TREATMENT STRATEGIES FOR EQUINE BACK DISEASES

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1 TREATMENT STRATEGIES FOR EQUINE BACK DISEASES Martin Waselau, Dr.med.vet, MS Diplomate ACVS, Diplomate ECVS - University of Helsinki - Eläinlääketieteellinen tiedekunta

.. Impossible To cover all topics in depth in 45 minutes... To provide a miracle cure.

2 OUTLINE We all know that Back problems are challanging to treat Broad variety of different disease and syndromes... Lots of rumors... Impossible To cover all topics in depth in 45 minutes... To provide a miracle cure... But I will try to provide List of treatment strategies to back problems in general Logical foundation of treatment

3 INTRODUCTION Back problems Reported for centuries Frequent complaint by owners Diagnosis Difficult to clearly localize Challange for Veterinarian Frustration for owner Treatment Many rumors... Frustration for owner How are we gonna resolve the problem For the horse? For the owner?

4 Copyright Martin Waselau CONSIDERATIONS BEFORE TREATMENT

well-trained and fit Humans do not race with underlying back

5 Copyright Martin Waselau CONSIDERATIONS BEFORE TREATMENT Similarities between human and equine athelets Need to be well-trained and fit Humans do not race with underlying back disease... Initially, treatment of acute injuries Rehabilitation thereafter

6 CONSIDERATIONS BEFORE TREATMENT

7 OUTLINE - TREATMENT STRATEGIES Modification of exercise schedule Management changes Medical treatments Surgical treatments Complementary treatments Consider all aspects...

8 I. EXERCISE SCHEDULE Stall rest Duration depending on lesion Wait-and-see-approach...? - Acute injuries; overworked horses... Paddock turnout Paddock Pasture! Keeps musculoskeletal system flexible Restricted or controlled exercise Lesion dependent - no standardized rules Part of a rehabilitation process

9 II. CHANGES IN MANAGEMENT Saddle Replace or revise Saddle pads Therapeutic...? Changes in stable and routine, daily work Schedule, barn, stress Changes in training approach Overworked horses... Exercise program Rider Graduated Evaluate equipment... (+/- capabilities)

10 III. MEDICAL MANAGEMENT General principles Analgesia, Anti-Inflammatiory Spasmolysis Acute phase Goal Permit healing Allow rehabilitation Prevent further injuries In many cases combination of pharmaceuticals used

2mg/kg, IV, SID Phenylbutazone (Equipalazone ) 2.2-4.4mg/kg, IV/PO, SID/BID +/- Carprofen (Rimadyl ) 0.

11 NSAIDs Principle Inhibition of inflammatory cascade and pain - COX 1/2 inhibitors Drugs Meloxicam (Metacam ) 0.6mg/kg, IV/PO, SID Flunixin (Finadyne ) 1.1mg/kg, IV/PO, SID/BID Ketoprofen (Romefen ) 2.2mg/kg, IV, SID Phenylbutazone (Equipalazone ) mg/kg, IV/PO, SID/BID +/- Carprofen (Rimadyl ) 0.7mg/kg, PO/IV, SID/BID +/- Vedaprofen (Quadrisol ) 1-2mg/kg, PO/IV, SID/BID +/- Naproxen 5-10mg/kg, PO, SID/BID

uniform in all horses Adjunctive therapy Drugs Diazepam - 0.

12 MUSCLE RELAXANTS Indications Reduce/resolve spasms/hypertonicity - Allow natural healing & additional therapeutics - Efficacy not uniform in all horses Adjunctive therapy Drugs Diazepam mg/kg IV Methocarbamol mg/kg PO, SID Dantrolene - 2mg/kg PO, SID

13 CORTICOSTEROIDS Indications Systemic use - Rarely indicated due to side effects (laminitis) - +/- orally Local therapy predominantly - Kissing spines ; sacroiliac joint - Combination...? - Sarapin, local anestheticum - Bovine serum etc. - CAVE! Local infections

14 CORTICOSTEROIDS Options Methyl prednisolon (Depo Medrol ) mg/site; (+) +/- Triamcinolone (Vetalog ) - 6-8mg/site; (+) - 14 d withdrawal +/- Betamethasone (Celestone ) mg/site; (++)

15 CORTICOSTEROIDS Dexamethasone mg/site d withdrawal? Flumethasone (Flucort ) mg/site; (+++) +/- Isoflupredone mg/site; (++++) Combinations...? Methyl prednisolone, isoflupredone and Sarapin ; (5ml)

SARAPIN Sarapin Aqueous solution derived from pitcher plant (Sarraseniaceae) Single / combi use with corticosteroids (1-2ml/site) Principle Block selectively C-fibers in

16 SARAPIN Sarapin Aqueous solution derived from pitcher plant (Sarraseniaceae) Single / combi use with corticosteroids (1-2ml/site) Principle Block selectively C-fibers in peripheral nerves - Peripheral nerve block - No pain sensation/transmission Indications Chronic diseases...? - Soft tissue (myositis, desmitis) - Osseous problems ( Kissing spines )

17 SCLEROSENTS Principle Increase / stimulate local perfusion ( blistering ) No scientific reports or proof of principle Options 2% iodine in oil (Hypodermin, McKay s Solution); 3-4ml/site Local administration into back muscles and massage Periartcular injections (?) CAVE! Can cause excessive inflammatory response +/- Necrosis

18 SWEATS AND COUNTERIRRITANTS Principle Stimulate local perfusion and resorption Reduce edema formation and pain Options +/- Nitrofurazone ointment +/- DMSO CAVE! Skin irritations

19 HORMONES Principle Supression of estrus in mares Supposed to cause back problems in heat Cold back in mares Options Altrenogest mg/kg PO, SID Estrone sulfate mg/kg IM, EOW

20 RVI - INJECTIONS Principle Immunomodulatory effect... Reduce chronic myofascial inflammation... Options Inactivated rubeola virus - 2ml, SQ SID for 6 days

MESOTHERAPY Principle Multiple intradermal injections into dermatomes - At level of lesion + caudal to it (segmental nerves) - 2-3 rows of injections on each side of

21 MESOTHERAPY Principle Multiple intradermal injections into dermatomes - At level of lesion + caudal to it (segmental nerves) rows of injections on each side of median Involves type I/II nerve fibers from skin - Have collaterals, that can inhibit pain transmission Rehabilitation - Improvement in 7-14 days - Lasts for 3-12 months

22 MESOTHERAPY Options (combination) Local anestheticum - e.g. 140mg lidocaine Corticosteroid (short-acting) - e.g. 15 mg dexamethasone Muscle relaxant - e.g. 20 mg thiocolchicoside

$fractures Kissing Spines - Pre-OP$

23 IV. SURGICAL MANAGEMENT Indcations Highly comminuted dorsal spinous fractures Kissing Spines - Pre-OP confirmation essential - local anesthesia! Courtesy J. Kidd

24 IV. SURGICAL MANAGEMENT Principle Resection of impinging parts Techniques Open approach - Lateral recumbency, standing - Long incision, leave 5mm interspinous gap Ventral drainage? - 72% complete return, 9% improvement Minimally invasive approach - Endoscopically assisted

25 IV. SURGICAL MANAGEMENT Courtesy J. Kidd

26 IV. SURGICAL MANAGEMENT Courtesy J. Kidd

27 V. COMPLEMENTARY TREATMENTS Physiotherapy Manual therapy / Osteopathy / Chiropractice Acupuncture Neutraceuticals Botanicals Homeopathy

28 PHYSIOTHERAPY Principles Thermal - Therapeutic ultrasound - Influence on inflammation and collagen extensibility - Alter nerve conduction Mechanical - Massage, stretching, hydrotherapy and swimming - For rehabilitation Electrical - Muscle stimulation, magnetic therapy, shock-wave - Pain control and neuromuscular modulation Goal Restoration of function and prevention of further injuries

29 PHYSIOTHERAPY Indications Generalized pain - Electrical/electromagnetic stimulation, thermal Joint motion restriction/stiffness - Passive stretching etc., thermal (cryo/ice packs) - Electric stimulation Altered back muscle tonicity - Hydrotherapy, electrical stimulation, rehabilitation - +/- ionophoresis, phonophoresis (drug delivery) Contraindications Open wounds, skin lesions, pain of unknown origin etc.

30 MANUAL THERAPY - OSTEOPATHY Classification Articular techniques - Chiropractice Soft tissue techniques - Physical therapy - Manipulation under general anesthesia - Massage - Stretching exercises

31 Chiropractic Copyright Martin Waselau

32 Chiropractic Principle Evaluation & localization of segmental vertebral dysfunction Subluxation or not being in place/straight - Characterized by localized pain, muscle hypertonicity, reduced joint motion - Altered mechanoreceptors and nociception - Joint capsule tension and hypersensitivity Goal Restoration of normal joint motion Stimulate neurologic reflexes Reduce pain Alliviate muscle hypertonicity

33 Chiropractic Mechanism of action Affect mechanoreceptors to - Induce reflex inhibition of pain and muscle relaxation - Correct abnormal movement patterns Audible cracking/popping sound - Force overcomes elastic barrier of joint resistance - Rapid articular separation = cavitation of synovial fluid (vacuum-phenomenon) - 80% CO 2 for 15-20min intraarticularly - Needs to reabsorbed before any further manipulation! - Otherwise painful!

34 Chiropractic Indications Complementary tx Lack of objective equine research... - Neck pain & regional joint stiffness (back) - Poor performance & altered gait Chronic, recurrent orthopedic diseases refractory to Tx +/- Part of post - OP rehabilitation program Contraindications Acute injuries Cannot reverse severe degenerative processes...

35 ACUPUNCTURE Principles Insertion of fine/solid needles in acupuncture points - Frequently into same dermatomes as lesion - Specific therapeutic actions when stimulated Relieve of pain via release of - Opioid (enkephalin, ß-endorphin) - Non-opioid (serotonin) Additional/alternative methods - Acupressure, aquapuncture, electrostimulation, low-level laser therapy; - +/- Moxibustion

36 NEUTRACEUTICALS Principle Maintain joint health - Antiinflammatory, chondroprotective etc Support smooth movements... Options Chondroitin sulfate Glucosamine Glycosaminoglycans MSM

37 BOTANICALS Western herbs Chinese herbs

38 HOMEOPATHY Principle Anti-inflammatory Products Traumeel - Arnica montana Indications +/- Systemic use Local therapy - Müller-Wolfahrt-Cocktail

39 HOMEOPATHY Müller - Wolfahrt - Cocktail Local infiltration / injection (day 0, 2 and 4 post injury) Intramuscular, paravertebral (nerve roots) Local perfusion + metabolism = support healing Components Traumeel + Zeel Actovegin (aminoacids) Medivitan (vitamin B6/12) Coenzym Q10 (antioxidant) Heparin +/- Mepivacain

40 VI. FUTURE DIRECTIONS To overcome current challanges / limitiations Objective evaluation of pain Diagnostic tools Lack of rehabilitation tools Treatment modalities Development of Training programs tailored for individual demands Objective measuring tools - Saddle evaluation - Kinematic evaluation of spine

41 CONCLUSIONS Back problems = Complex problems No rapid (re)-solution May take months... be patient Diagnosis of underlying disease Challanging... Treatment options Limited Rehabilitation important Essential

42 CONCLUSIONS Consider complementary treatment modalities Few scientific studies Client communication/education Important aspect Identify primary problem Find sustainable approach

43 QUESTIONS or COMMENTS? Copyright Martin Waselau

GENERAL PRINCIPLES FOR TREATMENT OF EQUINE JOINT DISEASES

GENERAL PRINCIPLES FOR TREATMENT OF EQUINE JOINT DISEASES Martin Waselau, Dr.med.vet, MS Diplomate ACVS, Diplomate ECVS - University of Helsinki - Eläinlääketieteellinen tiedekunta / Faculty of Veterinary