentanyl constant rate infusion, cytosine arabinoside, and gabapentin. On day 4 of hospitalization, he was referred for acupuncture treatment. Despite medications, his neck was still severely painful on manipulation and he continued to have nonambulatory tetraparesis.

Shortly after his first acupuncture treatment, he could stand on his own unassisted and his cervical pain was markedly improved-he could move his neck without yelping. His fentanyl was discontinued the next day because of an improved pain level. The next day, after his second acupuncture, he became ambulatory on 4 limbs with minimal assistance. He continued to make significant progress over the next 3 days with daily acupuncture. On day 7, he had full range of motion of his neck and was ambulatory with mild ataxia.

His acupuncture treatment consisted of the following:

1. DN: GV-20, LU-7, SI-3, LI-4, LIV-3, ST-36, Jing-jia-ji

2. EA: GV-16 to Bai-hui, GB-20 to GB-21 (crossing), BL-23 bilaterally, PC-8 bilaterally, KID-1 bilaterally; 2 to 20 Hz for 20 minutes

3. AA: Jing-jia-ji, GV-14, Liu-feng; 0.1-0.2cc per acupoint

SUMMARY

Given the low risk for adverse effects and observed benefits for acute and chronic pain, acupuncture can play a large role in pain management and can be incorporated into veterinary practice as part of a multimodal approach. With the increasing number of clinical trials and laboratory research, we better understand the mechanism of action and therapeutic effects of acupuncture. Nonetheless, larger randomized controlled trials are needed to verify its efficacy in veterinary medicine.

BL bladder

GB gallbladder

GV governing vessel

HT heart

KID kidney

LI large intestine

LIV liver

LU lung

PC pericardium

SI small intestine

SP spleen

ST stomach

TH triple heater

ACUPUNCTURE RESOURCES

World Association of Traditional Chinese Veterinary Medicine (AATCVM): watcvm.org

American Academy of Veterinary Acupuncture (AAVA): aava.org

American Holistic Veterinary Medical Association (AHVMA): ahvma.org

National Center for Complementary and Integrative Health (NCCIH): nccih.nih.gov

Xie's Veterinary Acupuncture, 1st ed.

Veterinary Acupuncture: Ancient Art to Modern Medicine, 2nd ed.

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Use of Acupuncture for Pain Management | Today's Veterinary Practice

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Successful pain management encompasses pharmacologic and nonpharmacologic interventions. This is especially true for chronic, neuropathic, or persistent pain. 1 While pharmacologic options remain the mainstays, nonpharmacologic interventions are an important part of a comprehensive pain management plan. Acupuncture is a safe, nonpharmacologic intervention with minimal adverse effects that most animals tolerate well.

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Meta-analyses and Systematic Reviews: Systematic review of the management of canine osteoarthritis

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Meta-analyses and Systematic Reviews: Systematic review of the management of canine osteoarthritis

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This systematic review assesses several case studies evaluating different therapeutic treatments for the management of osteoarthritis. Two case studies looked at the use of acupuncture, electrostimulated acupuncture and gold wire acupuncture, for the use of musculoskeletal disease. Both studies found that there was no statistical significance between the control groups or the treatment groups.

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Systematic review of the management of canine osteoarthritis

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This review assesses the evidence for the efficacy of therapies used in the management of osteoarthritis in dogs on the basis of papers published in peerreviewed journals in English between 1985 and July 2007. Sixty-eight papers were identified and evaluated.