DDFT in the hoof

[horses99]

Thank you for all your comments I am so pleased good or bad to have some conversation on this topic. I spoke to my vet again she gave him less than 5% chance of coming sound enough to go back to work. I have contacted Rockley farm I love my boy and will give him every chance if everything fails then I tried my best but he is the sweetest and most loving I have ever met. I am waiting for Rockley to get back to me and see what she says... meantime in response to some comments the wedges are temporary and then he is to be in the field likely barefoot at which point later on he could go to Rockley. He has such a large legion my vet advised a year to heal + injection to bursar just before a year to test soundness either way i will investigate Rockley and see what happens trying likely both who knows depends how he reacts. The biggest issue is re injury not just being sound.

 

[Ample Prosecco]

What do you mean by 'weren't that good'? People don't only publish 'good' stuff. Now funding, that's a whole different issue.

I don't think a controlled crossover trial would be appropriate really.

A vet from Leahurst was already working with them on a research trial. So ethical approval, funding etc all sorted. But they never published. I am assuming because in the end there were no significant differences between the groups and non-findings often get bottom drawered and not published.

 

[Ample Prosecco]

Horses99 good luck. I hope it works out for you.

X

 

[ester]

I know, I found the thread from 7 years ago where we were all saying very much the same as we are now.

I'm trying to check if that was ultrasound

 

[ester]

found it for anyone interested

'
Project Dexter

For those who are interested, the synopsis for Project Dexter, our research programme (for want of a better word), is below (and has been available for years to anyone who asked for it!). It was devised in, as I recall, 2009 with the help of Prof. Peter Clegg at Liverpool University.

"Project Dexter is a proposal for research into the rehabilitation of horses who are included in one of two categories:

1 horses where magnetic resonance imaging (“MRI”) of the affected limb has indicated lesions to the deep digital flexor tendon (“DDFT”) proximal to the navicular bone; or
2 horses with a clinical history of lameness over at least [3-6 months] where lameness is abolished or significantly improved (more than 50%) by perineural analgesia of the palmar or plantar (abaxial sesamoid) nerves.
These criteria will be demonstrated by the referring veterinary surgeon’s diagnosis, local analgesia, radiography and MRI.
The horses in the study will have received a variety of treatment prior to entering the study, but none will have returned to full work as a result of that treatment. This will be demonstrated by a questionnaire to be completed by the horses’ owners, in the form attached.
Background
In a recent study (Dyson et al, EVJ (2005) 37 (2) 113-121), horses diagnosed with lesions to the DDFT or damage to the navicular bone or distal interphalangeal joint (“DIP”) had a guarded to poor prognosis for return to full competitive work, with the majority (72-95%) failing to return to full work after treatment. The prognosis for horses with injuries to both DDFT and navicular bone was extremely poor, with 95% failing to return to full work.
Experience at Rockley Farm has indicated that very often it is possible to achieve significant improvements in soundness in horses showing similar patterns of lameness using the rehabilitation programme set out in section 2 (“RP”).
1 Research Question
Can the RP deliver a significant improvement on the previously poor prognosis for horses with these two types of lameness?
2 Methodology and rehabilitation
RP will be carried out at Rockley Farm. Horses within the RP will have their shoes removed and will be kept on supportive surfaces to maximise comfort levels and encourage movement.
All horses included in the RP will be fed a low fructans, high mineral diet and ad lib forage.
Horses within the RP will be exercised only on surfaces on which they are able to move soundly, but provided this criteria is met, exercise will be used as an important part of the RP.
3 Assessment criteria during and after the study
Before entering the RP, each horse will be assessed by his or her referring veterinary surgeon using the baseline lameness assessment protocol and using the information provided by owners, both in the form attached.
To provide a consistent comparable, each horse will be assessed by the same vet, in the same location, using the same protocol, at the beginning, end and, if possible, during participation in the RP. Owners will also be asked to provided feedback replicating the original questionnaire to document the horse’s return to work, or otherwise.
For horses in the first group, repeat MRI will be undertaken to assess whether previous DDFT lesions have improved. For horses in the second group, the referring veterinary surgeon will be asked to repeat the lameness assessment as far as possible in the same location and conditions as the original lameness assessment.
Each horse will be filmed using high definition frame by frame footage, to assess footfall (ie toe first/flat/heel first) and limb loading on the date of entry into the RP. This footage will be replicated on a monthly basis for each horse.
Still photographs of each hoof will also be taken, with external measurements,showing lateral, dorsal, solar and palmar views, to allow for assessment of hoof capsule changes throughout the RP and will be replicated on a monthly basis for each horse.
Follow-up information will be gathered from owners as to how horses that have responded well to the RP continue to perform.
4 Case control study
A control group of horses will be selected on the basis of case control study, using horses referred to the Unversity of Liverpool’s Equine Clinic at Leahurst, who fall into one of the two selection categories above, on the basis of the clinical assessment at Leahurst.
Control group horses will receive a range of treatments, but none will be included in the RP. Treatment outcomes will be monitored using the veterinary and owners questionnaires attached, supported by photographic and video footage as for the RP."
Rehab and research results

To date there have been over 70 rehab horses included in Project Dexter (I have no details of the control group at this stage). The last update on our results was done in February 2012 (full text below) and a new update will, I hope, be available later this year.
The 2012 update was compiled with the help of Emma Watts, an owner who also has a background in veterinary research, and was submitted to the BEVA congress last year in their required form (a 300 word abstract of preliminary findings). The full blog on that update is here but for whatever reason, it wasn't accepted by BEVA.
"Palmar hoof rehabilitation: a means of increasing soundness in horses with DDFT/collateral ligament injuries within the hoof.

End of part 1 as forum says too long!



Must go to bed though, or people will be waiting for their results in the morning

 

[ester]

part 2
Aims: To assess whether a specific rehabilitation protocol which improves palmar hoof development and medio-lateral balance provides a comparable/better prognosis for long-term soundness than current treatments. Methods: Forty-four horses with a history of more than 12 weeks forelimb lameness that was abolished/significantly improved by palmar digital nerve block were rehabilitated over approximately 12 weeks. Shoes were removed and horses kept on surfaces which maximised comfort and encouraged movement (including shingle and sand). Free movement on these surfaces was encouraged. Diets were low in sugar/starch with balanced minerals and adlib forage. In-hand and ridden exercise on varied surfaces formed an important element of rehabilitation. Palmar hoof development and medio-lateral balance were regularly monitored with photography, using video footage to assess foot placement (toe-first/heel-first). After ~12 weeks, horses returned home to continue a normal exercise programme. Results: Forty-four horses (aged 5-19yrs) were enrolled with 35 programmes completed and 9 still ongoing. Of the 35 horses who completed, 30 have since been maintained at the same level of work or higher than before their diagnosis, 4 improved but did not return to full work, 1 had rehab interrupted by colic surgery and is in light work. Improvements in palmar hoof development occurred relatively rapidly, with most horses’ landing changing from toe-first to heel-first within 2-6 weeks. Soundness on hard surfaces and on circles typically improved once this landing was established and palmar hoof development also improved with exercise on varied surfaces once horses were landing correctly. Conclusions: Horses with palmar foot pain may benefit from therapeutic rehabilitation which improves palmar hoof strength and medio-lateral hoof balance. Practical Significance: This type of rehabilitation may improve the prognosis for long-term soundness in horses with similar diagnoses. Acknowledgments: Constructive advice from Prof. Peter Clegg; Jeremy Hyde BVetMed MRCVS."
Assessing the effect of rehab
The only way to truly assess what is happening inside the hooves of the rehab horses is with MRI. If money were no object then every horse could undergo MRI before and after rehab; the reality is that to do this would cost £2000-3000 per horse - which is way more than rehab here costs. Naturally, no insurance company will fund MRI on a sound horse so without research funding we won't get follow-up MRI.
Its a problem that faces conventional therapies and remedial farriery as well, of course. There is as little research to support these as there is for barefoot rehab and I am not aware of any studies into palmar hoof pain where horses have routinely had follow-up MRIs even though this would be the veterinary "gold standard".

The veterinary profession is required to practice evidence-based medicine - something I blogged about in detail last year - but this is a broad onus. A famous article (Sackett, D.L. et al (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312, 71-72) on evidence-based medicine makes this clear:

"Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.
...Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the “gold standard” for judging whether a treatment does more good than harm.
However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external evidence and work from there."
Last year my own vet and I spent some considerable time (and quite a lot of my business' money) on using ultrasound on rehab horses in an attempt to identify a way of measuring soft tissue changes in a reasonably cost-effective way. We were unsuccessful, as its just not possible to get clear enough ultrasound of the DDFT within the hoof without some pretty drastic cutting of frogs, which would clearly be counter-productive for the soundness of our rehab horses.

Facts, evidence and reasons for blogging
I've talked to dozens of vets (including the referring vet for each horse who has come here whom I also update about the progress of the horse) and I've found most of them to be both interested and supportive even though, as I've blogged before, many have a curious view that shoes are "normal" and barefoot is not!

Meanwhile, I continue to find rehab horses and their hooves endlessly fascinating and I will continue to post blog updates so you and everyone else can draw your own conclusions.

The blog isn't an attempt to take the place of research, its just a factual record of how hooves are changing, how horses are moving and the work they are able to achieve, often despite being given poor prognoses for recovery. Its evidence, not research - but then I'm a lawyer, not a scientist ;-)
Posted by Nic Barker at 08:00 11 comments:
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[Ample Prosecco]

My phD was meant to be proving a new experimental treatment was better than treatment as usual in the field of addiction. I and the experimental folk all believed in the new approach. They got fab outcomes anecdotally. But in the end it was a non result - no differences. Gutting on a professional level but gave me a real insight into how successes shrink as you level up the playing field with robust controls and good randomisation. The phD was published but no papers came out of it as it was of no interest to any journals.

 

[ester]

Or in my case when you take them off an agar plate and put them in the product

 

[Ample Prosecco]

Cross posted with Ester. Well done for finding that! I will read with great interest tomorrow but I'm going to bed! I would be very happy to be wrong on this!!

 

[ester]

will leave this link here too as Nic posts on it. https://forums.horseandhound.co.uk/threads/we-all-want-barefoot-research-except-the-beva.534691/

 

[SEL]

SEL it can be difficult if they don't move enough. The one barefoot horse I one who got a ddft injury had far too little turnout or work during one winter, then a hooley in the field in spring, and it went bang. Thankfully Leahurst blew all the insurance money on diagnostics and the owner no longer felt the need to follow the vets advice, which was bar shoes and extensive medication. He went to Rockley instead and was sound in 8 weeks.
.

I've a feeling it's been building up for a while - but with all her other issues it looked like a straightness problem rather than obvious lameness. Horseback and Osteo vet would straighten her up, she'd come sound so the primary issue was thought to be hind end

Roll forward to Feb when she had gel in her hocks, a small amount of steroid in her SI and suddenly it's much more obvious. I suspect a hooley in the muddy field when 2 horses got loose didn't help!

So I'm praying for a dry winter where they can stay out for as long as possible. Deep mud will probably finish both of us off I think!

 

[ycbm]

A vet from Leahurst was already working with them on a research trial. So ethical approval, funding etc all sorted. But they never published. I am assuming because in the end there were no significant differences between the groups and non-findings often get bottom drawered and not published.

Since the anecdotal recovery rate for barefoot rehabs far exceeds the anecdotal recovery rate for conventional treatment, which is pretty much all the evidence that is available for either, I'm absolutely certain that it wasn't dropped because there were no differences.

If you are still researching what would be best for Amber, you could do worse than ask Michen for her vet's contact details and have a chat with him, I believe he is a strong advocate of barefoot rehabs.

I'm not trying to persuade you AE, you're between a rock and a hard place with a condition given a low probability of return to work and a set of experts who you have to trust or go it alone. If you're insured you have little choice. It can be a hard and lonely path to rehab your own horse. The good thing is, if conventional treatment fails, a barefoot rehab will often still work later on.
.

 

[ester]

Michen's vet did think it was a bit woo and had written a horse off before it went to Rockley and was rather interested by the results (I went to an open practice evening at one point where he spoke, their farrier was there too with a demo horse for remedial shoeing, his eyes rolled round in his head when the owner asked for road nails).

I think I've missed the news about Amber.

 

[Ample Prosecco]

Thanks for the links Ester. That was very interesting and the number of horses returning to former levels of work is encouraging. I'll send the abstract to my vet and see what he thinks. I don't really buy conspiracy theories but I do think new approaches just don't always break through as quickly as they should.

 

[Ample Prosecco]

I think I've missed the news about Amber.

Amber went lame in January. 3rd lameness episode since she twisted a shoe off in September and my vet believes that was the original cause. Blocks showed the pain was in the hoof and xrays were consistent with DDFT injury in hoof. She is field sound and sound in straight lines but the most recent work up showed still lame on that hoof on a circle. We are treating with shoeing by my own farrier and rest: initially box rest till she was sound in walk & trot in straight lines, then field rest. It's not making any vet any money! I am giving her at least a year off then we shall see. My vet believes time is the most useful treatment. But I appreciate this is exactly the kind of presentation RF see and I'd love to believe they had another avenue to try. Which is why I looked into them in the frst place but could not find the info you managed to uncover. So thanks for that. I am not picking holes in their evidence base for the sake of it. I'd love noting more than a more hopeful future for me and Amber than I am currently facing.

 

[SEL]

I have a tendency to obsessive googling when anything goes wrong with one of my horses & the current 3 have given me plenty to go at. I've never been precious about having shoes on or off the appaloosa but she is very, very tricky to even be trimmed so we would IV sedate if she needed shoes. Because of that (the stress and the cost!!) when the vet x rayed and found the navicular damage I really did want to see whether the barefoot rehab - for a horse who had always been barefoot - was an option or I needed to shoe. My friend has had a virtually identical diagnosis in her TB except he is insured and therefore she is going down the remedial shoeing route.

Google basically showed me that there was no guarantee of a return to soundness either shod or barefoot. In fact one of the founders of a 'barefoot for navicular' FB page has a horse who just hasn't returned to soundness and they can't see why. What I did find though were many, many owners who had been through the remedial shoes rehab, it had failed, and they were now going down the barefoot route with more significant improvements. So I thought I might as well just crack on with barefoot and see how she goes.

In a straight line off the stones she's now sound in walk. A good heel first landing and striding out. She had a bit of a silly moment in the field yesterday and for the first time in ages took right canter lead (its her right fore that shows damage and she has been avoiding that canter lead). Thankfully still sound today. Trot up for the physio last Friday and we did have a head bob so its still walk, walk and more walk. In order to get to that level of soundness the farrier has had to take a deep breath and let her keep her flare and wonky feet.

My yard facilities are the biggest frustration and that's not their fault! Our arena is too deep and our hacking involves a good mile on what has become a ridiculously busy road. If I can manage a big lottery win this weekend then I would try and build a track system of some description because I can really see how it would help. It is much tougher when you can't copy Rockley's facilities

 

[fairyclare]

My mare was 19 when she tore her DDFT, misdiagnosed by the vet as laminitis (WTF???) she was a little tubby but that was it! I got the weight off her, did all the pads, packing special shoes etc - lame, lame, lame.
Insisted on an MRI and hey presto, torn DDFT with scar tissue, the shoes were off because of the MRI so after a very heated discussion with the vet I sacked off the ridiculous priced shoes and started her on a barefoot rehab - sound!
She is 27 now and is still sound.
My farrier has been utterly amazing with her, he told me in the first place that he didn't think the shoes were the answer but as it was all on insurance it was a bit of ' we'll try it once'.

I did contact Rockley but its a 5hr drive in the car for us so I decided to try myself at home first, which worked well for us.

 

[Goldenstar]

What’s out of fashion atm is giving horses a period of enforced inactivity followed by small space turn out followed by a long rest in a large not lush field .
Not a lot money to made trying that .

 

[SOS]

Wow just popped back onto here and this has turned back into some debate!

For anyone’s interest on my previous (the first) post on my personal experience, I was recommended to have rolled shoes put on him. I had his shoes taken off a few weeks into box rest, he then was barefoot for the whole time he was out. When returning to work he was sound ridden on grass but any stoney tracks would have him pottering on them, so I put front shoes back on and he was much happier. The field he had been out on was a huge, steep hilled, rough and at times stoney place. But perhaps with further introduction to stoney ground he would of got used to it barefoot...

What’s out of fashion atm is giving horses a period of enforced inactivity followed by small space turn out followed by a long rest in a large not lush field .
Not a lot money to made trying that .

This is exactly what we did with my horse and what I was recommended by my vet and Rossdales.

 

[sbloom]

Wow just popped back onto here and this has turned back into some debate!

For anyone’s interest on my previous (the first) post on my personal experience, I was recommended to have rolled shoes put on him. I had his shoes taken off a few weeks into box rest, he then was barefoot for the whole time he was out. When returning to work he was sound ridden on grass but any stoney tracks would have him pottering on them, so I put front shoes back on and he was much happier. The field he had been out on was a huge, steep hilled, rough and at times stoney place. But perhaps with further introduction to stoney ground he would of got used to it barefoot...

I think many would argue that hoof boots for one hour a day when hacking on stony tracks, could be a better option than shoes 24/7. There just isn't enough emphasis on HOW to keep horses sound without shoes, when you have a hammer anything looks like a nail (ie put shoes on if you hit a tricky bit). Every horse is different and there are some, for sure, who do end up having to be shod. The brilliant farriers that have gone 90%+ barefoot are looking mostly at the newer composite and plastic shoes where they do have to be used, fascinating stuff.

 

[ycbm]

I have a bottle of champagne in the fridge for the day that they finally put trimming, booting, and managing working barefoot horses into the farriery syllabus!
.

 

[BBP]

I *think* I’m starting to see some improvement in the heels on mine in the last 2 months. (Not a ddft injury but chronic suspensory). Mine is a horse that has always been barefoot but always had very low heels behind so now I’m making a concerted effort with a new trimmer to improve the heels, bring back the toes for easier breakover and use of boots with pads during turnout to encourage as many reps as possible of a heel first landing, to develop his own digital cushion and stimulate more heel support.

 

[SEL]

I *think* I’m starting to see some improvement in the heels on mine in the last 2 months. (Not a ddft injury but chronic suspensory). Mine is a horse that has always been barefoot but always had very low heels behind so now I’m making a concerted effort with a new trimmer to improve the heels, bring back the toes for easier breakover and use of boots with pads during turnout to encourage as many reps as possible of a heel first landing,

Can see a real improvement on the view from behind. I need to get better at taking progress photos.

 

[ycbm]

I *think* I’m starting to see some improvement in the heels on mine in the last 2 months. (Not a ddft injury but chronic suspensory). Mine is a horse that has always been barefoot but always had very low heels behind so now I’m making a concerted effort with a new trimmer to improve the heels, bring back the toes for easier breakover and use of boots with pads during turnout to encourage as many reps as possible of a heel first landing, to develop his own digital cushion and stimulate more heel support.View attachment 53133View attachment 53134View attachment 53135View attachment 53136

BIG progress!

 

[BBP]

Can see a real improvement on the view from behind. I need to get better at taking progress photos.

I’m utterly obsessed with photographing and slow motion videoing everything now! His feet, his standing posture plus close ups of his eyes, nostrils, face, that show the change in tension and pain in him.

 

[BBP]

BIG progress!

So glad you can see it! ? Never sure if it’s me seeing what I want to see. This is from wearing boots and pads 23/7. He is now down to 12 hours out of 24. He spends 12 hours boot free on a grazed down grass track with plenty of movement, and the other 12 booted on a hard standing and sand turnout area. I would leave him booted on the grass but the ground is hard and the boots lose grip when he decides it is a racetrack (he hasn’t read the rehab manual). I’m really pleased at seeing small changes so quickly, on a horse that has never worn shoes.

 

[BBP]

Difference in side on is easier to see when I mark them up.

 

[BBP]

Something my osteopath said was the lightbulb for me. It’s all about good repetitions. So if the horse takes 24000 steps a day and is booted with pads for 1 hour, that’s 1000 comfortable steps vs 23000 where he is uncomfortable and reverting to his usual movement pattern. If I can boot and pad for 23 hrs, that’s 23000 good steps for every 1000 bad. So I should see changes more quickly than if I only boot for an hour a day.

 

[lme]

After intermittent lameness, our 12yo mare had an MRI in May and was diagnosed with navicular bone damage and DDFT lesions.

The Vet hospital advised not putting her back into work but thought she was a good candidate for a career as a brood mare. They recommended wedges and pads and a steroid jab but also said we ‘could try taking her shoes off / letting her build up her heels’. Our farrier wasn’t keen to put shoes back on (especially if she was going to be put in foal) so we left her shoes off.

We put her in foal, slowly increased turn out and she’s now now out full time on a large hilly field with a small mare herd. If she likes being out full time, we will leave her out until winter, when she will come in at night. We’re keeping her on a 6 week trim cycle and she is on a progressive earth foot supplement. 3 months in she’s doing well. We had an equine podiatrist come and look at her to advise on hoof boots but were told she doesn’t need them.

We did contact Rockley (our vet also spoke to them and was very impressed) but they advised us not to send her there in foal as their rehab requires a horse to be in work and she would not have time to rehab fully before needing time off. If all goes to plan (a big if) we will re-evaluate once the foal is born.

I am wondering whether one of the reasons for a full study not being published is the cost of MRIs. From what my vet told me, the MRI machines are not owned by the vet centres and there is a high fixed cost for each MRI. Would this make it prohibitively expensive for even a university that ‘has’ an MRI machine to do a study that included follow up MRIs?

 

[Gloi]

I spent yesterday afternoon watching this and now will be obsessively recommending watching it to everyone with a horse with this type of problem.