Acupuncture for Small Animal Neurologic Disorders

Veterinary Clinics of North America: Small Animal Practice Volume 48, Issue 1, January 2018, Pages 201-219 Author links open overlay panelPatrickRoynardDVM, MRCVSabLaurenFrankDVM, MS, CVA, CVCH, CCRTcHuishengXieDVM, PhD, MSdMargaretFowlerDVM, MSef a Neurology/Neurosurgery Department, Long Island Veterinary Specialists, 163 South Service Road, Plainview, NY 11803, USA b Fipapharm, 26 rue du marais, Mont-Saint-Aignan 76130, France c Physical Rehabilitation and Acupuncture Service, Long Island Veterinary Specialists, 163 South Service Road, Plainview, NY 11803, USA d Department of Small Animal Clinical Sciences, University of Florida, 2089 Southwest 16th Avenue, Gainesville, FL 32608, USA e Acupuncture and Holistic Veterinary Services, 105 Lilith Lane, Summerville, SC 29485, USA f The Chi Institute of Traditional Chinese Veterinary Medicine, 9650 West Highway 318, Reddick, FL 32686, USA Available online 14 October 2017. crossmark-logo https://doi.org/10.1016/j.cvsm.2017.08.003 Get rights and content Previous article Next article Keywords Traditional Chinese veterinary medicine (TCVM) Acupuncture Electroacupuncture (EA) Herbal Dog Intervertebral disk disease (IVDD) Cervical spondylomyelopathy (CSM) Pain Key points • Research in neuroscience is progressively unveiling the different mechanisms of action of traditional Chinese veterinary medicine (TCVM) and allowing the modern clinician to understand it as a several millennia–old metaphor. • Scientific literature demonstrates the efficacy of TCVM for many small animal neurologic disorders, including intervertebral disk disease (IVDD), other myelopathies, and painful conditions. • TCVM, including acupuncture and herbals, is overall innocuous and easy to implement clinically. • TCVM can be used as an adjunct or occasionally as an alternative to conventional treatment, and can improve functional outcome and pain management. Video content accompanies this article at http://www.vetsmall.theclinics.com. Introduction Traditional Chinese medicine (TCM), such as acupuncture and administration of Chinese herbal formulas, has been used for thousands of years to effectively treat many conditions, including pain and neurologic issues.1,2 The first known text about TCM, Huangdi Neijing (Yellow Emperor’s Classic of Internal Medicine) is estimated from approximately the period 475 BC to 225 BC.3 Traditional Chinese veterinary medicine (TCVM) started in Chinese agricultural culture and is often associated with an equine practitioner known as Bo Le.4–6 Bo Le’s techniques were recorded in what many consider to be the first TCVM text, Bo Le Zhen Jing (Bo Le’s Canon of Veterinary Acupuncture).7 Western interest in TCM/TCVM started in the 1970s, and in the past 40 years has mushroomed in popularity, both clinically and in research (Fig. 1). Although TCVM has long been overlooked by some practitioners, modern neuroscience has shed some light on the mechanism of action of acupuncture.8–10 Despite the perception that TCVM presents the clinician with an entirely different way of approaching a patient, parallels with “Western” medicine are numerous, especially for those familiar with neurophysiology and neurologic disorders. Download high-res image (139KB)Download full-size image Fig. 1. PubMed search results for the word “acupuncture” by year. (Data fromwww.ncbi.nlm.nih.gov/pubmed. Accessed April 20, 2017.) Due to the paucity of clinical studies in veterinary acupuncture, much of the data available are human or laboratory based, and indicate evidence for its effectiveness. This is further supported by a few veterinary clinical trials and case reports. This review is meant to help guide the use of TCVM for neurologic disorders in small animals, based on available information and recommendations from experienced TCVM practitioners. Traditional Chinese veterinary medicine treatment modalities Acupuncture is defined as the stimulation of specific point(s) on the surface of the body by insertion of a needle, resulting in a therapeutic or homeostatic effect.11 From a TCVM standpoint, the aim is to allow Qi (energy) to flow harmoniously, which for a Western practitioner can be seen as a stimulation of the nervous system. TCVM defines 2 important concepts that are opposites, Yin and Yang, whose functioning relationship can be paralleled to anabolism and catabolism or to the parasympathetic and sympathetic components of the autonomic nervous system.12 Although TCVM presents the acupoints as areas where Qi is concentrated in the body, modern studies have revealed that acupuncture points are located in areas of sensitive neuroimmune modulation.13,14 Histologically, acupuncture points are found in areas with a high density of mast cells, lymphatics, and arteriovenous plexi, in addition to regions of concentrated innervation.13,14 This dense innervation consists of somatic afferent/efferent fibers, autonomic norepinephrine (NE) sympathetic fibers and cholinergic acetylcholine (Ach) parasympathetic fibers, with an increased ratio of myelinated to unmyelinated fibers compared with nonacupuncture points.14 Along this parallel, TCVM describes the acupoints as organized along several meridians portrayed as channels, similar to rivers where Qi flows, often following peripheral nerve pathways (eg, the pericardium [PC] meridian and the median nerve, the gallbladder [GB] meridian and the sciatic nerve). New research allows us to better understand TCM/TCVM theory as a several millennia–old metaphor, with the nervous system as a cornerstone of its mechanisms of action. Acupuncture has been used effectively for the treatment of neurologic disorders, such as intervertebral disk disease (IVDD)15 and spinal cord injury.16–18 Stimulation of acupuncture points with a needle produces analgesia, and other physiologic effects through neural, neurohumoral, neuromuscular, and musculoskeletal mechanisms.19 It has been demonstrated that certain acupoints can regulate proinflammatory factors, such as interleukin-6 (IL-6), cyclooxygenase-2 (COX-2), tumor necrosis factor-α (TNF-α), and many others.8,10,20–22 One of acupuncture’s most studied mechanisms is the stimulation of production of β-endorphins, promoting a profound and long-term analgesic effect.22,23 Moreover, certain acupoints can reduce the damage of free radicals and improve microcirculation.24,25 These events may contribute to the efficacy of acupuncture for the neurologic diseases discussed here. Stimulation of acupoints can be achieved by various techniques: dry needle (DN), electroacupuncture (EA), aqua-acupuncture (AA), and moxibustion (Fig. 2). DN is the most commonly used technique in veterinary acupuncture, and involves the insertion of fine, sterile needles into acupoints. EA, the modern practice of stimulating inserted needles with electricity, has been shown to have more profound effects compared with other techniques. It is used in many cases because of its rapid onset of pain relief and its ability to stimulate peripheral nerves. It is especially useful for neuralgia, nervous system injury, and persistent pain.8–10 AA is the injection of sterile liquids (eg, vitamin B-12) into acupuncture points, which may result in a prolonged stimulus. Moxibustion involves heating of an acupoint (directly or over a needle) with moxa, a type of bundled herb consisting primarily of Artemisia (mugwort). The mechanisms of moxibustion mainly relate to the thermal and nonthermal radiation, and pharmacologic effects of moxa and its combustion products acting on a specific acupoint.26 Download high-res image (613KB)Download full-size image Fig. 2. Different acupuncture techniques used in patients with multifocal IVDD: (A) DN technique on a 12-year-old Devon rex cat. (B) Electroacupuncture technique on a 7-year-old dachshund. (C) Moxibustion technique. The stick of moxa is held close to the needles to provide warming Qi. In general, herbal medicine is also used in TCVM as an adjunct to acupuncture. However, the review of this topic other than Yunnan Baiyao use is beyond the scope of this article. Epilepsy/seizure disorders From a TCVM standpoint, seizures are Internal Wind or “Wind in the Sea in Marrow”; the text Huangdi Neijing considered the brain, encased in a bony skull, as a reservoir of bone marrow, the “Sea of Marrow.” A recent review from the Cochrane Library concluded that there is not enough current evidence to support the use of acupuncture for human epilepsy, but it also noted that both DN and catgut implantation at acupoints may be effective in achieving at least 50% reduction in seizure frequency when compared with valproate and antiepileptic drugs in several trials.27 Better quality of life after treatment was also reported in the acupuncture groups.27 Although the use of EA has traditionally not been recommended in seizure disorders (due to a suspected but unverified pro-epileptic effect), recent research has shown beneficial effects of EA in several models of epilepsy, without however a consensus on acupoints and frequency to use. While using stimulation points outside the brain, the use of EA for seizures/epilepsy is somewhat similar in concept to the different intracranial or vagus nerve stimulation techniques in human refractory epilepsy (as EA may suppress seizures by parasympathetic activation and generation of similar neurotransmitters as intracranial electrical stimulation).28 As an example, it has been suggested that response to EA could predict therapeutic effect of hippocampal high-frequency electrical stimulation in patients with pharmacoresistant temporal lobe epilepsy29 and of anterior nucleus thalamus high-frequency electrical stimulation in medically refractory epilepsy.30 A study in rats found that both low-frequency (10 Hz/1 mA) and high-frequency (100 Hz/1 mA) EA at select acupoints significantly (P<.05 compared with control) reduced epileptic seizures, with greater control at the high frequency.31 Further research has shown that low-frequency (10 Hz) EA at bilateral gallbladder 20 (GB-20) suppressed pilocarpine-induced focal epilepsy by action on the μ, δ, and κ opioid receptors of the central nucleus of amygdala.28 Furthermore, EA at stomach-36 (ST-36) +/− stomach-37 (ST-37) reduced spontaneous seizures and can decrease epileptogenesis by elevating the expression of GAD(67) mRNA in the dentate gyrus granule cell layer,32 and by reducing mossy fiber sprouting and COX-2 levels in the hippocampus.33,34 Few clinical data are available regarding the antiepileptic effect of acupuncture in dogs, but 3 separate studies/case series reported success. One study using 2-mm to 3-mm gold wire pieces implanted at multiple acupoints reported a 50% or more reduction in the seizure frequency of 9 (60%) of 15 dogs with idiopathic epilepsy.35 Another case series describes the use of small subcutaneous gold implants placed over the calvaria on the Bladder (BL), Governing Vessel (GV), and GB meridians in 5 epileptic dogs nonresponsive to anticonvulsants, with 5 of 5 dogs experiencing decrease in seizure frequency after treatment.36 As gold implants can create significant signal loss and other susceptibility artifacts on MRI, Clemmons37 used 1.0 × 0.5-mm polylactic acid beads inserted at multiple acupoints using a modified 16-gauge needle in 10 dogs with refractory epilepsy (unsatisfactory seizure control despite 2 anticonvulsant medications within therapeutic range). He reported significant reduction in amplitude of electroencephalogram activity, reduction of seizures by more than 50% in 9 (90%) of 10 dogs, and change in seizure characteristics from cluster seizures to singular seizures.37 This may represent a promising new method to help control canine refractory epilepsy. Disorders of the spinal cord/myelopathies Spinal Cord Injury From a TCVM standpoint, spinal cord injuries (SCIs) are due to Qi and Blood stagnation, and acupuncture has long been used for various disorders of the spinal cord. Modern neuroscience has established the importance of secondary injury in SCI, with calcium entry in neurons and glial cells resulting in a cascade of cytokine and free radical release by activated microglia and damaged mitochondrial membranes.38,39 Of special interest are the roles of proinflammatory cytokines and mediators, such as TNF-α, interleukin-1β (IL-1β), matrix metalloprotease-9 (MMP-9), and nitric oxide (NO). Such factors promote the inflammatory cascade, and neuronal and oligodendrocyte damage, which leads to demyelination of axons and progressive disruption of nervous tissue. Long-term consequences of neuronal inflammation are associated with the development of astrocytosis, glial scar formation, and syringohydromyelia.39,40 Although there is currently no proven pharmacologic protocol protective from these secondary damages available to veterinary patients, recent research has shed some light on how acupuncture may fill this void. An experimental study of SCI in rats with sham/placebo control showed that DN treatment significantly (P<.01) improved functional recovery after SCI compared with control groups. Acupuncture treatment resulted in significantly attenuated microglial activation and significantly reduced expression of TNF-α, IL-1β, IL-6, MMP-9, NO synthase, and COX-2, providing neuroprotection and reducing apoptotic cell death of both neurons and oligodendrocytes. A significantly decreased size of lesion and axonal loss were also confirmed on histology and immune-histochemical staining.8 Interestingly, another study in a rat model of cerebral ischemic stroke showed that these benefits of acupuncture in SCI may extend to brain injury, as EA treatment reduced the motor impairment following middle cerebral artery occlusion, via inhibition of microglia-mediated neuro-inflammation and significantly decreased levels of TNF-α, IL-1β, and IL-6 in both sensorimotor cortex tissue and blood serum.41 Intervertebral Disk Disease Acupuncture has been shown to accelerate recovery of motor function and improve analgesia in dogs affected with IVDD,42–47 and TCVM for IVDD is documented in the veterinary literature.45 In a randomized controlled study in rats, EA inhibited Wnt-β-catenin, which may contribute to its effect in delaying the degenerative process of the cervical intervertebral disks.48 Acupuncture also can reduce the amount of type I collagen in the nucleus pulposus while promoting the production of type II collagen, changes necessary for the proper hydration of proteoglycans leading to compression resistance,49 thus improving the ability of degenerated disks to repair.50 EA also increased blood flow in the vertebrae and increased micro-vessel density compared with control rats.51 The number of normal neurons in the spinal cord and pelvic limb motor function were also increased.51 Some clinical research suggests that EA may have a success rate of 83% in treating canine thoracolumbar (TL) IVDD.44,47 In one study by Hayashi and colleagues,43 50 dogs with signs of TL IVDD were classified with a scale of neurologic deficits from grades 1 to 5 (Table 1). Dogs were separated into 2 groups, either receiving conventional medical treatment alone or conventional medical treatment with EA. In grades 3 or 4, the time to recover ambulation was significantly (P = .0341) less (10.10 ± 6.49 days) in the group receiving EA than without EA (20.83 ± 11.99 days). The success rate, defined as the ability to walk without assistance, for grades 3 or 4 was significantly (P = .047) higher with EA (10/10) than without EA (6/9). The overall success rate was significantly (P = .015) higher with EA (23/26; 88.5%) than without EA (14/24; 58.3%). Although this study presented methodological flaws and researcher bias (groups not matched, evaluator not blinded), EA combined with conventional medical treatment was more effective than conventional medication alone and resulted in a shorter time to recover ambulation (Fig. 3).43 Table 1. Neurologic grading scale in canine intervertebral disk disease and suggested recommendation for use of traditional Chinese veterinary medicine (TCVM) 0 Normal 1 Cervical or thoracolumbar pain, hyperesthesia: TCVM as an adjunct or alternative to standard management (cage rest and analgesics) 2 Ataxia, paresis, decreased proprioception, ambulatory: TCVM as an adjunct to standard management (cage rest and analgesics) including rehabilitation 3 Paresis with absent proprioception, nonambulatory: TCVM as an adjunct to standard management with recommendation for advanced imaging ± decompressive surgery and rehabilitation 4 Paralysis, nociception present: TCVM as an adjunct to standard management with recommendation for advanced imaging ± decompressive surgery and rehabilitation 5 Paralysis, absent nociception: TCVM as an adjunct to decompressive surgery and rehabilitation Download high-res image (189KB)Download full-size image Fig. 3. Effect of EA on IVDD in dogs. (Data from Hayashi A, Matera J, Fonseca Pinto A. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc 2007;231:913–8.) In a retrospective study, the outcome of 80 dogs with paraplegia and intact nociception from TL IVDD (grade 4) treated with EA and prednisone versus prednisone alone were compared. The combination of EA with prednisone was significantly (P = .01) more effective than prednisone alone to recover ambulation, allowed faster return to ambulatory status (P = .011), relieved back pain (P = .001), and decreased relapse rate (P = .031).52 Another study compared EA, hemilaminectomy, and hemilaminectomy + EA in 40 dogs with more than 48 hours of severe neurologic deficits due to IVDD (only grades 4 and 5) confirmed by diagnostic imaging (MRI, computed tomography [CT], myelography). “Clinical success,” defined as a patient initially classified grade 4 or 5 being classified as grade 1 or 2 within 6 months of treatment, was significantly (P<.05) higher for dogs that received EA alone (15/19 or 79%) or EA and surgery (8/11 or 73%) than for dogs that had surgery alone (4/10 or 40%) (Fig. 4). Thus, it was concluded that EA alone or a combination of EA + surgery, was more effective than surgery alone for recovery of ambulation and improvement in neurologic deficits.42 Download high-res image (144KB)Download full-size image Fig. 4. Effect of EA on IVDD in dogs. (Data from Joaquim J, Luna S, Brondani J, et al. Comparison of decompression surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. J Am Vet Med Assoc 2010;236:1225–9.) TCVM can also be used for cervical IVDD and, in the authors’ experience, it may be one of the most rewarding conditions to treat with EA. A retrospective study described the use of 3 different acupuncture protocols using DN ± EA and Chinese herbs in 19 dogs with cervical myelopathy having previously failed conventional medical/surgical management (18 with IVDD, 1 with fibrocartilaginous embolic myelopathy). Conclusions regarding differences in efficacy between the protocols are difficult to surmise (operators not blinded; treatment based on severity and duration of clinical signs), but it is noticeable that all 19 dogs were improved from both a pain and neurologic function standpoint.53 A case report also describes the successful use of EA and herbals for IVDD at C3-C4 in a miniature pinscher.45 As noted in these publications, the investigators recommend using both local points (Jing-jia-ji, located dorsal and ventral to the transverse processes of the cervical vertebrae) and distal points when using acupuncture to treat cervical IVDD. Although the authors still recommend advanced imaging and decompressive surgery when indicated for cases of presumptive IVDD, these results justify offering EA as an adjunct to conventional treatment. A suggested recommendation for the use of TCVM based on grading of neurologic deficits is included in Table 1. Cervical Spondylomyelopathy A clinical trial of 40 dogs with presumptive or diagnosed cervical spondylomyelopathy (CSM) was conducted over 3 years to evaluate the efficacy of standard treatment (medical and surgical) versus standard treatment + EA. EA resulted in pain relief quickly, often after the first session, with proprioceptive deficits being slower to respond. The overall efficacy of EA was 85%, whereas surgery and conventional medications resulted in a low 20% efficacy in this trial.54 However, these results should be interpreted cautiously, as a number of dogs were only presumptively diagnosed with CSM, the method of randomization between the 2 groups was not clear, the assessors were not blinded, and the improvement rate reported with conventional management was markedly lower than reported elsewhere.55,56 In a retrospective study, medical records for 19 animals (13 dogs and 6 horses) with presumptive or diagnosed CSM treated with TCVM were reviewed.57 Treatment consisted of DN, EA, AA (1000 μg/mL vitamin B-12), Jing Tong Fang (Cervical Formula; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal, Reddick, FL) for all patients, modified Da Huo Luo Dan (Double P II; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal) in grades 2 or higher, and Shen Tong Fang (Body Sore; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal) in patients with cervical pain. Additional Chinese herbal medicines were given and modified according to the Chinese pattern diagnosis at the time. Of the 19 cases, 10 (52.6%) had complete clinical recovery and 8 (42.1%) improved 1 or more grade(s). Only 1 (5.3%) of 19 had no improvement, a horse for which poor tolerance of acupuncture precluded the completion of treatment, resulting in 13 of 13 dogs improving. All 18 cases that responded were observed for at least 6 months and demonstrated good quality of life with no relapse. Despite shorter follow-up in these 2 EA studies than in other clinical studies of canine CSM,55,56 these results of overall improvement rate of 80% to 95%, compared with the previous reports of 70% to 90% of dogs improved after surgery (∼50% for conventional medical treatment) and warrant further clinical trials of management of CSM with TCVM. Furthermore, there were no cases of worsening with TCVM, making it a viable adjunct or alternative to conventional medicine and surgery, specifically early in the course of the disease. As for IVDD, the authors still recommend advanced imaging and surgery (if indicated) for presumptive cases of CSM, but also recommend integrating TCVM for ideal pain management and functional recovery (Fig. 5, Video 1). Download high-res image (690KB)Download full-size image Fig. 5. (A) Sagittal and (B) transverse MRI of a 9-year-old female spayed (FS) Doberman presented for tetraplegia, diagnosed with disk-associated CSM at C5-C6 (arrow). A ventral slot was performed at C5-C6. (C) Patient receiving electroacupuncture in local (Jing-jia-ji) and distal points postoperatively. Herbal treatment was also used with Cervical Formula (proprietary Chinese herbal formula manufactured by Jing Tang Herbal) and Buyang Huanwu. The patient recovered ambulatory status within 1 month (see Video 1). Traditional Chinese veterinary medicine for painful neurologic conditions/miscellaneous: acupuncture and pain Numerous human clinical trials, many with low to moderate evidence, have been evaluated in large systematic reviews and meta-analyses, and acupuncture has proven effective for different types of pain associated with neurologic conditions, including postoperative, headaches, sciatica, diabetic neuropathy,58,59 cervical, and lumbar.60–62 Acupuncture acts on all levels of the pain pathway, with many of the bioactive chemicals involved in inflammatory pain models decreasing with acupuncture,20,63 and also a modulatory effect on endogenous adenosine, cannabinoids, corticosterone, and opioids. Other mechanisms at the spinal cord level include serotoninergic, catecholaminergic, dopaminergic, substance P, and glutamate-receptor-driven pathways.10 In neuropathic pain (NP) models, acupuncture effects have been primarily studied at the spinal cord level. Low-frequency EA (2–10 Hz) has been associated with a more robust, longer-lasting endogenous opioid response than higher frequencies (100 Hz), which correlates with a vast quantity of research indicating that low-frequency EA inhibits NP more effectively, although both showed a positive response.10 It has been proposed that very low-frequency EA (2 Hz) triggers prolonged synaptic depression in the dorsal horn of rats, leading to an increased duration of analgesia.64 In tactile allodynia, non-nociceptive fibers Aβ (faster than C and Aδ fibers associated with pain) become involved in the pain signal.65–67 These changes, along with the gate theory68 and with the ability of EA to recruit Aα and Aβ before Aδ and C fibers,69 is another explanation for the ability of acupuncture to relieve NP. NP and inflammatory pain share some similarities, such as the stimulation of N-methyl-D-aspartate receptors, which gives EA the ability to target both based on its ability to activate α2-adrenoceptors and 5-HT1Ars and inhibit GluN1.10,70 EA’s analgesic effects are at least partially due to the inhibition of excitatory amino acids, such as glutamate, and stimulation of inhibitory amino acids, such as GABA.10,71–76 Other mechanisms of EA on NP include its ability to inhibit nerve-damage–induced upregulation of glial fibrillary acidic protein, OX-42, MMP-9, MMP-2, TNF-α, IL-6, IL-1β, and microglia activation in the spinal cord.77,78 Clinical veterinary studies evaluating acupuncture’s effectiveness for NP are lacking, but the authors have used acupuncture successfully in many cases, specifically early in the course of the disease. In cases of painful radiculopathy/“nerve root signature” (eg, foraminal IVDD, cervical or at L7-S1 with resulting sciatica), EA can be extremely rewarding and result in a fast improvement. It is unclear if the sharp, acute pain encountered in these cases is a true form of NP or nociceptive/inflammatory pain due to involvement of the local nervi nervorum,79,80 but clinicians should not underestimate the role of the nervi nervorum in subsequent development of long-term NP, and EA can help prevent this phenomenon.81 The authors also have used acupuncture successfully in the management of cases with paresthesia/dysesthesia of unclear etiology (eg, feline hyperesthesia syndrome). For more chronic cases with central nervous system NP (eg, Chiari-like malformation with syringohydromyelia), the lack of efficacy of acupuncture mentioned by some investigators82 may be related to central sensitization but also remodeling of the dorsal horn and higher centers of pain processing, emphasizing the need for early treatment. Traditional Chinese veterinary medicine and veterinary neurosurgery Several studies on postoperative pain after abdominal procedure in small animals have shown that acupuncture can decrease the dosage of anesthetic agent(s) required for surgery and can provide analgesia comparable to that achieved with injectable opioids or nonsteroidal anti-inflammatory drugs.83–85 In a controlled, blinded study on 15 dogs undergoing hemilaminectomy for TL IVDD, total dose of fentanyl administered during the first 12 hours after surgery was significantly (P = .04) lower in the group receiving EA than in the control group. Pain score (P = .018) was significantly lower in the EA group than in the control group 36 hours after surgery.86 Another study indicated that EA combined with low-dosage morphine suppressed postoperative pain better than either one did individually.87 One human clinical study on preoperative EA indicated significantly decreased amount of morphine required during the first 24 hours postoperatively and significantly reduced incidence of nausea and dizziness during the same period compared with sham EA.88 The authors routinely use EA as part of the postoperative pain management of every spinal surgery, ideally with bilateral stimulation because it is associated with better analgesic effect.89 Yunnan Baiyao (literally “the white medicine from the province of Yunnan”) is an herbal formulation of relative innocuity, and is easily implemented with many potential benefits in veterinary neurology/neurosurgery. Although its complete formula is owned and kept partially secret by the government of the People’s Republic of China, recent research has proven numerous benefits: as an antihemorrhagic agent, but also as an analgesic and antineoplastic supplement.90 In recent human clinical publications, Yunnan Baiyao has been associated with significantly decreased intraoperative blood loss,91 significantly decreased postoperative C-reactive protein and IL-6,92 and significantly decreased postoperative inflammation and swelling,93 with no allergic reactions, thromboembolic events, or other side effects reported. One of the authors (PR) is now routinely using Yunnan Baiyao preoperatively for every patient undergoing neurosurgery, specifically when the procedure can be planned several days ahead and if intraoperative hemorrhage is expected to be significant in volume (eg, craniectomy for multilobular tumor of bone, combined suboccipital and rostrotentorial craniectomy with occlusion of the transverse sinus, cervical dorsal laminectomy in large-breed dogs) or in terms of impact on visualization of the nervous tissue (eg, ventral slot) (see Fig. 5; Figs. 6 and 7, Video 2). Yunnan Baiyao is commercialized in capsules of 250 mg (16 regular capsules + 1 small “emergency red pill” in the middle of the blister) and other forms, such as paste, patches, powder, and aerosol. Suggested dosage is 1 capsule/10 kg by mouth once to twice daily for dogs (the “emergency red pill” can be given preoperatively), and 0.5 to 1 capsule by mouth twice daily for cats. Download high-res image (692KB)Download full-size image Fig. 6. (A) Sagittal CT image of a 9-year-old male neutered (MN) Pitbull presented for a large mass in the occipital area (arrow). The osteolytic mass invades the occipital, parietal, and temporal bones of the calvaria bilaterally. Biopsy was consistent with an osteosarcoma of high grade and surgical removal was elected. As perioperative hemorrhage was expected to be significant, the patient was treated with Yunnan Baiyao for a week before surgery. (B) Surgical removal was uneventful, with minimal blood loss and no transfusion required. Patient 3 days postoperative, with normal neurologic examination (see Video 2A and B). Download high-res image (473KB)Download full-size image Fig. 7. (A) Dorsal and (B) transverse postcontrast brain MRI of a 5-year-old FS mixed breed dog. A large contrast-enhancing mass is seen at the level of the right cerebello-ponto-medullary angle (arrow), consistent with a choroid plexus tumor. Before surgery, the patient was treated with Yunnan Baiyao to help hemostasis. Gross total resection was achieved through a combined suboccipital and right rostro-tentorial craniectomy, with occlusion of the right transverse sinus. (C) The patient suffered neurologic worsening postoperatively, with nonambulatory tetraparesis, right facial paralysis, and severe right head tilt, and received extensive rehabilitation/EA with marked improvement of all deficits and recovery of ambulatory status (D). Discussion/controversies about the use of traditional Chinese veterinary medicine Although advances in neuroscience are slowly explaining the TCM/TCVM theory and the metaphor it constitutes, much remains to be discovered (eg, specificity of action of certain acupoints, role of the different frequencies used in EA). Before this is achieved, it is the authors’ opinion that TCVM is most successful when an experienced practitioner makes an accurate Chinese pattern diagnosis, then chooses the appropriate acupuncture and herbal prescriptions. Although often effective in straightforward simpler cases, “cook-booking” or using a predetermined routine set of acupoints may not be as effective in more complicated cases. Similar to conventional operator-dependent disciplines, such as neurosurgery, acupuncture treatments can be heavily dependent on practitioner expertise and a higher level might reflect on a better outcome for the patient, but also for the overall cohort in controlled studies. This may explain the discrepancy in the perceived benefits of acupuncture among clinicians and when comparing studies, as one’s assessment of his or her own performance is influenced by skill/capabilities level,94 the perceived difficulty of the task performed,95 and the self-relevance of the task.96 These could be some of the contributing factors to why there are few scientifically valid clinical studies on veterinary acupuncture, resulting in skepticism in some of the scientific community, but also raises the question of the role of formal education in the veterinary curriculum. Although nearly 25% of recent graduates face questions regarding the potential benefits of TCVM on a frequent basis, a lack in formal scholar training exists, with only 1 (3%) of 34 American Veterinary Medical Association–accredited colleges offering a required course in complementary and alternative veterinary medicine and 15 (44%) of 34 offering an elective course.97,98 There remains a need for an evidence-based, unbiased scholar training of acupuncture and TCVM modalities in the veterinary curriculum.98 Summary As research unveils the different mechanisms of action of acupuncture and Chinese herbals, TCVM can be better understood by Western practitioners. The laboratory models and limited clinical research available are supportive for the use of TCVM in the management of neurologic conditions in small animals, specifically in cases of IVDD, other myelopathies, and painful conditions. The relative innocuity of TCVM modalities (specifically acupuncture) make them easy to implement in a clinical setting, and provide a useful adjunct or occasionally alternative to conventional management. TCVM is best used in conjunction with a proper conventional diagnosis and can result in faster recovery and better pain control in neurologic conditions, whether the patient is managed medically or surgically (eg, IVDD). There remains a need for larger randomized controlled trials before further indications can be fully validated, along with an evidence-based approach to TCVM to reach unbiased conclusions in veterinary education and medical recommendations. Supplementary data Download video (15MB) Help with mp4 files Video 1. Nine-year-old FS Doberman 1 month postoperative C5-C6 ventral slot for disc-associated CSM (patient presented tetraplegic). Download video (7MB) Help with mp4 files Download video (11MB) Help with mp4 files Video 2. (A, B) Nine-year-old MN pitbull 3 days postoperative craniectomy (modified bilateral rostrotentorial and caudotentorial craniectomy), normal neurologic examination. References 1 H. Xie, V. Priest Xie’s veterinary acupuncture Blackwell Publishing, Ames (IA) (2007), p. xii 247, 260–261, 335 2 H. Xie, L. Wedemeyer, C. Chrisman, et al. Practical guide to traditional Chinese veterinary medicine small animal practice Chi Institute Press, Reddick, (FL) (2014) 2014: 241-250, 924–930 3 S. Cavalieri, M. Rotoli Huangdi Neijing: a classic book of traditional Chinese medicine Recenti Prog Med, 88 (1997), pp. 541-546 [in Italian] View Record in Scopus 4 C. Yu History Traditional Chinese veterinary medicine, China Agricultural Press, Beijing (China) (1987), pp. 1-6 [in Chinese] View Record in Scopus 5 J.Z. Zhou Bo Le L.F. Chen (Ed.), China agricultural encyclopedia: traditional Chinese veterinary medicine volume, China Agricultural Press, Beijing (China) (1991), pp. 25-26 [in Chinese] View Record in Scopus 6 C. Yu Introduction Traditional Chinese veterinary acupuncture and moxibustion, China Agricultural Press, Beijing (China) (1995), pp. 1-6 [in Chinese] View Record in Scopus 7 J.Z. Zhou Fan Mu Cuan Yan Fang L.F. Chen (Ed.), China agricultural encyclopedia: traditional Chinese veterinary medicine volume, China Agricultural Press, Beijing (China) (1991), p. 73 [in Chinese] View Record in Scopus 8 D. Choi, J. Lee, Y. Moon, et al. Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury Neurobiol Dis, 39 (2010), pp. 272-282 ArticleDownload PDFView Record in Scopus 9 H. Liu, X. Qian, J. An, et al. Analgesic effects and neuropathology changes of electroacupuncture on curing a rat model of brachial plexus neuralgia by cobra venom Pain Physician, 19 (2016), pp. E435-E448 View Record in Scopus 10 R. Zhang, L. Lao, K. Ren, et al. Mechanisms of acupuncture-electroacupuncture on persistent pain Anesthesiology, 120 (2014), pp. 482-503 CrossRefView Record in Scopus 11 A. Campbell History of medical acupuncture J. Filshie, A. White, M. Cummings (Eds.), Medical Acupuncture: a Western scientific approach (2nd edition), Elsevier, Philadelphia (2016), pp. 11-20 View Record in Scopus 12 D. Jaggar History and basic introduction to veterinary acupuncture Probl Vet Med, 4 (1992), pp. 1-11 View Record in Scopus 13 H. Langevin, J. Yandow Relationship of acupuncture points and meridians to connective tissue planes Anat Rec, 269 (2002), pp. 257-265 CrossRefView Record in Scopus 14 A. Li, J. Zhang, W. Xie Human acupuncture points mapped in rats are associated with excitable muscle/skin-nerve complexes with enriched nerve endings Brain Res, 1012 (2004), pp. 154-159 ArticleDownload PDFView Record in Scopus 15 G. Erol The clinical effectiveness and application of veterinary acupuncture Amer J Trad Chin Vet Med, 3 (2008), pp. 8-9 View Record in Scopus 16 B. Shin, M. Lee, J. Kong, et al. Acupuncture for spinal cord injury survivors in Chinese literature: a systematic review Complement Ther Med, 17 (2009), pp. 316-327 ArticleDownload PDFView Record in Scopus 17 P. Dorsher, P. McIntosh Acupuncture's effects in treating the sequelae of acute and chronic spinal cord injuries: a review of allopathic and traditional Chinese medicine literature Evid Based Complement Alternat Med, 2011 (2011), p. 428108 18 W. Tangjitjaroen Acupuncture for the treatment of spinal cord injuries Amer J Trad Chin Vet Med, 6 (2011), pp. 37-43 View Record in Scopus 19 J. Steiss The neurophysiological basis of acupuncture A. Schoen (Ed.), Veterinary acupuncture: Ancient art to modern medicine (2nd edition), Mosby, St Louis (MO) (2001), pp. 342-343 20 T. Su, Y. Zhao, L. Zhang, et al. Electroacupuncture reduces the expression of proinflammatory cytokines in inflamed skin tissues through activation of cannabinoid CB2 receptors Eur J Pain, 16 (2012), pp. 624-635 CrossRefView Record in Scopus 21 J. Lee, K. Jang, Y. Lee, et al. Electroacupuncture inhibits inflammatory edema and hyperalgesia through regulation of cyclooxygenase synthesis in both peripheral and central nociceptive sites Am J Chin Med, 34 (2006), pp. 981-988 CrossRefView Record in Scopus 22 P. Anand, G. Whiteside, C. Fowler, et al. Targeting CB2 receptors and the endocannabinoid system for the treatment of pain Brain Res Rev, 60 (2009), pp. 255-266 ArticleDownload PDFView Record in Scopus 23 R. Skarda, G. Tejwani, W. Muir Cutaneous analgesia, hemodynamic and respiratory effects, and β-endorphin concentration in spinal fluid and plasma of horses after acupuncture and electroacupuncture Am J Vet Res, 63 (2002), pp. 1435-1442 CrossRefView Record in Scopus 24 J. Hong, J. Liu, C. Zhang, et al. Acupuncture-moxibustion at Jiaji points for intervertebral disc herniation: a systematic review J Acupunct Tuina Sci, 13 (2015), pp. 217-221 CrossRefView Record in Scopus 25 R. Liu, Y. Jiang Analgesic mechanism of Huatuo Jiaji points Zhongguo Zhongyi Jichu Yixue Zazhi, 14 (2008), pp. 943-944 [in Chinese] View Record in Scopus 26 H. Deng, X. Shen The mechanism of moxibustion: ancient theory and modern research Evid Based Complement Alternat Med, 2013 (2013), p. 379291 27 D. Cheuk, V. Wong Acupuncture for epilepsy Cochrane Database Syst Rev (5) (2014) CD005062 28 P. Yi, C. Lu, S. Jou, et al. Low-frequency electroacupuncture suppresses focal epilepsy and improves epilepsy-induced sleep disruptions J Biomed Sci, 7 (2015), p. 49 View Record in Scopus 29 F. Meng, C. Kao, H. Zhang, et al. Using electroacupuncture at acupoints to predict the efficacy of hippocampal high-frequency electrical stimulation in pharmacoresistant temporal lobe epilepsy patients Med Hypotheses, 80 (2013), pp. 244-246 ArticleDownload PDFView Record in Scopus 30 N. Yan, N. Chen, J. Lu, et al. Electroacupuncture at acupoints could predict the outcome of anterior nucleus thalamus high-frequency electrical stimulation in medically refractory epilepsy Med Hypotheses, 81 (2013), pp. 426-428 ArticleDownload PDFView Record in Scopus 31 X. Kang, X. Shen, Y. Xia Electroacupuncture-induced attenuation of experimental epilepsy: a comparative evaluation of acupoints and stimulation parameters Evid Based Complement Alternat Med, 2013 (2013), p. 149612 32 J. Guo, J. Liu, W. Fu, et al. The effect of electroacupuncture on spontaneous recurrent seizure and expression of GAD(67) mRNA in dentate gyrus in a rat model of epilepsy Brain Res, 10 (2008), pp. 165-172 ArticleDownload PDFView Record in Scopus 33 C. Liu, Y. Lin, H. Hsu, et al. Electroacupuncture at ST36-ST37 and at ear ameliorates hippocampal mossy fiber sprouting in kainic acid-induced epileptic seizure rats Biomed Res Int, 2014 (2014), p. 756019 34 E. Liao, N. Tang, Y. Lin, et al. Long-term electrical stimulation at ear and electro-acupuncture at ST36-ST37 attenuated COX-2 in the CA1 of hippocampus in kainic acid-induced epileptic seizure rats Sci Rep, 7 (2017), p. 472 35 G. Goiz-Marquez, S. Caballero, H. Solis, et al. Electroencephalographic evaluation of gold wire implants inserted in acupuncture points in dogs with epileptic seizures Res Vet Sci, 86 (1) (2009), pp. 152-161 ArticleDownload PDFView Record in Scopus 36 A. Klide, G. Farnbach, S. Gallagher Acupuncture therapy for the treatment of intractable, idiopathic epilepsy in five dogs Acupunct Electrother Res, 12 (1987), pp. 71-74 CrossRefView Record in Scopus 37 R. Clemmons PLA Bead treatment of refractory epilepsy in dogs. 2015 ACVIM Forum Research Reports Program J Vet Intern Med, 29 (2015), pp. 1257-1283 View Record in Scopus 38 N. Olby The pathogenesis and treatment of acute spinal cord injuries in dogs Vet Clin North Am Small Anim Pract, 40 (2010), pp. 791-807 ArticleDownload PDFView Record in Scopus 39 N. Jeffery, J. Levine, N. Olby, et al. Intervertebral disk degeneration in dogs: consequences, diagnosis, treatment, and future directions J Vet Intern Med, 27 (2013), pp. 1318-1333 CrossRefView Record in Scopus 40 N. Olby, N. Jeffery Pathogenesis and physiology of central nervous system disease and injury K.M. Tobias, S.A. Johnston (Eds.), Veterinary surgery: small animal (1st edition), Elsevier, Saint Louis (MO) (2012), pp. 374-387 View Record in Scopus 41 W. Liu, X. Wang, S. Yang, et al. Electroacupuncture improves motor impairment via inhibition of microglia-mediated neuroinflammation in the sensorimotor cortex after ischemic stroke Life Sci, 151 (2016), pp. 313-322 ArticleDownload PDFView Record in Scopus 42 J. Joaquim, S. Luna, J. Brondani, et al. Comparison of decompression surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits J Am Vet Med Assoc, 236 (2010), pp. 1225-1229 CrossRefView Record in Scopus 43 A. Hayashi, J. Matera, A. Fonseca Pinto Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs J Am Vet Med Assoc, 231 (2007), pp. 913-918 CrossRefView Record in Scopus 44 L. Janssens, E. De Prins Treatment of thoracolumbar disk disease in dogs by means of acupuncture: a comparison of two techniques J Am Anim Hosp Assoc, 25 (1989), pp. 169-174 45 A. Hayashi, J. Matera, T. da Silva, et al. Electro-acupuncture and Chinese herbs for treatment of cervical intervertebral disk disease in a dog J Vet Sci, 8 (2007), pp. 95-98 CrossRefView Record in Scopus 46 L.A. Janssens Acupuncture for the treatment of thoracolumbar and cervical disc disease in the dog Probl Vet Med, 4 (1992), pp. 107-116 View Record in Scopus 47 L.A. Janssens Acupuncture treatment for canine thoracolumbar disk protrusions Vet Med Small Anim Pract, 10 (1983), pp. 1580-1585 View Record in Scopus 48 L. Jun, X. Qiaoyu, Z. Le, et al. Effects of electro-acupuncture on Wnt-B-catenin signal pathway in annulus fibrous cells in intervertebral disc in rats with cervical spondylosis Zhongguo Zhen Jiu, 34 (2014), pp. 1203-1207 [in Chinese] 49 J.F. Innes, J. Melrose Embryology, innervation, morphology, structure, and function of the canine intervertebral disc J.M. Fingeroth, W.B. Thomas (Eds.), Advances in intervertebral disc disease in dogs and cats (1st edition), Wiley Blackwell, Ames (IA) (2015), pp. 3-7 View Record in Scopus 50 X. Wang, Y. Li, X. Ma, et al. Effect of acupuncture at cervical Huatuo Jiaji on type I and II collagen and pulpiform nucleus ultrastructure in rat degenerative cervical intervertebral discs Shanghai Zhenjiu Zazhi, 28 (2009), pp. 674-677 [in Chinese] View Record in Scopus 51 D. Jiang, Z. Lu, G. Li, et al. Electroacupuncture improves microcirculation and neuronal morphology in the spinal cord of a rat model of intervertebral disc extrusion Neural Regen Res, 10 (2015), pp. 237-243 View Record in Scopus 52 H. Han, H. Yoon, J. Kim, et al. Clinical effect of additional electroacupuncture on thoracolumbar intervertebral disc herniation in 80 paraplegic dogs Am J Chin Med, 38 (2010), pp. 1015-1025 CrossRefView Record in Scopus 53 C. Liu, F. Chang, C. Lin Retrospective study of the clinical effects of acupuncture on cervical neurological diseases in dogs J Vet Sci, 17 (2016), pp. 337-345 CrossRefView Record in Scopus 54 H. Sumano, E. Bermudez, K. Obregon Treatment of wobbler syndrome in dogs with electroacupuncture Dtsch Tierarztl Wochenschr, 107 (2000), pp. 231-235 [in German] View Record in Scopus 55 C. Dewey, R.C. da Costa Myelopathies: disorders of the spinal cord C. Dewey, R.C. da Costa (Eds.), Practical guide to canine and feline neurology (3rd edition), Wiley Blackwell, Ames (IA) (2015), pp. 345-353 View Record in Scopus 56 R. da Costa, J. Parent, D. Holmberg, et al. Outcome of medical and surgical treatment in dogs with cervical spondylomyelopathy: 104 cases (1988-2004) J Am Vet Med Assoc, 233 (2008), pp. 1284-1290 CrossRefView Record in Scopus 57 H. Xie, F. Rimar Effect of a combination of acupuncture and herbal medicine on wobbler syndrome in dogs and horses Z. Yang, H. Xie (Eds.), Traditional Chinese veterinary medicine-empirical techniques to scientific validation, Jing-tang Pub, Reddick (FL) (2010), pp. 101-112 View Record in Scopus 58 C. Zhang, Y. Ma, Y. Yan Clinical effects of acupuncture for diabetic peripheral neuropathy J Tradit Chin Med, 30 (2010), pp. 13-14 ArticleDownload PDFCrossRefView Record in Scopus 59 A. Garrow, M. Xing, J. Vere, et al. Role of acupuncture in the management of diabetic painful neuropathy (DPN): a pilot RCT Acupunct Med, 32 (2014), pp. 242-249 CrossRefView Record in Scopus 60 Bartosz C. Acupuncture: evidence-based medicine. In: 2003 consensus statement WHO official position. 2014. Available at: http://www.evidencebasedacupuncture.org/who-official-position/. Accessed April 20, 2017. 61 R. Kelly Acupuncture for pain Am Fam Physician, 80 (2009), pp. 481-484 View Record in Scopus 62 A. Hopton, H. MacPherson Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses Pain Pract, 10 (2010), pp. 94-102 CrossRefView Record in Scopus 63 A. Ozaktay, S. Kallakuri, T. Takebayashi, et al. Effects of interleukin-1 beta, interleukin-6, and tumor necrosis factor on sensitivity of dorsal root ganglion and peripheral receptive fields in rats Eur Spine J, 15 (2006), pp. 1529-1537 CrossRefView Record in Scopus 64 R. Sun, H. Wang, Y. Wang Effect of electroacupuncture with different frequencies on neuropathic pain in a rat model Zhongguo Ying Yong Sheng Li Xue Za Zhi, 18 (2002), pp. 128-131 [in Chinese] View Record in Scopus 65 J. Campbell, S. Raja, R. Miyer, et al. Myelinated afferents signal the hyperalgesia associated with nerve injury Pain, 32 (1988), pp. 89-94 ArticleDownload PDFCrossRefView Record in Scopus 66 M. Koltzenburg, H. Torebjork, L. Wahren Nociceptor modulated central sensitization causes mechanical hyperalgesia in acute chemogenic and chronic neuropathic pain Brain, 117 (1994), pp. 579-591 CrossRefView Record in Scopus 67 H. Torebjork, L. Lundberg, R. LaMotte Central changes in processing of mechanoreceptive input capsaicin-induced secondary hyperalgesia in humans J Physiol, 448 (1992), pp. 765-780 CrossRefView Record in Scopus 68 R. Melzack, P. Wall Pain mechanisms: a new theory Science, 150 (1965), pp. 971-979 View Record in Scopus 69 P. Barlas, T. Lundeberg Transcutaneous electrical nerve stimulation and acupuncture S.B. McMahon, M. Koltzenburg (Eds.), Wall and Melzack’s textbook of pain (5th edition), Elsevier, Philadelphia (2006), pp. 583-591 View Record in Scopus 70 Q. Xu, T.L. Yaksh A brief comparison of the pathophysiology of inflammatory versus neuropathic pain Curr Opin Anaesthesiol, 24 (2011), pp. 400-407 CrossRefView Record in Scopus 71 L. Yan, X. Wu, Z. Yin, et al. Effect of electroacupuncture on the levels of amino acid neurotransmitters in the spinal cord in rats with chronic constrictive injury Zhen Ci Yan Jiu, 36 (2011), pp. 353-356 379 CrossRefView Record in Scopus 72 C. Ma, C.X. Li, J.L. Yi, et al. Effects of electroacupuncture on glutamate and aspartic acid contents in the dorsal root ganglion and spinal cord in rats with neuropathic pain Zhen Ci Yan Jiu, 33 (2008), pp. 250-254 [in Chinese] View Record in Scopus 73 J. Park, J. Han, S. Kim, et al. Spinal GABA receptors mediate the suppressive effect of electroacupuncture on cold allodynia in rats Brain Res, 1322 (2010), pp. 24-29 ArticleDownload PDFView Record in Scopus 74 A. Vidal-Torres, A. Carceller, D. Zamanillo, et al. Evaluation of formalin-induced pain behavior and glutamate release in the spinal dorsal horn using in vivo microdialysis in conscious rats J Pharmacol Sci, 120 (2012), pp. 129-132 CrossRefView Record in Scopus 75 I. Choi, J. Cho, C. An, et al. 5-HT(1B) receptors inhibit glutamate release from primary afferent terminals in rat medullary dorsal horn neurons Br J Pharmacol, 167 (2012), pp. 356-367 CrossRefView Record in Scopus 76 X. Li, J.C. Eisenach α2A-adrenoceptor stimulation reduces capsaicin-induced glutamate release from spinal cord synaptosomes J Pharmacol Exp Ther, 299 (2001), pp. 939-944 View Record in Scopus 77 G. Gim, J. Lee, E. Park, et al. Electroacupuncture attenuates mechanical and warm allodynia through suppression of spinal glial activation in a rat model of neuropathic pain Brain Res Bull, 86 (2011), pp. 403-411 ArticleDownload PDFView Record in Scopus 78 D. Choi, J. Lee, E. Lim, et al. Inhibition of ROS-induced p38MAPK and ERK activation in microglia by acupuncture relieves neuropathic pain after spinal cord injury in rats Exp Neurol, 236 (2012), pp. 268-282 ArticleDownload PDFView Record in Scopus 79 A. Ashbury, H. Fields Pain due to peripheral nerve damage: a hypothesis Neurology, 34 (1984), pp. 1587-1590 80 G. Bove, A. Light The nervi nervorum: missing link for neuropathic pain? Pain Forum, 6 (1997), pp. 181-190 ArticleDownload PDFView Record in Scopus 81 M. Teixeira, D. Almeida, L. Yeng Concept of acute neuropathic pain. The role of nervi nervorum in the distinction between acute nociceptive and neuropathic pain Rev Dor Sao Paulo, 17 (2016), pp. S5-S10 View Record in Scopus 82 S. Lindley Acupuncture in veterinary medicine J. Filshie, A. White, M. Cummings (Eds.), Medical acupuncture: a Western scientific approach (2nd edition), Elsevier, Philadelphia (2016), pp. 651-663 View Record in Scopus 83 B. Zuo, W. Jin-hua, L. Jia, et al. The regulatory effect of different amount of zoletil combined acupuncture anesthesia on canine stress hormones-catecholamine Chin J Vet Sci, 33 (2013), pp. 1750-1753 View Record in Scopus 84 N. Ruas de SousaI, S.P.L. LunaI, M.L. Buffo de Cápua II, et al. Analgesia of preemptive pharmacopuncture with meloxicam or aqua-acupuncture in cats undergoing ovariohysterectomy Ciência Rural, 42 (2012), pp. 1231-1236 [in Spanish] 85 P.M. Coletto-Freitas, P. Wangles, J.R. Simões, et al. Electroacupuncture and morphine on cardiorespiratory parameters on cat elective ovariohysterectomy Rev Bras Sande Prod, 12 (2011), pp. 961-969 [in Spanish] View Record in Scopus 86 A. Laim, A. Jaggy, F. Forterre, et al. Effects of adjunct electroacupuncture on severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar disk disease J Am Vet Med Assoc, 234 (2009), pp. 1141-1146 CrossRefView Record in Scopus 87 R. Zhang, L. Lao, L. Wang, et al. Involvement of opioid receptors in electroacupuncture-produced anti-hyperalgesia in rats with peripheral inflammation Brain Res, 1020 (2004), pp. 12-17 ArticleDownload PDFView Record in Scopus 88 J.G. Lin, M.W. Lo, Y.R. Wen, et al. The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery Pain, 99 (2002), pp. 509-514 ArticleDownload PDFCrossRefView Record in Scopus 89 R.N. Cassu, S.P. Luna, R.M. Clark, et al. Electroacupuncture analgesia in dogs: is there a difference between uni and bi-lateral stimulation? Vet Anaesth Analg, 35 (2008), pp. 52-61 ArticleDownload PDFView Record in Scopus 90 B. Yang, Z.Q. Xu, H. Zhang, et al. The efficacy of Yunnan Baiyao on hemostasis and antiulcer: a systematic review and meta-analysis of randomized controlled trials Int J Clin Exp Med, 7 (2014), pp. 461-482 View Record in Scopus 91 Z.L. Tang, X. Wang, B. Yi, et al. Effects of the preoperative administration of Yunnan Baiyao capsules on intraoperative blood loss in bimaxillary orthognathic surgery: a prospective, randomized, double-blind, placebo-controlled study Int J Oral Maxillofac Surg, 38 (2009), pp. 261-266 ArticleDownload PDFView Record in Scopus 92 Z.L. Tang, X. Wang, B. Yi, et al. Evaluation of Yunnan Baiyao capsules for reducing postoperative swelling after orthognathic surgery Zhonghua Yi Xue Za Zhi, 88 (2008), pp. 2339-2342 [in Chinese] View Record in Scopus 93 Z.L. Tang, X. Wang, B. Yi Reverse-engineering-based quantitative three-dimensional measurement of facial swelling after administration of Yunnan Baiyao following orthognathic surgery Zhonghua Yi Xue Za Zhi, 88 (2008), pp. 2482-2486 [in Chinese] View Record in Scopus 94 J. Kruger, D. Dunning Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments J Pers Soc Psychol, 77 (1999), pp. 1121-1134 CrossRefView Record in Scopus 95 K.A. Burson, R.P. Larrick, J. Klayman Skilled or unskilled, but still unaware of it: how perceptions of difficulty drive miscalibration in relative comparisons J Pers Soc Psychol, 90 (2006), pp. 60-77 CrossRefView Record in Scopus 96 Y.H. Kim, C.Y. Chiu, J. Bregant Unskilled and don't want to be aware of it: the effect of self-relevance on the unskilled and unaware phenomenon PLoS One, 10 (6) (2015), p. e0130309 CrossRef 97 M. Memon, L.K. Sprunger Survey of colleges and schools of veterinary medicine regarding education in complementary and alternative veterinary medicine J Am Vet Med Assoc, 239 (2011), pp. 619-623 CrossRefView Record in Scopus 98 M. Memon, J. Shmalberg, H. Adair, et al. Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges Open Vet J, 6 (2016), pp. 44-56 CrossRefView Record in Scopus Disclosure: Dr H. Xie is one of the owners of Chi Institute of Traditional Chinese Veterinary Medicine and Jing Tang Herbal, Inc. Drs P. Roynard, L. Frank and M. Fowler have nothing to disclose. © 2017 Elsevier Inc. All rights reserved.