Rehabilitation for horses with soft tissue injuries

Question 1

Aims of rehabilitation

Answer 1

• Hasten return to function following injury
• Improve function of the structure involved
• Reduce pain and inflammation
• Reduce re-injury rates
• Improve quality of life
• Improve range of motion or flexibility
• Improve proprioception and balance
• Adopt a whole animal approach

Question 2

Controlled exercise programs

Answer 2

• Consistently improve outcomes
• Included in all subsequent studies as
  accepted “best practice”
• Important part of ethical review

LOTS of variation in programs prescribed based on:
* Structure involved
* Severity of injury
* Practitioner preference
* Past experiences
* Discipline of horse
* Time of year (i.e. competing seasons)

Question 3

Factors and benchmarks to monitor progress and inform decision making re increasing levels of exercise

Answer 3

• lameness
• palpation
• US

Question 4

When to commence exercise? (historic vs modern approach)

Answer 4

• Historical approach to rehabilitation of tendon injuries involved protracted periods of box rest and VERY gradual incremental exercise plans
• Modern approach gets horses moving faster and tends towards goal-directed decision making
  – proliferative/reparative phase of wound healing is thought to be the window of opportunity
  -> roughly in the 2-4w mark

Question 5

Increasing exercise intensity

Answer 5

Walking in hand or under saddle ->
Trotting under saddle in straight lines (but walking around corners) ->
Trotting under saddle on circles and bends ->
Canter work in straight lines ->
Canter work on circles and bends

For a lot of injuries would only be spending 1-2w at each stage

Important for reassessment between each stage, either by a vet or the owner

Question 6

Uncontrolled exercise

Answer 6

• turnout
• lunging
• loose schooling

all come with a high risk of re-injury

Question 7

Time for uncontrolled exercise?

Answer 7

This decision making will depend on temperament,
* a calm horse with access to small individual paddock can be turned out sooner
* An anxious horse living in a herd will be kept indoors for longer

Anything we can do to help?
* Anxiolysis – acepromazine, can be safely used medium-long term
* Enrichment – access to stimuli and food

Question 8

How can we directly influence the injury site?

Answer 8

• Extracorporeal shockwave therapy (ESWT)
• Laser (class 4)
• Cold/heat treatment
• Therapeutic ultrasound
• Pulsed magnetic field therapy

Question 9

What is shockwave therapy?

Answer 9

Delivery of high-pressure waves to tissues – probably most focused at the junction between soft tissue and bone:
* Practical application to proximal suspensory ligament, suspensory branches, thoracolumbar spine

Question 10

Use of shockwave therapy

Answer 10

Shockwave seems to temporarily improve lameness, but has limited effects on structure and function:
* Commonly applied to chronic injuries as part of a management plan
* Probably doesn’t have a place in the acute management of the soft tissue injury

Fairly good evidence base for it, but not necessarily as impactful as manufacturers might lead you to believe

Question 11

Clinical application of shockwave therapy - Variables

Answer 11

• Number of “shocks” – often in the region of 1000-2000 per site
• Energy of impulses – measured in mJ/mm2\
• No evidence basis for selecting these variables

Question 12

Clinical application of shockwave therapy - Pt prep

Answer 12

• Restraint – sedation recommended as creates an odd sensation
• Clipping long haired horses
• Application of acoustic gel
• Delivered when NWB

Question 13

Clinical application of shockwave therapy - Protocol

Answer 13

• Often delivered weekly/fortnightly
• Treatment period of 4-6 weeks
• Not within 5d of FEI competition

Question 14

Laser (what is it? what is it’s use?)

Answer 14

• Best evidence of class 4 lasers, lower classes have some thermal effects
• Its still early days but there are some nice studies appearing
• Good evidence that high power laser can:
  – Reduce lesion size, increase doppler signal, change collagen deposition, improve US fibre pattern
• No evidence (yet) that this leads to reduced re-injury rates

Question 15

Clinical application of laser therapy

Answer 15

Contraindications for the use of high powered (class 4) lasers:
* Eye exposure, neoplasia, haemorrhage, pregnancy?
sex glands?
– No evidence (yet) that it affects the pregnancy animal or gonads but may be some merit to not using it for them

Probably more logically applied to more superficial structures:
* Suspensory branches, flexor tendons
* Penetration reduced with depth therefore better for superficial structures

Multiple treatments as for ESWT

Prohibited for use at FEI events, but can be used in the run up to

Question 16

How should we manage the whole horse?

Answer 16

• Core/dynamic stability is key

Question 17

Aims of core stability

Answer 17

• improve neuromuscular control
• reduce force/stride variability
• negate compensatory mechanisms
• reduce frequency and severity of abnormal loading events

Question 18

Methods to improve core/dynamic stability

Answer 18

• Water treadmill exercise * Swimming
• Ridden or in-hand exercises
• Whole body vibration (lacking evidence)

Question 19

Water treadmill exercise benefits

Answer 19

• Adds resistance to cranial phase of stride
• Increases limb retraction (stride height)
• Increases ROM of the axial skeleton
• Buoyancy (if deep enough)
  – Some evidence that buoyancy reduces the overall stresses and strains on soft tissues
• Induces flexion and extension of the thoracolumbar and lumbosacral spine

Question 20

What does water treadmill exercise improve?

Answer 20

• Strength
• Coordination
• Stability
• Postural control

Question 21

Clinical use of water treadmill exercise

Answer 21

• Can be prescribed as an intensive course
  or incorporated into ongoing training
  – Intensive course just post-surgery to get the horse engaged and hopefully rehabilitated quicker is of most value
  – But then a few months-years down the line 1x weekly session is a nice way to keep the benefits

Question 22

What is swimming improve?

Answer 22

• Aerobic fitness
• Brachiocephalicus tone
• Reducing stress on joints and soft tissues

Question 23

Clinical use of swimming

Answer 23

• Largely used in the training and
  rehabilitation of thoroughbred racehorses (improved fitness and reduced repetitive strain)
• Less useful for sports horses as it encourages an extended neck and thoracolumbar spine (the opposite of what we hope to achieve)
• Consider implications for a fit horse with reduced bone stimulation
  – i.e. consider whether it’s ethically right to get a horse aerobically extremely fit whilst not putting stresses and strains through the horses bone
  – Esp with racehorses: making them very fit to run faster on bones that are not conditioned for that speed, whether this increases their fracture risk?

Question 24

What exercises can be incorporated?

Answer 24

• Hill work (trot up and walk down)
  – Hills are a good way of inducing a good amount of hind end engagement and a little bit more flexion of the thoracolumbar spine
• Pole exercises (raised)
  – esp raised poles have some of the benefits of water treadmills
  -> improves retraction of the limb, increases range of motion
• Working on a range of surface types
  – improves conditioning of the soft tissues
• “cross training”
  – trying to increase strength on as many fronts as possible