Teamwork, handling the vet and farrier

In the first few months the hardest challenge that I faced was that I had serious doubts about whether my horse was getting the right treatment. I had already made contact with The Laminitis Site and had read all the information about laminitis rehabilitation that Andrea had sent me. It all made complete sense. I wanted to follow the TLS recommended protocol as a matter of urgency. My vet and farrier said that it could be “disastrous”! More than 2 months had passed and clearly Casareño was getting worse. I was feeling more and more desperate and helpless.

I found that my horse's recovery only started when I had a vet and farrier team in place that would work to the TLS guidelines. Good teamwork was the key to our eventual success. I needed the vet to take good marked-up x-rays so that accurate trimming guidelines could be produced and I needed the farrier to follow the guidelines. My main role was to make sure that Casareño's diet was correct, that I provided protection for his feet, sought help from TLS when in doubt and arranged regular trimming visits and x-rays, where needed, to provide ongoing guidance for the trim.

What do you do if your hoof-care team does not want to follow the guidelines that have been provided by The Laminitis Site? 

It is very difficult to challenge your vet's treatment plan. Your vet's reaction will typically be “I have studied for 7 years and practised for 'n' years and you have just read something on the internet!”. The farrier may have a similar attitude. The farrier may believe that remedial shoeing is the only solution. A barefoot trimmer may have no experience with laminitic feet or may have their own methodology that they want to follow. 

In addition, I had the language barrier. My vet and farrier's first language was Spanish – discussion and debate was difficult!

I only had 3 options:- 1) Get the team to buy-in to the TLS recommended rehab protocol; or 2) as the owner and the person paying the bills just insist  that they follow this protocol; or 3) change the team. In the end, I used a combination of all 3 options to achieve the eventual successful buy-in.

Getting vet/farrier to buy-in (this is so important because once you have this in place the rest is fairly plain sailing!)

First, you have to have confidence in the TLS guidelines. You may have heard or read different approaches to laminitis treatment. You will probably be feeling under a lot of stress but I urge you to take the time to read the material that TLS will have sent you and check out some of the Case Studies. If you are in the situation where you need to get the vet/farrier to change their approach, you will not be successful if you yourself show uncertainty.

It helps if the vet and farrier can be reassured that the TLS recommended protocol is based on evidence-based scientific research and has been produced by veterinarians and farriers that are highly regarded in this field of expertise (not just some latest fad on the internet!). 

Let the vet and farrier know, when you make the appointment with them, that you want to discuss the treatment plan with them and ask them to allow a little extra time for you to have these discussions. Be prepared to pay for a slightly longer visit if necessary. 

Give the vet and farrier printed copies of TLS's trimming diagrams and the scientific paper on which they are based – Clinical Outcome of 14 Obese, Laminitic Horses Managed with the Same Rehabilitation Protocol by Dr Debra Taylor et al 2014.  Make sure that they know that the authors of the protocol are highly regarded - the current leaders in this field.

Be confident and assertive that you want them to follow this protocol – even offer to put it in writing (professionals are very wary of being sued if things go wrong – if they have your clear instructions it takes that risk away for them).

Don't be shy to tell them that you have been in contact with The Laminitis Site. Give them the link so that they can see how much valuable evidence-based information is available there.

Show them that you are prepared for the rehabilitation – have boots/padding materials and supportive/conforming bedding at the ready.

If all else fails, do not be afraid to change elements of the team. I had to change to an English speaking farrier, partly because my Spanish farrier was going on holiday and was not prepared to carry out the trim before he went away and partly because I did not want to risk having language barrier problems when the situation had become so urgent.

Once I had buy-in from the professional team I nurtured it. I made sure that everyone who was interested in Casareño's case knew of the valuable roles played by my vet and farrier. If you use social network sites this can be a great way to give credit to them. I think they appreciated it and became even more committed to Casareño's recovery

For details of his rehabilitation, see Casareño's recovery

9 x-rays taken over 6 months illustrate Casareño's laminitis story:

24 June - reverse shoes and 5 degree heel wedges had been applied.  The palmar angle was around 23 degrees, dorsal rotation of 5.73 degrees was measured, and the hairline marker indicated considerable sinking.

TLS recommended the rehabilitation protocol published by Debra Taylor et al. (2014) - remove shoes, fully realign the feet, support with thick pads - and on 10 July the shoes and wedges were removed, but the feet were only trimmed to tidy up frogs and bars.  The vet declared that carrying out a realigning trim could be "a disaster" and that the long toes and high heels should not be corrected until more sole depth had developed (TLS disagreed!).  The frogs were infected with thrush, which is common when heels are too high.

17 July - x-rays showed slightly increased palmar and dorsal rotation, which would be expected with no recent trimming.  Personal correspondence from Debra Taylor backed the argument for commencing the realigning trim.  The vet admitted that the situation was very bad and that something must be done as soon as possible, and agreed that a barefoot trimmer could be instructed.  The owner feared that Casareño could be heading towards euthanasia.  

13 Aug - after two trims (apparently without reference to the TLS suggested trim), very little progress had been made with realignment, and an abscess was now evident in the sole beneath, and very close to, the tip of P3.  A third hoofcare professional was instructed, and guided by mark ups from TLS, realigning trimming finally got underway.

25 Aug - after just one trim the dorsal and palmar angles were reduced.  Casareño was finally off of NSAIDs and moving better.

15 Sept - after two further realigning trims the toe was looking much better, but the palmar angle was still too high.  Note the gas pocket indicating abscessing beneath the tip of P3, and the change in the hoof wall at the toe.  At this point Casareño had increased but not full comfort, due probably to a combination of the feet still not being fully realigned, the solar abscess on the right fore, and heel rubs from wearing boots in a sandy environment.

9 Oct - two trims guided by the previous x-rays brought the heels down, reducing the palmar angle further, but probably still not quite far enough.  Note how the frog apex, marked by a drawing pin (that should have had the pin shortened much further!), had migrated forwards - the true frog apex will always be behind the tip of P3.  Casareño was now being walked out in-hand.

01 Dec - the feet had remained stable but probably still needed a little more off the heels to bring the palmar angle down to between 3 and 5 degrees.  This should be guided by the live sole - which can be difficult to find on dry compacted feet that have had high heels for a long time.  Note that the black gas pocket indicating the abscess has grown out and healthy tissue appears to be supporting P3.  The true frog apex has been identified and the frog trimmed back, so the true apex can again be used to guide the trim.  Note the clear shape of the collateral grooves on the x-ray.  Note also the first radiographic signs of bone remodelling at the tip of P3 - we suspect this is due to the long-term high palmar angle and pressure on the tip of P3.    Casareño is now in regular in-hand work and being turned out, with his feet protected by boots and pads.

Sole photos of the right fore from July to November show the abscess and stretching forward of the frog.

In November Casareño's vet posted on owner Pat's Facebook page: "I'm super happy to see Casereño recovered. Now you're probably the person who knows most of laminitis in Spain and I must admit that you made me crazy with so many articles you've read ....hahaha!!
Was fortunate to have the help of people The Laminitis Site but especially with the professionalism of an expert as is the blacksmith Bryn Simmo ..... GRACIAS Pat!!!"

Raising the heel has unfortunately been advocated for laminitis cases for some time.  TLS can see no justification whatsoever for doing this - see Don't raise the heel!  Instead, in Care and Rehabilitation of the Equine Foot, p 351, Pete Ramey says "at the first signs of laminitis, restore P3 to a more natural ground plane, relieve pressure on the walls and pad the sole with foam rubber – vertical sinking and destructive pressure to the solar corium can be prevented”.  Pete also says, on p 350, "I believe that DDFT tension concerns have held back the veterinary and farrier world, preventing rotation reversal by leading people to stand P3 up on its tip and ultimately destroying the foot."  

Although Casareño's recovery from laminitis has been challenging and painful at times, he was lucky to have a vet and farrier who were open to different ideas, and owners who were totally committed to his recovery. The full story of Casareño's rehabilitation will follow soon.


The video below shows Casareño's progress from being crippled in July to jumping for joy in December:

References:
Taylor D, Sperandeo A, Schumacher J, Passler T, Wooldridge A, Bell R, Cooner A, Guidry L, Matz-Creel H, Ramey I, Ramey P
Clinical Outcome of 14 Obese, Laminitic Horses Managed with the Same Rehabilitation Protocol
Journal of Equine Veterinary Science Volume 34, Issue 4, Pages 556–564, April 2014