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?Is it a neurologic disease? –Seizures –Intention tremor –CN deficits Head tiltHead tilt NystagmusNystagmus –CP deficits –Dysmetria –Paralysis

Minimum Database CBCCBC ChemistryChemistry –Bile acids –Cholinesterase UrinalysisUrinalysis Chest and abdominal radiographsChest and abdominal radiographs Abdominal ultrasound Heartworm test Fecal

Ancillary Neurologic Tests ElectrodiagnosticsElectrodiagnostics –EEG –EMG –BAER CSF tap & analysisCSF 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 LesionLocalization of Lesion D A M N I T V O Def (Qi, Yin, Blood)Def (Qi, Yin, Blood) Jing DefJing Def Def (Qi, Yin, Blood, Yang)Def (Qi, Yin, Blood, Yang) Def (Qi, Yin, Blood)Def (Qi, Yin, Blood) Stagnation (Blood)Stagnation (Blood) Jing Def/Excess or DefJing Def/Excess or Def Phlegm FirePhlegm Fire TraumaTrauma Excess or DefExcess or Def Wind PhlegmWind Phlegm

Plan P Problem ListProblem List –? Differential Dx –? Diagnostic Approach –? Treatment –?

Seizures in Small Animals It is estimated that the overall incidence of seizure disorders in dogs and cats is around 1%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 %, due to the presence of inherited, primary epilepsy in those breedsIn pure breed dogs, this incidence may increase to %, 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 InactiveActive Reactive Epilepsy Probably Symptomatic Epilepsy Symptomatic Epilepsy Symptomatic Epilepsy

Seizure Diagnosis Minimum DatabaseMinimum Database –Abnormal in Reactive Epilepsy CSF tap & analysisCSF 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 EpilepsyAll 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) systemRepresent various aspects of the Liver (Wood) system Excess (3 types)Excess (3 types) Deficiency (3 types)Deficiency (3 types)

Seizures- -TCM ExcessExcess –Wind-Phlegm Tongue pale & greasyTongue pale & greasy Pulse wiry & slipperyPulse wiry & slippery –Phlegm-Fire Tongue red & greasyTongue red & greasy Pulse rapid, wiry & slipperyPulse rapid, wiry & slippery –Blood Stagnation Tongue & Pulse like Wind-PhlegmTongue & Pulse like Wind-Phlegm History of head traumaHistory 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 ExcessExcess –Wind-Phlegm expel phlegm, extinguish the wind, open the orifice and stabilize the seizuresexpel phlegm, extinguish the wind, open the orifice and stabilize the seizures Ding Xian WanDing Xian Wan –Phlegm-Fire clear the liver, drain the heat, transform phlegm and open the orificesclear the liver, drain the heat, transform phlegm and open the orifices Di Tan Tang and Long Dan Xie Gan TangDi Tan Tang and Long Dan Xie Gan Tang –Blood Stagnation expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate bloodexpel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood Ding Xian Wan and Tao Hong Si Wu SanDing 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 windInternal heat leading to generation of wind Clear wind & heat and calm the ShenClear wind & heat and calm the Shen PointsPoints –Constitutional points –Clear wind & heat GB20, LI4, LI11, GV14, LIV3GB20, LI4, LI11, GV14, LIV3 –Calm the shen PC6, HT7PC6, HT7 –Local points GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1, ST40GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1, ST40 TCM HerbalsTCM Herbals –Di Tan Tang (TCM phenobarbital) –Specific herbs for excesses or deficiencies present

Ear Staple Shen MenShen 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 ShenAn Shen –Half way around the back of the ear –Aim toward the opposite base of lips –Inject mg diluted with saline to 0.5-6ml

Basic Antioxidants Vitamin E 10 IU/lb dailyVitamin E 10 IU/lb daily Vitamin C 5-10 mg/lb twice a dayVitamin C 5-10 mg/lb twice a day Selenium 2 µg/lb dailySelenium 2 µg/lb daily Beta carotene 250 IU/lb dailyBeta carotene 250 IU/lb daily B Complex 2mg/kg twice a dayB Complex 2mg/kg twice a day Vitamin E IU daily Vitamin C mg twice a day Selenium 50 µg daily Vitamin A IU daily B Complex 10 mg twice a day DogsCats

Additional Considerations Probably safe parasite controlProbably safe parasite control –Interceptor –Frontline Top Spot –Revolution Should avoid –Heartgard –Proheart 6 –Program –Sentinel –Frontline Spray –Advantage –Advantix

Additional Considerations DietDiet –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 DiseasesInfectious Diseases –Species Specific Steroid Response ME (SRME)Steroid Response ME (SRME) Necrotizing Vasculitis (SRMA)Necrotizing Vasculitis (SRMA) Necrotizing ME (NME)Necrotizing ME (NME) Granulomatous ME (GME)Granulomatous ME (GME)

Meningoencephalomyelitis Pain to paresis to plegiaPain to paresis to plegia Dx with CSF tapDx with CSF tap Spinal radiographs normalSpinal radiographs normal Myelography normal (might be contraindicated)Myelography normal (might be contraindicated)

Meningoencephalomyelitis

CSF Tap Collection site for seizures is at the cisterna magnum.Collection site for seizures is at the cisterna magnum. Allows analysis for cells, protein and pressure.Allows analysis for cells, protein and pressure. Cytology and titers for infectious organisms can be obtained.Cytology and titers for infectious organisms can be obtained.

Menigoencephalomyelitis –Wind-Phlegm expel phlegm, extinguish the wind, open the orifice and stabilize the seizuresexpel phlegm, extinguish the wind, open the orifice and stabilize the seizures Ding Xian WanDing Xian Wan –Phlegm-Fire clear the liver, drain the heat, transform phlegm and open the orificesclear the liver, drain the heat, transform phlegm and open the orifices Di Tan Tang and Long Dan Xie Gan TanDi Tan Tang and Long Dan Xie Gan Tan

Brain Abscess in a Foal

Vestibular Disease Cardinal SignsCardinal Signs –Head Tilt –Nystagmus HorizontalHorizontal RotatoryRotatory VerticalVertical PositionalPositional –Circling (tight) –Imbalance & Incoordination

Vestibular Disease Idiopathic V.D. Inner Ear Disease Central V.D. 8th Nerve only 8th Nerve, 7th Nerve & Horner’s Syndrome Anything Else Brainstem V.D. Cerebellar Disease

Idiopathic Vestibular Disease Acute Onset of Vestibular SignsAcute Onset of Vestibular Signs –Head tilt –Horizontal or Rotatory nystagmus with fast- phase away from head tilt –Nothing else Can Be Very SevereCan Be Very Severe Acute, regressive diseaseAcute, regressive disease

Idiopathic Vestibular Disease -- TCM Wind (heat) invasionWind (heat) invasion Clear wind & heat and calm the ShenClear wind & heat and calm the Shen PointsPoints –Constitutional points –Clear wind & heat GB20, LI4, LI11, GV14GB20, LI4, LI11, GV14 –Calm Shen PC6, HT7, GV17, GV20, GV21PC6, HT7, GV17, GV20, GV21 –Local points TH17, TH18, TH21, SI19, GB2, Er jian, An shenTH17, TH18, TH21, SI19, GB2, Er jian, An shen

Inner Ear Disease 8th Nerve Signs8th Nerve Signs 7th Nerve Signs7th Nerve Signs –ear & lip droop –lack of palpebral reflex –nose turn –nostril flaring Horner’s SyndromeHorner’s Syndrome

Horner’s Syndrome Small AnimalsSmall Animals –Ptosis –Myosis –Enophthalmos Large AnimalsLarge Animals –Facial sweating (horse) –Lack of muzzle sweating (cow)

Inner Ear Disease Most cases are secondary to bacterial infection (otitis media & interna)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.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.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.Invasion of external pathogen leading to wind, heat, damp. Heat boils the fluids leading to the accumulation of phlegm.Heat boils the fluids leading to the accumulation of phlegm. Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.

Inner Ear Disease -- TCM PointsPoints –Constitutional points –Clear wind & heat GB20, LI4, LI11, GV14GB20, LI4, LI11, GV14 –Calm the shen PC6, HT7, GV17, GV20, GV21PC6, HT7, GV17, GV20, GV21 –Eliminate damp SP9SP9 –Activate Qi & blood ST36, ST40, Xin shuST36, ST40, Xin shu –Local points TH17, TH18, TH21, SI19, GB2, Er jian, An shenTH17, TH18, TH21, SI19, GB2, Er jian, An shen

Central Vestibular Disease Postural ChangesPostural Changes –CP Deficit –Dysmetria Reflex ChangesReflex 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, heat- damp or wind cold based upon the causative factor involved.Can be wind, heat- damp or wind cold based upon the causative factor involved. PointsPoints –Constitutional –8 Principle –Zang-Fu

IVD- -TCM Diagnosis Represents a “bi” syndrome often accompanied by “wei” syndromeRepresents a “bi” syndrome often accompanied by “wei” syndrome Under domain of KID (bones) & LIV (joints & free flow of qi & blood)Under domain of KID (bones) & LIV (joints & free flow of qi & blood)

IVD- - TCM Patterns Excess typesExcess types –Wind-Cold-Damp –Blood stagnation Deficient types –Yang deficiency –Yin deficiency –Yin & Yyang deficiency

Fibrocartilagenous Emboli Vascular occlusion from IVD materialVascular 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 infarctionGenerally affects a radicular penetrating branch which leads to a quadrant (wedge) of infarction Many will improve with timeMany 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)Acute invasion of external pathogen leading to stagnation (cold slows blood flow which is worsened by accumulation of damp) TongueTongue –Greasy PulsePulse –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)Antioxidant steroids (Solu Medral or Solu Delta Cortef) –30mg/kg –15mg/kg every 8 hours for hours Surgical correctionSurgical correction Acupuncture needle in wei jian (tip of tail)

Intervertebral Disc Disease: chondrodystrophic dogs Collagen fibers of the nucleus pulposus metamorphs into hyalin cartilageCollagen fibers of the nucleus pulposus metamorphs into hyalin cartilage IVD looses elasticity and leads to damage of annulus fibrosusIVD looses elasticity and leads to damage of annulus fibrosus

IVD- -chondrodystrophy Annulus ruptures extruding degenerate nuclear material into the neural canalAnnulus ruptures extruding degenerate nuclear material into the neural canal This leads to pain, paresis or paralysisThis leads to pain, paresis or paralysis

IVD- -Pain Only Cage Rest for 30 days or 3 weeks after patient becomes clinically normal.Cage Rest for 30 days or 3 weeks after patient becomes clinically normal. AcupunctureAcupuncture Oral steroids and diazepam only under supervisionOral steroids and diazepam only under supervision

IVD- -Paresis HospitalizeHospitalize –Prednisolone (2 mg/kg divided 2-3 times a day) –Misoprostol 3-4 µg/kg twice a day –Diazepam mg/kg TID Should improve in first 5-7 daysShould improve in first 5-7 days

IVD- -Paralysis with Deep Pain EmergencyEmergency –Give Solu Medral or Solu Delta Cortef 30 mg/kg –Refer May observe for 24 hours to see if dramatic improvementMay observe for 24 hours to see if dramatic improvement –If none, Emergency

IVD- -Paralysis No Deep Pain EmergencyEmergency –Give 30 mg/kg Solu Medral or Solu Delta Cortef –Refer 75% respond in first 24 hours75% respond in first 24 hours 50% in first 72 hours50% in first 72 hours 25% after that25% after that

Integrative Therapy of IVD Disease Acute IVD Disease is a surgical emergencyAcute IVD Disease is a surgical emergency –Even with no deep pain there is a 75% chance of success within the 1 st 24 hours & 50% chance in the 1 st 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 neededAfter surgery, healing is needed Physical therapyPhysical 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 antioxidantsBasic antioxidants –Vitamin E, vitamin C, vitamin B complex, selenium, beta carotene Anti-inflammatory membrane stabilizersAnti-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 controlDiet & weight control –Low carbohydrate diet –Basic antioxidants Chiropractic careChiropractic care MassageMassage ExerciseExercise

Hans

Hans Routine radiographs showed a narrowed IVD space at T11-12 with a cloudy IV foramenRoutine radiographs showed a narrowed IVD space at T11-12 with a cloudy IV foramen Incidentally there was calcification of T13-L1Incidentally there was calcification of T13-L1

Hans

IVD- -Blood Stagnation Most common type in chondrodystrophic dogsMost common type in chondrodystrophic dogs –KID Jing deficiency leads to failure to nourish LIV leads to joint problems & stagnation TongueTongue –Purple PulsePulse –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 PinchersYoung 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 RadiographsPlain Radiographs –mild changes which suggest problem CSF tapCSF tap –normal EMGEMG MyelographyMyelography –dynamic views

Myelograpgy- -dynamic views Ventral Flexion Dorsal Flexion

CSM- -Treatment Surgery is designed to remove IVD protrusion and to lessen ligamentous compressionSurgery is designed to remove IVD protrusion and to lessen ligamentous compression Best accomplished with distraction techniquesBest accomplished with distraction techniques –“Screw and Washer” –methylmethacrylate

LS Stenosis A Pain in the Butt! DVM

LS Stenosis- -Cardinal Signs LS Back PainLS Back Pain –pain on palpation at LS junction –pain on raising the tail head Diminished tail movementDiminished tail movement Urinary and Fecal continency problemsUrinary and Fecal continency problems

LS Stenosis

LS Stenosis- -Diagnosis EMGEMG –fibrillation potentials and positive sharp waves caudal to LS junction, distal limb and tail Imaging techniquesImaging techniques –CT Scan –MRI Scan

LS Stenosis- -Treatment Medical managementMedical management –corticosteroids & diazepam –carprofen & diazepam –acupuncture & TCM herbs SurgerySurgery –dorsal laminectomy ± stabilization

IVD- -Yang Deficient Old age leads to KID deficiencyOld age leads to KID deficiency –General weakness & cold back TongueTongue –Pale & wet (swollen with teeth marks) PulsePulse –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 YinChronic illness or old age consumes KID Yin –Weakness in back worse at night TongueTongue –Red & dry PulsePulse –Deep, thready & weak Rx principle –Nourish Yin & tonify KID TCM herbal –Di gu pi san Chronic IVD

Discospondylitis Infection of the intervertebral spaceInfection of the intervertebral space Common causesCommon causes –Staph. aureus –Strep. sp. –Corynebactrium SignsSigns –Pain (can be extreme) –Ataxia to plegia

Discospondylitis Diagnosis can be made on plain radiographsDiagnosis can be made on plain radiographs –May initially be normal, until 2-3 weeks of incubation Find organism viaFind organism via –Blood culture –Urine culture

Discospondylitis Also considerAlso consider –Nocardia or other fungal cause (aspergillosis) –Brucella canis –Spirocerca lupi Treatment (6-8 wk)Treatment (6-8 wk) –Cephalosporins –Sulfa drugs

Moose 9 year old M/C Labrador9 year old M/C Labrador HBC 4 months agoHBC 4 months ago –Recovered Chronic, progressive paresis over 2 weeksChronic, 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 bacteriaImpression smears from both the articular process and the epidural mass revealed PMN with intracellular bacteria

Moose- -CT scan

Moose- -Post OP AntibioticsAntibiotics –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 deficiencyAging leads to KID Yang & Yin deficiency –decreases resistance & allows low grade infection to start TongueTongue –Pink or pale PulsePulse –Deep & weak Rx Principle –Nourish Yin & tonify KID TCM herbal –Double P #1 (hindquarter formula) Very chronic

CNS Neoplasia Today’s Frontier

CNS Neoplasia- -Dogs Dog has 1-18 months average survival timeDog 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)All tumors are invasive (malignant)

CNS Neoplasia- -Cats Most common is meningiomaMost common is meningioma Usually extra- axial and benignUsually extra- axial and benign Seen in aged catsSeen in aged cats Present with depression and dementiaPresent with depression and dementia

Elvis

Elvis MRI revealed mass in the cerebral cortexMRI revealed mass in the cerebral cortex

Elvis

Treatment DietDiet –Low carbohydrate SupplementsSupplements –Antioxidants & membrane stabilizers Herbal medicationsHerbal medications –Western- -Canine Cancer formula –Traditional Chinese medicine- -Stasis in the Mansion of the Mind

TCVM Brain Cancer Max FormulaMax Formula Stasis in Mansion of MindStasis in Mansion of Mind Wei Qi BoosterWei Qi Booster Western herbsWestern herbs or and and Transports to Head

Cancer Recommendations 1.Low-Carbohydrate food (home prepared is best or use Pedigree Weight Loss Formula) 2.Canine basic antioxidant formula (Westlab Pharmacy WESTLA) 3.Canine arthritis formula (Westlab) 4.Canine cancer formula (Westlab)- -use at 2 times prevention dose 5.COX-2 inhibitor (daily- -particularly for carcinomas) 6.Melatonin at night ( mg/kg)