Practitioner Issue 2, 2018

Page 1

Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 2 • 2018






OCTOBER 18-21, 2018


Discounted Pre-Registration Ends September 6, 2018

The President's Line Ruth-Anne Richter, BSc (Hon), DVM, MS - FAEP President Dear Fellow Equine Practitioners, The lazy days of summer are upon us, but the FVMA and the FAEP remain active and continue to work on providing the equine practitioner with quality CE events. To that end, we are gearing up for the 14th Annual Promoting Excellence Symposium (PES) — themed “Insights into Equine Medicine, Lameness and Treatment” — this October. For this year’s program, FAEP will visit Naples again, and we are fortunate to have Dr. Jean-Marie Denoix return for lectures and an in-depth ultrasound wet lab. The FAEP Council is also excited to host the UF Student Appreciation Day again in August. Looking toward the future, preparations are underway for the 56th Annual Ocala Equine Conference in January 2019, where we look forward to another exciting beginning to the New Year. While the Legislature has been busy this season, only 166 bills passed both the House and Senate of the more than 2,000 bills presented, which is reported to be one of the lowest passage rates to date. Fla. Sen. Greg Steube of Sarasota (R-23) continues to be a voice for animal welfare rights and animal abuse, representing bills related to animals left stranded after major weather events including discussions about misplaced horses. The decoupling bill remains on the table with more discussions to follow in the 2019 legislative session. It is hoped that many of the bills presented affecting those of us in the equine industry will, again, be brought forward in 2019. Our voices through advocates like Sen. Steube can only be heard by our continued support and interest in these matters. Hurricane season is upon us, and already we’ve had named storms to remind us of 2017, and Hurricane Irma that upset our plans for PES. This reminds us to make preparations for an active season, not only for the weather but, more importantly, for our continuing education. The Naples Grande Beach Resort has undergone renovations to their conference area since the damage that ensued during Hurricane Irma’s wrath. They are ready to host us once again, and we look forward to seeing the updated venue. Let me encourage you to make your plans for PES 2018 and register for the conference early. Looking forward to seeing you in Naples — stay dry, safe travels and have a safe summer season.


Dr. Ruth-Anne Richter FAEP Council President


Anne L. Moretta VMD, MS, CVSMT

Armon Blair DVM


Adam Cayot DVM


Amanda M. House DVM, DACVIM

Opinions and statements expressed in The Practitioner reflect the views of the contributors and do not represent the official policy of the Florida Association of Equine Practitioners or the Florida Veterinary Medical Association, unless so stated. Placement of an advertisement does not represent the FAEP’s or FVMA’s endorsement of the product or service. 2  The Practitioner

Issue 2 • 2018


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Joint injuries are common in race and sport horses. The major causes of these injuries are the repetitive biomechanical stresses placed on the joint surfaces, subchondral bone and ligaments. Sometimes an acute extra-physiological movement may be responsible for damages in the joint. In complement to medication, rehabilitation is an essential part of the management of joint problems in horses. Corrective shoeing, selection of adequate ground surfaces, and an adequate level and type of exercise are the key factors to manage in order to bring the horse back to its expected level of activity and performance.



An accurate diagnosis of the affected joint(s), the affected structure(s) within the joint(s) and a good documentation of the evolution stage of the lesion(s) are essential for designing an appropriate rehabilitation program. It is essential to select the gait(s), speed, specific exercises and to establish an appropriate

exercise level that’s parallel to an adequate monitoring of the problem and the patient’s tolerance.



An adequate rehabilitation program consists mainly in manipulating the biomechanical stresses on the injured structures. (Image 1) These stresses must be reduced for acute or painful injuries and must be progressively adjusted to healing or pain level. In order to achieve this, the exercise program must be specifically adapted to every particular condition. For example, in a horse presenting an acute or subacute grade two or three desmopathy of the medial collateral ligament of the left distal interphalangeal joint, every turn on the left, at any gait, is contraindicated for at least two or three months — depending on data obtained from clinical and ultrasound follow up — to avoid lateromotion of the joint and tension of the affected ligament. This horse will be exercised at the walk and trot on straight lines and open right turns.

Image 1: Biomechanical stresses undergone by the distal interphalangeal joint structures during asymmetrical positioning of the foot inducing collateromotion and rotation within this joint.

6  The Practitioner  Issue 2 • 2018



Corrective shoeing is a unique modality for manipulating the biomechanical stresses on the affected structures. A specific corrective shoeing program can be rationally set up for each type of joint and ligament injury in the equine distal limb taking into account the precise nature of the anatomical structure(s) involved and the evolution stage of the lesion(s) and repair process. For most joint problems, rehabilitation will be performed on a soft, even ground surface. Corrective shoeing is also used to prevent joint injuries in horses with conformational defects. Intercellular communication or quorum sensing is carried out through the production of bacterial products that are able to diffuse away from one cell and enter another. Signaling between cells is critical in the development of a viable biofilm and in reacting to outside environmental stress.

A. Subchondral bone injuries

Subchondral bone trauma or cysts can be induced by chronic or acute overload of the joint surfaces in a specific location. Pressure on the diseased part of the joint may induce pain or worsening of the lesion. The objective of the corrective shoeing is to reduce pressure on the affected subchondral bone and distribute the load on the other sounder parts of the joint surfaces.

Therefore for horses presenting subchondral bone edema, lysis, sclerosis or cyst-like lesion on the medial part of a condyle or glenoid cavity, our goal is to reduce mediomotion (Denoix, 1999) and distribute the load laterally using a corrective shoe with a narrow medial branch (with a bevel on the outside rim) and a wide lateral branch to provide more support laterally (Image 2). The opposite is recommended for lateral subchondral bone injuries. Lateromedial and dorsopalmar radiographs proved to be of invaluable interest for the assessment of joint balance in order to help for adequate foot trimming.

B. Collateral desmopathies

Corrective shoeing is also an essential part of the management of desmopathies of the equine distal limb. The precise knowledge of the joint movements is required for corrective shoeing of sound as well as lame horses. An adequate trimming and shoeing program requires a precise diagnosis of each injured structure, based on radiography ultrasonography and/or magnetic resonance imaging (Table 1). The objective of the shoeing program for collateral ligament injuries is to reduce tension on the injured structure. This can be achieved through the control of collateromotion (Denoix, 1999), sliding and rotating the affected joint. For an injury of the medial collateral ligament, the corrective

Image 2: Asymmetric shoes (on the left: front foot; on the right: hind shoe) used for the management of collateral desmopathies and subchondral bone lesions. WWW.FAEP.NET |


@FLORIDA_VMA | The Practitioner  7

Structure involved

Cause of Injury

Corrective Shoeing

• Overload on medial part of the joint • Mediomotion

• Narrow medial branch with bevel outside • Wide lateral branch with lateral extension (wedge)

Medial collateral ligament

• Lateromotion • Medial rotation of the foot • Lateral sliding of P3

• Wide medial branch • Narrow lateral branch with bevel outside • No lateral extension (no wedge)

Lateral collateral ligament

• Mediomotion • Lateral rotation of the foot • Medial sliding of P3

• Wide lateral branch with lateral extension (wedge) • Narrow medial branch with bevel outside

Medial collateral sesamoidean ligament

• Lateromotion • Medial rotation of the foot

Reverse shoe with: • Wide medial branch • Narrow lateral branch with bevel outside

Distal sesamoidean ligament

• Distal interphalangeal joint hyperextension

• Egg bar shoe with dorsal rolling • Elevated heels + rolling toe, or: • Reverse shoe

• Rotation of P3 on the opposite side

• Narrow branch on the injury side

• Secondary to ligament injuries • Joint instability • Degenerative process

Rolling shoe in: • dorsopalmar direction • lateromedial direction Shock absorbing device

Medial subchondral bone lesion

Asymmetric distal sesamoidean ligament

Osteoarthrosis (Degenerative joint disease)

Table 1: Corrective shoeing of distal joint injuries. P3- Distal phalanx

shoeing consists in providing more support (wider branch) on the side of the lesion with improved rolling effect on the opposite (lateral) side. The reverse is recommended for lateral collateral injuries. As support to the heels increases interphalangeal joint flexion and fetlock extension, egg bar or reverse shoes are not recommended for metacarpophalangeal collateral desmopathies. All the anatomical structures of the distal limb are highly stressed during weight bearing and especially during the stance phase on uneven ground or asymmetric foot placement. Therefore, a soft and regular ground surface must be selected for the rehabilitation of distal joint injuries. Turns should also be limited and lunging exercise is contra-indicated.

C. Desmopathies of the podotrochlear apparatus

They may involve the collateral sesamoidean ligaments, the proximal and distal sesamoidean ligaments and the distal digital annular ligament. When symmetrical, the principles and recommendations are similar to the corrective shoeing used for DDFT injuries. Asymmetrical injuries need manipulation of the lateromedial balance of the shoe (Table 1).



• Avoid worsening of the lesions through inadequate management of the biomechanical stresses on affected structures; avoid doing blocks (nerve or intrasynovial) if there is any suspicion of bone or ligament injury. • Reduce pain: The rehabilitation program can be undertaken while the injured structure is at rest without supporting major biomechanical stress. This is achieved using corrective shoeing, selection of exercise surface and establishing an exercise program. Shock wave and laser therapy may be helpful. • Reduce inflammation: Cold therapy (packs +water) • Improve healing: There is still little evidence of the efficacy of treatment, whether general or local, compared to the spontaneous evolution of the healing process. The bone

8  The Practitioner  Issue 2 • 2018

heals spontaneously; the cartilage has little healing capacity; the ligaments heal except if they present an intrasynovial rupture. For us, progressive mechanical stimulation of the affected structures remains the most adequate in order to reach the ultimate functional restoration of these structures. • Improve functional properties and promote joint mobility: Once the healing process is sufficiently advanced, a progressive rehabilitation program with regular increase of the duration and difficulty of exercises is set up. This must be done taking into account the type of joint lesions presented by the patient. For traumatic desmopathies, once the healing process is finished, the horse can gradually return to a full exercise program. For degenerative conditions (i.e. cartilage injuries and some enthesopathies), stressful situations must be avoided during training. For subchondral bone lesion, exercises putting load on the affected articular surface will be limited. Again, monitoring clinical manifestations and imaging evolution regularly is essential for adjusting the exercise program. • Conditioning and body status: One important aspect of the exercise program is to maintain a good physical condition and avoid overweight. The exercise duration must be adapted to these objectives. Swimming may also contribute without putting too much stress on the distal joints.



• Collateral desmopathies of the distal interphalangeal joint • Medial subchondral bone failure of the metacarpal condyle • Cranial enthesopathies of the menisci of the femorotibial joint • Thoracolumbar intervertebral arthropathies

CONCLUSION Corrective shoeing is essential for the management of joint injuries in race and sport horses. It allows us to manipulate the mechanical stresses undergone by the subchondral bone and collateral ligaments at each step of the healing process, and to facilitate rehabilitation and reconditioning. A careful selection of the adequate ground surface and physical exercises must be done based on the knowledge of the biomechanical stresses placed on every injured structure of a specific joint. Manipulation of the training program, combined with a good clinical and imaging follow up of the patient, allows managing most of the horses with joint problems.

ACKNOWLEDGEMENTS Research on biomechanics and pathology of the equine locomotor system is supported by the Conseil Régional de Basse-Normandie and the European funds FEDER. They are contributing to the


Pôle de Compétitivité Filière Équine and Hippolia Foundation actions for the equine industry. Many thanks to the practitioners who contribute to improving knowledge of our profession and to their referring cases.

References 1. Chateau H., Degueurce C., Denoix J.-M. Three-dimensional kinematics of the distal forelimb in horses trotting on a treadmill and effects of elevation of heel and toe. Equine Vet. J. 2006, 38, 164-169. 2. Crevier-Denoix N., Roosen C, Dardillat C, Pourcelot P., Jerbi H., Sanaa M., Denoix JM : Effects of heels and toe elevation upon the digital joint angles in the standing horse. Equine Vet. J, suppl.33 (2001) 74-78 3. Denoix J.-M. Biomécanique interphalangienne dans les plans sagittal et frontal, in Proceedings. 4. Congrès de Médecine et Chirurgie Equine 1993; 44-49. 5. Denoix J.M.: Functional anatomy of tendons and ligaments in the distal limbs (manus and pes). 6. Veterinary Clinics of North America, 1994, 10 (2), 273-322. 7. Denoix J-M. Ultrasonographic examination in the diagnosis of joint disease. In: Mcllwraith WC and Trotter GW ed. Joint Disease in the horse. Philadelphia, Saunders, 1996;165-202. 8. Denoix J.M., Crevier-Denoix: Functional anatomy and biomechanics of tendon; corrective shoeing. 9. Sixth Annual Scientific Meeting European College of Veterinary Surgeons, Versailles, 1997, 97-98. 10. Denoix J-M. The collateral ligaments of the distal interphalangeal joint : Anatomy, roles and lesions. 11. Hoof Care and Lameness 1998;70:29-32.

Jean-Marie Denoix, DVM, Ph.D., Assoc. LA-ECVDI, DACVSMR, ISELP Certified Instructor Dr. Jean-Marie Denoix of the CIRALE (Center of Imaging and Research on Equine Locomotor Affections) in Normandy, France i s con side red the world ’s foremost equine musculoskeletal system anatomist as well as a leading equine diagnostic ultrasonographer. Dr. Denoix is a founder and current president of ISELP and was also the 2006 recipient of the Schering Plough Equine Research Award from the World Equine Veterinary Association for outstanding applied research work in Equine Diagnostic Imaging. Dr. Denoix has been the invited speaker at many international meetings in more than 30 countries around the world on topics related to clinical examination and imaging of equine locomotor problems.


@FLORIDA_VMA | The Practitioner  9

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INTRODUCTION Cough and poor performance are common complaints among pleasure and sport horses in equine practice. Many terms and abbreviations have been used over the years for various inflammatory and hyperreactive airway conditions causing cough in the horse. In a revised consensus statement by the American College of Veterinary Internal Medicine, it has been proposed that these various syndromes be characterized under the term “equine asthma.” Inflammatory Airway Disease (IAD) has been used to describe the condition seen in young horses, most often characterized by exercise intolerance and intermittent cough, which are normal at rest. They can completely recover, either with treatment or on occasion, spontaneously. Recurrent Airway Obstruction (RAO, also known as heaves, broken wind and chronic airway reactivity) is characterized by bronchoconstriction, mucus production and bronchospasm. Unlike IAD, horses with RAO are not normal at rest, and usually have an increased respiratory rate and/or cough. The most common signs of RAO are chronic cough, nasal discharge, exercise intolerance and respiratory difficulty. The classic “heave line” that can be seen along the bottom edge of the ribs is due to hypertrophy of the abdominal muscles, which becomes large from excess work. Severely affected horses may also exhibit weight loss, anorexia and exercise intolerance. Most affected horses do not have a fever unless a secondary bacterial pneumonia has occurred. The term COPD is no longer used to describe this condition in horses because many aspects of the disease are different from human chronic obstructive pulmonary disease. Two different forms of RAO are recognized in the horse: the barn-associated type often seen in stalled horses fed hay, and Summer Pasture-Associated RAO (SPRAO, also called summer heaves and pasture-associated heaves) often seen more commonly in horses living on a pasture in the Southeast. These horses may now be described as having equine asthma, characterized as mild to moderate for IAD and severe asthma for RAO.

HISTORY AND EXAMINATION A complete history and physical examination are critical for evaluating the patient with cough. Duration, severity, nasal discharge, presence or absence of fever, and inciting causes can all be helpful in determining the underlying etiology. A rebreathing examination should be performed as part of a complete respiratory examination. Horses with inflammatory, noninfectious lower airway disease may have a prolonged recovery and the presence of crackles and/or wheezes on examination. Horses with infectious pneumonia may have abnormal adventitial sounds as well, and, as such, this examination will not point to a specific etiology. A

complete blood cell count may be beneficial to determine whether evidence of infection is present, but could still be normal in horses with pneumonia. Changes in the white blood cell count, SAA or fibrinogen concentration should prompt further diagnostic consideration. Horses with a history of fever and changes on the CBC should be suspected of having infectious lower airway disease and/or pneumonia. Definitive determination of a bacterial etiology is best accomplished with a percutaneous transtracheal aspiration sample submitted for cytology and culture/sensitivity. Pneumonia is often characterized cytologically with degenerative neutrophils, with or without the presence of intracellular bacteria. Broad spectrum antibiotics should be initiated if cytology is suggestive of pneumonia while culture results are pending. Tracheal aspiration cytology can also be suggestive of inflammatory lower airway disease, when non-degenerative neutrophils are the predominant cellular population. Thoracic ultrasound examination and radiographs can be helpful in the evaluation of the horse with lower airway disease. Practically speaking, in a field setting, ultrasound examination of the thorax can be accomplished with a trans-rectal probe. This technique is most useful to determine if pleural fluid or pulmonary infiltrates are present.

SEVERE EQUINE ASTHMA (RAO, HEAVES AND SPRAO) Recurrent airway obstruction — also known as heaves, severe equine asthma, broken wind and chronic airway reactivity — is a common respiratory disease of horses characterized by periods of reversible airway obstruction caused by neutrophil accumulation, mucus production and bronchospasm. The classic clinical syndrome includes chronic cough, nasal discharge and respiratory difficulty. Most evidence suggests that RAO is the result of pulmonary hypersensitivity to inhaled antigens, although multiple theories exist regarding the exact pathophysiology. The most common antigens are mold, organic dust, and endotoxin present in hay and straw. Periods of reversible small airway obstruction are caused by bronchoconstriction and the accumulation of mucus and neutrophils. RAO occurs worldwide with the highest prevalence in stabled horses fed hay in the northeastern and midwestern United States. A similar condition that can occur in horses in the southeastern United States is termed summer pasture-associated RAO (SPRAO); however, horses with SPRAO typically improve when stabled. RAO is a common respiratory disease of mature horses (typically > seven years old). The average

12  The Practitioner  Issue 2 • 2018

- Continued from page 13

Image 1: Equine AeroMask TM is another type of mask used to deliver aerosolized equine medications

Corticosteriods will not provide immediate relief of acute, severe airway obstruction, and rapidly acting β2-adrenergic bronchodilators, such as albuterol sulfate, are indicated for treatment in those cases. Aerosolized albuterol sulfate (.8-2 µg/kg in MDI, metered-dose inhaler (Image 2); typically 5-10 puffs/500kg of 100 µg/puff MDI every four to six hours) improves pulmonary function by 70% within five minutes of administration; however, the beneficial effects last only one to three hours. Administration of albuterol will improve the pulmonary distribution of other aerosolized medications, such as aerosolized corticosteroids and speed mucociliary clearance. Ipratroprium bromide (20 µg/puff, 5-10 puffs/500 kg every six to eight hours) has also been utilized for inhaled bronchodilator therapy. Clenbuterol (.8-3.2 mcg/kg PO every 12 h), a β2-adrenergic agonist, provides long-acting bronchodilation in horses with moderate to severe RAO. Side effects include tachycardia and sweating, which are more common at higher doses and with intravenous administration. The clinical efficacy of clenbuterol is inconsistent at lower dosages if exposure to a dusty environment is maintained; however, it does appear to improve the objective parameters of pulmonary function. Down-regulation of β2receptors has been documented in horses after administration of clenbuterol for 12 days (.8 µg/kg IV, every 12 hours). Since β2-agonists have minimal to no anti-inflammatory activity, they should not generally be used alone for the treatment of RAO.

Image 2: Metered-dose inhaler

Systemic anti-cholinergic drugs are not recommended for longterm management of RAO due to their potentially severe side effects (CNS toxicity, ileus, mydriasis, tachycardia, etc). Atropine (5-7 mg IV/450 kg) can be administered as a rescue medication during a severe airway obstruction episode. Ipratroprium bromide is a synthetic anti-cholinergic drug that is administered via inhalation and produces bronchodilation, inhibits cough and protects against bronchoconstrictive stimuli. Its duration of effect is four to six hours, and it is administered at 90-180 µg/horse in an MDI (AeroHippus and the Equine Haler™). Aerosolized corticosteroids are effective in horses with IAD and with mild-moderate RAO, and they can be used in conjunction with systemic therapy in severe cases. The two aerosolized preparations for administration to horses via the Equine Haler™ are beclomethasone diproprionate (3500 µg/horse every 12 hours via MDI) and fluticasone propionate (2000 µg/ horse every 12 hours via MDI; typically 8-10 puffs/500 kg of a 220 µg/puff MDI twice daily). Fluticasone is the most potent and expensive inhaled corticosteroid, and due to its low oral bioavailability, it has the least potential for adrenal suppression. In affected horses, fluticasone proprionate reduces pulmonary neutrophilia, improves parameters of pulmonary function, reduces responsiveness to histamine challenge and speeds clinical recovery. Although the therapeutic effect is not immediate, pulmonary function typically begins to improve within 24 hours after administration of aerosolized corticosteroids. Additionally,

20  The Practitioner  Issue 2 • 2018


You are Invited





DVM, PhD, Assoc. LA-ECVDI, DACVSMR, ISELP Certified Instructor

rn EaC E 6 urs Ho

Internationally renowned professor of veterinary anatomy and equine lamenesses at the École Nationale Vétérinaire d’Alfort, France. Dr. Denoix is considered the world’s foremost equine musculoskeletal system anatomist. He will present his “Demonstration of Focused Physical Examination & Biomechanical Evaluation of the Live Horse.” He will also offer four hours of lectures during the symposium.

An Oasis of Serene Elegance




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OCTOBER 18-21, 2018














O NA L PA RT N E R S I T A C U D E 19 2018-20






Friday, October 19

Rehabilitation CASE STUDIES


8:00 a.m. 8:50 a.m.

8:55 a.m. 9:45 a.m.

Case studies presented by each speaker will follow the progression from diagnosis through the rehabilitation process. The focus will be on the following: 1. Preventing injury and improving poor performance 2. Science-based rehabilitation protocols when injury occurs

Room 1

Diagnostic Techniques: Specificity and Sensitivity for Stifle Disease Including How Standing Stifle Arthroscopy Fits In Dr. Frisbie

Video Gait Analysis of Runners Focusing on the Relationship of the Spine and Lower Limb in Creating Dysfunction in Knee Mechanics Dr. Flynn

Intra-Articular Biologics

Video Gait Analysis of the Horse: Common Problems of the Stifle

Dr. Frisbie


10:30 a.m. 11:20 a.m.

11:25 a.m. 12:15 p.m.

Room 1

Navicular Bursa Dr. Riggs

PRP in Acute Injury Dr. Riggs

Pain Recognition and Management: What’s New?

2:40 p.m. 3:30 p.m.

Case-Based Approach to Pain Management

Dr. Sanchez

1:45 p.m. 2:35 p.m.

2:40 p.m. 3:30 p.m.

Dr. Sanchez 3:30 p.m. - 4:00 p.m. Break

Dr. le Jeune Exercise Treatment Strategies and Functional Integration Focusing on the Knee Dr. Flynn

Nonexertional Rhabdomyolysis and Immune-Mediated Myositis

Exercise and Treatment Strategies Focusing on the Stifle in the Horse

Dr. Valberg

Dr. Schills

Genetic Testing: What Tests Are Available and When to Use Them

Integrative Rehabilitation Protocols for Stifle Dysfunction

Dr. Valberg

Dr. le Jeune

3:30 p.m. - 4:00 p.m. Break - Visit the Exhibit Hall

Working up Stifle Abnormalities, the Clinical Side Dr. Frisbie

4:00 p.m. 4:50 p.m.

Ocular Manifestations of Systemic Disease and Systemic Manifestations of Ocular Disease Dr. Sanchez

4:55 p.m. 5:45 p.m.

Integrative Rehabilitation Protocols for the Postoperative Stifle Patient

12:15 p.m. - 1:45 p.m. Complimentary Lunch in the Exhibit Hall

1:45 p.m. 2:35 p.m.

4:00 p.m. 4:50 p.m.

Dr. Schills

9:45 a.m. - 10:30 a.m. Break - Visit the Exhibit Hall

Attendees will leave with some solid ideas on protocols that can be used in their practices!

Thursday, October 18

Room 2

Specific Surgical Treatments to be Aware of in the Stifle Dr. Frisbie

Drs. Schils, le Jeune & Flynn Rehabilitation Cases

4:55 p.m. 5:45 p.m.

5:45 p.m. - 7:00 p.m. Reception - Exhibit Hall

Rehabilitation Cases

Drs. Schils, le Jeune & Flynn 5:45 p.m. - 7:00 p.m. Reception - Exhibit Hall


 AAVSB RACE, RACE Provider #532  Sponsor of Continuing Education in New York State  Florida Board of Veterinary Medicine, DBPR FVMA Provider # 31


This program 532-33238 is approved by the AAVSB RACE to offer a total of 37.00 CE Credits (24.00 max) being available to any one veterinarian: and/or 37.00 Veterinary Technician CE Credits (24.00 max). This RACE approval is for the subject matter categories of: Category One: Scientific | Category Two: Non-Scientific-Clinical | Category Three: Non-Scientific-Practice Management/Professional Development using the delivery method of Seminar/LectureLab/Wet Lab. This approval is valid in jurisdictions which recognize AAVSB RACE; however, participants are responsible for ascertaining each board's CE requirements. RACE does not "accredit" or "endorse" or "certify" any program or person, nor does RACE approval validate the content of the program.

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Saturday, October 20 Time

8:00 a.m. 8:50 a.m.

Room 1

Sunday, October 21

Offsite Location

Biomechanics & Ultrasound Wet Lab

Endocrine Disease in the Horse: Is it EMS, ID or PPID? Dr. McFarlane

Dr. Jean-Marie Denoix 8:00 a.m. - 5:30 p.m.

8:55 a.m. 9:45 a.m.

Understanding the Diagnostic Tests for Equine Endocrine Disease Dr. McFarlane 9:45 a.m. - 10:30 a.m. Break - Visit the Exhibit Hall

10:30 a.m. 11:20 a.m.

11:25 a.m. 12:15 p.m.

Clinical Applications of Laminitis Research

2:30 p.m. 3:20 p.m.

5:15 p.m. 6:05 p.m.

7:00 a.m. 7:50 a.m.

BASIC: 3 cases: Diagnosis, Management and Outcome (P3 Fracture, Biceps Brachii Trauma, and Laceration to the SDFT of Hind Limb) Dr. Denoix

8:00 a.m. 8:50 a.m.

BASIC: 3 cases: Diagnosis, Management and Outcome (P3 Fracture, Biceps Brachii Trauma, and Laceration to the SDFT of Hind Limb) Dr. Denoix

9:20 a.m. 10:10 a.m.

General Assembly: 8:00 a.m. – 10:30 a.m.

Dr. Riggs Electrophysical Rehabilitation Modalities: EvidenceBased Medicine Dr. Riggs

Hands-on (Group 1): 10:30 a.m. – 1:45 p.m.

10:15 a.m. 11:05 a.m.

Lunch: 1:45 p.m. – 2:30 p.m. Hands-on (Group 2): 2:30 p.m. – 5:45 p.m.

REHABILITATION (1) Lowering of the Neck: Biomechanics and Indications. (2) Back Up: Biomechanics and Indications (3) Muscle Injuries: Ultrasound Diagnosis and Rehabilitation Dr. Denoix REHABILITATION (1) Lowering of the Neck: Biomechanics and Indications. (2) Back Up: Biomechanics and Indications (3) Muscle Injuries: Ultrasound Diagnosis and Rehabilitation Dr. Denoix

Sunday Featured Speaker: Dr. Jean-Marie Denoix,

Managing Endocrine Disease in the Horse

Equine Musculoskeletal System Anatomist

Dr. McFarlane

Dr. Jean-Marie Denoix (Normandy, France) will be teaching lectures on Sunday, October 21 at PES 2018. Dr. Denoix is known for drawing crowds for his lectures about clinical examination and imaging of locomotor problems. His lectures will include the following case study topics:

An Update on Polysaccharide Storage Myopathy and Myofibrillar Myopathy in Warmblood Horses Dr. Valberg

• The diagnosis, management and outcome of main conditions of the hip in horses • Rehabilitation: ▶ reviewing the biomechanics and indication of lowering the neck and back up ▶ ultrasound diagnosis and rehabilitation of muscle injuries

3:20 p.m. - 4:20 p.m. Break - Visit the Exhibit Hall 4:20 p.m. 5:10 p.m.

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Naples Therapeutic Riding Center


Exertional Rhabdomyolysis in Endurance Horses Dr. Valberg

Don’t miss out on your chance to attend CE classes from the leading equine diagnostic ultrasonographer!

Medicine Case Studies Drs. Valberg & McFarlane

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age of onset in RAO-affected horses is 9-12 years, and both genders are commonly affected. Winter and spring appear to be the most common seasons for exacerbation of RAO. There does appear to be a heritable component to the etiology of this condition. The incidence of RAO in horses with healthy parents is approximately 10%, which increases to 44% if two parents are affected.


Clinical signs of RAO typically include a chronic cough, nasal discharge and a prolonged labored phase of expiration. The classic “heave line” is due to hypertrophy of the abdominal muscles which are assisting in respiration. Flared nostrils and tachypnea are frequently observed. On thoracic auscultation, wheezes, tracheal rattles and over-expanded lung fields may be present. Crackles may also be heard secondary to excessive mucus production in the lower airways. Severe cases may also exhibit weight loss, cachexia and exercise intolerance. Horses are typically afebrile with normal complete blood cell count and serum biochemical profile, unless a secondary bacterial pneumonia has occurred.


Diagnosis of equine asthma can be done on the basis of history and characteristic clinical examination findings in the majority of horses. Additional diagnostics to confirm and characterize the pulmonary inflammation include transtracheal aspiration (TTA), bronchoalveolar lavage (BAL), endoscopy (assessment of tracheal mucus), thoracic radiographs and ultrasound examination. Transtracheal aspiration can be done to characterize inflammation in the lower airways and to determine if sepsis is present. The presence of degenerative neutrophils and intracellular bacterial organisms suggests sepsis and warrants culture, as well as appropriate antimicrobial therapy. Typical RAO cases have no evidence of sepsis, and TTA results are consistent with mucopurulent (neutrophilic) inflammation. Bronchoalveolar lavage is indicated in horses with poor performance and coughing, and is not compulsory in horses with severe disease and suggestive clinical signs. Neutrophilic inflammation (with 20-70% of neutophils in total cell count, normal neutrophil count is <5-10%) confirms the presence of lower airway inflammation and is suggestive of RAO. Curschmann’s spirals may be present on cytologic evaluation of TTA and BAL samples, and represent inspissated mucus plugs from the obstructed small airways. BALs in horses with IAD typically demonstrate mixed inflammation with 5- 10% neutrophils and occasionally increased mast cells (>2-5%) or eosinophils (>1-5%). Thoracic radiographs will often demonstrate an increased broncho-interstitial pattern throughout the lung fields. These changes may be difficult to differentiate from normal ageing changes in older adults. Radiographs are recommended for horses that fail to respond to standard therapy or to further characterize pulmonary inflammation. Horses that have more WWW.FAEP.NET |

respiratory difficulty on inspiration rather than expiration may have interstitial pneumonia or pulmonary fibrosis, and radiographs are indicated to better characterize lung disease in these cases. Ultrasound may be utilized if primary or secondary infectious pulmonary disease is suspected. Lung function tests in horses with RAO typically demonstrate hypoxemia without hypercarbia due to V/Q mismatch. Function abnormalities will often include high resistance and poor compliance of the lungs with increased dead space ventilation. Lung function testing is not widely available, but it can be performed at The University of Florida and many other referral centers. It is beneficial to perform lung function testing in more subtle cases of poor performance and mild-moderate asthma (IAD).


The most important treatment for severe equine asthma is environmental management to reduce exposure to organic dusts and mold. As previously mentioned, the most common antigens are organic dusts, mold and endotoxin present in hay and straw. Round bale hay is high in endotoxin and organic dust content, and the presence of round bale hay is a potential cause of treatment failure in horses on pasture. Maintaining horses on pasture full time is generally recommended. Horses that must be stalled should be kept in a clean, well-ventilated environment and ideally be transitioned to a complete pelleted feed. Straw is not recommended as bedding for RAO-affected horses. Soaking hay, for at least two hours, and feed may alleviate the signs in mildly affected individuals; however, soaked hay may still exacerbate RAO in more severely affected cases. It is important to remember that although medications will alleviate the clinical signs of disease, respiratory disease will return if the horse remains in a mold- or dust-filled environment once the medications are discontinued. One study by Nogradi et al. demonstrated that supplementing the diet with Omega‐3 fatty acids, specifically docosahexaenoic acid (1.5 g/day for two months), in addition to switching horses to a low‐dust diet, was shown to provide more rapid improvement (within one to two weeks) in clinical signs of IAD and RAO when compared to only low‐dust diet (at least four to five weeks). Systemic corticosteroids and aerosolized bronchodilators are the most immediately helpful therapy for a horse in respiratory distress. Intravenous administration of Dexamethasone (0.1 mg/kg) should improve lung function within two hours of administration for severe cases. Dexamethasone has an oral bioavailability of about 60% and will improve pulmonary function within six hours if given by this route. Dexamethasone may be continued for one to several weeks at a tapering dose (usually quarter the dose every three to five days) for severe cases. For management of less severely affected cases of RAO, prednisolone is generally considered to be less potent and toxic than the previously mentioned drugs. Prednisolone should be administered at 1.0-2.2 mg/kg orally once daily for a week and then gradually tapered. Oral prednisone is poorly bioavailable and not recommended for treatment of RAO in horses. - Continued on page 20


@FLORIDA_VMA | The Practitioner  13

horses in apparent “remission” from RAO may benefit from lowdose, long-term aerosolized corticosteroid treatment.

References 1. ACVIM Revised Consensus Statement https://onlinelibrary. 2. Rush B. ACVIM Forum Proceedings 2006, pp 177-182. 3. Ainsworth DM, Hackett RP. Equine Internal Medicine, 2004, pp 333-336. 4. Lavoie, JP. Current Therapy in Equine Medicine 5, 2003, pp 417-421. 5. Couteil L et al. J Am Vet Med Assoc. 2003; 223 (11): 1645. 6. Couteil L et al. Am J Vet Res. 2005; 66 (10):1665. 7. Abraham G et al. Equine Vet J, 2003; 34 (6):587. 8. 9.

Amanda M. House, DVM, DACVIM Dr. House is a clinical professor in the Department of Large Animal Clinical Sciences at the University of Florida’s College of Veterinary Medicine. She is the director of student affairs and coordinates equine continuing education and outreach programs at the UF College of Veterinary Medicine. Dr. House is also the director of the practice-based equine clerkship program, which enables veterinary students at UF to have a clinical ambulatory rotation with private practitioners. She completed her B.S. in animal science from Cornell University. After graduating from Tufts University School of Veterinary Medicine in 2001, Dr. House completed an internship and large animal internal medicine residency at the University of Georgia’s Veterinary Teaching Hospital. Dr. House became board certified in large animal internal medicine in 2005. Her professional interests include neonatology, communication training, infectious disease and preventative health care. Dr. House became a faculty trainer for the Bayer Communication Project/Institute for Healthcare Communication modules for veterinary medicine in 2012. Dr. House is active on committees for the American Association of Equine Practitioners and the Florida Association of Equine Practitioners. She was president of the Florida Association of Equine Practitioners in 2010 and is currently on the FAEP Council.

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@FLORIDA_VMA | The Practitioner  21

THE IMPORTANCE OF WARM-UP AND ITS ROLE IN INJURY REDUCTION ERICA MCKENZIE | BSc, BVMS, Ph.D. DACVIM, DACVSMR Warming-up before focused exercise is a well-established critical factor in optimizing athletic performance. Warm-up activity can significantly influence the success of subsequent performance and initiates physiologic changes that promote a favorable environment for continued or high intensity exertion, while reducing the risk of soft tissue injury or technical faults. Warm-up should be considered a staple of any exercise bout, whether in training or before competition, to optimize the training benefits of the exercise stimulus and to prevent post-exercise soreness, injury or re-injury. Although warm-up routines will typically have specific or novel features that depend on the athletic activity that is to follow, there are also basic tenets that can be followed to ensure that the desired benefits of warming-up are achieved.

substrates and delaying fatigue. Non-temperature-related benefits include improved blood flow and oxygen supply to muscles as a result of increased heart rate, respiratory rate and splenic contraction; increased muscle power output; increased muscle fiber recruitment, reducing individual fiber load; mental preparation of horse and rider; and, finally, assessment of equipment function and potential review of the competition course. In regard to preventing injury specifically, greater force is required to injure a warmer muscle due to greater pliability of muscle tissue and muscle-tendon junctions, and improved range of motion. Improved metabolic processes also likely reduce the probability of post-exercise or delayed onset soreness.

Image 1: Warm-up is beneficial to nearly all athletic disciplines.

Image 2: Warm-up should be performed in a safe environment with minimal distraction.

Warm-up activity should ideally be performed prior to all directed work in training and competition, and it should be accounted for in the total duration or volume of work. Wherever possible, it should be “built into” the daily exercise regimen to enhance compliance, therefore, it must be practical, as convenient as possible, and designed to appropriately prepare the relevant muscles, tendons and ligaments for the impending exercise session. The physiologic effects of warm-up are multiple and are often separated into effects that relate to the increases in body temperature (of usually about 1-2o F) and nontemperature-related effects. Temperature-related effects include improved muscle, tendon and ligament flexibility, and increased muscle fiber, nerve conduction velocity and muscle relaxation rate which aids coordination and technical performance. Increased body temperature also promotes more rapid release of oxygen molecules from hemoglobin and myoglobin, and it also enhances metabolic processes, which increases aerobic contributions to energy supply subsequently preserving muscle

Warm-up activity can be classified into various types and phases. Warm-up type describes passive versus active warm-up, which is simply based on whether exercise occurs during the warm-up period. Passive warm-up is not commonly practiced in horses and involves applying external heat sources to specific parts (such as limbs) or to all of the body to raise core and/or muscle temperature. Methods include the use of warm water, heated rooms, or application of clothing or blankets. Passive warm-up is most often performed to create warming while avoiding depletion of intracellular substrates within the muscle prior to competition; however, it likely also has value when there are periods of rest between consecutive bouts of exercise if active work during the lull is not feasible or possible. Although passive warm-up avoids depletion of intracellular substrates and the risk of injury prior to competition, it is not particularly effective at increasing body or muscle temperatures. Furthermore, it will not provide the non-temperature-related effects derived from active warm-up techniques.

22  The Practitioner  Issue 2 • 2018

Active warm-up is broadly applicable to equine athletes regardless occurring when their speed is restricted during the initial phase of their discipline and involves applying gentle exercise stress of training exercise. Keeping that in mind, a thoughtful and that progressively increases in intensity or technical complexity, appropriate warm-up routine is ideally created on an individual preparing the horse appropriately for the impending focus basis based on the athletic discipline in question, along with activity. Active warm-up generates both temperature- and non- considering the horse and rider’s needs and desires. (Image 2) temperature-related benefits. Although exercise during warm-up also begins to create thermoregulatory stress on the athlete, there Warm-up activity should be divided into distinct phases, which is evidence to suggest that warm-up exercise can actually reduce is particularly important when preparing for demanding or total heat accumulation during intense exercise efforts, which technically complex activities. Phases are usually described in a is a critical regulator of pacing. Furthermore, active warm-up manner that reflects the activity that will be performed, such as can promote technical competence by employing drills that non-specific and specific phases; flatwork and jumping phases; emulate the impending competition activity. This might include or slow-work and fast-work phases, depending on the discipline proceeding over low jumps prior to a jumping competition or in question. Regardless, the general concept is similar in that the practicing modified versions of complicated dressage maneuvers activity should begin with uncomplicated, low-intensity work to improve horse responsiveness and whole body malleability and then should progress to more technical, specific or intense before entering the arena. (Image 1) efforts as warm-up continues. Ideally, the warm-up must include some component that specifically emulates the activity that the There are critical features that should be considered in the horse is preparing for. As stated, horses that will be jumping design of an appropriate warm-up session. It should always should cover several obstacles of increasing height to prepare be performed in a safe environment, as free as possible from their backs and limbs, in addition to helping the team work out distraction and stress so that the horse and rider can concentrate any technical issues with approaches and landings. Horses that on working as a team and continue that collaboration into their will be performing hard work expected to induce a rise in blood event. Warm-up activities must be timed appropriately to allow lactate should have some component of high intensity toward an adequate duration of time to gain body temperature and to the end of their warm-up. Incorporating high intensity efforts work into and complete any technical drills without leaving a (short bouts at 60 to >100% of maximal oxygen uptake) has long delay before competition. Ideally, warm-up exercise should been shown to positively influence subsequent oxygen delivery end with transition within minutes into the focused training or and lactate clearance in horses exercising immediately after the competition activity to avoid incidental cooling down. If this warm-up period. These high intensity efforts should be short in is not possible, external warming can be attempted to try to duration to avoid intracellular substrate depletion and the risk preserve the effects of the warm-up preparation such as placing of reduced power output or incidental injury prior to the main a warm blanket. exercise effort. They are also important because changes will only occur in muscle fibers that are actually recruited during an effort; The duration of warm-up sessions will vary depending on therefore, high intensity intervals are required to affect the highly what needs to be accomplished and what time is available, and glycolytic type IIX fibers, which may not be recruited until 70 to should also be modified depending on the ambient temperature. 80% of racing speed is achieved. (Image 3) Warm-up activity should be longer in cold conditions and shorter in hot conditions to achieve appropriate muscle temperatures without excessive heat accumulation. Ideally, a minimum of 10 minutes should be dedicated to this task to allow enough time for muscle and body temperatures to increase and stabilize; however, warm-up might be as long as 40 minutes depending on individual horse and rider needs and the ambient temperature. Warm-up in specific sports, such as Polo, can reportedly last as little as five minutes; though, this is not necessarily ideal from a physiologic perspective. In one high-level jumping competition in which warm-up time and activities were assessed, riders spent an average of 19 minutes warming-up (range six to 31 minutes) with about 10 to 12 minutes of flatwork exercise and about seven minutes of jumping. Warm-up time tends to be longer at higher level than lower level competition, which might reflect greater rider experience and focus. In endurance racing, warm-up may even be built into the first phase of the race by holding horses to a slower pace for the first few miles. This is less desirable than a dedicated warm-up, since some horses become hyper-stimulated during competition and may be more difficult to control and predisposed to episodes of rhabdomyolysis. A Image 3: Adding bouts of intensity to the warm-up is important to similar phenomenon is reported in Thoroughbred racehorses consider in high intensity disciplines such as track-racing. with recurrent rhabdomyolysis, with clinical disease commonly WWW.FAEP.NET |


@FLORIDA_VMA | The Practitioner  23

Warm-up exercise should be repeated if horses are participating in competitions or training exercises that are comprised of repetitive bouts of effort. Incidental cooling down between exercise bouts has been shown in a variety of human athletic disciplines to impair subsequent performance measured through variables such as jump height, sprint speed, muscle temperature and blood lactate accumulation. This has given rise to the concept of “re-warm-up.” This can involve continuous low-grade activity with or without concurrent passive warming during short breaks from exercise, or a period of rest followed by a bout of repeat warm-up exercise if longer breaks from competition are encountered. Stretching is commonly included in the warm-up period for human athletes and is a controversial topic. Multiple studies suggest that static stretching before exercise, in which a muscle is positioned at the end of its range of motion and held there for 15 to 60 seconds, can impair performance, particularly in events that require higher power output or speed. This negative effect can last possibly as long as two hours and tends to be more profound with increased duration of static stretching of a muscle. Impaired performance has been demonstrated consistently through a variety of different measures, including assessment of muscle force and torque, lifting ability, jump and sprint performance, and also measures of balance. Furthermore, there is no evidence that static stretching reduces the risk of injury despite the fact that it often increases range of motion. For this reason, dynamic stretching techniques have become more popular in human athletes since they may improve performance, or at least do not appear to harm it. Dynamic stretching is performed by moving through an active range of motion for relevant joints in a manner that emulates the impending exercise activity. However, in sports that requires a high degree of static flexibility, it may benefit the athlete to perform brief static stretches of low intensity. If static stretching is to be included, the stretch should not be applied to the point of discomfort, and the total stretch duration on any muscle should be less than 30 seconds, even if stretching is applied in individual bouts. Static stretching is probably most appropriate where increased range of motion is considered desirable/ protective and when the subsequent exercise to be performed does not require maximal power output, high velocities, quick changes in direction or optimal running economy. Dynamic stretching emulates normal activity more closely and should not extend muscles beyond their usual range of motion. Dynamic stretches should be designed to emulate the activity the animal will perform, and total durations of seven to 10 minutes have been shown to have positive effects on human performance. In some studies, dynamic stretching has been shown to improve static flexibility to a similar degree as static stretching yet without impairments to performance. Possible reasons why dynamic stretching is beneficial include increased muscle temperature, improved muscle recruitment and response, and possibly decreased inhibition of antagonist muscles which can improve force and power output. If it is to be used, dynamic stretching is best inserted into the warm-up after the general slow or flatwork phases, and before sport specific activities are used to complete the warm-up.

Dynamic stretches for the horse are also known as dynamic mobilization exercises, baited stretches or “carrot stretches.” They are typically performed from the ground with voluntary participation from the horse as it attempts to follow something enticing with its head and neck, keeping the feet in a fixed position on a safe surface. The main benefits that are reported are recruitment of the back and abdominal musculature with increased flexibility and range of motion in the spinal column. When repeated over time, there is evidence that these exercises can develop the musculature of the spine, which is challenging to achieve without targeted exercises. These stretches can be performed within or independent from warm-up activities in repetitions of three to five, four to seven days per week. One other aspect surrounding warm-up that is relevant to human athletes and may potentially have utility for some horses is that of pre-cooling, which is the deliberate cooling of the body prior to exercise to create greater capacity for thermoregulatory load. Multiple studies have demonstrated that pre-cooling improves performance and endurance in a variety of moderate to longduration sports, particularly in hot ambient conditions, since thermal stress represents a key influence on pacing. Humans perform pre-cooling in a variety of ways, including through the use of ice baths, cold vests and ingestion of ice slurries prior to exercise. Obviously, this competes with the concept of warming-up before exercise, but recent work suggests that both warm-up and the thermoregulatory performance benefits of precooling can be achieved if athletes ingest ice slurries after the warm-up period is complete instead of beforehand. Finally, “warm-down” should be performed at the end of exercise activities. Active warm-down is preferred, where the athlete continues low-intensity exercise instead of sudden cessation of activity in favor of events such as stretching since it has been shown to reduce post-exercise soreness and enhance lactate conversion. Warm-down should probably be about half of the duration of the warm-up and can be performed at 30 to 65% of maximal oxygen consumption. Post-exercise nutrition is also a key component that should be considered after training or competition; however, the benefits of targeted nutritional strategies at the end of exercise in horses are limited by the notoriously slow rate of muscle glycogen repletion in this species.

References 1. Behm DG, Chaouachi A. A review of the acute effects of static and dynamic stretching on performance. Eur J Appl Physiol 2011;111:2633–2651. 2. Bishop D. Warm up I: potential mechanisms and the effects of passive warm up on exercise performance. Sports Med 2003;33(6):439-54. 3. Bishop D. Warm up II: performance changes following active warm up and how to structure the warm up. Sports Med 2003;33(7):483-98. 4. Lacombe VA, Hinchcliff KW, Taylor LE. Interactions of substrate availability, exercise performance, and nutrition with

24  The Practitioner  Issue 2 • 2018

muscle glycogen metabolism in horses. J Am Vet Med Assoc 2003;223(11):1576-85. 5. McGowan CJ, Pyne DB, Thompson KG, Rattray B. Warm-Up Strategies for Sport and Exercise: Mechanisms and Applications. Sports Med 2015;45(11):1523-46. 6. Steiss JE. Muscle disorders and rehabilitation in canine athletes. Vet Clin North Am Small Anim Pract 2002;32(1):267-85. 7. Stubbs NC, Kaiser LJ, Hauptman J, Clayton HM. Dynamic mobilisation exercises increase cross sectional area of musculus multifidus. Equine Vet J 2011;43(5):522-9. 8. Takeshima K, Onitsuka S, Xinyan Z, Hasegawa H. Effect of the timing of ice slurry ingestion for precooling on endurance exercise capacity in a warm environment. J Therm Biol 2017;65:26-31. 9. Votion D. Metabolic responses to exercise and training. In: Hinchcliff, KW, Kaneps AJ, Geor RJ, eds. Equine Sports Medicine and Surgery, 2nd ed. Saunders Elsevier, 2014;757.


Erica McKenzie BSc, BVMS, Ph.D., DACVIM, DACVSMR Dr. Erica McKenzie graduated from Murdoch University, Western Australia in 1996 before completing a combined large animal medicine residency/Ph.D. program at the University of Minnesota in 2003, investigating nutritional and pharmacologic methods of controlling "tying-up" in Thoroughbred horses. This was followed by a twoyear post-doctoral fellowship at Oklahoma State University Performance Laboratory performing research investigations in exercising horses and racing sled dogs. Dr. McKenzie has been a faculty member at Oregon State University since 2005. She is a charter diplomate and member of the board of directors for the American College of Veterinary Sports Medicine and Rehabilitation, editorial chair for the International Conference on Equine Exercise Physiology, and the author of more than 30 research manuscripts relevant to exercising horses and dogs. Special interests include characterization and prevention of myopathies in horses; the factors relevant to successful athletic performance; and features of nutrition and disease relevant to long-distance exercise in horses, dogs and humans.


@FLORIDA_VMA | The Practitioner  25

PRINCIPLES OF INFECTIOUS DISEASE CONTROL JOSIE TRAUB-DARGATZ | DVM, MS, DACVIM Photos courtesy of Katie Flynn, BVMS, California Department of Food and Agriculture


Infectious diseases include those caused by a wide variety of pathogens, including viruses, bacteria and parasites. Not all infectious diseases are contagious. West Nile Virus (WNV) is an infectious disease of horses but not a contagious disease of horses. WNV is not spread from horse to horse. It is an example of an infectious but not contagious pathogen. Instead, horses are infected with WNV by the bite of a mosquito carrying the virus which it acquired from an infected bird. Examples of contagious disease agents would be equine influenza, equine herpesviruses and Streptococcus equi subspecies equi. For these contagious disease agents, direct horse to horse transmission is possible, but the pathogen can also be acquired from contaminated environments or fomites. For these contagious disease agents, unlike the WNV example, an intermediate host is not required. In addition, some equine diseases can endanger the well-being of the people who work with them (zoonoses). Some examples of these diseases include rabies and salmonellosis. Infection control at the highest level addresses two main areas: reducing risk of exposure and reducing risk of disease if exposure occurs. Optimizing resistance to disease has largely relied on technologies such as implementation of vaccination against selected disease agents and, to a lesser extent, on providing support for resistance to disease by providing optimal nutrition to support of the immune system as well as management to reduce stress. It is important to acknowledge there are diseases for which there are no vaccines and few vaccines protect all animals to which they are given. Reducing risk of exposure relies on general biosecurity principles with additional emphasis on specific control points based on the epidemiology of each disease condition. In determining options for infection control, those diseases of highest concern to the individual owner/operation should be the main focus. The level of concern for the owner/ operation may be related to a combination of the likelihood of exposure and disease occurrence, as well as the expected consequences of the disease should it occur. The selection and application of biosecurity principles will be the emphasis of this article.

all facilities and various equine populations, each equine operation should have a tailored infection control plan specifically designed for their equine population or facility. Practices designed to control infectious disease are only as effective as the weakest link in their implementation. For example, if nine of 10 equine care providers wash their hands when moving between segregated horses (different cohorts), the one provider that does not comply with the hand washing protocols can introduce or spread pathogens even though the other nine people did the right thing. Therefore, it is important that all those involved with equine care are oriented on the protocols and held accountable for adhering to the infection control plan. Options for controlling infectious diseases can be placed into two broad categories: actions that reduce the risk of horses being exposed to pathogens and actions taken that optimize resistance to infection or disease if exposure occurs. Advances have occurred in both categories during the last several decades.


An infection-control plan should take into account the level of disease risk; the risk aversion of stakeholders; and, for some diseases, the standards set by rules and regulations of the State Animal Health Official, USDA- APHIS-VS, or those overseeing a plan for an equine event. Every equine facility or equine population is unique. Even though overarching general principles for infection control apply across

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During equine events, horses commingle in confined spaces for the purpose of competition, exercise or stabling. Without a complete physical examination and diagnostic testing, the health status of these horses remains unknown. There is potential for an apparently healthy horse to be incubating and possibly shedding a disease agent.

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OPTIONS FOR INFECTION CONTROL Administering vaccines optimizes resistance to infection for at-risk equids. The American Association of Equine Practitioners (AAEP) has vaccination guidelines which are reviewed regularly and updated as needed.1 Equine practitioners play a key role in tailoring the vaccination recommendations for the horses they care for and in many instances often administer the vaccines to their patients. Recently, vaccines have been developed and licensed for control of selected equine diseases. For example, West Nile Virus (WNV) was first recognized in the United States in 1999. By summer 2001, a conditionally licensed vaccine was available for immunizing U.S. equids against WNV. Subsequently, this first WNV vaccine became fully licensed. Thereafter, new vaccine technology that had never been used in the production of equine vaccines was implemented in order to develop vaccine products for controlling WNV in equids. Examples of other relatively new vaccines for horses include vaccines for controlling Rhinitis virus, Pigeon Fever and Leptospirosis. An important point that practitioners can make while developing a vaccination plan for the operation’s equids is that vaccination alone, in the absence of good management practices directed at infection control, is not sufficient to prevent infectious disease. Furthermore, the use of technologies, such as vaccines and antimicrobials, where appropriate can be synergistic with implementation of disease agent exposure management. In addition to the use of vaccines, there are other options for improving resistance to disease, including providing optimal nutrition and reducing stress where possible. Transport can

result in stress due to confinement, movement, temperature fluctuations and noise. In addition, the presence of exhaust can physically impair the mucocilliary apparatus. An increase in the density of organisms in the inspired air due to confinement in some types of transport systems can also be a concern.2 Options to reduce stress that could be reviewed with equine clients include recommendations to: haul compatible horses together, where possible allow the horse to assume the orientation in the transport conveyance that is most comfortable for that horse, allow the horse to lower its head periodically in order to clear its airway, and transport during optimal environmental conditions when possible. Some studies suggest that horses are less stressed when hauled in a slant load trailer or in a transport that allows them to assume a face-rear position so that they can better balance their weight particularly during stops and starts.3-5 In a study of elevated body temperature among horses arriving at the air/ocean U.S. import centers, young horses (less than 4 years of age) were at higher risk of having an elevated temperature after transport.6 It is possible that younger age was a surrogate for lack of experience with air transport and/or susceptibility to transport stress.6 The findings in this study of recently transported horses suggests an emphasis should be placed on managing the stress of transport for young horses. An association between nutritional supplementation and risk for equine herpesvirus myeloencephalopathy (EHM) was found in a recent study. In this case control study, horses receiving a feed supplement containing zinc prior to exposure at an equine event were found to be at lower risk for development of EHM when compared with horses not receiving such a feed supplement.7 Although a causal protective effect of zinc cannot be assumed from this field-based epidemiologic study, it suggests the need to explore the effect of zinc supplementation on susceptibility to EHM. Reducing the risk of exposure to infectious disease pathogens is often equated to biosecurity practices, which requires understanding of how disease agents might be introduced and spread once introduced. Once there is an understanding of how disease agents may be introduced or spread, management interventions can then be developed to address potential control options. Today, equine veterinarians face sophisticated, often daunting, challenges. To effectively prepare and plan for a disease outbreak, veterinarians must have a good understanding of modern resources and strategies. In addition, veterinarians need to have the trust and financial support of owners, farm managers and event organizers. The main emphasis of this article in the principles of infection control will be on options for reducing exposure to disease pathogens.

IMPLEMENTING INFECTION CONTROL MEASURES Temperature monitoring is an easy, efficient, early detection tool for disease. By requiring recording of temperatures twice daily on a log displayed on stall, event management can easily monitor health of the horses on the event grounds.


Most university veterinary teaching hospitals have an infection control program. Some have dedicated personnel to oversee the implementation of the program and monitor the effectiveness of the biosecurity standard operating procedures (SOPs). Animals that are admitted to a veterinary hospital for evaluation and care are a different population than those in the general population. FLORIDAAEP |

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appropriate actions to restrict the spread of disease. Initial infection control measures should be aimed at limiting secondary exposure and controlling a possible outbreak until there is evidence confirming that no contagious disease is present.

Congregating horses creates the potential for exposure to disease agents by direct contact with another horse or indirect contact with a surface potentially contaminated with an infectious disease agent.

The hospital population is potentially at greater risk of shedding a pathogen — after all, the hospital is where sick horses go for care. However, they are also more likely to acquire an infection due to alteration in diet, recent transport and their underlying condition that brought them to the hospital. Having a standard of care at a veterinary hospital that is higher than is necessary for the general population is warranted; thus, the infection control programs at veterinary hospitals are more rigorous than those needed on most equine farms or at equine event facilities. With that said, there still is a need for an infectious disease control plan even at the small farm and event facility using lessons learned from biosecurity practices implemented in the hospital setting. Identifying facilities that can be used for isolation, whether to prevent disease introduction or to limit the spread of disease, is an important part of an infection control plan. Implementing effective isolation measures requires predetermined protocols to identify which equids should be isolated and to address personnel and vehicle movement, ventilation, insect control, handling of soiled bedding and waste feed, use of dedicated equipment, and assuring the availability of adequate supplies and facilities to implement the protocols. However, during some of the most important high-risk situations (e.g. where horses congregate and commingle), there is often no provision for isolation options, and there are no protocols for isolation of a contagious disease case(s) in a timely and effective manner. Often, the veterinary practitioner’s initial role is to respond to a suspect infectious disease event. The equine practitioner is likely to be the first medical professional to examine an infectious disease case. Some key steps the veterinarian can take when responding to a suspected infectious disease situation are: 1. Do no harm. Do not rush into a facility or a stall until you have a plan. 2. Take biosecurity precautions to avoid worsening the situation. 3. Communicate the findings to the equine owner, farm manager/owner and event organizer (if the horse is at an event when it becomes sick). At the same time, take

Veterinarians should carry a kit in their vehicle with materials designed to reduce the likelihood of them spreading disease agents from horse to horse. The kit should contain examination gloves (a pair for each horse to be examined), coveralls dedicated to each horse’s examination or to a group of animals of equal disease status, a covering for the upper body impervious to secretions such as nasal discharge, water proof footwear covers, and some kind of head covering. Once barrier precautions are removed, a disinfectant solution should be applied to the sole of footwear after the waterproof covers are removed, and a supply of hand sanitizer or access to soap and water should be available. If there is need for ongoing heightened biosecurity protocols, additional supplies can be ordered but a first response kit will allow the practitioner to use good hygiene in examination of the index case(s). Whether at a farm or an event center, it is important to ensure that there are adequate supplies on-hand to implement recommended biosecurity measures. Supplies include disinfectant, stall-cleaning equipment, dedicated feeding equipment and grooming supplies used to care for the isolated horses, barrier precaution supplies for personnel caring for isolated horses, and signage to delineate the isolation procedures. To ensure that effective disease-control practices are implemented, veterinarians should have a conversation depending on the venue with equine owners, farm managers or event organizers about how they plan to respond to a contagious-disease situation. For example, a plan that calls for isolating confirmed contagious disease cases while still caring for the animals can expedite the control of disease spread. The California Department of Food and Agriculture has developed Biosecurity Toolkit for Equine Events8 that can assist event veterinarians in developing a tailored plan for the events they work with. The Equine Biosecurity Toolkit for Equine Events8 has three parts. Part 1 emphasizes options for reducing the risk of disease introduction, and Part 2 emphasizes response to a suspect infectious disease situation. The third part is the Appendix, which has details on how to implement protocols discussed in Parts 1 and 2 of the toolkit. There is information about how to set up a temporary isolation area, implement movement restrictions within a facility, the use of barrier precautions, and how to determine the level of horse exposure to infectious disease. Veterinarians that work for an equine event are in an ideal position to implement a plan to reduce the risk of disease introduction and make a plan for response should a contagious disease occur at the event. If equine practitioners are in charge of biosecurity during an outbreak situation, it is important that they personally observe if and how people are following biosecurity recommendations. If necessary, veterinarians should physically show event personnel exactly how to follow isolation and other

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directly to the laboratory that is performing the test. Laboratory personnel can help you determine the most appropriate samples to collect, discuss available test formats, determine how you want to receive the results and establish a likely timeframe for reporting. It does make a difference which disease agent is causing an outbreak. For example, a response to an influenza outbreak will be different than a response to an EHM outbreak; thus, performing diagnostic testing combined with physical findings are critical in developing the most effective control strategies and are also important in providing communication about the outbreak. The AAEP’s “Guidelines for Managing Infectious Disease Outbreaks” can assist equine practitioners to develop disease-specific recommendations. It is important for the practitioner to determine who will pay for the diagnostic tests being requested. The available funds for testing may dictate the number of animals tested. It is also important to clarify with the laboratory when results will be available and how the results will be reported to the submitting veterinarian as this can help set expectations among the interested stakeholders Designated vehicle parking limits disease transmission risk.

protocols. Do not assume that oral instructions or signage will be obvious or understood. It is also important that veterinarians set the standard for good biosecurity compliance through their own behavior and that they never take shortcuts when performing biosecurity protocols. Veterinary textbooks have entire chapters about biosecurity, which can serve as a resource for equine practitioners as they serve their clients.9 A list of biosecurity resources is included in the white paper from the National Institute for Animal Agriculture and U.S. Animal Health Association.10 Also, there are multiple biosecurity resources listed in the Equine Disease Communication (EDCC) website.11

ROLE OF VETERINARIAN IN MAKING A DIAGNOSIS Initial response to an infectious disease situation should occur as soon as a suspect case is identified and should initially be based on a worst-case scenario. Making an empirical etiological diagnosis can allow for the initial response to be tailored to the specific suspect disease. Subsequent diagnostic confirmation can allow for refinement of the plan. History and physical findings should be considered when assessing an equine’s infectious disease status. These findings should dictate the required level of diagnostic testing. In addition, risk aversion and what is at stake are important factors to consider when making the decision to run tests. A key take-home message is do not run tests without first determining how you will use and communicate the results. Optimal sample collection and shipping are as important as appropriate testing. Identify laboratories and their respective testing capabilities before you need them. Some laboratories are able to offer a wide array of diagnostic testing by forwarding received samples to other laboratories. In time-sensitive situations, diagnostic test results can be expedited by submitting samples WWW.FAEP.NET |

Certain suspect or confirmed disease cases are reportable to State Animal Health Officials and/or to USDA- APHIS-VS. It is important that veterinarians know what their reporting responsibilities are in their state and act accordingly. Many states post the list of reportable animal diseases on their State Animal Health Official’s website. When in doubt about infectious diseases, equine practitioners should contact their State Animal Health Official to determine what steps to take next.

ROLE OF VETERINARIANS IN COMMUNICATION Effective communication is imperative for controlling an outbreak and for ensuring the confidence of managers, owners and the public. Effective communication can be as simple as talking to a manager/owner on a daily basis, yet for other situations it may require posting news releases around major show grounds and keeping the media informed when the scope of the situation warrants media interest. Training on how best to interact with media is advisable if an equine practitioner is going to act as a spokesperson for an equine event or farm with regard to the disease situation. It is important for the spokesperson to determine what key facts will be shared, including the actions being taken to address the situation prior to interview with the media. Determining how to get these key communications across in an unambiguous way is also important to avoid circulation of misinformation. It is also important to stay focused on the facts, to remain professional and to avoid speculation. Be sure to indicate what steps are being taken to deal with the incident at-hand. A take-home message is to never announce a disaster without at the same time sharing what steps are being taken to deal with the situation. Daily updates, even if no change in the situation has occurred, helps to keep concerned parties up to date and establish confidence in the person or entity managing the outbreak and providing the updates; however, do not make a prediction as to the final outcome of a disease outbreak even if your experience FLORIDAAEP |

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would allow you to do so. It is often best to plan for a worsecase scenario until the outbreak is under control and is going to stay that way. Outbreak situations are being shared on the Equine Disease Communication Center website.11 There is an option to sign up for email alerts which allow the industry, including equine practitioners, to remain aware of evolving disease situations, as well as providing access to information on biosecurity and select equine infectious diseases.

ACKNOWLEDGEMENTS: Portions of these proceedings were included in the American Association of Equine Practitioners 2016 Proceedings entitled: "Overview of Options for Equine Infectious Disease Prevention and Control."

References 1. American Association of Equine Practitioners Vaccination Guidelines 2. Leadon DP: Transport stress and the equine athlete. Equine Vet Educ, 7, 253-255, 1995. 3. Toscano MJ, Friend TH: A note on the effects of forward and rear-facing orientations on movement of horses during transport. Applied Animal Behaviour Science, 73, 2001, 281-287. 4. Gibbs AE, Friend TH: Horse preference for orientation during transport and effect on orientation on balancing ability. Applied Animal Behaviour Science 63, 1999, 1-9. 5. Clark DK, Friend TH, Dellmeiser G: The effect of orientation during trailer transport on heart rate, cortisol and balance in horses. Applied Animal Behaviour Science, 38, 1993, 176-189. 6. USDA APHIS VS National Animal Health Monitoring System Report, Demographic Characteristics and Prevalence of Elevated Temperature Among Horses Quarantined at the Three Air/Ocean Animal Import Facilities, 2011, http://www.usda. aphis.vs/nahms 7. Traub-Dargatz JL, et al: Case-Control Study of Multi-State Equine Herpesvirus Myeloencephalopathy Outbreak, J Vet Int Med, 27, 339-346, 2013. 8. California Department of Food and Agriculture Biosecurity Toolkit for Equine Events Animal_Health/Equine_Biosecurity.html. 9. Burgess, B; Traub-Dargatz, JL: Biosecurity and Control of Infectious Disease Outbreaks, In Equine Infectious Diseases, 2nd edition, Editors Sellon DC and Long MT, Saunders Elsevier, St Louis, MO, pgs 544-551, 2014.

Josie Traub-Dargatz DVM, MS, DACVIM Dr. Traub-Dargatz is a professor emeritus of equine medicine at Colorado State University (CSU), College of Veterinary Medicine and Biomedical Sciences in Fort Collins, Colorado. She is a graduate of the University of Illinois Doctor of Veterinary Medicine program and received her Master’s degree from Washington State University. She joined the faculty of the Veterinary Teaching Hospital at CSU in 1983 and worked in the clinics as an equine internist until 2007 when she put her entire focus into the area of equine population based studies with an emphasis on control of equine infectious diseases. Dr. TraubDargatz has served on the board of directors and the infectious diseases committee for the American Association of Equine Practitioners. She also serves on the United States Animal Health Association Equine Committee to develop guidelines for management of Equine Herpesvirus and is currently serving on a committee to address Equine Viral Arteritis control. Dr. Traub-Dargatz received the Colorado Veterinary Medical Association Outstanding Faculty Award Member in 2003. She received Honored Researcher Transfer Award from the Colorado State University Research Foundation (CSURF) in 2004. She was inducted into the Colorado State University, College of Veterinary Medicine and Biomedical Sciences Glover Gallery in 2004.

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10. Equine Disease Forum White Paper, 2016. Symposiums/2016%20Equine/Equine%20Diseases%20 Forum%20Whitepaper%20PDF%2 006.08.16.pdf 11. Equine Disease Communication Center,

Resources Equine Disease Communication Center (EDCC) Equine Disease Forum Resources American Association of Equine Practitioners (AAEP) Infectious Disease Control

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