Acupuncture for Neurological Disorders

1. 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.

2. Neurologic Assessment • Is it a neurologic disease? • Seizures • Intention tremor • CN deficits • Head tilt • Nystagmus • CP deficits • Dysmetria • Paralysis

3. CBC Chemistry Bile acids Cholinesterase Urinalysis Chest and abdominal radiographs Abdominal ultrasound Heartworm test Fecal Minimum Database

4. 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 Ancillary Neurologic Tests

5. When all else fails… Look at the patient!!!

6. Localization of Lesion D A M N N I I I T T V Outcome of Neurologic Assessment • Def (Qi, Yin, Blood) • 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 O

7. Plan • Differential Dx • ? • Diagnostic Approach • ? • Treatment • ? • Problem List • ? P

8. 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 15-20%, due to the presence of inherited, primary epilepsy in those breeds

9. Lesion Localization in Seizures • Cerebral Cortex • Diencephalon • Thalamus • Hypothalamus • Mesencephalon

10. Seizure Diagnoses Probably Symptomatic Epilepsy Symptomatic Epilepsy

11. 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 Seizure Diagnosis • All test are normal in Primary Epilepsy

12. Asymmetrical Seizures

13. Licking Seizure

14. Fly-Biting Seizure

15. 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

16. Seizures- -TCM • Represent various aspects of the Liver (Wood) system • Excess (3 types) • Deficiency (3 types)

17. 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

18. 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 Seizures- -TCM

19. 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

20. 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

21. 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

22. 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 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 Basic Antioxidants Dogs Cats

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

24. 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 Additional Considerations

25. Meningoencephalomyelitis • Infectious Diseases • Species Specific • Steroid Response ME (SRME) • Necrotizing Vasculitis (SRMA) • Necrotizing ME (NME) • Granulomatous ME (GME)

26. Meningoencephalomyelitis • Pain to paresis to plegia • Dx with CSF tap • Spinal radiographs normal • Myelography normal (might be contraindicated)

27. Meningoencephalomyelitis

28. 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.

29. 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. Meningoencephalomyelitis CSF cytology form a dog exhibiting a mixed reaction withneutrophils, lymphocytesand macrophages.

30. Meningoencephalomyelitis • Infection • virus • rickettsia • protozoa • fungus • bacteria • Inflammation • GME • NME • SRME • SRMA

31. Can be: peracute acute & progressive chronic In brainstem, tends to be a multifocal inflammatory disorder Responds temporarily to steroids. GME Patient with GME presenting with vertical nystagmus, long tract signs, and circling with incoordination.

32. GME GME histologically causes multifocal meningoencephalitis due to proliferation ofreticulohistiocytic cells.Lesions also showmultinucleated giant cells.

33. 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 Treatment of ME

34. 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

35. Brain Abscess in a Foal

36. Brain Abscess in a Foal

37. Vestibular Disease • Cardinal Signs • Head Tilt • Nystagmus • Horizontal • Rotatory • Vertical • Positional • Circling (tight) • Imbalance & Incoordination

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

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

40. 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

41. Inner Ear Disease • 8th Nerve Signs • 7th Nerve Signs • ear & lip droop • lack of palpebral reflex • nose turn • nostril flaring • Horner’s Syndrome

42. Horner’s Syndrome • Small Animals • Ptosis • Myosis • Enophthalmos • Large Animals • Facial sweating (horse) • Lack of muzzle sweating (cow)

43. 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

44. 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.

45. Ear Polyps in Cats • Treatment is surgical removal. • Damage can be permanent, if pressure necrosis has destroyed the inner ear structure.

46. 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.

47. 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

48. 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.

49. 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 withneutrophils, lymphocytesand macrophages.

50. Central Vestibular Disease • Inflammatory or Infectious Diseases • canine distemper • toxoplasmosis and neosporiosis • fungal • rickettsial • GME • SRME