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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 – Paralysis Minimum Database • CBC • Chemistry – Bile acids – Cholinesterase • Urinalysis • Chest and abdominal radiographs • Abdominal ultrasound • Heartworm test • Fecal 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 When all else fails… Look at the patient!!! Outcome of Neurologic Assessment • Localization of Lesion • D • Def (Qi, Yin, Blood) O • • • • • • • • • • A M N N I I I T T V • • • • • • • • • • 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 Plan • Problem List – ? • Differential Dx – ? • Diagnostic Approach – ? • Treatment – ? P 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 1520%, due to the presence of inherited, primary epilepsy in those breeds Lesion Localization in Seizures • Cerebral Cortex • Diencephalon – Thalamus – Hypothalamus • Mesencephalon Seizure Diagnoses SEIZURES Primary Epilepsy Secondary Epilepsy Inactive Probably Symptomatic Epilepsy Reactive Epilepsy Active 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 • All test are normal in Primary Epilepsy Asymmetrical Seizures Licking Seizure Fly-Biting Seizure Seizures and Signalment • Primary Epilepsypurebred dogs 1-3 years of age • Secondary Epilepsyany age but especially under 6 months and over 3 years Seizures- -TCM • Represent various aspects of the Liver (Wood) system • Excess (3 types) • Deficiency (3 types) Seizures- -TCM • 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 • 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 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 • 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 • 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 Dogs • 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 Cats • 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 Additional Considerations • Probably safe parasite control – Interceptor – Frontline Top Spot – Revolution • Should avoid – – – – – – – Heartgard Proheart 6 Program Sentinel Frontline Spray Advantage Advantix Additional Considerations • 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 Meningoencephalomyelitis • Infectious Diseases – Species Specific • Steroid Response ME (SRME) • Necrotizing Vasculitis (SRMA) • Necrotizing ME (NME) • Granulomatous ME (GME) Meningoencephalomyelitis • Pain to paresis to plegia • Dx with CSF tap • Spinal radiographs normal • Myelography normal (might be contraindicated) Meningoencephalomyelitis 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. 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 Brain Abscess in a Foal Brain Abscess in a Foal Vestibular Disease • Cardinal Signs – Head Tilt – Nystagmus • • • • Horizontal Rotatory Vertical Positional – Circling (tight) – Imbalance & Incoordination Vestibular Disease Vestibular Disease 8th Nerve only Idiopathic V.D. 8th Nerve, 7th Nerve & Horner’s Syndrome Inner Ear Disease Brainstem V.D. Anything Else Central V.D. Cerebellar Disease Idiopathic Vestibular Disease • Acute Onset of Vestibular Signs – Head tilt – Horizontal or Rotatory nystagmus with fastphase away from head tilt – Nothing else • Can Be Very Severe • Acute, regressive disease 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 • 8th Nerve Signs • 7th Nerve Signs – ear & lip droop – lack of palpebral reflex – nose turn – nostril flaring • Horner’s Syndrome Horner’s Syndrome • Small Animals – Ptosis – Myosis – Enophthalmos • Large Animals – Facial sweating (horse) – Lack of muzzle sweating (cow) 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 • 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 Cats • Treatment is surgical removal. • Damage can be permanent, if pressure necrosis has destroyed the inner ear structure. 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 -- 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 • 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 Disease MRI of Cerebellar Meningioma Central Vestibular Disease -- TCM • Can be wind, heatdamp or wind cold based upon the causative factor involved. • Points – Constitutional – 8 Principle – Zang-Fu 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 • Deficient types – Wind-Cold-Damp – Yang deficiency – Blood stagnation – Yin deficiency – Yin & Yyang deficiency 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 FCE • Generally affects a radicular penetrating branch which leads to a quadrant (wedge) of infarction • Many will improve with time Schatzie 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 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 • Collagen fibers of the nucleus pulposus metamorphs into hyalin cartilage • IVD looses elasticity and leads to damage of annulus fibrosus IVD- -chondrodystrophy • Annulus ruptures extruding degenerate nuclear material into the neural canal • This leads to pain, paresis or paralysis 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 • Hospitalize – Prednisolone (2 mg/kg divided 2-3 times a day) – Misoprostol 3-4 µg/kg twice a day – Diazepam 0.250.5 mg/kg TID • Should improve in first 5-7 days 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 • 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 IVD • 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- -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- -Prevention • Diet & weight control – Low carbohydrate diet – Basic antioxidants • Chiropractic care • Massage • Exercise Hans Hans • Routine radiographs showed a narrowed IVD space at T11-12 with a cloudy IV foramen • Incidentally there was calcification of T13-L1 Hans 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 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 Diagnosis of CSM • Plain Radiographs – mild changes which suggest problem • CSF tap – normal • EMG • Myelography – dynamic views Myelograpgy- -dynamic views Ventral Flexion Dorsal Flexion CSM- -Treatment • Surgery is designed to remove IVD protrusion and to lessen ligamentous compression • Best accomplished with distraction techniques – “Screw and Washer” – methylmethacrylate LS Stenosis A Pain in the Butt! DVM 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 LS Stenosis- -Diagnosis • EMG – fibrillation potentials and positive sharp waves caudal to LS junction, distal limb and tail • Imaging techniques – CT Scan – MRI Scan LS Stenosis- -Treatment • Medical management – corticosteroids & diazepam – carprofen & diazepam – acupuncture & TCM herbs • Surgery – dorsal laminectomy ± stabilization 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- -Yin Deficiency • Chronic illness or old age consumes KID Yin • Rx principle – Nourish Yin & tonify KID – Weakness in back worse at night • TCM herbal – Red & dry • Chronic IVD • Tongue • Pulse – Deep, thready & weak – Di gu pi san Discospondylitis • Infection of the intervertebral space • Common causes – Staph. aureus – Strep. sp. – Corynebactrium • Signs – Pain (can be extreme) – Ataxia to plegia 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 Discospondylitis • Also consider – Nocardia or other fungal cause (aspergillosis) – Brucella canis – Spirocerca lupi • Treatment (6-8 wk) – Cephalosporins – Sulfa drugs Moose • 9 year old M/C Labrador • HBC 4 months ago – Recovered • Chronic, progressive paresis over 2 weeks Moose- -Myelogram Moose- -Surgical Observation Abnormal articular process at T12 Epidural mass Moose- -Cytology • Impression smears from both the articular process and the epidural mass revealed PMN with intracellular bacteria Moose- -CT scan 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 • Rx Principle – Nourish Yin & tonify KID – decreases resistance & allows low grade infection to start • TCM herbal – Pink or pale • Very chronic • Tongue • Pulse – Deep & weak – Double P #1 (hindquarter formula) CNS Neoplasia Today’s Frontier CNS Neoplasia- -Dogs • Dog has 1-18 months average survival time – 1-3 with nothing – 6-9 with surgery – 12-18 with radiation treatment • All tumors are invasive (malignant) CNS Neoplasia- -Cats • Most common is meningioma • Usually extraaxial and benign • Seen in aged cats • Present with depression and dementia Elvis Elvis • MRI revealed mass in the cerebral cortex Elvis Treatment • Diet – Low carbohydrate • Supplements – Antioxidants & membrane stabilizers • Herbal medications – Western- -Canine Cancer formula – Traditional Chinese medicine- -Stasis in the Mansion of the Mind TCVM Brain Cancer • Max Formula or • Stasis in Mansion of Mind and • Wei Qi Booster and • Western herbs Transports to Head Cancer Recommendations 1. Low-Carbohydrate food or use Pedigree Weight Loss Formula) (home prepared is best 2. Canine basic antioxidant formula Pharmacy 1-800-4WESTLA) 3. Canine arthritis formula 4. Canine cancer formula prevention dose 5. COX-2 inhibitor (Westlab (Westlab) (Westlab)- -use at 2 times (daily- -particularly for carcinomas) 6. Melatonin at night (0.1-0.2 mg/kg)