Rehabilitation for horses with soft tissue injuries Flashcards
Aims of rehabilitation
- 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
Controlled exercise programs
- 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)
Factors and benchmarks to monitor progress and inform decision making re increasing levels of exercise
- lameness
- palpation
- US
When to commence exercise? (historic vs modern approach)
- 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
Increasing exercise intensity
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
Uncontrolled exercise
- turnout
- lunging
- loose schooling
all come with a high risk of re-injury
Time for uncontrolled exercise?
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
How can we directly influence the injury site?
- Extracorporeal shockwave therapy (ESWT)
- Laser (class 4)
- Cold/heat treatment
- Therapeutic ultrasound
- Pulsed magnetic field therapy
What is shockwave therapy?
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
Use of shockwave therapy
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
Clinical application of shockwave therapy - Variables
- 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
Clinical application of shockwave therapy - Pt prep
- Restraint – sedation recommended as creates an odd sensation
- Clipping long haired horses
- Application of acoustic gel
- Delivered when NWB
Clinical application of shockwave therapy - Protocol
- Often delivered weekly/fortnightly
- Treatment period of 4-6 weeks
- Not within 5d of FEI competition
Laser (what is it? what is it’s use?)
- 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
Clinical application of laser therapy
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
How should we manage the whole horse?
- Core/dynamic stability is key
Aims of core stability
- improve neuromuscular control
- reduce force/stride variability
- negate compensatory mechanisms
- reduce frequency and severity of abnormal loading events
Methods to improve core/dynamic stability
- Water treadmill exercise * Swimming
- Ridden or in-hand exercises
- Whole body vibration (lacking evidence)
Water treadmill exercise benefits
- 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
What does water treadmill exercise improve?
- Strength
- Coordination
- Stability
- Postural control
Clinical use of water treadmill exercise
- 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
What is swimming improve?
- Aerobic fitness
- Brachiocephalicus tone
- Reducing stress on joints and soft tissues
Clinical use of swimming
- 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?
What exercises can be incorporated?
- 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
