Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Cold Feet: The Science of Cooling Equine Hooves
Cooling treatments for equine laminitis have long been standard practice, but groundbreaking research now reveals that not all cooling methods deliver equal results. Drs. Andrew Van Eps and Sarah Ciamillo join us to discuss their study which found that distal limb immersion in ice and water dramatically outperforms other cooling techniques for equine hoof lamellae under real-world conditions.
Their research addresses a critical clinical challenge: while ice water immersion has been the gold standard in experimental settings, its practical application in everyday equine practice presents significant hurdles. The weight of water columns makes movement difficult, leading many practitioners to seek alternatives like ice packs or sleeves. This study definitively demonstrates that these alternatives simply don't match the cooling effectiveness of traditional ice water immersion.
What sets this research apart is its methodological approach. By measuring temperatures directly within lamellar tissue while horses moved freely in stalls, the team created truly clinically relevant conditions. The results were striking – even to researchers who anticipated ice water's superiority. "I just didn't expect there to be such a drastic difference between all the different methods," notes Dr. Sarah Ciamillo.
Beyond cooling techniques, our conversation explores the frontier of laminitis research, including exciting applications of artificial intelligence for predicting which horses might develop supporting limb laminitis. The team discusses ongoing collaborations with equipment manufacturers to develop more practical cooling solutions that maintain therapeutic effectiveness.
For horse owners and practitioners alike, the message is clear: when dealing with horses at high risk of laminitis or showing early clinical signs, ice water immersion should be the treatment of choice – even if that means referring to a hospital facility equipped to provide this therapy properly. This episode delivers critical insights that could change how we approach one of the most devastating conditions in equine medicine.
Have you dealt with laminitis in your equine patients? Share your experiences with cooling techniques and join the conversation about this research that's transforming our approach to equine foot care.
Open access AJVR article: https://doi.org/10.2460/ajvr.24.10.0291
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Sarah Wright:You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how distal limb immersion in ice and water is the most effective means of cooling the equine hoof lamellae under clinically relevant conditions, with our guests Sarah Ciamillo and Andrew Van Eps.
Lisa Fortier:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Andrew and Sarah joining us to talk about a very important clinical disease laminitis and cooling the hoof lamellae. Andrew and Sarah, thank you so much for being here today and bringing on an equine podcast for us.
Andrew Van Eps:Thank you.
Sarah Ciamillo:Thanks for having us.
Sarah Wright:All right, let's trot on over. So, Andrew, your AJVR article discusses how distal limb immersion in ice and water is the most effective means of cooling the equine hoof lamellae under clinically relevant conditions. Please share with our listeners the background on this article.
Andrew Van Eps:Well, I think a cooling feat for laminitis prevention has become and early treatment has become something that's fairly commonly done and our research group, going right back to when I did my PhD with Chris Pollitt, we have looked at the efficacy of cooling to prevent laminitis in experimental models and we've always used ice water immersion in those situations, either in boots or in recirculating tubs. And ice water immersion is difficult to practically do in the clinic. But our suspicion has always been and some of the data that has been generated has backed up the fact that ice water immersion is probably the most effective way to cool the lamellae themselves. But there's been at least a couple of papers in the last five years that have, um, uh, perhaps had results that are at odds with that, one that showed that an ice pack system could be effective and one that showed that an ice sleeve that didn't include the foot, that didn't include water, could also be effective, and in fact that method we'd used here at New Bolton for quite some years in a clinic.
Andrew Van Eps:The difficulty with ice water immersion is that the horse has to carry around the ice water column, so the weight of the water itself is very difficult and impractical to ambulate around with. So, I think in clinical situations we've always searched for methods that might be more practical. This paper we wanted to see if, by actually measuring lamellar temperature itself within the tissue and trying to perform these studies in clinically relevant conditions inside stalls with horses free to roam, whether in fact these other methods could be as effective as ice water immersion. That's the short answer.
Sarah Wright:No, it's a very good answer, actually Very good summary, thank you. So now, what are some of the more important take-home messages from this article?
Andrew Van Eps:Well, I think it shows pretty clearly that ice water immersion is much more effective than other means. Um, and I think, um, that's not a big surprise to us, um, but uh, I think the reason there's some disparate information in the literature is because the location at which you measure temperature and the conditions with which the horses are kept in these experimental studies make a big difference to how the temperature data appears. So, I think, um, we took a lot of care in this study to try to make it a realistic, um, uh, a realistic study.
Andrew Van Eps:The question I guess now is um, uh, you know, how cold does the tissue need to be? Um, and for how long? Uh, but I think this is at least a step that shows that, that these ice water immersions are better. What's the important take-home message? I think the important take-home message is in horses that are at high risk of laminitis, or in horses that are experiencing early signs of acute laminitis. If you want to cool their feet, I think you need to try to do ice water immersion, and if you can't do it in the situation you're in, it's a good reason to refer a horse to a hospital where it can be achieved.
Lisa Fortier:Andrew, it's a good point of like how cold is cold enough. Given your vast experience and obviously your key opinion leader in this area, what's your gut instinct? Tell you what is cold enough.
Andrew Van Eps:Yeah, I don't know, and we've always tried to make it as cold as possible because we've always been trying to look at changes, look at effects in experimental models. And so, we are always trying to go for the maximum defense. In those situations, the prophylactic effects are really profound, they're not small, they're really profound. But there is literature in models of acute lung injury and other things, in rodent models showing that small differences in body temperature, even five degrees of hypothermia, five degrees Celsius lower than normal, can make differences to the acute lung injury, for instance. So, you know, I think it's possible that even small differences can help. Um, small cooling effects can help, but I think our overwhelming experience is that the colder the tissue is, the better. Um, when you're talking about laminitis prevention and stopping it from progressing.
Lisa Fortier:That shouldn't be a problem. Here in New York it's pretty chilly, so the hoof capsule is plenty cold here.
Andrew Van Eps:Yeah.
Lisa Fortier:Sarah, I'm sure you know you're incredibly fortunate to be amongst Andrew and just the vast amount of experience around New Bolton Center. What sparked your interest in laminitis?
Sarah Ciamillo:Yeah, so I first came to New Bolton I guess in 2020, and I was a Mars equestrian research fellow and during that time I got to like kind of work with the laminitis lab and Andrew and really his passion for the like looking into laminitis and everything really made me interested in it, even though I would partially say it wasn't, you know, my ever my topic of choice previously. But I really enjoyed my time there and like he's so intrigued by it that it then makes me excited about it. So then, like my second year in the research as a research fellow, I really got more involved in it as well and really started to enjoy it.
Lisa Fortier:Yeah, it's nice to be around thinkers right, and Andrew and his group have always been. Like you said, it rubs off. It's the bane of my existence as an equine orthopedic surgeon. So, knowing that somebody's looking and really thinking about this horrible disease for our horses is really wonderful.
Sarah Ciamillo:Yeah.
Lisa Fortier:Andrew pointed out that you kind of predicted the main finding of the article, given all your other research experience. But every time we do studies we find something that surprises us. What surprised you from the findings in this article?
Sarah Ciamillo:Yeah, I think I was just surprised how much of a difference there really was between just using the plain, like ice, in a sleeve around the hoof, compared to submerging them in this ice water immersion, like I always knew. It would probably be better, but I just didn't expect there to be such a drastic difference between all the different methods.
Lisa Fortier:Yeah. Now, do you, now that you know that, do you watch like football players differently, where they jump in their little ice bath, or
Sarah Ciamillo:Right, yeah.
Lisa Fortier:Or you think of like the old cowboys right, they knew when their horse's feet hurt, they walked them into ice, cold streams, you know, they were onto something a long time ago. It just took the brains of Andrew and Pollack and others to prove it.
Sarah Ciamillo:Yeah, and when you walk around the racetrack they have them standing in like buckets of water up to their elbows and I was like, oh, okay, yeah.
Sarah Wright:So, Andrew, you talked a little bit about some next steps, like, for example, like how cold does it need to be but what are some other next steps for research in laminitis?
Andrew Van Eps:Well, um, in laminitis in general, um, you know, I think we, us, we still there's still some missing pieces in terms of exactly what causes laminitis at a, at the cellular level, uh, in different situations, although we have got a lot more information than we did, say, 10 or 20 years ago. But there's still a little bit more to go. And I think there's a lot of progress on, particularly the endocrine side, better management of endocrine disease for prevention and even treatment of laminitis. And even though there's some holes there in terms of better understanding and better management, I think overall that's where most progress has been made. Back at this sort of supporting limb laminitis side. There's still, um, uh, there's still some, some levels of understanding that we have to to get to, but I think we are making a little bit of progress there.
Andrew Van Eps:And then you know, funnily enough, that most of the research had always been done in sepsis related laminitis, that um, particularly with the cooling and the models that we were using to test it in the early days, and that's really stagnated and I think partially it's because the cooling does seem to be effective in the clinic and we here at New Bolton Center. Most of the laminitis we see in these sick horses now is botanicals fever, I'd say, and in those cases it just happens so rapidly. I think a lot of the time they're laminated even before we we see them. But I think that's an area that we're actually kind of interested in working out why that is such a profound cause of laminitis in our population.
Andrew Van Eps:But, um, but I think there there's still work to be done on understanding how we can better use cooling, how cool it has to be, and there's still development that needs to be done and hopefully we're working with some of these companies to come up with better solutions. So some of the companies that contributed equipment for this study have modified their boots to try to make them better. In the aftermath and there are some more prototypes coming. I'm hoping that we can come up with more practical ways to cool feet that are more effective and easier for people to use in the clinic.
Lisa Fortier:Yeah, I'm just going to take this opportunity, Andrew, to shout out to anybody who's listening don't let your horses get fat. You know, I think many, many of us. Now that there's a stall-side insulin test, it really should be part of your spring and fall checkup on your horse. You might not think your horse is overweight, but most horses in the show ring not racehorses the, but at least in the show ring most of them are over-conditioned, as my mother would say, well-covered. Yeah, and Andrew, I don't know what to think about those Potomac horse fever horses. You know, some of them are. I think they're close to they're in DIC before they even get across the threshold there.
Lisa Fortier:I don't know that any icing is going to help them
Andrew Van Eps:yeah, I think the interesting, my suspicion is that the near rickettsia actually um, it's replicating and causing havoc within macrophages that are resonant in the lamellae, the tissue itself in the foot, and so in most of these other causes and sick horses you've got this systemic inflammation and maybe endotoxin or other products circulating that are the tissue and the cells in the lamella reacting to and that's what's setting them off, whereas I think in Potomac it may be happening locally and it happens very rapidly and I think probably we we just don't get the chance to inhibit it.
Sarah Wright:Very cool.
Sarah Wright:Now, Andrew, since the last time we talked to you, we've added a fun new question. It's about AI. So, do you see a role for AI in laminais research?
Andrew Van Eps:oh, absolutely. I mean I think in laminais research, um, uh, there is, particularly as we start to get access to more of these tools for big data. AI can help sift through and look for patterns and look for associations in genetic basis or in protein profiles. But the other thing is we're actually quite into looking at in horses that are prone to supporting limb laminitis, horses with fractures, looking at locomotory patterns in those horses and how they might predict whether that horse is at high risk of developing supporting limb laminitis.
Andrew Van Eps:Until now we've mostly used these foot-mounted sensors and in fact Sarah, during her time in my lab, did a whole bunch of work with foot-mounted sensors on horses with fractures and that's shown us that those horses have lower rates of ambulation and don't move as much as normal horses and perhaps gives us some information on how we can predict risk. But I think now we're trying to take it a step further. We used a bit of machine learning in those protocols but now we have video cameras set up on these horses that have fractures and breakdown injuries and we are developing models that are AI-based to quantify ambulatory behavior and laying down and standing up, in the hope that we can use that to better predict risk in those horses and warn us early. I think it's an exciting time to be alive, probably the most exciting time, because maybe in 10 years the AI will be doing the thinking for us as well, and now we can do the thinking and apply it.
Lisa Fortier:I think you're safe. I remember, Andrew, probably 30 years ago at a VOS meeting, Jeff Watkins saying he preferred horses that had stall vices when he was doing fracture repair, like the weavers and the pacers, and that, and he said, because they don't, they're far less prone to founders than the horse that just stands there.
Andrew Van Eps:Yeah, and I think it was Larry Bramlage who was into walking, and still, I think down at Rue Real they do they like to walk them. I do think it's a. It's a, it's a kind of leap leap in understanding and I think we probably will have another podcast on this at some point, at least for the future, when I send this paper into you. But, um, you know, I think that it is something that we can potentially, um, uh, work on and and and uh and understand better. Similar to, you know, perhaps, some ileus in people postoperatively when they kind of worked out that, hey, you're just going to get people up the next morning after their surgery and get them walking up and down the highways.
Lisa Fortier:Yeah, because fortunately the walking the horses is a bit cumbersome when you want them to be iced, pick your poison.
Andrew Van Eps:Yeah.
Sarah Wright:For those of you just joining us, we're discussing how distal limb immersion in ice and water is the most effective means of cooling the equine hoof lamellae under clinically relevant conditions, with our guests Andrew and Sarah.
Lisa Fortier:Hey, Sarah.
Lisa Fortier:Uh, you've heard andrew talking about this this vast uh depth of manuscripts and articles and research that are behind this article and that came before here. How did your training and previous work prepare you to write this article?
Sarah Ciamillo:Yeah, I guess it was really all my time when I was the Mars Equestrian Fellow, working with Andrew and getting to do real-time Laminitis work and the different variety of projects that we are working on. To really help write this and put it all together to help further my knowledge in the topic would probably be key, as well as, like other clinical experiences you know, like firsthand treating clinical laminitis cases.
Sarah Wright:So Sarah's next set of questions is going to be really important for our listeners. The first one deals with the veterinarian's perspective. So what is one piece of information the veterinarian should know about equine distal limb immersion in ice and water in cases of laminitis?
Sarah Ciamillo:So kind of as a two-parter to that answer. So I think it's key for them to know that ice-water immersion is way more effective than just using plain ice and you'll get a should get a better response to these horses. But also that, since it is kind of cumbersome and these horses probably need a little bit more monitoring with the ice water immersion, that it would be better for them to be managed in a clinic or, you know, some sort of hospital setting as opposed to just managing at home under the owner's care for full effect.
Sarah Wright:Now, on the other side of the relationship, what's one thing clients should know about this topic?
Sarah Ciamillo:I guess it's kind of the same for clients, because you know, one thing the clients care about most is probably cost and effect. So it's probably going to be a little more costly to come refer them into hospital. They may want to manage them at home. I mean, if you have a really dedicated client, I think they could probably do it. But I know like here we usually are checking ice boots every two hours, making sure they're still on properly, they're still full, because some of them like to play with them and take them off themselves and all that. So I think that's something they need to be aware of as well.
Lisa Fortier:Yeah, it's hard to do that stuff on the farm. It's just hard. I remember my first horse that got a really bad foot abscess and you know I tried to follow my own instructions. I was like soak it in a bucket. That's the dumbest thing ever. I was wet. The bucket was under my horse's foot. It was flinging around. It was like who came up with these instructions?
Andrew Van Eps:yeah, I mean, until you do it yourself, you don't realize. And we, um, you know, we one of the boots that we used for the first experiment, one in this study, one of the SoftRide boots. We just had a terrible time keeping them on, and so we invited Monty from SoftRide to come and, yeah, he was kind of swearing and throwing his hat on the ground and stomping on it and you know, he went away with a bit of fire in his belly to make something better and he is actually still on it and, um, I think it is happening. So, um, but uh, yeah, I think you don't. You know, it's all well and good for us to say, hey, I just think continuously for, you know, several days, um, uh, and then you'll all be, you'll be good, but I think, in, in reality it's, it's difficult, particularly with the tools we have available to us right now. But, you know, hopefully, going into the future, we might have some slightly better ways to do it.
Lisa Fortier:Yeah, I think you're right. You know you showed the research in a clinical application, like in this manuscript, how important it is, and then technology will follow. Companies will follow along because they know it's real. Thanks again so much for filling my heart full of equine. Even if it is laminitis, it's a good way to end my day. So as we wind down, we like to ask a little bit more of a fun question. Sarah and I have a hypothesis about this question and we're going to do a follow-up study, a retrospective. Andrew, when you do a puzzle, do you begin with the exterior and border piece or do you do a theme? Do you do a color? Are you a hybrid person?
Andrew Van Eps:Totally the border, yeah, border, and the corners, no doubt. I don't think there's any other way, really true.
Lisa Fortier:Amen Sarah how about you?
Sarah Ciamillo:I'm the same. I like the border. It really like sets, the boundaries, I think. I mean, like you know, if I find a piece that matches while I'm doing the border, then I'll do that, but otherwise I think it's a little unhinged uh from the middle?
Lisa Fortier:yeah, it's. We do a lot of puzzles at my house, especially around the holidays, so my one daughter starts in the middle and she's in medical school and not going to be a surgeon. So now you know mine and Sarah's hypothesis. It drives me crazy and I'm like stop take your insides over there. It drives me nuts.
Sarah Ciamillo:I feel like they make a puzzle now that has no borders. I don't know.
Lisa Fortier:That's not a puzzle,
Sarah Ciamillo:Right
Sarah Ciamillo:would like. It's like no end pieces or something like that. I feel like I saw something like that and I was like I would never.
Lisa Fortier:Nope.
Sarah Wright:We had a weird one over the holidays where it was like four puzzles in one, so it was one picture, but you had to put together like all four parts. I was home with my family. My brother's an engineer, so he started with the border. I noticed because now I'm like paying attention to this after doing the podcast my sister does childhood development and she started with the middle, so it was really interesting. I'm a border girl myself, but the four in one was challenging. So, thank you so much again, Andrew and Sarah, for being here and for sharing your knowledge with our listeners. Sounds like we might have some more from you in the future, so hopefully we'll have you back on the podcast.
Andrew Van Eps:Thank you so much for having us.
Sarah Wright:Yeah, thank you. And to our listeners, you can read Andrew and Sarah's article in AJVR. I'm Sarah Wright with Lisa Fortier. Be on the lookout for next week's episode and don't forget to leave us a rating and review on Apple Podcasts or whatever platform you listen to.
