Correlation of Acupuncture Point Sensitivity and Lesion Location in 259 Horses

Palpation of Channels and acupoints is part of the equine traditional Chinese veterinary medicine examination. Sensitivity of acupoints and acupoint combinations have been used to localize disease to certain regions and structures in horses. The objective of this clinical observational study was to scan and record sensitive acupoints of horses presented for lameness, poor performance or pre-purchase examinations and then evaluate the anatomic sites previously suggested for problems, using ultrasound, radiography or nerve blocks. Between January and April 2007, 259 horses, presented for examination, had sensitive acupoints and were evaluated for lesions. Of these, 139/259 (53.7%) horses were presented for lameness and pain, 91/259 (35.1%) horses were presented for general complaints about poor performance and 29/259 (11.2%) horses were presented for pre-purchase examinations. Sensitive acupoints were associated with disorders of tendons (12.9%), ligaments (19.4%), muscles (5.8%), bone (1.4%), joints (23%), hooves (7.2%) and sciatic nerves (10.8%), as well as back pain (13.7%), metacarpal and metatarsal fractures (1.4%) and general poor performance issues (5.81%). Diagnosis was confirmed with ultrasonography (44%), radiography (40%) and/or nerve blocks (16%). In this group of 259 horses, there was 100% correlation with acupoint sensitivity and lesion location reported elsewhere. Integration of palpation of acupoints into the routine conventional examination can be useful to localized lesions in horses with musculoskeletal and performance problems and detect potential problems during pre-purchase examinations.

acupoints. 1 Acupuncture stimulates neuroendocrine responses via the same somato-somatic and somatic-visceral neural reflexes used to regulate normal physiological processes and heal the body. 1 Because of these neural reflexes, sensitivity of specific acupoints have been observed to indicate disease locally, elsewhere along the Channel and of specific internal organs. [1][2][3][4][5] Appendicitis in humans has been diagnosed since 1891 by finding pain on palpation of a visceral-somatic reflex point called McBurney's point. 6 McBurney's point is in the same location as the acupoint ST-30 in traditional Chinese medicine. 1,6 Acupoints can be used for both diagnosis and treatment. Methodically palpating and scanning acupuncture Channels with the tip of the finger or a blunt rounded object, such as a plastic hypodermic needle cap, pen or a smooth wooden or metal probe, can be useful to detect sensitivity of specific acupoints and regions of the body. [1][2][3][4][5] Many equine TCVM practitioners find acupoint and regional scanning to be an effective tool to detect current and potential problems, during the routine lameness and pre-purchase examinations. [1][2][3][4][5] The objective of this clinical observational study was to scan and record sensitive acupoints of horses presented for lameness or pre-purchase examinations and confirm problems at specific anatomic sites with ultrasound, radiography or nerve blocks.
To competently perform lameness and pre-purchase examinations veterinarians must acquire an accurate history and have excellent skills in observation, inspection, manipulation and gait analysis. 1 Gait evaluation is performed during walking, trotting and galloping with and without a saddle and any other appropriate gear. The horse should also be observed while performing the intended sport. The ability to accurately localize lesions and knowledge of conformational defects that can lead to future performance problems are also essential. The nutritional status, especially of young animals, is very important to evaluate, as it may relate to current and future problems. The ability to accurately perform and interpret imaging are also necessary for an accurate diagnosis. The traditional Chinese veterinary medicine (TCVM) evaluation includes the conventional physical examination plus added historical questions, tongue and pulse examination and palpation of Channels and

ABBREVIATIONS TCVM
Traditional Chinese veterinary medicine TMJ Temporomandibular joint

MATERIALS AND METHODS
Horses were presented to the author for examination between January and April 2007 and all horses with sensitive acupoints found on palpation were included in the study. As part of the complete TCVM examination, the author methodically palpated acupoints along the regular TCVM Channels of the head, neck, thoracic limb, dorsolateral vertebral column and pelvic regions (Table 1). Classical acupoints previously suggested to be diagnostic for specific locations were also palpated ( Table 1). 1-5 A 3 ml mepivicane vial with a smooth, rounded metal tip was used to put pressure on acupoints and along the Channels to detect sensitivity. Acupoint sensitivity was graded either +, ++ or +++ based on the criteria outlined in Table 2. Anatomic sites, previously suggested to be associated with sensitive acupoints, were  evaluated for lesions with ultrasound, radiography or nerve blocks. The author was the sole examiner of acupoint sensitivity and performed all the diagnostic tests.

RESULTS
A total of 259 horses had 1 or more sensitive (reactive) acupoints to different degrees on palpation. Of these, 139/259 (53.7%) horses were presented for lameness and pain, 91/259 (35.1%) horses were presented for general complaints about poor performance and 29/259 (11.2%) horses were presented for prepurchase examinations. To obtain a diagnosis at the suspected anatomic lesion location, ultrasonography was performed on 44% of horses, radiography on 40% of horses and nerve blocks on 16% of horses. An overview of the sensitive acupoints, locations and types of lesions and number of affected horses are outlined in Table 3. The percentages of the different types of tissue disorders diagnosed are shown in Figure 1. Sensitive acupoints were associated with disease of tendons (12.9%) ligaments (19.4%), muscles (5.8%), bones (degeneration 1.4%), joints (23%), hooves (7.2%) and sciatic nerves (10.8%), back pain (13.7%), metacarpal and metatarsal fractures (1.4%) and functional performance issues associated with equine ulcerative gastritis complex, temporomandibular (TMJ) disease, occipito-atlanto-axial disease and generalized Bladder Channel imbalances (5.81%). There was 100% correlation with acupoint sensitivity and lesion location suggested in the literature. 1,5 No structural lesions were found in 5.81% of the cases with Bladder Channel pain.

DISCUSSION
In the author's clinical experience and from the results of this study, acupoint palpation can be a valuable diagnostic aid. The author generally begins the palpation of acupoints around the head and TMJ, specifically GB-1, ST-7, GB-2 and SI-19. Pain around this area will normally indicate dental or occipito-atlanto-axial disease (if GB-20 and BL-10 are also sensitive). If only BL-10 and SI-16 are sensitive, then a possible contralateral sacral problem should be considered. In sacral disease, ipsilateral Ba-jiao, Lu-gu and Ba-shan acupoints are usually also sensitive.
Next the author palpates LI-18 for ipsilateral hoof problems, followed by TH-16 and SI-16 for ipsilateral fetlock and pastern disorders. Sensitivity of SI-16 and TH-15 usually indicates ipsilateral tendon disorders. If a very sensitive area between TH-15, GB-21 and LI-16 is found, then ipsilateral shoulder disease is suspected, and more severe structural damage is suspected if SI-9 is also painful. Sensitivity of LI-17 and Jing-jia-ji at C3-4 or C4 -5 indicates ipsilateral carpus disease. If scratching with the probe from LI-16 to LI-17 generates sensitivity, then suspensory ligament disease should be suspected. Acupoint PC-1 is located at the level of the point of the olecranon, in the 5th intercostal space and is more reactive if chronic heel pain, including navicular disease is present. Most of the time in the author's experience LI -18 will also be reactive. 1 Normally, the acupoints along the Bladder Channel are used as "mirror" points to find out whether lesions are more medial or lateral or to support the diagnosis of a hoof problem. For example, if LI-18 and PC-1 are reactive and so are BL-14 and 15, then ipsilateral hoof disease is more likely. If the presenting complaint is a behavioral problem, then sensitivity of Qi-hai-shu, ST-7, BL-20, 21, CV-12 suggests equine gastric ulcerative complex causing the behavioral problems. If sensitivity is found at acupoints BL-51, BL-52, BL-23, GB-24, GB-25 and LIV-13 the behavioral problem may be due to equine hormone-associated syndrome. For segmental intervertebral problems, the author prefers digital palpation over the paravertebral muscles and Hua-tuo-jia -ji acupoints to detect sensitive acupoints and local Qi Stagnation.
In the pelvic area, sensitive acupoints around the tuber coxae have a great deal of clinical significance. Sensitivity of GB-27 and SP-13 ("hock-point") indicate ipsilateral hock disease, in which case usually BL-35, BL-39a and BL-39b are sensitive also. If acupoints SP-11, SP-12, ST-31, Dan-tian and Ju-liao are sensitive, then stifle disease is likely and more severe if sensitivity is also found at BL-36, BL-37 and BL-38. If BL-53, Huan-tiao, Huan-zhong and Huan-hou are sensitive along with sensitivity at acupoints Ba-jiao, Lu-gu and Ba -shan, then coxofemoral joint disease is likely.
The detection of sensitive acupoints during the TCVM examination can be useful to localize lesions to local and distant sites ( Table 1). The results of acupoint sensitivity and lesion localization of the 259 horses in Table 2: Criteria for the grades of acupoint sensitivity

Degree of Response Symbol used Criteria
Mild + Palpation generates a short local muscle contraction that stops when palpation is discontinued Moderate ++ Palpation generates a local muscle contraction that continues after palpation is discontinued Severe +++ Palpation generates obvious pain as manifested by moving away or acts of aggression (e.g. biting, striking or kicking) this study outlined in Table 2 were in agreement with suggested sensitivity and locations for tendon and ligament disease, fetlock and pastern, metacarpus and metatarsus, stifles, hocks, hoofs, back, sciatic nerve, equine gastric syndrome, TMJ and atlanto-occipital and atlanto-axial disorders described in Table 1 from other authors. 1,5 During acupoint palpation, a superficial or mild response (+) usually indicates superficial functional damage associated with Qi Stagnation (e.g. mild myositis). 1,3,5 A moderate response (++) indicates a more serious problem with structural damage (e.g. early degenerative joint disease). Most of the time the lesion can be confirmed by thermography, ultrasonography or radiography. A severe response (+++) is related to damage of tissues and disease of the ligaments, tendons, joints or bones that can be confirmed with ultrasonography or radiography. 1,3,5 The author also found this to be the case in this clinical observational study.
Based on the acupoint diagnosis and confirmation with other diagnostic tests, all horses were treated with acupuncture, Chinese herbal medicine and Tui-na alone Ultrasound, local anesthesia Occipito-atlanto-axial disorder 5 *LDH = lactate dehydrogenase or combined with conventional treatment. By the end of 2007, the clinical signs of 94% of the horses in this study had resolved and the horses had returned to national and international competitions. Integration of Channel and acupoint palpation into the routine conventional examination may provide another tool to better evaluate horses with musculoskeletal and performance problems. Acupoint sensitivity may also be useful to better detect potential problems during the pre-purchase examination.