Acupuncture for Neurological Disorders Associated with the Liver It matters not whether medicine is new or old, it only matters that it is applied for the benefit of the patient. Neurologic Assessment Is it a neurologic disease?Is it a neurologic disease? Seizures Intention tremor CN deficits Head tiltHead tilt NystagmusNystagmus CP deficits Dysmetria Paralysis Minimum Database CBCCBC ChemistryChemistry Bile acids Cholinesterase UrinalysisUrinalysis Chest and abdominal radiographsChest and abdominal radiographs Abdominal ultrasound Heartworm test Fecal Ancillary Neurologic Tests ElectrodiagnosticsElectrodiagnostics EEG EMG BAER CSF tap & analysisCSF 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 When all else fails Look at the patient!!! Seizures in Small Animals It is estimated that the overall incidence of seizure disorders in dogs and cats is around 1%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 %, due to the presence of inherited, primary epilepsy in those breedsIn pure breed dogs, this incidence may increase to %, due to the presence of inherited, primary epilepsy in those breeds Lesion Localization in Seizures Cerebral Cortex Diencephalon Thalamus Hypothalamus Mesencephalon Seizure Diagnoses SEIZURES Primary Epilepsy Secondary Epilepsy InactiveActive Reactive Epilepsy Seizures- -TCM Represent various aspects of the Liver (Wood) systemRepresent various aspects of the Liver (Wood) system Excess (3 types)Excess (3 types) Deficiency (3 types)Deficiency (3 types) Seizure Diagnosis Minimum DatabaseMinimum Database Abnormal in Reactive Epilepsy CSF tap & analysisCSF tap & analysis Abnormal in Active Secondary Epilepsy CT or MRI Scan Abnormal in Active Secondary Epilepsy EEG Abnormal in Secondary Epilepsy All test are normal in Primary EpilepsyAll test are normal in Primary Epilepsy Asymmetrical Seizures Licking Seizure 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 Seizure Treatment Acupuncture alone Acupuncture in conjunction with drugs Traditional Chinese herbs Western herbal medicine Valerian Root Kava Kava Oats Hops Passionflower Western drugs Basic Antioxidants Vitamin E 10 IU/lb dailyVitamin E 10 IU/lb daily Vitamin C 5-10 mg/lb twice a dayVitamin C 5-10 mg/lb twice a day Selenium 2 g/lb dailySelenium 2 g/lb daily Beta carotene 250 IU/lb dailyBeta carotene 250 IU/lb daily B Complex 2mg/kg twice a dayB Complex 2mg/kg twice a day Vitamin E IU daily Vitamin C mg twice a day Selenium 50 g daily Vitamin A IU daily B Complex 10 mg twice a day DogsCats Additional Considerations Probably safe parasite controlProbably safe parasite control Interceptor Frontline Top Spot Revolution Should avoid Heartgard Proheart 6 Program Sentinel Frontline Spray Advantage Advantix Additional Considerations DietDiet 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 Phenobarbital Cheap and effective Dose 2-4 mg/kg for a serum level mcg/ml Takes 3-5 days to reach steady state Safe but can effect the liver in a few cases Controls 80% of seizures KBr (Bromide) Compounded by pharmacist dissolved in H2O at 250mg/ml Dose at 22 mg/kg q12h Blood level in 2 months between g/ml Use alone or in conjunction with Phenobarbital Bypass liver Good for cluster seizures Other Anticonvulsants With Efficacy DiazepamDiazepam 1 mg/kg q12h PrimidonePrimidone 15-22 mg/kg q12h FelbamateFelbamate 15-45 mg/kg q8h PhenytoinPhenytoin 3-5 mg/kg q8h GabapentinGabapentin 30-60 mg/kg q8-12h TopiramateTopiramate 15-25 mg/kg q8-12h No Efficacy Valproic acid Nimodapine Chorazepate Lamotrigine Note: TOXIC to Dogs Seizures- -TCM ExcessExcess Wind-Phlegm Tongue pale & greasyTongue pale & greasy Pulse wiry & slipperyPulse wiry & slippery Phlegm-Fire Tongue red & greasyTongue red & greasy Pulse rapid, wiry & slipperyPulse rapid, wiry & slippery Blood Stagnation Tongue & Pulse like Wind-PhlegmTongue & Pulse like Wind-Phlegm History of head traumaHistory 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 ExcessExcess Wind-Phlegm expel phlegm, extinguish the wind, open the orifice and stabilize the seizuresexpel phlegm, extinguish the wind, open the orifice and stabilize the seizures Ding Xian WanDing Xian Wan Phlegm-Fire clear the liver, drain the heat, transform phlegm and open the orificesclear the liver, drain the heat, transform phlegm and open the orifices Di Tan Tang and Long Dan Xie Gan TangDi Tan Tang and Long Dan Xie Gan Tang Blood Stagnation expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate bloodexpel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood Ding Xian Wan and Tao Hong Si Wu SanDing 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 8 Treasures 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 Wind Phlegm Spleen Disorder or Chronic Illness Accumulation of Phlegm (Tan) Emotional/Drug Stress Liver Qi Stagnation Liver Yang Rising Liver Wind (Feng) Obstruction of Shen/Mind Sudden Onset of Seizures Wind Phlegm HzHz Acute Seizures TongueTongue pale & greasy PulsePulse wiry & slippery Rx PrincipleRx Principle expel phlegm, extinguish the wind, open the orifice and stabilize the seizure AP CV-15, ST-40, PC-5, GV-1, GV-26, HT-7, ST-6, LIV-3, An Shen, Da Feng Men TCM Herbal Ding Xian Wan Horse: 15 g twice daily as top dressing on feed Dog/Cat: 0.5 g per 10 to 20 lb body weight twice daily Ding Xian Wan Pinellia Ban Xia Transform phlegm Citrus Chen Pi Move Qi, transform phlegm Bambusa Zhu Ru Transform phlegm Fritillary Chuan Bei Mu Transform phlegm Arisaema Dan Nan Xing Transform phlegm Juncus Deng Xin CaoClear Heat Bombyx Jiang Can Extinguish Wind, stop seizure Scorpion Quan XieExtinguish Wind, stop seizure Gastrodia Tian Ma Tranquilize Liver, extinguish Wind, stop seizure Ophiopogon Mai Men Dong Nourish Yin Polygala Yuan Zhi Nourish Yin, calm Shen Salvia Dan Shen Move Blood Poria Fu LingDrain Damp Poria Fu Shen Calm Shen Magnolia Hou Po Move Qi Licorice Gan Cao Harmonize Zingiberis Gan Jiang Harmonize Phlegm Fire Spleen Disorder or Chronic Illness Accumulation of Phlegm (Tan) Emotional/Drug Stress Wood Personality Liver Qi Stagnation Liver Yang Rising Liver Fire Obstruction of Shen/Mind Sudden Onset of Seizures Phlegm Fire Hz:Hz: Acute Seizures Wood Personality TongueTongue red & greasy PulsePulse Fast, wiry & slippery Rx PrincipleRx Principle Clear the liver, drain the heat, transform phlegm and open the orifices AP CV-15, ST-40, PC-5, HT-7, LI-11, LIV-3, An Shen, Da Feng Men TCM Herbal Di Tan Tang Long Dan Xie Gan Tang Di Tan Tang PinelliaBan XiaTransform phlegm CitrusChen PiMove and transform phlegm ArisaemaDan Nan XingTransform phlegm AcorusShi Chang PuOpen the orifice, eliminate Damp BambusaZhu RuTransform phlegm UncariaGou TengExtinguish Internal Wind, clear Liver Heat LumbricusDi LongExtinguish Internal Wind, stop seizure HaliotisShi Jue MingClear Liver Heat PoriaFu LingDrain Damp AurantiumZhi ShiMove Qi GinsengRen ShenTonify Qi LicoriceGan CaoHarmonize ZingiberisGan JiangHarmonize Long Dan Xie Gan Tang Gentiana Long Dan Cao Clear Liver Heat, Clear Damp- Heat Gardenia Zhi Zi Clear Damp Heat Scutellaria Huang Qin Clear Damp-heat Plantago Che Qian Zi Drain Damp-heat Alisma Ze Xie Drain Damp Akebia Mu Tong Drain Damp-Heat Angelica Dang Gui Nourish Blood Rehmannia Sheng Di HuangNourish Yin, clear Heat Bupleurum Chai Hu Soothe Liver Qi transporter Licorice Gan Cao Harmonize Mansion of Mind Damp-Heat LoniceraJin Yin HuaClear heat, Expel wind20 gm ForsynthiaLian QiaoClear heat, Detoxify20 gm IsatidisBan Lan GenClear heat, Cool blood20 gm AstragalusHuang Qi Move Qi (stimulate immune system)20 gm Akebia Mu Tong Drain Damp-Heat 10 gm PlatycodonJie GengTransporter15 gm LicoriceGan CaoHarmonizer10 gm Encephalitis, SRME, GME Meningoencephalomyelitis Infectious DiseasesInfectious Diseases Species Specific Steroid Response ME (SRME)Steroid Response ME (SRME) Necrotizing Vasculitis (SRMA)Necrotizing Vasculitis (SRMA) Necrotizing ME (NME)Necrotizing ME (NME) Granulomatous ME (GME)Granulomatous ME (GME) Meningoencephalomyelitis Pain to paresis to plegiaPain to paresis to plegia Dx with CSF tapDx with CSF tap Spinal radiographs normalSpinal radiographs normal Myelography normal (might be contraindicated)Myelography normal (might be contraindicated) Meningoencephalomyelitis CSF Tap Collection site for seizures is at the cisterna magnum.Collection site for seizures is at the cisterna magnum. Allows analysis for cells, protein and pressure.Allows analysis for cells, protein and pressure. Cytology and titers for infectious organisms can be obtained.Cytology and titers for infectious organisms can be obtained. Meningoencephalomyelitis CSF AnalysisCSF Analysis may be normal or show increased pressure, protein and/or cells. CSF TitersCSF Titers species specific tests many must be paired with serum titers. CSF cytology form a dog exhibiting a mixed reaction with neutrophils, lymphocytes and macrophages. Meningoencephalomyelitis InfectionInfection virus rickettsia protozoa fungus bacteria InflammationInflammation GME NME SRME SRMA GME Can be:Can be: peracute acute & progressive chronic In brainstem, tends to be a multifocal inflammatory disorderIn brainstem, tends to be a multifocal inflammatory disorder Responds temporarily to steroids.Responds temporarily to steroids. Patient with GME presenting with vertical nystagmus, long tract signs, and circling with incoordination. GME GME histologically causes multifocal meningoencephalitis due to proliferation of reticulohistiocytic cells. Lesions also show multinucleated giant cells. Treatment of ME Depends upon whether infectious or inflammatoryDepends upon whether infectious or inflammatory PrednisolonePrednisolone 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 Sugar Bear 5 year old, female/spayed Jack Russell Terrier5 year old, female/spayed Jack Russell Terrier Acute onset of dementia, change in behavior, seizures, progressing toward coma in 72 hoursAcute onset of dementia, change in behavior, seizures, progressing toward coma in 72 hours Tongue: RedTongue: Red Pulse: Fast & WiryPulse: Fast & Wiry Sugar Bear CSF AnalysisCSF Analysis Increased Cells & Protein consistent with inflammation CT scanCT scan Focal mass in the cerebral cortex Sugar Bear Biopsy confirmed GMEBiopsy confirmed GME Western TreatmentWestern Treatment Prednisolone Procarbazine TCM TreatmentTCM Treatment Di Tan Tang Mansion of Mind Damp-Heat Blood Stagnation Traumatic Injury Accumulation of Phlegm (Tan) Emotional/Drug Stress Liver Qi Stagnation Liver Yang Rising Liver Wind (Feng) Obstruction of Shen/Mind Sudden Onset of Seizures Qi Stagnation Blood Stagnation Fire/Heat to Cook Body Fluids Blood Stagnation Hz:Hz: Acute Seizures Head Injury TongueTongue red & greasy PulsePulse Fast, wiry & slippery Rx PrincipleRx Principle expel phlegm, extinguish the wind, open the orifice, stabilize the seizures and invigorate blood AP CV-15, ST-40, PC-5, HT-7, LI-11, LIV-3, An Shen, Da Feng Men TCM Herbal Ding Xian Wan Tao Hong Si Wu San Tao Hong Si Wu San Paeonia Chi Shao YaoNourish Blood, clear Heat Ligusticum Chuan XiongMove Blood, resolve stagnation Angelica Dang Gui Move and Nourish Blood Rehmannia Sheng Di HuangNourish Yin and clear Heat Carthamus Hong Hua Break Blood stasis Persica Tao Ren Break Blood stasis Use up to 1 month Stasis in Mansion of Mind Angelica Bai Zhi Warm the Channel, relieve pain Pinellia Ban Xia Transform phlegm Ligusticum Chuan Xiong Move Blood Salvia Dan Shen Move Blood Lumbricus Di Long Clear Wind, invigorate Channel Ligusticum Gao Ben Relieve pain Pueraria Ge Gen Bring Qi upward Carthamus Hong Hua Break down Blood Stasis Bombyx Jiang Can Transform phlegm, resolve nodule Scorpion Quan Xie Break down Blood Stasis Cimicifuga Sheng Ma Ascend Qi Fritillary Zhe Bei Mu Transform phlegm, resolve nodules ScolopendraWu Gong Detoxify, resolve nodules Use up to 6 months with Wie Qi Booster CNS Neoplasia- -Dogs Common TypesCommon Types Meningioma Astocytoma Oligodendroglioma Choroid plexus papilloma Lymphoma Neuroectodermal tumors Metastatic tumor CNS Neoplasia- -Dogs Dog has 1-18 months average survival timeDog has 1-18 months average survival time 1-3 with nothing 6-9 with surgery 12-18 with radiation treatment All tumors are invasive (malignant)All tumors are invasive (malignant) CNS Neoplasia- -Cats Most common is meningiomaMost common is meningioma Usually extra- axial and benignUsually extra- axial and benign Seen in aged catsSeen in aged cats Present with depression and dementiaPresent with depression and dementia Elvis Elvis MRI revealed mass in the cerebral cortexMRI revealed mass in the cerebral cortex Elvis Treatment Prednisolone ( mg/kg q12h)Prednisolone ( mg/kg q12h) Treats secondary effects Cover with gastroprotectants ChemotherapyChemotherapy Radiation therapyRadiation therapy Chemotherapy LomustineLomustine 60 mg/M 2 given Monitor CBC weekly If WBC and platelets okay in 5 weeks, then give 80 mg/M 2 Repeat every 5-8 weeks Procarbazine 2-4 mg/kg/day for 1 week, then 4-6 mg/kg/day Monitor CBC Continue as long as WBC levels are > 4000/l & platelet count is > 100,000/l Chemotherapy 5-hydroxyurea5-hydroxyurea Meningiomas 50 mg/M 2 given Monitor CBC weekly Repeat every 3-4 weeks Melatonin Gliomas mg/kg once a day in the evening Reduces growth of many tumors by 50% Cancer Recommendations 1.Low-Carbohydrate food (home prepared is best or use Pedigree Weight Loss Formula) 2.Canine basic antioxidant formula (Westlab Pharmacy WESTLA) 3.Canine arthritis formula (Westlab) 4.Canine cancer formula (Westlab)- -use at 2 times prevention dose 5.COX-2 inhibitor (daily- -particularly for carcinomas) 6.Melatonin at night ( mg/kg) Wiener Dog 3 yr old MC Dachshund3 yr old MC Dachshund Bitten on head as puppy Mild clonic seizure at 1.5 years lasting 1 minuteMild clonic seizure at 1.5 years lasting 1 minute 3 seizures so far Tongue: red-purpleTongue: red-purple Pulse: slightly wiryPulse: slightly wiry Tao Hong Si Wu San + Earthworms (Di Long) Reba 5 year old, German Shorthair Pointer5 year old, German Shorthair Pointer History of seizures starting 1 month priorHistory of seizures starting 1 month prior Responsive to phenobarbital Tongue: purpleTongue: purple Pulse: fast & wiryPulse: fast & wiry Reba Neurologic ExamNeurologic Exam Mild dementia CP deficits in both hind legs Babinskis sign on left side of the body LocalizationLocalization Cerebrum affecting both side (>right) Reba- -1 st CT scan Reba Di Tan TangDi Tan Tang Stasis in Mansion of MindStasis in Mansion of Mind Wei Qi BoosterWei Qi Booster Western herbsWestern herbs Liver Blood Deficiency Chronic Anemia or Chronic Illness Fails to Nourish Jin (sinews) Blood Deficiency Internal Wind Seizures Liver Blood Deficiency Hz:Hz: Chronic seizures Weakness, cool nose/ears TongueTongue Pale & dry PulsePulse Weak & thready Rx PrincipleRx Principle Tonify Qi and blood and quiet the wind AP BL-17, BL-18, BL-19, SP- 6, SP-9, SP-10, CV-15, ST-40, ST-44, HT-7, GV-14, GB-20, LIV-3, An Shen, Da Feng Men TCM Herbal Bu Xue Xi Feng San Di Tan Tang plus 8 Treasures (4 Gentlemen + 4 Substances) Bu Xue Xi Feng San Paeonia Bai Shao YaoNourish Blood, Soothe Liver Angelica Dang Gui Nourish Blood Rehmannia Shu Di HuanNourish Blood and Jing Ligusticum Chuan Xiong Move Blood, Resolve Stagnation Condonopsis Dang Shen Tonify Qi Atractylodes Bai Zhu Tonify Qi TyphoniumBai Fu Zi Clear Internal Wind, Transform Phlegm Cicada Chan TuiClear Wind Uncaria Gou Teng Clear Internal Wind, Cool Liver Bombyx Jiang Can Clear Internal Wind, Transform Phlegm Eight Treasures Four Gentlemen Condonopsis Dang Shen Tonify Qi Atractylodes Bai Zhu Tonify Qi and strengthen Spleen Astragalus Huang Qi Tonify Qi Poria Fu LingDrain Damp, strengthen Spleen Four Substances Paeonia Bai Shao Yao Nourish Blood Angelica Dang Gui Nourish Blood Rehmannia Shu Di Huang Nourish Blood and Jing Ligusticum Chuan Xiong Move Blood, resolve stagnation Su Ling 3 year old Shitzu3 year old Shitzu History of fly- biting seizures for 6 monthsHistory of fly- biting seizures for 6 months Tongue: pale & dryTongue: pale & dry Pulse: deep, weak & threadyPulse: deep, weak & thready Bu Xue Xi Feng San Liver Yin Deficiency Chronic Anemia or Chronic Illness Fails to Nourish Jin (sinews) Blood Deficiency Internal Wind Seizures Kidney Yin Deficiency Liver Yin Deficiency Hz:Hz: Chronic Seizures Night Seizures TongueTongue red & dry PulsePulse Fast, weak & thready Rx PrincipleRx Principle nourish Yin and extinguish wind AP BL-18, BL-23, SP-6, SP-9, ST-40, HT-7, GB-20, LIV-3, An Shen, Da Feng Men TCM Herbal Yang Yin Xi Feng San Di Tan Tang and Tian Ma plus II Yang Yin Xi Feng Paeonia Bai Shao Yao Nourish Blood, Soothe Liver Cornus Shan Zhu Yu Nourish Yin Rehmannia Shu Di Huang Nourish Blood and Jing Moutan Mu Dan Pi Cool Liver Typhonium Bai Fu Zi Clear Internal Wind, Transform Phlegm Cicada Chan Tui Clear Wind Uncaria Gou Teng Clear Internal Wind, Cool Liver Bombyx Jiang Can Clear Internal Wind, Transform Phlegm Tian Ma Plus II Gastrodia Tian Ma Clear Internal Wind, Relieve Pain Uncaria Gou Teng Clear Internal Wind, Cool Liver Cornus Shan Zhu Yu Nourish Yin Rehmannia Shu Di Huang Nourish Blood, Yin and Jing Polygonurn He Shou Wu Nourish Blood and Yin Pinellia Ban Xia Transform Phlegm Bambusa Zhu Ru Transform phlegm Cicada Chan Tui Clear Wind Arisaema Dan Nan Xing Transform phlegm Lumbricus Di Long Clear Internal Wind, Clear Heat Bombyx Jiang Can Clear Internal Wind, Transform Phlegm Draconis Long Gu Tranquilize Liver Yang, calm Shen, astringent Ostrea Mu Li Tranquilize Liver Yang, astringently consolidate Moutan Mu Dan Pi Cool Liver, resolve stagnation Licorice Gan Cao Harmonize Josie 4 year FS Corgi/Mix4 year FS Corgi/Mix 1 year history of seizures at night1 year history of seizures at night Tongue: redTongue: red Pulse: deep & weakPulse: deep & weak Yang Yin Xi Feng Kidney Jing Deficiency Fails to Nourish Jin (sinews) Blood Deficiency Internal Wind Seizures Kidney Yin Deficiency Liver Yin Deficiency Kidney Jing Deficiency Hz:Hz: Seizures < 1 year of age Dry nose & mouth TongueTongue Pale or red PulsePulse Weak & thready Rx PrincipleRx Principle extinguish the wind and astringe or nourish the kidney jingextinguish the wind and astringe or nourish the kidney jing AP KID-3, BL-23, SP-6, GV-20, ST-36, HT-7, GB-20, An Shen, Da Feng Men TCM Herbal Di Tan Tang and Epimedium Powder Epimedium Powder Epimedium Yin Yang Huo Tonify Kid Yang/Jing, Promote Sexual Desire Cuscuta Tu Si Zi Tonify Kid Yang, Jing & Yin Cistache Rou Cong RongTonify Kid Yang & Yin Paeonia Bai Shao Yao Nourish Liver Yin & Blood Polygonum He Shou Wu Nourish Blood & Jing, Benefit Hair Actinolite Yang Qi Shi Tonify Kid Yang Cynomorium Suo Yang Tonify Kid Yang Psoralea Bu Gu Zhi Tonify Kid Yang & Strengthen Bones Dipsacus Xu Duan Tonify Kid Yang & Promote Fracture Healing Lycium Gou Qi Zi Nourish Liver Yin, Benefit Eyes Condonopsis Dang Shen Tonify Qi Astragalus Huang Qi Tonify Qi Rehmannia Shu Di Huang Nourish Kid Yin & Jing Angelica Dang Gui Nourish Blood Ophiopogon Mai Men Dong Moisten & Nourish Yin Scrophularia Xuan Shen Cool Blood & Clear Heat Citrus Chen Pi Move Qi & Relieve Pain Chance 8 month M Lhasa apso8 month M Lhasa apso Seizures for 1 monthSeizures for 1 month Tongue: red purpleTongue: red purple Pulse: deep & weakPulse: deep & weak Di Tan Tang and Epimedium Powder Epilepsy -- TCM Internal heat leading to generation of windInternal heat leading to generation of wind Clear wind & heat and calm the ShenClear wind & heat and calm the Shen PointsPoints Constitutional points Clear wind & heat GB20, LI4, LI11, GV14, LIV3GB20, LI4, LI11, GV14, LIV3 Calm the shen PC6, HT7PC6, HT7 Local points GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1, ST40GV17, GV20, GV21, Long hui, GB9, GB13, BL5, GV1, ST40 TCM HerbalsTCM Herbals Di Tan Tang (TCM phenobarbital) Specific herbs for excesses or deficiencies present Vestibular Disease Cardinal SignsCardinal Signs Head Tilt Nystagmus HorizontalHorizontal RotatoryRotatory VerticalVertical PositionalPositional Circling (tight) Imbalance & Incoordination Vestibular Disease HorizontalHorizontal Fast-Phase away from head tilt Fast Phase toward head tilt RotatoryRotatory VerticalVertical PositionalPositional Peripheral V.D.Peripheral V.D. Central V.D.Central V.D. Positional Nystagmus Only present in certain positions especially when patient is placed on backOnly present in certain positions especially when patient is placed on back Vestibular Disease Idiopathic V.D. Inner Ear Disease Central V.D. 8th Nerve only 8th Nerve, 7th Nerve & Horners Syndrome Anything Else BrainstemCerebellum Pathology of Liver Heat Liver Heat Heat & Damp Liver Blood & Yin Deficiency Child Shen Disturbance SP/ST Grandchild LIV Organ Channel Feet Eyes GBEars KID/BLParent LU/LI Grandparent Idiopathic Vestibular Disease Acute Onset of Vestibular SignsAcute Onset of Vestibular Signs Head tilt Horizontal or Rotatory nystagmus with fast- phase away from head tilt Nothing else Can Be Very SevereCan Be Very Severe Acute, regressive diseaseAcute, regressive disease Idiopathic V.D. Minimum Data BaseMinimum Data Base Physical ExaminationPhysical Examination Neurologic ExaminationNeurologic Examination Only 8th nerve signs Odoscopic ExaminationOdoscopic Examination Idiopathic V.D. Re-check in one weekRe-check in one week Ought to be better Re-check in one monthRe-check in one month Should still be improving Re-check again if any signs persistRe-check again if any signs persist Head tilt may be permanent Thought to be secondary to an immune act on the 8th nerve Remember each cranial nerve is antigenically distinct Can re-occur Idiopathic Vestibular Disease -- TCM Wind (heat) invasionWind (heat) invasion Clear wind & heat and calm the ShenClear wind & heat and calm the Shen PointsPoints Constitutional points Clear wind & heat GB20, LI4, LI11, GV14GB20, LI4, LI11, GV14 Calm Shen PC6, HT7, GV17, GV20, GV21PC6, HT7, GV17, GV20, GV21 Local points TH17, TH18, TH21, SI19, GB2, Er jian, An shenTH17, TH18, TH21, SI19, GB2, Er jian, An shen Inner Ear Disease 8th Nerve Signs8th Nerve Signs 7th Nerve Signs7th Nerve Signs ear & lip droop lack of palpebral reflex nose turn nostril flaring Horners SyndromeHorners Syndrome Horners Syndrome Small AnimalsSmall Animals Ptosis Myosis Enophthalmos Large AnimalsLarge Animals Facial sweating (horse) Lack of muzzle sweating (cow) Inner Ear Disease Most cases are secondary to bacterial infection (otitis media & interna)Most cases are secondary to bacterial infection (otitis media & interna) extension from otitis externa pharyngitis with extension up the Eustachian tube hematogenous spread Inner Ear Infection Treat with bacterio- cidal drugs which penetrate bone and blood-tissue barriersTreat with bacterio- cidal drugs which penetrate bone and blood-tissue barriers Combination therapy cephalosporinscephalosporins sulfa drugssulfa drugs Enrofloxacin Must treat 6-8 weeksMust treat 6-8 weeks Ear Polyps in Cats Benign growth in the external ear canal which causes signs by extension.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.Can also be pharyngeal mass which grows into middle ear via the Eustachian tube. Ear Polyps in Cats Treatment is surgical removal. Damage can be permanent, if pressure necrosis has destroyed the inner ear structure. Bilateral Vestibular Lacks classical signsLacks classical signs Wide head excursionsWide head excursions No physiologic nystagmusNo physiologic nystagmus Inner Ear Disease Treat with antibiotics and recheck in 2 weeksTreat with antibiotics and recheck in 2 weeks if better, continue if worse, reassess Recheck in 1 monthRecheck in 1 month if normal, stop antibiotics if still residual problems, continue 2 more weeks Recheck at 6 months re-examine any abnormalities (such as abnormal bulla radio-graphs) If problems worsens or persists without change for 4 weeks, consider referral. Inner Ear Disease -- TCM Invasion of external pathogen leading to wind, heat, damp.Invasion of external pathogen leading to wind, heat, damp. Heat boils the fluids leading to the accumulation of phlegm.Heat boils the fluids leading to the accumulation of phlegm. Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation. Inner Ear Disease -- TCM PointsPoints Constitutional points Clear wind & heat GB20, LI4, LI11, GV14GB20, LI4, LI11, GV14 Calm the shen PC6, HT7, GV17, GV20, GV21PC6, HT7, GV17, GV20, GV21 Eliminate damp SP9SP9 Activate Qi & blood ST36, ST40, Xin shuST36, ST40, Xin shu Local points TH17, TH18, TH21, SI19, GB2, Er jian, An shenTH17, TH18, TH21, SI19, GB2, Er jian, An shen Ear Damp-Heat Artemisia Qing Hao Clear Damp-Heat Bupleurum Chai Hu Soothe Liver Qi Scutellaria Huang Qin Clear Damp-Heat Moutan Mu Dan Pi Cool Blood Prunulla Xia Ku Cao Clear Heat Lophatherum Dan Zhu Ye Clear Heat Tribulus Bai Ji Li Clear Heat Luffa Si Gua Teng Transform Phlegm, Resolve Stagnation Melia Chuan Lian Zi Move Qi TCM Ear Drops Coptis Huang Lian Clear Heat, Detoxify Alum Bai Fan Dry Damp, Transform Phlegm, Stop Bleeding, Relieve Itching Borneol Bing Pian Clear Heat, Relieve Pain, Open Orifices, Dissipate Swelling GlycerolGan You Carrier Western Ear Drops Detergent Solution:Detergent Solution: 1 drop of free dishwasher soap 8 ounces of water Vinegar Solution:Vinegar Solution: 1 ounce apple cider vinegar 3 ounces of water Vitamin E/garlic oil:Vitamin E/garlic oil: crush one clove of garlic (use press) into 1 ounce of extra virgin olive oil let sit overnight at room temperature pour oil into dropper container add content of a 1000 IU vitamin E capsule use 2-3 drops in the ear canals, plus 1-2 on the pinnae Central Vestibular Disease Postural ChangesPostural Changes CP Deficit Dysmetria Reflex ChangesReflex Changes hyperactive reflexes crossed-extensor reflexes Babinskis sign Conscious proprioceptive deficit may be on the same or opposite side of the lesion. Central Vestibular Disease CSF AnalysisCSF Analysis may be normal or show increased pressure, protein and/or cells. CSF TitersCSF Titers species specific tests many must be paired with serum titers. CSF cytology form a dog exhibiting a mixed reaction withneutrophils, a mixed reaction with neutrophils, lymphocytesand macrophages lymphocytes and macrophages. Central Vestibular Disease Inflammatory or Infectious DiseasesInflammatory or Infectious Diseases canine distemper toxoplasmosis and neosporiosis fungal rickettsial GME SRME Central Vestibular Disease Trauma or VascularTrauma or Vascular remember dogs dont get atherosclerosis ! NeoplasiaNeoplasia meningiomas choroid plexus papillomas oligodendrogliomas astrocytomas metastatic neoplasia Central Vestibular Disease Infectious DiseasesInfectious Diseases FIP FeLV toxoplasmosis cryptococcosis TraumaTrauma MetabolicMetabolic thiamine deficiency ToxicityToxicity organophosphates NeoplasiaNeoplasia meningiomas Central Vestibular Disease MRI of Cerebellar Meningioma Cerebellar Disease Signs include head tiltSigns include head tilt paradoxical (head tilt is away from the lesion) If horizontal nystagmus exists, the fast-phase is toward the head tiltIf horizontal nystagmus exists, the fast-phase is toward the head tilt Also signs of dysmetria and whole body tremors (including head)Also signs of dysmetria and whole body tremors (including head) Cerebellar Disease The output of the cerebellum is through the activation of the Purkenjie cells. This output is inhibitory. When the cerebel-lum is damaged, the result is disinhibition of brainstem nuclei. Asymmetrical damage cause increased in motor tone on the side of the lesion, leading to the head tilting away from the damage. The output of the cerebellum is through the activation of the Purkenjie cells. This output is inhibitory. When the cerebel-lum is damaged, the result is disinhibition of brainstem nuclei. Asymmetrical damage cause increased in motor tone on the side of the lesion, leading to the head tilting away from the damage. Central Vestibular Disease CorticosteroidsCorticosteroids 1 mg/kg/day in 3 divided doses for 3-7 days reduce prednisolone dose to 1/3 mg/kg twice a day find minimum daily dose and go to alternate-day therapy (over weeks) Misoprostol 3-4 g/kg twice a day may stop when at alternate-day steroids Doxycycline 5-10 mg/kg once a day for 2 weeks Sulfadimethoxine 15 mg/kg twice a day Central Vestibular Disease -- TCM Can be wind, heat- damp or wind cold based upon the causative factor involved.Can be wind, heat- damp or wind cold based upon the causative factor involved. PointsPoints Constitutional 8 Principle Zang-Fu Jerry 10 year old, Mx10 year old, Mx Progressive loss of coordination and head tiltProgressive loss of coordination and head tilt Personality changePersonality change Tongue: purpleTongue: purple Pulse: fast & wiryPulse: fast & wiry Jerry Neurologic ExamNeurologic Exam Left head tilt Positional, vertical nystagmus Mild CP deficits in rear L>R Xextensor R -> L in rear LocalizationLocalization L Cerebellar pontine angle with cerebral signs Jerry TCM Dx:TCM Dx: Liver Blood Stagnation TCM Rx:TCM Rx: Stasis in Mansion of Mind Wie Chi Booster Jerry- -MRI scan Conclusion Many conditions can be helped with TCM herbal medications, acupuncture and Western treatmentsMany conditions can be helped with TCM herbal medications, acupuncture and Western treatments TCM herbs offer a choice between them and Western drugsTCM herbs offer a choice between them and Western drugs