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Critical Review of the Evidence Supporting Physiotherapeutic Management of Equine Sacroiliac Regional Pain
Wareham, N., Hutson, P. and Tabor, G. (Hartpury University, Gloucester, GL19 3BE)
Introduction
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Equine regional sacroiliac pain (ERSP) encompasses a wide variety of symptoms and is a recognised cause of hindlimb lameness and poor performance (Dyson and Murray, 2003). ERSP is more commonly recognised in performance horses; in particular those competing in dressage and show jumping sports (Dyson and Murray, 2003).
The veterinary approach to managing ERSP aims to identify the underlying pathological process, followed typically by medical intervention; an imperative step in the veterinary physiotherapist referral pathway (Goff et al., 2008). Physiotherapy intervention utilises a range of assessment and treatment techniques, which act to identify and treat sensory and motor disturbances; restoring function, relieving pain and thus improving performance and quality of life (McGowen et al,. 2007). Current literature supports therapeutic exercise as an effective means of treating and managing ERSP (Clayton, 2012; Denoix and Jacquet, 2008; Goff et al., 2008; HeuftDorenbosch et al., 2006; McGowen et al., 2007; Stubbs et al,. 2011).
Background
ERSP is associated with causing poor performance, most commonly presenting with reduced hindlimb engagement, reduced willingness to move forwards into a contact and a poor quality canter (Dyson and Murray, 2003). ERSP can also be a result of referred pain from pathology affecting the thoracolumbar spine and hindlimb, which share complex neurophysiological pathways with the sacroiliac joint (SIJ) region (Van de Wurff et al., 2006) further supporting collaboration with the veterinarian to establish correct diagnosis.
The kinematic importance of the SIJ is to provide a stable means of transferring force from the hindlimb to the thoracolumbar spine via the surrounding musculoligamentous system (Bronlinson et al., 2003). Notably, Degruence et al., (2004) assessed equine SIJ movement in vitro reporting less than 1 degree of translation. Goff et al., (2008) use the term ‘functional instability’ to describe reduced postural control around the SIJ rather than a true joint instability; reported in human literature as subluxation often secondary to catastrophic trauma or pathology (Bronlinson et al., 2003). Functional instability has been noted to cause a mild increase in articular translation which may result in SIJ remodelling and ERSP if not addressed (Bronlinson, 2003; Goff et al., 2008). Such functional instability affords the potential for physiotherapy intervention to assess and treat muscular imbalance and postural disturbances (McGowen et al., 2007) therefore supporting long term reduction in ERSP and promoting improved performance.
ERSP secondary to SIJ dysfunction has been classified into two groups (Dyson and Murray, 2003; Goff et al., 2008); the first presenting with insidious onset of poor performance, responsive to local analgesia and the second, a more chronic picture encompassing poor performance and osseous, pathological SIJ change. Goff’s concept of functional instability is further supported by human research that suggests that it is the shearing and abnormal force closure of the joint that causes pain secondary to reduced postural control by the surrounding muscles (Hossain and Nokes, 2005; Snijders et al., 1998). It is proposed by Snijders et al., (1998) that the shearing forces are caused by the longitudinal muscles and that protection from this is sought from transversely aligned musculature such
as the internal oblique and abdominal musculature. This is reinforced in equine literature by Goff et al., (2008), Stubbs et al., (2011) and Clayton (2012) who emphasise the role of Multifidus, a deep spinal stabiliser, in supporting lumbopelvic stability.
Treatment of ERSP
The primary objective for both veterinary and physiotherapeutic treatment is to reduce pain and restore normal movement (Dyson and Murray, 2003; Engeli and Haussler, 2004; Goff et al., 2008; McGowen et al., 2007). Therapeutic exercise has been demonstrated to be effective in restoring long term improvements in SIJ function, pain reduction and consequently, overall performance status (Clayton, 2012; Dyson and Murray, 2003; Goff et al., 2008; Haussler, 2003; Laslett, 2008; McGowen and Goff, 2016).
Physiotherapy treatment is deemed to be more effective if pain is addressed and this sits well with the first line of veterinary treatment which is often analgesic periarticular joint injection (Dyson and Murray, 2003; Engeli and Haussler, 2004; Goff et al., 2008; McGowen et al., 2007). Dyson and Murray (2003) describe one technique of periarticular injection into the SIJ that improved performance in all horses (n=34) however they did not comment upon the longevity of the analgesic effect.
Reduction in pain associated with ERSP supports physiotherapy treatment and the physiotherapy treatment can offer the potential longevity in symptom reduction that analgesia alone may not (McGowen et al., 2007). The physiotherapist should consider the type of procedure undertaken by the veterinarian, for example, if injections are done ‘blindly’ there is a risk of anaesthetising the very structures that will be the focus of physiotherapeutic rehabilitation i.e. neuromuscular control of the SIJ (Engeli and Haussler, 2004). In the human field, joint injections are often carried out under guided imaging (ultrasound / CT) due to the significant improvements in accuracy and treatment effect (Balint et al., 2002; Cunnington et al., 2010; Sibbitt et al., 2009) and this may improve outcomes in the equine population.
Once analgesia is optimised, therapeutic exercise can commence and may be utilised to reduce ERSP secondary to SIJ dysfunction in the following ways; i) Early rehabilitation - restoration of pelvic stability, ii) Functional rehabilitation - improving dynamic stability of the SIJ and iii) Performance management - improving global muscle strength and conditioning, thereby reducing the risk of future ERSP.
Early Rehabilitation: Pelvic Stability
Dynamic mobilisation exercise (DME) is a veterinary physiotherapy term used to describe exercises to improve spinal and postural stability in horses (Clayton, 2012; McGowen et al., 2007; Stubbs et al., 2011). Stubbs et al., (2011) have demonstrated DMEs to be key in increasing cross sectional area (CSA) of multifidus; a deep stabiliser of the spine, at levels T10-L4.
The multi-layered and multidirectional fibres of multifidus stabilise the intervertebral joints and therefore activation and strengthening can result in reduced functional instability, which may be associated with injury and degenerative change (Clayton, 2012; Stubbs et al., 2011). Core stability exercises have been demonstrated as beneficial in the treatment of human SIJ pain (Akuthota et al., 2008; Richardson et al., 2002) however similar research in the equine field is limited.
Core stability exercises in humans and in equines focus on increasing neuromuscular control and increased cross sectional area of the deep stabilising musculature of the spine and pelvis and it is suggested that this could also influence the stability and postural control of the SIJ (Dyson and Murray, 2003; Denoix and Jacquet, 2008; McGowen and Goff, 2016).
The human biomechanical model utilised by Richardson et al., (2002) emphasises activation of transversely orientated muscles such as lumbar multifidus, transversus abdominis, piriformis and the pelvic floor muscles as being key to pelvic stability. This is because the transversely oriented fibres act to compress the sacrum against the ilia and maintain stability of the SIJ thereby reducing ligamentous ‘creep’ and/or damage to the joint capsule (Goff et al., 2008; Van Wingerden et al., 2004). Richardson et al., (2002) found independent activation of transversus abdominis and lumbar multifidus decreased SIJ laxity to a significantly greater degree than global abdominal exercise patterns. Laslett (2008) reinforces the importance of stabilisation exercises in the treatment of human SIJ pain but also highlights the limitations in outcome measures due to poor reliability and validity of tests for SIJ dysfunction. Richardson et al., (2002) in the human population, utilised real time ultrasound and EMG to provide objective means of resultant muscle patterns, however this would not be readily available to the veterinary physiotherapist and therefore more functional performance measures can be utilised as treatment outcomes e.g. assessment of gait (McGowen et al., 2007).
Future research could help support the use of DMEs in the treatment of ERSP caused by functional instability of the SIJ. Examples of DMEs include
baited exercises whereby the horse is encouraged to flex through the spine in order to engage the aforementioned deep spinal stabilisers and abdominal musculature (Stubbs et al., 2011).
Functional Rehabilitation: Dynamic Control
DMEs should be established prior to advancing the exercise/ treatment program, with the progression aiming to incorporate lumbopelvic and SIJ stabilisation into a more functional situation (Akuthota et al., 2008; Clayton, 2012).
For example, similarly to DMEs, longlining is a useful training aid in order to encourage the horse to flex through the thoracolumbar spine (McGowen et al., 2007). Incorporation of ground poles should encourage the horse to further recruit hypaxial and abdominal musculature in order to stabilise the spine and pelvis for increased limb flexion (over the poles) during the cranial phase of gait (Clayton, 2012; McGowen et al., 2007). During the stance phase of each hindlimb, stabilisation via means of abdominal, hypaxial and gluteal co-contraction is vital in order to provide spinal, pelvic and SIJ stability (Clayton, 2012). Further to this, Hodges and Richardson (1997) have shown that transverse abdominus activation precedes limb movement in humans regardless of the direction of the movement and it is transverse abdominis that is suggested by Dyson and Murray (2003) and Goff et al., (2008) as being vital in equine SIJ stabilisation. Therefore by incorporating dynamic therapeutic exercise, it can be hypothesised that there is an increased activation of the equine transversus abdominis.
In order for propulsion to occur effectively, the horse is required to engage and protract the hind limb under the body through the cranial phase in order to push and propel during stance/ ground reaction phase (Clayton, 2012). Hindlimb protraction requires activation of the hip and lumbosacral flexors, iliopsoas and psoas minor, which also provide an element of SIJ stability due to their skeletal attachments ventral to the SIJ (Goff et al., 2008). Therefore exercising the horse over poles for example, would aim to improve the local stability but also global activation of lumbopelvic musculature. A progression may incorporate circles and change of direction where ipsilateral contraction of longissimus dorsi in combination with the abdominal obliques supports
In performance horses, it is important that sufficient spinal and pelvic stability precedes this in a linear direction (hence the aforementioned DME’s) so that the horse is then able to stabilise effectively enough to generate sufficient lateral bend whilst maintaining a more vertical orientation and suspension through the lower limb (Clayton, 2012; McGowen et al., 2007, McGowen and Goff, 2016) as required in higher level dressage requirements. If the horse is able to generate sufficient stability through the spine and SIJ, the force produced through the hind limbs will be more effectively transmitted through the SIJ as per the intended biomechanical and physiological purpose (Dyson and Murray, 2003).
With less functional instability, it can be hypothesised that the SIJ is at less risk of injury due to ligament creep, increased force placed upon the joint capsule or indeed degenerative osseous change (Clayton, 2012; Dyson and Murray, 2003; Goff et al., 2008). Less risk of pain and / or injury supports improvements in horse welfare and increases potential to maximise performance and competitive longevity (Clayton, 2012; Dyson, 2000).
Functional exercise and ridden schooling are considered vital in the longer term prevention and management of ERSP, particularly in performance horses (Clayton, 2012; Dyson, 2000; Dyson and Murray, 2003; McGowen et al., 2007). Often the end goal of treatment is for the horse to return to the same, if not a greater level of competition (Clayton, 2012; Dyson, 2000; McGowen et al., 2007) and this can be used as an outcome measure by the physiotherapist in the treatment of performance horses.
Competition horses should benefit from schooling exercises focused on specific strength and conditioning for performance (Clayton, 2012). For example, dressage horses could carry out exercises that encourage spinal flexion and activation of hypaxial musculature to support engagement of the hind limb, such as collected, lateral and pole work, renvers and travers.
For show jumping horses, gymnastic exercises such as grid work, bounce fences, jumping on an angle as well as some of the aforementioned flatwork (Dyson, 2000). Although equine research is limited, human research indicates cross-training in this way as beneficial in improving overall fitness and the fitter the athlete the less likely for injury to re-occur (Harman et al., 2008; Smith et al., 2013). It could be argued that similarly the fitter the horse, the less risk there is of dysfunction at the SIJ and associated ERSP, hence the importance of the veterinary physiotherapist’s role in performance management of the horse.
Conclusion
ERSP can present with a multitude of symptoms and some of these may replicate differential diagnoses. A veterinary-led, holistic approach to assessment and treatment is therefore paramount. Physiotherapeutic exercises aimed at increasing postural control and reducing functional instability at the SIJ are deemed beneficial. Physiotherapy intervention can also drive improvements in strength and conditioning, reducing the risk of future dysfunction of the SIJ and associated ERSP. Future research is required into the effect of DMEs and progression of therapeutic exercises on SIJ stability and associated ERSP.
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