Vets - pain medication as a diagnostic aid. . ?

TarrSteps

TarrSteps

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I know there are a few vets and some other educated type folks on here so am just having a general musing.

We all know about the relative use of "bute trials" for diagnosing unsoundness and other discomfort issues that may impact on performance and behaviour. I get the feeling it's falling out of favour, although I don't really see the reasoning (other than that it's hardly hard and fast) in situations where the discomfort is not obvious enough or in a location that might easily respond to blocks.

But what would be the risks associated with using a single does or even a short course of something like flunixin, ketoprofen or even Tramadol if/when it gets approved, under a vet's approval combined with a thorough assessment, preferably gait analysis, strike plate measuring etc. SOME vets seem quick to say that a performance or behavioural issue can or cannot be the result of discomfort, often in cases where there is nothing obvious, but why do we not diagnose further before resorting to very specific tests?

I have no agenda for asking, I'm merely curious as to what vets are taught and advised professionally. Obviously there is the risk of further injuring a medicated horse but then we are quite often told to keep on and see what happens, or work a horse through shoeing changes, neither of which are much different.

Thoughts? Again, I have no agenda. I'm just curious why, when you have those conversations where someone says "pain" and someone else says "brain" there is not an immediate resort to a relatively definitive test.
 
I'm not a vet but I still use bute trials if any of mine are/were not right. The most recent example was when I gave my lad a couple of sachets of bute when he wasn't going forwards in right canter despite his trot/lateral work being ok. He felt better so I got my back lady out and it turned out he had tweaked a hamstring.

I think it's still a useful tool in figuring out whether a horse is actually in pain, problem you have is finding out where that pain is!
 
Tarrsteps - often further definitive diagnostics are not used straight off for financial reasons. In some cases there is no single diagnostic aid that will definitively diagnose an issue. Some cases are much more complicated and require ruling out - which could involve multiple diagnostics - all of which cost money and many of which require hospitalisation which may not be an option for the owner.
Vets are not in the same fortunate position as doctors are to be able to run through the entire list of available diagnostics in the hope that something will crop up - usually people have financial limits.

However, in most cases, professional competitors, racehorse trainers and the like go straight for the definitive option - where financially viable of course! It is far more pleasant to do this sort of work IMO. Bute trials have their use where money or facilities or client compliance may be an issue.
 
Thanks for the thoughts. I guess my question was more though, in a situation where the 'symptoms' are behavioural rather than obviously mechanical, why does there seem to be increasing reluctance to use an NSAID trial when that could help prove or disprove the opinion. After all, if you take a horse displaying an undesirable behaviour or way of going, fill it full of pain meds and suddenly it improves, that seems to be a good reason to start investigating not just assume the horse is being difficult. Is the objection of vets ethical or medical? Are the risks higher than I think?

This comes following a number of horses that were deemed to have attitude/training problems by their vets byr actually turned out to have physical issues. By the same token, sending a horse to be worked up before finding out if pain is actually the cause of the problem seems equally odd.
 
TS, many of the horses that are coming to 'us' as a veterinary referral centre, with behaviour or performance problems, have already had a bute trial. Some of these horses have apparently had 'worsened' behaviour on a bute trial - yet have come to be worked up and do have lameness issues. Equally horses that hve had improved behaviour on the bute trial also have lameness issues. Therefore I would agree with you that it is certainly not 'hard and fast'!

I don't think any of the vets that I have spoken to have any issues with a bute trial as an initial diagnostic tool - but if it does improve behaviour the whole process of diagnosing 'why' is still going to require extensive investigation.

As regards blocking, it is possible to block SI joints, individual vertebrae, and pretty much most joints within the legs including shoulder and stifle. So for a precise answer as to 'why' blocking is still likely to get the best accuracy so long as you have a vet who is capable/willing to block in difficult areas.

I don't really see why you would want to use a stronger NSAID as a diagnostic tool?? Equally I know vets who would say that there are very few training issues and most things do have a root cause of pain - just maybe so low grade it is near on possible to diagnose properly.
 
Sorry Tarrsteps, I had misunderstood your original post.
I have found that most behavioural problems are indeed pain related ... Or at least WERE pain related. Napping ime often isn't. I can remember doing a bute trial on a horse who carried his head in the air in canter only - diagnosis was sacroiliac and bone spavin. And another who grinds her teeth only on one rein and only in trot- blocked out to one hock - juvenile djd. And a third who refused to go into the corners of the school - blocked to stifle - and had surgery for a subchondral cyst. Modt recently, the horse who could not trot in hand and owner reported as dull and asked for a visit for blood test. Two weeks on a bute test and he hasnt been lame since!! And then there was the one who bucked out on hacks and refused point blank to move - at all(!) in the school. That one was taking the utter piss - after zero response to bute trial I rode him myself and he showed off his beautiful paces. He was sent away for a couple of weeks schooling and he and his owner are successfully competing now.
I currently have a horse with mild narcolepsy type symptoms on a bute trial - his problem does not appear to be painful.
 
I should add that with many of the above, when I say blocked out - these horses did not display ANY lameness even under work up conditions. I mean blocked out as in the sign that we were investigating ceased completely.
 
Thanks again for your thoughts, folks. I think I'm just feeling a bit frustrated, not by any particular case, but by a small succession of situations where vets have point blank told owners that the problem is training/behavioural. not medical, without doing any further investigation and then, when pressed, have offered a full diagnostic work up as the only correct course of action. It seems to me their might be stages in between! In one case the horse stopped spooking entirely on bute (only agreed upon after some forceful discussion) and the vet was adamant it must be fluke as pain would never be demonstrated that way! (In two cases, the horses were vetted at purchase, already showing signs of the behavioural/training weaknesses which later were traced to pain, and still under the care of the same vet.) But I also could just be hitting a bad patch! I was just wondering if I had the wrong end of the stick and for whatever reason, vets are being dissuaded from doing bute trials.

My question about stronger pain relief was more of a musing. IF we could thoroughly and reliably block out pain in ANY AND ALL areas initially and then test the horse by riding, gait analysis etc. and compare to the pre medicated state that would be a pretty definitive situation! Then the next step would be to narrow the focus. I agree we can pretty much presume the majority of horses presented for diagnostic work up DO have some pain, although I also think if you look, you will find, and you cannot be completely sure that the weakness or pathology that's found IS actually the cause of the behaviour. Even after, if a horse has had x weeks rested all sorts of issues MIGHT resolve in that time, besides whatever is being actively treated.

Interesting you say about the horse doing a bute trial and then never having another problem . . . in my dim and distant youth, in a less proscribed culture, it was fairly standard for some remedial trainers to medicate new horse almost as a matter of course, the feeling being that even if they did not hurt coming in, the changes in demands would make them hurt. Debatable ethics, to be sure, but a different time and place. I'll even admit, since then, I've ridden horses medicated for the very short term to "get over" specific changes in way of going. I hate to say it, but I've ridden horses on robaxin. . . that worked well, I have to say - the horse changed his way of going almost immediately and stayed "fixed" afterwards. I've also seen horses get worse on bute trials (what do we think the mechanism in play there is?) and some be significantly worse coming out of the trial, possibly returning to a previous level of discomfort.

I also agree there are horses that not every misbehaving horse has a pathology, although going incorrectly is going to make any horse sore. Chicken and egg. I'd say most horses I sit on have something in there, niggling, even if it's just some uneven loading or lateral stiffness. Life is a contact sport! The issue only really comes if there is accompanying loss of performance . . . I would disagree that there are only pain issues though, and none that result from training/riding. Although again, we could argue that bad riding causes pain!

Which suggest RF hit it, there are a fair number of horses that hurt at a level that's almost impossible to diagnose, even if there are "signs". Such as it ever was, I guess the difference now is we might be able to find the problem so are compelled to keep looking, whereas in days gone by we shrugged out shoulders and either took a guess or turned the horse away and kept our fingers crossed!

I guess what I really want is a way to definitively, quickly and comprehensively prove to OWNERS if and when their horses are hurting. It would make a lot of conversations much easier. ;)
 
Depending on what you mean by worse, I have had many phone alls rom owners whose horses have just been out on bute (either a trial or long term for arthritis) saying their "behaviour" has deteriorated and they are bucking/ taking off etc and they think they are having a reaction to bute - quite the opposite - many are actually feeling good for the first time in ages, sometimes years!
Occasionally you do get a horse who is genuinely worse on bute - sometimes that could be down to the effect on the gut ( ulceration etc) or possibly a mtifactorial lameness where the bute has greatly decreased the pain from one source but not from another resulting in strain being put on different muscle groups. Again probably something that would be seen more in chronic cases where their body has been compensating for a long time.Just a possible explanation.
 
Oh and as for certain vets being scathing of behaviour/ training issues being due to pain/injury - IME many of these vets are not "true" horsemen. Ie., they don't have a natural feel for riding or have not themselves. To be perfectly honest, I have come across very few equine vets in this country with a background in competition/racing/ producing young horses and it is infinitely more difficult for a vet to understand the difference a minute niggle may cause to, say perhaps a top level showjumper. I can't explain it very well tbh, but IMO the majority of "everyday horse-owning" vets would not be capable of treating and dealing with the competition horse with lameness/performance issues. There are of course exceptions and I have come across one or two exceptional lameness specialists who have never ridden. It is their mechanical mind that makes them so good but when it comes to "behaviour issues" rather than lameness they can sometimes lack understanding.
This is just my perception of things.
 
This has been very interesting, thanks.
Very good point from GR above about vets who are horsemen themselves too, they understand far better than the jobbing vet I feel. In China apparently, they make all their vet students learn to ride so that they can understand horses better; wouldn't be a bad idea if that happened here to my mind.
 
I am not a fan of bute trials because I really don't think they prove a thing. When a horse's pain is sharp and sudden such as nerve pain, then bute has no effect whatsoever. Kissing spines is an excellent example of this. There is a danger that a bute trial can wrongly indicate that it is a behavioural issue and so is highly detrimental to the subsequent treatment of the horse. Any person who has badly hurt themselves will know that common pain medications hardly touch very severe or stabbing pain. They only tend to relieve dull aches and pains.

I think that an improvement with bute CAN show there is a pain issue, but that horses that do not improve with bute are still just as likely to be in pain. Three horses at my yard made no improvement on bute, one has gastric ulcers, one kissing spines and one hock arthritis.
 
I can see your point, Wagtail, although I don't think of bute trials that way. IF the horse improves, even in a way that doesn't seem obvious, then it IS pain related but scientific method means that the reverse does not necessarily hold true. As you say, a negative bute trial doesn't mean the horse ISN'T in pain.

Tbh, the real use of a bute trial is to POSSIBLY prove to an owner (or even a vet) that the horse is in pain. It's not definitive (very few tests are) it's a tool in the box, cheap and easily done. And, like so many tests, interpretation is all. I rode a horse for a trial last year that did not improve in way of going, stride length etc but DID stop spooking. This, to me, is a positive result. When the horse came off the bute, it started spooking again. I'll confess the vet did not agree but subsequent events meant the horse went for a work up soon after and was significantly lame on both front feet from nerve blocks. (Quite frankly, with a horse showing behavioural issues, I'd probably start by blocking a front foot and laying money the horse will then look lame on the unblocked one.

I will say, too, I think the same about work ups. I cannot tell you how many times someone has told me it's IMPOSSIBLE their horse has a pain related behaviour because the vets have looked and found nothing, only to have something crop up later. Perhaps, as said above, it was just too mild at the initial investigation? Or, while waiting for the work up, the horse had weeks in the field and was therefore not as bad when the vet investigated? Or perhaps horses are just huge, complicated mechanisms and the problem might be the proverbial needle in the haystack?

Interestingly, I had a conversation with a physio they other day about what she feels are patterns she is now familiar with that indicated various problems, for instance patterns of tension in specific muscle groups that tend to go hand in hand with bilateral front end lameness. So yes, the physiotherapy makes the horse more comfortable in the short term but its necessity suggests another, more insidious issue, particularly if it's more than a one off.

Re the riding, one of the best diagnosticians I know is not a rider at all, BUT he did come to vet work from his original job as a farrier. He knows so much about horse horse should work that he has a very keen eye for how they don't. He is also very keen to get input for the rider, simply because he doesn't think he knows! Vets that have been most dismissive of riders' input, in my experience, are ones that ride a bit - I have been told flat out that the riders could not possibly be able to accurately assess things like changes in the quality of contact, or stride length or straightness!

Anyway, my point was not to vet bash! Many of my best friends are vets. :) I guess I just wish we could lean towards a more collaborative investigative practice, instead of making assumptions or finding a thing that MIGHT be (part of) the problem and then deciding that MUST be (all of) the problem.
 
I agree with everything you say. I have given up with my boy. He was found to have very bad hock spavin, so I had them medicated. No change at all. He was then found to have very severe kissing spine. So severe that the vets said don't bother with a bone scan as this is bound to be his problem (explosive when he moves after the girth is tightened). So he was operated on. I spent months rehabbing him only to have the problem return with a vengence. I could scope for ulcers, have a bone scan, any number of things. But after more than two years of poking and prodding, I have just realised that he is knackered. A bone scan would probably show up more hotspots to poke and prod and the cause may still not be found. He could have cracked ribs, trapped nerves, sensitive sternum, the list is endless. A true needle in a hay stack.
 
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