Adding physiotherapy to improve recovery results 

Traditional treatment of horses that have been diagnosed with equine protozoal myeloencephalitis (EPM) has relied heavily on medication, time and repeated neurologic examinations. It wasn’t until more recently that proactive rehabilitation was added as a consideration in the protocol.  

“If we look at equine veterinary medicine as a whole, especially neurologic disease, rehabilitation is an up-and-coming field,” noted Sarah Reuss, VMD, DACVIM, technical manager at Boehringer Ingelheim. “In human medicine, if you have a stroke, brain trauma or spinal cord injury, in addition to medical treatment, they are also going to instantaneously start you on some type of rehabilitation program to try and gain back anything that’s lost. In horses, it’s not something we’ve necessarily thought of until more recently. It used to be we had drugs and time. Now we’ve got drugs, time and some targeted rehabilitation.” 

Managing Client Expectations 

While proper rehabilitation can improve a horse’s prognosis, it’s not a magical overnight cure for neurological clinical signs. It’s important to level-set recovery expectations with the client, both during treatment and prior to beginning the rehab process.  

“A horse with EPM, or any neurologic issue, isn’t going to be headed back to the show ring anytime soon,” said Dr. Reuss. “This can be a very hard conversation to have, especially when we are talking about a range of recovery from being well enough to be a pasture pet or well enough to compete at a high level.” 

It’s important to work with a rehabilitation specialist to help evaluate the horse on an ongoing basis through the recovery journey and provide the client with the gold standard of care. Diplomates of the American College of Veterinary Sports Medicine and Rehabilitation (ACVSMR) are veterinarians specially trained in using a variety of modalities to help horses recover from athletic or neurologic injury. 

Stages of Rehabilitation 

According to Dr. Reuss, one of the reasons that rehabilitation hasn’t always been an immediate part of the neurologic treatment protocol is the danger of working with a horse with those issues.  

“A neurologic horse is a potentially physically dangerous animal to be around, not because they mean to be, but because they may be unstable on their feet,” she explained. 

Because of this, there are four progressive stages of rehabilitation and recovery that Dr. Reuss typically sees: survival, safe to handle, safe to be ridden, and return to full work or competition.  

The first concern when treating a horse with EPM, or any other neurologic issue, is simply survival. The severity of the case, how quickly it was identified, and when treatment started all contribute to whether a horse survives a case of EPM. According to rough estimates, approximately one-third of horses that contract EPM will not respond to treatment up to owner expectations, and may be euthanized. Horses that are going to respond favorably to medical treatment, generally do so and stabilize in the first four weeks.  

Safe Handling 

Determining whether a horse is ready for rehabilitation starts with a safety evaluation.  

“We want the horse to be at a point where they are at least safe for humans to be near and be handled and moved around,” Dr. Reuss said. “The nice thing is, there are some pretty simple things that can be done in their stalls before they have to move around a lot. The initial goal is for them to be able to maintain balance on all four feet before you start more intensive therapy.” 

Some in-stall exercises to help evaluate where the horse is on the rehabilitation spectrum include some simple exercises that many clients may already be familiar with.  

“Remember the carrot stretches we’ve all done since we rode ponies as a kid?” Dr. Reuss asked. “Just getting the horse to follow treats back to his stifles, and then down to the hock and hind fetlock helps with core engagement. If the horse is a little off-balance, and they can’t stretch to the carrot, that tells you they aren’t in a good balanced state yet.” 

Using balance pads, doing tail pulls, and simply being able to safely pick up their feet can also help determine their stability when just being asked to stand still and adjust their weight to balance. 

In-hand and Ridden Rehabilitation 

Once a horse is determined to be stable enough in the stall environment, the next phase is in-hand work. 

“This is where we see if a horse knows where its feet are,” stated Dr. Reuss. “We start with just walking in straight lines and circles on different surfaces. As the horse improves, pole work or walking up and down a curb is very helpful. They have to pick their feet up a little bit more, know where that foot is in the air, and then place it back down. 

“You can start with just one pole and get more complex from there with lines of poles, put them in a circle, and change the height of the poles. This will let you see if the horse is recognizing where each foot is.” 

In addition to poles, other in-hand work can include lunging, round- pen exercise and work with bands or other equipment. Prior to riding, one way to determine if a horse is ready for a rider’s weight is to use a dummy in a saddle or in a surcingle on the horse’s back to see if the weight of a ‘rider’ causes the horse to lose balance. If the horse is deemed safe to be ridden, Dr. Reuss recommends those initial rides be done by someone with considerable experience.  

She added, “I am going to try and have those rides done by a professional, if possible. They are going to be able to recognize if they should get off, or safely handle a situation if things start to go wrong.” 

Whether or not a horse will ever completely recover enough to go back to competition and/or its normal workload depends on the horse, and again, the severity of the case. “There’s really a spectrum of recovery,” concluded Dr. Reuss. “We think about a third of confirmed EPM cases will recover well enough to return to their full athletic potential. One- third return to some level of rideability, but it’s not always clear if that is limited by owner concerns, other orthopedic issues, or a true lack of full recovery.”  

Additional Resources 

To support rehabilitation practices, various continuing education programs are offered through American Association of Equine Practitioners. And, officially recognized in 2018, the American College of Veterinary Sports Medicine and Rehabilitation is an organization dedicated to providing specialist care in sports medicine and rehabilitation. Visit their website here to find a local specialist.  

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