Treatment Uses

Some general considerations

Because manual lymph drainage is working with the lymphatic system, which plays such a crucial role throughout the body, it’s been shown in human use to be successful with a wide range of conditions and no doubt this is also true with horses and other animals. It is strongly recommended that it should be used as soon as possible after conditions arise because with time tissue changes can take place which are less responsive to treatment. This doesn’t mean that MLD may have no effect then, but it takes a larger number of treatments to produce results, and may be less successful.

In many cases, MLD/CDT is used as an auxiliary treatment to conventional veterinary practice, but in cases of lymphoedema  where there is no veterinary answer it is a treatment in its own right.

As it’s a legal requirement in the UK that veterinary permission is given for treatment, proof of this will be needed in all cases. If recommended by your vet, MLD/CDT should be covered by insurance.

Acute cardiac insufficiency, acute infection and allergic response, thrombosis, and active cancer are all absolute contraindications for MLD, therefore it isn’t used for example, to treat lymphangitis which is often caused by acute infection, but should be employed to treat residual swelling as soon as this has responded to veterinary treatment. There are also a small number of relative contraindications for using MLD, which would require discussion with your vet first.

For treatment purposes please have a detailed, accurate history of the condition and of any treatments the horse has previously received, or changes in behaviour or way of going. Someone to assist by holding the horse if being bandaged, and to exercise it before and after treatment, will be required.

Where to treat?
I’m based in the Midlands in the UK and southern California when in America. I do travel within reason to treat, but bearing in mind that this is an intensive therapy which normally needs to be repeated daily, travelling over a certain distance becomes impractical. You may also feel that the time required of you to assist in holding and exercising your horse may be problematic, or that you don’t have suitable exercise/turnout areas. If any of these apply your horse can come to me, with excellent accommodation provided at an Equine Therapy Centre.  Alternatively I may be able to come to you if you can provide b and b accommodation for me.

Conditions, Equine

Oedema                                                                                                                                      

Oedema is excess fluid in the tissues and may have many causes, e.g. a bruise, sprain, inflammation, athletic activity, or can be lymphatic in origin.

The oedema produced by damaged tissue contains water-attracting protein molecules which increase the volume of swelling and proliferation of scar tissue, these can only be removed by the lymphatic system. Traditionally rest, ice, compression and elevation are recommended to minimise bruising and swelling, however RICE only supports the cardiovascular side of acute injury treatment, and ice and compression (except that used in CDT) stop the flow of lymph, and the body’s means of removing oedema and cellular debris. Therefore if icing is used it should always be before MLD, and the lymphatic system allowed 30 minutes to recover before treatment starts.

Competition fitness and recovery
Not a ‘condition’ as such but increasingly relevant as manual lymph drainage is now incorporated into the training, maintenance and competition routines of top class international human athletes. Intense physical activity can result in damage to muscle cells, indicated by raised enzyme serum levels. Scientific research has shown that MLD significantly decreases these indicating improved regeneration and repair to muscle cells. Mild inflammation and oedema associated with extreme effort is reduced, and nutrient supply to the tissues increased. Recovery time is shortened.

MLD is particularly useful when injury occurs, as it can be used around the site of trauma during the acute phase of healing. Deep Oscillation Therapy® can be effectively incorporated into this.

A major advantage of using MLD is that it is completely drug free and doesn’t contravene equestrian competition regulations.

Exertional rhabdomyolosis/tying up/azaturia
Rhabdomyolysis is a syndrome which may be caused by any condition which damages skeletal muscle and is the breakdown of muscle fibres leading to the release of the protein myoglobin into the bloodstream. Myoglobin breaks down into substances that can damage kidney cells, may result in kidney damage and if severe can cause death.
Several forms of equine rhabdomyolosis are recognised. Research in Germany using MLD as an auxiliary treatment in equine rhabdomyolysis syndrome confirmed that horses show less muscle symptoms and faster recovery when treated with MLD because it increases the elimination of metabolic products from the muscles, however MLD should only be used where there is no risk of kidney damage.

Because of its relaxing effect , MLD may be beneficial for horses prone to stress induced recurrent exertional rhabdomyolosis and because it’s drug free may be used with competition horses.

Inflammation

Although inflammation is not a specific lymphatic condition, the lymphatic system always has a crucial  involvement, so is included here.

Inflammation is the body’s reaction to harmful or irritating stimuli, which may be anything from a burn, allergy, or cut, to a serious infection, and begins the process of healing. The typical signs of inflammation – redness, heat, swelling, pain and sometimes lost function, are indications that this process is happening. Inflammation is frequently confused with infection, however infection is caused by a bacterium, virus or fungus, while inflammation is the body’s response to it.

Acute inflammation starts within seconds of irritation or damage. Typically, a highly complex process is initiated, causing local blood vessels to dilate, resulting in increased blood flow and bringing large numbers of white blood cells (leucocytes) to the inflammation site. Pain receptors are sensitised and blood becomes more viscous so that flow stops and the blood capillary walls become more permeable enabling the leucocytes to move from the bloodstream through the capillary walls into the tissues along with fluid and inflammatory mediators, and swelling results. The leucocytes absorb and devour pathogens (bacteria, viruses) and dead tissue before dying themselves, and are either excreted as pus or broken down by other white blood cells. The process then switches off and inflammatory triggers are removed and healing is completed.

Inflammatory swelling is partly caused by the role of the lymphatic system. During inflammation, lymphatic vessels dilate to remove more fluid, but if the amount is greater than they can initially cope with, oedema will develop. Those at the centre of the inflammation carry leucocytes to the lymph nodes where the pathogen is identified and an immune response started, but as it is very important to prevent the pathogen spreading further into the body, movement of lymph through the nodes beyond the site of infection has to slow down or stop so that the immune system functioning within them can identify and destroy it. Therefore these vessels close to stop the flow of lymph and allow the nodes time to work, increasing oedema. These vessels reopen when inflammation is over, and swelling subsides.

Unfortunately the acute inflammatory reaction can do more damage than its cause, as leucocytes release factors not only destructive to the source of inflammation but also to the body’s own tissues. This often appears to be the case in laminitis.

Sometimes chronic inflammation can develop, a degenerative condition in which active inflammation, tissue destruction, and attempts at repair are proceeding simultaneously. MLD is used successfully to treat many conditions involving or caused by chronic inflammation.

Acute tendon injury

CDT is recommended for acute tendon injury because the use of manual lymph drainage quickly drains fluid and cellular debris and reduces the inflammation which is so damaging to the tissues. When used with veterinary treatment it results in quicker recovery and improved longitudinal arrangement of tendon collagen fibres in the scar tissue, leading to a stronger repair. Lymphatic vessels reach deeper into tendons than blood vessels and play an important role in removal of leaking blood and oedema which quickly develops between the fibres of a damaged tendon. As pressure within the swollen tissues increases, blood capillaries are compressed, limiting supply of oxygen and nutrients, while the lymph capillaries open to reduce this by absorbing increased fluid and cell debris. However, enforced box rest means that lymphatic drainage is reduced.

MLD compensates for the  movement lost on box rest and has been shown to reduce tissue fluid and relieve compression of blood capillaries so that healthy blood flow is restored and oxygenation and nutrient supply improved, reducing risk of damage and cell death.

When used above the injured area MLD increases the amount of lymph and thus fluid and cell debris  removed without increasing pain, which is immediately reduced as the tissue pressure decreases.

The powerful compression bandage used for CDT supports and immobilises the affected area and protects the flow of lymph by applying a graduated pressure from the hoof upwards, whereas stable bandages have the opposite effect, interrupting the flow of lymph and resulting in reduced fresh fluid and nutrient supply to the tissues. Because of this, protein molecules remain which should normally be transported away, leading to an increase in connective tissue and scarring.

Treatment considerations
If cold hosing or application is used to limit inflammation, it should not be below 4 ° C as any lower slows down the transport of lymph preventing a decrease in swelling. For the same reason warm dressings over 40° C should not be applied.

Again, the sooner CDT is started the better, the results with chronic tendonitis are usually less successful.

Idiopathic Synovitis, Tendosynovitis
Where there is no longer an underlying cause of inflammation, these conditions (windgalls/windpuffs, bog spavin etc) are classed as blemishes not requiring treatment. However, the cause should be identified and if they become very large they may cause a mechanical lameness and owners may also find them unsightly. In these situations the use of MLD or sometimes CDT can reduce swelling and soften hardened fibrous tissue without the need for drugs or box rest.

laminitis

Laminitis

Laminitis
Laminitis is inflammation of the sensitive laminae or ‘suspensory apparatus of the hoof’ resulting in breakdown of the crucial connection between the pedal bone and the hoof wall. It can be a devastating condition, and one universally dreaded by those who care for horses. Over decades attempts have been made to find an exclusive cause for laminitis but increasingly it’s thought to more resemble a syndrome resulting from a number of predisposing conditions rather than a disease with one specific cause.

Because of the tight confines of the hoof, it is essential that damaging inflammation and consequent oedema are reduced as quickly as possible. Tissues, including blood and lymph vessels will be injured reducing lymph transport, but because the lymphatic vessels of the hoof empty directly into the deep vessels of the lower limb and these are accessible to manual lymph drainage, it is possible to stimulate and increase the transport of lymph, leaking blood, hormones and enzymes from the hoof.

It’s therefore recommended that MLD be used as an auxiliary treatment to veterinary care as early as possible. MLD works with the soft tissues and therefore cannot reduce displacement of the pedal bone, and when I trained was therefore only recommended for acute and sub-acute laminitis. However it is evident that inflammation and subsequently pain are frequently present in chronic laminitis and MLD may provide relief from this.

My own experience suggests that MLD may effectively reduce the symptoms caused by Equine Metabolic Syndrome in some horses with recurrent laminitis, and reduce ACTH in PPID without drug intervention.  The lymphatic system is known to be implicated in metabolic syndrome in people, and MLD causes the parasympathetic nervous system to predominate, which may be reducing levels of cortisol and raising dopamine, hormones involved in PPID. Positive ACTH blood tests results from a pony before being treated with MLD returned negative after treatment.

Treatment considerations

Cryotherapy, icing the legs from underneath the foot to half way up the canon, has been recommended for a long time for treatment of horses at risk of developing laminitis.  However, research presented at the 2013 International Equine Conference on Laminitis and Diseases of the Foot suggests that this may also be effective for controlling damage and progression of the condition if used when laminitis is first diagnosed at the walk.  It is important that a low temperature is maintained, horses in the study were treated for 36 hours.  An ice slurry should be used, not commercial cooling boots which do not reduce the temperature enough, and as the ice slurry should be under the sole and high enough up the leg to be effective, some inventiveness may be required for application!  Again, the success of this treatment would seem to support the value of reducing inflammation in the hoof as soon as possible.

Strangles

Strangles is a familiar highly contagious infection caused by the Streptococcus equi. bacterium, which features acute fever, nasal discharge and swelling with subsequent abscesses of the jaw and throat lymph nodes.  Fortunately most  cases resolve without complications.  MLD is not used for Strangles because of the risk of spreading the infection through the lymphatic system.

Bastard Strangles

This is an occasional but very serious complication, in which bacteria do spread to lymph nodes and organs elsewhere in the body, causing abscesses which can have potentially fatal consequences.  Again, MLD is not used with Bastard Strangles.

Purpura Haemorrhagica

This may appear 2 – 3 weeks after Strangles (or sometimes other streptococcal infections or influenza) when an overreaction by the body’s immune system causes an allergy type response, resulting in inflammation of blood vessels (vasculitis) and oedema. Vasculitis can cause red spots to appear on the mucous membranes, and can affect vessels anywhere in the body. Swelling is typically visible in the legs, underbelly and head.

MLD can be used safely to treat the oedema because the condition is already systemic.

Cellulitiscellulitis

Cellulitis is an acute inflammation of the deeper layers of the skin, usually caused by infection, and can occur anywhere in the body. If affecting the legs it is frequently confused with more serious sporadic lymphangitis, which can easily develop from it. Cellulitis is a risk for horses with lymphoedema, because of reduced immunity making infection easier, and the subsequent further damage to the lymphatic system.

Cellulitis requires immediate veterinary attention.  MLD can be used for removing residual oedema.

Lymphangitis

‘Lymphangitis’ means inflammation of the lymphatic vessels, caused by infection or allergy. (Lymphadenitis is inflammation of the lymph nodes). Lymphangitis can occur anywhere in the body, but there are three forms that most frequently affect horses.

Sporadic/ideopathic Lymphangitis

This is the form that most of us in the UK are familiar with. The horse develops one or more swollen legs, is in pain, feverish and clearly unwell. If the swelling is severe, fluid may ooze through the skin, which may split.  This is ‘lymphorrhea’, which is protein rich and very attractive to flies and bacteria.  It is also caustic and can damage the skin.  The cause of this lymphangitis is often bacterial, but may be an allergic response. Idiopathic lymphangitis often develops without warning, and bacteria can enter through the tiniest breaks in the skin which on examination may not be found. It’s a serious condition needing immediate veterinary attention, and (if due to infection) to be treated aggressively with the correct antibiotic, therefore whenever possible identifying  the cause is important. Anti-inflammatory medication to reduce the damaging inflammation is also prescribed, and painkillers.

Because lymphangitis is an inflammation the swelling is partly due to lymph vessels and nodes adjacent to the affected area responding to the presence of a potential invader. Therefore attempts to reduce the swelling by walking and bandaging during the acute phase of the disease (remember, it’s the lymphatic system not blood circulation which is responsible for removing fluid from tissues) may not be a good idea.  Again, applying heat, to a limb which is already hot because of inflammation, is also counterintuitive and possibly uncomfortable for the horse, gentle cool hosing may give temporary relief.

A first attack of sporadic lymphangitis may clear up without any visible harm done, but this doesn’t mean that the affected lymphatic vessels are healed, lymphangitis can obliterate lymphatic vessels and destroys their internal valves needed for lymph transport, and they don’t regenerate. This puts extra pressure on the remaining functioning ones, which over time may suffer and cease to work adequately because of their additional load.

Older horses may be at greater risk of lymphangitis simply because the lymphatic system works less well when aged.

Having had lymphangitis once, a horse is more likely to develop it again in the same limb because it’s immunity is impaired. There may be residual swelling after a lymphangitis attack – lymphoedema – described below. Lymphoedema results in ‘fibrosis’ which can enable bacteria to hide away beyond the reach of antibiotics and the body’s immune system.  Tests may not show the presence of this bacteria and lymphangitis can occur again.   It is therefore very important to use CDT as early as possible when lymphoedema appears, to limit the development of fibrosis, and certainly within six months of an attack of lymphangitis.

If a horse starts to develop a soft or ‘puffy’ swelling in a leg, which is clearly not related to a specific structure such as a tendon or joint, it is still important to get veterinary advice. It may not be the start of lymphangitis, but if it is, prompt treatment can limit long term problems.

Ulcerative Lymphangitis/Pigeon Fever

lymphangitisSometimes when lesions  appear with sporadic lymphangitis, it is called ulcerative lymphangitis, but more commonly cases of ulcerative lymphangitis are caused by the bacterium corynebacterium pseudotuberculosis, which exists world wide and can survive for months outside the body. The infection enters the body and travels along the lymphatic system into the nodes. The horse is clearly ill with fever and in pain, and the affected limb swells and develops tracts of multiple draining ulcerative lesions along the leg lymphatic vessels, which may initially stand out before oedema causes loss of definition in the limb. Again, damage to the lymphatic system may result in persistent swelling after the infection has been treated.

In the United States another form of corynebacterium pseudotuberculosis infection is more prevalent, causing swelling and external abscesses at the chest or under the belly and between the front legs. Because of the position of the swelling this is called Pigeon Fever.

Occasionally corynebacterium pseudotuberculosis can cause abscesses which affect internal organs.

Epizootic Lymphangitis

This is a notifiable contagious disease which can infect humans, caused by a fungus, histoplasma farciminosum, The disease was eradicated in the UK over a century ago but is endemic in countries bordering the Mediterranean, parts of Africa, Asia and Russia. The fungus may enter through a wound which may have healed months before the appearance of nodules found along the track of prominent lymph vessels, which erupt into spreading ulcers. Neighbouring lymph vessels are inflamed, and lymph nodes swollen and hard.  Nodes under the jaw may be enlarged and there may also be a nasal discharge. Once beyond an early stage epizootic lymphangitis is untreatable and fatal.

MLD is never used to treat any form of lymphangitis or lymphadinitis because of the risks described above of spreading the pathogen throughout the horse’s body, causing systemic infection.

For ‘chronic lymphangitis’ see lymphoedemas.

Glanders

Glanders caused by the burkholderia mallei bacterium,has been known for centuries, and has the dubious distinction of being used as a weapon of biological warfare against horses and humans. Again, this is a notifiable disease, untreatable with drugs, and any animals which survive become sources of infection, therefore Glanders is controlled by immediate euthanasia of positive cases. Although eradicated in Europe, Australia and North America, it is still seen in other parts of the world and in 2006 a case of Glanders was imported into Germany.  More recently, a donkey infected with glanders crossed the border from Mexico into the USA.

Glanders primarily affects the skin, lymphatic system and respiratory tract. Nodules, which break down as pus discharging ulcers usually appear in the lungs and respiratory tract, with fever, coughing and an infectious nasal discharge, and along lymphatic vessels, most frequently on the legs. Death usually occurs within days or months depending on how acute the infection is.

Glanders can be confused with epizootic and ulcerative lymphangitis and strangles, emphasising the importance of testing to establish the correct cause of symptoms, not only to provide correct treatment where possible, but because of the strict legal requirements to report and control dangerous diseases.

Cancer

Horses can also develop lymphatic cancers.  MLD is contraindicated  in these cases because of a potential risk of helping cancer to spread.

Lymphoedemas

lymphoedema
Sometimes oedema develops because too much fluid is entering the tissues for the lymphatic system to cope with, e.g. following trauma. This normally resolves with time,  but if the lymphatic system is unable to function properly, a lymphoedema develops, as fluid and protein build up in the tissue.  Lymphoedema is a specific chronic and progressive disease and one to which horses are prone, and is due to an inability of the lymphatic system to adequately remove fluid, waste products and plasma protein molecules from the tissues. Lymphoedema is accompanied by chronic inflammation.

In the horse lymphoedema most frequently appears in the legs, usually the hind limbs. There is currently no cure for lymphoedema, but within the last decade there has been greatly renewed scientific interest in the human lymphatic system which may one day improve this situation, and possibly provide incidental help to horses.

The most effective way to keep lymphoedema under control is through the use of combined decongestive therapy and it cannot be overemphasised that the sooner this starts the better the result.

Protein in the horse’s diet doesn’t cause lymphoedema, and a horse with this condition should have a healthy, well balanced diet to support its immune system.

Because fluid containing protein molecules and waste products isn’t being removed swelling results in the skin and subcutaneous tissues. It becomes more difficult for oxygen and other nutrients leaving the blood capillaries to reach cells and for waste products to be removed. The excess protein and its degradation causes changes within the affected tissues, and underlying structures such as ligaments, tendons, joint capsules and synovial membranes can be affected. The body’s attempts to deal with the excess protein result in ‘fibrosis’, increased connective tissue which over time hardens obstructing the flow of lymph and blood. The lymphatic vessels undergo damaging changes, as the elastic fibres which enable them to open and absorb lymph, and to stretch and contract are destroyed, and immune deficiency develops. The skin becomes more fragile and vulnerable, and may split, weeping a caustic fluid called ‘lymphorrhea’, and vulnerability to infection greatly increases. Infection then causes further damage to the lymphatic tissues. A chronic low grade inflammation is present.

The condition is broadly categorised into two types:

primary lymphoedema develops when a horse is born with congenital problems within the system, e.g the condition ‘chronic progressive lymphoedema’, The condition may initially be ‘latent’ i.e. symptomless for many years.

secondary lymphoedema occurs through damage to a previously healthy system, for example through chronic inflammation due to severe and/or prolonged bouts of pastern dermatitis. Lymphangitis infection, causing significant lymph vessel obliteration, is probably the most frequent cause of secondary lymphoedema in horses, to the extent that it is sometimes called ‘chronic lymphangitis’. Again secondary lymphoedema may initially be latent.

Lymphoedema normally follows a recognisable progress.

Latent lymphoedema is present when the lymphatic system is not adequate but is coping, in effect a lymphoedema waiting to happen, this may have a primary or secondary cause. It may remain symptomless or a ‘final straw’ e.g. a fly bite, injury or mud fever inflammation may tip the system beyond the point of coping.

At the start of visible lymphoedema there is a soft swelling which ‘pits’ in the way that warm butter does when pressed with a thumb. At this stage there is usually no pain associated and the soft swelling may be the only sign, and can easily be missed under the coat, especially in a heavily feathered horse. Treatment with combined decongestive therapy at this stage is normally effective,  restoring the leg to a healthy volume in a short time.

pc 5
Lymphoedema. Elephantiasis.

From this early stage fibrotic changes start to appear, when pressed the tissue no longer pits easily and starts to feel more resilient, physical landmarks such as the tendons and canon bone become increasingly obscured by swelling which may cause the skin to weep. If there is residual swelling following an episode of lymphangitis changes may develop quickly if the swelling isn’t treated. Because the local immunity is damaged, repeated infections often occur. The presence of fibrosis may prevent antibiotics and the body’s own immune system from fully reaching bacteria, which may remain causing abscesses or repeated bouts of lymphangitis. Discomfort or pain may be felt. As long as an active infection isn’t present, early use of combined decongestive therapy can improve immunity, reduce the swelling and support the lymphatic system, reducing the risk of further infections and increasing mobility.

If left untreated, the whole leg may become hard, grossly swollen and misshapen, the skin is damaged and vulnerable and may be crusty or weep, and is extremely prone to bacterial and fungal infections which may cause repeated episodes of cellulitis and lymphangitis. Movement may become limited or painful because of pressure from the swelling and fibrosis on nerves and joints. Because of its appearance in human patients, this is also known as elephantiasis. Although tissue changes cannot be completely reversed, in milder cases combined decongestive therapy is recommended to reduce oedema and help prevent further infections, otherwise euthanasia may be the kindest option.

pic 6
Lymphoedema. Note fibrosis damage to tendon. Photo Praezi tec

Until the disease becomes severe horses often aren’t lame, and this can make an owner think that, although unsightly, it isn’t serious, so frequently treatment isn’t sought until after a further infection or injury occurs. But lymphoedema is a serious condition, all the time damaging changes are occurring within the tissues which although not visible are doing long term harm. Therefore it’s very important that treatment is started as early as possible.

‘Filled legs’/’stocking up’

This is oedema which occurs when horses are deprived of movement to support the transport of lymph, and is thought to be a latent (because the swelling dissipates with movement) form of primary lymphoedema, possibly caused by a smaller than usual number of lymphatic vessels in the lower leg. It’s often dismissed as harmless, but it may possibly be connected to the development of lymphangitis in later life.

pic 7
CPL

Chronic Progressive Lymphoedema (CPL)
Although all lymphoedemas are chronic and progressive, the term ‘Chronic Progressive Lymphoedema’ is specifically applied to a primary lymphoedema which was first identified through research at the University of California, Davis. It appears to be caused by defective elastin, the protein so important to the structure and activity of the lymphatic system. Initially it was thought to be a therapy resistant form of pastern dermatitis until the realisation that this was due to an underlying problem with the lymphatic system.

CPL was initially thought to be a quite rare disease found in heavily feathered Shire, Clydesdale and Belgian Drought horses, but is now recognised frequently, and has been found in many Gypsy Cobs and most recently in Friesians. It is thought to be hereditary, as it appears noticeably in some blood lines but not at all in others. Interestingly, close breeding patterns, either because of rarity or to produce certain characteristics is a feature of all the affected breeds. Research into CPL is ongoing.

A good description of CPL can be found on the UC Davis website, which will hopefully be updated soon with much more information especially on care of affected horses. It’s important to understand that not all horses are affected to the degree shown on this site, and as it says, the disease presents with great variation.

LD cropped
Advanced CPL. Photo UCDavis

CPL starts with a soft pitting oedema, which can easily be overlooked especially on heavily feathered legs. Fibrosis is laid down, commonly starting as firm folds below the fetlock and in the back of the pastern, and folds at the rear of the lower leg, but this can vary. This is often dismissed as a reaction to mite infestation, and there is no doubt that the inflammation mites cause makes the lymphoedema worse, but it will progress without any mites being present. As increasing amounts of fibrosis develop, the lower leg circumference grows and the leg is disfigured by “bone hard” fibrosclerotic nodules which may interfere with movement.

Because the lymphoedema damages skin immunity, it is very vulnerable to infections from bacteria, viruses and fungi, and to infestation by mites, and the heavy feather helps create a perfect environment for these. Attempts to treat as pastern dermatitis are frustrated because they don’t address the underlying lymphoedema. This is a vicious cycle, inflammation further damages the lymphatic system, which makes the tissues less healthy and able to handle infections, encouraging the pastern dermatitis.

Some horses suffer more than others, it’s possible for one horse with CPL to reach a good age with relatively little visible damage, and for another much younger one to quickly develop fibrosis. As with all lymphoedemas, paying scrupulous attention to skin health and condition can make a big difference, especially if this starts at an early age, but the degree to which this will help cannot be guaranteed.

Although the existence of CPL has been established, there is resistance in some quarters to it being recognised. Researchers are looking for a ‘genetic marker’ which would identify horses born with CPL straight away to avoid breeding from them. However breeds such as the Clydesdale and Shire, narrowly survived extinction in the last century, and owners may feel that they cannot afford the loss of affected horses especially if they are from valued bloodlines. Some horses may only be affected mildly, and do well with care, and owners may feel that this is an acceptable price to pay for breeding from them. in other cases owners may feel that the price they have paid for an animal and the profit they hope to make from it justifies breeding them. But there are many owners who do recognise the seriousness of CPL and are committed to doing whatever is required to eliminate the disease.

For an authoratative  description of CPL visit the website of the Fenway Foundation, education page, which features a video of Dr Verena Affolter of UCDavis describing CPL in detail.

A small trial at UC Davis using combined decongestive therapy with horses with CPL showed that this treatment could make a big difference to the well being of affected horses.

One of the beautiful shire horses in the UC Davis trial
One of the beautiful shire horses in the UC Davis trial 

Treatment considerations
For treatment it makes little difference whether lymphoedema is primary or secondary, but the stage of the disease does affect its length and results. If started early, treatment of lymphoedema is most successful and takes less time, if fibrosis is present it will take time to break this down, and treatment becomes more expensive too, and may be less successful.

It’s important for an owner to recognise that caring for a horse with lymphoedema requires commitment, there is no cure and the purpose of treatment is to control the condition so the horse can have as normal and healthy a life as possible. Depending on the progression of the disease, treatment may take time. Initially it can produce a striking volume reduction (through elimination of water) which can encourage owners to think wrongly that treatment time should be shortened. If treatment is completely stopped and restarted the oedema quickly returns to its pre-treatment level, necessitating further treatments to reduce it again.

Antibiotic treatment doesn’t always completely clear infection especially when fibrosis is established, and during treatment it’s possible for an undiagnosed abscess to surface causing the compression bandaging part of CDT to stop until it has healed.

long standing abscess revealed by CDT
long standing abscess revealed by CDT

While the horse is being treated it may require certain conditions to be provided, e.g. exercise, flat, dry individual turnout if available. Assistance is required to hold the horse and walk it. In the second phase of treatment, the owner, with guidance, will either be obtaining, applying and replacing special support stockings needed for this, or may need to continue supportive bandaging. and some do find it wearying to apply this every day. If the owner can’t or doesn’t want to commit to these it would be better not to start treatment, than to do so and then try to change or stop it to the detriment of the horse.

The stockings are intended to support  the reduction of volume but there is no evidence they control fibrosis, therefore follow up MLD/combined decongestive treatments will be needed from time to time, depending on the individual horse’s requirements.

Regular skin care is also a requirement during the maintenance phase, lymphoedema dries the skin, allowing the upper layers to separate. Moisturising with a gentle product will help to keep it supple.  It’s important to use something gentle which does not cause a reaction, and this can vary between horses. Try to keep the horse turned out as much as possible, to allow freedom of movement.

In the long term a horse with lymphoedema needs to be observed carefully on a regular basis for increased swelling/heat, changes which may signify an imminent attack of cellulitis or lymphangitis, or the presence of an abscess, and for fibrotic hardening.

Post traumatic and post operative oedema:
ventral oedema2MLD can be used to reduce oedema and scarring and accelerate recovery after surgical procedures, e.g. for colic and gelding, and following trauma to tissues such as contusions, lacerations, burns, and blisters.

Long term box rest
Horses on long term box rest, for example when recovering from laminitis, may develop abdominal oedema and swelling in the legs, which is quickly eliminated by using MLD as soon as this starts to develop. When one limb isn’t weight bearing it’s worth considering the application of a CDT compression bandage to the contralateral limb, as this will provide support without impeding the blood and lymphatic systems.

 

Conditions, canine

Dogs can suffer similar conditions to horses which respond to MLD and CDT, and are described in greater detail in other sections. Some examples:

Lymphoedema
Lymphoedema in canines may be primary or secondary. Although it can affect all dogs, some breeds are considered to be more susceptible to primary lymphoedema and may show symptoms at birth or within the first few weeks of life. If severe, the condition can be fatal, but it is also known to sometimes resolve spontaneously and not recur. Secondary lymphoedema is rarer in dogs than horses, and the cause may be infection, injury, radiotherapy or unknown, or sometimes indicative of obstruction caused by another condition.

The hind limbs are most frequently affected, but other areas  including the front limbs, abdomen, tail and ears can also be affected. Initially pitting oedema may be felt, but fibrosis will develop with time, possibly leading to lameness and pain.

As with all lymphoedemas, care of the skin is very important, susceptibility to infection and delayed healing will be present, and it is essential to try and avoid inflammation and infection, if these are suspected veterinary advice should be sought as soon as possible.
Reasonable activity should be encouraged because of it’s stimulation of the lymphatic system.
Canine lymphoedema isn’t curable but the use of manual lymph drainage, possibly including deep oscillation therapy, and combined decongestive therapy can help to control the condition and reduce symptoms.

Rhabdomyolosis
As with horses, manual lymph drainage can be used after acute symptoms have been treated to support recovery.

Sprains, strains and muscle injury
MLD will help to resolve inflammation and encourage quicker healing. Regular use with athletic and competition dogs is recommended.

dogs playing