CHAPTER 79 Alternative Modalities in Feline Practice
In an era when increasingly sophisticated medical diagnostic tests, advanced surgical procedures, and conventional therapeutics are widely available to feline patients, it may seem ironic that clients’ interest in alternative modalities for their cats is increasingly keen. However, it is the rare feline practitioner who has not been asked by at least one client about the feasibility of nonallopathic treatments and alternatives for feline diseases.
What constitutes complementary and alternative veterinary medicine (CAVM)? Broadly speaking, any unconventional treatment that generally is not provided within the context of allopathic veterinary medicine can be included in CAVM. Acupuncture, herbal therapies, chiropractic/spinal manipulation, homeopathy, homotoxicology, Reiki, light/sound/color therapy, massage, and nutraceuticals—as well as other modalities—all can be included under this umbrella. However, as traditional veterinary practices incorporate some of these modalities increasingly into patient care, the line between CAVM and non-CAVM blurs.
Interest in the use of alternative therapies in veterinary medicine in general, and in feline practice in particular, most likely mirrors that seen in human medicine, although few statistics exist on the dollar expenditure for alternative veterinary care and treatments or the number of patient visits. In 2002 it was estimated that 36 per cent of the adult human population in the United States had visited an alternative practitioner.1 In 1990 (the last year for which such statistics exist), there were 425 million visits to alternative practitioners in the United States, compared with 388 million visits to primary physicians.1 In that year, an estimated $13.7 billion was spent with alternative practitioners; and of that, 75 per cent was paid out-of-pocket. This compared with $12.8 billion spent in that same year out-of-pocket for all U.S. human hospitalizations.
Surveys of users of alternative modalities in human medicine showed that these individuals tended to have higher educations, poorer health status, claimed to have had a “transformational experience” that changed their world view, and were more committed to spirituality, feminism, and environmental concerns than the general population.1 Dissatisfaction with conventional medicine, as well as gender, income, or age did not influence an individual’s desire to pursue complementary and alternative medicine (CAM) therapies. In many instances, patients utilized conventional and alternative therapies simultaneously, and it was estimated that 70 per cent of individuals who utilized CAM therapies did not share that information with their primary care physician.1
A survey of 254 clients presenting with companion animals to the Animal Cancer Center of Colorado State University was done regarding their use of alternative therapies.2 Of that sample, 76 per cent reported using some alternative medicine in their pets. Nutritional supplements were used most commonly, with 40 per cent of respondents stating that the supplements were part of the patient’s regimen. Only 46 per cent of those responding said that their veterinarian was the source of information on the use of these products. Of those persons surveyed, 57 per cent said they had discussed the use of the products with their pet’s veterinarian.
In veterinary medicine there has been a slow, yet steady shift toward acceptance of at least some CAVM modalities as part of patient care. In 2000, 120 personnel at the 27 U.S. veterinary medical schools were surveyed regarding their educational and research programs in alternative modalities.3 At that time, seven of the schools surveyed had educational programs in alternative modalities, and six had conducted CAVM research. Of the 41 completed surveys (from 23 of the 27 schools), 87 per cent of respondents believed that acupuncture, nutraceuticals, nutritional supplements, and physical therapy should be included in the curriculum; 61 per cent of respondents stated that botanical (herbal) medicine and chiropractic should be included in the curriculum, and 44 per cent believed that homeopathy had a place in veterinary medical education. The majority of the respondents thought CAVM should be offered as elective courses only.
The American Veterinary Medical Association’s policy statement on CAVM, written initially in 2001 and revised in 2007, recognized the interest in alternative modalities for nonhuman species and stated that the organization was “open to their consideration.”4 No determination of value was given to individual modalities, and practitioners were advised to exercise caution when extrapolating data from human usage of alternative modalities and to advise clients of “proven treatment methods” when presenting all treatment options. Cautions also were given regarding lack of Food and Drug Administration (FDA) premarketing evaluation of many animal nutritional supplements and botanicals, and that manufacturers of alternative veterinary devices need not be required to obtain premarketing approval by the FDA regarding efficacy and safety issues.
With few exceptions, veterinary medical boards generally limit the practice of alternative modalities in veterinary medicine to licensed veterinarians, or to nonveterinarians who work under the referral of a veterinarian. However, the boards vary on the requirements for veterinarians who utilize and practice alternative medicine, and practitioners who utilize alternative methodologies need to familiarize themselves with their state’s requirements. For example, in Texas, before veterinary “holistic medicine,” defined as the blending of alternative and conventional therapies, can be performed, the practitioner is required to have a written statement signed by the client that they are aware that holistic therapy is alternative practice.5 Additionally, the practitioner must inform the client of conventional treatments that are available and their “probable ability to cure the problem.”5 The signed statement becomes part of the patient’s permanent medical record.
Why do clients seek alternative therapies for their cats? The reasons are varied and range from seeking treatment for illnesses for which no conventional therapy exists to the desire to treat the cat (a species often viewed as a companion animal that, although domesticated, still possesses many characteristics of wild animals) as naturally as possible. Often clients wish to avoid possible side effects of conventional medications and therapies. Still others desire to combine conventional and alternative therapies in the hope of maximizing a positive outcome. However, despite these intentions, the same limitations often affect CAVM treatment of cats: (1) the reluctance of clients to travel with their cats for repeated treatments; (2) difficulty administering many oral medications; and (3) the cat’s perceived inherent dislike of many medical interventions. These either limit the types of alternative modalities that can be utilized, or demand creative use and administration of them in feline patients. Despite these concerns, however, many alternative therapies can be administered to cats and most of these patients are amenable to treatments and therapies. The author utilizes conventional and alternative therapies routinely for a wide range of feline diseases in practice.
It is beyond the scope of this chapter to discuss all possible alternative modalities that can be used in feline practice, and it is not the intent to present arguments regarding the validity of offering alternative therapies to feline patients. Instead, the alternative therapies used most commonly in feline practice will be discussed: acupuncture, chiropractic/spinal manipulation, and herbal medicine (Chinese and Western). These three modalities often are used synergistically in conjunction with conventional veterinary practice.
Horses were the first nonhuman beings treated with acupuncture and the first veterinary acupuncture textbook was produced in China in 650 bc. However, it was not until 1975, when the International Veterinary Acupuncture Society (IVAS) was formed and began to offer classes to veterinarians, that dogs and cats, as well as other small mammals and birds, began to receive acupuncture treatments.
Acupuncture can be viewed through its traditionally understood Chinese theory of normalizing the flow of energy (Qi) through the body by using various meridians (invisible channels that course through the body, beginning or ending at the distal points of the upper or lower extremities, as well as the chest or head). Alternatively, acupuncture can be explained using a Western medical approach by which it provides therapy by accessing points that coincide with vascular nerve bundles that contain more mast cells, as well as points that have been identified histologically as being located at motor points, at midline points where bilateral nerves meet, over superficial nerves or plexuses, or at Golgi tendon organs. Segmental anesthesia through stimulation of inhibitor interneurons; release of endorphins, serotonin, reproductive hormones, and cortisol through spinothalamic tracts; autonomic effects through the use of the somatovisceral reflex; and induction of microtrauma with attendant inflammation and healing also have been ascribed to acupuncture.6
Acupuncture points are named most commonly by the meridian (Lung, Large Intestine, Kidney, Bladder, Liver, Gallbladder, Heart, Pericardium, Small Intestines, Triple Heater, Stomach, and Spleen), and by a number that corresponds to a specific point along the meridian (Stomach 36; ST 36). The meridian names, which are familiar to practitioners (except for the Triple Heater, which is not associated with any specific anatomical organ or region and functions as a transporter of fluids in the pelvis, abdomen, and chest), do not correspond necessarily with the organ as it is known to Western medicine. Acupuncture points selected for treatment of certain conditions do not have to be chosen from the meridian named for the organ that is diseased. Hence points on the Bladder, Kidney, and Lung meridians can be used to treat some forms of heart failure. It is recommended that the interested practitioner obtain meridian charts from the books listed in Box 79-1.
Box 79-1 Veterinary Acupuncture References
Additionally, there are “classical points” that commonly have only a Chinese name and that are specific for certain conditions (for example, Ding-chuan or “Stop Cough/Asthma,” located on the dorsolateral cervicothoracic junction, midline between C7-T1).
Cats generally receive acupuncture on a tabletop that is covered by a soft blanket. Acupuncture needles are of very small gauges, with 0.5 inch by 0.2 mm diameter needles used for points along the back and 0.5 inch by 0.16 to 0.22 mm needles used for other points. Very sensitive points, located typically at the tips of the extremities, as well as around the eyes and nose, can be treated with extremely small Korean hand needles. Cats who are intolerant of the needles remaining in place for any period of time can be treated using “aquapuncture,” which involves the subcutaneous injection of small quantities (0.1 to 0.3 mL) of vitamin B12 into the points. Electrostimulation, which involves the creation of a small electrical circuit linking points, is surprisingly well-tolerated by cats, in the author’s experience. Moxibustion, which involves the burning of a small amount of mugwort on the tip of an acupuncture needle or by holding a specialized stick over the area to be treated, can be used on back points in another small subset of cats. Because the smell of burning mugwort is similar to that of some illicit drugs, “smokeless” moxa sticks can be purchased. The author has had selected clients use moxibustion on their cats at home. Low-intensity laser light therapy, involving the use of hand-held small lasers also can be used in feline patients.
Many clients and practitioners question the safety of acupuncture, particularly that done with needles. Pneumothorax, cardiac tamponade, broken needles, syncope, puncture of body cavities and vital organs, and abortion all have been cited by various authors as serious complications of acupuncture therapy.7
Using appropriately short needles, placing those needles with proper technique, care in needling areas of the thorax and shoulder muscles, and familiarizing oneself with certain points that can cause strong uterine contractions are all used to provide safe acupuncture treatments, regardless of patient species. Occasionally exaggeration of clinical signs can occur in human beings and animals who receive acupuncture. In human beings this can last up to 1 day posttreatment; in dogs, this may occur for up to 5 days posttreatment. The author has had patients on very rare occasion whose clinical signs were exaggerated after acupuncture treatment.
The traditional Chinese medicine (TCM) perspective holds that patient signs and symptoms are considered as being consistent with a variety of patterns. As such, patients can be described in the broadest sense as having an excessive or deficient condition. Additionally, they may have signs consistent with heat (blood in the stool or urine, or a purulent discharge from the eyes, nose, or urogenital tract) or cold (copious, clear urination, or mucoid diarrhea). Because of this classification system, patients with one Western diagnosis (chronic kidney disease) may not be treated similarly. A cat with chronic kidney disease who is polydipsic and polyuric and heat-seeking, for example, would be treated differently than a similarly azotemic cat who drinks only small amounts of water, urinates small amounts of urine, and prefers to lie on cool tile or avoids warm areas. A kitten who presents with a clear nasal discharge and sneezing, consistent with a presumptive Western diagnosis of viral rhinitis would be diagnosed as having a Wind-Cold pattern, and would be treated with slightly different acupuncture points than a littermate who presents with fever, nasal congestion, and a thick and yellow oculonasal discharge (signs of Wind-Heat by the TCM pattern).
An examination of the tongue and peripheral pulses (best assessed by palpation of the femoral arteries) generally is used prior to initiating acupuncture therapy, and allows for the patterns to be described more specifically. In TCM, the tongue is divided into several regions, each representing a different body organ. The kidney area is located at the most caudal part of the tongue; the spleen in the middle of the tongue, the liver on the lateral aspects, the heart at the most proximal portion, and the lung located just distal to the heart area.8
Tongue color, the presence or absence of fluid or phlegm on the dorsal lingual surface, as well as the presence or absence of a coating are all used to make a basic assessment of the patient’s underlying physical condition and diagnosis. A cat who presents with a history of watery diarrhea or vomiting may have a pale tongue, noting deficiency. The tongue also may be thick and flabby and often has some fluid located at the area dedicated to the spleen, which in TCM is the organ that “transforms” food and is involved in digestive issues.
Pulse diagnosis is used to characterize deficiency or excess patterns of various organs.8 In cats the pulses of the femoral arteries are assessed with the cat standing and the practitioner placing her or his fingers on the right and left femoral pulses with the index fingers placed proximally, the middle fingers placed medially on the arteries, and the fourth fingers placed more distally. On the left side, the proximal position is that of the heart; the middle, the liver; and the lowest, the kidney yin (cooling). On the right side, the upper position is dedicated to the lung, the middle to the spleen, and the lowest to the kidney yang (warming). The pulse quality (depth, speed, shape, strength, and rhythm) is assessed by pressing firmly on the pulses until they are obliterated. Very superficial and slow pulses may be consistent with a cold pattern; rapid and surging pulses would be more consistent with a heat pattern.
Another portion of the Traditional Chinese Veterinary Medicine (TCVM) examination is the palpation of various acupoints along the meridians that may allow a practitioner to diagnose certain disorders. These points are divided into Association (back-Shu) points, located along the dorsum and Alarm (Mu) points. The Association and Alarm points each reference certain organs, and pain elicited at the points can be useful in assessing possible internal medicine problems.
For example, the Association (back-Shu) point for the liver is Bladder 18, located about one inch lateral to the lateral aspect of the dorsal spinous process of T10; the Alarm (Mu) point for the liver is Liver 14, located on the lateral thorax in the sixth intercostal space at the level of the mammary glands. The Association (back-Shu) point for the Large Intestine is Bladder 25, located on the dorsolateral aspect of the spine, approximately one inch lateral to the caudal border of the dorsal spinous process of L5; the Alarm (Mu) point of the large intestine is Stomach 25, located on the ventrolateral abdomen, approximately 1.5 inches lateral to the umbilicus, in the center of the rectus abdominis muscle. Cats presenting with liver disease may be sensitive at Liver 14 and Bladder 18; cats with underlying colitis or constipation/megacolon, may have increased sensitivity at Bladder 25 and Stomach 25.9
While proper training in acupuncture is recommended before initiating therapy on a feline patient, four acupuncture points may be of benefit to feline patients that can be placed by veterinarians with only familiarity of their anatomical locations. These points are: Shen-Gan, at the junction between the haired and nonhaired area of the dorsal nasal planum, which is useful for stimulating appetite; Governing Vessel (GV) 26 (Jen Chung), a point that may be useful for resuscitation of patients with cardiac arrest or anesthetic complications; GV 20, a calming point that may be useful in cats with inappropriate urination or defecation, as well as stressed cats coming to the hospital; and Pericardium (PC) 6, a point that may be useful in antiemesis. The author uses these points in combination with conventional treatments and not as substitutes for allopathic therapies.
GV 26 is located on the nasal philtrum at the level of the ventral aspect of the nares. This point can be needled with a “pecking” technique, using a 25-gauge (or smaller) hypodermic needle in cats. Another technique is to twirl the needle vigorously at the point while advancing and retracting it. In dogs appropriate stimulation of GV has been shown to increase heart rate, stroke volume, and cardiac output, and produce increases in pulse pressures that are similar to that achieved with injections of epinephrine.10 Stimulation also causes a significant increase in mean arterial pressure with a decrease in total peripheral resistance. These changes have been shown to be mediated through alterations in sympathetic tone and are blocked by concurrent use of propranolol. Simultaneous stimulation of Kidney 1 (located between the third and fourth metatarsals under the central pad of the hind limbs) is useful as adjunctive therapy for cardiopulmonary resuscitation and anesthetic overdosage.10
GV 20, located on the dorsal midline on a line drawn from the tips of the ears level with the ear canal, has been shown to be a sedating point in many species. The author typically begins acupuncture sessions with a needle placed in this location (Figure 79-1). This point also may be useful in calming stressed cats in the clinical setting, and has been advocated as a point for weekly aquapuncture therapy in cats with inappropriate urination and defecation.11
Figure 79-1 Cat receiving acupuncture with needle placed at GV 20. This point is for calming and may help with inappropriate urination.