SPORTS MEDICINE AND REHABILITATION


area and applying a small amount of coupling gel. The TENS unit itself is secured to the mane. Chronic pain settings are used despite the acute nature of the laminitis and the unit is applied to 30 minutes twice daily. This is to stimulate endogenous opioid release—this will allow pain relief that lasts beyond the time the TENS unit is removed.


● Fentanyl patch: 2  10-mg fentanyl patches are applied over the antebrachium after clip- ping the hair. They are covered with elasti- con to keep them in place. The patches are changed every 36 to 48 hours.


● Perineural analgesia: 3 mL of 0.5% bupiva- caine is injected over the medial and lateral palmar nerves at the level of the fetlock (abax- ial nerve block) every 12 to 24 hours.


● Morphine: 0.1 mg/kg morphine is given IM as needed, not to exceed a frequency q3h administration.


Chronic Laminitis


Treatment in the Field A 25-year-old Paint gelding previously diagnosed with pituitary pars intermedia dysfunction (PPID) has a history of multiple episodes of laminitis affect- ing the front feet. While previous episodes have improved after a few days of phenylbutazone, this episode has already lasted 14 days with no signs of improving. The horse has been on 2 g phenylbuta- zone by mouth twice daily for the last 14 days. His appetite has decreased, and he has mildly loose stool. Radiographs show 3° to 5° rotation of the coffin bone in both front feet and chronic remodeling of the distal aspect of P3. On palpation, marked muscle hypertonicity and sensitivity is present through the brachiocephalicus bilaterally, as well as over the thoracolumbar epaxial musculature. The horse appears to be hypersensitive to light touch over the back and neck, and wind-up pain is suspected.


Pain Management Strategies


NSAIDs: Because of the reduced appetite and loose stool, place the horse on firocoxib, 3  57-mg tablets are given on the first day, followed by 1  57 mg tablet once daily by mouth. Supportive, therapeutic trimming/shoeing: Rec- ommend placing the horse in a therapeutic boot that provides support over the frog/sole as well as cush- ioning. Then consult with the horse’s farrier to have therapeutic trimming/shoeing performed. Gabapentin: Gabapentin is prescribed at 20


mg/kg q12h PO. This dose is slowly tapered over 3 to 4 weeks once the wind-up pain has resolved. Tapering of the dose (reducing total dose by 1


⁄2 every


week) has been advised to prevent rebound pain. Acupuncture: Perform both dry-needle and elec- troacupuncture; acupuncture points are chosen that target the front feet. Treatment is performed once


254 2020  Vol. 66  AAEP PROCEEDINGS


weekly for 3 to 4 weeks, then once every 2 to 4 weeks, depending on the horse’s response to treat- ment. Local points are also chosen over the neck and back to help with secondary muscle pain, as tolerated by the patient. This treatment may not be tolerated by the horse until the wind-up pain is addressed. TENS: TENS is applied for 30 minutes 2 to 3


times per day in the same manner as for acute laminitis. Manual therapy: Advise the owner to purchase a massager to gently massage over the back and neck, as tolerated by the patient. Gentle physiotherapy exercises, such as back wiggles, are also prescribed. It may not be possible to perform this treatment until the wind-up pain is addressed. Topical diclofenac: The hair above the coronary


band is clipped. Topical diclofenac ointment is ap- plied over the coronary band, twice daily. Lidocaine patches: After clipping the hair in the pastern region, 5% lidocaine patches are placed over the palmar digital nerves and secured with elasti- con. The duration of effect of the patches is not known, so it is elected to change the pads every 8 to 12 hours. Biologics: IVRP with mesenchymal stem cells is performed at 1-month intervals for 3 to 6 treat- ments. After placing a tourniquet above the fet- lock, 20 to 30 million stem cells suspended in lactated ringer’s solution are infused in the palmar digital vein. Intra-arterial administration via the palmar digital or medial artery could also be consid- ered. No tourniquet is used if intra-arterial injec- tion is to be performed.


Treatment in the Hospital


A 5-year-old Thoroughbred gelding has been hospi- talized for the past 3 weeks following fracture repair of the left hindlimb (LH) proximal phalanx. The horse has been only intermittently weight-bearing on the LH limb and has laminitis in the right hindlimb (RH) foot. The horse also has marked sensitivity to palpation of the gluteal and lumbar epaxial musculature, and central sensitization is suspected.


Pain Management Strategies


● NSAIDs: The horse is maintained on 2.2 mg/kg phenylbutazone IV twice daily, care- fully monitoring the horse’s kidney values, albumin, appetite, and stool. If phenylbuta- zone alone is not sufficient, administration of 4.4 mg/kg phenylbutazone IV twice daily or 2.2 mg/kg phenylbutazone IV twice daily plus 1.1 mg/kg flunixin IV twice daily for 2 to 3 days can be considered.


● Supportive or therapeutic boot: A cushioned boot is applied to the RH foot.


● Acupuncture: Perform both dry-needle and electroacupuncture; acupuncture points are


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