Injecting Perspective

We’re doing it all wrong. To effectively treat lameness conditions in sport and race horses we need a paradigm shift in how these animals are managed by horsemen and veterinarians. Attending the North American Veterinary Regenerative Medicine Conference here in Lexington last week underscored that belief. Here is the quick and dirty of what I learned at that meeting:

Not a magic trick

Stem cells injected into a joint are not magically finding their way to areas where the cartilage is worn off, and planting themselves there to generate new cartilage. Bummer. I was really hoping there was some possibility here, after other (non-equine) studies showed that stem cells might “home” to injured tissue.

Low numbers of stem cells are found in the area of tendon injury weeks after they are injected. In fact when using standard procedures, stem cells injected into a “tear” in tendons didn’t even fill up the length of the tear at the time of injection: they just hung out around the injection site. Pretty disappointing. This isn’t to say that the cells don’t slowly migrate afterward to areas of injured tissue, which has been shown in previous science, but at least the injection process isn’t as straight forward as we thought. And given the previous information (the cells don’t incorporate themselves significantly into the tendon, even if they get there), migration is fairly moot.

sad face.

During a break in action, I chatted with a colleague and friend who runs a very successful racetrack practice in Southern California, working on some of our most famous racehorses. He has had trouble finding anything that heals injured tendons with anything greater than 60% success rate. This 60% reflects the success rate of horses with bowed tendons that receive no therapy except time off, making it back to racing at the level where they competed before injury. It’s often possible to bring a horse back with soft tissue injury, to compete at a lesser job. The gold standard would be to heal tissue to the degree that the horse can compete where it was before injury.

but you probably won't see it here again.

So it was with some anticipation that we stepped into the lecture given by Dr Christiana Ober, who gave a nice report on her results of treating horses with soft tissue injuries using the various regenerative modalities: bone marrow, stem cells cultured from bone marrow, stem cells cultured from fat cells, and Platelet Rich Plasma. She did a great job by excluding the lesions which would easily heal on their own, and raised the bar showing real strength of healing, by only calling a positive result those horses who had come back post injury to compete at their previous level for two seasons. This would show not just that the horse made it back, but that the healing was substantial enough to keep the horse at its current job. Combining all the various therapies in her group of treated horses, guess what her overall success rate was. Any guesses?

60%

If you take my friend’s data, this means there was zero effect of regenerative therapies above what Dr Green can give you by turning the horse out in a field. This is a good time to bring up two points that I think are critical to this whole discussion:

1. It’s entirely possible that stem cells will eventually do exactly what we always dreamed of them doing: regenerating brand new, perfectly replicated tendons, ligaments  and cartilage, that will join hands with the existing healthy tissue, and become a seamless extension of that tissue, as if there never was an injury. The problem may very well be that this entire field is in its infancy, and we just need more time to learn how to tell these cells to go there and do that. We just aren’t there yet.  There is some pretty cool stuff being found in other applications. Dr Scott Morrison presented some cases of severe laminitis that were very near the end, that soon after regional limb perfusion of stem cells started to grow incredibly healthy foot, and may have saved some lives. He can’t say what exactly the stem cells are doing, but something in the soup seems to be sending a signal to create healthy tissue. We just need time and money to figure out specifics so we can optimize that effect.

2. Even if we are able to regenerate the tissue back to 100% of its original strength, we have to remember that this horse got injured with the tissue that God gave it; to go back to the same work program where the horse originally got injured, we need to get new therapies to exceed 100% of original capacity. This is a ridiculous expectation.

Achieving the founatin of youth is not likely to happen in a laboratory; we can spend years developing ways to ”fix” injured tissue to where it was pre-injury, but how will that prevent reinjury even if it’s 100% effective? The answer already exists, and it couldn’t be easier: prevention. This isn’t to say that we just keep talented but fragile horses from competing at levels that put them at risk. Rather, it means that we follow them very carefully, and manage their training and their careers in a way that  ensures their tissues are given the opportunity to fortify as the horse progresses.

This requires a good relationship among owner, trainer, veterinarian and farrier. It also demands a willingness for the owner to pay for regular visits by the veterinarian, even when the horse is seemingly sound. Early recognition, an accurate diagnosis, and appropriate management are the cornerstones to long careers in equine athletes. As long as we believe that we can create a miracle in a syringe, there will not be a need for horsemen to pay attention to what their horses are trying to tell them. I submit that there will never be a miracle in a syringe, so we should make every effort to become better listeners.

8% of all human DNA is viral in origin. Turns out, your little sister really does have cooties. Some of the genes she got from your parents that make her who she is: blue eyes and brown hair, started not entirely from human origin. Some came from viral infections of your ancestors many millenia ago. The theory is that over time the viruses that have become incorporated into our genome were at one time infectious, and may have in fact killed some of our distant relatives. But enough humans stayed alive and fought off the disease. That caused the viruses to keep mutating until eventually, they were rendered impotent.

While having drinks with one of the leading AIDS researchers a few years ago, I learned that many in the scientific community now believe that the eventual fate of hiv will be the same. Now that we have drugs that are effective at keeping people alive, genetic pressure will cause the virus to keep trying to mutate into new virulent forms, until it finally runs out of options that our immune systems can’t handle. It will then become completely innocuous to the human population, if we can keep enough victims alive to cause this to happen. And if we have the moral fortitude to get people in third world countries treated, the current hiv virus (as it hangs out in the nucleus of cells, and reproduces by hijacking our DNA replication process) will very likely, a thousand years from now, be found as a normal noninfectious part of the DNA in the human population, handed down from one generation to the next, without making anyone sick.

What the heck does this have to do with horses? Not much, unless you know someone who has been to Ogden, Utah lately.

Bet you can find it on a map now.

Or any other horse show in America.

Viruses are everywhere. Some infect pigs, some infect people, some infect horses. Very few jump across species. They have cousins that inhabit other species, but most of them have figured out their own host species pretty well, and try to stay on familiar ground. Or more accurately, haven’t figured out how to effectively reproduce inside a new species’s body. That’s why we don’t get sick from horses and they don’t get sick from us, almost ever.

But within their target population, viruses have learned where to hang out, and how to produce just enough sickness to spread to other hosts within the group, and not get completely eliminated. They breed like rabbits, so that when the host gets pretty good at killing them, there are always still enough hanging out around the nose and throat to start reproducing like mad again when the body has let it guard down.

You got it

The body kills viruses mostly through immune cells, which run around like Pacman after he swallowed the power ball, looking for just the right type of blue goblin to gobble up. When he finds one, he sends signals to make more Pacmen just like him, and the body mounts a pretty effective defense. When the body is going through a lot of stress though, it isn’t so good at motivating its troops of otherwise vigilant Pacmen. This is when the viruses that are normally hanging out like hoodlums on a street corner get to take over. Without abundant Pacmen to slow them down, they start breeding like rabbits again, and use the body as a virtual virus factory. And when you’re sitting in the economy seats next to a virtual virus factory for an 8 hour flight, it doesn’t matter how familiar your body is with this particular virus: there just aren’t enough Pacmen with the right key hanging out to bring these hoodlums under control right away. In a couple days, your body has figured out the problem, and there are a bunch of pacmen roaming the streets. But not before these hoodlums have had a chance to turn you into another virtual virus factory.

Vaccines are a great way to make your body aware of a hoodlum it hasn’t seen before, so that it can more quickly produce Pacmen when it finally does see one. They really aren’t enough to ever keep you from getting a little sick if you’re sitting next to a virus factory for an 8 hour flight though. But your body catches up in a couple days, and everything ends ok, with most viruses.

The only thing that’s additional to the above story with this latest outbreak, is that Herpes viruses in horses can end up infecting the spinal cord, and in unfortunate circumstances, lead to significant neurologic disease. But the rules of infection are the same: the chances are good that if your horse has been to a couple shows, it has seen this virus before (or at least a fraternal twin), but never in enough numbers that it became overwhelmed and showed sickness. The horses I deal with are mostly adults, and travel all over the place. Most are well vaccinated, some are not. But they are stabled next to new horses for many weeks of the year. And yet we show horse vets treat very little sickness. Oh sure, we see fat legs fairly regularly. It usually gets called scratches, and goes away in three days. I suspect most of the fat legs we see are actually mild vascular compromise from antigen-antibody complexes (see: infections the body is dealing with quite nicely) temporarily clogging up the lymph vessels, which in the lower leg of a horse don’t have the advantage of being surrounded by muscle tissue, to push the lymph along. But that’s an argument for another day. The bottom line is: if you sit next to a virus factory, you’re going to get sick. Period. If you don’t sit next to a virus factory, you’re probably not going to become one yourself.

Federal, state, and local vets are doing a great job (along with some vigilant citizens) of figuring out where all the horses that turned into factories went, to keep an eye out for new virus factories. A little bit like the sherrif running around looking for vampires, I suppose. If we know where all the vampires are, we can figure out who might next turn into a vampire, and keep them from the rest of the population. It only takes a few weeks for exposure to turn into disease, so as long as everyone stays away from those areas where the vampires are known to be, everyone will be ok. For the next three weeks, don’t go to a Cutting and stable next to horses who had been to Utah. After that, the whole thing will pretty much have blown over, and you can probably come out and horse show, and stable next to any horse, including those who had been to Ogden.

The herpes virus has been mutating, at times to a more virulent form. Extensive vaccination, thorough disease tracking, careful isolation techniques, and potent antiviral drugs, have kept the vast majority of infected animals alive, forcing the virus to look for new ways to create disease. It may be hard to believe this right now, but it looks to me like we are winning the war.

Is that Left Hind or Right Front?

Lions are like equine vets: they feed their families by finding lameness. If an animal in the back of the pack is limping, they are an easy target. Some animals of prey have evolved to minimize the appearance of limping, and maximize their ability to run efficiently in spite of pain, by compensation. Fear is a pretty good motivator too, I suppose, but that’s another discussion.

Compensation is the ability of the body to unconsciously limit the range of motion of a particular joint, to prevent it, or other areas of the body, from increased damage. I believe that the cerebellum (which controls balance and coordinates movement) has patterns of locomotion established, where it can figure out ways to continue moving forward (so as not to become an easy meal for a lion), even when there are limitations of normal locomotion. These limitations can be from mechanical causes, like bad conformation or crappy shoeing, or more commonly, simply from pain.

Body: “My shoulder hurts when I move in Pattern X” Or, “My left front clubbed foot is higher than my right front normal foot, and won’t allow me to walk in  a straight line using Pattern X”

Cerebellum: “No problem, let’s move using Pattern Y” . And presto! The cerebellum tells other parts of the body to do a little more of this, or a little less of that, to compensate for the clubby foot or the painful shoulder.

During patterns of altered locomotion, some joints stop going through their normal full range of motion, because they aren’t asked to. After time, the body will attempt to become a more efficient mover by making permanent this new pattern of locomotion, by stabilizing the effected joint(s) in its new, less elastic range of motion. The most obvious example of this is with fibrous adhesions within the joint capsule, like a fetlock on an old racehorse that just doesn’t bend like it used to. There are believed to be many other causes of stabilization, but they aren’t as well proven by science. In the early phase of this mummification process, range of motion can be reestablished physically (chiropractic, shockwave, physical therapy), or chemically (anti-inflammatories, local injections, acupuncture). Many horses do their jobs just fine with all kinds of compensations going on. But an athlete is being asked to compete at its very best, and hopefully for a long time. So working at full capacity is optimal.

When I examine a horse’s back, I’m always trying to answer one important question: are my abnormal findings related more to pathology or dysfunction? Is this lack of mobility I’m finding in the lumbar spine coming from arthritis of the facet joints in the lumbar spine? If I suspect so, I’m going to ultrasound the spine looking for pathology. Or is this lack of mobility actually because the cerebellum has figured out that the easiest way  for this horse with the clubbed foot to move efficiently includes minimizing movement of the lumbar spine (a dysfunction of the spine)? If so, I’m probably going to chiropract the horse and see if there’s anything else I can do for the clubbed foot.

Pathology means there is damage to the tissue: arthritis of the joints connecting the vertebrae, sprained or torn ligaments around the vertebral bodies (including the intervertebral disc, which many people are all too personally familiar with), torn or strained back muscles, the list goes on. Veterinary medicine has progressed in recent years to where we can now diagnose many of these conditions using x-ray, ultrasound and nuclear scintigraphy (bone scan). As a veterinarian, when my eyes and hands find something that raises alarms, I have the tools to make a diagnosis. Experience making these diagnoses informs my eyes and hands.

Dysfunction just means “it ain’t workin the way it’s supposed to.” The spine is made up of a bunch of vertebral bones that are linked together, like trains on a roller coaster. They have to make a continuous column of protection for the spinal cord, which is like a giant power cord running through the middle of them. But they also have to provide for movement in three dimensions: a roller coaster can go to the right and left, up and down over hills, and even twist through a corkscrew. For the most part, dysfunction of the spine just implies that two or more adjacent vertebral bodies are not going through their normal range of motion. When it’s quite painful, this dysfunction is often a sign that it hurts to go through that range of motion, and I need to explore the possibility of underlying tissue damage. So pathology can lead to dysfunction. When it’s not painful, my assumption is that the dysfunction is temporary, and has come from waking up on the wrong side of the bed, or working in an inefficient manner, like trotting around with an unbalanced rider.

The cerebellum has just started asking the body to change its locomotion. Left untreated, some of these can become chronic, and lead to painful conditions. Of particular importance to my profession, is that locomotion of the limbs does not exist independent of spinal movement. Watch a sound horse walk, trot, or canter on slow motion video.

It is unbelievable how much the back sways and gyrates in the three dimensions I talked about above, when it’s just moving in a straight line. In order to continue moving in a straight line, any limitation of this spinal range of motion, requires a compensation (there it is again) of the lower limb. So if the lower back on the right side does not comfortably allow the right hind leg to come through completely, something has to change about the way the left hind advances. Otherwise the horse will walk in a circle.

This alteration can (and does frequently, in my experience) lead to pathology of the structures of the left hind. So dysfunction can lead to pathology.

One of the overriding thoughts swirling in my head when my mouth is closed and my hands are moving over a horse (besides “did she say diapers, peas, milk and orange juice or diapers, peas, milk and apple juice?”) is, “can the subtle right hind lameness that I’m seeing be coming from lack of range of motion in the right sacroiliac joint, which has been COMPENSATING for an underlying left hind source of pain?” The horse could have a chronic left hock or stifle, which it has recently compensating for, by stiffening up the lower back region of the right hind, and creating what looks like a right hind lameness. This has allowed it to efficiently keep doing its job (moving in a straight line) and not get eaten by wolves. Recognizing this relationship has really contributed to the effectiveness of my lameness evaluation. Now I look for compensations, and can do something about it: make a chiropractic adjustment to the area in question, then watch the horse jog again. If he has switched lame legs, he was probably compensating, and now I can figure out where his real problem is, instead of working up a lameness on the wrong leg.

Nearly every horse I’ve come across flinches when you reach across their spine to the other side of their back, dig your finger tips into the muscle, and pull toward yourself.  This is a favorite way of examining backs by many people, including some vets. Does this mean they all have sore backs? Maybe. But if you sneak up behind nearly every foal I’ve come across, take out a couple finger tips and poke them firmly on their butt, they’ll kick you in the shins (or worse, if you’re short enough). Does this mean all foals have sore butts? Maybe, but it probably tells you more about horse nature, than whether or not there is actual pain there.

The tickle test

Examination of backs is a big part of my practice. In part because I think it’s a really important area of performance limitation. But also because so many horse people are themselves tuned into it, and are always checking for it. I think it’s great that folks are so involved with the medical management of their animals. Vets are an important part of the entire management team for equine athletes, but we rely on eyes and ears on the ground to give us accurate information which can help us make a diagnosis, and help us determine response to therapy. Those eyes and ears need to be careful with their hands, though.  It’s true that a large proportion of sport horses have some degree of back pain (at least in my always-looking-for-it opinion). But accurately identifying degree and source of the pain, and applying those to the decision making process in the competing animal, is an art form that veterinarians evolve over decades of looking at these things on a daily basis.

It’s the wise vet who can “play the piano”, not “bang on the keys” when it comes to any part of examining a live animal.

When examining an animal who has the ability to form an opinion of you, the more you get in their space the sooner you lose your window of fact finding, Poking, prodding, twisting, and cranking are handy ways of demonstrating to owners that a horse is sore when you do those things. But it hardly means that the horse is sore there, or wasn’t until all the poking and prodding begun. One day, I’ll sit down and write my opinion on how often splints cause actual lameness, and how often they’re used as a diagnostic crutch. But this isn’t that time.

As easy as it is to make a horse flinch, and as open as horse owners are to suggestion, it is no surprise that there are so many people trying to make a living by offering ways to reduce a horse’s response to poking it. I’m not opposed to capitalism; everyone is free to make a living. And I’m always open to suggestion, if someone has noticed something I haven’t, or has an idea that is alternative to my own. But it drives me (and my colleagues, almost to the man) nuts that these people are often getting called before we are, even though they often charge more for their “therapy” than we are for our exam, which often leads to an actual diagnosis, and occasionally, more appropriate therapy. Don’t get me wrong – I strongly support acupuncture and chiro practices (I’m trained in, and practice chiro everyday), but I believe in it being practiced by veterinarians. Not lay people who learned massage or pseudo chiropractic in a couple of weekend courses from another layperson. I’m happy that those people can make a living, but it’s annoying that in some cases, we have to answer questions that they raise about a horse, that they don’t have any business raising.

In the end, calling a vet first usually saves money. I sympathize with the owner whose regular vet is someone who in their estimation doesn’t do a lot of orthopedic work, or does, but perhaps emphasizes areas other than the neck or back. But there is a lot of amazing continuing education out there these days, and you might be surprised to find out what your vet has foregone family vacations to spend time (and thousands of dollars) getting better at. We have much better diagnostic skills and equipment on average, than we had not too many years ago, regarding these hard-to-reach areas. This has expanded our therapeutic regime in return. Many of us have learned how to apply chiropractic (the real kind, learned from chiropractors), acupuncture, ultrasound guided injections, shockwave, etc, to genuinely alter disease and dysfunction.

I’m not saying that alternative voices don’t offer something important to the mix. Indeed, my experience is that there are a few out there, who in spite of a formal education, can change something in a horse that vets and farriers were unable to.

The right touch

They have special skills, and belong in the horse community as part of the management team. But they aren’t a first line of defense. The most appropriate first expert is one who spent a handful of years and many thousands of dollars learning every aspect of anatomy, physiology and pathology of the animals they are treating, and have dedicated their lives since graduating to improving their skills. They are licensed by the state as experts, and carry insurance in case things don’t go as planned. But just as importantly, they  attempt to practice defensible medicine, rooted in scientific fact instead of anecdotal whim. There’s a lot of great research going on right now that is expanding our knowledge base of how horses function, and what to do when they don’t. Use someone who reads that research and can figure out how to apply it.

I have been driving cars for many years, but I barely know what it looks like under the hood. If you brought me your car and asked me why it’s making a knocking sound, I’d be happy to give you my opinion. But you probably shouldn’t pay me for it.

“I want to say one word to you. Just one word…Plastics.”
That famous quote from The Graduate was pretty good advice for the time. Plastics have become an increasingly indispensible part of our lives since 1967. In fact, modern engineering has fabricated all manner of amazing products that have improved our quality of life (sippy cups are my current fave), including medical therapies. But in the new millenium, so far it looks like the quote would be, “Just one word…Biologics” when describing the future, at least in terms of medical therapies. The world of basic science research has caught up to the fast paced uber capitalistic field of bioengineering, and we are now finding that man cannot design anything better at healing tissue, than the body is already capable of. So the current race has been focused on who can most effectively amplify the body’s own talents.

The best of modern science

The sexiest notion has always been that we can take stem cells, swirl them around in a cauldron with purple smoke spewing out, inject them into injured tissue and BAM! The stem cell transforms itself into a brand new tendon or cartilage cell, and the horse is like new again. In the decade or so since the research began however, it has become apparent that this dream is still a long way off, if it ever happens. But all is not lost. Because we’ve found that taking these cells and (plus or minus some fancy lab work) putting them in injured areas, really does have some benefit. It looks like there are some things going on there that we just haven’t gotten a full handle on yet. Are the cells themselves acting like conductors, and orchestrating who goes where and does what in the healing process? Or are there some other, non-cellular alphabets in the soup, that come along for the ride when the cells are harvested, and are themselves signaling (after being injected) to the body to speed up its healing process? Stay tuned.

And DOWN the stretch they come!!

PRP: If the stem cells end up being a dead end road, then what are the other important players that are actually doing the work (the alphabets in the soup)? We know that platelets (found in blood but not really cells per se) have a lot of different cool juices that get released when they “degranulate” as they bump into injured tissue. These juices are chemical signals that call out to other cells to start the healing process, like a biologic playground game: “Red Rover Red Rover, send TNF alpha over”. We routinely take blood and spin it down to concentrate

Stem Cells dividing to produce new cells

platelets, making Platelet Rich Plasma (aka PRP) before injecting it back into the body near injury. PRP has been used in a lot of humans and horses and does seem to be effective in improving healing for a lot of tissues. In fact, a few of us have started using it in joints; some joints that are pretty beaten up and need all the help they can get (traditionally IRAP joints), and some in the early stages of arthritis, in lieu of corticosteroids, which carry some risk. A recent study using rabbits, found that PRP caused cartilage to start producing its own glycosaminoglycans, which is what forms the spongy part of cartilage. So you inject a joint with PRP, and essentially cause the joint to start producing its own Adequan, if the research is accurate. I really like the idea of using the body to heal itself.

IRAP: The inflammatory process is like a marching band, with a whole bunch of instruments working together to produce something that is greater than the sum of the parts. Inflammation is the joint is regulated largely by Interleukin-1, which acts sort of like the conductor of the music. When there’s a lot of interleukin-1 around, all the instruments are playing loudly, and the joint is going to be inflamed and painful, because the interleukin key has opened the music-room door and allowed the other instruments to take the field. If we can block the lock so the interleukin key can’t fit, the rest of the marching band won’t be able to get out of the dressing room. This is where interleukin-1 receptor antagonist protein (IRAP) comes in to save the day. It just jams into the lock so the interleukin key can’t fit, and the other instruments have to keep it to a low roar. It is quite effective in minimizing pain in some joints.

If you can decipher this, they let you put letters after your name. Turns out, education isn't all it's cracked up to be

So here’s what it boils down to. Right now for arthritis, IRAP is standard, and lots of horses have safely been injected with it. That doesn’t mean that the other biologics won’t overtake it in the next couple of years, after we’ve had more time to play with using them in joints. For tendons, the argument between PRP and stem cells comes down to: PRP is less expensive and has known growth factors that stimulate healing, if put in the right area. Stem cells cost more, take longer to process, but probably carry more promise once the science has caught up, and there is some evidence that the cells might even have the ability to find their way directly to the injured site, if injected anywhere in the proximity. So what am I recommending? Talk to your vet. If they are good, they are spending a lot of time these days keeping up with research and talking to colleagues about what makes the most sense for different situations, including yours.

After my internship was over and before my next job began, I did a little stint covering a backyard practice in Virginia, while the owner of the practice went on an extended vacation. Her need for a long vacation should have been my tipoff. For the most part, the clients were really great people, who paid attention to their horses, would call a vet when there was a concern, and be genuinely grateful when you helped them. Occasionally in this type of practice though, you’ll come across people who really don’t take very good care of their animals and will only call in a vet when things have really gotten bad. And then you’re lucky if they have a couple pieces of plywood taped together to make a shed under which you can perform your highly sophisticated life- saving procedures. You can forget about power or running water. If you need electricity to take an x-ray, better hope they can pull the car out of the garage, so there’s room to pull the horse in.

The Act. Species have been changed to protect the innocent

It was in this position that I got called out by some people who lived just down the street from the office. The secretary said she hadn’t heard from them in years, but on this hot, sticky July day they decided their little paint horse behind the barbed wire fence had finally crossed the line. He had been losing weight, they couldn’t figure out why (even though the grass in their 200 sq ft yard had been grazed down to the dirt), and now he looked like he had a bit of a belly ache. So we tied him to the only post that still looked to be solidly in the ground, I got out the stethoscope and thermometer, and did an exam. My findings encouraged me to perform a rectal exam, to see if the horse had a bowel impaction. I, being the consummate professional, even in this less than idyllic setting and on a stifling hot day, was wearing my sunday best. So I donned the rectal sleeve, and clipped on a hemostat to hold the sleeve to my shirt at the armpit, so it wouldn’t slide down and allow feces to get on my nice clean shirt. I lubed up the fingers, inserted in rectum, and while pulling manure out of the colon, I found a large  roundworm in my hands. It was 12″ long, about as big around as a large earthworm, glistening white, where you could see it through the green stuff, and totally frickin gross. But I’m a calm, cool professional. So without moving away from the hind end of the horse, I took the opportunity to educate the client about deworming schedules, and how his weight loss and belly ache were probably caused by worm infestation. It was at that moment, when the worm was dangling from my sleeve- protected index finger, that the horse decided he was much more worried about the fly on the outside of his belly, than the worms on the inside, and swished his tail. Unfortunately, his tail made contact with the dangling worm first, which was swept up and onto my stunned face. So now I stood there, shiny boots, clean khakis, the sleeve of my pastel polo shirt carefully protected from a little bit of poop, with a 12 inch DUNG COVERED WORM plastered across my greenhorn face. And all I could do was laugh.

My teeth got a good scrubbing that night.

The Culprit, sans shinola

Served my self-righteous preppy butt right, I suppose.

“You know what it takes to be a successful horse trainer?” My boss asks, sliding a cold beer across the bar to me.

“No. What?”

He slowly raises his glass to his lips, then speaks out of the side of his almost covered mouth.

“Three things.”

He takes a draw off his longneck for dramatic effect.

“You have to have gray hair, be a good salesman, and be able to cheat on your wife without remorse.”

“Nothing to do with training horses?” I ask.

“Nothing to do with training horses.”

After I had dropped out of college to see what the racetrack was all about, the trainer I was working for gave me this little nugget. I was barely old enough to sit at the bar next to him, so this, like nearly everything he said, sounded like gospel to me. With a little time and lots of discouragement from wise folks to whom I am now indebted, I decided that vet medicine would make more sense for me than being a racehorse trainer. But I haven’t forgotten the advice I got that night. I’m not sure where the third tidbit fits in, but I’m quite sure the first two are good advice for becoming a successful vet as well as a horse trainer: perception is everything. You can be the smartest veterinarian ever to graduate, but if you can’t describe what you’re doing with confidence to your client, you won’t have any horses to work on. And you can be the most confident veterinarian ever to graduate, but without looking like you have some experience, they won’t believe you anyway. Gray hair and salesmanship don’t make you a more talented vet (well, the experiences that got you the gray hair are important), but they do make you more successful, as I’ve seen in my colleagues. This probably isn’t very different than most careers out there.

What is different from some careers, is the hours it takes to make a living. Like being a plumber, you can only make money when the phone rings. And your income is directly correlated with the number of hours you’re willing to work (assuming you’ve got the business, which means you have the gray hair and salesmanship parts down). Even more different is the inordinate amount of time you will end up spending with members of the opposite sex, either in the truck next to you for hours on end, or at their farms, sometimes late into the evening. Some of us are in other states or countries on a regular basis as well. It takes a strong person to be a horse vet’s spouse.

I come across a lot of people who say they dreamt of being a vet, but didn’t want to spend that long in school. Well I can’t blame them, because I wasn’t looking forward to that part either. But looking back on it, I had the most fun 4 years of my life in vet school. It turns out that living in a small town, and being forced to study all the time, with intermittent sessions of beer drinking (that part wasn’t required by the curriculum, but was by our therapists) is a great way to make really close friends. If I had known before that it would be so much fun, and I would make some of the best friends I would ever have, then I would’ve tried to get in earlier. Come to think of it, I probably shouldn’t have studied so hard. Maybe I could be on faculty now, and the fun would never end…

Some kids tell me they love animals, and their dream is to be a vet so they can spend their lives around them. My response to them is: don’t become a veterinarian. What makes a good veterinarian (not necessarily a successful one), is an intense interest in the medicine, not just an intense interest in the animals. Spending all day in front of a monitor staring at x-rays, or standing around in surgery all day dissecting tissue, has to sound like more fun than riding or hanging out around the barn. Otherwise, you’ll just get frustrated. If you’re the type of person who is turned on by learning new things, this profession might be for you. Which means you probably already have the personality for the four straight years of disciplined drinking and binge studying…I mean vet school.

I’ve always thought that experience, by itself, was an overrated virtue. The very best people at anything, are those who love what they do, and spend a lot of time trying to get better at it. I’ve known a lot of second and third generation horsemen. If all they ever knew was what they were told, but never went out into the world and challenged those things, I felt like they weren’t much horseman themselves. The same is true of many vets, who lost interest in learning new things, and have been practicing the same way for years. A gray haired salesman makes a successful vet, because he believes his own BS. But a great vet is one who never believes his own BS, regardless of his age.

Supplements

People often ask me what oral supplements I recommend for their horses. This is invariably after I just injected a joint or two, and their horse is still hanging in cross ties, groggy from the sedation. Before my eyes glaze over, and I start to look like their horse, I try to get out something along the lines of, “Spend the next 12 months saving that money, then you can pay me to put the medication right where it’s needed next year”. Then I slowly raise a finger and point at their handsome steed, at this point looking more like my victim, than something that could carry them into battle. Most of my clients recognize when I’m just makin a funny, and new clients usually pick up on it pretty quickly, due to my lack of a poker face. But it’s a serious question and it deserves a serious response, so I usually follow it up with a good visual that sums up my true convictions.

 I hold my index finger and thumb in the” I’m crushing your head” Kids-in-the-Hall pincer position, and say, “This is how much a difference oral supplements probably make in your horse’s soundness”, then I take both arms, straighten at the elbows to show the size of the fish I caught last week and say, “and this is how much difference you get from the training decisions you make every day.”

This is a good time to quickly summarize my feelings on the utlility of each product, before moving on to what really matters. If you want to know more, google Wayne McIlwraith. His group in Colorado are producing the most research these days on oral and injectable chondroprotectants in the horse anywhere. What follows is my slant on work they’ve done, colored by my experience. I hope some of my clients read this, so I don’t have to see them get glassy eyed in front of me when I try to explain it in person. Grab a coffee, here we go.

Wake me up when it's over

Chondroitin: a meta-analysis study (they take all of the research studies ever done, throw out the crappy ones, and weight the rest according to how well they were done, then combine the results) showed no real effect in humans. There’s no reason to think horses are any different.

Glucosamine: The same meta-analysis concluded that glucosamine also had no effect (no surprise- it basically does the same thing in the joint as chondroitin), but there was a trend that suggested that at a significantly higher dose there might be some effect. Trouble is, with horses a significantly higher dose gets kind of expensive, if fed daily. I suspect most of the horses I treat are on someone’s version of the above, (it’s pretty cheap to start your own supplement company, so there’s a ton out there) but I can’t tell when or if they take them on or off…

Omega 3 fatty acids: I still haven’t seen a lame horse go sound from it, but I keep trying. I like the idea of natural anti-inflammatory stuff. Just not sure it packs enough punch.

Unsaponified Avacado-Soy (ASU): McIlwraith’s group did a study and it showed promise, but in a lecture I attended during WEG, he said the source of the version they tested is now unavailable, and so he can’t be sure if the current product (Cosequin’s product) is equivalent. I don’t have enough experience with it yet to give it a grade, but it sounds promising

Adequan: I love what the company has done to promote equine sports. I have colleagues, equine and small animal, who say they really believe in this product . My experience has been a little less glamorous, but I’m a pretty hard guy to please; my clients vote with their feet if they aren’t winning. I have horses who live on adequan regularly (like once a week) that see me more often than other horses in my practice, who compete at the same level, but have never heard of the stuff. My advice is, if you can afford to use it on a regular basis, don’t hesitate; it might actually work a little bit. Just please buy it from me, because I’ve got kids that need to go to college.

Legend: Like Adequan, I’m not convinced that for the price you’re getting a huge long term benefit. One way I do use it though (like Polyglycan, which adds glucosamine and chondroitin for less money, but isn’t FDA approved), is just before showing, as in, within a few hours. Probably doesn’t go to the joint in significant quantities. It does pass through the liver though, which responds to it by releasing other anti-inflammatory products into the bloodstream, which can help optimize performance in a pharmaceutically innocuous way. The FEI has now approved use of Legend and Adequan within stable enclosures during competition, so everyone (myself included) is using it largely for the above purpose. Perhaps not in the spirit of the rules, but it certainly can’t hurt the horse, and may be a nice little Thank You to the sore horse who tries hard, since the FEI has decided it won’t allow other (even non performance enhancing levels of) pharmaceuticals to be administered between competitions.

now listen here, sonny...

So how do you really keep a horse sound? Simple: don’t do a lot more work this week than you did last week. It’s just that easy. In Kentucky we’re fortunate to have several championships that for some, are what they’ve been working all year toward. So the horses have accumulated a lot of miles, and in many cases, a lot of jumps. More of those jumps have often come in the last couple of weeks, in preparation (both horse and rider, often) for this finale, than were normally taken. In addition to this, many of the horses are also for sale, and this is the best venue in which to get them sold. So it’s like a perfect storm for injuries. And unfortunately- we see plenty of them. So if you have a horse leading up to a big competition, how are you to avoid this scary event? If the horse needs the miles, use your judgment and follow the not-a-whole-lot-more-this week than last rule. And if the rider needs the miles, find a school horse, even if you have to lease one. In my experience, the people who get in the worst trouble, are those who can’t afford the second horse, and aren’t willing to spend the time flatting the one they’ve got.

 I don’t make a lot of money in barns where they maximize the flatwork and minimize the jumping. Flatwork needs to include a lot of walking (it’s a gait too!), be done over good footing (too deep is worse than too shallow), and be done with a concerted effort to make horses work correctly: rounded spine, pushing from behind (yes, even hunters). Professional hunter and jumper riders aren’t always as good at this as they think, so I believe a little continuing education with a good dressage trainer (“eating your peas and carrots”, as my wife is fond of calling it) is a great thing to do.  Veterinarians, if we are to charge the public for treating their animals, are required to attend regular continuing education classes through our entire careers. If horse trainers are to charge the public for what they do, I think they should always be making efforts to improve themselves, by learning from their colleagues. Their clients deserve it; their horses deserve it.

From diapers til 12, my dream was to be a jockey. I grew up in Nova Scotia, where the only horses around were the Standardbreds that were too slow to make it on the local bush league tracks.  We lived too far from town to do much after school, but get off the bus and run to the pond to see if the ice was skateable . My only respite from the depression of what seemed like the last outpost of equine civilization, was the monthly anticipation of that which sustained my dreams: the arrival of The Bloodhorse magazine. I guarantee I was the only subscriber in the province of Nova Scotia, even though I could barely see over the counter at the $2 windows. Slowly pouring over those pages, I filled my head with stats of breeding stallions, names of stakes winners, and burnished the images of faraway Kentucky farms. As my older brothers had mockingly predicted, I soon grew too large to ever make jockey weight. In a tragic twist of fate, I eventually also stopped growing just in time to end up 0-for Tall, Dark, or Handsome. But that’s another story. This one ends with me moving to Kentucky for college, taking jobs on Thoroughbred farms and the racetrack, and eventually ending up in vet school. I became a veterinarian because I wanted a horse job that offered some financial security, and would make me use my brain a little bit.  After riding with a couple vets, I knew the medicine was something that I could sink my teeth into. And so far, it has been a fun career.

I never had the opportunity as a kid to become any kind of a rider. And for me, the connection to horses really wasn’t about throwing a leg over, and feeling the wind in my hair. I had a Schwinn bike that was pretty good at that, when you pointed it down a hill. Instead, for me the connection was just about being near them: the sounds, the smells, the feeling. My first job ever was to clean stalls and set feed for a lady down the road who had a couple horses. She paid me $1 a week for doing that every day after I got off the bus from school. I asked her for a raise one day and she told me she couldn’t afford it. True story. I kept doing it anyway, of course. I would’ve paid her for the opportunity to hang out in her barn and smell her horses. For some reason, she had a poster of Cheryl Tiegs in a red bikini on the wall above her feed.  I liked that part of the job too. In the summers I helped local dairy farmers put up hay, and saved enough money to buy my own horse at 12, that I showed in 4-H. I showed English, but only because it was closer to a jockey’s style saddle than those big western saddles. I figured that choice would be instrumental in helping propel me to the winner’s circle at Churchill Downs.  I ended up getting interested in other things, as young men have a way of doing, and sold my horse before anyone showed me how to get a lead change, or do anything else of real value on the back of a horse.

Fast forward a couple of years (decades), and I had become a show horse vet (racehorses were the dream til I saw how much divorce lawyers make). I was lucky enough to be married to a woman with a beautiful smile and patience for me. She makes her living riding and judging show hunters, which is fortunate, because it allows us to understand each others schedules without competing with each others’ egos. We produced two beautiful, tempestuous little boys, and I was pretty darn happy in spite of them. Other than the usual life concerns  and a couple more good weather days to fish, I wasn’t feeling like my life was missing anything. And then one day I got on a polo pony.

mixing business with pleasure

 The first time was just silly fun; I giggled the whole way through. But then I was asked to come back, and I started to make a habit of it, because if I could just work on my swing a bit, I could really hit this ball… And learning new things is one of my absolute biggest turn ons as a human being. So I’ve kept coming back, and my riding has slowly gotten better, and I’ve found that I can go a little faster and still stay on. And as my game has sped up, I’ve noticed that my horse is reacting to the ball as much as to me. If I would just let go of the handbrake, she’ll go to the next ball as fast as I’ll let her. And if I want to stop, and turn left or go right, she is right there with me. Doing whatever I ask her to do, but anticipating the next play. Not just because she is broke, but because she loves it too. She’ll run her heart out, then stop on a dime. Then take off and run again if I ask her to. And after years of making my living around horses: yearling  groom, hotwalker, racetrack groom, vet assistant, veterinarian, for the first time ever, I had a new level of appreciation for these animals. Not just this addiction thing of being around them, while focusing on the medicine. But of truly appreciating them in the moment, doing what they’re really amazing at. And feeling them give to you all they’ve got; ripping their heart out and handing it to you. You see racehorses do that and it’s incredibly moving. But I never before felt the amazing connection of feeling like they are doing that for me. What a gift, to have an animal do that for you. But what an incredible responsibility too. A good horse will lay down its life if we ask for it. We should reward their bravery with kindness

From the title, you might think this is a tabloid article about who’s sitting at whose table at the latest charity event. I’m actually talking microchips… in horses.

Straight from the horses mouth!

Unless they’re crazy famous, most horses in the sports world get handed around like foster kids, with occasional name changes along the way. Hiding its history works out really well if a horse needs to get sold but is always on the injured reserve list, or has a Charlie Sheen reputation. And while I’m on board with the whole Christian- every- horse-gets-a- second- chance ethic, it certainly isn’t good for the long term health of our industry when new owners find out they got the short end of the horse- deal stick. The industry relies on a regular influx of people with deep pockets, who are willing to trust others to do the right thing with their money. Like most fiction, buying horses is best enjoyed when starting with a “suspension of disbelief”.  But it’s a small world, horse people like to talk, and raw deals usually end up getting found out. And when they are, we often end up losing another customer to boys, or college, or some other lame excuse given by parents who are tired of getting screwed by the unscrupulous. We are doing ourselves and our industry a favor then, when we act with transparency. Being able to reliably identify every horse that is for sale, and know its entire show history may sound like a bad idea, but can end up being good for all of us.  So there’s my “what microchips can do for you” spiel.

Now that I’ve talked about you, I want to talk about me.

Microchip

Unlike racehorses, most sport horses have pretty long careers. We would have the luxury of seeing the long term results of what the vets are doing, if we were better at tracking down the complete show record of horses that we had treated in the past. Having objective data (how many times the horse showed at a rated horse show), versus subjective data (questionnaires of owner’s opinion of how the horse is doing) is significantly stronger science from which we can draw conclusions about what we are doing. We could study results for a specific treatment (shockwave vs. stem cells vs. rest for injured suspensories) that would help us make much smarter decisions about what to do today with the horse that is in front of us. In the thoroughbred world, it wasn’t very hard for researchers to go to an auction, find a bunch of yearlings with OCD chips, then call up the Jockey Club a couple years later, and check race results for that group of horses. Then researchers were able to compare the racing success of that group, against horses who did not have these bone chips. Guess what? The chips didn’t really matter (a quick foray back into “news that’s good for you” territory). If we were able to call up the USEF and just as quickly see the performance record of horses who were given a particular x-ray or ultrasound diagnosis (the USEF wouldn’t have a clue what we were studying, so confidentiality would be strictly maintained for each horse), we could find out how long most of them were actually able to compete, and at what level of competition. This research would be especially useful when applied to the prepurchase situation for example. It’s not uncommon to find a sound horse with a questionable x-ray that doesn’t really bother us personally. But we caution our clients that when they eventually go to sell the horse, the next vet might not be so forgiving of the x-ray. This lack of data has created a vicious circle that has killed plenty of solid horse deals. Lots of great information could be uncovered that would help us all. We could examine effects of footing, therapies, and intensity of show schedules on long term results for horses. But first, we need the ability to easily track these horses through their entire careers so the info could flow.

Measurement

I have confidence we’d find that some of those things that scare us now, wouldn’t make us so nervous after we looked at accurate data. No one wants to buy a horse older than 12, but there are a lot of horses in their late teens and twenties who are trucking right along. And I love it when I come across a horse that had a soft tissue injury years ago, that undoubtedly was given a grave prognosis by the first vet that saw it. But now years later, the horse has had a long and great career. The body really can be resilient, if tended to properly.

A handful of years ago the American Horse Council was doing some groundwork to see about getting more horses microchipped in this country. The USEF was talking about it too. Not being on the inside for either conversation, I’m not really sure why the issue died, but I’m disappointed no one is talking about it anymore.  Can anyone out there tell me why it died? And can anyone give me one solid reason why we aren’t willing to spend less than a hundred bucks on permanently identifying horses that are worth more than my house?