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The Latest in Objective Lameness Evaluation

Why Doctors Reject Tools That Make Their Jobs Easier

From the thermometer’s invention onward, physicians have feared—incorrectly—that new technology would make their jobs obsolete.

BY GINA SIDDIQUI ON OCT 15, 2018

I want to tell you about a brouhaha in my field over a “new” medical discipline three hundred years ago. Half my fellow doctors thought it weighed them down and wanted nothing to do with it. The other half celebrated it as a means for medicine to finally become modern, objective and scientific. The discipline was thermometry, and its controversial tool a glass tube used to measure body temperature called a thermometer.

This all began in 1717, when Daniel Fahrenheit moved to Amsterdam and offered his newest temperature sensor to the Dutch physician Herman Boerhaave.* Boerhaave tried it out and liked it. He proposed using measurements with this device to guide diagnosis and therapy.

Boerhaave’s innovation was not embraced. Doctors were all for detecting fevers to guide diagnosis and treatment, but their determination of whether fever was present was qualitative. “There is, for example, that acrid, irritating quality of feverish heat,” the French physician Jean Charles Grimaud said as he scorned the thermometer’s reducing his observations down to numbers. “These [numerical] differences are the least important in practice.”

Grimaud captured the prevailing view of the time when he argued that the physician’s touch captured information richer than any tool, and for over a hundred years doctors were loath to use the glass tube. Researchers among them, however, persevered. They wanted to discover reproducible laws in medicine, and the verbal descriptions from doctors were not getting them there. Words were idiosyncratic; they varied from doctor to doctor and even for the same doctor from day to day. Numbers never wavered.

In 1851 at the Leipzig university hospital in Germany, Carl Reinhold Wunderlich started recording temperatures of his patients. 100,000 cases and several million readings later, he published the landmark work “On the Temperature in Diseases: a manual of medical thermometry.” His text established an average body temperature of 37 degrees, the variation from this mean which could be considered normal, and the cutoff of 38 degrees as a bona fide fever.

Using a thermometer had previously suggested incompetence in a doctor. By 1886, not using one did. “The information obtained by merely placing the hand on the body of the patient is inaccurate and unreliable,” remarked the American physician Austin Flint. “If it be desirable to count the pulse and not trust to the judgment to estimate the number of beats per minute, it is far more desirable to ascertain the animal heat by means of a heat measurer.”

Evidence that temperature signaled disease made patient expectations change too. After listening to the doctor’s exam and evaluations, a patient in England asked, “Doctor, you didn’t try the little glass thing that goes in the mouth? Mrs Mc__ told me that you would put a little glass thing in her mouth and that would tell just where the disease was…”

Thermometry was part of a seismic shift in the nineteenth century, along with blood tests, microscopy, and eventually the x-ray, to what we now know as modern medicine. From impressionistic illnesses that went unnamed and thus had no systematized treatment or cure, modern medicine identified culprit bacteria, trialed antibiotics and other drugs, and targeted diseased organs or even specific parts of organs.

Imagine being a doctor at this watershed moment, trained in an old model and staring a new one in the face. Your patients ask for blood tests and measurements, not for you to feel their skin. Would you use all the new technology even if you didn’t understand it? Would you continue feeling skin, or let the old ways fall to the wayside? And would it trouble you, as the blood tests were drawn and temperatures taken by the nurse, that these tools didn’t need you to report their results. That if those results dictated future tests and prescriptions, doctors may as well be replaced completely?

The original thermometers were a foot long, available only in academic hospitals, and took twenty minutes to get a reading. How wonderful that now they are cheap and ubiquitous, and that pretty much anyone can use one. It’s hard to imagine a medical technology whose diffusion has been more successful. Even so, the thermometer’s takeover has hardly done away with our use for doctors. If we have a fever, we want a doctor to tell us what to do about it, and if we don’t have a fever but feel lousy, we want a doctor anyway, to figure out what’s wrong.

Still, the same debate about technology replacing doctors’ rages on. Today patients want not just the doctor’s opinion, but everything from their microbiome array and MRI to tests for their testosterone and B12 levels. Some doctors celebrate this millimeter and microliter resolution inside patients’ bodies. They proudly brandish their arsenal of tests and say technology has made medicine the best it’s ever been.

The other camp thinks Grimaud was on to something. They resent all these tests because they miss things that listening to and touching the patient would catch. They insist there is more to health and disease than what quantitative testing shows and try to limit the tests that are ordered. But even if a practiced touch detects things tools miss, it is hard to deny that tools also detect things we would miss that we don’t want to.

Modern CT scans, for example, perform better than even the best surgeons’ palpation of a painful abdomen in detecting appendicitis. As CT scans become cheaper, faster, and dose less radiation, they will become even more accurate. The same will happen with genome sequences and other up-and-coming tests that detect what overwhelms our human senses. There is no hope trying to rein in their ascent, nor is it right to. Medicine is better off with them around.

We are told the machines’ autopilot outperforms us so we sit quietly and get weaker, yawning and complacent like a mangy tiger in captivity. We wish we could do as Grimaud said: “distinguishing in feverish heat qualities that may be perceived only by a highly practiced touch, and which elude whatever means physics may offer.”

A children’s hospital in Philadelphia tried just that. Children often have fevers, as anyone who has had children around them well knows. Usually, they have a simple cold and there’s not much to fuss about. But about once in a thousand cases, feverish kids have deadly infections and need antibiotics, ICU care, all that modern medicine can muster.

An experienced doctor’s judgment picks the one in a thousand very sick child about three quarters of the time. To try to capture the remainder of these children being missed, hospitals started using quantitative algorithms from their electronic health records to choose which fevers were dangerous based on hard facts alone. And indeed, the computers did better catching the serious infections nine times out of ten, albeit also with ten times the false alarms.

The Philadelphia hospital accepted the computer-based list of worrisome fevers, but then deployed their best doctors and nurses to apply Grimaud’s “highly practiced touch” and look over the children before declaring the infection was deadly and bringing them into the hospital for intravenous medications. Their teams were able to weed out the algorithm’s false alarms with high accuracy, and in addition find cases the computer missed, bringing their detection rate of deadly infections from 86.2 percent by the algorithm alone, to 99.4 percent by the algorithm in combination with human perception.

Too many doctors have resigned that they have nothing to add in a world of advanced technology. They thoughtlessly order tests and thoughtlessly obey the results. When, inevitably, the tests give unsatisfying answers they shrug their shoulders. I wish more of them knew about the Philadelphia pediatricians, whose close human attention caught mistakes a purely numerical rules-driven system would miss.

It’s true that a doctor’s eyes and hands are slower, less precise, and more biased than modern machines and algorithms. But these technologies can count only what they have been programmed to count: human perception is not so constrained.

Our distractible, rebellious, infinitely curious eyes and hands decide moment-by-moment what deserves attention. While this leeway can lead us astray, with the best of training and judgment, it can also lead us to the as of yet undiscovered phenomena that no existing technology knows to look for. My profession and other increasingly automated fields would do better to focus on finding new answers than on fettering old algorithms.

***

ABOUT THE AUTHOR

Gina Siddiqui is an emergency room physician at Elmhurst Hospital in Queens, NY and a health systems delivery entrepreneur. She lives with her husband and son in Philadelphia, PA.

PUBLICATION RIGHTS

Why Doctors Reject Tools That Make Their Jobs Easier

Author: Gina Siddiqui

Publication: Scientific American

Publisher: SCIENTIFIC AMERICAN, a Division of Springer Nature America, Inc.

Date: Oct 15, 2018

Copyright © 2018, Scientific American, Inc.

Sensing Serious Injury: What Can Motion Detection Devices Tell Us About Horse Health?

Researchers update progress and new findings at the 5th Annual Tex Cauthen Memorial Seminar.

By Sara E. Coleman

Increased attention has been given to racehorse welfare in recent years, with key players working diligently to determine the best ways to keep these athletes safe and sound. Held virtually, the fifth annual Tex Cauthen Memorial Seminar brought farriers, veterinarians and researchers together to discuss racetrack safety and the use of motion-sensor technologies to monitor racehorse health, among a variety of other equine issues.

It has become increasingly evident that serious injuries and catastrophic breakdowns of racehorses do not appear from nowhere; it is now thought that these injuries are the result of minor physical issues that go unnoticed. It’s important to note that as horses are prey animals, any lameness or injury puts their survival at risk. Because of this, most horses will hide lameness and injury, potentially compensating on other limbs. 

Gathering Data

Until recently, the gold standard for equine lameness evaluations on racetracks was the completion of a subjective exam. Though many vets can notice overt lameness, small changes in equine gait may be imperceptible to the human eye. The morning session of the Tex Cauthen seminar focused on how data from advanced diagnostics like the Lameness Locator can provide data to help recognize lameness in racehorses and prevent more-serious injuries.

Dr. Abigail Haffner presented an overview of a pilot study that used body-mounted inertial sensors to monitor 73 racing and training Thoroughbreds at Thistledown Racino near Cleveland, Ohio, and Mahoning Valley Race Course in Youngstown, Ohio. The 16-week study sought to identify trends in Lameness Locator measurements over time that may indicate a horse was at risk of injury. The study was initiated by Drs. Clara Fenger and Brad Brown, and funded by the Equine Health and Welfare Association, and the Indiana and Ohio Horsemen’s Benevolent and Protective Associations. Haffner collected data alongside Dr. Margaret Smyth of Shell Equine, based in Chagrin Falls, Ohio. 

One aim of the study was to determine if horses display a gait signature–a pattern of asymmetry that is consistent overtime–and if deviations from this gait signature may be an early indication of musculoskeletal pathology. Information garnered from the study will help the research team see how stable the gait signature is from week to week, as well as determine the optimal frequency of inertial sensor exams to identify changes. 

For the study, researchers placed Lameness Locator sensors on the horse’s right front pastern, pelvis and head, and trotted the horse in-hand on a straight line for approximately 25 strides. Two trials were obtained for each exam to confirm consistency of the results. The horses were subjectively evaluated by Drs. Haffner and Smyth at the same time. Dr. Haffner estimated each evaluation from sensor application to data collection to returning to stall was approximately 3 to 4 minutes. 

Most horses were given Lameness Locator exams weekly or every other week; 59 horses were evaluated at least five times and 41 horses were evaluated at least 10 times. Though evaluation of the information gleaned is ongoing, many horses involved in the study were found to be lame, but no breakdowns occurred.

Interpreting the Information 

Dr. Kevin Keegan was the next panelist to present during the morning session and he deciphered some of the initial information gathered from the study for attendees. Keegan acknowledged that racehorse injuries are a complex, multifaceted problem. “We don’t really know if lameness is a substitute measure or proxy for a pre-existing injury or if lameness is itself a mediator or direct cause of injury,” he said. If lameness is associated with catastrophic injury, the body-mounted inertial sensors of the Lameness Locator can detect it—possibly preventing future injuries. 

Keegan notes that lameness is a clinical sign and not a disease. Keegan stressed that the sensors provide data, but no context with which to interpret the data—that onus is on the veterinarian. The data reported by the Lameness Locator is shown in both numerical and graph forms for veterinarians to interpret. Keegan emphasizes the importance of collecting multiple strides in a row, as was done in the study. By collecting many contiguous strides, the veterinarian can look for a central tendency. 

Establishing Thresholds for Change in Thoroughbreds 

Dr. Keegan compared some early analysis of the Ohio study data to a previous study using inertial sensors conducted in Thoroughbred racehorses in training.* “Our 90 percent weekly median absolute differences were actually tighter than [the other study], 13.2 mm for Diff Min head and 12.4 mm for Diff Max head which is an equivalent Vector Sum of 17.3 mm; and 5.3mm for Diff Min pelvis and 7.5 mm for Diff Max pelvis. This means that 90 percent of the weekly differences were below this value,” he noted (fig. 1). He further explained, “Despite the fact that the range in this study included horses that we know did become lame, this might be a place to start if we were looking at trying to find some reasonable range as a threshold for change that requires that a horse be more closely scrutinized.”

Dr. Keegan shared some of the longitudinal data collected to date, plotting each horse’s weekly measurements for forelimb lameness (using head Vector Sum), hindlimb impact and pushoff lameness (using Diff Min Pelvis and Diff Max Pelvis respectively). “Looking at the data like this, you can quickly pick out the horses and times when a horse measured with lameness way outside the pack,” Dr. Keegan says. He shared a few examples of horses with gradually increasing lameness or a sudden change from their usual measurements.

[It is] interesting to look at the progression, or lack of progression, of lameness over time in individual horses. Some patterns of lameness measurement over time may be hints that a horse should be more closely scrutinized for potential pre-existing injury,” Dr. Keegan said. One particularly intriguing example was a horse that sometimes measured with a mild left hindlimb pushoff lameness and sometimes measured with a mild right hindlimb pushoff lameness (fig. 2). Dr. Keegan opined, “This horse might have a bilateral hindlimb lameness that may be confusing to detect subjectively over time.” He added, “It was pointed out retrospectively that a similar pattern of shifting mild hindlimb lameness was reported for Mongolian Groom.”

While it is currently unknown why certain horses exited the Ohio study, Dr. Keegan did point out one horse that suddenly measured with a left hind limb lameness and then dropped out of the study. Reviewing race records, the horse raced the day prior and its Equibase speed factor had dropped 36 points. “We are still trying to accumulate historical information about potential injuries that may have caused [a] horse to stop racing or training, how well the horse is currently racing, etc., to see if we can identify any signature lameness measurement patterns to scrutinize.” 

Considerations for Implementation at Racetracks

Dr. Keegan closed with some additional insight on using lameness measurement to monitor racing and training Thoroughbreds. 

Race day may not be the most ideal time for a Lameness Locator exam, Keegan says. Anxiety can mask lameness as the horse becomes more difficult to handle.

“The best time to evaluate a racehorse is a day after or a few days after a race,” Keegan says.

“…this allows for the creation of objective data.”

He also suggested that it may be more relevant and easier to evaluate horses under saddle, jogging on the track. He cited the weight of the jockey to bring out lameness, the ability to better control the horse, and the ease of obtaining many strides are all advantages of evaluating the horse under saddle. He noted, “Now we can determine the side of lameness [in straight line trials] using pelvic rotation.” This would eliminate the need for a right front sensor, further simplifying lameness measurement at the track.

Keegan concluded that using body-mounted inertial sensors to measure lameness is not difficult, reduces doubt and difference of opinion, and that objective data from large numbers of horses can be collected, saved and studied. “The question on [whether] measuring lameness can help minimize the incidence of catastrophic racing injury is not answered, because I do not think we really know what the association between lameness and injury is.  But if they are associated, I am convinced that measuring and studying lameness with body-mounted inertial sensors is the way to go.”

Use of Lameness Locator Abroad

The next presenter at the virtual seminar was Dr. Bronte Forbes, a veterinarian with the Singapore Turf Club. Forbes spoke on his experience with the use of the Lameness Locator on Thoroughbred racehorses and its value in screening racehorses for soundness.

“I look at this as a ladder,” Forbes explains. “I want to get this technology on board so we can contribute to the overall situation [of increasing the possibility of racing sound Thoroughbreds]. The use of this technology could alert owners and trainers that something has changed or gone wrong [with the horse’s soundness] before a more-serious injury occurs.”

Forbes agrees with Keegan that a consensus must be reached on how lame is too lame to race. He questions if each racing jurisdiction will need its own local threshold of lameness or if racing as a whole should look at a more-global threshold that should be classified as “lame.”

“We must work together and share knowledge,” Forbes stresses. “I appreciate what regulatory vets do and see, but by adding this tool, the horse will benefit. If we put the horse first, a lot of problems will go away.” Buy-in from trainers, owners, clinicians and regulators is essential if the Lameness Locator is to be used as a regulatory tool.

Trainers in Singapore trust the technology of the body-mounted sensors, Forbes explained, and some trainers will ask specifically for the modality to be used. “This technology is often used for nerve blocking and in difficult lameness,” he reported. However, he noted, the vets in Singapore did receive push back if the horses were required to have a Lameness Locator exam done every day.

Forbes recommended that veterinarians and those involved in racehorse care continue to develop quality, evidence-based assessments of equine gait symmetry and what this means in relation to lameness. He also suggested that work be ongoing to help vets understand what information the Lameness Locator collects and how it can be extrapolated. 

He concluded that the education of vets, trainers, owners and racing management benefits the industry by increasing objectivity. “Removing bias from decision making [as to if a horse is lame] is important for improving the integrity of the process,” Forbes said.

***

Acceptance & Resistance of Lameness Measurement – Seasoned Lameness Experts Sound Off

By Nancy S. Loving, DVM

Wellness exams and lameness evaluations often pose challenges for equine practitioners to pin down the root of a horse’s problem. Get it right and the client is forever indebted and is quick to voice confidence in your skills. Get it wrong, and they may abandon your practice and look elsewhere for veterinary expertise.

Yet, in today’s diagnostic armamentarium, there is a powerful tool that has the potential to increase not just client confidence in your expertise but also your own confidence in developing a diagnosis. Inertial sensor systems provide an objective analysis of a horse’s gait. Despite access to this helpful tool, there may be pushback amongst horse owners and veterinary colleagues about its use. We thought it could be helpful to investigate the degree of resistance, how equine practitioners deal with reluctance (or not) to accept this technology, and how they find it benefits their practices.

Daily Use and the Learning Curve

Mark Baus, DVM of Grand Prix Equine in Connecticut focuses most of his practice on hunter/jumpers while performing solely lameness work. He uses the Equinosis Q on every single lameness exam, which means it’s in use constantly, and has for over 10,000 lameness trials through his career. He notes that it improves his work, and he stresses that he never pursues diagnostic blocks or prepurchase exams without using it.

Baus comments that he doesn’t make a big issue to his clients for using it. While he is taking the horse’s history, his assistant puts the system on the horse so seamlessly that clients don’t even notice, especially since it is very unobtrusive. He always discusses with the client what he sees subjectively before he reviews and discusses the findings from the Q.

Roland Thaler, VMD, DACVSMR of Metamora Equine PC practices in Metamora, Michigan and is enthusiastic about use of the Q. He says the device is exceptionally useful especially since many times the problem is in more than one limb and/or is multifactorial with a combination effect of limb asymmetries. It helps differentiate lameness into components to validate (or not) what he “sees.” Like Baus, as Thaler collects history from a client, he places the sensors on the horses. He feels the Q keeps him “honest” by providing objective information with accountability. He feels it saves time and improves his productivity, so he also won’t practice without it.

Some practitioners own the Equinosis Q and only bring it out for difficult cases. Thaler points out that a practitioner may not know they are dealing with a difficult case until they are well into the lameness exam and proceeding with diagnostic joint or nerve blocks. With that in mind, he advises to start the exam with the sensors in place to gather baseline information.

Scott Hay, DVM, a racetrack practitioner with Teigland Franklin & Brokken in Fort Lauderdale, Florida doesn’t try to talk a client into using it. He just puts the sensors on the horse without conversation. Clients’ acceptance level is good, he notes, especially once they see the information generated from the Q report.

Steve Adair, DVM, DACVS, DACVSMR has been using the Q for 10-12 years since its inception. His practice at the University of Tennessee College of Veterinary Medicine focuses not just on clinical patients but also monitoring rehabilitation progress. He sees 15-20 lameness cases a week with over 36 years of equine practice experience. Most cases he sees are referrals from other practitioners. He finds the Q is especially good for multiple limb lameness in conjunction with using his clinical judgment as to which limb asymmetry is the most significant. “It is simply another tool in one’s medicine bag,” says Adair. He not only has had no pushback from clients, but he says they accept and welcome its use in lameness cases. He uses it on most everything except for cases that are so lame that they cannot trot.

Hays’ comment about pushback is particularly interesting: “I find that the biggest pushback is from myself, or similarly from other practitioners’ reluctance to change their ways after decades in practice. People get set in their ways.” This applies to procedural changes that possibly take more time to implement, and he also notes that the daily pace in his racetrack practice is somewhat frantic with many things going on at one time and the need to multitask. It is sometimes necessary to adjust the daily schedule to take more time for a single case. “As creatures of habit, it is sometimes challenging to alter one’s comfort zone,” he muses. “This is true not just for veterinarians but also for trainers and horse owners.”

From a slightly different approach, Adair observes, “I get the most pushback from the lameness itself because most of our workups at the University are complex lameness events that take 2-4 hours to pursue with exam and diagnostics. This is especially true for hindlimb lameness and/or cases needing diagnostic blocks. The biggest complaint I hear is from clients about the duration of the full exam, which is not directly to do with the use of inertial sensors.”

Skill Refinement and Improved Work Productivity

Thaler advises that use of the Q can help to refine skills. He says, “The truth is the truth when achieved objectively.” Lameness is a complex issue with gait asymmetry often involving multiple components and with compensatory issues. While a horse owner may not always recognize multiple component contributions to a horse’s lameness, they do recognize that their horse is not performing well or up to expectations. Time, money and emotion are essential resources at risk, he says, with money seldom being the decider for an owner to proceed; usually it is the client’s time or emotion that decides. “The inertial sensor device helps reduce emotions and allows more productive discernment of the problem,” remarks Thaler.

“For a treating veterinarian, the Q is emotionally stabilizing as it validates the degree and location of an issue and obviates that gnaw of concern that you are missing something during the exam,” says Thaler. “The best part is the gratification that comes through productive time expenditure and helping to minimize time wastage while working.” Thaler advises that the Q holds a practitioner’s feet to the fire even if the “answer” is different from expectation. He points out that the human mind often sees what it wants to see, and this isn’t always correct, especially if performing a complex lameness workup late on Friday afternoon or Saturday when work fatigue sets in, and the vet is anxious to call it a day.

Baus says it is not unusual for him to disagree with the sensors, especially with hindleg lameness. Not only are there possible compensatory gait asymmetries, but he also notes that in many cases, horses experience lameness in more than one leg. “Lameness in one leg often affects another leg, as for example, a LF limb lameness may bring out other aspects of asymmetry in the RH, and conversely, a hind limb lameness will create the appearance of lameness in the front limb on the same side.” Baus also points out that if a horse appears lame on the outside of the circle, especially with a late push-off lameness, then the horse may be lame on the other front leg instead. The Q helps to define such confusing parameters.

The Q is able to pick up on subtle lameness issues that may not be detectable with the naked eye. Baus remarks, “The Q helps sort through subtle and/or compensatory issues.” He advises that the threshold for lameness in a front limb is about 8-1/2 mm, but lameness is only visible to his eye when it is 12-13 mm or more.

While there is a learning curve to use the Q, Hay says it is worth the undertaking. He observes that a common question asked is “Why do I need a computer to tell me what I already know?” Hay explains the advantages of the Q: a) it has increased sensitivity for picking up asymmetry, especially for subtle and/or multiple limb lameness; b) it increases the objectivity of working up a case; and c) it significantly helps to evaluate the response to diagnostic blocks. All these features help increase a practitioner’s level of confidence.

Adair mentions a common misconception of skeptical colleagues is the perception that it adds time to the exam. “Those not used to incorporate it into lameness exams feel it takes time.” In contrast, he believes it saves time because one doesn’t need to pursue a lot of lunging or flexion testing because the Q is able to identify quickly which limb or limbs are asymmetric. For his students, he still pursues lunging and flexion testing for their learning experience. Adair remarks that some practitioners aren’t comfortable using technology and prefer to use their subjective eyes on the horse. However, he emphasizes that the Q does not substitute for a practitioner’s clinical judgment of an exam.

Use for Further Diagnostics, Treatment Response, or Prepurchase Exams

The Q not only helps measure the degree of lameness, but it also creates a baseline for evaluating diagnostic blocks or response to treatment. The increase in confidence observed by Hay helps verify what a practitioner thinks he or she sees and directs one to pursue joint or nerve blocks in a specific area. The Q helps verify changes from blocks, especially for lameness that is a subtle Grade 1 out of 5.

Thaler stresses that the inertial sensor information enables him to continue anesthetic blocks in an effective, progressive, and productive manner with information coming immediately without the need to repeatedly re-evaluate partial improvements during the diagnostic blocking process. 

The trial reports help assess progression of a lameness, either getting better or not, advises Baus. He also uses the Q prior to joint injections, particularly when dealing with cases he’s seeing for the first time to help corroborate a correct approach. Following a joint injection, he can do a reevaluation to check efficacy and to establish changes from baseline.

Another benefit Baus has found, especially when looking at a front leg impact lameness, is that if the red line (Vector Sum of minimum and maximum head position) approaches the “equator,” i.e. where it is difficult to differentiate between right and left forelimb lameness and the horse has been  blocked up to suspensory ligament without improvement, then he looks to a neck problem – the gait asymmetry or “lameness” may result from compensation in movement due to spinal pain. “Currently, it seems that necks are commonly diagnosed and treated, maybe more than necessary, yet the Q substantiates following that line of diagnosis,” says Baus. Thaler concurs, “The Q helps isolate distal limb issues so focus can be placed on the axial spine (neck/back/sacrum) when appropriate.”

Thaler feels that objective documentation may provide legal protection especially for prepurchase exams because it removes subjective assessment while documenting the gait at the time of the exam. It also provides a baseline for comparison at later assessments. For prepurchase exams, he says it mitigates personality conflicts, especially between seller and buyer regarding the presence of gait asymmetries.

In contrast, Adair doesn’t use the Q for prepurchase exams since it measures asymmetry, not pain. He notes that it is sometimes difficult to tell if an asymmetry is due to a mechanical, pain, or neurologic problem or from a rider-elicited issue. He has concerns that if the Q picks up a mild asymmetry, then the buyer and owner may have increased concerns about a potentially subclinical gait abnormality that may have little significance for a horse being able to perform its job.

Another excellent application of the Q inertial sensor system noted by Baus is for wellness workups and prior to a competitive season to help devise a plan for owners and trainers to implement for pleasure and performance equestrian pursuits.

Thaler also uses the Q to provide a metric for rehabilitation to help develop a structural program. A horse’s performance can be monitored through repeated measurements to enable proactive protocols to be implemented.

Similarly, another of Adair’s primary objectives is to use the Q as a therapeutic monitoring device to compare results of intervention. He calls it a great “memory tool,” which is especially useful for weekly evaluations following an initial baseline report. The reports indicate whether the physical and therapeutic regimens are helping or if it is necessary to back off on the work intensity through the rehabilitation process.

Using the Q Reports as a Communications Tool

Adair emphasizes that clients love the graphic representation from the report generated by the Q software. This is especially helpful because with COVID-19, clients aren’t allowed into the vet school building to witness the lameness proceedings so he can bring out the report on the tablet and demonstrate to the client the results of the exam and diagnostic blocks.

As for the students, Adair notes that they don’t see the Q report until after they make a subjective assessment. The same process is used for diagnostic blocks. “It is great that this technology can give students first hand feedback right then and there,” he says.

“The Q report has a ton of information that is easy for clients to understand,” says Baus. The system can store the report into folders on the machine and then Baus puts it into a Dropbox to send to the client. He also feels that having a prepurchase exam report on file can provide protection for veterinarians. He doesn’t use euphemisms like “stiff” or “short” in his discussions with clients. A horse is lame or not lame, and while some sell a perfectly sound horse for perfectly good reasons, for prepurchase exams, it helps to sort through gait abnormalities that could impact a horse’s work.

Pushback from Clients, Trainers, and Veterinary Colleagues

Thaler says he gets zero pushback from clients, and in fact, horse owners in the barn get interested by the sensors and are curious how it works. The occasional pushback comes from sellers when he uses it for prepurchase exams.

The only pushback Baus has experienced is from a couple of trainers when he used the device before he was familiar with the system and he was not able to explain the discrepancies. This caused a loss of confidence by the trainers and they carry that concern forward into the present, even years later. He says that trainers, in general, are often shaken when the “human element” is perceived to be removed in the evaluation of lameness cases.

Some veterinary colleagues are resistant to using it, possibly because of concerns regarding its cost, and also an impression that it takes time to use. Thaler comments that there may also be reticence to use it because of a feeling of inferiority for having to lean on a device to help with decisions. Some colleagues have also remarked that “this is a cheater’s way to identify lameness.” Thaler notes that colleagues often think they don’t need to use inertial sensors and are way overconfident in their own abilities – this is especially true of young veterinarians.

In spite of time constraint concerns by practitioners, Hay feels the increased sensitivity of the technology is particularly helpful to racehorse injuries. However, rather than trainers being amenable to using it for comparisons of a number of works to a baseline evaluation, they seem to prefer to just see how a horse goes rather than “looking for something.” Some trainers may not be clear how to interpret the information, but it is helpful to use a technology that is sensitive to picking up subtle gait changes. Part of his job is to help educate racehorse trainers in the value gained from use of the Q. Hays says that the Q is more objective and can answer a lot of questions. One example he cites is cannon bone bruising, which is difficult to diagnose without advanced diagnostic imaging, yet the Q can pick up gait asymmetry related to this kind of problem and help point in the direction for appropriate diagnostics. Another help is with a multiple — quadrilateral or bilateral – limb lameness.

Cautionary Notes

The clinicians note some cautions when using inertial sensors as the standard of care.

While the Q produces repeatable results, Thaler advises “not to let it think for you.” It is best used to validate observations. He recommends paying attention to the horse and its history and also to watch how an owner handles the horse on lunge and trot-out as that could confound the results – for example, if the horse is jumping around, doesn’t keep a consistent trot, or throws its head. Thaler comments, “Some horses don’t move consistently enough for the Q to be effective. In some cases, it’s necessary to put a rider up to add that dynamic to evaluation of the symmetry of gait. In some cases, asymmetry only shows up under saddle.” He finds it useful to do flexions with a rider mounted.

While Equinosis inertial sensors are water resistant, they are not waterproof. They cannot be submerged in an underwater treadmill or if the pastern sensor stands in a deep puddle.

It is important to keep the equipment charged, and this can be challenging when considering all other veterinary practice equipment that has a similar need.

While it has a substantial price, Thaler feels that the increased productivity of his practice adds value to appointment times and is especially important for comparisons of a horse to itself over time.  But there is also the philosophical conundrum – not everyone wants to integrate and interface with technology in their practice.

In a perfect world, Thaler says you’d have perfectly even terrain for lameness evaluations but in his Michigan practice, this is rarely the case – he seldom has a hard or firm surface on which to work a horse. In many cases, the horses work in arena conditions with somewhat soft footing. Still, he feels the Q produces great information.

“The Q provides the best efficacy when used consistently so a practitioner develops an understanding of the nuances of the report,” says Adair. As some examples of things to remember in its use: a) an ipsilateral fore and hind limb lameness generally indicate that the primary lameness is in the rear limb; b) it is important to remember to have the horse trot at least 25 strides; and c) following a flexion test, the horse should trot at least 10 strides.

“One issue with the system,” remarks Baus, “is that each trial has a standard deviation that defines the validity of the report. At the bottom of the report it states mild versus moderate versus strong evidence. [Editor’s note: This is a qualitative interpretation of the statistical significance of the trial given the standard deviation of the data.]  There then needs to be an explanation or substantiation to make it a good legal document. If there is a question on results, it is best to redo the trial.” [Editor’s note:  One trial represents a 95% confidence interval. Two successive trials with similar results increase the confidence to 99%.]

Fee Strategies for Lameness Measurement Services

To his clients, Baus describes the Q as a “measurement tool” that uses sensors to help measure lameness and location. The invoice states: “lameness detection with inertial sensors.” This is bundled all in one as a lameness exam, so clients don’t have any pushback with fees charged for this. He claims it generates enough revenue to pay for itself each year.

Thaler also does not charge a separate fee or line item for using the Q for gait evaluation. Then, there is no opportunity for clients to push back on its use based on cost.

On the University of Tennessee invoices, Q is built in as part of a lameness exam. There are three tiers of lameness exam based on the amount of time spent and the diagnostics pursued. The Q is used in most every case.

Take Home Message

For practitioners who see lameness conundrums on a regular basis, these four equine practitioners are highly enthusiastic about incorporating the Q routinely into lameness and soundness exams.

While there is a learning curve and a price tag to invest in the equipment, they all concur that is well worth it, as it improves not only productivity in a practice but also helps to more accurately pinpoint the areas of concern.

This is beneficial to the horse and the owner/trainer, as well as being gratifying to the practitioner to be able to resolve a horse’s issues of pain or discomfort. They all remark that clients greatly welcome the use of this technology for tracking down a horse’s soundness issue.

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