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The Many Forms of Tying-Up Disease


by Dr. Martin Adams – Equine Nutritionist for Southern States

The symptoms of tying-up disease include muscle stiffness, painful contractions, sweating, reluctance to move, and rapid respiratory rates. Severe cases of tying-up disease can result in horses being unable to move their hindquarters after exercise, and muscle breakdown results in dark urine due to the release of myoglobin. Tying-up disease was first recognized in draft horses over 150 years ago. It became known as Monday morning disease as draft horses were affected when they were rested from routine work on Sunday and fed their usual grain ration. These horses developed signs of tying-up disease when they resumed work on Monday morning. Other terms for this syndrome include azoturia, shivers, and exertional rhabdomyolysis.

A study performed in 1932 showed that draft horses given large amounts of nonstructural carbohydrates, such as molasses, were more likely to develop muscle damage after exercise. Therefore, it has become common to recommend a low grain diet for all horses with tying-up disease. The same scientist who did the 1932 study believed the high carbohydrate diet given while horses were resting resulted in high levels of muscle glycogen, which in turn resulted in excessive lactic acid accumulation during exercise. While decreasing the amount of grain appears to be helpful for horses with sporadic tying-up disease, there are chroric forms of tying up disease that require more intensive nutritional management. Lactic acid is not the cause of chronic tying-up disease, as there have been no documented cases of horses developing severe lactic acid accumulation with tying-up disease developing after exercise. In addition, many horses have developed tying-up disease at slow speeds when lactic acid is not produced.

There has been much confusion and controversy regarding the cause and treatment of tying-up disease. Tying-up or exertional rhabdomyolysis is not one specific syndrome, but represents several muscle diseases that have common symptoms. By applying clinical protocols that include muscle biopsies and exercise testing, several specific disorders have been identified. Tying-up disease can be divided into two basic types: 1) sporadic rhabdomyolysis following exercise in horses that have a previous history of satisfactory performance, or 2) chronic exertional rhabdomyolysis in horses with repeated episodes of tying-up from a young age.

Sporadic tying-up is due to local muscle strain, which is a common injury in performance horses. Several factors can predispose horses to muscle strains, including inadequate warm-up, pre-existing lameness, exercise to the point of fatigue, and insufficient training. Horses affected with sporadic tying-up will not have previous signs of tying-up disease, and will have muscle cramping and stiffness following exercise. These affected horses will have moderate to high levels of blood markers for muscle damage, such as creatine kinase (CK) and aspartate transaminase (AST), that leak into the bloodstream when muscle is damaged.

Horses with signs of sporadic tying-up should stop exercising and be moved to a well-bedded stall with access to fresh water. A veterinarian should be called to assess whether horses need intravenous or oral fluids, tranquilizers, or pain relievers. Rest with a few minutes of hand walking, once the initial stiffness has abated is important. The diet should be changed to good quality hay with little grain supplementation, such as Triple Crown Lite, or provided a mineral/vitamin supplement, such as EquiMin Horse Mineral. Horses that appear to have damaged their muscles from overexertion will benefit from a rest period of 4 to 8 weeks with regular access to an exercise paddock. Training should be resumed gradually up to the previous level, along with an increase in grain feeding to maintain proper body condition. Feeds with high fat levels, such as Legends® CarbCare Performance, Triple Crown 10% or 14% Performance Formula, or Triple Crown Complete are recommended. More energy-dense feeds can be fed at lower levels, resulting in lower soluble carbohydrate (sugar and starch) levels in the horse's diet. Legends® Fortified Pelleted Rice Bran and Triple Crown Rice Bran Oil Plus are also recommended. Feeding 1 to 2 pounds of rice bran (18 to 20% fat) or four to eight ounces of Triple Crown Rice Bran Oil Plus as part of the horse's daily ration provide a large number of calories, and can greatly reduce the amount of grain required.

Chronic exertional rhabdomyolysis is seen in many breeds of horses including Quarter Horses, Paints, Appaloosas, Thoroughbreds, Arabians, Standardbreds, and Morgans. Diagnostic tests used to determine the cause of chronic tying-up include a complete blood count, serum chemistry panel, blood vitamin E and selenium concentrations, urinalysis to determine electrolyte balance, exercise testing, muscle biopsy, and dietary analysis.

Two forms of chronic tying-up have been identified using muscle biopsies as a definitive test. Polysaccharide Storage Myopathy (PSSM) is a form of tying-up in Quarter Horse-related breeds. Draft and warm blood breeds may be affected by a related disorder called Equine Polysaccharide Storage Myopathy (EPSM) that has slightly different clinical signs. These include loss of muscle mass, difficulty in standing with one leg raised, difficulty in backing without shaking a hind limb, and progressive weakness.

Muscle biopsies of PSSM horses show fast-twitch fibers that have a characteristic stain when treated with p-aminosalicylic acid and examined microscopically (PAS positive inclusions), which indicates an abnormally high accumulation of glycogen. Feeding two pounds of rice bran daily with grass hay to PSSM-affected Quarter Horses significantly reduced blood glucose and insulin levels, muscle glycogen levels, and tying-up symptoms in a research study. Horses affected with PSSM engaged in competitive events will have greater caloric requirements. These horses will need low-soluble carbohydrate feeds such as Legends® CarbCare Performance, Triple Crown Low Starch, Triple Crown Complete and Triple Crown Training Formula, or may require additional rice bran (Legends® Fortified Pelleted Rice Bran) or oil (Triple Crown Rice Bran Oil Plus) as supplements to reduce grain feeding and lower the soluble carbohydrate content of the total diet. Gradually increasing the amount of daily exercise, minimizing stress, providing a regular routine, and daily turnout are beneficial in prevention of further tying-up episodes.

Horses suspected of EPSM should be placed on a high fat, low soluble carbohydrate diet. Due to the greater amount of type 2a muscle fibers in draft and warm blood breeds than Quarter Horse-related breeds, these horses utilize more fat in the oxidative state and are less dependent on glycogen utilized by type 2b fibers. A high fat diet provides better muscle function for these horses, so high fat, low soluble carbohydrate feeds recommended include Legends® CarbCare Performance Pelleted, Triple Crown Complete, Triple Crown Senior and Triple Crown Training Formula. Rice bran (Legends® Fortified Pelleted Rice Bran) and oil (Triple Crown Rice Bran Oil Plus) can also be added to the diet to increase the fat content.

Recurrent Exertional Rhabdomyolysis (RER) is a disorder of Thoroughbreds, and may also occur in Standardbred and Arabian breeds. RER is most common in young Thoroughbred fillies, and factors that trigger an episode include excitement with exercise, galloping or breezing exercise, feeding large amounts of grain, and any lameness that would not interrupt the training regime, but would cause pain and stress. A diagnosis of RER is based on the horse's history and clinical signs, as well as elevations in muscle enzymes (serum AST and CK). Muscle biopsy findings in affected horses include signs of muscle necrosis and the development of contractures when exposed to halothane and caffeine.

Replacing the traditional grain-based feed with a high-fat, high-fiber feed that is low in soluble carbohydrates (Triple Crown Senior, Triple Crown Complete and Legends® CarbCare Performance Pelleted) will reduce excitability in horses on a high starch diet, and will significantly reduce muscle damage in horses afflicted with RER. Prevention of further episodes of RER in susceptible horses should include an environment that minimizes excitement and a standardized daily routine. Daily turnout in a paddock after 24 hours of an attack is recommended, with a gradual return to training that may be resumed once the serum CK level is within normal range.


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