17 Dec 2018
Eleanor Kelly, a freelance journalist, details the topics discussed by expert speakers at a one-day CPD course attended by equine veterinarians.
Eleanor Kelly
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Delegates had the opportunity to gain hands-on practical experience under the guidance of the speakers, including scanning and injection technique using cadaver limbs.
Vets are always eager to keep their skills and professional knowledge up to date – indeed, CPD is a requirement for royal college membership.
Equine vets from some of the UK’s leading practices congregated at Oakham Veterinary Hospital in Rutland to take part in a one-day CPD course, organised by Nupsala Veterinary Services, on advances in equine orthopaedic therapies and regenerative medicine.
These regular events are designed to have a small number of delegates, along with expert speakers, allowing a high degree of discussion and debate along with talks, case discussion and hands-on practical experience.
Speakers included:
The day’s objective was to increase knowledge and practical skills in the diagnosis and treatment of equine tendon, ligament and joint disease via an evidence-based approach.
Dr Anghileri kicked off the day with a highly illustrative discussion on various imaging techniques and for which structures they were the most appropriate when it came to diagnosis of lower limb conditions.
Besides ultrasound and radiography, he discussed where MRI and scintigraphy fits in the picture, and how to make the most of imaging, from positioning to settings. As with all the speakers, Dr Anghileri’s emphasis was on obtaining a diagnosis with many examples for the delegates to see.
Mr Anderson’s presentation was on a practical approach to tendon and ligament injuries. He discussed his methodology for a work-up towards the diagnosis of a variety of conditions, before discussing the treatment options available.
He also gave a detailed look at surgery and regenerative therapies, such as stem cells and platelet-rich plasma (PRP), along with their potential modes of action and harvesting techniques.
As well as drawing on his own experience, Mr Anderson gave a review of literature findings for the success of these treatments for the conditions discussed, covering speed of repair, return to work and re-injury rates, combined with his own views on postoperative monitoring, and management and rehabilitation. Finally, he gave a brief evaluation of more conservative options, such as remedial farriery and hydrotherapy.
Dr Koene focused on the equine joint and therapeutic approaches from pure rehabilitation, systemic treatment through to intra-articular surgery and therapies.
He reviewed these in light of the objectives we should be aiming for – pain relief, reduction in inflammation, joint effusion and cartilage degradation – as he said the ideal was to suppress further harm, slow down ongoing damage and perhaps even repair.
He reviewed the use of regenerative medicine, hyaluronic acid and polysulfated glycosaminoglycans, before turning to intra-articular polyacrylamide gels – a treatment he had been investigating and using in Germany with promising results.
He discussed their extensive use in human medicine, their mode of action in humans and equines, and the potential effects on the equine synovium in the short and long term.
Dr Koene said: “We need regenerative medicine because we have to work with sport horses and we always have to think about doping. I think, by learning from regenerative medicine, we are getting better, and I think even if you compare what we do as vets to the human field in this area, we have a lot of things where we may even be a bit more advanced – like the gels that are now reintroduced into human medicine because they are working so well in horses.
“The lasers are coming from soccer teams such as Juventus and Inter Milan, where they are using them on human athletes and they wanted to test things on horses… they knew it was working, but they couldn’t explain why, so we did the research for them.”
Dr Koene also took the opportunity to highlight the hazards of sport horse exercise management by many riders.
“I think we are spoiling our horses with surfaces that are too good because they lose the proprioceptive feeling,” he said. “You will never find a Shetland pony with a suspensory problem because when it puts its foot on the floor and feels if it is uneven, it learns to place it somewhere else.
“In our horses, they stand for 23 hours a day in a box having shoes and they lose this capability of feeling the terrain. That is why I think it is very important they go out in the field and they are ridden over varied terrain.”
The final formal talk was given by Dr Read on additional and adjunct therapies for the equine joint. She concentrated on the use of lasers, which have been used in human orthopaedics for more than 30 years, but here, clinical trials and meta-analysis found low-power lasers to be largely ineffective.
High-powered machines have been developed to address this by delivering high energy and the ability to penetrate tissues – and, consequently, systems have been produced specifically for use in horses. The high powered, multi-function class four laser from TLX Laser, known as the FP4 System, has been used by Rossdales Veterinary Surgeons.
Dr Read presented her research and analysis on some 60 horses where laser therapy was used as additional therapy to treatments given for these cases, which ranged from superior check ligament desmotomy to intralesional PRP or interlukin-1 receptor antagonist protein. These were all sports horses aged from 2 to 19 years old. Her preliminary results were encouraging, such that she would continue to use laser therapy on similar cases.
“Ultrasonographic appearance was subjectively improved to a greater extent than expected, had laser treatment not been used,” she said, and one could expect more dramatic clinical and ultrasonographic changes in the early stage of repair of an acute lesion. Some appeared clinically improved with regards to inflammatory signs and some had a quicker return to work.
Dr Read added that she had been impressed with results in chronic cases of tendonitis/desmitis and, in conclusion, discussed how she would ideally like to address the limitations of the study – a control group, a larger series and longer term follow-up for the future with more objective measurements.
The lively inter-group discussions continued with some case studies presented by the speakers of cases they had found challenging.
As always, this sparked lively debate that continued into the afternoon, with practical sessions including examining the lower limbs, along with ultrasound-guided injection techniques, giving delegates a chance to practise these under expert guidance from Mr Anderson.
Dr Anghileri reviewed bone marrow harvesting sites and Dr Koene demonstrated many of his methods of physically examining the sports horse with, again, delegates having the chance to practise these under his expert tutelage.
The day finished with Dr Luciani sharing his clinical experience with TLX lasers and emphasised the array of injuries where it could be beneficial – ranging from tendon and ligament injuries, and enthesopathy, to bone bruises and muscle sprains.
He showed a range of data in support of the laser, with good success rates after 12 months, but emphasised, as did all the speakers, that correct rehabilitation was still a key.
The feedback from the 19 delegates was full of praise for the content of the day, along with the quality of speakers. The day’s objectives had been achieved, and Nupsala Veterinary Service’s team was thanked for its hard work organising it all.
Dr Read said: “I really enjoy these smaller format CPD days because I think the clinical discussion and idea sharing that goes on seems to be a little bit more open in these smaller meetings.
“People are a little less afraid to stand up and say what they are doing, talk about some of the mistakes they have made and share some ideas about how we can all just get a little bit better about what we are doing in clinical practice, and we all know equine medicine lacks a little bit of evidence-based fact, so this idea sharing is something I enjoy.”
