ACPAT 2016 FourFront Journal

Four Front Number 7 | Sept 2016

ISSN 2055-267X

The Magazine of the Professionals in Animal Therapy

Association of Chartered Physiotherapists in Animal Therapy

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CONTENTS 4. Editorial

Daisy Collins, Nicola Smith and Amy Davis

5. A Review of Equine Flexor Tendon Injury and Management Daisy Collins PgDip BSc MCSP ACPAT Cat A

11. Turmeric for Osteoarthritis in Veterinary Medicine: a Review Veerle Dejonckheere MRCVS

18. Critical Review of the Evidence Supporting Physiotherapeutic Management of Canine Elbow Dysplasia R. Burton-Dadd, P. Hutson and G.Tabor

22. Mechanical Nociceptive Thresholds following Physiotherapy in Unridden Horses Fiona Winchester MSc BSc ACPAT Cat A

26. The Equine Sacroiliac Joint: a Review of the Pathology, Investigations and Treatment Marcus J. Head BVetMed MRCVS

33. Book Reviews

Maruska Aylward-Green Fiona Taylor

34. Equine Research Digest Kate Davy MCSP ACPAT Cat A

37. Canine Research Digest Kate Davy MCSP ACPAT Cat A

40. Recent Research Publications Kate Davy MCSP ACPAT Cat A

42. Acknowledgements

43. Writing for Four Front

Artwork and print by Intaglio - 01491 681650 www.intaglio-pms.co.uk

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EDITORIAL

Four Front continues to encourage all our members, whether students or experienced clinicians to submit their articles for publication. We have provided guidance within this journal to assist all our authors in ensuring their articles are to an excellent standard. Your editorial team would also like to encourage all prospective authors to get in touch.

Daisy Collins, Nicola Smith and Amy Davis welcome you to our seventh edition of Four Front. As you may have noticed, we have had an Editorial reshuffle; this journal being the first publication with the new team.

We would like to especially mention and recognise the exemplary efforts of Maruska Aylward-Green and Stephanie Brighton.They have achieved so much for our journal over the last four years. Their expertise and dedication has significantly raised the standard of the journal, and they have developed good relationships with the veterinary profession, thereby promoting our profession. Standards were set that improved the quality of writing and variety of content. Due to these improvements they attempted Medline status for the journal.

Although it was not accepted at the time, the feedback was a useful benchmark from which the current team will take things forward.

Alternatively, do you have any thoughts about our journal, the content or our vision?

If so, we would love to hear them, whether positive or negative, you can email journal@acpat.org Finally, we hope you continue to enjoy reading the articles we have sourced for this journal. We are delighted to include many topical equine articles within this issue, and hope to increase the publication of canine articles depending upon the amount of material we receive for our next issue.

However, we would like to specifically thank all the authors during this transition period, including Gillian Tabor who provided us with some excellent material at very short notice.

Your new editorial team will continue to raise the standard of our journal. Nicola Smith will be an integral component of our team during this process. She has experience in education, on CSP committees, also publishing for and reviewing peer reviewed journals. Nicola will lead the work to develop a timeline towards achieving Medline status in the future.

Thank you Your Editorial Team.

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A Review of Equine Flexor Tendon Injury and Management Daisy Collins PgDip BSc MCSP ACPAT Cat A Fellowes Farm Equine Clinic Daisy.Collins@fellowesfarm.com Introduction

aspect of the limb, joining the Common Digital Extensor (CDE), (Bischofberger, et al., 2006;Werpy and Denoix, 2012). This arrangement enables the CDE to counteract the strong flexor forces of the Superficial Digital Flexor Tendon (SDFT) and Deep Digital Flexor Tendon (DDFT).

Injury to the SL would thereby increase hyperextension to this joint during loading, placing increased tension through the SDFT and DDFT.

Suspensory ligament injuries are highly reported in dressage, however can occur in all athletic horses in either forelimbs or hind limbs. More recently documented is evidence that suggests injury to the proximal component of the Accessory Ligament of the Deep Digital Flexor Tendon (ALDDFT) may concurrently occur with proximal suspensory desmitis (Plowright & Dyson, 2015). This article is aimed at reviewing tendon injury and associated treatments.

During locomotion, the SDFT and SL store elastic strain energy instigated by inertial and gravitational forces that extend the metacarpophalangeal joint, stretching the tendinous structures (Wilson, et al., 2001). The DDFT muscle architecture remains different to the SDFT, influencing tendon loading; its primary function being distal phalangeal joint flexion in late swing phase, rather than the storage and return of elastic energy completed by the SDFT (Butcher, et al., 2009). This results in lower peak forces in comparison to those exerted through the SDFT and SL (Butcher, et al., 2007). During hoof contact the DDFT muscle contracts increasing the tendon stretch, generating greater elastic energy storage in comparison to the SDFT (Butcher, et al., 2009).

The SDFT and SL are primarily loaded during the early part of stance phase, acting as a spring-like storage of elastic strain energy in galloping speeds (Dowling and Dart, 2005; O’Sullivan, 2007).This intricate interplay between the tendons maximizes locomotor efficiency; injury would therefore hugely compromise the elastic recoil and passive support capabilities of the tendons.

Tendon injury in performance horses is common and can result in retirement from competition level performance. Superficial and Deep Digital Flexor tendon injuries have a good prognosis with many equines returning to lower levels of performance, however is associated with a high reoccurrence rates (Smith, et al., 2003).

Biomechanics of the Tendons

The Superficial Digital Flexor Tendon (SDFT) and Deep Digital Flexor Tendon (DDFT) prevent hyperextension at the fetlock and have short muscle fibres with a large physiological cross-sectional area (Wilson, et al., 2001). The Suspensory Ligament (SL) has an important stabilizing role within the passive stay apparatus, preventing metacarpophalangeal/ metatarsophalangeal joint hyperextension during the stance phase. In the forelimb it is thought to limit palmar bending of the third metacarpal when compressive and vibrational forces are subjected to the dorsal cortex of the bone, storing energy during hoof impact (Gibson and Steel, 2002; Wilson, et al., 2001).

The SL has medial and lateral branches continuing into extensor branches, inserting into the dorsal

Varying surfaces have been shown to influence tendon load, with harder surfaces demonstrating greater maximal strains to the SDFT and DDFT with significant reductions in maximal strain of the SL on asphalt 5

compared to sand (Riemersma, et al., 1996a). Maximal tendon force significantly increases further when increasing speed from a walk to trot (Crevier-Denoix, et al., 2013).

Interestingly, the duration of tendon loading on sand is significantly higher than on asphalt surfaces (Riemersma, et al., 1996a; Crevier-Denoix, et al., 2013).This indicates sand surfaces can also significantly impact the risk of SDFT injury.

Pathophysiology of Tendinitis and Tendinopathy

Tendinitis is the acute inflammation of tendons or tendon sheaths, whereas tendinopathy is the chronic, repetitive inflammation and degeneration with pathophysiological changes to the tendon (Benazzo et al., 2000). In humans, tendinopathy results in increases of type III collagen and glycosamin deposition, a disruption to collagen fibrils, increased ground substance, neovascularization and altered tenocyte morphology, all of which reduce the overall tensile strength of the tendon (Cook, et al., 2003; Morrey, et al., 2013). A positive correlation has been found between areas of neovascularization (excessive nerve and capillary growth to the tendon) and the site of pain and palpable tenderness (Divani, et al., 2010; Jonge, et al.

2014).

Pathobiological changes that have been reported include an increased expression of Peroxiredoxin 5, found in human tenocytes, which is a cytoprotective antioxidant enzyme, protecting against oxygen free radical damage (Wang, et al., 2001; Knoops, et al., 2011). Oxygen free radicals are created when ischaemia occurs within the tendon; when the tendon is released from maximal tensile load reperfusion occurs generating oxygen free radicals. These free radicals are thought to instigate damage to the tendon (Goodship, et al., 1994;

Beswick & Maffuli, 2000; Longo, et al., 2008). Cyclic strain to tendons results in an increase of Prostaglandin E2, tumor necrosis factor a, Interleukin-6 (IL-6) secretions and Interleukin-β1 gene expression (Khan, et al. 2005; Hosaka, et al., 2010; Legerlotz, et al., 2013) which are also chemical mediators thought to contribute to tendon degeneration. Equine flexor tendons have shown increases in collagen turnover mediated by matrix metalloproteinases in musculoskeletal disease, also seen in human tendinopathy (Hosaka, et al., 2010).

Equine and human tendinopathy remains similar; equine locomotion generates heat within the tendons with temperature increases of up to 45°C when galloping (Wilson and Goodship, 1994). In humans, running for 30 minutes generates similar temperatures (Farris, et al., 2011). In the equine, up to 10% of heat is generated from elastic strain energy (Riemersa and Schamhardt, 1985b).

Prolonged and repeated hyperthermia may induce cell death or compromise cell metabolism, leading to tendon degeneration (Birch, et al., 1997).

Diagnosis of Tendon Pathology

Clinical history taking is a vital component of beginning to diagnose tendon lesions. The level of competition, performance indicators and behaviours may all be contributing factors to the identification of tendon lesions. They also allow the Veterinary Surgeon to establish the rider’s aspirations and potential prognosis.

The age of the horse has also been positively correlated with the reduction in a tendons maximal strain, increasing its susceptibility to injury (Perkins, et al., 2011).

The horse is commonly examined and observed prior to any dynamic assessment to ascertain whether conformational aspects have contributed to the injury, figure 1.

Lateral deviations, namely valgus alignment, high carpal and tarsal angles are associated with increasing risk of injury to the SDFT (Weller, et al., 2006).

It is common to begin with a full palpatory examination, focusing particular attention on the limbs where tendon injury may be suspected. Palpation should be conducted thoroughly before observing gaits as this may lead the examiner to potentially ‘overlook’ other limbs, should a lame limb be identified (Ross and Dyson, 2011).

Gait is observed in straight lines at walk and trot to establish lameness grading. Circles then precede this and are conducted on both soft and hard surfaces at walk, trot and possibly canter. Soft surfaces may exacerbate tendinous lesions due to the higher duration of tendon load (Riemersma, et al., 1996a). Once a lame limb has been identified, the limb may be subjected to nerve blocks, beginning distally and moving proximally, with gait evaluation after each block (Schumacher, et al., 2013). Diagnostic analgesia allows lameness to be localized to a particular region.

Figure 1. A poor foot conformation with long toe and low heel The use of ultrasonography is widely accepted as a relatively reliable and cost effective tool to further confirm diagnosis of a tendon lesion (Coudry and Denoix, 2013). Diagnostic ultrasonography can identify alterations in tendon morphology, cross sectional area, echogenicity, fibre pattern and shape, however it is not without limitations (Padaliya, et al., 2015).

Treatment of Acute Injury

Tendon injury may be treated through the use of box rest, cold hosing and bandaging, to minimise further injury and facilitate tendon healing. In more severe cases cast immobilization may be employed but horses undergoing cast immobilsation should be carefully monitored due to the increased risk of developing secondary laminitis (David, et al., 2012). The Veterinarian may refer the case for corrective shoeing (heel wedge) to offload the strain on the SDFT (Lawson, et al., 2007). In the acute phases cryotherapy can be utilised to reduce capillary blood flow to the tendon and thereby subsequent cytokines responsible for tendon apoptosis (Knobloch, et al., 2006).

Treatments potentially used in the treatment of an acute SDFT injury are discussed in Table 1.

Figure 2. Core lesion within the SDFT tendon.

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Acute Physiotherapeutic Management

Acute management of tendon strain to the SDFT should begin with a period of immobilsation, dependent

Treatment

Pros

Cons

Reference

Mesenchymal Stem Cells (MSCs) Implantation of stem cells grown in vitro from stem cells of the same horse from the uninjured tendon.

Used as a biological scaffold system.

Re-injury rate in racehorses just 27% in three years. Injury reoccurrence reduces if implanted within one month of injury.

Minimal adverse effects reported.

Relatively few clinical trials or long-term studies. Little known about exact effects. Can be costly.

(Patruno and Martinello, 2014; Godwin, et al., 2012; Schnabel, et al., 2009; Richardson, et al., 2007;)

Platelet-rich Plasma (PRP) - blood plasma with a concentrated platelet content injected into the site of injury through ultrasound guidance

Aims to enhance normal healing processes after introduction of PRP. Easy to use, relatively cost effective. Induces significantly more neovascularisation.

Little known about exact effects.

Relatively few long-term trials.

Best used on acute injuries, effect on chronic injuries requires further investigation.

(Bosch, et al., 2011)

Hyalauronic Acid (HA) and Polysulphated Glycosaminoglycans (PSGAG) - injection of HA or PSGAG into core lesions

Thought to decrease adhesion formation during the repair process.

May work best in conjunction with MSCs. Incidence of re-injury is up to 44% in comparison to exercise alone.

(Dyson, 2004)

Controlled exercise regime beginning with a period of box rest followed by a guided and gradual return to work

Cost effective.

Long rehabilitation periods (8-9 months).

(Gillis, 1997)

Thought to stimulate an acute inflammatory process in chronic conditions, thereby resolving the injury.

Considered 'out of date' and much debate surrounding ethics.

Poor success rate.

(Renzi, et al., 2013)

Pin firing cauterization of the tendon tissue in more chronic injuries

Table 1. Five potential treatments in SDFT strain upon the extent of the injury. This usually results in the equine being confined to box rest for a period of time, as guided by the Veterinarian. As previously mentioned, severe cases may be immobilised with a cast, resulting in a period of being ‘cross tied’ ensuring the equine does not attempt to lie or roll. Casting and cross-tying may introduce a multitude of associated complications and postural adaptations. These may include contralateral limb laminitis, Peroneus Tertius atrophy and rupture, reduced joint range of movement, epaxial muscular spasm with the concurrent development of active trigger points as a result of sustained thoracolumbar extension (Janicek, et al., 2013).

Bandaging can provide additional support to the tendons whilst the use of cryotherapy will reduce swelling and minimise the infiltration of inflammatory mediators (Khoshnevis, et al., 2015). Ultrasound Therapy can be used on settings 3MHz, at a pulse ratio of 1:4 for 5 minutes at an intensity of 0.3W/cm² (Watson, 2013).

Ultrasound is thought to induce

healing processes and stimulate cell metabolism by using sound waves to penetrate tissues, however evidence for the use of therapeutic ultrasound in both humans and animals is sparse (Shanks, et al. 2010). Low-level laser therapy, see figure 3, is another adjunct to consider in acute management as it activates phagocytes, fibroblasts and the stimulation of macrophages thereby stimulating an immune response and increasing cellular metabolism (Jesus, et al. 2014; Vinck, et al. 2005).

However, a large proportion of the literature surrounding laser therapy has been conducted in rats and one should take

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Figure 3. Laser therapy to a tendon lesion

care when interpreting these findings due to the differences in tendon morphology.

Physiotherapeutic intervention should aim to treat compensatory problems such as muscular spasm, trigger points and soreness but also guide owners towards appropriate tendon loading.

Rehabilitation should begin with inhand walking to gently load the injured tendon. Prolonged immobilization results in a reduction of collagen fibril size and tendon cross sectional area, reducing their load to failure (Goodship, 1993). Therefore, high magnitude loading is thought to be the most effective at increasing tendon stiffness and elicit tendon adaptation (Bohm, et al., 2015). In hand walking should begin on firm surfaces within the early stages, as sand surfaces have shown to have a detrimental effect and increase tendon loading (CrevierDenoix, et al., 2013; Riemersma, et al., 1996a). During this ‘loading’ process, mechanosensitive tenocytes are activated through the upregulation of a number of growth factors, including transforming growth factor-β1 (TGFβ1), connective tissue growth factor and interleukin-6 (IL-6). Type I collagen synthesis is strongly linked with increases in TGF- β1 (Heinemeier, et al., 2003).

Interestingly, human studies measuring tendon hypertrophy during shortterm mechanical loading have found only proximal and distal parts of the tendons hypertrophy after approximately twelve-week programmes. This indicates that tendon rehabilitation should be ongoing for periods of longer than twelve weeks and often span many months to obtain optimal tendon

stiffness and strength (Heinemeier & Kjaer, 2011).

Soft surfaces should be gradually reintroduced at later stages in tendon rehabilitation, similarly with faster work and may take several months to return to ‘full work’ (Rapp, et al., 1992).

Chronic Management

Ultrasound settings can be increased in chronic cases, using 3MHz, at a pulse ratio of 1:1 or continuous and an intensity of 0.3 – 0.8W/cm² for 5 minutes. Similar principles apply to laser therapy with dose calculations increasing due to the chronicity of the lesion (Watson, 2013).

Tendon loading in chronic cases should follow the same principles as the acute stage, progressing on to walking up hills, stepping over poles (Figure 4) to cavaletti on a variety of

Figure 4. varying polework exercises to increase tendon loading.

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surfaces at an appropriate time following treatment. Eccentrically loading the muscle-tendon complex, through pain, is thought to increase tendon stiffness, reduce capillary blood flow and therefore pain, over prolonged periods of training (Fahlstrom, et al., 2003). The mechanism of eccentrically loading the tendon induces microtrauma, collagen turnover stimulating (Langberg, et al., 2007). In contrast, pushing an equine through painful loading exercises may have potential safety implications thereby a more gradual return to exercise is advocated.

Conclusion

Overall, tendon rehabilitation is a complex process with multi-faceted variables, which can influence recovery. The research presented however clearly identifies sand surfaces, increased speed and heating within the tendons can result in degradation and increase the risk of catastrophic injury. Rehabilitation progress will be dependent upon the treatment received, however a large proportion of techniques have not been subjected to longer-term studies. The overall process of rehabilitating tendons will inevitably span many months and may even take up to a year to return to full work.

The risk of re-injury is high and therefore owners should be educated in how to minimise the re-occurrence of the injury.

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Turmeric for Osteoarthritis in Veterinary Medicine: a Review.

Veerle Dejonckheere MRCVS Certified in Veterinary Chiropractic Care, Acupuncture and Herbal Medicine veerle@integratedveterinarycare.co.uk Abstract

Curcumin, a compound derived from Curcuma Longa, commonly known as turmeric, is widely used as an antiinflammatory. It targets a number of pathways that are central to osteoarthritis pathogenesis. The bioavailability of curcumin is low, but new formulations are being developed. Curcumin has an excellent safety profile but consideration should be given to the possible interactions and side effects when assessing patients who are supplemented with curcumin.There is a pressing need for large-scale clinical trials in dogs and horses, along with clinical veterinary studies to identify ways to increase the bioavailability and the clinical efficacy of supplementary curcumin in the management of osteoarthritis.

Keywords Osteoarthritis, Curcumin, Veterinary, Safety, Anti-inflammatory Introduction

Turmeric, Curcuma longa, is a member of the Zingiberaceae family of plants.

Other members include ginger, Javanese ginger and galangal. The rhizome of turmeric is used in herbal medicine. Rhizomes, also called creeping rootstalks, are underground horizontal stems. Turmeric is extensively cultivated in China, India, Indonesia, Thailand and throughout the tropics. Curcumin, one of the constituents of turmeric, was described more than two centuries ago as a yellow coloured matter derived from the rhizomes of Curcuma longa. Turmeric is used to flavour food in South East Asian cuisine (Gupta, et al., 2013). In Asian medicine, more specifically in Ayruvedic medicine, curcumin is used

for the treatment of skin disorders, pulmonary and gastrointestinal ailments, pain, wounds and liver disorders (Aggarwal, et al., 2007).

A search of the American website www.clinicaltrials.gov in September 2015 showed 124 recruiting, active or completed clinical trials on the use of curcumin in a wide variety of diseases.

In July 2009 a total of 34 clinical trials were recorded. This change is indicative of the dramatic increase in interest and research into the effects of curcumin, and its bioavailability, over the last decade. Anecdotally, enthusiasm for curcumin-based supplements for horses has increased so significantly in recent years that wholesale supply cannot always keep up with demand. Veterinary professionals are asked on a regular basis whether curcumin would be an appropriate adjunct treatment for osteoarthritis. This review is aimed at giving them the knowledge to effectively and safely advise owners who treat, or plan to treat, their animals with curcumin.This article is a narrative review of the use of curcumin as an anti-inflammatory agent. It focuses on papers published in the last decade on curcumin and its application in osteoarthritis although some of the material discussed also applies to other inflammatory pathologies.

Components

In addition to curcumin more than 300 different components, including phenolic compounds and terpenoids, have been identified in turmeric. Plant terpenoids are used extensively for their aromatic qualities and play a role in traditional herbal remedies.

Terpenoids contribute to the scent of eucalyptus, the flavours

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of cinnamon, cloves, and ginger, the yellow colour in sunflowers and turmeric, and the red colour in tomatoes. Curcumin is one of the major active components. However, research during the past decade has revealed that some of the activities of turmeric are independent of curcumin, and some studies suggest that whole turmeric exhibits activities superior to curcumin alone (Gupta, et al, 2013). The idea of using the whole plant rather than the extracted active ingredients in order to counteract side effects or achieve greater effect is very well known among herbal practitioners in Western herbal, Ayruvedic and Traditional Chinese medicine.

The selective constituents of turmeric are a volatile oil (6%) composed of monoterpenes and sesquiterpenses, including zingiberene, curcumene, α-turmerone and β-turmerone. The colouring principles (3 to 5%) are polyphenolic curcuminoids, 50% to 60% of which are a mixture of curcumin, monodesmethoxy curcumin and bisdesmethoxycurcumin (Wynn, 2007). Most research is centred around these polyphenolic components. Most commercially available curcumin is not pure but a mixture of curcumin (77%), desmethoxycucrcumin (18%) and bisdesmethoxy curcumin (5%).

Curcumin is readily soluble in dimethylsulfoxide, ethanol or acetone but is sparingly soluble in water (Basnet & Skalko-Basnet, 2011).

Bioavailability

Curcumin is well tolerated but its bioavailability is poor because of poor absorption, poor solubility in aqueous solution, rapid metabolism and rapid systemic elimination (Noorafshan and

Ashkani-Esfahani, 2013). Yang, et al., (2007) reported a bioavailability of 1% in rats when curcumin extract at dose of 500 mg/kg as administered orally.

Several formulations have been used to increase curcumin's bioavailability, provide longer circulation, improve resistance to metabolic processes and increase its permeation to a cellular level.

Metabolic enzymes can be bypassed by dissolving curcumin in oil before ingestion. Dissolution in oil does not modify the structure of curcumin but allows it to be directly absorbed into chylomicrons and subsequently into the lymphatic system, bypassing the liver and the first pass effect metabolism (Anand, et al., 2007). It has been suggested that ruminants and horses should absorb curcumin relatively well because the microbial fermentation in the rumen produces short chain fatty acids, which should dissolve curcuminoids, and prevent fast excretion. The hindgut of the horse may act in a similar way, but clinical studies of this hypothesis are yet to be investigated (English, 2016).

Piperine, the alkaloid responsible for the pungency of black pepper, inhibits hepatic and intestinal glucuronidation of curcumin (Patil, et al., 2011). The effect of piperine on the pharmacokinetics of curcumin was much greater in humans than in rats.

In humans, curcumin bioavailability was increased by 2000% at 45 minutes after co-administering curcumin orally with piperine, whereas in rats it only increased by 154 % for a short period after administering (Shoba, et al., 1998). It is unclear whether piperine can facilitate such significant increases in curcumin bioavailability in herbivores or dogs.

It has been found that after oral administration of polylactic-co-glycolic acid (PLGA) encapsulated curcumin nanoparticles, the relative bioavailability was increased 5.6-fold and had a longer half-life compared with plain curcumin extract. This is due to improved water solubility, higher release rate and residence time in intestinal flora and enhanced absorption by improved permeability (Xie, et al., 2011). In vivo

pharmacokinetics revealed that curcumin entrapped nanoparticles demonstrate at least 9-fold increase in oral bioavailability when compared to curcumin administered with piperine as a absorption enhancer (Shaikh, et al., 2009). Liposomes are able to solubilise hydrophobic components such as curcumin and hence alter pharmacokinetic properties (Takahashi, et al., 2009; Basnet, et al., 2012). Liposomal encapsulation of curcumin has been used to improve bioavailability. Encapsulation of curcumin with cyclodextrine both improved in vitro and in vivo bioavailability (Prasad, et al., 2014).

Cyclodextrins are cyclic oligosaccharides arising from the degradation of starch. The most important property of the cyclodextrines is the ability to establish specific interactions (molecular encapsulation) with various types of molecules through the formation of non-covalently bonded entities, either in the solid phase or in aqueous solution (Marques, 2010). One recent equine study used a lysine salt of curcumin in beta-cyclo dextrine NDS27, which had higher bioavailability and could be inhaled (Sandersen, et al., 2015).

Safety and toxicity

Curcumin is consumed daily in the spice turmeric in many Asian countries. In India the average intake of turmeric can be as high as 2000 to 2500 mg per day (corresponding up to approximately up to 100 mg of curcumin) but no toxicities or adverse effects have been reported or studied at population level (Chainani-Wu, 2003). Doses administered in clinical trials are, however, expected to be much higher than a normal dietary intake. A phase 1 human trial with 25 subjects using up to 8000 mg of curcumin extract orally per day for 3 months found no toxicity for curcumin (Cheng, et al., 2001).

Safety precautions and contraindications for therapeutic curcumin include: 1. Inhibition of drug metabolism.

Curcumin has been shown to inhibit

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the activity of drug metabolising enzymes such as cytochrome P450 (CYP450), glutathione-S-transferase (GST) and UDPglucuronosyltransferase (UGT) in vitro and in animal models (BurgosMorón, et al., 2010; Cho & Yoon, 2015). Consequently animals taking drugs such as digoxin, anticoagulants, cyclosporine, and non-steroidal antiinflammatories may be at risk of accumulation of drug concentrations in the plasma, which may be toxic (Gupta, Kismali & Aggarwal, 2013).

CYP450 are the most important enzymes in phase I metabolism (modification) in mammals. Phase I results in small changes that make a compound more hydrophylic, so it can be effectively eliminated by the kidneys. More drugs affected by CYP450 are listed on the University of Medicine of Indianapolis website: (www.medicine.iupui.edu/clinpharm/d dis/clinical-table). GST and UGT are transferase enzymes, which are responsible for some phase II reactions. Phase II reactions (conjugation) involves the attachment of an ionised group to make the metabolite more water-soluble. This facilitates excretion as well as decreasing pharmacological activity (McDowall, 2016) (Rolfe, 2016).

2. Iron chelation.

Curcumin has been shown to be an active iron chelator in vivo. In rodents fed diets poor in iron curcumin induced a state of overt iron deficiency (Jiao, et al., 2008; Badria, et al., 2015). It is not clear how much this would affect facultative carnivores such as dogs, or herbivores.

3. DNA damage.

Several studies have shown that curcumin at concentrations similar to those reported to be beneficial can cause DNA damage and chromosomal alterations both in vivo and in vitro.

For example, Burgos-Morón, et al, (2010) cite a report by the National Toxicology Program (USA) that an increase in carcinogenic activity in rats and mice in the small intestine was seen when curcumin was administered at an average daily dose of ~0.2 mg/kg body weight over periods ranging from 3 months to 2 years. However, epidemiological data

suggests a relatively low incidence of gastrointestinal cancers in India may be due to diet rich in curcumin. The estimated dose of curcumin ingested in the diet is ~ 0.15 g/day. This dose is up to 10 times lower than the therapeutic dose recommended by some health professionals (BurgosMorón, et al., 2010).

4. Gastrointestinal inflammation.

Curcumin has been associated with nausea, diarrhoea and increases in alkaline phosphatase and lactate dehydrogenase in humans (Gupta, Kismali & Aggarwal, 2013). It has been observed also in clinical practice with dogs. Canine patients with pre-existing inflammatory gastrointestinal conditions like eosinophilic plasmacytic lymphocytic enteritis, exocrine pancreatic insufficiency and gastritis or stomach ulcers tend to suffer adverse reactions more rapidly. However, once the underlying inflammation, irritation or liver dysfunction has been settled by other means, low doses of curcumin may be tolerated.

5. Gall bladder contraction Rasyid & Lelo, (1999) found that curcumin extract induces gallbladder contraction. This shows that use of any curcumin supplement in dogs with known gallbladder issues could be contraindicated if there is existing cholelithiasis. Certain dog breeds like Poodles, Schnauzers and Shetland Sheepdogs are more prone to these problems. A study by Li et al, (2015) showed that curcumin has the potential to decrease the formation of gallstones so in those predisposed breeds the use of curcumin might have preventive value if there are no pre existing gallstones.

6. Hypoglycaemia enhancement.

Some animal studies have shown that curcumin may enhance the hypoglycaemic effect of anti diabetic medication via inhibition of the CYP enzyme system or by reducing the low-density lipoprotein fraction in the blood (Basnet & Skalko-Basnet, 2011; Grynkiewics & Slifirski, 2012).

Therefore glucose levels should be closely monitored in diabetic patients.

7. Zingiberaceae extracts have been reported to have anti-coagulant

properties and could exacerbate clotting disorders (Kim, Ku & Bae, 2012; Lakhan, Ford & Tepper, 2015).

Clotting disorders are relatively uncommon in dogs, cats and horses, but turmeric discontinuation prior to any surgical intervention should be considered. In dog breeds with suspected Von Willebrand disease (from Type 1 to Type 3) such as German Shepherds, Dobermans, Standard Poodles, Golden Retrievers and Shetland Sheep dogs it is standard to do a Buccal Mucosal Bleeding Test (BMBT) preoperatively. Interestingly, these very same anticoagulant properties indicate that curcumin may have a preventative effect for disseminated intravascular clotting associated with colic in horses and thrombosis associated with inflammatory disorders.

8. Oxalate uroliths The consumption of supplemental doses of turmeric can significantly increase urinary oxalate levels, thereby increasing risk of kidney stone formation in susceptible individuals (Tang, Larson-Meyer & Liebman, 2008).This was seen in a human study but we know that Miniature Schnauzers, Lhasa Apsos, Yorkshire Terriers, Bichon Frises, Shih Tzus and Miniature Poodles are predisposed to form calcium oxalate uroliths. Both cats and horses can form calcium oxalate uroliths so questioning the owner of patients on supplement use when diagnosing urolithiasis is recommended.

9. Anecdotally, dogs receiving medicinal doses of curcumin may show a marked increase in body odour resembling that of cat urine.

Some owners find the odour too offensive and stop giving the curcumin or reduce the dose significantly. In most cases the odour decreases over time, or it may be neutralised by adding cinnamon.

Anti-inflammatory activity of curcumin in vitro and in vivo

Many of the activities associated with curcumin are related to the suppression of inflammation. It targets a number of pathways that are central to osteoarthritis pathogenesis, as

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detailed below.

1. Decreased synthesis of inflammatory mediators Curcumin induces down regulation of various inflammatory cytokines in vitro, such as TNF, Il-1, Il-6, Il-8, Interferon γ and other chemokines (Mathy-Hartert, et al., 2009; Aggarwal, Gupta & Sung, 2013; Comblain, et al., 2015). Cytokines are small soluble proteins that affect the activity of other cell types.TNF- α and Il-1β also induce the expression of matrix metallo proteases (MMP) and COX-2 (Shakibaei, et al., 2007). The involvement of pro inflammatory cytokines and MMPs in osteoarthritis is well documented. MMP-3 is produced by chondrocytes in cartilage tissues affected by osteoarthritis.

MMP-3 has the capacity to degrade collagens and proteoglycans, and activate other collagenases. Curcumin suppresses the gene expression of a number of MMPs, preserving the integrity of the joint matrix and thus having an anti-katabolic activity (Peddada, et al., 2015). Curcumin tested on equine cartilage explants stimulated with Il-1β showed the suppression of glycosaminoglycan (GAG) release (Clutterbuck, et al., 2013). GAG release is one of the indicators of cartilage damage. Dietary administration of Curcuvet, a stabilized extract of turmeric associated to a phytosome complex, resulted in significant down regulation of IL-1β and up regulation of IL6 gene expression (Farinacci, et al., 2010).The stimulation of IL-6 could have a beneficial effect since it has a protective role with respect to cartilage integrity.

2. Selective COX-2 inhibition but also some COX-1 inhibition.

COX-2 is the inducible form of cyclooxygenase predominant at inflammatory sites. Curcumin down regulates the expression of COX-2 enzymes and inhibits the expression of pro inflammatory enzyme 5-LOX, reducing prostaglandins, leukotrienes and thromboxanes. Curcumin inhibits COX-2 but not COX-1 gene expression (Park, et al., 2007; Henrotin, Priem & Mobasheri, 2013).

COX-2 appears to have also some important physiological functions, for

example in the kidneys. This role is greater in dogs than humans.

Apart from the well-known roles of COX-2, studies suggest that the COX1 iso enzyme also plays a role in inflammation and carcinogenesis.

COX-1 is over expressed in a significant number of ovarian cancers.

One study suggests that curcumin and its analogues had significantly higher inhibitory effects on peroxidase activity of COX-1 than that of COX2 (Handler, et al., 2007). This would potentially explain the occasional gastro intestinal irritation with curcumin seen in practice.The balance between the metabolic products of COX- 1 and COX-2 catalysis appears important in the physiological function and response to inflammation. There is some literature that suggests there is some cardiovascular protective role for the products of COX-2 and that not all COX-1 functions are good in terms of cardiovascular health (Parente, 2001; Vanhoutte, 2009).

Perrone, (2010) suggests that there is definite scope to develop new drugs whose activities are COX-1 mediated.

Maddison, (2015) however warns to not extrapolate results from one species to another.

3. Activator Protein-1 (AP-1) and Nuclear Factor-κB (NF-κB ) inhibition Nuclear factor κB (NF-κB) and activator protein 1 (AP-1) transcription factors regulate many important biological and pathological processes. Nuclear factor κ-B plays a critical role in signal transduction pathways that are involved in inflammatory diseases and various cancers. Curcumin has been shown to inhibit NF-κ-B and AP-1 pathways (Csaki, Mobasheri & Shakibaei, 2009).

This in turn reduces the downstream inflammatory effects of COX-2 and inhibits PGE2 synthesis. Prostaglandins and degradation of extracellular macromolecules lead to cartilage degeneration and joint inflammation.

Clinical trials in horses and dogs

The majority of large scale clinical trials to examine the anti inflammatory effects of curcumin have studied humans or rodents. There are a few big trials involving horses

and dogs.

One such trial, a randomised, doubleblind, placebo-controlled parallel group study of turmeric extract for the treatment of osteoarthritis in dogs, failed to reach statistical significant effects (Innes, et al., 2003).

A small study involving 12 osteoarthritic dogs found that curcumin resulted in inhibited macrophage proliferation, strongly down regulated TNFα and the activation of fibrinolysis (Colitti, et al., 2012). These positive findings need to be validated with larger trials. The pharmacodynamics of intravenous injection of liposomal curcumin in beagles has been studied, but this has no practical applications for the regular pet owner (Helson, et al., 2012).

A study in which a nutritional supplement containing curcumin and boswellia extract was fed to thoroughbred horses found a reduction in pro inflammatory cytokine expression and hence an enhanced adaptation to exercise (Horohov, et al., 2012). Once again, large-scale studies are required to validate these findings. A study at the University of Udine, Italy showed that administration of a phytosome complex of curcumin administered to seven mares with confirmed osteoarthritis and five foals with osteochondrosis changes for fifteen days had some significant results. Gene expression was monitored before the treatment and after four, eight, and fifteen days. In mares, curcumin inhibited the expression of COX-2, TNF-α, IL-1β, IL1RN, and IL6, even if only the down regulation of IL-1β and IL1RN were significant. In foals, curcumin significantly inhibited the expression of COX-2, TNF-α, IL1RN and significantly increased that of IL6.

These results show that curcumin has potential but again this is a very small study (Farinacci, et al., 2010).

Clutterbuck, et al, (2013) found that curcumin at concentrations lower than 25µM exerted a potent antiinflammatory effect on cartilage explants in vitro. This study did, however, express caution of extrapolating this data and recommended further research to

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establish curcumin's bioavailability and physiologically relevant serum and synovial concentration in vivo in humans and animals.

Conclusion

There is a vast amount of clinical observational and anecdotal evidence, together with some promising in vitro and in vivo studies, in support of the use of curcumin in the treatment of joint inflammation (Moreau, et al., 2014, Ulbricht et al., 2011). However, there is a pressing need for large-scale clinical trials in dogs and horses, along with clinical veterinary studies to identify ways to increase the bioavailability and clinical efficacy of supplementary curcumin in the management of osteoarthritis. The relative safety of curcumin should allow it to be used as a supplement for the management of osteoarthritis in the majority of cases. Recommended dose ranges are broad, ranging from 50 to 250 mg curcumin three times daily for dogs and 1200-2400 mg of curcumin daily for horses (Wynn, 2007). A lack of standardisation in extraction processes and quality control means that there may be considerable variability in the active constituents of veterinary nutraceutical products. However, further veterinary clinical trials with more bio available forms of curcumin will provide more accurate dosage guides and standardised products.

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Critical Review of the Evidence Supporting Physiotherapeutic Management of Canine Elbow Dysplasia R. Burton-Dadd, P. Hutson and G. Tabor Hartpury University Centre, Gloucester

This literature review was submitted as part of the MSc Veterinary Physiotherapy programme at Hartpury College, University of West of England.

Introduction

Canine elbow dysplasia (CED) is a term relating to clinical and radiographical manifestations of specific elbow joint pathologies (Hornof et al., 2000). These being ununited anconeal process, fragmented medial coronoid process, osteochondritis dissecans, erosive cartilage lesions and elbow incongruity. Consequently, abnormal development and concentration of forces occur within the joint; leading to osteoarthritis (OA) and clinical signs of lameness, pain, joint restriction and impaired neuromuscular control (Kirkberger & Fourie, 1998).

Historically, CED was managed with pharmaceuticals, exercise restriction and immobilisation.

However acknowledgement of atrophic changes; in bones, cartilage, muscle, ligament and tendons in response to exercise restriction and reduced loading, mean current management of post-surgical and conservatively treated cases, includes intensive physiotherapy. The aim is to reduce pain and swelling, to increase joint range of movement (ROM) and facilitate neuromuscular control (Michelson, 2013; Millis & Ciuperca, 2015). There is limited scientific research behind the veterinary physiotherapeutic techniques utilised and therefore many clinical decisions are based on scientific studies extrapolated from the human field (Millis & Ciuperca, 2015).

A variety of treatment options are available to veterinary physiotherapists managing CED, the main being manual therapy and therapeutic exercise.

Manual Therapy

Joint mobilisations Joint mobilisations are oscillatory movements performed upon the articular surfaces of a joint within the available physiological or accessory ROM, aiming to improve tissue extensibility, increase ROM, induce muscle relaxation, modulate pain and address arthrogenic joint restriction (Saunders et al., 2005). Physiotherapy management of CED should consider the arthrogenic restrictions resulting from altered biomechanics and stress within the elbow joint and surrounding structures. Therefore treatment should aim to maintain and improve soft tissue and joint integrity, thus maximising function and decreasing pain in the canine patient.

Supportive evidence for joint mobilisations within canine practice is lacking.

However, research extrapolated from human practice advocates joint mobilisations to address arthrogenic pathology (French et al., 2011) Moss et al, (2007) concluded joint mobilisations had significant hypoalgesic effects in humans with knee OA, together with a positive trend towards increased function. The use of 40 participants, considered a satisfactory sample size, gave reliability to the results, thus permitting their application to a wider population. The authors use of pain pressure threshold, measured with a pressure algometer and the â&#x20AC;&#x2DC;timed up and goâ&#x20AC;&#x2122; test as a measure of function, also increases reliability of results, as both of these outcome measures have a high level of reliability (Collins, et al., 2004; McMeekan, et al., 1999). This study did however fail to investigate long-term effects of joint mobilisation, meaning efficacy and longevity of 18

therapeutic benefits remains ambiguous. In addition, failure to record the grade of joint mobilisation utilised, makes application to clinical practice challenging. Further studies should investigate longevity of therapeutic benefits and whether results are cumulative.

Interestingly, Villafane et al, (2012) found whilst joint mobilisations significantly decreased pain in humans with carpo-metacarpel OA, no significant increase in function was noted. The authors measured pinch strength and grip strength, using a mechanical pinch gage and grip dynamometer, both having high reported reliability, (Schreuders, et al., 2003; Solanki, et al., 2000). However, the efficacy of joint mobilisations as part of a holistic treatment in a population normally managed with analgesia could be unfairly represented following the exclusion of pharmaceuticals 24 hours prior to assessment. Additionally, participants received nine minutes of joint mobilisations as a standard treatment, regardless of clinical signs. It would be beneficial to investigate the effects of clinically reasoned treatment prescriptions on function and pain response.

The mechanism behind the hypoalgesic effects of joint mobilisations remains uncertain, but is suggested to be due to activation of segmental inhibitory pain mechanisms and descending pain inhibitory systems within the central nervous system (Malisza, et al., 2002). Malisza et al, (2002) observed a decreased activation of pain processing areas of the brain in rats in response to injection of a noxious stimulus following joint mobilisations of the

ratâ&#x20AC;&#x2122;s knee. Brain activity was measured using Magnetic Resonance Imaging.

Study findings were in agreement with Sluka and Wright, (2001) who also concluded significant hypoalgesic effects of joint mobilisations following injection of noxious stimulus.

Interestingly, this study went further, concluding that optimum treatment time was between 9-15 minutes of joint mobilisation; which provides some insight into clinically effective treatment prescription.

These studies go some way to support joint mobilisations in the management of OA to improve pain and function. However, further research is required to investigate the efficacy of joint mobilisations in canine elbow dysplasia. Functional outcomes in gait could be measured using a force plate treadmill, elbow ROM with a goniometer and pain using a pressure algometry.

Passive Stretches Crook et al., (2007) found passive stretches, performed upon canines with OA in the elbow, stifle or carpus significantly increased joint ROM when measured using a goniometer.

Stretches were performed over the affected joint by the owners, with a 10 second hold at end range, 10 times consecutively, twice daily. Study reliability and application to clinical practice was increased through the maintenance of normal management for the canine participants, meaning therapeutic benefits can be attributed to passive stretches. Furthermore, Jaeggar et al, (2002) concluded that goniometry is a reliable method for measuring joint ROM in dogs.

However failure to provide classification for severity of joint pathology means the efficacy of passive stretches in increasing joint ROM in canines with varying severities of OA remains ambiguous. Ethical issues should also be acknowledged, as there is potential for harm with unqualified personnel performing manual therapy. The above study is supportive of passive stretching in the management of CED and subsequent OA, however further research is required to investigate ideal dosage, longevity of symptoms and efficacy of treatment when used against various

classifications of joint pathology and post surgery.

Massage Massage therapy has been utilised therapeutically to decrease pain and stiffness by increasing local circulation, muscle tone and joint flexibility (Cherkin et al., 2003). Perlmann et al, (2006) concluded massage was effective in conservative management of knee OA.Within the study, massage therapy administered weekly, for eight weeks, significantly increased Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC) scores and ROM, and significantly decreased visual analogue scale pain scores; benefits were still present eight weeks post treatment.

Participants received massage in the form of tapotement, effleurage and petrissage, however, failure to specify which muscle groups received the massage, limits external validity of the results. Participants received one hour of massage, however it is unlikely a canine patient would tolerate this.

Therefore, research is needed to detect whether therapeutic benefits are achievable, when participants are exposed to a lower dose before applying to a canine population. The authors failed to monitor medication and exercise over the study period, therefore it is difficult to attribute therapeutic benefits to massage therapy alone. Field et al, (2015) concluded that massage therapy to the quadriceps and hamstrings muscles, significantly reduced pain and increased ROM and function, in patients with knee OA. Similar to Perlmann et al, (2006) the WOMAC index was utilised, its proven reliability validating the study findings (Bennell et al., 2008). It should however be noted that, ROM of the knee was measured visually using an analogue scale of 0 for no movement to two for full movement; no research exists to validate this as an objective measure.

Study bias also exists in that the cohort comprised of medical school staff and faculty employees, which may have influenced the results.

These studies are cautiously supportive of massage therapy to target pain, ROM restrictions and reduced function in humans with OA

19

knee. However further research is needed to investigate whether therapeutic benefits apply to canines with elbow dysplasia. It would be interesting to investigate the efficacy of thoracic limb massage, alongside therapeutic exercises in canines with elbow dysplasia, to create the optimal treatment plan.

Therapeutic exercise

Therapeutic exercise is utilised to increase range of motion, decrease pain, improve balance, proprioception, neuromuscular control with the end goal to improve function (Saunders, 2007).

Canine elbow dysplasia CED typically presents with joint restriction, therefore physiotherapy management should incorporate land-based exercises to maintain and restore ROM and joint biomechanics (Millis and Ciuperca, 2015). Holler et al, (2010) investigated elbow ROM using gradients and obstacles, revealing no significant difference between elbow joint ROM during uphill or downhill walking, when compared to walking on a horizontal surface. Interestingly, a significant increase in elbow flexion was noted in dogs walking over obstacles in the form of a low cavaletti. This is in contrast to Carr et al, (2013) who found ascent of stairs and ramps significantly increased elbow flexion and extension. No significant difference was found between elbow flexion during ascent of the ramp and stairs. However elbow extension was significantly greater on the ramp, comparable to stairs. Overall, thoracic limb ROM was significantly greater when ascending the ramp, comparable to the stairs.

Whilst both studies investigated the effects of ramps on forelimb ROM, Holler et al, (2010) used a 6.3 degrees incline, whereas Carr et al, (2013) utilised a 35 degree incline; suggesting when encouraging ramps as a therapeutic exercise, a 35 degree incline ensures clinical efficacy. Study participants should also be considered on the basis that Carr et al, (2013) used a cohort of hound breeds similar in demographics, whereas Holler et al, (2010) utilised a larger inclusion criterion with regard to breed-type used. Voss et al, (2011) suggested

comparisons cannot be made between largely varying demographic groups when collecting kinetic data. It is therefore reasonable to suggest that results reported by Holler et al, (2010) lack reliability in the argument against the efficacy of ramps as a therapeutic exercise. This infers that the use of ramps, stairs and obstacles is valuable in management of CED. Therapeutic exercises for canine patients should also include balance and proprioceptive training (Drum et al., 2015). Diracoglu et al, (2005) and Mohammadi et al, (2008) confirmed humans with knee OA, had significantly decreased neuromuscular control, compared to age and gender matched controls without knee pathology, therefore predisposing to further injury and microtrauma.

Proprioceptive and balance training has been successfully employed prophylactically and in response to pathology in humans (Mallilou et al., 2004; Mattacolla and Dwyer, 2002).

Ahmed, (2011) found a significant increase in balance, proprioceptive acuity and quadriceps muscle torque, alongside a decrease in pain in subjects with OA, when engaging in balance training alongside a control group. This study only included subjects with Grade II classification of OA, meaning subjects presented with pain, joint space narrowing and osteophyte formation. This is therefore supportive of balance training in the management of Grade II knee OA. The authors insured no pharmaceutical or complementary treatment was received, increasing reliability of results. The use of the Biodex stability system is also significant, as it has been documented as a reliable method for objective assessment of balance and proprioception (Schmitz and Arnold, 1998). Whilst further research is needed to quantify balance and proprioceptive deficits in CED, it would be appropriate to suggest proprioceptive and balance training should have a place in the physiotherapeutic management of the condition. Future studies should investigate whether balance training in the form of perturbations, unstable surfaces, limb lifts and rapid changes in direction are effective.

It has been postulated that

arthrogenic muscle inhibition occurs in response to pathology and pain (Hopkins and Ingersoll, 2000). Rasch et al, (2007) found a significant decrease in cross sectional area of muscle and isometric strength in patients with unilateral OA of the hip or knee. It would therefore be reasonable to suspect that weakness would exist in the thoracic limb of canines with CED. Strengthening exercises should be encouraged to maximise neuromuscular control and support the elbow joint as a biomechanical structure. Functional exercises, such as swimming and walking on undulating surfaces, may be more simple to perform than specific exercises, which may positively impact the compliance of the owner to adhere to a prescribed exercise programme. It has been suggested that resistance strength training could be introduced through the use of weighted attachments to the forelimb or the use of theraband (Drum et al., 2015). Dynamic speed and plyometric exercises should be introduced in the later stages, after adequate tissue healing, muscle strength and endurance have been achieved, (Drum et al., 2015). Baker et al, (2001) found that strength training significantly improved strength, pain, physical function and quality of life in patients with OA. The study was carried out over a four month period, with a progressive strengthening exercise regime highlighting the need for therapist lead progression to achieve outcomes and ensure muscle hypertrophy. Findings were in agreement with Diracoglu et al, (2008), however this study found that strengthening and balance exercises combined saw significantly improved results compared to strength training alone. Before applying results to a canine population it should be acknowledged that study participants worked to fatigue and replication of high intensity exercise regimes would be challenging in a canine population.

Further research is needed to investigate the effect that strength training and combined strength and balance training of the thoracic limb could have in the management of CED. Comparisons should also be made to neuromuscular electrical stimulation and hydrotherapy to

20

the most effective ascertain strengthening modality available to veterinary physiotherapists.

Conclusion

Whilst very limited research exists on the physiotherapy management of CED, extrapolation from the human field suggests that manual therapy and therapeutic exercises are appropriate to treat canines with veterinary consent. It is however important to acknowledge study limitations and species variance.

Further research should investigate the efficacy of manual therapy and therapeutic exercises in the physiotherapeutic management of CED of varying severities.

References

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Mechanical Nociceptive Thresholds following Physiotherapy in Unridden Horses Fiona Winchester MSc BSc ACPAT Cat A All Creatures Physiotherapy fiona@allcreaturesphysio.com.au

This literature review was submitted as part of the MSc Veterinary Physiotherapy programme at the University of Liverpool. I would like to thank my supervisors Elizabeth Walmsley (Faculty of Veterinary Science, the University of Melbourne, Werribee, Victoria) and Katarine Varcoe-Cocks (Topline Equine Physiotherapy, Victoria) for their support and input.

Introduction

Equine thoracolumbar (TL) and lumbosacral (LS) back pain and associated epaxial and hypaxial neuromuscular dysfunction are significant problems in all types of performance horses (Stubbs, et al., 2006) leading to altered spinal kinematics, lost training days and poor performance (McGowan, et al., 2007; Wennerstrand, et al., 2004, 2009). Problems are often recurrent (Denoix, 1998), with prevalence rates ranging from 0.9 - 94% depending on the speciality and type of practice surveyed (Jeffcott, 1980).The ability to quantify and localise back pain is critical for injury diagnosis, treatment implementation and return to optimal function in humans and horses (Haussler & Erb, 2006; Richards, et al., 2013). Physiotherapists that treat humans have greatly improved their treatment and management of human back pain through scientific knowledge stemming from experimental science and clinical studies (Buchner & Schildboeck, 2006) and have more recently begun applying their skills to treat animals.

Traditionally, tenderness in the equine axial skeleton has been assessed with manual palpation (De Heus, et al., 2010), although the interpretation of its outcome is highly subjective (Haussler & Erb, 2006; Sullivan, et al., 2008). Large discrepancies have been reported between clinicians, particularly when interpreting mild-tomoderate back pain (Haussler & Erb, 2006, 2006a; Sullivan, et al., 2008; De Heus, et al., 2010) in the absence

of a quantitative measure. The use of pressure algometry (PA) has shown to be a valid, reliable objective measure of pain pressure thresholds (PPTs) in humans (Vanderweeen, et al., 1996) and mechanical nociceptive thresholds (MNTs) in equines (Haussler, et al., 2006). Few high quality studies have researched the effectiveness of physiotherapy intervention in horses with suspected TL, LS and sacroiliac pain using PA. As such, this literature review aims to; i) outline the similarities between human and equine back pain; ii) define muscle tension and mechanical nociceptive thresholds; iii) compare pressure algometry use in humans and horses and; iv) discuss physiotherapy assessments, palpation scales and treatments.

the multifidus muscle (Hides, et al., 1994, 1996, 2001), decreased functional activation patterns (Ng, et al., 2002) and a loss of preparatory stabilisation (Moseley, et al., 2002), which may increase the risk of recurrent back pain (Stubbs, et al., 2006). The multifidus muscle is comparable between humans and horses (Haussler, 1999), with the function of equine multifidus muscle suggested to be segmental stabilisation, proprioception and postural control (Haussler, 1999).

Atrophy of the multifidus muscle was apparent within 3 days in pigs following an experimental intervertebral disc lesion (Hides, et al., 2008) and a similar process is suspected in horses (Stubbs, et al., 2011).

Lower back pain in humans is a widespread condition, with multiple established aetiologies (O’Leary, et al., 2013). The rate of lower back pain in industrialised countries is over 70%, peaking between 35-55 years of age (O'Leary, et al., 2013). Lumbar pain recurrence within one year is reportedly 60-80% following the initial episode (Liebensm, 1996). The most frequent mechanism of lower back injury is intervertebral ligament sprains, muscular strain due to overuse or excessive force placed through the lumbar spine resulting in tearing or herniations of the intervertebral discs (O'Leary, et al., 2013). In humans, spinal dysfunction is accompanied by atrophy of

The exact prevalence of equine back pain remains unknown, however the perceived prevalence is high (van Weeren, et al., 2010). Back pain may develop secondary to lameness, incorrect training and shoeing, suboptimal rider ability or saddle fit (Greve & Dyson, 2013). Clinical signs of TL back pain in horses may include a change in temperament, restricted hindlimb gait, spinal rigidity with reduced dorsoventral movement at the caudal thoracic spine and thoracolumbar junction during walk and trot (Wennerstrand, et al., 2004; Faber, et al., 2003; Jeffcott, 1980). In some cases evidence of a lateral curvature secondary to increased muscle tone or spasm of the longissimus dorsi muscle is evident (Jeffcott, 1980). Causes of equine back pain include many different

Back pain in humans and horses

22

pathological processes. A review of 443 back pain cases revealed the major causes of thoracolumbar pathological lesions were vertebral lesions (39%), soft tissue injuries (25%), sacroiliac strain (13%) and nonthoracolumbar lesions (13%) (Jeffcott, 1980; McGowan, et al., 2007). Spinal muscular dysfunctions frequently ensue secondary to bony pathology, however may also occur due to muscle pathology or a generalised muscle disorder (Valberg, 1999; Quiroz-Rothe, et al., 2002; McGowan, et al., 2007).

Muscle Tension The physiology behind increased muscle tension is not yet fully understood. It is suggested that sustained tonic muscle contractions due to permanent central nervous system dysfunction (Bendtsen, et al., 1996) may contribute to muscle hypertonicity, tissue thickening and increased tenderness (Ashina, et al., 1999). Mense & Simons (2001) proposed the development of myofascial trigger points secondary to excessive acetylcholine release from the affected motor endplate, resulting in segmental sarcomere shortening in affected muscle fibres and is thought to account for the formation of palpably taut bands. Localised tissue oedema or metabolic disturbances may also occur secondary to altered microcirculation, exacerbating the problem (Henriksson & Lindman, 1993). A significant correlation between muscle tone and pain was described by Wolf (2002); particularly with chronic muscle irritation, which may lead to permanently increased muscle tone through positive feedback mechanisms.

Mechanical Nociceptive Thresholds (MNT) Nociception involves complex neural pathways, which originate from sensory nerve endings and projects to the thalamus and cerebral cortex via ascending pain pathways (Haussler et al, 2010). The ability to objectively assess and quantify nociception in animals presents a challenge to clinicians and researchers alike.

Nociceptive threshold testing involves the application of a quantifiable stimulus (e.g. mechanical pressure via

a pressure algometer) to affected tissues until either a behavioural or physiological response (muscle spasm or fasciculation) is elicited (Love, et al., 2011): the minimum pressure at which this occurs is known as the MNT in equines or pain pressure threshold (PPT) in humans, and has become an established quantitative measurement of muscle response in both species (Vanderweeen, et al., 1996; Haussler, et al., 2006). Lower MNT readings in animals and humans are indicative of greater pain (Haussler, et al., 2006).

Pressure Algometry

PA is an economical, non-invasive, mechanical form of pain assessment, which uses a calibrated spring-loaded instrument placed on a specific anatomical landmark (Tunks, et al., 1995; Fischer, 1998; Pöntinen, 1998).

Minimal pressure is applied via the pressure algometer until a pain response is elicited, with low MNTs being indicative of greater pain (Fischer, et al., 1998). PA has been used in human medicine for diagnostic purposes (Vanderweeen, et al., 1996), quantifying myofascial and musculoskeletal pain (Fischer, 1998) and for assessing the efficacy of manual treatment techniques (Potter, et al., 2006; Vanderweeen, et al., 1996, Fischer, 1998). It is a repeatable and reliable clinical tool for localising and quantifying MNTs objectively both in the axial skeleton and soft tissues of both humans (Fischer, 1998; Vanderweeen, et al., 1996; Potter, et al., 2006) and more recently, horses (Haussler & Erb, 2006; VarcoeCocks, et al., 2006; Keating, et al., 2001).

Limitations of PA use in human literature include, user experience, accuracy of anatomical landmark identification, correct perpendicular application, the rate of pressure applied, uniform endpoints, reaction time of the examiner, inability to reach deep tissue and the reliability of the instrument itself, particularly relevant for where electronic devices are used (Fischer, et al., 1987; Keating, et al., 2001; Kosek, et al., 1993; Pöntinen, 1998). Factors such as age, sex, exercise activity and weight have also shown to affect the variability of PPTs

23

in humans (Pickering, et al., 2002; Hogeweg, et al., 1992). Higher PPTs have been reported in younger human subjects (Brennum, et al., 1989), males compared with females (Chesterton, et al., 2003; Vanderweeen, et al., 1996), active individuals (Jones, et al., 1987) and overweight individuals, possibly associated with higher levels of endogenous opioids (Ramzan, et al., 1993; Zahorsak-Markiewicz, et al., 1988). Interestingly, similar variations exist in horses with higher MNTs found in young, heavy, nonThoroughbred, geldings (Haussler, et al., 2006a). Differing perceptions of nociception also exist between equine breeds (Bagshaw, et al., 1994) and human racial and ethnic groups, however definitive causative factors are yet to be established (Edwards, et al., 2001; Riley, et al., 2002).

PA and the quantification of MNT’s has been applied to a small number of experimental and clinical studies in horses, although data remains conflicting. Sullivan et al (2008) reported variations in algometry readings along the back (Sullivan, et al., 2008), whilst others were consistent (Haussler, et al., 2006). Substantially increased MNTs were reported for actively ridden horses compared with resting horses (Haussler, et al., 2006a), suggesting exercise increases tolerance in horses as in humans.

Haussler & Erb (2006) found cranial spinal MNT’s were lower than those measured more caudally, with similar results documented in human literature (Hogeweg, et al., 1992; Pöntinen, 1998). These findings are suggested to be due to greater nociceptor density in the cervical region in order to protect neurovascular structures, when compared to the lumbar region (Vanderweeen, et al., 1996; Keating, et al., 2001; Potter, et al., 2006).Variations between equine PA studies indicate the need for further research with larger sample sizes.

Anatomical Landmarks Anatomical landmarks for algometry measurements have been established using experimentally induced pain in the pastern, carpus and back (Haussler et al., 2006, 2007, 2008). The most

consistent anatomical landmarks tested within the TL and LS region using PA included T3, T9, T13, T18, L3, L6, S2, tuber sacrale and tuber coxae (Haussler & Erb 2006, 2006a; Sullivan, et al., 2008; De Heus, et al., 2010; Bierman, et al., 2013), with MNT values recorded 8-10cm lateral to the dorsal midline of these aforementioned vertebral landmarks (Haussler & Erb, 2006a; Sullivan, et al., 2008; Varcoe-Cocks, et al., 2006). anatomical landmarks These encompass the region of greatest dorsoventral and intervertebral movement (Townsend, et al., 1983), both of which are required for optimal performance and are associated with TL and LS pain (McGowan, et al., 2007).

Physiotherapy Assessment

Physiotherapists are trained in the assessment and management of an array of musculoskeletal issues, using manual therapy, exercise and cognitive-behavioural strategies (Bekkering, et al., 2003; van der Windt, et al., 2008). More recently specialist physiotherapists who have undergone extensive postgraduate training have emerged within the veterinary field, with animal physiotherapists working closely with veterinarians to treat animals (McGowan, et al., 2007).

Physiotherapists are trained to focus on the assessment and management of a patient's function, in contrast to both the medical and veterinary professions, which predominantly focus on specific pathoanatomical diagnosis (McGowan, et al., 2007). This includes analysing and addressing any relevant pathoanatomical and biomechanical abnormalities adopted secondary to pain and movement dysfunction (McGowan, et al., 2007). The aim of physiotherapy is to return each patient back to their optimal function and minimise further loss of function (McGowan, et al., 2007).

Palpation Scales Quantifying pain during palpation enables therapists to gauge the effectiveness of treatment techniques.

Both the numeric rating scale and the simple descriptive scale are used to

gauge human pain intensity and are based around a patient rating the intensity of pain on a 0-10 and a 0-3 scale respectively (Williamson, et al., 2005). Pain is manifest in animals through behavioural or physiological changes, which form the basis of similar pain rating systems used in veterinary medicine. Varcoe-Cocks, et al (2006) established a scoring system for the evaluation of muscle pain in horses, based on the palpation of muscle tone, behavioural responses and mobility. Behavioural responses, which facilitate the subjective scoring of pain during the palpation of horses with back pain including tail swishing, unruliness, rapid caudal movement of the ears and rearing (Wennerstrand, et al., 2004).

Treatment Techniques Regions of musculoskeletal discomfort are often alleviated by the application of manual pressure to soft tissue structures. An array of techniques are used by physiotherapists to alleviate discomfort and facilitate the return of homeostasis to affected tissues, these include monosynaptic stretch reflex, proprioceptive neuromuscular facilitation, trigger point therapy and myofascial release. Soft tissue therapy and stretching improve tissue extensibility, joint range of motion, stride length and coordination, whilst simultaneously enhancing flexibility blood flow and relaxation in horses (Lederman, 1997; Haussler, 2010; Clayton et al., 2010). Additionally, soft tissue therapy may alter neurological signalling in relation to pain processing and motor control via the stimulation of regional and systemic changes (Haussler, 2010). Each treatment technique has specific biomechanical and physiologic effects, with the aim being alleviation of pain and enhancing range of motion (Haussler, 2010).

The reliability and validity of PA use in humans has been well established, with similar findings now identified with age, sex and exercise activity in humans and horses. By extrapolating from the human medical literature, it is likely that PA would be of use in evaluating responses to treatments applied in horses. The application of physiotherapy in horses has not been widely investigated when compared to

24

human literature. With an emerging number of physiotherapists being involved in the treatment and management of equine back pain it is vital to quantitatively establish the effect of Physiotherapy. It is also reasonable to propose that the outcome of such an intervention may depend on the underlying disease process and/or site of injury. To investigate this hypothesis, we aim to quantify the effect of physiotherapy on MNTs in the thoracolumbar, lumbosacral and sacroiliac regions in un-ridden horses.

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The Equine Sacroiliac Joint: a Review of the Pathology, Investigations and Treatment Marcus J. Head BVetMed MRCVS Rossdales Equine Hospital & Diagnostic Centre marcus.head@rossdales.com

Introduction

The diagnosis of sacroiliac disease is popular in horses that display lowgrade hind limb lameness, have a history of under performance, give resistance during ridden exercise, have poor muscle development or possess vague gait deficits (Goff, et al., 2008; Dyson & Murray, 2003; Haussler, et al., 2003). In fact, accurate determination of sacroiliac-related discomfort is a challenge and requires a combination of clinical assessment, imaging techniques and assessment of the response to diagnostic anaesthesia and treatment. In many cases,

sacroiliac pain occurs in combination with other conditions (Dyson & Murray, 2003; Barstow & Dyson, 2015), all of which need to be addressed for a successful outcome.

Better understanding of the region and improved imaging techniques to help visualise the anatomy of the area now indicate that what has traditionally been referred to as sacroiliac disease is in fact a much more complicated group of conditions. It is now more common for people to discuss the sacroiliac region and perhaps diagnose sacroiliac syndrome, reflecting the increased 26

understanding of the variety of disease processes that may occur (Haussler, et al., 1999).

Anatomy

The sacroiliac region can be thought of to include the sacroiliac joints themselves and the lumbosacral joint.

The sacroiliac joint (SIJ) is often described as an atypical synovial articulation where the sacral joint surface is hyaline cartilage and the apposing iliac surface is fibrocartilage (Goff, et al., 2008). Sisson and Grossman (1948) describe it as

“a diarthrosis formed between the articular surfaces of the sacrum and ilium” (p 231).They state “movements are inappreciable in the adult – stability, not mobility, being the chief desideratum” (p 232). However, more recent studies suggest small but significant movements in the normal SIJ (Haussler, et al., 2009; Goff, et al., 2006).

The sacroiliac joint is supported by a number of ligaments: the sacrosciatic sacroiliac ligament; dorsal sacroiliac ligament (dorsal and lateral parts); interosseous sacroiliac ligament and the ventral sacroiliac ligament (figures 1a and1b).

The lumbosacral joint (LSJ) consists of five joints (figure 2): the intercentral joint (associated with a large intervertebral disc); two facet joints (intervertebral articulations/articular process joints) and two intertransverse joints (between the transverse processes of the last lumbar and first sacral vertebrae).

Almost all dorsoventral flexion and extension in the lower back occur at this joint, making it an important site to assess in the equine athlete (Stubbs, et al., 2006).

Figure 1b: Showing the interosseous sacroiliac ligament (ISIL) and ventral sacroiliac ligament (VSIL) (courtesy of Emmanuel Engeli MRCVS)

Figure 2: The lumbosacral joint viewed from cranially – the lumbar vertebrae have been removed – showing the left and right intervertebral articulations (a), the intercentral joint (b) and the left and right intertransverse joints (c)

Figure 1a: Showing the sacroiliac ligaments:The dorsal sacroiliac ligaments (dorsal (a) and lateral (b) parts) and the sacrosciatic ligament (c) – image modified from Sisson & Grossman’s Anatomy of the Domestic Animals. (1948) Historically, it is highly likely that the commonly performed interventions (diagnostic manipulations, nerve blocks, medication, and physiotherapy) have affected not just the SIJ, but also the LSJ (or at least one of its components). It could be argued that this possibility is immaterial, particularly if interventions were

successful. However, more detailed understanding of precisely which structure is affected allows targeted treatment, better results, happier clients, more comfortable horses and greater professional satisfaction.

Types of injury

The most common manifestation of sacroiliac disease is an underperforming horse with signs of low-grade hindlimb lameness or restriction of movement (Goff, et al., 2008; Dyson and Murray, 2003; Haussler, et al., 2003). This is typically referred to as sacroiliac syndrome, the broad term used to describe those horses with SIJ discomfort 27

chronic) not (often seemingly associated with trauma or a single overloading event but usually with insidious, often poorly definable signs.

Horses presented with SIJ syndrome may have a variety of complaints ranging from subtle issues in high level dressage or jumping horses to resistance issues (bucking, stopping, rearing) in general purpose ridden horses and ponies, often mimicking the signs of back pain (Dyson & Murray, 2003). The equine pelvis is not a rigid structure and significant deformation occurs during loading, which may lead to soft tissue or bone injury (Haussler, et al., 2009; Goff, et al., 2006). As discussed earlier, it is now known that many of these horses have issues not only with the sacroiliac joint (or potentially not with the SIJ at all) but also (or exclusively) one, or more, of the components of the lumbosacral joint.

Acute injuries of the sacroiliac joints also occur and are usually the result of a fall, slip or hard exertion. The degree of damage present covers a wide spectrum and mild injuries can be difficult to diagnose with certainty.

More severe injuries frequently involve anatomical disruption to the normal sacrum/ilium relationship associated with serious ligamentous injury. In these cases, affected horses are very lame (at least transiently) and develop rapid muscle atrophy (a common feature of serious pelvic damage). They may or may not have discernible bony asymmetry, but if they do then significant structural damage has occurred and long-term complications may arise. In other words, these are serious injuries; the term ‘sacroiliac luxation’, for example, is too commonly applied to horses with minor tubera sacrale asymmetry

than is rational. The vast majority of horses who suffer from chronic sacroiliac syndrome have not suffered an acute injury previously (although acute injuries can, of course, lead to chronic issues). Asymmetry of the tubera sacrale may be an incidental finding or the result of long-term uneven loading of the limbs. In one study (Dalin, et al., 1995), Swedish trotters had a lower left tuber sacrale three times more commonly than a lower right side: these horses train and race almost exclusively in an anticlockwise direction. Another post mortem study of California racehorses (Haussler, et al., 1999) found 94% with asymmetry of the tubera sacrale (3.4 +/- 2.7mm) and a 2:1 ratio (these horses also train and race anti-clockwise and were subjected to euthanasia for reasons unrelated to pelvic injury).

Physical examination

At the centre of many clinicians’ assessments of the sacroiliac region is the physical examination. Because of the absence of accurate or convenient imaging techniques, great significance is often attached to the results of palpation, manipulation and various stress tests (Haussler, et al., 2003).

However, there is a paucity of information correlating the results of the physical examination with the results of imaging, diagnostic anaesthesia or response to treatment and care should be taken when interpreting the results of the clinical examination; no single manual test of the ilium or sacrum is indicative of the presence of sacroiliac disease (Goff, et al., 2008). In one published study, only 10 of 74 horses diagnosed with sacroiliac disease responded positively to direct pressure over the tubera sacrale (Dyson and Murray, 2003).

Barstow & Dyson (2015) reported an exaggerated response to this test in only 8% of their cases of confirmed sacroiliac joint pain. Additionally, some clinicians have described typical gaits, response to flexion tests and changes in lameness/gait pattern when the horse is exercised on hard and soft surfaces, or when ridden, but objective evidence is scant (Dyson and Murray, 2003). Sacroiliac syndrome is a diagnosis best reached following

exclusion of other causes of lameness, back pain or poor performance in conjunction with the results of local anaesthesia, imaging or response to treatment (Dyson and Murray, 2003).

Diagnostic imaging

Imaging of the sacroiliac region is a challenge. Radiography is unrealistic in most cases, requiring general anaesthesia and huge exposures, and is difficult to interpret even when performed. Gorgas, et al., (2007) radiographed the sacroiliac joints of 79 horses and concluded that there was a large variation in the anatomy of the SIJs and LSJs and that modelling of the caudal aspect of the SIJ was seen in 86% of their cases (degenerative changes are known to occur with age). Other authors have concluded that radiography is not a very sensitive indicator of sacroiliac joint disease (Dyson, et al., 2003a).

Gorgas, et al., (2007) also published the results of the scintigraphic examinations of the same horses and concluded that bone scans alone were also inadequate to predict SIJ disease.

Gamma scintigraphy has the disadvantage that the tissues of interest are deep and any increase in radionuclide uptake will be attenuated by the overlying muscle (Dyson, et al., 2003a); this may lead to false negatives and must be taken into consideration when examining horses with asymmetric muscling over the quarters. Even in humans, it has been reported that only 13% of patients with pain abolished by injection of local anaesthetic into the SIJ had increased radionuclide uptake on a bone scan. It is perhaps most useful, therefore, with acute injuries where there may be significant bone damage.

In more long-standing conditions and in the investigation of subtle lameness or poor performance even mild uptake in the sacroiliac joints is often interpreted as significant, although this might not always be the case (it is easy to forget that gamma scintigraphy is not a ‘pain scan’ – increased radionuclide uptake is not always associated with discomfort). Dyson, et al., (2003b) described considerable overlap in the degree of radionuclide uptake by the sacroiliac joints between groups of horse that were

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free of lameness, lame because of SIJ pain or lame for other reasons. They did state that asymmetry of uptake is very likely to be significant (Dyson, et al., 2003b). Conformation of the pelvis has been cited as a reason for variability in uptake between individuals (Gorgas, et al., 2009).

Ultrasonography of the SIJ can be performed per cutem and per rectum (Engeli, et al., 2006). With both techniques only a small amount of the caudal aspect of the joint can be assessed, although this is the region of the SIJ reported to be most commonly affected by peri-articular new bone formation (Goff, et al., 2008; Haussler, et al., 1999), (figure 3).

Scanning externally, a low-frequency curvilinear transducer is positioned over the caudal aspect of the ilial wing, perpendicular to midline, and rotated slightly (on the left side of the horse, rotate the probe clockwise) to bridge the caudal aspect of the joint. The sciatic nerve, rectum and cranial gluteal vessels can be seen deep to this gap; it is the author’s experience that changes are seen in this position only with marked disruption to the SIJ (i.e. luxation/disruption). Scanning internally, the joint and the ventral sacroiliac ligament can be visualised (figure 4). The most common change seen is proliferative new bone around the joint, but it is not a frequent observation and it is generally assumed to be significant when present (M. Head, unpublished observations), (figure. 5).

Figure 3a. Ventral view of the ilial wing showing a normal sacroiliac joint

Figure 3b: Ventral view of the ilial wings showing a horse with severe bilateral modelling

Figure 4: per rectum ultrasonograph showing a normal sacroiliac joint (red arrow). The blue arrow points to the ventral sacroiliac ligament

Figure 6: per rectum ultrasonographs illustrating the appearance of a normal lumbosacral intercentral joint and the adjacent (and more irregular but still normal) L5/6 disc The lumbosacral intercentral joint can be assessed readily (or at least the ventral aspect of it) by palpation and with ultrasonography per rectum. It is usually positioned at the sacral promontory palpable on the roof of the pelvic canal, just caudal to the aortoiliac bifurcation. It contains a large fibrocartilaginous disc that should be evenly echogenic and confined within the bony boundaries of lumbar vertebra (L) 6 (occasionally L5) and sacral vertebra (S) 1, bordered by the ventral longitudinal ligament (figure 6). Anatomical variations do occur, with some horses having greatly reduced discs or even sacralisation (fusion) of the L6/S1 space and a larger disc at L5/6: the impact of this on spinal movement is unclear (Stubbs, et al., 2006). In other horses, there can be degeneration of the disc, which may cause discomfort or

Figure 5: per rectum ultrasonographs showing a normal sacroiliac joint on the left (this joint is wider than the one in fig 4, but within the normal range) and a joint with irregular new bone on the right

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functional limitations (figure 7).

The lumbosacral intertransverse joints (ITJs) can be imaged by moving the transducer to the left or right of midline, level with the intercentral joint. The normal ITJs present a sharp, clearly demarcated joint space (figure 8).Although disease of these joints can cause discomfort or reduced mobility, it is their proximity to the lumbosacral nerves that may be more important.

New bone formation and soft tissue swelling may cause impingement of the L6 nerve (radiculopathy) and lower motor nerve signs (figure 9), analogous to human sciatica. It is not possible to image the lumbosacral intervertebral (articular process) joints.

Sacroiliac ligament desmitis may also manifest as an acute or chronic issue. Presumably any of the ligaments can be affected, but only the dorsal sacroiliac ligament (dorsal and lateral parts) can really be evaluated

Figure 7: Severe changes to the lumbosacral disc

Figure 8: per rectum ultrasonograph of a normal lumbosacral intertransverse joint (red arrow).The blue arrows point to the L6 nerve

ultrasonographically per cutem (the ventral sacroiliac ligament can be seen per rectum). The dorsal parts of the dorsal sacroiliac ligament (D-DSIL) arise from the tubera sacrale and pass caudally to the sacral spines, blending with the thoracolumbar fascia. They can be imaged easily with a high frequency linear transducer (figure.

10). As with all ligaments, off-incidence artefacts are common (ligaments do not have the same highly ordered linear fibre pattern as tendons) and easily over interpreted. One study reported changes in the crosssectional area of the D-DSIL when manual force was applied to the tuber coxa and tuber sacrale, postulated to occur because of lengthening of the

Figure 9: Modelling of the intertransverse joint is evident in this per rectum ultrasonograph (red arrow). From this image, it is easy to imagine how the adjacent L6 nerve may be damaged with changes at this site (blue arrow) ligament due to movement of the sacroiliac joint (Goff, et al., 2006). The lateral part of the dorsal sacroiliac ligament (L-DSIL) can be seen as a thin, even echogenic band inserting on the lateral sacral crest. It is best imaged with a curvilinear transducer but seems to be rarely affected (or, at least, not sufficiently damaged to be evident ultrasonographically).

Injection of the sacroiliac region

This can be performed either for diagnostic purposes or for delivery of medication and a number of different techniques have been categorised and described by various authors (Engeli &

Figure 10. Ultrasonography of the dorsal parts of the dorsal sacroiliac ligaments (D-DSIL) in transverse (1a & b) and longitudinal (2) planes 30

Haussler, 2012, Cousty, et al., 2008, Engeli, et al., 2006; Engeli & Haussler, 2004). They can be divided into regional infiltration and more specific periarticular techniques. The â&#x20AC;&#x2DC;conventionalâ&#x20AC;&#x2122; approach to the SIJ, performed for years prior to the publication of ultrasound-guided techniques, is now described as regional infiltration and is the technique most widely performed for diagnostic anaeasthesia. Blocking the sacroiliac regions can be performed if the horse displays consistent signs that are reproducible every time the horse is lunged or ridden (i.e. overt lameness or resistance), (Dyson and Murray, 2003). A 10cm 18-gauge spinal needle is placed either in the midline or just cranial to the tuber sacrale opposite the side being injected (figure 11). The needle is then advanced ventrally and caudally, between the DSPs of the last lumbar and first sacral vertebrae until it contacts the ventral ilium on the side being blocked. It is then withdrawn slightly, the angle of injection is steepened, and the needle is then advanced for its full length, aiming for a point halfway between the ipsilateral tuber coxa and greater trochanter: 10-20ml of mepivicaine is then injected.The advantage this technique has is that is easily performed, with palpable bony landmarks and no need for ultrasound guidance, it is relatively safe (having a very low risk of inducing weakness or ataxia) and it blocks a large area. The downside is that it is not specific for SIJ pain (Goff, et al., 2008) and, in fact, it does not block the SIJ in the same way as a joint block in

Figure 11: Photograph showing the correct positioning of the needle for injection of the left sacroiliac joint via the midline approach

Figure 12: Dye study illustrating the wide dispersal of injected fluid following the midline approach (courtesy of Emmanuel Engeli MRCVS) the limb does, as the needle does not penetrate the joint (Dyson and Murray, 2003).The technique relies on widespread diffusion of the local through the soft tissues (figure 12).

Periarticular injection techniques involve more accurate placement of the needles, often with ultrasound guidance. They have the advantage of being more specific, more targeted and more likely to deliver medication to where it is required. The disadvantages are that they require deep injections (15-20cm) under ultrasound guidance and this greatly increases the risk of involving important neurovascular structures,

especially at the caudal aspect of the joint (Cousty and David, 2008). Three main techniques are described â&#x20AC;&#x201C; cranial, craniomedial and caudal. The cranial approach uses a curvilinear transducer positioned parallel to midline, over the cranial edge of the ilial wing: the aim is to guide the needle under the ilium, towards the sacroiliac joint. A 20cm 18-gauge spinal needle effectively

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forms the hypotenuse of a rightangled triangle and it can be useful to use this principle when assessing the correct position for needle placement.

The needle penetrates the skin, aiming caudoventrally, 4-6cm off midline and at a position cranial enough in front of the ilial wing to allow it to pass under the bone parallel with its surface and towards the sacroiliac joint (figure 13).

Some reports advocate the use of a curved needle for this technique, but this seems unnecessary and over complicated in most situations. The advantages of the cranial approach are that it is safe, reliable and it treats the SIJ, LSJ and ITJ. The disadvantages are that it requires ultrasound guidance and careful application. It is also not treating the caudal aspect of the SIJ, unless direct penetration of the joint occurs. The craniomedial approach is performed as described above for diagnostic anaesthesia. Finally, the caudal approach involves identifying the SIJ as described previously at the back of the ilium and directing the needle here.The main disadvantage of this technique is the greatly increased risk of hitting neurovascular structures or entering the retroperitoneal space (and the rectum), (Engeli and Haussler, 2012; Cousty, et al., 2008).

The authorâ&#x20AC;&#x2122;s preference for medicating the sacroiliac regions is to combine the craniomedial and cranial, ultrasound-guided, approaches.

Corticosteroids are the most commonly used agents (methylprednisolone acetate or

Figure 13: Photograph illustrating the correct positioning of the transducer and spinal needle for cranial ultrasoundguided injection of the sacroiliac joint

triamcinolone acetonide) and it is standard practice to treat left and right sides. Great care should be exercised in horses that may be subjected to drug testing when using methylprednisolone acetate – other corticosteroids should be considered, depending on competition schedules and withdrawal times. All injection sites are readied as for any intraarticular injection, with clipping of the hair and aseptic preparation and procedure after injections of small volumes of local anaesthetic to desensitise the skin. Cadaver studies indicate that successful treatment of the LSJ and SIJs can be achieved without including the caudal approach (Marcus Head, unpublished data).

Following treatment, horses are allowed restricted turn out or walking only for 7 to 10 days followed by the resumption of ridden work. Clients are encouraged to involve a Chartered Veterinary Physiotherapist from the outset and not to rest the horse for prolonged periods; it is important to increase the strength and support from muscles and extraarticular soft tissues while the horse is as comfortable as possible following treatment. Most clinicians agree that, in the absence of structural instability, complete rest is contraindicated (Goff, et al., 2008).

Summary

• Sacroiliac region discomfort may arise from the sacroiliac joints themselves, the supporting soft tissues, or any of the components of the lumbosacral joint • Lumbosacral joint pathology is an important and previously under recognised cause of sacroiliac region discomfort • Obtaining diagnostic images is a challenge and in many cases only a limited amount of information can be obtained, which may be difficult to interpret. Pain may be present in the absence of imaging abnormalities • The sacroiliac regions can be desensitised with local anaesthetic, providing definitive evidence for discomfort here if the horse improves after the procedure. However, consistently reproducible signs are required to evaluate the block and

there is a very small risk of inducing hindlimb paresis • Medication of the sacroiliac regions and evaluating the horse’s response to treatment is a perfectly reasonable procedure to perform as sacroiliac discomfort can be very difficult to prove or disprove any other way.

Owners should be informed of the risks, especially laminitis (if corticosteroids are used) and infection.

References

Bartsow, A. and Dyson, S. 2015. Clinical features and diagnosis of sacroiliac joint region pain in 296 horses: 2004-2014. Equine Veterinary Education. 27 (12), pp.637-647.

Cousty, M., Rossier, Y. and David, F. 2008.

Ultrasound-guided periarticular injections of the sacroiliac region in horses: a cadaveric study.

Equine Veterinary Journal. 40(2), pp.160-166.

Dalin, G., Nagnusson, L.-E. and Thafvelin, B. 1995.

Retrospective study of hindquarter asymmetry in Standardbred trotters and its correlation with performance. Equine Veterinary Journal. 17, pp.292-296.

Dyson, S. and Murray, R. 2003. Pain associated with the sacroiliac joint region: a clinical study of 74 horses. Equine Veterinary Journal. 35, pp.240-245.

Dyson, S., Murray, R., Branch, M., Whitton, C., Donovan, T. and Harding, E. 2003. The sacroiliac joints: evaluation using nuclear scintigraphy. Part 1: the normal horse. Equine Veterinary Journal.

35, pp.226-232.

Dyson, S., Murray, R., Branch, M., Whitton, C., Donovan, T. and Harding, E. 2003. The sacroiliac joints: evaluation using nuclear scintigraphy. Part 2: lame horses. Equine Veterinary Journal. 35, pp.233-239.

Engeli, E. and Haussler, K. 2012. Review of injection techniques targeting the sacroiliac region in horses. Equine Veterinary Education.

24(10), pp.529-541.

Engeli, E.,Yeager, A., Erb, H. and Haussler, K. 2006.

Ultrasonographic technique and normal anatomic features of the sacroiliac region in horses. Veterinary Radiology & Ultrasound.

47(4), pp.391-403.

Engeli, E. and Haussler, K. 2004. Review of sacroiliac injection techniques. Proceedings of American Association of Equine Practice. 50, pp.372-378.

Goff, L., Jeffcott, L., Jasiewicz, J. and McGowan, C. 2008. Structural and biomechanical aspects of equine sacroiliac joint function and their relationship to clinical disease. The Veterinary Journal. 172, pp.281-293.

Goff, L., Jasiewicz, J., Jeffcott, L., Condie, P., McGowan,T. and McGowan, C. 2006. Movement

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between the equine ilium and sacrum: in vivo and in vitro studies. Equine Veterinary Journal Supplement. 36, pp.457-461.

Gorgas, D., Luder, P., Lang, J., Doherr, M., Ueltshi, G. and Kircher, P. 2009. Scintigraphic and radiographic appearance of the sacroiliac region in horses with gait abnormalities or poor performance. Veterinary Radiology & Ultrasound. 50(2), pp.208-214.

Gorgas, D., Kircher, P., Doherr, M., Ueltshi, G. and Lang, L. 2007. Radiographic technique and anatomy of the equine sacroiliac region.

Veterinary Radiology & Ultrasound. 48, pp.501-506.

Haussler, K., McGilvray, K., Ayturk, U., Puttlitz, C., Hill, A. and McIlwraith, W. 2009. Deformation of the equine pelvis in response to in vitro 3D sacroiliac joint loading. Equine Veterinary Journal. 41(3), pp.207-212.

Haussler, K. 2003. Diagnosis and management of sacroiliac joint injuries. In: Diagnosis & Management of lameness in the horse. Ed: S. Dyson & M. Ross. Saunders. pp.501-508.

Haussler K., Stover, S. and Willits, N. 1999.

Pathological changes in the lumbosacral vertebrae and pelvis in Thoroughbred racehorses. American Journal of Veterinary Research. 60, pp.143-153.

Sisson, S. and Grossman, J. D. 1948.The Anatomy of The Domestic Animals. 3rd Edition, W. B. Saunders Company.

Stubbs, N., Hodges, P., Jeffcot, L., Cowin, G., Hodgson, D. and McGowan, C. 2006. Functional anatomy of the caudal thoracolumbar and lumbosacral spine in the horse. Equine Veterinary Journal Supplement. 36, pp.393-399.

Book Reviews

useful reference to provide when directing vets to a text that explains equine physiotherapy and its benefits.

Overall a very enjoyable read that succeeds in presenting a very holistic approach to equine performance.This book would be a very useful part of a personal, practice or university library.

Maruska Aylward-Green

Training for equestrian performance Edited by Jane M. Williams and David Evans Published by Wageningen Academics ISBN 978-90-8686-258-0 Available through Publisher Website £90, awaiting availability on Amazon This book is highly recommended for physiotherapists either considering applying to do the MSc Veterinary Physiotherapy course, those currently enrolled or those in clinical practice.

It would be of equal value to other professionals working or training to work within the equine industry including vets, trainers and professional riders. It is divided into four main sections entitled, Performance Analysis, The Rider, The Equine Athlete and The Horse and Rider Partnership. Each section has individual chapters written by experts in the particular area. Contributors include Dr Hilary Clayton, Dr Thilo Pfau, Dr Inga Wolframm and Gillian Tabor ACPAT Cat A and Hartpury MSc Vet Physiotherapy course lecturer to name but a few.

The book does an excellent job of drawing together the latest academic research and established practices whilst providing the practical applications in an easy to read reference text. It is by no means light “bed time” reading but its lay out and overall style allows the reader to digest detailed information in a logical and progressive manner and in bite sized pieces.There are some concepts described and illustrated that require extra concentration and a few re reads but more experienced practitioners may not experience this.

The physiotherapy chapter is extremely well written and is a very

This book is very good for helping the horse owner to understand the consequences of various topics such as the effects of over training their horse, why various terrains can cause injury, why over working a horse in a collected outline can cause fatigue and pain, why sitting asymmetrically can cause problems, how lameness can cause spinal problems and much more. The clinical detail is of a basic academic level if you compare this book to those written by Hilary Clayton for example but the in my opinion the level is just right to encourage owners to think about what and how they are schooling their horses.

Maruska Aylward-Green

Posture and Performance.

Principles of Training Horses from the Anatomical Perspective Gillian Higgins with Stephanie Martin ISBN 978-1-910016-00-8 This is an interesting book. It covers a lot of topics on equine biomechanics at a basic level that would be suitable for the horse owner, which I would suggest is the target audience. It is broken into two parts.

Part 1 (The principles of Training) covers topics including equine anatomy, skeletal maturity, principles of posture, effects of riding on symmetry and asymmetry and the different equine gaits. In this part, the most useful section for Veterinary Physiotherapy here I think is the diagram showing different growth plate closures, this is good diagram to show owners when trying to help them to understand why young horses need time to develop before beginning too much loaded work.

Part 2 (Exercises for Performance) covers the importance of training on different terrains, and how various training techniques such collection work effect the horse both physically and with regards to why you would wish to add this into your training regime. It also covers strengthening exercises such as pole work and jumping exercises.

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Equestrian Pilates Schooling For The Rider Sue Gould-Wright ISBN: 978-1-908809-33-9 J.A Allen This is a useful reference book perhaps for Physiotherapists to suggest to riders should they wish to carry out some basic core stability training independently.The description of transabdominus activation is basic but correct and there are useful descriptions of different postural positions between people. It doesn’t give specific exercises for specific problems, it more lists a variety of low level Pilates exercises that any rider could perform in the yard when with their horse. It also gives awareness to owners of poor postural positioning when mucking out, riding etc. If one is familiar with the APPI method (the Association of Pilates Institute), this book is roughly on a par with the Level 1 APPI method.

Fiona Taylor

Equine Research Digest Kate Davy MCSP ACPAT Cat A Swing phase kinematics of horses trotting over poles

S. Brown, N. C. Stubbs, L. J. Kaiser, M. Lavagnino and H. M. Clayton

Common goals of rehabilitation are to restore full range of movement and strength in horses following lameness or surgery. Previous studies of rehabilitation techniques designed to aid this have shown tactile stimulators and/or pastern weights to increase the elevation of the flight arc of the hoof due to increased stifle, tarsal and metatarsophalangeal flexion. These techniques do not increase swing phase hip flexion however and this is considered important as it determines the range of hindlimb protraction and retraction during trotting. Trotting poles either at ground level or raised are frequently used in both fittening and rehabilitation programmes and yet the gait changes associated with trotting over poles has not yet been described. The aim was to provide evidence-based research that can be applied in developing rehabilitation programme for horses.

What they did 8 sound horses were used in a repeated measures experimental study. Swing phase kinematics were measured using a motion analysis system with skin reflective markers on the horses trotting on level ground, over low (11cm) and high (20cm) poles spaced 1.05± 0.05m apart.

Spatiotemporal stride variables and peak swing phase joint flexion angles were measured and compared using repeated measures ANOVA (P<0.05).

What they found Trotting speed decreased significantly from no poles though to high poles due to increased stride duration. Both forelimb and hindlimb swing durations and suspension increased over poles but stride length was unaffected. The peak heights of both forelimb and hind limb hooves increased significantly from no poles to low poles and low

to high poles. All joints in the fore and hind limbs contributed to this increase in hoof height through swing phase and the clearance was achieved though increases in joint flexion rather than by raising the body higher in the suspension phase of stride. For the hind limb, the markers at the hip and stifle were only slightly elevated when trotting over poles compared to a more marked elevation at markers on the tarsus, MTP ad DIP joints. For the forelimbs the markers over the proximal scapula, shoulder joint and elbow appeared only slightly elevated in swing phase over poles in comparison to markers over the carpus, MCP and DIP joints which showed considerable elevation.

Take home message Trotting over poles produced equivalent amounts of hoof elevation in the forelimbs and hindlimbs with just over a two fold increase over low poles and a 3 fold increase over high poles. By comparison tactile stimulators produced a 3 fold increase in hindlimb hoof height but only a 2 fold increase in forelimb hoof height.

When tactile stimulators and weights were used in conjunction it produced hind limb hoof elevation equivalent to a horse trotting over low poles but notably less than that seen when trotting over high poles. Raised poles are deemed more effective for achieving maximal joint flexions and hoof elevations than the use of tactile stimulators or pastern weights.

The poles were also the only intervention to show a significant increase in hip flexion. A mean increase of 3° was small but thought to be important as it indicated concentric activity in the hip flexor musculature, suggesting the activity may improve hindlimb protraction and retraction.

An advantage to poles over tactile stimulators is the lack of habituation to a normal gait pattern yet a limitation is that joint flexions are only

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achieved during the time over the poles. This study did not investigate any learning effect but it thought possible a similar learning effect may occur in horses as has been evidenced in people walking over obstacles. In horses peak elbow and hip flexion occurs later than in other joints and it is proposed that the contributions of each joint to overall limb flexion may change depending on the proximity to the obstacle at take-off. Further investigation would be needed to see the effects of altering spacing between poles on angles of specific joints but this may show the technique can have more selective therapeutic effects.

Equine Veterinary Journal 2015; (47): 107-112 DOI: 10.1111/evj.12253 Does a magnetic blanket induce changes in muscular blood flow, skin temperature and muscular tension in horses?

A. Edner, L.-G. Lindberg, H. Broström and A. Bergh

Magnetic products are manufactured and promoted for use in animals for disease prevention, muscle soreness, delayed wound healing and pain. The effects of magnets have been investigated on man, rats, mice, rabbits and in a few equine studies but to date there are no studies which confirm the proposed beneficial effects of magnets on back muscle in healthy horses.

What they did The study was a prospective, randomised, blinded placebo controlled cross-over study. 10 horses that did not show initial lameness at trot or react positively to back palpation were used. Four parameters were measured; muscle blood flow using photoplethysmography (PPG), skin temperature using thermistors

and digital infra-red thermography , mechanical nociceptive thresholds (MNT) using pressure algometry and behaviour which was filmed and scored on an ethogram. For 30 minutes baseline recordings were taken before a rug was placed on the horse containing either active static magnets (900 Gauss) or placebo magnets.

Measurements were performed for the 60min treatment period and up to 30min post treatment period. The alternative treatment was performed on the consecutive day.

What they found Blood flow results were available for 6 horses and showed no significant overall difference between groups when each time point was compared.

Skin temperature measurements were available for 9 horses; these increased significantly in both groups during treatment but showed no significant difference between the groups.

Thermography results were available for 7 horses and showed no significant difference in maximum temperature between the two groups at any time point. Pressure algometry was carried out in 8 horses and showed no significant differences in the MNT at the three locations, between the groups or within the groups. 7 horses were filmed for the behavioural study a significant increase in the values for general appearance was seen from pre- treatment to during treatment but no significant difference between the two groups was shown. Magnetic strength readings on the active blanket were between 400 and 900 Gauss and below 20 Gauss for the placebo.

When read at the level of the skin on 3 horses directly under an active magnet it varied from 20-250 Gauss, which increased to approximately 300-400 Gauss when manual pressure was applied.

Take home message For healthy horses wearing a static magnet rug no additional significant effects were seen on muscle blood flow, skin temperature, MNTS or behaviour in comparison with a placebo magnetic rug. The wearing of a rug increases skin temperature due to insulation and this was further enhanced locally under both active

and inactive magnets in some horses.

The study identifies a number of limitations, most significantly the use of non-symptomatic horses and the strength of the static magnet. It is hypothesised that blood flow readings may have been different for tissue in an altered state and that the magnitude of the magnet was limited by the distance from the horse’s skin and presence of the PPG probe between the two. It concludes that further studies are needed in symptomatic horses.

Equine Veterinary Journal 2015; (47): 302-307 DOI: 10.1111/evj.12291 Foot placement of the equine forelimb: Relationship between foot conformation, foot placement and movement asymmetry

A.Wilson, R. Agass, S.Vaux, E. Sherlock, P. Day, T. Pfau and R. Weller Movement asymmetry is thought to lead to asymmetrical loading of the limb with a consequence for performance, injury and lameness. As a result hoof conformation, foot placement and movement asymmetry are often assessed during a lameness examination to gain insight into the nature of the lameness and its potential causes. Variation in foot placement and its relationship to conformation and lameness has been studied in specific horse populations but not to date in a general horse population.

What they did 43 horses both ridden and unridden and shod and unshod were used in an observational cross- sectional study.

Foot conformation was assessed from three views of digital photographs and foot placement was categorised from simultaneous video recordings from two views in both walk and trot. An inertial sensor attached to the horse at the poll to assess head movement was used to assess movement asymmetry.

What they found A geometrically balanced foot was

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rare even when recently trimmed and there were significant differences between left and right forelimbs in 50% of the foot confirmation parameters.

For conformation parameters only dorsal angle and palmer angle were found to have a significant impact on foot placement, with a ‘lateral toe’ placement in trot significantly associated with a more acute dorsal and palmer angle. Foot placement was highly variable between horses and within horses, in walk the most common foot placement in both forelimbs was ‘lateral heel’ and in trot it was ‘lateral’.

No association was found between predominant foot placement of the forelimbs and movement asymmetry in either walk or trot. Five of the conformation parameters were significantly related to movement asymmetry and indicate increasing amounts of movement asymmetry of the head are related with shorter and or narrower hooves.

Take home message A relationship has been shown between foot conformation and movement asymmetry with decreasing hoof width and hoof length related to increasing amount of movement asymmetry in 43 general purpose horses. Foot placement was found to be independent of movement asymmetry and largely independent of conformation parameters. These findings support other studies that found foot placement to remain similar despite trimming and despite the changes in hoof morphology that occur over an 8 week shoeing interval.

Foot placement may be influenced by other foot conformation parameters not measured here or it could be that horses have a preferred foot placement, which overrides any influence of conformation or movement asymmetry.

Equine Veterinary Journal 2016; (48): 90-96 DOI: 10.1111/evj.12378

The Association of Chartered Physiotherapists in Animal Therapy

The Professionals in Animal Physiotherapy

ACPAT SEMINAR 2017

Saturday 18th & Sunday 19th February 2017

Dunchurch Park Hotel & Conference Centre, Rugby Road, Dunchurch, Rugby, Warwickshire CV22 6QW Speakers to include: Canine:

Lowri Davies MRCVS

Richard Whitelock MRCVS

Christoffer Johansen Orthotist & Di Messum ACPAT A Janet Lloyd-Jones MRCVS Equine:

Ollie Crowe MRCVS

Andrew Bowyer AWCF

Jean-Marie Denoix DVM + Plus equipment servicing by Optional Meal with Evening Speaker on the Saturday night, Several Exhibitor stands and chances to win great Raffle prizes!

Programme may change at the discretion of ACPAT

Copyright © The Association of Chartered Physiotherapists in Animal Therapy (ACPAT) 2007 All rights are reserved. Unauthorised copying or use of this information is prohibited.

Email: secretary@acpat.org Website: www.acpat.org ACPAT is a Clinical Interest Group of the Chartered Society of Physiotherapy

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Canine Research Digest Kate Davy MCSP ACPAT Cat A

Effects of Flexion and Extension on the Diameter of the Caudal Cervical Vertebral Canal in Dogs Renato M. Ramos, Ronaldo C. da Costa, Andre L. A. Oliveira, Manoj K. Kodigudla and Vijay K. Goel

The common neurological disease cervical spondylomyelopathy (CSM) has a pathogenesis, which is thought to be multifactorial. Primary developmental abnormalities along with secondary degenerative changes result in vertebral canal stenosis and spinal cord compression. Cord compression can be due to protruding dorsal annulus fibrosis and vertebral body abnormalities and may also be as a result of soft tissue hypertrophic changes at the ligamentum flavum, facet joint capsule or dorsal longitudinal ligament. For dogs with CSM it is proposed that repeated flexion and extension movements could cause intermittent pressures and spinal cord elongation thus having a significant role in the pathogenesis of CSM.The purpose of this study was to quantify changes occurring in the cervical vertebral canal upon flexion and extension and with additional tension and compression forces. Also under investigation were vertebral columns with degenerative changes to see if they showed greater changes in the diameter compared with normal vertebral columns.

What they did 16 canine cervical vertebral columns from mature dogs were used in a biomechanical study. MRI was used to evaluate vertebral morphology and divide specimens into Group 1 (normal vertebral columns) and Group 2 (vertebral columns with intervertebral disc degeneration) Barium sulphate cream was applied to the dorsal longitudinal ligament and ligamentum flavum to outline the ventral and dorsal aspects of the canal.

A custom designed testing apparatus was used to fix and apply moments to

create movements and loads to generate compression and tension.

Fluoroscopy was used to obtain the images and measurements of the sagittal vertebral canal diameters (VCD) were made using a digital imaging software program. Flexion, extension, compression and tension were applied to the caudal cervical region C4-5, C5-6, C6-7. A randomeffects linear regression model was used to analyse the differences between groups under various conditions and to compare all combinations of movement and load for both groups.

What they found For all levels and movements measurements for Group 2 were lower than Group 1 but not significantly, so the results were combined for both groups. With no load the difference in VCD between flexion and extension was 2.2mm (28.9%; P< 0.001). From neutral into extension showed a reduction of 1.5mm (16.5% p<0.001) and neutral into flexion showed an increase of 0.7mm (7.7% P=0.001) in VCD. From neutral with no load to neutral with compression produced a reduction of VCD by 0.5mm (5.5% P =0.006).

When comparing extension without load to extension with tension, an increase in VCD of 0.7mm (9.2% P<0.001) was found.

Take home message A flexed position increases the vertebral canal diameter whereas extension narrows the vertebral canal and these were highly significant changes confirming dynamic movements of the canine cervical vertebral column cause vertebral canal impingement in extension.

Vertebral canal stenosis is a key finding that separates Dobermans with CSM versus those deemed clinically normal and whilst stenosis itself does not lead to the clinical signs of CMS it does reduce the area available for the spinal cord.

Combine this with

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intervertebral disc protrusion and even less diameter is available. It is proposed that the combination of this static stenosis with the dynamic stenosis seen on extension could cause repetitive spinal cord compression, which may result in the development of clinical cervical spondylomyelopathy. Though the reduction in diameter on extension was significant it was not extensive enough to cause spinal cord compression signs in clinically normal dogs, nor did the presence of intervertebral disc pathology change the degree of narrowing. Highlighting the role of several factors in the development of clinical signs of cervical myelopathy.

Surgical management of CSM often uses techniques involving distraction and stabilisation to achieve decompression and the findings of an increase in canal diameter of 0.7mm (9.2% P< 0.001) when extension was applied with tension may explain the clinical improvements seen with these techniques. The study is not without limitations, a small sample number may have resulted in the lack of significance between groups. Biomechanical studies compared to in vivo always have limitations due to the loss of spinal musculature.

A new methodology for measuring vertebral canal diameter was used when previously documented methodology proved unsuccessful. Whilst this appeared more effective and caused less damage to the vertebral column it was not validated before use.

Veterinary Surgery 2015; (44): 459-466 DOI: 10.1111/j.1532950X.2014.12310.x

The Effect of Low-Level Laser Therapy on the Healing of Open Wounds in Dogs

Lindsey M. Kurach, Bryden J. Stanley, Krista M. Gazzola, Michele C. Fritz, Barbara A. Steficek, Joe G. Hauptman and Kristen J. Seymour Low-level laser therapy (LLLT) is now widely used for post-operative pain relief; musculoskeletal injuries, closed incisions and open wounds, yet the effects of this adjunctive therapy remain controversial due to conflicting outcomes from studies.

Variation in methodology due to; laser class, wavelengths, energy density and frequency of treatment together with poor research design have meant the scientific evidence is difficult to interpret. A number of systematic reviews and meta-analyses have been carried out on the studies utilising controls, with sound methodology and consistent outcome variables and conclude that LLLT can modulate wound healing, typically by stimulation.

From these reviews the most effective laser types appear to be krypton, argon and helium neon (HeNe).

Recent wound studies tend to use a HeNe laser or one with a very similar wavelength (635 nm). Lower energy densities (0.5-5J/cm2) have been shown to promote the most stimulatory effects compared to higher energy densities (>10J/cm2) which can cause inhibitory effects.This study aimed to compare the effects of LLLT on open wounds compared to non-LLLT on open wounds and to assess any systemic effect of LLLT on wounds by comparing with historical controls that received no LLLT.

What they did 10 healthy adult male dogs had two 2x2 cm2 full thickness wounds created bilaterally on their trunks.

Each side was randomly assigned to either laser treatment (LAS) or control (CON), three times a week for 32 days. A class II hand held dual diode laser (7.5mW/diode), wavelength 635nm and total energy density of 1.125 J/cm2 was used to administer treatments of 5 minutes duration. Wound planimetry images were used to calculate percentage contraction and epithelialisation and

wound biopsies were taken to analyse histological features.This data was also compared to that from a historical female control group (HCON).

What they found No difference was found between LAS and CON wounds for all parameters.

The HCON wounds had significantly greater contraction and epithelialisation along with significantly more fibroblast infiltration and collagen deposition compared to both LAS and CON wounds. At early wound healing significantly less inflammation was found in LAS and CON in comparison to HCON wounds but this effect was reversed by day 21 with inflammation being significantly higher in LAS and CON. Take home message No clinically significant benefit of LLLT was found on wound healing in healthy dogs. Gender may influence healing in intact dogs as all of the HCON dogs were intact females who displayed significantly superior wound healing.

Whilst gender differences are known to affect healing in rodents and people with superior healing seen in intact females compared to males it has never previously been reported in dogs.

The complete lack of differences between LAS and CON wounds may suggest the protocol was not optimal.

The energy density (1.125 J/cm2) was selected from previous positive studies but may not have been high enough and the shape and location of wound was different to those commonly used. Under consideration is that LLLT is beneficial during the proliferative phase of wound healing but could have an inhibitory effect in the early inflammatory phase.

Decreased inflammation in the first 4 days post injury may result in a prolongation of the inflammatory phase, delaying the proliferative phase and slowing wound healing. The LLLT in this study, administered immediately after wounding, may have modified the cellular processes to delay the onset of the proliferative phase thereby explaining the reduced histological repair scores of CON wounds compared to HCON during the early stages. If LLLT does produce a true

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anti-inflammatory effect this could support its use as a modality for pain control. The authors conclude that further investigations are needed into LLLTâ&#x20AC;&#x2122;s role in wound healing with a focus on optimal delivery protocols.

Veterinary Surgery 2015; (44): 988-996 DOI: 10.1111/vsu.12407 Peak Vertical Force and Vertical Impulse in Dogs With Cranial Cruciate Ligament Rupture and Meniscal Injury

Brandan G.Wustefeld-Janssens, Rob A. Pettitt, Emily C. Cowderoy, Myles B. Walton, Eithne J. Comerford, Thomas W. Maddox and John F. Innes Meniscal injury can occur in almost half of dogs with cranial cruciate ligament (CCL) disease and late meniscal injury has been reported in up to 15% of CCL-deficient stifles post-op.The caudal horn of the medial meniscus has been shown to be a significant stabiliser in the CCL deficit stifle but the excessive cranial tibial translation occurring causes entrapment of the caudal horn between the femoral and tibial condyles. This excessive shear stress to the longitudinal and radial fibres of the meniscus leads to longitudinal tears. Whilst it is accepted that dogs with a displaced caudal horn meniscal injury are painful it is not clear to what extent this adds to joint pain in dogs with CCL disease considering the other contributing elements of synovitis, osteoarthritis and joint instability. There is currently no information on the contribution meniscal injury may have on the degree of lameness in dogs with CCL disease and this studyâ&#x20AC;&#x2122;s aim was to determine the effects of displaced or unstable meniscal injury concurrent with CCL disease on peak vertical force (PVF) and vertical impulse (VI).

What they did Forty client owned dogs referred for unilateral hindlimb lameness and with naturally occurring CCL disease requiring surgery took part in a prospective case series. Each

underwent force plate analysis in the 24hrs pre-surgery, at walking gait with a speed between 1m/s and 1.3m/s and acceleration no greater than Âą0.5m/s2. All dogs had surgery either arthroscopically or via mini arthrotomy during which the menisci were inspected and probed and then categorised as meniscal injury or not.

Meniscal findings were classified as bucket handle, flap, radial, vertical longitudinal, complex or degenerative tears. Dogs were categorised as having meniscal injury if the damaged part was displaced or unstable and was debrided at surgery that is those with bucket handle, flap, capsular detachments and complex tears. Dogs were categorised as not having meniscal injury if the meniscus was normal or the damage present did not require surgery, that is those with radial, stable vertical longitudinal or degenerative tears. The primary outcome was PVF and the secondary outcome was VI. Comparisons were made between dogs with or without meniscal injury and with partial or complete CCL rupture.

What they found Meniscal injury was present in 18 of the 40 dogs (45%, 95%CI 30-60%) all of whom had a displaced complete vertical longitudinal tear (bucket handle tear) of the medial meniscus.

The other 22 dogs had either normal menisci or non-displaced radial tears not requiring treatment. 10 dogs had partial CCL rupture and 30 dogs had complete CCL rupture assessed at surgery, there was no significant association between meniscal injury and CCL status (Fisherâ&#x20AC;&#x2122;s exact test, P=0.08) . No significant associations were found between meniscal injury and contra-lateral hind limb orthopaedic disease, neuter status or drug treatment. Both the PVF (P=.003) and VI (P=.01) were found to be significantly lower in dogs with meniscal injury than in dogs without

Veterinary Surgery 2016; (45): 60-65 DOI: 10.1111/vsu.12419

Take home message These findings support the view that meniscal injury which is unstable or displaced has a significant contribution to the degree of lameness seen in dogs with CCL rupture. They

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recommend menisci should be assessed and probed at the time of surgery and that those menisci which are displaced or unstable should be treated. The way meniscal findings were categorised in this study does not consider that certain meniscal tears such as stable vertical longitudinal could still have an effect on force plate data; however an exvivo study showed the same contact mechanics in both normal menisci and those with stable vertical longitudinal tears suggesting that biomechanically it would still function normally. This combined with other studies findings shows little support for resection of these types of tears as a precaution.

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

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 regardomg 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 as 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 EqUINE VETERINARy JOURNAL

July 2016 Volume 48, Issue 4 Atypical myopathy – insights on pathogenesis (pages 401–402) R. Naylor Version of Record online: 16 JAN 2016 | DOI: 10.1111/evj.12562

Samaras and seedlings of Acer pseudoplatanus are potential sources of hypoglycin A intoxication in atypical myopathy without necessarily inducing clinical signs (pages 414–417) E. Baise, J. A. Habyarimana, H. Amory, F. Boemer, C. Douny, P. Gustin, C. Marcillaud-Pitel, F. Patarin, M. Weber and D.-M.Votion Version of Record online: 6 OCT 2015 | DOI: 10.1111/evj.12499

Equine atypical myopathy caused by hypoglycin A intoxication associated with ingestion of sycamore maple tree seeds (pages 418–421)

A. Żuraw, K. Dietert, S. Kühnel, J. Sander and R. Klopfleisch Version of Record online: 16 JUL 2015 | DOI: 10.1111/evj.12460

Treatment of equine metabolic syndrome: A clinical case series (pages 422–426) R. A. Morgan, J. A. Keen and C. M. McGowan Version of Record online: 18 JUN 2015 | DOI: 10.1111/evj.12445

Bar shoes and ambient temperature are risk factors for exercise-induced pulmonary haemorrhage in Thoroughbred racehorses (pages 438–441)

E. J. Crispe, G. D. Lester, I. D. Robertson and C. J. Secombe Version of Record online: 14 JUL 2015 | DOI: 10.1111/evj.12458

The centrodistal joint interosseous ligament region in the tarsus of the horse: Normal appearance, abnormalities and possible association with other tarsal lesions, including osteoarthritis (pages 457–465) E. Skelly-Smith, J. Ireland and S. Dyson Version of Record online: 14 JUL 2015 | DOI: 10.1111/evj.12457

Lamellar pathology in horses with pituitary pars intermedia dysfunction (pages 472–478) N. P. Karikoski, J. C. Patterson-Kane, E. R. Singer, D. McFarlane and C. M. McGowan Version of Record online: 4 JUN 2015 | DOI: 10.1111/evj.12450

The suspensory apparatus of the distal phalanx in normal horses (pages 496–501) C. C. Pollitt and S. N. Collins Version of Record online: 2 JUL 2015 | DOI: 10.1111/evj.12459

Preliminary data on the effect of osseous anatomy on ex vivo joint mobility in 40

the equine thoracolumbar region (pages 502–508) K. E. Jones Version of Record online: 23 JUL 2015 | DOI: 10.1111/evj.12461

Determination of vertebral range of motion using inertial measurement units in 27 Franches-Montagnes stallions and comparison between conditions and with a mixed population (pages 509–516) C. Heim, T. Pfau,V. Gerber, C. Schweizer, M. Doherr, G. SchüpbachRegula and S. Witte Version of Record online: 14 JUL 2015 | DOI: 10.1111/evj.12455

Movement asymmetry in working polo horses (pages 517–522) T. Pfau, R. S. Parkes, E. R. Burden, N. Bell, H. Fairhurst and T. H. Witte Version of Record online: 21 AUG 2015 | DOI: 10.1111/evj.12467

The effect of acute unilateral inflammation of the equine temporomandibular joint on the kinematics of mastication (pages 523–527) T. T. Smyth, J. L. Carmalt, T. T. Treen and J. L. Lanovaz Version of Record online: 18 JUN 2015 | DOI: 10.1111/evj.12452

Plasma concentrations, analgesic and physiological assessments in horses with chronic laminitis treated with two doses of oral tramadol (pages 528–531) A. Guedes, H. Knych and D. Hood Version of Record online: 21 MAY 2015 | DOI: 10.1111/evj.12448 May 2016 Volume 48, Issue 3

Medial patellar ligament splitting in horses with upward fixation of the patella: A long-term followup (pages 312–314) C. Andersen and A. Tnibar Version of Record online: 26 MAY 2015 | DOI: 10.1111/evj.12435

Head and pelvic movement asymmetry during lungeing in horses with symmetrical movement on the straight (pages 315–320) M. Rhodin, L. Roepstorff, A. French, K. G. Keegan, T. Pfau and A. Egenvall Version of Record online: 29 MAY 2015 | DOI: 10.1111/evj.12446 March 2016 Volume 48, Issue 2

Neuromodulation using percutaneous electrical nerve stimulation for the management of trigeminalmediated headshaking: A safe procedure resulting in medium-term remission in five of seven horses (pages 201–204) V. L. H. Roberts, N. K. Patel and W. H. Tremaine Version of Record online: 8 APR 2015 | DOI: 10.1111/evj.12394 JANUARy 2016 Volume 48, Issue 1

Rater agreement of visual lameness assessment in horses during lungeing (pages 78–82) M. Hammarberg, A. Egenvall, T. Pfau and M. Rhodin Version of Record online: 2 FEB 2015 | DOI: 10.1111/evj.12385

Lungeing on hard and soft surfaces: Movement symmetry of trotting horses considered sound by their owners (pages 83–89) T. Pfau, C. Jennings, H. Mitchell, E. Olsen, A. Walker, A. Egenvall, S. Tröster, R. Weller and M. Rhodin Version of Record online: 18 DEC 2014 | DOI: 10.1111/evj.12374

Foot placement of the equine forelimb: Relationship between foot conformation, foot placement and movement asymmetry (pages 90–96) A. Wilson, R. Agass, S.Vaux, E. Sherlock, P. Day, T. Pfau and R. Weller Version of Record online: 18 DEC 2014 | DOI: 10.1111/evj.12378

Dynamic testing of horseshoe designs at impact on synthetic and dirt thoroughbred racetrack materials (pages 97–102) C. A. Mahaffey, M. L. Peterson, J. J. Thomason and C. W. McIlwraith Version of Record online: 20 JAN 2015 | DOI: 10.1111/evj.12360

A comparison of seven methods for continuous therapeutic cooling of the equine digit (pages 120–124) A. W. van Eps and J. A. Orsini Version of Record online: 2 FEB 2015 | DOI: 10.1111/evj.12384

November 2015 Volume 47, Issue 6

Effect of hoof angle on joint contact area in the equine metacarpophalangeal joint following simulated impact loading ex vivo (pages 715–720) C. A. McCarty, J. J. Thomason, K. Gordon, M. Hurtig and W. Bignell

September 2015 Volume 47, Issue Supplement S48 -Special Issue:

Clinical Research Abstracts of the British Equine Veterinary Association Congress 2015 Head and Pelvic Movement Asymmetries at Trot in Riding Horses Perceived as Sound by Their Owner (pages 10–11) M. Rhodin, A. Egenvall, P.H. Andersen and T. Pfau Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_22

Objective Assessment of Back Kinematics and Movement Asymmetry in Horses: Effect of Elastic Resistance Band Training (page 11) V. Simons, R. Weller, N.C. Stubbs, N. Rombach and T. Pfau Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_23

Thoracolumbar Movement in Sound Horses Trotting in Hand and on the Lunge (page 11)

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L. Greve, S. Dyson and T. Pfau Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_24

What Effect Does Medium and Extended Trot Have on the Kinematics of the Forelimb in Dressage Horses? (pages 12–13) V.A. Walker, C.A. Tranquille, S.J. Dyson, R. Newton and R.C. Murray Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_27

Identification of Disease Specific Metabolic Fingerprints in Early Osteoarthritis (page 13) M. Peffers, C. Riggs, M. Phelan and P. Clegg Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_28

Effects of Time of Day, Ambient Temperature and Relative Humidity on the Repeatability of Infrared Thermographic Imaging in Horses (pages 13–14) G. Satchell, M. McGrath, J. Dixon, T. Pfau and R. Weller Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_30

Proximal Suspensory Desmopathy in Hindlimbs: A Correlative Clinical, Ultrasonographic, Gross Post Mortem and Histological Study (page 15) S. Dyson and M.J. Pinilla Version of Record online: 6 SEP 2015 | DOI: 10.1111/evj.12486_34

JOURNAL OF SMALL ANIMAL PRACTICE

June 2016 Volume 57, Issue6

Short-term outcome and complications of TPLO using anatomically contoured locking compression plates in small/medium-breed dogs with “excessive” tibial plateau angle (pp 305–310) D. C. Barnes, T. Trinterud, M. R. Owen and M. A. Bush Version of Record online: 5 MAY 2016 | DOI: 10.1111/jsap.12486

April 2016 Volume 57, Issue 4

Systematic review of the prevalence, risk factors, diagnosis and management of meniscal injury in dogs: Part 2 (pages 194–204) D. J. McCready and M. G. Ness Version of Record online: 18 MAR 2016 | DOI: 10.1111/jsap.12462 Acute change in neurological level following canine intervertebral disc herniation(page 220) A. Castel and N. J. Olby Version of Record online: 18 MAR 2016 | DOI: 10.1111/jsap.12445 February 2016 Volume 57, Issue 2

Diagnosis and management of meniscal injury in dogs with cranial cruciate ligament rupture: a systematic literature review (pages 59–66) D. J. McCready and M. G. Ness Version of Record online: 27 JAN 2016 | DOI: 10.1111/jsap.12433

December 2015 Volume 56, Issue 12

Chiropractic abnormalities of the lumbar spine significantly associated with urinary incontinence and retention in dogs (pages 693–697) T. R. Thude Version of Record online: 7 DEC 2015 | DOI: 10.1111/jsap.12420

Bilateral calcaneal stress fractures in two cats (pages 417–421) M. Cantatore and D. N. Clements Version of Record online: 30 APR 2015 | DOI: 10.1111/jsap.12358

October 2015 Volume 56, Issue 10 Lumbar paraspinal muscle transverse area and symmetry in dogs with and without degenerative lumbosacral stenosis (pages 618–622) A. L. Henderson, S. Hecht and D. L. Millis Version of Record online: 27 AUG 2015 | DOI: 10.1111/jsap.12385

June 2015 Volume 56, Issue 6 Feeding obese dogs during weight loss is on average cost-neutral (pages 366–369) A. J. German, J. Luxmore, S. L. Holden, P. J. Morris and V. Biourge Version of Record online: 12 FEB 2015 | DOI: 10.1111/jsap.12338

Acknowledgements Thank you to all our Canine and Equine Consultant Editors, many of which are new to the team. We thank you for all your time and your expertise is integral to the professional development of Four Front. ACPAT thanks you for the huge amounts of time you have committed to reviewing all our articles and the excellent feedback you provide.

Thank you.

Canine Articles Mr. Nigel Smith BVetMed CertSAS MRCVS

Equine Articles

Editors

Dr Tracy Crook PhD MSc BSc MCSP ACPAT Cat A tc@chilternvetphysio.com Mrs. Amanda Hemingway MSc BSc MCSP ACPAT Cat A Some of our peer reviewers wished to remain anonymous, but we would just like to acknowledge them for their support, time and efforts in driving our journals standards higher.

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Daisy Collins PgDip BSc MCSP HCPC ACPAT Cat A Fellowes Farm Equine Clinic Ltd Dr Nicola Smith PhD MSc BSc (Physio) ACPAT Cat A Amy Davis PgDip BSc MCSP HCPC ACPAT Cat A Veterinary Physiotherapy Oxfordshire

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, a case study, research project or have a philosophical viewpoint that you would like to express we would love for you to get in touch.

The aim of the magazine is to inform our members about clinical, research and business developments that affect physiotherapist working with animals.

It also provides a channel of communication between ACPAT member by informing and debating all aspects of animal physiotherapy.

We invite you to present material under the following sections: Editorial Product Reviews Literature Reviews Business Related Topics Clinical Articles/ Case Reports Letters to the Editor Research Articles Useful Addresses Conference/ Course Reviews 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 you would like to write, please do not hesitate to contact ACPAT secretary who will pass on your information to the Journal Team.

Email: secretary@acpat.org

Submitting an article

Dates for submission:

Research articles – Dec 2016

Clinical articles/ Case study’s – Dec 2016 Literature Reviews – Dec 2016 Product/ Book/ Course/ Conference reviews – March 2017 Small Adverts/ Useful Addresses/ Useful Tips – March 2017 Please send all articles in electronic form (ideally Microsoft Word) by attaching the file to an email, along with any original photographs to the Editor.

We can accept articles of up to 3,000 words and encourage the use of tables, photographs and illustrations. If the article is longer, please discuss this with the Editor.

Where appropriate, articles must be supported by a reference list using the Harvard style system. In the text quote the authors surname and year of publication. In reference listings 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 pages of the article.

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 also supply your full name, address, telephone number and email address that you would like to be published with your article.

Format and structure of manuscripts

Manuscripts should be headed with the full title of up to 15 words, which should accurately describe the subject matter. Authors should avoid including within the text: the name of the institution at which the work was 43

performed, initials of the authors; and must remove institution names from illustrations in order to maintain anonymity for the review process.

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A title page is required for all manuscript types, it must contain the title of the paper, names and qualifications of all authors, affiliations and full mailing address including email addresses and contact telephone number of the 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.

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Each paper should comprise the following sections: Structured summary – maximum of 200 words, divided, under separate headings, into Objectives, Methods, Results and Clinical significance/ Discussion.

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 – states 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

Reports of single or a small number 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 History – containing clinical detail Discussion – describing the 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 a peer review process and publishing preference will be given to reports of original or retrospective studies.

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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.

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Writing should conform to UK English, and good English useage must be presented within the manuscript.

Where abbreviations are used, the word or phrase must be given in full on the first occasion.

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line the

All units of measurement should be given in the metric system or in SI units. Temperatures should be in °C. Medication should be referred to by their Recommended International Non-proprietary Name, followed by proprietary name and manufacturer in brackets when first mentioned e.g. fenbendazole (Panacur; Intervet).

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

World Association of Veterinary Anatomists, Ithaca, New York.

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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.

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Book, product and course reviews should be between 500 – 700 words long. Book reviews should quote the title, publisher, ISBN number and price of the book.

Points to consider

Try to produce a structured abstract and a list of key messages before you begin, this will assist you in focusing the article around a key point. It will enable the article to be more succinct and focused, therefore more interesting for the reader.

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Try to make the article as concise as possible, think hard about what needs to be in the article to get the message across. Very few articles are longer than 2000 words.

Ensure all references cited for tables and legends are done in sequence at the point where the table or figure is first mentioned within the text.

Finally, check the final copy carefully.

Previous publication

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 physiotherapists.

We may use material on the ACPAT website, if you do not wish for us to publish such information please explain this when submitting your article.

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 ad current e-mail for correspondence. We now aim to publish the corresponding author’s email in every article.

Copyright and exclusive licence

Many publishers traditionally ask authors to assign their copyright, as this allows them to tackle copyright infringement, to republish and reproduce on the 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 licence upon the publication of the article in any medium owned or controlled by ACPAT.

No article, drawing or photograph may be reproduced without prior permission from the Editor.

Corrections

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 a specific correction, please contact the Editor.

Final notes from the Editor

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

The views expressed in 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. Four Front is an annual publication and aims to be published in the autumn 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 contributions that we receive.

Thank you, the Editors.

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DIARY OF EVENTS Date

Event

Location

7-9th October 2016

BVNA Congress

Telford International Centre

12-13th November 2016

Your Horse Live

Stoneleigh Park, Warwickshire

17-18th November 2016

London Vet Show

ExCel London

18-19th February 2017

ACPAT Seminar

6-9th April 2017

BSAVA Congress

Dunchurch Park Hotel & Conference Centre, Dunchurch, Rugby

TBC

Animal Rehab Expo

9-10th June 2017

Vet Festival

Loseley Park, Guildford

13-16th September 2017

BEVA Congress

Liverpool

7-10th September 2016

BEVA Congress

Please see www.acpat.org for further details

The ICC, Broad St, Birmingham

The ICC & Barclaycard Area, Birmingham ExCel, London