From Our Practice to Yours Emagazine

NORTHEAST ASSOCIATION OF EQUINE PRACTITIONERS

from our practice to yours emagazine

THE SCIENCE OF HORSESHOEING: FACT VS FICTION

DIAGNOSIS AND TREATMENT OF SACROILIAC JOINT DISEASE

MANAGING STRANGLES OUTBREAKS

VETERINARIANS DEALING WITH DISSATISFIED CLIENTS

NEAEP SESSIONS AND SPEAKERS

September 2020 www.theneaep.com OPEN SEPTEMBER 23RD THROUGH DECEMBER 31ST!

NETWORKING 100+ HOURS OF

OPPORTUNITIESNortheast Association CE CREDITS of Equine Practioners

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Volume 10, Number 8 Special Edition September 2020

Executive Committee Board Of Directors President Ronald B. Gaeta, DVM Veterinary Industry Council Rep Jim Zeliff, DVM, MBA Dunbarton Equine Mr. Keith Wacker Allegheny Equine Associates Sound Technologies Inc. Sasha Hill, DVM Vice President Cleveland Equine Clinic Farrier Industry Council Rep Sarah Cohen, DVM Stuart Muir, NZCEF, CJF, DIPWCF, APF Miller and Associates Remco van der Linden Podiatry Department, Delta Mustad Hoofcare Center Inc. Treasurer Rood and Riddle Equine Hospital Gregory S. Staller, DVM Christopher Penola, APF Executive Director/CEO Running ‘S’ Equine Veterinary Services Christopher Penola Farrier Services David G. Dawson Past-President Bob Pethick, APF, CJF Raul J. Bras DVM, CJF, APF Bedminster Forge Podiatry Department, Katherine Chope, VMD, DACVSMR Rood and Riddle Equine Hospital Tufts University contents

The Science of Horseshoeing: 6 Fact vs Fiction

Diagnosis and Treatment of 11 Sacroiliac Joint Disease

26 Managing Strangles Outbreaks

30 Veterinarians Dealing with Dissatisfied Clients

33 NEAEP Sessions and Speakers

The Clinician 3 THE CLINICIAN SEPTEMBER 2020

From Our Practice to Yours President’s Letter

Greetings fellow practitioners,

Like many of you, I have been enjoying the opening week of the NEAEP Virtual Symposium: From Our Practice to Yours. The board of directors and the virtual education committee have been working around the clock to provide interesting and innovative ways to bring you quality continuing education credits. We’re all a bit sad to have missed our annual opening reception in Saratoga Springs, but we had a great virtual opening reception and plan to continue with these weekly lounge events. While it won’t be quite the same as being together in person, we hope you are able to utilize the networking tools in our symposium platform to sit down and have a drink or a snack and catch up with your colleagues. Make sure to mark your calendars for Wednesday evenings to participate in the virtual lounge with our speakers for live question and answer sessions. You can view their presentations at any time, but you’ll only have one opportunity to ask your questions to the speakers in real time. If you have any questions about the symposium please do not hesitate to contact the office. Remember you can register at any time!

Regards, Dr. Jim Zeliff President Northeast Association of Equine Practitioners

The Clinician 4 There’s nothing else like it.

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BRIEF SUMMARY: Prior to use please consult the product insert, a summary of which follows: CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Adequan® i.m. is recommended for the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. CONTRAINDICATIONS: There are no known contraindications to the use of intramuscular Polysulfated Glycosaminoglycan. WARNINGS: Do not use in horses intended for human consumption. Not for use in humans. Keep this and all medications out of the reach of children. PRECAUTIONS: The safe use of Adequan® i.m. in horses used for breeding purposes, during pregnancy, or in lactating mares has not been evaluated. For customer care, or to obtain product information, visit www.adequan.com. To report an adverse event please contact American Regent, Inc. at (800) 734-9236 or email [email protected]. Please see Full Prescribing Information at www.adequan.com.

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1 Data on file. 2 Adequan® i.m. Package Insert, Rev 1/19. 3 Burba DJ, Collier MA, DeBault LE, Hanson-Painton O, Thompson HC, Holder CL: In vivo kinetic study on uptake and distribution of intramuscular tritium-labeled polysulfated glycosaminoglycan in equine body fluid compartments and articular cartilage in an osteochondral defect model. J Equine Vet Sci 1993; 13: 696-703. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57. 5 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse.St. Louis, MO: Elsevier, 2016; 33-48. All trademarks are the property of American Regent, Inc. © 2020, American Regent, Inc. PP-AI-US-0372 02/2020

6424 Clinician Trade Ad .indd 1 9/15/20 10:56 AM THE CLINICIAN SEPTEMBER 2020 NEAEP

The Science of Horseshoeing: Fact vs Fiction WillIam Moyer, DVM, ACVSMR Billings, Montana

INTRODUCTION would have to be in place to answer the question: l The application of “devices” placed on the bottom of horse’s feet Approximately 100 horses (preferably the same breed and age) (leather, wood, bronze, iron, synthetics, even gold!) is an ancient who, in fact, have a con- firmed diagnosis of navicular disease. I practice. I believe it safe to say that trimming and shoeing is both think one can understand that alone is an difficult task. l “art and science.” Foot problem are frequent and as such some are A means would have to be in place to record and grade the caused by trimming and shoeing and some are solved via trimming degree of lameness. This requires video taping and at least three and shoeing. Unfortunately useful research, employing strict lameness evaluators each of whom would do their own scientific technique, is reasonably limited for a variety of reasons individual grading. l (access to research dollars, animal welfare issues, and limited A farrier (not several) would do the shoeing so as to avoid research personnel). Thus often what we “think we know” is based differences in technique). Half the population would be shod on experience, interest, history (anecdotal information), and with a selected flat shoe and half would be shod influences also known as marketing. This presentation is simply with a raised heel (the degree of rise designed to help those who are interested in discerning fact from would be the same for those horses). l fiction. It is not intended to lessen the strength and usefulness of All the “research” horses would experience but is focused on “why we believe what we believe” and be on the same property, the influence of marketing. same feeding schedule, and same exercise program. RESEARCH l At a designated time Research is defined as the systematic investigation into and the (to be determined study of materials and sources in order to establish facts and reach by the design of the accurate conclusions. Useful attempts at research regardless of the program) all horses subject and question being pursued is an onerous task requiring would be examined sufficient numbers, accurate equipment, expert personnel, and for lameness in the clearly sufficient financial support. The goal is the truth, getting same manner as the there requires very strict adherence to eliminate a variety of initial examination variables which would or could influence the outcome. utilizing the same A way to understand the task will be through an example. The graders. Ideally that “made up” question being pursued is: does raising the heels of a should be done multiple horse with known navicular disease work?” Thus the following with multiple re-sets.

6 www.theneaep.com 585-205-5122 American Association of Equine Veterinary Technicians

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l Data submitted would be collated Thus one can understand the complexity of and undertaking as and statistically worked to well as the cost. Equine research is expensive and time consuming; decide the outcome. yet, we as interested beings, are often led to believe that a given Submitted data as well as conclusion was based on research when it was not. research protocol and ultimately a conclu- “WHY DO WE BELIEVE sion or conclusions would be in the WHAT WE BELIEVE” The very basis of marketing is dependent upon getting someone form of a submit- or more to believe in a given idea or product (that includes elected ted publication. officials, drugs/herbs/lasers, surgical procedures, horse shoes, and l The involved concepts). It appears that marketing, in the author’s opinion, has at journal would times replaced common sense. We, as an interested public, are upon receipt exposed a good bit of the time to a variety of marketing techniques. request that three or Simple examples may include: more expert l A very dynamic power point reviewers exam the (edited, well spoken, and convincing). data and conclusions. l The technique has been around forever therefore That is to say, a given paper it must be correct. may or may not be published l Famous person (farrier or Vet) uses it or it worked until it is peer reviewed. on a famous horse. l It’s novel idea, makes sense (might be based on a different species, for example), it should work, and I want it to work. l And lastly a variety of false claims. It becomes somewhat difficult at times to know that the information being placed in front of us is real, how often doesn’t the technique work, what other variables were included in management of a given situation (change in exercise, working surface, medications, etc.).

An excellent example of how information becomes fact which later turns out to not being the case was the introduction of high doses of vitamin C to decrease both incidence and severity of the common cold. This initially came from a very well known scientist who, I am sure, believed it. Clearly the introduction of this

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concept greatly helped the local pharmacies and retailers of vit C l Be “on alert” when you sense that providers of information view tablets as well as the citrus fruit industry. Investigators at one of the criticism of their thoughts and activities as opposition. largest hospitals in the US decided to test the concept which the l When listening to or reading something that seems out of place public had already bought into. A huge study over a two- three year in your experience – question it or wait until others have tried period was undertaken (half the of the population in the study were whatever it is that is being proposed. It is wonderful and given a placebo) [a look alike product] and half vit C. The data laudable to be on the “cutting edge” but be careful about collected indicated that vit C had no influence on occurrence or being cut. severity, but it did find that those who actually took the vit C had a l Be ”on alert” when percentages of success greatly exceed your greater incidence of gastric ulcers. success rate. l Be impressed with presenters who often answers questions with “RED FLAGS” “I do not know” as that is often the only accurate answer. l How many horses has whatever one is talking about The following are suggestions in helping one to determine the been used on? validity of a statement, publication, presentation (to include this l How many times did the product/technique not live up to one), video, and other forms of communication: expectations (no change or worse?) l Always be careful with information that is 2nd or 3rd hand as it is l What are the complications/risk beyond not working? often wrong, inadequate, taken out of context, or exaggerated l What does it cost? (watch the news in the a.m.!) l Read “case reports” in various publications with interest but always note that invariably the only reported cases are those that SUMMARY are successful - what about the others not in the report? The author has watched, used, read about, and tried all sorts of l Be impressed with articles/publications that involve large “this is better than sliced bread” ideas and products which have numbers of horses and long term follow-up (very important since disappeared. The number of people at all levels being influ- in dealing with chronically foundered horses, for example). enced by a variety of modes is incredible. The percent of “amateurs” l Be wary of “studies” that are being featured or paid for by the in our equine industry is growing, in my opinion, and further that manufacturer or provider. common sense is losing the battle with marketing. Most foot l Be impressed with articles/presentations that discuss the risks problems that have improved in my experience were solved (got and failures of a given procedure or application. better) with a combination of trimming/shoeing, medications, l Be very careful about “buying into” articles/presentations with changes in management, time off, and/or environment. Thus when little or no references – always be aware that very, very few ideas a “success” is claimed - was it the farriery, medication, time off, are original and lack of acknowledgement is a “sign: of a poor management or all of the above. Always beware that many things publication. get better on their own without a vet or a farrier.

10 www.theneaep.com 585-205-5122 THE CLINICIAN SEPTEMBER 2020 NEAEP

Diagnosis and Treatment of Sacroiliac Joint Disease Kevin K. Haussler, DVM, DC, PhD Diplomate, American College of Veterinary Sports Medicine and Rehabilitation Orthopaedic Research Center Colorado State University, Fort Collins, CO

INTRODUCTION DIFFERENTIAL DIAGNOSIS Most of what we know about the sacroiliac joint has been Causes of sacroiliac joint pain or injury have been postulated limited mostly to gross anatomic or pathologic studies. Anatomic to be the result of sacroiliac or lumbosacral arthrosis, sacroiliac features of the sacroiliac joint and associated soft tissues have been desmitis, sacroiliac subluxation or luxation, pelvic stress fractures, documented.1-3 Description of the normal sacroiliac joint via complete ilial wing fractures, or sacral fractures.21 Additional routine diagnostic imaging has only begun in the last few years.4-6 differential diagnoses include thrombosis of caudal aorta or iliac Sacroiliac joint pathology has generally been categorized into arteries, exertional rhabdomyolysis, trochanteric bursitis, and articular injuries (i.e., osteoarthritis or ilial wing stress fractures) or impinged dorsal spinous processes in the lumbar vertebral region. soft tissue injuries (i.e., desmitis or muscle strain). Nuclear scintig- Horses with presumed thoracolumbar vertebral problems may also raphy and ultrasonography have provided new insights into have concurrent chronic sacroiliac joint injuries. In a report on 443 documenting sacroiliac joint pathology.7-11 Unfortunately, there horses with back problems, chronic sacroiliac joint problems were continues to be limited understanding or research into the patho- identified in 15 percent of horses.15 Clinical signs of lower hind physiology of specific sacroiliac joint injuries.12,13 Therefore, our limb lameness may overlap and mimic signs of presumed sacroiliac understanding of sacroiliac joint injuries is often extrapolated from joint pathology. It is important that a through and complete lower seemingly similar disease processes in other articulations, which limb lameness evaluation is completed prior to or along with an may or may not be appropriate. upper hind limb or sacroiliac joint work-up. The ante-mortem diagnosis of sacroiliac joint injury in horses is difficult and often based on a diagnosis of exclusion.11 Diagnosis PATHOPHYSIOLOGY is complicated by anatomic inaccessibility, mild chronic clinical Based on a review of the literature, osteoarthritis of the signs so that opportunities for correlation with necropsy findings sacroiliac joint is the most prevalent disease process affecting horses are uncommon, and ongoing controversies over the clinical with sacroiliac joint pain or dysfunction, although its clinical significance and prevalence of articular surface and ligamentous significance remains uncertain.2,14,15,22 Degenerative changes 14 pathology. Terms used to describe sacroiliac joint pathology tend to be bilaterally symmetrical and localized to the medial aspect 15,16 include sacroiliac sprain or instability, sacroiliac joint sublux- of the sacroiliac joint. In a necropsy survey of 36 Thoroughbred 17 14,18 ation, and sacroiliac arthrosis. The prevalence of sacroiliac racehorses with no known back or sacroiliac joint problems, we joint pathology in performance horses is probably quite high and observed various degrees of degenerative sacroiliac joint changes in 14,19,20 many cases may go undiagnosed. all specimens.22 The clinical significance of sacroiliac joint osteoarthritis is difficult to determine since many presumed normal horses have similar degenerative joint changes as horses with known back

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or sacroiliac problems.2,14 It is possible that the majority of sacroil- most commonly located at the caudomedial aspect of the articula- iac joint pathology is subclinical however, if similar findings were tion.2,22 The pathogenesis of proliferative sacroiliac joint changes noted in any other musculoskeletal location, the articular changes is uncertain but is thought to be related to chronic instability would be considered clinically significant and a likely contributing resulting in gradual remodeling and subsequent enlargement of the cause of lameness.23 A more likely scenario is that deep sclerotoge- caudomedial joint surfaces.14 Histologically, the caudomedial nous pain (e.g., vertebral or sacroiliac joint osteoarthritis) is often extensions consist of apparently normal cancellous bone. Articular poorly localized and perceived as deep aching pain, based on cartilage erosion is a lytic process of articular surfaces which reports of similar sacroiliac joint pathology in affected humans. presumably leads to eventual sacroiliac joint ankylosis.22 However, Clinically, the most common reported signs of sacroiliac joint ankylosis of the sacroiliac joint has not been reported, which is disorders in horses are poor performance, lack of impulsion, and a surprising based on the limited joint motion and the potential mild, chronic hind limb lameness, which can easily be overlooked or severity of osseous pathology present.2,22,24 Fibrous inter-connec- dismissed as not clinically significant.11,14 Obvious signs of tions between the articular surfaces have also been reported in lameness and localized pain or inflammation are not typical clinical presumed normal sacroiliac joints.2 Articular cartilage discolor- characteristics of sacroiliac joint or pelvic injuries, unless pelvic ation, a presumed indicator of sacroiliac joint degeneration, is fractures or substantial joint disruption are present. common in racehorses but has a reported higher prevalence in Osseous changes of the sacroiliac joint include (in apparent Standardbreds compared to Thoroughbreds.19 It has been theorized order of increasing severity) articular surface lipping, cortical that these changes are due to differences in pelvic and sacroiliac buttressing, articular recession, osteophytes, and intra-articular joint biomechanics associated with pacing and trotting erosions. In our survey of 36 Thoroughbred racehorses, sacroiliac (i.e., lateral bending or shear forces) in Standardbreds compared degenerative changes were classified as mild in 8% of specimens, to galloping (i.e., flexion and extension movements) in Thorough- moderate in 61%, and severe in 31%.22 Age has not been associated breds.25 Biomechanical studies are warranted to support or with the overall prevalence or severity of sacroiliac joint degenerative refute these claims. changes.22 Osseous changes are usually bilaterally symmetrical and Sacroiliac ligament desmitis, the most common soft tissue injury, has been documented ultrasonographically in the dorsal portion of the dorsal sacroiliac ligament.8,10,26 A diagnosis of sacroiliac ligament desmitis is based on loss of normal echogenicity on a short-axis view and a decrease in parallel fiber pattern on the long-axis view. Sacroiliac ligament injuries usually occur due to acute trauma, but few documented cases have been reported.22,27 Acute sacroiliac desmitis is more prevalent in horses jumping at speed and may contribute to the development of chronic sacroiliac joint instability.14,15 However, the presence and significance of chronic sacroiliac ligament injury and sacroiliac joint laxity are controversial. Rooney reported on chronic sacroiliac joint injuries of the cranial portion of the ventral sacroiliac ligaments, which were found to be elongated or torn on the affected side.27,28 Desmitis of the insertion site of the dorsal portion of the dorsal sacroiliac ligament at the insertion on the tuber sacrale has been reported.26 In other studies, osseous changes were found at the caudomedial sacroiliac joint margins in horses suspected of having chronic sacroiliac injury, however no obvious sacroiliac ligament laxity was observed.14-16 Radiographically, some of these cases had an apparent increase in the sacroiliac joint space, however no visible sacroiliac ligament

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injury, joint laxity, or subluxation was observed at necropsy.14,16 In are usually supportive and non-specific. Treatment regimes for our necropsy survey of 36 Thoroughbred racehorses, no evidence of sacroiliac joint pathology are often extrapolated from treatment chronic ligament injury or sacroiliac joint subluxation was ob- recommendations for similar acute or chronic disease processes in served.22 However, this could be related to the prior removal of other articular locations. Very few studies have investigated the horses from race training with poor performance or hind limb efficacy of specific treatment recommendations for sacroiliac joint lameness associated with chronic sacroiliac joint injury. injuries.14,23,25 In addition, there are no prospective, case-con- Complete sacroiliac ligament disruption is most likely due to trolled studies on sacroiliac joint disease management. Most acute substantial trauma, such as flipping over backwards or catastrophic sacroiliac injuries involve soft tissue injuries or osseous pelvic musculoskeletal injuries associated with race training.22 However, pathology associated with a traumatic incident. Chronic sacroiliac few cases of complete rupture of the sacroiliac ligaments have been joint problems are usually insidious and difficult to definitively reported in the veterinary literature.22,28 Post-mortem findings diagnose without advanced imaging modalities and extensive associated with traumatic sacroiliac ligament injuries include either lameness evaluation. Since many sacroiliac joint problems are unilateral or bilateral joint capsule disruption, avulsion fractures of chronic in nature, multiple treatments may have been applied. It is the sacroiliac ligament attachment sites, and noticeable sacroiliac always important to know what type of medications or therapy has joint laxity. Both dorsal or ventral sacroiliac ligaments can be been tried in the past and whether or not it has provided any affected, depending on the inciting mechanism of injury.22,26 improvement in the condition. Complete sacroiliac ligament disruption may produce either unilateral or bilateral dorsal displacement of the tuber sacrale, SACROILIAC OSTEOARTHRITIS depending on the extent of injury. The basic principles of conservative management of sacroiliac The pathogenesis of apparent spontaneous or insidious osteoarthritis are to reduce pain and inflammation in order to 14 differences in tuber sacrale height needs to be further researched. improve healing, followed by a program of rehabilitation and The presumed diagnosis of sacroiliac joint subluxation based solely exercises to prevent further injury or stress to the sacroiliac joint. on the presence of tuber sacrale height asymmetry is inappropri- Therefore, it is necessary in many cases to use a combination of 29 ate. Variable degrees of tuber sacrale height asymmetry occur medications (e.g., NSAIDs, corticosteroids, or muscle relaxants) frequently and may be due to chronic asymmetric muscular or lig- and physical or manipulative therapies. amentous forces acting on the malleable osseous pelvis, and not due The deep overlying croup musculature and seemingly inaccessi- 30 to direct sacroiliac ligament injury. Horses with chronic sacroiliac ble anatomic location of the sacroiliac joint has limited the clinical problems and presumed sacroiliac joint subluxation have not had application of intra-articular sacroiliac joint injections in horses.11,14 14 identifiable changes in the sacroiliac ligaments at necropsy. In Regional perfusion of the sacroiliac joint region with local anesthet- addition, Standardbred trotters with substantial tuber sacrale height ics or anti-inflammatories for diagnostic or therapeutic purposes is asymmetries did not have significant increases in sacroiliac pain a viable alternative, but inappropriate needle placement or the use 20 compared to horses with lesser degrees of asymmetry. Tuber of too short of needles are why most techniques have had subopti- sacrale height asymmetries are also common in horses without mal diagnostic or therapeutic effects.21,31,32 A medial approach to documented sacroiliac joint injuries. In only a few horses have the sacroiliac joint provides the most direct, safe and consistent tuber sacrale height asymmetries been associated with chronic periarticular injection technique.33 Periarticular injections are 28 sacroiliac ligament injuries or joint laxity. An ante-mortem made as close as possible to the caudomedial sacroiliac joint margin diagnosis of sacroiliac joint luxation can only be supported if an due to the high prevalence of degenerative changes affecting the acute change in tuber sacrale height asymmetry due to substantial caudomedial sacroiliac joint margin.2,34 The injection mixture trauma has been documented or if sacroiliac joint instability includes methylprednisolone acetate, isoflupredone acetate, and (i.e., crepitus or independent tuber sacrale movement) is evident serapin.35 Improvement usually takes 2 to 6 days and repeated during physical examination). treatment is sometimes necessary. Injections of corticosteroids in the sacroiliac joint region have been used quite extensively however, TREATMENT APPROACHES there are not any well designed or controlled trials currently The proposed treatment of sacroiliac joint injuries is only as reported in the literature.36 good as the diagnosis. Since definitive diagnosis of sacroiliac joint Musculoskeletal health depends on movement and use. pathology remains difficult at times, treatment recommendations Scientific evidence suggests that long-term rest or inactivity is

15 www.theneaep.com 585-205-5122 ESSInc_TheClinician_SEP2020_FIN.pdf 1 7/10/2020 4:49:58 PM

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contraindicated for osteoarthritis in humans.37 Similar recommen- problems, unless specific sacroiliac ligament laxity has been dations are appropriate for horses with sacroiliac osteoarthritis. documented. With such haphazard and potentially injurious Horses that are stalled for the majority of the day or large portions treatment modalities, there appears to be a better chance of of the year do not have the opportunity to maintain back or pelvic inducing further injury than of stimulating any healing response, flexibility, which may contribute to sacroiliac joint stiffness and unless ligamentous laxity has documented and can be objectively dysfunction. In-hand on the lunge line or round pen without a monitored during healing. rider is indicated for several weeks to allow movement of the sacroiliac region without the excessive stress associated with the GENERAL RECOMMENDATIONS 38 weight of a rider. In chronic, low-grade sacroiliac osteoarthritis, a A clinical trial of phenylbutazone (2 g, p.o., b.i.d. for 4-5 days) progressive exercise program can be used to help build up and is often used to assess the inflammatory component of any sacroili- supple the gluteal and hindlimb muscles. A tapering dose of oral ac joint problem. The use of nonsteroidal anti-inflammatory drugs phenylbutazone can be given as the exercise is gradually increased. (NSAIDs) will often produce an improvement in osseous or Once comfortable in-hand or on the lunge line, light riding at a articular pathologies although this may be incomplete and short- walk, then trot may begin as long as the horse is monitored daily for lived. Other NSAIDs include ketoprofen (2.2 mg/kg (1 ml/100 lbs), willingness and ability to do the work. i.v., s.i.d. for up to 5 days) or naproxen (5-10 mg/kg, p.o., b.i.d. for up to 14 days). Long-term use of phenylbutazone at low doses (1 g, p.o., SACROILIAC DESMITIS s.i.d.) for mild aches and stiffness can be beneficial, but may mask In general, rest is indicated for most ligamentous injuries.39 the signs of other musculoskeletal injuries or compensation.36 The Prolonged rest (6-12 months) and systemic anti-inflammatory additional use of glucosamine, chondroitin sulfate, or methylsulfo- medications have been prescribed for both acute and chronic nylmethane (MSM) has been reported to help reduce inflammation sacroiliac joint injuries. Complete box stall rest for at least 45 days and improve the clinical signs of osteoarthritis in some horses.41 has been recommended to support ligamentous healing in acute Muscle relaxants have been advocated for back and gluteal injuries.40 Extended rest is contraindicated since reduced muscle muscle hypertonicity, but their effectiveness seems to be inconsis- tone may exacerbate the sacroiliac instability or desmitis. Hand tent and varies between horses.21 A clinical trial of methocarbamol walking for 5 minutes, twice a day, for up to 5 times a week is (15-44 mg/kg, p.o., s.i.d.) or dantrolene sodium (2 mg/kg, p.o., suggested during the first month of recovery. Backing up exercises s.i.d.) will help some horses with back or gluteal muscle-related are also recommended for the rehabilitation of the sacroiliac soreness or hypertonicity. These drugs may not have any specific ligament injury.40 Ground pole and obstacle work is then indicated effects other than reducing muscle tension or spasm in order to for the next several weeks to help stimulate proprioception and to allow the normal healing process to occur. induce slow, slightly exaggerated movements in the sacroiliac joint. Soft tissue and articular motion restrictions (i.e., stiffness) can Exercise is gradually increased, as the horse is able, for up to a be directly addressed with specific stretching exercises to induce maximum of 20 minutes a day, twice a week, for 5 times a week. If creep and stress relaxation within fibrotic or shortened periarticular the lameness continues to be managed, then short durations of soft tissues. With minimal training, horses and their owners can be turnout in a small paddock are provided with continued gradual taught how to do simple but effective passive joint mobilization increases in exercise. Periodic re-evaluation is required to monitor and active stretching exercises (i.e., carrot stretches) to improve the progression of the rehabilitation. It has been reported that it both axial skeleton and limb flexibility. These concurrent therapies usually takes 8-0 months of rest and controlled exercise before also help to encourage owner participation in the healing process horses are ready to return to regular training and performance.40 and provide close monitoring of the patient’s progress. Cryotherapy Intravenous administration of sodium hyaluronate at weekly (i.e., ice packs or ice massage) is indicated in the first 24-48 hours intervals for 4 weeks, followed by monthly administration has been post-injury to reduce pain, induce muscle relaxation, and reduce recommended.40 The local injection of irritants or sclerosing agents inflammation. The application of heat or electrical stimulation can have also been suggested to stimulate fibrosis and subsequent sacro- provide increased soft tissue extensibility, reduced inflammation iliac joint stability.7 Horses are reported to improve their perfor- and adhesion formation, and pain control to help facilitate the mance, but no scientific reports of their isolated use are available. In restoration of normal joint motion.42 the author’s opinion, there is no scientific support or clinical Treatment of chronic sacroiliac joint injury typically focuses on indication for such proposed treatments of sacroiliac joint a gradual return to a low level of exercise to maintain muscle

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development of the back and gluteal regions in order to counteract the Acupuncture and chiropractic are non-traditional approaches clinical signs of poor performance and reduced hind limb impul- that have been used by some practitioners to assist in the symptom- sion.43 In acute sacroiliac joint injuries, cantering or galloping is atic treatment of horses with presumed sacroiliac joint problems. contraindicated due to high stresses on the sacroiliac joint, which may The principal indications for equine chiropractic evaluation and exacerbate pre-existing pathology. The high musculoskeletal demands treatment are localized musculo-skeletal pain, muscle hypertonicity required during these activities may also cause horses to decompen- and restricted joint motion. This triad of clinical signs can be found sate and injury muscles or other soft tissues. Many repetitive-use in a variety of lower limb disorders, but is most evident in upper disorders benefit from cross-training activities (i.e., alternating limb, neck or back problems. A thorough diagnostic workup is dressage, hacks, and cavelletti work) are often helpful in rehabilitation required to identify soft tissue and osseous pathology, neurologic of the sacroiliac joint problems. Modifications in exercise or training disorders, or other lameness conditions that may not be responsive program duration, frequency or intensity need to be tailored to to chiropractic care. Chiropractic care can help manage the individual horses and their ability to compensate and increase the muscular, articular and neurologic components of select musculo- work load. Recommendations for a re- duction in jumping, turning in skeletal injuries in performance horses. Chiropractic care is usually tight circles or abrupt transitions (e.g., canter-halt-canter) or changes contraindicated in the acute stages of soft tissue injury. However, as in direction (e.g., barrel racing or reining) or other high impact the soft tissue injury heals, chiropractic has the potential to help maneuvers are also important. Query into the size and the time spent restore normal joint motion, thus limiting the risk for future in stalls, paddocks, or turnout in pasture is indicated for any horse reinjury.37 Chiropractic care may provide symptomatic relief in with sacroiliac joint problems. In addition, horses that are turned out early degenerative joint disease if related to joint hypo-mobility and in paddocks with deep mud, large rocks, poor footing, or steep hills subsequent joint degeneration. Chiropractic is usually much more may aggravate sacroiliac joint problems. effective in the early clinical stages of disease versus end-stage

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disease where reparative processes have been exhausted. Forceful tors, altering pain perception and transmission, and increasing manipulative therapy is contraindicated for acute inflammatory beta-endorphin levels. Physical therapy modalities involved in pain conditions, since any induced joint movement would be expected control include electrical stimulation (i.e., muscle stimulation, to aggravate the existing inflammatory process. transcutaneous electrical nerve stimulation (TENS)), the applica- Clinical studies and experimental reports indicate that tion of hot or cold, mechanical vibration, and electromagnetic acupuncture is a safe and effective modality for specific musculo- modalities. Abnormal muscle tone can be addressed with modali- skeletal conditions if used properly.44 Disease conditions managed ties that increase or decrease muscle contractility or coactivation by acupuncture include trauma, osteoarthritis, and muscle hyperto- and nerve conduction or inhibition. Some of these modalities nicity. Acupuncture is often the treatment of choice for trigger include hydrotherapy, electrical stimulation, and rehabilitative points, which are characterized by localized tight, painful bands of exercises that specifically address issues of reduced flexibility, muscle at characteristic locations within the middle gluteal muscle. coordination, strength, and endurance. In humans, anti-inflamma- The primary benefit of acupuncture for sacroiliac joint problems is tories and other drugs can be delivered into superficial soft tissues pain management via opioid (i.e., enkephalin and betaendorphin) via electrical currents (i.e., iontophoresis) or via mechanical sound and non-opioid (e.g., serotonin) pathways.45 Pain relief is often waves (i.e., phonophoresis). However, preliminary equine research immediate, but may have variable durations of effectiveness, in- dicates that a heavy hair coat, thick skin, and deep articular depending on the type and severity of musculoskeletal dysfunction. structures may limit the overall effectiveness of these novel drug Acupuncture does not have any known direct effects on reducing delivery systems for sacroiliac joint problems. joint stiffness, as do manual therapies. Therefore, synergistic effects are often obtained with combined chiropractic and PROGNOSIS acupuncture treatment that cannot be obtained consistently with Long-term follow-up suggests that prognosis for sacroiliac joint either modality by itself. injury is poor for return to the previous level of activity.11 This of Physical therapy modalities that may have direct application to course depends on the amount and extend of sacroiliac osteoarthri- sacroiliac joint problems in horses include devices that apply tis or desmitis present. Some horses may have an improvement in electrical currents for pain control or neuromuscular rehabilitation; performance or lameness, but will not be able to return to normal ther- mal modalities (i.e., superficial and deep heat or cold applica- athletic activities due to recurring, low grade lameness.40 Complete tions) for influencing inflammatory mediators, collagen extensibili- recovery from chronic sacroiliac desmitis has been reported to be ty and altering nerve conduction; and mechanical approaches about 47%.16 Most horses will be pasture sound or able to function (e.g., massage, vibration, stretching, and training exercises) for only at low levels of exercise. Improvements in providing a specific maximizing musculoskeletal rehabilitation. Many forms of physio- diagnosis of the sacroiliac joint injury will provide affected horses therapy may give temporary improvement, but a lasting success is with better and more specific treatment options in the future. unlikely without establishing a definitive diagnosis of the sacroiliac joint problem. References In the absence of trauma or documented pathologic findings, Dalin G, Jeffcott LB. Sacroiliac joint of the horse. 1. Gross the primary goal of treatment should address restoration of function morphology. Anat Histol Embryol 1986; 15:80-94. 37 and prevention of future disability. Management should be sys- Dalin G, Jeffcott LB. Sacroiliac joint of the horse. 2. Morpho- tematically and methodically directed toward developing coordina- metric features. Anat Histol Embryol 1986;15:97-107. tion and proprioception, flexibility strength, and endurance. The Ekman S, Dalin G, Olsson SE, et al. Sacroiliac joint of the horse. negative effects of immobilization and deconditioning should be 3. Histological appearance. Anat Histol Embryol 1986;15:108-121. minimized with early mobilization and controlled activity. In- Dyson S, Murray R, Branch M, et al. The sacroiliac joints: creased mobility is addressed with joint mobilization and muscle evaluation using nuclear scintigraphy. Part 1: The normal horse. stretching.46 Altered movement patterns are addressed with coor- Equine Veterinary Journal 2003;35:226-232. dination via proprioceptive retraining, postural reeducation, muscle Erichsen C, Berger M, Eksell P. The scintigraphic anatomy 37 strengthening, and endurance training. of the equine sacroiliac joint. Vet Radiol Ultrasound 2002; 43:287-292. The primary indications of physical therapy for sacroiliac Tomlinson JE, Sage AM, Turner TA, et al. Detailed ultrasono- problems include localized or general- ized pain, joint motion graphic mapping of the pelvis in clinically normal horses and ponies. 47 restrictions, and altered back or gluteal muscle tonicity. Pain Amer J Vet Research 2001; 62:1768-1775. modulation can be provided by influencing inflammatory media-

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Dyson S, Murray R, Branch M, et al. The sacroiliac joints: evalu- Jeffcott LB, Dalin G, Ekman S, et al. Sacroiliac lesions as a cause ation using nuclear scintigraphy. Part 2: Lame horses. Equine of chronic poor performance in competitive horses. Equine Veterinary Veterinary Journal 2003;35:233-239. Journal 1985;17:111-118. Gillis C. Spinal ligament pathology. Vet Clin North Am Equine Jeffcott LB. Disorders of the thoracolumbar spine of the horse - a Pract 1999;15:97-101. survey of 443 cases. Equine Veterinary Journal 1980;12:197-210. Pilsworth RC, Shepherd MC, Herinckx BM, et al. Fracture of Jeffcott LB. Pelvic lameness in the horse. Equine Pract the wing of the ilium, adjacent to the sacroiliac joint, in thoroughbred 1982;4:21-47. racehorses. Equine Veterinary Journal 1994;26:94-99. Adams OR. Subluxation of the sacroiliac joint in horses. Tomlinson JE, Sage AM, Turner TA. Ultrasonographic abnor- Proc Amer Assoc Equine Practitioners 1969;15:191-207. malities detected in the sacroiliac area in twenty cases of upper Jeffcott LB. Radiographic appearance of equine lumbosacral and hindlimb lameness. Equine Veterinary Journal 2003;35:48-54. pelvic abnormalities by linear tomography. Vet Radiol 1983;24:201-213. Tucker RL, Schneider RK, Sondhof AH, et al. Bone scintigraphy Rooney JR. Sacroiliac arthrosis and “stifle lameness”. Mod Vet in the diagnosis of sacroiliac injury in twelve horses. Equine Pract 1977;58:138-139. Veterinary Journal 1998;30:390-395. Dalin G, Magnusson L-E, Thafvelin BC. Retrospective study of Crawford WH. A controversy on mechanics of sacroiliac hindquarter asymmetry in Standardbred Trotters and its correlation arthrosis in the horse. Can Vet Journal 1982;23:143-144. with performance. Equine Veterinary Journal 1985;17:292-296. Rooney JR. A controversy on mechanics of sacroiliac arthrosis Marks D. Back pain In: Robinson NE, ed. Current therapy in in the horse. Can Vet Journal 1982;23:144-145. equine medicine. 4th ed. Philadelphia, PA: W.B. Saunders Company, 1997;6-12.

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Haussler KK. Osseous spinal pathology. Vet Clin North Am Haussler KK, Stover SM, Willits NH. Pathologic changes in the Equine Pract 1999;15:103-112, vii. lumbosacral vertebrae and pelvis in Thoroughbred racehorses. Dyson S, Murray R. Pain associated with the sacroiliac joint Amer J Vet Research 1999;60:143-153. region: a clinical study of 74 horses. Equine Veterinary Journal Hardy J, Marcoux M. L’Athrose sacro-iliac chez le cheval 2003;35:240-245. Standardbred. MedVetQuebec 1985; 15:185-189. Stecher RM, Goss LJ. Ankylosing lesions of the spine. JAmVet- Snyder JR. Selected intra-articular injections in the horse. MedAssoc 1961;138:248-255. Proceedings of the 7th Congress on Equine Medicine and Surgery Rooney JR. The cause and prevention of sacroiliac arthrosis in 2001;115-123. the Standardbred horse: a theoretical study. Can Vet Journal Engeli E, Haussler KK, Erb HN. How to inject the sacroiliac 1981;22:356-358. joint region in horses. Proc Amer Assoc Equine Practitioners Denoix J-M. Ligament injuries of the axial skeleton in the horse: 2002;48:257-260. Supraspinal and sacroiliac desmopathies. First Annual Dubai Haussler KK, Stover SM. Stress fractures of the vertebral lamina International Equine Symposium 1996;273-286. and pelvis in Thoroughbred racehorses. Equine Veterinary Journal Rooney JR, Delaney FM, Mayo JA. Sacroiliac luxation in 1998;30:374-381. the horse. Equine Veterinary Journal 1969;1:287-289. Denoix JM, Thibaud D, Riccio B. Tiludronate as a new Rooney JR. Sacroiliac luxation. Mod Vet Pract 1979;60:44-46. therapeutic agent in the treatment of navicular disease: a dou- Cassidy JD, Townsend HGG. Sacroiliac joint strain as a cause of ble-blind placebo-controlled clinical trial. Equine Veterinary Journal back and leg pain in man - Implications for the horse. Proc Amer 2003;35:407-413. Assoc Equine Practitioners 1985;31:317-333. Marks D. Medical management of back pain. Vet Clin North Am Equine Pract 1999;15:179-194, viii. Liebenson C. Rehabilitation of the spine. 1st ed. Baltimore, MD: Williams & Wilkins, 1996. Dyson SJ. Lameness associated with the stifle and pelvic regions. Biometric Monitoring Proc Amer Assoc Equine Practitioners 2002;48:387-411. by the smart halter™ Jeffcott LB. The diagnosis of diseases of the horse’s back. Equine Veterinary Journal 1975;7:69-78. Hendrickson DA. The pelvis In: Stashak TS, ed. Adams’ lameness in horses. 5th ed: Lippincott Williams & Wilkins, 2002;1044-1053. Jones WE. MSM reviewed. J Equine Vet Sci 1987;7:2. Cameron MH. Physical agents in rehabilitation. Philadelphia: W.B. Saunders Company, 1999. Jeffcott LB. Diseases of the lumbosacral region In: Colahan PT, Mayhew IG, Merritt AM, et al., eds. Equine medicine and surgery. 5th ed. St. Louis, MO: Mosby, Inc., 1999;1730-1733. Altman S. Small animal acupuncture: scientific basis and clinical applications In: Schoen AM, Wynn SG, eds. Complementary and alternative veterinary medicine: principles and practice. St. Louis: Mosby, 1998;147-167. Fleming P. Equine acupuncture In: Schoen AM,Wynn SG, eds. Complementary and alternative veterinary medicine: principles and REDUCE staff burden practice. St. Louis: Mosby, 1998;169-184. IMPROVE quality of care Porter M. Stretching for the horse In: Porter M, ed. The New INCREASE revenue Equine Sports Therapy. Lexington, KY: The Blood-Horse, Inc., 1998;31-42. smarthalter.com Porter M. Physical therapy In: Schoen AM,Wynn SG, eds. Complementary and alternative veterinary medicine: principles and practice. St. Louis: Mosby, 1998;201-212. 24 www.theneaep.com 585-205-5122 American Farrier’s Association BECOME A MEMBER Being an AFA Member means that you are a part of a community that takes pride in delivering quality hoof care while protecting the welfare of the horse. As part of your membership you have access to benefits, discounts and a variety of educational resources. To find out more, contact us!

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American Farriers Team is selected from the Cultural Exchange Program — The exchanges top competitors at the annual National Forging with the United Kingdom, South Africa, and & Horseshoeing Competition during the AFA Australia offer farriers a once-in-a-lifetime Convention. The AFT represents the USA in experience of living and working with top international competitions. international farriers who will broaden your knowledge and improve your skills. Jim Linzy Memorial Fund sponsors the Keynote Speaker at the convention and helps fund Equine Research Fund supports a grant system benefit clinics for injured and ill AFA member that allows farriers to produce research that is farriers. Through the Bruce Daniels Memorial sophisticated enough to be read in veterinary Scholarship it awards $500 for the purchase of and research circles and makes an impact on tools to nominated recent graduates of our everyday shoeing. horseshoeing schools. THE CLINICIAN SEPTEMBER 2020 NEAEP

Managing Strangles Outbreaks Ashley G. Boyle, DVM, DACVIM Assistant Professor of Medicine, Section Field Service Department of Clinical Studies, New Bolton Center, University of Pennsylvania Kennett Square, PA

PATHOPHYSIOLOGY for up to 2.5 years. These outwardly healthy horses S. equi subsp equi is inhaled or ingested after direct contact (i.e., carriers) that still shed organisms are a source of infection 6,7,8 with mucopurulent discharge from infected horses or contaminated when introduced into a new population of horses. Transmission equipment. The bacterium attaches to the crypts and epithelium of occurs through nose-to-nose contact; proximity; equipment the lingual and palatine tonsils. The organism enters the mandibu- (e.g., water buckets, feed buckets, tack, twitches); clothing; and lar and pharyngeal lymph nodes. Clinical signs develop 3 to 14 days equipment of owners, caretakers, farriers, and veterinarians.1 Under after exposure.1,2 laboratory conditions, S. equi subsp equi has been shown to persist on wood for 63 days at 35.6°F and for 48 days on glass and wood at 68°F.9 One study modeling field conditions revealed that the CLINICAL SIGNS organism was found to persist for less than 4 days, 23 but moist The first clinical sign of strangles is acute-onset fever (often environments (e.g., water buckets) allow the organism to persist for >103°F), followed by lethargy, depression, bilateral mucopurulent extended periods.1,2 Seventy-five percent of horses that have been nasal discharge, lymphadenopathy, and abscessation of the infected with S. equi subsp equi and have not been treated with retropharyngeal and mandibular lymph nodes. Occasionally, the antimicrobials develop lasting immunity for approximately 5 years parotid and cranial cervical lymph nodes are affected. Retropharyn- or longer. 1,2,10,11 geal lymph node enlargement can lead to narrowing of the pharynx, resulting in upper respiratory noise, dysphagia, and neck extension. Empyema results when the retropharyngeal lymph nodes drain pus DIAGNOSTIC TESTING into the guttural pouches. Horses may develop respiratory distress Early definitive diagnosis is essential for containing this highly due to retropharyngeal abscesses that are not externally mature. infectious disease. Cytologic evaluation reveals gram-positive Clinical signs are more severe in immunologically naïve (1 through extracellular cocci in long chains supports a diagnosis of a ß-hemo- 5 years of age), geriatric (older than 20 years), and immunocompro- lytic streptococcus organism. Historically, the gold standard for mised horses.1,2,3 Some horses may develop complications such as diagnosis is bacterial culture of abscess aspirates, nasopharyngeal metastatic abscessation, purpura hemorrhagica, and myositis. swabs, nasopharyngeal revealing S. equi subsp equi. This is the preferred method on aspirates of mature abscesses, but takes a minimum of 24 hours to obtain results. In our clinical practice, we TRANSMISSION now use polymerase chain reaction (PCR) testing to detect the DNA Shedding of S. equi subsp equi begins 2 to 3 days after onset of of the organism as the gold standard which can also be performed fever. In most cases, shedding persists for a minimum of 2 to 3 on nasopharyngeal swab, nasopharyngeal wash, and guttural pouch weeks. Horses that have recovered from strangles have been shown wash samples.1 Nasopharyngeal washes are preferable to nasopha- to shed for an additional 6 weeks.1 If organisms are harbored in the ryngeal swabs due to a larger sampling area, but guttural pouch guttural pouches, horses have been shown to shed S. equi subsp equi sampling is the most reliable, although more expensive and requires

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specialized equipment. PCR testing is more sensitive than bacterial infected horses should wear barrier precau- culture22 and should always be used in combination. tions (i.e., gowns, gloves, plastic boots that cover shoes) and, ideally, should TREATMENT not handle noninfected horses or The goal of treating strangles is to control transmission and should handle infected horses eliminate infection while providing future immunity to the disease. last. Water buckets should be 1,8 Uncomplicated cases of strangles are often left to run their course disinfected daily. Facilities with supportive care, providing lasting immunity. Affected horses and equipment should be should be isolated in a clean, dry stall and fed moist, palatable food. cleaned first to remove all NSAIDs should be used judiciously to decrease swelling and organic material and then promote eating. Hot compresses or topical 20% ichthammol can be disinfected with phenols, used to accelerate maturation of abscessation. Mature external iodophors, or chlorhexidine abscesses should be lanced to allow drainage, followed by daily compounds or steam 1,9 lavage of open abscesses using dilute povidone iodine solution. This cleaned. Surfaces and speeds resolution of abscessation as well as alleviation of compres- equipment must be allowed to sion of the pharynx. 2 dry thoroughly. Paddocks that hold infected horses should be rested for 4 weeks. A minimum of METHODS OF two weeks after all cases of strangles have OUTBREAK CONTROL resolved, one guttural pouch lavage along Most outbreaks are thought to originate from introduction of with an endoscopic examination for empyema or an infected horse to a naïve population. All new horses should be chondroids should be obtained from convalescing horses and their isolated for 3 weeks and monitored for any signs of disease, includ- contacts at approximately weekly intervals and tested for S. equi ing fever. If cost is not prohibitive, horses should be screened for S. subsp equi via PCR to detect carriers. This is preferable to the equi subsp equi infection using nasopharyngeal washes. Many previously recommended three nasopharyngeal washes. Horses farms with repeated infections have resorted to screening for have been found positive in their guttural pouches despite three infection via endoscopic evaluation and PCR testing of guttural negative nasopharyngeal washes. 16 A series of 3 nasopharyngeal pouch lavages. The Animal Health Trust in the United Kingdom swabs, collected 1 week apart, will result in detection by a positive recently developed a new serologic test that detects antigens differ- culture on at least one of the swabs in approximately 60% of carrier ently than the SeM ELISA. This new test appears to be more animals. Concurrent testing of these swabs by PCR increases the sensitive for detecting animals with recent exposure (as little as 2 likelihood of detection to over 90% of carrier animals. 15 For the weeks) to S. equi subsp equi and has been used as a screening tool to purpose of efficien- cy, I recommend treating each guttural pouch determine who needs endoscopic examinations upon arrival to a with penicillin at the time of endoscopic examination unless there is farm during quarantine prior to introduction into the herd. gross contamination of the guttural pouch which would require However, this test is currently not available in the United States and aggressive lavage. A minimum of three weeks should be waited prior there is no way to distinguish vaccinated animals from recently to retesting a treated, previously positive guttural pouch via PCR . exposed animals.15 The percentage of carriers per outbreak could be as high as 10%.1,8, Once an outbreak has occurred, twice-daily monitoring of 12,17,18 It is important to remember that SeM ELISA does not detect rectal temperatures of all horses on the farm is essential to contain carrier status.19 the outbreak. Because febrile horses do not shed disease for the The use of vaccination during an outbreak is controversial. The initial 2 days, immediate identification of febrile horses enables 2005 ACVIM Consensus Statement recommends that live vaccine caretakers to isolate these horses before shedding occurs. All should be administered only to healthy animals with no known movement of horses to and from the farm should be stopped exposure to infected horses during an outbreak, but no published until they are determined to be noninfectious. All equipment data show that use during an outbreak is detrimental.1 The AAEP (e.g., pitchforks, buckets, grooming tools) for an affected horse Infectious Disease Committee does not recommend vaccination should be isolated and used only for that horse. Personnel handling during an outbreak.13 It is suggested that horses recovering from

28 www.theneaep.com 585-205-5122 THE CLINICIAN SEPTEMBER 2020

infection should not be vaccinated for 1-2 years. 20 Newton JR, Wood JN, Dunn KA, et al. Naturally occurring Eradication of this disease will not be possible until the persistent and asymptomatic infection of the guttural pouches of subpopulation of carriers is eliminated and the development of new horses with Streptococcus equi. Vet Rec 1997;140:84-90. vaccines that distinguish vaccinates from exposed are available. 21 AAEP. Strangles (Streptococcus equi). Accessed June 2009 at www.aaep.org/strangles.htm. REFERENCES Waller A, Robinson C, Newton JR. Further thoughts on the Sweeney CR, Timoney JF, Newton JR, Hines MT. Streptococcus eradication of strangles in equids. JAVMA 2007;231:1335. equi infections in horses: guidelines for treatment, control, and http://www.aht.org.uk/cms-display/bact_bloodadvice.html prevention of strangles. J Vet Intern Med 2005:19:123-134. Accessed January 2012. Boyle AG. Streptococcus equi subspecies equi Infection Getting a grip on Strangles, Havermeyer Workshop, (Strangles) in horses. Compendium Continuing Education for the October 2012. Practicing Veterinarian 2011; 33:online. Newton JR, Wood JN, Dunn KA, et al. Naturally occurring Sweeney CR, Benson CE, Whitlock RH, et al. Description of an persistent and asymptomatic infection of the guttural pouches of epizootic and persistence of Streptococcus equi infections in horses. horses with Streptococcus equi. Vet Rec 1997;140:84-90. JAVMA 1989;9:1281-1286. Verheyen K, Newton JR, Talbot NC, et al. Elimination of Ford J, Lokai MD. Complications of Streptococcus equi infection. guttural pouch infection and inflammation in asymptomatic carriers Equine Pract 1980;4:41-44. of Streptococcus equi. Equine Vet J 2000;32:527-532. Radostits OM, Gay CC, Blood DC, et al. Purpura hemorrhagi- Davidson A, Traub-Dargatz JL, Magnuson R, et al. Lack of ca. In: Veterinary Medicine: A Textbook of the Diseases of Cattle, correlation between antibody titers to fibrinogen binding protein of Sheep, Pigs, Goats and Horses. 8th ed. London: Balliere Tindall; Streptococcus equi and persistent carriers of strangles. J Vet Diagn 1999:1713-1714. Invest 2008;20:457-462. Carlson GP. Diseases of the hematopoietic and hemolymphatic Wilson JH. Vaccine efficacy and controversies. Proc 51st Annu systems. In: Smith BP, ed. Large Animal Internal Medicine. 3rd ed. Meet AAEP 2005;409-420. St. Louis: CV Mosby; 2002:1043. Waller A, Robinson C, Newton JR. Further thoughts on the Galan JE, Timoney JF. Immune complexes in purpura hemor- eradication of strangles in equids. JAVMA 2007;231:1335. rhagica of the horse contain IgA and M antigen of Streptococcus equi. Boyle, AG, Boston RC, O’Shea K, Young S, Rankin SC, J Immunol 1985;135:3134-3137. Optimization of an in vitro assay to detect Streptococcus equi subsp. Newton JR, Verheyen K, Talbot NC, et al. Control of strangles equi. Vet. Microbiol. 159: 406-410, 2012. outbreaks by isolation of guttural pouch carriers identified using PCR Weese JS, Jarlot C, Morley PS, Survival of Streptococcus equi and culture of Streptococcus equi. Equine Vet J 2000;32:515-526. on surfaces in an outdoor environment. Can Vet J. 2009 Jorm LR. Laboratory studies on the survival of Streptococcus Sep;50(9):968-70. equi on surfaces. In: Plowright W, Rossdale PD, Wade JF, eds. Boyle AG et al. J Am Vet Med Assoc 2009;235: 973. Proceedings of Equine infectious Diseases VI. Newmarket, UK: R https://equimanagement.com/articles/veterinarians- & W Publications;1992:39-43. dealing-with-dissatisfied-clients Pusterla N, Watson JL, Affolter VK, et al. Purpura haemorrhag- ica in 53 horses. Vet Rec 2003;153:118- 121. Freeman DE. Diagnosis and treatment of diseases of the guttural pouch (part 2). Compend Contin Educ Pract Vet 1980;2:S25-S31.

29 www.theneaep.com 585-205-5122 THE CLINICIAN SEPTEMBER 2020 NEAEP

Veterinarians Dealing with Dissatisfied Clients Compassionate listening and appropriate boundaries are the key elements to successful management of client dissatisfaction. Amy L. Grice, VMD, MBA

If you are in the veterinary profession for any length of time, Angry clients make their dissatisfaction easy to detect! That’s sooner or later you will encounter a client who is dissatisfied. This one positive thing about it. Another is that you might discover disgruntlement might be with lack of results after a treatment, the some things about your practice’s performance that you might cost of services, an interaction with your office staff, or with just never have known about otherwise. about anything related to your practice. There are well-established Adopt an attitude of openness about learning where your methods for easing clients’ irritation, and most of them require practice’s performance is failing to meet your clients’ expectations. taking a step back from the situation so you can think clearly. It is essential to be a good listener and make sure your frustrated Clients can get rude or angry for many reasons, and while client feels heard. You must remain calm and control your own some are justified, others are not. How you respond can make the emotions. If a client starts yelling or being otherwise rude, there is difference between a client who feels satisfied with the resolution absolutely nothing to be gained by responding in a similar manner. and one who vows never to use your practice again and to tell all his However, setting boundaries is important. Utilize the phrase “I or her friends about the bad experience. want to listen and try to resolve this issue, but you may not speak to Unfortunately, according to the White House Office of my staff (or me) like that.” Consumer Affairs, a dissatisfied customer will tell between nine to An angry or dissatisfied client wants to be heard and vent his 15 people about his or her experience, and 13% of customers will or her emotions. By listening patiently, you can often defuse a tell more than 20 people! In contrast, customers who get their issues situation, as long as that person feels acknowledged. After the client successfully resolved tell about four to six people about their has finished explaining his or her angst, reflect back what you’ve experience. heard and ask any clarifying questions. In his book “Understanding Customers,” Ruby Newell-Legner Because up to 90% of communication occurs nonverbally, pay stated that it takes 12 positive experiences to make up for one close attention to your body language! Maintain eye contact and a unresolved negative experience. Clearly, it is important to make a relaxed posture, keeping your arms uncrossed. Actively sympathize sincere effort to mitigate the complaints of unhappy clients. with the emotions the individual might have expressed. If an The first step in resolving dissatisfaction is to know that it apology is in order, express it with sincerity. If it is appropriate, exists! According to a study by First Financial Training Services, verbalize that you would never want your clients to feel the way this 96% of unhappy customers don’t complain, 91% simply leave and person feels. Respecting the client’s perspective goes a long way never come back, and 5% suffer in resentful silence. toward smoothing things over. Share your perspective only after Consider polling your clients with a short survey about their hearing the complaints of the client. satisfaction with your practice, utilizing a simple online platform Compassionate listening and appropriate boundaries are the such as Survey Monkey. Examples of surveys can be found on the key elements to successful management of client dissatisfaction. AAEP Touch website.

30 www.theneaep.com 585-205-5122 NETWORKING 100+ HOURS OF SYMPOSIUM OPENS OPPORTUNITIES CE CREDITS SEPTEMBER 23rd Northeast Association of Equine Practioners

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AMY JOHNSON DENNIS BROOKS DVM, DACVIM DVM, PHD, DIP ACVO (LAIM & NEUROLOGY) Eye Examination EDM is more common than you think: of the Horse Part 1 An updated clinical perspective Eye Examination of the Horse Part 2 What’s new in neurology? Corneal Ulcers in Horses Testing and treatment tips Nonulcerative Corneal Disease in Horses

AMY POLKES DVM, DACVIM EARL GAUGHAN Heart Murmurs and Arrhythmias D.V.M., DIPL. ACVS in Horses When Are They Significant Wellness and YOU Cardiac Cases Ultrasound Lab - Flash Abdomen 33Ultrasound Lab - Thorax www.theneaep.com 585-205-5122 THE CLINICIAN SEPTEMBER 2020

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ELAINE CLAFFEY GUY LESTER DVM BSC (HONS), BVMS, PHD, DACVIM Bandaging Wet Labs (LAIM) Exercise-induced pulmonary hemorrhage – An update Gastric ulcers – Therapy update and what the future may bring

GARNETTA SANTIAGO MA, LVT Chasing Serenity: Work-Life Balance On Your Terms JAMES CONWAY

DVM Navicular Syndrome

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JANE MANFREDI JENNY HAGEN DVM, MS, PHD, DACVS-LA, PROF.DR. HABIL.MED.VET DACVSMR (EQUINE) Equine gait pattern in swing and EMS, IR, ID, PPID, OST, stance phase and how it is influenced TRH Stim- sorting out the equine by trimming and shoeing endocrine alphabet soup Adaption of therapeutic shoeing on the rehabilitation status of the patient Gait analysis related to trimming and change in hoof angulation, weight and breakover

JENNIFER QUAMMAN DVM, MPH Telemedicine for The Veterinary Technician/ Assistant JOYCE GUTHRIE RVT, EQUINE ANESTHESIA & SURGERY TECHNICIAN 36 www.theneaep.com 585-205-5122 Anesthesia Overview: Be Prepared for Your First Anesthesia Experience THE CLINICIAN SEPTEMBER 2020

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LAUREN SCHNABEL JULIE SETTLADGE DVM, PHD DACVS, DACVSMR DVM, DACVS-LA Advances in the Diagnosis and Using Boundaries to Feed Your Why Treatment Approaches of Tendon and Ligament Injuries Point-of-care-biologics for the treatment of tendon and ligament injuries Use of stem cells for the treatment of tendon and ligament injuries: what type, how, and when? Rehabilitation and monitoring of tendon and ligament injuries:

KATE CHOPE CLINICAL ASSISTANT PROFESSOR Ultrasound Lab - Ultrasound Principles and Maximizing your Image Ultrasound Lab - Cervical +/- Poll

LIZ RIGBY

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LORI BIDWELL MEG GREEN DVM, DACVAA, CVA DVM, SPEAKER, COACH Monitoring Under General Anesthesia & TRAINER Communication Skills Influence and Leadership

MARK BAUS DVM Using Technology to Streamline MIKE POWNALL the Equine Practice DVM, MBA

How to manage staff in times of uncertainty

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MIKE WILDENSTEIN NETTIE LIBURT FWCF (HONS), CJF SENIOR EQUINE A Farriers Perspective of NUTRITION MANAGER Equine Conformation Nutritional Management of Equine - Sponsored by Farrier Product Distribution Gastric Ulcer Syndrome (EGUS) Using Information Gained From Basic Nutrition for the The Evaluation Of Equine Equine Veterinarian Conformation To Assist In Defining Nutritional Management of the Hoof Care Needs Obese and Laminitic Equine Cases - Sponsored by Farrier Product Distribution Trimming Methods Based On Conformation Evaluation

RAUL BRAS DVM, CJF, APF The Basic Principles of Equine Podiatry 39 The Mechanicalwww Thought.theneaep.com Process 585-205-5122 of Equine Podiatry

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Northeast Association of Equine Practioners 7/6/2020 Renate Weller.jpg

RENATE WELLER RYLAND EDWARDS DRVETMEF, PHD, MSCVETED, DVM, PHD, DACVS, DACVSMR FHEA, NTF, ECVSMR, ACVSMR, Radiographic imaging tips and MRCVS, HONFWCF techniques

The Horse: A Miracle of Musculoskeletal injury and lameness Bioengineering Or A Really Stupid in the English Sport Horse

Design? The Biomechanics Of How does the neck factor in to Orthopaedic Injuries In The Horse lameness issues in the horse?

It’s All About Leverage – Or Is It?: Management of wounds with How Podiatry Can Influence Injury synovial involvement

Mechanics 10 peer-reviewed articles that will change the way you practice when you leave NEAEP

https://drive.google.com/file/d/11cBYN9-A6CzTi09DmEF-IbxBTNp0HGQM/view 1/1 RON GENOVESE VMD 40Ultrasound Lab - Metacarpus and SANDY LESLIEwww.theneaep.com 585-205-5122 Carpal Canal-antebrachium TECHNICIAN, OFFICE MANAGER Ultrasound Lab - Metacarpus - Career Transitions

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SARAH-MARY BROWN SHERRY JOHNSON FWFC DVM, MS, DACVSMR Ugly Shoes Make Pretty Feet Lameness Localization in Western - Sponsored By Mustad Hoofcare Center Performance Horses Laminitis on a Timeline Rehabilitation of the Equine Athlete: Qualifications And Their Relevance A Glimpse Into The Evolving World of To Everyday Work?? Equine Rehabilitation Getting The Best From Our Tools Rehabilitation of the Western To Look After Your Main Tool .... Performance Horse: Putting It Your Body Into Play Clinical Exam Meets Imaging: The Complexities of Navigating The Diagnosis

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SUZAN OAKLEY THOMAS DIVERS DVM, DACVSMR, DABVP DVM, ACVIM, ACVEVV Ultrasound Lab - Stifle Newer Discoveries in Equine Ultrasound Lab - Fetlock Medicine That Have Direct Ultrasound Lab - Back Application to Clinical Practice Ultrasound Lab - Shoulder Biceps Toxicities and Adverse Drug Region Reactions in Horses Living in Ultrasound Lab – Pelvis the Northeastern States.

WADE TENNEY ASSISTANT CLINICAL PROFESSOR -- LARGE ANIMAL ULTRASOUND Ultrasound Lab - Basic Pastern(P1) 42 Ultrasound Labwww - Advanced.theneaep.com 585-205-5122 Pastern(P2) and DIP Collaterals

Volume 10, Number 8 September 2020