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Integrative Approach to the Diagnosis & Treatment of COMS/SHM (Caudal Occipital Malformation Syndrome/Syringohydromyelia) in Small Dogs
Introduction
Caudal Occipital Malformation Syndrome (COMS) & Syringohydromyelia (SHM) represent issues with alterations in fluid dynamics within the central nervous system (CNS) which is commonly seen in the Cavalier King Charles Spaniel but has also been observed in many other small breeds like the French Bulldog, Chihuahua, Pomeranian, Yorkie, Maltese, Japanese Chin, Brussels Griffon, and others.

Cause
In the late 1800s, Cleland described a condition in a child, but it was a Viennese pathologist, Hans Chiari, who described the cerebellar herniation under the foramen magnum which became known as Chiari malformation. Caudal Occipital Malformation Syndrome (COMS), also known as Chiari-like malformation with syringomyelia, was not described in dogs until 1993. This disease affects the spinal cord and sometimes the brain. The malformation leads to changes in CSF fluid dynamic and there are several theories as to how it evolves. Under normal conditions cerebrospinal fluid flows smoothly from the brain into the spinal cord. In this disease there is a pinching at the beginning of the spinal cord that causes abnormal fluid flow within the spinal cord and spinal cord lining (meninges). This results in a cavity of fluid within the spinal cord (syringomyelia). Another theory which seems to fit the data better is related to local hypertension which results in compression of spinal vasculature leading to localized edema which is driven by the cardiac cycle. This leads to progressive focal loss of the tissues in the spinal cord to cause syringomyelia. Regardless of the actual cause, the condition is progressive and while only 30% of patients show syringomyelia before 2 years, 70% or greater show large syringomyelia by the age of 5 to 7. This has prompted some to say that the diagnosis of “clear” should not be made in breeding stock until the age of 5.

Syringomyelia affects the part of the spinal cord (dorsal horn) that carries sensory information from the body to the brain. In COMS, syringomyelia may cause abnormal handling of this information leading to neuropathic pain; however, recent evidence suggests that the compression of the cerebellum and meninges at the foramen magnum are most responsible for the pain seen in COMS. The paresthesia caused by changes in the dorsal horn are related to the scratching episodes which are seen. This may explain the diverse nature of clinical signs. The most common sign of disease include pain manifested as spontaneous yelping out, yelping out when being picked-up, holding the head low, lethargy (as though there is a headache) and spontaneous, excessive itching of the ears and neck. Less common observations include weakness (paresis), incoordination/poor balance, episodes of weakness and poor balance, seizure, and an inability to blink. Because this defect exists at birth it may be hard for an owner to know what is truly normal for a particular patient. Many patients are asymptomatic throughout life, and it has been suggested that 95% of the Cavalier King Charles Spaniels show some degree of the defect. Some have suggested that this is an autosomal recessive trait, but, in my experience, the overall regulation of the bony structure development of the brain is more complicated than that explanation. Based on our clinical experience we believe that all dogs with COMS have some degree of discomfort or headache. This can be demonstrated by compression of Nao Shu and also the Jing Jia Ji which show evidence of neck discomfort. These tests are non-specific but do indicate a reason to look for a cause of their condition.

Diagnostics
The diagnosis is made by visualizing the defect with MRI (can also be seen on high resolution CT scans, but MRI is diagnostic of choice) and ruling-out other common diseases that can cause the same clinical signs. Because this defect is commonly identified and is not always the cause of significant problems, a spinal tap should be performed to rule out meningoencephalitis. From a TCVM perspective, these patients suffer from Jing deficiency which leads to varying degrees deficiency of Qi and Yin. In protracted cases, this may become yang deficiency. However, due to the presence of spleen qi deficiency, damp accumulates in the nervous system and leads to phlegm (tan). There is stagnation leading to pain, particularly in the head (Nao Shu) and in the neck (Jing Jia Ji). Since the syringomyelia can affect the entire spinal cord, there is also weakness and rear leg ataxia of focal pain in the lumbar region, as well. While none of these TCVM clinical signs are specific, they support the diagnosis and help in monitoring the effects of treatments.

Progression
The prognosis with this disease is good, especially with an early diagnosis and surgical intervention. The surgical intervention with foramen magnum decompression is probably best for the pain syndrome, but medical management is still necessary to control other clinical signs including paresthesia and hydrocephalus. All dogs will show progressive changes in the syringomyelia over time, and this can lead to progressive quadriparesis or paraparesis. This is sometime mis-diagnosed and degenerative myelopathy. That is one reason that asymptomatic dogs may eventually begin to show symptoms as other problems develop which compound the diagnostic challenge.

Treatment
Medical management of this condition is often with pain modulators like gabapentin (Neurontin) or pregabalin (Lyrica) for neuropathic pain, and other pain medication (opiates, NSAIDS or steroids) and medication to try to decrease fluid production such as steroids (prednisolone), omeprazole (Prilosec), and furosemide (Lasix). These approaches can be helpful initially but lead to long term complications and so TCVM herbal therapy and supplementation can help control patients long term. From a TCVM perspective, compounds which suppress internal wind may help the itching (Di Tan tang, Bu Xue Zi Feng or Yang Yin Zi Feng) may replace gabapentin. Licorice root extract (Gan Chiao) may replace prednisolone. Hydrocephalus formula may replace omeprazole. Finally, body sore may help with pain, in general. Of course, Epimedium powder will help astringe the Jing. Acupuncture helps in human patients and once report suggests that it also helps dogs with COMS/SHM. Most of these reports are based upon pain management, but scalp acupuncture and EA along the vagus nerve may also help generate endogenous neural stem cells to reduce glial scarring and disease progression.

I generally start with a decreasing dose of prednisolone at 1 mg/kg/day divided twice a day, then decrease to 0.5 mg/kg once a day in the morning and finally 0.5 mg/kg every other day in the morning. If all is going well, I will add licorice root extract to maintain the effect so I can stop the prednisolone. I add hydrocephalus formula to gradually reduce and replace the omeprazole. I will use a ½ dose of Epimedium powder and use one of the TCVM AED and body sore as needed. I also believe in using balanced antioxidants of vitamin E, vitamin C, beta carotene, vitamin B complex, gamma linoleic acid, omega-3-fatty acid, and selenium.

Surgery for this condition is called a foramen magnum decompression (FMD) and has the goal of alleviating the pinching of the spinal cord, smoothing out the flow of spinal fluid, and therefore eliminating the impetus for neuropathic pain and weakness. A FMD has a success rate of about 90% to improve or resolve the pain and weakness, although there is a reported recurrence rate as high as 25% following surgery.

Interesting result and may help animal patients, too.

http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1718-acupuncture-matches-drug-for-high-blood-pressure?platform=hootsuite

Acupuncture Matches Drug For High Blood Pressure Acupuncture provides advantages over medications for the treatment of hypertension.

Integrative Treatment of Dogs with Arthritis such as Canine Hip Dysplasia

Introduction:
Osteoarthritis associated with degenerative joint disease (DJD) is a common problem in all dogs, but particularly in large dogs who are susceptible to hip dysplasia (a genetic disorder of dogs controlled by 5 gene pairs). Even without a genetic predisposition in patients to arthritis, many dogs will develop joint disease for the same reasons that we as human beings do so. Often patients are overweight and the micro-traumas associated from carrying this extra weight takes its toll as the patient ages. One important aspect of the treatment of patients with arthritis is to reduce or maintain an ideal body weight. Most dogs in the United States are overweight due to dietary habits or from lack of exercise. It is clear from longevity studies in animals that lean body weight is associated with improved overall health and increased resistance to disease, including arthritis and cancer.

Dogs do develop immune-mediated joint diseases (Systemic Lupus Erythematosis, non-SLE immune joint disease and Rheumatoid arthritis), infectious joint diseases (Lyme disease, Rocky Mountain Stopped Fever, and septic joint disease), and traumatic joint diseases (ruptured anterior cruciate ligament and traumatic hip dislocation). The diagnosis of these diseases requires laboratory tests (CBC, Chemistry profiles, urinalysis, and immune tests), radiographs of the affected joints and joint fluid analysis. In some cases, special diagnostic procedures like bone scans, computer axial tomography (CAT scans) or magnetic resonance images (MRI scans) are necessary to make the correct diagnosis. In acute disease, traditional medical and/or surgical treatments can be extremely effective in providing relief and assisting in repair of the damaged joint. This is particularly true with traumatic disease. On the other hand, traditional therapy may fall short in the long-term control of immune-mediated joint disease and in the control of chronic degenerative joint disease. Even following surgical repair of acute lesions, the patient must still heal and will benefit from the principles of integrative medical therapy.

In dogs with a breed or familial predisposition for developing DID, regular exercise, good nutrition and supplemental support may moderate or forestall the development of joint disease. Once DJD does surface, the same principles can be use to treat and control the process of joint deterioration. This involves the use of anti-oxidants, anti-inflammatory compounds and chondroprotective agents. Western medicine powerful steroid medications which can reduce inflammation, but these drugs do possess many detrimental effects during long-term usage. In addition, steroids may reduce collagen synthesis, which delays healing. Non-steroidal anti-inflammatory drugs (NSAIDs) reduce inflammation by controlling prostaglandin production and reduce discomfort through their analgesic properties. On the other hand, NSAIDs increase stomach acid secretion and diminish the muscosal protective barriers, leading to gastrointestinal (gi) irritation and upset. Although many new medications have developed which have less gi side-effects, little data is available to show that NSAIDs actually delay the onset or progression of DJD. NSAIDs appear to be most useful in reduction of discomfort from joint pain. Many herbal products have anti-inflammatory properties similar to NSAIDs, yet do not appear to cause the same gi irritation, making herbal products ideal in treating DJD. While veterinary pharmaceutical preparation of chondroprotective drugs are available, there is no data to suggest that they are more effective than less expensive products available from health food stores. In fact, no chondroprotective drug may be more effective than supplementation with dietary cartilage (which contains the chondroprotective compounds and additional useful materials).
Treatment of Acute and Chronic Joint Disease:
Treatment of Acute Joint Injury:

All dogs may from time to time suffer from acute joint injuries (stretching of ligaments, partial tears of ligaments or sprains). These conditions are different from chronic DJD. Although the healthy dog diet and supplements may help these patients from developing injuries and speed their recovery from the injuries, nothing can specifically prevent accidental injury to joints. In acute lameness secondary to joint disease, rest is very important to minimize further injury in the acute phase. Rest should continue until significant healing has taken place, usually for a minimum of 14 days up to 6 weeks. To accomplish this may require kenneling the dog to enforce the rest. Walks should be limited to leash-controlled potty duties. Cold compresses may help minimize swelling and reduce pain and inflammation (this is the opposite of chronic DJD). One way to apply cold is to use bags of frozen peas which can be held in place with a loose "Ace" bandage. This should be applied for 15 minutes 2-3 times a day. Sometimes, application of moist heat following the initial and subsequent "cold" treatments (5-15 minutes after each "cold" treatment) will improve circulation and help rid the area of toxic metabolites. This can be done by placing a slightly moistened towel into the microwave (or oven) for a short period. The towel should be warm, but not so hot as to burn the patient. (Cautiously, test it on yourself. If you feel it is too hot, it is too hot for your dog. Don't burn yourself!!!)

In addition to "cold" and "heat" therapy, NSAID compounds may help reduce pain and inflammation. NSAID compounds should only be used for the first few days (3-5) when the inflammation is most acute. Aspirin (particularly enteric-coated, buffered aspirin) is usually well tolerated by dogs at doses of 1-5 mg/kg up to 3 times a day. This can cause gi upset and gastric bleeding in some sensitive dogs or dogs with inherited bleeding tendencies. Carprofen (Rimadyl) may also be a good NSAID product which dose not appear to have the same level of side-effects as other NSAID drugs. Acetaminophen (Tylenol) does not have an anti-inflammatory action and, therefore, does not help in acute joint injury (other than providing analgesia (never exceed 20 mg/kg/day since it can cause liver damage in dogs) Ibuprofen seems to cause (sometimes severe) gi upset much more frequently than aspirin and I do not recommend it for dogs. An alternative to the NSAID drugs with fewer side-effects is to use a cocktail of garlic powder, dry ginger and dry mustard (¼-1 teaspoon each, depending on your dog's size) 2-3 times a day with food. These can also be dissolved in a small amount of vinegar (1 teaspoon, mixed with 1 tablespoon of honey and diluted with an ounce of warm water) and given orally. Another natural NSAID compound which can be given is feverfew (see below).

If your dog's lameness does not improve rapidly in a few days or worsens, see your veterinarian for proper diagnosis and additional therapy. Some acute joint injuries require surgical correction. Others may need specific therapy. On the other hand, if the resolve quickly, the injury was likely to be self limiting. Recurrent symptoms could indicate a chronic disease process.

Prevention of DJD:

The methods of prevention of arthritis are based upon the principles of exercise and dietary measures useful in maintaining health in all dogs. Of these components, antioxidants and membrane stabilizers are most important. Vitamin C is necessary for normal bone development and may stabilize the vascular supply to healthy bones and joints. Tofu has phytoestrogens which improve bone development and calcium incorporation into the bone matrix. Garlic, ginger and mustard provide anti-inflammatory actions to minimize micro-traumas during the life of the patient. In those dogs who have a genetic predisposition to DJD, the addition of dietary cartilage and Perna mussel (see below) as dietary supplements may provide additional chondroprotection to minimize genetic influences. While it is not always possible to prevent genetic diseases, reducing their impact may allow the patient to lead a longer, desease-free life.

Therapy for Active DJD:

Feverfew:

Feverfew is a natural NSAID compound without the side-effects of prescription drugs. It can be used in dogs with pain or arthritis to help reduce inflammation and discomfort. I do not recommend it for routine use; but, if your dog has pain from arthritis, give 1 capsule every 8-12 hours as needed. You can use this for 5 days out of the week, safely.

Dietary Cartilage:

In many cases of DJD with arthritis, recent studies have suggested that glycosaminoglycans and chondroitin sulfate may help reduce pain and inflammation from osteoarthritis, assisting in the healing process. While these products are available through health-food stores or a pharmaceutical medication through your veterinarian, you can give these to your dog directly by giving cooked cartilage. Sources of dietary cartilage would included cooked and "de-bone" chicken wings or using cooked spare ribs as the meat source in the diet. Why pay for cartilage products if it can be gotten for free in the dietary source. Some people taught the benefits of shark cartilage, but there are no scientific studies to support these claims. (It is also ecologically unsound to kill sharks to harvest their cartilage.) On the other hand, increase dietary cartilage can do no harm, particularly in the face of arthritis. In patients with arthritis, I recommend 1-2 grams of dietary cartilage with each meal. Another alternative is bovine gelatin (Knox gelatin or Knox Nutrajoint) which can be added to the food (1-2 packages per feeding). In some dogs, using glucosamine/chondroitin sulfate complex will be beneficial in controlling joint pain and stimulating healing; however, dietary cartilage has these compounds along with other important ingredients. Forms of glucosamine/chondroitin sulfate complex are available at health food store. (These are cheaper than products available from your veterinarian and may work as well) I recommend around 1200 mg of glucosamine and 1500 mg of chondroitin sulfate daily, if other forms of cartilage are not available.

Perna Mussel:

The marine bivalve mussel, Perna canaliculus, has been used to treat DJD for many years. This mussel contains many bioactive compounds, including glycosaminoglycans, an anti-iflammatory component and an antihistamine compound. In a number of scientific studies, Perna mussel has been shown to reduce the inflammation of rheumatoid arthritis and DJD of the stifle. While the exact mechanism for this beneficial effect in arthritis is not known, it may be due to the unique combination of complex proteins, glycosaminoglycans, amino and nucleic acids and chelated minerals which it contains. It seems to enhance the regenerative capacities of joint chondrocytes, regulating the chondroitin sulfates and hyaluronic acid production needed to maintain healthy chondrocytes. Perna mussel is available a most health food stores (Sea Mussel by FoodScience or green lipped mussel). I recommend that this be given based upon the recommendations for human beings. In small dogs, reduce the amount by one-third. Perna mussel is also available as a veterinary pharmaceutical (Glyco-Flex) which can be obtained from your veterinarian. The dosage of Glyco-Flex is 1 capsule (contains 300 mg of Perna mussel) for every 15 lbs of body weight per day, divided into 2 or 3 doses.

Bromelain/Curcumin:

Bromelain is an extract of pineapple stems which has the property of decreasing circulating immune-complexes. As such, there is no Western medicine which is its equal. Since many of the complications and the direct initiation of the immune damage may be caused by the elevated immune-complexes in some forms of DJD, bromelain may be an important key in helping to control the progression of DJD. Curcumin (the yellow pigment of turmeric plants) is a potent anti-inflammatory agent. Bromelain and curcumin have a synergistic effect whereby they assist the absorption of each other from the gastrointestinal tract, increasing their potency. As such, they should be given together. Many health food stores carry combinations of bromelain and curcumin. For dogs with DJD, give 400-500 mg of bromelain with 500-400 mg of curcumin twice a day. (Curcumin is found in low concentrations in the spices turmeric and yellow mustard. As such, it is possible to replace the "capsule" form by adding 1-2 Tbs of turmeric and 1-2 tsp of dry yellow mustard to the diet.)

Carrot/Pumpkin Herbal Cupcakes

Use Betty Crocker Carrot Cake Mix and follow directions to make the cake mix including the egg and oil, but do not add water. To the dry ingredients add the herbal you want based upon how much you need. The box says that you can make about 24 regular cupcakes or 48 mini-cupcakes for the recipe. So, you will need to add the amount of herbal needed based upon how many cupcakes you want to give. For example, if you have a 60 lb dog and want to make regular cupcakes give one cupcake per dose, you take the dose (plus 20%) to be in each cupcake. So, this would normally be 0.5 gm/10 lb body weight. Or you need 3 gms per cupcake (plus 20%) which is 3.6 gm per cupcake. The whole recipe needs 24 X 3.6 or 86.4 gm. The scoop is 2 gm so you need 43.2 scoops (round it to 44 scoops) to make the cupcakes in the concentration you want. For mini-cupcakes, the calculation is the same, but times 48. So for the same example you would need 172.8 gm in the batter to have 3.6 gm per each mini-cupcake (about 87 scoops). Once you have mixed the dry ingredients (cake mix and herbs), then add the wet ingredients. Add one 15 ounce can of pure pumpkin puree and mix. Add small amount to water to get the consistency of batter you need. Bake as normal. If you need to, then you can top with softened cream cheese and bacon bits. Just remember that this does have calories and you probably should reduce the food ration accordingly. This is one way to provide something which is good for the GI tract and at the same time allows easy medicating with even the nastiest tasting herbals.

http://animalwellnessmagazine.com/feeding-your-dog-from-a-tcvm-perspective/ While is is a simple overview, it is a good rationale for the principles. Interesting that it appeared just as the Chi Institute Food Therapy Course is being taught.

Feeding your dog from a TCVM perspective | Animal Wellness Magazine Traditional Chinese Veterinary Medicine (TCVM) teaches that foods affect the body in multiple ways. Feeding your dog using this approach can enhance his well-being. Food ...

http://www.healthcmi.com/Acupuncture-Continuing-Education-News/1468-acupuncture-point-microstructure-discovery

Acupuncture Point Microstructure Discovery The structure of acupuncture point LU11 has been discovered. Researchers used microscopy to learn about the anatomical makeup of this point.

Check out our lecture on pain mechanisms!

http://dog2doc.com/ap_pain/scientific_basis_of_pain.htm

The Dog2Doc Pain Video Providing information about pain management in neurologic patients.

Check out our Neural Imaging lectures.

http://dog2doc.com/neural_imaging/neural_imaging.htm

The Dog2Doc Basic Neural Imaging Providing information about neural imaging (radiography, CT scans & MRI) to help work up neurologic patients.