Perhaps no other modality of equine therapy has grown as rapidly as the "hands on" therapies have in the past five years. This growth is patterned after human physical therapy, where the use of the hands to relieve soft tissue discomfort and joint movement restrictions has expanded over the last 20 years. The many techniques of massage, acupressure, and joint mobilizations always have been used, but only lately studied scientifically and refined. With your hands, you can reduce pain and swelling, as well as increase joint range of motion, and the functionality of the musculature.
Manual therapy brings the horse and handler into close and intimate contact, an act which helps the horse develop trust in the handler.
Human physical therapy began as a largely "hands-on" profession. With the development of therapeutic equipment, such as ultrasound and electrical stimulation, manual techniques fell out of favor in the early half of the century. As we approach the beginning of a new century, we find that therapists are employing the "laying on of hands" in a wide variety of techniques.
Benefits of Manual Therapy
Imbalances in muscle tension or in energy are very early warning signs of injury. By using your hands on your horse regularly, you have an opportunity to see into the future and to change it. Manual therapies can be used effectively in preventing injury by keeping the soft tissues mobile.
Manual therapy brings the horse and handler into close and intimate contact. A horse is able to detect kindness and love conveyed through touch and develops trust in the handler. When a horse is in critical health or discomfort, hands-on therapy can be the element that encourages survival. As Ric Redden, a veterinarian who has taken care of many horses with chronic laminitis, says, "Those loving hands can talk them into living."
Techniques of Manual Therapy
It would be a very big job to list and describe all of the manual therapy techniques that have been developed over the last 20 years. Several of the popular techniques will be described, but certainly some will be left out. Common to all of the techniques is the physical connection between therapist and horse, a means for evaluation and a channel for energy flow.
Massage
Massage is the use of the hands and fingers, and even the elbow, to manipulate the soft tissues. Goals of massage include promotion of circulation and tissue drainage, muscle relaxation, and pain relief. Conditions that would benefit from massage include tight muscles and joints, contracted tendons, immobile scar tissue, and chronic edema. Massage to the coronary band promotes blood flow and can increase the rate of hoof growth.(1) Massage loosens and stretches dense connective tissue, has a sedative effect on the central nervous system, and can enhance lymphatic and blood circulatory activity. For massage to be effective, the affected structure must be sufficiently superficial to be accessible to the force imparted by the therapist's hand.
Massage often is used as part of the warm-up before exercise. By increasing circulation in the tissues, they are warmed and made ready for stretching exercises. Establishing a routine of massage before activity enables the horse to go into the activity in a relaxed manner.
If massage is used as a part of the rehabilitation process, it is applied after the initial inflammatory phase is under control, at least 24 to 48 hours post injury. In this stage, young fibroblasts begin to migrate to the area and lay down new collagen fibers. These new fibers initially have a random orientation, but later acquire definite arrangement. Tension plays an important role in this phase of the healing process as collagen fibers re-orient themselves in line with the tensile forces applied to the tissue. An injury can repair with shortened connective tissue when pain prevents use. Massage and stretching exercises help maintain normal tissue mobility.
Surgery or injury often results in an accumulation of edema around the wound. A stall-bound horse often will develop edema in the lower legs, a condition known as "stocking up." Because the lymph vessels of the horse's lower leg do not have valves to counteract the effects of gravity, movement is needed to assist blood and lymph circulation. Massage techniques can assist the circulatory systems and aid in edema reduction.
Massage tools such as tennis balls or vibrators often are used to reach deeper muscles and to reduce the wear and tear on the therapist. My advice is to develop manual sensitivity first, before you begin to use other tools. Learn to be sensitive to muscle energy, tissue temperature, and feedback on the horse's comfort level. Make your hands the conduit for your intent to soothe and to heal.
Ice Massage
Ice massage can be helpful during the inflammatory stage of the injury process. Cooling the tissues has a direct effect on inflammation by reducing the need for oxygen in the surrounding tissues, restricting blood flow through vasoconstriction, and reducing the release of inflammatory substances. Ice massage is so simple that its value often is overlooked. By simply freezing water in a Styrofoam cup and using this block of ice for five to ten minutes over the injury site, one takes a most significant step in shortening the inflammatory process. To use a popular term, you are being "pro-active" in reducing the amount of the debris of injury that contributes to scar tissue formation.
Trigger-Point Therapy
Trigger-point massage is sometimes called myotherapy or myofascial trigger-point therapy. Before these terms became popular, this technique was called ischemic compression, which describes the mechanism of action. This technique involves sustained pressure from the thumbs, the fingers, or the elbow directly on myofascial trigger points. The firm, sustained pressure causes blanching of the skin and superficial muscle due to compression of capillaries. The pressure initially causes ischemia, followed by reactive hyperemia when the point is released. The return of blood warms the area and stimulates metabolic processes. Active trigger points are always tender and eliminating them relieves a source of pain.
The myofascial trigger point contains a muscle spindle at its core. The muscle spindle is a nerve structure that is sensitive to stretch and pressure and keeps the surrounding musculature in contraction.
The goal of trigger-point therapy is to deactivate the point and thus eliminate a source of pain. Trigger-point myotherapy makes use of ice as another means of deactivating the points, followed by stretching to assist the muscle in returning to its normal resting length. It might be necessary to carry out a series of icing and stretching over several cycles to deactivate the point.
Acupressure
Acupressure is an ancient technique that uses the fingers to press specific points on the surface of the skin to stimulate natural repair processes. Acupuncture and acupressure use the same points, but acupuncture is a veterinary procedure using needles while acupressure may be done by the therapist and is non-invasive. While acupuncture can be used as a medical treatment for injury or illness, the philosophy behind acupressure is that it is used to maintain well being.(2)
Acupressure massage is similar to trigger- point massage in technique, but different in theory. The treatment approach for acupressure centers on the Chinese meridian theory, that all organs of the body are connected by a network through which energy flows. This vital energy, or chi, becomes blocked by injury or illness and its functional flow is inhibited. According to acupuncture theory, specific areas on the skin surface relate to specific organs or remote parts of the body through a system of channels. Systematic pressuring of these points keeps the channels open and maintains the flow of energy.(3)
Acupressure inhibits the transmission of pain signals to the brain through two mechanisms. When superficial stimulation, such as finger pressure, is perceived by the recognition centers of the brain, a "gate" is closed to other sensations.(4) Acupressure massage requires accurate location of specialized areas of fascia known as acupuncture points. Stimulating these points releases endorphins and other chemical catalysts for pain relief. This chemically mediated pain relief is long lasting and can have a relaxing effect on the body as a whole.
Joint Mobilization
Joint mobilization involves passively moving the joint to the end of its normal range of motion, then passively flexing and extending the limb, only to the point where resistance is met. Gliding movements are used to restore motion normally allowed by the joint capsule. Passive movement means that the therapist moves the limb unassisted and unresisted by the horse. Range of motion means the full motion possible for the joint structures and the surrounding muscles. This manual therapy has its roots in a study done in Sweden in 1955 that showed the articular cartilage is nourished from both the underlying epiphysis and from the synovial fluid. It was also demonstrated that joint motion promoted the nutrition of the cartilage.(5)
The mobilization movements are done repeatedly, as many as 10 or 20 repetitions, depending on the tolerance of the horse. Continuous Passive Motion machines that move the joint for hours at a time are now available in human physical therapy . It is thought that gentle natural tension on the new collagen bundles orients the fibers along the lines of force, rather than allowing the random deposition characteristic with disuse.
Joint mobilization uses low velocity (slow movement) and large amplitude (large range of motion, but within normal limits) in contrast with joint manipulation, where more high velocity (quick, forceful thrust) is used to extend the joint beyond its normal physiological limits. Mobilizations are done in repetition, while manipulation is done only once. When a horse is the patient, joint manipulation is in the domain of the veterinary chiropractor.
Joint mobilizations are useful in stimulating metabolic processes within the joint, increasing joint range of motion, and reducing tension in connective tissue. Pain of a chronic nature and joint restrictions that have existed over a long period might not respond to mobilization, unless other therapies also are used. This technique should be used as a preventative measure to keep your horse flexible and fully functional.
Joint mobilization is carried out within what is called the zone of physiological movement. This zone includes the range of normal active joint movement, or movement that the muscles normally can accomplish, plus a small range beyond this. To demonstrate the zone of physiological movement, extend one finger as far as the muscles will extend it. Now use the other hand to push that finger into further extension, stopping when you feel tension. When a joint is moved to the end of its physiological zone, the resistance encountered is due to tensing of the joint capsule. Should a joint be taken beyond the limits of its physiological range, tearing of the joint capsule could occur, resulting in a sprain.
Joint mobilizations are slow, careful movements, using the long lever of the horse's leg to mobilize lower joints. No thrusting or rapid movements are used; rather, fluid circular motions are used. The leg is picked up, flexed, and extended, and moved in a rotary manner both clockwise and counterclockwise. Each joint of the leg is flexed and extended to its physiological barrier, repeatedly and slowly, through the normal plane of motion to the point where tension is felt. The process is repeated until free movement is achieved or until no further gain is apparent. Joint mobilizations are contraindicated where active inflammatory arthritis is present.
Chiropractic Manipulations
Chiropractic joint manipulations require specific, high velocity, controlled thrusts directed at a joint. These movements might take the joint beyond its initial barrier of resistance, to the limits of its physiological range of motion. The joint surfaces suddenly separate and a "crack" often is heard. The sound, so often associated with a successful "adjustment," results from gasses being released from the synovial fluid, much like popping the cap off a carbonated drink. Indeed, there is great similarity as the synovial fluid contains hydrogen and carbon dioxide. This phenomenon of a dramatic alteration of pressure within the joint space distinguishes chiropractic manipulations from therapeutic mobilizations. This is a veterinary procedure due to the necessity of a detailed knowledge of anatomy.
Chiropractic terminology has led to confusion about what the manipulations are attempting to accomplish. An adjustment is characterized by a specific force applied in a specific direction to a specific joint or vertebra.(6) Because the target lesions are termed subluxations, the idea that a bone is out of place has persisted. Chiropractic manipulations must take into account the whole of the organism--the nerves, fascia, muscles and tendons, and ligaments, as well as the osseous structures. The spinal adjustment impacts all of the tissues around the joint. The goal of the adjustment is not to put a vertebra or other bone back into place, but to impact fascial and muscular restrictions that put torque, or force, on the bone, affecting its normal movement. Joint "fixation" can be traced to fascial shortening and muscle spasm. The "adjustment" is a release of soft tissue tension. The chiropractic manipulation stretches the fascia, nerves, and muscle by rapidly forcing the joint beyond the fixed region of joint motion. The process inhibits the relentless neural bombardment that has maintained the spasm, allowing relaxation around the joint. Chiropractic manipulations have been documented to reduce electrical activity in the muscle comparable to local anesthetic injection.(7) This technique is contraindicated in the presence of arthritis, fractures, or bone disease, calcification around joints, ankylosing spondylitis, or any undiagnosed pain.
Myofascial Release
Fascia is a single structural entity that extends from the tip of the horse's ears to his feet and supports and envelops every organ of the body. A gelatinous substance in the normal state, fascia can become rigid and fibrous. It is elastic, but susceptible to shortening and forming fibrotic bands when subjected to chronic stress. It is piezoelectric, meaning that when pressured or stretched, it gives off electromagnetic signals.
Fascia is richly endowed with nerve endings and produces pain of a burning nature. Trigger points exist in taut bands of muscle or tendon tissue and will twitch when pressed. The area of a trigger point is tight, but not fibrosed, and will soften and relax with the appropriate treatment. Myofascial release aims at softening and relaxing fibrotic fascia, based on the contention that tension, shortening, or thickening anywhere in the fascia can affect total body function and might set up a chain of malalignments and restrictions throughout the body.
Fascia can place enormous tension on both osseous and soft tissue structures. Because fascia extends throughout the body, all musculoskeletal trauma involves the fascia. The goal is to allow the fascia to release its tension. Prolonged light pressure is used, although deep pressure might be used in some cases.
Craniosacral therapy sometimes is called energy work because some of the techniques suggest that the therapist direct his own energy to the patient. John Upledger, a proponent of this technique, suggests that the electrophysiological potentials of the therapist's hands might directly influence electrical activity in the patient.(8) Although the idea of energy work sounds new, the technique is ancient, perhaps originally called laying on of hands.
The craniosacral concept is based on identifying the cranio-sacral rhythm, or the movement of the cerebrospinal fluid in the spinal canal. The body moves in a subtle motion that corresponds to the movement of the cerebrospinal fluid. The strength and synchronicity of the rhythm can be used to detect restrictions in the body. The removal of these restrictions is called a release.
A general description of the basic technique of craneosacral therapy is that the therapist places her hands gently on the horse and senses subtle body motions. The therapist follows the movement to its greatest range without any attempt to influence the movement. When the body movement begins to return from this point, the therapist presents resistance by being immobile. No pushing or overt movement is involved. Inherent movement of the tissues again will move away from the therapist, and the therapist moves with it. At the end of this excursion the therapist again becomes immobile. After several cycles of this, the tissue will soften and a release will occur. The theory behind this approach is that a small force over a long time can do more for the body than a strong force over a short time. Some experts believe that a small force produces much less resistance in the patient's body.
Deep relaxation in the horse's body is the primary goal for craniosacral therapy. There are many techniques in this classification of manual therapy. For the therapist wanting to improve tactile skills and awareness, a course in craniosacral therapy is a must.
Contraindications For Manual Therapy
As with any other modality, one must have personal experience with any manual therapy before applying it to a horse. Only through personally experiencing the therapy can one get an idea of its effects.
There are few contraindications for manual therapy, but a few cautions should be kept in mind. Avoid manual therapy when bacterial or viral lesions are present. The skin over the target tissue must be intact. Manual therapy should not be applied over a torn muscle or to an area of internal bleeding, such as an acute hematoma. Manual therapy can cause further damage to an acute injury. Manual therapy should be avoided in the presence of phlebitis, thrombosis, or inflammatory arthritis. Manual therapy over areas of calcification in the soft tissues will increase the inflammation in these areas and should be avoided.
It was once thought that the positive benefits of touch were reserved for humans alone. The sensitivity of horses to our loving touch now is widely recognized. A horse can feel the rider's subtle changes in body position right through the saddle. They easily detect tension in the handler and the emotional state of the rider. The therapist using manual techniques must be aware of the horse's response to tactile stimuli. Some people transmit confidence with their hands and attitude--others transmit distrust.
The therapist should have a complete knowledge of the horse's state of health before applying any manual therapy. This requires veterinary consultation and evaluation of the horse. Although not a substitute for veterinary medicine, manual therapies are appropriate for injury prevention and can be combined with other therapeutic modalities for rehabilitation.
REFERENCES
1. Rodriguez, C. "A Different Approach for the Treatment of the Laminitic or Foundered Horse." 12th Annual Bluegrass Laminitis Symposium.1998.
2. Irwin, Y. Shiatzu. Philadelphia: JB Lippincott:1976.
3. Gach, M. R. Acupressure's Potent Points. Bantam Books:1990.
4. Melzack, R. and Wall, P. D. Pain Mechanisms: a new theory. Science. 150:1965. 971-979.
5. Ekholm, R. Nutrition of Articular Cartilage. Acta Anatomica. 1955:24. 329-338.
6. Willoughby, S. Chiropractic Care. in Complimentary and Alternative Veterinary Medicine. Schoen and Wynn eds. Mosby:1998. p.185-200.
7. Haldeman, S. What is Meant by Manipulation? in Approaches to the Validation of Manipulation Therapy. Buerger and Tobis eds. CC Thomas:1977. p. 229-302.
8. Upledger, J. E. and Vredevoogd, J. D. Cranio-sacral Therapy. Eastland Press:1983