Thursday 10 May 2012

"...or, alternatively, shoot the horse."

This is a blog post I've been mulling over for a few weeks but didn't want to publish it while I was annoyed and disappointed - there is no denying though that this post is an attempt to find the silver lining(!).
A few months ago I saw that the British Equine Veterinary Association (who have their annual conference in September) were asking for submissions of abstracts of clinical research papers.  These are for a section of their conference where short presentations are made on various research topics, often where research has been done by practitioners in the field.  The call for abstracts said:

"Abstracts should report recent clinical research. This may include observational reports on clinical case series, accounts of new techniques in vitro or in vivo experimental studies; preliminary findings will be considered. "

Encouraged by Nico's owner Emma, who has herself presented abstracts at the conference, I approached Professor Peter Clegg (who has provided regular help throughout Project Dexter) and asked whether he thought it would be worth submitting the results so far.  He was supportive, and said that to increase credibility we should focus only on the horses who had been diagnosed using MRI.  With his help and Emma's we put together an abstract in the required form (300 words or less) giving brief details of the rehab we do and a summary of the results.

Palmar hoof rehabilitation: a means of increasing soundness in horses with DDFT/collateral ligament injuries within the hoof. 
Aims: To assess whether a specific rehabilitation protocol which improves palmar hoof development and medio-lateral balance provides a comparable/better prognosis for long-term soundness than current treatments. Methods: Twenty-three horses with forelimb lameness that had been diagnosed on MRI as having damage to the DDFT and/or collateral ligaments of the DIP joint were rehabilitated over approximately 12 weeks. Shoes were removed and horses kept on surfaces which maximised comfort and encouraged movement (including shingle and sand). Free movement on these surfaces was encouraged. Diets were low in sugar/starch with balanced minerals and adlib forage. In-hand and ridden exercise on varied surfaces formed an important element of rehabilitation. Palmar hoof development and medio-lateral balance were regularly monitored with photography, using video footage to assess foot placement (toe-first/heel-first). After ~12 weeks horses returned home to continue a normal exercise programme. Results: Twenty-three horses (aged 5-13yrs) were enrolled with 17 programmes completed and 6 still ongoing.  Of the 17 horses who completed, 14 have since been maintained at the same level of work or higher than before their diagnosis, 2 improved but did not return to full work, 1 had rehab interrupted by colic surgery and is in light work. Improvements in palmar hoof development occurred relatively rapidly, with most horses’ landing changing from toe-first to heel-first within 2-6 weeks.  Soundness on hard surfaces and on circles typically improved once this landing was established and palmar hoof development also improved with exercise on varied surfaces once horses were landing correctly. Conclusions: Horses with this type of diagnosis may benefit from therapeutic rehabilitation which  improves palmar hoof strength and medio-lateral hoof balance.  Practical Significance: This type of rehabilitation may improve the prognosis for long-term soundness with specific lameness conditions of the foot Acknowledgments: Constructive advice from Prof. Peter Clegg; Jeremy Hyde BVetMed MRCVS. 

As this is an area where conventional treatments don't have a particularly good success rate, I had hoped that our results - even as preliminary research - would be good enough for BEVA to want to learn more.  It was therefore very disappointing to be told that the abstract had been peer-reviewed but not accepted.  Although I asked for feedback, no reasons were given as to why they were not interested or how I could improve the data to make it more useful to them.
I would have fully expected a healthy level of scepticism, even incredulity and was certainly up for tough questions but, as always, I was hoping to generate enough interest for someone to undertake further research and maybe even - the holy grail - obtain funding for follow-up MRIs on horses who have undergone rehab.

Its all the more frustrating given that a significant proportion of the vets I talk to ARE interested.  They want to offer better alternatives to horses and owners than a "guarded prognosis", prolonged box rest, "inevitable" degeneration or euthanasia and - like me - they would love more information as to exactly what is happening when these horse's feet change so fast during rehab.

I'll keep on plugging away gathering data for the research, of course, and meanwhile if any of you have bright ideas for galvanising interest, then please email me!

There are a couple of other avenues I am still exploring so I am trying not to be disheartened. My favourite quote, from David Wootton's "Bad Medicine", always cheers me up at times like this and is so good that I make no apologies for including it here on the blog for the umpteenth time:

"Think for a moment what surgery was like before the invention of anaesthesia in 1842...  Imagine taking pride above all in the speed with which you wield the knife - speed was essential, for the shock of an operation could itself be a major factor in bringing about the patient's death. 

Now think about this: in 1795 a doctor discovered that inhaling nitrous oxide killed pain..yet no surgeon experimented with this.  The use of anaesthetics was pioneered not by surgeons but by humble dentists. One of the first practitioners of painless dentistry, Horace Wells, was driven to suicide by the hostility of the medical profession.

When anaesthesia was first employed in London in 1846 it was called a "Yankee dodge".  In other words, practising anaesthesia felt like cheating.   Most of the characteristics that the surgeon had developed - the indifference, the strength, the pride, the sheer speed - were suddenly irrelevant. 

Why did it take 50 years to invent anaesthesia?  Any answer has to recognise the emotional investment that surgeons had made in becoming a certain sort of person with a certain sort of skills, and the difficulty of abandoning that self-image.

If we turn to other discoveries we find that they too have the puzzling feature of unnecessary delay...if we start looking at progress we find we actually need to tell a story of delay as well as a story of discovery, and in order to make sense of these delays we need to turn away from the inflexible logic of discovery and look at other factors: the role of emotions, the limits of imagination, the conservatism of institutions.

If you want to think about what progress really means, then you need to imagine what it was like to have become so accustomed to the screams of patients that they seemed perfectly natural and must first understand what stands in the way of progress."


dreams579 said...

oh Nic :( I'm thoroughly pissed off on your behalf and on behalf of all the horses with foot pain.

Bollocks to them! especially that they wouldn't give you feedback as well. my only guess would be that maybe its because its not through a recognised institution or vet practice... don't know. They always took my research which was a) crap! b) had very very little to do with day to day clinical practice.

I'll give you a ring later as it may be easiest to go to full publication - you've got a broader range of journals to chose from etc.

Debbie & Paddy said...

How massively disppointing. It defies belief! Any chance you could email me a word doc copy of your document detaiing your work at Rockley as it is an excellent summation and useful to explain to people the process Paddy has been through. Keep up the great work! :o)

Anonymous said...

Very sad. It's always true that those who hold to "accepted" medical or veterinary practices often are close-minded about new approaches, perhaps because they perceive it as a threat to their (supposed) position of authority.

We've got a somewhat similar situation over here with the diagnosis and treatment of EPM. The existing tests are inaccurate and the existing treatments are often ineffective and very expensive. The disease if not treated effectively is often devastating. There is a new test - accurate, easy and even identifies particular strains - and a new treatment protocal that seems to be very effective for about 95% of the horses. The test and treatment are now in clinical trials and seeking FDA approval. There have been peer-reviewed studies, and there are still many in the veterinary "establishment" who are ignorant or even hostile to the new proposed test and treatment.

One of the darker aspects of the human personality, I fear.

Buck up - there are lots of us who do get it and who support what you are doing. It's going to take time and continued effort, and more effort, and more . . .

Nic Barker said...

Thanks guys - Emma, yes please to a chat about what to do next - I will try and call you this evening.

Debbie and Kate, thanks for the encouragement and kick up the metaphorical backside :-) I do agree that its sometimes hard for any of us to think outside the box or step outside the comfort zone.

jill said...

I totally agree with Kate. She and I use a vet who has an open mind and has developed and uses a chromium supplement that has helped many horses in our area with "footsoreness" and hormonal issues. Most of the vets think its crazy... but you know works and my 2 horses are proof! This vet is also part of the new EPM field trial...thank god...she gave a lot of us our horses back when they were suffering with the mysterious symptoms of EPM.
BTW I gave her a copy of your book and she thought it was spot on!

jenj said...

Oh Nic, how disappointing. Sometimes academia can be completely ridiculous about accepting other views, particularly "outsiders" (e.g. those who don't have the little three letters after their names). So frustrating. I really feel for you.

Having said that... your work is absolutely worth publication, and it may just be the matter of getting with the right vet and submitting to the right publication. I do hope Emma can provide some assistance with that - it's time for the veterinary community to sit up and pay attention!!!

Maria said...

It's probably simply because the research you have done applies to limited numbers and there probably is some statistical benchmark that makes them rubber stamp it or not.

Don't give up, the more horses go through this, and the more you can record, the sooner they will accept the results.

Nic Barker said...

Thanks Jen - without the support of you guys and the brilliant practical help that Emma, Sarah and numerous other owners provide I would be at my wit's end, but they are such fantastic ambassadors :-)

Maria - that was my thought initially too, but we sent a 2nd abstract with all the horses included (not just those who'd had MRI) which was a sample twice as big, and that was rejected too(!). Originally I was told that a sample size of 10+ would be worth looking at...

Still you are right - the greater the numbers, the more persuasive the argument.

Val said...

Maybe they wanted to see a measurable difference on follow-up MRI post-treatment. Perhaps they took the results to be subjective. Any chance you could get to the holy grail first?

Keep on, keeping on. I am rooting for you and Rockley.

Nic Barker said...

Thanks Val :-) The problem is ££ - MRI per horse runs at £1000-1500, even if the follow ups are done as a package with the original MRI. The company which makes the scanners is supportive in principle of research but same old story - to get the funding you need the backers, to get the backers you need the funding -all a bit circular!

Nic Barker said...

Jill, Kate, very interesting comments, and your vet sounds great :-) Believe it or not, chromium supplementation is illegal in the UK(!)...Would love to know more about the EPM trial though.

amandap said...

Nic Barker wrote...

" Believe it or not, chromium supplementation is illegal in the UK(!)... "

I don't understand here Nic. Chromium is in many supplements you can buy in UK. Do you mean as a single supplement?

Nic Barker said...

Sorry Amanda - I should have been clearer - chromium is banned as a specific supplement (or was the last I heard), not as a naturally occurring component of another feed (eg yeast). As far as I recall, its EU legislation. If I track down the source I will let you know, or if anyone else does perhaps they can post here?