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3 . Further environmental enrichment. The authors correctly sug- gest common ideas for additional environmental enrichment such as a treat ball or hung vegetables. Enrichment is commonly considered the provision of choice and is designed to stimulate the senses (Hoy et al., 2010 ); therefore, it should be noted that adding an object or food source only acts as a source of envi- ronmental enrichment if the horse chooses to engage with it (Bacon, 2018 ). Providing choice in sources of available fibre (hay- lage, grass blocks and chaff, for example) as well as considering novel textures (lettuce vs. swede vs. chopped vegetables frozen in a fruit juice ice block) and tastes helps maximise the senses. Ideally, different ideas should be rotated to maintain novelty. As well as food some people suggest the use of different scents for the horse to investigate, safe branches to chew and a broom head screwed into the wall can provide an inviting scratching post. The Blue Cross (Court, 2024 ) and BHS (Harrison, 2024 ) provide excel- lent online resources for owners to consider.
4 . Psychopharmaceuticals: These medications can positively im- pact the horse ' s mood and help them cope with the stress as- sociated with confinement. It should first be remembered that Acepromazine has no anxiolytic properties, and in companion animal medicine is contraindicated where anxiety is a compo- nent (Pereira et al., n.d. ). As a dopamine agonist, Acepromazine will reduce the amount of movement you may observe in the horse, externally making them appear calmer, but without actu- ally changing how they feel, that is not improving their welfare. Having said that, Acepromazine can be successfully combined with a drug that does act to reduce anxiety as anecdotally the effects appear to be synergistic. Fluoxetine, a selective serotonin reuptake inhibitor, has been used successfully to help horses cope with box rest (Fontenot et al., 2021 ). Fluoxetine is not one that we tend to use as it can take several weeks to see the benefi- cial effects, and it is often the initial period of confinement that can be problematic. Nonetheless, as this case was on box rest for 9 months, Fluoxetine may have been indicated. More commonly, we would use Trazodone, which has also been documented as useful under these circumstances (Davis et al., 2018 ). Under more extreme circumstances or for cases that are really struggling, for example we had a horse with a nondisplaced radial fracture in the sling that became increasingly aggressive to handle, we will also use Alprazolam. Normally, we would start with Trazodone, adding
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Acepromazine if needed and then Alprazolam as well for the most difficult cases. The apparent synergistic activity of this triple com- bination often allows a reduction in all three medications to very low levels. Alprazolam is an excellent anxiolytic but we should be mindful of the potential for ataxia at higher doses and, as a benzo- diazepine, the potential for addiction and so we advise reducing the dose slowly if use exceeds several weeks. Fundamentally, I believe these medications can be a game changer if used appro- priately in horses subject to the stressors of box rest.
5 . Reintroduction of exercise. How and when increased movement is allowed will be very dependent on the individual circumstances of the case. Here Peeters et al. ( 2024 ) reflected, in hindsight, in- hand walking could have been started earlier to stimulate remod- elling at the fracture sight. Most equestrians will be familiar with the perils of turning horses out after a period of confinement and/ or hand walking a horse on restricted exercise, where the moti- vation to run, rear and buck can overshadow the handler ' s cues. This occurs due to post- inhibitory rebound, a process where a behaviour is performed to excess following a period of restric- tion (Chaya et al., 2006 ). This is another scenario where psy- chopharmaceuticals are helpful for both horse and human safety. Furthermore, introducing restricted paddock exercise earlier, if possible, reduces the build- up of frustration and thus minimises post- inhibitory rebound (Chaya et al., 2006 ; Freire et al., 2009 ). Grazing is one of the best activities to promote relaxation and reduce stress in horses (Ruet et al., 2020 ; Stomp et al., 2018 ). The use of several small (stable- sized) pens that are linked by gaps on alternating sides (Figure 2 ) is an excellent way of allowing horses to quietly graze and wander without being able to get into trot. In cases where a gradual exercise programme is not feasible, especially where there are concerns for horse or human safety, multiple connecting larger pens can be used. These allow a horse to achieve a steady trot before having to slow to get through a narrow passage into the next pen (Figure 3 ). Gradually making them bigger allows increased, but still relatively controlled, free exercise. For the slightly larger pens, a sensible companion horse can usually be added, again helping improve welfare and reduc- ing the risk of jumping out. The use of pens will not be appropri- ate for every scenario but where feasible introducing the horse into them early, even starting for just a few hours a day can have a positive impact on well- being and facilitate safer hand walking.
FIGURE 2 Using electric tape to create several adjoining stable- sized pens allows horses to wander up and down grazing without being able to easily trot.
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