Understanding how an integrative approach can be used to diagnose and successfully treat laminitis.

Laminitis is a frustrating disease commonly encountered by equine practitioners. In a 2000 USDA-NAHMS study, laminitis was noted on 13% of horse operations.  Fortunately, integrative methods such as acupuncture and related techniques can help treat this difficult disease.

Laminitis explained

Laminitis is defined by Gary M. Baxter, VMD, MS in Adams and Stashak’s Lameness in Horses, 6th Edition (Wiley-Blackwell, 2011) as “a disease in which failure of the soft tissue structures that suspend the distal phalanx within the hoof wall, the interdigitation between the dermal and epidermal laminae of the digit, commonly results in a crippling lameness due to displacement of the distal phalanx within the hoof capsule.”

There are several important structures within the equine limb. The equine digit is composed of four main bones: the navicular bone (distal sesamoid) and the first (proximal), second (middle) and third (distal) phalanges. The primary nerve that innervates the distal thoracic limb is the median nerve, which arises from C6-T2, and splits into the median and lateral palmar nerves just distal to the carpus. Once the nerves reach the metacarpophalangeal joint, they’re termed the palmar digital nerves. There is also some contribution from the ulnar and musculocutaneous nerves. The equine foot has no motor nerves, but it does have significant input from autonomic, sensory and autonomic vasomotor nerve fibers. An understanding of the anatomical structure of the hoof, nerves and neurovascular bundles is imperative when performing acupuncture on a laminitic equine patient.

The majority of laminitic episodes originate in the thoracic limb. During a laminitic episode, the distal phalanx can be displaced and/or rotated due to lamellar separation or failure. I explain this concept to horse owners using a trampoline analogy. I describe the outer support structure of the trampoline as similar to the hoof wall; the springs equating to the lamina; and the black center of the trampoline as the coffin bone. Once inflammation occurs, fibrosis, or a metabolic event that causes the lamina (springs) to lose their ability to function properly, the coffin bone will begin to rotate or displace.

Causes of laminitis

Laminitis is commonly a consequence of five primary clinical events. These include:

1. Disease associated with sepsis and/or endotoxemia
2. Excessive weight placement on a limb
3. Cushing’s disease
4. Equine Metabolic Syndrome (EMS)
5. Ingestion of black walnut bedding.

Cushing’s disease and EMS can be difficult to differentiate, but they contribute to laminitis with equal intensity. Hyperadrenocorticism, Cushing’s disease, causes excessive glucocorticoid production, as well as vascular changes within the body. The most notable outward signs associated with Cushing’s disease is a long curly coat, cresty neck, and polyuria/polydipsia. Equine Metabolic Syndrome is an insulin resistant disease predisposing horses to laminitis through vasoregulatory processes that insulin helps to regulate. EMS horses are typically obese and middle-aged.

Three stages of laminitis progression

1. The first stage is developmental, in which the horse is undergoing one of the aforementioned primary diseases processes, but is considered “at risk” and has not developed clinical symptoms.
2. The condition then progresses to the acute phase, where there is no radiographic evidence of changes to the coffin bone. The acute phase is considered to last 72 hours.
3. Finally comes the chronic stage. At this point, radiographic evidence of coffin bone displacement can be seen. Patients in the chronic stage of laminitis can be extremely frustrating and difficult to maintain with conventional medicine. These horses tend to have ongoing structural and hoof problems that can change the shape of the hoof, cause chronic pain, or generate visible rings. Horses with chronic laminitis should be managed with a combination of medical, dietary, exercise and holistic approaches.

Conventional treatment for laminitis

Conventional approaches for laminate include analgesics, vasodilators, hypertensive agents, cryotherapy, and a reduction of mechanical forces on the lamellae. Monitoring total protein intake is important when giving analgesics such as phenylbutazone and flunixin meglamine. Both these analgesics, when used for long-term pain management, can lead to edema and colitis.

An integrative physical exam

• To perform an integrative physical exam, practitioners must obtain a thorough history of the horse. As veterinarians, we must ask for information regarding illnesses, diet changes, management changes, ande prior treatment for similar events, as well as the clinical signs the owner is noticing. Historically, one of the first signs most owners mention is that their horses are “walking on egg shells”.
• Once a thorough history is obtained and the traditional PE is performed, we assess the horse using integrative medicine and a DAPE examination. A DAPE examination is derived from a traditional Japanese approach to acupuncture by means of palpation; it’s used to assess the whole body for noted trigger points, regions of pain, loss of sensations, change in range of motion, areas of heat, and general pathologies. When performing a DAPE examination, it is important not to use more than three pounds of pressure to find reactive or painful areas. Palpation of the myofascial planes, bony insertions and trigger points will guide the practitioner in an assessment of the horse. According to Traditional Chinese Medicine, we want to achieve uninterrupted “Qi” with our patients.
• Using TCM, we must also assess the patient based on the Five Elements — Wood, Fire, Earth, Metal and Water. These elements help the practitioner pick up on individual characteristics as well as the horse’s personality, and can guide him or her in an appropriate assessment for treatment.
• Many laminitic patients will need their Qi-Blood to move in order to resolve stasis/stagnation. If the flow of Qi is interrupted, there is noted insult or disease within the body. Qi is the energy that flows through the body’s meridians. These 12-paired meridians connect and unify the internal organs with the external body, allowing the body to experience harmony. Significant scientific support emphasizes the connection between meridians and peripheral nerve pathways. According to TCM, it is also important to check the pulse and tongue appearance to see if there is any excess Heat, Qi deficiency, Blood deficiencies, stagnation, etc. associated with different organs in the body. These portions of the integrative physical examination are important to helping assess the patient for whole body wellness and deficits.
• Finally, radiographs are highly recommended for any horse with laminitis, or suspected laminitis, in order to help assess the staging and rotation/displacement angles.

Acupuncture for laminitis

Acupuncture can help achieve whole-body wellness, provide better control of chronic disease processes, aid in healing and manage pain. It has been of great benefit to our laminitic patients. Originally, acupuncture points were based on a human model. These ting points have been modified to fit our equine counterparts, who have single digits as opposed to five phalanges. Around the horse’s digit, there are six ting points. These points are located around the coronary band in a rich web of joint, ligament, tendon and neurovascular input.

As previously stated, the meridians are in direct correlation with peripheral nerve pathways. When assessing the equine thoracic limb, the LU meridian is correlated to the musculocutaneous nerve; PC is correlated with the median nerve; and HT is associated with the ulnar nerve. The ting points for the front limb are: HT 9, LU 11, SI 1, LI 1, TH 1 and PC 9. The ting points for the pelvic limb are: ST 45, SP 1, GB 44, BL 67, KI 1, LR 1.

Laminitis treatment is based on local as well as systemic pain, myofascial dysfunction, and the need for inflammation management. This can all be achieved through dry needling and electric stimulation. Taking into consideration that forelimb laminitis is most common, it is also important to assess the thoracic limb, shoulders and cervical spine for point selection. Additionally, one should take into consideration any myofascial tension and windup that can occur, especially over the bladder meridian.

Additional treatment

The goal of all laminitis treatment methods is to make our patients comfortable, halt disease progression, and stabilize the horse.

• Horses suffering from laminitis should always have deep bedding in their stalls to give them as much support as possible.
• The team of horse owner, veterinarian and farrier should all be in contact.
• Dietary management is a key topic to discuss with clients. Horses going through a laminitic episode should not be fed high concentrate feeds or lush pasture. Devices such as grazing muzzles, in cases where horses lives outside on pasture, may be a suitable recommendation to offer owners. Forage is a great alternative for feed concentrates, and monitoring hydration status should be a priority since most patients are reluctant to move during agonizing laminitic episodes.
• Chiropractic care works well in conjunction with acupuncture, primarily when focusing on the spinal column to decrease joint dysfunction and help the animal find homeostasis. It has been noted that when animals have a misalignment, they enter a state of stress that can lead to a metabolic decline. Equine metabolism is directly associated with laminitis, which it why it is important to keep our equine patients well-balanced, both physically and physiologically.
• Moxibustion involves burning an herb called mugwort. It can be used on or over an acupuncture point. The heat from the herb helps modulate pain and loosen muscle tension.
• Additional herbal supplements that can aid in treating laminitis include Move Freely and Four Marvels Combination. Four Marvels is a combination of Atractylodes rhizome, Achryanthes root, Coix seed and Phellodendron bark. It should only be used in acute cases of laminitis. Move Freely is a combination of Cyathula root, Chinese angelica root, safflower, tumeric rhizome, Corydalis tuber, Persica seed, Ligusticum rhizome, licorice root, myrrh, and Sappan wood. This combination is beneficial for chronic inflammation and increasing peripheral circulation, but should not be used in pregnant mares. When using herbal supplements, it is very important to first assess what stage the laminitis is at.
• Cold laser therapy or low-level laser therapy (LLLT) has recently gained popularity in the equine community. LLLT can aid in sole and heel growth during laminitis episodes, as well as cause autonomic nervous system stimulation. LLLT is based on photochemical and bio-stimulation, without the generation of heat.

As outlined in this article, acupuncture is not just a supplemental tool for treating equine laminitis; it is also a way to achieve whole body wellness in horses. In addition to acupuncture, several other holistic modalities that go beyond Western medicine can be used for treating laminitis. Laminitis is a difficult disease process to treat and requires teamwork by the owner, veterinarian and farrier. By integrating Western with holistic medicine, and working as a team, we can give our equine patients long and healthy lives.

Resources

Baxter GM, Adams OR. Adams and Stashak’s Lameness in Horses (6th ed). Oxford: Wiley-Blackwell, 2011.

Boldt Jr., Ed. “Veterinary Acupuncture and Chiropractic: What, When, Who?” Am Assoc Equine Pract, 2016.

Crisman, Mark V., DVM, MS, CVA, DAVVIM. “Equine Acupuncture — Beyond the Qi Concept”. Proc. of ABVP 2012, Blacksburg, Virginia. n.d. Web. 1 Feb. 2017.

Haussler K. “Equine chiropractic: general principles and clinical applications”. Proceedings Am Assoc Equine Pract. 2000;46:84–93.

Holt, Tim, DVM. “Implementing Equine Manual Therapy”. Western Veterinary Conference 2008. Fort Colling, CO. n.d. Web 1 Feb. 2017.

Lancaster, Lisa S, Bowker, Robert M. “Acupuncture Points of the Horse’s Distal Thoracic Limb: A Neuroanatomic Approach to the Transposition of Traditional Points”. Animals : an Open Access Journal from MDPI 2.3 (2012): 455–471. PMC. Web. 18 Mar. 2017.

Palm, Janet Gordon, DVM, CVCP. “LLLT in the Management of Laminitis, and Inflammatory Equine Conditions”. Proc. of Wild West Veterinary Conference 2015, Animobility, Minneapolis, MN. n.d. Web. 1 Feb. 2017.

Parks, Andrew Hugh, MA, Vet MB, MRCVS, DACVS. “Acute and Chronic Laminitis — An Overview”. Proc. of 64th Convention of the Canadian Veterinary Medical Association, Athens, GA.  n.d. Web. 1 Feb. 2017.

Schoen A. Veterinary Acupuncture: Ancient Art to Modern Medicine. 2nd ed. Mosby; St. Louis, MO: 2001.

Schott, Hal, DVM, PhD, DACVIM “Fat, Foundered Horses: Equine Metabolic Syndrome and Laminitis”. Proc. of Pacific Veterinary Conference 2015, East Lansing, MI. n.d. Web. 1 Feb. 2017.

Dr Megan McCorkel is a practicing veterinarian with a mobile acupuncture practice in Denver, Colorado. She is interested in both large and small animal medicine, alternative therapies, HVHQ surgery, and sports medicine. She graduated from the Western University of Health Sciences with her DVM, and completed her acupuncture certification through One Health SIM, formerly known as MAV, in Fort Collins, Colorado.