"Pearls of Wisdom" from the Palm Beach Laminitis Symposium
- Mar 8, 2004
The key points presented by each speaker during the Second International Equine Conference on Laminitis and Diseases of the Foot, Nov. 10-11, 2003, were sent to conference attendees by James A. Orsini, DVM, Dipl. ACVS, course director, and follow for your benefit:
Gordon Brumbaugh, DVM, PhD
Complementary/Alternative Techniques for Pain Management
- What you consider to be alternative or complementary treatments depends on what you consider to be conventional treatment.
- All treatments (conventional, alternative or complementary) should be evaluated with a multinational, controlled, clinical study.
Robert Boswell, DVM, FRCVS
Demystifying Radiographs: Class 101
- Know your anatomy, proper positioning and technique.
- With respect to the coffin bone’s position within the hoof capsule, its change in position over time is more useful as a prognosticator than any single set of X rays.
- If you perform the test do not ignore the results.
- Anyone can euthanize a horse.
Mark T. Donaldson, VMD
Physical Examination of the Laminitis Patient:
Physical examination of the horse with laminitis has 3 functions: assessing pain, determining the underlying cause for laminitis, and identifying concurrent problems and complications.
How Can I tell if My Horse is in Pain?
- Because horses are prey animals, they may minimize the manifestation of pain as a protective mechanism.
- There is a poor association between subjective assessment of pain and objective parameters.
- Behavior may be a better way of assessing pain in horses.
Other Diseases that affect the Horse with Founder: MSH/Cushing's
- Cushing's disease is the most common cause of laminitis in primary care practice.
- Not all horses with Cushing's disease have hirsutism.
- In horses with laminitis and Cushing's disease, an abnormal distribution of fat is the most common clinical sign.
David M. Hood, DVM, PhD
Physiology of the Foot and Normal Growth
- Geometric, architectural, and metabolic data indicate that a large number of cells are added to the internal surface of the stratum medium layer of the hoof wall during normal growth.
- Cells of the primary epidermal lamina and inner stratum medium are metabolically active transitional epithelial cells and cannot be considered inert or insensitive.
- Changes in the appreciation of hoof wall growth have altered the understanding of hoof wall diseases and their treatment.
A Clinician's Evaluation of the Foot
- Examination of the external foot is only one part of assessment of the horse with acute or chronic laminitis.
- Using the appearance of the external foot as the only guide in patient management is an inadequate level of care.
- Changes in the appearance of the external foot should always be further investigated clinically to determine the underlying cause.
Venogram: Is it Useful for Foot Problems?
- Assessment of the digital circulation is necessary for optimal rehabilitation of the horse with chronic laminitis.
- Venograms allow subjective evaluation of the digital circulation but interpretation is sometimes difficult due to technical and disease related factors.
- The accuracy, specificity, sensitivity, and repeatability of digital venography as a technique has yet to be established.
Radiographing Feet: Techniques and Interpretations
- The magnitude of capsular (rotation) or vertical (sinking) displacement should not be used alone to establish prognosis
- Radiographs should always be used as an aid in rehabilitative shoeing of the horse with chronic laminitis.
- Radiographs should always be used to investigate suspicious findings (flat sole, widened white line, etc.) to document the presence and severity of internal changes even if the horse is not lame.
Pathophysiology of Pain
- The causes of pain in the foot in laminitis vary with the phase of the disease and a differential diagnosis is essential to proper management.
- Chronic pain, by decreasing the willingness to bear weight on the foot, can induce secondary changes in the foot including contraction of the deep digital flexor tendon, hoof capsule, and remodeling of the distal phalanx. Therefore, adequate pain control should always be a part of rehabilitation efforts.
- The stress induced by chronic pain may play a significant role in causing the systemic endocrine and cardiovascular pathologies frequently present in the horse with chronic laminitis.
Andrea Fascetti, VMD, PhD, ACVIM
Neutraceuticals, What Do We Know?
- Neutraceuticals are often marketed in the same manner as approved drugs, which may erroneously lead the consumer to assume a certain degree of safety and efficacy with their use.
- Clinicians should specifically inquire about the use of neutraceuticals and dietary supplements on every visit.
- Veterinarians may assist their clients in evaluating the efficacy and safety of the neutraceuticals clients elect to use on their horses.
Autumn M. Fiester, MD, PhD
What are the Ethical Concerns in Human Medicine: A Comparison
- Veterinary ethics lack a bioethical framework from which to decide ethical dilemmas arising in clinical veterinary medicine.
- A comparison with one branch of human bioethics, namely pediatric ethics, offers a possible model for thinking about these dilemmas.
- The vulnerability shared by both children and animals may be a fruitful starting point in developing the model.
Connie K. Swenson Larson, PhD
Nutritional Requirements of the Normal/Abnormal Foot
- Strength and function of the equine foot begins at the cellular level.
- Balanced nutrition is a key concept.
- Protein, energy, zinc, copper, manganese, selenium, vitamin E, vitamin A and biotin all have a role in hoof wall growth.
Lori S. Mann, VMD
Are There Ethical Considerations in the Care of the Horse with Founder? A Veterinarian’s Overview.
- When you are talking about animals, Ethical Considerations = Emotional Considerations.
- Where do you draw the line?
- Science fails us where emotions rule supreme.
Richard S. Mansmann
Pain Relief: What Can I Do At Home?
- Taking care of your horse's sole is very important.
- Good shoeing on a very regular basis .
- Weight control and avoiding soluble carbohydrates like too much grass and grain.
- Early recognition of sole pain.
- Wrap foot up, put horse in properly bedded stall and call your Veterinary/Farrier Team.
Is Laminitis a Preventable Disease? A Foot Care Program
- Laminitis is very often preventable.
- Have a good regular weight and exercise plan for your horse.
- Develop a preventive foot care program for your horse to know its hooves' base lines.
- Discuss any changes that occur on an annual basis with your Veterinary/Farrier Team.
Nora Matthews, DVM
Pharmacology of Pain Management
In treating pain, treat aggressively, treat early and use combinations of drugs when one drug does not work.
James A. Orsini, DVM
What Did We Learn in the First International Equine Conference on Laminitis and Diseases of the Foot
- Proper sole support and stall rest, are two of the most important factors in the successful treatment of laminitis.
- Appropriate treatment in the acute phase of laminitis can make the difference between soundness and lameness, and life and death.
Terminology—Simplifying the Language
- Laminitis is an inflammation of the lamellar within the hoof. Lamellar and laminar are synonymous. Lamellar and lamellae are the best descriptive terms.
- Laminitis is a condition that involves a metabolic disturbance in the lamellae of the digit with clinically normal hooves and no hoof distortions typical of chronic founder.
Chris Pollitt, BVSc, PhD
New Developments in Understanding Laminitis
- The hoof lamellar region is a "loaded gun" and inadvertent / uncontrolled laminar matrix metalloproteinase (MMP) activation triggers laminitis.
- Hindgut fermentation of excess grass fructan, a carbohydrate, causes laminitis.
- Hypometabolic and vasoconstrictive effects of cryotherapy may prevent the development of laminitis.
- Natural laminitis may occur in situations where glucose uptake by lamellar basal cells is compromised
- The biological basis of laminitis has become molecular.
Laminar Biopsy/Histology—What does it tell us?
- Laminar tissue can be sampled post mortem or when alive (biopsy).
- Serial biopsies monitor progression of lesions enabling accurate diagnosis/prognosis.
- PM samples reflect state of tissue at time of death (mild, moderate, severe).
- Laminar biopsy/histology analysis aids understanding of laminitis disease mechanism.
Classification of a Laminitis Case
- Laminitis trigger factors (LTF) cause laminar separation during the developmental phase of laminitis. The appearance of clinical foot pain and lameness marks the start of the acute phase of laminitis.
- Chronic laminitis follows with downward displacement of the distal phalanx within the hoof capsule.
- Disturbances of the gastrointestinal tract are commonly involved in the pathology of laminitis.
- These problems are often caused by the consumption of excess starch or fructan when animals consume large amounts of grain or have unlimited access to pasture, respectively.
- In the caecum, the presence of excess starch or fructan produces an environment that favors the rapid proliferation of Gram-positive bacteria.
- A period of sublamellar vasodilation occurs during the developmental phase in horses that become laminitic, raising the possibility that microbes produce blood borne laminitis trigger factors.
Unlocking the Complex Anatomy of the Foot: Normal and Abnormal
- The weight of a horse is supported by four modified fingernails (hooves) which encase the horse’s terminal finger bones (distal phalanges).
- The lamellar corium has dermal lamellae that interdigitate with the epidermal lamellae of the inner hoof wall and bars, thus providing a connection between the hoof wall and distal phalanx.
- Secondary epidermal lamellae, located along the length of each primary lamella, increase the surface area to provide better attachment.
- The basement membrane connects the basal cells of the secondary epidermal lamellae and the connective tissue of the secondary dermal lamellae at specialized junction sites called hemidesmosomes.
- Anchoring filaments, consisting of laminin-5, bridge the gap between the hemidesmosomes and the basement membrane.
- Laminitis causes cleavage of laminin-5 and ultimately destruction of the complex anatomy of the foot.
What Worked, What didn’t: Trials by Fire
- No matter how innovative (or expensive) no single approach works for every case.
- The greater one’s repertoire, the greater one’s chance of success. Look to make your treatment techniques easily and readily modifiable. Can you make significant changes to that shoe (should the horse become worse) without removing the shoe and/or inducing additional trauma?
- Not every case is going to be successful. Do not lead owners to believe otherwise!
Management of Hoofwall Lesions with the Chronic Laminitis Patient: Hoofwall Resection
- Know and understand hoof wall anatomy, not just the digital anatomy.
- Careful palpation of the hoofwall is important in evaluating the hoof for abscess tracts, wall separation, deviations of the coronet, etc.
- Hoof wall that is unattached does not reattach. If it is separated, remove it!
Stephen T. Teichman
Examination of the Foot: A Farrier's Approach
- A craftsman eye's always work twice as hard as his hands.
- If you always do what you always did--you will always get what you always got!
- No pessimist ever discovered the secrets of the stars, or sailed to an uncharted land, or opened a new heaven to the human spirit!
POLL: University Equine Hospitals