Close this window to return to IVIS www.ivis.

org

Proceedings of the American Association of Equine Practitioners - Focus Meeting Focus on the Foot
Columbus, Ohio, USA 2009

Next Focus Meeting: July 18-20, 2010 - Focus on Upper and Lower Respiratory Salt Lake City, Utah, USA September 22-24, 2010 - Sport Horse Symposium Lexington, KY, USA (Joint with Alltech and Rood and Riddle Equine Hospital)

Reprinted in the IVIS website with the permission of the AAEP http://www.ivis.org

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

Why and When to Initiate a Pain Plan

Debra C. Sellon, DVM, PhD Authors address: Department of Veterinary Clinical Sciences, PO Box 646610, Washington State University, Pullman, WA 99164-6610; e-mail: dsellon@vetmed.wsu.edu.

Take Home Message Untreated pain can have negative physiological consequences that may delay recovery or have long-term adverse effects. Horses experiencing pain often show subtle clinical signs that could easily be overlooked. Pain management should be included as part of the therapeutic plan for any patient in which pain is considered likely. Introduction Veterinary practitioners witness behavioral evidence of the perception of pain on a daily basis as they work with equine patients. Injections and sharp surgical incisions can induce violent aversive reactions that endanger the veterinarian and the patient if pain is not managed effectively. While the perception of pain by horses is rarely questioned, the nature, quality, and significance of pain perception in horses are points of marked debate. Historically, veterinarians have considered pain control in large animal species as synonymous with restraint. As a result, they routinely utilized analgesic medications when performing a procedure with the potential to induce pain or distress (e.g. castration) but did not often continue analgesic therapy into the postoperative period. Reasons for the lack of continuing analgesic therapy are still considered quite compelling by many veterinarians: possibility of adverse effects from analgesic medication, risk of further injury if the protective function of pain is removed, lack of availability of analgesic drug options, cost of therapy, or practical concerns regarding client compliance with medication recommendations. In 2001, a letter to the editor of Veterinary Record from a highly experienced equine practitioner suggested that horses experience little or no pain after castration and questioned the routine administration of postoperative analgesic medications for all equine castrations.1 This conclusion was based on the lack of behavioral signs of inguinal or abdominal pain (sweating, rolling, stretching, etc) after the procedure. Rebuttal letters from other, equally experienced equine practitioners argued eloquently that horses do, indeed, experience significant pain after castration but that pain is manifest in more subtle changes in behavior.2-4 What is the truth? Despite the universality of pain, it is a uniquely personal experience that is difficult or impossible to quantify. None of us can know the extent to which another individual or animal truly feels pain in any given situation. The neural pathways and higher centers of perception in horses bear enough similarity to those of humans to convince most knowledgeable individuals that the physiology and perception of pain is very similar in our equine patients. However, domestic animal species probably have significantly less ability to appreciate the psychological component of fear of death or impending doom that contributes greatly to the emotional response to pain

203
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

that occurs in injured human patients.5 It is impossible to know to what extent this difference in emotional response impacts the physiological responses to painful stimuli in domestic animals. This manuscript will review the available evidence describing the physiological effects and behavioral indicators of pain. As a necessity, much of the information related to physiological consequences of acute and chronic pain is drawn from studies in species other than the horse. The need to extrapolate information from diverse species clearly limits the validity of interpretation and questions the applicability of this information to equine patients. However, in the absence of a large body of work related specifically to horses, and taking into consideration the consistency of results across multiple mammalian species in which pain has been more extensively studied, it is appropriate for equine practitioners to be aware of this information as they consider why and when to initiate a pain plan for their equine patients. Consequences of Untreated Pain Much of our knowledge of the role that pain plays in overall health and healing after injury or illness derives from investigations into the importance of postoperative pain in the recuperative process after surgical interventions in species other than the horse. Pain responses are an important part of an overall neurohumoral stress response to surgery that is also influenced by anxiety, fluid loss, hemorrhage, endotoxemia, or fear, and infection. The stress response induces neural, endocrine, immune, hematologic, and metabolic changes that are intended to restore homeostasis in the patient. Not surprisingly, uncontrolled pain and its associated stress responses can have a variety of adverse consequences on organ and tissue function. These are summarized in Table 1. Pain activates the autonomic nervous system with a resultant overall increase in sympathetic tone. This manifests as an increase in heart rate, peripheral vascular resistance, arterial blood pressure, myocardial contractility, and myocardial oxygen consumption.6 Effective analgesia mitigates these responses and may lessen the risk of cardiovascular morbidity and mortality. The net cardiovascular benefits of effective post-surgical analgesia in humans include decreased risk of heart attack, thromboembolism, and stroke. In cats, systolic blood pressure is a good clinical predictor of postoperative pain after ovariohysterectomy.7 In a study of horses with experimentally induced tarsocrural synovitis, blood pressure, as measured non-invasively with a tail cuff and oscillometric device, had excellent sensitivity and good specificity as an indicator of postoperative pain.8 Increased sympathetic tone also has negative effects on gastrointestinal function with increased smooth muscle sphincter tone, decreased intestinal motility, increased risk of postoperative ileus, and increased incidence of postoperative nausea and vomiting in humans.9-11 Postoperative ileus is one of the most common adverse sequelae of abdominal surgery in horses. Contributing factors for ileus in horses likely include prolonged preoperative intestinal distension, manipulation of intestine at surgery, effects of drugs administered before and during surgery, and a variety of fluid/acid/base/electrolyte disturbances. Focus on reduction and alleviation of these contributing factors is routinely recommended for prevention and treatment of postoperative ileus in horses, but increased attention to the possible role of improperly controlled pain may also be important. Continuous rate intravenous infusion (CRI) of lidocaine has been widely used as a

204
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

System or Function Affected Cardiovascular

Primary Sequelae Tachycardia Hypertension Arrhythmias Anorexia Gastric ulceration Ileus Nausea, vomiting Hypoxemia (V/Q mismatch) Oxygen deficit Pulmonary edema Pulmonary hypertension Respiratory acid-base imbalance Tachypnea Decreased GFR Impaired concentration of urine Renal hypertension Cachexia Increased oxygen demand Negative nitrogen balance Insomnia Immune response impairment

Secondary Effect Impaired cardiovascular function Cardiac dysrhythmias Increase in visceral pain Acid-base imbalance Electrolyte imbalance Negative energy balance Cardiac dysrhythmia Impaired respiratory function Global ischemia

Gastrointestinal

Pulmonary

Renal

Decreased renal clearance

Metabolism

Impaired wound healing

Sleep pattern Immune function

Behavior changes Increased incidence of secondary infection Hemorrhage

Platelet function

Clotting disorders

Table 1. Common sequelae of pain. (From, Gaynor JS et al. The Essential Guide to Pain Management: A Complete Resource for Veterinary Pain Management, authored by the Companion Animal Pain Management Consortium.)

promotility agent for prevention and treatment of postoperative ileus in horses.12,13 However, administration of CRI lidocaine to normal, anesthetized horses does not alter gastrointestinal motility patterns.14 It is possible that the improved gastrointestinal motility observed in patients at risk for postoperative ileus after treatment with CRI lidocaine are a result of indirect analgesic and anti-inflammatory drug effects rather than direct effects on gastrointestinal motility. Postoperative pain in humans contributes to involuntary spinal reflex responses, reflex muscle spasm, and splinting of the abdominal and thoracic muscles. The inability or reluctance to appropriately expand the thorax leads to hypoventilation and hypoxemia. This may be

205
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

compounded by diaphragmatic dysfunction with a resultant decrease in vital capacity of 40 to 60%. This contributes to risk for pulmonary thromboembolism, hypoxemia, tissue hypoxia, and decreased wound healing.15,16 Uncontrolled pain leads to an overall hypercoagulable state in human patients.17-19,29 Relative venous stasis, in part a result of decreased mobility in response to pain, contributes to an increased risk of deep vein thrombosis and pulmonary thromboembolism. While these specific complications are not often recognized in equine patients, alterations in hemostasis are extremely common in critically ill horses and contribute significantly to postoperative morbidity and mortality. It is reasonable to consider that adequate pain control may lessen the incidence or severity of disseminated intravascular coagulation, decreasing incidence of microvascular thrombosis and resultant organ dysfunction in critically ill horses. Alterations in cortisol, insulin, glucagon and other stress hormones lead to a catabolic state characterized by hyperglycemia, lipolysis, and protein catabolism with resultant weight loss and impaired wound healing.20-26 Humoral and cellular immunity are inhibited during the surgical stress response because of sympathetic stimulation, increased cortisol release and endogenous opioid activity. This leads to an increased incidence of postoperative infection and enhanced risk for tumor metastasis in humans.27,28 There are very few studies in horses that examine the effects of pain on stress and metabolic responses. However, investigators have demonstrated significant increases in plasma cortisol concentrations and decreased weight gain after surgery in horses experiencing pain.8,29 The long term benefits of early, aggressive pain management in humans are now being investigated in an effort to improve long-term outcomes.30 In addition to the acute impacts of poor pain control that are described above, inadequate analgesia after trauma is associated with development of chronic pain and posttraumatic stress disorder.24,31 In one recent study of U.S. service members with burns, the use of ketamine during the perioperative period was associated with a significant decrease in symptoms of post-traumatic stress disorder.32 Soldiers with battlefield injuries are receiving local anesthetic pumps at the site of injury within a few hours of trauma. Their response to this intervention will be monitored over the next several years to determine whether chronic pain is lessened for these patients. In 2005, Joshi33 stated the following in a review of the consequences of inadequate postoperative pain relief and chronic persistent postoperative pain in human patients: It is now well accepted that inadequately treated pain and associated stress response have significant physiologic and psychologic consequences, which may lead to organ dysfunction and increase postoperative mortality and morbidity. It is quite likely that the same associations between inadequate pain management and poor patient outcomes will eventually be described in horses. However, at this time there is a dearth of available information regarding the impact of analgesia on recovery in horses. In a randomized, placebo-controlled double blind study of horses undergoing exploratory celiotomy for abdominal pain, horses receiving flunixin meglumine and butorphanol for 24 hours after surgery lost significantly less weight and were discharged from the hospital earlier than horses

206
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

receiving only flunixin meglumine.29 These findings are consistent with reports of hastened recovery after abdominal surgery if human patients receive adequate postoperative analgesia. Additional equine studies are needed to confirm these results and determine the significance of the role that pain may play in equine patient morbidity and mortality. Recognition of Pain in Horses If uncontrolled pain has adverse pathophysiologic consequences that may contribute significantly to morbidity and mortality, it becomes imperative to recognize the presence of pain so that an appropriate therapeutic plan may be designed to optimize patient recovery. It is hypothesized that prey species, such as the horse, have evolved over time in ways that result in diminished outward expression (behavioral indicators) of pain and injury. Most equine veterinarians readily recognize signs of acute severe abdominal pain (pawing, rolling, flank gestures, etc.) or injury to the appendicular skeleton (varying degrees of lameness) but our ability to recognize more subtle pain or pain secondary to surgery or trauma is less certain. There is a paucity of objective scientific data regarding recognition and interpretation of pain behaviors in horses. This lack of basic information is compounded by the recognition that the intensity of pain perception and the subsequent behavioral responses after trauma or surgery can vary greatly depending upon individual genetic and environmental factors.34,35 The net result is that the degree of pain perceived by a patient and the extent of behavioral changes exhibited as a result of that perceived pain can vary markedly between individual patients after apparently identical noxious stimuli such as routine castration of a healthy colt. An informal survey of equine veterinarians within the United States asking them to grade the severity of pain after routine castration of a young colt on a scale of 0 (no pain) to 10 (worst possible pain) resulted in scores ranging from 1 to 9 (Sellon, 2005, unpublished data). The inability of equine veterinarians to agree on the severity of pain experienced by horses after castration is not surprising if we consider the experiences of small animal veterinarians. For many years, analgesic medications were considered unnecessary after routine spay and neuter surgeries of dogs and cats. In 1997, Hardie et al described behavior after ovariohysterectomy in normal dogs with or without analgesic medications.36 This work demonstrated that differences in behavior between dogs given analgesics and those given placebo drugs were readily quantifiable but that sometimes subtle changes in behavior were the most reliable indicators of post-operative pain. This work and several similar studies have led the way to a new level of consciousness about the importance of pain management in companion animals. However, the lessons learned have not been readily extended to equine patients. Pain assessment in small children and animals may be attempted using a variety of subjective behavior instruments. The most simple of these are the visual analog scale and the simple descriptive scale. A visual analog scale requires an observer to score the severity of pain in a patient on a range from 0 (no pain) to 10 or 100 (worst possible pain). The advantage of this type of instrument is its simplicity and internal consistency with a single observer. However, the agreement between untrained observers is often poor, making it difficult to determine trends in degree of pain in a patient that is monitored by multiple care-givers. A simple descriptive scale requires an observer to score pain severity as one of a few levels of severity (e.g. mild, moderate, severe). Numerical rating scales for assessing pain are more complicated than visual analog or

207
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

simple descriptive scales and may provide a more sensitive technique for assessing pain if appropriately validated prior to use. Several numeric rating scales have been devised for assessment of canine pain. Most of these assign a numeric value to a variety of defined behaviors and the sum of the individual values is defined as the pain score for that patient. A number of studies of small animal pain have used these types of instruments with some success. However, as with visual analog scales, individual observers are quite consistent in the use of numeric rating scales but inter-observer reproducibility is generally poor. What do we know about the behavioral expression of postoperative pain in horses? When equine veterinarians in the United Kingdom were asked how they recognize pain in their patients, the most common answers were evaluation of heart rate and subjective assessment of behavior.37 It is widely believed among veterinarians and veterinary students that increased heart rate is a reliable indicator of pain in horses. However, studies of postoperative pain in small animals, horses, and laboratory animals fail to support this belief.8,29,38-41 While heart rate increases with severe pain, the variety of other factors that can influence it (hydration status, sepsis, arrhythmia, anxiety, fear) render heart rate unreliable as a sole indicator of pain in most clinical settings. There are remarkably few reported attempts to develop behavior-based pain scoring systems for horses. A few simple or multidimensional scoring systems for assessing pain after arthroscopic surgery have been described. Raekallio et al used a total post-operative pain severity index (TPPSI) to assess pain after arthroscopic surgery in horses.39,40 The TPPSI incorporated simple behavioral observations, a subjective pain score, assessment of degree of lameness, heart rate, and evaluation of stress hormones. The authors concluded that the behavioral assessment provided little useful information over the more subjective pain scoring and more objective physiologic measurements. The poor correlation between their subjective pain score and their attempt at a more objective behavior assessment supports the conclusion that the techniques used did not permit sensitive or reliable evaluation of postoperative pain. Price et al analyzed data from video recordings of horses before and after arthroscopic surgery to identify behaviors suggestive of postoperative pain.42 There was a wide variation in individual responses and the effect of general anesthesia on postoperative behavior was not assessed. The behaviors that differed most in postoperative horses as compared to presurgical behavior included indicators of restlessness, locomotion and positioning in the stall. These behaviors were more apparent in review of videotapes than in direct behavioral observation for a limited period of time. The authors concluded that evaluation of activity budgets over time may be more useful for assessing pain than short-term direct behavioral observations. In 2004, Sellon et al used a numerical rating score incorporating direct postural observations (head height, ear position, location in stall, spontaneous locomotor activity) and social interactions with care-givers (response to human, lifting a foot, response to grain) to assess pain after colic surgery.29 Horses receiving flunixin meglumine and butorphanol infusions had more normal posture and social behaviors than horses receiving only flunixin meglumine. Horses in pain were characterized by lack of locomotion, standing quietly in the back of the stall with head and neck lowered and ears immobile, and exhibiting minimal responses to human interactions.

208
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

In 2007, Bussieres et al described a composite orthopedic pain scale to assess pain in horses after experimental induction of synovitis with amphotericin B injection into the tarsocrural joint.8 The most sensitive and specific behavioral indicators of pain were response to palpation of the painful area, posture, and to a lesser extent pawing on the floor. These behaviors included the classic altered weight distribution and altered limb loading/position that is recognizable by most equine practitioners as lameness or limb pain. Conclusions The equine veterinarian has minimal evidence from specific equine studies on which to make informed decisions regarding analgesic strategies for their patients. However, the preponderance of available evidence from other species strongly supports the need for aggressive, multimodal analgesia to enhance patient comfort, physiological function, and outcome. As awareness of these considerations increase among equine clinicians and horse owners, it is hoped that specific research will emerge to better support clinical decision-making. References 1. 2. 3. 4. 5. 6. Green P. Castration of horses and analgesia. Vet Rec 2001;149:160. Capner C. Castration of horses and analgesia. Vet Rec 2001;149:252. Harris R. Castration of horses and analgesia. Vet Rec 2001;149:279-280. Jones R. Castration of horses and analgesia. Vet Rec 2001;149:252. Campbell CM, Edwards RR. Mind-body interactions in pain: the neurophysiology of anxious and catastrophic pain-related thoughts. Transl Res 2009;153:97-101. Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 2004;101:153-161. Smith JD, Allen SW, Quandt JE, et al. Indicators of postoperative pain in cats and correlation with clinical criteria. Am J Vet Res 1996;57:1674-1678. Bussieres G, Jacques C, Lainay O, et al. Development of a composite orthopaedic pain scale in horses. Res Vet Sci 2008;85:294-306. Baig MK, Wexner SD. Postoperative ileus: a review. Dis Colon Rectum 2004;47:516526. Fotiadis RJ, Badvie S, Weston MD, et al. Epidural analgesia in gastrointestinal surgery. Br J Surg 2004;91:828-841. Kuo CP, Jao SW, Chen KM, et al. Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery. Br J Anaesth 2006;97:640-646. Doherty TJ, Frazier DL. Effect of intravenous lidocaine on halothane minimum alveolar concentration in ponies. Equine Vet J 1998;30:300-303. Murrell JC, White KL, Johnson CB, et al. Investigation of the EEG effects of intravenous lidocaine during halothane anaesthesia in ponies. Vet Anaesth Analg 2005;32:212-221. Milligan M, Beard W, Kukanich B, et al. The effect of lidocaine on postoperative jejunal motility in normal horses. Vet Surg 2007;36:214-220.

7. 8. 9. 10. 11.

12. 13. 14.

209
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

15.

16. 17. 18. 19. 20. 21. 22. 23.

24. 25. 26. 27. 28. 29.

30.

31. 32.

33. 34. 35.

Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998;86:598-612. Desai PM. Pain management and pulmonary dysfunction. Crit Care Clin 1999;15:151166, vii. Jorgensen LN, Rasmussen LS, Nielsen PT, et al. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth 1991;66:8-12. Rosenfeld BA, Faraday N, Campbell D, et al. Hemostatic effects of stress hormone infusion. Anesthesiology 1994;81:1116-1126. Tuman KJ, McCarthy RJ, March RJ, et al. Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991;73:696-704. Flecknell PA, Roughan JV, Stewart R. Use of oral buprenorphine ('buprenorphine jello') for postoperative analgesia in rats--a clinical trial. Lab Anim 1999;33:169-174. Lattermann R, Belohlavek G, Wittmann S, et al. The anticatabolic effect of neuraxial blockade after hip surgery. Anesth Analg 2005;101:1202-1208, table of contents. Liles JH, Flecknell PA. The effects of surgical stimulus on the rat and the influence of analgesic treatment. Br Vet J 1993;149:515-525. McGregor NR, Zerbes M, Niblett SH, et al. Pain intensity, illness duration, and protein catabolism in temporomandibular disorder patients with chronic muscle pain. J Orofac Pain 2003;17:112-124. Schricker T, Meterissian S, Wykes L, et al. Postoperative protein sparing with epidural analgesia and hypocaloric dextrose. Ann Surg 2004;240:916-921. El-Husseini T, El-Kawy S, Shalaby H, et al. Microcurrent skin patches for postoperative pain control in total knee arthroplasty: a pilot study : A pilot study. Int Orthop 2006. Ueno C, Hunt TK, Hopf HW. Using physiology to improve surgical wound outcomes. Plast Reconstr Surg 2006;117:59S-71S. Page GG. The immune-suppressive effects of pain. Adv Exp Med Biol 2003;521:117-125. Page GG. Surgery-induced immunosuppression and postoperative pain management. AACN Clin Issues 2005;16:302-309; quiz 416-308. Sellon DC, Roberts MC, Blikslager AT, et al. Effects of continuous rate intravenous infusion of butorphanol on physiologic and outcome variables in horses after celiotomy. J Vet Intern Med 2004;18:555-563. Malchow RJ, Black IH. The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit Care Med 2008;36:S346-357. Zatzick DF, Rivara FP, Nathens AB, et al. A nationwide US study of post-traumatic stress after hospitalization for physical injury. Psychol Med 2007;37:1469-1480. McGhee LL, Maani CV, Garza TH, et al. The correlation between ketamine and posttraumatic stress disorder in burned service members. J Trauma 2008;64:S195-198; Discussion S197-198. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005;23:21-36. Mogil JS, Wilson SG, Bon K, et al. Heritability of nociception II. 'Types' of nociception revealed by genetic correlation analysis. Pain 1999;80:83-93. Mogil JS, Wilson SG, Bon K, et al. Heritability of nociception I: responses of 11 inbred mouse strains on 12 measures of nociception. Pain 1999;80:67-82. 210
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009

Published in IVIS with the permission of the AAEP

Close this window to return to IVIS

36. 37. 38. 39.

40. 41.

42.

Hardie EM, Hansen BD, Carroll GS. Behavior after ovariohysterecomy in the dog: what's normal? Appl Anim Behav Scie 1997;51:111-128. Price J, Marques JM, Welsh EM, et al. Pilot epidemiological study of attitudes towards pain in horses. Vet Rec 2002;151:570-575. Hansen BD, Hardie EM, Carroll GS. Physiological measurements after ovariohysterectomy in dogs: what's normal? Appl Anim Behav Sci 1997;51:101-109. Raekallio M, Taylor PM, Bennett RC. Preliminary investigations of pain and analgesia assessment in horses administered phenylbutazone or placebo after arthroscopic surgery. Vet Surg 1997;26:150-155. Raekallio M, Taylor PM, Bloomfield M. A comparison of methods for evaluation of pain and distress after orthopaedic surgery in horses. J Vet Anaesth 1997;24:17-20. Dzikiti TB, Hellebrekers LJ, van Dijk P. Effects of intravenous lidocaine on isoflurane concentration, physiological parameters, metabolic parameters and stress-related hormones in horses undergoing surgery. J Vet Med A Physiol Pathol Clin Med 2003;50:190-195. Price J, Catriona S, Welsh EM, et al. Preliminary evaluation of a behaviour-based system for assessment of post-operative pain in horses following arthroscopic surgery. Vet Anaesth Analgesia 2003;30:124-137.

211
Proceedings of the AAEP Focus Meeting on the Foot - Columbus, OH, USA, 2009