Four Front Issue 5 September 2014

Four Front

Number 5 | September 2014 ISSN 2055-267X

The Magazine of the Professionals in Animal Therapy

A regulatory body for all considered A new treatment for Impinging Dorsal Spinous Processes New treatments in the management of chronic pain discussed Research Digest

Association of Chartered Physiotherapists in Animal Therapy

CONTENTS Editorial

Do we need a Regulatory Body for all, and what are our individual responsibilities to our Profession?

Sonya Nightingale MCSP SRP Grad Dip Phys ACPAT Cat A

Chronic pain perception: could stress reduction play an effective part in medical treatments for large and small animals to help reduce chronic pain?

Amber Batson BVetMed MRCVS

Treating kissing spines in horses without a hammer and chisel Richard Coomer MA VetMB CertES (Soft Tissue) Diplomate ECVS MRCVS European registered specialist in equine surgery

A Review of Neuromuscular Electrical Stimulation in Human Cruciate Rupture Rehabilitation: Relevance to Limb Function following Cranial Cruciate Ligament (CCL) Surgery in Dogs Elizabeth Hughes PgDip BSc MCSP HCPC ACPAT A

Consideration into the effects of the noseband as part of a physiotherapy assessment Sue Palmer MCSP, MSc Veterinary Physiotherapy, ACPAT Cat A, BHSAI, IHRA and Hannah Mace MPharmacol, ITEC Dip, EEBW

Thoracolumbar hemilaminectomy for the treatment of intervetertebral disc herniation/extrusion: The evidence reviewed as a precursor to a post operative physiotherapy protocol Melanie Haines Chartered Veterinary and Human Physiotherapist MSc Vet Physio, BSc (HONS) Physiotherapy MCSP, ACPAT cat A Equine Research Digest Kate Davy MCSP ACPAT Cat A

Canine Research Digest Kate Davy MCSP ACPAT Cat A

Diary of events Course reviews Book reviews Journals of Interest Recent news Writing for Four Front

Front Cover supplied by Moorcroft Racehorse Welfare Centre Designed by Three Hats Design . threehatsdesign@gmail.com (Part of INTAGLIO Print Management Services) 07810 300730

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EDITORIAL

Maruska Aylward and Stephanie Brighton welcome you to our fifth edition of Four Front, the second under our guidance.

Four Front, allowing us to initiate the climb towards meeting the criteria outlined by Medline.

Four Front continues to encourage ACPAT members to submit their articles for publication, please see the ‘writing for Four Front’ section. As editors, we are happy to assist authors in raising the standard of articles to reach publication, so please utilise us.

Please also be encouraged to provide us with your thoughts, both negative and positive, either via a ‘letter to the editor’ or by emailing journal@acpat. org. We welcome your thoughts.

We hope that you enjoyed our fourth edition and found it an informative and educational read. Being new to the editorial role for Four Front last year, we were keen to maintain the professional standard that had been laid out by our predecessors (Di Messum and Polly Hutson). Thank you to all our authors for the time they have spent writing their articles, without your efforts we would not have a Four Front.

Our committee continues to evolve and we would like to welcome Daisy Collins to our editors team. We would also like to thank Louise Carson (chairman) for all her hard work and leadership over her term as chair, please see her ‘Letter from the Chair’ in the recent news for more details.

We continue to strive for a high professional standard and we have been fortunate to have dedicated peer reviewers whom have been integral to Four Front and its overall profile and development for the past four years. Unfortunately however, their term being peer reviewers for ACPAT has now ended and we are hugely grateful for their efforts during this period. They are extremely busy professionals themselves and on behalf of ACPAT we would like to say thank you.

Finally, well done to our committee for all of their continued hard work for ACPAT and let’s hope with the coming year comes new exciting developments and challenges.

As a result, and in order to supplement the move toward Medline status, we are currently securing and expanding our panel of peer reviewers. This will assist in raising the standards of all articles in

Thank you again Your Editorial Team

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Do we need a Regulatory Body for all, and what are our individual responsibilities to our Profession?

Sonya Nightingale MCSP SRP Grad Dip Phys ACPAT Cat A

Highworth Physiotherapy Clinic, 13 High Street, Highworth, Swindon, SN6 7AG ‘We are tomorrows past and responsible for constructing the knowledge of physiotherapy, finding our voices, and articulating a position that will enable physiotherapists to play a key role in shaping provision of care in the 21st century’...... ‘Our increasing knowledge about physiotherapy depends on the activity of thousands of physiotherapists throughout the world who add small points to what will eventually become a splendid picture’ (Parry, 1980). I make no apologies for quoting large segments of other authors for this article as their definitions and observations are far wiser than any I can articulate.

Regulation and professionalism, or the ability to call yourself a practitioner of a profession go hand in hand and affect us all whether we like it or not. So to start lets first understand what we are talking about!

What is a Profession?

A profession is a vocation founded upon specialized educational training, the purpose of which is to supply objective counsel and service to others, for a direct and definite compensation, wholly apart from expectation of other business gain (Webb, et al. 1977). The term is in essence a rather vaguer version of the term “liberal profession”, an anglicisation of the French term “profession libérale”. Originally borrowed by English users in the nineteenth century, it has been reborrowed by international users from the late twentieth century.

“Liberal professions” are, according to the Directive on Recognition of Professional Qualifications (2005/36/EC) “those practised on the basis of relevant professional qualifications in a personal,

responsible and professionally independent capacity by those providing intellectual and conceptual services in the interest of the client and the public” (Wictionary: Liberal profession). Figure 1 lists the major milestones which may mark an occupation being identified as a profession.

Figure 1. The Developmental Ladder (Perks, 1993) 1. An occupation becomes a full-time occupation 2. The establishment of a training school 3. The establishment of a university school 4. The establishment of a local association 5. The establishment of a national association 6. The introduction of codes of professional ethics 7. The establishment of state licensing laws A profession arises when any trade or occupation transforms itself through “the development of formal qualifications based upon education, apprenticeship, and examinations, the emergence of regulatory bodies with powers to admit and discipline members, and some degree of monopoly rights” (Bullock, et al.

1999).

So to extrapolate, what are the characteristics of a profession?

According to Larson (1987) a profession has a “professional association, cognitive base, institutionalized training, licensing,

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work autonomy, colleague control... (and) code of ethics, to which Larson then also adds, “high standards of professional and intellectual excellence,” that “professions are occupations with special power and prestige,” and that they comprise “an exclusive elite group,” in all societies.

Members of a profession have also been defined as “workers whose qualities of detachment, autonomy, and group allegiance are more extensive than those found among other groups...their attributes include a high degree of systematic knowledge; strong community orientation and loyalty; selfregulation; and a system of rewards defined and administered by the community of workers” (Brown, 1992).

A profession has been further defined as: “a special type of occupation...(possessing) corporate solidarity...prolonged specialized training in a body of abstract knowledge, and a collectivity or service orientation...a vocational sub-culture which comprises implicit codes of behaviour, generates an esprit de corps among members of the same profession, and ensures them certain occupational advantages... (also) bureaucratic structures and monopolistic privileges to perform certain types of work...professional literature, legislation, etc” (Jackson, 2010).

What is professionalism?

Professionalism defines what is expected of a professional, and what it means to be professional. Broadly, it can be summarised as: 1. A motivation to deliver a service to others

2. Adherence to a moral and ethical code of practice

Pros and cons of a regulatory body

3. Striving for excellence, maintaining an awareness of limitations and scope of practice

Originally, any regulation of the professions was self-regulation through bodies such as the College of Physicians or the Inns of Court. With the growing role of government, statutory bodies have increasingly taken on this role, their members being appointed either by the profession or (increasingly) by the government, the Health and Care Professions Council (HCPC) provides a good example.

Proposals for the introduction or enhancement of statutory regulation may be welcomed by a profession as protecting clients and enhancing it’s quality and reputation is generally seen as a positive. However the opposing view sees it as restricting access to the profession and hence enabling higher fees to be charged.

Another con is that regulation may be seen to limit the members’ freedom to innovate or to practise as, in their professional judgement, they consider best. The introduction, therefore, of an HCPC equivalent in the animal world could be welcomed as evidence of a mature well regulated profession, or abhorred as a restrictive practice by an elitist group.

4. A commitment to empowering others (rather than seeking to protect professional knowledge and skills).

A profession that fulfils these expectations establishes and maintains credibility with the public and demonstrates it’s capacity to carry the privileges of professional practice – autonomy and selfregulation. In turn, fulfilment of these expectations demonstrates a profession’s ability to fulfil the parallel responsibilities of professional practice - accountability, transparency and openness.

Professionalism recognises that professional activity has the following: (CSP, 2013).

1. Strong ethical dimensions 2. Is complex and diverse, constantly changing, and uncertain and unpredictable 3. Cannot be defined simply in terms of possessing and implementing a fixed body of knowledge and skill 4. Cannot be undertaken in isolation 5. Depends on engaging in career-long learning and adapting and developing activity accordingly 6. Requires individual practitioners to cope with the non-routine, unknown and incomplete, and potentially conflicting, information.

All of this illustrates a general consensus that to be counted as a mature profession and therefore be professional, a secure form of self and or state regulation must exist.

All professions have power (Johnson, 1972). This power is used to control it’s own members, and also its area of expertise and interests. A profession tends to dominate, police and protect it’s area of expertise and the conduct of its members, and exercises a dominating influence over its entire field which means that professions can act as monopolies (Larkin, 1983), rebuffing competition from ancillary trades and occupations, as well as subordinating and controlling lesser but related trades (Freund, et al. 1995). A profession is characterized by the power and high prestige it has in society as a whole.

It is the power, prestige and value that society, and other professions, confer upon a profession that more clearly defines it. Professionals acquire some of their power and authority in organisations from their expertise and knowledge

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(Benveniste, 1987).

This all implies that regulation brings with it a need for maturity and responsibility, to ensure that a profession does not abuse its position, with either other professionals or the public.

What is on the horizon?

As Chartered Physiotherapists we are part of a well defined profession that has matured through the pathways and processes that we can see above, and are now well regulated professionals in our own right. As Animal Physiotherapists we are part of something that is much less clear. ACPAT has recognised for many years that lack of protection of title has allowed a proliferation of ‘physiotherapists’ who may not be recognised as professionals under the terms listed above.

Indeed, the Veterinary Surgeons Act itself undermines the idea of Physiotherapy being a profession as it only refers to it with a small ‘p’ and makes no reference to the type of person who may administer it. Because of this we are all (ACPAT members and everyone else) legally in the same boat with no requirement to complete any process recognisable as turning someone into a professional. This, in time, will only serve to send Animal Physiotherapy back down the professional development ladder identified by Perks (1993) (Figure 1). That is if it actually can be recognised to have climbed it in the first place! At best we have reached step 5 and are in the process of developing step 6 (See Figure 1).

At the moment we have a unique, maybe once in a lifetime, opportunity to influence this and ensure that Animal Physiotherapy is properly recognised as the profession that we all believe that it is. However this will require unheard of amounts of cooperation from all sides, some of whom view ACPAT with distinct suspicion and consider ACPAT physiotherapists to be elitist and unapproachable (and that is the polite version!). This must all be discussed and developed with

the background knowledge that standards cannot be undermined and, legally, everyone must be given the chance to ‘up their game’ and join in. In addition, of course, there is no general agreement on what the ‘correct’ standard is and how it should be achieved, and considerable debate from some quarters as to whether anyone actually needs to ‘up their game’ at all.

There is a good argument that if an organisation does not see the need for change, and the fact that with this comes a need for regulation and professional responsibility, then they and their members have no right to expect to be counted as professionals or their practise part of a profession. A lack of understanding often underpins this view point. As talks progress some organisations are developing an understanding and have therefore become more engaged in the process. Others have decided, as is their right, that they don’t wish to be involved, and presumably will relinquish any right to be called a professional once a regulatory format is agreed. Indeed they will be forced to as with statutory regulation comes protection of title.

So to summarise, yes I believe we do need a regulatory body for all, to ensure that the title of ‘Physiotherapy’ can finally be properly protected. And as ‘The Professionals in Animal Therapy’ we all have an individual responsibility to ensure that, as this process evolves, we work together to ensure the high standards of all the practitioners who may end up with the right to call themselves a ‘Physiotherapist’.

References Benveniste, G., (1987) Professionalizing the Organization. San Francisco: Jossey-Bass.

Brown, J., (1992) The Definition of a Profession: the Authority of Metaphor in the History of Intelligence Testing. 1890-1930, Princeton, NJ: Princeton University Press, p.19.

Bullock, A., and Trombley, S., (1999) The New Fontana Dictionary of Modern Thought.

London: Harper-Collins, p.689.

Chartered Society of Physiotherapy (CSP), (2013) Regulation and the Scope of Physiotherapy. London.

Freund, P. and McGuire, M., (1995) Health, Illness, and the Social Body: A Critical Sociology. New Jersey, USA: Prentice Hall.

Jackson, J.A., (2010) Professions and Professionalization.

Volume 3, SociologicalStudies, Cambridge: Cambridge University Press, pp.23-24.

Johnson, T., (1972) Professions and Power.

London: Heinemann.

Larkin, G., (1983) Occupational Monopoly and Modern Medicine. London: Tavistock.

Larson, M.S., (1978)The Rise of Professionalism: a Sociological Analysis. Berkeley, California: University of California Press, p.208.

Parry, A., (1994) Physiotherapy Journals-Why Bother? Physiotherapy; Jan, 80(1), pp.27.

Perks, R.W., (1993) Accounting and Society.

Chapman and Hall (London); ISBN 0-41247330-5. pp.2.

Webb, S. and Webb, B., (1977) Report by the UK Competition Commission, dated 8 November, entitled Architects Services (in Chapter 7).

Wictionary: Liberal profession.

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Chronic pain perception: could stress reduction play an effective part in medical treatments for large and small animals to help reduce chronic pain?

Amber Batson BVetMed MRCVS

Priory Veterinary Surgeons,10 Evesham Road, Reigate, Surrey, RH2 9DF The following article discusses the physiological effects of chronic pain in large and small animals and how this can relate to ‘stress’ and provide an insight into the causes of stress in animals. Thus aiming that by improving the understanding for allied veterinary health practitioners of this area, such as Chartered Veterinary Physiotherapists, may help them to treat these chronic pain cases more effectively in clinical practice.

Introduction A wide variety of medical conditions and orthopaedic disorders or injuries can result in chronic pain in dogs, cats and horses. Veterinary medicine has seen a large increase in both drugs and complementary therapies offered as treatment options for animals suffering with such conditions over the last 5-10 years (Hellyer, 2007). Chronic pain can be defined as “continuous, longterm pain of more than 12 weeks or after the time that healing would have been thought to have occurred in pain after trauma or surgery” as defined by the British Pain Society. However, it has also been discussed as being more appropriate to consider pain not as acute or chronic, but to consider whether pain is ‘adaptive’ or ‘maladaptive’ (Woolf, 2004).

Pain is frequently a cause of stress resulting in related endocrine and neural pathway activations.

The definition of stress itself is complicated as the term has been used widely in biological as well as in non biological fields. Stress can be acute, typically defined by the production of catecholamines from the sympathetic-adrenalmedullary system (SAM) or chronic, typically defined as the production of glucocorticoids including

cortisol following activation of the hypothalamic-pituitaryadrenocortical system (HPA) (Moberg, 2000). Stress is most frequently defined as “an organism’s total response to environmental demands or pressures” (Medical dictionary, 2008) which encompasses these physiological changes in SAM or HPA activity.

Psychological stress still results in physiological changes, and is defined as “what occurs when an individual perceives that environmental demands, tax or exceed his or her adaptive capacity” (Cohen, 2007).

The production of cortisol during activation of the HPA system can result in ongoing pain by a variety of its effects. Persistent elevations of cortisol can result in ‘maladaptive’ features such as vasoconstriction, reduced tissue healing and sleep deprivation (Hellyer, 2007).

Persistently elevated cortisol levels in chronic stress that will accompany ongoing pain will lead to changes in the central 5-hydroxytryptamine (serotonin) pathways. Serotonin pathways act to modify perception of pain and nociceptive processing; this includes descending serotonin projections into the spinal cord that modulate received nociceptive information, as well as, brainstem raphe serotonin projections to the brain cortex and limbic systems affecting the psychological interpretation of the pain. Therefore reductions in serotonin activity that result from increased cortisol are one of the main ways that stress affects chronic pain perception (Berger, 2009).

Studies continue into the exact actions of hypercortisolaemia on serotonin pathways, but to date, findings suggest that excess cortisol affects the availability of serotonin at the post synaptic membrane, reducing the central effects of

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serotonin. A good review of the detail of such neurophysiology is found outlined by Tafet (2003) and in the article by BlackburnMunro (2001). For this reason, medications used for both chronic and maladaptive pain, in human and more recently veterinary medicine, have included serotonin re-uptake inhibitors such as amitriptyline (Egbunike, 1990).

Veterinary Treatment of Chronic Pain There are a number of desired outcomes from the treatment of animals with chronic pain: •

Limit ongoing inflammation and tissue damage.

•

Reduce chemicals that are known to trigger pain perception and enhance chemicals that are known to lower pain perception.

•

Allow for increased behaviours to be undertaken that are necessary for the animal to have good ‘quality of life’.

•

Allow the animal (normally in the case of ‘performance’ animals such as agility dogs or ridden equines) to undertake the range of physical activities that human carers / trainers perceive essential to the animal’s function.

Non-steroidal anti-inflammatory agents are useful in reducing prostaglandin production and as a result typically reduce inflammation associated with the source of the disease/injury as well as helping to limit the sensitisation of neural pathways that respond to the pain’s origin (Hellyer et al, 2007). The side effects of Non-Steroidal anti-

Inflammatory Drugs (NSAIDs) are well documented and are reduced by the use of COX 2 specific NSAIDs which are becoming increasingly available in the veterinary market – a good review of the available NSAIDs in the veterinary market can be read as part of the online Merck Veterinary Manual 2012. Corticosteroids can be potent anti-inflammatory agents useful in the treatment of pain, but due to undesirable side effects, they are most frequently used ‘intralesion’ such as directly into the joint, epidural space or topically onto the skin, rather than being given systemically (Sturgess, 2002).

Drug class

Comments

Alpha-2 agonists

Analgesic, sedative, muscle relaxant; dose-related duration, reversible.

Antianxiety (anxiety enhances pain); pre-appointment or pre-anaesthetics.

Analgesic; anti-inflammatory.

Anxiolytics Corticosteroids Local anaesthetics NMDA receptor antagonists

Opioids Topical anaesthetics

Most other medications frequently used in chronically painful animals rely on modification of pain perception rather than acting as ‘anti-inflammatory’ agents. Additional medications to reduce pain perception are included in Table 1.

Certain types of surgery, physical aids and a range of complementary therapies such as rehabilitation therapies (physiotherapy techniques applied to animals) including hydrotherapy, shockwave, electrical therapy, magnetic therapy, as well as acupuncture and some neutraceuticals, have all been suggested as treatment options for the chronically painful patient within the veterinary industry (Hellyer, 2007). Due to the activation of stress pathways caused by chronic pain, and the resulting sensitisation of pain perception that accompanies, reduction in stress may have considerable merit when addressing chronic pain in a patient (Blackburn-Munro, 2001) (Table 2).

Sleep deprivation Different mammals have evolved to require different amounts of sleep, during which periods the body, including the brain, are undertaking processes required

Tricyclic antidepressants

Miscellaneous drugs Gabapentin

Analgesic; anaesthetic-sparing; blocks pain recognition.

Amantadine Reduces ‘wind-up;’ good for chronic pain management in dogs; typically not used for adaptive pain.

Ketamine Somatic analgesia; reduces ‘wind-up.’

Analgesic; anaesthetic-sparing; reversible; short duration of action.

Dermatologic conditions, anal/genital procedures, hospital procedures (e.g., catheter placement).

Antidepressant and anxiolytic, with analgesic properties. Used as adjunctive analgesic; enhances opioid analgesia. Used in humans to treat chronic and neuropathic pain at lower doses than those used to treat depression.

Comments Reduces ‘wind-up;’ good for chronic pain management in dogs and cats; typically not used for adaptive pain.

Analgesic; good for chronic pain management in dogs and some cats.

Tramadol

Table 1: Pain relieving medications for veterinary use (Hellyer, 2007)

Causes of stress in the ill / injured patient Pain Sleep deprivation that results from pain when resting, or as a result of hypercortisolaemia Frustrations that arise from not being able to undertake highly motivated, species specific activities Anxieties and fears that result from being unable to move away from threats easily and without pain, or from feeling vulnerable due to illness or injury Fear that results from repeated veterinary visits / and or treatments including surgery Negative feelings that arise from medications used in the patient’s treatment: nausea / sedative effects of drugs / anorexia / heightened anxiety caused by central side effects Table 2: Causes of stress in the ill / injured patient

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for homeostasis (Empson, 2002).

Empson (2002) explains that domestic animals such as dogs and horses each require different amounts of sleep within 24 hours as part of their normal species behavioural repertoire (ethogram), and also require different ratios of slow wave sleep compared to rapid eye movement sleep and require different sleeping body positions.

Studies with adult horses have shown that slow wave (SWS) and rapid eye movement (REM) forms of sleep total less than 3 hours out of each 24 hours – with SWS making up 2/3 of sleep and REM as 1/3 (Waring, 2003). Horses are polyphasic sleepers, meaning that this total amount of sleep is not taken all in one go, but rather, is taken in several smaller periods throughout the 24 hour period.

Horses must lie down in order to undertake REM whereas their stay apparatus allows for some amount of SWS in a standing position (Waring, 2003).

Studies with dogs have been very variable, predominantly as many 24 hour sleep studies have been undertaken in laboratories where confounding effects related to sleep are high, or as a result of studies being undertaken only during the night time when it is well recognised that dogs acquire a good amount of sleep during the day (Takeuchi, 2002). It is also shown that age plays a large factor in amounts of sleep in dogs and with such a variety of breeds, each having a different typical life span, the effect on when an individual breed is ‘young’, ‘adult’ or ‘aged’ is high. Overall, summarising as is best possible across the variety of studies available, adult dogs sleep between 8 and 14 hours daily with an approximate 50% of that sleep as REM (Lucas, 1977; Adams, 1993; Takeuchi, 2002).

Total or partial sleep deprivation has been linked to chronic pain, both because pain prevents effective sleep but also because of the physiological changes arising from sleep deprivation can affect

the neurotransmitters that help provide and control effective sleep patterns (Lautenbacher, 2006).

Understanding how an animal species evolved to take effective sleep, and how much they require in a 24 hour period, and then ensuring this is achieved in a chronically painful patient may help reduce the overall pain experience, as has been shown in human studies (Edwards, 2008).

Frustrations that arise from not being able to act out species specific behaviours Different species have evolved to undertake a wide variety of different behavioural patterns in order to survive and reproduce: a species specific list of behaviours for an animal species is known as an ethogram. There is a ‘hard wired’ drive to act out certain key behaviours which, if thwarted, can cause marked frustration and even lead to the development of coping strategies such as stereotypical or obsessive compulsive behaviours or poor welfare of the individual (Timberlake, 1995; Bracke, 2006).

Examples of such stereotypies in horses include wind sucking, crib biting, weaving, tongue lolling, box walking, and head shaking. Examples in the dogs include acral lick granulomas, kennel pacing, kennel jumping, tail chasing and pica (eating of non-nutritive objects such as human clothing).

Stress can accompany the frustrations that follow from being unable to act out certain species specific behaviours; either because the chronically painful animal is unable to physically act out the activity, or because management techniques such as cage rest / wearing of Elizabethan collars/ or physical effects of medications, prevent the animal’s behavioural options. Considering the animal’s natural ethogram, and ways in which key elements can be achieved in the chronically painful patient, is likely to be a useful adjunct to reducing their stress and therefore modulating their pain experience.

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Anxiety and Fear Anxiety is defined as “A feeling of worry, nervousness, or unease about something with an uncertain outcome” (Oxford University Press, 2014).

Anti-anxiety medications both for pre-surgery use and in the ongoing treatment plans for some animal patients have been considered as part of pain management, given that fear and anxiety can enhance the perception of pain (Hellyer, 2007). Because HPA axis activity will increase with fear caused both by veterinary treatments (such as visits to the practice, restraint and injections) and also occurances in day to day life depending on the animal’s experiences and environment, a review of the chronically painful patient’s individual situation may be useful. Avoidance of stimuli that are likely to trigger fear: overshadowing (the simultaneous use of a second stimulus that the animal finds highly enjoyable and therefore blocks out much awareness of the fear inducing stimulus) and the use of anti-anxiety medications (such as benzodiazepines or neutraceuticals with anti-anxiety properties such as alpha-caseins or appeasing pheromones) can be considered as part of a ‘big picture’ approach to pain management.

Recognising stress in domestic animals Stress is a complicated word as discussed at the beginning of this article, having been over used in society to define a wide variety of both positive and negative emotional states. Stimuli and experiences resulting in physiological changes related to HPA axis activity or activation of the sympathetic nervous system are known as stressors (Kemeny, 2003).

A sense of control over exposure to stressors and predictability of these stimuli are extremely important in determining the level of stress response that a stimulus creates in an individual at any given time.

Activation of stress physiology can

be a result of a positive emotion, for example: chasing a rabbit for a dog or cat or cantering around in play with the herd for a horse, as examples, but can also be the result of a negative emotion such as fear or pain. In general it is chronic stress, activation of the HPA axis on a cumulative or persistent basis, which results in maladaptive effects (Tafet, 2003).

While stress can be measured in the

form of physiological changes such as outlined by Russell (2012), and includes persisting elevated heart rate, elevated cortisol in blood/ urine/saliva/faeces and exaggerated responses to physiological challenges such as ACTH (adrenocorticotrophic hormone) stimulation tests, it is more practical and often more relevant, to recognise signs of stress in body language and behaviour (Dawkins, 2004). Again, these are specific to

the individual animal species but some common features of body language or behavioural patterns during stress are outlined in the following Tables 3, 4 and 5. It should be noted that many signs of stress must be taken in context, as signs such as ‘panting’ may occur on a hot day as a normal method of heat loss, pupil dilation may be a sign of poor environmental lighting, reduction in normal behaviour range may be a sign of illness etc.

Body Language

Behavioural Signs

Dilated pupils

Flight

Holding eyes closed

Aggression

Increased rate of blinking

Reduced range of normal behaviours

Lip licking

Development of abnormal behaviours eg. Overgrooming / pica

Repeated yawning

Increased frequency of urination/defaecation including indoor toileting

Purring

Prolonged periods of sitting/lying ‘withdrawn’ without sleeping

Trembling

Over reactive to being touched

Growling Repeated hiss spit sequences Tail lashing Tucking feet and tail tightly against or under body Freeze response Table 4: Signs of stress in the cat (Bradshaw, 1992; icatcare.org, 2013)

Body Language

Behavioural Signs

Dilated pupils

Flight (including rearing)

White of eye showing (‘whale eye’)

Aggression

Increased rate of blinking

Reduced range of normal behaviours

Triangular appearance of upper eyelid Repeated yawning

Development of abnormal behaviours eg. Stereotypies such as crib biting / weaving / tongue lolling Regular vocalisations

Licking and chewing

Poor concentration

Head lowering

Hyper reactivity to stimuli (over vigilant)

Tail swishing

Over reactive to touch

Head shaking / nodding

Non responsive to social interactions

Freeze response Table 5: Signs of stress in the horse (Waring, 2003; McDonnell, 2003)

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Common causes of stress in ill or injured domestic animals have been previously outlined.

Additional causes of stress in any individual are varied but would include a not exhaustive list of: •

•

Repeated fear / anxieties from • under socialisation • a lack of habituation to common surroundings • inappropriate handling • regular restraint or confinement • use of punishment or negative reinforcement orientated training Frustrations caused by prevention of highly motivated activities in the ethogram • lack of social contact • confinement • physical restrictions (muzzles / Elizabethan collars) • lack of appropriate diet (chewing and variety for dogs & cats / foraging and browsing for horses) • lack of suitable environment for exploration and play

Conclusions

then to work with the owner and carers of the patient to minimise these, as well as a full assessment of medicines and complementary therapies that can continue to reduce any ongoing inflammation and physical pain present.

Lautenbacher, S., Kundermann, B., & Krieg, J. C., (2006) Sleep deprivation and pain perception.

Sleep medicine reviews, 10(5), 357-369.

Lucas, E. A., Powell, E. W., & Murphree, O. D., (1977) Baseline sleep-wake patterns in the pointer dog. Physiology & behavior, 19(2), 285291.

McDonnell, S. (2003) A practical field guide to horse behaviour: the Equid ethogram. The Blood Horse Inc, Kentucky: USA.

References Adams, G. J., & Johnson, K. G., (1993) Sleepwake cycles and other night-time behaviours of the domestic dog< i> Canis familiaris</i>.

Applied animal behaviour science, 36(2), 233248.

Aloff, B., (2005) Canine body language: a photographic guide Dogwise: USA. Berger, M., Gray, J. A., & Roth, B. L., (2009) The expanded biology of serotonin. Annual review of medicine, 60, 355-366.

Blackburn-Munro, G., & Blackburn-Munro, R. E., (2001) Chronic pain, chronic stress and depression: coincidence or consequence?

Journal of Neuroendocrinology, 13(12), 10091023.

Bracke, M. B. M., & Hopster, H., (2006) Assessing the importance of natural behavior for animal welfare. Journal of Agricultural and Environmental Ethics, 19(1), 77-89.

Bradshaw, J., (1992) The behaviour of the domestic cat CABI publishing, Oxon: UK Cohen, S., Janicki-Deverts, D., & Miller, G. E., (2007) Psychological stress and disease. Jama, 298(14), 1685-1687.

Chronic pain physiology is complicated and best assessed practically from an adaptive versus maladaptive view point.

Stress involving over activation of the HPA axis and resulting hypercortisolaemia can significantly worsen an animal’s perception of pain predominantly from the effects cortisol and its precursory neurotransmitters, have on central serotonergic pathways.

Dawkins, M. S., (2004) Using behaviour to assess animal welfare. Animal Welfare 13, S3S8.

Lowering chronic stress, caused by ongoing pain, sleep deprivation, frustrations of highly motivated species-specific goals, anxiety and fear, is likely to be a beneficial ‘big picture’ approach to managing the chronically painful patient. This requires detailed knowledge of the species’ ethogram including body language and behavioural signs in order to identify stressors in the patient’s environment and

Empson, J., (2002) Sleep and dreaming 3rd edition Hampshire, UK: Palgrave.

Edwards, R. R., Almeida, D. M., Klick, B., Haythornthwaite, J. A., & Smith, M. T., (2008) Duration of sleep contributes to next-day pain report in the general population. Pain, 137(1), 202-207.

Egbunike, I. G., & Chaffee, B. J., (1990) Antidepressants in the management of chronic pain syndromes. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 10(4), 262-270.

Hellyer, P., Rodan, I., Brunt, J., Downing, R., Hagedorn, J. E., & Robertson, S. A., (2007) AAHA/AAFP pain management guidelines for dogs and cats. Journal of Feline Medicine & Surgery, 9(6), 466-480.

Icatcare.org.

(2013) Stressed Cats http://www.icatcare.org/advice/problembehaviour/stressed-cats Kemeny, M. E., (2003) The psychobiology of stress. Current Directions in Psychological Science, 12(4), 124-129.

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Medical Dictionary (2008) Stress http:// medical-dictionary.thefreedictionary.com/ Stress Merck Veterinary Manual. (2012) Non steroidal anti-inflammatory drugs http:// www.merckmanuals.com/vet/pharmacology/ anti-inflammatory_agents/nonsteroidal_antiinflammatory_drugs.html March 20th 2014 Moberg, G. P., (2000) Biological response to stress: implications for animal welfare. The biology of animal stress: basic principles and implications for animal welfare, 1-21.

Oxford University Press. (2014) Definition of anxiety in English http://www. oxforddictionaries.com/definition/english/ anxiety Rugaas, T., (2006) On talking terms with dogs: Calming signals Dogwise, UK. Russell, E., Koren, G., Rieder, M., & Van Uum, S., (2012) Hair cortisol as a biological marker of chronic stress: current status, future directions and unanswered questions.

Psychoneuroendocrinology, 37(5), 589-601.

Scholz, M., & von Reinhardt, C., (2007) Stress in dogs Dogwise, USA. Sturgess, K., (2002) Rational use of corticosteroids in small animals. In Practice (0263841X), 24(7).

Tafet, G. E., & Bernardini, R., (2003) Psychoneuroendocrinological links between chronic stress and depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 27(6), 893-903.

Takeuchi, T., & Harada, E., (2002) Age-related changes in sleep-wake rhythm in dog.

Behavioural brain research, 136(1), 193-199.

Timberlake,W., & Silva, K. M., (1995).Appetitive behavior in ethology, psychology, and behavior systems. Perspectives in ethology, 11, 211-253.

Waring, G., (2003). Horse behaviour. 2nd edition. Noyes publications, New York: USA. Woolf, C.J., (2004) Pain: moving from symptom control toward mechanism-specific pharmacologic management.Annals of Internal Medicine 140, 441-451.

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Treating kissing spines in horses without a hammer and chisel Richard Coomer MA VetMB CertES(Soft Tissue) Diplomate ECVS MRCVS

European registered specialist in equine surgery Cotts Equine Hospital, Robeston Wathen, Narberth, Pembrokeshire, SA67 8EY, United Kingdom. richcoomer@hotmail.com

Summary Kissing spines is one of the most commonly encountered causes of back pain in horses. Recognition of back pain is made through careful physical examination both passively (at rest) and dynamically (during exercise). Diagnosis of kissing spines is a jigsaw exercise involving analysis of elements of history and signalment, conformation, physical examination and diagnostic imaging.

Muscular pain in the trunk and low grade/chronic lameness issues are commonly present in association with back pain. Treatment should be of the whole horse, rather than addressing individual problem elements separately at different times. Lameness treatment is best addressed before treating the back pain as failure to control lameness can impede rehabilitation and cause recurrence of back pain. To this end, remedial farriery and lameness diagnosis are commonly carried out before starting treatment.

Treatment options for kissing spines fall into 2 types: analgesic and physical. Analgesic treatments include anti-inflammatory and analgesic injections, physical therapy, shockwave and acupuncture. It also includes interspinous ligament desmotomy (ISLD), a minimally invasive surgical means of achieving a long lasting respite from back pain.

Physical treatment involves open surgical removal of impinging dorsal spinous processes. Active physical rehabilitation is critical to success regardless of the method chosen.

One hundred and twenty-eight horses have undergone ISLD to date, of which 115 had follow-up of 80 days or more. Of these, 103 (90 %) returned to normal work during the follow up period. Not all these successes were maintained in the long-term: at their longest follow up date, 83/115 (72 %) horses remained

in full work, 20 (17%) being lost through full retirement, sale or death. 3/115 (2.6%) experienced recurrence of back pain whilst 2 more failed to resolve symptoms of back pain under saddle.

Diagnosis Dorsal spinous process (DSPs) impingement or overriding, a condition often described as “kissing spines”, has been reported as a common cause of back pain in horses (Jeffcott, 1980), although it is rare in ponies in this author’s caseload. Recognition of back pain is made through careful physical examination both passively (at rest) and dynamically (during exercise).

Horses with back pain typically suffer poor ridden performance and may appear uncomfortable or agitated during tacking up, be reluctant to jump and/or experience discomfort or difficulty going downhill (Munroe, 2009). The most painful horses can become difficult, dangerous or even impossible to ride and can become unsafe to handle. Most affected cases lose definition of the interspinous space during palpation of the tips of the dorsal spinous processes, often in combination with relative epaxial muscle wastage (Henson and Kidd, 2009). On palpation, focal muscular pain is common, along with exaggerated dorsiflexion and resentment of any digital pressure, particularly in the area of impingement. Allodynia, a pain response to a non-noxious stimulus, can also appear in this acute phase in my experience. Chronically, they appear to splint the back and are unable to dorsiflex, although they will often willingly ventroflex. Most affected individuals fail to engage the back, easily visible during canter and gallop (Munroe, 2009).

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Diagnosis of the cause of back pain is a jigsaw exercise involving analysis of elements of history and signalment, conformation, physical examination and diagnostic imaging.

Muscular pain in the trunk and low grade/chronic lameness issues very commonly present in association with back pain of all types (Dyson, 2005; René van Weeren, 2009). I divide kissing spines into 2 broad types: conformational and acquired.

It seems that some horses have a propensity to spinal crowding which only manifests as back pain when we start to try and ride them. I call this conformational, based on the absence of a better explanation.

Conformation is heritable, but there is no evidence, I am aware, of a congenital cause; there are no reports of foals that have ever been found with kissing spines. Whatever the underlying cause in this category of horse, it is thankfully rare in my caseload.

Much more commonly in my caseload, kissing spines appear to develop in young to middle age horses, cases I regard as acquired.

Kinetic chain theory, a concept borrowed from engineering and long established in human sports medicine, dictates the functional interconnectedness of the whole musculoskeletal system (Karadikar and Vargas, 2011). I believe that kinetic chain dysfunction provides an attractive and logical explanation for the frequent observed presence of concurrent lameness issues in cases of equine back pain. Whether the back pain or the lameness is primary is very likely casedependent, but having one without the other is rare in my experience and that of others (Gomez Álvarez, 2007; Gomez Álvarez, 2008).

The increased rate of back pain and kissing spines in middle aged horses may well be when the cumulative effects of suboptimal conformation join with poor riding technique, poor fitting tack, poor foot balance/ farriery and unrecognised lowgrade lameness to reach a tipping point in the kinetic chain. I believe that many acute injuries and lameness problems in horses are misidentified as sole/primary issues.

Vets ‘see only what they look for, and they look only for what they know’ (Macintyre and Joy, 2000).

This ‘tunnel vision’ approach to lameness allows underlying kinetic chain dysfunction elsewhere, such as back pain, to persist untreated.

The result is at best a compromised long-term prognosis for the injury; at worst, ongoing lameness and poor performance. It is a tragedy that equine orthopaedics often lags so far behind human sports medicine, where the kinetic chain concept is so well established and accepted (Macintyre and Joy, 2000). This concept is at the heart of my approach to back pain and lameness. Unfortunately for the time being, acquired back pain, poor performance and lameness are all common in most types/ disciplines within ridden equine sport, professional and amateur, both in my experience, my colleagues’ and that of others’ (Lesimple, et al., 2013). The potential negative synergy between multiple conditions in a single animal is as yet a black box that few seem willing to contemplate.

Treatment options Different treatment options are available, often beginning with physical therapies focussing on postural strengthening and manipulation through all the various types and sub-types of physiotherapy, chiropractic and osteopathy. Interventionist veterinary assessment and treatment is usually reserved for refractory or recurrent cases. Traditionally vets usually recommend one of 3 options: medical, surgical or rest/retirement.

Retirement is a moderately effective

method of managing the problem to make it go away, but I regard treatment options in 2 broad groups: analgesic and physical.

Analgesic treatments aim to promote remobilisation of the back through inhibition of back pain. This can be achieved through treatments along a varying spectrum of invasiveness. Back pain is a complex pathological process involving elements of inflammatory, muscular, neurogenic and referred pain. Inflammatory pain is frequently conspicuous by its absence in kissing spines in my experience. This probably explains the often-disappointing results obtained using oral antiinflammatory medication, such as phenylbutazone. More potent analgesic drugs can be injected locally. They include corticosteroids, Pitcher plant extract (Sarapin® and Saragyl®) and intradermal local anaesthetic and corticosteroid mix, called mesotherapy (Costantino, et al., 2011). Other parts of the pain pathways can be addressed by physical therapy, shockwave and acupuncture. The use of bisphosphonate drugs like Equidronate® (Ceva) has some rationale in very reactive cases but there is no published evidence that it has any benefit for kissing spines when used in isolation. I use it frequently as part of a multimodal approach for cases with concurrent distal tarsal osteoarthritis (Gough, et al., 2010). This condition is commonplace in horses I see with back pain and any additional benefit for kissing spines is welcome (Henson and Kidd, 2009).

Under the ‘analgesic treatment’ title comes interspinous ligament desmotomy (ISLD), a comparatively new and minimally invasive surgical means of achieving a long lasting respite from back pain secondary to kissing spines (Coomer, 2012). It has proven to be highly successful in the management of kissing spines, removing pain and even allowing impinging dorsal spinous processes to separate and providing a minority of cases with full radiographic cure (Coomer, 2013).

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Traditional surgery Physical treatment of kissing spines involves the surgical creation of space between kissing spines.

Resection of the summits of one or more DSPs in horses exhibiting chronic back pain attributed to impingement and/or overriding of the dorsal spines was first described

by Roberts (1968) and later by a number of different authors (Jeffcott and Hickmann, 1977; von Salis and Huskamp, 1978; Petterson, et al., 1987; Walmsley, 1995; Lauk and Kreling, 1998; Walmsley, et al., 2002). Petterson, et al. (1987) concluded that surgical treatment was associated with better outcome than conservative treatment, hence surgery is generally recommended when rest, intralesional corticosteroids and physiotherapy all fail (Walmsley, et al., 2002; Henson and Kidd, 2009). This seems sensible given the invasive nature of the procedure and the lengthy rehabilitation.

The original method of surgical resection of the DSPs involved a midline, or occasionally a paramedian, skin incision. The supraspinous ligament was divided or reflected to one side to allow resection of the relevant DSPs using an oscillating saw or osteotome and mallet (Walmsley, 1995). An open technique has been described in the standing sedated horse (Perkins, et al., 2005; Brink, 2013).

An alternative minimally invasive technique has also been described whereby the affected portion of the DSPs is identified endoscopically and removed with rongeurs and burrs under general anaesthetic (Desbrosse, et al., 2007) Interspinous ligament desmotomy (ISLD) Interspinous ligament transection is a minimally invasive alternative surgical treatment for kissing spines (Coomer, et al., 2012). It appears that ISLD rapidly abolishes the sensation of pain, possibly through relief of tension on sensory nerves within the ISL. The exact mechanism of action of ISLD has not been

established in horses, yet extrapolation of spinal function in man gives tantalising clues.

Changes in tension in the supraspinous and interspinous ligaments have direct protective effects on electromyographic (EMG) activity within the multifidus muscle for up to 7 hours (Solomonov, et al., 2003). Prolonged exposure to cyclic loading can have dramatic changes in the physical and nervous properties of ligaments, modifying protective muscular activity to become hyperexcitable (Olson, et al., 2004). This effect is highly likely to occur in horses as well, potentially explaining the early spasm seen in acute back pain and the chronic muscle wastage that follows as epaxial muscles fatigue.

By releasing the dysfunctional ligament during ISLD, back function appears to be restored by allowing normal motor control to the epaxial muscles to be re-established.

This supposition is supported by the dramatic enlargement of the multifidus muscle that occurs after comparative short periods of postoperative rehabilitation (Coomer – unpublished data).

Whether or not the neural feedback system exists and in what form in normal and abnormal horses is unknown at present.

ISLD was readily applicable to standing sedated horses and could be accomplished through a genuinely minimally invasive skin incision. Initial results in 37 cases had been published (Coomer, 2012) and in 82 horses (Coomer, 2013). Encouraging results of treatment have included widespread improvement in postoperative back pain coupled with visual evidence of interspinous space enlargement on postoperative radiography.

There are positive implications of patient safety, reduced cost in performing this technique, reduced complication rate and accelerated postoperative recovery (Coomer, 2013).

Method I diagnose kissing spines based on

the identification of focal back pain with the radiographic presence of one or more narrowed, obliterated or overlapping interspinous spaces in the area of pain. It has been suggested that diagnostic analgesia be must performed to connect the two (Walmsley, et al., 2002; Henson and Kidd, 2009). I encourage this approach wherever doubt exists.

However, my experience is that it is potentially misleading and unrelated to postoperative success providing the history, physical examination and radiographic findings support the diagnosis. Blocking relieves pain but does not restore function or promote ventroflexion, therefore it cannot be expected to work in every case. To this author’s knowledge there is no objective data in existence to support the current established view that local diagnostic analgesia offers 100 % sensitivity and specificity for kissing spines. This is because there is no gold standard with which to compare; as such it remains a wellestablished and well-referenced assumption.

Radiographic signs range from subtle narrowing of an interspinous space with sclerosis visible on the cranial and sometimes caudal DSP (See Figure 1) to clear overlapping of multiple adjacent DSPs, with all gradations in between. The radiographic grade is unrelated to outcome (Walmsley, 2002).

All spaces judged visually to be significantly narrower than normal are operated on.

I use a disposable plastic sterile drape secured to the horse using sterile skin staples. Reference is made both to the shape of the DSPs and to the angle of the interspinous space using the pre-operative radiographs. The stylet from a 3.5” 18 gauge needle is used to directly probe the interspinous space, which shows the orientation of the space and facilitates the proposed desmotomy. A 1 cm paramedian skin incision is carried out 3 cm to the left of the space, and then curved 6” Mayo scissors used to progressively cut the interspinous ligament in the area of impingement. An audible rasping sound of ligament dividing is usually heard as the scissors cut the ISL and working space often seems to increase as progress is made. Closed and overlapping spaces are more challenging but it is exceptionally rare to be unable to divide the interspinous ligament in the area of impingement. The desmotomy stops at the ventral limit of impingement, rather than moving any further down towards the vertebral body where more severe hemorrhage may ensue.

Several checks are made to ensure the space is entirely free, either by fully closing the scissors several times in the space, or probing it.

Other than the occasional skin vessel, little hemorrhage is normally encountered, allowing skin closure with 2 simple interrupted sutures of monofilament nylon. A sterile adhesive dressing is placed for 24 hours postoperatively.

Postoperative treatment Horses are discharged on the day of surgery, or later if preferred.

Prophylactic oral antibiotics (enrofloxacin 7.5 mg/kg, q 24 h, per os) are continued for 3 days and a reducing dose of phenylbutazone (starting at 4.4 mg/kg, q 24 h, per os) over 7 days. Stitches are removed at 12 to 14 days.

Figure 1: A pre-operative radiograph of a horse diagnosed with impinging dorsal spinous processes

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No riding is allowed during the 6-week rehabilitation period. Box rest is maintained along with 30 minutes hand walking twice per day from day 1. Thoracic flexion

stretches are also recommended in conjunction with a veterinary physiotherapist. After 2 weeks, small paddock turnout is allowed in addition to the hand walking.

Daily lunging with a Pessoa is commenced in week 4, starting with 10 minutes per day and increasing by 10 minutes per week. I routinely recommend that the advice of a Chartered Veterinary Physiotherapist be sought within days of surgery to assist in the rehabilitation, and thereafter as required and advised by the Physiotherapist. Having a professional expert on rehabilitation in charge of the rehabilitation makes sense to me and takes much of the difficulty out of the decision on when the horse is ready and strong enough to ride again.

The proportion of horses not receiving professional physiotherapy postoperatively is falling, but a significant minority still copes without. In these cases the horse is reassessed at 6 weeks to ensure wounds have healed prior to resuming full work and riding.

Optional repeat radiography is carried out at this stage (See Figure 2). Riding is then allowed and exercise and training gradually increased as normal. Owners are strongly encouraged to obtain a saddle refit prior to riding and to maintain foot balance.

352, median 322, range 80 days to 3.1 years). Median age was 7, mean 7.8, range 3 – 17 years. They comprised of 46 mares, 80 geldings and 2 stallions. A median of 5 ISLDs were carried out, range 2 to 13. At the time of writing, 103/115 (90%) horses had re-entered normal work at least once after surgery.

Of the 103 horses that had managed to resume normal work, 54 (47%) were also treated for lameness problems: 38 (33%) were already or diagnosed as lame at the time of surgery, whilst 16 more (14 %) went lame postoperatively.

At the time of long-term review 20/115 horses had been lost through full retirement, sale or death: Of the remaining 95 horses, 83 remained in normal work (72% of 115) and 12 were in reduced work.

Reviewing back pain: 2 horses experienced no change in the presenting symptoms of back pain when riding resumed and 3 (2.6%) had recurrence of back pain. The 3 experiencing recurrence did so around 6 weeks, having been very comfortable at their first postop check. Two of these were likely conformational based on history and radiographic appearance.

The third was lame at the time of surgery, went much more lame postoperatively and was not diagnosed and treated by the referring vet before severe back pain returned.

Discussion

Figure 2: A post-operative radiograph of the horse seen in Figure 1, 6 weeks post ISLD surgery

Results of ISLD (Jan 2014 audit) A total of 128 horses were treated of which 115 had 80 days or more postoperative follow up (mean

The technique of ISLD is conceptually simple and noninvasive compared to traditional kissing spines surgery. It appears to cause a rapid and profound improvement in back pain attributable to kissing spines.

Subjective improvements in pain reaction, avoidance behaviour and demeanour are commonplace from soon after surgery. Alleviation of symptoms of back pain attributable to kissing spines has been achieved for just over 3 years using the technique described here. This technique is the only surgical

17

treatment for this condition carried out in my practice and owner feedback is very positive.

It seems obvious, but if back pain can be controlled along with the underlying risk factors, such as lameness, poor riding/tack and unsympathetic farriery, then back pain and kissing spines can usually be resolved. Cases presenting with back pain and kissing spines are rarely simple and commonly have several chronic conditions present at the same time. This reduces the overall chances of success, the ultimate prognosis being dependent on the worst condition present. I treat a significant number of less severely affected horses medically, by treating any lameness and supplying remedial farriery where appropriate. This is coupled with specific back therapy including: corticosteroid medication, physiotherapy, acupuncture and shockwave therapy. The importance of checking the saddle fit after rehabilitation is underlined because horses frequently change shape dramatically following surgery, increasing epaxial muscle bulk.

It is inevitable that a proportion of cases that undergo ISLD could also experience a permanent solution with medical treatment, such as intra-lesional injection with corticosteroid (Coomer, 2012).

Although the technique developed in the most severely affected horses, I have found it to work very well in all types of horse, regardless of clinical or radiographic severity.

The less severely effected horses often experience the opening of interspinous spaces postoperatively, giving them full ‘cure’ from kissing spines. In contrast, horses which were treated medically and which underwent post-treatment radiography showed no enlargement of treated spaces (Coomer, 2012).

This possibly explains the higher rate of recurrence in medically treated horses. There may be less time or money to spend on these cases, limiting my recommended ‘holistic’ approach and reducing the overall success rate.

Lameness affects a significant proportion of horses, reducing overall success, as it has in previously published series following ostectomy (Jeffcott and Hickman, 1977; Walmsley, et al., 2002; Dyson, 2005; Coomer, et al., 2012; Lesimple, et al., 2013). A quarter of the horses treated were undergoing treatment for known causes of lameness at the time of ISLD surgery and a further fifth experienced lameness postoperatively. Based on the diagnoses made, this complication is likely a combination of new problems and recrudescence of old problems. Horses with induced lameness rapidly show back dysfunction (Gomez Alvarez, et al., 2007, 2008) and horses examined under saddle show increased lameness (Licka, et al., 2004). It may be that individuals with chronic back pain develop modified gait or spinal movements to relieve pressure and pain, leading to secondary compensatory pathology elsewhere in the back or limbs. There is clearly a very close association between lameness and kissing spines that warrants further investigation. Based on the potentially negative effect of lameness on back pain, I now look very closely for lameness at first assessment and treat it wherever possible before or at the time of kissing spine treatment, rather than waiting for it to appear later on.

Whichever treatment is carried out, an integrated and proactive approach focusing on back strengthening is a pre-requisite to long-term success. ISLD is different from ostectomy because it focuses treatment on back remobilization by promoting normal back function, rather than attempting to create a version of physical ‘normality’ immediately during surgery. As such it offers an attractive means of treating kissing spines that is growing in popularity.

Acknowledging both the presence and huge importance of a fully functional kinetic chain is mandatory to optimize success from the technique.

References Brink, P., (2014) Subtotal ostectomy of impinging dorsal spinous processes in 23 standing horses.Vet Surg 43:95-98.

Coomer, R.P.C., McKane, S.A., Smith, N., Vanderweerd, J. M.E., (2012) A Controlled Study Evaluating a Novel Surgical Treatment for Kissing Spines in Standing Sedated Horses.

Vet Surg 41:890 – 897.

Coomer, R.P.C.,(2013) Standing resection of the interspinous ligament for the treatment of kissing spines. Proceedings BEVA Congress ;111-112.

Costantino, C., Marangio, E., Coruzzi, G., (2011) Mesotherapy versus Systemic Therapy in the Treatment of Acute Low Back Pain: A Randomized Trial. Evid Based Complement Alternat Med. Desbrosse, F.G., Perrin, R., Launois, T., Vandeweerd, J. M., Clegg, P. D., (2007) Endoscopic resection of dorsal spinous processes and interspinous ligament in ten horses.Vet Surg 36:149-55.

Dyson, S.J., (2005) The interrelationships between back pain and lameness: a diagnostic challenge. Proceedings BEVA Congress p137.

Gomez Alvarez, C.B., Bobbert, M.F., Lamers, L., Johnston, C., Back, W.,Van Weeren, P.R., (2007) The effect of induced forelimb lameness on thoracolumbar kinematics during treadmill locomotion. Equine Vet 39:197 - 201.

Gomez Alvarez, C.B., Bobbert, M.F., Lamers, L., Johnston, C., Back, W., van Gough, M.R.,Thibaud, D., Smith, R.K.W., (2010) Tiludronate infusion in the treatment of bone spavin: A double blind placebo-controlled trial.

Equine Vet J 42:381 – 387.

Henson, F.M., Kidd, J.A., (2009) Overriding dorsal spinous processes, in: Henson FM (ed): Equine Back Pathology. Oxford, Blackwell Publishing, p147 156.

Jeffcott, L.B., Hickman, J., (1975) The treatment of horses with chronic back pain by resecting the summits of the impinging dorsal spinous processes.

Equine Vet J 7:115-9.

Jeffcott, L.B., (1980) Disorders of the thoracolumbar spine of the horse: A survey of 443 cases. Equine Vet J 12:197.

Karadikar, N., Vargas, O.O., (2011) Kinetic chains: a review of the concept and clinical applications. Physical Medicine and Rehabilitation 3:739-745.

Lauk, H.D., Kreling, I. (1998) Behandlung des Kissing spines-Synroms beim pferd- 50 Falle Teil 2: Ergebnisse. Pferdeheilkunde 14:123-130.

Lesimple, C., Fureix, C., Biquand,V., Hausberger, M., (2013) Comparison of clinical examinations of back disorders and humans’ evaluations of back pain in riding school horses. BMC Vet Res 9:209-217.

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Licka,T., Kapaun, M., Peham, C.,(2004) Influence of rider on lameness in trotting horses. Equine Vet J 36:734 – 736.

Macintyre, J., Joy, E., (2000) Foot and ankle injuries in dance. Clinical Sports Medicine 19:351-368.

Munroe, G.A., (2009) The clinical Examination, in: Henson FM (ed): Equine Back Pathology.

Oxford, Blackwell Publishing p63-72.

Olson, M., Li, L., Solomonow, M., (2004) Flexion-relaxation response to cyclic lumbar flexion. Clinical Biomechanics 19:769-776.

Perkins, J.D., Schumaker, J., Kelly, G., Pollock, P., Harty, M., (2005) Subtotal Ostectomy of Dorsal Spinous Processes Performed in Nine Standing Horses.Vet Surg 34:625-629.

Petterson, H., Stromberg, B., Myrin, I., (1987) Das thorkolumbale, interspinale Syndrom (TLI) des Retpferdes - Retriospecktiver Vergleich konservativ und chirurgisch behadelter Falle. Pferdeheilkunde 3:313-319.

Roberts, E.J., (1968) Resection of thoracic and lumbar spinous processes for relief of pain responsible for lameness and some other locomotory disorders in horses. Proceedings.

Am Assoc Equine Pract 14:13–30.

René van Weeren, P., (2009) Kinematics of the Equine Back, in: Henson FM (ed): Equine Back Pathology. Oxford, Blackwell Publishing, p39-59.

Solomonow, M., Baratta, R.V., Zhou, B., Burger, E., Zieske, A., Gedalia, A.,(2003) Muscular dysfunction elicited by creep of lumbar viscoelastic tissues.

Journal of Electromyography and Kinesiology 13:381-396. von Salis, B., Huskamp, B., (1978) Vorlaufige Erfahrungen mit der konservativen und chirurgischen Behandkung der Wirvelsaulenerkrankung der Pferde. Prakt Tierarz 4:291- 294.

Walmsley, J.P., (1995) Dorsal spinous process resection in 21 horses: indications, surgical technique and prognosis. Proceedings. 4th European Coll Vet Surg 61-62.

Walmsley, J.P., Pettersson, H., Winberg, F., McEvoy, F., (2002) Impingement of the dorsal spinous processes in two hundred and fifteen horses: case selection, surgical technique and results. Equine Vet J 34:23-8.

Weeren, P.R., (2008) The effect of induced hindlimb lameness on thoracolumbar kinematics during treadmill locomotion.

Equine Vet J 40:147 – 152.

MOORCROFT RACEHORSE WELFARE CENTRE Huntingrove Stud, Slinfold, West Sussex. RH13 0RB

Tel: 07929 666408 Email: info@mrwc.org.uk

At Moorcroft all ex-racehorses go through a very careful rehabilitation and training system with the invaluable help of Vets and ACPAT registered physiotherapists. In order to give these horses an honest sustainable future after their racing career, much help is needed from the vets and physiotherapists who are equipped to get to the source of the problem and treat it long-term. Much success is achieved and it could not be done without this help.

At the centre we run regular demonstrations/talks/demos on the work that we do â&#x20AC;&#x201C; all details are on our website: www.mrwc.org.uk If you would like to know more about giving these horses a good home, please also get in touch.

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A Review of Neuromuscular Electrical Stimulation in Human Cruciate Rupture Rehabilitation: Relevance to Limb Function following Cranial Cruciate Ligament (CCL) Surgery in Dogs Elizabeth Hughes PgDip, BSc, MCSP, HCPC, ACPAT A. Ock Valley Physiotherapy Introduction Injury or disease of the cranial cruciate ligament (CCL) is a highly prevalent orthopaedic condition in the dog (Witsberger, et al., 2008; Ralphs and Whitney, 2002). The long term prognosis for the affected joint is poor, frequently displaying osteoarthritis (OA) even after corrective surgical intervention (Monk, et al., 2006). Wilke, et al.

(2005) estimated that in the year 2003 CCL ruptures cost US dog owners $1.32 billion. Cook (2010) concluded that disease and injury to the CCL is caused by both biological and biomechanical factors and Jerram and Walker (2003) advise that management of CCL damage requires a multifactoral approach. This literature review evaluates research around post operative physiotherapy following CCL surgery, specifically the role of neuromuscular electrical stimulation (NMES). The quality and relevance of available human and canine research in this area will be considered.

Conservative Vs Surgical Management Conservative management is rarely advocated, particularly in large breed dogs (Casale and McCarthy, 2009) for which research findings of long term joint instability, (Harasen, 2011) increased osteoarthritic changes (Jerram and Walker, 2003) and ongoing lameness (Corr, 2009) have been reported. Numerous surgical techniques have been developed over the years and there

is much debate and conflicting research surrounding the most effective surgical technique for CCL stabilisation (Conzemius, et al., 2005). Au, et al. (2010) suggest that the post operative rehabilitation programme may be of greater influence on outcomes than the surgical technique employed, which is supported by earlier work of Jerram and Walker (2003).

Physiotherapy following human ACL Surgery Physiotherapy has routinely been undertaken following human Anterior Cruciate Ligament (ACL) surgery for many years (Shumway, 2007; Monk, et al., 2006) with literature advising early intervention to facilitate accelerated return to function (Kvist, 2004; Shelbourne and Nitz, 1990). Risberg and Holmâ&#x20AC;&#x2122;s (2009) single blinded randomised control trial (RCT) concluded that a combination of neuromuscular and strengthening exercises should be incorporated into a rehabilitation programme following ACL surgery.

However, the interventions were studied in isolation to one another and not in conjunction, identifying a need for further research into effectiveness of independent modalities and relevant combinations. The sample size was 74 and therefore representativeness may be questionable. In addition, high follow up drop out rates may have impacted on statistical power of the study. The primary outcome measure was a self administered questionnaire. Additional subjective and objective measures used

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were considered highly reliable, particularly in inter-rater reliability, each providing quantitative data.

Whilst human research may provide useful information on principles of physiotherapeutic techniques and a basis on which to guide veterinary research, its application to clinical work with animals must be viewed with caution. Barrett, et al. (2005) found important microbiological and histological differences between canine CCLs and human ACLs, highlighting the importance and value of specie specific research.

Physiotherapy following canine CCL surgery The objective of physiotherapy is the same, despite the species under consideration (Shumway, 2007); to maintain or return to optimum function (Gordon-Evans, et al., 2011; Saunders, 2007). Benefits of early post-operative rehabilitation have been documented by Shumway (2007) who claimed that a combination of joint range exercises, massage, Neuromuscular Electrical Stimulation (NMES), Transcutaneous Electrical Nerve Stimulation (TENS) and application of ice within the first 2 days post surgery, speeds up recovery and return to function.

However, much of Shumwayâ&#x20AC;&#x2122;s (2007) article is based on theory and personal experience with little supporting research of unknown quality, therefore its credibility as evidenced based literature is questionable.

Physiotherapy treatments similar to those outlined in Shumway’s (2007) work, with the addition of underwater treadmill exercise, were found to be effective for accelerating recovery in regards to muscle bulk and range of motion compared with a more conventional phased walking programme when commenced on day one post surgery (Monk, et al., 2006). These findings were based on a clinical trial of dogs with CCL deficiency and therefore are relevant to the subject area under consideration.

The findings were based on data collected for 8 subjects, which could be considered a small sample size. However, they were all large breed dogs over 4 years old which have been found to have the highest incidence of CCL rupture (Witsberger, et al., 2008) Results may be representative of the target population although caution must be given when applying the results to smaller breed, younger dogs. Lack of randomisation to the control or treatment group reduces reliability of the research, however as dogs were assigned according to owner preference it could be argued that external validity is increased.

Confounding variables including the home environment, subject activity levels and owner compliance reduce internal validity. To address these issues, the authors provided concise written directions and activity diaries. In addition, there was a standardised protocol for the physiotherapy group, although this consisted of several interventions and therefore the role and effectiveness of each is inconclusive.

Lack of investigator blinding possibly caused experimenter bias as the investigator conducted all assessments including subjective scoring. Monk, et al (2006) identified that there may be more objective tools available to assess limb function and that additional RCTs are required to establish rehabilitation protocols post CCL surgery.

of limb function than clinical gait examination or assessment of owner satisfaction” (Voss, et al., 2008). Force plate systems are considered “reliable, repeatable and objective means for gait analysis but require appropriately standardized procedures, calibration, intensive training, are financially and labour intensive…” (Hesbach, 2007).

Early post operative rehabilitation was found to significantly increase limb function compared to a control protocol of phased increased walking, when measured using force platform gait analysis (Marsolais, et al., 2002). Similarly to Monk, et al’s. (2006) study, Marsolais, et al’s.

(2002) work lacked randomisation and investigator blinding and the same confounding variables were present, impacting on the quality of the study. Although, it could be argued that external validity was increased by allocating dogs through owner choice, lack of control of the environment and varying degrees of owner compliance which commonly occur in practice. In Marsolais, et al’s. (2002) study, dogs were admitted for physiotherapy treatment and housed in steel cages which may have affected internal validity as the control groups remained at home throughout the study.

NMES in human rehabilitation

Force plate gait analysis

Physiotherapy programmes commonly consist of several modalities but there is little high quality veterinary evidence for the effectiveness of individual interventions (Bockstahler, et al., 2012). NMES is extensively utilised in human rehabilitation following ACL Surgery to recruit and strengthen the quadriceps and restore limb function (Feil, et al., 2011; Kim, et al., 2010).

The electrical current applied by NMES activates motor nerve fibres resulting in muscle contraction, the intensity of which depends largely on chosen electrical parameters (Kim, et al., 2010).

Force plates are considered a “more objective method of evaluation

Early human studies into the use of NMES, in conjunction with

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and compared to exercises on performance measures, found little support for its use following ACL Surgery (Wolf, et al., 1986). A more recent systematic literature review (SLR) by Bax, et al. (2005) of RCTs, studying the effects of NMES on quadriceps strength also concluded that its implementation did not provide any significant benefits compared to volitional exercise. However, use of NMES was found to be beneficial in cases of immobilisation where volitional exercise was limited, thus compared to no exercise it provided significantly better outcomes. Whilst Bax, et al’s. (2005) review was based on RCTs which are generally considered the most scientifically valid of methodologies for research (Robson, 2011), the quality of the trials were assessed and found to be poor with regards to blinding and therefore bias. Many of the studies had small sample sizes with a high drop out rate of >10%, decreasing the validity of their findings.Additional limitations such as the variability of NMES parameters, the rehabilitation protocols used, the lack of detailed information and the diversity of the outcome measures used to assess NMES, meant the data collated was heterogeneous, questioning the usefulness of the meta-analysis.

Many of the articles included in Bax, et al’s. (2005) review were over ten years old, therefore it could be argued that the recommendations are outdated. In addition, some of the results were based on healthy subjects or those having undergone knee replacements and therefore not representative of an ACL injury population. Bax, et al. (2005) suggest that recommendations from their findings are treated with caution until further high quality research is undertaken.

A later SLR conducted by Kim, et al. (2010) studied the effects of NMES post ACL Surgery in humans.

The conclusions, based on 8 RCTs, suggest that NMES is a useful and effective adjunct to exercise for maintaining and strengthening the quadriceps early post ACL surgery.

In terms of functional outcome and patient perception, the benefits of NMES were debateable. This is attributed to the variability in clinical application and patient compliance (Kim, et al., 2010). In Comparison to Bax, et al. (2005) the authors of the study recognised that lack of quality RCTs to review, questions the validity of the SLR itself. Additionally, the need for investigator blinding to reduce bias was highlighted; standardised, detailed NMES protocols were required to ensure accurate measurement of the effect, with reliable outcome measures. This ensures validity and reliability of their findings for both pre and post operative measurements (Kim, et al., 2010).

Minetto, et al. (2013) suggests that variability in muscle fibre changes identified between subjects is far greater and less predictable when provoked by NMES application compared with voluntary exercise modalities. This may account for the disparity of previous research findings. In addition to inter-human differences in muscular adaptations to NMES, Sawaya, et al. (2008) found important dissimilarity between human and canine impulse duration thresholds, concluding that pulse duration protocols for humans are not suitably transferrable to dogs and may in fact cause pain through activation of nociceptive fibres, reducing the tolerance and thus the effectiveness of NMES. NMES in canine rehabilitation The use of NMES is now extensively documented in veterinary physiotherapy text books such as McGowan, et al. (2007) and Millis, et al. (2004). It is also widely recommended as a treatment option for preserving or restoring muscle strength in dogs (Cannap, 2007) particularly when weight bearing is limited or contraindicated, such as following CCL surgery (Steiss and Levine, 2005). Hind limb musculature plays a crucial role in the functioning of the stifle (Jerram and Walker, 2003), therefore it can be assumed that muscle atrophy

results in reduced stifle function.

NMES may therefore be a useful rehabilitation modality at helping to restore joint function following CCL surgery. However, following an extensive literature search, the author found only one published peer reviewed study into the effects of NMES as a rehabilitation tool post CCL surgery.

Johnson, et al. (1997) studied the effect of NMES using subjective scoring and objective measures post clinically induced CCL transection and stabilisation surgery. NMES was found to significantly improve limb function post CCL surgery in some functional measures, including reduced lameness, degenerative changes along with an increase in muscle bulk, but not all. A finding of concern was the greater incident of meniscal damage in the NMES group on follow up assessment, although this may be explained by chance, due to the small sample size or lack of detection during the surgery (Johnson, et al., 1997).

Johnson, et al. (1997) blinded the radiologist and physiotherapist who conducted the objective measurements to the control and treatment dogs, however the surgeon who also carried out the subjective orthopaedic assessment was not blinded, possibly resulting in bias. The objective measures used including goniometry and tape measures were reported as being high in intra-rater reliability with the standard error of the mean being low. However, there are considerations to be given to both measurements; passive range of joint motion does not necessarily correlate with active movement and therefore may not be a valid measure for assessing limb function and muscle bulk does not necessarily result in increased muscle strength in canines (Johnson, et al., 1997). In humans, strength is measured by maximum voluntary contraction (Feil, et al., 2011), this outcome measure is not possible for use with dogs. Large breed laboratory dogs were used which may increase the reliability of the study but external validity and

22

representativeness of the findings for application to the target population may be questionable.

Research paradigm and research limitations All of the seminal studies produced quantitative data of which the research paradigm is commonly associated with positivism (Webb, et al., 2009). Positivists approach research from a scientific and realist angle, seeking to find facts to which theories can be tested with the overall aim being to establish laws of cause and effect (Robson, 2011). In order to develop laws, the researchers input must not influence the outcome of the study and thus an objectivist approach is taken. In true positivist research, variables would be controlled in order to use a deductive method to establish the actual cause of the patterns identified (Robson, 2011).

The critiqued studies included in this literature review all have common limitations including small sample sizes making the representativeness and ability to generalise findings to the target population questionable. Lack of true randomisation and blinding in many of the studies can result in bias, reducing validity of the findings.

Diversity of outcome measures used in the various studies and lack of detailed, standardised protocols for physiotherapy programmes and NMES parameters makes comparing findings difficult. In addition, many of the outcome measures used are subjective and lack reliability and validity. The authors of studies included in this review recognise limitations to their work and emphasize the need for further high quality research. This supports a post positivist view in that a general law cannot be determined from a single piece of research but if similar findings are recorded in multiple related studies then a conclusion can be reached (Robson, 2011).

Conclusion CCL injury is a highly prevalent and costly condition in the dog

therefore the most effective and appropriate physiotherapy treatments and protocols must be identified. As this literature review demonstrates, there is limited current research on the use and effectiveness of NMES in dogs following CCL surgery and application of the findings are largely restricted due to design and methodological limitations. There is greater availability of current human research which can be useful for providing knowledge into possible benefits and limitations of NMES. However, caution must be taken when applying results to veterinary practice as there are important histological and anatomical differences between the two species.

References Au, K.K., Gordon-Evans, W.J., Dunning, D., Oâ&#x20AC;&#x2122;DellAnderson, K.J., Knap, K.E., Griffon, D., Johnson, A.L. (2010) Comparison of Short- and Long- Term Function and Radiographic Osteoathrosis in Dogs After Postoperative Physical Rehabilitation and Tibial Plateau Leveling Osteotomy or Lateral Fabellar Suture Stabilization. Veterinary Surgery.

39(2) 173-180.

Barrett, J.G., Hao, Z., Graf, B.K., Kaplan, L.D., Heiner, J.P., Muir, P. (2005) Inflammatory Changes in Ruptured Canine Cranial and Human Anterior Cruciate Ligaments.American Journal of Veterinary Research. 66(12) 2073-2080.

Bax, L., Staes, F., Verhagen, A. (2005) Does Neuromuscular Electrical Stimulation Strengthen the Quadriceps Femoris? Sports Medicine. 35(3) 191-212.

Bockstahler, B.A., Prickler, B., Lewy, E., Holler, P.J., Vobonik, A., Peham, C. (2012) Hind Limb Kinematics During Therapeutic Exercises in Dogs with Osteoarthritis of the Hip Joints. American Journal of Veterinary Research. 73(9) 1371-1376.

Cannap, S.O. (2007) Select Modalities. Clinical Techniques in Small Animal Practice. 22(4)160-165.

Casale, S.A., McCarthy, R.J. (2009) Complications Associated with Lateral Fabellotibial Suture Surgery for Cranial cruciate Ligament Injury in Dogs: 363 cases (1997-2005). Journal of American Veterinary Medical Association. 234(2) 229-235.

Conzemius, M.G., Evans, R.B., Besancon, M.F., Gordon, W.J., Horstman, C.L., Hoefle, W.D., Nieves, M.A.,Wagner, S.D. (2005) Effect of Surgical Technique on Limb Function After Surgery for Rupture of the Cranial Cruciate Ligament in Dogs.

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226(2) 232-236.

Cook, J.L. (2010) Cranial Cruciate Ligament Disease in Dogs: Biology Versus Biomechanics.

Veterinary Surgery. 39(3) 270-277.

Corr, S. (2009) Decision Making in the Management Cruciate Disease in Dogs. In Practice. 31(4)164-171.

Feil, S., Newell, J., Minogue, C., Paessler, H.H. (2011) The Effectiveness of Supplementing a Standard Rehabilitation Program With Superimposed Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 39(6) 12381247.

Gordon-Evans,W.J., Dunning, D., Johnson,A.L., Knap, K.E. (2011) Effect of the Use of Carprofen in Dogs Undergoing Intense Rehabilitation After Lateral Fabellar Suture Stabilisation. Journal of American Veterinary Medical Association. 239(1) 75-80.

Harasen, G. (2011) Making Sense of Cranial Cruciate Ligament Disease Part 3: Therapy.

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Hesbach, A.L. (2007) Techniques for Objective Outcome Assessment. Clinical Techniques in Small Animal Practice. 22(4)146-154.

Jerram, R.M., Walker, A.M. (2003) Cranial Cruciate Ligament Injury in the Dog: Pathophysiology, Diagnosis and Treatment. New Zealand Veterinary Journal. 51(4) 149-158.

Johnson, J.M., Johnson, A.L., Pijanowski, G.J., Kneller, S.K., Shaeffer, D.J., Eurell, J.A., Smith, C.W., Swan, K.S. (1997) Rehabilitation of Dogs With Surgically Treated Cranial Cruciate LigamentDeficient Stifles by Use of Electrical Stimulation of Muscles. American Journal of Veterinary Research.

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Kim, K.M., Croy,T., Hertel, J., Saliba, S. (2010) Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function and PatientOrientated Outcomes: A Systematic Review.

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Consideration into the effects of the noseband as part of a physiotherapy assessment Sue Palmer MCSP, MSc Veterinary Physiotherapy, ACPAT Cat A, BHSAI, IHRA www.holistichorsehelp.com; email: sue@holistichorsehelp.com

Hannah Mace MPharmacol, ITEC Dip, EEBW

www.perfectponieskent.co.uk; email: info@perfectponieskent.co.uk Physiotherapy is an important aspect of maintaining the horses well being. One aspect of the role of the Physiotherapist is in assessing and treating pain and performance issues relating to the tack the horse wears. Whilst poor saddle fit has long been of concern, this article puts forward the case for greater emphasis being placed on the effect of the bridle, in particular the noseband.

No jaw, no horse?

There has been increasing controversy in the equestrian world over the past few months about nosebands, and how tight they should or shouldn’t be. The International Society for Equitation Science (ISES) has recommended a taper gauge to be used at all competitions to ensure that the amount of space under the noseband allows a horse to express certain behaviours that are potentially restricted through over tightening (International Society of Equitation Science Position Statement on Restrictive Nosebands).

For an animal that chews approximately 30, 000 times per day (Mayes and Duncan, 1986), good temporomandibular joint (TMJ) movement is vital. TMJ movement is controlled by the mandibular nerve which supplies the muscles of mastication including the temporalis, masseter and pterygoid muscles.

The sensory innervation of the face is provided by the trigeminal nerve, and in human studies the TMJ joint disk has been shown to be richly innervated with sensory nerves (Asaki, et al., 2006). Restriction of TMJ movement, or muscular tension and pain in this area, can

lead to difficulties in chewing, ridden problems and behavioural issues.

Why does the horse need TMJ freedom during exercise?

In humans, clenching the TMJ creates a concurrent activation potentiation leading to simultaneous activation of remote muscles and increased activation of the H-reflex (Ebben, et al., 2006). A horse resisting against a tight noseband would be likely to contract the muscles activating the temporomandibular joint, potentially leading to a concurrent activation potentiation and therefore increasing muscular resistance throughout the cervical spine and potentially the body.

To breathe properly The Animal Welfare Act 2006 states that the animal needs “to be able to exhibit normal behaviour patterns”. The horse is an obligate nose breather – they can only breathe through their nostrils, not their mouth (Dyce, et al,. 2002).

As for human athletes, sufficient oxygenation of the muscles is essential for their optimal performance during exercise, so it is extremely important that the horse’s air supply is not restricted during exercise. If the horses’ airways are restricted, as is potentially the case with a drop noseband or ill fitting noseband, the horse can only display discomfort through behaviour changes, perhaps by throwing their head in the air, or not working willingly for as long as you might expect.

To show us when they are in pain Horses are non-verbal animals, and communicate with their

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rider or handler through their behaviour.

Some of those behaviours, particularly in the ridden horse, include opening the mouth, sticking out the tongue or by crossing the jaw. We should remember that the behaviour has a root cause, and stopping the horse from demonstrating the behaviour by strapping his TMJ tightly shut does not address the underlying problem. There is then the potential that the horse will choose a different behaviour in an attempt to communicate with the rider, such as rearing or refusing to go forwards. World Horse Welfare says ‘’Restrictive nosebands should not be used in such a way that it causes the horse pain or discomfort as apart from the fact it would be wrong to do so this it will only make matters worse when dealing with a horse that is having issues with acceptance of the bit” (Fordham, 2014).

Dentistry As a prey animal, horses are inclined to mask pain (Hall, et al., 2013) and problems such as dental pain can distract the horse from it’s work and affect performance (Johnson and Porter, 2006). Therefore, it is extremely important for equine welfare and performance that pain is identified as early as possible.

Allowing the horse freedom to move it’s TMJ during exercise means that the rider can detect pain behaviours.

When a horse raises or lowers its head, the TMJ naturally moves slightly. Dental problems can limit this movement. If a rider asks a horse with an undiagnosed dental problem to change it’s head position or carriage during the course of its

work, the horse may be unable to do so, or find such a movement very painful. The horse may try to oblige the rider by instead opening it’s jaw, which could allow the mouth to move in the way described despite the dental problems. A tight noseband may prevent the horse from doing this. This can, in turn, lead to performance problems (Johnson and Porter, 2006).

Tooth grinding and attempts to avoid the bit can also both be indicators of pain (Hall, et al., 2013), and excessive bit pressure can damage the bars and cheeks (Johnson and Porter, 2006).

These can all be hidden by a tight noseband. A tight noseband can also sensitise the mouth (McLean and McGreevy, 2010; Randle and McGreevy, 2011) and can press the inner surface of the cheeks against any sharp edges on the teeth (McGreevy, et al., 2012).

To show us that they are anxious Horses may also chew on the bit due to anxiety, nervousness or boredom (Johnson and Porter, 2006). Freedom to move the TMJ means that the rider can also detect these subtle signs from their horse and address these issues before they escalate into behavioural problems. A tight noseband is likely to be an additional stressor, rather than lead to relaxation of the TMJ (McLean and McGreevy, 2010). A stressed horse will be tense with restricted movement, and less able to perform their job to the best of their ability. Equestrianism is about the relationship of trust and respect between horse and rider, and masking your horse’s freedom to display his emotions could damage that relationship.

For effective training The working horse is generally trained using a system of ‘pressure and release’. In other words pressure is applied (e.g. leg aids) until a certain response is obtained, at which point the pressure is released (e.g. the horse moves forward and the rider stops applying the leg aids). The same system

is applied to the use of the reins and bit and forms the basis of the tiny, subtle rein and bit aids that the horse learns, which result in different responses. This type of learning (negative reinforcement) can be effective and humane when pressure is applied subtly and removed at the instant the horse responds. This is part of the basis of the widely held theory that a bit is only as gentle or harsh as the hands using it. An important aspect of effective horse training is the horse making this clear association between the behaviour and what happens as a result of it.

An effective way of ensuring that this clear link is made is allowing the horse to feel an immediate comfort or relief from discomfort (McGreevy, 2007). An over-tight noseband will not allow the horse to escape the pressure in such a clear manner when the rider gives with their hands, thus undermining the skilled rider’s use of the aids and of pressure and release. Failing to allow the horse to gain freedom from pressure when they offer the required response can create behavioural and performance problems and welfare is compromised by excessive tension (McGreevy, 2007).

An over-tight noseband is also likely to mask training issues. For example, a study has shown that shortening reins by 10cm causes shortening of stride, the head to be behind the vertical more often, increased weight on the horse’s mouth and causes horses to open their mouths more often (Ludewig, et al., 2013). An overtight noseband may mask a horse’s response to overly short reins (e.g. mouth opening), and make it difficult to detect this as a cause for subsequent training issues. A horse that does not understand rein aids is likely to fight the bit; again, a tight noseband would mask this issue and mean the rider was unable to address the true cause of the ridden problems.

The latest scientific evidence and recommendations The FEI dressage rule book states

25

that ‘a cavesson nose band may never be as tightly fixed so as to harm the horse’ (FEI, 2013).

However, until recently there has been no objective, scientific way of assessing how tight a noseband needs to be before it causes harm.

Last year, the President of the International Society for Equitation Science (ISES) Professor Paul McGreevy published scientific data on noseband tightness that guided their subsequent position statement and recommendations (ISES, January and March 2012).

Professor McGreevy and his colleagues used infrared thermography to measure the temperature of the horse’s eyes and facial skin, as these measures correlate to the level of stress the horse is experiencing. The results show that tightening nosebands led to increased eye temperature and decreased skin temperature, indicating that horses were experiencing a stress response and also that the circulation to the facial skin had been affected (McGreevy, et al., 2012). The ISES recommends that ‘the use of nosebands that constrict with potential to cause injuries should not be permitted in training or competition’ (ISES, January and March 2012). The research group also found that while many equine texts state that a noseband should be fitted such that it is possible for an adult to insert two fingers under the noseband, this can be an inaccurate measure.

The tightness varies depending on the size of the fingers and their position under the noseband. They developed a simple taper gauge device to solve this problem. This can be used to standardise this measurement, making it easier for judges to apply this measure across the board (McGreevy, et al., 2012). ISES recommends that all equestrian stewards use a device like this to check the tightness of nosebands, at the nasal midline (ISES, January and March 2012). Professor McGreevy says “Sadly, the practice of restricting jaw movement has become entrenched, as it prevents the horse from opening its mouth, which, in dressage, is regarded as a sign of resistance or lack of compliance and attracts

penalties for the rider. So, here is the paradox: rules that penalise evidence of rough riding (e.g., mouth opening) have prompted the development of gadgets that mask such evidence.”

What should you do if your horse moves their TMJ excessively during exercise?

The horse is a sensitive animal that uses subtle, non-verbal methods of communication. If your horse is moving his or her TMJ excessively during ridden work, there may be a reason for this. Scientist and equine sports massage therapist Hannah Mace says “To optimise our horses’ performance we need to find the root cause of any issues. In this way we can solve the problem. Tight nosebands act more like a mask; covering the problem temporarily, but not allowing true improvement.”

As with any ‘problem behaviour’ it is necessary to find out what the horse is trying to communicate in order to resolve the issue.

Physiotherapists are in an ideal position to help the owner to address this. A detailed history, including questions regarding veterinary history, saddlery and dentistry checks, work levels, training, environment, and tack may reveal relevant information.

Gait analysis, palpation and range of movement assessment are essential components in analysing the problem and determining appropriate management or treatment.

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Mayes, E., Duncan, P., (1986) Temporal patterns of feeding in free‑ranging horses Behaviour 96: 105-129.

McGreevy, P. (2007) The advent of equitation science. The Veterinary Journal. 174: 492–500.

McGreevy, P., Warren-Smith, A., Guisard, Y., (2012) The effect of double bridles and jawclamping crank nosebands on temperature of eyes and facial skin of horses. Journal of Veterinary Behavior: Clinical Applications and Research 7(3):142–148.

Cook, W.R., (1999b). Pathophysiology of bit control in the horse. Journal of Equine Veterinary Science. 19(3):196–204.

McLean, A.N, and McGreevy, P.D., (2010) Horse training techniques which may defy the principals of learning theory and compromise welfare. Journal of Veterinary Behaviour. 5: 187–195.

Dyce, K.M., Sack,W.O.,Wensing, C.J.G., (2002).

Textbook of Veterinary Anatomy 3rd Edition.

Randle, H. and McGreevy, P., (2011) The effect of noseband tightness on rein tension in the

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ridden horse. International Equitation Science Conference, The Netherlands: Wageningen Academic Publishers. Available at: http:// www.equitationscience.com/documents/ Proceedings/Netherlands2011_Proceedings. pdf

Last chance to register for BEVA Congress 2014! ACPAT Members receive a discounted rate - visit www.beva.org.uk

A date for your diary

BEVA Congress 2015 9th-12th September, Liverpool, UK 27

Thoracolumbar hemilaminectomy for the treatment of intervetertebral disc herniation/extrusion: The evidence reviewed as a precursor to a post operative physiotherapy protocol Melanie Haines Chartered Veterinary and Human Physiotherapist MSc Vet Physio, BSc ( HONS) Physiotherapy MCSP, ACPAT cat A Thoracolumbar intervetertebral disc herniation- treatment and prognostic indicators Canine thoracolumbar intervetertebral disc herniation (IVDH) is a spontaneous disease that bears similarities to acute spinal cord injury (SCI) in humans (Levine, et al., 2011). Thoracolumbar IVDH is the most common cause of pelvic limb paresis in dogs and can result in paraplegia, urinary incontinence or long term disability (Davis and Brown, 2002; Levine, et al., 2006).

The most commonly affected dogs are young to middle aged, male, chrondystrophoid breeds (Davis and Brown, 2002; Ferreira, et al., 2002; Levine, 2006; Levine, 2011; Aikawa, et al., 2012). Epidemiological data indicates Dachshunds are the most frequently affected breed (19%-24% of all dachshunds effected within their lifetime) with some studies stating they account for up to 80% of the dogs affected by thoracolumbar IVDH, see Figure 1 (Levine, et al., 2006; Levine, et al., 2011; Aikawa, et al., 2012). Chrondrostrophoid breeds have early onset disc degeneration due to genetic factors. Disc degeneration reduces the ability of the annulus fibrosus and nucleus pulposus to resist loading forces. Mechanical failure of a disc ensues resulting in an extrusive IVDH or a disc extrusion, see Figure 2 (Levine, et al., 2006; Levine, et al., 2011).

Surgical decompression and removal of the extruded disk material via a hemilaminectomy with or without disc fenestration is a widely accepted treatment, see Figures 3 and 4.

Figure 1. A photograph of a Dachshund presenting with hind limb paraplegia

Figure 2. An MRI scan of a thoracolumbar spine showing an IVDH that is causing spinal cord compression.

However, this is only if the dog is found to have neurological deficits and cord compression due to IVDH as found with diagnostic investigation (Aikawa, et al., 2001; Ferreira, et al., 2002; Davis and Brown, 2002; Olby, 2004; Levine, et al., 2011). Neurological deficits are commonly graded on the 5 point scale (Figure 5).

28

Figure 3. An illistration of a surgical hemilaminectomy to decompress the spinal cord (Green).

Figure 4. A hemilaminectomy viewed on a skeletal model.

Grade

Symptoms

Comments

0

Normal

1

Pain

2

Paresis with or without pain

3

Plegia.

4

Plegia with loss of voluntary urinary function.

5

Plegia with loss of voluntary urinary function and loss of deep pain in the affected limbs (and/or tail).

Not serve enough to result in any neurological dysfunction As the lesion becomes more severe the degree of paresis and/or proprioceptive deficits becomes more severe.

Total loss of voluntary movement in the affected limbs (and/or tail).

Figure 5. Neurological grading 5 point scale: originally developed by Ian Griffiths, but modified by Sharp and Wheeler (2005)

The main prognostic marker for recovery has been found to be the pre- operative presence of intact deep pain. Voluntary ambulation occurs in 86-96% of dogs with IVDH that had pelvic limb deep pain intact prior to decompression (Davis and Brown, 2002; Ferrira, et al., 2002; Ruddle, et al., 2006, Aikawa, et al., 2012). However, in many of these studies their measure of ambulation often means the dog can take up to 5 steps unaided and not that the dogs have return of normal hind limb (HL) function. In those dogs with a loss of deep pain only 43-62% of cases will ambulate following decompression surgery.

Time to ambulate has been showed to be on average 9-14 days for dogs who had deep pain present pre-operatively. There are fewer published figures for those dogs that had lost deep pain pre- operatively as many studies have excluded this group from the tr. However,

Olby (2003) found an average time to ambulate of 7.5 weeks, whereas Aikawa, et al. (2012) found a median of 9 months. A number of dogs that never recover deep pain sensation will demonstrate ambulation at 18 months (so-called “spinal walking”), however in these cases the gait is obviously abnormal and the dogs never recover voluntary urination.

Another prognostic marker for recovery that has been discussed in several papers (Ferreira, et al., 2002; Davis and Brown, 2002; Aikawa, 2012) is the rate of onset of clinical signs. They discussed that dogs with rapid loss of motor function had poorer prognosis, compared to dogs with a slow progressive loss of ability to ambulate. It was hypothesised that dogs that rapidly deteriorate (high velocity disc movement) would have a more severe spinal cord injury (causing haemorrhage and oedema).

Therefore these cases would take a longer time to ambulate even once the compressive factor has been removed due to the nature of the damage to the spinal cord being a concussive or ischemia trauma (Olby, et al., 2005; Smith and Jeffrey, 2006; Levine, et al., 2011).

Delayed post operative recovery or deterioration as well as persistent or newly raising pain is commonly associated with newly developed and/or remaining compressive lesions or myelomalacia and may require further surgery or euthanasia (Forterra, et al., 2010).

No correlation between age, weight or fitness of dogs has been found in the prognostic indicators studies therefore these should not be used to exclude dogs from surgical treatment (Davis and Brown, 2002).

Long term complications include incontinence, permanent neurologic

Study

Physiotherapy

Aikawa, et al., (2012)

“Owners were instructed to perform massage, range of motion exercise in pelvic limbs and assisted standing with support” “Basic physical rehabilitation exercises (passive range of motion (PROM), supported standing and toe picking withdrawal) were discussed with the owners and recommended for at – home use of all the patients in this study).

“During hospitalisation, all dogs had physiotherapy consisting of underwater treadmill training for 10 min twice a daily starting on day 3 after surgery, massages and coordination training (postural reaction, proprioception) starting on day 1 after surgery, 5 times a day.

“Physiotherapy was routinely recommended and consisted of massage, passive and active hind limb movements as well as swimming exercises in warm water.”

They acknowledged that “ the post operative care provided by owners was variable between dogs and could contribute to variations in time to ambulate”

Draper, et al., (2012)

Forterre, et al., (2010)

Ferreira, et al., (2002) Brown and Davis (2002)

Figure 6. A table showing the information published within articles about physiotherapy for post-operative thoracolumbar hemilaminectomy used in their research.

29

deterioration and self-mutilation (Aikawa, et al., 2012).

The mobility of the vertebral units T13-L1 and T12-T13 is the most important among the thoracolumbar spine segments (Viguier, et al., 2002). Forterre, et al. (2010) discussed the surgical technique and stated that both the multifidus muscle and longissimus tendons were elevated during the surgery. Viguier, et al. (2002) looked at mobility of the T13-L1 after spinal cord decompression procedures in dogs (an in vitro study). They found there was an increased spinal range of motion following surgery.

Physiotherapy research Some studies into thoracolumbar IVDH in dogs state that physiotherapy and hydrotherapy was carried out post operatively either by nursing staff or owners. The detail published within the literature on what this physiotherapy entailed is varied. Figure 6 shows a table summating the detail published about physiotherapy in the research papers found.

This author can find no research into the effect of physiotherapy on the outcome of these cases or documented protocols of the post operative management and physiotherapy of dogs with thoracolumbar hemilaminectomy but there has been a paper (Olby, 2005) and several chapters written discussing physiotherapy for animals with spinal cord disease and rehabilitation of the neurological patient (McGowan and Stubbs, 2007; Mills and Levine, 2013). There is however some published literature about neurological physiotherapy for other conditions. Gandini, et al. (2003) looked at the factors influencing the recovery rate of 75 dogs who had suffered from a fibrocartilaginous embolism. They carried out an individually tailored physiotherapy program for each individual case starting within 2448 hours of the injury. They stated that “physio/hydrotherapy instituted immediately after the diagnostic work-up seemed to have a major

influence on the recovery rate”.

Kathmann, et al. (2006) looked at daily controlled physiotherapy with relation to survival time in dogs with suspected degenerative myelopathy in 50 dogs. A positive association between prolonged ambulation time and increased survival rates and intensive physiotherapy was found.

Conclusion Male chrondystrophoid breeds are the most effected dogs with IVDD and with a loss of neurological function they are likely to undergo surgery. There is currently little or no research into the effect of physiotherapy on the rehabilitation of dogs following spinal cord injury, but there are a number of papers (Ferreria, et al., 2002, Draper, et al., and Brown and Davis, 2002; Forterre, et al., 2010; Aikawa, et al., 2012) that discuss physiotherapy techniques. Future research should be undertaken to identify the effectiveness of physiotherapy techniques in maximising the dog’s function.

The second part of this article series is a discussion of the post-operative veterinary and physiotherapy guidelines for thoracolumbar hemilaminectomy in canine patients from day 1 postoperatively in the experience of one ACPAT physiotherapist working at an orthopaedic and neurological referral centre. This will be planned for publication in the next edition of Four front.

Ferreira,A.J.A., Correia, J.H.D. and Jaggy,A., (2002) Thoracolumbar disc disease in 71 paraplegic dogs: influence of rate of onset and duration of clinical signs on treatment results. Journal of small animal Practice. 43:158-163.

Forterre, F., Gorgas, D., Dickomeit, M., Jaggy, A., Lang, J. and Spreng, D., ( 2010) Incidence of Spinal Compressive lesions in Chondrodystrophic Dogs with Abnormal recovery after Hemilaminectomy for treatment of Thoracolumbar Disc Disease: A Prospective Magnetic Resonance Imagining study.

Veterinary surgery. 39:165-172.

Gandini, G., Cizinauskas, S., Lang, J., Fatzer, R. and Jaggy, A., ( 2003) Fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate. Journal of Small Animal Practice. 44:76-80.

Kathmann, I., Cizinauskas, Doherr, M.G., Steffen, F. and Jaggy A., (2006) Daily controlled Physiotehrapy Increases Survival time in Dogs with Suspected Degenerative Myelopathy. Journal of Veterinary Internal Medicine. 20:927-932.

Levine, J.M., Levine, G.J., Kerwin, S.C., Hettlich, B.F. and Fosgate, G.T., ( 2006) Association between various physical factors and acute thoracolumbar intervertebral extrusion or protrusion in Dachshunds. Journal of the American Veterinary Medical Association.Vol 229, No 3. 370-375.

Levine, J.M., Levine, G.J., Poter, B.F., Topp, K. and Noble-Haeusslein, L.J., (2011) Naturally Occuring disc Herniation in Dogs: An opportunity for PreClinical Spinal cord injury Research. Journal of Neuotrauma. 28:675-688.

Mc Gowan, C., and Stubbs, N., (2007) Animal Physiotherapy, Assesment, treatment and Rehabilitaion of animals. Blackwell Publishing, Oxford.

Mills, D. and Levine, D., ( 2013) Canine rehabilitation and Physical therapy, 2nd Edition.

Saunders Elsevier, Philadelphia.

Olby, N., Harris, T., Munana, K., (2003) Long term functional outcome of dogs with severe thoracolumbar spinal cord injuries. Journal of the American Veterinary Medical Association.

223:762-9.

Olby, N., Harris, T., Burr, J., Munana, K., Shrap, N. and Keene, B., (2004) Recovery of Pelvic limb function in dogs following Acute intervertebral Disc Herniations. Journal Neurotrauma.

21(1):49-59.

Olby, N., Halling, K. and Glick, T.R., (2005) Rehabilitation of the Neurological patient.

Veterinary Clinics, Small animal practice. 35:13891409.

Sharp, N., and Wheeler, S., (2005) Small Animal Spinal Disorders: Diagnosis and Surgery, 2e.

Elsevier Mosby, Philadelphia.

References Aikawa, T., Fujita, H., Kanazono, S., Shibata, M., and Yoshigae, Y., (2012) Long-term neurologic outcome of hemilaminectomy and disk fenestration for treatment of dogs with thoracolumbar intervertebral disk herniation: 831 cases (2000-2007). Journal of the American Veterinary Medical Association. Vol 241:No 12.

1617-1626.

Davis, G.J. and Brown, D.C., ( 2002) Prognostic Indicators for Time to Ambulation After Surgical Decompression in Nonambulatory Dogs With Acute Thoracolumbar Disk Extrusions:112 Cases.Veterinary Surgery. 31:513-518.

Draper, W.E., Schubert, T.A., Clemmons, R.M. and Miles, S.A., (2012) Low-level laser therapy reduces time to ambulation in dogs after hemilaminectomy: a preliminary study. Journal of small animal Practice. 53:465-469.

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Smith, P.M. and Jeffery, N.D., (2005) Spinal shockComparative Aspects and Clinical Relevance.

Journal Verterinary Internal Medicine. 19: 788793.

Ruddle, T.L., Allen, D.A., Schertel, E.R., Barnhart, M.D., Wilson, E.R, Lineberger J.A., Klocke, N.W. and Lehenbauer, T.W., (2006) Outcome and prognostic factors in non- ambulatory Hansen type I intervertebral disc extrusions:308 cases.

Veterinary and Comparative Orthopaedics and Traumatology. 19, 29-34.

Viguier, E., Petit-Etienne, G.J., Magnier, J., Diop, A., Lavaste, F., (2002) Mobility of T13-L1 after spinal surgery cord decompression procedures in Dogs (an In-vitro Study).Veterinary Surgery.

31(3).297-298.

Equine Research Digest Kate Davy MCSP ACPAT Cat A Subtotal Ostectomy of Impinging Dorsal Spinous Processes in 23 Standing Horses.

Brink P. Subtotal ostectomy is an effective treatment for horses displaying back pain, secondary to impingement of the dorsal spinous processes (DSP).

It is conventionally performed with the horse anesthetised and positioned in lateral recumbency.

The aim of this study was to report a safe and efficient surgical technique for removing DSP in the thoracic region in standing horses and both short-term and long term outcomes of the subjects.

It was hypothesised that this technique would result in minimal haemorrhage, few intraoperative complications and avoid the need for postoperative hospitalisation.

What they did 23 horses were included with radiographic abnormalities of the DSP between the 12th and 17th thoracic vertebrae and whose clinical signs of back pain were eliminated temporarily with local anaesthetic into the surrounding tissues. All had had an unsatisfactory clinical response to 3-6 months of conservative treatment. Horses were sedated and restrained in stocks and had the surgical site de-sensitised. Affected DSPs were resected through a dorsal median incision and radiography was used to confirm removal of impinging bone. They were discharged on the day of surgery, had 2 weeks box rest before turn out and a 12 week programme of incrementally increasing exercise was begun.

Horses were examined for back pain and rehabilitation progression at 6 and 12 weeks by the referring veterinarian. Short and long term outcomes were obtained by telephone interviews with trainers or owners.

What they found

What they did

1 horse was lost to follow-up. No serious complications occurred. At < 1 year 19 horses returned to full athletic function, 2 improved but failed to return to full function, 1 horse had no improvement.

At > 1 year 17 horses had full athletic function. 2 horses had improved and 3 horses had no improvement.

Two-dimensional kinematic video analysis of 5 thoroughbred racehorses galloping at high speeds on a dirt racetrack and synthetic racetrack was taken. Kinematic markers were positioned to quantify joint angles and hoof orientation. The position, velocity and acceleration of joint angle and hoof translation during stance phase were calculated in the sagittal plane. The effect of surface was evaluated using a mixed model analyses of covariance.

Take home message When subtotal ostectomy of impinging DSP is performed with the horse standing, preoperative preparation, surgical time and hospitalisation are short and the costs and risks of general anaesthesia are eliminated. The study is limited by its lack of a valid, reliable and responsive outcome measures, its results cannot be compared statistically because the definition of â&#x20AC;&#x2DC;athletic useâ&#x20AC;&#x2122; may have been dissimilar to other studies.

Veterinary Surgery 43 (2014) 95-98 DOI: 10.1111/J. 1532-950X.2013.12078.x Distal Hindlimb Kinematics of Galloping Thoroughbred Racehorses on Dirt and Synthetic Racetrack Surfaces.

Symons JE, Garcia TC and Stover SM. The animal welfare of racehorses is dependent upon reducing the incidence of musculoskeletal injury.

Track material and conditions are two factors implicated in racehorse musculoskeletal injury yet the optimal mechanical properties of race surfaces remain unknown.

The aim of the study was to compare distal hind limb and hoof kinematics during stance of breezing (unrestrained gallop) racehorses, between dirt and synthetic racetrack surfaces.

31

What they found Statistically significant effects were found for hind limb fetlock and hoof kinematic variables but not for pastern and coffin joint variables.

Horses showed greater fetlock angle at heel strike and a greater maximum angle on a dirt surface (P<0.05) compared to a synthetic surface. Maximum fetlock angle occurred earlier during stance on the dirt surface (P<0.05) and horses showed a greater horizontal displacement of the heel during slide on the dirt surface (P<0.05).

Take home message Synthetic surfaces reduce fetlock hyperextension and thus may lessen risk of strain to the fetlocks supporting structures. On the synthetic surface horses had less horizontal hoof translation during slide contributing to different distal hind limb kinematics. This may alter skeletal loads on other structures in the hind limb. Limitations of the study include atypical weight and thickness of shoes altering limb behaviour and parallax and perspective errors due to the kinematic technique.

Equine Veterinary Journal ISSN 0425-1644 DOI: 10.111/EVJ.12113

Effect of Water Depth on Amount of Flexion and Extension of Joints of the Distal Aspects of the Limbs in Healthy Horses Walking on an Underwater Treadmill.

Mendez-Angulo JL, Firshman AM, Groschen DM, Kieffer PJ and Trumble TN. Underwater treadmills have become widely used for horses, with the aim of musculoskeletal rehabilitation being to re-establish biomechanically normal ranges of movement in affected joints, the effects of buoyancy may be utilised to assist in this. The authors are to date unaware of any published information on the effects of water rehabilitation on range of movement (ROM) of the distal joints of horseâ&#x20AC;&#x2122;s limbs. The authors hypothesised that ROM of the joints would increase during walking of horses on an underwater treadmill (UWTM) at any depth of water compared to baseline and that the amount of joint flexion and extension and the percentage duration of swing phase of the stride would increase with increasing water depth.

What they did 9 healthy horses who were trained to UWTM at 0.9m/s had kinematic video analysis carried out; at a baseline of <1cm water and at the levels of the metatarsophalangeal, tarsal and stifle joints. Using 2-D motion analysis software, maximum amounts of joint flexion and extension at the fetlock, carpal and tarsal joints and the percentage durations of swing and stance phase of stride were determined.

What they found ROM was greater for all assessed joints in any level of water compared to baseline conditions; this was mainly due to increases in joint flexion. The ROM varied with water depth and some depths of water produced an increase in joint extension. The greatest ROM for carpal joints was at tarsal joint water depth, for tarsal joints it was at stifle joint water depth, for metacarpophalangeal, it was metatarsophalangeal joint depth and for metatarsophalangeal it was tarsal joint depth. Joint flexion and extension did not consistently

increase with increasing water depth. Significant differences were detected in percentage durations of stance and swing phases for forelimbs and hind limb strides.

As water depth increased the percentage duration of stance phase decreased and the percentage duration of swing phase increased for forelimbs and hind limbs.

Take home message Varying the depth of water affects each joint differently including joints in the same limb. Physiotherapists should be aware of the effects of water depth on motion of joints and should consider that alternating exercise between 2 water depths may be needed to increase both flexion and extension at a particular joint. The study was limited by the use of a 2-D imaging system allowing only sagittal plane motion to be analysed and the video camera required placement at an angle potentially reducing sensitivity of measurements. Further studies are required to determine the effects of varying water levels on horses with reduced limb ROM.

Canine Research Digest Kate Davy MCSP ACPAT Cat A The Role of Muscle Activation in Cruciate Disease.

Adrian CP, Haussler KK, Kawcak C, Reiser RF, Riegger-Krugh C, Palmer RH, Mcllwraith CW and Taylor RA. Historically the focus of investigations into the etiopathogenesis of canine cranial cruciate ligament disease (CCLD) has been on joint instability secondary to failure of passive structures such as the cruciate ligaments and menisci. Research on anterior cruciate ligament (ACL) rupture in people has explored the role of muscle activity in supporting joint stability and preventing reinjury. As a result rehabilitation

programmes have been developed to optimise muscle activation. The mechanisms of motor control in both intact and cruciate deficient human knees may have direct translation to canine patients despite moderate anatomic and biomechanical differences, the sensory and motor components are similar. Understanding motor control mechanisms, as they relate to canine CCLD, is vitally important in identifying modifiable risk factors, applying preventative measures and developing improved surgical and rehabilitative treatment strategies.

What they did Provided a comparative overview of the current knowledge of motor control and muscle activation in

32

relation to ACL injury in people and explored the role of motor control strategies in canine CCL disease in relation to future research and clinical rehabilitation.

What they found Within humans, muscle activation is linked to joint stability and prevention of ACL injury with the quadriceps and gastrocnemius muscles being the primary stabilisers.

Mechanoreceptors within the ACL control the stiffness of these stabilising knee muscles via the gamma motor neuron system. With ACL rupture comes reduced muscle activation in the quadriceps musculature and increased knee flexion during stance

phase of gait. The compensatory muscle recruitment that can occur increases the incidence of muscle co-contraction and joint stability but may also initiate articular cartilage degeneration. Reinnervation of mechanoreceptors has been reported in ACL remnants and autografts.

Therapeutic exercise, proprioceptive training, neuromuscular electrical stimulation and cryotherapy can retrain muscle activation and improve motor control.

Improved understanding of the role of individual muscle contributions to stifle stability would be expected to benefit non-surgical management of CCLD. A greater understanding of the cause of CCLD could reduce the incidence and long-term morbidity associated with CCL rupture and OA.

articular regions for villus reactions and vascularisation. Orthopaedic and radiographic examinations and synovial fluid analysis were also performed before transection, then at two, four and six weeks postoperatively.

Veterinary Surgery 42 (2013) 765773 DOI:10.1111/J.1532950X.2013.12045.X

Within canines, motor control as a contributing factor in CCLD has not been studied. As in humans, the collateral and cruciate ligaments provide passive stabilisation but they require additional musculature support because of the 120째 joint angle and possibly the steeper tibial slope. This comes from the quadriceps, gastrocnemius and biceps femoris musculature. Similar to people, the CCL contains mechanoreceptors that influence muscle spindle activation via the gamma motor neuron system.

The primary gait alterations post CCL rupture of muscle weakness, pain and joint effusion are thought to contribute to altered motor control, there is reduced loading and increased stifle flexion but it is not known how these gait changes affect motor control; Altered motor controls contribution to OA (Osteoarthritis) has not been studied. Whilst innervation of mechanoreceptors has been reported in CCL remnants, it remains unknown how rehabilitative techniques affect motor control.

Effects of transection of the cranial arm of the medial glenohumeral ligament on shoulder stability in adult beagles.

Fujita Y, Yamaguchi S, Agnello KA and Muto M.

The orthopaedic examinations at two, four and six weeks showed no significant changes compared to baseline in flexion, extension and abduction angles. There was also no evidence of radiographic changes or synovial fluid changes using an analysis of variance.

Arthroscopic findings at six weeks when compared with baseline, showed no changes to the articular surfaces but there was significant evidence of inflammation using a Wilcoxon signed-rank test. This was indicated by villus reactions in the cranio-medial and caudal joint capsules and significant vascularisation of the subscapularis tendon and medial glenohumeral ligament.

Take-home message Future surgical techniques should minimise tissue trauma and disruption of proprioceptive signalling. Future studies should explore the role of residual proprioceptive function and retraining of stifle proprioception after surgery and CCL remnant resection.

Restoring muscle strength and normal activation should be considered in the development of post-operative rehabilitation programmes.

Whilst medial shoulder instability is the most common form of shoulder instability to be reported, its pathophysiology remains unclear.

The joints stability is dependent on a complex interaction between the articular surfaces and surrounding ligaments, tendons, muscles and joint capsule and disruption to just one of these can cause dysfunction and discomfort. Transection of the medial glenohumeral ligament can lead to total luxation, but the respective contributions of the cranial and caudal arms have not been fully studied.

The authors hypothesised that a lesion in the medial glenohumeral ligament is one cause of shoulder instability in dogs and that instability can be detected by measurement of the abduction angle during arthroscopy but not via orthopaedic examination, plain shoulder radiography or synovial fluid analysis.

What they did Six adult beagles with no history of orthopaedic disease had the cranial arm of their medial glenohumeral ligament surgically resected via arthroscopy.

Arthroscopically before transection and at six weeks the articular surfaces were assessed for cartilage damage using the modified outerbridge grading system, along with five intra-

33

What they found

Take-home message The authors conclude transection of the cranial arm alone did not appear to affect shoulder stability, however the vascular and villus reactions in the medial compartment suggest damage to the medial arm may trigger inflammation which could lead to enzymatic breakdown of cartilage. Over time, and exacerbated by weight-bearing and repetitive motion, this may lead to instability. They do note the significant limitations of lack of a control group or blinding, difficulty in assessing lateral structures, assessment by one investigator only if still shots and most significantly short-term follow-up. 15minutes of lead controlled exercise twice daily for the duration of the study also minimises the stresses place upon the joint and may not typify normal conditions.

Vet Comp Orthop Traumatol 2013; 26: 94-99 DOI:10.3415/VCOT-12-03-0034

The Canine Orthopaedic Index. Step 3: Responsiveness Testing.

Brown, DC. In 2006, a group of veterinary surgeons determined to provide mechanisms and tools for improving the quality and impact of clinical studies in veterinary orthopaedics, initiated the canine outcome measures program (COMP). Their goal was to produce one or more validated outcome instruments that would effectively assess safety, quality of life and function in dogs undergoing orthopaedic diagnostic, prophylactic and or therapeutic procedures. They wanted to create an instrument broadly applicable, easy to use for clinicians and researchers alike and to make it freely available online to everyone interested in using it. 5 years of rigorous scientific research in a three step process has culminated in the development and validation of the Canine Orthopaedic Index (COI).

The purpose of this study was to

test the responsiveness of the COI by establishing if it could detect changes in dogs with osteoarthritis (OA) that were treated with an intervention of known efficacy. They hypothesised that there would be a significant decrease in COI scores in dogs that were treated with Carprofen compared with dogs treated with a placebo.

showed statistically significant (p=.002) decreases in their total instrument score as well as in the stiffness p=0.15, gait p=.001 and function p=0.008 factors. The change in quality of life score was not significantly different between the two groups (p=.124).

What they did

The COI is responsive to clinical changes and this in combination with previous reliability and validity testing, supports the use of these scores to obtain quantifiable assessments of osteoarthritic dogs by their owners. Further studies are required for the quality of life score to be used as an outcome measure alone. The author notes a limitation of the study may be small sample size per group leading to a Type II error in relation to the quality of life score.

A single-centre, double blind, randomized, placebo-controlled clinical trial was carried out. 80 dogs with radiographically assessed OA were split into two equal groups.

Owners completed the COI on day 0 and dogs were administered either Carprofen or placebo by their owners on days 1 through to 14. Owners completed the COI gain on day 14. The change in stiffness, gait function, quality of life and total scores were assessed between groups.

What they found Dogs

who

received

Take-home message

Vet Surg 2014 Mar;43(3):247-54.

DOI: 10.1111/j.1532950X.2014.12162.x.

Carprofen

DIARY OF EVENTS Date

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BEVA

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8-9th November 2014

Your Horse Live

Stoneleigh Park, Warwickshire

20-21st November 2014

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London

22nd-23rd February 2014

ACPAT Seminar

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1-4th May 2015

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Please see www.acpat.org for further details

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Association of Chartered Physiotherapists in Animal Therapy - The Professionals In Animal Physiotherapy

ACPAT Seminar 2015 21st & 22nd Feb 2015 Dunchurch Conference Centre, Rugby

Speakers to include: Canine: Peter Smith MRCVS & Di Messum ACPAT A Mark Moreton MRCVS & Kim Sheader ACPAT A Veerle Dejonckheere MRCVS Paul Freeman MRCVS Equine: Anna Johnson ACPAT A Jo Paul ACPAT A Louise Broom MCSP

Contact EMAIL for further details and Russell Guire BSc booking information or visit www.acpat.org Programme and times may change at the discretion of ACPAT Copyright Š The Association of Chartered Physiotherapists in Animal Therapy (ACPAT) 2007 All rights are reserved. Unauthorised copying or use of this information is prohibited.

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Course Reviews Musculoskeletal and Spinal Assessment in canines Laurie Edge-Hughes, BScPT, MAnimSt(Animal Physio), CAFCI, CCRT November 24-25th 2013 This practical course was run at a north and south location and was organised by ACPAT’s course organisation team. The course started by covering spinal anatomy and specific surface anatomy palpation.

to mobilisation of the lumbar spine and in particular discussed the beneficial effects of traction when treating intervetebral disc disease.

Here, one can use the load of the dog to create the traction, for example if holding them securely under the forelimbs and allowing them to effectively hang down with their spine supported by the handler’s trunk.

Laurie is a fabulous and inspiring teacher with excellent practical skills and knowledge.

The course covered a good range of mobilisation techniques which are

and jumping horse, conformation, training methods and rider biomechanics. Throughout all 3 days we heard about the research that has been done and that is being done in all of these areas. Half a day was spent with Haydn Price looking at shoeing for conformation and performance. We even assessed a horse before and after Haydn had shod it with the opportunity to ask questions as he carried out shoeing. On day 3 we saw the data from a gait analysis of a horse we had assessed on day 2. It highlighted the limits of the human eye and the importance of video analysis in our day to day assessments. Russell is passionate about his work and this was so evident in his teaching.

Personally I’m just hoping I can remember 5% of what he told us!

It was 4 days ago and I can honestly say that attending the course has definitely improved my assessment of horses and riders.

These are some comments on the course feedback form:

Picture 1: Laurie demonstrates thoracic spinal assessment on Tilly, an obliging model.

The course then went on to cover specific mobilisation and manual handling techniques (See Figure 1) Each course attendant had easy access to various canine patients to practise techniques on and Laurie was always on hand to check handling skills. We started by assessing the cervical spine.

Here we covered mobilisation of the atlanto-axial joint, in particular, we were reminded to maintain flexion at the atlanto-occipital joint during this technique. Next, we practised mobilisation techniques of the thoracic spine, here I learnt an incredibly useful technique when mobilising thoracic segments into flexion. Here, using a dorsally directed pressure on the sternum whilst blocking specific thoracic vertebral segments this can be very a useful technique for treating canines with thoracic extension dysfunctions. Next, we moved on

all very applicable to varying canine conditions. This course certainly improved my confidence in applying manual therapy to my canine patients and I would be happy to attend another should it become available again.

Maruska Aylward ACPAT A 3 Day Equine Biomechanics Course Russell Guire of Centaur Biomechanics July 4-6th 2014 This was a course attended by ACPAT members only and was a brilliant insight into equine biomechanics research.

The programme included anatomy and physiology, mechanical power outputs, mechanics of the dressage

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‘Inspiring and informative course with up to date and relevant research. I will now include some video analysis within my daily physio work.’

‘Russell brings so much energy, drive and passion. You are driving research forwards for the benefit of the horse industry/horse welfare plus to understand more about horse biomechanics.’

‘Fantastic course, well presented and would recommend it to other professionals and horse owners.’

‘Absolutely fantastic – I am going home inspired’ ‘Very informative course in a relaxed atmosphere. Russell is very good at explaining complicated biomechanics in a simple easy to understand way. It will have an influence on my every day practice which is what I want to get out of a course’ Megan Rees ACPAT A

Book Reviews Stretch Exercises for your horse Karin Blignault

physiology of muscles and how to perform active and passive stretching exercises.

The pages in this book are held in a ring binder which is great when using the book outside and there is a detailed passive and active explanation for each muscle group.

The diagrams are clear and concise and easy to follow for owners and trainers alike.

Stephanie Brighton ACPAT A

Horse Massage for horse owners. Improve your horse’s heath and wellbeing Sue Palmer

Hardcover: 160 pages Publisher: J A Allen Language: English ISBN: 978-1-908809-16-2 RRP £19.99

Paperback: 128 pages Publisher: J A Allen Language: English ISBN: 978-0-85131-999-5 RRP £16.99 This is a reference book that gives a detailed look at massage and how / what the effects are for the horse with an emphasis on how the reader can work with their own horse. It considers seven key muscles in depth and looks at the anatomy, physiology and biomechanics each of the seven muscles individually and then explains in detail how to find each muscle on the horse and the practical application of each massage technique. The content is detailed, interesting and easy to read and follow for a wide-range of horse owners.

Stephanie Brighton ACPAT A

This is a reference book that shows that the principals of stretching applied by human athletes can be applied to the horse. The book looks at the importance of stretch exercises to prevent injury, improve performance and alleviate pain. It looks at the anatomy and

Recent Research Publications Here are some journal titles that may be of interest to you from the Equine Veterinary Journal and the Journal of Small Animal Practice.

All these articles are available online via www.onlinelibrary.wiley. com to all ACPAT members using the ACPAT Wiley username and password. If you require these details or have any questions regarding accessing these journals then please feel free to email me at physio@swanimalrehab.co.uk.

In particular, ACPAT members please be encouraged to access the supplement of the more recent EVJ journal as the majority of EVJ articles noted in june and July are only abstracts and accessing the supplement may provide a better idea of the focus of current research and what may be published.

Many Thanks Kate Davy MCSP ACPAT Cat A Research Officer

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EQUINE VETERINARY JOURNAL July 2014 Volume 46, Issue 4 Pages 393–523 Science-in-brief: What is needed to prevent tendon injury in equine athletes?

A conversation between researchers and industry stakeholders (pages 393–398) T. Rich and J. C. Patterson-Kane Article first published online: 9 JUN 2014 | DOI: 10.1111/evj.12269

Bone fatigue and its implications for injuries in racehorses (pages 408–415) S. Martig, W. Chen, P.V. S. Lee and R. C. Whitton Article first published online: 1 APR 2014 | DOI: 10.1111/evj.12241 Do radiographic signs of sesamoiditis in yearling Thoroughbreds predispose the development of suspensory ligament branch injury? (pages 446–450) J. McLellan and S. Plevin Article first published online: 6 NOV 2013 | DOI: 10.1111/evj.12154 The effect of insertional suspensory branch desmitis on racing performance in juvenile Thoroughbred racehorses (pages 451–457) S. Plevin and J. McLellan Article first published online: 6 NOV 2013 | DOI: 10.1111/evj.12161 Pain control in horses: What do we really know? (pages 517–523) L. C. Sanchez and S. A. Robertson Article first published online: 15 MAY 2014 | DOI: 10.1111/evj.12265 Special Issue: Abstracts from the 9th International Conference on Equine Exercise Physiology, 15-20 June, 2014 Chester, UK June 2014 Volume 46, Issue Supplement S46 Pages i–vii, 1–55 Preliminary Assessment of Dressage Asymmetry within Sitting Trot and Shoulder-in (page 5) J Baxter, S Hobbs and A Chohan Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_13 Does Swim Training Improve Athletic Performance of Mangalarga Marchador Horses? (pages 5–6) C Coelho, B Drumond, G Silva,V

Fardin and CR Giuberti Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_15 Kinetics of the Forelimb in Horses Trotting an Uphill and Downhill Slope (page 37) H Chateau, M Camus, L HoldenDouilly, J Lepley, S Falala, B Ravary, C Vergari, JM Denoix, P Pourcelot and N Crevier-Denoix Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_113 Individual Limb Contributions to Centripetal Force Generation during Circular Trot(page 38) HM Clayton, SD Starke and JS Merritt Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_114 Variations in Muscle Activity of Vastus Lateralis and Gastrocnemius Lateralis with Increasing Draft Load (pages 38–39) T Crook, E Hodson-Tole and A Wilson Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_117 The Effects of Chiropractic Treatment on The Range of Motion of the Carpus and Tarsus of Horses (pages 40–41) J Guest and C Cunliffe Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_123 An Investigation Into the Relationship of Pelvic Misalignment with Forelimb Hoof Size (page 42) A Ireson and C Cunliffe Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_128 The Equine Cervical Spine: Comparing MRI and Contrast-Enhanced CT Images with Anatomic Slices in the Sagittal, Dorsal and Transverse Plane (page 48) J Sleutjens, A Cooley, S Sampson, I

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Wijnberg, W Back, J van der Kolk and C Swiderski Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_146 Effect of Lungeing and Circle Size on Movement Symmetry in Sound Riding Horses(pages 49–50) MH Thomsen, C Sahl-Tjørnholm, H Sørensen and A Tolver Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_151 Back-Shape Changes in Sports Horses (page 53) L Greve and S Dyson Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_161 Muscle Fibre Type Distribution of the Thoracolumbar and Hindlimb Regions of Horses: Relating Fibre Type and Functional Role (page 53) H Hyytiäinen, A Mykkänen, A HielmBjörkman, N Stubbs and C McGowan Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_162 Thoracolumbar FlexionExtension During Water Treadmill Walking (pages 53–54) K Nankervis, L Entwistle, S GervaiseBrazier, S Earl and A Twigg-Flesner Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_16 Changes in Movement Symmetry During Long-Term Exercise in Horses (page 54) AL Nissen, PH Andersen, R Buhl and MH Thomsen Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_164 Is There a Relationship between Tail Carriage and Lameness in Horses? (page 55) R Weller, A Love, B Clark, R Smith and T Pfau Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_167

Vertical Displacement of the Equine Pelvis When Trotting on an Aqua Treadmill(page 55) J York and A Walker Article first published online: 12 JUN 2014 | DOI: 10.1111/evj.12267_168 May 2014 Volume 46, Issue 3 Science-in-brief: Clinical highlights from the American Association of Equine Practitioners 59th Annual Convention and Equine Veterinary Journal Supplement 45(pages 259– 261) A. Dwyer Magnetic resonance imaging and foot lameness. Problem solved? Or do we know we know less now that we know more? (pages 264–266) B. Bladon Polymorphisms in TNC and COL5A1 genes are associated with risk of superficial digital flexor tendinopathy in National Hunt Thoroughbred racehorses (pages 289–293) L. J. Tully, A. M. Murphy, R. K. W. Smith, S. L. Hulin-Curtis, K. L. P.Verheyen and J. S. Price Horse-, rider-, venue- and environment-related risk factors for elimination from Fédération Equestre Internationale endurance rides due to lameness and metabolic reasons (pages 294–299) A. Nagy, J. K. Murray and S. J. Dyson Contrast-enhanced computed tomographic evaluation of the deep digital flexor tendon in the equine foot compared to macroscopic and histological findings in 23 limbs (pages 300–305) S. E. van Hamel, H. J. Bergman, S. M.

Puchalski, M. W. de Groot and P. R. van Weeren The effect of exercise on plasma concentrations of inflammatory markers in normal and previously laminitic ponies (pages 317–321) N. J. Menzies-Gow, H. Wray, S. R. Bailey, P. A. Harris and J. Elliott A new technique for subtotal (cranial wedge) ostectomy in the treatment of impinging/ overriding spinous processes: Description of technique and outcome of 25 cases (pages 339–344) B. D. Jacklin, G. J. Minshall and I. M. Wright Arthroscopic anatomy of the equine cervical articular process joints (pages 345– 351) M. Pepe, M. Angelone, R. Gialletti, S. Nannarone and F. Beccati Outcome of horses with synovial structure involvement following solar foot penetrations in four UK veterinary hospitals: 95 cases (pages 352–357) J. A. Findley, G. L. Pinchbeck, P. I. Milner, B. M. Bladon, J. Boswell, T. S. Mair, J. M. Suthers and E. R. Singer Three dimensional, radiosteriometric analysis (RSA) of equine stifle kinematics and articular surface contact: A cadaveric study (pages 364–369) S. E. Halley, M. J. Bey, J. A. Haladik, M. Lavagnino and S. P. Arnoczky Vascular perfusion of the dorsal and palmar condyles of the equine third metacarpal bone (pages 370–374) M. T. Alber, M. P. Brown, K. A. Merritt and T. N. Trumble March 2014

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Volume 46, Issue 2 Science-in-brief: Clinical highlights from BEVA Congress 2013 (pages 131– 134) N. Kerbyson Distal hindlimb kinematics of galloping Thoroughbred racehorses on dirt and synthetic racetrack surfaces (pages 227–232) J. E. Symons, T. C. Garcia and S. M. Stove Variation in training regimens in professional showjumping yards (pages 233–238) A. C. Lönnell, J. Bröjer, K. Nostell, E. Hernlund, L. Roepstorff, C. A. Tranquille, R. C. Murray, A. Oomen, R. van Weeren, C. Bitschnau, S. Montavon, M. A. Weishaupt and A. Egenvall An endoscopic test for bitinduced nasopharyngeal asphyxia as a cause of exercise-induced pulmonary haemorrhage in the horse (pages 256–257) W. R. Cook January 2014 Volume 46, Issue 1 Advances in the understanding of tendinopathies: A report on the Second Havemeyer Workshop on equine tendon disease (pages 4–9) R. Smith, W. McIlwraith, R. Schweitzer, K. Kadler, J. Cook, B. Caterson, S. Dakin, D. Heinegård, H. Screen, S. Stover, N. Crevier-Denoix, P. Clegg, M. Collins, C. Little, D. Frisbie, M. Kjaer, R. van Weeren, N. Werpy, J.-M. Denoix, A. Carr, A. Goldberg, L. Bramlage, M. Smith and A. Nixon Heritability estimates of tarsocrural osteochondrosis and palmar/plantar first phalanx osteochondral

fragments in Standardbred trotters (pages 32–37) S. Lykkjen, H. F. Olsen, N. I. Dolvik, A. M. Grøndahl, K. H. Røed and G. Klemetsdal Descriptive epidemiology and risk factors for eliminations from Fédération Equestre Internationale endurance rides due to lameness and metabolic reasons (2008– 2011) (pages 38–44) A. Nagy, J. K. Murray and S. J. Dyson

the American Association of Equine Practitioners Comparative kinematic analysis of the leading and trailing forelimbs of horses cantering on a turf and a synthetic surface (pages 54–61) N. Crevier-Denoix, S. Falala, L. Holden-Douilly, M. Camus, J. Martino, B. Ravary-Plumioen, C.Vergari, L. Desquilbet, J.-M. Denoix, H. Chateau and P. Pourcelot

A long-term study on the clinical effects of mechanical widening of cheek teeth diastemata for treatment of periodontitis in 202 horses (2008–2011) (pages 76–80) P. M. Dixon, S. Ceen, T. Barnett, J. M. O’Leary, T. D. Parkin and S. Barakzai

November 2013 Volume 45, Issue 6

Radiographic configuration and healing of 121 fractures of the proximal phalanx in 120 Thoroughbred racehorses (2007–2011) (pages 81–87) M. R. W. Smith and I. M. Wright

A cohort study of equine laminitis in Great Britain 2009–2011: Estimation of disease frequency and description of clinical signs in 577 cases (pages 681–687) C. E. Wylie, S. N. Collins, K. L. P. Verheyen and J. R. Newton

Are there radiologically identifiable prodromal changes in Thoroughbred racehorses with parasagittal fractures of the proximal phalanx? (pages 88–91) M. R. W. Smith and I. M. Wright Current status and future directions: Equine pituitary pars intermedia dysfunction and equine metabolic syndrome (pages 99–102) J. E. Sojka-Kritchevsky and P. J. Johnson December 2013 Volume 45, Issue Supplement S45 Special Issue: 59th Annual Convention of the American Association of Equine Practitioners. Guest Editors: B. Ball, A. Pease, D. Sellon and N. White. Editor: J. Moore. Publication of this supplement was supported by

Stress and pain: Their relationship to health related quality of life (HRQL) for horses(pages 653–655) W. W. Muir

Seasonal and annual influence on insulin and cortisol results from overnight dexamethasone suppression tests in normal ponies and ponies predisposed to laminitis (pages 688–693) K. E. Borer-Weir, N. J. Menzies-Gow, S. R. Bailey, P. A. Harris and J. Elliott Profiling the careers of Thoroughbred horses racing in Hong Kong between 2000 and 2010 (pages 694–699) B. D.Velie, B. D. Stewart, K. Lam, C. M. Wade and N. A. Hamilton JOURNAL OF SMALL ANIMAL PRACTICE July 2014 Volume 55, Issue 7 Pages 341–387

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Radiographic and MRI characteristics of lumbar disseminated idiopathic spinal hyperostosis and spondylosis deformans in dogs (pages 343–349) A. Togni, H. J. C. Kranenburg, J. P. Morgan and F. Steffen Article first published online: 12 APR 2014 | DOI: 10.1111/jsap.12218 June 2014 Volume 55, Issue 6 Pages 291–339, E10–E68 Guidelines for Recognition, Assessment and Treatment of Pain : WSAVA Global Pain Council members and coauthors of this document: (pages E10–E68) Karol Mathews, Peter W Kronen, Duncan Lascelles, Andrea Nolan, Sheilah Robertson, Paulo VM Steagall, Bonnie Wright and Kazuto Yamashita Article first published online: 20 MAY 2014 | DOI: 10.1111/jsap.1220 March 2014 Volume 55, Issue 3 Therapeutic options for the treatment of chronic pain in dogs (pages 127–134) P. D. MacFarlane, A. S. Tute and B. Alderson January 2014 Volume 55, Issue 1 Arthroscopic-guided ulnar distraction for the correction of elbow incongruency in four dogs (pages 46–51) J. D. Coggeshall, D. J. Reese, S. E. Kim and A. Pozzi November 2013 Volume 54, Issue 11 Associations between obesity and physical activity in dogs: a preliminary investigation (pages 570–574) R. Morrison,V. Penpraze, A. Beber, J. J. Reilly and P. S.Yam

Recent News LETTER FROM THE CHAIR The time has truly flown by as I near the end of my term both as ACPAT Chair and as part of the committee.

My previous hat was in a PR role, producing new leaflets, a new Zeus stand, taking ACPAT to the London Vet Show, writing a few articles and starting the small animal consult calendar to name a few things. The Chair role has certainly been a new challenge and I’ve been incredibly lucky to have a supportive and proactive committee and a very organised secretary in Sharon!

We would like to welcome to the committee and introduce Irene Menaged and Daisy Collins who both have dual roles in dealing with insurance and member awards and cat B liaison and editorial help, respectively.

I am pleased to confirm that ACPAT passed its re-recognition process as a

Special Interest Group of the CSP with flying colours thanks largely to the hard work of Helen Millward and Kim Sheader.

2015. The courses team of Kate, Catherine, Nycky and Anna have put on some excellent courses and have a lively schedule set for next year.

Once again Maruska and Stephanie, with the additional help of Daisy Collins, have to be congratulated on producing a fabulous fifth edition of Four Front, the amount of work that goes in to producing this journal is immense. It continues to be peer reviewed prior to publication with plans afoot to try and achieve Medline status.

Congratulations must also go to to Polly Hutson who won ACPAT member of the year 2014, Polly does a stirling effort at Hartpury as well as working in her own practice.

The PR team has been as busy as ever taking the stands to Crufts,The Rehabilitation Expo, BEVA,Your Horse Live and The London Vet Show. The 2014 small animal consult room calendar was very well received so look out for your copies of the 2015 edition.

2014’s seminar was exceptional and Megan and Annelise have organised another stimulating programme for

On a personal level I would like to thank everybody for supporting me as Chair and to the fantastic team of committee members, not all have been mentioned individually, but each one gives up a huge amount of personal time to maintain the organisation that is ‘ACPAT’. Here is to 2015 and ACPATs continued growth.

Louise Carson ACPAT Chair

VETERINARY PHYSIOTHERAPIST RECEIVES CSP AWARD Among recipients of the CSP excellence awards 2013 was Veterinary Physiotherapist Berna Lindfield (Figure 1). She received a Distinguished Service Award for her contributions to education in the field of veterinary physiotherapy.

In 1996, as Education Officer for ACPAT, Berna established the first formalised education programmes in animal physiotherapy. This led in 1998 to her assistance with the development of ACPAT’s in house experiential training and recognition programme.

This programme involved the development of a Continual Assessment Record Book that specified, for the first time, the skills and knowledge required of these wishing to practise in the animal field.

Berna also initiated and contributed to the development and delivery of the Royal Veterinary College postgraduate (PG Dip and MSs) course in Veterinary Physiotherapy.

The Masters

Figure 1: Berna Lindfield receives her Distinguished Service Award

component of this course involved pioneering research projects in veterinary physiotherapy – the first such research in the world.

Berna would like to thank all those ACPAT members who contributed

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to the development and delivery of the above programmes, in particular Amanda Sutton, Melanie Poynter and Dr. Tracy Crook together with veterinary surgeon Dr. Kathy McGowan.

AMANDA SUTTON IS RETIRING

in their own countries and here in the UK.

Amanda Sutton is retiring after 28 years of animal physiotherapy practice.

Over many years Amanda has attended all the major equine sporting events including Blenheim, Badminton and Burghley Horse Trials. In the 1990’s Amanda was appointed Chartered Physiotherapist for the riders and horses of the British Three Day Event Team, which included attending the Olympics in Atlanta.

Initially, Amanda worked in human sports medicine and outpatients, she soon set up her animal physiotherapy practice to fulfil her life long ambition of offering the same expertise and treatments to animals as given in human physiotherapy practice (Figure 2).

Over the years Amanda has spent time learning from experts including Janet Ellis, Anthony Pusey DO and Julia Brooks DO. She has travelled all around the world (USA, South Africa & Australia) to gain knowledge and lecture to peers and other professional groups. Over the years she has offered apprenticeships and been involved in developing the careers of many pioneering and leading animal physiotherapists (Narelle Stubbs, Jane Hutton, Anna Johnson and Fiona Doubleday to name a few) who are now successful

In 2000, Amanda was involved in helping to initiate the MSc in Veterinary Physiotherapy at the Royal Veterinary College’ off the ground. She subsequently gained the MSc in Veterinary Physiotherapy and authored two books on equine therapy. She also contributed chapters in “Lameness in the Horse

by Ross and Dyson” and “Canine Rehabilitation and Therapy by Millis and Levine”.

It is impossible to fully portray in words how much Amanda has achieved and given to the world of Veterinary Physiotherapy and

Figure 2: Amanda Sutton demonstrates some baited stretches to a client at her practise.

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ACPAT but the fact that her name is recognised by all leading veterinary and sport professionals starts to give you an idea. Her knowledge and skills are truly outstanding and will be hugely missed by physio’s and patients alike.

I hope after a break Amanda will become restless and begin looking for new challenges. We certainly plan to utilise her skills at least for the development of the ACPAT journal.

She has skills we just can’t ignore!

But, for now, Amanda has achieved a tremendous amount and deserves a well deserved break, so from all ACPAT physiotherapists’ we wish her well.

Stephanie Brighton ACPAT A

Acknowledgments Thank you to our Canine and Equine Consultant Editors who will be stepping down from the peer review panel this year. You have both been integral to the professional development of Four Front.

ACPAT thanks you for the huge amounts of time that you have committed to reviewing our articles.

Thank you.

Canine articles James Grierson BVetMed CertVR

CertSAS DipECVS FHEA MRCVS RCVS Specialist in Small Animal Surgery, European Specialist in Small Animal Surgery

Thank you also to all of our authors that have contributed this 5th Four Front edition.

Anderson Moores Veterinary Specialists The Granary, Bunstead Barns, Poles Lane, Hursley, Winchester, Hampshire, SO21 2LL Reception: 01962 767920 Fax: 01962 775909

Editors

Equine articles Wishes to remain anonymous

Maruska Aylward MSc BSc MCSP HCPC ACPAT A Bridgefield physiotherapy Ltd Stephanie Brighton MSc BSc MCSP HCPC ACPAT A Daisy Collins BSc MCSP ACPAT Cat B

Writing For Four Front The Official Magazine Of The Association Of Chartered Physiotherapists In Animal Therapy Guidelines and Information for Authors The Editor would like to encourage ACPAT members to get involved in the magazine. If you are doing interesting clinical work, have a philosophical viewpoint that you would like to express, would like to share some research findings, have read a relevant book, article or attended an interesting course; please write something for the ACPAT magazine.

The aims of the magazine are to inform members about clinical, research and business developments that affect physiotherapists working with animals. It also provides a channel of communication between ACPAT members by informing and debating all aspects of animal physiotherapy.

Literature Reviews Business Related topics Clinical Articles/Case reports Letters to the Editor Research Articles Useful addresses Conference / Course Reviews Small Adverts Product News Book Reviews

How to contact us If you have an article that you would like to submit for publication or you would like to discuss the outline of an article that you would like to write, please do not hesitate to contact ACPAT secretary who will pass on the information to the Journal Officer.

Post: M. Sharon Morgan Pembroke House Middle Lane We invite you to present material Shotteswell OX17 1JQ under the following sections: Email: secretary@acpat.org Editorial Product Reviews

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Submitting an article Please send all text in electronic form (ideally in Microsoft Word) by attaching the file to an e-mail or on a disk, along with any original photographs to the editor.

DATES FOR SUBMISSION – Next Issue Due out March 2015 Research Articles – By end of September Literature ReviewsBy mid-October Clinical Articles/Case ReportsBy Mid-October Product/Book/course/ conference reviews –

By December Small adverts/Useful addresses/useful tips –

By December

We can accept articles up to 3,000 words and encourage the use of tables, illustrations and photographs.

If an article is longer please discuss with the editor.

There is no need to spend time adjusting fonts, columns etc, as we will adjust these to match the current publishing style.

Where appropriate, articles must be supported by a reference list using the Harvard system. In the text quote the authors surname and year of publication. In your reference list please include the full reference, to include authors name, initials, year of publication, full title of the paper, name of the journal, volume number and the first and last page numbers.

Any identifiable photographs must be accompanied by written permission from the owner of the animal, otherwise the image will be obscured, so that recognition is not possible.

Please supply your full name, address, telephone number and e-mail address that you would like to be published with your article.

Format and manuscripts

structure

of

Manuscripts should be headed with the full title of up to 15 words, which should describe accurately the subject matter. Authors should avoid including within the text: the name of the institution at which the work was performed, initials of the authors; and must remove institution names from illustrations in order to maintain anonymity for the review process.

Title Page A title page is needed for all manuscript types, it must contain the title of the paper, names and qualifications of all authors, affiliations and full mailing address including e-mail addresses, and contact telephone number of corresponding author. No author details are to be submitted in the

manuscript. In addition details of any acknowledgements should be given on the title page.

Original Articles

Papers/Research

Each paper should comprise the following sections: Structured Summary - maximum of 200 words, divided, under separate headings, into Objectives, Methods, Results, Clinical Significance.

Keywords - maximum of five, for use as metadata for online searching.

Introduction - brief overview of the subject, statement of objectives and rationale.

Materials and Methods - clear description of experimental and statistical methods and procedures (in sufficient detail to allow others to reproduce the work).

Results - stated concisely, and in logical sequence, with tables or figures as appropriate.

Discussion - with emphasis on new and important implications of the results and how these relate to other studies.

Case Reports Full Case Report Reports of single or small numbers of cases will be considered for publication if the case(s) are particularly unusual or the report contributes materially to the literature. A case report should not exceed 1500 words and must comprise of: Summary (maximum 150 words); Keywords - for use as metadata for online searching Introduction - brief overview of the subject Case Histories - containing clinical detail Discussion - describing the

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importance of the report and its novel findings To be considered for publication in a single case report must: - Exemplify best practice All papers and case reports are subject to peer review and publishing preference will be given to reports of original or retrospective studies.

Letters to The Editor Letters describing case reports or original material may be published and will be peer-reviewed prior to publication. Letters commenting on recently published papers will also be considered and the authors of the original paper will be invited to respond.

Style of manuscripts Writing should conform to UK English, and acceptable English usage must be presented within the manuscript. Where abbreviations are used, the word or phrase must be given in full on the first occasion.

All Manuscripts must be doublespaced for the purpose of peer reviewing.

All manuscripts must be numbered throughout for purpose of peer reviewing.

line the

All units of measurement should be given in the metric system or in SI units. Temperatures should be in 째C. Drugs should be referred to by Recommended International NonProprietary Name, followed by proprietary name and manufacturer in brackets when first mentioned, eg, fenbendazole (Panacur; Intervet).

Anatomical terminology should conform to the nomenclature published in the Nomina Anatomica Veterinaria (1983) 3rd edn. Eds R. E. Habel, J. Frewein and W. O. Sack.

World Association of Veterinary Anatomists, Ithaca, New York.

Length

physiotherapists.

The maximum length for research papers is 3000 words and for case reports is 1500 words. Review articles should not exceed 4000 words. All word limits include the summary but exclude the reference list. Authors should indicate the word count at the beginning of the manuscript.

We may use material on the APCAT website, if you do not want us to publish information on the website, please explain this when you submit your work.

Tables and Figures The minimum number of tables and figures necessary to clarify the text should be included and should contain only essential data.

Presentation of Book, Product and Course Reviews Book, Product and course reviews should be between 500 â&#x20AC;&#x201C; 700 words long. Book reviews should quote the title, publisher, ISBN number and price of the book.

Some points to consider before and during writing an article Try to produce a structured abstract and a list of key messages before you begin, this will help the article to be more focused and succinct and therefore more interesting for the reader.

Try to make the article as concise as possible, think hard what needs to be in the article to get the message across. Very few articles are longer than 2,000 words.

Terms and Conditions Material accepted for publication will be edited. All articles will be treated as though all authors have read and approved the manuscript.

Each author should give his or her name as well as the address and current e-mail for correspondence.

We now aim to publish the corresponding authorâ&#x20AC;&#x2122;s e-mail address in every article.

Copyright and exclusive licence Many publishers traditionally asked authors to assign their copyright as this allows them to tackle copyright infringement, to republish and reproduce on a website.

We however require all authors for an irrevocable licence so that we can reproduce articles on our website without the need to seek further permission.

All articles submitted to the editor are therefore accepted on the basis that all authors of the material agree to ACPAT acquiring this irrevocable license upon the publication of the article in any medium owned or controlled by ACPAT. Corrections

Try to ensure that references cited for tables and legends are done in sequence at the point where the table or figure is first mentioned in the text.

Finally check the final copy carefully.

We try hard not to make mistakes, but errors, both by authors and editors can creep into the journal.

We publish corrections when necessary. If you want to notify us about the need for a specific correction, please contact the editor.

Previous publication Final note from the Editor We do not have a strict policy on publishing material that has appeared elsewhere, but welcome authors to do so, especially where the subject is important to animal

The Editorial Board reserves the right to edit all material submitted.

The

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Four

Front are not necessarily those of ACPAT, the Editor or the Editorial Committee.

The inclusion of advertising does not imply any form of endorsement

by ACPAT. No article, drawing or photograph may be reproduced without prior permission of the Editor.

Four Front is an annual publication and aims to be published in the summer of each year.

We are looking forward to receiving articles from any member of ACPAT on any relevant topics that you wish to share with fellow members.

The success of the magazine and its benefit to members is ultimately dependent on the collective contributions that we receive, thank you, the Editor.

M. Sharon Morgan, Pembroke House Middle Lane, Shotteswell, OX17 1JQ secretary@acpat.org