The hot topic of evidence-based medicine sparks debate between integrative medicine practitioners and the mainstream because many incorrectly assume that complementary medicine treatment strategies cannot withstand scientific scrutiny. The door swings both ways, however. Evidence-based veterinary medicine (EBVM) requires “the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients.”1 For veterinary medicine to establish itself as an evidence-based profession, regular approaches to everyday conditions require re-evaluation according to this new standard. In their introduction to EBVM, Holmes and Ramey warn against relying overmuch on common sense, educated guesses and uncontrolled observations instead of results from “reliable empiric research.”2 They advise that in addition to having the capacity to critically appraise scientific literature, “(A) good clinician needs good powers of observation, empathy with patients and clients, manual dexterity and a host of other skills.” Now it seems that acupuncture may become one of those skills based on accumulating results indicating substantive benefits. One area where evidence is mounting in favor of acupuncture concerns spinal cord injury. Medical management methods for dogs with thoracolumbar intervertebral disk disease (TL IVDD) deemed non-surgical candidates typically include steroids, analgesics and cage confinement. Where’s acupuncture? Unfortunately, this effective and safe neurophysiologic intervention frequently finds itself forgotten. Omitting acupuncture, however, is not evidentially supported; acupuncture has increasingly well-defined value for various aspects of both acute and chronic spinal cord injury (SCI).3 Value and Safety Certainly, acupuncture cannot pack the powerful anti-inflammatory punch of corticosteroids. That said, an evidence-based clinician cannot long ignore the value and safety of this needling treatment for patients with disk disease. A 2007 report in the Journal of the American Veterinary Medical Association showed that for dogs with TL IVDD, electroacupuncture combined with steroids yielded shorter time to return of ambulation and deep pain perception than steroid treatment alone.4 A 2009 review by the Mayo Clinic’s Dorsher and McIntosh pointed to the accelerated improvements made possible on multiple measures with acupuncture. Indeed, they indicated that one study showed a “much larger effect of electroacupuncture on ultimate neurologic recovery from acute SCI than any pharmacologic intervention to date.”5 The authors called for more research: “This landmark study should be replicated by another center(s), and if these impressive results are confirmed, then this treatment should be integrated into the acute management of SCIs.” In addition, Dorsher and McIntosh cited a study evaluating electroacupuncture in experimentally induced, incomplete SCI in dogs. Electro-acupuncture produced a twice as fast recovery of proprioception and thrice as quick motor return, which was then enhanced further with the addition of corticosteroid.6 The review indicated that neuroanatomic acupuncture could address neurogenic bladder and bowel dysfunction as well as pain. In contrast, the evidence on steroids for preservation of neurologic function, considered by some a standard for non-surgical management of TL IVDD, stands on shaky territory. Often prescribed for the pain, edema and inflammation from disk disease, corticosteroids have definite drawbacks. They may impair the survival of injured neurons by interfering with glucose metabolism.7 In dogs with medically managed, presumptive TL IVDD, glucocorticoid administration led to lower owner-reported quality of life scores; steroids also decreased the odds of having a successful outcome.8 Dexamethose ranked worst, with dogs given dex before surgery experiencing 11 times likelier urinary tract infections and 3.5 times as likely diarrhea.9 A 2008 study showed no outcome differences between dexamethasone, other glucocorticoids or no steroids at all.10 Even the effectiveness of methylprednisolone sodium succinate (MPSS) has come into question; given too late, MPSS may worsen the outcome.11 Steroids can pose serious risks; 90 percent of dogs exhibited subclinical gastrointestinal bleeding after receiving “roids.”12-13 Rest Isn’t Always Best Cage rest has little to no evidential justification. A study of medical management for dogs with TL disk herniation showed no correlation between a successful outcome and cage rest, regardless of the duration.14 Fewer physicians are recommending long periods of bed rest for humans after disk damage based on findings showing disuse osteoporosis, decreased physical fitness, more muscle atrophy and reduced disk nutrition following prolonged recumbency.15-20 Cage rest without analgesia or anti-inflammatory medication in dogs with TL IVDD sounds archaic. Back in 1965, the advice of the day held that, “The clinician here must also be aware that pain and muscular splinting certainly offer some measure of help in immobilizing the area. So judgment in the use of anti-inflammatory drugs, analgesics and sedatives becomes very important.”15 This suggests keeping an animal in discomfort to aid restraint. Surely, the veterinary profession should have moved forward after four decades, based on scientific proof of the long-term damage caused by unrelenting pain. In fact, inappropriate or insufficient pain management has become a source of liability exposure in the medical profession.16 Nevertheless, at least one recent textbook on small-animal spinal disorders recommends that veterinarians intentionally leave animals in pain “when feasible in order to encourage the animal to rest.”17 Clearly, medical management approaches for TL IVDD in dogs need an update, with a scalpel poised to eliminate or at least question those that lack not only evidence, but compassion for patients and clients. Techniques shown to offer value, such as acupuncture, should be instituted early after injury, when chances of improvement are greatest. That acupuncture benefits patients with back pain would have come as no surprise to the father of modern medicine, Sir William Osler, who practiced acupuncture over half a century before Chairman Mao invented Traditional Chinese Medicine. Near the end of the 19th century, Osler wrote in his most famous work, “The Principles and Practice of Medicine” (1892) that acupuncture for acute back pain provided “the most efficient treatment.”18 In addition to lumbago, Osler suggested acupuncture for sciatica and neuralgia.19 Following in the footsteps of physiologist and physician Sydney Ringer (of “Ringer’s lactate”), Osler wrote, “In many instances the relief is immediate, and I can corroborate fully the statements of Ringer, who taught me this practice, as to its extraordinary and prompt efficacy in many instances.” <HOME> Narda Robinson, DVM, DO, Dipl. ABMA, FAAMA, offers an evidential and scientific perspective on the latest trends in complementary and alternative veterinary medicine. She oversees complementary veterinary education at Colorado State University. <HOME> FOOTNOTES: 1. Holmes MA and Ramey DW. An introduction to evidence-based veterinary medicine. Vet Clin Equine. 2007;23:191-200. 2. Holmes MA and Ramey DW. An introduction to evidence-based veterinary medicine. Vet Clin Equine. 2007;23:191-200. 3. Dorsher PT and McIntosh PM. Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries: a review of the allopathic and Traditional Chinese Medicine literature. eCAM. 2009;doi:10.1093/ecam/netp010. 4. Hayashi A, Matera JM, and PACBdF. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc. 2007;231:913-918. 5. Wong AM, Leong CP, Su TY et al. Clinical trial of acupuncture for patients with spinal cord injuries. Am J Phys Med Rehabil. 2003;82:21-27. Cited in: Dorsher PT and McIntosh PM. Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries: a review of the allopathic and Traditional Chinese Medicine literature. eCAM. 2009;doi:10.1093/ecam/netp010. 6. Yang JW, Jeong SM, Seo KM, et al. Effects of corticosteroid an delectroacupuncture on experimental spinal cord injury in dogs. J Vet Sci. 2003;4:97-101. Cited in: Dorsher PT and McIntosh PM. Acupuncture’s effects in treating the sequelae of acute and chronic spinal cord injuries: a review of the allopathic and Traditional Chinese Medicine literature. eCAM. 2009;doi:10.1093/ecam/netp010. 7. Smith-Swintosky VL, Pettigrew LC, et al. Metapyrone, an inhibitor of glucocorticoid production, reduces brain injury induced by focal and global ischemia and seizures. J Cerebral Blood Flow and Metabolism. 1996;16:585-598. 8. Levine JM, Levine GJ, et al. Evaluation of the success of medical management for presumptive thoracolumbar disk disease in dogs. Vet Surg 2007;36:482-491. 9. Levine JM, Levine GJ, et al. Adverse effects and outcome associated with dexamethasone administration in dogs with acute thoracolumbar intervertebral disk herniation: 161 cases (2000-2006). J Am Vet Med Assoc. 2008;232:411-417. 10. Ibid. 11. Sansam KAJ. Controversies in the management of traumatic spinal cord injury. Clinical Medicine. 2006;6(2):202-204. 12. Rohrer CR, Hill RC, et al. Gastric hemorrhage in dogs given high doses of methylprednisolone sodium succinate. Am J Vet Res. 1999;60:977-981. 13. Hanson SM, Bostwick, DR, et al. Clinical evaluation of cimetidine, sucralfate, and misoprostol for prevention of gastrointestinal tract bleeding in dogs undergoing spinal surgery. Am J Vet Res. 1997;58:1320-1323. 14. Levine JM, Levine GJ, et al. Evaluation of the success of medical management for presumptive thoracolumbar disk disease in dogs. Vet Surg 2007;36:482-491. 15. Wilcox KR. Conservative treatment of thoracolumbar intervertebral disc disease in the dog. J Am Vet Med Assoc. 1965;147(12):1458-1460. 16. Shapiro RS. Health care providers’ liability exposure for inappropriate pain management. Journal of Law, Medicine & Ethics. 1996;24(4):360-364. 17. Sharp NJH & Wheeler SJ. Thoracolumbar Disc Disease. In: Small Animal Spinal Disorders: Diagnosis and Surgery. 2nd Ed. Toronto: Elsevier, 2005. P. 123. 18. Osler W. The Principles and Practice of Medicine. New York: Appletone & Co., 1892, p. 397. 19. Osler W. The Principles and Practice of Medicine. New York: Appletone & Co., 1892, pp. 1040, 1072.
