Using an integrative approach to treat feline brachial plexus avulsion

This article illustrates how a multi-modal, integrative approach effectively restored limb function in a feline brachial plexus avulsion lesion.

Presentation

Brachial plexus avulsion – causes, signs and standard treatment

Luca, an 18-month-old neutered male domestic short-haired cat, presented as an emergency after being involved in a road traffic accident. On physical examination, he was depressed, slightly responsive to stimuli, and had miosis of the left pupil, consistent with partial Horner’s syndrome. He exhibited complete absence of function and sensation in his left forelimb and had a dropped elbow with carpal flexion. Deep pain was absent. Panniculus reflex was absent on the affected limb, which was cold and flaccid with pale pads. After stabilization, Luca was diagnosed with brachial plexus avulsion of the left forelimb.

Integration of treatment modalities

Luca’s brachial plexus avulsion treatment plan consisted of an integrated approach, including the following:

  1. Conventional pharmaceuticals and support

  • NSAID: Metacam — 0.2mg/kg injection, then 0.1mg/kg for four consecutive days
  • Opioid: Buprenorphine — 0.02mg/kg IM every eight hours until discharge
  • Intravenous fluid therapy: 4ml/kg/h until discharge
  1. Homeopathic medicines

  • Aconitum napellus 30c: Two doses on gums, twice on the day of admission, to help with recovery from shock and fear, and for its pain relief properties
  • Secale cornutum 30c: Three doses on gums, every 12 hours, for numbness, insensibility and coldness of limbs
  • Arnica montana 30c: Twice daily doses on gums for four days, for bruising and effects of paralysis and trauma
  • Hypericum perforatum 30c: Twice-daily doses on gums for eight weeks, for paralysis, neuralgia and paralytic pain, and spinal concussion
  1. Acupuncture using a TCVM approach and Tui-Na (Chinese therapeutic massage)

At the TCVM examination, Luca’s tongue was pale. The pulse was deep and weak with depressed Shen. It was initially difficult to establish his constitution due to the opioid influence, but it was later was identified as Earth-Metal. Earth constitution animals are happy, lively and eager to please their owners. They love attention and cuddles but are quite laid back, without the excitability of Fire animals. Metal constitution personalities prefer routine and order. Luca was a laid back cat, and while he loved attention and cuddles, he showed a preference for the comfort and security of his basket. He tolerated his treatments well, but they were done in the same order each time, in his preferred location and position.

By applying TCVM theories of Yin/Yang, Eight Principles, Five Elements and Zang Fu physiology and pathology to make the TCVM diagnosis,* one main TCVM pattern is associated with trauma to the brachial plexus: Nerve Qi/Blood Stagnation with local Qi Deficiency (after trauma). Trauma induces Qi/Blood stagnation at the site of injury, causuing Qi deficiency of the local tissues, including nerves. The result is the acute onset of paresis or paralysis of the affected limb.

The guiding treatment principles for Luca were to resolve Qi/Blood Stagnation, tonify local Qi deficiency, and promote peripheral nerve regeneration.

Electroacupuncture (EA) was selected over dry needles alone for its efficacy at resolving Qi/Blood stagnation and promoting nerve regeneration.

Electroacupuncture points and indications:

  • Liu-feng (six needles) – for limb paresis and paralysis
  • LI4 — master point, Yuan-source point, and local point, for paralysis
  • Li15 — for shoulder pain and lameness, cervical pain, intervertebral disk disease
  • SI9 bilateral — for shoulder pain, thoracic limb lameness, paresis, paralysis, and generalized pain
  • Gb 21 bilateral — crossing point of the TH, GB, and Yang-Wei Channels, for shoulder pain, thoracic limb paresis and paralysis

EA settings were continuous: discontinuous pattern 80:120 Hz, for 30 minutes.

Case photo 1Dry needle points and indications:

  • LI10 and St 36 — general Qi tonic
  • SI3 and Liv 3 — to relieve pain and stagnation of Qi
  • TH5 — Luo-connecting point of the TH Channel, confluent point of Yang-Wei Channel, paresis or paralysis
  • TH14 — for shoulder and thoracic limb pain and lameness
  • Shan-gen — classic point for appetite stimulation
  • Da-Feng-Men — calming point

Tui-na included gentle Moo-fa (massaging up and down the affected limb for three to five minutes twice daily), Ba-shen-fa stretching, and Ban-fa flexing and extending all joints, including the digits, to improve Qi/Blood flow to the peripheral nerves

Luca received these TCVM treatments for four consecutive days while hospitalized after the incident. The EA and dry needling were done once daily in the evening while Tui-na was performed twice daily. Case photo 2

  1. Photobiomodulation/laser therapy

Photobiomodulation uses specific wavelengths of light (red and near-infrared) to stimulate the body’s natural ability to heal. The effects of laser energy include improved healing time,​ pain reduction, increased circulation and decreased swelling.​

During laser therapy, infrared laser light interacts with tissues at the cellular level, increasing metabolic activity within the cell. By improving the transport of nutrients across the cell membrane, the increased production of cellular energy (ATP) is stimulated. The cascade of beneficial effects that follows includes increased cellular function and tissue repair.

A Class IV laser treatment protocol for the affected elbow and shoulder was given each morning, at a dose of 540 Joules, just before the first Tui-na treatment, to help with muscle pain and encourage relaxation.

Outcome

After the first day of treatment, Luca began to regain sensitivity in his affected limb, with daily improvement thereafter. He was discharged on Day Four with full sensation in his carpal joint though it was still lacking in functional response. The owners were instructed how to massage the leg at home, and advised to continue with the homeopathic medicines as prescribed and the oral NSAID for one more week. The electroacupuncture and laser therapy sessions were reduced to once per week.

By Week Five, Luca started to place his paw in a normal position. He would no longer tolerate electroacupuncture, so only dry needles were used. He was walking slowly but limping, as he had moderate muscle atrophy. By eight weeks after the accident, Luca had recovered 100% of his limb function.

To this author’s knowledge, one other similar case report has been published of a cat presenting with a brachial plexus avulsion injury. The patient underwent daily physiotherapy and indoor confinement, recovering full ambulatory capacity after six weeks.1

Case reflection

There is an increasing demand for alternative and complementary therapies in both human and veterinary medicine. Working in a holistic clinic has given me the opportunity to integrate these modalities into case protocols, especially in situations where existing conventional treatment options offer a poor to very poor prognosis. In Luca’s case of brachial plexus avulsion, homeopathic medicines were used alongside Chinese acupuncture for their own properties and to complement the TCVM approach. Homeopathic medicines can be very beneficial in emergency situations, as they are safe and gentle, supporting the natural ability of the body to restore itself in a short period of time. Acupuncture, especially electroacupuncture, is a very powerful tool, but can be used only when a TCVM diagnosis has been reached, and not in acute presentations when the patient is unstable. Incorporating both modalities into Luca’s treatment plan led to a successful outcome for this cat.

Note

*The Yin-Yang theory is fundamental to Chinese medicine. Yin is closely related to anatomy (the organ itself) while Yang is closely related to the physiology (the organ’s function). In other words, a change in the organ’s shape (Yin) can affect the organ’s function (Yang) and vice versa. Yin-Yang is the basis for the Eight Principles diagnostic system, which is used to diagnose disease. The Eight Principles system associates Interior, Cold and Deficiency Patterns with Yin. Exterior, Heat and Excess Patterns are associated with Yang. The ancient Chinese divided the natural world into five elemental categories: Wood, Fire, Earth, Metal and Water. All organs correspond to an element and will be divided into Yin or Yang. Traditional Chinese medical practitioners use the properties of the Five Elements and the relationships between them to describe the relationships among the body’s internal organs, as well as the relationship between the body and the natural world.

References

1Santifort, KM. “Return of function in a feline thoracic limb after suspected traumatic brachial plexus injury with loss of nociception”.Veterinary Record Case Reports, August 29, 2016.

Clarke, John Henry. A Dictionary of Practical Materia Medica, B. Jain Publishers (P) Ltd, 2017.

Curtis W. Dewey (Editor), Ronaldo C. da Costa (Editor). Practical guide to canine and feline neurology, 3rd Edition, Wiley Blackwell, 2015.

Huisheng Xie Dr.; Cheryl Chrisman ACVIM-Neurology; Lisa Trevisanello Dr. Traditional Chinese Veterinary Medicine for Neurological Disease, Jing Tang Publishing, 2011.

Huisheng Xie Dr.; Vanessa Preast Dr. Traditional Chinese Veterinary Medicine: Fundamental Principles, 2nd Edition, Chi Institute Press, 2013.

Huisheng Xie Dr.; Vanessa Preast Dr. Xie’s Veterinary Acupuncture, Blackwell Publishing, January 2007. 

msdvetmanual.com/nervous-system/diseases-of-the-peripheral-nerves-and-neuromuscular-junction/trauma-of-the-peripheral-nerve-and-neuromuscular-junction#:~:targetText=Brachial%20Plexus%20Avulsion%3A,attachment%20to%20the%20spinal%20cord.

vetstream.com/treat/felis/diseases/brachial-plexus-avulsion.

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