Wednesday, February 15, 2017

Rehabilitating the Sport Horse (PNER Convention Notes)

The following is the write-up based on notes taken by the presentation given by Sara Sammons, DVM, MS at the 2017 PNER Convention.

I know Dr. Sara Sammons from when Deli and I lived in Davis, CA (where I attended undergrad and lived for many years afterward, and where Dr. Sammons attended vet school). I actually was fortunate enough to board Deli the same place Sara had her sweet gelding, Dave. This was in the early days of my Deli ownership – about a year and a half in and just after Deli had returned from 30 days under-saddle training. It was at that barn that Deli and I could finally settle into some training and truly form our bond, which up until that point had been unreliable. I made some great friends at that barn – Sara included – and I have never boarded someplace since where I felt that sense of community. Then a vet student, Sara helped me out with the antibiotic injections Deli needed when she sustained a puncture wound to her leg and I had to leave on a trip. Deli was an absolute monster for her (she was bruised from so many injections, so its not entirely her fault) but Sara never held that against her!

I sometimes regret moving up to Oregon simply because I left behind a barn where Deli and I felt safe. At the same time – even though boarding in Oregon has often been a nightmare – I’ve made SO many new friends and have joined the awesome PNW endurance community here.

Imagine my delight when, many many years later, Dr. Sara Sammons moved into our area! Now Dr. Sammons is helping Deli with her rehabilitation for kissing spines and her related conditions. Deli is a very particular horse who can be suspicious and tense around strangers. She absolutely moves to have Sara work on her though – whether it be chiropractic adjustments or acupuncture. I’d highly recommend her for rehabilitation work, since that’s what she specializes in. I think she is particularly good for horses (like mine) who need a calm, gentle, presence. Deli is super chill when Sara works on her.

If you would like more information about Dr. Sammons and her rehabilitation business with her partner, check out her website Lavender Equine Veterinary Rehabilitation Services. They also do work on small animals (cats and dogs)!

Common sport horse injuries include:
Hoof injuries – bruise; crack; laminitis, etc.
Soft tissue injuries – muscle strains & tears; tendon & ligament strains & tears; cartilage and meniscal damage.
Bone injuries – arthritis; exostoses (popped splints fit into this category); bone bruises; fractures; cysts/developmental orthopedic conditions (these are usually not injury-related).

Why do we need these therapies? And which therapies are used for particular conditions?
Essentially, your treatments may vary widely depending on the rehabilitation needs and original problem! There are several general ways people approach rehabilitation. First, some folks turn their horse out for basic pasture rest (the “turn them out” method). This assumes you have a specific kind of herd where your horse stays quiet and won’t aggravate whatever injury they have. Basic rehab can also be done at home. This includes rehab work like hand walking, or even the exercises I’ve done with Deli during our many many rehabilitation stints. With at-home rehab it is sometimes harder to evaluate the progress. When rehabbing at a rehab facility it is usually more expensive but usually has faster healing and there are multiple modalities available to the horse (and usually professional application of those modalities). The key is that the facility is on a controlled program.

Common modalities used in rehabilitation and injury treatment:


Supportive pressure wraps – increased pressure to reduce edema formation. The warmth will also increase blood flow to the area. It also offers some degree of support for damaged tissue depending on structure of bandage. These wraps are good for use for the first week to first month of injury. You will decrease the frequency that you wrap over time to wean them off.

Cold therapy – it decreases pain and decreases blood flow to the area (which can have pro-inflammatory enzymes to the area, decreasing inflammation), decreases tissue extensibility (meaning it makes the tissue stiff). Cold therapy is something important to do right when the injury began (especially the first 24 hours). Repeat 2-4 hours for first 24-48 hours to reduce inflammation & edema, Cold therapy is only effective to a depth of 1-4cm of skin surface (so it’s really good on their lower limb). Cold therapy includes tools like: cold hosing, ice boots, gel packs, and ice water machines (game ready machines – which are expensive but also have the benefit of putting pressure/massaging the leg along with the cold therapy). 

For at-home treatments, horse owners also use ice and alcohol (50:50) ziplock baggies (a way to make your own gel packs – you can also add dish soap to make it squishier!). Application of cold therapy for 10-15 minutes is usually needed for tissue temperatures are around 50-60 degrees. After about 15 minutes, cycles of vasoconstriction & vasodilation occurs (this is the warm tingling when hands are cold long-term) that will bring more circulation to the area. Horses have vascular shunts in their lower limbs – this is how they can stand in snow without getting frost bit – but target tissues will still be chilled by the outside cold.

Heat therapy – It increases blood flow, increases metabolism (increasing activity of tissues enzymes); it relaxes muscle spasm (decreasing firing of muscle spindles, breaking any cycles of pain-spasm-pain); it also makes their tissues more extensible (stretchy). It’s important to be careful when applying heat, as you don’t want to scald or burn your horse! One suggestion for a homemade heat pack is to put uncooked rice in pillowcase and warm it up in a microwave. These are great for draping over backs.

Manual therapies (getting hands on)
  • Passive range of motion is movement within the normal confines of the joint. You must ensure support of other structures. This modality will not increase strength and endurance and it will not prevent muscle atrophy. The indications are when you are worried about contracture of a muscle or tendon; it will maintain elasticity, assists, circulation, and increases awareness of limb in space. The idea is to go to the point of tension and then stop.
  • Active range of motion is where the horse is doing it themselves (often with cookies!).  The horse moves its own joints within the comfortable range. Hand walking is an example of active range of motion. Range of motion can be increased depending on the surface – for example some horses will pick their legs up more when walking over a novel surface or poles. This maintains some coordination and balance.
  • Passive and active range of motion is NOT the same as stretching! If you hold the active range of motions longer you can build up supporting muscles.

Stretching
Indications for stretching are: to improve reduced range of motion (ROM); increase flexibility; lengthens tight muscles (important – opposing weak muscles will strengthen as well); to prevent dysfunction and injury. Tight muscles lad to abnormal bio-mechanics.

There are passive and active stretching. In active stretching the horse is doing it themselves. There is controversy with stretching – some folks say not to stretch more than 2 joints at a time. 

How to stretch
  • Move slowly through the range of motion to point of tension-restriction (or just before)
  • Hold the stretch for 15-30 seconds ideally (though you may not be able to get that from day one)
  • Only stress one joint at a time (over-stretching can occur otherwise, soft tissue injury, nerve irritation)
  • Repetition is important – give the horse the opportunity to stretch even further.
  • Daily stretching may be too much and stretching when they are warm (after exercise) is the better way to go.

Joint mobilization – the restoration of “joint play”, safe stretch of joints, breaks down adhesions, restores normal joint mechanics (some patients cannot stretch!), decrease joint stiffness, and pain reduction. Joints and bones van get slightly out of place, and if they are re-aligned then the joint will have greater range of motion. Mobilization is a combination of rolling the joint, compression and traction. It can also move synovial fluid around and increase intra-articular nutrition.

You practitioner must be knowledgeable about equine anatomy to do this properly! Otherwise traction and rotation of a joint can be harmful. You also need to know if there are torn supporting structures in the joint – if so, you don’t want to mobilize that joint or you can cause more damage to the area.

Chiropractic – adjustment involves joint manipulations plus the additional gentle thrust at the limit of range of motion. 

Promoting Tissue Repair


Some modalities can accomplish multiple goals! These can include:

Acupuncture!
Acupuncture – you put needles in near nerves that need to be stimulated. Blood vessels dilate, blood flow increases; it can also improve lymphatic flow. Segmental analgesia provides reduced response to pain in particular areas as well as entire body. This process calms through autonomic nervous system stimulation. You can also affect organ function through acupuncture points.

Which horses benefit from acupuncture? Those with nerve deficits (EPM, head shaking, facial nerve paralysis). Those with back pain (from muscle, bone & connective tissue problems), because the acupuncture increases blood flow and calms nerves that are hyper-active in the back. Chronic colic is also assisted by acupuncture (especially spasmodic colic, gas colic).

Electrical stimulation/TENS – With this modality, you can add electrical stimulation to your acupuncture needles. It can pack a bigger punch than just needles by themselves. TENS units themselves require clipped hair to attach to the needed area, which can be awkward. this method can be very good for very superficial issues (such as superficial nerve issues). 

Therapeutic Ultrasound – this therapy not the same as the ultrasound used to diagnose injury. Therapeutic ultrasound sends pressure waves into where you point it. It helps wounds heal by increasing protein synthesis, fibroblast proliferation, etc. This therapy does not go very deep. There are different modes to the machine for heating vs. not heating. In addition, this therapy needs to be repeated routinely if you want the beneficial effects.

One of the best uses for therapeutic ultrasound is to help break up calcified structures in tendons.

Laser – How does it work? Stimulates cell function, by photochemical means (not being thermal like surgical lasers are). What does it do? Laser therapy releases endorphins, bradykinins to provide analgesia, increases metabolic rate in tissues, and improves nerve regeneration.

Disadvantages to laser therapy include: the cost is high, patient/practitioner and owner safety (class 4 lasers you definitely need goggles for to protect your eyes), inability to penetrate through hair, dark skin (only 2% on laser may get through a dark-skinned animal), and it may not penetrate to deep tissues. Skin color is actually very important for a horse so surgical shaving of the treatment area is important!

Extracorporal Shockwave Therapy – This therapy can help break down scar tissue! Essentially this modality is supersonic acoustic pressure waves cause a pressure bubble when they impact tissues.  This pressure bubble has an effect on those tissues: it causes micro-trauma which forms new blood vessels to trigger of body’s natural healing mechanisms and repair. This is great for suspensory injuries at the top of the suspensory.

Other things of note regarding shockwave therapy:
  • Requires sedation – it does hurt during the therapy (and can be loud)!
  • Provides analgesia to the area (which can have risk of abuse)
  • Recommended 1-3 treatments at approximately 2 week interval.
  • Can also help with kissing spines – especially if a horse has pain there.
  • Bone pain and navicular disease.
  • This treatment is effective in backs.

Restoring Function


Restoring function to the equine athlete is all about getting them back to a level of work and comfort.

Suppling exercises (circles & lateral work) and theraband/equicore use (as a strengthening mechanism) are examples of tools that can be used to help restore function. The Theraband has been a primary tool in Deli's current rehabilitation! Cavaletti exercises are also great because you are increasing range of motion and they are also proprioception exercise. Doing exercises that help the equine figure out balance, such as varying surfaces, or putting cat collars with bells/bell boots on their feet to get them to step higher can be useful.

Deli in her Theraband early on in the rehab.
Water therapy – Water therapy claims to help restore function. This is different than swimming – instead picture a horse on a treadmill in different water levels (the water level can be adjusted depending on the animal’s needs). Water therapy claims to reduce stress on limbs by reducing weight-bearing 40-60% and reducing impact on limbs. Water therapy proponents also claim that water therapy can reduce recovery time by 50-60%, that the hydrostatic pressure reduces swelling and assists with blood flow, improves conditioning and increases cardiovascular fitness (by the water providing resistance to their movement – it’s a workout!). Flexibility can also be improved by water therapy.

Underwater treadmills are the primary aquatic therapy. The water level can be easily adjusted depending on the animal’s need. The primary uses for underwater treadmills are for tendon injuries, arthritis, and conditioning after layup.

Swimming pools are used for horses as well, but swimming is not a super natural things for equines and the only real benefit to them swimming regularly are cardiovascular benefits. Horses have to move aggressively when swimming, so it’s not recommended for many injuries (especially back issues). There is also a risk drowning. And as endurance riders know, cardiovascular fitness is not the same as bone/tendon/tissue fitness!

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