The Laminitis Site recommends following Pete Ramey's advice on p 351 of Care and Rehabilitation of the Equine Foot: “at the first signs of laminitis, restore P3 to a more natural ground plane” (so 3-5 degree palmar angle), “relieve pressure on the walls and pad the sole with foam rubber – vertical sinking and destructive pressure to the solar corium can be prevented”.

If laminitis is suspected or diagnosed, the feet should be supported/protected, x-rayed and realigned (if necessary) as soon as possible.  For more information, see Laminitis and the Feet.

Just a reminder that if a horse is showing signs of footiness/laminitis between Aug and Oct (in the northern hemisphere), particularly if for the first time or if older than 10 (although plenty of horses are diagnosed younger than this), and there hasn't been an obvious diet/management change that might bring on laminitis, PPID should be seriously considered and eliminated as the cause. ACTH testing is currently free in the UK (Sept - Nov 2013) - http://www.talkaboutlaminitis.co.uk/. Tests for PPID are often negative in the early stages of the disease, so be aware of the symptoms of PPID (see http://www.thelaminitissite.org/ppid.html and http://www.prascend.com/Content/PDF/BIVM-12015%20Prascend%20Diagnosis%20Booklet_WEB.pdf) and don't be afraid to ask for a trial of Pergolide - see Question 3 under Therapy - http://www.prascend.com/Veterinarian/VetFAQs:

"Question: When should horses be treated with PRASCEND?
Answer: A horse exhibiting clinical signs of PPID, including unexplained laminitic episodes, should undergo evaluation for PPID. A horse exhibiting clinical signs or that has positive results on ACTH or DST testing should be treated with PRASCEND. Currently available diagnostic tests are not sensitive in detection of early disease. Therefore, if test results are negative, but a high index of clinical suspicion exists that the horse suffers from PPID, a 6-month trial of PRASCEND may be instituted and response to treatment observed."

NB TLS does NOT advise the use of the dexamethasone suppression test - ever - because of the high risk of causing/exacerbating laminitis in horses that are insulin resistant, and it can't be used between Aug and Oct anyway. The basal ACTH test is the best test for PPID, possibly followed by the TRH stimulation of ACTH if a basal ACTH test is equivocal - although a trial of pergolide (Prascend) and clinical symptom response to treatment may be assumed to be diagnostic.

Despite what some vets are still saying, testing ACTH between Aug and Oct is the best time of year to test, when the difference between normal and PPID horses is more pronounced, as long as seasonally adjusted reference ranges are used. See: http://liphookequinehospital.co.uk/wp-content/uploads/Lab-Book-PPID.pdf. Interpretation of ACTH results is far from an exact science - as already mentioned, horses often test negative in the early stages of PPID, and clinical symptoms must be taken into account too. It is now thought that between Nov and July, although a cut-off of 29 pg/ml is often suggested, results below 20 pg/ml are likely to be negative for PPID, results over 40 pg/ml are likely to be positive for PPID, and horses with a result in the "grey area" between 20 and 40 pg/ml should have further testing (figures based on CIA testing using Immulite as used at Liphook Equine Hospital, other assays may require different interpretation) - see http://onlinelibrary.wiley.com/doi/10.1111/evj.12114/abstract. Between Aug and Oct the cut-off is 47 pg/ml, with the "grey area" likely to extend 10 pg/ml or so either side - so perhaps less than 37 pg/ml is likely to be negative for PPID, and more than 57 pg/ml likely to be positive, although we haven't seen these figures confirmed.

I've just started reading British vet John Stewart's recently published book Understanding the Horse's Feet (now available from many book sellers including Amazon in both the UK and USA: http://www.amazon.co.uk/Understanding-Horses-Feet-John-Stewart/dp/1847974767 and also as an E-book: http://www.crowood.com/details.asp?isbn=9781847974761&t=Understanding-the-Horse%27s-Feet) and so far I'm impressed - more about the book later.

This interview on The Naturally Healthy Horse website talks about how John's training at vet school (Cambridge) focused on the use of shoes, and he voices the interesting opinion that farriers consider foot form, but those involved with the barefoot movement are more likely to consider foot form AND function.

When talking about trimming, the environment and individual horse will greatly influence the trim, but in principle he leaves the sole and frog alone, trims the walls to just above the sole and applies a bevel.

For acute laminitis he advocates confining the horse, providing support under the sole as well as the back of the foot, reducing mechanical forces on the foot and easing breakover, and importantly, reducing heel height as soon as possible to enable the horse to load the back of the foot and reduce the force on the tip of the pedal bone. He doesn't agree with wedging the heels up - hurray! Interestingly he suggests the use of EVA pads - TLS is currently experimenting with the use of EVA foam pads inside boots and finding significantly increased comfort for the horse. 

He goes on to say that in his opinion the biggest mistakes people make when dealing with laminitis are to underestimate the seriousness of laminitis, to over-use Bute, and to not deal with insulin resistance (by controlling sugar and starch in the diet).

I'd add not realigning the feet quickly enough, the over-use of box rest (usually because the feet haven't been realigned quickly enough), and not recognising PPID.

Great news to have a British vet understand feet, the importance of a correct barefoot trim and the role of insulin resistance in laminitis! From only £20 for a full colour hardback version of Understanding the Horse's Feet, this book deserves a place in every vet, farrier/trimmer and horse owner's library.

Slowing Feed Intake Reduces Glycemic Response in Horses - Kentucky Equine Research - August 2013

Nothing new here, but a reminder that feeds should be as spread out as possible through the day to avoid glucose and therefore insulin peaks. Horses with laminitis/EMS/PPID shouldn't (generally) be fed any form of cereal/grain - recommendations are to keep NSC (non-structural carbohydrates, that's sugar, starch and fructan) below 10% for insulin resistant horses. Average NSC for cereals: bran 29%, oats 48%, barley 59% and maize/corn 73% (figures averages from Equi-Analytical common feed profiles http://www.equi-analytical.com/CommonFeedProfiles/). Many horse are now working at higher levels on a high fibre diet based on hay, haylage, grass, sugar beet, alfalfa, with minerals, vitamins, protein and essential fatty acids supplemented according to forage analysis. Insulin resistant horses generally do well on diets based on hay, either analysed <10% or soaked to reduce sugar, plus sugar beet (ideally rinsed/soaked/rinsed to remove excess iron and sugar) to carry minerals and for weight gain/additional energy if required. 

More ideas for slowing eating and general management strategies for insulin resistant horses:
http://www.thelaminitissite.org/management-strategies-for-emsir.html

At TLS we advise owners to ask vets for a copy of all test results.

Here's a good example of why we do this.

A pony with long term chronic laminitis had blood taken for ACTH and insulin tests in mid-August. 2 weeks later the owner spoke to the vet and was told that the pony didn't have PPID, the insulin result wasn't given. TLS advised that the owner should obtain the actual results, not an interpretation of the results. 

Several days later the vet advised of the insulin result, which was well over 100 uIU/ml - a large increase on an insulin test carried out at much the same time last year. The pony's diet, management and foot care were improved on the previous year (when the pony tested negative for PPID) - something had to have worsened.

The following day the lab's results arrived in the post - the pony had an ACTH of 107 pg/ml, the lab was using Liphook's reference range of <47 for Aug to Oct - we know the blood wasn't frozen without being centrifuged, and the pony wasn't ill, wasn't in pain or stressed, hadn't been exercised - there seemed no reason for the high ACTH other than a pretty definitive diagnosis of PPID (plus mild clinical signs - increased hairs on jaw, neck, back of legs, muscle loss, weight loss, fat pads, worsening laminitis in the autumn...).

The pony will soon start on Prascend, and hopefully treatment for his PPID along with a low sugar/starch diet and good management will help to lower his insulin levels. But what would have happened if the owner hadn't asked to see the results - would the pony have been assumed by all to not have PPID? Would another year or more have gone by with worsening symptoms, uncontrolled laminitis, a suffering pony and owners tearing their hair out in frustration at not being able to help their pony?

Looking after a horse with laminitis needs to be a team effort - owner, vet and farrier/trimmer all have an important role to play - for that to be effective, there must be good communication between all parties. We know of at least one owner who changed vets because they wouldn't provide copies of test results....

Some excellent points are made in this hour long webinar by Dr Scott Morrison:

He says rehabilitation of the laminitic foot involves simple mechanics and is easy, the foot is trimmed to realign the hoof to P3 - just as TLS has been saying for some time!

The foot must be set up to relieve pressure on the sole under the tip of P3 and to decrease tension on the laminae.

The foundered foot typically grows a lot of heel, the toe becomes jammed up, there's a lot of pressure on the sole corium and coronary band at the toe - the foot needs to be set up for normal growth to take place.

The sole is designed to be a supporting structure as well as the laminae. The main goal is to thicken the sole depth and use the sole to support P3 while the laminae are compromised. Barefoot horses naturally bear weight on the sole and develop a tough and strong sole callus.

He says domestic (but perhaps this should be shod) horses often have a dysfunctional thin sole that will bend with thumb pressure, which provides no secondary support structure for P3, and which can quickly lead to a "train wreck" when the horse develops laminitis.

Laminitis isn't necessarily failure of laminae at the toe, laminae can fail at any point around the hoof.

The centre of pressure needs to be behind the apex of the frog - TLS recommends trimming the laminitic foot to maximise weight bearing in the back half of the foot.

I struggle to agree with Dr Morrison about the pull of the DDFT and the use of wedges and tenotomy - Pete Ramey's explanation that the DDFT cannot exert a rotational force and oppose the laminae if the sole is in ground contact (active) and the wall at the toe is out of ground contact (passive) seems to make perfect sense. On p 350 of Care and Rehabilitation of the Equine Foot Pete says that although elevating the heels may temporarily reduce tension in the DDFT in a standing horse (although the muscle will quickly adjust), it may increase tension when the horse moves. He believes that concerns about DDFT tension have held back vets and farriers, "preventing rotation reversal by leading people to stand P3 up on its tip and ultimately destroying the foot". Dr Eleanor Kellon and the ECIR group have similar views: http://www.ecirhorse.org/index.php/ddt-overview/ddt-trim

However Dr Morrison goes on to say that wedges and shoes "trash the heels" and he only uses them short-term to shift the centre of pressure back (which others would claim can be done with a good realigning trim) while he tries to fix the toe and develop sole depth, then he likes to rehabilitate laminitics barefoot to allow the heels to recover.

He made me smile when he said that the trim is really important, he never touches the sole, just cleans the frog slightly, trims the heels back to the widest part of the frog (or as far back as possible), rockers the toe and applies a good bevel to the wall all the way round - exactly as we have advised for all our successful rehabs!

He also says that the bars are very important and shouldn't be aggressively trimmed - they have a purpose in stabilising the heels and wall.

He points out that horses often can't stand with one foot up for long - seconds only. I would take this further and say that they should always be allowed to put their foot down (so nail on shoes are not appropriate), and trimmed when standing on a soft supportive surface. 

There are some interesting x-rays of bone remodelling - Dr Morrison says that horses can usually handle a bit of remodelling of the tip of P3, but in his experience when there is a lot of erosion and demineralisation of P3, horses never become completely comfortable, and that once the surface of P3 is damaged, completely healthy laminae will never grow back. However, as long as P3 is healthy, he says feet can be amazingly rehabilitated following laminitis and rotation. This emphasises how important it is to get rotation realigned as soon as possible after a laminitis attack, to prevent changes to the bone from ever happening.

In conclusion, a very positive lecture stressing the importance of a mechanically correct barefoot trim, and whether you agree with everything he says or not, well worth spending an hour watching.