REST, REPAIR, REHABILITATE or...replace?
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By Jay Merriam DVM, MS ........................................................................................................................................... he injured working horse can present an Diagnostic Dollars unpleasant series of decisions. In my early years of practice, we often turned to “Dr. Green”, (pasture therapy) for the hoped for results after some sort of a major leg or body injury. And many times, come spring, the once hobbling worker would show up looking sound and slick after his winter vacation. Problem was that we often knew less about his health after he came back than we did before we let him out. And we had no idea if the work ahead would be tolerable or just a short term respite from what he’d had. Of course, back then we rarely had more than a vague idea in the beginning of the specifics of the injury…hmmm. “Curb” splint ,Nope front tendon? Hock? Pins? Whatever. The terms we had to learn from the old vet books,” wind gall” , smudge, hip bound, stifled.. were pretty vague and known to only a few old timers. We’d be told of various toxic rubs, blisters or injections to memorize and produce and how to use them. And since pasture time was cheap and readily available as was replacement horseflesh, often there was no better alternative. Those days are gone! Let’s do the math. Better diagnosis…. this is the key. Knowing the very deep specifics of the injury and it’s extent can lead to a better understanding of appropriate therapies with proper outcome the result. This then leads us to several aspects of the costs involved i.e. does surgery need to be done? With rest following. or some other invasive therapy? shoeing then a program of rehabilitation? or can we go straight to some sort of rehab/ physical therapy? Will there be a need for long-term therapy or can we expect full healing and return to function? Once we have an idea of these things, we can start to cost it out. Are we looking at a cost in rest time (which should be expressed as per diem), or a cost in lost work? or cost of (and this is usually the big one) knowledge, training, compatibility and continued work at a high level? Or is the outlook so bad that we consider retirement or even euthanasia from a welfare perspective? We’re not replacing a set of bad tires on a truck, we have to consider a lot of factors and moving, living parts before we can make a decision. And usually, with severe injuries acquired while working at a high level the pressure is on to repair and restore a good horse, not junk him and run to the sales. In the Internet age, Dr. Google has replaced Dr. Green for the most part. Once your vet has uttered the words of a possible range of diagnoses, Dr. Google or Wickipedia can cut through the babble and start you down a road.. Unfortunately, consulted too early it is often the wrong one, because it takes the literal diagnosis and goes directly to the Worst Case scenario. This has led to the early demise of some very salvageable animals in my experience over the last 45 years and is unfortunately a pretty common approach by an owner who stops on the diagnostic path too soon e.g there’s a huge difference between Superficial Digital tendinitis and Superficial and deep digital tendinopathy with involvement of superior check ligament desmitis. We need to be very clear on the diagnosis before we start writing checks since not much of what I’m going to talk about is covered by insurance (But that may be changing).
80 Working Horse Magazine 2018 December
This is where, at least up front, you will get the most bang for the buck. And now it’s pretty easy to find someone or a wellequipped clinic that can help refine the diagnosis to the point of getting the answers that will allow us to make decisions. Lets look at some of the things that need to be considered in decision making. 1.Physical Diagnosis by a skilled clinician familiar with your discipline is still the number one choice: hands on, eyes open and listening carefully are the hallmarks to look for. Localization by nerve blocks is critical in many cases, but not always possible or necessary. 2.Appropriate imaging. This is simply the use of digital Ultrasound/x-ray after localization. Once read, further images may be needed via CT or MRI or Bone Scan. No matter which one is used, interpretation by someone in the field is critical. 3.Appropriate immediate therapy i.e surgical removal or repair of bony lesions. Cast or splint application, corrective or supportive shoes or appliances (hospital plates, wooden shoes, slings or other support as needed). 4.Rehabilitation/PT according to a clear plan with a qualified team. Look at long-term prognosis, available facilities, finances and even insurance (loss of use etc). 5.Go in with realistic expectations and humane or welfare considerations in mind. Once we’ve gone down this list it is decision time, and no doubt finances must enter the picture here. Factors include; replacement cost, work time income lost, training of a new horse or re-training of the injured one. And who is going to supervise, where is the nearest facility and what do you look for as far as credentials? Certifications: ACVSMR (American College of Veterinary Sports Medicine and Rehabilitation) is a newer group formed for just this reason, made up of individuals who are practicing Equine Sports Medicine and have gone on to get further training in the various types of diagnosis and rehabilitation available. They can do everything from PT to stem cell and regenerative therapy to supervising exercise programs on underwater treadmill, oscillating floors, laser, infra-red, and much more. Facilities: These are sometimes hospital based as this one in Europe (Equitom.com). Weatherford Equine, TX, Colorado State University Equine Sports Medicine, Myhre Equine Clinic New Hampshire. Others are independent but available to vets of your choice to prescribe appropriately; The Otherside ranch (tosranch.com) Snowmass, CO. Turner Equine, Minnesota. (Specialty diagnosis with Thermal imaging and surgical services) To name just a few.
Treatment Modalities available, a partial list. Underwater treadmills have been a part of equine therapy for many years, but the latest models provide a wider therapeutic range and a lot of science based information to their use. One of the big considerations during rehab is “load”. How much weight is appropriate for how long? does concussion help or
