Lameness

Lameness is one of the primary reasons that people seek alternative and complementary medicine in horses [1]. It is also the most researched of all conditions that affect the horse in the literature, and acupuncture is the most common alternative intervention that is sought. It has been shown that acupuncture can both change a horse’s gait and reduce lameness scores, and recent publications using objective measures such as inertial sensors have confirmed these findings [2]. While encouraging, it is important to note when choosing acupoints for intervention that a standardized approach to therapy using a single formula for all causes of lameness has shown a poor outcome [3, 4]. This supports the use of tailored interventions and personalized medicine using pattern diagnosis to treat orthopedic disease.

Use of acupoint and Meridian (or Jing-Luo) sensitivity for identification of lameness is well described in TCVM literature and an established diagnostic tool [5, 6]. In this technique, acupoints are stimulated with a blunt instrument, and the response to an acupoint or select set of acupuncture points is used to guide/locate the source of lameness. Responses to the acupoint scan can be as subtle as a skin twitch, or can be more intense, such as biting or striking out. Recent research has corroborated the observations seen during acupoint scans and correlated them to other objective measures of lameness evaluation, lending support for the use of this diagnostic tool for identification of the site of orthopedic pain in horses. For example, in one report, sensitivity for acupoints that are representative of stifle pain were correlated with findings on ultrasound, radiographs and thermography, with a sensitivity of 88% and specificity of 57% for the presence of a stifle lesion [7]. In another study using acupoints to localize and identify lameness during a clinical examination, acupoints showed a sensitivity of 82% and specificity of 78%, with an overall accuracy of 80% [8].

Lameness is typically caused by a local Qi or blood stagnation, however there are other patterns that can be associated with acute and chronic arthritis and other musculoskeletal disorders [9]. The practitioner should use the scan, as well as a detailed history, motion palpation, physical exam, and a dynamic exam when formulating a treatment plan. Treatment using acupuncture will involve local acupoints in combination with acupoints along meridians that run through the affected structures and acupoints to treat the constitution and TCVM pattern(s). The addition of herbal medicine to move blood and Qi provides synergism to the acupuncture protocol.

In addition, Tui-na can be used to treat musculoskeletal injuries using targeted massage. For example, Ca-fa, a rubbing technique, can be used to warm arthritic joints. Tui-fa, or deep tissue massage, can loosen tissues, move Qi and improve circulation. Ji-ya-fa techniques, including An-fa or Dian-fa pressing techniques can treat acupoints or Ah-shi points and relieve pain. Gun-fa, a rolling technique, can smooth joints and invigorate blood and is useful in arthritic patients. Dou-fa, a shaking technique, can loosen joints and reduce muscle atrophy while Yao-fa, or passive range of motion, is good at releasing joints and maintaining cartilage health.

One of the most frustrating musculoskeletal conditions that is presented to the equine veterinarian are horses that have developed laminitis. This debilitating disease is difficult to manage and can progress to the point that euthanasia is the only option. There are a number of publications that support the use of TCVM, and specifically acupuncture, as part of a multimodal therapeutic strategy for this disease; and the results are encouraging [10, 11]. While hemoacupuncture, dry needle acupuncture and electro-acupuncture have all been used for treatment of laminitis, in one report electro-acupuncture showed improved benefits compared to dry needle stimulation, which may require additional investigation [12]. In addition, low level laser therapy may improve outcomes in both acute and chronic cases of laminitis when applied at acupoints, and when treating wounds surrounding the hoof [13]. Acupuncture, Tui-na, food therapy and herbal medicines all may be used to help reduce pain and regain function in laminitis cases. It is important for each case to treat the TCVM pattern, rather than only the symptoms of laminitis, for best results.

Back pain is another condition that has been well-studied in regards to alternative interventions, including TCVM. Stimulation of acupuncture points appears to provide a significant improvement, allowing horses to return to athletic performance [14–19]. In one report, electro-acupuncture performed better than the conventional therapy using phenylbutazone when treating hoses with chronic thoracolumbar pain [18]. Interestingly, different types of acupoint stimulation, including laser, injection or needles, produced similar effects for back pain in horses in a different study [15]. Other therapeutic modalities, including chiropractic and massage, also have shown improved nociceptive thresholds compared to phenylbutazone and rest, with kinematic studies demonstrating that chiropractic therapies improve symmetry and thoracic extension [20, 21]. The evidence thus far is supportive for the use of alternative therapies in treatment of back pain in horses.

Gastrointestinal Disease

Colic is the second most common condition seen by equine practitioners and is a general term for any sign of abdominal pain. The causes of colic include parasympathetic dysfunction, obstructive lesions, inflammatory or infectious diseases, and strangulating lesions. It is important to obtain a thorough history to help narrow the list of suspected causes, and to assist in the approach to therapy, as the list of differentials is long. A thorough physical exam and work-up, including nasogastric intubation, trans-rectal palpation, and transabdominal ultrasonography is indicated, with a minimum hematology profile for assessment of hydration and serum electrolytes.

Most colic can be medically managed and should respond within 12–24 hours, as the cause is often a functional obstruction such as vagotonia (“gas colic”) or an impaction caused by obstruction of the flow of ingesta. These diseases are commonly due to changes in the balance of the autonomic nervous system, systemic dehydration, or inappropriate feeds. In TCVM, these causes of colic can be due to Qi-Blood or liver Qi stagnation, which disrupt the normal transformation and transportation of food by the spleen and stomach [22]. Obstructive syndromes causing impactions are referred to as Jie Zheng in TCVM. Patterns associated with this syndrome can include excess or acute patterns such as food stagnation and excess heat, as well as deficiency patterns of spleen Qi, Yin and/or blood. It is well described in other species that acupuncture can improve and modulate gastrointestinal motility by somatoautonomic reflexes, modulation of the enteric nervous system, and direct stimulation of the brain to integrate the effects of the CNS on gastrointestinal function [23]. Therefore, an integrative approach to medical management of colic in the horse can be applied along with conventional treatments to improve and speed recovery.

Treatment of colic starts with pain management, followed by therapies that address the source of the colic signs. Conventional medications should be provided in an integrative approach, including non-steroidal medications and anti-spasmodic drugs (n-butyl scopolammonium bromide), along with judicious sedation for the exam and initial treatment. Fluid imbalances should be corrected, and feed should be withheld until the horse is passing feces and vital parameters are within normal limits. Treatment of concurrent issues, including intestinal parasites and gastric ulceration, is indicated with proper anthelmintics and proton-pump inhibitors. Dietary and lifestyle management changes are helpful to prevent recurrence.

As described, integrative therapies are useful in treatment of medical colic, and acupuncture is indicated at acupoints to treat the pattern. Acupuncture points for pain management can include ST-36 to move and support Qi, and LIV-3 to treat stagnation. Classical acupoints to treat colic include Jiang-ya over the tip of the alar cartilage and Er-ding at the ear base, and the horse’s response to these acupoints can help to differentiate between surgical and medical causes of colic [22]. Herbal therapies such as Wei Le San or Yu Nu Jian for gastric ulcers, and the laxative/purgative Fan Xie Ye are alternatives to conventional medications used for these clinical conditions, and may be used alongside traditional therapies [24, 25]. Administration of senna as a laxative should be used with caution, as it can result in abdominal distension and increased discomfort when compared to other similar medications [26]. Long term herbal medicine support for the gastrointestinal system can be provided with the use of Ma Wei Chang He to strengthen spleen Qi and move stomach Qi [27]. Food therapy is very useful in horses with colic, to treat the TCVM pattern after colic and to prevent recurrence. Neutral grass hay is recommended for all horses after colic, which is slowly reintroduced starting at a quarter of the normal ration. Wheat bran or flax seed is useful for gas colic caused by stagnation or heat, and Qi can be supported with oats, rice bran, sweet potato, and carrots [28].

Wound Management

Injuries to skin, muscle and deeper tissues including bone, joints, or other synovial lined structures is a relatively common issue in equine practice. Wound healing occurs in four overlapping stages which include acute inflammation, debridement, proliferation with restoration of the injured tissues, and then maturation of the new tissues into a functional scar. Acupuncture and moxibustion have been shown to help improve acute wound management by reducing inflammation, accelerating fibroblast proliferation, and angiogenesis [29, 30]. Acupuncture is also useful in later stages, to activate and improve remodeling of scar tissue, especially when using the technique called “surround the dragon.” [31

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