Category Archives: Treatment

A Month Later

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Luckily, after about one week of stall rest and hand walking, along with a stronger anti-inflammatory, Chance has begun to show improvements over the last couple weeks of treatment.

Chance has almost completed his first 30 days of EPM treatment and has about a day or so left of the Protazil. He is going to continue his other medications and supplements:

1. SmartPak: senior flex and immune boost
2. Vitamin E
3. MicroLactin (amazing) to help with regrowth of his cells, inflammation, and pain.

As I’m doing research, and trying to come up with a plan of action, once again I am inundated with opinions…medication, exercise, holistic, massage, acupuncture, chiropractic, organic, shoeing, etc.

I know I need to continue therapy, or start a new therapy. But which one do I choose?

Do I go the holistic approach and work with an acupuncturist, chiropractor, massage therapist, and vitamins such as Vita Royals? Do I go organic? Or do I try Marquis? Another month of Protazil? Oraquin-10? Rebalance has been linked to a number of recent deaths in the past handful of months. If I go the organic or holistic approach do I run the risk of the disease progressing? If I go with the medication do I run the risk of yet another “treatment crisis”?

I contacted Vet4 and he suggested doing another round of the Protazil or Marquis.  I decided on trying Marquis and waited for it to arrive.

Chance after a month on Protazil 

Treatment Crisis (WARNING: DISTURBING)

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Sure enough Chance experienced his very own treatment crisis about a week into treatment.  The twisting of his back right hind was the worse it has ever been!

We gave him a dose of the Equinox (pain medication that is easier on his stomach) and the Ulcer Guard and wrapped his hind legs.  He was on stall rest for about a week and was hand walked twice daily.

Below is Chance during his treatment crisis.

Our Regiment

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Chance receives the following:

AM:

1. Protazil 50mls

2. Vitamin E 4 scoops (Watch for loose stools.  This would indicate that his VitE should be cut down)

PM:

1. SmartPak: Immune Boost

2. SmartPak: Senior Flex

3. Equinyl 2 scoops first two weeks, 1 scoop after

OTHER:

If Chance’s symptoms are worse, he can receive Equinox and UlcerGuard.

An All Natural Option?

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While doing research on EPM, and ways to prevent a treatment crisis, I came across something called MicroLactin. Below are two of the many studies I found regarding the use of MicroLactin and its use for EPM.

STUDY 1: Journal of Equine Veterinary Science (Impact Factor: 0.89). 09/2005; 25(9):380-382. DOI: 10.1016/j.jevs.2005.08.004
ABSTRACT Fifty-eight horses with inflammation from lameness/foot trauma, muscle and skin trauma, and respiratory, gastrointestinal, and soft tissue toxins were fed MicroLactin (Duralactin Equine, Veterinary Products Laboratories, Phoenix, AZ) as an aid to therapy to inhibit neutrophil participation in the inflammatory response. Based on clinical signs of observed improvement and owner's observations, there was 86% positive effect, 14% no effect. Owner's satisfaction of results was seen by continued use of MicroLactin instead of nonsteroidal anti-inflammatory drugs and steroids in respiratory inflammation and in chronic lameness, myositis, and skin inflammation.
STUDY 2:  Sandhill Equine Center, Southern Pines, NC Journal of Equine Veterinary Science (Impact Factor: 0.89). 06/2009; 29(6):547-550. DOI: 10.1016/j.jevs.2009.05.004
ABSTRACT MicroLactin is a patented milk protein concentrate whose mode of action is proposed to inhibit neutrophil activation in inflammation and to bolster the immune response in musculoskeletal diseases. MicroLactin was empirically used in the treatment of a series of equine clinical cases. MicroLactin was given in two trials to 166 horses in which neutrophils were associated with an inflammatory response. The primary clinical groups having the greatest positive responders to the use of MicroLactin were: respiratory (92%), joint lameness/foot trauma (90%), muscle injury/myositis (92%), equine protozoal myeloencephalitis (EPM) (81%), skin trauma/hypersensitivity (89%), and toxic enteritis (89%). Positive clinical results were seen within 10 to 14 days when MicroLactin was used as a daily treatment either alone or in combination with other anti-inflammatory agents or as an adjunct to the primary treatment.

Every study I read claimed MicroLactin to be a “miracle anti-inflammatory” that aided in cell regrowth. People were raving about this substance that is derived from cow’s milk. The studies dated back to the 80’s and not only suggested that MicroLactin truly was a natural cure all, but that it also had zero side effects or interactions.

I figured that I should give it a try. Again, I looked everywhere and nobody carried it. I looked online and saw that there was a brand called DuraLactin but that I would not be able to actually receive it for about a week. I began looking for supplements that contained the same ingredients as DuraLactin. Sure enough, I was able to find it!

The brand is called Vita-Flex Equinyl.

Vita Flex® Equinyl™ Combo is designed to help ease pain and inflammation associated with training and competition without causing gastrointestinal side effects. This supplement provides joint health support and increases flexibility. It shortens recovery time by reducing the emigration of neutrophils to the site of the inflammation. Contains glucosamine, which helps maintain synovial fluid that lubricates the joints for all day pain associated with daily exercise and activity. 5,000 mg glucosamine, 875 mg chondroitin. 7500 mg MSM. 3.75 lb (60-day supply).

How to we get there?

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As I said previously, the idea of Chance collapsing and no one being there terrifies me. Vet4 is shipping me the Protazil and I am trying to find another vet to come and administer the DMSO before beginning treatment.  DMSO typically helps the Protazil adhere better, thus making the treatment more effective.

EPM: Is DMSO the Cure for Treatment Issues?

By Stacey Oke, DVM, MSc Aug 3, 2009

New research on treating horses with equine protozoal myeloencephalitis (EPM) has found dissolving toltrazuril sulfone, commercially known as ponazuril, in dimethylsulfoxide (DMSO) instead of water prior to oral administration in horses increases the bioavailability by three times and achieves therapeutic levels in both the blood and cerebrospinal fluid.
Ponazuril and related triazine-based antiprotozoal agents used to treat horses with EPM are highly lipid (fat) soluble. As a result, these agents dissolve poorly in the gastrointestinal systemand are therefore poorly absorbed.
Poor drug absorption results in variable drug concentrations in the bloodstream, which translates into a variable therapeutic effect in the treated horse, explained Levent Dirikolu, DVM, PhD, from the Department of Veterinary Biosciences at the University of Illinois, and co-researchers from the University of Kentucky Gluck Equine Research Center and the United States Department of Agriculture (USDA) Animal and Natural resources Institute.

I finally found a vet who was able to come to the farm to meet Chance and administer other medications.

Vet6 felt that DMSO wasn’t necessary and that Chance would be fine. I called Vet4, explained the situation, and he advised beginning Chance on 1/2 a dose of Protazil for the first couple days in conjunction with a mild anti-inflammatory.

So, that is what we did. I had also read that Vit E (only in its all natural form) was helpful during treatment, along with Ulcer Guard to keep his stomach safe from the medications.

I called 5 different vets and no one has what I was looking for in stock. I finally found it in Chantilly!

Other EPM Therapies

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The below research was found athttp://www.epmhorse.org/Treatment/Other_Therapy.htm

Veterinarians should discuss other drug therapies, in addition to the protozoa killing drugs, to address symptomatic problems that may occur during treatment.  Limiting inflammation of the cerebrospinal column, stimulating the immune system, and anti-oxidants are three things that the owner should be prepared to handle during treatment.  If the veterinarian does not discuss these, ask about them.

Inflammation

An active S. neurona infection in the central nervous system (CNS) will produce both temporary inflammation and permanent nerve damage. The inflammation can get worse when the protozoa start to die during treatment.  This can happen as the treatment drug level builds in the CNS, and is known as a ‘treatment crisis’.  Watch for symptoms to get worse 7 to 14 days after the start of treatment drugs.

Inflammation by itself can cause permanent nerve damage, so treating it is important.  Veterinarians report that horses with higher neurologic deficiencies, and possibly higher levels of protozoa, tend to get treatment crises more often that horses with a Mayhew score of 1.  Some veterinarians will place a horse on anti-inflammatory drugs immediately, to prevent additional damage to the CNS.

Banamine   Many owners already have the non-steroidal anti-inflammatory drug (NSAID) Banamine at the barn.  Even if your horse is a 1 on the Mayhew scale, you may wish to have Banamine on-hand to deal with any worsening of the symptoms. Banamine can cause gastro-intestinal side effects such as ulcers when given in high doses, or longer than five days.  A January 2009 cost was $35 for 5 doses.

MicroLactin   This supplement is gaining recognition as an overall, mild anti-inflammatory.  This non-prescription supplement is a derivative of cows milk, and is known as Duralactin, or the ingredient ComfortX in Equinyl.  MicroLactin does not have side effects, so it can be used over the entire course of treatment.  It is possible to supplement with Banamine during a treatment crisis.  March 2009 price was $50 per month.

Dexamethazone   (Dex) This steroid suppresses the immune system, so it should not be used as an anti-inflammatory for EPM horses except in an extreme neurological case.  Used longer than 5 days, it can cause Laminitis.

DMSO   Dimethyl sulfoxide given intravenously, can be useful when the horse has extreme neurological symptoms.  The veterinarian should administer this drug, it should only be used for short time periods, and it can interact with other drugs.

Immune System

In many regions of the U.S. more than 50% of the horses have been exposed to EPM. Researchers do not know why less than 2% of them get an active infection in the CNS.  Studies on blood of EPM horses indicate a change in the immune system response and cells.  Relapse rates for EPM are high, often with the same symptoms. Some researchers believe that the relapses are latent infections which were never completely killed, and the immune system does not recognize.  Immune system stimulants have been suggested to help the horse fight the infection.

Levasimole   This drug has been used as part of a wormer, and anti-inflammatory.  It is known to increase immune response.  It has not been clinically tested specifically for use with EPM, but is being used for it.

Transfer Factor    This supplement has been around since the 1940’s for human use. The older studies on humans suggest it increases the cell-mediated immune response.  It has not been clinically tested in horses.  The supplement is suggested to increase the cell-mediated immune response (see research below).  It WILL NOT kill the protozoa; it is only an immune booster.  It is made from cow colostrum, eggs, and mushrooms.  At least two companies produce this for equine use, and while the main ingredients are the same, there are differences.  4 Life Research and Nutrition Horizons USA offer this at March 2009 prices of $150 to $200 per month.

Vitamin E

Vitamin E has been shown to relieve inflammation, promote regeneration of nerve cells, and is an anti-oxidant protecting the CNS.  This vitamin is suggested by many veterinarians for supplementation during and after drug treatment for EPM.  It crosses the blood-brain barrier to work in the CNS.  A deficiency in Vitamin E is thought to impair the blood-brain barrier.  It is suggested at therapeutic rates from 5,000 to 10,000 total IU per day.  Add the total Vitamin E content of all supplements and feed to reach the target rate.  Research has shown that natural source vitamin E (D-alpha tocopherol) is absorbed by the body better than manufactured E (DL-alpha-tocopherol).

Recent Research

A 2006 study published in Veterinary Parasitology indicated: “Our results demonstrated that naturally infected horses had significantly (P < 0.05) higher percentages of CD4 T-lymphocytes and neutrophils (PMN) in separated peripheral blood leukocytes than clinically normal horses.  The product MicroLactin has been shown to limit neutrophil activity thereby reducing the inflammation process in the CNS.  The study goes on to say, “Leukocytes from naturally infected EPM horses had significantly lower proliferation responses, as measured by thymidine incorporation, to a non-antigen specific mitogen than did clinically normal horses (P < 0.05).  Cell-mediated immunity is lowered in EPM positive horses.

An ongoing study by Dr. Bello, Journal of Equine Veterinary Science, vol. 28, issue 8 (2008), uses Marquis, MicroLactin, and transfer factor in a protocol.  The initial study involved 28 horses, and 8 more have been studied.  This study was presented at the AVMA conference in 2007, and was published in 2008. The full text article is available below with permission from Dr. Bello.

Continuing research by others indicates controlling inflammation is a large part of the treatment process, and immune system stimulation is critical to avoiding relapses.

January 2012

References:

Veterinary Parasitology 138 (2006) 200–210

J Appl Res Vet Med 2003;1:272-8.

J Eq Vet Sc, vol. 28, issue 8 (2008) 479-482
An Intensive Approach in the Treatment of Clinical Equine Protozoal Myeloencephalitis 

Am J Vet Research, June 2008  Vitamin E

J Eq Vet Sc, vol. 25, issue 9 (2005) 380-382

TheHorse.com articles # 12025, 4829

“I will not get on that trailer!”

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The treatment crisis terrified me.  I decided to try to get Chance to the hospital.

Tried I did.  For a total of 8 hours over the course of two days.

WE TRIED EVERYTHING!

Treats, grain, Quietex, walking, crossing lead ropes, talking, begging, pleading, more treats, another horse, a different loading angle, backing the trailer up to the barn doors, and 100000 other things.  I even rubbed lavender oil on his face.  After about 5 hours of trying calmly to coax him, I stopped.

The next day I decided to try it alone…just me and Chance….maybe the group of people was too scary?  I noticed his ataxia was worse and remembered that stress can increase the symptoms.  So, he and I walked and talked and I let him smell the trailer. Very low key.  After 3 hours of walking and talking, he finally walked up the ramp…and decided, nope!  That is when I knew that this wasn’t worth it.

He was scared and confused and that was okay.  We will figure out what to do from here, like we have with every other obstacle over the last 6 months.

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Yet Another Obstacle

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Chance has been doing great since his Stem Cell treatment.  He has not had a single flare up of Lymphangitis since he arrived in Sperryville.  He no longer stocks up when he stays inside due to weather. He is gaining weight.  AND he has not been on daily pain medication! He is finally happy, healthy, and pain free!

Until one day I noticed that he began twisting his back right leg inward at the walk.  I figured that it was due to the long term injury to the DDFT and lack of muscle on that side.  I asked Vet4 and he agreed.  I called the farrier, who had previously worked on Chance when we arrived in Lynchburg many years prior, and he did a more supportive back shoe.  The shoes seemed to help a bit- Chance’s twist was less extreme.

A few weeks later, I realized that I needed to find a local vet due to Vet4 being 2 hours away.  I called and Vet5 came out.  She watched Chance walk down a small hill and immediately said, “He is a wobbler!  We need to test him for EPM.”  I tried to justify Chance’s ataxia by suggesting that he was walking down a hill, after a long standing injury, and it was a bit muddy.  And, to be perfectly honest, I was a bit peeved!  My horse did NOT have EPM!  Not after all he had already been through!  He was healthy!  He just needed some rehab to rebuild the muscle.  I was thinking to myself, that EPM was the first condition that I had addressed with Vet1.  The very same diagnosis he had shot down.  There was no way….

Well, we tested him anyway.  I convinced myself that the test would come back negative.

I began to do what I do best- hours of research. The journals and articles I read said, that while 50% of horses have come in contact with contaminated feed, only 1% actually develop symptoms!  1 PERCENT!  The Protazia attack the CNS, eventually moving from the spinal cord to the brain.  Symptoms can, and will, differ from horse to horse, but usually a horse with the parasite on the spinal cord shows lameness and ataxia on one side of the body (usually hind end).  Where as horses whose brain has become infected, show anything from paralysis of the face, to personality changes, choking, difficulty chewing, etc.

A week or so later, I received a call that Chance did have EPM!  I was heartbroken! And, honestly, I was angry!  Angry at Vet1 for dismissing my initial thoughts about Chance having EPM!  I was reassured that he was not in any pain, but in order to ensure his safety, we needed to get him on medication ASAP!

Again, hours of research…looking at the different medications (Protazil, Marquis, etc) and the outcomes and side effects.

I called the vet I trusted with my horse’s life, Vet4, and he walked me through what should be done.

Spoke to Vet4 ie EPM results:
He state there were two choices- Marque and Protazil & typically he sees an improvement with 85% of horses.

Plan:
Day 1: DMSO and Banamine
Day 2: Same
Day 3: Same
Day 4: Begin Protazil with DMSO and Banamine

After reading about my opinions, I was inundated with talk about what is referred to as, “the treatment crisis”.  Some horses will begin the medication and, due to the kill off of the parasite, their body reacts with severe inflammation.  Some horses will collapse and not be able to get back up, and others will have an increase in their initial EPM related symptoms.  This scared me.  I did not want Chance to fall and be laying there all alone for hours; I wanted him to be under 24/7 watch.

Vet4 said that If I wanted to trailer him to the hospital, I was looking at around $1500.00 for one month.
~$800.00 (1 month)
~$700 (1 month) board

Typically, the outcome of the medication, when EPM is caught early, is a decrease in 2 grades of Ataxia.  Chance was deemed a 3 on the Ataxia Scale.

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Lovely Healing

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Vet4 came out to Sperryville to do an ultrasound recheck of Chance’s back hind leg.
The stem cell site laceration are healing well. Due to his weight being low, and his difficulty putting weight back on, I asked for a fecal exam to test for any parasites, etc.(The test came back negative.)

I also wanted to do a skin scrape on scratches to try and knock them out for good.

Vet4 said that Chance “looked great” and the laceration on his tendon was almost healed. I receive bute, banamine, and meds for his scratches. I was also provided a name to schedule a consult with a well known nutritionist in the area.

Stem Cell Injections

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We decided to go ahead with the Stem Cell injections through the company Vet-Stem.  Though expensive, they carry virtually zero risk, aside from a site infection, in comparison to the surgery.

Vet4 will gather the cells from his rear and stitch up the incisions made.  From there, if there are enough cells, the culture will be sent to the lab, and in about two days, they are able to be injected into the leg!

UPDATE:

There were enough Stem Cells to inject!  Chance is doing extremely well and is able to come home in a few days!!!

I asked if Vet4 could get Chance supportive back shoes before he left and he said he would.

Time to set up a trailer and get his stall ready in Sperryville!!!!

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DDFT Lesions

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Text from Vet4 after ultra sound #3:

“I can see that he has a deep digital flexor tendon lesion and the medial side of the tendon sheath has improve but lateral side is about the same. The DDFT may the cause of all this in the first place and everything else is secondary. We will re ultrasound in 10 days or so just to confirm my findings. If they are correct, it would help to treat that area.”

Conversation with Vet4 :
So far, Chance has received; shock wave therapy, compression therapy and laser therapy.

Chance has a hole in his tendon. Vet4 believes that this is due to an infection/bowed tendon and severe lameness. The ultrasound, done yesterday, shows no change in size of the tendon hole after the previous two rounds of injections.

“Lymphangitis is a symptom rather than a cause and the cause was never treated.” Vet1 continued to treat it like a disorder rather than a symptom!

The swelling and infection have dissipated, as has the severity of the lameness. Though still lame, he is running around in the pasture.
Pain meds were started again due to increased discomfort and soreness.

Vet4 suggests doing one of the following:

1. Stem cell- which can take about two days if sample drawn has enough stem cells. If not, it could take about 4-6 wks to culture. Once injected he can move home. He is to be hand walked for a few days and then can go out as normal. Vet4 will come out in about a month to do another ultrasound and, depending on the size of the hole, may need to do further injections.

2. Surgery to clean out but NOT repair the tendon. This was not discussed in detail.
Payment plans may be an option. I emailed the office for payment options.

Time to make another decision!

100% Turn Around!

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Spoke with Vet4 today. He said Chance has made a “100% turn around”. He trotted him today and Chance was putting full weight on both hind feet! Swelling is disappearing as well!

We spoke about further treatments aside from the Baytril.

I asked about potassium penicillin- He is apprehensive to do potassium penicillin due to horses on antibiotics having DNA changing effects. That it is best to stick to the Baytril and do an ultrasound tomorrow (Friday) to view any changes to the masses. He suggests to have Baytril on hand when Chance leaves to begin immediately if swelling occurs again, which he believes will not be the case after this hospitalization.

I asked about Hydraulic acid: He also is hesitant to inject the SS with the Hydraulic acid due to it’s effects on certain bacterial strains- often allowing the bacteria to hide from the antibiotics. He does agree that another round of injections would probably be helpful and will know more after the next ultrasound.

When asked whether scratches can lead to Lymphangitis, thus leading to the infected SS, he said it is hard to tell but certainly possible.

Chance is currently receiving laser therapy and cold compression therapy along with Baytril, pain meds, and supplements.

Vet4 believes that Chance should be able to leave within a week to two weeks depending on progress!

CHRONIC PROGRESSIVE LYMPHEDEMA (CPL) due to Scratches

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Chance has always been fighting “scratches” on his back legs.  Frustrating, painful, and never seem to completely go away.  Could scratches have caused this?  My thoughts- scratches allowed bacteria to enter the leg, the infection settled on the DDFT sheath and caused the current flare up.  Below is some research I found on possible conditions due to scratches that caused similar symptoms Chance had been experiencing.

CHRONIC PROGRESSIVE LYMPHEDEMA (CPL) due to Scratches

A condition characterized by progressive swelling, hyperkeratosis and fibrosis of distal limbs has been characterized in Shires, Clydesdales and Belgian Draft horses and unfortunately affects numerous horses within these breeds. The disease has also been recognized in Gipsy Vanners; however, only a few horses have been evaluated at this point of time. This chronic progressive disease starts at an early age, progresses throughout the life of the horse and often ends in disfigurement and disability of the legs, which inevitably leads to the horse’s premature death. The pathologic changes and clinical signs closely resemble a condition known in humans as chronic lymphedema or elephantiasis nostras verrucosa. The condition has therefore been referred to as chronic progressive lymphedema (CPL). The lower leg swelling is caused by abnormal functioning of the lymphatic system in the skin, which results in chronic lymphedema (swelling), fibrosis, decreased perfusion, a compromised immune system and subsequent secondary infections of the skin.

The clinical signs of this disease are highly variable. It is often first addressed as a marked and “therapy-resistant” pastern dermatitis (scratches). The earliest lesions, however, are characterized by skin thickening, slight crusting and possible skin folds in the pastern area. While readily palpable, these early lesions are often not appreciated visually as the heavy feathering in these breeds covers these areas. Upon clipping of the lower legs, it becomes obvious that the lesions are far more extensive than expected. Secondary infections develop very easily in these horse’s legs and usually consist of chorioptic mange and/or bacterial infections. Pigmented and non-pigmented skin of the lower legs are affected. Appropriate treatment of the infections (pastern dermatitis) is not successful as underlying poor perfusion, lymphedema and hyperkeratosis in association with the heavy feathering present perfect conditions for repetitive infections with both chorioptic mange as well as bacterial infections. Recurrent infections and inflammation will enhance the lymphedema and hence, the condition becomes more chronic. As a result, the lower leg enlargement becomes permanent and the swelling firm on palpation. More thick skin folds and large, poorly defined, firm nodules develop. The nodules may become quite large and often are described as “golf ball” or even “baseball” in size. Both skin folds and nodules first develop in the back of the pastern area. With progression, they may extend and encircle the entire lower leg. The nodules become a mechanical problem because they interfere with free movement and frequently are injured during exercise. This disease often progresses to include massive secondary infections that produce copious amounts of foul-smelling exudates, generalized illness, debilitation and even death.

TREATMENT/MANAGEMENT

Please keep in mind that none of these treatments listed below will “heal” chronic progressive lymphedema (CPL). However, a rigorous management following our suggestions below will assist you to slow down the process and even make some of the nodular lesions disappear. Your horse will need this management the rest of its life.

• Clipping of the feathers
Long and dense feathering makes management of lymphedema more difficult. We highly recommend clipping the feathers and keep them short, if horses are not presented at shows. If you have a show horse, we still recommend to clip the feathers to initiate a rigorous treatment. As the skin condition improves and the edema is reducing – you may have a better chance to keep the horse’s legs in better condition by. careful repetitive treatment, while the feathering is growing back. The feathers are usually back to their original length in about 10-12 months.

• Treatment of skin infections
Progression of lymphedema is also associated with deposition of fibrous tissue and formation of fibrotic nodules.. As a result, these horses have a poor blood circulation and immune response in the skin of their legs. They tend to built up a thick keratin layer. The long feathering further occludes the skin surface, which then remains humid. These factors provide the perfect culture environment for infectious pathogens. This explains why horses with CPL constantly battle recurrent infections with mites (Chorioptic mange) and bacterial infections (Staphylococcus, Dermatophilus).

Horses with CPL should consistently be treated against reinfestation of mites and bacteria:

Topical treatments:

• Careful washing, cleaning and drying of the legs on a routine basis is essential. Horses with long feathering may require blow-drying of their legs. We recommend using a product manufactured by HydroSurge Inc. ( http://www.hydrosurge.com ) called Apricot Sulfur Skin Treatment Shampoo.

• Frontline spray to treat chorioptic mange (do not use Frontline on pregnant and nursing mares)

• The best and most economical topical treatment is to find a source of wettable sulfur powder (“flowers of sulfur”). This can usually be found through a vineyard supply or at your local nursery (certain “rose dust” preparations). Mix this powder with mineral oil in to form a creamy paste. You can mix a moderate amount in a plastic lidded container or glass jar so that you have enough to last 2-4 weeks at a time. Apply this mixture to the ulcerated and/or affected areas of skin daily. This preparation is the best and most economical topical treatment we have found. You can use it indefinitely. Sulfur is safe to use in pregnant mares.

Systemic antiparasitic treatment: Frequent ivermectine treatment will also assist to keep the mites away.

• Exercise
Regular exercise is crucial. It will increase the circulation and the lymph drainage.

• Manual Lymph-drainage
Manual lymph-drainage is regularly used in humans with lymphedema as long as there is no inflammation present within the tissue. MLD has been successfully used in horses with more acute lymphedema, but has not been established yet in horses with progressed CPL. A massaging coldwater stream may assist a massage. It is important to dry the skin before applying anything else after massage and rinsing. If the feathers were not clipped this may take a long time and you may have to use a hair dryer. Your horse may become more compliant to this treatment as swelling reduces over time

• Bandaging and stockings
We have some limited experience with using special bandages developed for people with lymphedema. For horses, which always move around, “short-stretch” bandages should be used (example: Rosidal ®). Short stretch bandages have been successfully used in three horses with clipped feathering; but bandaging was not as successful on horses with long feathers. Of course it is crucial to have very good padding and keeping the bandages fairly tight. If tolerated, the best results will be achieved by keeping the bandages on 24/7. Of course they need to be redone at least every other day – better every day to control the legs. At first, there will be oozing from the lymphedema through the skin – so the bandages will get wet and have to be changed every day. With the reduction of the edema – this will stop. If the horse is only walked quietly the bandages can be left on for the exercise; very likely the legs have to be rewrapped after the exercise as the swelling will somewhat reduce. For more exercise it may be better to take the bandages off, use working bandages and then switch back to the short–stretch bandages after work. Again make sure the skin is dry when you rewrap.

After the edema has been reduced by using bandages – stockings are used for people to maintain avoid recurrence of lympedema. The use of such stockings in horses are currently under investigation.

It should be noted that horses suffering from CPL often are susceptible to reapeated bouts of “Thrush”. Consequently, thorough and routine foot trimming care is an essential part of the health care management for these horses.

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Dr. Fortier’s “Lameness Originating from Tendon Sheaths”

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Lameness originating from tendon sheathes.
Lisa A. Fortier, DVM, PhD, Diplomate ACVS Cornell University, Ithaca, New York, USA
Laf4@cornell.edu

(Below is cut and pasted from Dr. Fortier’s “Lameness Originating from Tendon Sheaths”)

The most commonly affected tendon sheathes associated with lameness is horses are the digital, carpal, and tarsal sheaths. In general, the diagnoses of lameness originating from tendon sheathes is increasing with awareness and with the more common use of MRI. Clinical signs associated with tendon sheath lameness are variable with respect to degree of lameness and extent of synovial distension. In general, the lameness will worsen with flexion and with work, but the degree of lameness is not directly associated with prognosis for return to athletic performance.

Lameness associated with the digital sheath

Lameness can be localized to the digital sheath with a low 4-point block or intrathecal anesthesia. If sepsis is suspected, a clean (non blood-contaminated) synovial fluid sample can be obtained at the base of the sesamoid bones and axial to the palmar digital neurovascular bundle.

Simple annular ligament constriction, without involvement of the superficial (SDFT) or deep digital flexor tendons (DDFT) is a common cause of lameness associated with the digital sheath. When viewed from the side, the palmar/plantar profile of the digital sheath will have a “notched” or “cut-in” appearance at the fetlock joint. The integrity of the annular ligament (thickness and structure) should be evaluated using ultrasonography to be sure there are no other structures involved such as the SDFT or DDFT. Horses can be treated with intrathecal hyaluronic acid with variable success prior to surgical intervention. If the annular ligament is the sole structure involved and there are no adhesions within the tendon sheath, then a closed or semi-open annular ligament transection could be performed rather than a tenoscopic transection. If ultrasound examination reveals adhesions or synovial masses within the sheath, then tenoscopic exploration and removal of the masses/adhesions is warranted.
Performing surgical maneuvers or exploratory surgery under tenoscopic guidance has distinct advantages as compared to open approaches. Tenoscopy allows for more complete examination of the entire tendon and tendon sheath, resulting in a more accurate diagnosis than can be provided by ultrasonography and the surgeon has an opportunity for removal of pathologic tissues such as synovial proliferative masses, hyperplasic synovial tissue, and adhesions. Additionally, the use of tenoscopic portals instead of an open approach reduces potential iatrogenic damage to neighboring structures and decreases the incidence of postoperative synovial fistulation. The biggest take-home message of these notes should be that the presence or extent of synovial masses/adhesions is not directly correlated with prognosis and many horses return to full athletic performance after tenoscopic surgery and removal of adhesions/masses and annular ligament transection.

Longitudinal tears in deep flexor tendon are increasing commonly diagnosed. Like adhesions and masses, tears are frequently worse on tenoscopic exam than on ultrasound. In these cases, the tendon tear appears to be the primary cause of the tenosynovitis and the annular ligament constriction is likely secondary. Currently, debriding the tendon edges is the only treatment, but some tendon repair technique seems warranted. Ian Wright described a combined approach to repair these tears, but has subsequently discontinued this practice and simple debridement of the granulation tissue between tendon edges is recommended.