Joint Therapies

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  • IA (Steroids, HA, IRAP), NSAIDS, PRP (collateral), surgery, Legend, Adequan, Neutraceuticals, Shock wave, acupuncture, chiropractic, herbal, homeopathy, nutrition.
  • Vet cl NA p 584 Chrondroitin sulfate: 8kd 32% bioavailable vs. 22% for 17 kd.
  • Soaked with Cr SO4 beads
  • Not to be used in tendon sheaths, bursae, OCD, chip fragments, advanced OA with extensive cartilage loss), subchondral bone cysts.
  • Platelets growth factors: (including PDGF, TGF β , VEGF)
  • Harvest tech BM centrifugation.
  • Bone scaffold: Tricalcium phosphate
  • 1. Vet cl na 2008 p48.
  • Joint Therapies

    1. 3. To locate the source of the lameness
    2. 4. <ul><li>Joint injury </li></ul><ul><li>Tendon or ligament injury </li></ul><ul><li>Hoof pain </li></ul><ul><li>Bone pain (fracture) </li></ul><ul><li>Muscle pain </li></ul><ul><li>Neurological disease (EPM) </li></ul><ul><li>Mechanical </li></ul>
    3. 5. <ul><li>Excessive force and loading </li></ul><ul><ul><li>Stiffens bone- denser but less elastic </li></ul></ul><ul><ul><li>From heavy work, hoof imbalances, poor surfaces, </li></ul></ul><ul><ul><li>Can be an accumulation of loading or a single event </li></ul></ul><ul><li>Blunt or sharp trauma to the joint </li></ul><ul><li>Infection </li></ul><ul><li>Defects in the joint </li></ul><ul><ul><li>Chips, fragments, OCD </li></ul></ul><ul><ul><li>Poor conformation/deformities </li></ul></ul><ul><ul><li>Poor cartilage structure </li></ul></ul>
    4. 6. <ul><li>inflammation of the joint </li></ul>
    5. 7. <ul><ul><li>Chronic inflammation will cause release of cytokines that degrade cartilage and collagen. </li></ul></ul><ul><ul><li>Cartilage becomes less able to absorb shock </li></ul></ul><ul><ul><li>Continued exercise increases trauma to joint </li></ul></ul><ul><ul><li>Synovial membrane scars and enlarges, fluid amounts increase, viscosity decreases. </li></ul></ul><ul><ul><li>Osteophytes form, subchondral bone loss </li></ul></ul>
    6. 8. <ul><li>Subchondral bone sclerosis osteocyte death loss of blood supply microcracks in subchondral bone chips of bone at the edges cartilage and bone collapse </li></ul><ul><li> fracture </li></ul>
    7. 9. PAIN
    8. 10. <ul><li>Pain comes from both inside the joint and outside the joint </li></ul><ul><ul><li>Intraarticular: synovial and cartilage attachments </li></ul></ul><ul><ul><li>Extraarticular: Increased pressure in the marrow speculated as well as inflammatory cytokines or in ligaments surrounding the joint capsule. </li></ul></ul>
    9. 11. <ul><li>Non medical therapies </li></ul><ul><li>Cold therapy 30 minutes for up to 72 hrs for acute injury </li></ul><ul><li>Liniments, poultice </li></ul><ul><li>Limit motion- hand walk, limit turnout if “new” keep in light regular exercise if “chronic” </li></ul><ul><li>Bandage to reduce swelling </li></ul><ul><li>Corrective trimming/shoeing </li></ul>
    10. 12. <ul><li>Systemic medical therapies </li></ul><ul><li>Adequan ® </li></ul><ul><li>Legend ® </li></ul><ul><li>Glucosamine HCL best glucosamine injectable </li></ul><ul><ul><li>N- Acetyl glucosamine less reliable in inhibiting degredation </li></ul></ul><ul><ul><li>Glucosamine SO4 more easily incorporated but less stable than HCl </li></ul></ul><ul><li>NSAIDS </li></ul><ul><ul><li>Bute </li></ul></ul><ul><ul><li>Banamine ® </li></ul></ul><ul><ul><li>Surpass cream ® topical </li></ul></ul><ul><ul><li>Equioxx ® </li></ul></ul>
    11. 13. <ul><li>Joint injections </li></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Hyaluronic acid (HA) </li></ul></ul><ul><ul><li>Adequan ® </li></ul></ul>
    12. 14. <ul><li>Remove physical causes of inflammation </li></ul><ul><ul><li>Chip removal, OCD surgery. </li></ul></ul><ul><ul><li>Infection- flush joint, antibiotics. </li></ul></ul><ul><ul><li>Reduce exercise level. </li></ul></ul>
    13. 15. <ul><li>Acupuncture </li></ul><ul><li>Chiropractic </li></ul><ul><li>Nutrition </li></ul><ul><li>Herbal </li></ul><ul><li>Homeopathy </li></ul>
    14. 16. <ul><li>Look for products that contain: </li></ul><ul><ul><li>Glucosamine HCL </li></ul></ul><ul><ul><ul><li>5000mg per serving or lower amounts combined with chondroitin sulfate (e.g. Cosequin) </li></ul></ul></ul><ul><ul><ul><li>Best for minor/early lesions- decreases progression </li></ul></ul></ul><ul><ul><ul><li>Mixed reviews on success </li></ul></ul></ul><ul><ul><ul><li>Takes 4-8 weeks for effect. </li></ul></ul></ul><ul><ul><li>Chondroitin sulfate low MW better- </li></ul></ul><ul><ul><ul><li>Takes 2-4 months for effect, continued benefit after discontinued. </li></ul></ul></ul><ul><ul><ul><li>Decreases inflammation </li></ul></ul></ul>
    15. 17. <ul><ul><li>Oral Hyaluronic acid </li></ul></ul><ul><ul><li>MSM </li></ul></ul><ul><ul><li>Omega 3 fatty acids (fish oil best) EPA and DHA </li></ul></ul><ul><ul><ul><li>Enhance Animal Wellness </li></ul></ul></ul><ul><ul><li>Combination Supplements </li></ul></ul><ul><ul><ul><li>Platinum performance ortho con series </li></ul></ul></ul><ul><ul><ul><li>Cosequin ASU </li></ul></ul></ul>
    16. 18. <ul><li>Look for name brand products that have a history of quality products and good quality control </li></ul><ul><ul><li>Examples: </li></ul></ul><ul><ul><ul><li>Cosequin </li></ul></ul></ul><ul><ul><ul><li>Platinum performance </li></ul></ul></ul><ul><ul><ul><li>Enhance animal wellness </li></ul></ul></ul><ul><ul><ul><li>Michael Plumbs horse journal tests products randomly for ingredient content and publishes the good and bad. </li></ul></ul></ul>
    17. 19. <ul><li>Shock Wave </li></ul><ul><ul><li>Unknown how it works </li></ul></ul><ul><ul><li>Anecdotally helps with hock arthritis, navicular pain </li></ul></ul>
    18. 20. <ul><li>IRAP (Interleukin 1 receptor antagonist) Orthokine ® made by Arthrex ® </li></ul><ul><ul><li>Made from horse’s serum. Inhibits IL-1 in people. May also stimulate anti-inflammatory interleukins </li></ul></ul><ul><ul><li>(IL-4, 10) and growth factors (FGF TGF β ). </li></ul></ul><ul><ul><li>Successfully used in Europe in 30,000 patients </li></ul></ul>
    19. 21. <ul><ul><li>Used with horses with joints that do not respond to steroids </li></ul></ul><ul><ul><li>Potentially good for Cushing’s horses which can’t tolerate steroids. </li></ul></ul><ul><ul><li>Appears to be safe, non reactive, significantly improved lameness scores 5-8 weeks post injection (not tested beyond that date- may be longer.) </li></ul></ul><ul><ul><li>Can freeze serum for later use, and use in multiple joints. </li></ul></ul>
    20. 22. <ul><li>Platelet Rich plasma (PRP) therapy </li></ul><ul><ul><li>Made from the horse’s own plasma. </li></ul></ul><ul><ul><li>Platelets have growth factors stored in them which are released when activated over a number of days. </li></ul></ul><ul><ul><li>Growth factors help speed tendon and ligament repair- helps joints by helping the supporting structures. </li></ul></ul><ul><ul><li>Used for difficult wound repairs </li></ul></ul><ul><ul><li>Possible indication for navicular disease or other bursal issues. </li></ul></ul>
    21. 23. <ul><li>Stem cell therapy </li></ul><ul><li>Fat and bone marrow both have stem cells and growth factors. </li></ul><ul><ul><li>Fat- Vet Stem ® system- great concept, recent study shows effectiveness. </li></ul></ul><ul><ul><li>Bone marrow aspirate- works well with ligaments </li></ul></ul>
    22. 24. <ul><li>A Cell (ligament repair) </li></ul><ul><ul><li>A collagen scaffold material. </li></ul></ul><ul><ul><li>Best for severe tendon ligament injuries </li></ul></ul><ul><ul><li>Is reactive to tissues. </li></ul></ul>
    23. 25. <ul><li>Grafts for bone cysts </li></ul><ul><ul><li>PRP+ bone scaffold </li></ul></ul><ul><ul><li>Bone Marrow+ bone scaffold </li></ul></ul><ul><ul><li>Cartilage grafts- promising </li></ul></ul><ul><ul><li>Bone grafts- poor results </li></ul></ul>
    24. 26. <ul><li>Joint fusion </li></ul><ul><li>For lower hock and pastern joints </li></ul><ul><ul><li>Surgical fusion </li></ul></ul><ul><ul><ul><li>Laser </li></ul></ul></ul><ul><ul><li>Chemical fusion </li></ul></ul><ul><ul><ul><li>MIA </li></ul></ul></ul><ul><ul><ul><li>Alcohol </li></ul></ul></ul>
    25. 27. <ul><li>Foals need to have light exercise- encourages normal cartilage development in the first year of life. </li></ul><ul><li>Good shoeing and trimming practices distribute forces properly across the joint </li></ul>
    26. 28. <ul><li>Good nutrition </li></ul><ul><li>Controlled growth of young horses don’t overfeed. </li></ul><ul><li>Balance of micronutrients including: Copper, Zinc, Manganese, Selenium, monitor Su and Fe in water. </li></ul><ul><li>Use name brand Feeds- Nutrena ® , Purina ® , etc. </li></ul><ul><li>Don’t mix and match supplements! </li></ul>
    27. 29. <ul><li>Legend ® , Adequan ® </li></ul><ul><li>Supplements- </li></ul><ul><ul><li>Cosequin ASU ® , </li></ul></ul><ul><ul><li>omega 3 FA (Enhance Animal Wellness ® ) </li></ul></ul><ul><ul><li>Platinum Performance </li></ul></ul>
    28. 30. <ul><li>Good riding surface </li></ul><ul><li>Regular exercise </li></ul><ul><li>Good conditioning </li></ul><ul><li>Don’t overstress joints too often (tight circles, long rides etc). </li></ul><ul><li>Help minor lamenesses before they get worse </li></ul>
    29. 31. Ledgewood Equine Veterinary Clinic David Trachtenberg, DVM
    30. 32. <ul><li>1 o impact- vertical force </li></ul><ul><li>First collision of hoof with surface. Force gets dissipated by joints. </li></ul><ul><li>2 o impact – horizontal breaking </li></ul><ul><li>Increase in force second collision of body with leg </li></ul><ul><li>Support </li></ul><ul><li>Most of second collision; puts maximal force on limb </li></ul><ul><li>Breakover </li></ul><ul><li>decrease in force, strain applied in toe. Up to 2.5x body weight- most likely time that injury occurs. </li></ul><ul><li>Post Breakover- Tendon forces rotation of hoof/ joints </li></ul>

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