Extracorporeal Shock Wave Therapy was the first step into the century of non-invasive kidney stone treatment. Ten years ago High Medical Technologies AG (HMT) invented the technology of shock wave application in the field of orthopedics – the step towards a millennium of non-invasive treatment in orthopedics. Nowadays Shock Wave helps in avoiding surgery of soft tissue and bone related disorders.

Who is a candidate for ESWT?

ESWT is recommended for horses suffering from chronic pain and lameness, who have not responded to conservative treatment for a period of at least three months. Up until now, surgery was the only option for these horses. Particularly problems caused by degenerative or acute processes in tendons and superficial bones can be treated by ESWT.

How is treatment performed?

ESWT is a non-invasive procedure. Horses are treated on an outpatient basis using the Equi-Tron. The average treatment time is about 10-15 minutes and the procedure is performed by using a mild sedation and/or local anesthesia where necessary.

What are the results?

Success rates for ESWT are good to excellent; however, it must be stated that ESWT in veterinary medicine is still in a developmental stage and research is on going. Nevertheless, ESWT is a useful non-invasive therapy for animals suffering from chronic pain and an alternative to surgery.

 

Nuclear Scintigraphy

Nuclear Scintigraphy or Bone Scanning, is the most commonly performed equine nuclear medicine procedure because it offers high sensitivity for detecting early disease. In addition, it allows veterinarians to evaluate the entire equine skeleton (or a region) making it an ideal tool for diagnosing difficult or multi-factorial lameness. Nuclear scintigraphy is an imaging modality that emphasizes physiologic processes – it is the physiologic evaluation of bone metabolism. It is especially useful in detecting bone inflammation when a lameness is difficult to diagnose or when the complaint is that the horse is not performing up to his/her athletic expectations. A bone scan is tremendously more sensitive than radiographs in detecting lameness related to bone inflammation. At Virginia Equine Imaging, we provide state of the art nuclear medicine services complete with motion correction software.

Frequently Asked Questions About Nuclear Scintigraphy:

When Should I consider nuclear scintigraphy for my horse?
In general, the indication for bone scanning is to identify and describe physiologic information that cannot be discerned by other imaging methods. For instance:
• Competition horse not performing up to athletic expectations.
• Severe lameness of unknown origin.
• Difficult multiple limb lameness.
• Suspected fracture with no radiographic evidence.
• Lameness localized to a general area with no radiographic or ultrasonographic abnormalities apparent.
• Horse suffers from a lesion that induces a lot of bone metabolism such as: stress fractures, ligamentous avulsions, sclerosis, osteomyelitis, etc.


How is the bone scan performed?
Upon arrival at the clinic, the patient is injected intravenously with a short acting radio-isotope, Tc 99 MDP, linked to bone tracer agent. If appropriate, the horse is next exercised on the lunge pad in order to evaluate the lameness. Following the evaluation, the patient is stabled in a secure stall for approximately two hours while the radio-isotope circulates systemically throughout the horse’s body. The horse is next tranquilized (standing sedation) and imaged with the gamma camera. Areas of bony inflammation are indicated in the computerized pictures as areas of increased uptake and described as focal or diffuse and mild, moderate or intense.

How long does the procedure take?
Depending on whether a hindend, frontend or a full body bone scan is performed, the procedure usually takes place several hours after the radio-isotope has been injected. Therefore, the bone scan images are often not read by the doctors until the late evening or early the following morning. After reviewing the images, the doctors devise the best plan for more extensively working up the lameness including: additional nerve blocks, intra-articular injections, digital radiographs, ultrasound, etc. Prior to the work-up and therapeutic treatment, the owner will be contacted to discuss the bone scan findings and further diagnostic options.

As a lameness specialty practice, we treat lameness due to arthritis more than any other pathology. There are many therapeutic options available today including the gold standard – intra-articular steroids with hyaluronic acid – and other supplemental treatments such as shock wave therapy, systemic injectables such as Legend and Adequan, and oral nutraceutical products such as glucosamine, chondroitin sulphate, and hyaluronic acid. Even with this arsenal of therapeutics, we still sometimes find osteoarthritis a frustrating management issue.

Recently, a new therapeutic option has become available which involves gene therapy. The technique is called IRAP – or Interleukin-1 Receptor Antagonist Protein. In order to understand how IRAP therapy works, it is necessary to understand the basics of osteoarthritis and joint pathology.

What causes osteoarthritis? Osteoarthritis can occur for a variety of reasons, including acute trauma, joint sepsis and soft tissue injury; however it is most commonly caused by some initial insult to a joint followed by daily wear and tear from performance use. Regardless of the cause, a cycle of events continues the inflammatory process, resulting in continual degradation of the cartilage matrix. Until now, the goal in managing osteoarthritis has been breaking this cycle of inflammation with the use of steroids and hyaluronic acid. While steroids can be very successful in reducing inflammation in a joint and thus slowing the degradation of cartilage, it is a short-term fix and they do little to protect actual joint tissues. That's where IRAP therapy comes in. There are a number of inflammatory proteins that play a role in increasing the degradation of cartilage and decreasing the production of cartilage matrix. One of the most important proteins in this process is called Interleukin -1, (IL-1). IL-1 binds to receptors on the surface of tissues within a joint. In an attempt to decrease inflammation in the body, another protein is produced called IL-1 receptor antagonist (IRAP), which blocks the binding of IL-1, therefore reducing its deleterious effects.

What IRAP therapy does is to “harvest” anti-inflammatory mediators that are then injected into an affected joint. What does the procedure involve? Blood is drawn aseptically from the horse into a syringe containing prepared beads that induce an inflammatory response while being incubated for 24 hours. The blood is then spun and separated, and the serum which contains these anti-inflammatory proteins is put into individual dose syringes which can then be frozen for future use. The intra-articular treatments are administered every 7 to 10 days for three treatments. Results are typically seen by the second treatment. IRAP can also be used as maintenance therapy throughout a competition season to reduce the amount of steroid use. IRAP therapy is not for every horse. There are some factors that make a horse a less successful candidate; however the therapy shows great promise for horses that have become refractory to traditional management of osteoarthritis. Ask if your horse is a candidate for IRAP therapy at your next appointment!

Platelet Rich Plasma (PRP) is a regenerative therapy that uses the body's own healing factors.  Platelets contain numerous growth factors that improve the healing process.  Blood is collected from the patient and immediately spun in a special centrifuge that concentrates and separates out the platelets.  The PRP is then injected into the injured area.  PRP can be used to treat tendon, ligament, and joint injuries.

Below is a series of ultrasound images from a horse with an injury to the superficial digital flexor tendon.  The first image was taken at initial diagnosis of the injury.  The second and third images show the area of injury 60 and 90 days after PRP was injected by ultrasound guidance directly into the tendon lesion.  We notice that the hypoechoic (black) region of the injured tendon has filled in with a normal fiber pattern indicating the tendon has healed well.

 

 "The Arteriocyte Magellan (R) Autologous Platelet Separator has allowed our practice to provide highly concentrated PRP with platelet concentrations from 7-14 times baseline on a consistent basis. The machine's optical detector takes away human error in the preparation of the PRP, so that we know our patients are being treated with platelets, not just blood. The closed system also lessens the chance of contamination. That is a very important feature for us. Being able to process bone marrow aspirate concentrate (BMAC) gives us the added benefit of being able to provide some of the properties of stem cell therapy, but in a much more timely fashion and at a cost that is more affordable for some clients. The combination of PRP/BMAC has been great for our severe tendon injuries and we are very pleased with the results from PRP in the treatment of ligament and joint problems."

- Sallie Hyman, VMD, DACVIM

Mesotherapy

Dr. M. Pistor originated the technique of mesotherapy in France in 1952. Today, it is commonly practiced in France, where more than 15,000 practitioners utilize mesotherapy for the care of their human patients. Mesotherapy is also practiced in many other countries around the world, including: Belgium, Columbia, Argentina, and throughout Europe. This technique was introduced into the United States by veterinarian, Dr. Jean Marie Denoix, for the equine patient at the Veterinary Thoracolumbar Spine (Back) Seminar presented at Virginia Equine Imaging in the Spring of 2002.

Mesotherapy is a treatment that stimulates the mesoderm, the middle layer of the skin, which will, in turn relieve a wide variety of symptoms and ailments. The treatment is used to stimulate the Giant fibers. The technique involves the injection of substances to stimulate the mesoderm for various biological purposes. The mesotherapy injections involve extremely small needles that penetrate the interdermal layer of the skin only a very small depth, which is typically four to six millimeters. The number of treatments needed depends on many variables including the condition, the abnormal physiology causing the condition, as well as the chronicity of the problem. A minimum of one to two sessions of mesotherapy is performed generally to assess the horse’s response. Mesotherapy is effective for a multitude of conditions because it helps reverse the physiology of that condition, and stop the pain spasm cycle. At our clinic, we have used this technique on a number of horses with conditions such as chronic back pain and degenerative arthritis of the back and cervical vertebrae (neck).

MRI                                                
                               
The Magnetic Resonance Imaging (MRI) system in collaboration with the Marion duPont Equine Medical Center has been functioning since April 1, 2004. Since that time, nearly 200 horses have been examined predominantly for foot problems. Magnetic resonance imaging provides images with unmatched tissue contrast and anatomic definition, thus offering numerous diagnostic advantages over other imaging technologies. MRI displays anatomic and physiologic detail in both bony and soft tissue structures through a series of tomographic slices using magnetic properties of the horse’ tissues. The MRI has provided the diagnosis in many cases when other imaging modalities failed to clearly identify the lameness. This is especially true for soft tissue injuries around joints, and in the areas difficult to palpate or image by other means such as radiographs or ultrasound. MRI is the only method presently available that can assess all tissues during a single examination.

The equipment at the Marion duPont Equine Medical Center is a standing open MRI system, which allows the patients to stand under mild sedation, so distal extremities can be scanned in a weight-bearing state. This enables our doctors to more precisely pinpoint your horse’s source of pain. In order to obtain images, a receiving coil is placed closely along the horse’s anatomic region of interest to collect emitted signal. The patient’s legs are positioned within the center of a strong magnetic field generated by the MRI system. The sequences are selected, and a radiofrequency signal is collected to create the image. The typical MR exam of an equine patient yields 300-500 high-detailed images to review.

MRI should be considered as a diagnostic tool when the site of pain or injury can be localized, but the problem cannot be distinguished by other forms of imaging such as radiographs, ultrasound or thermography. For instance, if your horse has been diagnosed with navicular disease, but has been unresponsive to therapy, the MRI may be the next logical approach. The MR exam because it can more precisely evaluate soft tissue and bone within the hoof capsule provides a more concise diagnosis such as navicular bursitis, impar ligament desmitis, or supensory ligament desmitis of the navicular bone. It is particularly useful for lameness localized to the foot. Importantly, MRI is capable of demonstrating cortical erosions along the flexor surface of the navicular bone, and adhesions to the adjacent deep digital flexor tendon. The use of MRI in equine veterinary medicine allows more timely intervention, and an improved prognosis and long-term outcome for equine athletes.

MRI has become one of the most important diagnostic tools in equine lameness. For further information concerning specifics of the procedure or in order to make an appointment please consult our website.

Diagnostic Thermography

Thermography is the pictorial representation of the surface temperature of an object. It is a non-invasive technique that measures emitted heat. The circulatory pattern and relative blood flow dictate the thermal pattern, which is the basis for thermographic interpretation. This ability to noninvasibly assess inflammatory change makes thermography an ideal imaging tool to aid in the diagnosis of certain lameness conditions in the horse. In addition, thermography is an excellent adjunct to clinical examination as well as being complementary to other imaging techniques such as radiology, ultrasonography and nuclear scintigraphy.

There are at least three ways in which thermography can be used in an equine veterinary practice. The first is as a diagnostic tool or a physiologic imaging method, where a difference of one degree between two anatomically symmetric regions indicates a region of inflammation. The second method is to enhance the physical examination. In these cases, thermography is used to identify changes in heat and to locate areas of suspicion. Thermography cameras are approximately 10 times more sensitive than the human hand in determining temperature difference; therefore, this method helps the veterinarian identify asymmetry between the horse’s anatomical structures. The third method of using thermography is as a preventative measure to enhance training. Thermographic changes occur two weeks before many clinical changes; thus, thermography can be used in a training program to identify subclinical problems so that conditioning alterations can be made to avoid injuries.

SPECIFIC APPLICATIONS:

• CONDITIONS OF THE FOOT
• JOINT DISEASES
• LONG BONE INJURIES
• TENDON INJURIES
• LIGAMENT INJURIES
• MUSCLE INJURIES
• VERTEBRAL COLUMN INJURIES (LUXATIONS, SUBLUXATIONS, FRACTURES)

Acupuncture is one of the most widely used and successful complementary and alternative therapies available in equine practice.  It has been practiced in China for over 3000 years in both people and animals and now has become an exciting tool for American practitioners since its introduction to the Western world.  Many scientific studies have been performed that validate the effectiveness of acupuncture treatments.  It can be used for a variety of musculoskeletal and medical conditions such as back pain, arthritis, non-sweating, and heaves.  Acupuncture can be a valuable addition to the management of the performance horse, helping to keep him at the top of his game.

Lameness Locator^TM is an inertial sensor-based motion analysis system designed at the University of Missouri as an aid to practicing equine veterinarians for evaluation of lameness in horses.  The system consists of 3 small inertial sensors that are attached in a few minutes to the horse’s body with tape or Velcro.  Each sensor weighs less than 40 grams and is a self-contained unit with a sensing element (accelerometer or gyroscope), radio transmitter and receiver, antennae, microcomputer, battery and other circuitry.  Each sensor is about 1.5 by 1.25 by 0.75 inches in dimension.  Data from the sensors is transmitted wirelessly up to ¼ mile to a hand-held tablet computer in real time.  The data is then analyzed by algorithms developed over the last 15 years that detect lameness and then identify which forelimb and/or hindlimbs are contributing most to the lameness.  Other algorithms estimate the timing of lameness to the stride cycle, in other words, “is the pain from lameness occurring at impact, pushoff or during the swing phase of the stride?”.  This information can be useful to equine veterinarians trying to localize the foci of lameness within the affected limb or limbs.  Data processing is fast and conducted in the field while the horse is being evaluated. 

The University of Missouri and Equinosis^TM, the company holding the intellectual property rights for Lameness Locator development, has secured NSF (National Science Foundation) support to further test Lameness Locator^TM, in more rigid experimental conditions and in 6 field sites around the United States; the University of Missouri Veterinary Teaching Hospital (Columbia, Missouri), Virginia Equine Imaging (Middleburg, Virginia), North Carolina State Veterinary Teaching Hospital (Raleigh, North Carolina), Hagyard Equine Medical Institute (Lexington, Kentucky), Texas A& M Veterinary Teaching Hospital (College Station, Texas) and Pioneer Hospital (Oakdale, California) . For more information www.equinosis.com

Radiograph 1: A horse with a normal hoof-pastern angle.  The angles of the coffin bone and the short pastern bone are the same.

  Radiograph 2: A horse with a broken back hoof-pastern angle.  The angle of the short pastern bone is more upright than the angle of the coffin bone.  Although this horse does not have a negative palmar angle (the is when the coffin bone is closer to the ground at the heel rather than at the toe) this often occurs along with a long toe, low heel, and broken back angle conformation.  The result is increased pressure and concussion on the navicular bone and navicular bursa, increased tension on the deep digital flexor tendon, and more force required for breakover.  These horses can become chronically heel sore.

Radiograph 3: A horse with a broken forward hoof-pastern angle.  The angle of the coffin bone is more upright than the angle of the short pastern bone.  This conformation puts more stress on the coffin joint and can lead to coffin joint effusion and synovitis.

  Radiograph 4: A horse with a medial-lateral imbalance, broken-in foot.  Notice that the lateral (outside) hoof wall is higher than the medial (inside) hoof wall.  This can cause the heels, distal interphalangeal (coffin) joint, proximal interphalangeal (pastern) joint, and metacarpophalangeal (fetlock) joint to suffer uneven compressive forces.

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