\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Welfare considerations for management of horses on prolonged periods of
box rest}



\author[1]{Gemma Pearson}%
\affil[1]{University of Edinburgh}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
** Other clinical commentaries don't have an abstract, so I have assumed
one is not expected?%
\end{abstract}%



\sloppy


\textbf{Welfare considerations for management of horses on prolonged
periods of box rest}

Gemma Pearson

The Horse Trust, Buckinghamshire, HP27 0PP

The Royal (Dick) School of Veterinary Studies, Edinburgh, EH25 9RG

Gemma.pearson@ed.ac.uk

\textbf{Introduction}

Peeters \emph{et al} describe the presentation, diagnosis and successful
management of an unusual fracture, of the femoral greater trochanter, in
an eight-year-old Warmblood mare. Internal fixation was not considered
feasible due to the high likelihood of implant failure at this location
and financial constraints. However, based on successful outcomes with
similar proximal limb bony protuberances, conservative management was
undertaken with an excellent outcome -- the horse returned to its
previous level of exercise. The authors should be commended in this case
report for considering the welfare implications of horses on prolonged
box rest and reflecting on what further steps could have been taken to
improve this mare's welfare. This clinical commentary will discuss the
welfare implications of confinement in horses before expanding on
further options for optimising the management of horses undergoing box
rest.

\textbf{Welfare}

The term welfare is often associated with negative connotations, at
least in part, this may be due to historical teaching of the subject
revolving around the five freedoms (Brambell, 1965). The five freedoms
focused on the absence of negative's to ensure animals have a life worth
living. As welfare science has evolved, we now strive to provide animals
not just with a life worth living but with a good life (Mellor, 2016)
and we now recognise that welfare represents how that individual animal
feels, i.e. their mental state, which is dependent on the balance of
negative to positive experiences. This balance can be measured using the
five domains model, which has evolved over nearly 30 years and now
specifically includes intra-species interactions in addition to
inter-species ones (Mellor et al., 2020).

When considering the welfare of a horse on box rest we should therefore
consider the experience from that individual horses perspective. To do
this we use the horse's behaviour as a proxy for their mental state, and
some behavioural indicators of stress were suggested by the authors.
However, previous work has shown poor agreement on the perceived level
of stress a horse is experiencing amongst equine veterinarians (Pearson
et al., 2021). Evaluating stress is challenging as individuals across
all species employ different coping mechanisms (Koolhaas et al., 1999;
Budzy\selectlanguage{polish}ń\selectlanguage{english}ska, 2012; Vindas et al., 2017). It is easy to recognise the horse
that employs a pro-active coping mechanism, it may be doing the wall of
death round the box or frequently vocalising. But we should not forget
that horses may also utilise a reactive coping mechanism (Budzy\selectlanguage{polish}ń\selectlanguage{english}ska
2012). Reactive coping often results in the horse appearing content in
the situation, despite mounting a similar physiological stress response
to those clearly not coping (Yarnell et al., 2013). Mice kept in a cage
environment that meets minimum legal standards spend more time inactive
but awake compared to those in an enriched environment, yet visibly they
appear content. However, either moving them to enriched cages or
providing anti-depressants significantly reduces time spent inactive but
awake (Fureix et al., 2022). When you consider the depth and breadth of
research demonstrating the negative welfare implications of keeping
horses stabled, as reviewed by Krueger et al. (2021), we should always
remain mindful that this is inevitably stressful, even in horses that
appear outwardly to be coping. As demonstrated by Fureix et al. (2022)
providing an enriched environment improves welfare. The term
environmental enrichment is appealing and suggests we are creating a
positive experience for the animal. But perhaps it would be better
described as reduced impoverishment - as at best we are returning them
to a life worth living, not a good life (Langford, 2023).

\textbf{Don't forget about human behaviour change}

There is no magic bullet for successfully managing horses on box rest.
Instead, treatment should be individually tailored to that horse-owner
combination. Try to encompass a suit of interventions that the owner
will find easy to implement by employing the COM-B model (Michie et al.,
2011), for a review of how this can be implanted in equestrianism see
(Wolframm et al., 2023).

\begin{itemize}
\tightlist
\item
  Capability does the owner have psychological and physical capability
  (i.e. knowledge and physical skills) to implement each suggestion?
\item
  Opportunity -- is each suggestion something that is feasible in the
  physical environment? And will there be social support or social
  pressure that will impact on compliance? Suggesting the use of a small
  electrically fenced pen on a livery yard that does not allow electric
  tape will not only be unfeasible but may result in a demoralised
  owner.
\item
  Motivation -- Most human behaviours are habits and so strategies that
  fit in with an owner's normal routine will be easier to implement than
  those that require reflective processing, i.e. planning new
  behaviours.
\end{itemize}

Engaging owners in the management plan whilst understanding their
Capability, Opportunity and Motivation to change their Behaviour (COM-B)
regarding their horse's care will increase compliance.

\textbf{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:

\begin{enumerate}
\tightlist
\item
  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 Mazi\selectlanguage{ngerman}ères,
  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.
\item
  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.
\item
  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.
\item
  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.
\item
  Reintroduction of exercise. How and when increased movement is allowed
  will be very dependent on the individual circumstances of the case.
  Here Peetres \emph{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.
\end{enumerate}

\textbf{Conclusion}

Box rest is inevitably stressful for the horse and usually also the
owner, yet we often underestimate both. Careful consideration should be
given to how we can improve the horse's welfare under these challenging
conditions. Involving the owner in decision making, discussing a range
of potential options and the feasibility of each option in their
individual circumstances maximises the likelihood of success.

\textbf{References}

Bacon, H., 2018. Behaviour-based husbandry---A holistic approach to the
management of abnormal repetitive behaviors. Animals 8, 103.

Borthwick, E.J., Preshaw, L., Wheeler-Launder, C., Challinor, C.,
Housby-Skeggs, N., Boalch, E., Brown, S.M., Pearson, G., 2023. Stable
design influences relaxation and affiliative behavior in horses during
short isolation bouts. Journal of Veterinary Behavior 69, 1-7.

Brambell, F.W.R., 1965. Five Freedoms.

Budzy\selectlanguage{polish}ń\selectlanguage{english}ska, M., 2012. Behavioural and physiological mechanisms of
reactions to stressful stimuli in Arab horses, Lublin, Poland: DSc
Dissertation, University of Life Sciences, Lublin.

Chaya, L., Cowan, E., McGuire, B., 2006. A note on the relationship
between time spent in turnout and behaviour during turnout in horses (
Equus caballus). Applied animal behaviour science 98, 155-160.

Clayton, H.M., 2016. Core Training and Rehabilitation in Horses. The
Veterinary clinics of North America. Equine practice 32, 49-71.

Court, R., 2024. Blue Cross Environmental Enrichement.

Davis, J.L., Schirmer, J., Medlin, E., 2018. Pharmacokinetics,
pharmacodynamics and clinical use of trazodone and its active metabolite
m-chlorophenylpiperazine in the horse. Journal of veterinary
pharmacology and therapeutics 41, 393-401.

Feh, C., de Mazi\selectlanguage{ngerman}ères, J., 1993. Grooming at a preferred site reduces
heart rate in horses. Animal Behaviour 46, 1191-1194.

Fontenot, R.L., Mochal-King, C.A., Sprinkle, S.B., Wills, R.W., Calder,
C.D., 2021. Retrospective Evaluation of Fluoxetine Hydrochloride Use in
Horses: 95 Cases (2010--2019). Journal of Equine Veterinary Science 97,
103340.

Freire, R., Buckley, P., Cooper, J.J., 2009. Effects of different forms
of exercise on post inhibitory rebound and unwanted behaviour in stabled
horses. Equine veterinary journal 41, 487-492.

Fureix, C., Trevarthen, A.C., Finnegan, E.M., Bu\selectlanguage{polish}č\selectlanguage{english}kov\selectlanguage{ngerman}á, K., Paul, E.S.,
Mendl, M.T., 2022. Do greater levels of in-cage waking inactivity in
laboratory mice reflect a spontaneous depression-like symptom? A
pharmacological investigation. Pharmacology Biochemistry and Behavior
212, 173311.

Gmel, A.I., Zollinger, A., Wyss, C., Bachmann, I., Briefer Freymond, S.,
2022. Social Box: Influence of a new housing system on the social
interactions of stallions when driven in pairs. Animals 12, 1077.

Harrison, J., 2024. BHS Environmental Enrichment.

Holcombe, S.J., Shearer, T.R., Valberg, S.J., 2019. The Effect of Core
Abdominal Muscle Rehabilitation Exercises on Return to Training and
Performance in Horses After Colic Surgery. Journal of equine veterinary
science 75, 14-18.

Hoy, J.M., Murray, P.J., Tribe, A., 2010. Thirty years later: Enrichment
practices for captive mammals. Zoo Biology 29, 303-316.

Koolhaas, J.M., Korte, S.M., De Boer, S.F., Van Der Vegt, B.J., Van
Reenen, C.G., Hopster, H., De Jong, I.C., Ruis, M.A.W., Blokhuis, H.J.,
1999. Coping styles in animals: current status in behavior and
stress-physiology. Neuroscience and biobehavioral reviews 23, 925-935.

Krueger, K., Esch, L., Farmer, K., Marr, I., 2021. Basic needs in
horses?---a literature review. Animals 11, 1798.

Langford, F., 2023. Personal communication.

McAfee, L.M., Mills, D.S., Cooper, J.J., 2002. The use of mirrors for
the control of stereotypic weaving behaviour in the stabled horse.
Applied Animal Behaviour Science 78, 159-173.

McBride, S.D., Parker, M.O., Roberts, K., Hemmings, A., 2017. Applied
neurophysiology of the horse; implications for training, husbandry and
welfare. Applied animal behaviour science 190, 90-101.

Mellor, D.J., 2016. Updating animal welfare thinking: Moving beyond the
``Five Freedoms'' towards ``a Life Worth Living''. Animals 6, 21.

Mellor, D.J., Beausoleil, N.J., Littlewood, K.E., McLean, A.N.,
McGreevy, P.D., Jones, B., Wilkins, C., 2020. The 2020 five domains
model: Including human--animal interactions in assessments of animal
welfare. Animals 10, 1870.

Michie, S., Van Stralen, M.M., West, R., 2011. The behaviour change
wheel: a new method for characterising and designing behaviour change
interventions. Implementation science 6, 1-12.

Pearson, G., Waran, N., Reardon, R.J.M., Keen, J., Dwyer, C., 2021. A
Delphi Study to determine expert consensus on the behavioural indicators
of stress in horses undergoing veterinary care. Applied Animal Behaviour
Science, 105291.

Pereira, C.H., Mariti, C., Mc Peake, K., Leyvraz, A.M., ESVCE position
statement on the use of medications to manage acute phobic states in
dogs as an alternative to acepromazine.

Ruet, A., Arnould, C., Levray, J., Lemarchand, J., Mach, N., Moisan,
M.-P., Foury, A., Briant, C., Lansade, L., 2020. Effects of a temporary
period on pasture on the welfare state of horses housed in individual
boxes. Applied Animal Behaviour Science 228, 105027.

Stomp, M., Leroux, M., Cellier, M., Henry, S., Lemasson, A., Hausberger,
M., 2018. An unexpected acoustic indicator of positive emotions in
horses. PloS one 13, e0197898.

Vindas, M.A., Gorissen, M., Höglund, E., Flik, G., Tronci, V., Damsgård,
B., Thörnqvist, P.-O., Nilsen, T.O., Winberg, S., Øverli, Ø., 2017. How
do individuals cope with stress? Behavioural, physiological and neuronal
differences between proactive and reactive coping styles in fish.
Journal of Experimental Biology 220, 1524-1532.

Visser, E.K., Ellis, A.D., Van Reenen, C.G., 2008. The effect of two
different housing conditions on the welfare of young horses stabled for
the first time. Applied Animal Behaviour Science 114, 521-533.

Wolframm, I.A., Douglas, J., Pearson, G., 2023. Changing hearts and
minds in the equestrian world one behaviour at a time. Animals 13, 748.

Yarnell, K., Hall, C., Billett, E., 2013. An assessment of the aversive
nature of an animal management procedure (clipping) using behavioral and
physiological measures. Physiology \& behavior 118, 32.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

