Kissing Spines: A Case Study

Equine Case Study - Impinging Dorsal Spinous Processes: “Kissing Spines”

Diagnosis

Impinging Dorsal Spinous Processes T12-15

History

Horse was a 17 year old Thoroughbred gelding, who had been competing at 1* Eventing level up until December 2014.

At this time the horse went out for a short spell, and when he came back into work about 1 month later, started to show signs of not wanting to work during flatwork, largely lacking forwards momentum and avoiding the contact. These signs progressively worsened, and the horse began to demonstrate behavioural signs in other phases, including bucking, landing from jumps with the head up, and extending/hollowing through the spine.

The horse had an initial vet review in April 2015 in which X-rays were taken and a diagnosis of Impinging Dorsal Spinous Processes at T12-15 was made. The vet prescribed phenylbutazone (bute) and advised the owner to stop riding and to start lunging the horse in a pessoa. The vet also made a referral to physiotherapy. The owner had an osteopath treat the horse initially (mid 2015) and noticed no change in signs or symptoms. She reported that the horse didn’t respond well to going in the pessoa, stating that he tended to rush forwards in an extended spinal position.

The horse had an initial physiotherapy review in December 2015, following a 1 month rest from all work.

In January 2016, approximately 1 month after the initial physiotherapy review, the horse had another vet review, and cortisone injections were administered to the affected levels.

Objective Findings

Upon initial physiotherapy assessment in December 2015 the horse was noted to have a body condition score of approximately 3 out of 10, based on obvious accentuation of neck, withers and shoulders, with the ribs easily discernible. Visually the horse was noted to have significant atrophy of the epaxial and neck (particularly trapezius and rhomboideus), bicep femoris and gluteal muscles.

The horse demonstrated a pain response on palpation of the supraspinous ligament from mid thoracic spine and bilaterally through longissimus over the thoracolumbar region, more so on the left. He had an extended spinal posture with lax abdominal musculature, causing a dropped abdomen. He was sound on both walk and trot in hand and demonstrated decreased thoracolumbar lateral bend on tight turns bilaterally, with a greater loss of range to the right. He had no other significant musculoskeletal issues or conformational faults.

Treatment Objectives

1. Increase thoracolumbar ROM, particularly into flexion, to reduce further impingement of spinous processes
2. Increase muscle bulk of epaxial, neck and hindquarter muscles to improve core and pelvic stability, motor control and strength needed to carry a rider
3. Improve body and overall conditioning
4. Educate owner re the horse’s condition and physiotherapy management, along with the possibility of changing horse’s occupation and retiring from high level eventing
5. Return to light riding in 3 - 4 months - trial riding / pleasure

Treatment Methods

1. Soft tissue release/massage

Soft tissue releases and other massage techniques are commonly used on human patients in the management of soft tissue pain and restriction, reduced joint mobility and muscle spasm. It stands to reason that similar principles would apply to address soft tissue dysfunction in the horse.

Research by Hill and Crook (2010) demonstrated an improvement in range of hindlimb protraction in the horse following massage therapy and hypothesised that massage may play a role in improving a horse’s locomotor function during rehabilitation or training. Likewise Sullivan et al (2008) found that massage (in combination with chiropractic and phenylbutazone) increased spinal mechanical nociceptive thresholds in horses not exhibiting signs of lumbar pain. While further research needs to be conducted to examine horses with back pain, the research suggests that treatment in horses suffering from spinal pathology will likely be effective.

As the horse demonstrated significant muscular spasm and tightness through his longissimus and middle gluteal muscles, massage was applied to these regions for a period of 10 minutes per session. The research by Hill and Crook (2010) applied massage for 30 minutes to the hindlimb caudal muscles, however due to the horse’s pain reactions over the affected region it was decided to reduce the treatment time to a level that the horse was better able to tolerate. The owner was taught how to perform basic massage techniques and was advised to perform 10 minutes once daily as able.

2. Exercise therapy

The goal of exercise therapy is to restore normal movement and/or muscle patterns resulting from injury or lameness. Research by Stubbs et al (2010) found that in horses with osseous pathologies there was atrophy of the deep spinal stabilising muscles, notably multifidus, ipsilaterally at the same spinal level. Human studies have shown that specific exercises are needed to retrain these deep stabilising muscles and that episodes of back pain recurrence are significantly reduced. It is certainly my experience as a physiotherapist that this is true in my human patients. The researchers performed a series of dynamic mobilisation exercises involving cervical flexion, extension and lateral bending, with 5 repetitions of each exercise, performed 5 days per week for a 3 month period. They found that multifidus cross-sectional area increased significantly bilaterally at 6 spinal levels (from T10 to L5) and became more symmetrical side to side.

a. Core stability and dynamic mobilisation exercises: Based on this evidence, the horse was prescribed a series of baited carrot stretches, notably into flexion and lateral bending. The owner was instructed to perform the exercises 5 days per week, for 3-5 repetitions of each, holding for several seconds. The horse was also prescribed specific core strengthening exercises, which aimed to strengthen the abdominal and sub lumbar muscles. The 3 exercises given were the sternal lift, lumbo-sacral lift and lumbar lift with lateral bend. It was advised to perform 3-5 repetitions of each exercise.

b. Walking up and down hills in hand: to encourage activation of the hindquarters and abdominals, starting with 5 minute intervals up to 15 minutes per day. The horse was kept in a paddock which had hills, and was turned out 24 hours per day.

c. Lunging with equiband system: The owner performed 15 minutes lunging 5 times per week with either the equiband system or kinesio tape. Recent research by Simons et al (2015) suggested that the equiband system may aid dynamic stabilisation of the spine. The use of both the equiband and tape are proprioceptive facilitation techniques, which can have an affect on neuromechanical control via the closed loop system. It was certainly visually evident that the horse had increased spinal flexion and abdominal activation whilst working with the system on, resulting in overall improved posture and locomotion. The owner did not always have access to the equiband system, so we also used kinesio tape in an attempt to facilitate similar abdominal activation. The tape was applied from the ribs at the level of the thoracolumbar spine, passing underneath the abdomen to attach to the correlating rib position on the other side. Before applying the tape, the horse was asked to perform a sternal lift exercise, with the theory that the tape would help encourage the horse to maintain this posture whilst working.

3. Medical management

The horse continued to be under the care of the vet throughout the rehab program. He was prescribed an initial course of bute, 10ml daily for 10 days, and then to be administered as the owner felt necessary. The horse had 1 course of cortisone injections into the affected levels 1 month after the initial physiotherapy review. The horse commenced taking Rose-Hip Vital (supplement) upon vet recommendation.

4. Ridden work

The horse was trialled under saddle 4 months after commencing the rehab program, once it was showing a significant improvement in clinical signs and symptoms. The horse was able to tolerate the weight of the rider, and commenced light work in walk only, starting with a maximum of 10 minutes and gradually increasing as tolerated. The owner advised that the horse would occasionally put his ears back when she first mounted, but then he quickly settled down. After a period of 4 weeks walking only, the owner introduced some trot work into the sessions.

5. Owner education

A discussion was had with the owner during the course of the rehab regarding the horse’s occupation and likelihood of returning to 1* Eventing. It was decided that the horse would be retired from competing at that level, and the owner decided to re-home the horse to a smaller rider who would use him for trial riding/pleasure riding only.
The owner was very diligent in performing the rehabilitation program, ensuring a more successful and faster outcome from treatment, as the therapist wasn’t able to be present on a daily basis.

Outcome Measures

  • Increase in body condition score to 4/10
  • Increase in epaxial, neck and hindquarter musculature by visual estimation of approximately 50%
  • Improved thoracolumbar ROM - measurement against a horizontal marker on the wall, horse was able to flex through the thoracic and lumbar spine by an increase of 5cm
  • Decreased pain response on palpation of supraspinous ligament and longissimus
  • Symmetrical range on tight turns, with a visual estimate of increased range by 25%
  • Horse displayed minimal to no negative behaviours under saddle and owner felt comfortable working the horse lightly

References

Hill C, Cook T The relationship between massage to the equine casual hindlimb muscles and hindlimb protraction. Equine Vet J Suppl 2010 Nov; (38): 683-7

McGowan C, Goff L, Stubbs N Animal Physiotherapy: Assessment, Treatment and Rehabilitation of Animals 2007; Blackwell Publishing pp 243

Simons V, Weller R, Stubbs NC, Rombach N, Pfau T Clinical Research Abstracts of the British Equine Veterinary Association Congress 2015. Equine Vet J 2015 Sep; 47 Suppl 48:11

Stubbs NC, Clayton HM, Hodges PW et al Osseous spinal pathology and epaxial muscle ultrasonography in Thoroughbred racehorses. Equine Vet J 2010 42 Suppl s38: 654-661

Stubbs NC, Kaiser LJ, Hauptman J, et al Dynamic mobilization exercises increase cross sectional area of musculus multifidus. Equine Vet J 2011 43: 522-529

Sullivan KA, Hill AE, Haussler KK The effects of chiropractic, massage and phenylbutazone on spinal mechanical nociceptive thresholds in horses without clinical signs. Equine Vet J 2008 Jan; 40 (1): 14-20