TCVM for Lameness in Horses – Diagnosis and Treatment
Every horseperson knows the adage “no foot no horse”. Indeed, much equine lameness involves the distal limb. Some equine lameness arises from acute, targeted trauma, but most patients suffer chronic discomfort in multiple body regions. This may be secondary to the strain of performance, or can result from abnormal body carriage used to compensate for a primary lameness. Even with advances in sophistication and a variety of diagnostic technologies, accurate and thorough equine lameness diagnosis remains a signifi cant challenge in veterinary medicine. Most clinicians are only able to diagnose and treat one or two regions that display the most severe clinical signs, potentially overlooking root causes that are more diffi cult to detect or treat.
Acupuncture and the Channels (Jing Luo) provide a diagnostic modality for equine musculoskeletal problems, and can also be used to help gauge response to treatments. Sensitivity at specifi c groups of acupoints along the meridians is highly correlated with discomfort originating at various local and referred body sites in people1-5 and in veterinary literature.6-13 Clinicians skilled at assessing Jing Luo diagnostic points fi nd it to be a straightforward, non-invasive, low cost and invaluable clinical skill. Subtle and even subclinical musculoskeletal problems can be identifi ed and treated, enhancing the horse’s performance and well being, and potentially helping prevent progression to more serious conditions.
performing the diagnostic scan The clinician must be familiar with the Jing Luo and the acupoints, and develop a consistent and sensitive approach to the technique. As with any procedure, there is considerable individual variety in the approach to the diagnostic scan. Most practitioners utilize a small, blunt instrument such as a hypodermic needle cap, thermometer case, acupuncture needle guide tube, or the paired tips of a closed forceps as a tool for their scan.
First, the skin overlying a neutral area of the horse – one that does not contain diagnostic acupoints, such as the region at the base of the neck commonly used for intramuscular injection – is stroked fi rmly with the scan tool. This preliminary step both familiarizes the horse with contact by the tool and helps the clinician gauge the amount of pressure to exert on the skin of the individual. Pressure should be suffi cient to be easily felt by the horse in the skin and underlying musculature, but should be well tolerated – below the threshold necessary to elicit a response from the horse (twitching skin, local muscle spasm or increased tension, stepping away from the pressure, turning to look at the veterinarian).
Once a suitable pressure for the patient is established, the scan should be executed in a brisk, methodical fashion. Most practitioners run the scan tool in short, overlapping, gentle but decisive strokes in a cranial-to-caudal direction, beginning with GB-20 or ST-7 and ending at BL-39 or Feng-long. Points that elicit reactions can be re-scanned three to four times to determine the consistency and magnitude of the horse’s reaction. It is helpful to semi-quantitatively grade responses on a numeric scale of 0 to 5: • 1 for mild local reactions • 2 for moderate local reactions • 3 for moderate regional or mild whole body reactions • 4 for moderate whole body reactions • 5 for horse that kicks, bites or attempts to run away when a point is scanned
The severity and patterns of sensitive acupoints should be considered in conjunction with history, chief complaint, and other examination fi ndings in formulating a treatment plan.
The diagnostic scan can be used to assess the effi cacy of treatment. A decrease or disappearance of reactivity at acupoints during an acupuncture treatment, or over a more protracted clinical course, is generally indicative of improvement in the associated body regions. Serial evaluation of diagnostic acupoints may be particularly useful in gauging response to subtle, vague or subclinical problems, such as those that result in a chief complaint of suboptimal performance, and/or lack signifi cant fi ndings on Western physical examination. Practice Tips • Reactions to acupoints can be quite profound, and may be directed at the examiner or handler, so exercise both compassion for the horse and sensible horsemanship.
• Horses that seem reactive “everywhere” cannot be meaningfully assessed. This hypersensitivity can often be cleared by inserting 25-gauge hypodermic needles at acupoints TH-1 and BL-67 and allowing a few drops of blood to drain from both sites.
• Be calm and focused; minimize bias by performing the scan prior to inquiring about the history.
• Consider that sensitivity at diagnostic acupoints may correlate with internal medicine conditions14-15 or local discomfort, rather than always indicating pain at the corresponding musculoskeletal region. For example, BL-13 is associated with pain at three different body regions. It will be reactive in patients suffering local back pain, splints, or lung issues. It is therefore critical to assess patterns of reactivity.
• Musculoskeletal pain is caused by Qi-Blood Stagnation, but may have other root causes.
• Wood and Fire constitutions are more likely to show signs of lameness compared to more stoic Earth horses. Thus, abnormal scan fi ndings and/or clinical lameness in Earth horses should be attended to promptly.
• Chronic disease conditions may result in “fatigue” of the diagnostic acupoints. When this occurs, the magnitude or even presence/absence of a response at the points are no longer reliable indicators of discomfort in the corresponding body regions.
• Perform Western medical examinations and diagnostics as appropriate for each patient.
Diagnosis Acupoints of Foot and Heel Pain Four primary categories of pain in the foot and heel region can be detected with the diagnostic scan: general hoof/heel pain, laminitis (acute, chronic, metabolic or “road founder”), low and high ringbone, and navicular disease/caudal heel pain syndrome.
The reactive acupoints are indicative of Qi-Blood Stagnation in the meridians of the foot region, and can be re-scanned during an acupuncture treatment of foot pain to help gauge efficacy. In addition to local points such as Qian-ti-men, insertion of acupuncture needles in the distal points including LI-3 and SI-3, or Jing-well points including PC-9, LU-11 and TH-1, can help clear Stagnation in the foot and therefore ameliorate or eliminate the reactivity in the diagnostic acupoints. Certainly, changes in reactivity at the acupoints may also be among the clinical indicators used to evaluate other treatment protocols such as therapeutic shoeing.
• Lameness or foot soreness • Very sensitive to palpation at LI-18 and PC-1 • Other points including BL-13, BL-14, BL-15, GB-21, LI-15, TH-14, SI-9 or SI-10 may also be sensitive • Tongue: normal or red/purple • Pulse: normal or fast/wiry
TCVM DIAGNOSIS: Local Qi-Blood Stagnation
TREATMENT PRINCIPLES: Move Qi-Blood to resolve local Stagnation
ACUPUNCTURE TREATMENT: • Six local points (per session): TH-1, PC-9, Qian-ti-men, SI-3, LI-3 and LU-11 (can alternately use other local points including LI-1, LI-2, HT-9, SI-1, TH-1, TH-2, TH-3). • Two distal points (2 points per session): TH-15 and GB-21 (can alternately use other distal points including TH-14, SI-9, SI-10, LU-1, LI-14, LI-15, LI-16, HT-7). • Pattern/balance points: BL-11, BL-23, Shen-shu
ACUPUNCTURE PROTOCOL: • Hemo-acupuncture (22 to 25 gauge hypodermic needles) for acute onset of laminitis: LU-11, LI-1, HT-9, SI-1, TH-1. • Dry needles (six to ten points): LU-1, LU-7, LU-9, LI-2, LI-3, LI-4, LI-11, LI-14, LI-15, LI-16, HT-7, SI-2, SI-3, SI-4, SI-9, SI-10, BL-11, BL-13, BL-23, PC-1, PC-6, PC-9, TH-2, TH-3, TH-5, TH-14, TH-15 • Electro-acupuncture (for chronic hoof/heel pain cases including navicular disease and laminitis): GB-21 + LI-16, BL-11 + TH-15, Qian-ti-men + LI-3, PC-9 + SI-3, BL-18 + BL-18, Shen-shu + Shen-shu.
HERBAL TOPICAL APPLICATION: Zhi Tong Gao (Relief Salve)18-19 • Invigorates Blood, moves Qi, relieves pain and dissipates swelling. • Massage into the skin for fi ve to ten minutes per day for 10 to 20 days, wrapping the limb for 12 hours on, 12 hours off . • Discontinue if blistering or irritation occurs. • Do not use on open wounds.
HERBAL ORAL MEDICATION: Modifi ed Shen Tong Zhu Yu or Body Sore 18-19 • Invigorates Qi/Blood, resolves Stagnation and relieves pain, tonifi es Kidney Qi and strengthens the bones. • Dosage: 15 grams of each, PO BID for one month. Modifi ed Yin Chen San or Hot Hoof II 18 • Clears Damp-Heat and Heat-Toxin, activates Blood and relieves pain. Has been used for laminitis for over 300 years. • Use for acute onset of laminitis. Use as early as possible because the greatest eff ect is achieved if Hot Hoof II is given before the distal phalanx has rotated. • Best results are obtained if this is used in combination with topical treatment as above. • Acute laminitis: Give 30 to100 grams PO BID for up to 14 days, then reduce to a lower dose as necessary for up to two months • Discontinue and replace with Hot Hoof I after local infl ammation is under control. Modifi ed Hong Hua San or Hot Hoof I 18 • Clears Damp-Heat, moves Qi, activates Blood and relieves pain. • Use after local infl ammation of laminitis is controlled and Hot Hoof II has been discontinued. Hot Hoof I has a primarily pain-relieving eff ect with a reduced anti-infl ammatory eff ect in comparison to Hot Hoof II. • Give up to 100 grams PO BID for one to three months. • May also be used for prevention of laminitis. Sang Zhi San + Body Sore 18 • Use together to treat navicular disease or chronic foot pain due to Qi-Blood Stagnation with Yang Defi ciency and Damp/Cold. • Sang Zhi San tonifi es Kidney Yang, dispels Wind, Damp and Cold, invigorates Qi and Blood, warms the Channels and relieves pain. • 15 grams of each, PO BID for up to three months. • Do not use Sang Zhi San if there are signs of Yin Defi ciency. Herbs including Shen Tong Zhu Yu, Yin Chen San, Hong Hua San are contraindicated in pregnant mares.