Meet Mr P. He is a 5 year old thoroughbred gelding who has just recently come off the track due to an injury to his right front superficial digital flexor tendon. He is the newest member of the Equimotion team, working with us for his rehab and is graciously letting us share his journey with you all.
Head over here to follow along.
Just because a website or practitioner states that there is "research" behind something, how do you determine if the research that has been conducted is in fact any good? While no means exhaustive, here's a good checklist to help you get you started.
Un1. Is the research question clear and informs us of its aims?
2. Is the study a systematic review or meta-analysis?
These will provide the highest level of evidence as they evaluate the results of all available studies on the same subject. Ten or more studies with the same conclusion provides much better evidence than just one. While a randomised controlled trial that has been well conducted with a large sample size is good, the more studies showing a positive effect, the more we can trust in the research.
3. How many participants are included in the study?
Studies with a high number of subjects are always better than those with less subjects, as it’s more likely to be a better representative of the general population. For instance, a trial with 500 participants is much more likely to have a statistically valid conclusion than a trial with 20 participants. Unfortunately, in many horse studies this can be challenging, and there are many papers published that have less than 10 horses included. Be wary of basing too much emphasis on the results of small sample sizes.
4. How were participants recruited and were they randomised to groups?
Participants should be randomly assigned to the experimental and control conditions (e.g., sealed envelope assignment or computer generated random assignment). Look also at how participants were recruited. The sample can be biased when researchers use volunteers, especially those targeted through social media or special interest groups. Those who volunteer to participate in studies do not necessarily represent the general population, as they will often be people who already have an interest or bias towards the study subject.
5. Is the study blinded?
Trials should involve blinding, meaning that researchers, experimenters, subjects, and assessors should not know which group subjects are in during the experiment. Say for example one of the measurements in a study was lameness of the horse. If the person assessing the lameness was aware of which horses had been in the treatment group and which horses were in the control group, there is an increased risk of bias in their assessment of that lameness (i.e. they may be more inclined to “see” an improvement in the horses they know had the treatment).
6. Is there a good description of the methods used?
It should clearly state in the methods if subjects were randomised to groups and whether the subjects and assessors were blinded. If the information is not included this can suggest that the trial’s methodology is unknown (or the researchers are purposefully leaving it out) and therefore may be questionable.
7. Was there a control group?
Without one it’s very difficult to conclude that the results were due to the intervention applied.
8. Is there risk of bias?
This can include:
9. Does the study have validity?
A study should have 3 different types of validity. These are:
10. Where was the study published?
A study published in a well-known and respected journal will always be preferable to one published in an unknown publication. A “study” that has only been published on the website of the manufacturer who developed the product being researched should always been viewed with scepticism.
An impact factor is a measurement that shows how often articles within a journal have been cited by other articles. A higher impact factor means that studies published within that journal are more likely to be seen as important within their field. While a study published in a low impact factor journal isn’t necessarily going to be a poor, chances are it won’t have had the same level of rigorous review that a study published in a high impact journal will have been through.
11. Has the research been peer reviewed?
Peer reviewed research has been evaluated by external experts with experience in the subject matter. It is considered higher quality.
12. Are there appropriate statistical methods?
Statistics are complicated! Proper and accurate analysis of data requires appropriate statistical tests. The tests used to analyse the data must be appropriate for the type of study and the research question they are trying to answer. Any tables and figures should be clearly labelled. Ideally, effect sizes should be included throughout giving a clear indication of the variables’ impact.
13. Are the findings statistically significant and/or clinically significant?
This can be confusing, but it’s important to understand the difference. Statistical significance indicates the reliability of the study results and quantifies the probability of the study’s results being due to chance. Clinical significance reflects the impact on clinical practice and refers to the magnitude of the actual treatment effect.
The “P” value is frequently used to measure statistical significance. It is the probability that the study results are due to chance rather than to a real treatment effect. A statistically significant “P” value is usually 0.05 (or 5%). What a P < 0.05 implies is that the possibility of the results in a study being due to chance is <5%, and therefore more likely to be due to treatment effect (i.e. the treatment very likely is what made a difference).
While there are established, traditionally accepted values for statistical significance testing, such as the P value, this is lacking for evaluating clinical significance. More often than not, it is the judgement of the clinician (and the patient/client/rider) which decides whether a result is clinically significant or not. This can include whether the change from having the treatment makes a real difference to the subject lives, how long the effects last, consumer acceptability, cost-effectiveness, and ease of implementation.
For example, a study may show that an electrotherapy treatment demonstrated a statistically significant improvement in the appearance of a lesion in a tendon on ultrasound 3 weeks and 6 weeks post-treatment compared to a control group (who had the same type of tendon lesion but who did not receive the treatment). The clinical relevance of this study is the “treatment effect”, which looked at the time at which the horse returned to competition. The results showed that the treatment group returned to competition only 5 days earlier than the control group, which most researchers, clinicians and riders would agree is a clinically irrelevant “improvement” in outcomes.
While the study may have shown that initially the tendon appeared visually to have been healing faster (statistical significance), there was actually no real difference between groups in the time that the horses were able to get back to competition (clinical significance). In this instance the clinician and horse owner must decide if the time and financial investment is worth the horse having the treatment or not, which will differ from person to person depending on their goals and financial position.
14. Is the conclusion appropriate?
In the discussion and analysis of data, researchers should note whether findings are statistically significant and if they consider there is any clinical significance. They should be careful not to make the outcomes seem more relevant than they really are. It’s a common mistake to emphasise results that are in accordance with the researcher’s expectations while failing to focus on the ones that are not. Will it can be tempting to jump straight to the conclusion when reading a research paper, make sure you read the results carefully first to see if you draw the same conclusions yourself. Even in a well-designed trial, further research and affirmation of outcomes in equivalent studies are needed before trial outcomes can be accepted as factual. Limitations of the study should also be mentioned.
15. Last but not least, were the ethical standards met?
The Goldilocks principle when applied to training loads in rehab is basically what you would expect - training just enough to cause adaptive changes, but not enough to cause injury. You should feel like you’ve worked but recover within 24-48 hours (JUST RIGHT). Soreness that lasts longer than 48 hours suggests you need to back off a little (TOO HOT), while no soreness or feeling of effort suggests you need to push a little more (TOO COLD).
However, when our horses can’t tell us if they are sore or not following training, how do we enough if what we are doing is “just right”?
For this post, we are applying these principles to injury management and rehab. Similar principles for training and performance can apply, but it’s a little more complex depending on your sport and your level. But essentially, we know that for regular training we need to train at a consistent level that increases gradually in order to improve. Sometimes we will have larger increases in training load (such as during competition or clinics) and sometimes we will have decreases (light work days or holidays/spelling). The body can cope with these well, as long as we have kept up training at an otherwise consistent level on all the other weeks.
When it comes to injury management and rehabilitation though, often we see people training themselves or their horse in the ‘too cold’ zone, either by training not enough, not long enough or at too low intensity. While we have to be mindful of not doing too much and allowing the injured tissue to recover, it’s important to remember that the body and its tissues require load in order to heal. One of the most important concepts in orthopaedics in this century is the understanding that loading accelerates healing of bone, fibrous tissue, and skeletal muscle. Ever had a knee or hip replacement? If so you’ll know those pesky physios want you up and walking on day 1! Those of you who have had episodes of back pain will know that you usually feel worse lying in bed and that getting up and doing some gentle exercise typically makes you feel better. That's because the human (and horse) body is adaptable and transformable, it's not like a machine that simply breaks down.
Signs your horse may not be working hard enough will simply be that you are seeing little to no change in their injury recovery, muscle development or movement (NO CHANGE = TOO COLD). Signs that you may be doing too much will be increased resistance to training, behavioural changes, lameness, heat or swelling that doesn’t go away after 24 hours or persistent pain response on palpation of the affected area (NEGATIVE CHANGE = TOO HOT). It’s important to note that sometimes this will occur if there is an underlying issue in the recovery and in these cases you should always seek veterinary advice.
But if your horse appears to be gaining muscle, is moving better and seems happier in their work, chances are you’re getting the loads “just right” (POSITIVE CHANGE = JUST RIGHT).
However, this can be difficult to achieve, and you will have ups and downs.
We next assessed her using high-speed video and 2D kinematic analysis. She again measured quite symmetrically comparing joint range of motion between the left and right limbs, suggesting that there were unlikely to be any underlying soundness issues.
It was when we looked closely at her stride characteristics that we were able to identify some things that may have been limiting her performance.
1. Diagonal Advanced Limb Placement
This refers to the placement of diagonal forelimb and hindlimb in trot and canter. The USDF's Glossary of Judging Terms defines it as being when the “hooves of a diagonal pair of limbs (in trot or canter) do not contact the ground at the same moment."
We found that the:
This demonstrates a negative diagonal advanced placement (each forelimb lands before its diagonal hindlimb pair). In dressage horses we know from research that a positive diagonal advanced placement (hindlimb landing 20-30m/s before forelimb) is important for propulsion of the hindquarters. While this has not yet been studied in racehorses, we hypothesised that a similar limb placement pattern would be important for propulsion in the racehorse, and thus performance. This is something we hope to study further in racehorses to examine the effect on performance.
Upon performing a physiotherapy assessment, we found that this horse had some loss of muscle bulk in her hindquarters, particularly the right hindlimb, along with some pain response around the pelvic region. She had a tendency to overuse the muscles in the shoulder and lower neck region to pull herself along rather than really push from behind.
2. Stride Frequency
In a study of thoroughbred racehorses tested at maximal speed, the best performers were found to have a stride frequency of 2.81 strides/sec at the gallop. Stride frequency is positively correlated with performance – ie the best performers have higher stride frequencies. We found that this horse had a stride frequency of 1.9 strides/second.
3. Ground Contact Duration
Ground contact duration is defined as the time elapsed between the non-lead hindlimb contact and the lift off of the lead forelimb, expressed as a percentage of the total stride duration.
In a study of thoroughbred racehorses tested at maximal speed, horses that won short distance races (<1400m) were found to have a longer relative ground contact duration (68%). Long distance winners had shorter ground contact durations (58%). Sprinters tend to have higher stride frequencies but longer ground contact durations to give more time for propulsion.
This horse (a sprinter) had a ground contact duration of 69% which is similar to top performing sprinters.
Looking at parameters such as these were really useful for the trainer to know, as several studies have found that stride parameters such as frequency and duration can be influenced by training. Based on these findings, the trainer of this horse was able to make any adjustments to her training as he felt appropriate. We also put in place an exercise program which focused on improving her hindquarter strength and symmetry. Not long after this was put in place this horse had 2 great runs, placing a very close second in both races!
This type of analysis is not just beneficial to racehorses, but for horses of all disciplines. Please feel free to get in touch to discuss in more detail how we can use gait analysis to assess your horse's performance.
You may have heard of our gait analysis services, but do you know when it would be actually useful for you to utilise this service?
"Bob" was a 14 year old warmblood gelding competing Prix St George Dressage. His owner had noticed that he had started to have some issues in left canter only - she couldn't quite put her finger on it, but described that the left canter "just didn't feel right".
We were asked to do a joint consultation with the vet, as while you could see that the left canter looked different to the right, it was quite difficult to see with the naked eye why this was so. The horse was not positive on any flexion tests or visibly lame at the trot. The vet did not want to waste time or money blocking or imaging regions that weren't relevant, so asked us to use our gait analysis technology to help determine where the problem was coming from.
We first trotted Bob in hand, using both the high-speed video with 2D kinematic analysis, and the inertial motion units. We then used the high-speed video with 2D kinematic analysis to compare the left and right canter under saddle. (Learn more about these technologies here).
The inertial motion units measure symmetry between the left and right sides of the body, and are able to detect if an asymmetry is occurring in a particular limb during the push off or support phase (or both) of the gait cycle. With 2D kinematic analysis we are able to measure joint angles, velocity and acceleration of all of the joints in each limb.
So what did we do with this information?
This is where the team approach is so important. The gait analysis allowed us to determine in which limb and which area the problem was occurring. Based on the information from the gait analysis regarding protraction distance, joint angles and velocity, the vet was able to deduce where the problem was likely occurring and upon scanning they found very early changes in the affected soft tissue. This saved the vet time and the owner money on not having to perform multiple nerve blocks or take images of a number of joints before finding the problem.
Finding the changes this early meant that the recovery time for Bob was much faster than if the area continued to be loaded and the issue not investigated until Bob was noticeably lame. In this case the injury would likely have been worse and he would have probably required a much longer recovery period.
The vet and our physiotherapist put in place a management plan for Bob, and we are pleased to report that he fully recovered, his performance issues resolved and he returned very successfully to his dressage career!
Struggling to move up to the next level of competition and training? Do you feel that perhaps you may not be reaching the performance heights that you're capable of? Here are 5 ways that can help to improve your horse's performance.
1. Know your horse's baseline gait pattern, strength, fitness and symmetry - and improve it if you can!
When most professional athletes start a new year of training & competition, they undertake a screening assessment which determines where their current level of fitness and ability lies and a training program is put in place in order to to maximise their performance for the year. This doesn't just apply to professional athletes however, when any of us join a new gym or training group, we would typically undertake an assessment first so that our progress can be monitored, showing us the improved outcomes (we would hope!) at the end of our program.
We feel that it's equally important to have a good understanding of how your horse naturally moves and performs. Very few horses are perfectly symmetrical, however it's good to know your horse's baseline asymmetry in order to be able to differentiate its normal movement pattern from abnormal movements, which could be indicative of injury. It also allows us to highlight any areas in which we may be able to address, through the use of physiotherapy or with other equine professionals, which may help to lead to improved performance and even reduce potential risk of injury.
It's worth considering a regular 'check-up' for your horse, to monitor how they are going, identify any areas that could be improved on and potentially identify any risk factors for injury before they become serious.
2. Follow a consistent and progressive training schedule
You would never go out and run a marathon without training (we hope!), so it stands to reason that we really shouldn't ask our horses to perform work that they just aren't fit to do. Just because your new horse has performed at 2* eventing previously, you shouldn't expect that they would have the fitness or stamina to go and compete at the same level straight away after having only been in light work for the past year. It has been well documented in human research that a sudden increase in training load or volume is an increased risk for injury. Similarly in horses, research conducted by Hernandez et al in 2001 found that thoroughbreds that had ≥ 33 days since their last race had an increased risk of injury.
The type and frequency of training that you do is also very important. In a study conducted by Murray et al in 2009 looking at risk factors for injury in dressage horses, they found that a high number of training sessions per week and a low level of training at specific movements for each competition level was associated with the likelihood of injury. While incorporating jumping into the training schedule, spending a large proportion of training time in working paces and greater than 10% of training in transitions and extended paces were suggested as protective against injury.
It's important to plan and implement a progressive and specific training schedule for you and your horse, that will not only be specific to your discipline, but will also help to protect against the risk of injury. We recommend working closely with an experienced coach or trainer to help you with your training schedule, along with other professionals such as physiotherapists who are highly experienced in the area of workload progression and exercise training principles.
Technology is a fantastic way to help us also and there are a lot of different activity trackers available now which allow you to objectively monitor your horse's fitness and performance. These include apps that can be downloaded to your phone, heart rate monitors and sensors that attach to the girth or bridle.
3. Get yourself fit and strong
The general public may not see it, but as riders we know that we do way more than just 'sit there' on the horse's back. Horse riding is a partnership, and we don't want to be the one letting the team down because our strength and fitness isn't up to scratch.
Research published by Gunst et al in 2019 found that a rider sitting asymmetrically increased the force on one side of the saddle, which can be reasonably assumed to be also increasing forces through one side of the horse's back. Another research paper published this year by Dyson et al found that larger riders can induce temporary lameness and behaviours consistent with musculoskeletal pain in the horse.
The good news is that research has also shown that these effects on the horse can be lessened through exercise. Hampson and Randle in 2015 looked at the effects of an 8-week rider core fitness program on the horse's back at sitting trot. By the end of the program they found that subjects in the study had reduced asymmetry at the end of the 8 weeks and that on average the horse's had an increase in stride length of 8.4%.
You may think that riding your horse (and all the work that goes along with that) is enough, but in reality we find that many riders aren't as fit as they think and should be doing more work out of the saddle to improve their strength, mobility and fitness. Join a gym or group fitness class and get in some training out of the saddle. There are lots of practitioners out there now (us included!) who run rider specific exercise programs. We even offer online programs so you really have no excuse!
4. Have your saddle fitted at least once a year
When did you last have your saddle/s checked? There is a growing body of research investigating the effect of the saddle on horse and rider performance. A lot of that research is being conducted by Dyson and Greaves from the Animal Health Trust in the UK. In a study they conducted in 2013, they found that back pain and minor thoracolumbar asymmetries in the horse were associated with ill-fitting saddles. They also found that an ill-fitting saddle not only affected the horse but the rider too, with a link between poor saddle fit and rider back pain. Their research suggested that well-fitted saddles were associated with frequent saddle fit checks, and that saddle fit should be checked more often than once yearly to lower the number of ill-fitting saddles.
We recommend working with a master saddle fitter, who will have undertaken extensive training in their field. And be mindful that your saddle fitter should actually watch you ride your horse in the saddle that they are checking. After all, that's what the saddle will be used for!
5. Understand nutrition and know your horse's dietary needs
Nutrition plays an extremely important role in the health and performance of your horse, however is an area that is often poorly understood by owners. There is a wealth of information out there on horse nutrition, so much so that it can often be overwhelming to know where to start. It's important to know not only the type of food your horse should be eating based on their weight, age, condition and job, but also how much and when they should be fed.
Your vet or an equine nutritionist is the best place to start in helping you to determine the appropriate feeding program for horse in order to maximise their health and performance.
Please note that we're aware that we've only scratched the surface here, and haven't even touched on the importance of the other areas that are vital to your horse's performance, such as farriery, dentistry, environment, training surfaces, bits, coaching, training - the list goes on! Suffice to say that a well rounded, team approach is absolutely essential in order to optimise both horse and rider performance!
At first glance, this first picture would look like a great advertisement as a 'before and after' – the rider was crooked on the left but is looking much more straight on the right. However, these are actually screenshots of the same video, one stride length apart. We hadn’t yet done anything to try and improve the rider’s position.
If you look closely at the horse’s hind legs, you can see a difference. The picture on the left is when the horse’s right hind leg is hitting the ground as the left hind leg pushes off, while the one on the right is the next stride – the left hind leg hitting the ground as the right pushes off. I think you can see that there is a really big difference in the rider’s posture in each stride. This was consistent in each stride we analysed.
This tells us a few things. First and foremost, it’s really important to not analyse yourself just from a picture or under one circumstance. If we were just to analyse the picture on the left, we would be commenting that the rider is collapsing over to the right with more weight through the right stirrup and rotating the trunk slightly to the left. If we were to examine just the right, we would remark that she’s looking fairly symmetrical in the body, with slightly more weight through the left stirrup. We can see some similarities - in both pictures leg position is pretty much the same, with slightly more turn out of the left toe, but on the whole the rider’s position looks markedly different.
We did some ridden exercises and positional changes with this rider that helped improve her alignment slightly, but not 100%. The rider was also experiencing pain on just one side of her body, which would improve with physio or other therapies and specific exercises but would return again once she rode. So, we had to consider the other moving variable in this partnership, and that is the horse.
We did an assessment of the horse without a rider on board. You can see from this second picture, that there is a marked difference between the symmetry and muscle bulk of the hindquarters. We can see that the right side of the pelvis is sitting higher than the left, with considerably less muscle bulk on the right side. We found that the horse had less strength on the right side of the hindquarters and was compensating for this in other areas of the body. It starts to make more sense now that it’s when the right hind leg is in contact with the ground, that the rider sits asymmetrically.
So, for the next step we wanted to assess the same rider on a different horse. The picture on the left is the same rider on a different horse, with the picture on the right the same horse as previously. These pictures are of the same phase of the gait cycle – right hind leg and left foreleg in contact with the ground, with the left hind leg and right foreleg in swing phase.
Again, we see some marked differences between them. While the right leg position is almost identical in each, the left leg position is quite different, with the lower leg coming way off the horse in the picture on the right. This was happening consistently in the video each time at this phase of the gait cycle. We can see the rider is again shifted over to the right. In the left picture there is still a slight difference in shoulder height (although in the opposite direction now), however you can see that the rider looks more balanced and centred in the saddle on this horse.
What this case highlights is the need to not review a rider (or a horse) in isolation but to look at the whole picture. If we tried to just address the rider’s asymmetries in this particular case, we likely would not achieve a great outcome, as we can conclude that the horse is contributing to her asymmetry. We are uniquely placed to be qualified to work with both horse and rider, however if you do not have a horse and rider practitioner available, we strongly recommend having your equine practitioner and your rider practitioner working together. By assessing, and then treating if necessary, both horse and rider, we have a much better chance of improving performance.