Physical Therapy for Healing and Health
- May 1, 2003
Call it what you will--equine physical therapy, equine therapy, physiotherapy, rehabilitation therapy, equine sports therapy, or even alternative therapy. The treatment, rehabilitation, and prevention of movement dysfunctions, orthopedic ailments (soft tissue, joint, and bone problems), and neurologic disorders through manual therapies, electrical therapies, and exercise has become increasingly utilized and recognized as a valuable, non-invasive means of promoting healing and maintaining soundness in the horse.
Still, many don't understand what equine physiotherapy is, what it does, or the various modalities it includes.
First, let's start with those various names and what they mean. In England where this whole thing began, professionals who wish to be chartered (accredited) in human physiotherapy can complete a three- or four-year university course to earn a diploma or Bachelor of Science (BSc) in physiotherapy. Explains animal physiotherapist Victoria Spalding, MSc (Veterinary Physiotherapy), member of the Chartered Society of Physiotherapy and of the Association of Chartered Physiotherapists (ACPAT) in Animal Therapy, of Leeds, England, "Chartered physiotherapists who wish to specialize in animal therapy must then complete two years of general practice before embarking on postgraduate training in animal therapy. All treatment given by ACPAT members is done so with veterinary approval."
In Canada, the terms "physical therapist" and "physiotherapist" are used interchangeably, states Kathy Broughton, a registered physiotherapist and member of the Canadian Horse and Animal Physical Therapists Association (CHAP) in Ottawa, Ontario.
"In Canada," she says, "only registered physiotherapists can use the titles and terms, 'physical therapist' or 'physiotherapist', and only registered physiotherapists can state that they perform physiotherapy, as all terms are regulated, controlled acts."
Registered physiotherapists complete a four-year undergraduate degree in rehabilitation, after which those interested in animal physiotherapy can take post-graduate courses in animal rehabilitation.
Broughton notes that in the United States, most lay people use the term "equine physical therapist." That's probably so, but the term doesn't sit well with Kentucky-based equine therapist Mimi Porter, MS, a certified and licensed athletic trainer and Midway College's director of the equine therapy program.
"Human physical therapists are opposed to the title being used in association with therapy for animals," Porter explains. "Please use the term 'equine therapist'."
As yet, there is no U.S. industry standard for certification or licensure for establishing a standard of practice or education for equine therapy, but equine therapists who complete Midway's bachelor's degree therapy program receive a comprehensive exam that serves as a certification from the Midway College program. It is the only educational standard in existence at present, and these graduates have completed the most comprehensive and advanced educational program in equine therapy available anywhere. They call themselves ETs--equine therapists.
"Equine therapy is used to reduce or control pain, control swelling or edema, increase joint range of motion and muscle function, and maintain a level of functionality and comfort for the horse throughout recovery from injury or surgery, or maintain functionality and comfort for the horse in training and competition," says Porter.
Silvia Lavallée of Dugald, Manitoba, a licensed physiotherapist with a focus on equine and canine rehabilitation who serves as current director and instructor for CHAP, states therapies are indicated for: Muscle strains, weakness, spasm, and atrophy; tendonitis and bowed tendons; joint sprains; stiffness, arthritis; inflammation; wounds; spine/pelvis dysfunction; nerve paralysis and neuralgias; pain control; and gait abnormalities.
How this is accomplished might not be wholly understood, but enough research and knowledge exists to provide a reasonable explanation. Explains Porter, "Blood flow through muscle and muscle enzyme levels are stimulated, waste products of activity are mobilized through the blood and lymph systems, pain response is over-ridden by the input of the physical agents, and neurotransmitters are stimulated. The mechanism of action of all the physical agents is the stimulation of neurotransmitters; there is some documentation of this."
Studies found that neurochemical assays taken from human blood samples prior to treatment with electrical stimulation demonstrated that agents associated with pain reduction, mood enhancement, and tissue healing increased within a 20-minute treatment and remained elevated for at least 24 hours after treatment.
In less scientific but more familiar terms, think about one of the physiotherapy's simplest and most recognizable applications--massage. Massaging the muscles draws healing, oxygenating blood into the region, thus helping to reduce inflammation and stiffness. Maybe we lay people don't understand the science that's behind massage therapy and other physiotherapeutic tools, but most of us have probably felt the dreamy effects of a nice shoulder rub delivered by an obliging friend or relative.
Obviously, physiotherapy is far beyond simple massage. There are many modalities that can be employed by equine physiotherapists, depending upon the problem and personal preferences, but all sharing the same goal of helping the horse.
Physiotherapy interventions include, but are not limited to, manual therapy, thermal agents, electrotherapeutic techniques, mechanical agents, therapeutic exercise, and acupuncture.
Manual therapies include massage, stretches, joint and soft tissue mobilization, and/or manipulation, says Spalding. These therapies are performed at the spinal and peripheral joints, says Lavallée. "Manual therapy can give pain relief by affecting the neurophysiological feedback mechanisms present in the joints of all animals," she says. "These graded gliding and traction movements are used to restore optimum joint movement by reducing adhesions, mobilizing tight joint structures, and providing enhanced joint lubrication and joint nutrition."
Massage can promote circulation, decrease muscle spasm, mobilize adhesions and scar tissue, and aid lymphatic drainage. Reports Lavallée, "Massage can be used in the acute and chronic stages of injury, and prior to and following exercise to prevent injury."
Myofascial release is the use of the hands and fingers to apply pressure (gently or with some controlled force) to cause a release of tension in muscle or fascia. "Areas of tension are described as 'knots' or taut bands that cause pain or restrict movement," Porter explains. "These areas respond to direct pressure and the increased local temperature resulting from manual pressure. This modality should be followed with gentle controlled exercise such as ground exercises or walking."
Stretching can provide pain relief from tight muscles and connective tissue that are responsible for pressure or tension on nerve pathways, restore normal muscle length after injury as well as maintain normal muscle length, avoid stiffness related to age or inactivity, and protect from stresses and strains. "End range stretching enhances nutrition to all local tissues," explains Lavallée. "It reduces lactic acid for post-exercise-related soreness."
Acupressure is the use of the hands and fingers to apply pressure to acupuncture points. Porter states, "An understanding of traditional Chinese medicine and a knowledge of point location is necessary to get the most benefit from this approach."
These include hot and cold applications.
Heat can be applied via dry, moist, or infrared applications. "Heat affects circulation and metabolism, and relaxes muscles spasms," says Lavallée. "Heating decreases the thickness of synovial fluid and allows muscles to relax, become more pliant, and thus more easily stretched."
Cold, applied as a cold bath, ice, or ice packs, is used for acute injuries as it constricts the capillaries, thus reducing swelling, inflammation, and pain transmission. "The first 48 hours are critical to slow down the inflammatory process," Lavallée states, "Apply for approximately 12 minutes, but no longer, otherwise reactive vasodilation (widening of the blood vessels) occurs, re-warming the tissues and eliminating the beneficial therapeutic effects of cold."
Electrical Therapeutic Techniques
These techniques include laser, muscle, and nerve stimulation, H-Wave, interferential, and magnetic field therapy.
Electrical muscle stimulation (EMS) works by making the muscle contract through motor nerve stimulation using an interrupted direct current. "It is useful for identifying painful or immobile muscle groups following injury in the chronic or acute phase," says Spalding. "Electrical muscle stimulation also improves venous and lymphatic drainage, prevents muscle atrophy, prevents the formation of unwanted adhesions, reduces scar tissue formation, builds and re-educates damaged or weakened muscle, and encourages nutrition into the affected area," adds Lavallée. "EMS usually uses a low-frequency output."
Transcutaneous electrical nerve stimulation (TENS) reduces swelling and assists wound healing by stimulating the top layer of the skin, by attracting white blood cells (which fight infection), and stimulating nerve function. "The electrodes deliver low-voltage intermittent stimulation to nerves in the skin," says Lavallée. "Electrical nerve stimulation elevates blood cortisol (thus acting as an anti-inflammatory agent), releases endorphins (thus reducing pain), relaxes spasms, and causes muscle contractions to maintain strength on injured or surgical muscles."
Electro-acupuncture, micro-current, and codetron are electrotherapeutic agents used to treat pain and aid healing. They differ from the previously discussed methods in terms of frequency, pulse width, and rate, Lavallée states. "They are used to block pain transmission and stimulate the body's natural pain killers," she says. "There are two range frequencies: Low frequency is used on chronic conditions, where relief lasts for days and is cumulative; high frequency is used for acute conditions for immediate pain relief."
Pulsed electromagnetic units, i.e., electromagnetic blankets and electromagnetic boots, placed over affected joints are useful for decreasing or minimizing inflammation, says Jack Snyder, DVM, PhD, Dipl. ACVS, chief of equine surgery at UC Davis Veterinary Medical Teaching Hospital and director of the UC Davis' new equine physical therapy program. "They are easy to use, very popular, and are utilized all the time in performance horses to try to minimize inflammation and to keep horses performing at their best," he says. "This system can have a soothing or relaxing effect on horses; when horses relax, they tend to have less injuries, which is a benefit."
Adds Kristinn I. Heinrichs, diplomate in human sports physical therapy from the American Board of Physical Therapy Specialties, PhD (education in sports medicine), MEd (exercise physiology), of Peak Sports Performance International, Savannah, Ga.: "Pulsed electromagnetic units have been shown to increase circulation, improve fracture healing, reduce pain, and promote healing."
She cautions that there's a difference between pulsed electromagnetics and static magnets; while anecdotal evidence suggests that static magnets in blankets work, research "overwhelmingly" shows no effect, she says. "The scientist in me can't recommend static magnet therapy without this caveat: Static magnet therapy is very different than the application of pulsed electromagnetic therapy, the effectiveness of which is supported by clinical research," she says.
Laser therapy, which uses an intense beam of light, stimulates the body's processes, activates waste removal, increases repair activity, relieves swelling, heals surface wounds, and stimulates blood and lymphatic systems. It also increases serotonin, thereby achieving a calming response. "Laser is especially useful," says Spalding, "to enhance the repair process in tendon and ligament injuries, superficial joint and bone injuries (including fractures), open and post-surgical wounds and ulcers, old fibrous injuries, bursitis, osteoarthritis, and rheumatoid arthritis. Laser has also been shown to be effective when used over acupuncture points."
Notes Snyder, "Therapeutic lasers seem to be very good on open wounds that are not healing well; lasers are very good at promoting and stimulating healing."
Lavallée says that physiotherapists mostly work with cold (low-intensity) lasers. "This is ideal for acute cases as it does not increase tissue temperature, increase bleeding, or aggravate the inflammatory phase."
These agents include ultrasound and devices such as mechanical massagers.
Ultrasound is a form of acoustic energy used to treat musculoskeletal injuries, including inflammation and wounds. It offers deep heating without excessive heating of the skin. Explains Spalding, "Ultrasound can stimulate cell behavior and activity, which aids the healing process of soft tissue structures in both the acute and chronic stages, affecting the inflammatory, proliferative, and remodeling phases of repair. Ultrasound can also be used to decrease pain and muscle spasm, promote wound healing, aid re-absorption of hematoma, reduce swelling, and reduce scar tissue."
Although an effective and long-standing modality, Snyder cautions that therapeutic ultrasound requires a degree of experience to use properly. "Ultrasound produces heat and can cause damage to tissue when misused. Therapeutic ultrasound has many positive effects and can be very effective on sore muscles, improving healing, and for decreasing inflammation."
Acupuncture stimulates specific points on the body to achieve therapeutic effects and to repair abnormally functioning tissues and organs by affecting the neurological and endocrine systems. "Acupuncture affects the central and peripheral nervous systems to activate the body's own pain relief mechanism as well as to stimulate the release of several neurotransmitters," Lavallée states. "Acupuncture blocks the pain signals to the brain and spinal cord, increases blood supply, relaxes muscles, and influences the autonomic nervous system. Increasing the blood flow and decreasing waste products reduces inflammation."
Therapies for Treatment
Prior to initiating any therapies, the physiotherapist obtains a veterinary diagnosis of the problem, evaluates the disorder, and applies the most appropriate therapy for that particular condition. "In an ideal situation," Spalding says, "the vet and physiotherapist would assess together, but in the majority of cases the patient has been seen by the referring vet, and a diagnosis made."
The physiotherapist evaluates the condition, Heinrichs states, by getting a full history of all factors--rider, injury, injury mechanism, observed behavior, saddle, shoes, etc. "I observe the horse from all angles (relaxed standing and moving through the gaits with and without the rider) and examine conformation," she says. "I then do a complete physical examination to determine the cause and status of the injury (signs of inflammation, stage of tissue healing, etc.), range of motion (passive/active), joint mobility, status of the muscle (muscle guarding, trigger points, flexibility, strength, atrophy, etc.). Most importantly, I work very closely with the attending veterinarian and rider."
Once the problem has been identified, the physiotherapist determines which modality would be best. There are many factors that help weigh the decision. "The treatment plan," Heinrichs states, "really depends on what the horse's presenting problem is--acute traumatic injury vs. pre-competition preparation, post-competition recovery, or old injury that has been treated by others without resolution. I emphasize that successful physical therapy intervention is more than the application of therapeutic modalities. It involves a comprehensive program to facilitate injury healing; restore strength, flexibility, and proprioception; retrain proper neuromotor patterns and posture in both horse and rider; and return the horse and rider to their optimal performance levels."
Sometimes the physiotherapist does a little detective work to uncover an underlying condition that's creating a problem. Notes Lavallée, "The heart of the physiotherapy profession is understanding how and why movement and function take place. For example, a problem could have been started by dental work that affected the jaw and the hyoid bone of the neck. These areas in turn influence the neck. The physiotherapist strives to track down and solve these biomechanical puzzles."
Some problems lend themselves to different therapies. Reports Snyder, "For example, electromagnetic units are commonly used to minimize inflammation or to relax the horse. But some people use direct electrical stimulation, lasers, acupuncture, or chiropractic for various problems." Decisions are often based on personal experiences and preferences.
Keep in mind that variables among individual horses prevent physiotherapists from applying a one-size-fits-all solution to specific problems. Nevertheless, physiotherapists do have their preferred applications for different disorders.
Repetitive Strain Injuries
About 75% of the time, Broughton uses some form of manual therapy for these cases. "This includes a lot of specific joint mobilization to re-establish the normal mobility and decrease pain within a joint to allow it to have the potential of full range of motion," she states.
Also tending to favor manual therapies for repetitive wear and tear is Amanda Sutton, the official physiotherapist at the Blenheim, Windsor, and Burghley three-day events. A Chartered Physiotherapist MCSP, SRP, Grad dip phys, ACPAT member, MSc (Veterinary Physiotherapist), and author of The Injury Free Horse and The Injured Horse, Sutton utilizes various manual therapies before and at competitions to decrease nerve irritability, improve joint mobility, and relax muscle spasm.
"Most eventers have falls, sudden stops, whiplash, strains, and corkscrews through the spine over fences," she explains. "This accumulates over time leading to a domino effect. For example, a small problem at the neck ends up with compensatory problems throughout, leading eventually to asymmetric pelvic limb gait and, perhaps over time, excessive wear and tear on the lower limb structures."
Racing soreness--Porter uses several physical agents such as electrical stimulation, phototherapy, or therapeutic ultrasound to stimulate acupuncture and trigger points to reduce pain and encourage muscle relaxation. Manual therapies such as acupressure or myofascial release can also be used. She follows that with stretching, passive range of motion, and ground exercises that can be done in the stall to further stimulate blood and lymph circulation.
Stiffness--Lavallée might use a dual approach of heat or ultrasound (applied to affected tissue to ready the area for stretch or to decrease pain before joint mobilizations) and exercise. Afterward, home stretching exercises are required. These include flexibility and strengthening exercises such as walking in small circles to encourage spinal side-bending or encouraging horses to step over poles to increase appropriate muscle work, gain collection, and strengthen appropriate muscles.
Muscle strains--"Minor strains can be 'trigger massaged' (with localized, deep pressure massage to a certain point) and stretched," Lavallée suggests. "Follow this with gentle progressive exercise. The goal is to catch the problem before other areas begin to compensate and then break down."
Muscular back pain--Spalding uses multiple tools, including laser and soft tissue mobilization techniques, followed by massage and stretches (the last two can be done by the owner) to encourage lengthening through the back and hamstring mobility.
Direct trauma--For peripheral nerve injuries occurring from a direct blow such as a kick, sacroiliac joint strains that can occur from slipping on the ice, and impact injuries (such as trailering accidents), Broughton generally favors manual therapy along with electrotherapeutic modalities (ultrasound, laser, electrical muscle stimulation, etc.), which significantly aid in the healing process of soft tissue injuries (ligaments, tendons, muscles, peripheral nerves etc.). "Recent studies have shown up to 4.7 times the healing rate of tendon injuries with ultrasound vs. no treatment in the laboratory setting," she says.
Wounds--"Acupuncture, laser, and ultrasound are useful in assisting the healing of superficial wounds or ulcers," Lavallée says. "Electrical nerve stimulation and infrared heat can stimulate healing in a general area. As wounds can cause a proliferation of scar tissue, gentle stretching, massage, and electrical nerve stimulation can assist by aligning collagen fibers. Wounds require rest, so afterwards re-introduce exercise in a controlled way to regain strength."
Bone repair--Porter favors very low levels of ultrasound to stimulate repair of non-union fractures. "Electrical stimulation is also added to this treatment for soft tissue soreness that results from the horse standing in a guarded posture," Porter states.
Laminitis--To stimulate circulation in the hoof, Porter likes the Equi-Light photon therapy device (which produces infrared light). "I have observed significant improvement in the venogram of a laminitic horse following only 16 days of treatment with this device," Porter says. Some believe that the venogram alone can improve circulation in the compromised hoof.
Additionally, because of its ability to reduce inflammation and improve joint motion and muscle function, equine therapy lends itself to reconditioning unfit horses, enhancing performance, and maintaining health/preventing problems.
Equine therapy seldom achieves full resolution with the first application. Notes Porter, "Although equine therapy can reduce the length of the inflammatory stage of healing so that the repair stage can begin earlier, the maturation stage still needs the appropriate time to effect a strong repair."
Repeat applications are usually necessary. Porter treats most cases for at least 30 minutes, three times per week.
The number of treatments varies, depending upon the disorder and its severity. States Spalding, "Acute back pain may require six to 10 sessions whilst a routine check or performance issue may be resolved in one or two sessions."
Adds Heinrichs, "Response to the intervention (therapeutic modality application, manual therapy, and exercise therapy) should be assessed after each session. For example, patients should see some response to therapeutic ultrasound within a few sessions; the upper limit (based on the literature) is 13-14 ultrasound treatments."
Regardless, Snyder encourages using physiotherapy on an ongoing basis for keeping problems resolved, and fit horses fit. "Physical therapy becomes beneficial when you do it religiously, even when things look okay. Don't want to wait until you have a problem: Then you have to go into treatment modality."
About the Author
Marcia King is an award-winning freelance writer based in Ohio who specializes in equine, canine, and feline veterinary topics. She's schooled in hunt seat, dressage, and Western pleasure.
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