Subjective Assessment of the Equine Patient: Difference between revisions

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== Introduction ==
== Introduction ==
Animal physiotherapy is an emerging profession.<ref name=":1">McGowan CM, Stubbs NC, Jull GA. Equine physiotherapy: a comparative view of the science underlying the profession. Equine veterinary journal. 2007 Jan;39(1):90-4.</ref> Physiotherapists who treat human patients are able to use their skills to treat animals. Animal physiotherapists work alongside a multidisciplinary team and usually receive referrals from a veterinarian.<ref name=":1" /><ref name=":4">Paulekas R, Haussler KK. Principles and practice of therapeutic exercise for horses. Journal of equine veterinary science. 2009 Dec 1;29(12):870-93.</ref> Physiotherapists complete a functional assessment to identify pain or loss of function caused by pain, injury, disorders or disability. Animal physiotherapists are now part of the team of professionals that equine athletes and their riders now regularly access.[[File:Gallop.jpg|thumb]] <ref name=":1" />
Equine physiotherapists are now an established part of the multidisciplinary team (MDT) that looks after equine athletes and their riders. Equine therapists work closely with this team and usually receive referrals from a veterinarian.<ref name=":1">McGowan CM, Stubbs NC, Jull GA. Equine physiotherapy: a comparative view of the science underlying the profession. Equine veterinary journal. 2007 Jan;39(1):90-4.</ref><ref name=":4">Paulekas R, Haussler KK. Principles and practice of therapeutic exercise for horses. Journal of equine veterinary science. 2009 Dec 1;29(12):870-93.</ref> The aim of the equine therapist is to conduct a thorough assessment in order to identify pain or loss of function caused by pain, injury, disorders or disability.[[File:Gallop.jpg|thumb]] <ref name=":1" />


== Process of Assessment ==
The following skills are considered useful for equine physiotherapists:<ref name=":6">Goff L. Physiotherapy Assessment for the Equine Athlete. Vet Clin North Am Equine Pract. 2016 Apr;32(1):31-47.</ref>
Equine physiotherapists do not need a pathoanatomic  diagnosis to develop management plans for their patients.<ref name=":4" /><ref name=":6">Goff L. Physiotherapy Assessment for the Equine Athlete. Vet Clin North Am Equine Pract. 2016 Apr;32(1):31-47.</ref> Rather, they approach the assessment from a functional perspective, observing and noting any movement dysfunctions / impairments that may be contributing to a problem, in addition to careful palpation of the horse.<ref name=":6" /> 
 
'''The following skills are considered useful for equine physiotherapists:'''<ref name=":6" /> 
* The ability to communicate well with a horse's owner, handler and trainer  
* The ability to communicate well with a horse's owner, handler and trainer  
* Excellent observation skills (of the horse in motion and at rest)
* Good understanding of the anatomy, functional anatomy, and biomechanics of the horse
* Being able to carry out functional movement tests, having effective palpation skills and being able to interpret the findings of an equine assessment


* Excellent observation skills (of the horse in motion and at rest)
== Subjective Assessment ==
 
When working with horses, the ability to obtain subjective history is limited - it is very difficult to determine the severity, irritability, nature (i.e. SIN) of a condition, its 24- hour pattern and the exact area of pain/ discomfort. [[File:Equine Subjective Assessment.jpg|center|frameless|alt=|400x400px]]The following subjective information can also help the therapist to develop his / her treatment plan:<ref name=":7">Chelin S. Assessment of the Equine Patient Course. Plus , 2021.</ref>
* Good understanding of the anatomy, functional anatomy, and biomechanics of the horse
*'''Background information''': It is important to have background information (age, gender etc) so that you can identify the horse and contact the MDT for information
 
*'''Discipline, training history, the reason for referral:''' These areas provide clues about the type of injury, mechanism of injury and cause of injury (i.e. over-training)
* Being able to carry out functional movement tests, have effective palpation skills and be able to interpret the findings of their assessment
*'''Present medical history:''' It is important to consider what the problem is and how it has been assessed. What treatment has been given thus far and how has the horse responded?
 
*'''Past medical history:''' This provides clues as to whether or not a previous injury may be associated with the horse's current issue. It also indicates what treatments the horse responds to and if the horse has been provided with sufficient rehabilitation
=== Subjective Assessment ===
*'''Special questions /red flags''': These are similar to those seen in [[An Introduction to Red Flags in Serious Pathology|human patients]] such as a sudden weight loss, general health issues, respiratory conditions etc
When working with horses, the ability to obtain subjective history is limited - it is very difficult to determine the severity, irritability, nature (SIN) of a condition, its 24- hour pattern and the exact area of pain/ discomfort. Unlike in human physiotherapy, you cannot interview an equine patient, so the animal therapist often has to interview the wider team to find out all the relevant information, including the:<ref name=":7">Chelin S. Assessment of the Equine Patient Course. Physioplus, 2021.</ref>
[[File:Equine venn diagram.jpg|right|frameless]]
Unlike in human physiotherapy, you cannot interview an equine patient, so the animal therapist often has to interview the wider team to find out all the relevant information, including the:<ref name=":7" />
# Rider - what are they feeling during training?
# Rider - what are they feeling during training?
# Coach - what they are seeing during training?  
# Coach - what they are seeing during training?  
# Owner and Groom - how is the horse at home and has it developed any abnormal behaviours?
# Owner and Groom - how is the horse at home and has it developed any abnormal behaviours?
# Veterinarian and other medical professionals - what was found on examination and other investigations?
# Veterinarian and other medical professionals - what has been found on examination and have there been any other investigations?
All of this information can help the therapist to develop his / her treatment plan.<ref name=":7" />
=== Age ===
* '''Background information''': It is important to have background information (age, gender etc) so that you can identify the horse and contact the MDT for information
Age gives us clues about potential pathologies and should be considered in a differential diagnosis.<ref name=":7" />
* '''Discipline, training history, the reason for referral:''' Provides clues about the type of injury, mechanism of injury and cause of injury (i.e. over-training)
*'''Present medical history:''' Consider what the problem is and how it has been assessed. What treatment has been given thus far and how has the horse responded?
*'''Past medical history:''' This provides clues as to whether or not a previous injury may be causing the horse's current issue. It also indicates what treatments the horse responds to and if the horse has been provided with enough rehabilitation?
*'''Special questions /red flags''': These are similar to those seen in [[An Introduction to Red Flags in Serious Pathology|human patients]] such as a sudden weight loss, general health issues, respiratory conditions ...etc.
These areas will be discussed in further detail below.
==== 1. Age ====
Age gives us clues about potential pathologies and can be considered in a differential diagnosis.<ref name=":7" />
 
===== Young Horses (2-6 years) =====
* Developmental problems i.e. osteochondrosis dissecans<ref>Naccache F, Metzger J, Distl O. Genetic risk factors for osteochondrosis in various horse breeds. Equine Vet J. 2018;50(5):556-63.</ref>
 
* Injuries related to poor motor control to cope with work demands. Still developing soft tissue structures


==== Young Horses (2-6 years) ====
* May present with developmental problems (e.g. osteochondrosis dissecans<ref>Naccache F, Metzger J, Distl O. Genetic risk factors for osteochondrosis in various horse breeds. Equine Vet J. 2018;50(5):556-63.</ref>)
* Young horses are still developing soft tissue structures, so injuries may be related to poor motor control or a lack of adequate conditioning of the soft tissue structures to cope with work demands
* Competing racehorses are under huge stress - young thoroughbred horses have been shown to experience a significant number of physiological and anatomical adaptations in response to exercise training<ref>Miglio A, Cappelli K, Capomaccio S, Mecocci S, Silvestrelli M, Antognoni MT. Metabolic and Biomolecular Changes Induced by Incremental Long-Term Training in Young Thoroughbred Racehorses during First Workout Season. Animals (Basel). 2020;10(2):317.</ref>
* Competing racehorses are under huge stress - young thoroughbred horses have been shown to experience a significant number of physiological and anatomical adaptations in response to exercise training<ref>Miglio A, Cappelli K, Capomaccio S, Mecocci S, Silvestrelli M, Antognoni MT. Metabolic and Biomolecular Changes Induced by Incremental Long-Term Training in Young Thoroughbred Racehorses during First Workout Season. Animals (Basel). 2020;10(2):317.</ref>


===== Mid-Aged Horses (7-15 years) =====
==== Mid-Aged Horses (7-15 years) ====
* Sport horses are often competing at their peak at this age, so soft tissue injuries due to overuse are more common<ref name=":7" /> - ageing and exercise are considered important risk factors for tendon injury<ref>Dakin SG. A review of the healing processes in equine superficial digital flexor tendinopathy. Equine vet. Educ. 2017;29(9):516-20.</ref>
* Sport horses are often competing at their peak at this age, so soft tissue injuries due to overuse are more common<ref name=":7" /> - ageing and exercise are considered important risk factors for tendon injury<ref>Dakin SG. A review of the healing processes in equine superficial digital flexor tendinopathy. Equine vet. Educ. 2017;29(9):516-20.</ref>
* Biomechanical problems can also play a role in soft tissue injuries at this stage
* Degenerative joint disease (DJD) may already be present in some horses at this age especially when the animal has pre-existing developmental joint abnormalities


* Biomechanical problems will also cause soft tissue injuries
==== Older Horses  (15-20 years) ====
 
* Wear and tear is common especially in joints (e.g. DJD / arthritis)
* Degenerative joint disease (DJD) may already be present in some horses at this age
 
===== Older Horses  (15-20 years) =====
* Wear and tear is common especially in joints (i.e. DJD / arthritis)


==== 2. Gender ====
=== Gender ===
Hormonal changes may mimic behavioural changes that are associated with musculoskeletal pain:
Hormonal changes may mimic behavioural changes that are associated with musculoskeletal pain. Common behavioural problems can occur in performance mares when they exhibit heat or oestrus.<ref>Crabtree JR. A review of oestrus suppression techniques in mares. Equine Vet Educ. 2021.</ref> Mares begin periods of heat due to increasing day length. In general, these periods of heat last five to seven days out of a 21-day cycle. Clinical signs of oestrus in mares that can affect performance include attitude changes, tail swishing, difficulty during training sessions, squealing, horsing, excessive urination, kicking, a decrease in performance and colic like pain that is associated with ovulation.<ref>Wessex Equine. Behavioural problems in performance mares. Available from: http://wessexequine.co.uk/wp-content/uploads/2016/07/Hormonal-problems-in-mares-.pdf (accessed 19/4/2021).</ref>
* A common behavioural problem can occur in performance mares when these mares exhibit heat or oestrus.<ref>Crabtree JR. A review of oestrus suppression techniques in mares. Equine Vet Educ. 2021.</ref> Mares begin periods of heat due to increasing day length. In general, these periods of heat last 5 to 7 days out of a 21-day cycle. Clinical signs that affect performance mares include attitude changes, tail swishing, difficulty in training, squealing, horsing, excessive urination, kicking, a decrease in performance, and colic like pain associated with ovulation<ref>Wessex Equine. Behavioural problems in performance mares. Available from: http://wessexequine.co.uk/wp-content/uploads/2016/07/Hormonal-problems-in-mares-.pdf (accessed 19/4/2021).</ref>


* Asking the owner or rider about previous problems with oestrus, or whether there appears to be a regular monthly pattern to the pain or if the mare is experiencing performance-related symptoms can be helpful
Asking the owner or rider about previous problems with oestrus, or whether there appears to be a regular monthly pattern to the pain or if the mare is experiencing performance-related symptoms can be helpful.{{#ev:youtube|l2BeIZzfnBc}}<ref>Kim Hallin. Why are Mares so "Mareish"? Available from: https://www.youtube.com/watch?v=l2BeIZzfnBc [last accessed 21/4/2021]</ref>


==== 3. Length Of Ownership ====
=== Length Of Ownership ===
* During the change of ownership of a horse, it is very rare that all the previous medical history is passed on. We are guided by pre-purchase vetting and unfortunately, not all previous musculoskeletal injuries will be obvious during a vetting<ref name=":7" />
Horses may often change hands a number of times throughout their life. However, during these changes of ownership, it is very rare for a horse's entire medical history to be passed on.<ref name=":0" /> Therapists are guided by pre-purchase vetting but unfortunately, not all previous musculoskeletal injuries will be obvious during these assessments.<ref name=":7" /> One of the most effective methods to identify musculoskeletal pain or discomfort is a horse's behaviour. New owners may not, however, yet know what ‘normal’ behaviour is for their horse.<ref name=":7" />


* One of the most effective methods we have to identify musculoskeletal pain or discomfort is a horse's behaviour. However, new owners may not know what is ‘normal’ behaviour for their horse yet<ref name=":7" />
=== Discipline and Training History  ===
[[File:Horse jumping.jpeg|right|frameless|326x326px]]
'''Discipline and Level -''' It is important to understand a horse's training level, what discipline it competes in or the type of work it does as these factors may affect symptomatology and help establish a diagnosis. They may also provide clues about the mechanism and severity of the injury.<ref name=":7" /><ref name=":0" />


==== 4. Discipline and Training History  ====
'''Last Competition -''' Finding out about a horse's last competition will provide the therapist with an understanding of:<ref name=":7" />
* It is important to understand a horse's training level and what discipline it competes in as these factors will help determine the type of injury /  problem, the mechanism and severity of the injury
* When the horse was (possibly) last put under great strain
* How long the horse has been out of action
[[File:Dressage.jpeg|right|frameless]]
'''Training Programme:''' It is also important to gain an understanding of a horse's training programme. This will enable the therapist to determine how often the horse is working and what it is doing. Questions to consider include:
* Does the horse cross-train?


* Finding out about a horse's last competition will provide the therapist with an understanding of:
* Does it participate in a range of work / activities (e.g. pole work, jumping, flatwork, hill work or track work and hacking)<ref name=":7" />
** when the horse was (possibly) last put under great strain
** how long the horse has been out of action


* It is important to gain an understanding of a horse's training programme. This will enable the therapist to determine how often the horse is working and what are it is doing. Questions to consider include whether or not the horse is cross-training and if it participates in a range of work / activities (e.g. pole work, jumping, flatwork, hill work or track work and hacking)<ref name=":7" />
You may not have access to this history in horses who are newly acquired, but details such as the length of a horse's racing career can provide additional clues about the amount of wear and tear a horse may have experienced.<ref name=":0" />  


==== 5. Present Medical History  ====
=== Present Medical History  ===
It is important to find out:<ref name=":7" />
It is important to establish the general area and nature of a horse's symptoms during a subjective interview.<ref name=":0" /> You will need to find out:<ref name=":7" />
* What the horse's main complaint is
* The horse's main complaint (SIN)
* What behavioural issue has caused the owner to phone an animal therapist (e.g. the horse recently started biting while being tacked up or the horse has stopped wanting to work forward)
* Which behavioural issues have caused the owner to contact an animal therapist
* How long the complaint or issue has been present
* How long the complaint / issue has been present  
* If the veterinarian has seen the horse - were there any investigations, is there a diagnosis and has the horse been prescribed any medications and, if so, for how long?  
** Also find out if it has improved, deteriorated or remained unchanged
* If there is a 24-hour pattern - does the horse worsen or improve with work? Is the horse worse on walking out the stable in the morning? How long does it take for the horse to improve?
* What caused the issue in the owner's opinion - remember that this is entirely subjective as it is based on his / her interpretation of events
* If there are any other professionals involved in the horses's care - what have they done and how have these interventions helped (other professionals might include: saddle fitter, dentist, chiropractor etc).
* Has a veterinarian seen the horse for this issue - and if so, were there any investigations, is there a diagnosis, has the horse been prescribed any medications and, if so, for how long?
* The 24-hour pattern - does the horse worsen or improve with work? Is the horse worse on walking out of the stable in the morning? How long does it take for the horse to improve?
* Which other professionals (e.g saddle fitter, dentist, chiropractor etc) are involved in the horses' care - what have they done and how have these interventions helped?


==== 6. Past Medical History ====
=== Past Medical History ===
Information about a horse's medical history may not always available / accurate, but where possible it is important to know:<ref name=":7" />
Information about a horse's medical history may help you to identify potential presenting conditions, but it is not always available or accurate. Where possible it is important to ask:<ref name=":7" />
* What veterinary treatment the horse has had
* What veterinary treatments have the horse had?
* Was there a pre-purchase vetting?
* Was there a pre-purchase vetting?
* What was picked up on this pre-purchase vetting?
* What was picked up on this pre-purchase vetting?
'''Vetting'''<ref name=":8">Equine World UK. Vetting a horse. Available from: https://equine-world.co.uk/info/buying-loaning-selling-horses/buying-a-horse/vetting-a-horse (accessed 19/4/2021).</ref> is the process where a veterinarian is asked to conduct a comprehensive assessment of a horse, including a general health check, a gait assessment, examination of the horse performing strenuous exercise, and a re-assessment 30 minutes post-exercise and finally another trotting assessment.<ref name=":8" /> During this process, certain problems may be discovered. X-rays may also be taken during more extensive vettings.<ref name=":7" />
'''Pre-purchase vetting''' refers to the comprehensive assessment of a horse by a veterinarian before a horse is purchased. It typically includes a general health check, gait assessment, examination of the horse performing strenuous exercise, a re-assessment 30 minutes post-exercise and finally another trotting assessment.<ref name=":8">Equine World UK. Vetting a horse. Available from: https://equine-world.co.uk/info/buying-loaning-selling-horses/buying-a-horse/vetting-a-horse (accessed 19/4/2021).</ref> X-rays may also be taken during more extensive vettings.<ref name=":7" />
 
The price of the horse often determines if there is vetting and how extensive it is. Some horses (i.e. those with great potential or expensive horses) may be x-rayed every few years as a preventative measure. The equine therapist should also try to find out if a veterinarian has ever recommended any diagnostic tests for a horse that were not actually undertaken as these can provide clues to potential causes of dysfunction.<ref name=":7" />


The price of the horse often determines how extensive a vetting is or if there is even a vetting. Some expensive horses or horses who have great potential will be x-rayed every few years as a preventative measure. It is important to note that while these horses may be asymptomatic, the therapist should still attempt to find out if the horse’s veterinarian ever recommended any diagnostic tests that were not actually undertaken.<ref name=":7" />
{{#ev:youtube|9JDfrYhXw9Y}}<ref>SmartPak. Equine Pre-Purchase Exams. Available from: https://www.youtube.com/watch?v=9JDfrYhXw9Y [last accessed 21/4/2021]</ref>


==== 7. Red Flags ====
=== Red Flags and Special Questions ===
[[File:Points of a horse.jpg|thumb|320x320px]]Red flags are signs or symptoms that suggest serious pathology may be present.<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.</ref>
[[File:Points of a horse.jpg|thumb|320x320px]]Red flags are signs or symptoms that suggest serious pathology may be present.<ref>Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.</ref>
* The horse's general health should be considered, including if there could be:<ref name=":7" />
** Metabolic diseases such as Cushing’s
** Respiratory diseases such as COPD
* Also consider what medications /  supplements the horse may be on. Remember that your subjective assessment should give you an indication of:<ref name=":7" />
** What / where to look for the source of the problem?
** Whether something is not adding up / making sense - this may require a referral
=== Objective Assessment ===
The functional assessment should include:<ref name=":6" />
* Active physiological movements
* Palpation and testing of soft tissues
* Passive physiological joint assessment
* Passive accessory joint assessment
Objective physiotherapy tests in the equine assessment are very much based on functional assessment and palpation skills. The assessment consists of four key elements:<ref name=":7" />
=== Functional Assessment ===
The functional assessment includes an analysis of conformation, gait and a horse's reflexes.
==== Conformation ====
Proper conformation is believed to be important for a horse's balance, power, manoeuvrability and soundness over the lifespan.<ref name=":0">Duberstein KJ. Evaluating horse conformation. Available from: https://extension.uga.edu/publications/detail.html?number=B1400&title=Evaluating%20Horse%20Conformation#Summary (cited 20/4/2021).</ref> It cannot be changed and is usually related to skeletal development. It also includes structural joint alignment.<ref name=":7" /> Conformation is considered one of the most reliable predictors of athletic ability and long-term soundness in most horses<ref name=":0" />
NB: Posture, unlike conformation, can be improved. It is dynamic and related to muscle tone and activation.
To assess conformation and posture:<ref name=":7" />
Observe the horse standing on a flat, firm surface.
* First observe the horse’s natural stance – how is the horse most comfortable standing?
* Now try to make the horse stand as square as possible
View the horse from the left, right, front and rear.
* How easy is it for the horse to stand square/ balanced?
* When the horse is made to stand square, can he/she maintain the posture? Is the muscle development symmetrical? Are the feet balanced? What is the limb alignment like?
{| class="wikitable sortable"
!2. Range of Motion (ROM)
!3. Palpation
!4. Special Tests and Neurological Assessment
|-
|Baited stretches, reflexes, limb ROM
|Temperature, swelling, bony landmarks, musculature
|Neurological tests
|-
|It is very difficult to do an active ROM assessment on most of the joints in isolation. Thus, animal therapists try to assess active ROM during functional movements and then test range passively.
However, baited stretches can be used to test cervical and thoracic
movements, as well as reflex tests
|
|
|-
|
|
|
|}
===== Back Conformation =====
Typically, a horse's back should be 1/3 of its length (from the highest vertebra of the withers to the point of the hip).<ref>Melbye D. Conformation of the horse. Available from: https://extension.umn.edu/horse-care-and-management/conformation-horse#back-1158661 (cited 20/4/2021).</ref> '''Long backed''' horses are generally more flexible, but they are generally weaker<ref name=":0" /> and can be prone to injury as they generally find it harder to work correctly and strengthen their core. '''Short backed''' horses are generally strong, but they are more ridged and can be difficult when fitting saddles as they ”run out” of the thoracic spine.
The following table summarises some common leg conformational faults:<ref name=":7" /><ref name=":0" />
{| class="wikitable sortable"
|+
!
Conformational Faults
!Explanation
!Predisposed issues
|-
|Base Wide
|Standing with forelimbs outside the plumbline
Distance between the hooves is greater than
the distance between centre of thighs;
commonly associated with cow-hocks
|Tend to toe out - this results in more weight being distributed to the medial side of the horse's hoof, which can lead to medial stress on joints, medial splint bone stress
|-
|Base Narrow
|Standing with forelimbs inside the plumbline
Distance between the hooves is less than
the centre of the thighs, heavily muscled
horses (often accompanied by ‘bowlegs’
with hocks too far apart)
|Tend to land on the outside of their hoof wall - can lead to ringbone, lateral sidebone, lateral heel bruises and lateral strain on joints
|-
|Toed Out
|Toes pointing outward
|Inward arc when advancing; results in interference with opposite forelimb especially if combined with base- narrow stance.
|-
|Pigeon Toed
|Toes pointing inward
|Outward deviation of foot during flight (paddling or winging-out) which interferes with the hind limb
|-
|Bowlegged
|Varus deformity of carpus
|Increased tension on the lateral collateral ligament and medial surface of carpal bones
|-
|Knock-Kneed
|Valgus deformity of carpus
|Increased stress on medial carpal collateral ligaments, outward rotation of cannon bone, fetlock and foot
|-
|Camped Out
|Entire forelimb from body to ground is too far forward
|Causes excessive pressure on the horses's hooves, knee and fetlock joints. This stance might be due to conformational defects, but could also indicate hoof pain (e.g. navicular syndrome, laminitis)
|-
|Calf Kneed
|Backward deviation of carpus
|Causes excessive strain on the back ligaments and leg tendons, and pressure on the front of the carpal joint. This means that the horse is more prone to carpal arthrosis, carpal chip fractures, and injuries to the check ligaments
|-
|Camped Under
|Entire limb below elbow placed too far underbody; can occur with a disease as well as be a conformational fault
|Overloading of forelimbs, shortened cranial phase of stride and low arc of foot flight can lead to stumbling
|-
|Buck Kneed
|Forward deviation of carpus; knees knuckle forward, so this conformation is dangerous for the rider
|Distributes pressure unevenly over the leg, so causes strain on sesamoid bones, suspensory ligament, and SDFT and extensor carpi radialis muscle
|-
|Sickle Hocked
|Excessive angulation of the hock (<53)
|High stress on the hock joint and ligaments / tendons. It can result in issues such as curbed hocks, bog spavin (i.e. tarsal hydrarthrosis or tarsocrural effusions<ref>Dar KH, Dar SH, Qureshi B. Bog Spavin and Its Management in a Local Horse of Kashmir-a Case Report. SOJ Vet Sci. 2016;2(1):1-2.</ref>) and bone spavins (i.e. osteoartosis in the distal tarsal joints<ref>Björnsdóttir S, Arnason T, Lord P. Culling rate of Icelandic horses due to bone spavin. ''Acta Vet Scand''. 2003;44(3-4):161-9. </ref>)
|-
|Post Legged
|Opposite to sickle hocked - extremely straight hock angle
|High stress on back of the hock joint and the soft tissue support structures. It can also result in bog and bone spavins
|-
|Cow Hocked
|Medial deviation of the hocks and
accompanied by base wide from hocks
to feet.
|Excessive stress on hock can lead to bone and bog spavins
|}
===== Hoof Conformation<ref name=":0" /><ref name=":5">McIlwraith CW, Anderson TA, Douay P, Goodman NL, Overly LR. Role of conformation in musculoskeletal problems in the racing Thoroughbred and racing quarter horse. In ''Proceedings of the 49th Annual Convention of the American Association of Equine Practitioners, New Orleans, Louisiana, USA, 21-25 November 2003'' (pp. 59-61). American Association of Equine Practitioners (AAEP).</ref> =====
Hoof conformation and the hoof pastern axis may also interfere with more proximal joints and ligaments. The pastern helps to absorb shock when the hoof lands on the ground. It has an impact on the soundness of the entire leg.<ref name=":0" /> The hoof pastern axis refers to an imaginary line which runs from the centre of the fetlock, through the pastern, continuing straight from the coronet to the ground.<ref name=":9">Genius Equestrian. The Importance Of Hoof Pastern Axis And Working Together To Achieve Good HPA. Available from: https://www.geniusequestrian.com/the-importance-of-hoof-pastern-axis-and-working-together-to-achieve-good-hpa/ (cited 20/4/2021).
</ref>
* Normal angle: 48 – 55 degrees
* Sloping angle: 45 degrees or less
* Upright angle: 60 degrees or more<ref name=":9" />
'''Broken back''' occurs when this imaginary line is broken at the coronet through to the ground surface. The hoof angle is less than the pastern angle.<ref name=":9" /> This can cause strain on the tendons and may result in wear on the navicular.
'''Broken Forward''' also occurs when this imaginary line is broken at the coronet through to the ground surface. The hoof is greater than the pastern angle.<ref name=":9" /> This can cause strain on proximal joints.
==== Gait Assessment<ref name=":3">Tabor G, Williams J. Objective measurement in equine physiotherapy. Comparative Exercise Physiology. 2020 Feb 5;16(1):21-8.</ref><ref name=":2">McGowan C, Goff L, editors. Animal physiotherapy: assessment, treatment and rehabilitation of animals. John Wiley & Sons; 2016 May 2.</ref> ====
When performing a gait assessment in hand have the horse:<ref name=":7" />
* Walk away from you, past you and towards you
* Trot away from you, past you and towards you
* Walk in a circle with limbs crossing (turn on the forehand)
* Rein back
* Trot on a circle in both directions (usually on the lunge)
It is important to consider the surface you are examining the horse on as this can influence lameness. As a rule of thumb, soft tissue lameness (i.e. tendons and ligaments) will generally show greater lameness in soft or deep surfaces such as a sand arena. Joint lameness is usually more evident on hard ground. Trotting on bricks or concrete may sometimes assist when assessing lameness as you can better hear the foot-fall rhythm.<ref name=":7" />
===== Grading Lameness =====
There are many types of scales which grade lameness, but as Tabor and Williams note, there is significant variation when veterinarians score lameness.<ref name=":3" /> The most widely accepted grading is the American Association of Equine Practitioners (AAEP) scale.<ref>American Association of Equine Practitioners. Lameness exams: evaluating the lame horse. Available from: https://aaep.org/horsehealth/lameness-exams-evaluating-lame-horse (cited 20/4/2021).</ref>
{| class="wikitable"
!Grades
!Degree of lameness
|-
|Grade 0
|No lameness under any conditions
|-
|Grade 1
|Lameness difficult to observe, not consistently present under any conditions, including weight-bearing, circling on inclines or hard surfaces 
|-
|Grade 2
|Lameness is diffcult to observe at walk or trotting in straight line, but it is consistently present under certain conditions such as weight-bearing or circling on inclines or hard surfaces   
|-
|Grade 3
|Lameness is consistently seen when trotting under all conditions 
|-
|Grade 4
|Lameness is obvious - the horse mobilises with clear head nodding or short stride
|-
|Grade 5
|Lameness is obvious - the horse has minimal weight-bearing in motion or and at rest. or is unable to move
|}
Veterinarians also commonly use the lameness locator to assess lameness. This is a machine which analyses movement through motion sensors. It objectively quantifies how a horse moves through space and bears weight.<ref>Equinosis Lameness Locator. How it works. Available from: https://equinosis.com/veterinarians/#q-analysis (cited 20/4/2021).</ref>
=== Range of Motion (ROM) ===
==== Flexion Test ====
Flexion tests are often performed during a lameness examination to exacerbate any lameness that may be present. The animal's leg is held in a flexed position for around a minute. The horse is then trotted off and its gait is analysed for any abnormalities.<ref>Kaneps AJ. Diagnosis of lameness. In: Hinchcliff KW, Kaneps AJ, Geor RJ, editors. Equine sports medicine and surgery. Second Edition. Edinburgh: Elsevier, 2014. p239-51.
</ref> Applying this sort of pressure to the joint tends to exacerbate problems that may not otherwise be obvious.<ref name=":10">Marshall JF, Lund DG, Voute LC. Use of a wireless, inertial sensor-based system to objectively evaluate flexion tests in the horse. Equine Vet J Suppl. 2012;(43):8-11. </ref> A horse may take a few uneven steps after the test or be lame for several minutes. However, these tests are not specific, its interpretation is subjective and there is a significant amount of variation between observers.<ref name=":10" /> Recalling the baseline level of lameness during both trotting on the lead rope and on the longe line (if appropriate) is crucial to objectively evaluate the results of both flexion tests and diagnostic local anaesthesia. 
==== Active ROM ====
It is very difficult to do an active ROM assessment on most joints in isolation. Thus, equine therapists usually attempt to observe ROM during functional movements and assess passive range in detail. However, baited stretches (i.e. providing a food treat to encourage the horse to move) are used to assess cervical and thoracic movements, as are reflex tests.<ref name=":3" />
==== Reflexes ====
===== Ventrodorsal Lift Reflex (Withers Test) =====
This tests thoracic vertebra flexion. To perform this test:<ref name=":7" />
* Apply a firm pressure with fingernails, pen cap or blunt hoof pick to the midline of the level of the horse's girth. This will cause the horse to ‘lift’ the cranial thoracic region
===== Lateral Reflex =====
This tests lateral flexion. To perform this test:<ref name=":7" />
* Apply a firm pressure with fingernails, pen cap or blunt hoof pick to the bricep femoris line on the contralateral side and around the buttocks. This causes the horse to laterally flex the lumbar and caudal thoracic regions. Consider the horse's ROM
===== Rounding Reflex =====
This tests lumbar flexion. To perform this test:<ref name=":7" />
* Apply a firm pressure with fingernails, pen cap or blunt hoof pick to the caudal border of biceps femurs bilaterally. Ensure you are standing to the side of the horse and beware of being kicked. The horse will flex. Consider the horse's rotation and ROM
===== Extension Reflex =====
This tests lumbar or thoracic extension. To perform this test:<ref name=":7" />
* Stand on a box behind the horse, draw your fingers or two hoof picks caudally along the lumbar/ thoracic paravertebral musculature. Observe for quantity and symmetry of movement
==== Baited Stretches ====
Baited stretches are used to assess active movement of the spine<ref name=":4" /> (cervical and cranial thoracic regions). During these movements, the therapist uses a treat to encourage a movement. Remember to compare both sides for lateral movements.
===== Cervical Spine =====
* Extension - guide the horse's muzzle upwards and forwards with a treat
* Flexion - guide the horse’s muzzle towards its upper chest to effect a nodding movement (at the poll)<ref name=":2" />
===== Caudal Cervical Spine =====
* Flexion - for lower cervical / upper thoracic flexion, guide the horse’s muzzle down between fetlocks (or observe horse grazing – check for even weight distribution between forelimbs); also guide the horse’s muzzle towards the sternum to check mid-cervical flexion<ref name=":2" />
* Lateral flexion.- guide the muzzle around along horse’s lateral trunk towards the flank and compare range side to side
* Lateral flexion / flexion - guide the muzzle around towards the carpal region and compare range side to side.
===== Thoracic Spine =====
It is important to note that when testing the caudal cervical spine, you will get some flexion and lateral flexion of the thoracic spine.<ref name=":7" /><ref>Clayton HM, Kaiser LJ, Lavagnino M, Stubbs NC. Dynamic mobilisations in cervical flexion: Effects on intervertebral angulations. Equine Vet J Suppl. 2010;(38):688-94. </ref>
==== Passive ROM ====
===== Cervical Spine =====
* Extension - guide the muzzle upwards and stabilise with one hand gently over C1. Apply a gentle overpressure from underneath the muzzle. Assess end-feel<ref name=":4" />
* Flexion - guide the muzzle towards the upper chest and stabilise with one hand gently over C1. Apply a gentle overpressure to the front of the muzzle. Assess end-feel<ref name=":4" />
* Rotation - stabilise with one hand over C2 and guide the horse’s muzzle toward you on a rotatory axis. Apply gentle overpressure via the muzzle. Compare range of motion and end-feel side to side<ref name=":4" />
* Lateral flexion - motion at each cervical level between C3–C6 can be assessed by palpating the ‘opening’ of the cervical vertebra when an assistant laterally flexes the horse’s neck away from the assessor. Alternatively, you can stabilise over the vertebral body with one had to effectively ‘block’ motion from the chosen level, and gently guide the horse’s muzzle toward you, in a lateral flexion direction. Apply gentle overpressure and assess range of motion and end-feel. You will need to compare sides<ref name=":7" />


===== Thoracic Spine =====
The horse's general health should be considered, including if there could be:<ref name=":7" />
It is very difficult to assess the passive ROM of the thoracic spine due to deep joint levels, tight connective tissue structures and restrictive facet joint morphology. It is possible to mobilise the wither, but there is very little movement. Some rib springing may be possible depending on soft tissue tone


===== Lumbar Spine =====
* Metabolic diseases such as Cushing’s
* Unilateral dorsal-ventral mobilisations - standing on a tall box or step, apply a gradual downwards force over the transverse process of each consecutive lumbar vertebra. Repeat on the other side.
* Central dorsal-ventral L5 and L6 - standing on a tall box or step, apply a gradual downwards force over the spinous processes of L5 and L6. Horses with pain in this area (usually ligamentous in origin) will dip away from the pressure. Horses who have no pain will show no response (and no movement should be palpable)
* Lateral mobilisations - standing on a tall box, stabilise the lumbar segment above the testing vertebra and grip the dock of the tail with your other hand. Pull gently on the dock towards you and grade the mobs


=== Sacroiliac Joint ===
* Respiratory diseases such as COPD
It is also beneficial to find out what medications /  supplements the horse may be on. Remember that your subjective assessment should give you an indication of:<ref name=":7" />
* The source of the problem
* Whether something is not making sense in the history - this may indicate that a referral is necessary
Horses who require regular treatment by a range of therapists to remain comfortable should:<ref name=":0">Zikmann P. Assessment and Management of the Equine Spine Course. Plus. 2021.</ref>


==== Active Testing ====
* Have a history of being recently reviewed by a veterinarian or should be referred for review in order to check that there are no underlying pathologies
Weight-bearing weight displacement - sand on a box behind the horse (or next to the horse if you suspect he may kick). Palpate the tuber sacrale bilaterally, and have an assistant lift one hindleg. Feel for any cranial shift of the contralateral tub sacrale as the SIJ of the weight-bearing leg assumes close-packed position. Repeat with the other leg.
* Should be reassessed for other causes of pain such as saddle / bridle / bit fit, teeth problems or issues with foot balance


Movement during limb protraction, Stand on a box behind the horse (or next to the horse if you suspect he may kick). Palpating the tuber sacrale bilaterally, have an assistant lift one hind leg and stretch it forward. Feel for a slight caudal shift of the contralateral tub sacrale.
Where possible, it is important to try to corroborate any information obtained from the owner with the relevant professional. You should obtain a history from the horse's veterinarian, as well as consent for you to treat the horse. In instances where a change in the horse's behaviour is the main complaint, it can be useful to talk with the riding instructor in addition to the owner. If it is indicated, it is also useful to communicate with the horse's farrier or dentist in order to hear their opinions on the horse's feet / teeth.<ref name=":0" /> 


==== Passive Testing ====
== Summary ==
Stand on a box or step next to the horse. Apply a slow, repetitive downwards force on the tuber coxae. Feel for reflex muscle guarding in response to the movement. A horse who does not have pain should allow a soft oscillation of the ilium. Compare to the other side. NB movement of the pelvis also causes movement in the lumbar spine and hip, so it is important to carefully observe where the movement is originating.
* It is difficult to obtain a subjective history directly from your equine patients
* You can, however, obtain a significant amount of information by working closely with the horse's entire team, including the coach, rider, owner, groom and veterinarian
* You will structure your [[Objective Assessment of the Equine Patient|objective assessment]] based on your findings in the subjective interview


== References ==
== References ==
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Latest revision as of 11:49, 18 August 2022

Original Editor - Sasha Chelin Top Contributors - Shaimaa Eldib, Jess Bell, Kim Jackson and Tarina van der Stockt

Introduction[edit | edit source]

Equine physiotherapists are now an established part of the multidisciplinary team (MDT) that looks after equine athletes and their riders. Equine therapists work closely with this team and usually receive referrals from a veterinarian.[1][2] The aim of the equine therapist is to conduct a thorough assessment in order to identify pain or loss of function caused by pain, injury, disorders or disability.

Gallop.jpg

[1]

The following skills are considered useful for equine physiotherapists:[3]

  • The ability to communicate well with a horse's owner, handler and trainer
  • Excellent observation skills (of the horse in motion and at rest)
  • Good understanding of the anatomy, functional anatomy, and biomechanics of the horse
  • Being able to carry out functional movement tests, having effective palpation skills and being able to interpret the findings of an equine assessment

Subjective Assessment[edit | edit source]

When working with horses, the ability to obtain subjective history is limited - it is very difficult to determine the severity, irritability, nature (i.e. SIN) of a condition, its 24- hour pattern and the exact area of pain/ discomfort.

The following subjective information can also help the therapist to develop his / her treatment plan:[4]

  • Background information: It is important to have background information (age, gender etc) so that you can identify the horse and contact the MDT for information
  • Discipline, training history, the reason for referral: These areas provide clues about the type of injury, mechanism of injury and cause of injury (i.e. over-training)
  • Present medical history: It is important to consider what the problem is and how it has been assessed. What treatment has been given thus far and how has the horse responded?
  • Past medical history: This provides clues as to whether or not a previous injury may be associated with the horse's current issue. It also indicates what treatments the horse responds to and if the horse has been provided with sufficient rehabilitation
  • Special questions /red flags: These are similar to those seen in human patients such as a sudden weight loss, general health issues, respiratory conditions etc
Equine venn diagram.jpg

Unlike in human physiotherapy, you cannot interview an equine patient, so the animal therapist often has to interview the wider team to find out all the relevant information, including the:[4]

  1. Rider - what are they feeling during training?
  2. Coach - what they are seeing during training?
  3. Owner and Groom - how is the horse at home and has it developed any abnormal behaviours?
  4. Veterinarian and other medical professionals - what has been found on examination and have there been any other investigations?

Age[edit | edit source]

Age gives us clues about potential pathologies and should be considered in a differential diagnosis.[4]

Young Horses (2-6 years)[edit | edit source]

  • May present with developmental problems (e.g. osteochondrosis dissecans[5])
  • Young horses are still developing soft tissue structures, so injuries may be related to poor motor control or a lack of adequate conditioning of the soft tissue structures to cope with work demands
  • Competing racehorses are under huge stress - young thoroughbred horses have been shown to experience a significant number of physiological and anatomical adaptations in response to exercise training[6]

Mid-Aged Horses (7-15 years)[edit | edit source]

  • Sport horses are often competing at their peak at this age, so soft tissue injuries due to overuse are more common[4] - ageing and exercise are considered important risk factors for tendon injury[7]
  • Biomechanical problems can also play a role in soft tissue injuries at this stage
  • Degenerative joint disease (DJD) may already be present in some horses at this age especially when the animal has pre-existing developmental joint abnormalities

Older Horses (15-20 years)[edit | edit source]

  • Wear and tear is common especially in joints (e.g. DJD / arthritis)

Gender[edit | edit source]

Hormonal changes may mimic behavioural changes that are associated with musculoskeletal pain. Common behavioural problems can occur in performance mares when they exhibit heat or oestrus.[8] Mares begin periods of heat due to increasing day length. In general, these periods of heat last five to seven days out of a 21-day cycle. Clinical signs of oestrus in mares that can affect performance include attitude changes, tail swishing, difficulty during training sessions, squealing, horsing, excessive urination, kicking, a decrease in performance and colic like pain that is associated with ovulation.[9]

Asking the owner or rider about previous problems with oestrus, or whether there appears to be a regular monthly pattern to the pain or if the mare is experiencing performance-related symptoms can be helpful.

[10]

Length Of Ownership[edit | edit source]

Horses may often change hands a number of times throughout their life. However, during these changes of ownership, it is very rare for a horse's entire medical history to be passed on.[11] Therapists are guided by pre-purchase vetting but unfortunately, not all previous musculoskeletal injuries will be obvious during these assessments.[4] One of the most effective methods to identify musculoskeletal pain or discomfort is a horse's behaviour. New owners may not, however, yet know what ‘normal’ behaviour is for their horse.[4]

Discipline and Training History[edit | edit source]

Horse jumping.jpeg

Discipline and Level - It is important to understand a horse's training level, what discipline it competes in or the type of work it does as these factors may affect symptomatology and help establish a diagnosis. They may also provide clues about the mechanism and severity of the injury.[4][11]

Last Competition - Finding out about a horse's last competition will provide the therapist with an understanding of:[4]

  • When the horse was (possibly) last put under great strain
  • How long the horse has been out of action
Dressage.jpeg

Training Programme: It is also important to gain an understanding of a horse's training programme. This will enable the therapist to determine how often the horse is working and what it is doing. Questions to consider include:

  • Does the horse cross-train?
  • Does it participate in a range of work / activities (e.g. pole work, jumping, flatwork, hill work or track work and hacking)[4]

You may not have access to this history in horses who are newly acquired, but details such as the length of a horse's racing career can provide additional clues about the amount of wear and tear a horse may have experienced.[11]

Present Medical History[edit | edit source]

It is important to establish the general area and nature of a horse's symptoms during a subjective interview.[11] You will need to find out:[4]

  • The horse's main complaint (SIN)
  • Which behavioural issues have caused the owner to contact an animal therapist
  • How long the complaint / issue has been present
    • Also find out if it has improved, deteriorated or remained unchanged
  • What caused the issue in the owner's opinion - remember that this is entirely subjective as it is based on his / her interpretation of events
  • Has a veterinarian seen the horse for this issue - and if so, were there any investigations, is there a diagnosis, has the horse been prescribed any medications and, if so, for how long?
  • The 24-hour pattern - does the horse worsen or improve with work? Is the horse worse on walking out of the stable in the morning? How long does it take for the horse to improve?
  • Which other professionals (e.g saddle fitter, dentist, chiropractor etc) are involved in the horses' care - what have they done and how have these interventions helped?

Past Medical History[edit | edit source]

Information about a horse's medical history may help you to identify potential presenting conditions, but it is not always available or accurate. Where possible it is important to ask:[4]

  • What veterinary treatments have the horse had?
  • Was there a pre-purchase vetting?
  • What was picked up on this pre-purchase vetting?

Pre-purchase vetting refers to the comprehensive assessment of a horse by a veterinarian before a horse is purchased. It typically includes a general health check, gait assessment, examination of the horse performing strenuous exercise, a re-assessment 30 minutes post-exercise and finally another trotting assessment.[12] X-rays may also be taken during more extensive vettings.[4]

The price of the horse often determines if there is vetting and how extensive it is. Some horses (i.e. those with great potential or expensive horses) may be x-rayed every few years as a preventative measure. The equine therapist should also try to find out if a veterinarian has ever recommended any diagnostic tests for a horse that were not actually undertaken as these can provide clues to potential causes of dysfunction.[4]

[13]

Red Flags and Special Questions[edit | edit source]

Points of a horse.jpg

Red flags are signs or symptoms that suggest serious pathology may be present.[14]

The horse's general health should be considered, including if there could be:[4]

  • Metabolic diseases such as Cushing’s
  • Respiratory diseases such as COPD

It is also beneficial to find out what medications / supplements the horse may be on. Remember that your subjective assessment should give you an indication of:[4]

  • The source of the problem
  • Whether something is not making sense in the history - this may indicate that a referral is necessary

Horses who require regular treatment by a range of therapists to remain comfortable should:[11]

  • Have a history of being recently reviewed by a veterinarian or should be referred for review in order to check that there are no underlying pathologies
  • Should be reassessed for other causes of pain such as saddle / bridle / bit fit, teeth problems or issues with foot balance

Where possible, it is important to try to corroborate any information obtained from the owner with the relevant professional. You should obtain a history from the horse's veterinarian, as well as consent for you to treat the horse. In instances where a change in the horse's behaviour is the main complaint, it can be useful to talk with the riding instructor in addition to the owner. If it is indicated, it is also useful to communicate with the horse's farrier or dentist in order to hear their opinions on the horse's feet / teeth.[11]

Summary[edit | edit source]

  • It is difficult to obtain a subjective history directly from your equine patients
  • You can, however, obtain a significant amount of information by working closely with the horse's entire team, including the coach, rider, owner, groom and veterinarian
  • You will structure your objective assessment based on your findings in the subjective interview

References[edit | edit source]

  1. ↑ 1.0 1.1 McGowan CM, Stubbs NC, Jull GA. Equine physiotherapy: a comparative view of the science underlying the profession. Equine veterinary journal. 2007 Jan;39(1):90-4.
  2. ↑ Paulekas R, Haussler KK. Principles and practice of therapeutic exercise for horses. Journal of equine veterinary science. 2009 Dec 1;29(12):870-93.
  3. ↑ Goff L. Physiotherapy Assessment for the Equine Athlete. Vet Clin North Am Equine Pract. 2016 Apr;32(1):31-47.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Chelin S. Assessment of the Equine Patient Course. Plus , 2021.
  5. ↑ Naccache F, Metzger J, Distl O. Genetic risk factors for osteochondrosis in various horse breeds. Equine Vet J. 2018;50(5):556-63.
  6. ↑ Miglio A, Cappelli K, Capomaccio S, Mecocci S, Silvestrelli M, Antognoni MT. Metabolic and Biomolecular Changes Induced by Incremental Long-Term Training in Young Thoroughbred Racehorses during First Workout Season. Animals (Basel). 2020;10(2):317.
  7. ↑ Dakin SG. A review of the healing processes in equine superficial digital flexor tendinopathy. Equine vet. Educ. 2017;29(9):516-20.
  8. ↑ Crabtree JR. A review of oestrus suppression techniques in mares. Equine Vet Educ. 2021.
  9. ↑ Wessex Equine. Behavioural problems in performance mares. Available from: http://wessexequine.co.uk/wp-content/uploads/2016/07/Hormonal-problems-in-mares-.pdf (accessed 19/4/2021).
  10. ↑ Kim Hallin. Why are Mares so "Mareish"? Available from: https://www.youtube.com/watch?v=l2BeIZzfnBc [last accessed 21/4/2021]
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Zikmann P. Assessment and Management of the Equine Spine Course. Plus. 2021.
  12. ↑ Equine World UK. Vetting a horse. Available from: https://equine-world.co.uk/info/buying-loaning-selling-horses/buying-a-horse/vetting-a-horse (accessed 19/4/2021).
  13. ↑ SmartPak. Equine Pre-Purchase Exams. Available from: https://www.youtube.com/watch?v=9JDfrYhXw9Y [last accessed 21/4/2021]
  14. ↑ Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.
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