SPORTS MEDICINE AND REHABILITATION Surgical Treatment


Surgical treatment of kissing spines is becoming increasingly common. Surgical resection of im- pinging or over-riding dorsal spinous processes was first described in 196825 and is still commonly per- formed. Results following ostectomy are quite good, with 72% (n  209) to 100% (n  9) of horses achieving normal function in the long term.26–29 A newer procedure that is gaining favor is interspi- nous ligament desmotomy (ISLD), which can be per- formed standing. Outcomes of ISLD surgery are comparable (95% of 35 horses) to previously re- ported ostectomy outcomes.7 The same study showed that while horses managed medically (with corticosteroid injections of the affected sites) and had good short-term outcomes (89% of 34 horses), recurrence of back pain was common (19 of 34). Horses treated with ISLD were 24 times more likely to have long-term resolution of symptoms compared to medically managed counterparts. In the author’s opinion, many cases of kissing


spines can be successfully managed medically, es- pecially when coupled with core strengthening and conditioning exercises. However, surgical treatment is a good option for horses that require repeated corticosteroid injections to maintain pro- longed comfort. If the owner would like to pursue surgery as an initial treatment step, the author prefers to trial corticosteroid injections once, to ensure the horse has an adequate response to treatment, prior to pursuing a more invasive treatment option.


Increasing and/or Restoring Back Strength and Function


After breaking the pain cycle, building core strength and stability is essential for the long-term, success- ful management of back pain cases.


Dynamic Mobilization Exercises


The function of the multifidus muscle as a spine stabilizer, or a vertebral motion segment stabilizer, has been demonstrated in multiple species, includ- ing horses.30,31 Atrophy and inhibition of the mul- tifidus muscles is a common finding in humans with acute and subacute lower back pain32 and can de- velop quickly (within 3 days) following induced back pain in an experimental animal model.33 This cre- ates instability of the vertebral motion segment, and perpetuates the underlying condition. Addition- ally, even once the underlying pain has been treated, the multifidus muscles do not spontaneously resume normal activity.34 Exercises that target strength- ening and mobilizing the multifidus muscles greatly reduce the recurrence of back pain in humans; with targeted exercise, recurrence decreased from 84% to 30% within 1 year and from 75% to 35% over 2 to 3 years.35 Thus, increasing multifidus strength, symmetry and function is a major focus of managing back pain in horses. Horses (n  8 Arabians not in ridden work) that performed a series of core strengthening exercises


236 2020  Vol. 66  AAEP PROCEEDINGS


(consisting of 5 sets of 3 cervical flexions, 1 cervical extension, and 3 lateral bending exercises to the left and right) 5 days per week for 3 months had in- creased cross-sectional area (CSA) and symmetry of the multifidus muscles at 6 different locations throughout thoracolumbar back.30 Similar results were seen in Thoroughbreds in race training; those that underwent dynamic mobilization exercises (consisting of 10 repetitions of 3 cervical flexions, 1 cervical extension, 3 lateral bending exercises to the left and right, performed 5 days per week for 12 weeks) had significantly increased CSA of the mul- tifidus muscles in as soon as 6 weeks.36 Examples of some of these exercises can be seen in Fig. 3. Additionally, the book, Activate Your Horse’s Core37 is an excellent resource for these and other core strengthening exercises.


Elastic Resistance Bands


Exercises that encourage hindquarter engagement are very useful in rehabilitation of back pain and include resistance band training, hill work, and cav- aletti exercises. A recent study of 7 general pur- pose riding horses showed that 4 weeks’ training with elastic resistance bands increased dynamic sta- bility of the back.38 The exercise protocol started with familiarization to the bands in week 1 and then progressed to lounging and ridden work 10 minutes 5 times per week, to 20 minutes 4 times per week, to 30 minutes 3 times per week, in weeks 2, 3, and 4, respectively. It is proposed that the bands (Fig. 4) provide proprioceptive input that results in in- creased recruitment of the abdominal and hindquar- ters muscles during exercise.


Additional Core Strengthening Exercises


Gymnastic-type exercise, both in hand and on the lounge can increase core strength and therefore should be incorporated into the long-term manage- ment plan. As discussed above, dynamic mobiliza- tion exercises can increase the size of the multifidus muscle, but this effect can be furthered with the addition of gymnastics exercises. Horses that per- formed gymnastic exercises (including pelvis tilts, backing, turning small circles, and walking over a raised pole) 3 days per week for 3 months, in addi- tion to dynamic mobilization exercises, had more increase in multifidus muscle CSA than horses that performed only dynamic mobilization exercises.39 Considerations for cavaletti work include varying


pole placement and height. Placing elevated rails closer to one another will encourage more hindlimb flexion while placing rails on the ground spaced far- ther apart results in a longer stride, with more limb protraction. Changing the spacing and height of the rails can have the added benefit of challenging the proprioceptive system, as can having only one side of the rail elevated off the ground. Backing is an additional exercise that can be considered and seems to be particularly useful for horses with SI pain. Initially, backing is performed in hand on a


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