Equine Abstracts

ESWT Extracorporeal Shock Wave Therapy in Equine Veterinary Medicine WHITE PAPERS A COMPENDIUM OF SCIENTIFIC ARTICLES (ABSTRACTS), HELD AT CONGRESSES & PUBLISHED IN JOURNALS

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A.P. Bathe

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The role of extracorporeal shockwave therapy in the rehabilitation of soft tissue injuries in the equine athlete Andrew P. Bathe, MA VetMB DipECVS DEO MRCVS Rossdale and Partners, Newmarket, UK

LARGE ANIMAL

Shockwave therapy has become an established tool to assist in the management of soft tissue injuries in athletic horses. The initial application was for proximal suspensory desmitis (Boening 2000) and whilst the suspensory ligament remains the most commonly treated site, its use has now broadened into other areas.

EXPERIMENTAL STUDIES McClure et al (2004) studied the effects of shockwave therapy in a collagenase-induced model of suspensory desmitis of the forelimb. They demonstrated an improved rate of healing as assessed ultrasonographically. Histologically the treated suspensory ligaments had a more concentrated area of metachromasia associated with healing than the untreated ligaments.

A number of experimental studies have examined the affect of extracorporeal shockwaves on tendons.

Rompe et al (1998) demonstrated dose–dependent changes in the tendon and paratenon of rabbits, showing that high intensity treatments could lead to marked histological changes. Beneficial affects of shockwaves had been shown experimentally in a traumatic model in the rat Achilles tendon (Orhan et al 2004) and in a collagenase-induced model in the rabbit patellar tendon (Hsu et al 2004). Wang et al (2003) demonstrated increased neovascularisation associated with the early release of angiogenesis-related markers at the Achilles tendon/bone junction in rabbits.

The mechanisms of shockwave therapy in promoting tendon healing have been studied by Chen et al (2004).

Rats with collagenase-induced Achilles tendinitis demonstrated increased TGF-beta1 and IGF-1 expression following shockwave treatment.

Kersh et al (2004) studied extracorporeal shockwave therapy in an equine collagenase model. The results were initially reported as encouraging but subsequently it was claimed that extracorporeal shockwave therapy did not change the ultrasonographic appearance of the tendons when compared to untreated controls, however it did increase neovascularisation. As ever, there have to be concerns over the accuracy of collagenase-induced lesions as a model for naturally occurring tendonitis CLINICAL EXPERIENCES • Proximal suspensory desmitis – I have found treatment of chronic, active forelimb proximal suspensory desmitis to be extremely rewarding in alleviating pain and permitting horses to continue competing. Unfortunately the success rate for shockwave treatment of hindlimb proximal suspensory desmitis is not as high. I have found it fairly ineffective in severely lame horses and now reserve its use for mild and acute cases. Overall our success rates are comparable with those published by Crowe et al (2004). With repeated treatments it can be used to successfully manage poor performance due to mild chronic active proximal desmitis. It also appears helpful in the management of suspensory branch desmitis including those with an entheses component involving the proximal sesamoid bones.

• Extracorporeal shockwave therapy is my current treatment of choice for mild or chronic cases of superficial digital flexor tendonitis. In clinical cases I will see a quicker ultrasonographic resolution of the lesion, and in comparison to other treatments a more rapid development in longitudinal fibre pattern.

Adverse reactions are extremely rare, especially in comparison to tendon injections. We have shown a decrease in the recurrence rate in Event horses (20%) and National Hunt racehorses (47%), using the same criteria to compare to the results of conservative treatment (43% and 56% respectively) reported

by Dyson (2004).

• The analgesic actions of shockwave therapy can be beneficial in the treatment of back problems. This can include impingement of the dorsal spinous processes, caudal thoracic arthropathy, supraspinous ligament strains and non-specific soft tissue pain. I feel that it is best employed as the plane of exercise is increased especially using lunging and long reining exercise to encourage muscle development over the back without the weight of a rider. After a course of three treatments the analgesic effect will often last five months or so. Some horses will have worked through the problem by this stage or others may require repeat treatments. In some horses there is a failure to respond.

Reprinted in the IVIS website with the permission of the ESVOT

03) Large animal27-8-06 26-09-2006 13:59 Pagina 171

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13th ESVOT Congress, Munich, 7th - 10th September 2006

A.P. Bathe

BOENING, KJ, LÖFFELD, S, WEITKAMP, K, MATUSCHEK, S. (2000) Radial extracorporeal shock wave therapy for chronic insertion desmopathy of the proximal suspensory ligament. Proc. Amer. Assoc. Equine Pract. 46: 203-207.

CROWE OM, DYSON SJ, WRIGHT IM, SCHRAMME MC, SMITH RK. (2004) Treatment of chronic or recurrent proximal suspensory desmitis using radial pressure wave therapy in the horse. Equine Vet J 36:313-316.

DYSON SJ. (2004) Medical management of superficial digital flexor tendonitis: a comparative study in 219 horses (19922000). Equine Vet J 36:415-9.

CHEN, YJ., WANG, CJ., YANG, KD., KUO, YR., HUANG, HC., HUANG, YT., SUN, YC., WANG, FS. (2004). Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinitis and increase TGF-betal and IGF-1 expression. J Orthop Res. 22: 854-61.

HSU, RW., HSU, WH., TAI, CL., LEE, KF. (2004) Effect of shock wave therapy on patellar tendinopathy in a rabbit model. J Orthop Res. 22: 221-7.

KERSH, KD, MCCLURE, S, EVANS, RB, MORAN, L. (2004) Ultrasonograhic evaluation of extracorporeal shock wave therapy on collagenase-induced superficial digital flexor tendonitis. Proc. Amer. Assoc. Equine Pract. 50: 257-260.

MCCLURE, SR., VAN SICKLE, D., EVANS, R., REINERTSON, EL., MORAN, L. (2004) The effects of extracorporeal shock wave therapy on the ultrasonographic and histologic appearance of collagenase-induced equine forelimb suspensory ligament desmitis. Ultrasound Med Biol. 30: 461-7.

ORHAN, Z., OZTURAN, K., GUVEN, A., CAM, K. (2004) The effect of extracorporeal shock waves on a rat model of injury to tendo Archillis. A histological and biomechanical study. J Bone Joint Surg Br. 86: 613-8.

ROMPE, JD., KIRKPATRICK, CJ., KULLMER, K., SCHWITALLE, M., KRISCHEK, O. (1998) Dose-related effects of shockwaves on rabbit tendo Achilles A sonographic and histological study. J. Bone Joint Surg. Br. 80: 546-52.

WANG, CJ., WANG, FS., YANG, KD., WENG, LH., HSU,CC., HUANG, CS., YANG, LC. (2003) Shock wave therapy induces neovascularisation at the tendon bone junction. A study in rabbits. J Orthop Res. 21: 984-9.

LARGE ANIMAL

REFERENCES

Radial Shockwave Therapy in an Equine Referral Practice Extracorporeal shockwave therapy (ESWT) is an active component in our equine physical treatment armamentarium. This modality is most commonly used for treatment of soft tissue injuries that are closely adjacent to bone that would benefit from the stimulatory and analgesic properties of shockwaves.

Basic shockwave therapy principles A shockwave is an acoustic pulse with characteristics that include: short rise time, high peak pressure, rapid decompression and tension. The waves pass through tissue and are amplified at tissue interfaces where the tissue density changes substantially (such as where ligament inserts into bone).

Common applications of ESWT include desmopathies at origins and insertions, such as suspensory, sesamoidian, accessory and collateral ligaments, dorsal MC3 Disease/ “bucked shins”, sacroiliac desmitis, chronic back pain, joint capsulitis, dorsal spinous process disease, navicular/caudal heel pain, ringbone and other osteoarthritis.

Equipment and protocols Our hospital uses radial shockwave therapy (RSWT) using focused and non-focused applicator heads. The shockwave is generated by driving a metal plug with high pressure air to strike the applicator head. It is called radial shockwave because the energy wave expands and dissipates in a conical pattern into the tissue. The focused applicator head narrows the pattern of dispersion thus concentrating the energy. Each horse is sedated prior to treatment (3 – 5 mg detomidine IV for 500 kg body weight), the site is clipped and ultrasound gel is applied to the treatment site. Each treatment consists of 2,000 to 5,000 impulses at 3 – 3.5 bar, frequency of 10 -15 Hz. Horses undergo 3 to 5 treatments at two week intervals. Following treatment, and continued for two more days, ice is applied to the region treated for 20 to 30 minutes twice daily and phenylbutazone is administered daily.

Case #1: 17 year old Appaloosa gelding, eventer Injury to the left rear pastern during competition 6 weeks before presentation.

Conservative therapy of rest and NSAIDs did not improve the lameness. On examination the horse was toetouching grade 4 of 5 lame at the walk on the left rear limb. An irregular fiber pattern and increased cross-sectional area of the lateral collateral ligament of the left rear pastern joint was evident on ultrasonography. Radiography revealed wider lateral joint space on a stressed view. The horse was treated with three RSWT treatments at two week intervals. Stall confinement was maintained during initial treatment. At the second treatment the horse was sound at the walk. Sixty days after RSWT was started, controlled exercise at the walk was initiated. The horse did not work over the winter and had hand walking only. At the last follow-up 6 months after therapy was started, the horse was

sound on examination and had returned to light work. This case exemplifies the analgesic and healing properties of RSWT for soft tissue injuries in difficult-to-access locations.

Case #2: 8 year old Hanoverian-cross gelding This horse was kicked in the left shoulder 1 ½ weeks prior to presentation.

Phenylbutazone had not improved a noticeable lameness. Marked lameness of the left fore limb was evident at the walk (grade 4 of 5). There was a small wound over the lateral aspect of the proximal humerus. Multiple bone fragments were present over the surface of the deltoid tuberosity, but the shoulder joint was normal. RSWT was conducted over the deltoid tuberosity. Two weeks later the horse was sound at the walk.

Follow-up radiographs revealed a possible developing sequestrum. The sequestrum resorbed without the need for surgery and the horse returned to pleasure riding. This case illustrates the analgesic and bone healing properties of RSWT. Case #3: 7 year old Thoroughbred gelding, hunter A scar was noticed on the right rear biceps femoris muscle about three years before.

Lately the horse had developed a shortened anterior phase to the right rear stride and reluctance to engage the rear end. The horse is 1+ of 5 lame in the affected limb and had a shortened anterior phase to the stride. A palpable thickening is evident at the scar site (measuring 12 by 3 inches). On ultrasound evaluation the thickened area blocked sound waves (acoustic shadowing), thus it was surmised the lesion was mineralized scar adherent to the biceps femoris and semitendinosus muscles. Following four RSWTs, the horse was sound on examination, no longer reluctant to engage the rear limbs and the shortened anterior phase to the stride was resolved. The mass remained palpable and measured 8.75 by 2.4 inches. This case illustrates the potential of RSWT to encourage resorption of mineralized tissue.

Case #4: 6 year old Canadian Warmblood gelding, eventing prospect.

This horse had marked bilateral fore limb lameness (right worse than left) that was localized to the heel. The horse was 2+/5 lame right fore and 1/5 lame left fore. A MRI identified a core lesion in the lateral lobe of the right fore deep digital flexor tendon. The flexor tendon injury was treated with six RSWTs, corrective shoeing and rest. The focused probe was used to concentrate the shockwaves at the lesion. The horse responded only marginally to treatment. He was functionally sound as long as corrective shoeing was meticulously attended to, but was not sufficiently sound to be marketed.

Case #5: Two month old Thoroughbred foal This foal had a 6-degree valgus angular deviation at the fetlock joint. The foal was treated with RSWT at 3 Bar, 15 Hz, 2000 pulses on the convex side of the distal metacarpal physis. RSWT reversibly retards cartilage proliferation at the physis and allows the ‘shorter’ side to catch up in growth. After 3 treatments at two week intervals, the foals distal; limb was straight.

Recent research findings on ESWT in horses: Increased osteoblast numbers and radiopharamaceutical uptake have been measured in horses following ESWT of the suspensory origin and proximal MC4 (Bischofberger AS, Ringer SK, Geyer H, et al. Histomorphologic evaluation of extracorporeal shock wave

therapy of the fourth metatarsal bone and the origin of the suspensory ligament in horses without lameness. Am J Vet Res. 2006 Apr;67(4):577-82.)

ESWT has been recognized as a valuable treatment for OA in horses. (Revenaugh MS. Extracorporeal shock wave therapy for treatment of osteoarthritis in the horse: clinical applications. Vet Clin North Am Equine Pract. 2005 Dec;21(3):609-25, vi) Results have indicated that ESWT appears to facilitate the healing process in horses with experimentally induced hind limb suspensory ligament desmitis. (Caminoto EH, Alves AL, Amorim RL, et al. Ultrastructural and immunocytochemical evaluation of the effects of extracorporeal shock wave treatment in the hind limbs of horses with experimentally induced suspensory ligament desmitis. Am J Vet Res. 2005 May;66(5):892-6.) ESWT improved the rate of healing of experimentally-induced suspensory desmitis as assessed ultrasonographically. (McClure SR, VanSickle D, Evans R, et al. The effects of extracorporeal shock-wave therapy on the ultrasonographic and histologic appearance of collagenase-induced equine forelimb suspensory ligament desmitis. Ultrasound Med Biol. 2004 Apr;30(4):461-7)

Author Andris J. Kaneps, DVM, PhD, Dipl. ACVS and Patricia A. Quirion-Henrion, MS, NAVPT New England Equine Medical & Surgical Center, 15 Members Way, Dover, NH 03820 USA Presented at the 5th International Symposium on Rehabilitation and Physical Therapy in Veterinary Medicine - August 13-16, 2008 in Minneapolis, Minnesota, USA

Abstract 25

Radial Shock Wave Therapy For Chronic Insertion Desmopathy of The Proximal Suspensory Ligament in Sports Horses Authors: A. Morral*, J. Grau**, L. Mata**, . Viu**, M. Prades***, ; T.Ramon*** Institution: *EUIF Blanquerna. Universitat Ramon Llull. **ClĂ­nica Equina Jordi Grau, ***Facultat de Veterinaria.Universitat Autonoma de Barcelona,Spain

Introduction Suspensory ligament desmopathy is a common disease causing primary and compensatory lameness in the sport horse. The disease can cause long-term lameness restricting the horse's ability to perform at the level of competition achieved prior to the onset of lameness. Current medical treatment options include confinement and rest, controlled exercise protocols, intralesional injections, corticosteroid therapy, anti-inflammatory therapy, bone marrow injection, and corrective shoeing. However, none of these methods consistently result in a satisfactory outcome.(McClure 2004) Subjects

Between April 2002 and August 2004, 40 sports horses with chronic proximal insertion desmopathies (23 in the hind limb, 1 7 in the front limb) have been treated with Radial Shock Wave Therapy (RSWT) The horses must have had clinical symptoms for at least 3 months and at least one failed conservative treatment approach prior to RSWT. Lameness was graded from 0 to 5 using a AAEP scale (American Association of Equine Practitioners) Methods The horses were treated in 3 sessions (at intervals of one/two week, mean: 12 days) with 4000 shockwaves per session. Pressure of 3,5 bar (Energy flux density: 0,14 mJ/mm2 approx.) and 6 Hz of frequency.

Device used: RSWT The horses received sedation with Domosedan and Torbugesic.

The affected leg was lifted and the superficial and deep flexor tendon was pushed laterally and medially in order to be as close as possible to the origin of the proximal suspensory ligament.

2000 shockwaves were applied from each side (medial and lateral).

Evaluation was performed before the treatment, before 2nd RSWT, before 3rd RSWT, 30 days after last RSWT, 90 day after last RSWT: A special training program was elaborated for the time between the sessions and post shock wave therapy.

Analyses The no parametric Wilcoxon test for dependent samples to compare means of AAEP lameness scale.

Results

The horses showed a considerable lameness decrease 30 days after last RSWT (p<0,05), and 90 days after last RSWT (p<0,01).

90 days after last RSWT, 26 horses (65%) were free of lameness (return to full work) and 8 horses had a distinct lameness reduction. 6 horses showed no improvement.

Side effect and complications were not observed Conclusion RSWT is an effective treatment method for chronic insertion desmopathy of the proximal suspensory ligament in sports horses. Further randomized and controlled studies are necessary to underline the results of this investigation.

Abstract 30

Reviewing The Biologic Effects: Radial And Focussed Shockwaves Induce New Bone Formation Authors: Maier M., Tischer T., Hausdorf J., Saisu T., Schmitz C. Munich, Chiba, Maastricht

In recent years, extracorporeal shock wave application to the musculoskeletal system has been established in the therapy of non-unions. However, there is a controverse discussion whether both focused and ballistic (radial) shock wave devices lead to comparable new bone formation. Maier et al. used focussed shock waves with energy flux densities between 0 mJ/mm2 (sham-treatment) and 1.2 mJ/mm2 were applied in vivo to the distal femoral region of rabbits (1,500 pulses at 1 Hz frequency each). To investigate new bone formation, animals were injected with oxytetracycline at the days 5 to 9 after shock wave application, and were sacrificed on day 10 after shock wave application. Application of shock waves with energy flux densities of 0.9 mJ/mm2 and 1.2 mJ/mm2 resulted in new periosteal bone formation and the presence of cortical fractures and periosteal detachment. After application of shock waves with energy flux density of 0.5 mJ/mm2, however, for the first time clearly detectable signs of new periosteal bone formation were observed without cortical fractures or periosteal detachment.

In 2004 the study group of Haupt described new bone formation in a rabbit animal model following radial shock wave application of at least 2000 pulses with 3 bar or 4 bar. 60 days after the treatment new bone formation was found. The activity was osteoblasts was described to be high with extended osteoid formation. Haupt et al. concluded from their rabbit experiment that radial shockwaves might be used in future times for the treatment of e.g. non-unions or diseases with decreased bone turn-over such as parodontitis.

This present reviews actual basic science studies dealing with the effects on bone following focused and radial shockwave application. It seems to be possible that radial shockwaves have comparable effects on healthy bone as focused shock waves in an rabbit animal model.

Poster presented at the VOS Meeting, Snowmass, CO, March 2005

Treatment of Angular Limb Deformitis in Foals using radial Extracorporeal Shockwave Therapy: A Prospective Clinical Trail Introduction: Angular Limb Deformitis (ALD) are a common problem in foals, and many cases respond to conservative treatments. However, a significant number require surgery, with the associated costs, risk to the patient and adverse cosmetic effects. Experimental work in neonatal rats has suggested that extracorporeal shockwave therapy (ESWT) may have a growth retardation effect on the physis (Yeaman, Jerome, and McCullough 1989 J Urol.

141, 670-4). Our hypothesis was that ESWT would modulate physeal function sufficiently to be a useful non-invasive method of treating ALD.

Materials and Method: Seventeen Thoroughbred foals from Newmarket stud farms under the care of Rossdale and Partner were selected for treatment on the basis of radiologically confirmed ALD. Treatments were performed at approximately weekly intervals on sedated foals using a radial shockwave generator at 3 bar, 15 Hertz and 2000 cycles. Younger foals were treated in recumbency and older foals were treaded standing. Treatments were applied to the region of the physis on the convex side of the deformity, aiming to slow growth on that side, after wetting of the coat and application of ultrasound gel. The foals were clinically monitored an a weekly basis and treatment was stopped when the limb angles were deemed satisfactory (≤4°). Digital photographs were obtained at each treatment and radiographs were taken at clinically indicated.

Results: There were 10 colts and 7 fillies in the treatment group. The age at start of treatment ranged from 7-120 days, with a median of 24 days. There were 12 unilateral cases of carpal valgus (8 left, 4 right): one bilateral; two cases of unilateral carpal varus (1 left, 1 right); one unilateral (right) case of fetlock varus and 3 unilateral cases of fetlock valgus (2 left, 1 right). Two of the latter cases also had carpal valgus. Fife foals were graded a mild (5-6° deformity), four a moderate (7-8° deformity) and 8 as severe (>9). At the time of commencing treatment 6 foals would normally have had a periosteal strip and 4 would have had transphyseal bridging.

The number of treatment ranged from 2-5, with a median of 3. The time until satisfactory straightening ranged from 15-76 days, with a median of 25. 15/17 cases (88%) were deemed clinically successful. Two cases went for surgery: one periosteal strip of carpal valgus and one transphyseal bridge for a carpal varus. Two foals had transient lameness after the first treatment only and one foal was very lame after each of two treatments, so no more treatments were performed. One foal showed radiological signs of physitis before treatment, and this did not change during treatment period. Three foals developed

very mild radiological signs of periosteal reaction in the treatment side, but this was also evident in one severely affected foal before treatment.

Conclusions Our clinical experience, supported by the results above, has shown a beneficial effect with the use of ESWT for the treatment of ALD in foals. In the forthcoming breeding season it is to be the first choice treatment for ALD in foals under our care. The speed of response, lack of untoward sequelae and good cosmetic results have made it extremely popular with clients. Given the difficulty in assessing treatment response in a condition which will often spontaneously improve, a controlled trail is planned to further validate these results.

Example 1: 21 day old filly at initial treatment. Moderate severity carpal valgus right fore. Treatment of this limb only.

After 31 days. Two treatments administered. Note satisfactory straightening and that right fore has improved further than untreated limb.

Example 2: 22 day old colt at initial treatment. Severe carpal valgus bilaterally. Skin abrasions medially.

3 months later at 4th tx. Dramatic improvement. Majority of residual deformity is rotational.

Example 3: 14 day old colt at initial treatment. Severe right carpal valgus, mild on left. Right fore treated.

After 7 weeks. Significant improvement. Limbs now a pair.

Authors Barthe AP, Rowlands DS, Boening KJ* Rossdale and Partners, Rossdale Equine Hospital, Newmarket, UK. *Tier채rztliche Klinik, Telgte, Germany

Rogue Valley Equine Hospital

14099 Hwy 62 P.O. Box 235 Eagle Point, OR 97524 Phone (541)826-9001 Fax (541)826-1099 www.roguevalleyequine.com

William W. Ferguson, D.V.M. Thomas R. Timmons, D.V.M. Alison K. Northcutt, D.V.M. Mitchell K. Benson, D.V.M.

April 8, 2008 Case Report: Urolith removal via a standing perineal urethrotomy in a quarter horse gelding using radial shock waves.

This case report describes the use of a modified shockwave probe inserted through a perineal urethrotomy incision to fragment a Type 1 bladder urolith in a quarter horse gelding.

The Probe was made by welding a 42 cm length of Âź inch stainless steel rod onto a 10mm probe of the MASTERPULS MP 100 radial shock wave machine. The tip of the probe was rounded to prevent trauma to the bladder or urethra should the horse become agitated during the procedure.

A 14 year old quarter horse gelding was referred to us for removal of a 6 cm urolith that was discovered when the gelding was examined for polyuria and stranguria. The referring veterinarian treated the gelding with Trimethoprim-Sulfadiazine 20 mg/kg PO once daily for one week prior to referral.

The gelding was maintained on Trimethoprim Sulfadiazine and given 500 mg of flunixin meglumine IV presurgically. Under detomedine hydrochloride (Dormosedan) sedation and an epidural of 100 mg xylazine and3 ccâ&#x20AC;&#x2122;s of 2% mepivacaine hydrochloride (Carbocaine) qsâ&#x20AC;&#x2122;d to 10 cc with sterile saline, the gelding was prepped and a sterile stallion catheter was passed into the bladder. A routine 6 cm. perineal urethrotomy incision was done just above the ischial arch exposing the catheter within the urethra. The catheter was withdrawn to a point just distal to the incision to prevent fragments of the urolith from becoming lodged in the distal urethra. A lubricated, shortened 16 mm nasotracheal tube was inserted through the proximal uretha and into the bladder to protect the proximal urethra.

An IV injection of 60 mg of N-butylscopolammonium bromide (Buscopan) was given to reduce rectal straining. Using a hand inserted per rectum the urolith was manipulated into the caudal bladder and a modified shock wave probe was inserted through the 16 mm tube in the proximal urethra. The urolith was held against the modified shock wave probe with moderate pressure. Once the tip was held in contact with the urolith, shock waves were delivered at a frequency of 10 Hz and at a maximum setting of 4 bars on the MASTERPULS MP 100. In several short bursts the urolith was reduced to 4 or 5 fragments ranging from .5 to 1.5 cm in diameter, and the remainder of the urolith was reduced to the consistancy of coarse sand. The gelding was only moderately sedated at the time, and stood quietly in the

stocks during the entire procedure. The 16 mm tube was removed and several large fragments were grasped and removed with sponge forceps. The appearance of the fragments was consistant with a Type 1 urolith. A large silicone stomach tube was inserted through the urethrotomy incision into the bladder, and the bladder was lavaged with saline repeatedly to remove the smaller fragments. Endoscopic examination of the bladder revealed the presence of two remaining fragments in the apex of the bladder that were too large to pass through the lavage tube.

Several attempts were made to retrieve the fragments, and to reduce their size by using the shock wave probe, but their small size and the thickened bladder wall prevented them from being manipulated easily. Due to concerns over traumatizing the bladder and urethra excessively, the decision was made to attempt to retrieve them when a second lavage of the bladder was scheduled. The gelding was placed in a stall, continued on Trimethoprimsulfadiazine and given 1 gram of phenylbutazone orally twice daily.

48 hours later, under detomedine sedation and using a loop snare through the endoscopeâ&#x20AC;&#x2122;s instrument portal the remaining fragments were removed relatively easily. The bladder was lavaged with saline using the large diameter silicone tube until the bladder was free of any remaining fragments. The incision was left to heal by second intention. The gelding was hospitalized for 48 hours until the hemorrhage from the incision abated, then he was discharged. The owner was instructed to keep him on Trimethoprim- sulfadiazine 20 mg/kg once daily orally for fourteen days. Recovery was uneventful.

This case demonstrated the effective use of radial shock waves to remove a bladder urolith via a standing perineal urethrotomy.

William W. Ferguson, DVM Rogue Valley Equine Hospital Eagle Point, OR

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Case Report for DVM News Kate Chope José M. García-López A four year old show hunter pony presented to the large animal hospital at the Tufts University School of Veterinary Medicine with a chronic history of hind limb lameness, unwillingness to move forward under saddle, bucking and refusing jumps. The pony had originally presented to Tufts University School of Veterinary Medicine five months earlier and was diagnosed with early osteoarthritis of the distal tarsal joints (bone spavin) which was treated at the time with intra-articular injection of long acting corticosteroids. In addition, radiographs of the dorsal spinous processes (DSPs) at that time revealed mild sclerotic changes and narrowing of the interspinous spaces, potentially resulting in “kissing spines”. The affected spaces were treated by injection with a combination of anti-inflammatories and analgesics. Despite treatment, the pony continued to become increasingly less willing to perform under saddle.

On return to the Large Animal Hospital at Tufts University, the pony exhibited a 1-2° out of 5° (0= sound, 5=nonwieghtbearing) lameness of his right hind limb which was exacerbated following hind limb flexion. Palpation of his back elicited a moderate painful response. Due to the chronicity of his clinical signs a nuclear scintigraphic (bone scan) evaluation of his hind end and back regions was performed. The bone scan revealed moderate and diffuse evidence of radioisotope uptake (hot spot) throughout the dorsal most aspect of the DSPs at the level of the caudal thoracic-cranial lumbar spines.

Additionally, there was moderate evidence of radioisotope uptake at the level of the distal tarsal joints bilaterally. Radiographs of the DSPs were repeated which showed further evidence of remodeling, narrowing and mild impingement of several processes, which together with the scintigraphic findings is compatible with “kissing spines”. Radiographs of the hocks revealed evidence of osteoarthritis at the level of the distal intertarsal and tarsal metatarsal joints, compatible with “bone spavin”.

Based on the lack of clinical response following injection of the DSPs five months earlier, we decided to treat the affected area with high energy focused extra corporeal shock wave therapy (ESWT). With the pony mildly sedated, total of three thousand shocks were applied (500 per site) to the affected

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region. Additionally, the distal intertarsal and tarsal metatarsal joints of both hocks were injected with a long acting corticosteroid (Depo-Medrol®; 80100 mg/joint). Following 10-14 days of stall rest with hand walking and restricted turn out in a small paddock, the pony was gradually returned to full work under saddle (two weeks walk-trot before introducing cantering and avoiding sharp turns for four weeks). He returned to jumping a month afterwards (8 weeks). He was also placed on a 14-day course of phenylbutazone. Recommendations to have the saddle professionally fitted were made, as well as the use of a gel pad. A course of acupuncture was recommended but was not performed. Follow-up communication with the owner five months later indicated that the pony was sound, performing well under tack with a significantly improved attitude, jumping, and able to be used successfully as a child’s show pony.

Impingement of the DSPs, better known as “kissing spines” is a common condition that affects sport horses. It can be a primary issue or seen in conjunction with hind end lameness. Signs can range from mild reluctance to move forward under saddle to complete inability to perform. Factors that predispose horses to impingement include conformation, level of fitness, saddle fit and rider technique. Diagnosis is made by physical examination, thorough lameness evaluation, radiographic examination and most importantly, nuclear scintigraphy. Traditional medical management has consisted mainly of injection, acupuncture and proper saddle fitting. In some cases non-responsive to medical management, surgery consisting of the removal of every other affected dorsal spinous process has been shown to have very good success for return to intended use.

Recently, a new therapy adapted from human medicine, called extra-corporeal shock wave therapy (ESWT), has been used to treat a variety of equine musculoskeletal disorders. It has been granted approval by the FDA for the treatment of heel spurs and tennis elbow in humans. A shock wave is a high amplitude acoustic (sound) wave. The mechanism by which it provides its therapeutic effects is not yet fully understood. However, initial studies have shown that it has a healing as well as short-term analgesic effect. The treatment can be performed on an outpatient basis under mild sedation. The standard protocol consists of a single treatment for bony conditions and a series of three treatments spaced three weeks apart for soft tissue injuries.

Conditions most commonly treated at this time with ESWT include impingement of the DSPs, insertional desmopathies (high suspensory injury), bucked shins, maladaptive bone disease, navicular disease and ringbone.

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Study of shock wave therapy in horses with the "MASTERPULS" system offered

by Storz Medical AG

by Dr. Mark Kaminski, DVM I) Abstract: In the past, shock and pressure wave therapy has gained a strong foothold in equine orthopaedics. In this field, mainly chronic tendon and connective tissue diseases as well as metaplasia and small bone fissures are treated. A study carried out with a total of 18 horses exhibiting different syndromes shows the treatment course and the results obtained. A positive effect of shock wave therapy on the treatment results was observed.

II) Introduction: Since the middle of the nineties, the use of shock and pressure wave therapy for the modern treatment of equine orthopaedic disorders has gained increasing importance.

This acoustic wave revealed by chance in aeronautical engineering was originally applied in human medicine for the disintegration of kidney stones, the treatment of shoulder calcifications and heel spurs as well as of other types of insertion desmopathy.

In physical terms, one has to distinguish between extracorporeal shock waves and unfocused ballistic pressure waves.

Extracorporeal shock waves are acoustic waves with extremely high intensity and very short duration. In this case, a coupling cushion is employed to couple the shock waves to the patient's body with a focusing device designed to allow the waves to be focused on the desired target zone under continuous ultrasound control.

In order to generate these high-energy waves, shock wave therapy employs three different types of generator systems: spark gap systems, which work like automotive spark plugs, piezoelectric systems and electromagnetic shock wave emitters which are characterized by the fact that the generated energy is converted into sound waves by means of electro-acoustic converters. With the ballistically generated unfocused pressure wave, the kinetic energy is transmitted to the skin in the treatment area by an elastic shock imparted by means of a stamp. The pressure waves thus generated propagate radially inside the tissue without requiring any focusing device with optical control.

Owing to this radial pressure propagation in the tissue and the easy handling of the shock transmitter, the ballistic shock wave therapy has gained ground in equine orthopaedics as compared to ESWT (extracorporeal shock wave therapy). As the defect inside the tissue is treated over a large area, ultrasonic shock wave focusing is not necessary.

The disorders of the locomotor apparatus treated most frequently by means of shock wave therapy are insertion desmopathy, sesamoidosis, chronic tendonitis, metaplasia, myopathy and partly small fissures.

The shock wave produces a locally restricted vasodilatation of the vessels within the tissue with simultaneous tissue hyperemization. In addition to this, effects on the peripheral nervous system, stimulation of cell division, alignment of the fibrous tissue, dissolution of fibrosis and improvement in the tissue elasticity are being discussed.

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III) Materials and method: Eighteen horses of different sex with the age of four to sixteen years were treated with the shock wave system MASTERPULS of Storz Medical AG in the fourth quarter of 2003 and the first quarter of 2004. This patient group is subdivided into nine horses with disorders of the pastern tendon origins (six of which at one fore leg, three at one hind leg), four horses with disorders of the flexor tendon apparatus, one horse with sesamoidosis, two horses with metaplasia of the superficial flexor tendon, one horse with calcification of the m. semimembranosus and one horse exhibiting myopathy of the m. longissimus dorsi.

All horses were subjected to an extensive lameness examination accompanied by a corresponding picture recording process (sonograpy, digital luminescent radiography).

Each therapy session comprised 2000 shock wave units with a pressure intensity adapted to the specific treatment area. The treatment sessions were repeated at intervals of 14 days.

With sensitive horses, sedation with approx. 0.5 ml Domosedan administered intravenously is recommended.

MASTERPULS therapy of Storz Medical AG: Number of horses treated: 18 Number of horses sedated with Domosedan: 5 (0.5 ml, intravenous injection) Syndrome

Number of patients Number of pre-treated horses Lameness for more than 4 weeks Single treatment One treatment repetition Two treatment repetitions More than two treatment repetitions

Supplementary therapies Heparin, vitamin B12 Thermotherapy Controlled walk exercises Egg shoe Feed supplement (inorganic sulphur)

PTO

SFT/DFT/ SL

Sesamoid bones

Metapl.

SFT

M. semimembr. Back

9 4

4 1

1 1

2 -

1 1

1 1

7

3

1

2

1

1

1 4 4 -

2 1 1

1 -

1 1

1

1 -

3 6 9 8 7

1 4 4 4 3

1 1 1 -

2 2 1 -

1 -

1 1

PTO: pastern tendon origin / SFT: superficial flexor tendon / DFT: deep flexor tendon / SL: suspensory ligament of the deep flexor tendon

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Four of the nine horses exhibiting disorders of the pastern tendon origins had been pretreated; seven horses had suffered from the injury for more than four weeks. One horse required a single shock wave therapy, with four horses the treatment session had to be repeated once and four animals had to be treated three times.

In addition to this, three horses were treated locally with subcutaneous injections with a mixture of heparin (25000 I.U.) and a vitamin B12 preparation (2 ml).

Six horses were subjected to supplementary thermotherapy in the form of ointment application. All horses performed controlled walk exercises on hard ground. While eight of these horses were provided with egg shoes, inorganic sulphur was administered as feed supplement to seven animals.

One horse of the four horses suffering from flexor tendon disorders had been pretreated; three of the horses had already suffered from the disease for more than four weeks. With two horses the treatment had to be repeated once, one horse required two repetitions of the treatment. One of the horses had to undergo more than three treatment sessions.

While heparin and vitamin B12 was administered to one horse as supplementary measure, all horses were subjected to thermotherapy and controlled walk exercises and provided with egg shoes. Three of the horses were additionally fed with inorganic sulphur.

The horse exhibiting sesamoidosis had suffered for more than four weeks from this disease and required two treatment repetitions. This horse was additionally subjected to thermotherapy and controlled walk exercises and provided with egg shoes.

Both animals suffering from metaplasia of the superficial flexor tendon had not been pretreated and the syndrome had appeared more than four weeks before the Masterplus MP100 treatment. One of these horses required two treatment repetitions, for the other horse more than three treatment sessions were necessary. In addition to this, both patients underwent thermotherapy and performed controlled walk exercises. One horse was provided with egg shoes.

At the time of the therapy, the horse suffering from m. semimembranosus calcification had been pre-treated and suffered for more than four weeks from this disorder. The treatment was repeated two times with controlled walk exercises being carried out as supplementary measure.

The horse subjected to the therapy that had suffered for more than four weeks from myopathy of the m. longissimus dorsi had been pre-treated and required two treatment sessions combined with supplementary thermotherapy and inorganic sulphur being additionally administered.

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IV) Result: Re-examination carried out 14 days after the last treatment PTO Aggravation Cont. lameness Minor improvement Clear improvement No sign of lameness Relapse

SFT/DFT/SL

2

1

3

2

4 -

Sesamoid bones -

Metapl. SFT

M. semimembr. Back

1 -

-

-

1

1

1

1

1

-

-

-

-

-

-

-

-

-

The re-examination of the patients with disorders of the pastern tendon origins showed a slight improvement for two horses, a clear improvement for three horses, while four horses were absolutely free from signs of lameness.

It can generally be observed, that the chances of recovery are better with disorders of the pastern tendon origins at the front limbs than with those at the hind limbs.

During the re-examination of SFT / DFT and SL disorders, a minor improvement was obtained in one case, a distinct improvement in two cases and one horse exhibited no lameness at all.

While the re-examination of the horse suffering from sesamoidosis revealed a distinct improvement of the clinical picture, the treatment of the m. semimembranosus also resulted in a clearly improved footing of the leg concerned.

With the horse treated for myopathy of the m. longissimus dorsi, the re-examination showed a considerable improvement of the clinical picture as well.

Up to now, none of the examined horses showed signs of recurrent lameness.

V) Discussion: Shock wave therapy should not be considered as competitive treatment to classical and conventional forms of therapy. With acute inflammatory processes, antiphlogistic therapies are recommended in order to achieve an interruption of the inflammation cascade in the tissue. However, with long-term and/or chronic disorders, the noninvasive and generally accepted shock wave therapy represents an excellent alternative to the application of caustic ointments, "M체ller-Wohlfahrt injections", and hyaluron acid injections or to outdated treatment methods like "firing".

The presented therapy results obtained within the frame of this study emphasize and complement existing experience gathered by other clinics and underline the prior importance and high efficiency of this type of therapy in equine orthopaedics.

Additional research work and examination results in terms of cytological modifications after shock wave therapy are being prepared at the University of Zurich.

Tier채rztliche Praxis f체r Pferde Mark Kaminski, DVM & F.E.I.-event veterinarian Munscheider Strasse 136 D-44869 Bochum, Germany

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CESMAS 2000 Taormina, Italy, May 2000

CLINICAL AND ULTRASONOGRAPHIC FINDINGS AFTER TREATMENT WITH EXTRACORPOREAL SHOCK WAVES (ESW) OF SPORTS COMPETING HORSES AFFECTED WITH INJURIES OF TENDONS AND LIGAMENTS. Stefano Donati, Luigi Fusetti, Rodolfo Ferrario*, Marina Berta§, Roberto Frairia §§ Clinica Donati Vet, Casorate Sempione; *Clinica della Brughiera, Cardano al Campo; § Med & Sport, Torino; §§ Dipartimento di Fisiopatologia Clinica, Università di Torino.

Extracorporeal Shock Waves (ESW) passed through a watery substance are the underlying principle of Lithotripsy, a method used in the human field as early as 1980, to crush renal, biliary and salivary stones.

From the early nineties on, this technology has been adopted in the treatment of certain bone pathologies in man (faulty consolidation after fracture, pseudo-arthrosis), while the use of ESW was later extended to injuries of the muscle and tendon system (insertional tendinitis, periarthritis of the shoulder, epicondilitis, bursitis, heel spurs). The high percentage of success in the human field (from 70 to 85%, according to the cases treated) gave rise to an extension of the application of this technology to the pathology of bones in the veterinary field. At the beginning of 1998 a work group of veterinary surgeons and doctors was set up in Italy to combine their specific experiences. They scheduled suitable treatment protocols using ESW in the most frequent injuries of the locomotor system in sports competing horses.

Principle of the method The shock wave (ESW) is an acoustic wave in which pressure increases on the forward edge, in the space of nanoseconds (10-9 seconds) from the level of the pressure of atmosphere (1.01-1.02 bars) to values 1001000 times greater. The impulses produced by the generators of ESW must be suitably focalised. The “focal area” of the ESW is defined as the area in which 50% of the maximum induced energy is concentrated: the increase in pressure induced in the tissue of the focal area causes microlesions and hence an increase in vascular permeability and subsequent healing neo- capillarogenesis.

In the bone tissue, as a result of the microtrauma, we observe both an osteoclastic and osteoblastic response, prevalently osteoblastic; while an anti-inflammatory response is induced in the soft tissues (tendons, ligaments and muscles), as well as a vascular response (with neocapillarogenesis and consequent activation of the healing processes).

There are various types of shock-wave generators: electro-hydraulic generators, as well as piezoelectric and electromagnetic ones. Each kind of equipment is characterised by a special focal area. In general, the length following the propagation axis of the ESW varies from 20-50 mm, while the breadth (perpendicular to the direction of the propagation of ESW) is much smaller (2.5 - 3.5 mm). Hence, we need to pin down the precise, constant area under treatment, since the power of the ESW decreases exponentially, with the increase in the distance from the focal area. To this end, the treatment is constantly monitored ultrasonographically, as far as possible with the probe coaxial to the source of the ESW.

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Cases From 1998 on, 158 horses (race-horses, show jumpers, three-day eventers) were given therapy with ESW for acute and chronic tendinitis or ligament disorders: lesions of the superficial flexor tendon in the acute (n= 55) and chronic (n=35) phases; lesions of the deep flexor tendon in both acute (n=7) and chronic (n=13) phases; lesions of the carpal bridle (n=8; two of them in the acute phase); lesions of the suspensory ligament of fetlock to the proximal insertion, both of the fore and hind limbs (n=19, four of them in the acute phase); lesions in the chronic phase of the central part of the suspensory ligament and its branches (n=21).

Of the 68 horses with lesions in the acute phase, 57 had had no previous treatment before the ESW. Eleven horses with lesions of the flexor tendon in the acute phase had had intra-tendon infiltrations of jaluronic acid and/or cortison or sarapinaceal infiltration immediately after the trauma. Of the 90 horses with lesions in the chronic phase, 6 had undergone infiltration, 35 had been treated with revulsives and 2 had been cauterised.

Methodology A therapeutic unit with an electromagnetic-type shock wave generator was used. It had a cylindrical coil and parabolic reflector (Minilith SL1 - Storz Medical, Kreuzlingen, CH).

A 7.5 MHz ultrasonographic probe was placed in the center of the generator, coaxial to the EWS source, to pin down the focal area precisely during treatment: the generator, which is mounted on an articulated arm so that it can be rotated on several axes and hence easily placed against the skin, produces power (â&#x20AC;&#x153;peak of pressureâ&#x20AC;?) ranging from 80 to 800 bars such that the density of power can be regulated between 0.005 and 0.5 mJ/mm2. The ESW are propagated (interposed with echography gel) through a buffer of water of varying volume placed in the head which contains the electromagnetic source. The fact of being able to vary the focal depths, under constant echographic control, ensures localisation of the part to be treated, with penetration ranging from 0.4 to 5 cm.

Each horse is sedated and the pathological area is shaved; then, each one undergoes diagnostic ultrasonography and is treated in the standing position. At every therapeutic session, which lasts from 15-20 minutes, 1500-2500 shocks are administered (240 bits/minute frequency), the levels of power being suitably regulated (according to the extent of the lesion and the characteristics of the horse) between 0.03 and 0.11 mJ/mm2. The number of treatments varies, with fortnightly intervals, according to the disorder (acute or chronic) and the constitutional characteristics of the horse.

The horse does not need to be hospitalised after therapeutic treatment and can travel 30 minutes after ESW treatment. Complete rest for 2-3 days is generally prescribed after treatments; subsequently, a complete return to normal activity can be made one month after the last treatment. Later echographic check-ups are generally carried out by the horseâ&#x20AC;&#x2122;s customary veterinary surgeon 30-40 days from the last therapeutic session.

Results The average follow-up of the cases treated is at 18 months. Over all, 87% of the horses treated with ESW therapy recovered completely.

In 97% of the cases with acute ailment there was a definite improvement, with a reduction of intra-tendon oedema, 7 days after the first therapeutic session. A further clinical improvement was observed after the second ESW application, so pronounced that it was considered unnecessary to give the horse any more treatment. The ultrasound scan carried out 30-40 days later was found to be negative.

A positive response was observed in 94 % of the cases with chronic disease which had undergone three ESW therapy sessions. In 50% of the cases a temporary increase in oedema was observed after the first ESW treatment, as had been foreseen by the treatment protocol. Complete recovery generally took 30-60 days from the last application.

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A relapse of the tendon lesion was observed in 5 out of 11 cases (in the acute phase) which had been submitted to infiltration before ESW therapy. In two cases (one of them had had no previous treatment before ESW) was there no response to treatment at all.

In every instance when the horse had returned to full sporting activity, echographic check-ups were carried out 60-80 days from the last application; they demonstrated the complete “restitutio ad integrum”, the tendon fibres being perfectly re-aligned.

Only four of the 57 horses treated in the acute pathological phase which had taken part in competitions again, suffered relapses. One of these was given a further ESW session and had suffered no relapse six months after returning to sporting activity.

Of the 90 horses treated for chronic pathologies, 61 returned to sporting activity: four of them did suffer a relapse after taking part in competitions.

Concluding remarks.

In the great majority of cases included in this study, treatment with ESW gave a positive response with perfect re-alignment of the tendon fibres, ultrasonographically documented and with the disappearance of the disorder. In only 10 horses with lesions of the superficial tendons in the acute phase, which had undergone infiltration immediately after the trauma, did we fail to obtain a high percentage of recovery (with 5 relapses and one failure to respond to treatment). We have found that horses given traditional treatment (cauterisation, vesicants) for analogous disorders, still do not have a complete re-alignment of the tendon fibres after considerable time and in any case recovery takes considerably longer.

By relatively short recovery times, with restitutio ad integrum (in any case the time needed for the lesion to heal by cicatrization cannot be shortened) obtainable with ESW therapy, we mean the capacity of the tendon to start work-loads after one month from when there is no sign of the lesion under ultrasonographic examination. The fact that the treatment is extracorporeal, as well as painless, makes it easier to deal with even especially “difficult” animals. Rehabilitation exercises can be done in the swimming pool 2-3 days after the second treatment and no further precaution is needed, apart, possibly, a supporting bandage when the horse is in the stable.

ESW therapy can prevent the formation of adherences and intratendon or peritendon calcification in lesions in the acute phase and reduce those in the chronic phase. Moreover, we can treat different ailments in different places in the course of the same session.

It is absolutely unnecessary and may even be inadvisable, to administer pharmaceutical products (analgesics, anti-inflammatory substances, corticosteroids, etc.) after the therapy.

ESW applications should not be given in cases of infections, broken tendons or complete insertional avulsions.

It has to be pointed out that the high cost of ESW therapy - transport of the horse to the specialised clinic must also be included under this head - is amortised by the short time during which the horse is unable to take part in sports competitions. Furthermore, the absence of marks or scars left on the skin means that the animal’s market value is not affected.

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