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 Urinalysis 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 A M N I T V Def (Qi, Yin, Blood) Jing Def Def (Qi, Yin, Blood, Yang) Stagnation (Blood) Jing Def/Excess or Def Phlegm Fire Trauma Excess or Def Wind Phlegm O

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 15-20%, due to the presence of inherited, primary epilepsy in those breeds

Lesion Localization in Seizures Cerebral Cortex Diencephalon Thalamus Hypothalamus Mesencephalon

Probably Symptomatic Epilepsy Seizure Diagnoses Probably Symptomatic Epilepsy Symptomatic Epilepsy

Seizure Diagnosis Minimum Database CSF tap & analysis CT or MRI Scan 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 Epilepsy- purebred dogs 1-3 years of age Secondary Epilepsy- any 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 Deficiency Wind-Phlegm Phlegm-Fire 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 Kidney Jing Def. Tongue pale or red & dry < 1 year of age

Seizures- -TCM Excess Deficiency Wind-Phlegm Phlegm-Fire 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 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 Cats 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

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.

Meningoencephalomyelitis 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 with neutrophils, lymphocytes and macrophages.

Meningoencephalomyelitis Infection virus rickettsia protozoa fungus bacteria Inflammation GME NME SRME SRMA

GME Can be: peracute acute & progressive chronic In brainstem, tends to be a multifocal inflammatory disorder Responds temporarily to steroids. Patient with GME presenting with vertical nystagmus, long tract signs, and circling with incoordination.

GME GME histologically causes multifocal meningoencephalitis due to proliferation of reticulohistiocytic cells. Lesions also show multinucleated giant cells.

Treatment of ME Primor (activated sulfadimethoxine) 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

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 Circling (tight) Horizontal Rotatory Vertical Positional Circling (tight) Imbalance & Incoordination

Vestibular Disease Vestibular Disease Idiopathic V.D. 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 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 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 Horner’s Syndrome ear & lip droop lack of palpebral reflex nose turn nostril flaring Horner’s Syndrome

Horner’s Syndrome Small Animals Large 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 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 with neutrophils, lymphocytes and macrophages.

Central Vestibular Disease Inflammatory or Infectious Diseases canine distemper toxoplasmosis and neosporiosis fungal rickettsial GME SRME

Central Vestibular Disease Trauma or Vascular remember dogs don’t get atherosclerosis ! Neoplasia meningiomas choroid plexus papillomas oligodendrogliomas astrocytomas metastatic neoplasia

Central Vestibular Disease MRI of Cerebellar Meningioma

Central Vestibular Disease Infectious Diseases FIP FeLV toxoplasmosis cryptococcosis Trauma Metabolic thiamine deficiency Toxicity organophosphates Neoplasia meningiomas

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 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 Blood stagnation Deficient types Yang deficiency 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

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 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 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 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 Should improve in first 5-7 days 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 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

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

IVD After surgery, healing is needed Physical therapy Acupuncture 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 Anti-inflammatory membrane stabilizers 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 Chiropractic care Massage 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

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

IVD- -Yang Deficient Old age leads to KID deficiency Tongue Pulse 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 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

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 Treatment (6-8 wk) 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 Tongue 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

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