Recognizing Red Flags

by Kevin Haussler, DVM, DC, PhD

The problemwhy is this important?

When deciding whether the animal we have before us is a candidate – or not – for our manual therapy treatment, it is important to have a thorough knowledge about contraindications and a systematic list of points to consider.

Contraindications refer to instances where a treatment should not be used for a specific patient at a given time or for a particular reason. Some contraindications relate to the perceived harmful effect of the applied treatment (e.g., a too intense stimulation), or an adverse reaction in the patient (e.g., increased pain or stiffness after our treatment), or the application of a treatment at the wrong time (e.g., too early in the inflammatory phase) or for the wrong reason (e.g., chiropractic care for a hoof abscess).

This blog post was written with the equine community in mind. Contraindications for treatment of small animal patients, rodents, or exotics are expected to be quite different.

Close up of a horse neck that shows a vaccine reaction

Contradictions definitions

Contraindications can be categorized into two general types: Absolute and Relative. While most contraindications will relate to the whole horse, others may be site-specific.

Absolute contraindications mean that everyone would agree that if a patient has this type of injury or disease process, they should not be treated with manual therapies. Full stop.

A few examples might include fractures, open wounds, or infections. 

Obviously, horses affected with these disease processes are readily managed with appropriate veterinary emergency, medical or surgical care. Aftercare or post-operative rehabilitation may then include some form of manual therapy, if indicated.

Relative contraindications fall into the category of “It depends”. Depending on the following list of factors, one can either decide to take the risk and treat the patient or decide that this case is an absolute contraindication given our assessment and the situation today.

A few of the factors that we need to consider if we want to treat a patient with a relative contraindication include:

  • The type of injury or disease process (see below)
  • The depth, location, onset, severity, distribution, and duration of injury
  • The tissues affected and stage of tissue healing
  • Chronicity and concurrent disease processes
  • Prior treatments and response to treatment
  • Age, body condition score, and horse’s athletic discipline
  • Owner compliance and expectations
  • Veterinary consultation and development of an approved treatment plan
  • Active liability insurance that covers the practitioner, his/her practice, staff, patient, and owner

So, it becomes quickly evident that just reading on a website a few bulleted disease processes listed as “red flags” (such as, dehydration and shock) is misleading and not very helpful.

The challenge

Contraindications for treatment are based on the injury or disease process, and most veterinarians have access to a wide variety of critical care, medical, surgical, and reproductive procedures, medications, preventative health and wellness, integrative therapies, and physical rehabilitation, which provides them with many different options for managing both routine and difficult cases. There is also a well-established referral network to colleagues, boarded specialists with expertise in specific areas of interest, and large clinics and universities that have specialized facilities and equipment for advanced diagnostic or treatment procedures.

Unfortunately, some practitioners are often working at a distinct disadvantage when doing an assessment and trying to determine if a patient has a treatment contraindication, unless there is an obvious issue that can be readily identified while taking the medical history or during the assessment. Some may lack the formal education, clinical training or acumen, or access to diagnostic imaging or laboratory tests that could provide the added breadth and depth of knowledge needed to help make well-informed decisions on how, when, and with what to best treat their patients – or not, if there are clear contraindications.

Most contraindications require, at the minimum, a consultation with the managing veterinary to inform them of your assessment and concerns. Or better yet, to schedule a phone call or meeting to discuss how you and the veterinarian might provide future collaborative care for this patient given the current contraindications for your conservative care. If this collaboration is not readily available, then practitioners may need some basic guidelines to help determine whether or not to proceed.

Absolute contraindications

Awareness of issues before we ever lay hands on the horse

Animal healthcare providers must have a working knowledge and awareness of all infectious, contagious, zoonotic, and reportable diseases in their region to help prevent the spread of disease to other animals or people. Contagious diseases readily spread within species (animal to animal), whereas zoonotic disease spreads across species (from animals to humans). Reportable diseases are of great public health importance as they are severe and fatal (e.g., plague, rabies). They are the disease equivalent of a natural disaster – you may only see one in your lifetime, but they can be very widespread, destructive, costly, and scary.

Infectious, contagious, and zoonotic diseases – depends on the diseases in your area

  • Nasal discharge – equine influenza
    • Running noses come in a rainbow of colors. Knowing what each color, smell, consistency, and amount is useful in determining contraindications. Clear (serous) – white (mucous) – yellow-green (purulent) – red (blood)
  • Coughing – equine influenza
  • Drooling – vesicular stomatitis
  • Urinary incontinence – equine herpesvirus (EHV-1)
  • Diarrhea – salmonella
  • Sudden behavior change (head pressing, circling) – rabies
  • Altered mentation (stupor, withdrawn, aggression) – rabies
  • Acute neurologic disease (weakness, incoordination, paresis, paralysis) – equine herpesvirus (EHV-1)

Skin infections or injuries

The skin is the most readily observable part of the horse. For the horse, the skin serves as the interface with its external environment. Therefore, injuries or diseases of the skin are common and are most observed. As manual therapists, our access to the body is through the skin so any abnormalities that we observe need to be closely assessed to determine if they might be contraindications or not.

  • Wounds come in a wide variety of sizes, depths, locations, causes, and stages of healing or infection. All these factors help determine the contraindication. Open (torn skin), infected (yellow discharge), incision (colic surgery), lacerations (barbed wire), bites (horse, snake), scrape (slip and fall), puncture (fence posts), foreign bodies (wood).
  • Swelling – skin (vaccine reaction), joint (effusion), ligament (desmitis), muscle (strain), head (eyes, lips)
  • Bleeding or bruising
  • Abscess or draining tracts – coronary band (hoof abscess)
  • Dermatitis – bacterial, fungal (contagious, zoonosis)
  • Allergic reactions – urticaria (hives)

Emergency, medical or surgical issues (only a partial potential list)

  • Recumbent, rolling, or thrashing – colic
  • Fractures, trauma
  • Moderate to severe lameness
  • Weight loss, not eating
  • Severe, debilitating pain – acute laminitis, colic
Awareness of issues after we have touched the horse
  • Acute inflammation – swelling, heat, altered function, pain
    • Joint effusion
    • Tendons, synovial structures
    • Myofascial
  • Fever – elevated body temperature
    • Often confused with a palpable increase in local tissue temperature associated with inflammation
  • Foul odors – originating from the nose (sinuses, guttural pouch), mouth (teeth), feet
  • Pale mucous membranes, delayed capillary refill time (< 2 seconds)
  • Dehydration – delayed skin tent test (elasticity), tacky mucous membranes
  • Enlarged submandibular lymph nodes – strangles (Streptococcus equi)
  • Swelling in jugular groove – phlebitis
  • Muscle fasciculations – acute myopathies, West Nile virus

Relative contraindications

Relative contraindications are dependent on a series of factors related to the patient’s clinical condition, the practitioner’s decision making, and the owner’s consent. All the disease processes listed below require clear communication and a combined management plan with the treating veterinarian. The practitioner also needs to be aware, and inform the owner, that the prescribed manual therapy, when applied alone, may be less effective in the presence of acute pain processes and inflammatory mediators.

Local diseases or disorders

Skin infections or injuries are listed above as absolute contraindications; however, the horse does have a large body surface so it might seem reasonable to avoid the affected site but treat other sites of the body to provide overall relaxation, pain relief, and minimize compensatory issues. 

  • Acute, local inflammation – may treat regionally
  • Wound management – may treat regionally
  • Acute osteoarthritis – may require local anti-inflammatory medications
    • Chronic osteoarthritis is common in most horses in a variety of limb or axial skeleton locations. Affected horses will have periodic episodes of pain, stiffness, or joint effusion that may be relative contraindications for treatment.
  • Tendonitis or desmitis – may require local treatment and prolonged physical therapy

Behavioral or neurologic diseases

  • Neurologic disease of known etiology – only if mild clinical signs and horse is safe to handle
  • Cranial nerve deficits – head tilt, ptosis
  • Cervical vertebral compressive myelopathy and post-surgical cervical stabilization procedures. Absolute contraindication for spinal manipulation at the affected sites, likely a relative contraindication for low or non-force manual techniques
  • Dangerous or fearful horses – dependent on one’s horsemanship skills and available time

Myofascial disease

  • Myofascial pain and dysfunction – may treat depending on the modality and owner preference
  • Lymphedema, lymphangitis, cellulitis – requires aggressive medical management and physical therapy, mild cases of lymphedema may benefit from some forms of lymphatic drainage 

Post-surgical procedures

  • Dependent on the surgical procedure, location, stage of healing, communication with the managing veterinarian or surgeon – may treat regionally

Medical or metabolic disorders

  • Dependent on the type, severity, and management of the disease process

A few additional contradictions fall into the “carryover from humans” category:

Cancer

  • In humans, breast, lung and prostate cancers are the top three cancers. 
  • In dogs, lymphoma, osteosarcoma and mast cell tumors are the most common types – extreme caution needs to be taken with any notice of swollen lymph nodes, enlarged or painful bones, or skin masses.
  • In horses, cancer is a relatively uncommon disease. Skin cancers make up to 80% of cancers in horses. These include sarcoids, melanoma, and squamous cell carcinoma. Most cases are benign or readily treated; however, melanomas in gray horses can become quite large under the tail and often spread to other body regions.

Heart conditions

  • In humans, heart disease is the number one cause of death world-wide.
  • Heart disease is uncommon in horses and mostly causes mild exercise intolerance.

Pregnancy

  • It is interesting that pregnancy is often listed as a contraindication for manual therapy in both humans and animals. There are human manual therapy practices that exclusively focus on female patients and treat them through all stages of their reproductive cycles – prior to conception, throughout all trimesters of the pregnancy, and post-partum. In horses, anecdotal evidence and case reports suggest that manual therapies can help to improve conception in mares and breeding soundness in stallions and bulls.
  • Any therapy has the potential to create adverse effects; however, I am unaware of any scientific literature that reports the negative effects of manual therapies in pregnant animals. Obviously, clinical judgment, dosage, site of application, and type of applied treatment are all considerations, but any pregnant mother will tell you that carrying that extra weight in that last trimester is no easy task and places a tremendous strain on your body. It seems that perhaps some of these recommendations have come from a place of extra caution (or fear) on the part of the practitioner and have disregarded the needs of the patient.

Issues that may get confused with treatment contraindications

Treatment contraindications relate to whether to treat a disease condition or not. This requires an extensive diagnostic process, clinical decision-making skills, use of the scientific method, reliance on evidence-based medicine, and open lines of communication with the other members of the horse’s care team. Therefore, some of these other required clinical skills may get folded into and confused with what are considered actual treatment contraindications.

Here are a few examples:

  • Prior approval of care by the managing veterinarian
    • This is a communication and case management issue. A treatment plan needs to be developed and, depending on the situation, approved for this case.
  • Observe something that you chose not to treat or is outside of your scope of practice
    • This is a referral issue. Refer to a veterinarian or other paraprofessional (dentist, farrier, saddler) for their expertise and consultation, or evaluation and treatment.
  • Concurrent procedures – chiropractic care, dental work, hoof trimming
    • This is a scheduling issue. Sometimes you may want to be there at the same time as the farrier to have a conversation or to do a combined treatment with the chiropractor.
  • Concurrent treatments – joint injections, vaccines, shockwave
    • Again, a scheduling issue. Requires communication with owner and other members of the horse’s care team. Any adverse reactions need to be observed and reported to the managing veterinarian.
  • Concurrent medications – antibiotics, nonsteroidal anti-inflammatories (Bute, Equinox)
    • These are case management issues. An important component of any medical history is knowing what medication a horse is taking, and for what purpose, dosage, and duration. Communication with the treating veterinarian is critical but does not make this a treatment contraindication. Many horses with chronic pain are often given several types of medications and supplements, which need to be considered in the overall management plan.
  • Geriatric patients and foals
    • These are case management issues. We need to know the specific needs of the patient (indications), preexisting conditions (chronic disease), possible need for gentle restraint (foal and mare), and how much they may tolerate or not (dosage).
  • Legal constraints
    • These are scope of practice and licensure issues. For example, in the U.S., depending on the particular state practice act, many licensed or unlicensed practitioners are required to have direct veterinary supervision, or are allowed to work from verbal or written prescriptions from a veterinarian. In other regions, licensed practitioners with proper certification are allowed to serve as primary care providers. Unlicensed practitioners, as unregulated individuals, do not work under any requirements but may face certain liability vulnerabilities.
  • Anti-doping regulations
    • This is a sports-specific regulation issue. Depending on the athletic discipline and the overseeing regulatory body (FEI, Racing Commission, AQHA), there are rules that prevent the use of certain drugs and therapies that are considered performance enhancing. 
  • Treatment during active competition
    • This is an ethical issue. Some practitioners may apply therapies immediately prior to and during active competition with little to no assessment provided. While this may be a common practice for human sport professionals, there are known risks associated with masking pain and removing critical protective mechanisms in animal athletes. Obviously, there is a need for close monitoring and management of sports-related injuries in these highly competitive environments, but therapies need to be applied by qualified persons following event guidelines and treatment regulations.

In closing…

To identify treatment contraindications, practitioners need to readily identify clinical signs of serious injuries or disease processes and have a keen awareness of common infectious diseases. This is critically important for the safety of the horse, owner, handler, and practitioner. (Please see the references listed on this page.)

Other factors to consider may include scope of practice, available equipment, technical support, and clinical experience, which may warrant the need for a veterinary referral. No matter what, it is always best to have an active support network with open lines of communication.

Were you taught all the above contraindications during your training? Do you fully assess the horse to decide whether or not to apply your manual therapy treatment? If you decide not to pursue, what are your next steps? 

Please join the conversation on our Facebook page Veterinary Compendium. And join me and my guest Lola Michelin at our January 31st Community Gathering to share your experiences regarding this important topic. 

Resources

American Association of Equine Practitioners, Infectious Disease Guidelines 

Equine Disease Communication Center

Center for Food Security & Public Health 

USDA, Animal and Plant Health Inspection Service

National Center for Emerging and Zoonotic Infectious Diseases 

Centers for Disease Control and Prevention (CDC)

Interested in learning more?