IN-DEPTH: LAMENESS REHABILITATION Table 1. Rehabilitation Protocol


Time After Injury, wk


0–4 5–8


9–12


13–16 17–20


21–recovery Exercise


5–10-min hand walking 2–3 times daily. 10–15-min hand walking three times daily.


Increase time at the walk 5 min per week. Continue three times daily. By 12 wk good progress is walking 30–35 min each session.


If sound and continued improvement in lesion parameters: ride at the walk 20–25 min daily, hand walk 30 min daily.


Ride at the walk 30 min, add 3–5-min trot. On wk 18 add 3–5 min additional trot per wk.


Ride at the walk 30 min, ride at the trot 15 min per session, add 3-min canter. On wk 22–24 add 3–5-min canter per session.


Rehabilitation Protocol Modified from Gillis et al.7 Stall


Stall or small paddock Stall or small paddock


Stall or small paddock Stall or small paddock Small paddock


Confinement


distal limb and secured with ice between the bags. Ice-water immersion of the equine digit for 30 min- utes resulted in significant decreases in laminar temperatures. Vascular perfusion decreased, but not significantly.5 Cold therapy is indicated in acute injuries to re-


duce edema, slow the inflammatory response, and reduce pain. It is particularly effective during the first 24–48 hours after injury. Cold should be ap- plied for 30 minutes three or four times daily during the acute phase of injury. This modality is also very useful to apply to the injury site following re- habilitation exercise during the convalescent period.


4. Exercise


Controlled exercise remains the most important methodology for rehabilitation of soft-tissue inju- ries. Exercise is necessary to align the newly syn- thesized collagen fibrils along the lines of stress in the limb.6 Without the addition of controlled stress to the injured ligament or tendon, the lesion would heal with disorganized scar. Exercise is slowly in- creased as indicated by interpretation of sequential ultrasound and lameness examinations (Table 1). Hand walking for 5–10 minutes once or twice daily (depending on lesion severity) should begin very soon after injury to encourage optimal fiber align- ment and prevent restrictive adhesions. Ultra- sound and lameness evaluations should be repeated every 8–10 weeks and exercise levels may be in- creased as parameters improve. According to Gil- lis, controlled exercise alone resulted in successful outcomes for 67–71% of horses with soft-tissue inju- ries. Pasture turn-out resulted in successful out- comes in 25–51% of horses.7 All exercise must be adjusted for the level of soundness. If there is increased lameness, swelling is noted at the injury site, or ultrasound parameters deteriorate, the exercise level must be decreased. Work at the trot should only begin after a solid 10–15 minutes of hand walking for warmup. Ini- tially, time at the trot should be broken into short 1–1.5-minute segments.


242 2016  Vol. 62  AAEP PROCEEDINGS


5. Regenerative Therapy


Regenerative therapy is a common term for the use of biological agents to repair and restore damaged tissues. The ultimate goal for use of these modali- ties is to improve the quality of repair. Regenera- tive therapies include stem cells derived from sites such as bone marrow and umbilical cord, fat-derived regenerative cells, platelet-rich plasma (PRP), and autologous conditioned serum (ACS).8,9 These techniques enhance matrix and collagen production, recruit stem cells, and enhance cytokine levels. ACS contains the anti-inflammatory cytokine IL-1 receptor antagonist protein and down-regulates in- flammation.9 ACS also contains cytokines that promote healing such as TGF-, PDGF, IGF-I, and VEGF, among others.9 In a placebo-controlled study of experiment


equine tendinitis, a single intralesional injection of PRP was found to result in increased collagen, gly- cosaminoglycans, and DNA content compared with controls. The tendons treated with PRP also had higher strength and improved elastic modulus. The PRP tendons had enhanced collagen organiza- tion and increased metabolic activity.10 This study is very strong evidence for the positive effects of PRP for treatment of equine soft-tissue injuries. PRP has high levels of PDGF and TGF-, among other cytokines.9 Growth factors such as IGF improve equine tendon healing in vitro and in vivo.11,12 TGF- enhances collagen production in cultured equine tendon cells.9 Injection of stem cells to treat a soft-tissue lesion


via intralesional, IV, or intrarterial approaches was originally hoped to result in healing with tissue characteristic of the original tendon or ligament.8,13 Additional effects of stem cells include stimulation of local vasculature, release of a variety of cytokines that enhance healing, inhibition of T and B lympho- cytes and killer-T cells, and recruitment of local stem cells.8,13 PRP and stem-cell sources may be autologous or allogeneic. Allogeneic products permit rapid treat-


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