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 µg/lb dailySelenium 2 µg/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 µg 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 µg/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/µl & platelet count is > 100,000/µl

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 –Babinski’s 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 & Horner’s 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 Horner’s SyndromeHorner’s Syndrome

Horner’s 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 –Babinski’s 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 don’t 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 µg/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