Sunday, August 11, 2013

Normal and Not So Normal Horse Feet

Hoof conformation and internal anatomy are vital to the performance of the horse; whether if they are an elite athlete or back yard pleasure critter.  It is easy to visually look at the foot or hoof and see that things appear to be normal, but sometimes we need to pull back the covers and get a better look through x-rays.  Unfortunately, most x-rays are only taken when problems develop and it is then that we discover that things have gone off course over time.  It is common to trim the feet to meet our expectations visually and sometimes to alter performance or movement of the foot, but we need to take a look at the inside and see how things are balanced before major work occurs. 

As a veterinarian, I don't get the chance often to take x-rays of 'normal' feet.  Every time that I do take films of a horse, especially the feet, I take time to review them with the owner, pointing out structures so that they can understand what is going on inside and how this impacts things on the outside.  Often feet are trimmed too small, too short, have under run heels or very thin soles; which then contributes to the performance and well being of that animal. 

Anatomy is important and I think every horse owner should understand what is going on internally.  Given this, let's look at a couple of 'normal' or actually as close to normal as I can find in my data bank and review some structures.  In order to know abnormal, we must first know normal.  This holds true for everything.  The second thing to remember is that no horse is perfect in conformation or anatomy.  If they are not perfect, we need to resist the temptation to make them perfect by trimming or shoeing.  It is when we strive for perfection that we create problems, especially lameness.

Normal Foot Anatomy

The x-ray to the right is of  the LF foot of a QH gelding.  Again, this is the closest to 'normal' as I can find, but it will serve the purpose of helping us to determine what is normal and where things should be.  This x-ray is from the fetlock down, including the hoof capsule.  For starters, let's identify the bones present.  Here we have P1 (fetlock bone), P2 (Pastern bone), P3 (Coffin bone) and N (navicular bone).  Now we have a series of colored lines that have been assigned to the film.  The YELLOW line indicates the angle of the bony column of P1, 2, 3.  Ideally, they should be at the same angle as seen in this film, all in alignment with one another. The YELLOW line should also be relatively close to external or visual angle of the fetlock region when grossly looking at the horse.  Next we have the WHITE line, which indicates the angle of the front hoof wall.  This angle should be relatively close the angle of the bony column, so White should equal Yellow for all intensive purposes.  Now, we have the BLUE line, which indicates the solar angle of P3.  This line or angle should not be flat but should have a slight upward slope, as we move towards the heel.  The final line is the RED line, which indicates grossly, the sole thickness, which is the distance between the bottom of P3 and the outside world or bottom of the sole.  In my book, the absolute minimum sole thickness is 10 mm.  Anything less is too thin.  I'd rather have too much than too little.

Not So Normal Hoof Anatomy

So, as I mentioned, sometimes things look good on the outside but when x-rays are taken, we get a whole new picture of what is really happening.  Take for instance this photo
of the LF of a QH mare.  Taking into consideration points we mentioned above, let's look at the angle of the fetlock in relation to the angle of the front hoof wall.  In this horse, the fetlock angle is not exactly the same as the front hoof wall angle, which ideally they should be close.  The heel region of the foot appears to be decent, could be a little better in terms of heel height, slightly under run but not horrible on the outside.  The hoof itself is in rough condition, dry and brittle with cracks evident.  The hoof  is non-pigmented, which generally to me is a weaker tissue than pigmented, but if we look closely, we can see a red area on the outside quarter, which is actually a bruise or gathering of blood. This horse actually presented for a chronic lameness, which was isolated to the foot by examination.

Now, lets take a look at the inside with an x-ray.  Again, you have to remember normal to know abnormal.  Here for starters, we see that the bone column is off in terms of angle, it is too steep and doesn't match the angle of the front hoof wall.  When these angles are off, it signifies generally that we have rotation of P3 or laminitis.  We can also see that P3 is essentially pointing directly down towards the ground surface with the tip of the bone almost penetrating the sole.  The soles are extremely thin as well, which is complicating matters and making it easier for P3 to push through the sole.  This mare was essentially walking on the tip of P3 and when looking at the solar surface visually, the sole was pushed outwards due to bone penetration.  We can also appreciate the lack of health of the hoof as well in this x-ray due to the cracking and breakdown noted at the tip of the hoof.

Lets take a look at another for comparison sake.  This is an mid-aged Hanoverian gelding.  He was actually sound with intermittent flare ups of lameness.  Visually looking at the foot, we should for starters look at the angle of the fetlock and compare to the angle of the front of the hoof wall.  If you look closely, you will see that they are different.  The hoof angle is more upright and the pastern more sloped. The hoof looks good with decent heel angle and height in my opinion.  The disparity of these angles can be due to a lot of issues, but in this horse the problem was that he was born club footed.  The severity is not too bad but likely contributed to his ongoing lameness issues.

Here is another photo of a more severe case of club footed in a youngster.
As you can see in this photo, the front hoof angle is very steep and actually is about the same as the fetlock angle.

There are so many changes that can be detected when x-rays are taken.  So much information can be gathered.  Let's take a look at couple x-rays of more abnormal foot pathologies.

In the case the right, we have a very upright bony column or pastern angle when compared to the front of the hoof wall.  On x-ray, we have evident rotation in the amount of 11 degrees.  The solar angle is too steep as well but the sole thickness is actually really good and is helpful in this case in terms of aiding in he realignment of the anatomy during trimming.

The case to the left is a patient presented for ongoing lameness.  This case demonstrates many issues at hand.  First, you can see that the hoof wall is abnormal, kind of lumpy bumpy with abnormal growth.  The sole thickness is decent, but we have a rotation of the coffin bone (P3) in relation to the front of the hoof wall as well as the angle of the bony column, which is designated by the RED line.  The rotation was ongoing or chronic and there are changes here to indicate this.  First, the tip of P3 is worn, more or less rough looking due to ongoing trauma to that region.  Second, we have low and high ringbone development present likely due to ongoing stress to those joints as well as genetic conformation issues.

The foot of the horse is a very interesting topic to me and I love to explore with x-rays to really get a good idea of what is going on.  Sometimes, we will be presented a horse for a pre-purchase examination with evidently good looking feet and soundness, but discover many problems when we look inside.  I don't feel that there is a specific angle for each and every horse, many do, but I do not.  I do believe that it is important to try to keep angles as close to one another as possible, but we have to accept deviations from the normal, especially in cases of a horse being club footed.  I feel that in many of these cases, we try to trim that poorly angled foot to match the more normal one and in the process, we create more problems due to shifting of anatomy that was not meant to be shifted or stressed.  I also feel that it is important to monitor sole thickness as one of the biggest problems we encounter is thin soles due to genetics, poor nutrition or just over zealous use of the rasp.  We have to understand that once a problem is created, it can take months if not years to correct that due to slow hoof regrowth.  It is always best to air on the side of caution and snap an x-ray if there is any question before removing hoof or sole tissue.

I hope you find all of this useful!  There is much to discover and no two horses are exactly the same. 

All my best,

Tom Schell, D.V.M.
Nouvelle Research, Inc.

Sunday, July 14, 2013

Lyme's Disease In Horses

Lyme's disease is unfortunately a common condition affecting not only horses and pets, but also a major health problem for people.  The disease is actually associated with a type of bacteria or spirochete, Borrellia burgdorferi, which is transmitted by either the deer tick, the blacklegged tick or the sheep tick, when feeding on the host.  The ticks are very small in size and often go undetected, but rates of infection can often times be very high dependent on geography with the northeast United States being the highest region.  The highest rates of infection generally occur from May to July due to the ticks being more active during this time. The rates of infection actually correlate with deer populations as the white tailed deer are the host for the adult stages of the tick.

Clinical Signs:
Clinical signs of Lyme's disease vary and often involve multiple organ systems and can be general in nature.  In humans, often there is a skin rash which develops then progresses to joint involvement, muscular pain and further progression.  In horses, clinical signs can range from non-specific lameness, muscle pain, fever, overall lethargy, laminitis, joint pain and swelling as well as other clinical problems.  Meningitis is also a potential outcome in all cases as the parasite can enter the central nervous system in some instances.

Borrelia burgdorferi strongly activates an inflammatory response in the host by triggering many type of cells involved in the immune response.  This activation leads to the release of many pro-inflammatory proteins (TNF, Interleukins) which contribute to ongoing pain, stiffness, myalgia as well as tissue deterioration, such as in joints.

The diagnosis of Lyme's disease can be difficult in some instances.  In humans, the skin rash is generally readily apparent and aids in the diagnosis, but is not commonly obvious in animals. In most instances, general blood work is performed to rule out other likely conditions as well as a performing antibody titers for Lyme's.  Often, when the disease is active, there will be a significant rise in antibody levels when performing paired serum titers 1-2 weeks apart.  In other instances, serum levels may just be persistently elevated in chronic cases.  Response to treatment is also commonly used as current diagnostics may prove uncertain or definitive. 

Treatment of Lyme's disease generally involves the use of tetracycline based antibiotics, twice daily, intravenously or orally for extended periods.  Response to the antibiotics can be very rapid in some cases, while in some it may result in slight worsening of clinical signs while the parasite is being killed off.  In other cases, the response to the antibiotics may be marginal or only partial, with relapses in the future.  It is difficult to determine the actual response rate to antibiotics but they are almost always used as a line of primary treatment.

Outcome and Persistence of Disease:
Lyme's disease is increasing in prevalence in humans as well as animals, likely due to uncontrolled deer populations and exposure.  Treatment of Lyme's disease often is disappointing and infections may persist for months to years, leading to prolonged pain and clinical problems for the patient.  The lack of complete response to antibiotics suggests that the spirochete has a way of hiding or evading antibiotic exposure or by evading the immune response.  Borrelia burgdorferi has been known to have many stages of development within the host, with some stages more susceptible to antibiotics than others.  B. burgdorferi can also actually invade various cells intracellularly, which allows them to directly evade immune detection as well and be protected in a sense.  Through these methods, B. burgdorferi can continue to cause clinical problems through activation of pro-inflammatory proteins for years.  Vaccines are not available at this time, but some have been developed with promising results.  The best method of reducing the incidence is by reducing the deer population as well as protecting yourself, your horses and pets from tick exposure by using repellents.

Options for Therapy:
We have had several horses with diagnosed Lyme's disease with elevated serum titers respond very well to our Cur-OST line of products.  The majority of these horses not only demonstrated a reduction in serum antibody titers over 3-4 months but also dramatically improved clinically with reduced lameness, lethargy and overall enhancement of life quality.  Most of these horses were currently or had been treated with tetracycline antibiotics.  We need more targeted therapy to support health and help the host defenses.

In most instances, we have used a combination of products, EQ Plus GTF and our EQ Immune & Repair formula.  The theory in use of these formulas is to approach and direct our attention at the inflammatory response, reducing inflammatory proteins at a cellular level as well as providing potent antioxidants to combat oxidative stress.  By managing these factors, we can improve the patient clinically as well as potentially reduce cellular damage inflicted by constant inflammation and free radicals.  Pain is reduced, fever is reduced and health is restored in less than 30 days in most reports.  The EQ Immune & Repair formula provides potent levels of concentrated mushroom beta-glucans which help to modulate the immune response, in theory reducing an overactive immune response or enhancing an underactive one.  This formula also provides essential amino acids such as L-glutamine which are needed to improve intra-cellular antioxidant levels of glutathione.  

The recoveries reported by our customers as well as seen in some of our patients can be remarkable with reduction of antibody titers and restoration of performance.  Nothing is 100%, but in cases of Lyme's disease that are non-responsive to antibiotics or those that have relapses, it is essential to try a new approach!   

Options are available for Lyme's disease support and management.  Do not give up on these patients as they can be restored in many instances.

All our best,

Tom Schell, D.V.M.
Nouvelle Research, Inc. 

Monday, July 8, 2013

Cancer Prevention & Health

It seems that for the past several years, you can't turn on the TV or even talk to a small group of friends without the mention of the word "CANCER".  Either there is someone close that you know with cancer or they are making new discoveries regarding the pathology and process of the disease.  It is everywhere, it seems, but there are several noteworthy things one can do to prevent or lower the risk of disease.

The whole goal of the field of medicine should be aimed at disease prevention, but unfortunately, most of the time is dedicated to disease management.  I feel at times, even as a veterinarian, that if we spent more time with younger patients focusing on good life habits, we would reduce the incidence of disease.  This is not done for several reasons, time being one of them, but also we have to keep in mind that profits are not as good for disease prevention as they are for disease management.  Cancer is a huge, profit driven force that often times does not take the best interest of the patients into consideration.  This is true whether if we are talking about people or animals. 

Cancer is a complicated topic, but one has to look much deeper than the obvious problem at hand to find similarities and areas of possible intervention.  One major area of focus for the past decade has been the connection between ongoing inflammation, cellular changes, immune dysfunction and cancer development.  I have talked many times before about inflammation from the perspective of joint dysfunction and pain, but the scope of the problem goes beyond this topic.  We have to keep in mind the concept of cellular function and mitochondrial health, which has been discussed before. 

What it is....
Cancer at its essential basics is cellular dysfunction.  It is a mutation to some degree that leads to abnormal cellular function which may include changes as to how the cell replicates and dies.  In most instances, the cells are altered to the point where they no longer are subject to normal cell death, which allows them increased ability to further mutate, divide and create offspring with their new abilities.  Pretty soon, if allowed, these altered cells begin to become the majority instead of the minority, leading to organ malfunction and even tumor development.  In many instances, cancer is slow to develop and actually can be present for years before being diagnosed or discovered. 

Players in the Game . . .
There are many contributors to cancer development including; genetics, lifestyle, environmental influences and ultimately diet.  In Chinese Medical cultures, emotions are often linked to disease and cancer development, due to changes in the movement of energy throughout the body.  This energy can accumulate and cause tumors or the energy can be depleted, which impacts cellular function.  A study performed many years ago through interviewing human cancer patients actually made the direct link between cancer and emotions.  They found that a high percentage of cancer patients reported a major emotional event within the 10 years preceding their diagnosis. Emotions play a major role in our life and fall into the Lifestyle influences in my book.  Think of stress in our jobs or our lives in general and the impact on our health.  Genetics of course also play a major role, which can impact cellular function from a mechanical point of view. Lifestyle factors can include emotions as well as daily activities that we may partake in that impact our health such as smoking or excessive alcohol consumption.  Environmental influences include toxin exposure from our environment or even our diet.  Dietary factors speak for themselves.  Ultimately, we are what we eat and either you aid in disease prevention or provide fuel to speed the process.

What to do??
Many of these factors are under our control, while many are not. The first thing that I did personally, as a cancer patient, was modify my stress levels and increase my exercise.  Work related stress, to me, was a huge factor in my disease course and something that could be changed.  It was not easy and ultimately led to my change in career focus, but it needed to be done.  In some instances, we can decrease our exposure to toxins, while in others we cannot.  Lifestyle and diet are controllable on most levels.  Genetics factors are difficult to get around, but the outcomes can be potentially modified.  The bottom line is that we have a choice, each and every one of us.  The question is whether or not if you make those changes?  It is not an easy step, but being proactive and seeing things from a prevention standpoint, can make all of the difference.  There are no guarantees in life, but I do feel that people that make changes live a longer and healthier life.

Aside from lifestyle, diet and environmental are my key nutrients to health maintenance.  Many of these nutrients impact cellular health or down regulate inflammatory pathways that contribute to a host of clinical diseases.

  • Curcumin (solid research on cancer prevention and disease management)
  • CoQ10  
  • Medicinal Mushrooms
  • Vitamin D3
  • Alpha Lipoic Acid
  • Green Tea 
  • Blueberries, Noni and Bilberry Fruit extracts
  • Amino Acids (glutamine, arginine and Pea protein base)
We have to remember that 'Disease' by definition is the absence of health.  Considering this, it is possible from my perspective to control or reduce many clinical diseases, cancer included, by maintaining a high level of health.  Cancer is not a contagious disease and therefore not something we 'caught' from another individual.  It is self induced, from my perspective, and there fore can be controlled or better managed by seeking health.  

Each of us only has one life.  We can choose to be a victim or we can choose to be proactive. I choose the proactive route!

All my best,

Tom Schell, D.V.M.