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.
www.curost.com

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.

Diagnosis:
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:
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.
www.curost.com 

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 changes...here 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. 
www.curost.com
 

Impact of Exercise on Health

Exercise is something that we are all told to increase in our daily lives, but unfortunately, many equate this to a 45 minute, hard core workout performed in a gym on a daily basis.  Although this is true, it is not true in all situations.  Exercise can be walking, working in the yard, working in the barn, doing house chores...the list goes on.  In terms of horses, exercise can be a long turn out with running in the pasture, routine daily training as well as a hard run at a jumper course.  It is good for us and them, as it improves cellular function and oxygen metabolism, but also helps to strengthen muscle, improve circulation, burn calories and just improve overall health. But there is a bad side...

The thing about exercise is that people tend to forget that it is not beneficial at all levels.  With exercise, we force our cells to go to levels potentially that they have never been before, making demands on them to produce energy and function beyond capacity in some cases.  Although this is not the norm, we do need to realize that there is always some bad with the good.  I recall years ago when studying herbal medicine with a Chinese practitioner, we were discussing overall energetic balances in humans.  He had commented that some of the most "unbalanced" individuals in his practice were hard core athletes and bodybuilders.  I questioned why, but the answer became clear to me in the essence of "too much of a good thing is a bad thing" or "everything in moderation".  

With increased demands on our body, or exertion, our cells need to produce energy in the form of ATP.  In order to produce this energy, they must have fuel or substrates themselves, generally in the form of sugar and oxygen.  During the process of energy production, free radicals are generated as part of normal course.  These free radicals then, if allowed to accumulate, can cause damage or hinder the cells in their performance.  If oxygen is not available for the cells to utilize for fuel or is depleted from the tissue, we then switch to anaerobic respiration, which then can result in lactic acid production and muscle fatigue.  We have all experienced this when pushing our bodies to the limit, whether if that is on the treadmill or on the city streets running.  The burn we feel in our thighs is a result of lactic acid buildup and a sign of tissue oxygen depletion and free radical accumulation.  Oxygen depletion and cellular malfunction as a result of overexertion is also the cause of acute heart attacks in many individuals as well as strongly linked to acute or catastrophic breakdowns in horses during training. This cellular malfunction is also a direct cause of injury, fatigue and joint degeneration.

So, here is the thing through my eyes.  If we take all of this into consideration, we then are able to see the possible negative impacts on health.  One can push the limits to the max in themselves as well as their horses, expecting output from the body that was never intended.  If we continue to push and push, even in what is perceived light training, injury can occur and will occur...it is just a matter of time.  That injury is a result of cellular damage, oxygen depletion and free radical formation/inflammation.  These three things weaken the cell, whether if it is a cardiac cell, muscle cell or tendon cell.  This weakness then predisposes to injury in the long term.  So, let's take what we know and apply it to see if we can change the course of events.

Let's take for instance of horse in light training that injures his suspensory ligament or deep flexor tendon.  Taking what we know, we now realize that the tendon itself was likely weakened due to pushing those cells beyond their limits with free radical production and cellular damage.  In most of these cases, the prescribed treatment is rest (which is great) along with non-steroidal anti-inflammatories (which is also not a bad thing in the short term).  The horses are usually put on stall rest with no exercise or even limited walking for months with the usual recovery in 6-12 months.  Now, take into consideration that a high percentage of these horses rarely even return to the same level due to persistent tendon/ligament associated lameness.  The same statement often holds true for humans with damaged cruciate ligaments or other joint injuries. If we apply what we know, we should be asking, "what can one do to prevent or minimize that cellular damage to begin with or what can I do to aid in cellular repair after the injury has occurred?"

First, we need to combat oxidative stress through the use of not just one antioxidant but ideally a synergistic blend that help to neutralize free radicals at all stages of energy production.  Using one antioxidant is not ideal as that single nutrient can then become a free radical itself in the end and cause more harm than good.  In many cases, some nutrients, such as CoQ10 and Lipoic Acid are not only antioxidants but are directly connected with improvement in energy production.  Other nutrients such as amino acids Glutamine, Arginine, Carnitine and even Creatine all contribute to increased intracellular antioxidant levels and improve cellular energy production.

Second, we need to combat the inflammatory process that is being triggered as a result of excess free radical production and other environmental/dietary factors.  This inflammation is directly connected with cellular damage, changes in blood flow and overall poor health/performance.  This inflammation occurs on multiple levels and thus is best to conquer on as many levels as possible.  Herbs such as Curcumin, Boswellia, Ashwaghanda and many others strongly down regulate the inflammatory process as well as act as secondary antioxidants themselves. They help to combat inflammation naturally and without side effects by helping to return inflammatory protein levels to normal versus completely inhibiting them as in the case of many NSAID medications.  These inflammatory proteins are needed and necessary, but just not at elevated levels.

Third, we need to supply basic nutrients to help aid in tissue repair and regeneration.  One cannot expect to lift weights with the intention of building muscle if they do not provide the necessary nutrients for those cells to grow and multiply.  You must provide nutrients such as protein, b-vitamins and many different minerals.  Pea protein, spirulina and various mushrooms are my favorite sources of natural nutrients to aid in cellular energy production, repair and regeneration.  Protein and nutrient depletion is a major problem in today's society either as a result of shear depletion (not providing enough to meet added demands) or due to excessive consumption of an 'empty calorie' diet with no nutrient benefit.  We all need to up our protein intake for several reasons and there are many supplemental choices.

Whey protein is one of the most common sources of protein used by serious athletes, but unfortunately a high percentage of humans are allergic to dairy products on many levels.  Some don't even realize that they are allergic, but just tolerate the increased gas, bloating and discomfort after consuming dairy products, not realizing the connection.  This intolerance actually contributes to inflammation that is occurring in the gut, which then manifests systemically in many forms such as skin or respiratory allergies.  Pea protein is part of a few new Cur-OST products that we are offering for both humans and horses.  Peas are in the legume family, related to alfalfa, and provide a high level of protein with a similar amino acid profile to whey.  The difference is that pea protein is more digestible and as a result, we are able to extract more nutrients and reduce ongoing inflammation within the gut.  This equates to an improved overall performance not only for us but our equine athletes as well!

Going back to our analogy of the horse with a tendon injury, we can now hopefully see that there is much we can to to prevent and manage these conditions with improved outcomes all around.  By using our Cur-OST products, we can manage the inflammatory process, provide antioxidant support as well as nutrients to aid in repair/regeneration.  If these three conditions were met initially, in many cases the injuries would be much less likely to happen and if they did, addressing these three conditions usually results in a much better and quicker recovery.  By addressing these three issues adequately, we not only reduce the rate of injury, but we enhance performance on all levels as well as fatigue.

Athletics is a big part of our family and as a result we spend a great deal of time at tennis tournaments for our son.  It is amazing to me to see some of these kids with potentially career ending injuries as a result of the demands that they place on their bodies at such a young age.  I often wonder if they are 'feeding' their cells properly and protecting them against injury, then I get my answer when I see these same kids eating fast food during match breaks.  Their parents then continue to feed them soft drinks and sport drinks, thinking that this in some way will help them.  One in particular had a severe back injury which almost sidelined their career.  After some coaxing to this young adult, they recovered after some guidance and support as well as use of our Ultimate Human formula.  Their recovery was swift and strong.  Their endurance improved 50%, match success skyrocketed and people were left wondering how this player recovered. 

We see it and experience it all of the time. Whether if it is us or one of our horses in training, fatigue is a huge factor as well as injury.  The good news is that this fatigue and injury should be perceived as a sign that something is not right, not just and inconvenience.  The proper fuel and recovery substances are not there, which then opens the door for problems. 

In the end, you do have a choice whether if it is for yourself or your horse athlete.  You can choose to continue down the same road with the same results or worse OR you can make a conscious choice to understand what it going on and supply what is needed to enhance health. We shouldn't have to be dependent on pharmaceuticals to get us through the day or for our horse to get through that event.  There is so much more that can be done to aid in success and improve outcomes. If you want to run faster, play harder,have more energy or just be less stiff post working in the yard...you have options.  If you want your horse to run faster, jump higher or have more stamina...you have options.  You must supply the nutrients and protective factors needed for cellular health. The choice is yours and our job is to be here to guide and support you!

Yours in health,

Tom Schell, D.V.M.

Disease, Injury and Mitochondrial Dysfunction

Back in the days of high school biology class, we all learned the components of the cell.  Chances are that most of us have forgotten what we learned back then and that is okay, but in today's medical society this knowledge is becoming important whether it is our health or that of our pets and horses.

Mitochondria and Energy
One of the most important components of the cell is the mitochondria, which the name may ring a bell.  The mitochondria has been termed the "Power House of the Cell" because it is the main source of energy production in the form of ATP.  Every cell in the body, with the exception of the red blood cell, has a mitochondria and actually, the number of mitochondria contained in a given cell varies dependent on the type of cell we are talking about.  Some have more and some have fewer, it is really dependent on the nature of the cell and energy output required.  Muscle and nervous tissue require more energy and thus usually have more mitochondria per cell.

The mitochondria is also involved in many other aspects of cellular function, including cell signaling, cellular differentiation as well as cell growth.  Most of these aspects or jobs are dependent on the presence of energy or ATP and when that is impacted, they cannot perform their other jobs.

The process of energy or ATP production within the mitochondria is complicated but is essentially dependent on the shifting of protons across membranes and the creation of a proton gradient.  This process depends on the presence of many enzymes, co-factors and nutrients to function smoothly.  One main component needed is oxygen as well as glucose.  The process of energy production in the presence of oxygen is termed cellular aerobic respiration.  If oxygen is not present or in low levels, the energy production will shift outside of the mitochondria and result in anaerobic respiration with lactic acid production.  Excessive lactic acid production creates the burn in the muscles that we feel when exercising intensely. One interesting thing to note is that an end product of ATP production by the mitochondria are free radicals such as superoxide and hydrogen peroxide, which results in oxidative stress.  This oxidative stress can then inflict damage to the mitochondria itself, resulting in cellular malfunction.

Dysfunction & Disease
Mitochondrial disease is connected with many conditions affecting humans as well as animals including:

• cardiovascular disease/ arrhythmias
• respiratory conditions
• neuromuscular disease
• gastrointestinal problems
• immune system disorders
• diabetes/insulin resistance
• exercise intolerance/ fatigue
• joint deterioration/tendon injuries
• cancer
• overall tissue weakness and predisposition to injury  

Actually, any time there is a problem in the body, whether if it is a disease or ongoing injury, it can be traced back to poorly functioning mitochondria. A cell requires energy to be produced to function correctly and if there is no energy being produced, then the cell malfunctions.

Malfunction of the mitochondria is directly associated with genetic mutation to some level, which can be acquired or inherited.  Many mitochondrial diseases are inherited on a genetic level, while others are actually induced or acquired as a result of ongoing uncontrolled oxidative stress, dietary influences, medications, toxins, lifestyle influences and many other factors.  The bottom line end result is that if the mitochondria is not functioning correctly, then cellular function is impaired on multiple levels. This can result in disease formation, joint deterioration, poor performance and even just a predisposition to injury.  The resultant poor functioning mitochondria actually then triggers the activation of a transcription factor (NF-kB) which results in the production of inflammatory proteins such as interleukins, prostaglandins, MMP's and a host of others.  These inflammatory proteins then contribute to a host of conditions including joint deterioration, cancer, respiratory conditions....the list goes on and on, but they themselves feedback and injure the mitochondria.  It becomes a vicious cycle.

Mitochondrial dysfunction is also present when injuries occur such as a strained ligament, tendon or muscle group.  First, those cells were likely predisposed to injury due to ongoing low level cellular malfunction.  Second, when that tissue is injured, it needs to repair itself through cellular differentiation and growth, all of which are regulated by the mitochondria.  If mitochondrial function is poor, not only will injuries be more likely but those same injuries may take excessive time to heal or never recover.

Prevention & Treatment
So, what can we do to improve mitochondrial function?  There are many factors we can control including diet,lifestyle influences and stressors that may aid in their function.  We can also try to minimize the exposure to various toxins, which includes vaccines.  Over vaccinating is an issue in my opinion and can be tapered back in many instances without causing increased risk to the patient. Minimizing excessive prescription drug use can also play a role in maintaining healthy mitochondrial function as many medications can create problems indirectly.  The other main factor that we need to keep in mind is that with energy production (ATP) comes oxidative stress.  It is a part of doing business, but fortunately something that can be controlled.  People and animals that are worked or exercised heavily create an increased demand on their mitochondria for energy production.  Unfortunately, with this comes a higher level of free radicals being produced which then contribute to mitochondrial dysfunction.  This may explain why some athletes (human or animal) are at more risk for injury and joint deterioration, not to mention breakdowns.

We can prevent, manage and improve mitochondrial function through two simple avenues:
        1.   Specific Antioxidant Therapy
        2.   Complete Inflammation Control

Antioxidants come in many forms, some we are familiar with and some not so much.  Vitamin C and vitamin E are too commonly recognized antioxidants.  Vitamin E is commonly used in horses with neuromuscular problems and the reason is that it tends to aid the mitochondria in nerve and muscle cells by neutralizing free radicals.   Another important antioxidant is CoQ10, which is directly involved with the production of ATP in the mitochondria.  Many conditions of mitochondrial dysfunction are directly tied to low cellular levels of CoQ10.

We cannot forget the other arm of mitochondrial protection and that is through inflammation reduction.  Many herbs are antioxidants as well, including curcumin and boswellia, which not only combat the free radicals but also have the added benefit in that they aid in the reduction of the inflammatory arm of the cascade by reducing inflammatory proteins.  Curcumin has been shown to directly impact mitochondrial function as well as improve cellular antioxidant levels.  It is one of the most important herbs for mitochondrial health, but must be taken at specific doses to yield benefits.  All of our Cur-OST products take advantage of the synergism between herbal anti-inflamamtories and antioxidants to achieve these results.

The bottom line is that we can do a lot to improve cellular health and function, through the use of natural occurring antioxidants and anti-inflammatories.  Prescription anti-inflammatories generally combat a small part of the inflammatory process and do nothing to improve mitochondrial function.  They are essentially band-aids and are not addressing the bottom line problem.  If you want more energy for yourself, your pets or your horse or are looking to reduce injuries and prevalence of disease.... you want to protect and enhance the mitochondria. By improving and protecting mitochondrial function, we can improve overall performance, slow degeneration and reduce injury.

Our goal at Nouvelle Research, Inc. has always been to impact health through inflammation reduction and antioxidant support.  The process is complicated but by reducing this inflammatory process on a consistent basis, we can protect the cells from deterioration, slow progression of many diseases, reduce pain and encourage normal tissue repair. Inflammation and oxidative stress are a normal part of all of our daily lives, whether if we are human or animal.  Certain conditions such as stress due to lifestyle or even trailering worsen the situation and we need to be aware of the consequences.  The good news is that we can mitigate and control the problem at a cellular level to improve overall health.

All the best,

Tom Schell, D.V.M.

Performance Enhancing or Performance Restoring

I read the line "performance enhancing or performance restoring" as part of a quote from a regulatory veterinarian from a discussion regarding drug use in the equine industry.  I like the line, because it helps to create potential criteria that determines a drug or herb's potential use and implications.

In recent news, a well known and respected TB trainer was in the spotlight due to having a high incidence of acute deaths in horses under his care.  The exact cause is unknown, however, early reports from veterinary autopsies have indicated possible cardiac failure as well as diffuse hemorrhage internally.  I am hopeful that further conclusions can be made regarding the final diagnosis in order to help curb the issue in the future, but my concern is that the deaths are closely linked to medication abuse.

When reading many of the articles regarding these events, one becomes engulfed by the large number of corresponding comments being made, usually from other trainers in the industry.  Overall, the biggest concern and implications being made are regarding abuse of various 'performance enhancing' medications.  It would be one thing if it was the public (non-horse owners) making these statements, but in this case, the majority of them are coming from trainers themselves, calling for action and calling for change in the industry.

I brought up a discussion regarding banned substances several weeks back, but it continues to weigh on my mind as a veterinarian as well as horse lover.  This issue crosses disciplines, from the TB industry to barrel racing.  Drugs are being abused and used for the wrong purposes.  Using the title of this blog as a guide, let's look at a short list of commonly used medications, their original intended uses as well as what they are being used for,  by their generic names:

• Furosemide:  a commonly used diuretic intended to reduce fluid accumulation in the body associated with heart failure.  Currently being used to aid in the management of EIPH by inducing a low level of dehydration, leading to a reduced pulmonary (lung) blood pressure and hopefully reduced bleeding.  Side effects include dehydration and electrolyte abnormalities.
• Clenbuterol:  a bronchodilator (opens the airways) used to help alleviate the clinical signs associated with COPD and certain airway conditions.  Currently being used to open the airways to enhance air movement as well as for its purported stimulatory effects.  Side effects include cardiac stimulation, possible arrythmias, death and excitement.
• Dexamethasone:  a corticosteroid used most commonly to reduce the clinical signs of allergic type reactions in the horse.  Currently being used to reduce inflammation and pain associated with a variety of conditions.  Side effects include possible induction of hyperadrenocorticism, increased water consumption/urination, water retention and gastric ulcers.
• Methylprednisone:  see above description for dexamethasone. Commonly injected into joints to reduce inflammation and pain.
• Phenylbutazone/Flunixin Meglumine:  both are non-steroidal anti-inflammatory medications designed to reduce pain by blocking COX enzymes and prostaglandin formation.  Side effects include gastric ulceration as well as potential kidney/liver complications.

There are many other medications, but overall we need to ask ourselves if they are performance enhancing or performance restoring and whether if we are inflicting more harm upon these animals than good? In the view of the equine industry, most medications are viewed as performance enhancing, but one really has to look at how they accomplish this feat.  In most instances, the medications are covering up a medical condition that is holding the athlete back in terms of performance.  Maybe the condition is an arthritic joint, or a tight back or a respiratory condition such as EIPH.  Performance is restored indirectly by reducing the inhibiting condition.  The problem that comes with this approach is that in many instances there are secondary complications produced such as bone fractures due to blocking pain response or overall worsening of the condition due to masking of clinical signs.  This can lead to a need to increase the medication dose, use of multiple medications to achieve more pronounced results or euthanasia of the animal due to catastrophic injury.

In many cases, herbs can be used to achieve "performance restoring" effects which are different than the effects of many medications.  Most medications are simply covering up clinical signs without addressing the underlying problems.  Herbs can have similar effects, but tend to also address the bottom line problem whether if it is a nutrient deficiency, poor circulation or impaired cellular health.  Herbs can reduce inflammation naturally as well as pain,similar to various medications, but they do it differently and more completely by returning inflammatory protein levels to normal levels and without side effects.  Performance is restored in many cases through the use of herbs not only due to the reduction of inflammation and pain, but cellular health is restored which means improved energy production and tissues are stronger.

Users of our Cur-OST products not only report improvement in pain and inflammation levels, but healing of wounds are noted, energy levels are increased and likewise performance is restored.  In many cases, the damage to the body is done whether if it is in the joint or the lungs and is unlikely to be reversed.  That being said, it is possible to slow progression of the condition and minimize clinical signs through the restoration of health.  In many instances, this is accomplished through restoring healthy cellular function, which impacts every tissue in the body.

The bottom line is that we can "cover up" clinical problems through the use of various medications or we can take a deeper look at what is causing those problems to manifest.  When we look deeper, we find opportunities to improve cellular function and restore health.  This then reduces the need for those medications but more importantly creates a healthier and stronger athlete...naturally!  Considering that herbs are plant material and essentially food, it then drives the point home that nutrition is the key to overall health.

Just my thoughts.

Tom Schell, D.V.M.

Stem Cells and Potential For Therapy

Stem cells are essentially specialized cells that possess the ability to transform or differentiate into one of many different types of cells present within the body.  That includes the potential ability to differentiate into cardiac, nerve, muscle, tendon, bone and many other types of cells.  Stem cells are classified into two broad groups, dependent on their origin: embryonic or adult.  Embryonic stem cells are the cause of much of the controversy surrounding stem cells, due to be derived from the blastocyst, which is an early stage embryo.  Adult stem cells are derived from the patient themselves and usually extracted from the blood, bone marrow or adipose (fatty) tissue.  

Stem cells have gained tremendous popularity in veterinary medicine and seem as if they have been the talk of the medical industry for the past couple of decades.  For several years, there was much controversy regarding stem cells, especially regarding morals and ethics amongst many religious communities.  So, what is all the hype about stem cells and what is their potential? 


In order to be classified as a stem cell, the cell line must demonstrate potency as well as the ability to self renew, which means that that particular stem cell can divide and produce more stem cells.  Potency is by definition the ability to differentiate into specialized cells or any adult cell type.  The terms generally assigned to potency in true stem cell lines are Omnipotent and Pluripotent.  Omnipotent stem cells are produced as a result of the joining of an egg and sperm cell.  Essentially, omnipotent stem cells yield embryonic cells and could, if allowed, produce a complete living organism.  Pluripotent cells are the next step down and are a result of the further division of Omnipotent stem cells, which creates the blastocyst.  Embryonic stem cells usually demonstrate Omnipotent or Pluripotent capabilities.  Adult stem cells are generally classified as having multipotent capabilities, which means they can differentiate into many different cell types but usually only of closely similar cell types from which they were extracted.

Embryonic stem cells have demonstrated the highest level of capabilities and potential, mainly due to their assigned potency, however, due to their source or origin, much debate has been raised.  Given their controversy, there are no approved medical therapies at this time in regards to embryonic stem cells and some research has actually been halted.  The other major drawback to using embryonic stem cells is the risk for rejection as they are transplanted from one source to the next.

Adult stem (somatic) cells are present in all individuals as a means of repair and regeneration.  The actual number of adult stem cells drops with age, but the hope is that with extraction, self renewal can take place in culture and increase their numbers for clinical use.  The positive side to using adult stem cells is that risk of rejection is very low and in fact non-existent due to using cells derived from the patient themself.  Adult stem cell therapies have been used for many years and a prime example is in patients receiving bone marrow transplants for treatment of various leukemias.  There are many other potentials for adult stem cell therapies including cardiovascular disease, liver and kidney disease, bone disorders including fractures and tendon conditions.  In the veterinary community, the biggest focus is on tendon therapy as well as some bone related conditions such as arthritis and OCD lesions. 

Adult stem cells are most commonly obtained either through the bone marrow or fatty tissue.  In my experience, the number one source, due to ease of extraction, is the fatty or adipose tissue.  As mentioned, one drawback is that with age, cell numbers appear to decrease, which may yield low numbers upon extraction.  The other concern regarding adult stem cells is their level of potency and ability to differentiate into the particular cell type needed.  It appears, based on research, that adult stem cells are most likely to differentiate into cell types similar to that which they were extracted.  Dependent on their origin, they appear to be already locked in, per se, on forming that particular cell type.  Essentially, it may prove to be difficult to get a stem cell programmed for muscle or tendon repair to differentiate into a cardiac or nerve cell.  This process of differentiation is rather complex and involves many signaler chemicals.  Given this process of differentiation, the concern has been raised that it is possible that injection of stem cells could produce the formation of various tumors, mainly due to the process of differentiation being hard to control.



In the end, stem cells offer much hope and potential for aiding in the management of many diseases affecting humans and animals.  There is much research and discovery still to be made regarding their extraction and overall usage, but right now, we are just in the infancy stages.  The results thus far are promising, but overall response rate statistics are hard to find and are variable, which may reflect patient to patient variability in terms of cell line potency. The process of harvesting, culturing and re-injecting stem cells is an expensive process and one that is not covered by many insurance carriers due to their research nature, but may be a worthwhile consideration for medical conditions that are unresponsive to traditional therapies.

Tom Schell, D.V.M.
www.curost.com

(Images borrowed from Wikipedia)

IRAP Therapy In Horses

Joint disease in the horse is the number one cause of ongoing lameness and a result of many factors including excessive or ongoing trauma, genetics, diet and lifestyle influences.  Degeneration within the joint leads to cartilage erosion, remodeling of the joint, ongoing pain and reduced range of motion in more severe cases.  It is a condition that is best prevented and managed in the early stages versus in the advanced stages.

Therapies for joint disease in the horse now includes joint injections with corticosteroids, hyaluronic acid, polysulfated glycosaminoglycans and over the past several years, there is a new kid on the block termed IRAP or Interleukin-1 Receptor Antagonist Protein. IRAP therapy is supposed to help manage the inflammation and joint deterioration more effectively through the use of the body's own natural resources.

As we have discussed in prior blogs and emails, inflammation is a complex subject and involves the ongoing release of several cytokines responsible for cellular changes and deterioration.  Interleukin-1 is one of many cytokines, which act at many levels and are thought to be directly involved with cartilage loss.  As a result of ongoing inflammation, IL-1 is released by various types of cells and binds to receptors at other cellular locations to inflict action.  IRAP therapy works on the principle of blocking the receptor at which IL-1 binds within the joint, thereby reducing inflammation and pain.  Blood is withdrawn from the horse, incubated in a special syringe that helps to stimulate the IL-1 receptor blocker and then injected into the joint.  In most cases, it is recommended to complete a three injections series, one week apart.  Cost can vary between clinics, but is reported to be between $1000 and $2500 for the complete series.  Effectiveness is variable and at the time of this writing, I am unable to find published research dictating response rates, but it has been reported that if there is going to be a response, it will be seen by the second or third injection.  Length of response rate is again variable, with most horses benefiting from results lasting 6-12 months, but then requiring either a booster injection or potentially a restart to the injection series.  It has been noted that horses requiring further injections tend to show a reduced response rate.

Considerations:
IRAP therapy blocks the receptor in which IL-1 binds to within the joint, thereby in theory reducing inflammation, pain and further joint deterioration.  As we have discussed in the past, inflammation involves several cytokines being produced and IL-1 is not the only one responsible for cartilage deterioration and pain production.  For instance, there are other Interleukins that play a part in the cycle of inflammation and there are other cytokines such as MMP's (matrix metaloproteinases) that are responsible directly for cartilage erosion.  Even though we may be able to block the receptors at which IL-1 attaches within the joint, we are doing very little to impact the production of the other destructive cytokines.  By using IRAP therapy, we are also doing little to impact the production of IL-1 overall and systemically, IL-1 levels will likely be on the rise even though they may be blocked from exerting their action within that specific joint.  Overall, the effects of IRAP are localized and impact only a small portion of the inflammatory cycle.

The other consideration of course is cost and potential side effects from therapy.  It is reported that side effects to the IRAP are very low due to using blood from the patient as part of the therapy, which is good, however, we are still sticking a needle into the joint on weekly intervals.  With each repeated injection comes the risk of bacterial infection and the act of sticking a needle into the joint actually spurs on the process of inflammation.

Inflammation is Systemic:
Inflammation is an ongoing process and involves many cytokines, each with their own specific action.  IRAP therapy is a new tool in the medicine chest for equine veterinarians, but from my perspective may have some major limitations.  Considering the large number of cytokines being produced as a result of the inflammatory cascade, why not potentially target them at their source, instead of just trying to block their action?  After all, inflammation is a systemic problem and in most instances, if there is one joint affected, there is another close by or potentially higher up in the leg or even the back that is taking extra pressure due to favoring or shifting of weight.  We need to look at the problem from a systemic point of view, because that is where the problem lies.

Blocking Cytokines At Their Source:
Is it possible to reduce the production of these cytokines at their source or at a cellular level?  The answer is yes, but it is somewhat complicated.  The process of inflammation involves the production of cytokines but also involves the release of free radicals with resultant oxidative stress, which actually can be a viscous circle of events, all playing a role in joint deterioration.  Wouldn't it possibly be better to reduce the production of IL-1 systemically, versus just blocking where it binds?

Curcumin, as a case example, has been shown in research trials to block the NF-kB transcription factor, which is directly responsible for the production of several cytokines, including IL-1.  Curcumin has been shown to downregulate the production of many types of Interleukins, Prostaglandins, TNF and MMP's.  The effects are seen systemically instead of just locally, so the patient is benefiting overall from the health effects of mitigating the inflammatory response.  Curcumin has also been shown to upregulate NRF2, which is directly responsible for production of naturally occurring antioxidants within the body, which help to reduce oxidative stress damage.

It sounds like Curcumin is the 'end all be all' of inflammation therapy, but it too has its limits.  One of the limitations is dosing, which can vary dependent on the severity of the condition. There are many herbs that impact the process of inflammation and considering some limitations of curcumin, I have found it best to herbs together to get the best effect overall.  Boswellia, for instance, counteracts inflammation at a different level than curcumin, which is mainly through lipoxygenase inhibition.  When combined with curcumin, along with other anti-inflammatory herbs, the results can be incredible.  This was demonstrated in our published paper in 2006 evaluating synovial cytokines pre and post curcumin administration in which 80% of horses responded with reduced synovial cytokine levels and a reduced lameness score.  

Again, there are always going to be limitations.  IRAP is generally listed for use in mild to moderate cases of osteoarthritis.  Usage of herbal formulas, like our Cur-OST formulas, are also best for early or mid stage cases, but can still have profound effects in later cases.  Joint deterioration is not reversible and generally involves more than one joint.  The progression of joint disease can be potentially mitigated by reducing cytokine production, but it is best when done at a systemic level. 

In my experience, it may be a more sound decision to try to reduce systemic cytokine levels first before performing a more invasive and targeted therapy.  The results may actually be seen sooner and affecting the patient systemically, not to mention at a much reduced cost.

Just my opinion.

Tom Schell, D.V.M.

Equine Protozoal Myeloencephalitis; A Veterinarian's Perspective

EPM has plagued horse owners for several decades with an estimated clinical prevalence of less than 5% of horses being affected, causing not only a potential loss of function and performance but also high costs to the owner in terms of diagnostics and treatment.  When I was in vet school, the disease was first being clinically recognized and treated.  In those days, we saw the worst of the cases that were admitted into the veterinary school and many of these horses were recumbent and unable to stand or even turn themselves.  As students on the late night watch, we were often given the chore of hooking these horses to overhead hoists and physically turning them every few hours to minimize bed sores.  It seemed futile in many cases as often, they were unable to eat due to body positioning, which contributed to the body wasting and further muscle weakness.

Cause:

The disease is caused by a parasite called Sarcocystis neurona, which gains entrance the body and then targets peripheral nerves or the central nervous system, eliciting an inflammatory reaction which impairs nerve function.  The parasite is thought to be transmitted by the opossum primarily, but barn cats and various birds have also been implicated in the past, with the horse inevitably being exposed while grazing on pasture or through contaminated feed.  The horse is considered an aberrant host and once infected, they are not a risk to spreading the parasite to other horses.

Prevalence:

In my practice, the exact prevalence of the disease amongst our patients was less than 5%, but may be higher in other regions of the country.  Blood testing of horses has indicated a positive antibody titer in up to 80% of horses (in my practice area), but the majority of these do not demonstrate clinical signs. A positive serum Western Blot simply implies exposure to the parasite and does not define clinical infection. It seems as if the prevalence of the disease, at least in my area, has actually declined over the past several years or quite possibly, they are just not being recognized as having a problem by their owners.

Clinical Signs:

When I was a student, we saw the worst of the worst when it came to EPM cases.  Upon graduation, often we were misled in thinking that they always presented this way.  With more clinical practice years under my belt,  I learned that there were many clinical presentations with the majority of them being mild.  In many cases, mild EPM cases have presented as an unexplained or ‘shifting’ lameness.  The lameness may be present in one limb one day then the next in another area.  If I was presented with a lameness that I could not pinpoint or localize, we would often screen for EPM.  The clinical examination involves not only a full physical exam, but evaluation of neurological function.  Peripheral and cranial nerves are evaluated for deficits, which may help us in localizing the disease.  Limbs may be flexed and evaluated for lameness, but they will also be evaluated for conscious proprioception (CP) by crossing the limbs at times.  In most cases, when limbs are crossed over, they are quickly replaced to normal position by the horse.  Those with neurological impairment may have a delayed or no response.  Tail and anal tone are also evaluated, in addition to the tail pull to determine if there is muscle weakness present. The parasitic infection generally targets nerves and with this, we can have many types of presentation with varying degrees of severity. The condition is progressive in most cases, with time being of the essence in terms of best outcomes for treatment. The most common types of presentations would involve one of the following

• ·         Lameness

• ·         Muscle weakness / atrophy

• ·         Poor performance/intolerance

• ·         Ataxia (uncoordination)

• ·         Stumbling or tripping

• ·         Recumbency/unable to stand

• ·         Difficulty eating/swallowing or ‘choke’

• ·         Head tilt

• ·         Behavioral changes

Diagnosis:

The diagnosis of EPM can be tricky, but in most cases we base the diagnosis upon the combination of clinical signs in addition to other laboratory data.  In our patients, if there is a suspicion of EPM, we would submit a blood antibody titer (Western Blot) to rule in or out the disease.  A positive test on blood is NOT confirmative for a diagnosis of EPM, but a negative result generally rules out the parasite.  If the blood test is positive, which equates to a history of exposure to the parasite, often the next step is to perform a spinal tap in the lumbar region, again looking for antibodies or parasite DNA (PCR) in the spinal fluid. In more recent years, technology has allowed for more refined antibody testing of serum in order to obtain specific titers, which may help to differentiate between exposure and actual clinical disease.

Several issues have risen over the past few years regarding spinal taps.  First thing to remember is that there is risk to the procedure for both the patient and veterinarian.  It can be painful at times, resulting in a horse kicking out to the side which may injure people around the horse.  In other cases, horses have been known to buckle upon insertion of the needle, resulting in potential injuries.  Spinal taps may also potentially worsen ataxia or uncoordination in clinical horses and may be difficult to perform successfully in recumbent animals. The biggest problem with spinal taps is blood contamination of the sample.  If a horse is positive, they will have antibodies present in the bloodstream.  In order to perform a spinal tap in the horse, the needle actually has to pass through several inches of muscle, which are saturated with blood.  The current thought process is that there is a potential for the needle to be exposed to the blood, gather antibodies and thus produce a positive spinal fluid sample.  In the end, it is hard to prove that a positive spinal tap is not due to blood contamination and thus a false positive.

Due to this fact, we stopped performing spinal taps several years ago and have more or less relied on clinical signs along with a positive blood antibody titer.  It certainly is not 100% definitive, but is safer and less expensive in the short run to gather data and assess for a response to medications.

Differential Diagnosis:

Other considerations for a horse demonstrating neurological clinical signs includes toxicity, herpes viral infection, Easter/Western encephalitis, West Nile, Rabies, equine degenerative myelopathy, equine lower motor neuron disease and cervical vertebral stenosis (wobbler syndrome).  Either clinical signs or further testing can help to rule in or out these diagnoses.

Treatment:

For many years, we have used a combination of antibiotics; sulfatrimethoprim with rifampin, to help manage the parasite infection.  The combination was often fairly successful, but required many months of therapy.  Over the past decade, we have seen some improvement in therapies, which include a medications such as diclazuril, toltrazuril, ponazuril and NTZ, which have all shown promise and require less time for treatment.

Results from therapy can be variable with noted improvement in less than 75% of cases and a full recovery in less than 25%.  In some cases, the patients would actually get worse during therapy for a brief period due to the parasite being killed off and eliciting an inflammatory type reaction.  In many cases, the patients would recover but continue to have neurological issues or deficits resulting in loss of use, decreased performance and even euthanasia in some cases.

One of the biggest problems when treating an EPM horse are relapses, which can be quite high.  In many situations, horses would appear to recover, only to demonstrate clinical signs again within the next 6-12 months.  This is not only frustrating but expensive for the owner as it often entailed another course of medication.

Other therapies often used adjunctively include non-steroidal anti-inflammatories, corticosteroids, DMSO and antioxidants, with vitamin E being most commonly used.

Thoughts / Prevention:

Many years back, an astute veterinarian raised the question as to how the parasite was gaining access to the systemic circulation.  After all, most bacteria and parasites are killed off by high acid levels in the stomach or by other factors in the gut.  In order for the parasite to gain access, there would have to be a breakdown in the gut barrier in some shape or form.  Upon further exploration of this theory, it was proposed that many of these clinical horses had gastric ulcers, which may be allowing the parasite to gain access to the body.  There are many theories out there, many of them still unproven, but this ulcer theory opens the door to many questions.

If we blood test 10 horses for antibody titers, approximately 8 of them will be positive and maybe 1-2 of those 8 will actually be clinically sick.  Why?  What makes those 1-2 horses different or more susceptible to clinical disease?  When we look at the ‘ulcer theory’, this raises the question regarding the impact of stress on the body, which may be hindering the immune response.  The body creates many barriers to prevent invasion by bacteria, viruses and other parasites, but the immune system is ultimately responsible for detecting and eliminating invaders into the body.  So, what potentially causes a deficiency in the immune response?  This can be a genetic cause, dietary related, stress induced….the list goes on.  It has been noted that stress and immune compromise increase the susceptibility to a horse contracting EPM.  Likewise, the incidence of EPM also appears to be higher in competitive horses, which may be undergoing increased levels of stress.

What I have found and explore with these patients is the status of the immune response.  In all of our cases, I have submitted what is termed a CBC (complete blood count), which is fairly routine.  What I am looking for is the level or status of the white blood cells, specifically the lymphocyte.  I have noticed that many EPM cases have lowered lymphocyte levels upon presentation. Those horses with lowered lymphocyte counts also appear to be more likely to experience relapses.  It is potentially a crude means of evaluating the immune response and predicting relapse rates, but none the less is valuable in my opinion.

When we were first treating these patients years ago, I would almost always add in some type of immune supplement along with traditional therapies.  Originally, I would use a cattle dewormer called Levamisole, which has demonstrated immune enhancing properties.  It would help in most cases, but there was always a need for something better.  Several years later, I discovered and researched medicinal mushrooms and their impact on immune health.  There are several types of mushrooms that demonstrate immune enhancing capabilities and have been researched for decades with verifiable results.  We soon developed and began to utilize what became our EQ Immune &Repair formula in our EPM cases and noted a tremendous impact along with traditional therapies.  The patients did better overall and recovered more completely. 

Aside from the immune component, we have to remember that there is also a strong inflammatory reaction that is occurring and contributing to neurological deficits.  In many severe cases, especially in recumbent horses, clinicians would utilize a steroid or DMSO to help combat the inflammation.  The steroid would help in a high percentage of cases, but potentially came at a cost due to a high incidence of side effects, including gastric ulcers, further immune suppression and even laminitis.  We used these steroids in some of our cases, but needed something more complete, gentler and more effective for systemic inflammation.  We began to utilize our EQ Plus  formula in our EPM cases to combat inflammation as well as provide antioxidants in addition to our Immune & Repair formulas, alongside of the traditional therapies.  Again, we noted a more complete and quicker recovery in a high percentage of cases.  In some cases, due to the expense of pharmaceutical medications, many owners were unable to afford traditional therapies and we were forced to manage them using our EQ Plus and Immune & Repair formulas.  It was stunning to see that a high percentage of these horses recovered and obtained remission without the need for anti-parasitic medications.  The results were achieved based on improving overall immune health and managing inflammation.

Our results have been confirmed by many of our Cur-OST® customers, stating an enhanced recovery as a standalone therapy or even in cases that have relapsed and were no longer responsive to traditional therapies.

Prevention of EPM from my point of view is rather simple. We can make attempts to 'clean up' the environment and make it less attractive to the Opossum, but it is next to impossible to eliminate the parasite completely from the environment.  We can, however, enhance overall health in these patients by improving immune function and controlling ongoing inflammation.  Factors such as stress, lifestyle, diet, genetics and many others directly contribute to inflammation, which then potentially impacts immune health.  It becomes obvious in many EPM cases that inflammation was a preliminary problem as many of these horse have other concurrent issues such as lameness, poor performance, laminitis, COPD and even insulin resistance.  We need to look at the patient as a whole to get a better understanding on how poor health influences the prevalence of these diseases.

In the end, EPM is a complex condition with a multitude of opinions on how to treat and manage.  We need to stop looking to pharmaceutical medications as being the end all be all answer and start looking at the patient as a whole, including their environment and lifestyle.  

All my best,

Tom Schell, D.V.M.
www.curost.com