Involving the Physio
by Ben Sturgeon, Bsc, BVM&S, Cert EP, MRCVS
I am often asked why equine medicine continues to hold interest? The answer is easy. Medicine in the horse is not just about getting it better; it is about making it perform. For fear of flippancy, an injury to almost any other species can be managed to allow that animal to remain ambulatory or mobile and perform most daily functions. But for a horse it is not just about returning to work, it is about carrying a rider, travelling at 30 miles an hour, jumping 6 feet, or doing a pirouette, or pulling a cart or any other myriad of activities that define performance and give that animal a “job”. To return an animal, any animal to per-injury levels is difficult and that’s precisely why it’s interesting.
As a result the magic panacea both owners and often us vets seek to perform a miracle cure rarely happens. Many conditions, medical and musculoskeletal carry a need for multi-modal and or multi-disciplinary therapy; treating the condition directly as a primary problem but also treating the complex “side-effects” of the condition whilst also considering the long term management, both clinically and athletically, of the condition. This long term management also carries a level of complexity because the aims, goals and levels of performance in horses invariably rise with an owners’ expectations, experience and skills meaning that the management must then suit this altered long term expectation.
Perhaps the commonest examples of these changes are in treating a horse with an orthopaedic injury or disease. This may be conformational in nature such a spinal scoliosis predisposing to kissing spine, or have a genetic component predisposing to joint disease such as osteochondrosis affecting the coffin, fetlocks or stifles or more; or indeed be the result of direct individual single trauma (such as a fracture) or be the result of accumulated micro-trauma (bone spavin, bucked shins, tendinous and ligamentous inflammation). Each condition individually will have a rough “gold standard” of treatment from surgical intervention for example with osteochondrosis, to medical or biological manipulation with osteoarthritis and soft tissue injuries. But more usually a combination of conservative management with exercise amelioration, remedial farriery with medical adjunctives and leading to surgical interference aligned with medical manipulation are pursued.
All of this depends, perhaps obviously, on many factors – age and aim of the horse, severity and chronicity of the condition, individual veterinary surgeon governance of the case, owner wishes and dedication, and ultimately finances.
Of course, prevention is king. If prevention is indeed possible and given the very nature of horses, given the athletic demands placed upon them and our own desires, is it any wonder they “break”? Advances have been made and it would be terse to ignore them; dietary management, stable management, exercises tailored to discipline, and now exercise testing to begin to assess early deteriorations and response to the demands placed upon them.
Irrespective of the precise immediate and medium term therapy, the long term management of the condition to both avoid further deterioration and to aid in rehabilitation and development of the overall animal is important.
Complete injury rehabilitation is not then just limited or localised to the injured area but to the entire axial skeleton (and indeed although not directly part of this discussion, also the cardiovascular and respiratory systems). We all have this. Whether one leg is longer than the other or we have a low grade, subclinical issue, eventually an imbalance in the ideal, mirrored, anatomically correct skeleton will result in stiffness, soreness and reduced mobility, and a cycle is set up. Hence, involvement of manipulative therapies are increasingly vital in both the rehabilitation and in management, and indeed arguably in the magic pre-habilitation. For example, a horse with heel pain will often short stride creating not only a short choppy gait but also a horse with reduced shoulder mobility, neck stiffness and epaxial back muscle pain. A horse with osteoarthritis in its hind limbs or one with proximal suspensory desmitis will often also present as a “back problem” or develop one subsequent to injury requiring therapy as part of the treatment regime.
Before going any further it is important to remember that the converse is also true. It is very common to attend a lame or stiff horse that has had months of “physical therapy” often with some incremental improvement. It is important that in such a position, if the same problem, such as a sore back re-presents and despite manipulation providing some level of correction, that there is a likely underlying primary problem. I do receive many referrals from physiotherapists who recognise this but there are equally some practitioners without qualification who fail to see the bigger picture and simply run up a bill.
So when would you begin physiotherapy? The answer is at all stages. In an acute injury the commonly used acronym RICE (rest, ice, compression, elevation) is a form of physical therapy which when aligned to tissue massage and long-wave ultrasound will have a hugely beneficial affect on hastening the phases of wound healing and in the return to exercise.
In the healing or post-operative or post-therapeutic stage physical mobilisation with developmental exercises are vital for a full return. A simple example would be in the increasingly recognised condition of sacroiliac desmitis or osteoarthritis where poor epaxial muscle development, poor core stability and gluteal action are prevalent. Post-treatment mobilisation and development incorporating static stretches (carrot stretches) leading to unridden long-reining pole and maze work, leading to ridden pole, maze and hill work, leading to bungy reins etc can all occur depending on treatment response and regular review with potential further medical or surgical treatment or even further investigation and diagnostics if the responses are either not as complete as expected or deteriorations occur.
Finally, in the long-term phase re-assessments are important to ensure the improvements are maintained and further discipline specific developments can be added. For example, leg yield “triangle” stretches in walk for spinal mobility, ¼ to full turn about the forehand (the “half split”) for building the epaxial multifidus muscle along the spine, and a ¼ to ½ pirouette to develop shoulder suppleness. There are many such exercises but each is dependent upon the stage of recovery or the horse and requires a careful stepped and controlled approach.
I definitely feel that the co-operative work vets, owners, physios and farriers can have on a horse injured or with a condition, is and can be hugely beneficial. The hard part is in making the diagnosis first and then in getting everyone around a “table” and putting a plan in place. Do that and progression will be yours.