IN-DEPTH: LAMENESS REHABILITATION
ment without the necessary lag for obtaining a sam- ple, processing, or proliferation of cells. Allogeneic PRP and stem cells have been used in horses and found to be safe and effective.14 PRP or stem cells are injected 21–30 days after
injury or at a time when other therapies have not been effective in resolving the lesion. The horse is often administered a single dose of parenteral anti- biotics such as ceftiofur (2.2 mg/kg IV). The site is aseptically prepared and regional anesthesia is used to desensitize the area of injection. The injections are usually placed with ultrasound control. A ster- ile bandage is applied and left in place for 2 days. Following injection, the horse is confined and only allowed hand grazing. Bandaging is continued for 2 weeks. At 2 weeks following injection, the in- hand exercise regimen that was being used before injection is resumed. Follow-up ultrasound and lameness evaluations are made approximately 30 days later. In the author’s practice, PRP is used to treat mod-
erate to severe soft tissue injuries. Stem cells are used to treat moderate to severe injuries that in- clude considerable tissue loss. Either modality is used to treat lesions that have failed to continue healing regardless of the original treatment method used. Most horses are treated with only one injec- tion of PRP or stem cells.
6. Therapeutic Ultrasound
Therapeutic ultrasound (US) is useful for treatment of soft-tissue injuries. The modality may be used between ESWTs or used on its own. Therapeutic ultrasound selectively heats tissue
with high protein/collagen content. The most in- tense heating occurs at tissue interfaces. Equine muscle does not heat to the same degree as dog muscle treated with US.15,16 However, equine ten- dons and ligaments are heated substantially when exposed to therapeutic US. As reported by Mont- gomery et al,15 superficial digital flexor tendon (SDFT) mean temperature increase was 3.5°C and 2.5°C in the deep digital flexor tendon (DDFT) fol- lowing 10 minutes of treatment at 1.0 W/
cm2.In the 1.5 W/cm2 treatment group, mean temperature increase was 5.2°C in the SDFT and 3.0°C in the DDFT.15
Increased tissue temperatures enhance tissue me- tabolism and likely increase local circulation. Both of these effects of therapeutic US support tissue healing. An additional benefit of therapeutic US is the deep massage of tissues caused by the sound waves referred to as cavitation and streaming of fluids and ions.17 These nonthermal effects result in compression and expansion of tissues and tissue fluids that may improve tissue healing.2 Fibrous connective tissue scars may be more effectively stretched following heating with therapeutic US. Treatment is usually performed once or twice
daily for 10 to 14 days. Hair must be clipped, the skin cleaned with a moist cloth, and US-coupling gel
must be applied to provide good contact between the transducer and the skin. In horses, treatment for most superficial tendon or ligament injuries is con- ducted with a 3-MHz transducer at 1 W/cm2 for 10 minutes twice daily. Low-intensity US may be applied for 2–3 hours of treatment for acute injuries and 4–6 hours once daily for chronic injuries. A commercially available low-intensity ultrasound device has output perma- nently set at 2.75 MHz at 0.85 W/cm2. For acces- sible anatomic locations, the device is placed on the limb for the appropriate treatment timea.
7. ESWT
ESWT results in reduced levels of inflammatory me- diators, increased collagen production,18,19 small vessel proliferation,18 growth factors,18,19 and re- cruitment of stem cells. Improved outcomes in equine suspensory desmitis have been reported fol- lowing ESWT.20,21 The pressure-tension gradient of the sound energy pulse is responsible for the biological effects. Most ESWT is conducted be- tween 0.25 and 0.45 mJ/mm2. Low-level ESWT en- ergy provides the most beneficial regenerative effects to tissue.18,19,22 The full course of treatment consists of three to
five ESWT applications at 2–3-week intervals. The most common settings for treatment with a focused shockwave device are 1500–2000 impulses, energy at 0.25–0.4 mJ/mm2, focused at the depth of the lesion. ESWT is often the primary treatment modality for many soft-tissue injuries.
8. Laser Therapy
Low-level laser therapy is beneficial for wound ther- apy, pain reduction, and healing of soft-tissue inju- ries. The biological effects of laser identified in research settings include release of endorphins, blocking of pain sensation through reduced nerve depolarization, enhanced adenosine triphosphate (ATP) production, and reduced IL-1 levels. In a rat model of Achilles tendinitis, laser therapy improved tendon strength and reduced inflammatory cyto- kines more than treatment with diclofenac.23 La- ser light energy is optimally absorbed through the skin at wavelengths of 805–980 nm. The dose of energy required for treatment depends on the na- ture of the injury, depth of the tissue, and desired effect (biostimulation or anti-inflammatory/pain re- lief). A recent study by Haussler24 found laser com- bined with chiropractic therapy to result in more pain relief for equine back pain than laser or chiro- practic alone. Recommended treatment dose ranges from 4 to 12 J/cm2.25 The most challenging issue with laser treatment is delivering an effective dose to the target tissues. Absorption and disper- sal of the laser energy by the skin, hair, and deeper tissues significantly reduces the energy at the treat- ment site.26
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