dr. stacey oke | Horse Racing Free Tips

Survey: Two-Thirds Of Vets Concerned About Injecting Horses’ Joints Too Frequently

Joint inflammation and osteoarthritis (OA) are common in athletic horses, frequently resulting in lameness, poor performance, and economic losses. Veterinarians can provide symptomatic relief from joint discomfort caused by OA via intra-articular injections using a variety of medications. Examples include corticosteroids (e.g., triamcinolone acetate, methylprednisolone acetate), hyaluronic acid, polysulfated glycosaminoglyans, and various biologic therapies, such as stem cells, platelet-rich plasma (PRP), autologous conditioned serum (ACS, interleukin-1 receptor antagonist protein, IRAP), and autologous protein solution.

Which medication(s) veterinarians inject into which joint and how frequently that joint can be medicated are factors ultimately determined by the veterinarian using their own clinical experience. These choices therefore rely heavily on anecdotal evidence rather than scientific guidelines. In other words, there are no hard and fast rules regarding joint injections due to the lack of head-to-head comparisons of the various treatment options.

To gain a deeper understanding of how veterinarians are injecting joints, a survey sanctioned by the American Association of Equine Practitioners (AAEP) was conducted in 2019. Those data were subsequently analyzed by Dr. Gustavo Zanotto from the department of large animal clinical sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University. Dr. David Frisbie from the department of clinical sciences, Collage of Veterinary Medicine and Biological Sciences, Colorado State University was co-author of the study.

Zanotto recently presented data garnered from that 2019 survey at the 2021 AAEP Annual Convention held in Nashville, TN.

In total, 407 equine practitioners participated in the survey, the majority of which worked with racehorses (Thoroughbreds, Quarter Horses) and Warmbloods. Those veterinarians had extensive (>20 years) of clinical experience from which to draw their survey answers from.

Here are some of the most important take-away points garnered from the survey applicable to Thoroughbred racehorses.

Frequency of Injection

Approximately two-thirds of veterinarians were concerned about treating joints too frequently with corticosteroids for fear of causing harm, presumably to the articular cartilage.

“About 75% of responding veterinarians said that they believed joints can be damaged by treating too frequently. Most believe you can inject a joint once only every six months, whereas 30% of practitioners say you can do it every three months,” said Zanotto.

Despite these beliefs/recommendations suggested by practitioners on the survey, Zanotto says, “There is no strong scientific evidence regarding minimum frequency of joint injections.”

Steroid Selection

Triamcinolone and methylprednisolone are used most often in high- and low-motion joints by equine veterinarians, respectively. Nonetheless, almost three-quarters of practitioners still feel that triamcinolone is either somewhat likely or very likely to contribute to laminitis. As a result, survey respondents reported using limited amounts of triamcinolone, both in a single joint and as a total dose per horse. Based on the survey, most practitioners reported using 5-10 mg triamcinolone in a single joint and 20-40 mg of methylprednisolone. Most practitioners use less than 40 mg of triamcinolone per horse, and about 50% used no more than 18 mg triamcinolone per horse.

Based on scientific evidence, however, Zanotto said, “Triamcinolone does not appear to increase the risk of laminitis in healthy horses, and a safe total body dose has not yet been established.”

Antibiotic (Ab)use

In this survey, 55.6% of veterinarians admitted to always using an antibiotic such as amikacin when injecting medication into a joint. Perhaps more disquieting was the fact that the number of veterinarians using an antibiotic when medicating a joint actually increased from a similar survey in conducted back in 2009.

“This increased use of antibiotics is an alarming finding because there is evidence that amikacin is toxic to cartilage cells, as well as increased concern regarding antibiotic resistance,” explained Zanotto.

Reasons that veterinarians cited for using antibiotics intra-articularly were poor environmental conditions and “coincident corticosteroid injections.”

Such statements should give us pause for two main reasons. First, Zanotto pointed out that no evidence actually exists supporting the notion that joints medicated with corticosteroids are at an increased risk of infection.

Second, there is no evidence that the environmental conditions in which most equine practitioners inject joints contributes to joint infections. In fact, according to Dr. Lynn Pezzanite from Colorado State University, joint infections are exceedingly rare.

During her presentation at the 2021 AAEP Annual Convention, Pezzanite relayed data she retrospectively collected from joint injections performed between 2014 and 2018. In total, 3,866 synovial injections were performed on 1112 horses over 1623 sessions. Of those, 643 sessions were performed in the field.

Pezzanite's data revealed that the risk of sepsis (infection) was similar between joints injected in the field and hospital and between joints that had or had not been treated with an antibiotic. Overall, the frequency of sepsis was 1 in 967 injections, or about 0.1%.

Biologic Therapies Gaining a Foothold

Perhaps due to equine practitioners' ever-increasing familiarity with the various commercially available biologic therapies available as well as the perceived benefits of such therapies, their use is increasing. According to the survey, IRAP is the most popular biologic therapy, followed by PRP, autologous protein solution, stem cells, then bone marrow aspirate/concentrate. Cost is a major determinant of which biologic is ultimately used.

In sum, despite how frequently joint injections are being performed there is still a profound lack of evidence-based guidance regarding frequency of injection and recommended doses, particularly for corticosteroids. One of the more alarming findings, however, is the rampant and unnecessary overuse of antibiotics in routine joint injections for prophylactic purposes.

Dr. Stacey Oke is a seasoned freelance writer, veterinarian, and life-long horse lover. When not researching ways for horses to live longer, healthier lives as athletes and human companions, she practices small animal medicine in New York. A busy mom of three, Stacey also finds time for running, hiking, tap dancing, and dog agility training.

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Seeing Reduced Performance In Your Racehorse? Study Suggests Switching Steamed Hay Or Haylage Could Help

Pinpointing the cause of poor performance in athletic horse is often a challenge. If it turns out there could be a respiratory cause, then mild equine asthma (EA) could be to blame. Luckily, the common saying that “prior preparation prevents poor performance” can be taken to heart in such situations. While hay steamers have been marketed to horse owners for several years, new research demonstrates that steamed hay and haylage can make measurable differences in a horse's

Mild EA, the preferred term that replaces inflammatory disease, describes horses with a chronic low-grade cough (defined as having gone on for longer than three weeks), decreased/poor performance, and the presence of tracheal mucous when the horse is scoped. Many underlying conditions can be confused with EA. Those include infectious causes (viral or bacterial), upper airway obstruction (dorsal displacement of the soft palate, for example), and exercise-induced pulmonary hemorrhage. Some veterinarians have even speculated that those conditions may even predispose horses to mild EA.

“The most important factor contributing to mild EA in Thoroughbreds is the small dust particles horses breathe in primarily as a consequence of feeding dry hay,” explained Dr. Laurent Couëtil, section head of Large Animal Internal Medicine at Purdue University, in West Lafayette, Ind.

Dry hay contains fungi, molds, mite debris, inorganic particles, endotoxins, and other inflammatory molecules. This microscopic particulate matter contaminates the horse's breathing zone, causing inflammation in the lower airways.

“Particulate matter measuring less than 4 microns in diameter results in a sharp and significant increase in the number of neutrophils in mucus collected from the lungs,” said Couëtil.

Particles this small cannot be seen to the naked eye but can be measured with specific, wearable equipment fastened to a horse's halter.

Mucus — a hallmark of EA — can easily be collected from horse's lungs via bronchoalveolar lavage (BAL) and microscopically analyzed. The presence of neutrophils in this BAL fluid indicates inflammation. Other inflammatory cells may also be appreciated, such as mast cells and eosinophils.

The amount of tracheal mucous, which can be scored on a scale ranging from 0 (no excess mucous) to 5 (defined as a profuse amount pooling throughout the trachea) can also be used to gauge the severity of mild EA.

According to Couëtil, studies in both Standardbred and Thoroughbred racehorses have demonstrated an association between severity of mucus score and poor performance. As mucous scores increase, speed of the horse decreases.

“A 2006 study performed by Sue Holcomb showed that horses with tracheal mucous scores of 2 or greater were significantly behind in finishing place than horses with a score of 0 or 1,” Couëtil relayed.

Because forage is the most important source of dust that triggers EA, various tactics designed to minimize dust have been explored. Recently, Couëtil and colleagues conducted a study at an Indiana Thoroughbred racetrack. They demonstrated that racehorses actively involved in training and competition that were fed steamed hay or haylage had reduced exposure to dust by approximately 30% when compared to horses fed dry hay.

In that study, Couëtil's team recruited 69 Thoroughbreds and divided them into three groups based on type of forage fed: haylage, steamed hay, and dry hay. All horses were fed this diet for a total of 6 weeks. On weeks 0 (baseline), 3 and 6 of the study, endoscopy was performed after coming back from the track to assess respiratory function and to grade mucous. In addition, all horses were equipped with sensors to measure respirable particles (less than 4 microns in diameter) for 3 hours after returning from training and being fed.

Haylage is grass that is cut and baled at a higher moisture content (about 30%) than regular hay (about 15%) and is package in sealed plastic films similar to shavings bales. This packing prevents molding of the moist forage and allows preservation of the nutritional value of fresh grass similarly to what is achieved with silage for cows. This moist forage results in a marked decrease in dust exposure when horses eat haylage. For the purposes of this study, trainers were each given a hay steamer provided by Haygain.

Key findings of the study were:

Respirable dust particles (less than 4 microns in diameter) were significantly higher in the breathing zones of horses fed hay. Both the steamed hay and haylage generated the same, significantly lower level of dust particles;
By the end of the study, mucous scores were significantly higher in the hay group. Both the steamed hay and haylage groups had the same, significantly lower mucous scores;
BALF analysis showed that the number of neutrophils, an indicator of airway inflammation, increased significantly as the respirable dust concentration in the horse's breathing zone increased; and
Over time, the number of neutrophils in BALF decreased in horses fed steamed hay and haylage but only reached statistical significance for horses fed haylage.

“In sum, our results clearly demonstrated the benefits of feeding low-dust forages on airway health in just 6 weeks,” Couëtil concluded.

Another conclusion that Couëtil highlighted was that BAL can be performed safely in Thoroughbred racehorses without interruption in racing or training.

“For some veterinarians, owners, or trainers, the idea of a BAL can be off-putting,” Couëtil said. “Many veterinarians are not familiar with the procedure, and others think that a BAL will require resting their horses for an extended period of time after infusing fluid in the lungs.”

The reality is that even if only 50 percent of the sterile saline solution administered is recovered, the rest is rapidly absorbed. Couëtil's study proved that a BAL can be performed without interfering with the training and racing schedules.

“Owners and trainers shouldn't hesitate to perform a BAL in any case of chronic cough, poor performance or when excess mucus is seen by endoscopy after the race,” Couëtil said. “This test can be highly beneficial especially when used in conjunction with the mucous score. The BAL rules in mild EA while endoscopy can help rule out other causes of cough and poor performance.”

One caveat worth noting is that medications are sometimes used for sedating the horse and to decrease coughing during BAL, and it is important to respect drug elimination times prior to racing.

In sum, identifying realistic ways of decreasing airway inflammation, such as a small change in hay preparation, is important because an estimated 80% of Thoroughbred racehorses have mild EA and are not living up to their potential.

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Kissing Spines: What Is It, And Why Does It Seem Like It’s Everywhere?

The seemingly innocent term “kissing spines” actually refers to a potentially painful, performance limiting condition of the equine back. While kissing spines (impinging spinous processes) may seem like a diagnosis du jour, garnering only intermittent fad-like attention, Sue Dyson, an internationally renowned equine lameness expert, says this back problem occurs quite commonly in young, fit racehorses. In fact, Thoroughbreds have a higher frequency of occurrence of kissing spines than many other breeds.

In a normal spinal column, the individual vertebrae are lined up like a row of ducks. Long, thin bony projections called spinous processes extend upwards from these bony vertebrae (dorsally). Normally, these skyward reaching spinous processes should be physically separated from one another, even during locomotion. In some cases, however, the spinous processes end up crowding one another, gently touching or “kissing.” In severe cases, the spinous processes actually overlap one another.

As one can imagine, having these bony projections compressing on one another can severely limit performance.

“In the racehorse world, there seems to be a lack of awareness of the presence of musculoskeletal pain unless a horse shows overt lameness. In turn, there is a lack of recognition that back pain can compromise performance,” said Dyson.

According to Dyson, back pain may be mistaken for bilateral forelimb or hind limb lameness because it often results in shortened steps without overt lameness. In some cases, back pain is overlooked completely with the horse instead being described as a “scratchy mover.”

“Many racehorses have back pain that goes unrecognized, which may be compounded by a poorly-fitting saddle or a work rider who is not always in balance with the horse at all gaits,” Dyson said.

In fact, poor behavior or behavior changes may be the only obvious “abnormality” appreciated in horses with back pain, but this often goes unrecognized.

Horses with back pain, including those with kissing spines, may manifest their discomfort by:

Displaying abnormal behavior when tacked up
Stiffening the back when first mounted
Dipping (extending) the back when first moving forwards
Bucking
Exhibiting an unwillingness to bend or move forward as freely as normal
Bunny hopping in the canter
Failing to pick up or hold a specific lead on their canter

“Horses can even show behaviors that are sometimes attributable to the horse's untoward demeanor rather than as a result of pain,” Dyson explained.

Recognizing that behavior may be a valuable indicator of pain, Dyson developed a pain ethogram to help identify musculoskeletal pain in horses. This ethogram uses a set of 24 well-described and named behaviors that Dyson identified much more frequently in lame/painful horses compared with sound horses.

Those behaviors were subsequently categorized by Dyson based on the type of behavior, such as facial, body, or gait markers.

For example, facial markers suggestive of musculoskeletal pain included head tilting, rotating ears back behind vertical or lying flat for >5 seconds, closing eyelids for two to five seconds, and repeatedly exposing the sclera. Body markers included clamping the tail tightly and tail swishing, and gait markers were rushed gaits and spontaneous changes in gait.

To use this pain ethogram in real life, one or more evaluators observe the horse move during their typical work and specific exercises (i.e., straight lines, circles, and transitions in walk, trot, and canter under saddle). If the horse exhibits any of the 24 behaviors included in the ethogram, those behaviors are recorded.

“When this ethogram was validated in sport horses, the presence of eight or more of the 24 behaviors was highly likely to reflect the presence of musculoskeletal pain,” said Dyson.

While originally described by Dyson as a ridden horse pain ethogram (RHpE), she that research shows this RHpE can be used to help detect any form of musculoskeletal pain, including primary back pain associated with impinging spinous processes.

“I have not specifically tested the RHpE in racing Thoroughbreds, but I would be surprised if, with some modifications, it was not helpful,” she added.

If a racehorse performs poorly or displays abnormal behavior during ridden exercise, then the back should be examined carefully. The presence of muscle tension and pain or limited range of motion of the back should prompt radiographic assessment.

“Low-grade impinging spinous processes may not be a cause of pain, so infiltration of local anesthetic solution around the close spinous processes is necessary to determine their clinical significance,” Dyson suggested.

In other words, some horses with radiographic evidence of kissing spines may not be experiencing pain at those sites.

In sum, back pain and kissing spines should be considered even in young, apparently healthy Thoroughbred racehorses, especially those with behavior issues, a short-stepping gait or a reluctance to work. Failure to recognize primary back pain may lead to an alteration in gait predisposing to other problems.

Training and racing performance may be improved substantially by successful treatment of impinging spinous processes. Local infiltration of corticosteroids close to the narrowed interspinous spaces, extracorporeal shockwave therapy (ESWT), acupuncture, and mesotherapy are possible treatment options, with surgery as a last resort.

“Any treatment program should be combined with physiotherapy to help to release tight muscles and reduce muscle pain,” she said. “Management changes such as feeding from the ground to encourage back flexion, use of heat lamps or other heating methods prior to exercise, warming-up by walking on a horse walker before ridden exercise, and improving saddle fit will also helpful to try to optimize performance.”

Another factor to consider is that kissing spines may not only affect a racehorses' training and performance, but also their future careers once they have moved on from the track.

“In my role as a veterinary advisor to a racehorse rehabilitation center, we assess all horses' backs clinically and radiographically,” said Dyson. “We have had many horses that we have not been able to rehome as riding horses because of chronic back problems relating to severe impinging spinous processes and other secondary problems.”

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Can Diet Coke Really Treat Colic? Veterinarian Says His Viral Social Media Post Isn’t Meant To Answer The Question Simply

Old wives' tales spread as rapidly through the equine community as a wildfire during a dry, hot summer. One of the latest rumors to gain momentum fueled by the so-called power of social media involves drenching horses with Diet Coke to cure colic.

Dr. Oliver Liyou, a veterinarian and Director at Equine Veterinary and Dental Services Pty Ltd. in New South Wales, Australia was recently the victim of social media gone awry after posting himself administering Diet Coke to a horse with a gastric impaction.

Gastric impactions are caused by poor gastric motility leading to a mass of feed in the stomach, which leads to signs of colic and sometimes rupture of the stomach. These masses are called Phytobezoars, or masses made of organic materials (rather than body tissues such as polyps or other abnormal growths). They can form in the stomach and blocks or slow the passage of digesta from the stomach into the intestines. These masses can also irritate the lining of the stomach and cause the horse pain.

As a result, horses with gastric masses made of organic materials can suffer weight loss and exhibit signs similar to those seen with gastric ulceration: decreased appetite, abdominal pain, poor performance, dull haircoat, and behavior changes.

Liyou was recently presented with an 8-year-old stock horse gelding with signs of dull, dry coat and poor condition. Suspecting gastric ulcers, Liyou performed a gastric endoscopy, which involved passing a small, fiberoptic camera into the stomach through the horse's nasal passages and throat. As part of the scoping procedure, horses are not fed for 18 hours before the scope in order to empty the stomach so the lining can be checked for ulcers.

Instead of ulcers, Liyou was surprised to find a mass the size of a football.

“Based on recommendations made by other practicing veterinarians and a scientific paper on the use of it treating similar cases, I chose to try Diet Coke to help dissolve the mass,” said Liyou.

An initial two-liter drench of the refreshing beverage was administered via a stomach tube. The patient was re-scoped two hours later. Finding the mass still present, but softer, another three liters of Diet Coke was given. Another two hours later, the scope identified a soft, soup-like concoction in the stomach. Fueled by the progress, Liyou administered eight liters of an electrolyte drench to encourage the material to soften more and exit the stomach. The horse was given access to only water overnight, and a gastroscopy the next morning found the stomach impaction had fully resolved.

The use of Diet Coke is not a universally adopted technique by any stretch of the imagination despite its use by licensed veterinary practitioners in a few, select cases. In fact, the nasogastric administration of Diet Coke has rarely been mentioned in the peer-reviewed veterinary literature or continuing educational materials.

One case report published in the Journal Equine Veterinary Education in 2007 does, however, describe the successful resolution of a gastric mass composed of persimmons and other organic debris. In that report, the pony was severely colicky when first examined by the veterinary team, and traditional steps in colic diagnosis and treatment were attempted. Specifically, full physical examination and bloodwork, siphoning the stomach contents, and an abdominal ultrasound were performed.

“We then used gastroscopy to evaluate the stomach. This technique revealed a large mass comprising 80% of the volume of the stomach with black seeds consistent with persimmon ingestion and impaction,” said Dr. Allison Stewart, specialist in equine internal medicine and emergency and large animal critical care at the University of Queensland. Stewart was one of pony's attending veterinarians and a co-author of the case report.

Treatment with gastric lavage, intravenous fluids, anti-inflammatory medication, and the nasogastric administration of a DSS, a sort of laxative to help the mass pass out of the stomach and into the small intestine, were unsuccessful. Gastroscopy revealed that the mass remained unyielding.

The next step was taking the horse to surgery to remove the gastric foreign body, but this was not financially feasible for the owners. Instead, the veterinary team suggested using Diet Coke to try to break down the persimmon mass as previously reported in human patients with similar persimmon impactions.

“We administered two cans or 700 milliliters of Diet Coke on day three of hospitalization,” said Stewart. “Another gastroscopy on day five of hospitalization revealed that the mass was half its original size. The same 'dose' of Diet Coke was repeated, and by Day seven of hospitalization the gastric mass was no longer visible on gastroscopy.”

Although that veterinary team was able to treat the persimmon pony and with Liyou's own success, Liyou warns owners that Diet Coke does not always help resolve gastric obstructions.

“I recently tried using Diet Coke over an eight-day period along with electrolyte drenches on a third case, but repeat gastroscopies revealed that I was unable to resolve the gastric impaction,” Liyou said.

By day nine, with no further emptying of the stomach taking place, Liyou allowed the horse to eat short grass for one day then rescoped him after 12 hours of fasting. A normal stomach would have emptied in that time. Unfortunately, the stomach remained full.

“The stomach had been impacted and distended for so long that the stomach wall was likely stretched and weakened and did not function properly to contract and empty the stomach,” said Liyou. “I offered to refer the horse to a specialized veterinary internist for additional treatment, but that was not possible for the owner.”

He emphasized that the entire point of his recent Facebook post—which reached 1.5 million people and received 6.5 thousand likes—on drenching a horse with Diet Coke was actually to stress the value of gastroscopy in these cases, not help Diet Coke sales.

“The key point I wanted to highlight was that gastroscopy is absolutely necessary to diagnose a gastric impaction and 100% essential for monitoring treatment response,” said Liyou. “I am also concerned at the hundreds of thousands of dollars being wasted by owners on stomach ulcer treatments when the horse may have something very different, like an impaction, for which the ulcer treatments will do nothing. We cannot treat a colicky horse without an accurate diagnosis, with Diet Coke or any other remedy.

“I am fearful that owners will be drenching their horses with Diet Coke if ever they colic or develop signs that may suggest the presence of a gastric impaction.”

Diet Coke may help some cases of gastric impaction, but most patients won't benefit from this approach. Owners need to appreciate that not all gastric impactions can be dissolved and that other forms of colic are not amenable to this approach.

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