Welcome to this edition of the webinar vet entitled My Horse Has Back Pain. Now what? I am Matthew Sinnovich, a surgeon and layman's diagnostician at the Lipo Eine Hospital based in Hampshire in the United Kingdom.

Let's see if I can advance my slides. There we go. So today, we will be going to some of the current research and ideas surrounding back pain in our equine patients, looking at how we decide if horses have back pain, where that pain comes from, and what we can do about it.

I certainly don't have all the answers, but we'll happily share with you sort of the current research and experience as we look at what is actually a very complex topic. So the learning objectives for today's talk are listed here. We're gonna go through some of the causes, some of the anatomy, clinical signs, diagnosis, including specialised imaging, and then therapeutics.

So from conservative therapies to surgical outcomes along the way, we'll be looking at some outcomes as well as at some alternative therapies. So, back pain is a very emotive topic, both in human and animal medicine. In human medicine, there is a well-described emotional component to back pain, and this can lead to very difficult and complex requirements in the effective treatment protocols.

And those may even include psychotherapy and chronic back pain patients. In veterinary medicine, we often have to deal with anthropomorphism, and this is particularly true when it comes to pain in our equine patients. In a French study titled Comparison of clinical examinations of Back disorders and humans evaluations of back pain in riding school horses, the researchers found that subjective caretaker reported evaluation via questionnaire survey was not efficient to detect back disorders.

Only about 12% were reported as suffering from back pain. Whereas when the examiners evaluated the horses, they detected about a 50% uptake of back pain in the, in the patients. While most caretakers actually under-evaluated back disorders, there were a few that over-evaluated it.

And what was interesting is that there were more horses reported as affected that were found with clinic with clinical evaluations with the underreported, whereas the people who were more sensitive to it tended to actually have less clinical findings. So, the horses were actually less prone to present with back pain when they were under the care of over attentive caretakers. A number of studies have also found a very strong correlation between back pain and lameness.

And in some work by Anna Ola, describing the innovation of the supraspinous and interspinous ligaments, has been shown that there's a very dense sensory innervation of both of those, which could explain the severe pain experienced by horses with back pain. And that slide there shows just in a field study showing that about 20% of horses, with, with lameness had, about 12% of those had back problems. There are any number of reasons why a sports horse may present back pain.

These include and are definitely not limited to the following slides, so confirmation. Interestingly, this horse presented for a pre-purchase vetting. The primary complaint was not back pain.

But you can see there's a marked dosis there. Shoeing rider position and posture, young horses, especially thoroughbreds, less than 5 years old, and particularly dressage horses seem to be predisposed to back pain. And this is according to work by Tracy Turner.

He speculates that the discipline of dressage requires that the horse progressively use its back and its hind end to perform collection and lateral movements. And in doing so, it predisposes some horses to problems. In an interview, he said during training and competition, the horse may overuse its back, resulting in inflammation and pain at the spines at the site of the spinous impingement.

And as we go into the anatomy, you'll see how far up the lumbar spine, the actual glutes go, which is quite an interesting finding. Obviously, then moving on to training and conditioning methods used over training, over conditioning, etc. May predisposed to back pain.

In some studies on back pain, changing the tack fit has helped up to 71% of the time. This is to improve performance and reduce clinical signs, and up to 30% of the time change in tact fit may actually completely resolve the signs of back pain, depending on the underlying cause. Obviously, horse and rider disproportion.

Large horses with small riders and small horses with large riders, may end up and doing the incorrect job may also lead to back pain. And then obviously things like acute trauma, including falls and muscle and ligament strains and strains and spasms. And these may affect the dorsal spinous ligament, the interspinous ligament, the multiitous muscles, and cause atrophy of those.

There are other muscular disorders such as rhabdomyolysis or other myopathies or muscle diseases that may also be interpreted as back pain. And then ultimately, one of the most common causes of back pain is bony problems, and bone-related disease. So the most common there being overriding dorsal spinous processes, commonly referred to as kissing spines, or articular process, joint arthropathy or arthritis.

This tends to be referred to as facet joint arthritis, and then virtual body pathology, which is fairly rare in horses. And often we get a secondary sacroiliac joint pathology, although that may also be primary. Horses certainly don't seem to be born with kissing spines.

And this has been shown in warmblood folds, which were radiographed somewhere between 9 to 88 days. And this definitely seems to be a developmental disease. As you can see there, most of the horses in that study were when they were X-rayed as fals had large spaces between the spines.

Unfortunately, there wasn't a good follow-up study with this to go on to see how many of them developed back problems through their careers. So here's a summary of the most likely distribution of bony pathology, and some of its associated aetiology. Obviously, the most common, as we said, up the top there impinging dorsal spinous processes.

Certain breeds seem to be predisposed, most commonly affected, caudal thoracics, so T12 to T16, anticlinal vertebra being T15, often one of the most common ones affected. Then trauma through causing fractured dorsal spines processes predominantly usually occurs in the weather area in sports horses. Sacroiliac disease often occurring secondary to hind limb lameness.

And this may also affect the ligaments and cause desmitis then we'll get on to that a little bit later. Then primary muscle disorders, and virtual body or process and joint disease. So moving on to the anatomy a little bit.

Horses have 7 cervical vertebrae, 18 thoracic vertebra, 6 lumbars, then 5 sacral, and a variation to the coccygeal vertebra. And the back is a very complex structure which must perform a variety of motion. This includes flexion and extension, and this is in both dorsal and ventral and lateral lateral axes, as well as rotation around the axis and the combinations of the above as well, in both loaded and unloaded states.

So it's quite a phenomenal structure and it's got a resist bend and maintain essentially the weight of all the viscera as well, while often maintaining a rider on top. So it's quite a phenomenal structure. Here we have the skeletal anatomy.

So there's an overview in the top image over there. In all the images, the head will be to the left and corner will be to the right. There usually is a little diagram in the bottom to orientate yourself, while we're going through the anatomy.

So on the bottom left image there, we're just highlighting the articular process joints or facet joints. This is in the lumbar region, so you can see the transverse processes there of the vertebra and the dorsal spinous processes, dorsally. That's highlighted in the picture to the right.

DSP is dorsal spinous process and TP is transverse process. And you can see the mammillary processes there and the facet joints highlighted by the white arrow. Looking at the sacroiliac joint.

Now, this is not like a big diarthroal joint. It's a gliding joint and it sits deep in the pelvis. This is the junction of the spine to the back end.

And as such, when there is pathology either in the spine or in the hind end, often you get a secondary or compensatory inflammation through the structure. It has a lot of ligaments, as you can see in the bottom left. Picture over there, nicely described, and these can be ultrasounded and we'll get into that in a little bit as well.

This is a quite a nice schematic diagram just to show the structure and essentially associations of both the interspinous ligament and the supraspinous ligament, and their large myofascial attachments with the multifidus and the longestimus. And the glute mead, which actually comes quite far up through the lumbar spine. And that obviously is involved in getting the horse to round its back and bring its quarters in underneath it.

And on the next one here, we can just see a little bit of a closer dissection of the multifidu muscle, which seems to be very important in stabilising the back. As you can see there, it's attached to the millary processes and it reaches forward for sort of 2 to 3 vertebrae. And this is essentially able to then tension and balance the back, the big longissimus muscle, which is the one that we see from the outside and often the one that we are palpating, is usually where we get the spasm of pain and the atrophy associated often with back pain.

This next slide just shows quite a nice cross section of how the back changes shape from cranial to caudal. So on the top left there, you can see at the level of T9, the large dorsal spinous process, the articulations with the ribs. Then going on to the bottom left where you have T13.

You have That longusimus dorsalis, as well as the multifidus, they start to flatten out and then become flatter as you then go cordially, to about T16. And then by the time you're getting into the lumbar region, so they're at L3, you can see it bulks up again. And that's due to the addition of the glute mead, which you can see they're labelled GM.

The tongue of that. It extends quite far forward, and it's quite a large component of the musculature of the back. And this has been shown in lots of work by neural stubs and many good physiotherapists that glute dysfunction can also lead to lower back pain.

Here we just have an overview of the ligaments. So essentially, the nucle ligament is contiguous with the supraspinous ligaments. And then cordially, we have the dorsal sacroiliac ligament, which then branches out into the lateral as well.

They are then interspinous ligaments in between, and those go between the dorsal spinous processes and then attached to the fascia as well. And then here just a nice lateral view of the equine pelvis showing those ligaments. Again, both the dorsal sacral ligament, which has a long part and a short part, and the sacro tuberous ligament as well, as well as the insertion of the tendon of the longestsimus dorsi muscle there.

Right. So how do we then decide that a horse has back pain and how do we come to a diagnosis of what is causing that pain? And in order to do this, we need to employ a range of clinical exams, diagnostic techniques, and imaging modalities.

And these include palpation, having a look at the horse. Range of motion tests, a dynamic exam or lameness exam, and then moving on to more traditional methods like regional anaesthesia, some specialised imaging like thermographic imaging, nucleus integraphy, X-rays, and or ultrasound. Many of the diagnostics that we've spoken about here, including many of the exams, can be performed at the horse's own yard.

Certainly, facilities in some places may limit a full examination as well as limit the ability to come to diagnosis, which is why sometimes horses do need to be referred into a specialised hospital where facilities are present and all of the imaging modalities are available as well. Thermography has come in and out of favour through many years. It's, has been reported as a very useful modality, particularly in the diagnosis of back pain.

The concern with its use on yard is the inability to control for many of the environmental variables, temperature, wind, distance, etc. And all of those may affect the outcome of the images. So while it is often very useful in a hospital setting, some of its use may be limited on yard.

One of the mainstays, and traditional ways of diagnosing back pain is through palpation. It's very important to understand that horses have normal flexion and extension reflexes through the thoracic as well as the lumbar spine. It's very important to know what the normal ones are, and these should not necessarily be confused with pain.

A horse should be able to move laterally or side to side, up and down, and often move away from your fingers. In fact, these reflexes are often used to form the basis of many physiotherapy and rehabilitation programmes. So many of the carrot stretches type things done to strengthen the multifidus are relying on normal reflexes.

Anyone can cause a horse to drop away from them by excessive pressure into their back. So your palpation should be firm, it should be systematic, and any spots of pain or reaction you find should be repeatable. When you're doing palpation, you should be focusing on pain responses.

So specifically things like swishing the tail, ears, pulling back, facial grimaces, or guarding signs, which are often more common. So that would be a very stiff and very bordered back. Having a look at symmetry of musculature is also very important.

Horses with the long-term back pain may have atrophy. Horses that have had, trauma such as the one in the lower left there may have atrophy through the pelvis and the pelvic musculature as well. Moving on then, once you've decided that a horse has back pain, how do you prove it?

Diagnostic anaesthesia with subsequent resolution of clinical signs has been proposed as the most definitive method of diagnosing horses with thoracic lung disease or back pain. This is performed in some places, but not necessarily everywhere. It also often is interpreted anecdotally to have very variable results, but certainly I think is a very valid technique and definitely a very valid part of the diagnostic process.

This research article over here showed that the long-term outcome and effects of diagnostic analgesia and horses undergoing this is specifically inspinous ligament osmopathy, had a better long-term improvement. As we can see over there, when they had responded previously to diagnostic analgesia. So what does normal look like?

Here we have a composite image built up of the horse's spine. So thoracic in the front, going into caudal thoracic, and then lumbar. That's a fairly normal spine.

Radiographs can also be overinterpreted or under-interpreted, depending on the Level of the horse's head. So by getting them to drop their head when they're sedated often opens those spaces up or lifting their head if a hand is not paying attention may close some of those spaces down. So very important to have a fairly standardised protocol when you're taking your radiographs, preferably with a headstand where the horse is sedated in sedated, stood nice and square with the head rested at a set height.

And that's at about the height of the weather preferentially. Moving on then to some advanced imaging modalities. Here we have a a composite cytographic image, so nucleus integraphy.

Bone scanning involves the intravenous injection of a labelled radioisotope, specifically technetium 99M, which is MDP methyl diphosphonate. So this is attached to diphosphonate protein. It's injected in 2 to 3 hours before scanning.

The radioisotope distributes around the horse's body and the bloodstream and is then taken up first through the soft tissues and ultimately settles in the bone where it attaches to the phosphorus proteins localised within the bone. The gamma camera then sweeps over the body, and we can pick up essentially the emitted radiation, and accumulations of those will obviously give us a good idea of increased metabolic activity of the bone, so we know what the normal is, and then we can look for asymmetry or increased uptake for inflammation, fracture, etc. Never underestimate the use of ultrasound.

It's a very limited technique in backs and on yard is a very, very useful technique. There are some images to the left there, so, side on, on the left and sort of sat through it on the right. .

Where you can see the dorsal spinus processes, the space between them, in with some good machines you can actually get and getting in plane, you can also get some of the interspinous ligament as well. But you can evaluate the dorsal spinous ligament very nicely there and then facet joints as well. So, ultrasonographic examination of the sacroiliac region has been described this both transcutaneously and internal exams, and transcutaneously has provided clear images of the quadromedial border of the sacroiliac joint and its adjacent structures.

It's a useful aid in the diagnosis of sacrolic joint disease and some adjacent lesions. It's externally, it's a useful method for examining and differentiating the longest was dorsi muscle, looking at some of the multivious muscles, as well as the dorsal sacroiliac ligament at the level of tubal sacralla. Now, transrectal ultrasound has also been described, as well as a grading system for lesions found.

This takes a fair amount of practise and may sometimes require specialised probes in some horses. But it's interpretation has, should definitely be correlated to clinical findings, certainly according to the authors in the study here. And then over here we have a composite image of a postmortem specimen and an ultrasound image showing what the normal articular process joints, the facet joint should look like.

This again is in the lumbar region where they are slightly sharper and you can see the arrow pointing to the millary process over there. So what does this look like when we have pathology? Over here we have again, a composite image, nucleus intigraphy of the thoracic region.

And you can see there's increased radiopharmaceutical uptake highlighted by the circle. So that's what a positive bone scan would look like. Facet joints, we would do specific oblique views of the back to highlight the facet joints, but the normal straight DSPs usually when they're overriding and fairly active, will come up as quite a hot, bright spot.

The intensity obviously is related to the to the amount of uptake and assumed to be associated to the activity in the underlying bone. Then we do lateral lateral radiographs. So over here we have quite a badly affected back.

You can compare that to the previous image which had nice open spaces between them. This has marked new bone formation, cystic formation, there's lysis and sclerosis all over the place. And there are some very useful scoring systems radiographically.

I've included one here. This is one that's used in a number of research papers. Going from not being a completely normal back to 7, where you have essentially a completely fused back with variation in between.

So what you'll find with most horses is, or certainly many normal horses if you X-ray them somewhere around a one with some mild radiolucency or sclerosis, mild narrowing of some interspinous spaces or some closeness. Then heading on into 2, where you have decrease of that space, increase numbers of radiographic findings, moving up to 3, where you're kind of getting moderate modelling, some enthusiast processes. So it's often, you can see that with the X-ray as well, and up to proper overlapping as well as cystic formation in the dorsal sites.

Here is some ultrasound images of a, of an abnormal back. You can see a decrease in the space. What you can also do is assess some of those enthusiast attachments as well of the interspinous and dorsal spinous ligament.

And certainly in some horses, we have diagnosed lesions in both of those, focally as well as extensively. So I don't underestimate the use of ultrasound. It is a very useful modality, both in the diagnosis and the treatment of, of backs when you're looking at injecting backs, and you want to do, guided injections, ultrasound is often a very good way to do those as well.

And then as we said, we've kind of touched on the sacroiliac as well. Here we have some cytographic images of increased uptake unilaterally. So This is just a study showing that with the evaluation of ultrasound and correlating it to outcomes in sacroridic disease, the objectives here would determine if the findings on ultrasound, the differences in injection technique or medications, what could be correlated to a return to function, in horses that had sacroiliac region pain and or dysfunction.

They looked at a large sample of horses. Return was found in 62% of them after injections. 42% or 4 or 42 to 10% of horses returned to a lower level of work, and some did not return to work at all.

Horses that were injected with methyl prednisolone were 4.2 times more likely to return. But interestingly, findings on ultrasound did not always correlate to outcome, and should be judged with care according to this study.

Here we have some of those oblique images with some increased uptake in the facet joints correlated there to some radiographs and pathology in the facet joints is highlighted there with the red arrows. In this case, there's some sclerosis and some per-articular new bone in those coal facets. So once we've come to a diagnosis through both our clinical exam as well as our advanced images, we then have to go, what are we gonna do about it?

And essentially, we have 3 goals in our therapeutic plan. In the first instance, to decrease pain, long term to increase strength and to increase mobility, so that the horse will reduce its poor performance and go back to doing what it was doing before, hopefully at the same or even a better level. The most important part of any poor performance exam, any lameness exam, and essentially anything in veterinary medicine is addressing the owners' concern.

This is key to compliance and ultimately getting the associated para veterinary professionals on board with your plan will ultimately help the patient, and hopefully lead to the most successful outcome. Most riders have a team of people around them, be it their friends, their trainers. They will very often have a close relationship with their barrier.

Some will have chiropractors or physiotherapists, and many will also have often used a saddler before. It's very important to get those people on site before in any back rehab programme. As much as possible, where, where possible, have a chat with them, get, get their feelings, get their concerns as well, because these are very often the people that the client is listening to or has been speaking to very often before they've come to, to seek veterinary attention.

So the treatment plan in the acute phase of pain relief, this is usually done with systemic medication that may be anti-inflammatory medication, so non-steroidals, phenolbutisone, and meloxicam, any of those sorts of things, muscle relaxants here, we're talking about things like methocarbamol, or Robaxin, which is often used. To treat back pain and horses and pain medication. So non anti-inflammatories, things like paracetamol, and the morphine, those sorts of opioids, in very, very acute, certain things with acute trauma, or very, very sore and painful backs, a combination of these is often used.

Getting onto a more long-term plan, which you're then talking about in a conservative setting is exercise modification. So that may be getting the rider off the horse to start, starting with pole work, progressive in hand programme, changing the saddle. As we've said before, in combination with intralegional medication.

Now, this could be corticosteroid, pitcher plant extract, serra and things like that. Steroids, as we've touched on before, methyl, prednisolone, trilo acetonide, and or a combination of both. Where there has been atrophy of the multifidus or the longestimus muscle, rehab exercises have been shown to be very beneficial, and these can include stretches as well.

Often it's very important as well to have these guided by an APA registered physiotherapist or under veterinary supervision. Range of motion to end of range, if you have facet joint arthritis or things like that, can often exacerbate inflammation, certainly in necks and in backs as well. So it's very, these programmes should be tailored.

It's not a one size fits all for the horse. Physiotherapy programmes need to be tailored to the specific problem at hand. Part of the physiotherapy or chiropractic plan as well, will in the first instance, be to reduce the spasm, but also increase proprioception, and get the back moving correctly long term, many the outcome of many conservative programmes relies very heavily on increased proprioception and the correct use of the muscles.

Ancillary therapeutics. So things like extracorporeal shock wave therapy have been shown to have very good long-term results and often can maintain horses in competition, although it has now that the use of shockwave therapy has been limited under the FAI, certainly for a week before competitions. And then moving on to other systemic medications like bisphosphonates and things like that, have also been shown to have some good results in back pain.

So there are many, many therapeutic plans. There are also many ancillary things and other medication or other treatments. These include and are not limited to things like acupuncture, mesotherapy, the, and other alternative therapies like a beer blanket, .

I was always very doubtful of the effects of the beer blanket, but was of the impression that it probably did not do anything bad. Mesotherapy as well, probably increases some proprioception feedback in the back, which probably is, is where part of its anecdotal resolution or improvement comes from. But there was a study out of 313.

Sorry about that. There was a study out of America here looking at the effects of a bioelectric energy regulation blanket on thoraculum pain in horses. And this did show that it had positive effects.

So interesting, and certainly probably doesn't do any harm. The mainstay of most conservative plans is still corticosteroid. These are under either blind, ultrasound guided or radiographic control injection, in combination with bisphosphonates, that could be children and or Osos, as well as substance pee inhibitors, so pitch plant extract things like sarrain.

It's difficult to measure conservative outcomes, as there are few outcomes reported for straight conservative therapy and equine back pain. Most reports are generally used as comparisons for surgical intervention. There has been a systemic review here, which was looking at manual therapy, so that's physiotherapy, outcomes.

It was very difficult in the systematic review to draw firm conclusions because, you weren't essentially comparing apples with apples. But, despite sort of many, reported benefits, we can't come to a firm conclusion about, conservative management. And there we go.

Moving on next, we have surgical options. And essentially there are 3 mainstays in surgery. The interspinous ligament doesmotomy, a subtotal or partial cranial, or what's referred to as a cranial wedge ostectomy or a total ostectomy, which is sort of cutting off the tops of the spinous ligaments.

Initially described by Richard Kuma, the interspinous ligament dismotomy. We have here a long-term follow-up between 2012 and 2017 of 71 cases. And we can see there that had a fairly good outcome, sort of 80% owner satisfaction, and 82% of owners would recommend, the procedure again, but certainly up to 80% going back to what they were doing in their previous level.

This is slightly below the original outcome, described by Kuma. And this surgery still requires relies quite heavily on a post-operative physiotherapy plan, which is a very important part of the rehabilitation. These are some images pre and post, so A is a pre-dismotomy, B is post, C is pre, and D is post there.

And the idea is that you stick that, so that pair of scissors goes in through the into the interspinous space, resects that ligament, saves the dorsal spinous ligament, just resects, there's a demotomy of the interspinous ligament. And that then allows up to a formal increase in space in between those spines and very often, hopefully then allows a little bit more movement. It's postulated also that a neurectomy is done at the same time, and this has also led to some studies showing that you might get some, muscle atrophy or white hair formation at the surgical sites.

Although that does not seem to affect horses long term. Moving on then to a different technique, the cranial wedge or subtotal or partial mastectomy. This was described by Jacqueline Mitchell and Wright, and again, has a very good outcome, cosmetic outcome described at 81% and sort of an 80, 78 to 80% return to previous function.

What does that look like in practise? So here are some images from the original paper. As you can see in the dorsal image, quite a marked change to the dorsal spinous processes there, quite a lot of sclerosis, and a large incision over the top, as is highlighted by the staples in the lower image and the cranial or rottal third of the dorsal spinous.

Processes is taken off either with an osteotome, an oscillating sore, or a chisel. And that then opens up the spaces, in this surgery and interspinous ligament dismotomy is performed at the same time. It has to be by because the interspinous ligament is attached to the bone.

So essentially you're doing both procedures, . Oh, opening the spaces as well as removing the, the interspinous ligament at the same time. And then the last would be a full or partial ostectomy.

So we can see there are some images pre and post-surgery, with very close spaces. The, metallic objects there are used as markers in the planning stage. And then you can see in the lower left image and lower right image, the entire dorsal summit has been taken off.

And very often what we'll do with these is where there are a number of spaces is alternate, so every 2nd or 3rd 1 will be taken out through a planning process in order to make as much space as possible. Cosmetic outcomes for these generally are very acceptable, and again, ranging somewhere about an 80% return to previous function. Rehab for both the cranial wedge and total ostectomy is usually within about 12 weeks.

So within 3 months, there's a fair amount of exercise. And at that stage, you'll be getting patients back under saddle pending the outcome and pending wound healing. So then the age-old question, is kissing spine always a problem?

And the prevalence of back problems in lame horses in practise has been reported generally at about 2.2% of all horses. In this large cohort study here, 4,407 horses were evaluated for lameness or poor performance.

The back pain was identified in about 7% of those. 212 of them, or 68% were diagnosed with kissing spines. 70 horses that had never shown any signs of back pain had their back radiographed.

And 27 of those, or 39%, showed overriding dorsal spinous processes. There also has been a large postmortem study of clinically normal horses, and in that study, kissing spines were reported at somewhere between 70 and 83%. So definitely as we do get overriding dorsal spinous processes in non-lame horses and in horses that are not affected or show no clinical signs of back pain or are performing to the level they are expected at.

However, forces that present for back pain have a 3 times higher likelihood to have overriding dorsal spinous processes. Medical treatments designed to reduce pain and induce the muscle relaxation are usually combined with routine exercise to stretch and strengthen the back, and these can be very effective in maintaining those, . Treatment is 20% less likely to be successful in horses where there are 5 or more vertebrae involved.

And as we said previously, saddle fit was changed in 20 saddle fit was changed in 29 horses, and this has helped 71% of the time. So coming back in summary, it's very important to have a very good team. It's very important to come to the correct diagnosis.

And certainly before embarking on any surgical intervention, you need a positive diagnosis, which is at least 3 or 4 of the above. So clinical signs, diagno positive response to diagnostic anaesthesia, and a combination of advanced imaging, including X-rays, ultrasound, and or bone scan. And non-response or partial response to a conservative therapy in the first instance before embarking on a surgical Intervention unless there is a very marked pathology, so showing that more than 5 spines involved may limit your effect of a conservative therapy outcome.

And then also choosing the correct therapy for the problem. So not all things are gonna work for all problems, and having the correct conservative plan in place or the correct ancillary physiotherapy plan in place for a surgical intervention will only improve your outcomes long term. Many of these will require ongoing correct management and that may be some variation of tactic change as well as exercise change.

I hope that hasn't confused you too much, and hopefully, shed some light on what is a very complex, and challenging topic. Thank you.