Meanwhile, Roald Oates, Claire Lomax is at 9 in over the first narrow hedge, down through the road crossing out over the second, and here is a whistle. Hi everyone, it's a great pleasure to have you join me today and I'm gonna share my story with you. I think a lot of us have had a rough time recently and life always has ups and downs.

So hopefully my story will make you realise that we can get through these if we persevere. When I was at school, there's nothing I hated more than speaking in front of groups of people. In fact, I'd do anything to get out of it, even reading a line from a textbook, I'd be thinking, Please don't pick me, please don't pick me.

Avoiding eye contact with the teacher, and then they'd be like, Claire, and I would hate it. And now I find myself doing it all the time and absolutely love it. It's funny how life can change, and mine certainly did that back in May 2007.

So before my accident, I was a chiropractor, been to university, got my degree, and set up my clinic that I treated my patients from just part-time at home, but my passion with horses. And right from the age of 2 or 3, I was on ponies and eventually got into the sport of evening. It was only a few months before my accident, I was competing at the Burleigh horse trials.

It was my childhood dream. I went to school in Stamford in Lincolnshire, and Burleigh is the back of where I went to school. So in September each year when the horse trials are on, I'd be going there after school or in the lunch hour to be riding there.

I felt like all my dreams were coming true. It was a really exciting time for me. I had 6 lovely horses to compete with good owners, and my goals and ambitions were set high for the future.

And then on the 6th of May in 2007, I went off to Osberton horse trials. It was an event I'd competed at loads of times before. I wasn't particularly worried about it.

It was just a training run for a bigger event coming up a few months later. And the horse I was riding was actually the one you saw on the video. We knew each other really well.

I'd ridden him for about 5 years, and we actually went around the exact course only the year before. Anyway, I set off to the event and the horse box broke down on the way there, so it didn't even look like I was gonna get there and get this to run. I was pretty disappointed because I wanted it in good preparation for, for Bramham horse trials coming up.

Anyway, they managed to fix the horse box so back on the road and got to the event. But because of the delay, I ran around the cross country course. I didn't have to think about it.

I just put one leg in front of the other. It was easy. Then I got on the horse, did my dressage, show jumping, nipped the loo.

Again, it was pretty straightforward. Got on the horse and set off onto the cross country. It's going really well.

It's about 2/3 of the way around, and we're in the woodland track, and the track then split into two. It's actually the photo you can see now. The horse thought we were going one way, we're meant to be going the other way.

It was the smallest misunderstanding, the tiniest of errors. He clipped his shoulder onto the tree, flung me into the tree, and when I hit the ground, I knew I was paralysed. I knew that tinies of errors had totally shattered my life.

I'd had bad falls before, but always got up. This time I couldn't feel the ground I was lying on. I knew I was paralysed.

We all see these signs around, but ever disabled people, you never think they're going to be significant to you possibly for the rest of your life. So there wasn't going to be without some hard times ahead. I was airlifted to the Queen's Medical in Nottingham.

And they operated on me that night. My injuries were that I dislocated my spine at T4 level, so I'm paralysed from the chest down. That's where the spinal cord damage was.

I also fractured my neck, but luckily no spinal cord damage. I fractured ribs, punctured the lung, and ended up getting pneumonia and I was in intensive care for 10 days. It was after they operate on me that evening and they realigned my spine where the dislocation was, they, they put titanium rods into my spine.

And the consultant came in after that and he told me it was highly unlikely I'd ever walk again. It's a huge thing to take on board, but actually it's far more than that. So everyone can see that I'm in a wheelchair and that I can't walk.

But a spinal injury affects nearly everything from that injury level down, so my bowel and bladder don't work properly, sensation, I can't feel anything from the chest down, blood pressure's affected, temperature regulation, nearly everything. So, there's gonna be a lot of time where I'd actually need to adapt to my new circumstances and it wasn't gonna be easy. They did an amazing job at intensive care.

The, the treatment I got there was exceptional. And then I was transferred to Sheffield Spinal unit. And this is where I thought my hard rehab would start.

Again, they were fantastic at getting me gradually off the ventilator, getting used to breathing on my own and strong enough. Getting from bed rest into a wheelchair. You can't just do it, kind of go from one to the other.

You gradually get used to even sitting up, and then you can manage 5 minutes in a wheelchair and you extend it to 10 minutes and so on from there. And when I got, so I was able to spend longer periods of time in the wheelchair, my physio session started. And it wasn't like what I thought it was going to be like.

So I got 3 sessions a week for 45 minutes. And I'd go down to the physio rooms and they've got amazing equipment, and I'd go around and I'd say. You know, how about I try this equipment or try that, but they only wanted to work the parts that weren't paralysed, so arms and my balance really.

They didn't want to work the paralysed parts at all. They said, if you've shown any signs of recovery, then we would. But as I wasn't making any recovery, they just wanted to leave that.

And I thought, well, if, if I never sent another signal to my legs, my body, then they're less likely to work. But in the worst case scenario, I didn't get any neurological gains back, but it would help keep me fit and healthy. Any kind of hope was false hope, and any positivity was denial.

So I've been in there about 8 weeks and I'd had a day at home and I got on OK and then I had a night at home and I survived that. So I went in after that and I told them I was leaving. And they just looked at me like I was totally mad.

They said I'd been there for 5 or 6 months, so this was only 2 months in there. And I had all day of them speaking to me why I shouldn't leave. I had the consultant, the, nurses, the physiotherapist, the occupational therapist, everyone.

Of the reasons I shouldn't leave, but I really felt like I was doing the right thing, so I packed all my stuff up in my room and and decided I was going, but there was a slight problem, they wouldn't give me a wheelchair when I left. They said, how are you gonna get from your car into your house? So I just looked at them and said, well, I'll just have to walk, won't I?

Of course I knew I wasn't really going to. I just wanted them to think I've got a little bit more false hope. Anyway, eventually, I persuade them to let me, borrow a wheelchair to get to the hospital car park.

They were a bit reluctant, but in the end, they agreed, and they said make sure someone brings it back. So I said, yeah, they will. Mom will bring it back.

And just as I got to the car in the car park, and I was about to transfer using the slide board that I've got, to get in. I peed all over their wheelchair, and it wasn't deliberate because I can't do that. Sometimes in life you're just looking and I was just lucky at that moment.

So Mom pushed away their pissy wheelchair back to them and I escaped the hospital. I found a place in America called Project Walk, and all it was was intensive rehab. If my accident was now, I wouldn't need to go to America.

The centres like it in the UK, but at the time there wasn't. So I went over there with the help of the question world to fund it and got a home programme. Instead of 3 sessions a week for 45 minutes and not working, the paralysed parts, I spent 3 hours a day in the gym and was working both parts I could still move and the other parts.

And I then worked with the neurophysio at home, and I kept doing that, but it was hard. It was frustrating. If it was all I focused on, it'd be pretty depressing.

So I had to tackle my injuries really from 22 different aspects, from doing my rehab to keep me fit and healthy and try and make any, improvements if I could, but also rebuilding my life. Bearing in mind I felt like everything had come to a grinding halt. I felt like I'd lost everything really that I'd worked so hard for.

So I had to tackle it from those two points, but going home was amazing. But it was also very, very difficult because things that I could do not many weeks before were now very challenging, things like just having a shower. I wrote my book a few years ago and I started from the scene from the shower because I don't know about you, but I never really appreciated having a shower.

I just got in the shower, had a shower, got out, job done. Now it become quite a huge thing for me. I hated the look of the shower chair, it's a big, ugly sturdy thing I'd got at the time, hated it.

I'd have to heave myself into it, so physically it was hard, but mentally it would destroy me. I'd looked down at my body and at this point, my legs had wasted. I hadn't got the electrical stimulation bike that I found out about a few years after my accident.

I hadn't got that. I would now see my stomach was now soft and floppy, not toned like it was that morning in the horse trials, and then I see the water running down my body. I didn't know if it was hot or cold.

I felt 2/3 dead, and I thought, how will I ever be happy and be paralysed? I didn't think it'd be possible. So how did I do it?

I did it by taking every little opportunity, things that wouldn't seem like anything to most people, like going out for lunch with friends. It's very easy to say no when you're feeling sorry for yourself, sad, why me, angry, all the emotions that I went through. It's very easy to, to kind of sit there and think of those things, but most of the time I'd make myself go out and see people and, It was actually way more important than I knew at the time.

It's a bit like a jigsaw to get the bigger picture, you've got to put all the little bits in, and these were the first few pieces. It was so much more significant than I realised. And I was kind of building up these gradual small little things like that.

And, I also had kind of a point in my life where I knew I had to make my first big change because I was with someone who I'd been with for 4 years, and I knew the relationship just wasn't going to work. The spinal injury affects everyone around you, not just yourself, and it was hard. I decided that in order to move on, I had to get rid of that negativity.

So after 10, I think it's 10 months after my accident, I finished that relationship, and I thought I could be on my own for the rest of my life. Who would ever want someone that's, you know, in a wheelchair and paralysed, and I felt very low in confidence at the time and had very little self-esteem. I was still doing all my rehab, and I was standing in a standing frame with a strap in front of my knee, one behind my pelvis, and it's got like a table in front of me.

So, I'd just be on my laptop to pass the time because it's so boring. And one of my friends had been around and she'd accidentally clicked on an advert. I think it was off Facebook.

It was a dating website, so I thought, I know what I'll do. I'll fill that out. So I did.

I put photos of me mainly before the accident really of things that I'd done before the event in and skydive and various things, but I said that I've had the accident. I was in a wheelchair and I was determined to give it my all. Anyway, I'd been on it 3 days and I got a message from Dan.

And I looked at his profile, I thought he looks all right. Anyway, I went to read his message and had to pay 20 quid to read it. I thought, nah, I'm not wasting 20 quid, but all my friends persuaded me to and I bought my husband off the internet for 20 quid.

So that was that job done. The other thing to really start rebuilding my life, was I needed to replace the sport of event in, and it's a hard one to replace. It's huge commitment.

Dedication, a lot of adrenaline involved, a lot of fun, but also a lot of disappointments, but it left a huge gap in my life and nothing really compared to it to start with. I tried riding again, but it just wasn't the same. The thing is with the spinal injury, you still feel like the same person and just sitting and walking and trotting around on a horse didn't really give me a buzz.

I still felt like I should have been able to go vent and, obviously couldn't. And then I did find skiing, and this was my kind of thing, and it's the first thing that really got me away from my spinal injury. So when I got into my monoski.

I had to really focus, partly because I was so bad. I felt and felt and felt, but I always knew that I wanted to be able to do it. So the focus I needed to be able to get, to get better and be able to do it.

I felt more like my old self and because of the concentration required and the perseverance I needed, it made me forget about my spinal injury, so it got me away from that. And as I got better, my self-esteem started to come back and my confidence. So it was a big kind of turning point in my life.

And it's like that jigsaw again, more bits were put in, as I started to rebuild my life. I also got offered a job around this time through a mutual friend to work in a ski office close to where I live. Part of me felt angry.

You're probably thinking, why would you feel angry being offered a job? It's a good thing. The reason why is because I could have done this when I was 16.

I'd been at university for 4 years and worked hard to be a chiropractor, and in some ways I was going backwards, but I actually wasn't. And like the other things, I'd make myself go and do it, and I did take that job, and even on the days I didn't feel great, I'd make myself go into the office. And again, like going out for lunch with friends, I always felt better for doing it, rather than sitting there, thinking of all the things I'd lost.

And I also thought I could. Possibly race with the ski and it'd be probably the most similar thing I could find to leaving the start books on the cross country courses. And I went on a weekend course to possibly get onto the, development squad.

For the Paralympics, and I got a place on there, but when I was on the weekend course, I knew it wasn't really for me for a couple of reasons. The dedication that you have to put in to doing any sport at a high level, and I did that with the event in. I wouldn't change it for the world.

I loved it, but I didn't really want to go back to that now. Life was changing a bit, but there was one other reason which was a very big reason, is this little one was about to come along. I was 12 weeks pregnant.

And it still amazes me now that nothing really works and the chest down yet I can grow a beautiful little girl. And it was a real turning point in my life. When Maisy came along, everything changed.

I could go to the horse trials and actually enjoy watching. Whereas I used to, you know, go there and really miss it. She made total change in how I saw things.

It wasn't long before she knew all the little hiding places. I couldn't get her under the table and things. I'd be like, Maisie, get out.

And when she was about 3, I told her why Mummy was in a wheelchair, that I had an accident, broke my back and my legs don't work. And I asked her a couple of days later, I said, Maisie, can you remember why mummy's in a wheelchair? She just looked at me and said, She's got a fat bum.

I was like, Great, I don't know which of my friends told her that. Possibly Dan maybe. Anyway, alongside now having a job in the office, having the love of skiing, having done in my life and obviously Maisy as well, I was still doing all my rehab to keep myself fit and healthy.

I didn't get any neurological gains back, but it did help things like prevent getting pressure sores and circulation problems, so it really felt the right thing to do. And I saw the reor suit on the internet, and I thought, God, it'd be a brilliant bit of kit. It's made to stand up in a better posture than a standing frame, get weights on weight onto my legs, which is good for your muscles and your bone density, and to be able to take some steps.

I also thought it'd be a brilliant bit of kit as a fundraising thing to do a bigger event than I've been doing. And my fundraising had started, with various events that I'd planned. But I thought this could really be something a little bit bigger.

And the reason my fundraising had started is because even though. I felt like my world had turned upside down, and I really did. There were times where I just wish I hadn't survived the accident.

I, you know, I didn't know how I'd get through it. It really was difficult, but there's also times where I looked around me in the hospital and felt genuinely lucky because I got used to my arms, and there's a lot more with neck injuries. They couldn't even wipe their own tears away.

Some even on a ventilator to breathe, possibly for the rest of their lives. So that's when I decided that I'd do what I could to help cure paralysis. And I fundraised with the help of the Equestrian world and the Matt Hanson Foundation to get the suit and.

It wasn't quite as straightforward as I hoped, because the suit wasn't in the UK. I managed to get the money, which was great, and I'm forever grateful for the support I've received. But as it was made in Israel, I emailed the company and said, When are we going to get it in the UK?

But it wasn't a case that I could just buy the suit because I'd raised this money. A rehab centre needed to get the suit, and then they would train me to use the suit. Anyway, it didn't look like it was going to happen that quick, and I saw an Israeli guy walking around in it, Birmingham.

NEC, and he made it look easy. So I thought, I know what I'd do. I'll enter the London Marathon.

That would encourage them. So I did. I got a place in the London Marathon, emailed the company again and told them.

And again, it didn't look like it was going to happen. And eventually I did get an email saying I could be the first person in the suit in January 2012. And it gave me 12 weeks to learn to walk in it.

Sadly, I wasn't like the Israeli guy. I found it seriously difficult. Even just standing in it when you can't feel the ground beneath you, it's hard to trust your legs are even there.

And then each step was challenging. I would catch a foot and stop. You basically, it doesn't just walk for you, it waits for you to give you instruction.

So there's a sensor on it and it waits for you to tilt your pelvis, and then I tilt my pelvis by using my crutches to shift my weight. But you have to get the timing exactly right. And I was going on things like daybreak and different TV interviews saying, yeah, I was walking the London Marathon.

And I still could hardly walk across the room. I thought, how am I actually going to do it? And I did get better across the room, and then I went outside and it was like back to square one.

Every little bump was an obstacle, the camber, everything, and I just thought, I don't know how long it's gonna take me, but I just went with the mindset every step would get me a step closer. So on the 22nd of April in 2012, I took that first step over the start line. When I had my accent, I never thought I'd have the highs that I had at like the Burley horse trials and the big events.

This was a million times better. When I took that first step, the crowds went mad and I knew it was for me because everyone had run off in about 2 seconds and I was on my own for 17 days, but people did come and join me in support and donate along the route, which made a huge difference. And, I did eventually reach the finish line, and I think in those first couple of years where I really wished that I'd make some recovery and want to walk, never wanted to walk again.

I was like, where's my wheelchair? I set a goal of raising £10,000 to help cure paralysis, and I ended up raising £220,000 so exceeded my expectations by a long, long way. I thought 10,000 pounds was quite ambitious.

And that year, the organisers had brought in a new rule and said anyone slower than the cut-off time couldn't have a medal. The media got hold of that story to try and get me a medal, but they admin I couldn't have one. But it actually worked in my favour because it got more media and that's how I raised more money.

And Matthew Pinson was one of the people who'd come out and walk with me, I think on day one, and then he came back again and then he was at the finish line. But I didn't realise he'd put on Twitter that any One that had run that year, would they donate their medal that he could present to me, and he presented me with a box of about 18 medals at the finish line. So you can imagine how emotional and, and what it was like, and I never expected all those people to turn out and it was just incredible.

It still feels very surreal when I watch it now. But of course, that just makes you want to do more. So I wasn't going to stop there.

Later that year, in 2012, I had the honour of lighting the Paralympic cauldron. I didn't realise what a huge thing it was. I got there that day, and I've got to walk up in the suit.

And you saw on the video, it can go wrong, can fall flat on my face, and I, I got to walk up in front of Boris Johnson, Sebco, and David Cameron. And it was all on live TV and I've got to lift this torch up. Even putting both arms out in front of me, it's hard without stabilising with my hands.

I've got to lift the torch and light the cauldron, standing on the legs that I can't feel. And then Boris Johnson was stood so close to the cauldron, I thought, God, if I don't set his hair alight, it'd be a miracle. Anyway, he's still got his hair, and again, it's another opportunity that I wouldn't have had if it wasn't for that day that I thought could ruined my life back in May 2007.

So after this I started planning another challenge, and it's actually how my speaking started. So I was just asked, I think it's just on Twitter. I got a message and it said, you know, would you come into a school and speak?

And I looked at it and I thought, I don't do that. How many times I told myself I couldn't do it, hated it. And then that other voice said, no, go and try it.

Sometimes in life we change, we go through different experiences, and we develop and. What's the worst that can happen? Go and give it another go, and I did, and I absolutely loved it.

And the response from the children made me come up with my next challenge. So I decided to hand cycle around parts of England while visiting schools, and I went to about 2 schools a day, and they range from primary schools to secondary schools, state schools, independent schools, schools for children with disabilities, where I went in supposedly to inspire them, but came out absolutely inspired myself. They were amazing.

Went to schools, for bad boys, where they, then came cycling with me and they were just incredible, asking so many questions. And the first thing they said when I got there, the teacher says, lock your bikes up. I thought this one sounds exciting.

It really was brilliant and having these kids, which had had very difficult upbringings with me, was just amazing. And I did it over 3 weeks and managed to raise £85,000 for the Nicol Spinal Injury Foundation. I was absolutely shattered when I finished.

I was greeted by a little Maisie at the finish line again. It's after this I decided to write my book, and a lot of books were written by a ghostwriter and I started that way, but when I got the first chapter about, I just thought it didn't sound like me. The only person who could do this is myself.

So I picked up the pen and actually wrote it myself. And I'm so pleased I did because I think anyone who reads it, really knows that that is my words. And also I wanted some of the money to go to the Nichols Spinal Injury Foundation.

It's actually a charity I found after the London Marathon because one of the presenters on Daybreak was a patron of the charity, and she said, you must go and meet David Nichols. So I did. I went along and, and, had a good chat to him and straight away I knew this was a charity I wanted to support.

David's son was paralysed in his gap year. He broke his neck, dived into sandbank on Bondi Beach, so he lost the use of his arms as well as his legs. David has the same passion as me for finding a cure for paralysis, not a penny is wasted.

And also he showed me a scan of a patient they just treated. So this was in 2012 I had this meeting. And they just treated this patient.

He got a 7 millimetre gap in his spinal cord. It was a stabbing injury and he'd been injured over 18 months, so it was long term. And they used the olfactory in sheathing cells, which they got from just behind the eye and put them into the injury site along with 4 ankle nerve fibres.

And he showed me a scan of a few months later and the spinal cord had regenerated. And this is the first patient. It can take a few steps.

It's hard. He has got some sensation back, some bowel and bladder back, but they're now doing 2 more patients. And if they see similar results, then it could open a lot of doors.

And like I said, it's not just about walking again. It's about being able to feed yourself again if you've got a neck injury, dress yourself again, all those things that give you the independence. It's way more important than just the bit that everyone sees is not being able to walk.

I didn't realise that 2016 was going to be such a big year. I saw that the Nichols Foundation had got one place in the Vitality 10K in London, and it'd been four years since the London Marathon. So I thought, oh, maybe I could go and go and do it.

I'd about got over the London Marathon by then. And I said that I would have a place they were keen, but the organisers banned me. They said I've got an unfair advantage because the suit's got a motor.

I thought, well, I know where I'm going to come last by a long way. Anyway, I I decided that if I raised over £1000 that I'd go and walk it at the side of the road, get the route and do it anyway. But in the end, they did let me in as the unofficial competitor.

So I didn't have a number or anything, but I started at 5 a.m. And finished at 5 p.m.

And raised around 10,000 pounds on that challenge. And then every race started inviting me to do theirs all over the country. I don't even like walking.

I thought, no. Anyway, one that did appeal to me was the, Great North run. And the great run company had been in touch and we discussed various events, and I said it's probably the only one I'd consider as the Great North one.

And they came back to me and said, I could do it and I could have a 5-day head start, which meant that if I did it, I'd beat Mo Farah. And not many people have done that. So it really appealed to me.

But my training was far from ideal. It's actually been sick in a bucket all summer because I was pregnant with my second little girl. And eventually I did manage to get in the suit.

I carried on hand cycling to keep my fitness up, but there's nothing quite like being in the suit and actually, you know, training and, and walking and taking those steps. So it wasn't, it wasn't great. But I thought if the sickness went the same as Maisie, I'd get a couple of weeks and do as much as I can in the suit.

But God, I did struggle with blood pressure. It kept dropping because second trimester of pregnancy, that can happen, and also spinal cord injury. Combination of two, quite honestly, was rubbish, but I just thought I'd go with the same mindset as I did on the London Marathon, that every step would get me a step closer, and I did, and I went and did it in the 5 days.

There's times where I seriously wondered if I would. Day two, my blood pressure dropped so often I was sitting down and the suit rubbed my back, which I can't feel, but it got quite nasty. I ended up in A&E having that dressed.

And, I thought, no, I didn't know if I'd managed to get there with how I was feeling, but I did, and raised, around 40,000 pounds for the Nickel Spinal injury Foundation. This is the little one that made it so difficult. I think everything I ate and my energy, she, she stole off me during that walk.

And at the end of 2016, I got a very exciting bit of post and it said I'd been awarded an MBE. Of course I was absolutely delighted. So I sent the form back saying I'd love to accept, but please avoid end of February baby due.

Anyway, I had complications with Chloe and I was in hospital, all of January in 2017. And Dan bought me some formal looking mail in and I looked and I thought, surely not. And it was the investiture.

28th of Feb, baby due 26th. I thought, God, I'm gonna have my baby in Buckingham Palace. Anyway, she decided to arrive five weeks early so she could come with us and celebrate on that very, very special day.

And it was a great chance really to thank my friends and family for helping me get to where I am now because I couldn't have done it without their support, and it was certainly memorable for us all. And Maisie's such a proud big sister. She absolutely adores Chloe and helps me so much with her.

When I did the Great North Run, I really thought that was the last walk I'm doing. And then something happens a couple of weeks later. I started to think of the good bits of it and forget the bad bits.

And I started to focus on what, you know, the money it raised and, and why I wanted to do it, and I thought maybe I could do one more. I could do the great South run. And I emailed the great rum company.

They were keen, my team were keen, and I set off on that challenge at the end of 2017. And here's a little video to show you that. I I can now say we finish simple house, great South today.

Yeah. So I set off, just ahead of all the runners, it was live on Channel 5. And they said, if you are in Portsmouth, do go and support Claire, and they did.

They came out 1:30 a.m. With cups of tea, 20 a.m.

Cups of tea, 2:30 a.m. Cups of tea.

This is as when we passed their house like throughout the night, they ran out with their trays of tea. So I had to drink it and pretend we'd not had one for ages. So I was peeing tea for a week after the Great South run, but it shows the kind of support we got when we were out there, and I managed to do it in the 24 hours, and it was, amazing to raise another 33,000 pounds for the Nicholas Spine andrew Foundation.

And then in 2018, the start of it, I'd had a virus, I was trying to get back from that, and it was snowy, so I couldn't go out on my hand bike on the roads, so I was on the rollers, and I was halfway through a session. Because I was struggling a bit because I hadn't got a goal set. I think we all need goals and not just long-term goals, but also your short-term goals.

Hadn't got one for that year, so I stopped during this session and I emailed Vassus Alexander, who was on the Chris Evans Breakfast show on Radio 2, because I knew that he'd got 10 places for the, Manchester Marathon. I knew he'd already chosen his 10 people. But I thought, oh, well, if someone drops out, so I emailed him that and said, you know, if anyone does drop out, then perhaps you'd consider slow on me to, to be part of your team.

Anyway, I got an email back about an hour later and he said, love to have you see you in Manchester. I thought, oh, then I'm doing another marathon. I thought I better check with mom and dad that they help with the girls and, if my team were up for coming in, and luckily everyone was.

So I ended up going and doing. Manchester marathon. And the best thing about being so slow, bearing in mind most people are trying to shave a few seconds or maybe minutes to get a PB, I shaved it days off mine.

I got 17 days down to 9 days and like the other ones the people stopping and donating as we were making our way around the course, and raised over £40,000 in the process, it made it so when I get tired, I just, you know, remember why I'm doing it. And when I'm struggling and you can usually find enough energy to get to the next lamp posts, I break it down and you end up getting there in the end. And then a challenge that I've taken on, which I still think's quite strange, is riding motorbikes.

I never thought I'd be riding a motorbike. I never sat on a motorbike before my accident. And when I was asked if I'd just like, if I'd like to have a go, I thought, how am I going to do that?

I'm paralysed from the chest down. And it was a charity that usually got injured motorbike riders back on bikes, so they knew what they were doing, and I haven't got a clue. All I know about a motorbike is the colour, started with a yellow one and blue one, and now I've got a white one.

That's about it. But anyway, I started with stabilisers and then eventually they took them off, but just as a, I was in a straight line to start with, and I'd have catches and launchers. It took me ages.

I scraped along them, I scraped along them and thought I'm not going to manage this. And eventually I got my balance and I did it a couple of times. And they said, Right, we're going to remove the stabilisers now.

And I thought, but I've relied on them like 95% of the time, and they said, you need to take them off in order to turn because the lean of the bike. Anyway, I thought, well, I've got to trust them. They know what they're doing.

And just as they're taking them off, someone crashed and broke the collarbone. I said, What are they doing? They said, ignore them.

I'm not sure about this. Anyway, they removed them, and I had a really good first session. Second session wasn't so good.

I braked too hard. It started to rain. The bike ended up over there.

I was over there. And I thought, maybe it's not that easy. Anyway, I carried on going and eventually I got my race licence, in 2017.

And I go out on track days, mainly men, mainly able bodied, and you wouldn't know I was paralysed once I was out there. I have a bit of vel on my knee, toe clips, so my feet can't fall forward off the foot bar, and then a gear shifter, so I changed my gears with the, with my left hand. Here's a little video.

So, my ultimate aim is to do a lap of the TT over at the Isle of Man, and I was invited there to do it and then they had an incident over there, so they couldn't have me that year, and then they've changed the how long the roads are closed for, and they want to try out a new timetable of how they're going to run the event. And then of course with the coronavirus it was cancelled, so. I'm still hoping one day they'll have me go and do that challenge, but in the meantime, I'll keep working hard and and getting more experience and I trained with the California Bike School just based in the UK, but had such amazing people helping me, so I felt I came on a lot that year.

And, and yeah, I've been looking forward to getting back out on the track, hopefully next year. And then a recent challenge has been learning to fly, so I'm very close to my first solo flight. I am certainly out of my comfort zone, but I've done most of my written exams now.

And I did the radio exam, just recently and that was quite daunting. But I managed to get through that. So, yeah, not too far away, but I love doing something that really does kind of make me quite nervous and, and when you go and do that, the kind of buzz you get from being out of your comfort zone makes it all worth it.

And like the other things, I'd like to turn it into something to fundraise. Already I've got, a flying suit that someone gave to me and it was all black. I thought it looked a bit dull.

So to raise a bit of money, I got badges put on all over and people have donated 100 pounds, either businesses or personal donations, and about half the suit is probably over half the suit's covered now, and raised £6000 from doing that. So hopefully I'll get the whole suit covered in the end. But I'm looking forward to planning more things with that challenge.

And then I was supposed to be doing the London Marathon, in 2020, but like most things, it was cancelled. And because the TT lap wasn't going to happen, and I got offered a guaranteed place in the London Marathon, which is actually quite strange because the London Marathon organisers awarded me, a Spirit of London award where they picked the 26 best stories, and people have done it and . They wouldn't even give me a medal when I did it and said I wasn't an official entry then as well.

But anyway, they gave me this award and gave me a guaranteed entry with it, so I can't turn that down. It's really hard to get into the London Marathon. So with not doing the TT, I decided to push it in motorcycling gear, and it was so hard.

I got up to about 13 miles and then they cancelled us, so everyone was like, oh you must be so disappointed. I was really relieved, but it does still mean I've got it to come. So, I'm aiming to do that.

In October 2021. And I'd love to get there by the cut-off time, which I think I'll have about 8 hours. It's like that, whether I make it or not, but I'll give it my all, and I'm doing it for two charities, Nichols Foundation and Whiz Kids, that helps.

Children with mobility problems, have equipment that they so, so deserve. I also set another goal, which was supposed to be this year, but it's now going to be in 2021, and that's doing the Great South run and doing it with a team of people. So I had about 50 or 60 people that I'd managed to persuade at various speaking events, and the list was growing.

So if any of you, want to join me, just pop me an email and we're going to have such a good time. It doesn't matter whether you want to walk it, jog it, run it, I'm pushing around in my wheelchair, not in my leathers on this one. And it's 10 miles flat.

And it's just such an amazing atmosphere. And all I ask is everyone to raise £100 for the Nichols Foundation, and we have an evening event there as well. We're gonna have a pasta party and yeah, just have a real good team event.

And, you know, it's not often, not until you lose something that you realise that how lucky you are to be able to move and do the things that you can do. So it doesn't matter like I said, if you're not a runner, just to set yourself that goal and, and come and experience the event. And help others in the future regain their independence.

So just get in touch if that is of interest to you. So really my message to you all is to believe in yourself, get out there, take on challenges. I know that I've been lucky.

I couldn't have done what I've done without the huge support of a lot of people, friends, family, and even strangers. But I also Know that you make your own look. If I'd carried on dwelling on that list that felt this long in the early days, all the things that I couldn't do, all the things that I'd lost, if I'd carried on thinking of all those things, then I wouldn't have had the best days of my life after my accident.

If I had to name the best 5 times in my life, they all come after my accident, meeting Dan, having my little girls, some of the challenges I've done in schools that I've been into. So when things feel tough, just keep going because you can get through them. And go on and have good times.

You know, we're all gonna have ups and downs in life and, and that is inevitable. So just keep pushing on, keep persevering and you'll get through them. Thank you very much.

All right, well, good morning, everyone. I, a beautiful sunny Saturday morning out there. I, the kids have been banned from my room, so I'm hoping that they don't make any guest appearances.

My youngest has got form on that, but that's another completely separate story. . So today's remit is to give a little bit of an overview on wound management and just to see what's out there on the horizon in terms of research, so that you don't have to go digging out all the papers and just give you a flavour of, what, you know, might be, products or, techniques that you might be using going forwards.

And I don't think I have to tell anyone who works in equine practise how important, being familiar with how to approach equine wounds is, because it's a a a critical aspect of, equine primary care. And we know that it's a common cause of emergencies, second most common in one study. And we know that most of these are trauma, traumatic injuries are sort of wound related.

And again, it's not just UK studies. We know that, other international studies, you know, for example, a study in New Zealand, that was wounds for the 3rd most common reason for vets seeing, horses. I'm thinking a little bit more broadly for those of you who are dealing with working Equis, which, are, you know, a population that I think is so vital and maybe a little bit underrepresented in some of our publications.

We know that wound management, traumatic wounds, rubs and sores, etc. Really important in that. Population and obviously have not only equine welfare issues, but also issues for the owners and, you know, livelihoods.

And as you'll know, horses have an amazing propensity to develop all sorts of wounds in some of the most unlikely situations, and can create some, some real challenges for us. And as a vet, we may be dealing with a very acute wound, or we may be dealing with something more chronic that an owner might have started treating themselves, or your colleagues may have been treating for a while. In any any anatomic location that you can think of.

And, obviously, with our training, it's really important that we have a a good knowledge of the possible anatomic structures involved, because that wound may not just involve the skin, but the, the deeper structures that involved may actually be the ones that are potentially more life-threatening. And wounds can be fairly simple to treat in some situations, but other wounds can require quite long-standing, very expensive, treatments, and which can create lots of challenges for owners. And, I think challenges for us as vets and finances often is something that can really limit what we're able to do.

And that initial decision making and what, how we choose to manage a wound is, is really important. I've already mentioned that you might have life-threatening complications, either a need to, stop acute haemorrhage or identify a horse that's got, a potential septic synovial structure, a fracture. And identifying those wounds were actually surgical repair is optimal.

And my mantra when I'm teaching the finding of students is that, you know, wounds around eyes in particular, and, and nostrils, we can do lots of reconstructive techniques with, with lots of other areas, but, the eyelids in particular are just something that we're never able to, to reconstruct properly using other types of skin. So, those, those areas are absolutely, critical. And the principles around surgical management of wounds is covered in in many textbooks and review articles.

So I'm not going to run through all of that today. But the main factors for me, when I'm thinking about wounds and horses is economics, I think, becomes the overriding factor, because there's lots of things that we can do, but ultimately, how much money an owner is able to or is willing to spend on a horse is often one of our constraints. We have to think about function, because that's what we want our horses to do.

you know, most of them are not necessarily paddock pets. They've got a role to play. Horses are not cheap to keep, for, you know, horse owners.

And then finally, we think about the, the cosmesis. And for most horses, and we're lucky with our veterinary companions certainly compared to the human field where obviously cosmetic, outcome, particularly in facial areas, is, is really key and has an impact on people's quality of life. For our hairy aqui friends, cosmesis might not be the primary outcome that's most important.

But then if you think about your show horses, actually a cosmetic outcome may be fairly critical for that horse's, ongoing, sort of life and, and use. So there are a few things I was going to pull out from some of the from some of the research, and I haven't, this isn't going to be a sort of a really structured and include absolutely everything that's in the literature at the moment, but I just pulled out some studies that I thought were useful sort of talking points. And an area that I think is really key, and I think we all know it anyway, but it's recognising.

How important it is, that we, educate our owners, and not just at the time that we're necessarily called out to see a horse, but just in our general interactions with our clients, whether it be through, emails, with newsletters, client evenings, Facebook, and, and Twitter communications. And I think this article, you know, really highlights the fact that, a lot of horse owners are quite keen, I think, maybe more so compared to other, owners, you know, like your small animals. A lot more horse owners are quite keen to treat vets without the expense and hassle of getting a vet out.

But very depressingly, in that paper, you know, wounds and trauma were the most, one of the most common causes of death or euthanasia in those horses. And it's an area that particularly interests me. We've done some work at the University of Liverpool, looking at sociology and understanding how people and different groups of people think and behave.

And just remembering that it's not our patient making decisions about when they need to be seen and whether they think that their wound is healing as it should be. You're relying on the owner, who is the gatekeeper to that horse's treatment. So, you know, any discussion that, you know, we have around wounds has always got to take into account how we communicate the need to do things, to owners and finding out what buttons we have to press to get different types of horse owners, whether it's the A hobby, horse owner who has very little knowledge about horses right through to the professional horse owner who's had horses for 50 years and, and possibly, considers themselves to know a bit more than vets in, in some situations.

So, that's really important. And I, I find it quite depressing, seeing some of the posts on some of the horse owner forums, just about this, sort of, Lay sort of opinions on, on how to treat wounds and lack of veterinary intervention. I'm not even going to go into the turmeric, arguments, but, all these lotions and potions that owners love concocting that probably do, do more harm than good, but we'll, we'll come back onto that.

And this is a study that was done at the University of Nottingham, and I, I would imagine they're in the process of getting this already for publication. But I thought this, again, was a very timely, study, and actually looking at, you know, what the, the sort of the horse owner, this is obviously a UK study. You know, surprising that, you know, there are a number of horses that aren't vaccinated, in the UK, you know, it's variable as to how many horses are insured, but also that owners don't, you know, get that some wounds actually, even if they're small, might be.

Potentially life threatening and some wounds may be really in a status where they're not gonna heal for a very long time because there's something delaying treatments, but the owners don't recognise, you know, the importance of having a veterinary opinion. So, that, that owner education really is, key. So coming on to a sort of a an evidence-based, approach, and this is an area that I'm really passionate about.

My research background is, as an epidemiologist, whilst I'm an equine surgeon, as my sort of my main clinical interest, epidemiology is, something that, I've been, sort of undertaking and epidemiological studies for a number of years. And wound healing is, you know, an area that I think has probably received less attention from an evidence-based veterinary medicine approach compared to some other topics, such as, you know, equine colic. And I'm sure you'll be familiar with this, pyramid of evidence, and, just this awareness that the type of studies dictate, you know, what that quality of, of evidence, is, and that when we're making, decisions about how to manage a wound, that we are, using an evidence base, to, to try to justify that.

And I think The veterinary profession is a little bit behind in our medical colleagues, when you hear our our medical colleagues discussing about the pros and cons of various treatment options, they have the advantage of a lot more high quality evidence to to go on. But that doesn't mean to say, just because we don't have it there, that we shouldn't just give up on the idea that we can use an evidence-based approach. So what's new and potentially exciting in the equine wound healing area?

Well, I thought this was quite a timely topic, given that in the equine Veterinary Journal, the beaver primary clinical care guidelines have just literally been published. So I'm going to run through these, just to give you an idea of, of, of what they looked at. And I'm going to need to make sure that I don't forget about my poll questions as well.

There will be a poll question coming up shortly. So this was a panel based review of the literature and use of a framework to appraise the evidence out there. It's a framework that's used in, in the human field to try to develop some evidence-based guidelines on how optimal wound management, should be, you know, potentially conducted in the horse.

And there were 3 main areas that they were asked to focus on based on feedback from equine vets, looking at how we lavage and, you know, what topical treatments we apply to wounds, debriding and closing wounds and therapies, that might be used to aid wound healing. So my first, I think my first poll question is going to come up if the team are able to to pull that up. So, I just wanted to get an idea of what you most commonly used to lavage your equine wounds, and I think we were going to give 30 seconds to to run this poll.

I'll read those out for you, Deborah, so you know what they what people come back with. So people can vote as Jonathan Pecock was on yesterday, was calling people lurkers who would answer the question. So, let's see if everybody will have a go at it.

There is No wrong answer. I know some people maybe aren't involved as much in equine but do . Do give it your best shot.

To vote So we've got 73% same sterile saline, 7% saying dilute chlorhexidine, and then 20% just lavage it with water, and there's nobody using povidone, iodine or commercial wound cleanser. OK. All right.

That's, that's really interesting, and I guess that is what I would, generally expect. So, listen to these, these guidelines that have come up. So one of the first questions was, is tap water as effective as saline for flushing, wounds and horses?

And, oh, I don't know why it's . Yeah. So, there were actually no veterinary studies looking at this, so they had to go into the into the human literature.

And some of you may be aware of some of these studies from the human literature. But actually, there is no evidence that sterile saline is any better than than clean tap, you know, sort of drinking quality tap water, and then the absence of cleaner drink. Standard tap water, use of cooled boiled water or distilled water would be, a, a, a better option than sterile saline, which I think is really interesting, because I think a lot of people have been taught over the years to use sterile saline.

But actually, there isn't actually any evidence about that. And obviously, a bag of saline, you know, does tot up to the the costs for, for treatments. And then looking at use of antiseptic solutions, to reduce the rate of wound infection.

And again, you'll notice a sort of common theme from here and we'll come back onto this, and there were no sort of veterinary studies identified that were of a high enough level to be considered, and there was actually very limited evidence from the human studies. But there was some limited evidence that, dilute povidone iodine, had some benefits, compared to, not, lavaging with a povi iodine solution for contaminated wounds. So I thought that was, that was quite interesting.

And I think from a, an equine point of view, I think it is an area that we do need to do, some, some more work on. But we'll, we'll come back on, onto that. And then looking at antiseptic and best concentration for primary wound lavage again, something that we, you know, really hammer home to the students and trying to avoid, use of any, lavage solutions that might be cytotoxic.

And again, no veterinary studies, that were sufficient quality to be considered. But in human patients, there were, fewer surgical site infections, when, patients had had wounds irrigated with antibacterial solutions, versus those not having antibacterial solutions. But they were, they surprising, there was no evidence on the optimal concentrations on antiseptics for, for wound lava.

So again, you know, an area that does need a lot more study, but I think, again, the principles of lavage, I was always taught that dilution is the solution to pollution, and I think that probably holds true that actually getting rid of as much debris, including organic matter, soil, hair, etc. From the wound is probably the most important thing in reducing that bacterial load. And obviously, thinking about antimicrobials and this is an area that I'm sure there have been other other talks in this area given.

Via webinar bets, but, being very aware of our duty to reduce, antimicrobial, usage, looking at whether, topical, antimicrobials reduce the rate of wound infection compared to systemic antimicrobials. And again, a, a real lack of, suitable quality, veterinary studies. Some moderate evidence from the human literature that topical silver sulfurizing reduces microbial loads, but again, a little bit of a sort of a caveat there that, silver can have some detrimental effects and wounds in the jury in, in human form was a little bit out on that.

But again, it just highlights that we really don't have the answers to all these questions through, proper, properly conducted studies. Lavage pressure, again, no veterinary studies, but, in human studies, the 13 pounds per square inch is one of my favourite student questions asking what PSI stands for. And, that was found to be the optimal one, which when you think about what we're generally, using, with a 35 or 60 mil syringe and an 18 or 19 gauge needle, those are generally the, the pressures that that we're using.

So, it's interesting just to, to see the human studies that have, demonstrated that and and know that we're, we're kind of at the right sort of ballpark for, for doing that. So then they asked about, you know, a variety of different things and whether they, you know, improve, healing, rates and, outcomes. So these ones are, are listed here.

So for debridement, there was some evidence, again from the human fields that these debridement pads, debrief soft can be quite useful. There was no clear evidence about use of chemical agents for wound debridement. And again, quite limited evidence, again, from the human field, there are some veterinary studies, but again, looking at very specific aspects of wound healing.

So things like the versagettes, 2 is the, current model, are certainly things to consider for highly contaminated wounds, but again, the evidence, base out there is quite limited. And maggot therapy again, very limited evidence within the veterinary fields, but certainly is something to consider for necrotic hoof defects and some deep-seated abscesses that can't, can't really be treated by any other means. And looking at wound closure, again, no evidence about sutures or staples, no clear evidence.

There was some contradictory findings in equine studies about those closure methods on surgical site infections and wound complications. And as you know, that's often dictated by, the, the location, and whilst staples are faster to apply, that they're not suitable for, areas under, under high tension. And then methods to enhance wound healing that they looked at, they looked at manuka honey and found evidence that it does improve and speed of healing.

We'll come back onto Manuka, honey. But there's, that there was insufficient evidence about use of, light, sort of laser therapy or therapeutic, ultrasound, which again, is quite interesting, given that, they're quite heavily, marketed for, for use in, in non-healing wounds. So that's just a very sort of quick summary of of those guidelines.

And I think that, you know, if you're interested in wound healing, they're certainly worth reading. And it is, it's clear that obviously we need to do, more, sort of well conducted field studies in, in equine wound healing, and I think, you know, something that is really important for us to do over the next few years is develop ways in which, vets, within first opinion practise can, participate, more easily in those kind of studies. Because what I'm going to show you next is, obviously, the more sort of research side of things, which uses wound healing models, which are another sort of, challenge, but they're different to what, you know, the wounds that we're seeing in the real life situation, which is so variable.

And that's why, these studies haven't been conducted. It's not that people aren't interested in it, it's just the complexities of comparing. Ponies and horses and a wound on a distal limb compared to a, a thorax.

And obviously, every individual wound is different in terms of how long it's been there, how it's been sustained, comorbidities. So, it is a challenging area, but that isn't to say that we shouldn't be be doing it. And, I think it would be great to have, first opinion vets really, geared up to help assist generating this evidence.

So, in terms of achieving optimal outcomes, I think what we generally aim to do is get first intention healing. And you, as you can see with the the nostril wound here, you know, it's critical to get good anatomic position. This is not suitable for second intention healing, and is going to heal quite nice and quickly.

But obviously, if we've got, loss of tissue, particularly over an area of of movement, or, this is a, a horse out in the Gambia that had fallen onto a fire, sustaining a nasty burn injury. You just may not have the ability to get first intention healing and you're going to have to rely on second intention healing. And these, I think for vets in practise and vets in referral centres as well can be incredibly frustrating and expensive to deal with.

And I think the expense and the economic limitations that as vets, we have to deal with compared to our human medical counterparts does make wound healing incredibly, frustrating for everyone involved. So, is there anything we can do to assist second intention wound healing in our equine patients? So, again, I'm just gonna present a series of studies, and I'm not going to go into a huge amount of depth with these, if you're interested in particular aspects of this, a lot of the papers actually are open access, so you can, you can go and have a read of them.

But it's all about thinking about things that we can do to, to, to speed, wound healing and get that wound to heal as quickly as possible and remove those factors that might be delaying it. And we know from, research, previously conducted and ongoing research that the bacterial load within a wound are really, really critical. And that this, a propensity for bacteria, particularly bacteria like pseudomonas, to form these biofilms that prevent, sort of effective penetration by systemic antimicrobials are really, really important.

So thinking about that, that wound environment and how we can, minimise that bacterial load, from those bacteria that really do delay, wound healing is, is really important. So, some recent studies I've just pulled out, some that were done in the last few years, looked at, you know, how we can sort of get a better handle on how much of a bacterial load. And this is a classic example of a wound that's got a biofilm.

This is a slimy, quite smelly wound that, quite, you know, clearly is likely to have a significant load of bacteria. But, are we, you know, able to sort of get a handle on, how much of a, a load is there? And I'd strongly, you know, if you're not, a vet who doesn't use, bacteriology and culture and sensitivity testing in your, equine wounds, I think it is something that is really, important to get a handle on, on what's going on in there.

So this was a study that was conducted just to look at, you know, how best you can judge a bacterial load going on in a wound. And the bottom line is that you don't need to take a biopsy, which is more invasive, that you can, take a swab and get an idea of, the sort of the quantitative, you know, load of bacteria. In a wound, and, that actually it was quite difficult to clinically, just grossly assessing wounds, actually, get a good idea of, you know, how, yeah, many sort of bacteria species and, and how intense that load was, was very difficult to determine.

And I, I put this slide up. This is a different study that was published in fairly recently, looking at, thinking about what's going on at a cellular and and molecular level and stepping back from this, sort of looking at it with our own eyes and just thinking what is actually going on at a cellular level in those wounds. And this study was looking at patterns of, differences in wound healing between limbs and thorax, which we know are different, and in response to, bacterial inoculation with Staph aureus and and Pseudomonas.

And, they showed that obviously, the, the healing of distal limbs was less, was slower and was less organised, which we, we know from previous studies already. And that there were similarities in, the expression of, different factors such as, interleukin 1 beta, IL 6, MP9. And, importantly, they identified that this, cellular communication network factor, CCN1, might be something that requires further investigation.

So, obviously, we still, we, we've got a, a, a better handle on what's going on at a cellular level, but there are lots of things that we still don't know about horse wounds. And again, the more we understand about optimising healing in in horse wounds, the more it gives us an idea of therapeutic strategies to, to assist that. And I thought this was a really interesting study.

Again, this is one that's been published relatively recently. Just looking at, the microbiome of, of wounds. And I'm sure you've heard quite a lot about the microbiome.

It's something that in the human research fields, at the gut microbiota, for example, is, something that's been shown. It's been really interesting in people because it doesn't just affect your gut function, it can have effects on, neurological function, immune system and function. But I think it's, really interesting seeing how, you know, the improvements in, next generation, sequencing can be used to look at back normal bacteria in so many different situations.

So this study, looked at, some, created sort of standardised, wounds. These were full thickness wounds, either in the distal extremity. Of the, forelimbs or the thorax, and they looked at differences, on horses, whether they were bandaged or not as well, and looking at the bacterial, composition.

So, the interesting thing was that the normal skin microbiota is actually quite similar, between horses, which may not, come as a, you know, complete, surprise. But, again, it was quite interesting to see that, you know, use a bacterium and actinnobacillus were, more common, particularly in the limb wounds compared to the thoracic wounds, and the impact that bandaging had on that, skin, microbiome. And, they, they saw some quite predictable changes in patterns of how, the bacteria changed, and particularly as wound healing, progressed.

And this sort of thought that those normal bacteria that should be in, in the skin actually might be key to assisting, wound healing. And what we're really wanting to avoid is those, more, nasty sort of bacterial species, for example, Eseudomonas becoming the predominant population. So I think this is really interesting and again may help us better understand the effects of some of the therapies that we can use to try and improve wound healing.

And sort of stepping onto that, when you're thinking about bacteria, good and bad bacteria, you'll hear all the TV adverts on use of probiotics, you know, good gut bacteria. And I thought this was a, a really interesting study. This was one that was Jacintha Wilming did.

It was a randomised, single blinded multi-enter study that and they looked at use of a commercial topical pro probiotic that had a variety of three sort of main bacterial species to Lactobacillus ones and one biidobacterium species. And they looked at this in wound healing. These were sort of traumatic wounds seen in the general equine population.

And I thought this was quite interesting because it did show that the probiotic treated wounds did have a quicker reduction and halving of the wound surface area compared to untreated wounds. And importantly, they also looked at the safety aspects and looked at systemic effects, like, for example, increases in serum amyloid A, of which there were none. So, I think again, you know, those may be things that we start to see being used a little bit more and manipulating that, microbiome more in a topical way, rather than, relying on, systemic antimicrobials.

And coming onto antimicrobial use, I think, the, veterinary profession has recognised the importance of us being really careful about our choice of bacteria, and really thinking about, antimicrobial resistance, which obviously from a global perspective is one of the key challenges that we face together with. Pandemics, as we know all too well, and a variety and, and climate change, but antimicrobial resistance is, is one of the big ones on that list. So we do have a responsibility to consider how we're using antimicrobials.

And I think from my experience of dealing with with wounds, I think that antimicrobials are overused, particularly systemic ones, and particularly in wounds healing by second intention. And in the human fields, this is an area that's been looked at and this is a sort of a consensus statement that was put out by medics involved in wound healing, just about, you know, proper use of antimicrobials. Obviously, we've got the Protect me guidelines, but I think, it's a, a particular emphasis on these, granulating wounds and horses on very, very long, antimicrobial, therapies that probably, have minimal effects, and we should, really think about whether those antimicrobials are justified and whether we need to be doing something different with that wound.

So thinking, you know, away from systemic use of antimicrobials might think of more regional use, and this was a study that was performed relatively recently, that looked at intravenous regional profusion with Amicain and actually demonstrated that it had no effect on the Staph aureus, sort of model of, of wound healing. So. You know, we, we really need to be, sort of coming away from that, sort of throwing antimicrobials that, wounds that are slow to heal, and really, thinking about other, other strategies, that may be more effective in, controlling that, that, bio burden on that wound.

So I'm gonna come into some of the more pure sort of research wound studies now, and I'm I'm only gonna cover them sort of briefly just to give you a taster of some of the things that are probably, you know, being looked at most at the moment. And I think one good thing is that the horse is actually a really good model for human research. And whenever you have a model like that, that usually means that there's money there because in the human healthcare field.

Wound healing is a massive industry. I've just cited some of the, the costs, that have come out, some of the private, US, health providers. And there's a huge amount of money spent on, on wound healing and then the effects that, wounds, have, on, on people.

So, horse wound models, do have benefits, and not only for human health, and obviously the money that we may be able to get to conduct these studies, but also, obviously, then benefits our, equine patients. Manuka honey, that's my next poll question. So if you could bring that one up for me.

So, the question was, do you use honey routinely in your equine wound management? So we've got a choice between no. Yes, but you only use medical grade manuka honey.

Yes, you use manuka honey only, but you're not sure if it's medical grade or not. Or yes, you use any type, including non-medical grade honey. And if you use, if you maybe use multiple things, maybe choose the one that you use most frequently.

So I'll give you time to get your answers in. So people are voting away at the moment, so there's 36% who say they don't use honey. 21% who use medical grade, 14% saying they're not sure, but you know they use me for honey.

And then 29% saying use any type including non-medical grade honey. So it's a bit of a split there I suppose if you say manuka honey altogether is 35%, no is 36%, and yes, anything basically is 29%. Yeah, so, yeah, so I think honey, is, I'll just I'll just I'll get you to close that.

And so I think honey is a really interesting area and it's, it's encouraging, and I think it's that reflects that honey has come much more into the fore in equine wound healing. And, so it's, I'm sure you know that manuka honey, there's a manuka tree, which is produced by, and it has, this, antibacterial property that provides this unique manuka factor, and the more sort of of that UMF factor, the higher rated it is. So this is an example of a study that looked at, Manuka honey that was UMF 20, which contains obviously more of the manuka factor versus 1 of 5, which is a sort of lower strength.

These, the higher the the manuka the UMF level, the more expensive, it's always the way, the more expensive these are. So it's that sort of balance between cost and and benefits. But this was a a wound healing.

The one, the study on the left that looked at some wounds and the manuka honey of UMF 20 healed quicker and better than either the the food grades, honey or the UMF 5. But, you know, the differences were not, you know, really much, and it's sort of thinking of that, you know, these sort of studies that show a significant difference or not, and sort of weighing up that sort of, you know, how clinically relevant is that, that difference and what's the cost benefits of it. So, certainly, there is really good evidence out there that Manuka honey, does, aid wound healing in certain stages of wound healing.

And I thought this is a, a study, oh, sorry, that's only just been published. I'll come back onto my side, that's only just been published in equine Veterinary Journal, but looked at use of honey, just over the top of the linear alba prior to closing the absocutaneous tissues and skin in horse laparotomies and showing that it was protective against surgical site infections. So, I think honey is a really, interesting, product, and it's good to see that, you know, bats out there are are using it and obviously it's been used since Egyptian, times, as well.

OK. So, I was just going to look at some other therapies that that might be used. So, I've already mentioned about light therapy, and again, the evidence in the literature is sort of quite sort of poor and quite mixed, but this is a relatively recently published study that demonstrated that it had no Difference on healing.

And actually, the light treated wounds did actually have slower healing, which I think is really interesting. So, again, you know, you see owners, and particularly the professional horse owners, you know, wanting their their laser machines for wound healing, but actually the scientific evidence to support it's actually not really there. Negative pressure wound therapy devices, there've been a few case reports out there over the years, and, and they do have benefits, obviously, in taking away some of that, sort of fluid that accumulates obviously creates opportunities for bacterial multiplication.

But again, I don't think we're quite there with using these for aids, and this study demonstrated that whilst, you know, it was a, a, a useful, product to try to use, there are still problems with, particularly adhesiveness, and getting these to stick on our, our, hairy horses, which is very different, obviously, to human skill, skin, sorry, and, sort of flexibility of these devices and how well horses tolerate them. And again, cost with these is sometimes an issue, but I'm aware that there are some options for renting some of these devices. So it may be an option that more of us are able to use in a more cost effective way, but I don't think we're quite there with the systems, at the moment.

Just gonna mention gallium. This is a study that looked at gallium in in wound healing. It's a sort of a semimetallic .

sort of product. It's, it's got antimicrobial, effects. And this was used in the model of, of wound healing, in the horse, and it did show, reduced healing times, reduced fire burden with Staphylococcus aureus, reduced formation of excessive granulation tissue, and improved, sort of the histology scores and things like increased TGF beta.

So, again, this was looking at a sort of a commercial product, and I think it's, it's really good to see that, you know, that there is some testing. I think it's really important to show, show that there has been some evidence of efficacy before these products just get blindly marketed. Out there.

So that is something that we may see a bit more, and again, good to see, you know, a sort of a, a non, sort of a topical therapy with, you know, an option to reduce, you know, you know, have an antimicrobial effect rather than using systemic antibiotics. It's interesting that, cannabis related products seem to get in there and I do sort of see, these products being sort of used a bit randomly for any, you know, anything seems to go, but again, it's important that, you know, these studies are actually tested. So this was, a honey, a sort of, based study that looked at, a kind of bidiol, I can never say it, act, agent being added to it, and actually they didn't show, any, positive, you know, sort of beneficial effects, but they did feel that it warranted, further study.

So I think, you know, when these sort of things, these new exciting products come out, you know, there there is a lot of use of these without proper testing and certainly at the moment, there's a bit of a lack of evidence about their use in wound healing. And I'm not gonna spend too much time on this, but, you know, we're all aware of stem cell therapies, you know, being used for, for lots of different areas and wound healing wouldn't be an exception to that. And again, I think it's an area that we're only really just starting to really understand, you know, the sort of the cellular mechanisms.

And, you know, it's an area that I think we're gonna see more research coming out in, but, you know, there's still quite a lot of work to do there to show, you know, the, the true benefits and in a practical situation. And I think, you know, this is the sort of the holy grail of wound healing is trying to get them to, to heal faster and all these lotions and potions and expensive therapies. But we also have to remember that wounds can only epithelialize at a maximum rate.

And thinking about the cost benefits and these, you know, quite sometimes quite expensive products or devices. But actually, if that wound isn't healing, is there another, you know, more sort of basic fundamental reason why? So this horse pictured has got an excessive granulation tissue and clefting, which would be one of the characteristic signs of a sequetrum.

So until this sequetrum has been removed, this wound is going to be in a perpetual state of chronic ongoing inflammation. And obviously thinking of factors such as movements and infection, etc. So I suppose it was just whilst for companies, it's great that they can make money out of, you know, having all these fancy products, but actually, when we're already in a situation where also only have a finite limit on how much they want to or are able to spend on wound healing, then we have to really think about, you know, the cost benefits of these products, and actually, you know, not neglect the fact that we need to think about other ways to speed healing.

And surge, you know, the surgical option, I think horse donor always perceive surgical management as more expensive option. But the minute you start, you know, reaching out for the bandaging materials for that, you know, double layer band limb bandage and a horse, you know, automatically, the costs start mounting, especially if you're performing, you know, a bandage changes every, you know, 3 days. And actually, you know, having that discussion with an owner at an early, early stage before they've spent 9 months having a limb, repeatedly bandaged and invariably the horse sedated, because they've got sick and tired of their wounds being fiddled with, and they've been on box rest.

That actually, you know, surgical wound reconstruction and grafting might be the more economic and result in better quality healing. And I, I thought this, this is slightly, slightly off topic, with the, what we're talking about. We're not talking about hip replacements, but I think it's sort of just resonated with me in that we always, the the key thing that we're Trying to get is something perfect.

And you realise the skin how perfect it is and trying to replace it with something else. You never get something that's quite perfect. But, skin grafting can result in something that maybe isn't absolutely perfect and cosmetically doesn't look absolutely the same, but it's actually very high quality and high functioning.

So something to consider. So, wound construction can be performed at the time of injury or as a delayed thing. And I've just put in an example, this, typically, it's always a show horse, isn't it?

But typically, this was a horse that presented to me, and this was the wound as, not long after it happened, actually, it was right down to the, right down to the periosteum, and, it was a, a hind limb, and had this sort of flap of skin that had concertinaed back, and actually this flap of skin was a saving grace. And this, I'm not going to show you all the photos in between, but this was the wound by the time we'd surgically reconstructed it a number of weeks later, when the owner had already realised that she was going to run out of money by bandaging it, you know, and going down that route. But we were able to get, well, the horse went back to the showroom, we were able to get a very, very nice, wound reconstruction, which wouldn't have been achieved, by allowing it to heal by second intention and also would have been much more expensive and taken much longer.

So don't, you know, do consider the surgical options, and I think it's really important to spell it out to horse owners that it might actually be the cheaper option of the two, and might be the better quality, end results. And you can, even if a wound is a few weeks down the line, you can still in in some ways, it's sometimes better because you can get a hold on the bacterial infection if the wound's been grossly contaminated at the time. And just a little word about skin flaps, unless they're obviously necrotic, those skin flaps can be an absolute godsend.

So before you reach out for that scalpel blade to chop away a skin flap, think twice. Because without this skin, this skin flap, which you can't really see properly, but that could Be extended all the way across the wound, even several weeks later, there are various techniques you can use to, to, you know, use that skin, but that skin was absolutely precious and allowed us to get a really good outcome. So I'm just gonna briefly mention skin grafting, and I think that was one of my final poll questions if we're able to bring that up.

So, how many of you would feel confident performing pinch or punch skin grafting? So you've got a choice of no, you wouldn't be prepared to try. No, but you'd like to learn more about how to do it.

Yes, you've never done it, but you'd like to give it, you'd give it a go, and yes, you would perform it routinely. I'll just give you a little bit of time to to do that. Yeah, we've got Nobody not willing to try, so that's, that's good.

Just allowing people to vote for another couple of seconds. Nobody's performing it routinely. Deborah, so we've got no, but I would like to learn more about how to do it.

Yes, never done it, but we'd give it a go. It's 54% and no, but I'd like to learn more is 46%. So it's really split between those two.

It's a sort of Brexit result, 446. So, yeah, so, pinch and punch graphs are easy to perform in in field situations. It doesn't take much in the way of equipment, and, maybe, maybe that's a topic, maybe for a future, webinar, a real practical how to, but, you know, it's described in some textbooks, but I think there are some key tips and and tricks.

One thing to say, it doesn't get absolutely perfect healing. I'd say this is the extreme, that, most of them would heal a little bit sort of better with this. The owner actually loved this because, she thought her horse was very unique in having tufty hairs, but you don't necessarily get the, the most cosmetic outcome, but it definitely speeds healing, and it is, I would strongly encourage as a new graduate, I had, I'd never seen it being done.

And I can think of several cases that I would have saved, owners and horses and myself a lot of time and tears, trying to get wounds to heal if I'd actually, tried that. So, just to finish off, this is a little bit more advanced, but just so you're aware of some of the things that we've got, wound reconstruction, if you've got enough skin. You've got the techniques for pinch and punch grafting in the fields, slightly more advanced here, but, full thickness skin grafting is something that is fairly, easy to do and could be done in the standing patient.

The key thing is making sure that you've got, wherever you're placing the graft is ready to take a graft and that the graft doesn't, fail, but, this paper very nicely describes the technique and, and various applications of it. And meek micrografting, just to finish off, this was a case, that I dealt with, that, meat can be done quite easily, in a standing patient. It's just having the, equipment, but you don't need the full, meat kit to be able to do this.

But this was a horse who'd sustained a wound to the metatarsis that the owner didn't want to go down the route of doing anything with, because she thought it was going to be too expensive and wanted to trim and ended up sort of starting to treat it themselves. But they soon realised that this wound was really going nowhere. And these are not taken that far apart.

This is just a matter of a couple of weeks apart and just showing the effect that bandaging, appropriate, topical, medications and antimicrobial dressings, can have, we didn't have this source on any systemic antimicrobials, but this is ready for grafting. Jacintha Wilming actually gave us a hand doing this. She's the person who's really driven, this technique and knows more about it than anyone else.

But this was, us performing the, the skin grafting, these are the grafts, a few days down the the road. And this is once the, the horse had actually gone home and the, the sight is, this is just, you can see the bits of hair. And actually, now you can, you can notice that there's a slight difference in the colour of the skin, but it's head and it, it's regular and it looks absolutely beautiful and a delighted owner.

And this cost far less than leaving this horse to heal by second intention and got a much better cosmetic effect. So, just so you know that those things are out there. All right, so just to sort of type of sort of gone through a variety of things, in this talk, which I hope give you some things to think about.

It is really important before you start treating that equine wound to think about what's the evidence, particularly with the novel therapies, which are not without their expense and thinking about the cost benefit. And I think it is really important that we keep wound care affordable for horse owners, otherwise, we're just gonna price ourselves at the market and actually make the situation even worse and owners aren't going to seek our help. It's really important that we do reduce our use of systemic antimicrobials, particularly with these wounds healing by second intention.

And, you should be thinking about sort of topical antimicrobial agents and, and dressings. We do need more veterinary studies, and I think these should include not just the experimental ones, which obviously have their limitations and obviously from a general public point of view, you know, we have to think about, you know, experimental models and the challenges that provides. And I think it is really important that vets in the field, understand that they can play a really, key role in generating that evidence and that you can do field studies.

And thinking about owner education, and not just at the time that the horse has developed that wound, but thinking about it beforehand, and, that it's appropriate, wound management, and they understand, you know, what a difference we can make and that that turmeric isn't everything. And finally, that, again, sort of, I think vets in practise, to a degree, and certainly horse owners have the perception that sending a wound off for surgical reconstruction or advanced grafting can be expensive, but actually it can be a much more cost effective time saving, saving alternative that actually results in a much, much better outcome for the owner and the horse. So thank you very much and I'm very happy to take any questions.

OK. So, good morning, everybody. I hope you're really enjoying the virtual congress, and the presentations.

I really enjoyed that one by, Debbie just then. But no, I don't, I don't actually work with, with horses myself. And today, we're gonna be talking about the subject of pain, but I am gonna be talking about it, in both species.

So. I've titled it What Who Says I'm not in Pain? Because I think one of the big challenges when we're looking at the importance of considering pain in behaviour cases, is that it can be really difficult to identify the role of pain.

We can, therefore, need to look really carefully at behavioural responses and, and spend a lot of time observing our patients in great detail. Something that can be really difficult, of course, in a consult room context, something we'll touch on as we go through this presentation. So starting off by what is pain, that might sound like a really obvious question, because we're very familiar, aren't we, as vets about it being a physiological response to a noxious stimulus.

We're used to knowing about that sensory and that motor component to the pain response. But we also need to remember that there is a cognitive and an emotional component. Pain as well.

And pain's talked about as having these four quadrants or 4 components. So what we're looking at when we look at the role of pain in behavioural medicine is the interplay between those 4 components, including that emotional and that cognitive, diagonal as well. So, I wanna just think a little bit about acute pain, concentrate mainly on chronic pain, but, of course, acute pain needs to be considered in this context as well.

And the commonly encountered sources of acute pain, then are going to be those that are rather accidental, so it fits in with the, the wounds we were just talking about. Or, of course, surgical, surgically induced pain, what we have done through our own surgical intervention. And what's the importance of acute pain in terms of behaviour?

Well, of course, there are short term, very practical consequences of acute pain, and I'm sure we're very familiar with overt confrontational behaviour that's shown by our patients when we need to handle them or manipulate them when they are in acute pain. And, of course, their reaction to that handling is often used as part of the way of assessing the level of acute pain in our patients. We also need to remember there are going to be individual differences.

Not all animals are what we might call active responders to pain. So, for example, cats are really renowned for their passive expressions of pain. And some dog breeds as well, are talked about as being stoic or having a high pain threshold, whereas others, we may associate.

With more excessive reactions to acute pain. We need to remember, of course, that the way in which they demonstrate pain, pain being emotionally a protective emotion, and therefore, one that can be expressed in the various ways that protective emotions are expressed. So, pain is a form of the fear anxiety system, and they can respond.

Using repelling behaviours, go away, leave me alone, which we see very readily as those confrontational behaviours. But of course, they can also show inhibition, that just collecting information, as this cat is doing in this picture here. You can see there's sensory input of information for this cat.

So, there is a response to the pain. But it's not an active confrontational response. We might see avoidance as well, trying to avoid us coming near them, which may be more obvious.

And with dogs, who are socially obligate mammals, we may also see appeasement trying to get closer and interact, even though they're in pain, because they're using that active information gathering response to their emotional state. So the differences that we see are associated with the individual animal, but also associated with the difference in selection of behavioural response to their pain. And as well as the short-term implications with acute pain, we also do need to consider the longer term practical consequences.

So, we need to think about the fact that they are also learning whilst experiencing pain. So, we talk about the health triad, the emotional, physical, and cognitive health being all parts of Healthcare, and remembering that when we have an animal in acute pain, maybe post-surgically, for example, that that's a learning opportunity, and that they can maintain some behavioural signs associated with the pain, even once that acute pain episode is either over because of healing, or managed through pain relief. And the consequence of the classical conditioning that can occur, so the associative learning, is that any interaction or any event, or the presence even of a particular individuals that coincide with the experience of that pain can become associated with that.

And therefore become triggers for the fear anxiety system in their own right. So, we need to think about our acute pain patients, about the management of that pain, in order to also limit the potential for unwanted associative learning. There are lots of ways, of course, of monitoring acute pain.

We have the Glasgow Composite Pain scales, both for dogs and for cats. And we have a range of other ways in which we can monitor for acute pain. The Colorado State University accute pain scale for cats, for example, Bohringer and Sheila Robertson did a lot of work on looking at body posture and facial expression, particularly eyes, in order to monitor acute pain in our patients.

Now, what's important as well is the management of pain has the potential to have emotional, and cognitive consequences. So what's important is that we, engage in very adequate pre, peri and post-operative analgesia. Cause if we don't do that, if there are problems with analgesic control around surgery, there is a possible ability of the development of so-called chronic post-surgical pain.

Of course, chronic pain, as we'll explore a bit more in a moment, is a maladaptive state of pain and has serious implications in terms of the emotional health of that patient. So, by managing our analgesia during surgery, both before, during, and after, we can lower the risk of chronic post-surgical pain. The other thing that's interesting, there's some work being done by a lady called Irene Tracey, who works at Oxford University.

I had the privilege of listening to her speak at the meeting, the College of anaesthesia and Analgesia meeting. She's a fascinating person. She was also on Desert Islandists on Radio 4, giving another fascinating.

Insight into her work. But she works on this link between emotion and pain. And one of the things that she's done a lot of work on is the influence of negative emotional state on your perception of acute pain, but also on the potential for that to be a risk for chronic post-surgical pain.

So, the work that Irene's done in human animals is, is fascinating, and leads us to really think. Carefully about our patients, because so often at the point of induction of anaesthesia, our patients are in a negative emotional bias, either because of their illness or because of their experience or lack of experience of the veterinary practise. We can often have patients in a negative emotional bias at the point when we induce anaesthesia.

And so, it's really important that we think. About the potential for that to influence their perception of that acute pain, but also potentially have a role in the risk factors for chronic pain post-surgically. So, that leads us to think really carefully about pre-medication, about handling during induction.

So we're seeing the difference here between handling styles at the top that may induce some More negative emotional state, whereas that less minimal handling approach, leading to a potential for there to be a less negative emotion induced. The same, of course, for cats. And also, if we're in a situation of using things like masks, the way in which we restrain that animal, whilst it's going through that induction process is crucial, combined with What we gave as pre-medication.

And maybe even thinking about whether we have given suitable premedication at home, things like the use of trazodone in dogs or bunzodiazepines, or the use of gabapentin in cats pre-vet visit, in order to act as an anxiolytic prior to the point of coming in for that premedication. Appropriate handling and management of their emotional state during recovery is also important. So, if we have animals who are hospitalised, not only about their pain relief, but also about the way in which we interact with them and and handle them, and how much we know about them as individuals in terms of their likely emotional response to being hospitalised can be really important in this overall management and limiting the potential for going on to have more serious, implications of chronic pain in association with their behavioural, output and what and how they behave at home.

So I want to go on then to concentrate in this presentation on chronic pain. And when we think about chronic pain, we've got a range of different potential sources of chronic pain that could be interesting to us in terms of understanding behavioural change. So, when we think about chronic pain, I think most of us automatically think about orthopaedic pain.

And, of course, orthopaedic pain, OA and DJD are really important for us, working in the field of behavioural medicine. We are frequently treating, chronic pain in, in the association with these conditions in our patients who have behavioural presentations. But other sources of chronic pain are also important to consider.

For example, things like ear. Very, very common for there to be not only chronic nature to ear pain, but also to have the potential for there to have been learned associations with that pain, leading to behavioural responses such as avoidance of handling around the head, for example. That may go on to have consequences that the client presents as behavioural change in terms of not being able to get on leads or harnesses.

And so, because the animal doesn't want to be touched around the head. So, other things, dental pain. Dental pain, I think, is often underestimated.

And one of the things we've noted in patients, particularly feline patients, is the, the reporting from caregivers after dental intervention to say there's been significant change in the temperament or personality of the cat and in their tolerance of being handled, for example. So, for example, cats who've had, oral disease, or have had fractured teeth, for example. And then they've come in and had dental work done, but when they go home, not only are they not as sore around their mouth, but the clients find that they change their interaction with people.

They're more friendly. They make, joking comments about, did you do a personality transplant whilst you did that dental? And so, that is a very significant source of pain to be considered when there's behavioural change.

Also, abdominal or visceral pain of various sorts, things like pancreatitis, for example, or gut pain. Also skin related discomfort, and also neuropathic pain in the form of conditions such as illustrated here in the cavalier, of course, Kiri malformations during the myia situations with the Burmese cat, illustrated here, we also have the potential for. Feline or a facial pain syndrome.

And also here, of course, acrylic, dermatitis Legion. Association of chronic pain, and then leading to, again, behaviours that may be presented primarily as behavioural change need to be considered. The other thing that's really important in our canine patients is to remember that they are particularly prone to soft tissue related discomfort.

So pain that is a myofascial or associated with muscular pressure. And this is particularly important, of course, in our canine patients who engage in sport, whether that's fly ball, agility. Or, greyhound racing.

Because these individuals are often put into situations where they are making movements repetitively, and they're putting particular strain, you know, on their musculature. And we need to remember that pain, chronic pain associated with mobility is not always related to orthopaedic disease. So this chronic pain situation raises this question of what is chronic pain?

Why is chronic pain even in existence? Does it have a purpose? Well, actually, chronic pain has no evolutionary benefit.

It's a maladaptive state, it's a disease state. And that's why we've come a long way in recent years in talking about the need to treat chronic pain. The chronic pain is not something that we can just ignore or something that we can overlook, not only because of the behavioural aspect, which obviously what I'm talking about, but also in terms of overall welfare, and also in terms of the risk of it escalating in terms of sensitization when left untreated.

So why do we have chronic pain? What are the factors that affect the presence of chronic pain in the population? There are many, but some of them, are related to the sort of work that we do.

So, surgical procedures, whether it's us as veterinary surgeons, or whether it's human surgeons, we do surgical procedures which lead to tissue damage, which clearly would result in death if they were in a Non-domestic environment, these not these domesticated species. Or if humans were not in medical care. So the way in which we manage our surgical procedures is crucial.

Also, one of the problems with chronic pain is that it often stems from a lack of treatment of disease in the early stages. So, things like osteoarthritis, which is Often diagnosed quite late in the progression of the disease. Or things like ear disease, which can be overlooked at the, caregiver level and not brought to our attention early enough.

Or when it is brought to our attention, we forget to deal with the pain component of that condition. So, lack of treatment of disease at an early stage can be a factor. Also, of course, we have the problem with domesticated, animals and non-human animals, that there is human control over breeding, which is resulting in some situations, in confirmations which predispose those animals to chronic pain.

And I'm sure we can think of various examples here of animals that have been bred in ways in which their skeletal formation. Or their musculature and the way it works, or, their movement is compromised by their confirmation and then leads to the risk of chronic pain. And in addition, we need to think about the environments in which animals live as domesticated pets in relation to their species specific behavioural needs.

And sometimes inappropriate housing in either a physical or a social sense can result in physical and emotional compromise associated with the development of chronic pain. So why behavioural medicine? Why are we talking about pain in behavioural medicine?

Well, pain, of course, is perceived in the brain, and the limbic system is involved in the physiology of pain. And therefore, emotional disturbance influences the perception of that pain process. So, of course, behavioural medicine being the veterinary discipline, which concentrates on the functioning of the limbic system in relation to emotional responses, has a direct involvement in the situation of pain and pain management.

Presence of pain alters the expression of emotional responses. So, we find with individuals, osteoarthritis work done by Doctor Kevin McPeak, who's a veterinary specialist in behavioural medicine, at Edinburgh University now. He looked at, sound-related fear in patients with osteoarthritis, and it's now, commonly accepted that If animals have chronic pain from DJD and OA, that there's a risk factor for accentuated sound-related fear in those patients.

Also, emotional disorders, which involves those disorders of pain, reduce the so-called emotional capacity of the individual, and we'll look at that in a little bit more detail this morning. So behavioural medicine is the discipline that deals with the link between emotional health and physical disease. And those of us specialising in behavioural medicine treat animals who have issues related to the functioning of their limbic system, and therefore, that overlaps with the issue of pain.

And pain is always what the patient expresses it is. That's a phrase which has been adapted from human medicine, where they talk about pain being what the patient says it is. But of course, for our non-human animals, that may not be verbally expressed.

So how do non-human animals express pain? They can do it in a variety of ways, but behavioural change is a very important indicator. Things like reluctance to walk on certain surfaces.

We have a number of cases that present as fear behaviours associated with not wanting to go into particular rooms of the house, for example, or being reluctant to go into certain locations, which actually are attributable to a reluctance to walk on certain surfaces because of chronic pain. We also have gait changes, which may not be obvious. Subtle gait changes are very common in presentation of chronic pain.

And they may actually present as behavioural change. So, difficulty in going on walks, for example, or changes in the way in which they interact with other animals in the household because of a difference in their gait. And we spend hour upon hour watching video footage, as I'll explain in a moment.

Also, of course, it could be that there's a response to manipulation, but it's important not to think that that is the only way, or to think that absence of response to manipulation is going to tell us that pain is not a factor. Because we need to remember that pain, as part of the fear and. Anxiety system can lead to an inhibition behavioural response.

So, when you manipulate that painful joint, the animal may go into an inhibitory response and show no reaction at all to that manipulation. That does not mean that pain does not exist. The other thing that's important is that during physical examination, other emotional factors can alter their response to handling, particularly if that physical examination is taking place in a consulting room.

So, it could be the style of our handling has actually led to overriding fear, anxiety, disassociated from the pain, which Then results in inhibitions. So this cat being inappropriately handled, this scruffing here, for example, or inappropriate heavy handling of cats, is likely to send them into an inhibition response, because cats use inhibition or avoidance as their primary responses to protective emotion. And when we do that, we may Lower the possibility that we may detect through physical responses, any pain in the consulting room.

And the same, of course, the dogs, with dogs, we may see selection of appeasement behaviour, where the dog engages more with the individual during the examination. And that may lead to a misunderstanding of the presentation. And if they have other emotional health issues, so if they are an animal with a natural cognitive bias, and emotional bias towards protective emotions where they've learned and they have emotional responses associated with feeling the need to protect.

Themselves, which is disassociated from the pain. This is an underlying emotional problem, then that also will make it far more difficult for the animal to express pain in a consulting room through responses to handling or manipulation. The other thing is that our clinical examination must always be interpreted in the light of the context.

So we need to know what happened just prior to that individual coming into the consulting room. Was that animal needing to walk across a car park, it's terrified of cars and the Individual needed to be lifted and manhandled to get it across the car park, which increased its negative emotional bias before you ever got it in the consulting room. Or is it through previous learning of the, veterinary context being a negative environment?

So when we're doing our clinical examination, we also need to interpret the body language and the behavioural responses of the individual to assess whether or not our physical examination for pain is actually going to be beneficial. Pardon me. And when it comes to chronic pain, pain assessment, therefore, in a routine, general practise consultation is extremely difficult to achieve.

House visits may be beneficial for pain assessment or virtual visits using things like Zoom, but even then, there are limitations. And when we are in our normal lives, not during COVID, but when we're doing house visits, we can be in the home for 2 to 3 hours. And even so, we still spend a lot of time watching video as supplement to the investigation.

I had a video like this, which was supplied by a caregiver, the German Shepherd was our patient. This very well, but. That movement issue and being suspicious of some chronic.

OK . So And breathe badly. Or we may supplement with videota and our rehabilitation.

That's what we did. Next Observing their movement and looking for those. So diagnosis.

We also take videos when we're in the home, so I'll just show you some examples. So this is the same dog. The, the colouring of the dog is very different.

I don't know why that is. It's to do with the light, but it's actually the same dog. So, here, I'll just turn the sound off on, on these.

It's not important to hear the sound. So we're looking here at the movement of this dog. Hopefully, you can see some difference in musculature at the back end as well.

But you can see that on the flat, There's quite, it's quite subtle, the change. But if we look at the same individual on steps, and you can see him going down the steps here, and then we're actually, getting him to go up and down these steps to watch, you can see that that accentuates that gate problem. And the same.

The often pass video which he's going up and down steps either in the top or often happen. To assess their movement. But whilst we concentrate a lot on lameness or alteration of movement for our diagnosis of chronic pain, we also need to remember there may be other signs.

That in there at the centre. So chronic change in the behaviour of our presentation. But we also, as I say, use home videos as well.

This cat video is actually in slow motion, so I'm gonna forward it properly. So we're starting to move, it takes ages in these slow motion videos for them to actually start moving. But when you do see the cats start going up the stairs, you start again, slow motion video can be extremely helpful in improving our detection of abnormal movement.

But as I said, it's not only movement. So other signs of chronic pain may be overlooked. So things like excessive licking or grooming behaviours, other repetitive behaviours, such as circling like this, but also repetitive behaviours associated with pain are seen in things like, or a facial pain syndrome.

So I will leave the sound on for this video, because it really is quite important to hear how this cat is responding. Oh Hey honeyball. Hi honeyba.

Hey, hey. You can see the caregiver there trying to intervene, trying to make it better. This, this cat has feline facial pain syndrome.

You can see that repetitive clawing at the mouth was what the cat was presented for. Other things like sit postures. So if we're looking at sit postures that are indicative of the potential for pain.

We also ask questions about toileting behaviour, particularly, in dogs. So, we ask them, what caregivers about how the dog, deposit when to things. So we look at them they hold what this is somebody that they have a.

I think I see in multiple locations. I Thank you So it's an indicator that we need to investigate more. And often, when we do that, when we are investigating, we need to think about extending our questionnaires to start with.

So, as well as asking about the presence of behaviours, the other thing we're gonna ask about is the absence of behaviours. Particularly in cats, we You know that chronic pain is associated with less movement, with lowered levels of grooming behaviour. So dishevelled coats, for example.

Not going to use your resting places if those have been elevated locations. And we also may see the absence of behaviour as a presentation of chronic pain in our canine patients as well. So behavioural change can be the result of the emotional effects of pain.

So pain, it's an emotional motivation, as we've just said, related to the fear anxiety system. It's related to protection of the individual in a physical sense. And the activation is really related to any environmental stimuli which are related to either actual or potential tissue damage.

Remembering that pain, like fear, anxiety has either the component where it's a response to the presence of pain, or to the anticipation as anxiety is an anticipatory form of that protective emotion. Pain also can be anticipatory in nature. And the behavioural responses we said earlier, ones we think about are particularly the more active responses.

So in a veterinary examination room, we often think about the animal who's trying to pull away, and we think about pain, trying to avoid interaction with us. I've used the terminology avoidance from the sink analogy, the sync model of understanding emotional health, but put in brackets here, flight, which is a term you may be more familiar with. But of course we we restrict the ability to use fight because we need to get our clinical examination done.

And then of course repulsion, and I think that's the one we most readily identify with the potential for pain. But the other two that we mentioned earlier, the inhibition may also be shown in the consulting room here this staring inhibition is the gathering of information to try to resolve protective emotion. Try and find out more.

About the situation that is perceived as being threatening. And so when we have our patients staring at us, we have this concentrated auditory, taking in of information, it's really important not to overlook that. And, as I said, appeasement, where dogs actually appear to be more proactively interacting with us.

So if they are leaning into us, or if they're trying to sniff at faces or lick to gather scent information, not this, not just ignoring that, but making sure we realise that could be an indicator of increased protective emotional bias, one of which may be pain. And appeasement is sometimes thought of at home as demanding behaviour. So, some of the animals that we see with pain as a component in behavioural cases have been presented for so-called demanding or attention-seeking behaviour.

These behaviours are actually information gathering behaviours. So, caregivers reporting their dog is more clingy than usual. It's following them more is, showing signs of separation.

Re-related problems, they may also be, a, a flag for us to consider pain because of the fact that if the dog is using appeasement as its coping strategy, then when the caregiver is not present, there will be an increase in anxiety and potentially an increase in that pain perception in the absence of the caregiver, which then manifests itself as a so-called separation problem. Ignoring and rejecting those demanding behaviours, if people are given misinformation about this being attention seeking and sometimes given misinformation related to the dominance myth where people believe these attention seeking behaviours are related to a high level of status, that often the advice that they're given is to ignore or even to reject the animal when it's engaging in this behaviour. But actually if you reject or ignore information gathering behaviours that are rooted in anxiety or pain, you will increase the anxiety and the negative bias and also increase the potential for frustration, which is the emotion that's triggered when you can't achieve an expected outcome.

In patients with chronic pain, these negative emotions of increased anxiety and frustration will also exacerbate the perception of the pain itself. So it's really important that we not only teach our caregivers, but also our veterinary professionals to be able to be more aware of body language and facial expression. Because the expression of pain is not likely to be verbal in the same way.

So that, this idea that the pain is what the patient says it is in human medicine is translated into this pain is what we our patients express it is, because we need to have good understanding of their species-specific communication. As well as their gross behavioural changes, which may actually present to you as a behavioural case, we also need to look for passive responses such as inhibition, behavioural responses that are actually appeasement, which may be misinterpreted as being very friendly or very needy or very demanding, and also more subtle communication signals associated with emotional arousal, so what we call displacement behaviours. So relying on just caregiver recognition of chronic pain is certainly not appropriate in determining whether or not to use medical treatment.

Animals in pain need to be treated, particularly when it's chronic pain, which is a disease state. It's not acceptable to instruct caregivers to give pain relief when they think that the animal needs it. The problem with this is the risk of sensitization, and humans are not in a position to make a judgement over the use of pain relief, not particularly not based on their own perception of medication use, and whether they would think they would need it.

If they were limping like that. And so often we hear caregivers saying, well, in behavioural cases, when we detect pain, oh, yes, yeah, yeah. I did get given some non-steroidal, anti-inflammatory drugs.

And I give them when I feel he needs it. But, you know, he's not actually limping. Therefore, I don't really think it's necessary.

But that can result in unintentional withholding a very necessary treatment for our patients. So sometimes the behavioural changes that are associated with chronic pain are dramatic. Sometimes we can readily identify them with the underlying pathology.

So, for example, if we have confrontational responses when arthritic joints are manipulated or when a Another animal, goes too close to an animal that has osteoarthritis or DJD, or an inability to get into the car because of something like osteoarthritis, a physical effect of that chronic pain, that may be quite readily associated. But in others, the behavioural changes are very subtle, and we may also need to do what we call chronological history taking, using a timeline to facilitate the gathering of information before we can reveal the association. So things like altered elimination behaviours are a flag for us in our behavioural history taking, asking questions about how often they eliminate, but also the posture they adopt when eliminating.

That's particularly important as well for cats. Also, the frequency, or as I said just before, with the dogs, as to whether they eliminate in small parcels of faeces in lots of places, or one large deposition of faeces from a stable squat position. Alter roaming behaviours is another flag, and also alterations in interaction with their caregiver.

Sensitivity to sound, I mentioned earlier as well, is another thing that we would always ask about in terms of our behavioural history and think about that as a potential red flag for the involvement of pain. The other thing to think about is this concept of emotional arousal. So, the outward manifestation of a behavioural change is dependent on the valence.

So that's on whether the emotions are protective or engaging. And we've talked about the protective nature of pain as an emotional response. But it's also reliant on the salience of the stimulus.

So, how In how, significant that pain is to that individual. So, if it's a high salence, the perception of that pain is significant. And remember, that may be out of proportion to the lesion.

I mean, chronic pain may be actually disassociated from the lesion altogether. So, chronic pain can occur without the presence of a detectable lesion. It's also dependent on the emotional state of the individual at the point when it experiences that pain.

So we have the valence, we have the salience of the stimulus, and then we have the emotional state of the individual. Earlier on, I mentioned the sink model for understanding emotional health in, in our non-human companions. And according to that model, increased residue increases the risk of flooding.

So this is, the diagram from the sink model. And the risk of flooding, and flooding is where the animal can no longer cope with the emotional situation that it's in, is is related to. High inflow.

So it's related to a large input of that protective emotion through pain. That's related to the salience of that chronic pain for the individual. It's related to the size of the sink of the individual.

So that would be related to their genetics and their early rearing, and their capacity for emotional arousal. It's also related to their drainage. It's related to how well they Cover what their emotional resilience is.

And that would be related to factors such as sleep. And we know that sleep deprivation is a massive problem in the canine pet population. Dogs need to sleep between 16 and 18 out of 24 hours, and very few domestic dogs get enough sleep.

So that could also be a factor in relating to the amount of emotion that these animals are holding onto in In terms of what we term the residue, so that's how, how high the level is in this metaphorical sink. And so, salience of the pain, the individual's genetic makeup and early experiences and overall emotional capacity, their drainage and their residue are all going to be important as to whether the chronic pain in this individual is significant in terms of affecting emotional health and giving behavioural consequences. And anything that increases the level of residue in the emotional sink makes it more likely that the animal will exceed its capacity when it's challenged with a particular stimulus.

So, it makes sense that if you have a sink that is already full with residue that could come from another emotional health. Health issue, or from the pain. So it could be an generalised anxiety disorder that exists in this individual, which is taking up some of that emotional capacity.

And then, when the chronic pain happens on top of that, that that's the point when they're unable to cope. Or it could be that the pain itself is the emotional issue. But it can also be the emotional consequences of that physical issue, and we're talking today about pain, but of course there are other physical health issues which also are important and lead to behavioural change because of this association.

So when we look at chronic pain, it's really important to remember that this is a multidisciplinary problem. So, dealing with pain is, of course, something we readily associate with our colleagues in anaesthesia and analgesia, who have a vital role to play in these cases. But also, we need to think.

About our colleagues as well in surgery, our colleagues in neurology, behavioural medicine, and also in rehabilitation and sports medicine. All of these individuals have a contribution to this, treatment of chronic pain, whether it's presented with behavioural presentation initially, or with physical presentation. And when there is behavioural consequence, behavioural modification from our suitably qualified non-veterinary behaviourists, so the Animal behaviour and Training Council is a place to look for suitably qualified people, but also the er Fellowship of Animal behaviour clinicians.

There's also ASAB, the Association for Study of Animal behaviour, who have the qualification of certified clinical Animal behaviours. So CCAB, very important letters to look for when you're looking for a non-veterinary colleague to refer to. And of course in some cases of chronic pain, a surgical approach may be indicated to resolve that underlying source if we do have an identifiable lesion.

But in many of the situations, it's a medical approach that's also important. And investigating, treating and managing any underlying medical condition is obviously crucial in order to tackle any behavioural expression that may have been presented by the caregiver. So giving effective and appropriate analgesia is crucial.

And because in chronic pain, we have this potential for a lack of link with a . With a, an actual lesion, we also need to remember that trialling with analgesia, doing analgesic trials, can be a really important part of the diagnostic process. So, this poor correlation between chronic pain and our imaging derived information means that these therapeutic trials can be very helpful.

While we're doing those, it's also important to think about how we monitor that pain. And there are many of these scoring systems that are available, which increase caregiver observation, help them to be more aware of what they're looking for, and also improves their reporting to us, which enables us to monitor the response to treatment. And there are, as I say, a number of scoring systems available.

I've listed a few of them here. The one that we use a lot is the canine brief pain inventory. We also sometimes use the Helsinki score.

There's a very good review article here from today's veterinary practise, from NABC.com. So there's a a link for you there, to gain access to that as an overview.

And the other thing I would really strongly urge you to do is visit a website called Zero PainPhilosophy.com. It's, organised by Doctor, Matt Gurney and his colleagues.

It's an extremely useful, website, very vital tool for you in practise for understanding, chronic pain. Also acute pain, it's not just about, it's also about anaesthesia. So, Matt and his colleagues are anaesthesia and analgesia specialists, so extremely useful resource.

Also, we have a more challenging situation with monitoring chronic pain in our feline patients, but we do have scores. We have the North Carolina state score, particularly for musculoskeletal pain. But of course, in our feline patients, it's also can be beneficial to use clinical specific outcome measures, and that can be extremely useful tailored to the needs of that individual patient.

So the emotional implications of the advice we give with our pain patients is also something to consider. Another overlap between behavioural medicine and other disciplines, particularly, we think of orthopaedic, but also remember that we may give advice about managing chronic pain from a visceral point of view. But when we think about the sorts of things we might give as advice, let's take that, orthopaedic situation as an example.

Quite often we say that we want to restrict exercise. Well, yes, that may be an important thing to do, but we need to think about the potential for there to be emotional implications of advice that we give. So thinking about restriction of exercise, if we say on lead only, then that has the potential to lead to frustration.

So, with individuals who are used to exploring their environment through Desire seeking, or used to engaging in social play with other individuals or object play through desire seeking, motivation and chasing a ball, then being on lead only can lead to frustration. And it's important to give other advice about the sorts of places where you might exercise in this on lead format, making sure you don't go to venues where the expectation is too. Be let off.

Don't walk in the same locations where there's a learned association. This is where my ball is thrown, or this is where I meet my friends. Don't walk with those dogs they have a high expectation to socially play with.

People tend to think, I want to keep their life as normal as possible. I want them to still see their friends. But if by seeing their friends, they have to be frustrated, that emotionally could be damaging.

Thinking about creating another thing we quite commonly give as advice, can also lead to anxiety because of uncertainty, because of a novel experience. There's an extremely good book available called No Walks, No Worries written by Sean Ryan and Helen Zul. Very good, document to advise clients to look at, particularly if you're doing elective surgery where you could actually do some preparation for having this alteration in exercise.

We can do some crate training, for example, so they see the crate as a safe and secure location. Need to remember crates can also lead to frustration through association with desire seeking being unfulfilled, inability to spend time with their social companions. So the positioning of the crate, which room it's in, those sorts of things are useful to consider.

And we talked about a multi-disciplinary approach. So, in addition to any surgical or medical approaches, we may also be thinking about physio, thinking about physiotherapy in terms of things like hydrotherapy, but also in terms of physical therapies. We actually have, our rehab training.

Within our behavioural medicine referral practises now in the 2nd year of her master's in physiotherapy, because we've recognised how important it is as a behavioural practise, to have a physiotherapist on our staff because of this interplay between our behavioural, presentations and pain. And acupuncture is also may play a role for these patients. And then we also need to think about the implications of the advice that we give in terms of environmental modification.

So one of the things that we're often needing to do, as well as treating and any associated emotional disease, which we do have in some of these patients, treating their chronic pain, and also modifying the environment such that they can function better within that environment. Now, environmental advice can be divided into different types. So it's important to differentiate between environmental optimisation, environmental modification, and environmental enrichment.

So environmental optimisation is catering for the species-specific behavioural needs of the individual. And environmental optimisation is always necessary for every individual. Environmental modification is what we're talking about in these chronic pain cases, and I'll show some examples in a second.

Environmental enrichment is the addition of, things to the environment which increase emotional motivation, primarily, and the idea of environmental enrichment is to increase the positive or engaging emotional bias. But you need to remember that in some behavioural cases, enrichment is actually counterproductive because enrichment turns on emotional input. Going back to that diagram I showed you, where we said that problems occurred if you had a high inflow related to a small sink and poor drainage, because it Results in more arousal, more residue.

If you enrich an environment, particularly in chronic pain cases, actually enriching the environment can run the risk of increasing emotional inflow to the point where it contributes to emotional compromise. So, optimisation always necessary. The modification important in these cases, but enrichment may actually be counterproductive.

So excessive emotional stimulation leading to high levels of arousal can actually exacerbate the pain response. So very simple alterations to the environment in terms of modification can be hugely beneficial, make a massive difference to the impact of chronic pain. Another website for you to think about.

Is the, canine arthritis Management website, and Doctor Hanna Hannah Capan's website. They produce some very useful caregiver focussed material for the caregiver to access, and also information for us as veterinary professionals as well. And of course, although canine arthritis management is, is there, as a massive resource for our dog patients, we also need to remember that environmental modification may be also necessary for our feline patients.

So, enabling them to access elevation, which is so important for them in control of their emotional health. So, if they're unable to get up onto things because of their mobility issues and their chronic pain. Issues, then providing steps or providing beds like this that just slightly elevated, that still give that sensation.

Improving access to litter trays by, providing trays with scooted fronts or these homemade storage box form of litter trays to make sure that these cats can access the tray readily. Because if they can't and they start house soiling, there are other emotional implications. So, once we've identified, that pain is part of a behavioural presentation, then we must also treat that, treat that as we've talked about in a very multimodal approach.

But then we also need to think about the potential for behavioural therapy to also be needed. So, treatment of the emotional component. And that may be through a combination of behavioural modification, potentially the use of medication as well in a psychoactive sense.

So, things like anxiolytics, for example. We also need to consider the potential for the development of anticipation of that pain, and think about how we may need to use learning theory approaches, counter-conditioning, and desensitising approaches to limit that. And also think about the potential for other learned associations with the pain, particularly contextual associations if the pain has been experienced within the veterinary practise, for example.

We also need to consider that you may get more obvious expression of other behavioural motivations once the pain is under control. So sometimes as you treat the pain, other behavioural expressions become problematic. So things like, desire seeking behaviours of counter surfing and stealing, they were unable to jump up at the surface before because of pain, now they can.

We also talked about the fact that anxiety related appeasement may become more obvious because the pain may have been leading to more inhibitory responses, but also we may find that the the treatment of the pain doesn't remove the appeasement behaviours, and actually there is some other underlying anxiety related condition that we need to identify and treat. So, other comorbid, non pain related emotional disorders such as anxiety or frustration may also be uncovered in the process of treating their pain and lead us to have to focus more on the behavioural medicine approach. So pain is complex.

Pain is not only a sensory and a motor response, it also has a cognitive and an emotional dimension. Consideration of pain is absolutely essential when dogs and cats present with behavioural change. The University of Lincoln has released quite a lot of data on this link.

They say that 68% of the 50 most recent cases have involved pain. And also, we need to remember that there's an absence of potential diagnosis in a more conventional state that may lead to us missing the potential significance of pain. So, I want to finish by leaving you with a reference I would urge you all to read, which is this one from, Daniel Mills and his team, Pain and behavioural Problems in Cats and Dogs, which was published in Animals in 2020.

And I want to, with very kind permission of Hannah Cappan, just leave you with this video to watch. So this will just take, a couple of minutes. So I'm gonna sit back and just allow you to watch and digest the content of this video, courtesy of Hannah Cappan.

How can I be of help? Can you describe how you're feeling to me? OK, can you show me?

Can you point to where the problem is? I'm afraid I can't help you if you don't tell me. Stop.

You're in pain. So the message is pain is always what the patient expresses it is, and when in doubt, we should always treat. Thank you.