Equine Sports medicine Flashcards
Goals in sports medicine?
- MAximising performance
- Minimising injury
- Optimising recovery
How to we start to investigate poor performance?
- Comprehensive history
- Presenting complaints discipline dependent
- Often requires: repeated CE; eval ono soft and hard surface, lunge, flexion, ridden assessment ; ancilliary diagnostics
Why is poor performance complex?
Multiple body systems involved often (91%)
Causes of poor performance?
- Lameness tends to be most common cause, followed by resp dx
- Some evidence Gi ulcers big imapct on perf
- Mechanisms multifactorial
How to measure poor racing performance?
- Days lost from training (Dyson et al 2008)
- Race performance analysis (Wilsher et al 2006)
- Rates of death
How to measure poor reprod performance?
Proportion of coverings which did not lead to progeny which
raced within first 4 years of life
Measure of poor performance in equestrian sports?
- Rates of retirement
- Failure to re-register with British Eventing (O’Brien et al 2005)
- Number of horses achieving certain grade or status within
discipline. - Injury statistics
T/F Lameness is the msot common condition in fays mossed from training ?
True
Incidence fo lameness in racing?
20% of all days availabel for trainign lost due to lameness
Most common cause of lameness?
Stress fracture
Why do we need to research lameness more in poor performance?
- To identify training regimens that minimise risk of fracture and joint injury
and the effects of training and racing surface on injury risk - Into the potential interactions between genetic and environmental factors
What are some ethical issues to consider?
» Confidentiality
» Conflicts of duty
» Patient Autonomy – Possible if patient an animal?
» Unrealistic expectations of treatment
» Use (and abuse) of medication
» Rationale for treatment
* Excessive treatment versus routine maintenance of elite athletes
In terms fo welfare when we lack evidence what should we do?
Act as an advocate for the animal
Evidence Based Medicine - is it always possible?
» Not always possible!
» Often small numbers
» Poor quality studies common (few randomised controlled studies)
» Lack of evidence basis for treatments not uncommon in sports
medicine in particular
» This doesn’t make it impossible to make good clinical decisions!
Describe use of Iron Tonics
» Commonly used for anaemic or slightly ‘under the weather’ horses
» Nutritional Iron deficiency = very rare in horses
If a horse is anaemic is primary iron deficiency likely the cause?
NO
* Anaemia of inflammation (Anaemia of Chronic Disease)
* Systemic Iron stores are normal to increased, but altered iron mobilisation. Oral iron not indicated
* Underlying disease > Investigate!
How should we approach anaemia ?
Ensuring adequate vit & mineral supply (good balancer) NOT with iron supp
Use of Turmeric?
» Reported benefits of curcumin:
* Anti-inflammatory, Anti-oxidant, Anti-microbial, Hepato-protective, Anti-ulcer
» Bioavailability
Decision making factors for therapeutics in joint dx?
- Clinical signs/degree of lameness
- Joint involved (high versus low motion)
- Stage of OA/synovitis
- Current & intended use/discipline
- Regulations (FEI,BHA)
- Timing (detection times, competition)
- Cost
- Client
- Age
- Response to therapy
What options for intra-articular steroids?
» Anti-inflammatory, Chondroprotective properties
» ‘Steroid arthropathy’: Overuse of a pain-free joint > accelerated degeneration?
* Negative effects on chondrocyte metabolism
» Triamcinolone acetonide
» Methylprednisolone acetate (MPA)
* More deleterious effects > use only in low motion joints?
What CONSIDERATIONS with intra-articular steroids?
- Type? dose? frequency?
- With hyaluroan?
- Local for diagnostics? inc risk of infection?
- Duration of rest?
- Precautions to prevent sepsis?
What is the purpose fo physical therapy?
The restoration of movement and fucntion
What must physical therapy tx plan be based on ?
ACCURATE diagnosis & high quality diagnostic imaging
What does RCVS say?
» The Veterinary Surgeons (Exemptions) Order 2015 allows the treatment of an
animal by physiotherapy if the following conditions are satisfied:
1. The person providing the treatment is aged 18 or over
2. The person is acting under the direction of a qualified person who
a. Has examined the animal, and
b. Has prescribed the treatment of the animal by physiotherapy.
WHO is a qualified person?
a person who is registered in the Register of Veterinary
Surgeons or the Supplementary Veterinary Register.
What does physiotherapy incorporate?
Osteopathy & chiropractic
What should equine physio be part of?
» Practitioners ideally members of the Association of Chartered Physiotherapists in Animal Therapy
ACPAT members:
» Are registered with a professional body (Chartered Society of Physiotherapy) and adhere to
regulations and Standards of Practice
» Maintain up to date knowledge through Continuing Professional Development (CPD)
» Exercise clinical reasoning and judgement in the treatment of animals
» Work with veterinary referral in accordance with the Veterinary Surgeons Act.
» Have professional and public liability insurance
What are some other organisations with physio?
- Register of animal MSK PRactitioners (RAMP) -> voluntary register for animal MSK practitioners
- British Veterinary Chiropractic Association (BVCA) -> Members must either be vets registered with RCVS OR chiros reg with General Chiropractic council => must have passed exams with IVCA
Osteopaths?
Must be human osteopath with further training in animal osteopathy
What are the different physio techniques?
» Hands on techniques: eg manipulation, massage, myofascial release, trigger point release…
» Electrotherapy: eg therapeutic ultrasound, laser, TENS, etc…
» Exercise therapy: eg rehabilitation programmes, core stability exercises, sport specific training, hydrotherapy…
» Invasive treatments (eg acupuncture) not permitted unless performed by a vet
What are some stretches we might do for horse?
Describe what chiropractic is?
“Use of controlled forces which are applied to specific joints or anatomical regions to induce therapeutic responses through induced changes in joint structure, muscle function and neurological reflexes”
→ Joint mobilization and manipulation to restore function
How do we plan a tx program?
What to do in the Acute phase?
- NSAID
- Corticosteroids contraindicated in ST injuries!
- Support (bandage)-
- Diagnostics - US 1 wk post injury
- Rest
- Cold Therapy
What is the use of rest?
» Reduce force and strain on tissue
→enables repair
» Complete Immobilization
* Cast?
* Internal fixation?
* Splint and RJB?
» Box rest
* Reduce energy content of diet
* Clean, well-ventilated stable which enables visualisation of other horses
* Well tolerated in general
‘Paddock rest’?
» Following box rest + hand-walking
→Ridden walk often preferable to paddock rest as more controlled
» Risk of re-injury at turnout
* Small Paddock first? - 6 x 6 metres
* First time they are turned out:
* Sedation?
* Protective boots
* Avoid bad weather conditions
Cold therapy in the acute phase -> benftis?
Reduced local circulation, tissue swelling and pain sensation
» Rebound vasodilation (cycles of vc and vd after cold hosing) can help to resolve oedema
» Most effective in early period following injury or surgery (24-48 hrs)
Pathophys of cold therapy?
Indications for cold therapy?
Indications:
* Acute soft tissue injuries
* Acute laminitis: Decreased
activity of laminar matrix
MMPs; laminar
vasoconstriction
How to admin Cold therapy?
» 15-19°C most effective
» ~20-30 minutes
» Repeat q2-4 hours for first 48-72
hours, then reduce frequency
Chronic Phase program?
- Exercise program
- Physio/chiro
- Adjunct therapies (heat therapy, US , TENS, laser, Shock wave, Acupuncture, Hydro)
Detail IMPORTANCE of exercise portion of program?
» Vitally Important component of
rehabilitation
» Tissue healing after injury:
* Inflammation
* Proliferation
* Maturation
» Rate of healing linked to intrinsic properties
of the injured tissue
What different ‘exercise’ options?
- PAssive
- handwlking
- Ridden walking
Detail passive exercise?
» Joint mobility immediately following joint surgery
» Reduction of post-op immobility
» Reduction of adhesions
» Joint is flexed just to the position that produces discomfort
* e.g 15-20 times BID 30 days
Detail hand-walking?
» Often done while horse is still on box rest – consider
temperament
» Begin with 5-10 minutes and slowly increased by 5 minute
increments weekly
» Can be done on horse walker for some injuries
» Need consistent surface
What muscle injuries may we see?
» Direct trauma: laceration, contusion, strain
» Indirect: ischaemia, neurological disfunction
How does a muscle injury behave over time?
» Muscle regeneration 7-10 days after injury
» Peaks at 2 weeks
» Decreases 3-4 weeks after
» Scar tissue formation (fibrosis) begins 2-3 weeks after injury
How should we manage a muscl einjury?
» Immobilization for 4-7 days after injury
* Avoid rupture of muscle fibres in acute phase healing
» Introduce controlled exercise program
How long do muscl einjuries take to heal?
» Minor injuries: heal within 4 weeks
» Severe injuries: take months
How do bone injuries progress?
How do tendons & ligs heal?
After injury tenocytes migrate to injury site from adjacent tendon and ligament cells and via blood supply
» Collagen synthesis initiated
* Fibres orientated perpendicular to long axis
What are the PHASES of Tendon & lig healing?
- Acute phase 1-2wks => aim to limit & resolve inflammation. cold hosing & compression
- Sub acute phase 2-6wks=> Controleld exercise with US monitoring
- After 6 weeks => contorlled exercise regime , modelling & remodelling, collagen orientation becomes parallel
What does ultimate maturation depend on ?
Appropriate loading
unstressed collagen =
remains haphazard in organisation and is weaker
How to balance exercise loading in chronic phase
- Promote orientation and remodellign of collagen and quality of longitudinal pattern linked to prognosis for return to work but excess loadfing will delay ro disrupt healing process
If CSA increased by > ..% ….
> 10% -> exercise level should be reduced
horses rested for less than … months have a … prngosis
<6 months => poorer prognosis
Indications for heat therapy?
» Chronic stage of soft tissue injury
» Joint injury/ osteoarthritis
» Nerve injury
» Only use after acute inflammation
has subsided
» 40-45°C produces best effects
Superficial vs deep heat?
Superficial heat
» Hot pack
» Hydrotherapy: Hose, wet towel, water immersion
» Blanket
» Circulating treatment
Deep heat
» Therapeutic Ultrasound
Benefits of therapeutic US?
- Stimulating healing, pain relief, reduction of tissue oedema and reduction of fibrous scar tissue
- Sound waves results in micromassage of the tissue and acoustic steaming of fluids and ions
How does therapeutic Us work?
» Different frequency range to diagnostic ultrasound
» Raises the temperature of deeper soft tissue structures
» Wound healing, tendon and ligament, oedema, nerve injuries.
No effect on bone.
Detail use of TENS (Transcutaneous Electrical nerve stimulation)
» Provides pain relief via segmental inhibition through pain gaiting mechanisms
» Secondarily can stimulate central release of opiate-like substances →inhibitory effect on pain
» Uses: pain relief (acute or chronic), muscle stimulation, stimulation of de-enervated
muscles, oedema reduction, wound healing
What is the effect of Laser therapy?
Antiinflamamtory & analgesic effects
How does it create this?
- Stimulation of cellular metabolism
- Activation of mitochondrial calcium channels
- Upregulation of ATP production and synthesis
- Increases fibroblast activity
- Increases cellular division/ fibroblast migration/production of cellular
matrix
Complications of Laser ?
Overheating tissues, damage to operator’s cornea
used of Laser therapy?
» Performance maintenance » Prevention of re-injury » Synergistic with PRP or stem cell treatment » Tendon and Ligament Injury » Chronic joint disease * Synovitis/osteoarthritis » Back pain/injury » Wound healing » Pain relief » Neurological injuries » Alternative to acupuncture?
How does Extracorporeal Shock wave therapy work?
Overall => ↓ inflammatory mediators, ↑ cytokines resulting in vessel proliferation, ↑ growth factors, ↑ osteoblasts
and recruitment of mesenchymal stem cel
How do we administer Extracorporeal Shock wave therapy?
» Requires sedation due to discomfort
» Approximately 3 treatments given at 2-3 week intervals
» Analgesic (peaks at 48h post tx)
» Good tissue contact: Clip hair, clean site, gel ++
Indications for ESWT?
- Tendon or ligament injuries (eg PSLD)
- Bone/non-healing fracture
- Back pain
How can acupuncture be done? & how does it work?
» Traditional Chinese medicine versus Western approach
» Western medicine theory: Acupoints in areas with a high density of free nerve endings, mast cells, small
arterioles and lymphatic vessels.
» Stimulation > release of beta-endorphins, serotonin and other neurotransmitters.
Effects of Acupunture?
» Local: stimulate nerve fibres to increase blood flow
» Segmental analgesia: reduces response to painful stimuli
Uses of Acupuncture?
» Maintenance of performance
» Cervical, thoracolumbar and lumbosacral pain
→ treat muscular spasm or “ trigger points”
Hydrotherapy use?
- OA, geriatric, neurological, overweight and weak patients, soft tissue injury of the distal limb
- Depth of water can be adjusted/gradually increased
How do we PREVENT injury in sports horses?
- Appropriate shoeing
- Avoid working on surfaces that are incosistent, too deep/soft or too hard
- Warm up and coll down
- Good fitness
- Good conformation
- Goot nutrition
- Constant monitoring
