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The Treatment Of Legg Calve Perthes With Acupuncture
By Marlene Smith-Schalkwijk, DVM
Introduction
Legg-Calve- Perthes disease is mostly diagnosed in young dogs of
the miniature breeds. It is characterized by an increase in trabecular
bone of the femoral head, followed by aseptic necrosis secondary
to ischemia. Revascularization of the bone is followed by demineralization
(1). Diagnosis is made on the basis of signalment, a small breed
6-10 months of age with persistent reduced weight bearing on
one hind limb or limping. Radiographs show demineralization of
the femoral head and/ or neck. There is often a fracture of the
neck and displacement of the femoral head. Conservative treatment
is often to no avail and femur head resection is performed (or
total hip replacement) to alleviate the pain.
The following case history describes two small breed dogs diagnosed
with Legg Perthes disease. Both dogs were treated with acupuncture,
nutraceuticals and herbal medicine. Both dogs returned to full
weight bearing and follow up radiographs showed re-mineralization
of the femur neck and head.
Case 1
Male Toy Poodle, DOB November 1996. Weight 6 pounds.
First presented September 1997 with the following history:
For the last few months the owner had noticed gait abnormalities
of the dog’s left hind leg. Two weeks earlier the dog did
not weight bear after a rough play, he was sensitive over the hip
area and showed muscle atrophy. The owner rested the dog and had
the hips radiographed and evaluated in California by an orthopedic
specialist. Legg Calve Perthes was diagnosed and the owner was
given the option of a femur head resection or total hip replacement.
The radiograph showed obvious demineralization of the left femur
neck and slight luxation of the femoral head with minor demineralization.
The owner requested acupuncture and alternative treatment prior
to making a surgical decision.
On examination the dog was only 10-20% weight bearing on the left
hind leg, there was pronounced muscle atrophy of the left rear
limb and he was painful on palpation and manipulation of the hip
area. The rest of the physical examination did not reveal any other
abnormalities.
The TCM diagnosis was Qi stasis, followed by a stasis of blood
and blood not nourishing the local area (bone) resulting in a loss
of bone material (Yin). The root of the problem was considered
a kidney jing deficiency, resulting in a developmental (bone) deficiency
and insufficient Qi to move the blood. The treatment plan was to
nourish postnatal Qi, invigorate (activate) and nourish the blood,
move stagnant Qi and nourish the kidney. A combination of acupuncture,
herbal supplementation, neutraceuticals and homeopathy was used.
The following points were used in different combinations:
BL 23 ( Shen Shu) Back Shu points for the Kidney; influences Kidney
Qi and Bones.
GB 29 ( Ju Liao ) interception of the Yang Heel Vessel on
the GB channel. Local point for the hip, partner of the Liver,
helps to move (local) stagnant Qi and increases local circulation.
(2,4)
BL 54 ( Zhi Bian ) local point, part of the hip triangle points,
close to the sciatic notch, good point to relieve hip pain also
used for atrophy of the hind limb. (2,4)
GB 30 (Huantiao). The third point of the hip triangle. Indicated
for hip pain and hind limb atrophy. (2,4)
GB 30 extra. This extra point was selected to complete the hip
points as indicated by Dr. Luc Janssens. Location just below the
greater trocanter ( Luc Janssens) ( 3)
ST 36 (Zu San Li) strong tonification point, master point for hind
leg weakness, tonifies the Stomach, Qi and Blood. It is indicated
in general and hind leg weakness and nourishes postnatal Jing. (2,4)
SP 6 (San Yin Jiao). Intersection of the Ki and Liv channel on
the Spleen channel. This point was chosen for its nourishing action
on Blood, Qi, Kidney, Liver and moving Qi and Blood. (2,4)
LIV 3 (Tai Chong) This point was selected for its influence on
the Liver, to regulate the Qi and spreading, moving the Qi, to
move the Blood, and influence on tendons and ligaments. (2,4)
GB 34 (Yang Ling Quan), influential point for sinews (and joint
capsules). It also benefits the joints and spreads Liver Qi. (2,4)
LI 4 (Hegu) as a balancing point, part of the “ four gates” in
combination with LIV 3. It also helps relaxing the sinews. (2,4)
In the first session, needles were placed in GB 29 and 30, BL 54,
LIV 3, GB 34 and left in place without manipulation for 15 minutes.
As neutraceuticals Glucosamine Sulfate + Chondroitin at 100mg BID,
Vitamin C 100 mg SID Vitamin E 100 IU SID was prescribed, for 6
months. Arnica 30 CH (Dolisos) at 2 BID for three days as needed,
was used for a short period of time to resolve any inflammation
and blood stasis. Cruroheel (Heel) and Osteoheel (Heel) were also
added at 1 BID for three months. Herbal choice was Eucommia (7
Forest) ½ BID for three months, to nourish bones, tendons
and ligaments and blood. In subsequent sessions, needles were placed
in GB 29, 30, 30 extra and BL 54. Electro acupuncture for 20 minutes
was performed over these points. Static needling was performed
at ST 36 + SP 6 and BL 23. These last points were alternated with
GB 34 and LIV 3 + LI 4. The dog received 7 treatments, one week
apart, followed by physiotherapy. The dog was also cage rested
for 1 month followed by restricted exercise for two more months. Hydrotherapy
was attempted and unsuccessful in this patient.
Case 2:
Male Skipperke DOB June 27, 1996, weight 10 pounds.
The patient was first presented January 28, 1998 with intermittent
limping of the left hind leg. Long walks made it worse. The hip
was sensitive on palpation, the tongue slightly pale and the pulse
was a little wiry. The rest of the physical exam did not show any
abnormalities and the dog was sent for radiographs of the hips.
The X- rays showed a marked demineralization of the femoral neck
with deviation of the femoral head. Based on the symptoms and radiographs,
the diagnosis of Legg Calve Perthes was made. The owner had previous
experience with femur head resection for the same problem in an
aunt of this dog and requested acupuncture and alternative approaches
before deciding on surgery.
The TCM diagnosis was kidney jing deficiency plus local (Liver)
Qi stagnation, resulting in a stagnation of circulation (blood).
The treatment plan included moving Qi, nourishing postnatal and
kidney Qi and invigorating (moving) and nourishing blood.
The following acupuncture points were chosen:
BL 18 (Gan Shu) back Shu point of the Liver, to nourish Liver Blood
and move the Qi
BL 17 (Ge Shu) influential point for Blood (2)
BL 23 (Shen Shu) Back Shu point for the Kidney to nourish Kidney
Qi and bones. (2,4)
GB 30, 29 and 30 extra BL 54 (see rationale in Case 1)
SP 6 and ST 36, LIV 3, LI 4 and GB 34 were selected for the same
reason as in Case 1
Procedure was the same as in Case 1, with static needling in session
1. In the follow up visits, electro acupuncture was performed on
the hip points. The neutraceuticals Glucosamine Sulfate (Glycoflex),
150 mg BID, Vitamin C 100 mg SID and Vitamin E 100 mg SID were
used for 6 months. Homeopathic Cruroheel and Arnica (short term)
as in Case 1. Herbal supplement Astra Essence (Health Concerns) ½ tablet
BID to nourish the postnatal Qi essence. Later this was changed
to Eucommia at ½ tablet BID for three months. The dog received
4 treatments 1 week apart, then 1 treatment a month for two
months, was cage rested, followed by restricted exercise and physiotherapy
as in Case 1.
Results:
Case 1 was 100% weight bearing in four months. In January 1998
he was x-rayed again. Both the original and the repeat X Ray were
sent to the same specialist for re-evaluation. The femoral neck
and head were both well mineralized. The slight deviation of the
femoral head seen on the original X ray was still visible. The
owner agreed not to breed the dog and the dog continued its show
career and was placed several times. No lameness was detectable
and muscle atrophy was completely resolved. On the last follow
up visit August 1999 the patient continued to do well without any
signs of lameness. In a more recent conversation in 2001, the owner
reported that the dog still did not show any sign of hip pain.
Case 2 improved significantly and after 4 months would have a minor
limp after a long walk. He was re X- rayed in July 1998 and the
femoral neck and head were completely mineralized. The pronounced
deviation of the femoral head was still present and it was assumed
that this was causing the pain. Gold bead pellets were implanted
around the hip as described and used for hip dysplasia. (3). The
dog’s lameness was completely resolved after this procedure
and he was more sound then his aunt, who had been treated for the
same condition with a femur head resection. Follow up over the
three following years were mostly to do acupuncture on the hips
of the aunt. Occasionally we had to do acupuncture and chiropractic
treatment on patient number two mostly during the damp cold season
of the winter. Supplementation of Glycoflex (glucosamine) has been
maintained through life.
Conclusion:
Aseptic necrosis of the femoral head is a progressive disease,
which often leads to fracture of the femoral neck due to demineralization.
Standard treatment is femur head resection or a total hip replacement.
This was the first time that the author used acupuncture and supplements
for this disease. The positive outcome is encouraging to include
acupuncture and neutraceuticals as an option to treat this disease.
More data and research is needed in this respect and it should
be pointed out that both cases were in an early stage and fracture
of the femur neck had not yet occurred. Because of the genetic
component of this disease, affected individuals should be excluded
from the breeding stock.
References:
- Stephen J. Ettinger, Edward C. Feldman ; Textbook
of Veterinary Internal Medicine Volume - 2 fourth edition, pg
2116 WB Saunders Company 1995
- Lade, Arnold Acupuncture points,
Images and Functions 1989 Eastland Press
- IVAS Acupuncture Course notes 1987
- AVAC Acupuncture Course notes 2002, Maria
Glinski Acupuncture point
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