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Joint Therapy in the Miniature Horse Olivia Inoue DVM MS DACVS Loomis Basin Equine Medical Center What is a Joint? • Cartilage • Bone supporting the cartilage • Joint Fluid • Synovial Membrane • Ligaments Joint Cartilage Types • Fibro-cartilage • Meniscus in stifles, human knee • Inferior to Hyaline cartilage in joints • REPLACES HYALINE CARTILAGE • Hyaline cartilage • Distribute loads evenly into subchondral bone Hyaline Cartilage • Very smooth, shiny, resilient - normal • Contains no nerves or blood vessels • Fed by diffusion • Limited ability repair • Cartilage wears w/ time • Replaced with fibrocartilage • Inferior to hyaline Cartilage Matrix • • Type II collagen (90%) Proteoglycan • Protein core • Glycosaminoglycans GAG’s • Chondroitin and keratin sulfate • • glucosamine subunits Hyaluronan Subchondral Bone • Bone supports cartilage • Provides shock absorption • Some nutrition • Substance P nerve fibers • Abnormal joints only Synovial Membrane • Removes unwanted cells and debris • Important for balanced “wear and repair” cycle • Produces synovial fluid • Acts as a permeable barrier • • Filters out blood, excludes protein and normally WBC’s Completes range of motion • Abnormal synovial membrane - thickened stiff joints Synovial Fluid • Lubricant of joint capsule/synovial membrane • Removes waste and nourishes cartilage • Thick clear yellow – Normal • High in hylauronic acid • Cloudy, red-amber - Abnormal What is Arthritis? • Joint Pain/Joint stiffness • Osteoarthritis • OA • Degenerative joint disease • VERY Complex and Complicated!!! What is Arthritis? • Progressive degradation and destruction of articular cartilage • Enzymes of inflammation • WBC recruitment and release destructive enzymes • Failure of articular cartilage to withstand cyclic trauma of athletic activity • Complicated by aging Degenerative Joint Disease • Roughening - complete loss of cartilage • Loss of Joint Surface • W/ fibrocartilage & bone • Collapse of joint • Loss of ROM • Bone on bone contact • PAIN How Arthritis Develops • Trauma – inciting event/factor • Kick, fall, sprain, wound • Intra-articular, collateral ligament injury, fracture at joint • Arthritic pain not occur immediately • Use trauma – repeated/repetitive events • Jumpers • Poor confirmation - abnormal stress on joint How Arthritis Develops • Inflammation unmanaged • Eroded damaged cartilage • Forces of movement unevenly distributed into subchondral bone • Damage to subchondral bone with bones spurs • Pain from bone spurs or chips • Increase inflammation • Vicious cycle! Diagnosis of Arthritis • Visual examination and palpation comparison normal leg for • Lameness examination - simple to complex • Radiographs - permanent bony changes • Ultrasound - great for soft tissue • Useful hard to radiograph areas Diagnosis of Arthritis • Physiologic imaging - what is happening this very moment • Bone/nuclear scan • Subchondral bone inflammation • ACTIVE BONE • Before permanent bone changes • Thermography • Detect heat (pain) before your hand Thermography Diagnosing Arthritis • Response to Therapy • Rest and Rehabilitation • Bute therapy • IA joint treatment • Joint preventatives Goals of Therapy • Reduce Pain and Inflammation • Stop cartilage matrix degeneration and further loss of articular cartilage • Early and appropriate therapy • Improve range of motion with return to function • Each horse and its situation is unique • Not one therapy for every horse!! • Combination therapies Types of Therapies • Rest and Rehabilitation • Pain relief - Topical therapy and oral treatments • Intra-articular therapy - Steroids, hyaluronic acid, IRAP • Parenteral therapy - non-oral therapy • Shockwave therapy • Acupuncture Rehabilitation • Stall confinement or small turnout • “tissues at rest heal the best” • May not be enough to properly rehabilitate horses • Must stretch and loosen tight joint capsules • Length of time is injury dependent • Manage the rest of the horse • Weight and hoof balance Rehabilitation and Physical Therapy • Passive range of motion exercise • Low impact work • Slow distance • Time and distance variable • Regular and routine !!!! • Underwater treadmill Topical Pain Relief • Ice - acute injuries 15 minutes then let area warm then repeat 2-3 times • Heat - chronic injuries 15 minutes then let area cool then repeat 2-3 times • Running cold water stimulates circulation • Game Ready system • Circulating cold/warm water compression wraps Topical Pain Relief • Surpass - liposomal-based cream of diclofenac (NSAID) • • Symptom and disease-modifying effects • More benefit than systemic phenylbutazone Capsaicin - extract of chili pepper’s • Blocks substance P in inflamed joints • Decreases pain with cumulative effectiveness • Eye and skin irritation Topical Pain Relief • Liniments - sooth pain and relieve stiffness • Poultice - (cataplasm) - reduces swelling or draws an abscess out • Variable ingredients • Some caustic • Use care Oral Non-Steroidal AntiInflammatory Drugs • Bute and Banamine • Decreases inflammation by inhibiting cyclooxygenase (COX-1) • Side effects - GI and kidney issues • Individual response to side effects • Equioxx - newer NSAID for Horses • More specifically targeted against COX-2 enzymes • Less side effects • Very useful - first line of defense Oral Joint Support Products • MANY available -powders, pelleted, liquid, pastes • Nutraceuticals • NOT REGULATED by FDA • Variable product content and efficacy • Biased research? Oral Joint Support Products • Components of cartilage - often shark • GAG’s complexes • Chondroitin and keratin sulfate +/- from shellfish • Glucosamine subunits • Hyaluronan • Vitamins C and E • Magnesium Oral Joint Support Products • MSM - source of sulfur for protein production • Proteoglycans and chondroitin sulfate • S adenosylmethionine - SAMe • ATP + methionine • Cell energy + sulfur based amino acids • Avocado soybean unsaponifiable • Decreases harmful enzymes Oral Joint Support Products • Loading dose required • Decrease to maintenance dose • Twice a day • 4-6 weeks before results are seen • Cost effective? • Absorbed into system? Intra-articular Therapy • Spot treatment of inflamed, diseased joint • Medication directly to site • Requires joint penetration • Risk of infection • Requires additional care before joints injected • Usually corticosteroids - “cortisone” Intra-articular Steroids • Most potent anti-inflammatory drug • Unfair bad rap • Not all corticosteroids have negative effects on joint cartilage • Marked beneficial effects from triamcinolone • Steroid choice depends on joint treated Intra-articular Hyaluronic Acid • Component of joint fluid and cartilage • Disease-modifying • Decrease inflammatory/harmful enzymes • Long-term value • Decreased synovitis and pain • Higher molecular weight (~thicker) better • Numerous IA choices Intra-articular Therapy • Combination of drugs often used • Steroid(s) with HA • Addition of antibiotics to minimize potential for joint infection • Increases length pain-free interval? Intra-articular Adequan • Polysulfated glycosaminoglycans (PSGAGs) • Highly beneficial for inhibiting acute inflammation • • Decreases effects of harmful enzymes in inflamed joint • Slight increased risk for joint inflammation/ infection • Combine with IA antibiotics Used more IM than IA due to infection risk Intra-articular Therapy • IRAP - interleukin-1 receptor antagonist protein • “Conditioned” serum • Serum processed from horse’s blood to be used in same horse • 4-6 doses frozen • Injected into affected joint • Once a week for three doses IRAP • Blocks Interleukin -1 - a promoter of inflammation • Stop the inflammation cycle therefore decreases cartilage matrix degradation! • Symptom-modifying • Less pain • Disease-modifying • Less permanent bony changes • OA that is no longer responsive to HA/Vetalog combination therapy Parenteral Therapies • IV or IM • All need a loading series before maintenance regimen • Not degraded by strong GI acids and enzymes • Treat more than one joint/problem area • Adequan IM, Legend IV, N-acetyl-d-glucosamine IM Adequan® Intramuscularly • Relieves pain from swelling & inflammation • Inhibits harmful enzymes from attacking the synovial fluid, membranes and cartilage • Decreases inflammation of synovial membranes • Increase of synovial hyaluronic acid within 24 hours • Preventative Legend Intravenously • Decreases the enzymes of inflammation • Less damage to synovial fluid, membranes and cartilage • Stimulates normal joint fluid • Relieves pain from swelling & inflammation • Preventative Legend IV and IA Glucosamine Intramuscular • Subunits of glycosaminoglycans • Decreases enzymes of inflammation • Less damage to synovial fluid, membranes and cartilage • Lacks scientific proof? • Subjective data • Reasonable cost Shock Wave Therapy • Human and horses • Generates concussive type pulses through skin to bone and soft tissue • Non-invasive • Soft tissue injuries, inflamed or arthritic joints • Decreases inflammatory response • Decrease in lameness Acupuncture • Ancient Chinese therapy • Arthritis due to stagnation and stasis • Thin gauge needles placed in specific places • Restoring normal circulation and blood flow • Several treatments needed Other Therpies • Chiropractic therapy • Therapeutic laser • Therapeutic ultrasound • Anodyne light therapy • Gene therapy • Others Arthritis Prevention • Well trimmed feet • Manage weight • Stretching/ROM exercises before work • Regular controlled exercise • Genetics Case #1 • Horse used for lesson driving • Does not want to use hind end • • Sore to rear fetlock flexion Blocks to fetlock anesthesia • No changes on X-rays or with ultrasound • Nuclear scan suggested - opted to wait • Adequan IM and bute as needed • More regular routine exercise with weight loss • Pony greatly improved Case # 2 • Breeding stallion • Seems sore in the hind end during breeding • Positive to hock flexion • Moderate arthritis in the lower hock joints • Inject lower joints with steroids • Legend IV during breeding season and bute if needed • Regular work to improve muscle tone and strength Case # 3 • Pony mare with mild low ring bone coffin joint arthritis • Shock wave therapy 3 treatments • Farrier changes • Adequan IM • Improved but not great • Opted to treat coffin joints with steroids and HA • Better • While much more has become known in recent years about the causes of arthritis, there is still a lot to be studied and discovered in order to successfully prevent and treat OA
