16 Integrative Treatment of Common Musculoskeletal and Neurological Conditions

Ronald B. Koh^* and Janice Huntingford^*

^* Corresponding authors

Introduction

Integrative practitioners are frequently asked to evaluate patients with musculoskeletal or neurologic diseases. Most of these patients can benefit from a multi-modal approach integrating pharmaceutical and non-pharmaceutical therapy. Treatment of orthopedic and neurologic disease form the basis of what most rehabilitation practitioners do. Integrating these therapies with TCVM acupuncture, food therapy, manual therapy, and modalities improves outcomes for patients with these issues.

Orthopedic Conditions

Degenerative Joint Disease (Osteoarthritis)

From a TCVM standpoint, conditions such as degenerative joint disease, osteochondritis dissecans, and hip and elbow dysplasia are considered Bi syndrome [1, 2]. Bi syndrome simply refers to pain and stiffness (stagnation) in bones, joints, tendons, ligaments and muscles, and the resultant aberration of gait or deformities associated with the stagnation [2, 3]. Integrative treatment can improve the quality of life (QOL) of patients with Bi syndrome by improving circulation, strengthening muscles and tendons, and decreasing pain. Each treatment is individual and must fit the TCVM pattern as well as the Western diagnosis.

Bi syndrome is a disorder resulting from the obstruction of meridians, sluggishness of Qi and blood circulation after the invasion of pathogenic wind, cold, dampness or heat, and is characterized by pain, numbness and heaviness of muscles, tendons, and joints, or swelling, hotness, and limitation of movement of joints [1, 2]. Invasion of pathogenic factors and deficiency of healthy Qi are the two underlying causes of this disorder. Six types of Bi syndrome have been identified owing to difference in body constitutions and pathogenic factors [1–3].

1) Wind or Wandering Bi Syndrome

This occurs when wind-cold-damp, predominantly wind, invades the body causing Qi and dlood stagnation and wandering pain (difficult to localized painful area).

2) Cold or Painful Bi Syndrome

This occurs when wind-cold-damp invades the body with cold predominating. Cold cause Qi and blood stagnation and severe pain. Cold Bi is worse in cold wet weather.

3) Damp or Fixed Bi Syndrome

This occurs when wind-cold-damp invades the body with damp predominating. Dampness creates heavy and stiff movements and impairs the flow of Qi. It is worse in damp weather.

4) Heat or Re Bi Syndrome

Either wind-cold-damp Bi syndrome or deficient heat from Yin deficiency Bi syndrome can turn into heat Bi syndrome resulting in inflamed and swollen joint. It is aggravated by warmth or pressure.

5) Kidney Qi/Yang Deficiency Bi Syndrome

This is a chronic Bi syndrome, and when bony degeneration is involved it is called bony Bi.

6) Kidney Qi/Yin Deficiency Bi Syndrome

This is another form of bony Bi but occurs when the Yin is depleted in chronic disease. This is a very common pattern in geriatrics with arthritis.

Degenerative joint disease (DJD) occurs most commonly in weight bearing joints and joints which are overused [4]. The main symptoms of DJD are pain and stiffness in the affected joint. Pain is aggravated by movement, but stiffness generally follows a short period of inactivity. The affected joint may be swollen, and crepitus may be palpated on movement. Rehabilitation of DJD is multimodal utilizing pharmaceuticals (such as non-steroidal anti-inflammatories (NSAIDS), gabapentin, amantadine, tricyclic anti-depressants, or opioids) and non-pharmaceutical supplements and modalities [5–7]. A discussion of pharmaceuticals for use in DJD is beyond the scope of this chapter but more information on integrative pain management appears in Chapter 18.

Treatment for DJD may be different from joint to joint depending on the Bi syndrome being treated. Hip dysplasia, elbow dysplasia and osteochondritis dissecans are all classified as DJD from a conventional perspective. From a TCVM perspective, they all have underlying components of kidney deficiency and need to be treated as such [2]. Dogs and cats with DJD may show a myriad of different signs related to the severity of the pathologic change in the joint. Degree of lameness may be inconsistent with radiographic signs of disease particularly in cats. The wide range of factors affecting this disease make it difficult to provide recommended blanket treatments thus underscoring the need for multimodal individual treatment.

Integrative treatment of DJD focuses on pain relief. Weight loss has been shown to decrease the severity of pain in dogs with DJD [6]. A combination of weight loss and PT was demonstrated to improve patient mobility by Mlacnik Purina study. These studies show that restricted diet or weight loss alone may be an important aspect of managing dogs with OA [8].

Rehabilitation modalities such as cryotherapy, thermotherapy, physical exercises, hydrotherapy (pool or treadmill), laser, ultrasound, shockwave, and massage therapy are all valuable in treating patients with DJD [5–10]. These modalities increase circulation of blood and lymph, decrease inflammation, improve joint range of motion, improve strength, balance and proprioception, and help restore normal joint function. A discussion of common therapeutic modalities appears in Chapter 14. Frequently acupuncture, Tui-na and food therapy are employed for pain relief and to help relieve Qi stagnation and bring the DJD patient back into balance [2]. DJD is a lifelong management issue for the client and the veterinarian alike. See Figure 16.1.

**Figure 16.1** A dog with DJD receiving acupuncture.

TCVM treatments for DJD and other common orthopedic conditions are summarized in Table 16.1. Rehabilitation modalities for common orthopedic conditions are summarized in Table 16.2. Table 16.3 summarizes herbal treatments for Bi syndrome.

Table 16.1 TCVM diagnosis and treatment of common orthopedic conditions [1]. Zhang, EQ, 2010; [2]. Preast V, Xie H, 2007; [3]. Hu, J., 2003.

Condition	TCVM patterns	TCVM treatments
Degenerative joint disease or Osteoarthritis	Excess patterns: wind, cold, damp, heat Bi Deficiency patterns: kidney Qi, Yin or Yang deficiency bone Bi	Wind Bi: GB-20, BL-17, SP-10; Juan Bi Tang Cold Bi: GV-4, CV-4, Bai-hui, moxibustion; Du Huo Ji Sheng Tang Damp Bi: ST-40, BL-20, SP-9; Yi Yi Ren Tang Heat Bi: GV-14, LI-11, LIV-2; Bai Hu Tang Kidney Qi-Yin Deficiency: SP-6, KID-3, KID-7; Di Gu Pi San Kidney Yang Deficiency: BL-23, GV-4, Bai-hui, Moxibustion; Sang Ji Sheng San *
Osteochondritis dissecans/hip or elbow dysplasia	Kidney Jing deficiency with Qi blood stagnation	Kidney Jing Deficiency: BL-23, BL-26, KID-3; Sheng Jing San * Qi Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Bicipital/supraspinatus tendinopathy	Liver Yin or blood deficiency with Qi- blood stagnation	Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San * Qi Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Medial shoulder instability	Liver Yin or blood deficiency with Qi- blood stagnation	Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San * Qi Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Contractures	Qi or blood stagnation with or without spleen Qi deficiency	Qi Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang Spleen Qi Deficiency: BL-20, ST-36, SP-9; Si Jun Zi Tang
Carpal hyperextension	Liver Yin or blood deficiency	Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San *
Cranial cruciate rupture	Liver Yin or blood deficiency with Qi blood stagnation	Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San * Qi Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Patellar luxation	Kidney Jing deficiency with or without liver Yin deficiency	Kidney Jing Deficiency: BL-23, BL-26, KID-3; Sheng Jing San * Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San *
Calcaneal tendon/Achilles injury	Liver Yin or blood deficiency with Qi blood stagnation	Liver Yin or Blood Deficiency: BL-18, LIV-3, GB-34; Bu Gan Qiang Jin San * Qi-Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Iliopsoas and other muscle injuries	Qi or blood stagnation	Qi-Blood Stagnation: LIV-3, ST-36, BL-60; Shen Tong Zhu Yu Tang
Sang Ji Sheng San^*: Loranthus Formula (Dr Xie’s Jing Tang Herbal) Sheng Jing San^*: Epimedium Formula (Dr Xie’s Jing Tang Herbal) Bu Gan Qiang Jin San*: Tendon Ligament Formula (Dr Xie’s Jing Tang Herbal)

Table 16.2 Rehabilitation treatments for common orthopedic conditions [5]. Millis DL, Levine D., 1997; [7]. Mosley C, et al., 2022; [11]. Vezzoni A, Benjamino K, 2021; [12].Tan DK, et al., 2016.

Condition	Rehabilitation modalities	Rehabilitation exercises	Supplements/injections
Degenerative Joint Disease – can occur in any joint secondary to injury, genetic predisposition, congenital deformity, or growth aberration (osteochondritis dissecans or hip or elbow dysplasia) or surgery	Pain Control: Pharmaceuticals, herbs, modalities Photobiomodulation EWST Acupuncture UWTM PEMF Hot and cold therapy Manual therapy – Massage, Chiropractic, Joint mobilization, Stretching TENS Weight loss if needed	Depends on location and condition of patient but could include Sit to Stand, Cavalettis, Backwards walking, Swimming, Ball work, Obstacle course, Hill walking. Goals include pain relief, weight loss, increased joint movement, and strengthening adjacent muscles.	Joint injections with platelet rich plasma (PRP), stem cells, hyaluronic acid (HA), steroids, Synovetin^®; Injectable monoclonal antibody (MAB) or polysulfated glycosaminoglycan (PSGAG); Dietary supplements with undenatured collagen type II (UCII), green lipped mussel (GLM), omega (ω)-3 polyunsaturated fatty acids (ω3-PUFAs), glucosamine and chondroitin, egg shell membrane, cannabidiol (CBD)
Osteochondritis dissecans/Hip or elbow dysplasia	See DJD above OCD is most often a surgical problem that requires follow up rehabilitation and therapies to minimize future DJD. Surgery may be indicated for hip and elbow dysplasia if recognized early enough. If no surgery is performed it is treated in the same manner as DJD	As for DJD above For elbows can add Commando crawling and rocker board work	Joint injections with PRP, stem cells, HA, steroids, Synovetin^®; Injectable MAB or PSGAG; Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD
Medial shoulder instability	Treatment depends on severity but may include: Hobbles, EWST, laser, acupuncture UWTM, PEMF, stretching and mobilization Surgery may be needed for severe cases or canine athletes	Sit to Stand, Cavalettis, swimming, ball work, hill walking Avoid exercises that require lateral movement	Joint injections with PRP, stem cells, HA, steroids; dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, Fortetrophin
Bicipital/Supraspinatus Tendinopathy	Treatment depends on severity but may include: rest, NSAIDs, EWST, laser, acupuncture, weight control UWTM, PEMF, stretching and mobilization, cross friction massage, therapeutic ultrasound surgery may be needed for chronic cases or canine athletes	Note: acute injuries should not be stretched PROM (flexion/extension of limb while not weight bearing) In acute phase exercises increase strength of muscles Controlled leash walking, therapy ball work, rocker board balancing, cavletti, weaves (slow), figure 8s and hill walking	Joint injections with PRP, stem cells, HA, steroids; Tendon injections with PRP or stem cells; Dietary supplements with UCII, ω3-PUFAs, CBD
Contractures	Ultrasound, cross friction massage Mature contractures usually require surgery UWTM and general conditioning, leash walking also appropriate	Depends on location but heating with therapeutic ultrasound and then stretching is recommended. PROM	Regenerative medicine with PRP or stem cells may help some patients
Jump Down Syndrome (Traumatic Fragmented medial coronoid process)	Arthroscopic removal of fragments followed by rehabilitation therapy, pharmaceuticals, herbs modalities UWTM, massage	Cavalettis, high fives, weaves, backward walking, zig zag hill walking – timing of exercises depends on healing	Injectable PSGAGs; Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, other supplements as per DJD
Carpal Hyperextension	Acupuncture treatment, braces, UWTM	Exercises on textured surfaces, rocker board, ball work, cavaletti, backwards walking, zigzag hill walking	Joint injections with PRP or stem cells; Injectable PSGAGs; Dietary supplements with UCII, ω3-PUFAs
Cranial Cruciate Rupture	If complete rupture and unstable, surgery is indicated Post surgery or for medical treatment use acupuncture, laser therapy, EWST, UWTM, massage NOTE: according to tissue healing principles complete healing of CCL injury may take 6 to 12 months even post surgery	Sit to stand, Controlled leash walks, cavaletti, paws up on ball, backward walking, Weaves, progress to zig zag hill walking, cross legged standing,	Joint injections with PRP or stem cells; Injectable PSGAGs; Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, avocado soybean unsaponifiables (ASU), CBD
Patellar luxation	Medical therapy indicated for Grade 1–2 luxation, chronic or Grade 3 or 4 often have surgery Treatments include pharmaceutical, herbs and modalities acupuncture, laser therapy, EWST	Sit to stand, backward walking, cavaletti, weaves, circles, zigzag hill walking, cross legged standing	Injections with PRP or stem cells; Injectable PSGAGs; Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, other supplements as per DJD
Calcaneal tendon/achilles injury	Chronic conditions may not require surgery. Acute traumatic conditions do require surgery Treatments include pharmaceutical, herbs and modalities. Post surgery rehabilitation often involves a brace and gradual return to flexion. After tendon has healed then exercises commence Laser, EWST, acupuncture, UWTM are common modalities used.	Sit to stand, backward walking, cavaletti, weaves, circles, zigzag hill walking Can Progress to backward walking up hill when tendon is sufficiently healed	Injections with PRP or stem cells; Injectable PSGAGs; Dietary supplements with UCII, GLM, ω3-PUFAs, Fortetrophin
Iliopsoas and other muscle injuries	Treatments include pharmaceutical, herbs and modalities Trigger point therapy Laser, massage, stretching, UWTM	Sit to stand, cookie stretches, cross legged standing	Injections with PRP or stem cells; Dietary supplements with UCII, GLM, ω3-PUFAs, Fortetrophin

Condition

Rehabilitation modalities

Rehabilitation exercises

Supplements/injections

Degenerative Joint Disease – can occur in any joint secondary to injury, genetic predisposition, congenital deformity, or growth aberration (osteochondritis dissecans or hip or elbow dysplasia) or surgery

Pain Control: Pharmaceuticals, herbs, modalities

Photobiomodulation

EWST

Acupuncture

UWTM

PEMF

Hot and cold therapy

Manual therapy – Massage, Chiropractic, Joint mobilization, Stretching

TENS

Weight loss if needed

Depends on location and condition of patient but could include

Sit to Stand, Cavalettis, Backwards walking, Swimming, Ball work, Obstacle course, Hill walking.

Goals include pain relief, weight loss, increased joint movement, and strengthening adjacent muscles.

Joint injections with platelet rich plasma (PRP), stem cells, hyaluronic acid (HA), steroids, Synovetin^®;

Injectable monoclonal antibody (MAB) or polysulfated glycosaminoglycan (PSGAG);

Dietary supplements with undenatured collagen type II (UCII), green lipped mussel (GLM), omega (ω)-3 polyunsaturated fatty acids (ω3-PUFAs), glucosamine and chondroitin, egg shell membrane, cannabidiol (CBD)

Osteochondritis dissecans/Hip or elbow dysplasia

See DJD above

OCD is most often a surgical problem that requires follow up rehabilitation and therapies to minimize future DJD.

Surgery may be indicated for hip and elbow dysplasia if recognized early enough. If no surgery is performed it is treated in the same manner as DJD

As for DJD above

For elbows can add

Commando crawling and rocker board work

Joint injections with PRP, stem cells, HA, steroids, Synovetin^®;

Injectable MAB or PSGAG;

Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD

Medial shoulder instability

Treatment depends on severity but may include: Hobbles, EWST, laser, acupuncture

UWTM, PEMF, stretching and mobilization

Surgery may be needed for severe cases or canine athletes

Sit to Stand, Cavalettis, swimming, ball work, hill walking

Avoid exercises that require lateral movement

Joint injections with PRP, stem cells, HA, steroids;

dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, Fortetrophin

Bicipital/Supraspinatus Tendinopathy

Treatment depends on severity but may include: rest, NSAIDs, EWST, laser, acupuncture, weight control

UWTM, PEMF, stretching and mobilization, cross friction massage, therapeutic ultrasound

surgery may be needed for chronic cases or canine athletes

Note: acute injuries should not be stretched

PROM (flexion/extension of limb while not weight bearing)

In acute phase exercises increase strength of muscles

Controlled leash walking, therapy ball work, rocker board balancing, cavletti, weaves (slow), figure 8s and hill walking

Joint injections with PRP, stem cells, HA, steroids;

Tendon injections with PRP or stem cells;

Dietary supplements with UCII, ω3-PUFAs, CBD

Contractures

Ultrasound, cross friction massage

Mature contractures usually require surgery

UWTM and general conditioning, leash walking also appropriate

Depends on location but heating with therapeutic ultrasound and then stretching is recommended. PROM

Regenerative medicine with PRP or stem cells may help some patients

Jump Down Syndrome

(Traumatic Fragmented medial coronoid process)

Arthroscopic removal of fragments followed by rehabilitation therapy, pharmaceuticals, herbs modalities

UWTM, massage

Cavalettis, high fives, weaves, backward walking, zig zag hill walking – timing of exercises depends on healing

Injectable PSGAGs;

Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, other supplements as per DJD

Carpal Hyperextension

Acupuncture treatment, braces, UWTM

Exercises on textured surfaces, rocker board, ball work, cavaletti, backwards walking, zigzag hill walking

Joint injections with PRP or stem cells;

Injectable PSGAGs;

Dietary supplements with UCII, ω3-PUFAs

Cranial Cruciate Rupture

If complete rupture and unstable, surgery is indicated

Post surgery or for medical treatment use acupuncture, laser therapy, EWST, UWTM, massage

NOTE: according to tissue healing principles complete healing of CCL injury may take 6 to 12 months even post surgery

Sit to stand, Controlled leash walks, cavaletti, paws up on ball, backward walking, Weaves, progress to zig zag hill walking, cross legged standing,

Joint injections with PRP or stem cells;

Injectable PSGAGs;

Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, avocado soybean unsaponifiables (ASU), CBD

Patellar luxation

Medical therapy indicated for Grade 1–2 luxation, chronic or Grade 3 or 4 often have surgery

Treatments include pharmaceutical, herbs and modalities acupuncture, laser therapy, EWST

Sit to stand, backward walking, cavaletti, weaves, circles, zigzag hill walking, cross legged standing

Injections with PRP or stem cells;

Injectable PSGAGs;

Dietary supplements with UCII, GLM, ω3-PUFAs, glucosamine and chondroitin, egg shell membrane, CBD, other supplements as per DJD

Calcaneal tendon/achilles injury

Chronic conditions may not require surgery. Acute traumatic conditions do require surgery

Treatments include pharmaceutical, herbs and modalities. Post surgery rehabilitation often involves a brace and gradual return to flexion. After tendon has healed then exercises commence

Laser, EWST, acupuncture, UWTM are common modalities used.

Sit to stand, backward walking, cavaletti, weaves, circles, zigzag hill walking

Can Progress to backward walking up hill when tendon is sufficiently healed

Injections with PRP or stem cells;

Injectable PSGAGs;

Dietary supplements with UCII, GLM, ω3-PUFAs, Fortetrophin

Iliopsoas and other muscle injuries

Treatments include pharmaceutical, herbs and modalities

Trigger point therapy

Laser, massage, stretching, UWTM

Sit to stand, cookie stretches, cross legged standing

Injections with PRP or stem cells;

Dietary supplements with UCII, GLM, ω3-PUFAs, Fortetrophin

Veterian Key

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Integrative Treatment of Common Musculoskeletal and Neurological Conditions

16 Integrative Treatment of Common Musculoskeletal and Neurological Conditions

Introduction

Orthopedic Conditions

Degenerative Joint Disease (Osteoarthritis)

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Veterian Key

Fastest Veterinary Medicine Insight Engine

Integrative Treatment of Common Musculoskeletal and Neurological Conditions

Introduction

Orthopedic Conditions

Degenerative Joint Disease (Osteoarthritis)

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