Restoring the balance – minimising the negative and providing
opportunities for positive experiences.
The aim should be for the horse to return to full physical health whilst
minimising the detrimental impact on their mental health and, just as
importantly, keeping horse and owner safe during both confinement and
restricted exercise. Possible considerations to achieve this include:
- Companionship. In this scenario the authors ensured another horse was
always visible and this is certainly better than being completely
socially isolated. Nevertheless, physical contact is important to
horses and stress can be offset by social buffering (Visser et al.,
2008). The concept of a social box with full length vertical bars,
allowing a horse to pass its head and neck through to the neighboring
stable, has been shown to improve welfare when compared to visual and
olfactory contact only (Gmel et al., 2022). Even in horses that spend
23 hours a day in a herd, when stabled for just one hour those with a
half wall between stables used the opportunity to engage in physical
contact, spent more time resting and less time stood vigilant compared
to those with a full dividing wall (Borthwick et al., 2023). Altering
the structure of stables is clearly unfeasible for most. A simpler
solution may be tying the horse up to allow grooming over a stable
door with a preferred companion, if it is safe to do so (see Figure
1). This could be undertaken whilst mucking out twice a day to improve
equine well-being whilst easily fitting into the owner’s routine. If
physical contact with another horse is not possible then encouraging
the owner to spend time scratching their favorite areas (those where
the horse twitches their upper lip or leans into the pressure) will
still lower heart rate and promote relaxation (Feh and de Mazières,
1993). Additionally, horses will often stand resting next to a large
stable mirror. If physical contact is limited this can be very
effective way to promote resting behaviour and reduce stress (McAfee
et al., 2002), especially if the horse would otherwise lose sight of
other horses when it chooses to lay down. In our hospital horses
maintained initially in a sling to manage a fracture are unable to see
conspecifics, here the use of a manikin horse outside the stable door
is highly beneficial.
- Training. Learning new tasks and performing trained ones results in
dopamine spikes (McBride et al., 2017) and so provides valuable mental
stimulation. The authors already suggested physiotherapy exercise as a
resource for maintaining physical strength and suppleness. Clayton
(2016) provides examples of how to undertake these exercises and has
shown their beneficial effects in horses returning to work after a
period of box rest (Holcombe et al., 2019). Whilst commonly performed
as carrot stretches, these exercises can also be trained using a
target with clicker training. Altering the novelty and complexity of
the tasks will keep the horses brain engaged, so mix up exercises that
will help physical fitness with others the horse and owner find fun.
- Further environmental enrichment. The authors correctly suggest common
ideas for additional environmental enrichment such as a treat ball or
hung vegetables. Enrichment is commonly considered the provision of
choice and is designed to stimulate the senses (Hoy et al., 2010),
therefore it should be noted that adding an object or food source only
acts as a source of environmental enrichment if the horse chooses to
engage with it (Bacon, 2018). Providing choice in sources of available
fibre (haylage, grass blocks and chaff for example) as well as
considering novel textures (lettuce vs swede vs chopped vegetables
frozen in a fruit juice ice block) and tastes helps maximise the
senses. Ideally, different ideas should be rotated to maintain
novelty. As well as food some people suggest the use of different
scents for the horse to investigate, safe branches to chew and a broom
head screwed into the wall can provide an inviting scratching post.
The Blue Cross (Court, 2024) and BHS (Harrison, 2024) provide
excellent online resources for owners to consider.
- Psychopharmaceuticals. These medications can positively impact the
horse’s mood and help them cope with the stress associated with
confinement. It should first be remembered that Acepromazine has no
anxiolytic properties, and in companion animal medicine is
contraindicated where anxiety is a component (Pereira et al.). As a
dopamine agonist Acepromazine will reduce the amount of movement you
may observe in the horse, externally making them appear calmer, but
without actually changing how they feel, i.e. not improving their
welfare. Having said that, Acepromazine can be successfully combined
with a drug that does act to reduce anxiety as anecdotally the effects
appears to be synergistic. Fluoxetine, a selective serotonin reuptake
inhibitor, has been used successfully to help horses cope with box
rest (Fontenot et al., 2021). Fluoxetine is not one that we tend to
use as it can take several weeks to see the beneficial effects, and it
is often the initial period of confinement that can be problematic.
Nonetheless, as this case was on box rest for nine months Fluoxetine
may have been indicated. More commonly we would use Trazodone, which
has also been documented as useful under these circumstances (Davis et
al., 2018). Under more extreme circumstances or for cases that are
really struggling, for example we had a horse with a non-displaced
radial fracture in the sling that became increasingly aggressive to
handle, we will also use Alprazolam. Normally, we would start with
Trazodone, adding Acepromazine if needed and then Alprazolam as well
for the most difficult cases. The apparent synergistic activity of
this triple combination often allows a reduction of all three
medications to very low levels. Alprazolam is an excellent anxiolytic
but we should be mindful of the potential for ataxia at higher doses
and, as a benzodiazepine, the potential for addiction and so we advise
reducing the dose slowly if use exceeds several weeks. Fundamentally,
I believe these medications can be a game changer if used
appropriately in horses subject to the stressors of box rest.
- Reintroduction of exercise. How and when increased movement is allowed
will be very dependent on the individual circumstances of the case.
Here Peetres et al reflected, in hind sight, in-hand walking
could have been started earlier to stimulate remodeling at the
fracture sight. Most equestrians will be familiar with the perils of
turning horses out after a period of confinement and/or hand walking a
horse on restricted exercise, where the motivation to run, rear and
buck can overshadow the handler’s cues. This occurs due to
post-inhibitory rebound, a process where a behaviour is performed to
excess following a period of restriction (Chaya et al., 2006). This is
another scenario where psychopharmaceuticals are helpful for both
horse and human safety. Furthermore, introducing restricted paddock
exercise earlier, if possible, reduces the build-up of frustration and
thus minimises post-inhibitory rebound (Chaya et al., 2006; Freire et
al., 2009). Grazing is one of the best activities to promote
relaxation and reduce stress in horses (Stomp et al., 2018; Ruet et
al., 2020). Use of several small (stable-sized) pens that are linked
by gaps on alternating sides (Figure 2) is an excellent way of
allowing horses to quietly graze and wander without being able to get
into trot. In cases where a gradual exercise programme is not
feasible, especially where there are concerns for horse or human
safety, multiple connecting larger pens can be used. These allow a
horse to achieve a steady trot before having to slow to get through a
narrow passage into the next pen (Figure 3). Gradually making them
bigger allows increased, but still relatively controlled, free
exercise. For the slightly larger pens a sensible companion horse can
usually be added, again helping improve welfare and reducing the risk
of jumping out. Use of pens will not be appropriate for every scenario
but where feasible introducing the horse into them early, even
starting for just a few hours a day can have a positive impact on
wellbeing and facilitate safer hand walking.