SPORTS MEDICINE AND REHABILITATION


more aggressive therapies such as intra-articular injections. The author has not experienced any ad- verse effects with mesotherapy but is aware of one horse that developed diffuse, painful subcutaneous edema throughout the thoracolumbar epaxial region after being treated with mesotherapy once weekly for 3 weeks.


Extracorporeal Shockwave Therapy


Fig. 1. Photograph of the right side of a horse following meso- therapy treatment. Note the parallel rows of subdermal injec- tions along the thoracolumbar epaxial musculature.


colic-like symptoms, although this seems to be more common with tiludronate than clodronate. Clodro- nate has infrequently been associated with acute renal failure and therefore should not be given in the face of abnormal serum blood urea nitrogen (BUN) or creatinine levels, nor should it be given in con- junction with NSAIDs. Clodronate appears to be the more widely used bisphosphonate in the United States, likely due to the ease of administration, the cost, and the infrequency of negative side effects. However, how the efficacy of clodronate compares to that of tiludronate, especially in the treatment of thoracolumbar conditions, is unknown.


Mesotherapy


Mesotherapy is a technique that began in human medicine in the 1950s that involves multiple, small- volume subdermal injections of analgesic and/or anti-inflammatory medications. One study in hu- mans (n  84) demonstrated that mesotherapy (consisting of lidocaine, ketoprofen, and methylpred- nisolone injected at days 1, 4, 7, 10, and 13) was, at less than half the dose, as effective as systemic ad- ministration of the same medications for treating lower back pain.18 In horses with thoracolumbar pain, the injections are typically administered in three parallel rows, on either side of the spine (Fig. 1). There are a variety of “cocktails” used by prac- titioners; the author prefers a combination of mepi- vacaine, flumethasone, and traumeel diluted in saline. Injection of methylprednisolone in meso- therapy should be avoided due to anecdotal reports that the hair at the injection sites can turn white. Like many treatments for the lower back and pelvis, mesotherapy is often insufficient when used in iso- lation, but it can be very useful as an adjunct ther- apy, in combination with other treatments, and/or as a way to lengthen the time required between


234 2020  Vol. 66  AAEP PROCEEDINGS


Shockwave therapy is another very useful adjunct therapy that, until recently, was being used based on the positive effects reported anecdotally. A re- cent study reported the effects of shockwave therapy on a group (n  12) of riding horses with thoraco- lumbar back pain.19 Treatment consisted of 1500 pulses applied to the epaxial muscles from T12 through L5 with an 80-mm trode at an E4 energy setting, and was performed 3 times, spaced every 14 days. The authors found a significant and clini- cally relevant increase in mechanical nociceptive threshold (MNT), measured with pressure algome- try along the thoracolumbar epaxial muscle, 7 days following the second and third treatments, but not after the first treatment. Interestingly, the in- creased MNT persisted for at least 1 month follow- ing the last treatment. In contrast to the results of this study, in clinical practice, many practitioners report significantly de- creased back pain following even a single treatment of shockwave therapy. It is a good option for treating muscle pain that may develop in the interim between corticosteroid injections, and should be strongly con- sidered as an alternate treatment for horses that can- not receive corticosteroid injections (e.g., for metabolic reasons or due to competition drug regulations). Ad- ditionally, it is a safe and non-invasive treatment, with few to no reported side effects. It is also a good first- line treatment, but in the author’s practice the cost of treatment is sometimes prohibitive. The author typ- ically treats the thoracolumbar epaxial muscles as needed with a total of 1500 to 2000 pulses, half deliv- ered with a 35-mm probe and half with an 80-mm probe, to try and target both superficial and deeper pain. Shockwave cannot be used within 5 days of Fe


´de ´ration Equestre Internationale (FEI) competition.


Under USEF guidelines, shockwave of the back spe- cifically (but not elsewhere on the body) is permitted 12 hours before competition.


Laser Therapy


In general, the scientific evidence for the efficacy of laser therapy in the treatment of musculoskeletal conditions is lacking. However, a recent study investigated the outcome of laser therapy in actively competing horses.20 Sixty-one Quarter Horses with acute lower back pain were treated with low- level laser therapy (series of 3 treatments over 5 to 7 days), chiropractic, or a combination of both. Horses treated with laser alone had decreased epax- ial muscle pain, trunk stiffness, and muscle hyper- tonicity lending support toward the use of laser to


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