Pain

Its Diagnosis and Management in the

Rehabilitation of Horses

a b,
Jodie Daglish, BVSc , Khursheed R. Mama, DVM *

KEYWORDS
 Equine  Pain  Analgesia  Musculoskeletal  Rehabilitation
 Interventional therapy

KEY POINTS
 Pain recognition in the horse is assisted by use of evolving observational and objective
measures, including composite pain scales and gait analysis technology.
 Pain modulation may be provided to the horse using pharmacologic, manual, and inter-
ventional therapies.
 Pain recognition, modulation and consistent monitoring may help to provide specifically
tailored rehabilitation programmes that can optimize return to athletic function.

INTRODUCTION

Assessment of acute or chronic injury must include determination of pain related to

tissue damage to facilitate development of an appropriate treatment and rehabilitation
plan. The International Association for the Study of Pain defines pain as an unpleasant
sensory and emotional experience associated with actual or potential tissue damage
or described in terms of such damage.1 Assessing pain in the horse is complex and
dynamic, and techniques regularly used to assess pain in humans and other species
do not readily transfer to the horse.2,3 Recent interest has resulted in increasing knowl-
edge and availability of objective measures for pain evaluation in horses.4–8 Following
a brief review of pain physiology, the focus of this article is on the tools available for the
diagnosis and management of musculoskeletal pain and their consideration in devel-
oping rehabilitation protocols.

Disclosure statement: The authors have nothing to disclose.

a
Equine Sports Medicine and Rehabilitation, Department of Clinical Sciences, College of Vet-
erinary Medicine and Biomedical Sciences, Colorado State University, 300 West Drake Road,
Fort Collins, CO 80523, USA; b Veterinary, Anesthesiology, Department of Clinical Sciences, Col-
lege of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins,
CO 80523, USA
* Corresponding author.
E-mail address: [email protected]

Vet Clin Equine 32 (2016) 13–29

http://dx.doi.org/10.1016/j.cveq.2015.12.005 vetequine.theclinics.com
0749-0739/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
14 Daglish & Mama

BRIEF REVIEW OF PAIN PHYSIOLOGY

The perception of pain is highly complex and multifaceted, relying on differential

processing of noxious stimuli by specialized neural pathways depending on the
type and intensity of signal.
 Nociceptors are sensory receptors that transduce and encode signals in
response to noxious stimuli from chemical, thermal, and mechanical sources.9
 Nociceptive stimulation triggers action potentials within high-threshold afferent
neurons (unmyelinated C-fibers or weakly myelinated Ad-fibers) whose cell
bodies are located in the dorsal root ganglia.10
 Nociceptive stimuli are projected through central pain signaling neurons in the
spinal cord to the higher brain centers where pain is perceived by the animal.
 Excitatory glutamate receptors and inhibitory GABAergic and glycinergic recep-
tors11 are considered the primary dorsal horn nociceptive pathway neuropeptides.
 Transmission of nociceptive signals from the peripheral nerve through the spinal
cord is subject to modulation by alternate input, intrinsic neurons, and controls
emanating from the brain. For example, nociceptive input can be modulated
by increasing afferent input from nonpainful stimulus (eg, rubbing area of wound
following touching a hot stove).12
 In people the somatosensory cortices are associated with sensory pain percep-
tion, and the cerebellum is involved in the processing of responses to noxious
stimulation.13,14
 Descending neural pathways are broadly considered inhibitory and are modu-
lated by concentrations of endogenous opioids, cholecystokinin, neurotensin,
acetylcholine, cannabinoids, a2-adrenergic agonists, and serotonin, propagating
inhibitory signals from the higher centers to the peripheral tissues.15
 Local and neural effects at the site of injury result in upregulation of vasoactive
compounds and neuropeptides.10 These compounds and neuropeptides, in
turn, stimulate epidermal and immune cells, leading to vasodilation, plasma
extravasation, and smooth muscle contraction.
Although the complexity and plasticity of the pain pathway provides challenges in
pain recognition, advances in diagnostic technologies and knowledge of targets for
therapeutic modulation have improved our capacity to provide pain relief. Treatment
approaches are likely to differ further depending on the nature of the pain state, which
broadly may be categorized as acute or chronic.
Acute Pain
This pain generally follows injury wherein the withdrawal from noxious stimulus alone
fails to prevent tissue damage and results in activation of the afferent nociceptive
pathway.10 The response generated by the body is intended to facilitate removal of
injured or damaged cells, eliminate foreign material, minimize further damage, and
provide an environment for tissue regeneration. Heat, swelling, redness, and loss of
function are caused by actions of chemical substances (eg, bradykinin, cytokines,
prostaglandins), result in inflammatory pain and may cause primary hyperalgesia.9 If
uncontrolled, the inflammatory process may result in exacerbation of the pain state
following removal of the insult. Hence, the common goal with acute injury is to limit
the inflammatory response, which in turn is likely to reduce discomfort.
Chronic Pain
Chronic pain is considered maladaptive when pain resulting from an acutely painful
episode persists beyond the expected period of tissue healing. This maladaptive state
 Management of Pain 15

progresses to cause alterations in physical components of the peripheral and central

nervous systems, including changes to the membrane proteins, neurotransmitters,
neuromodulators, and synaptic connectivity.16 In horses this is recognized in muscu-
loskeletal disease (eg, chronic laminitis, navicular disease); it is thought that pain
perception is altered, resulting in increased sensitivity to noxious (hyperalgesia) and
non-noxious (allodynia) stimuli.9 Treatment of chronic pain states, therefore, generally
requires a multifaceted approach.

TOOLS AVAILABLE TO ASSESS PAIN IN HORSES

Individualized subjective (eg, response to palpation) and semi-objective (eg, lameness

grades, response to intra-articular medication) observational and interactive mea-
sures have been used by veterinarians to assess pain in horses. Issues surrounding
these approaches include inconsistency between observers17 and lack of universally
applicable methods. Available tools and their limitations in obtaining repeatable and
reliable results are described:
Physiologic Measurements
Heart rate, respiratory rate, temperature, blood pressure, beta-endorphins, and
endogenous corticosteroids have all been measured in an effort to correlate with
pain level.6,18 These physiologic parameters, although easy to acquire and quantify,
have been shown to have low sensitivity and specificity for pain in part because of mul-
tiple factors influencing these responses. For example, although pain may cause alter-
ations in heart rate, other factors, such as shock, medications, stress, or exercise, may
also be influential.3,19 Physiologic parameters should, therefore, be assessed in
conjunction with the remaining described measurements.
Observational and Interactive Methods
Behavior assessment
 Behavior assessment in the horse can be highly instructive if used carefully and
applied systematically. This assessment may be used alone or as part of a com-
posite scale.
 Behavior in the horse is influenced by temperament, age, sex, breed, and envi-
ronment20 necessitating individualized assessment. As interaction with people
and other horses can alter demonstrated behavior, remote observation via
closed circuit television (CCTV) or observation from a distance is recommended.
 Evaluations conducted in this manner should include demeanor, posture, and
activity at rest. Signs of pain may include but are not limited to quietness, inap-
petence or reduced appetite, low head carriage, restlessness or frequent weight
shifting, pointing a front limb or resting one limb, increased or reduced lying
down, standing at the back of the stall, standing hunched over or stretched
out, and looking at a painful area of the body.18
 Subtle signs that may be associated with pain, including bruxism, sweating,
muscle fasciculations, and facial appearance, are observed in proximity to the
horse.21,22
 Willingness to interact, and type of interaction, with a known owner/handler who
is familiar with the horse’s behaviors may provide additional information.
 Repeated behavioral assessment is often a useful marker during the initial inves-
tigation of a cause of musculoskeletal pain, for example, improvement in posture
at rest or responsiveness during dynamic evaluation (eg, riding) following
regional anesthesia and removal of pain.23
16 Daglish & Mama

Fig. 1. (A) Horse during pain induction displaying low ears, an angled eye with an intense
stare, mediolaterally dilated nostrils, and tension of the muzzle. (B) A horse during the
control trial, relaxed with attentive ears and a relaxed stare. (From Gleerup KB, Forkman
B, Lindegaard C, et al. An equine pain face. Vet Anaesth Analg 2014;42:111; with
permission.)

Facial expression patterns

 Altered facial expression in response to varied stimuli has been recognized in the
horse. Studies to document this and to determine if facial expressions in
response to painful stimuli were consistent have been performed.18,21,22
 Observed via CCTV, the facial expressions most frequently associated with pain
were low and/or asymmetrical ear positioning, an angled appearance of the eyes,
a withdrawn or tense stare, mediolaterally dilated nostrils, and tension in the jaw,
chin, lips, and certain facial muscles (Fig. 1).

Lameness grading
Lameness scales Veterinarians have used subjective lameness grading scales for
many years. Several scales exist24,25; but often each veterinarian has their own criteria
and their own application of the grading scale, based on personal clinical experience.
The American Association of Equine Practitioners (AAEP) lameness grading scale is
the most commonly used and is among the simplest and more repeatable (Table 1).

Lameness scale modifiers With the AAEP lameness grading scale veterinarians may
assign a grade and additionally document the characteristics of the lameness to aid
with repeatability of the observation; others have derived their own 0- to 8- or 0- to
10-point numerical scale.26,27 Stride characteristics, such as abduction or adduction
of the limb, toe drag, and weight shifting, can also be helpful.
Bilateral lameness may confound lameness assessment, as may the inability of the
horse to trot because of significant lameness. Additionally, although scoring repeat-
ability by the same examiner is high, interobserver repeatability is poor.17 It has, there-
fore, been proposed that for improved validity the observer should be consistent
between examinations and video recording of the examination with detailed
 Management of Pain 17

Table 1
AAEP lameness scale

Grade 0 Lameness not perceptible under any circumstances

Grade 1 Lameness is difficult to observe and is not consistently apparent, regardless of
circumstances (eg, under saddle, circling, inclines, hard surfaces).
Grade 2 Lameness is difficult to observe at a walk or when trotting in a straight line but is
consistently apparent under certain circumstances (eg, weight-carrying, circling,
inclines, hard surfaces).
Grade 3 Lameness is consistently observable at a trot under all circumstances.
Grade 4 Lameness is obvious at a walk.
Grade 5 Lameness produces minimal weight bearing in motion and/or at rest or a complete
inability to move.

From http://www.aaep.org/info/horse-health?publication5836. Accessed August 21, 2015. Copy-

right AEEP.

documentation of lameness characteristics should be included in medical records.

Technology to objectively grade lameness (discussed later) is available.

Functional tests
Functional tests are incorporated in general clinical and dynamic examinations by
most veterinarians (eg, flexion tests as part of lameness evaluation). The amount of
flexion achieved, duration flexion is tolerated, and response to increased weight
bearing on the stance limb provides useful information. Worsening lameness following
flexion is assessed as increased or decreased and graded. Additional gait changes
and contralateral limb response are also noted.

Pain scales

Results of studies detailing the development of composite pain scales for horses
based on pain scoring systems used in humans and small animals are available.28,29
Pain scales should be easy to use, broadly applicable and provide consistent and
repeatable results.28

Composite pain scales frequently incorporate objective measurements (eg, physio-

logic parameters) with assessment of behavioral and interactive observations. An
example of such a scale is one developed by Bussières and colleagues28 for assess-
ment of orthopedic pain following induction of tarsocrural joint osteoarthritis (Table 2).
On re-evaluation by another research group,29 consistency and interobserver repeat-
ability were considered excellent under different study conditions.

Objective Methods
Biomechanical analysis
Kinetic and kinematic analysis are considered the gold standard approach to lame-
ness evaluation and are increasingly used in research to document objective measure-
ments of lameness with improved confidence.

Kinetics Kinetics is the study of forces acting on a body, for example, how forces
generate motion in locomotion. Kinetic analysis is used in equine research to evaluate
ground reaction force of each limb compared with another, with reduced ground re-
action force correlating well with identified lameness. Typical patterns have been
documented with respect to different types of lameness and replicated with high
18 Daglish & Mama

Table 2
Multifactorial numerical rating composite pain scale for evaluating pain in horses

Physiologic Data Criteria Score: 12

Heart rate (compared <10% increase 0
with baseline) >11%–30% increase 1
>31%–50% increase 2
>50% increase 3
Respiratory rate <10% increase 0
(compared with >11%–30% increase 1
baseline) >31%–50% increase 2
>50% increase 3
Digestive sounds Normal motility 0
Decreased motility 1
No motility 2
Hypermotility 3
Rectal temperature <0.5 C variation 0
(compared with <1 C variation 1
baseline) <2 C variation 2
>2 C variation 3
Response to interaction Criteria Score: 6
Interactive behavior Pays attention to people 0
Exaggerated response to auditory stimuli 1
Excessive to aggressive response to auditory stimuli 2
Stupor, prostration, no response to auditory stimuli 3
Response to palpation of No reaction to palpation 0
painful area Mild reaction to palpation 1
Resistance to palpation 2
Violent reaction to palpation 3
Behavior Criteria Score: 21
Appearance (reluctance Bright, lowered head and ears, no reluctance to 0
to move, restlessness, move
agitation, anxiety) Bright, alert, occasional head movement, no 1
reluctance to move
Restless, pricked up ears, abnormal facial 2
expressions, dilated pupils
Excited, continuous body movements, abnormal 3
facial expression
Sweating No obvious signs of sweat 0
Damp to the touch 1
Wet to the touch, beads of sweat apparent over 2
body
Excessive sweating, beads of sweat running off the 3
animal
Kicking at abdomen Quietly standing, no kicking 0
Kicking at abdomen 1–2 times/5 min 1
Kicking at abdomen 3–4 times/5 min 2
Kicking at abdomen >5 times/5 min, intermittent 3
attempts to roll
Pawing on floor (includes Quietly standing, no pawing 0
pointing or hanging Occasionally pawing (1–2 times/5 min) 1
limb) Frequent pawing (3–4 times/5 min) 2
Excessive pawing (>5 times/5 min) 3

(continued on next page)

 Management of Pain 19

Table 2
(continued )
Posture (weight Stands quietly, normal walk 0
distribution and Occasional weight shift, slight muscle tremors 1
comfort) Non–weight bearing, abnormal weight distribution 2
Analgesic posture, attempts to urinate, prostration, 3
muscle tremors
Head movement (lateral No evidence of discomfort, head straight ahead 0
or vertical head mostly
movements) Intermittent head movement, looking at flanks or 1
lip curl 1–2 times/5 min
Intermittent, rapid head movement, looking at 2
flanks or lip curl >5 times/5 min
Continuous head movements, looking at flanks or 3
lip curl >5 times/5 min
Appetite Eats hay readily 0
Hesitates to eat hay 1
Little interest in eating hay, takes hay but does not 2
chew or swallow
Neither shows interest in nor eats hay 3
Total CPS 39

From Bussières G, Jacques C, Lainay O, et al. Development of a composite orthopaedic pain scale in
horses. Res Vet Sci 2008;85(2):296–7; with permission from Elsevier.

repeatability.30 Limitations to this method of gait analysis do exist and should be

considered with respect to the clinical or research scenario. Several methods of ki-
netic data collection have been developed: the static force plate, the dynamometric
horseshoe, in-shoe measurement systems,31,32 and the hoof wall strain gauge.33
The most valuable resource for measuring equine kinetic data currently is the force
measuring equine treadmill at the University of Zurich,34 a custom-built facility that
has provided invaluable information on this subject.

Kinematics Kinematics is the study of movement of a body. This information is used to

generate information on motion characteristics of the limb through the stride phases to
establish range and duration of motion of each joint within the limb. Changes have
been reported to correlate well with specific alterations in gait.8 Kinematics are
more easily measured than kinetics, and equipment is less expensive allowing for
its broader use in clinical settings.

Gait analysis technology Clinical applications of kinematic technology have been

developed for lameness examinations using inertial sensors alongside an accelerom-
eter to document movement symmetry.8 Commercial systems suggest suitability for
use at the trot in a straight line, in a circle, and after blocking; programs established
for different surface types are also part of the standard package.

Goniometery
Goniometery may be used to assess joint range of motion through a rehabilitation pro-
gram and may be particularly useful in horses with advanced joint disease or those
with lordosis of the thoracolumbar spine.35

Pressure algometry
Pressure algometry has been shown to provide reliable and repeated objective
assessment of mechanical nociception thresholds in studies investigating thoracic
20 Daglish & Mama

limb pain associated with induced synovitis or osteoarthritis, muscle pain, mechanical
nociceptive thresholds of the pastern region and the axial skeleton, and to measure
the effect of sedative drugs in the provision of analgesia7,36 This technique is used
increasingly in research studies investigating pain and has been suggested for use
in the objective clinical evaluation of axial skeleton pain.4,37 Pressure-calibrated
hoof testers have been used to quantify pain in laminitic horses.

Thermography
Thermography documents skin and superficial tissue temperature, providing refer-
ence for identification and monitoring of sites of inflamed or injured tissue. Limitations
include environmental influence (eg, sensitivity to drafts, sunlight).38

Response to Treatment
Diagnostic anesthesia
Intra-articular or regional anesthesia and subsequent assessment may be performed
to localize the source of pain before diagnostic imaging and treatment. Although mul-
tiple limb lameness can confound results, this tool is still of value and use may be
enhanced by dynamic evaluation (eg, under saddle).

Response to medication
Although a less direct evaluation of pain, this method is used for horses when circum-
stances limit a thorough work-up and may include systemic or regional medications. In
addition to the potential for inappropriate treatment, there is a potential to worsen the
pathological condition.

MODULATION OF PAIN IN EQUINE PATIENTS

Research evaluating the efficacy of analgesia provided by different therapeutic modal-

ities in the horse is limited. Often articles of studies show a lack of appropriate inclu-
sion of control groups, and several demonstrate investigator bias. Others involve only
research horses with induced pain at focal sites, limiting the capacity to draw conclu-
sions on the effect of analgesics in clinically painful conditions and more so with
chronic pain states. To ensure the best outcome, treatment of pain should be based
on the likely mechanism of action causing pain and aim specifically at targeted
improvement (eg, anti-inflammatory, nerve regeneration) and then further tailored ac-
cording to response.39 The next section focuses on how treatment modalities provide
pain modulation in equine patients with musculoskeletal pain. The interested reader is
referred to additional sources for more detail.40–42

Pharmacologic Options
Nonsteroidal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used via intravenous
(IV) or oral routes. Phenylbutazone, flunixin meglumine, firocoxib, ketoprofen,
aspirin, and diclofenac are licensed for use in the United States. NSAIDs inhibit
cyclooxygenase to reduce concentration of prostaglandins PGE2, PGI2, and throm-
boxane A2 (TXA2) within tissues, providing a local anti-inflammatory effect and
dampening down peripheral sensitization. Excellent analgesic efficacy, alone or in
combination with other pharmacologic agents, is reported.43,44 There is no current
evidence for combining NSAIDs in the management of pain in horses.45 Adverse ef-
fects include gastrointestinal tract ulceration (particularly in foals), nephrotoxicity,
and hepatotoxicity.
 Management of Pain 21

Corticosteroids
Triamcinolone and methylprednisolone are among medications administered intra-
articularly for anti-inflammatory effects mediated by inhibition of phospholipase A2.
Although efficacious when used correctly, adverse effects include systemically
reduced glycosaminoglycan concentrations in joints,46 immunosuppression, and
laminitis.47

Opioids
Although many drugs with actions at mu and/or kappa receptors are available, use of
systemic opioids for analgesia in horses remains controversial as clear benefits have
not been elucidated and side effects (eg, gastrointestinal stasis, excitation) with esca-
lation in dose are of concern. When administered via alternative routes (eg, epidural,
intra-articular), efficacy is demonstrated48,49 and adverse effects are fewer. These
considerations and the need for strict record keeping will likely limit opioid use to
the hospital setting where monitoring is more frequent and additional drugs may be
used in conjunction.

Tramadol
Currently investigations of pharmacodynamics and pharmacokinetics of this codeine
analogue following oral and IV administration do not support its use as an analgesic in
horses.

Alpha-2 agonists
Alpha-2 agonists decrease neuronal excitation by activating presynaptic and postsyn-
aptic alpha-2 receptors in the descending inhibitory pain pathway centrally and in
joints peripherally.41 Clinically used most commonly for sedation, alpha-2 adrenocep-
tor agonists are also good analgesics and in acute conditions supplement a multi-
modal approach to analgesia. Sole or chronic use is limited by sedative,
musculoskeletal (eg, ataxia), and physiologic effects (eg, bradycardia, sweating, res-
piratory gastrointestinal stasis).

Local anesthetics
This class of drugs may be administered regionally (eg, intra-articular, perineural) or
systemically (lidocaine) for pain management. When regionally administered, local
anesthetic drugs block sodium channels, thereby preventing conduction through sen-
sory nerve fibers. Efficacy may be affected by low tissue pH as with inflammation50;
although adverse effects are limited, detrimental effects on articular cartilage are re-
ported and warrant further investigation.51 When systemically administered, data sup-
port lidocaine’s anti-inflammatory and analgesic effects50; however, because of its
short action it must be given by IV infusion. If dosed inappropriately, systemic admin-
istration of lidocaine can result in hypotension, seizures, and collapse; bupivacaine is
not recommended for systemic IV use because of reported cardiovascular toxicity.

Ketamine
Noncompetitive N-methyl-D-aspartate (NMDA) antagonism by ketamine limits binding
of the excitatory neurotransmitter glutamate to NMDA channels, inhibiting potentiation
of action potentials within the sensory central nervous system. Via this mechanism ke-
tamine is thought to reduce the occurrence of wind up (increased responsiveness),
hyperalgesia, and central sensitization that results from chronic or continuous noxious
stimulation of polymodal C nociceptive afferent nerve fibers.40 Ketamine is used
extensively as a general anesthetic and in limited circumstances as an adjunct to
alpha-2/opioid sedation for standing procedures. The elimination half-life of ketamine
is approximately 1 hour,52 again necessitating its administration via constant rate
22 Daglish & Mama

infusion, although other routes are described (eg, epidural, intramuscular). Adverse ef-
fects include hyperexcitability, muscle tremors, tachycardia, tachypnea, and ataxia.53

Gabapentin
Gabapentin is an anticonvulsant drug that has shown promise in human and small an-
imal patients as a treatment of neuropathic pain. Gabapentin is rapidly absorbed and
has an elimination half-life of 3.4 hours in horses. Although the collective experience
with this drug in horses is limited, reports indicate there may be possible benefits.

Polysulfated glycosaminoglycans
Polysulfated glycosaminoglycans (PSGAGs) are used in clinical practice for the treat-
ment of joint-associated pain via intramuscular administration or intra-articular injec-
tion. PSGAGs have been reported to decrease inflammatory mediators, including
PGE2 and upregulate collagen synthesis in joints.54 In a study on the effects of
PSGAGs on induced osteoarthritis of the carpus, lameness grading improved with
treatment and joint effusion decreased compared with controls, suggesting anti-in-
flammatory properties.

Sarapin
A distillate of powdered Sarracenia purpurea (pitcher plant), Sarapin has been advo-
cated as an analgesic in chronic pain, especially if of neural origin despite the method
of action being unknown.39 In equine patients, Sarapin is used for the treatment of
muscle pain associated with the thoracolumbar spine and for infiltration around the
sacroiliac joints. No known side effects have been documented following such use.

Interventional Therapies
Interventional therapies have become increasingly available in recent years, with
advances in sports medicine research in the human and equine field. The following
therapeutic options have been covered elsewhere in this text and so are discussed
only with respect to provision of analgesia.

Manual therapy
This therapy focuses on alleviating sensory, neuromuscular, and mechanical abnor-
malities. Pain is modulated along with proprioceptive and motor retraining. Therapeu-
tic exercises are designed to be specific to the function of the injured tissue35 and
aimed at reparative or healing processes within the neuromusculoskeletal system.55
Examples of different modalities within this broad group are listed:
Chiropractic Chiropractic treatment is characterized by high-velocity, low-amplitude
thrusts, applied to the spine56 and has been shown to reduce spinal pain.4 Chiro-
practic induced a 27% increase in mechanical nociceptive thresholds for up to
7 days compared with baseline in a clinical trial comparing changes in mechanical
nociceptive thresholds in response to pharmacologic and nonpharmacologic thera-
pies.57 The specific mechanisms of analgesia are not well known; however, influences
on biomechanical, physiologic, neurologic, and psychological mechanisms58 have
been proposed. Long-term benefits are thought to occur via actions on the ascending
and descending pain-modulating spinal cord pathways.59

Physiotherapy Physiotherapy refers to passive or assisted active movements applied

to address impairments in the articular, neural, and muscular systems.60 Ongoing
research into the analgesic mechanism underlying physiotherapy suggests that focally
induced movement may activate afferent neurons and stimulate neural inhibitory
systems at multiple spinal levels, producing hypoalgesia.61 Passive accessory
 Management of Pain 23

mobilization of the cervical spine (as compared with placebo) has been demonstrated
to provide pain relief in specific conditions.62 Similar benefits of physiotherapy are re-
ported in people.63

Massage Although there are limited case-controlled data to support clinical observa-
tions of improvement in pain states following massage, studies have demonstrated
an increased mechanical nociceptive threshold in the thoracolumbar region57 and
improved stride lengths at walk and trot64 after massage. Tissue manipulation effects
changes in neurologic signaling relating to pain processing and motor control60 and
upregulates signaling within large-diameter nerve fibers to provide inhibition of the
ascending nociceptive signals.65 Soft tissue mobilization improves blood flow
improving tissue viability and so reduces pain associated with tissue damage.66 Release
of endorphins and serotonin via these mechanisms may also modulate pain perception.
Therapeutic exercise Exercises, such as hand walking, walking over poles, backing,
and hill work, aim to return the soft tissues and bones to normal physical capacity.
Sensory, neuromotor, and mechanical abnormalities that occur as a consequence
of injury may be alleviated by the analgesic effects of therapeutic exercise.35 However,
alternative pain modulation may also be necessary to ensure that therapeutic exer-
cises are executed optimally.

Other Therapeutic Modalities

Hydrotherapy
In people, aquatic therapies have been reported to decrease pain67; it is shown that
exercising in water has beneficial effects through the following mechanisms68:

Buoyancy Buoyancy reduces weight bearing of the affected limb and, thus, second-
ary compensation; it also allows increased joint stability.69

Hydrostatic pressure Circumferential compression is achieved by immersion in water,

and the effects are proportional to water depth. Increases in hydrostatic pressure
allow increased circulation and reduction of tissue edema.67

Tissue temperature Increasing water temperature provides stimulus for increased cir-
culation and decreased muscle spasm in warm water70 and in cold-water stimulus for
vasoconstriction to reduce the influx of inflammatory mediators.71

Hydrotherapy, therefore, provides significant opportunity for analgesia in the reha-

bilitation period through reduction of local tissue edema and inflammation to reduce
pressure, thermal and chemical nociceptive stimulation, and via periods of off-
weighting the injured tissues, in static and dynamic conditions, such that therapeutic
exercise can be achieved in minimally loaded conditions.

Cryotherapy
Ice packs, ice boots, ice-water circulating boots, cold hosing, and products, such as
the Game Ready (Game Ready, Concord, California), can deliver cold therapy, making
cryotherapy very accessible. Cold therapy is most beneficial when applied immedi-
ately after injury and reapplied every 2 to 4 hours. Cold therapy provides analgesia
to an area of injury by initiation of local vasoconstriction, decreasing vascular perme-
ability, reducing the influx of inflammatory markers to the area, depressing neuronal
conductivity, and decreasing the metabolic rate, thereby reducing cell hypoxia and
death.72 Cryotherapy has been demonstrated to reduce the activity of enzymatic me-
diators of acute laminitis in the horse.73
24 Daglish & Mama

Acupuncture
Acupuncture is effective for treating pain74 via release of locally active neuropeptides,
which initiate a systemic analgesic response mediated by endogenous opioid peptides,
serotonin, dopamine, and norepinephrine after needle placement or acupressure.75
Increased concentrations of endogenous opioids in plasma and cerebrospinal fluid
following acupuncture have been documented in the horse.76
Electroacupuncture has been demonstrated in humans to significantly increase me-
chanical and thermal pain thresholds over manual and sham acupuncture in healthy
patients.77 In horses, a series of 3 electroacupuncture treatments has been shown
to resolve chronic thoracolumbar spine pain.78 The mechanism of analgesia for
chronic pain states with electroacupuncture seems to be mediated via endogenous
opioid peptides, b-endorphin and cortisol.76

Low-level laser therapy

Protocols for treatment of wounds, tendinitis, desmitis, osteoarthritis and muscular
soreness are available for horses. A systematic review of studies evaluating low level
laser therapy in human osteoarthritis suggests a positive analgesic effect when the
recommended low level laser therapy guidelines were adhered to.79 It is postulated
that analgesia for osteoarthritis is the result of inhibiting inflammation of the joint
capsule and is therefore reliant on appropriate patient and energy selection.80

Extracorporeal shockwave therapy

Extracorporeal shockwave therapy has been shown to have modifying effects in
induced carpal osteoarthritis models.81 Initial analgesic effects were demonstrated
to last 2 to 3 days, but overall improvements in lameness score and range of motion
were observed 14 days after treatment. In humans extracorporeal shockwave therapy
has been successful at reducing pain and improving healing in chronic plantar fasci-
itis82 and chronic low back pain.83 The origin of the analgesic effect is unclear,84 but it
is thought that extracorporeal shockwave therapy induces neovascularization and
reactivation of healing in damaged tendons, ligaments and bone.85 Analgesia may
also be provided by appropriate motor stimulation of muscles and tendons through
application of extracorporeal shockwave therapy.83

Transcutaneous electrical nerve stimulation

Electrotherapy provides pain relief through transduction of electrical current into the
body to depolarize sensory neurons to suppress pain.86 Analgesic efficacy is variable,
but TENS has been demonstrated to provide excellent short-term relief from chronic
pain in humans. TENS is used with similar perceived effects in the horse, but to date no
scientific basis for treatment has been documented.

Therapeutic ultrasound
Ultrasound waves produce thermal and nonthermal effects on tissues to improve local
circulation, increase cell membrane permeability, enhance collagen extensibility and
reduce muscle spasm.86,87 Increased pain thresholds are hypothesized to be due to
vasodilation, increasing intracellular calcium and/or increasing fibrous tissue extensi-
bility.86,88 Use in the horse is increasing in popularity, with treatment effects inferred
from studies in human and small animals.

Kinesiotaping
Despite a recent review concluding that there is no substantial evidence for analgesic
efficacy of kinesiotaping in humans89 it is still extensively used in people and increas-
ingly in horses. Taping provides release of pressure on tissues from skin and increases
space for movement of lymphatic fluid.89 It is proposed that the application of
 Management of Pain 25

kinesiotape provides consistent mechanical stimulation to downregulate nociceptive

transmission.90 Its usefulness in horses is undocumented.

SUMMARY

Although there is much to do to improve our evaluation and management of equine

pain, advances are ongoing and newer modalities for diagnosis and therapy are
increasingly available.

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