Great, thank you very much, Sylvia, and, thank you for the invitation to, to come and speak. It's excellent event. It's absolutely incredible, the, the, the breadth of speakers and the, and the platform, everything, it's just amazing.

I look forward to exploring it a little bit more, after my presentation. . Just touch on that brief thing about being understood.

I mean, I, I'm, I've grown up in this country. I think I have a tendency to mumble and face masks and not be my friend, I found, in terms of people understanding, and I think that's done, hopefully, once we can, dispense a face mask at some point in the future, that will help. So, I'm looking at the diagnosis and treatment of back pain.

It's quite hard to cover it in quite a short space of time, but I try to sort of whittle it down to an approach that is, would be useful, in, in your early days, out in, in practise. The thing is, is that, a great many, of, The horse owners will believe their horse has back pain. It's, it's a difficult thing to prove or disprove in, in many situations.

The kind of things that the horse might be presented for would be the, the rather nebulous term of poor performance, which Of course, that's a lot of people can believe that horse isn't quite performing where they want it to. The tricky thing is all the, the truth has to be, has the horse ever performed where they want it to? Have we seen a reduction in performance or simply is the horse not achieving the heights which the owner believes the horse should, and that could be associated with lameness, gastric ulcers, dental related issues, all sorts of different things.

Bucking, . Or problems with transitions into cancer and out of cancer can certainly be related to to back problems. Rearing loss of a bascule is the shape over the fence.

We want a horse to make a nice inflexion of the spine. This cold back scenario where horses dip down when they're initially mounted, but then that is usually resolved easily with just warming them up. They may be sensitive when brushed or palpated around the back.

And resistance to girthing. Now that can also be due to gastric ulcers, etc. And then hanging on one rein, well, of course, that can also be associated with dental abnormalities as well.

It is certainly difficult to achieve a secure diagnosis, unlike in, in people, of course, where you simply ask the question, in, in horses, you know, with lameness, it's very easy. We've got another limb to compare it to. We see asymmetries, but the back, only having one back doesn't make that very easy.

And the same is, yeah, I said when we're looking at measuring back movement with the inertia sensors which, Sylvia mentioned. It would be lovely to have an objective system of quantifying, but we are not really there yet, and it's as much about ruling things out as ruling things in. So I thought I'd show some videos of me palpating a horse, and hopefully these will, will, will, run relatively smoothly.

And now here I'm feeling along the dorsal spinous processes here. I've got these inertia centres on, that's just for lameness. But I'm literally feeling very gently along the back.

Now I say gently because anyone can make a horse flinch, if you press hard enough, especially in the sort of rather ticklish spot along those spinous process. So I'm literally going along the centre and. You can usually feel the spineless process, especially in a thin horse, and get an idea of what the horse's reaction is.

You're reading what is normal for that horse. That will be different if it's a cob versus a thoroughbred. I then clasp my hands together, a little mini workout for me as well.

At my age, I need these little ups in the day to sort of keep the, the upper body a bit toned, and this is quite tiring, but you clasp your hands together and rather like bouncing a ball, you sort of time your downward pressure to get the horse literally bouncing, and you're looking again, is the horse swishing its tail a lot? Is it trying to kick you? Is it just resenting that?

And you might go back and forth, and revisit areas that you think might be uncomfortable, but I'm literally putting downward pressure as they get the timing right so you can bounce it like a ball. Here, I'm using a biro pen, remember to put the lid on. I've made that mistake once and just draw all the way along this about, it's about sort of 4 inches or so off the spine to one side and the other, and it's an induced ventroflexion and Induce dorsiflexion.

So it's ventroflexion when they get to this point and then dorsiflexion when you go over the back of the gluteals. And that's the horse cannot help but do that. And it's not so much the fact the horse does it, it's, it's more about the reaction to it.

So the horse may move away from you, try to kick. With its tail, etc. And and that implies that that movement is uncomfortable sometimes to make.

Literally just palpating round. I normally, to be fair, would be looking at the muscles towards me. I'm just doing this, it's easier to film.

But literally just with your fingertips and just palpating these arepas your muscles. You've got longusus dorsi, just here, I'm also just doing some induced retroflex. Just literally there in front of the pelvis, and then ticklish, horses will do it more just at the back.

So, if you can't get a horse to do this, don't worry, it's probably a carbon it'll just stand there looking at you and you're like a bit of a wally trying to press it and make it do things. Don't worry, that's simply some horses will do this more effectively than others. But when you palpate the muscles, you're looking for trigger points.

So you're looking for the muscles to be sort of quiver under your fingers. And of course, any signs of tension or pain on, on palpation. This, again, we start looking at horses that start to sort of show these are these quivers you see here, these, these trigger points, we're seeing the muscles spasms, and that indicates a certain amount of discomfort.

You see the horse is somewhat distracted, it's got its ears back, OK, in, in a certain area. It's not so bad working backwards. It's, it's literally in these sort of T of 15 to 18 region under the the back of the saddle.

This is another horse I went to a clinic to operate on, and again, you know, you can see it sort of fidgeting around, lots of swishing of its tail, going to sort of . That to try and kick me as well. I it's just about drop out this horse and I was just a part pain just in that sort of region again around about the T15, 180, it's trying to move away from me, anything it can to try and lots of swishing tail, anything it can to try and sort of say, get off that hurts a little bit.

And then this horse here, again, this is one that was a show jumper that was showing a reduction in performance, and it really looks like I must be palpating really hard to get a big horse like this to practically sink down underneath me. And I promise you I am not palpating hard. That's not what I'm in the business of.

OK? Just stop these videos trying to get a little bit smoother, but, You know, this was a horse that had started becoming very painful and was having a difficulty maintaining cancer on the left brain, and it's jumping performance is somewhat reduced. But it is a it's a bit jumping the video, but this horse is sinking down whenever I get to this lumber region that came, which is quite, quite marked.

And this horse ended up having . Caudal thoracic, and cranial lumbar region pain. You see just what a reaction, that is.

Another thing we would look at is the horse when they're, when they're cantering, and this is I've tried to put together this video to to make it to really clarify what I mean. This is a horse with quite reduced hind limb separation during Canter. You want basic.

When the horse puts its legs down, to, to take a bigger stride, and then suddenly it becomes disunited. It's now landing inside hind leg first. So the shorter they get the strides, the closer they are to bunny hopping and the closer they become to becoming disunited.

You see, it switches and then becomes disunited. It's united at the moment, just in a second, it's gonna switch there, it's switched. So what's out and look at this quite interesting to see what happens in slow motion.

This horse is coming around, it's taking this slamming outside hind leg first. What happens just in a second next stride, I think. Next one, sorry.

That Seems to be no rhyme or reason why it decides to put that inside hind leg down first, probably because it's aching, it feels a bit painful and and as a consequence. It decides to think I need to put the other leg down first. This does it again there.

OK, let's just follow this round again. Outside hind leg going round and landing first, and then it just switches. It seems to be somewhat effortless and seamless, but this is the kind of thing you'll see in horses with back pain or indeed sacreac pain, and you know it's something which really the horse should is probably doing to try and alleviate discomfort in that region.

It can be associated with lameness, of course you must always chase a lameness if you . If you have that, present, i.e.

A lameness present, but, if you haven't, then that's the kind of thing you might see with, with back pain. So impinging spinous processes are probably the most common thing that we associate with back pain, otherwise known as kissing spines. But it's important to recognise that there's a lot of forces out there which will have impinging spinous processes, and appear not to be painful, which is obscure.

Because, you know, it's hard to believe why would some be painful, some not, but it certainly seems to be the case. Now, in racehors, it has a huge prevalence in postmortem specimens, euthanas for reasons, not associated with back pain. About 92%, or even up to 100% in some studies, of racehors have evidence of impinging spinous processes radiographically and then subsequently at postmortem.

It is not present in foals, but it seem to be born with it, so it does seem to be a product of the domestication and a product of riding and the way horses are actually trained and ridden day to day. Certainly, X-rays do obviously allow diagnosis relatively straightforward. The nucleus intigraphy is another way.

This is bone scan, and this is the same horse, this is the back x-rays of that bone scan, and we can see here, uptake here in the sort of mid to thoracic spinous processes. And this simply indicates that we've got active bone remodelling, and that we can see is sclerotic regions on the back of T15 here, and a little bit of remodelling even between 14 and 15. OK?

So, bear in mind though that we don't commonly see this condition in dressage horses, but when you consider the way dressage horses are ridden, they are flexing their spine and working very well. This I put in really to to appreciate that even when you do this a lot, you can get it very wrong. What I've tried to do here is on palpation, is to put the needles in the gaps that I can feel on palpation.

And this is to illustrate the point that it is remarkably difficult to actually find the gap simply on palpation alone. Some horses are easier than others, of course, but if they're impinging, there's less of a gap there by definition, and so it's difficult to feel. So you really must do this under radiographic guidance, so then you can correct them more this kind of region.

And what we're seeking to do here is to put local anaesthetic, dispense it around this region just ventral to the site of impingement, bearing in mind the dorsal spinal nerve runs in the interspinous ligament. And we are looking to remove sensation. What we need, just like a lameness, is a reproducible sign that is blockable, so that might be bucking on the saddle, perhaps being disunited, difficulty counting on countering on one rein or the other, but something you can tangently say, I can see that, and I can block it.

A written assessment, after about 15 minutes, ideally, two riders. This was a, an interesting case that, this, it's a teenage boy, who had a very relaxed riding style, really didn't seem to be too bothered by the fact that the horse. Which is bucking incessantly.

But it was only when the horses in Canter, it didn't look particularly comfortable in Trot, but certainly in Canter, whenever he went into Canter, off it would go into this bucking bronco, really, really reproducible. And he did well to stay on this chap. He's got a rather amusing riding style.

Very, very relaxed, like he's in an armchair, but, this is after blocking the back. And you can see what a huge difference that is. The horse looks more comfortable, the riders riding monkeys in an armchair, but certainly we've managed to change things there.

We've managed to improve things. And if you get that response, then that's great. You can say, well, that's, that's perfect.

We know we've got a. a, a clinically relevant impinging spinus processes. But it, of course, it has to be borne in mind.

You are responsible for the safety of both horse and rider, and if a rider falls off during a test that you're doing, then, even with consent, they are not consenting to being injured, and that's a difference legally. So you have to be a little bit careful about how you Approach these situations. This was a horse, courtesy of Roger Smith, this video, with the saddle on, OK, not, not too bad really, trotting around.

This is, with a weighted saddle. We've got a weighted surfing here, and this was the, what the owner complained of, and you can see it's not, . Looking like the most comfortable horse in the world, to get on.

So it really was the weight in the horse's back, which was significant. And this, this is lead shot bags that are in the pockets of this single. And the idea is to simply make this test safer, OK?

And we then blocked this horse and . But local anaesthetic around sites impinging spinous processes, and, you know, clearly there's a, there's a big difference here in terms of the way the horse is responding. And this is what it looks like just flat, these are pockets, these aren't commercially available, something we homemade ourselves, but, you know, we can, certainly, you know, similar things can be created.

But just bear in mind this is safer, and we have to take that into consideration. So how do you take X-rays of the horse's back? Well, this is the lateral lateral x-rays, and here we, we normally take about 4 shots with markers on to make sure that we've got, the, we know where we are, so we can then correlate that with our sights and pigeons.

And we've got, you know, quite marked. Degrees. Normally the worst impingement will be in the centre, and this is where it first occurred, and then it sort of radiates out to become less as you come outwards.

Not to say that these aren't painful, I really think there's a poor correlation between the degree of impingement, and, the pain the horse is experiencing. Do not forget though that even though you may have normal spinous processes or especially if you've got abnormal spinous processes, you will likely or should probably check for articular process joints. So these are the joints at the back, further down, the spinous processes are obviously up high, you can see down here, and they come down and then they form a joint just here.

And the most likely affected joints about T16, 17, the call of thoracic region. But we take it via this 2 degree oblique radiograph. Not easy with some portable machines it has to be said, although they are getting much, much better.

But don't dismiss that a horse doesn't have back pain if you haven't checked for this. You can check the spinous process is easy enough, but you must check these. You can ultrasound scan these articular process joints, and this is a curvilinear probe, OK, and these are your spinous processes here, and this is your transverse process, and your articular process joint is just here and here.

Now it should look like this one, it should look like you can appreciate the joint space, it's like a box, it should look like a nice distinct box. If you can't appreciate the joint space, or sometimes you'll have you know an uneven bony surface just here. Then we assume that this has got some remodelling because we cannot see that joint space down through.

And this is easier done in a thoroughbred, no doubt about that. You know, I find in this, you'll notice this is not a thoroughbred that I'm scanning here, but it is, nevertheless. Trying to just get used to doing this, especially if you think there may be articular process joint osteoarthritis.

And this will be evident on X-rays, but there's a, there is an argument for saying that ultrasound is actually more, more sensitive. So the aims of treatment are to alleviate pain. The horse won't work properly unless it's in, in, in the absence of pain.

And this has really come a long way. We've borrowed it from the human field in terms of generating exercise or exercise being as, as soon as possible. The horse must not be painful, and in trying to improve flexibility.

The saddle must be checked as well, that's imperative, and this was a study by Sue Dyson, Greve back in 2014, and some take home messages really, that back dimensions change regularly, especially with work and even after a work session, and this is really important. That if you're gonna get a back, a saddle checked, it must be checked after the horse has worked. We all know that muscles swell during exercise, and that includes the back muscles.

And so, there are, these are certain things which we must take into consideration when we are . Looking at getting the saddle checked. And even in sport horses, the saddle should check probably every 2 months, but certainly, every year is probably not enough, in your, other horses because of these changes in time, heavier rider as well.

And, . And that's just something to be considering. When it comes to the the working the back, we know there's the bow and string theory, which was proposed by Leo Jeffcott back in 1979, and it's essentially saying that what we have got is the, the bow is the back and the string and all the sort of weight of abdominal muscles and so forth.

OK, and we've got these muscles which are the stabilisation muscles of the back, especially this multifidu muscle which wastes away, certainly in humans and it's been demonstrated in horses as well. What we're looking to do and we're we're we're addressing back pains, we want to flex the spine, that makes perfect sense because the spinous process is sticking up and we need those spinous processes to separate. So anything that retracts the leg, the forelegs, and protracts the hind legs, things like walking poles, trotting poles, walking up hills, anything that has the head down will rotate those cranial spinous processes forward, so feeding from the ground and also lowering the the the horse's head.

These are baited stretches, which are something the physio would, do with the, with the client, and these have been proven to be useful at, improving the core stabilisation muscles, in particular that multiferous muscle as well. And the clients find these quite fun, you can see that they get better and better at them, and this is something that the client can be doing with the horse, twice a day. When it comes to impinging spinus processes, the treatments, well, we would normally, obviously a robust diagnosis, but we would normally reach for the corticosteroids medication in the first instance and try and get them to exercise out of it.

Certainly in the UK we're kind of on our own a little bit in terms of how early we reach for surgical treatment. On the continent in Europe and in the States, it's far more common for them to exercise out of it or use conservative therapies. Bee may be simply enough, we're trying to get them pain free so that they engage in these exercises.

So we may just infiltrate in the same way that we did with local anaesthetics and corticosteroid around the sites of impingement. Extracorporeal shock wave therapy has been demonstrated. A recent study, 2020 demonstrated that 3 treatments 2 weeks apart over the affected back, part of the back, caused pain relief that lasted for 56 days, and that could be useful as well.

Certainly useful for competition horses, although you cannot use Shockwave within 7 days of an FEI competition. There's obviously withdrawal periods, of course, around about 11 days with triston alone. I normally allow a bit longer, around about 2021 days for methyl prednisolone.

After medication, you'll box rest them for 48 hours and then they enter a non-ridden exercise programme. And this is a standard programme that I would use. It's one that I've sort of come up with based on sort of experience, and it's incremental walking.

I want the head to come down, not necessarily a per se. I like this Equi core, which you can look online, it's a good device. It doesn't have the sort of the, the rope around over the head.

Obviously you adjust it according to the horse's ability. Concurrent be medication can be given the horse must be not in pain. This, a registered physiotherapist can help in, in sort of supervising the exercise programme that can visit more frequently and help the owner with these exercises.

With these water, with these carrot stretches. Water treadmill is useful as well, and after 7 weeks commenced ridden exercise, this is the ideal scenario if you're really trying to address with a more long, medium to long term aim at resolving back pain rather than simply managing it. There are surgical options with impinging spinous processes here.

This is the cranial wedge ostectomy, that was described by Ben Jacline at all in from Newmarket equine Hospital. There is a danger you sort of cut a bit, you know, sort of never ending cut as we, we call it, but essentially your, your remit. Keeping the height of each spinous processes.

This is something we wrote up in the RVC and then Parley Brink as well wrote up doing every other spinous process so that you can actually, you can actually separate the incisions doing this. But this shouldn't be seen as a first resort, but it is effective, 72 to 79% success rates, but there's a longer convalescence. I tend to have them in work actually around about the 8 to 12 week mark, but it is quite a long convalescence.

What's risen in popularity now is the interspinous ligament desmotomy. And this is where we go burrow underneath the supraspinous ligament and cut the interspinous ligament. Probably it's a neurectomy, the dorsal spinal nerve exits the frame in here and goes up through the interspinous ligament to innervate this region just here.

OK. Now, by severing the interspinous ligament, we probably sever the the dorsal spinal nerve. Certainly the initial success rates were huge, about 95%.

It's minimally invasive, which is quite nice. And the horses are back being ridden after an exercise programme of six weeks. Three year follow up, showed that about 53% are still in their previous performance, 91% though are still being ridden in some form or another, with about 80% recommending the procedure.

And generally speaking, because it's minimally invasive, people quite like this. We use I use a special blade now to assuage John sort of scalpel to cut down the interspinous ligaments. So here I'm just burrowing into the from the side about just off the supraspinous ligament.

And then I literally cut down, once I found the slot between the spinus processes, OK, and then I cut down to, sever the . Interspinous ligament there so you can just see the movement in my hand, I'm just severing that ligament. And these sutures are then just, these sites are closed up with a single, single suture.

And that works, very nicely. So in summary, it's really important to ensure all lameness has been addressed. I can't stress that enough.

I've focused on back pain, but lameness must be addressed first. We're well, we're well aware that lameness affects back movement, and so muscular back pain is almost always going to occur secondary to prolonged lameness. Obviously, we talked about palpation, a thorough physical examination as well as mandatory.

Diagnostic analgesia if you've got a reproducible clinical sign, and you can do it safely. Radiographs and ultrasound we've also looked at, are very useful. And really when it comes to treatment, focus on exercise based therapy.

It's like I always say to owners like, can you take your horse to the gym, doing horsey Pilates, horsey yoga, and really get them going. This is not messing around, this is hard work, they have to be engaged in it. Provide pain relief, whether that's in the form of medication, that could be steroid medication directly or phenylbutasone or both, potentially acupuncture, which we've not talked about, that could be useful and shockwave I've also mentioned.

Surgical options may provide a better long-term solution, and there are two options, the spinous process resection, which we looked at, and the interspinous ligament desmotomy. So, I tried to catch up on a bit of time because we're quite late starting, we've got, I'm not sure if we've got any questions.