Transcript AP-Neuro-2009

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.
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
• 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
•
•
•
•
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
• 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, 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
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
– 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
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
–
–
–
–
–
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
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
– 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)
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