Ask The Vet: Equine Rehabilitation - February 08

Typical approaches to rehabiliation for post-colic surgeries vary nationwide and also depend on surgeon preference. General programs involve 30 days of stall rest immediately postop, followed by 30 days of small or medium sized paddock turnout, then followed by an additional 30 days of pasture rest. After this 90 day postop period, general recommendations include slow gradual return to an exercise program.

Depending on the age and physical nature of the horse at this 90 day period post operatively, it could take anywhere from one to three months to return a horse to its original fitness or physical level. One would take the approach they initiated when training the horse for its original particular use when returning after colic surgery. During the 90 day postop graduated turnout program, this allows those individuals that have lost a significant amount of weight post-operatively to hopefully return to a positive energy balance and gain some weight, returning to their original weight pre-colic surgery. This 90 day postop period also allows adequate time for the exploratory celiotomy incision (colic incision) to heal appropriately and hopefully avoid incisional complications such as hernias or partial dehiscence.

Rehabilitation includes this 90 day postop period with minimal exercise period and also includes the post 90 day period of a graduated exercise program. The horse again, will dictate how long the graduated exercise program will take in order to return the individual to its original fitness or activity level.

I'm not sure we can obtain the correct answer for the horse from your description, however, we can cover a few scenarios. In general, horses that appear to be more uncomfortable during cold weather (i.e. become worse during colder months of the year) potentially happen for two fold
reasons: 1. cold weather affects osteoarthritis of joints just as it does in humans and 2. during these colder months, owners allow their horses stall confinement in order to allow for more comfortable environment from the cold weather conditions. Both of these scenarios can lead an older horse with osteoarthritis to have similar symptoms as you describe in your horse. So, the first question we need to ask ourselves, is the change in your horse's behavior due to his previous laminitic episode or does he have other cause or causes of lameness/discomfort?

When you turn your horse out during the warmer months, does he do better and get around much more comfortable and reliable than his current situation? If so, this would be an additional indicator that something else may be going on with your horse. Generally, laminitic patients are uncomfortable in any environment they are placed, but actually tend to better on soft ground in a stall environment. This in contrary to arthritic equine patients who do better, just like human patients with arthritis do better, when they have consistent exercise or the ability to move about more often in pasture-like environments.

These two very different disease processes can be sorted out by having your equine veterinarian evaluate your horse and using physical exam, hoof tester and diagnostic anesthesia techniques to identify the causitive agent. Diagnostic radiographs may also shed light on possible arthritic changes at different locations within the equine distal limb, as well as evaluate the current status of the coffin bone located within the hoof capsule (evaluate previous founder/laminitic episode for a more active/acute stage). A diagnostic thorough evaluation, by your veterinarian, should answer these questions for you and provide better quality patient care for your horse. Laminitic horses generally have elevated digital pulses, warm feet to the touch and are sore to hoof testers around the solar toe region. Patients with osteoarthritis of any or one particilar joint, generally, do not exhibit extremely elevated digital pulses and warm feet. Hoof tester examination in arthritic patients generally does not exhibit positive symptoms over the solar toe region, but may respond positively in other areas located of the hoof (i.e.: central third of the frog in some navicular syndrome cases). Again, your veterinarian will be helpful in sorting these questions out and allowing you to more objectively provide a better lifestyle for your horse.

In regards to your mare's condition around foaling time, it is always good to have the individual at hand in better shape than not! This same concept goes for human patients as well. If we feel better, things in general are more likely to go better and the recovery process is easier.

All that being said, complications can and do happen no matter what the condition is of the mare during foaling time (ie: abortion or dystocia).

It sounds like your mare is recovering well from colic surgery post-operatively. Post-operatively or recently, have you had an examination to evaluate the fetus' viability (rectal exam for movement or fetal heart rate)? One wouldn't expect any horse to bounce back immediately from a major surgery such as colic surgery. In general, post-operative colic patients receive 90 to 120 days off of exercise with graduated amounts of turnout during this time. After this time period, it generally takes several months to get a horse back into shape following this dramatic event. So, it sounds like your mare is right on track. One thing to maybe consider is cutting back as you had suggested and evaluating her recovery or behavior with the shorter, more frequent pony trips. If she responds better, stick with this schedule for a period of time, before gradually increasing interval and time periods. If she appears to do the same, it might suggest that this is her normal response while carrying a fetus and trying to get herself back in shape. It may just take a little longer than usual.

The following website:
http://lacs.vetmed.ufl.edu/Infection_Control/index.htm, addresses common concerns regarding Salmonella in the environment and specifically in relation to the equine patient. It covers various ranges of topics including environemental conerns, individual patient contact and spreading or passing of the agent, as well as preventative measures for your own horse. See below:

What is Salmonella?
Salmonella is a type of bacteria that can cause intestinal disease (eg,
diarrhea) in horses, cattle, sheep, goats, llamas, dogs, cats, birds and humans just to name a few.

Can horses have Salmonella and not be sick?
Yes. Published studies have found that as many as 20 percent of healthy horses shed Salmonella bacteria in their manure. It is possible that a horse with Salmonella in its feces may show clinical signs if the organisms multiply and increase in number. This over-growth usually occurs in times of stress (eg, transportation, illness, summer months). Nevertheless, in a hospital we must assume that all horses shedding Salmonella pose a potential risk to other patients and to people until proven otherwise. A component of our Infection Control Program is typing of the particular strain of Salmonella, as some strains are known to be more likely to produce disease.

Can people be infected with Salmonella from animals?
Yes. Any human is at risk and there should be an effort to minimize exposure to contaminated animals shedding the organisms and the environment (eg, stalls). Young children and immune-compromised people may have less functional immune systems than other people and may be more likely to become ill if infected with Salmonella. Consequently, it is essential to prevent them from being exposed to animals or humans with Salmonella.

How do horses get Salmonella?
Horses may acquire the bacteria from other horses and other animals. Transmission is by the feco-oral route, which means manure from one animal (not necessarily a horse) was ingested. Horses may pick up Salmonella from the pasture, feed or water sources when the feces of other animals (including birds and other horses) are in these sources.

What are the signs of Salmonella in horses?
Signs may vary. While one animal may seem apparently normal, another may have severe illness that could lead to death. Horses sick with Salmonella may be referred to as having salmonellosis. Diarrhea, which can range from cow-pie manure to watery diarrhea, is a common sign. Horses may exhibit signs of colic (especially before they break with diarrhea), tenesmus (straining to defecate) and shock. Sometimes Salmonella can get into the circulatory system (the blood stream) and go to many different organs, including the liver, lungs, joints, lining of the spinal cord and brain, and others. This can cause many different problems and clinical signs. If there are questions regarding these signs, please contact your veterinarian.

What are the signs of Salmonella in other animals, including humans?
These may vary from being apparently normal to showing severe gastrointestinal disease, such as abdominal pain, diarrhea, vomiting and cramps. Consult your physician if you have these signs.

How is Salmonella diagnosed?
The most common diagnostic test is culturing a manure sample in a laboratory. Blood and other tissues can also be sampled. Culture results may take two to five days from when the sample is received at the laboratory. Fecal cultures can be negative in horses with salmonellosis, but it has been shown that culturing serial samples increases the probability of finding Salmonella when it is present. The usual protocol is once per day for five days.

What is the treatment for Salmonella?
Treatment varies with the severity of salmonellosis, ranging from no treatment to intensive medical care in a referral hospital. Treatment may include intravenous fluid therapy (for the shock and to replace fluid losses from diarrhea), antibiotics (to support the horses system while its immune system responds), non-steroidal anti-inflammatory drugs (eg, Banamine* to reduce signs of shock) and plasma (to provide protein to replace fluid losses in the diarrhea and to reduce signs of shock etc).

What is the prognosis (expected outcome) of Salmonella?
The prognosis varies with the case. Some horses may have Salmonella and never show clinical signs. Other can become sick and require intensive therapy. Some sick horses may die suddenly despite intensive therapy.

Should I have an infection control program on my farm?
Yes. Many of the principles in place at the University of Florida Large Animal Veterinary Medical Center would apply to infection control at other hospitals and even on farms. While a farm-program need not be as extensive as that in a hospital, some method of isolating new additions and ill horses is advisable. New horses introduced to a barn should be isolated for approximately two to three weeks to minimize the chance of spread of disease. This time also allows monitoring of the new horses manure to ensure that it is not soft or watery. New horses (even if they are isolated correctly) may still have Salmonella in their intestine and may later shed it if stressed for a number of reasons.

Ideally, horses identified by fecal culture to be shedding Salmonella should be isolated from the rest of the horse population (ie, horse, foal, pony, donkey, mule any equine) and possibly other animal populations. General guidelines are to isolate the horses for six to 12 months. Isolation means that the horse has its own separate area and equipment. Manure and straw from the horses stall should be disposed in a landfill facility and not spread on the pasture.

Humans should exercise great care to minimize exposure. Horses may shed Salmonella for a variable time, unfortunately we cannot predict how long this will be. Hygiene is important for people managing the isolated horse. Frequent hand washing is critical, while gloves and protective clothing are recommended. Do not let other animals (eg, dogs and cats), children or the elderly have contact with the isolated horse.

Isolation for this length of time is often impractical, most owners and trainers find facilities in which a horse can be isolated for one to three months and then have their veterinarian submit a manure sample for culture once daily for five days. If these cultures are negative for Salmonella, then there is a lower likelihood that the horse is actively shedding, and it is probably (although this can no be guaranteed) a low risk to bring the horse out of isolation. If the horse's fecal culture proves to be positive, it should remain in isolation and be re-tested the following month.

Currently, there is no restrospective data evaluating those individual horses that have recieved ligament splitting to correct intermittent upward fixation of the patella.

The procedure of splitting the medial patellar ligament gained popularity a few years ago over the previous described technique of completely transecting the medial patellar ligament. A previous study described in the literature, warranted against completely transecting the medial patellar ligament, due to the fact that some horses in an experimental study evaluating this technique developed problems associated with the patella itself post-operatively.

Currently, the technique of choice for this reason is first, splitting the medial patellar ligament. Of course, there are a group or number of horses that do not respond to this procedure. If the individual continues to show effects from upward fixation of the patella after receiving the initial splitting technique, with careful discussion with your regular veterinarian, a complete transection may be warranted.

This is assuming the original diagnosis is still correct and the owner is willing to accept the risks or complications associated with completely transecting the medial patellar ligament itself. Anecdotal evidence of splitting the medial patellar ligament, combined with appropriate physical therapy (i.e. increasing levels of daily exercise, riding or exercising up and down elevated areas or hills), appear to suggest a prognosis of approximately 80-90 percent success. If increasing levels of exercise has not improved the condition, it seems plausible with consultation with your veterinarian, that the tendon splitting procedure would possibly be the next natural choice.

On a side note, there are some veterinarians and owners who elect to place their horse on various regimens of estrone sulfate intramuscular injections to evaluate for possible improvement of this common musculoskeletal condition. The mechanism of action is still unknown for this procedure, however positive results have been suggested. The only drawback to this procedure is sometimes this requires continued intramuscular injections verses the surgical procedure. Still, some individual owners and veterinarians use this treatment option as a sort of trial to evaluate if a horse will improve for future potential use. Again, its mechanism of action is unknown and there is no documented literature stating its positive effects.

See below response attached from another owner question:

Currently there is no restrospective data evaluating those individual horses who have recieved ligament splitting to correct intermittent upward fixation of the patella. The procedure of splitting the medial patellar ligament gained popularity a few years ago over the previous described technique of completely transecting the medial patellar ligament. A previous study described in the literature, warranted against completely transecting the medial patellar ligament, due to the fact that some horses in an experimental study evaluating this technique developed problems associated with the patella itself post-operatively.

Currently, the technique of choice for this reason is first, splitting the medial patellar ligament. Of course, there are a group or number of horses that do not respond to this procedure. If the individual continues to show effects from upward fixation of the patella after receiving the initial splitting technique, with careful discussion with your regular veterinarian, a complete transection may be warranted. This is assuming the original diagnosis is still correct and the owner is willing to accept the risks or complications associated with completely transecting the medial patellar ligament itself. Anecdotal
evidence of splitting the medial patellar ligament, combined with appropriate physical therapy (i.e. increasing levels of daily exercise, riding or exercising up and down elevated areas or hills), appear to suggest a prognosis of approximately 80-90 percent success. If increasing levels of exercise has not improved the condition, it seems plausible with consultation with your veterinarian, that the tendon splitting procedure would possibly be the next natural choice.

On a side note, there are some veterinarians and owners who elect to place their horse on various regimens of estrone sulfate intramuscular injections to evaluate for possible improvement of this common musculoskeletal condition. The mechanism of action is still unknown for this procedure, however positive results have been suggested. The only drawback to this procedure, is sometimes this requires continued intramuscular injections verses the surgical procedure. Still, some individual owners and veterinarians use this treatment option as a sort of trial to evaluate if a horse will improve for future potential use. Again, its mechanism of action is unknown and there is no documented literature stating its positive effects.

Unfortunately, you are completely right. For such a basic musculoskeletal problem, which inhibitis ability of an athletic horse, we have not seen to found a perfect solution to the problem. In relation to your horse specifically, if the tendon splitting procedure and increased levels of exercise/fitness has not improved the condition, this individual may require the complete transection of the medial patellar ligament to improve the condition. This, of course, would suggest you are aware of the risks and have fully consulted your options with your regular veterinarian. Personally, I have had a few horses, I have had to repeat the tendon procedure a second time with success. I am unsure as to why some of these respond and others do not to a second splitting procedure. This might also be a patient or individual worth seeing the effects of intermittent estrone sulfate intramuscular injections to observe for a response.

If this injury occured eight years ago and there does not appear to be any secondary effects from the original injury, this horse can be treated like any other unfit athlete. Your regimen should be implemented slowly and consistently over an extended period of time (weeks to a few months). Most horses require a minimum of a few weeks of active, increasing levels of exercise to return to a physically fit status.

Most individuals begin work on a lunge line or walker with walking initially and increasing to trotting within the first week. This can also be done under saddle if lunging or placing on a walker is not feasible. Consistent, steady increasing levels is the key. You can begin with warming the individual up at a walk and progress to specific amounts of time, trotting or lunging (canter). Once the horse is able to work the desired amount without becoming or appearing too exhausted (elevated respiratory rate, intense sweating, etc.), one can begin to add additional time or elevated amounts of work. It is important again, when increasing exercise level or time, to slowly make adjustments (i.e. add five minutes each week or increase level each week).

This sort of horse would most definitely warrant a visit to your local veterinarian. It appears or sounds like this horse had a severe injury to its hindlimb if it is currently non-weight bearing. Pursueing a diagnosis before initiating rehabilitation would be advised in order to assess what kind of injury the horse originally sustained. If the horse fractured its pelvis (which sounds highly suspect), strict stall confinement may be the best treatment plan verses a different injury affecting the flexor tendons or quadriceps muscle area. Initiating rehabilitation therapy without a confident diagnosis, may further harm the horse by not allowing sufficient time for healing of the original injury to occur. Some injuries can take up to a year to improve or visualize any significant results. If the horse is non-weight bearing, I would also be worried about support limb laminitis developing in the opposite hindlimb at any point. Your regular veterinarian can evaluate this limb or foot as well for you.

It is not uncommon for the topline and other unique areas of the body not to fully recover initially after severe neglect or injury. It sounds like you have made significant progress, however and are on the right track. Continuing to offer good balanced nutrition, will over time slowly improve these portions of the body you are concerned about.

It also sounds like you have rehabilitated the horse superbly and the horse needs to be physically in shape after all this time off. Increasing riding intervals and levels of exercise (trotting, canter, etc.) will help to condition the muscles in all areas of the body, your horse probably has not used in a long time. Due to the anatomy of the horse, there are few exercises you can do to aid in improving muscle tone in these areas. Making sure the horse is in good physical riding shape should take care of these attributes. Physical therapy, in the form of neck extensions and flexions can be performed with treats and may possibly help the cervical (neck) region. Scratching the underside of the abdomen (so as to make your horse raise his back - dorsiflexion) and the same principles applied over the lumbar portion of the back (so as to make your horse lower his back - ventriflexion) may help, but not nearly as much as actively promoting physical fitness by routine riding. Personal experiences with aquatred systems or pool exercise systems for the horse, are extremely beneficial for returning or improving a horse's fitness level.

It sounds as though your horse is currently stable and doing well from the previous founder episode. Do we happen to know what the inciting cause that lead to this episode of founder (i.e.: lush pastures, stress related events, support limb laminitis, etc.)? Also, did he founder in the forelimb, hindlimb, one leg or both?

That being said, recommendations when bringing a horse back from any catastrophic or severe injury such as laminitis requires slow, increasing amounts of controlled exercise. It is important each day to evaluate the horse's comfort level on the affected limb(s). Generally, with a foundered horse, it is advisable to have the horse comfortable on pasture or large paddock turnout before beginning additional exercise therapy. From there, controlled exercise in the form of placing on a hot walker or walking under saddle two to three times a week for the first few weeks is a good start. Each day following this new exercise program it is important again to evaluate the comfort level of your horse from the previous day's activity. Evaluate his comfort level by walking in lead, turning to the left and right, followed by checking for increased digital pulses in the affected limb(s). After you feel your horse is comfortable with this regimen, you may slowly begin to increase the amount of time under saddle each day or increase the riding intervals.

Only until you feel comfortable riding the horse at the walk under saddle under all conditions, should you begin increased forms of exercise. These would include trotting and loping (cantering). All increases in exercise levels would begin initially with small daily amounts, increasing time and intervals subsequently. This form of controlled exercise can take anywhere from a couple of weeks to a couple of months depending on the horse's comfort level and your comfort level as well.

If for some reason, you have a set back and notice your horse extremely lame one day, it is advisable to confine to a stall until you can have your regular veterinarian reevaluate your horse.

As with any injury, slow, gradual controlled exercise is the key to bringing back any horse from injury.