Jenna Week 1: Balancing Blood Sugar Levels
Jenna is an approximately 26yr old Arab/Welsh pony and was acquired by her current owners in September 2012. Prior to this she was used as a lesson horse in Southlands but the exact time frame of her career there is unknown. She then moved to a large acreage in the interior and was a working trail and lesson horse. It's presumed that she foundered at some point in the past and was very heavy at the time of rehoming to current owners in September of 2012. For the past seven years she has been relatively injury free and successfully competing in endurance racing events. Unfortunately, she suffered an injury last year which set off a chain of distressing events.
In February 2018 she caught her blanket on a fence post and ended up dragging the post about 50 yards but did eventually manage to wriggle out of the blanket. Initially she seemed ok but after about 10 days was presenting as very lame. The vet came to do ultrasounds and concluded that there was no stifle or soft tissue injury present and that it was likely a hairline fracture of the pelvis. The vet also noted arthritic changes in the hocks and right front leg that were presumably long standing. She was placed on stall/pen rest to recover the lameness. Five weeks later she started showing signs of laminitis in both front feet. A series of tests, x-rays, and bloodwork were carried out as well as a rigorous routine of icing feet every 30min in the daytime, IV Bute, and a radical trim/protective shoeing protocol.
By May 2018 Jenna began showing small signs of gradual improvement but not enough before she had a major relapse in July that set her back months of recovery. She was again placed on stall rest, Bute, and Laminil. Previcox eventually replaced her Bute dosing and remains at half a dose per day. In September 2018 she was tested for PPID (Equine Cushings Disease). Results showed an extremely elevated level of insulin and ACTH at which time the vet also prescribed Prascend to manage these levels.
In October 2018 Jenna’s insulin levels were retested and still showing up as well over normal at which time she was also put on Metformin (3 doses per day) to manage and hopefully decrease her rising insulin levels.
Since then Jenna has been gradually improving in all aspects with minimal acute flare ups in the feet, but she remains on the above noted medications. She had begun hand walking and turnout in her pen during the day in January 2019. She was also started on some intestinal supplements in February 2019 to help improve insulin absorption. At her time of arrival to my farm she was reported to be doing quite well overall with soreness seen only on hard ground and on tight turns. She has elevated digital pulses from time to time but nothing that seems to persist beyond a day or two at this point. Owners report that her energy levels seem to be improving and that she is becoming her old self again.
From the posterior view a left hip drop is noted indicating imbalance in the hips and/or sacroiliac joint. Anteriorly, stiffness is noted in the right pastern joint with a slight toeing out into external rotation upon on landing. I am not sure exactly where that rotation is coming from at this point but it could be originating from the shoulder or any joint below that. Based on case history of arthritis at the pastern joint it would be logical the rotation is a result of difficulty within that joint for full flexion and extension. Lateral and medial views show reduced scapular movement with the left side being more restricted than the right. Slow motion reveals a somewhat flat footed landing on both fronts, hinds are closer to heel first. The goal is to move towards a heel first landing which allows the flexor tendons in the legs to be released upon toe off and reduce their friction and compression. Furthermore, a heel first landing allows for better self carriage in the horse throughout the rest of the body.
There was moderate discomfort in the upper cervical and poll nerve flinch tests as well as positives on most of the organs related to digestion. It is very common that when an organ is inflamed or irritated that the associated nerve pathways are also affected. With this pony it is likely a result of the medication she has been required to take for such an extended period of time combined with the mandatory stall rest at the time of her acute laminitic episodes. The organs become fatigued and overworked when processing foreign substances leading to irritation of the nerve pathway. Much like muscles become inflamed and contracted when having to over work, think repetitive strain injuries such as tendonitis or carpal tunnel syndrome. Organs too are made of contractile tissues and must contract (peristalsis) at an increased rate and amplitude in response to an overload in the system. She is also quite braced in her body with any type of palpation to these areas indicating a bit of a guarding pattern.
Range of Motion
There is difficulty lifting through her thoracic spine and restriction in hind end into extension and external rotation at the hips bilaterally. There is also restriction into both flexion and extension noted in her front right short pastern joint. She is highly sensitive to any range of motion being applied in the hind end, presents with discomfort when either hind leg is raised, and general anxiety to therapeutic techniques in and around the SI joint and gluteal muscles. For these reasons it has been difficult to fully assess without causing her emotional or physical discomfort. With such a strong reaction to this area, I have decided to address the organ issues first in order to free up any sort of myofascial restrictions that could be compounding the hind leg ranges of motion. As for the front leg ranges of motion I have been applying gentle oscillatory and joint play techniques discussed in the next section.
ASSESSMENT SUMMARY AND TREATMENT GOALS
Based on the assessment results, it is evident that there are organ restrictions present with accompanying nerve entrapments as well as some joint issues that I would like to address. In my estimation there is most likely a nerve entrapment of the cervical spinal nerves exiting around C5-C6 that has been caused by the organ restrictions. When collectively looking at the flinch test results, her discomfort with lifting the scapula seen in the joint range of motion video, and the reduced shoulder tracking seen in the movement video, there is strong evidence of entrapment. The fact that the shoulder blade isn’t moving optimally and that the nerves sit directly in front of that as well as her intolerance to palpation in the area all point to this suggestion. If the shoulder blade is pinned down to the thorax and the accompanying muscle and connective tissue is in a state contraction, the nerves underneath can easily become compressed and irritated. Secondly, it is my belief that the potential cause of this shoulder restriction could be due to the organ contractions/dysfunctions as well as the extended stall rest she previously. My goals will seek to address these as root causes.
Since much of the body issues noted in Jenna have arisen from primarily metabolic root causes (i.e. laminitis, Cushings, etc), I feel that an osteopathic approach in conjunction with physical and massage therapy will work best in addressing her needs at this time. For those who are not so familiar with the study of osteopathy it is well respected for its ability to guide healing and rebalance the internal structures of the body all while using the innate nature of the body to heal itself. That’s right, the body has the ability to heal itself. Sometimes it just needs a little nudge when things fall out of balance or external factors such as injury or chemicals have intruded the system. The osteopathic techniques I apply will work to rebalance organs, blood, nerves, lymph, and the bones themselves. The physical therapy will aid in re-balancing blood sugar levels via guided exercise and address the structural concerns via manual therapy. Lastly the massage therapy will aid in promoting circulation and supporting the muscles through this transition.
This week the major focus was working on resetting her craniosacral system, releasing any restrictions in and around the heart, and getting her moving pain free. When organs become irritated or inflamed and there are multiple positives down the chain in testing, my approach is to start with two of the most central systems to the body which in my opinion lie in the circulatory and neurological systems respectively. By helping to restore a healthy craniosacral rhythm every part of the body is able to receive input and nutrients that are needed within the spinal canal itself and exiting off the spinal cord directly. The cerebrospinal fluid feeds all of the nerves exiting and entering the spine and subsequently all the associated muscles as well as the brain. Nerves innervate all of our soft tissues such as muscles and organs so are of utmost importance to restore function to. Next, by working on releasing tension in and around the heart it will help to restore circulation to the rest of the body and as we know blood is life, without blood we could not live. Blood feeds all of the tissues in our bodies. Lastly, movement promotes blood circulation and joint range of motion in addition to giving mental stimulation and physical stimulation (also to the feet). Integrated structural work will come down the road once I feel that her system and tissues can handle more direct type mobilizations. As she does have some joint restrictions in her neck, shoulders/front limbs, spine, and SI joint this will become a second stage goal to be addressed in the weeks to come but first working with the internal stasis of her body is what is most important to me.
Treatments have been very slow and gentle as Jenna started out being quite conservative in her willingness to fully enter into a therapeutic relationship with me. I have spent quite a bit of time just sitting with her, grooming, and taking her out for walks in order to build a relationship and promote circulation through her body via cutaneous stimulation (grooming, stroking) and movement. I also started doing some gentle oscillatory work through individual joints in the limbs. Joint fluid is only produced via friction either in the form of movement or by an external force (i.e. me the therapist). When joints become restricted and movement has been limited, the joint fluids are produced at a much slower rate or even not at all, which can lead to degeneration. Joint fluid is essential to the functionality of a joint. Within this fluid, nutrients are carried to nourish and lubricate the joints. If there is a lack of joint fluid production for a sustained period of time (even overnight can be long enough), the joint becomes stiff and rigid similar to how some people start to feel stiffer in the morning as they age or following large bouts of exercise. This is why it is so important to promote movement as much as is permitted pain free if you have a horse on stall rest. Helping them move their joints gently will stimulate fluid production within the joint capsule. Otherwise it can become a vicious cycle of stiffness, lacking hydration, leading to more stiffness, and degeneration due to lack of nutrients.
I shot a video giving a demonstration of the gentle joint play and oscillations I have started applying to her front limbs. These techniques not only stimulate fluid production and increased range of motion they are proven to reduce pain (if pain is present). This is where her discomfort with scapular slide and glide becomes obvious. I also took a short video of one of her first releases when I was working on her heart.
Goals for the next week include increasing movement tolerance via walking, starting to free up her thoracic spine, continue working the organs of digestion, and beginning to address hind end joint restrictions.