Equine Veterinary Journal ISSN 0425-1644

DOI: 10.1111/evj.12384

A comparison of seven methods for continuous therapeutic cooling

of the equine digit
A. W. VAN EPS and J. A. ORSINI*†
University of Queensland, Gatton, Australia
†
New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, USA.

*Correspondence email: orsini@vet.upenn.edu; Received: 03.06.14; Accepted: 06.11.14

Summary
Reasons for performing study: Digital hypothermia may be effective for laminitis prophylaxis and therapy, but the efficacy of cooling methods used in
clinical practice requires evaluation.
Objectives: To use hoof wall surface temperature (HWST) to compare several cooling methods used in clinical practice.
Study design: Experimental crossover design with a minimum washout period of 72 h.
Methods: Seven cooling methods (commercially available ice packs, wraps and boots) and one prototypical dry-sleeve device were applied to a single
forelimb in 4 horses for 8 h, during which HWST of the cooled forelimb and the uncooled (control) forelimb was recorded hourly. Results were analysed
descriptively.
Results: The median (range) HWST from 2–8 h was lowest for the ice and water immersion methods that included the foot and extended proximally to at
least include the pastern: 5.2°C (range: 4.8–7.8°C) for the fluid bag and 2.7°C (2.4–3.4°C) for the ice boot. An ice boot that included the distal limb but not
the foot resulted in a median HWST of 25.7°C (20.6–27.2°C). Dry interface applications (ice packs) confined to the foot only resulted in a median HWST of
21.5°C (19.5–25.5°C) for the coronet sleeve and 19.8°C (17.6–23°C) for a commercial ice pack. For the dry interface applications that included the foot and
distal limb, the median HWST was much higher for the ice pack device, 19.9°C (18.7–23.1°C), compared with the perfused cuff prototype of 5.4°C (4.2–7°C).
Conclusions: Immersion of the foot and at least the pastern region in ice and water achieved sustained HWST <10°C as did a prototype perfused cuff device
with a dry interface. Variation between cooling methods may have a profound effect on HWST and therefore efficacy in clinical cases where laminitis
prophylaxis or therapy is the goal.

Keywords: horse; hoof; cryotherapy; hypothermia; laminitis

Introduction
Continuous cooling of the equine digit has been shown to limit effectively
the biochemical, histological and clinical abnormalities of experimentally
induced acute laminitis in the oligofructose model [1–5]. Although the
mechanisms have yet to be fully elucidated, recent work has shown that
digital hypothermia (cryotherapy) interrupts multiple inflammatory
signalling pathways and increases expression of the anti-inflammatory
interleukin IL-10 in the lamellar tissue [4]. It is likely that local vascular and
metabolic mechanisms are also involved [6].
Prophylactic digital cryotherapy has been associated with a reported
decreased incidence of laminitis in horses diagnosed with colitis in a 10
year multicentre retrospective clinical case series. Application of
prophylactic digital cryotherapy to the distal limb in that case series was by
means of a 5 l fluid bag (Plasmalytea or Normosol-Rb) secured to the limb
using duct tape and regularly replenished with ice [7].
The current recommendation for laminitis prevention in horses at risk is
to maintain a hoof wall surface temperature (HWST) of 5–10°C for 48–72 h
(typically the maximum length of the developmental phase in experimental
systemic inflammatory models), and longer if the risk persists [6]. Digital
hypothermia has recently been confirmed in an oligofructose model to
prevent or limit lamellar failure even when initiated after the onset of
lameness (Obel grade 2 laminitis) [5]; but, as with prophylactic
hypothermia, therapeutic hypothermia may be required for several days
when used in this way for clinical cases [2–4].
In the aforementioned studies, an ice-water immersion bath or boot
were used to continuously cool the hoof and distal limb for the requisite
treatment period. However, albeit effective, this is impractical in many
clinical situations, as horses must be continuously restrained for these
methods and the ice must be replenished every 1–2 h or the water
continuously cooled using another method, such as circulation through a
refrigeration system. Simpler methods of cooling the hoof that are used in
clinical practice include commercial or home-made ice packs, commercial
gel wraps that are chilled in a residential freezer, addition of ice or
ice-water to a wader-style hydrotherapy boot and standing the horse in a
cold pond or stream. These methods vary in the extent to which the distal
120
limb and hoof are in contact with the cooling device and whether there is
wet (water immersion) or dry contact with the limb. Although they may be
more practical than an ice-water immersion bath/boot, there have been no
published studies evaluating the cooling effects of these methods on the
equine distal limb.
Although an effective clinical temperature range has not been
established, experimental studies have consistently demonstrated a
therapeutic and prophylactic effect when either mean hoof internal or
surface temperature has been reported in a range from 3.5 to 7.1°C [1–6].
For clinical use, it has been recommended (based on these results) that
hoof temperature should be maintained at <10°C with the goal of targeting
the experimental study temperatures reported in the literature, since the
efficacy of less profound cooling has not been evaluated [8]. The goal of
this study was to obtain data on the hoof temperatures achieved using
several methods that are currently used in clinical practice for cooling the
equine distal limb and also to evaluate a prototypical dry-sleeve cooling
device. By comparing each method under identical experimental
conditions, the goal was to determine which of these cooling systems
could be expected to provide effective and sustained cooling of the
lamellar tissues under field conditions.
Materials and methods
Experimental design and animals
This prospective cross-over study used 4 healthy, mature Thoroughbred
horses with no history or clinical signs of laminitis. The study followed
institutional guidelines for the humane treatment of experimental animals
and was approved by the ethics review committee. During each treatment
period, the horses were cross-tied in a stall on rubber flooring and
provided with hay and water ad libitum. The horses were monitored
throughout the study for signs of discomfort or other adverse events.
Each horse served as its own control and underwent treatment with
each of the 7 cooling devices in turn, the experiments each separated by at
least 72 h. The order of treatments was randomised for each horse. During
Equine Veterinary Journal 48 (2016) 120–124 © 2015 EVJ Ltd
A. W. van Eps and J. A. Orsini
a) b)
d) e)
the experiments, the cooling device under investigation was applied to
only the left forelimb, the right forelimb serving as the untreated control.
Before application of the cooling device, surface temperature probesc
attached to data-logging devices (Tinytag)c were applied to the dorsal hoof
wall of both forefeet to measure hoof wall surface temperature (HWST); the
probes were attached to the hoof wall with an adhesive tape and centred
2.0 cm distal to the coronary band [4]. Temperature measurements were
recorded hourly for both the treated and untreated feet throughout the 8 h
experimental period. Ambient temperature was also recorded hourly.
Cooling methods
Seven cooling methods were evaluated:
1 Coronet sleeve: a thin plastic rectal sleeve (OB Sleeves)d filled with
crushed ice was applied to the coronary band, over the dorsum of the
foot and extending around the lateral and medial sides of the foot to the
heel bulbs; it was held in place using adhesive tape (Fig 1a). This method
provided dry contact, but to the foot only.
2 Ice pack, foot only: a commercially available cooling gel wrap
(TheraMed)e was applied to the hoof wall, after having been chilled
according to manufacturer recommendations in a freezer; it was held in
place using its own fasteners (Fig 1b). This method provided dry
contact, but to the foot only.
3 Ice pack, foot and distal limb: a commercially available cooling gel wrap
(TheraMed)e was applied to the hoof wall as described for Method 2, and
a second, identical gel wrap was applied proximal to it, over the fetlock
and metacarpus, after both wraps had been chilled in a freezer; the
wraps were held in place using their own fasteners (Fig 1c). This method
provided dry contact to the foot and distal limb.
4 Ice boot, distal limb only: a commercially available ice boot (Jack’s Ice
Boot)f was applied to the distal limb, extending from pastern to proximal
metacarpus. A cuff fitted snugly around the pastern kept the ice from
falling out the bottom of the boot, and the body of the boot was a
loose-fitting nylon sleeve into which ice was added. The boot was held in
place using its own fasteners and suspenders (Fig 1d). This method
provided wet contact, but to the distal limb only.
5 Ice boot, foot and distal limb: a wader-style boot was used as an
ice-water immersion boot encompassing hoof and distal limb, as
Equine Veterinary Journal 48 (2016) 120–124 © 2015 EVJ Ltd
Seven methods for continuous therapeutic cooling of the equine digit
c)
Fig 1: Various methods of cooling the hoof.
a) Coronet sleeve; b) ice pack (foot only); c) ice pack
f) (foot and distal limb); d) ice boot (distal limb only);
e) ice boot (foot and distal limb); f) fluid bag with ice.
previously described [1] (Fig 1e). This method provided wet contact to
the foot and distal limb.
6 Fluid bag with ice: an empty 5 l i.v. fluid bag (Plasmalytea or Normosol-Rb)
was repurposed as an ice boot by cutting off the infusion end, placing
the horse’s foot inside the bag, and filling the rest of the bag with ice; the
top of the bag was closed and held in place with adhesive tape (Fig 1f).
This method provided wet contact to the foot and pastern.
7 Perfused cuff: a prototype of a portable dry-sleeve cooling device
(GameReady)g, which uses continuously recirculated coolant (kept
refrigerated at a constant 1°C using a custom adapted refrigeration
system), was applied to encase the entire hoof and distal limb to the
proximal metacarpus (Fig 2). The cuff device consisted of 2
polyurethane layers; the inner layer served as a heat-transfer interface
between the skin and hoof and a circulating chilled coolant confined
within in a closed system. The outer layer was an air-bladder that was
inflated to 5–15 mmHg that enhanced contact between the inner
(heat-transfer) layer and the skin of the distal limb. This method provided
dry contact to the foot and distal limb.
With the exception of Method 7, the ice or cold pack/wrap was
replenished or replaced every hour during the 8 h treatment period.
Data analysis
Data were analysed descriptively, with the low number of replicates (n = 4)
precluding meaningful statistical comparisons between treatment
methods. Values are expressed as median (range) (GraphPad Software)h.
Results
All 7 cooling methods were well tolerated and no adverse effects were
observed at any time. The HWST for the treated limb for all application
methods decreased initially before reaching a relatively steady state from
2 h onwards (Fig 3). The median control limb HWST 32.3°C (range:
28.6–35.4°C) was similar across treatment groups, as was ambient
temperature: 27.5°C (25.1–29.8°C). For dry cooling applications that
included the foot only, there was a median HWST (from 2–8 h) of 21.5°C
(19.5–25.5°C) for the coronet sleeve and 19.8°C (17.6–23°C) for the ice
121
Seven methods for continuous therapeutic cooling of the equine digit A. W. van Eps and J. A. Orsini

(2–4) or actual lamellar temperature [9] may not have reflected true
temperature fluctuations within the lamellar tissue. There have been no
published studies comparing HWST with internal hoof temperature or
actual lamellar temperature; however, in a study where surface
temperature was measured [4] the mean HWST was only 1°C greater than
that measured deep in the stratum medium in another study [1] which
used an identical limb cooling method.
The benefits of therapeutic hypothermia in the prevention and early
treatment of acute laminitis in horses are well established in experimental
models and now also in naturally occurring disease [1–8]; however, it is
unclear what tissue temperature is actually required for an effect. As the
mean HWST of the uncooled foot was approximately 30°C in the current
study as well as in previously reported experimental conditions [5], the
empirically recommended target HWST of <10°C represents a decrease of
at least 20°C below normal HWST and approximately 27°C below the
normal equine core body temperature. The practical challenges of such an
intervention in the average equine patient and clinical setting are obvious,
particularly as the cooling must be continuous and for a prolonged period
(often several days). There is a requirement for regular replenishment of
ice, which is labour intensive, and some methods restrict ambulation of the
horse and require confinement or restraint. Most of the cooling methods
a) Dry applications: foot only
40
Control
Ambient

Temperature (°C)
30
Coronet sleeve
Ice pack, foot only
Fig 2: Prototype of a portable, dry-sleeve cooling device. Contact with the distal limb 20
is aided by air pressure in an outer compartment, while the inner compartment serves
as a heat-transfer interface between the skin and hoof and a circulating chilled coolant
10
confined within in a closed system. The coolant is continuously circulated through a
refrigeration system (not shown).
0
0 1 2 3 4 5 6 7 8
pack (Fig 3a). For the dry applications that included the foot and distal limb, Time (h)
the median HWST (from 2–8 h) was much higher for the ice pack
application (19.9°C [18.7–23.1°C]) compared with the perfused cuff b) Dry applications: foot and distal limb
prototype (5.4°C [4.2–7°C]; Fig 3b). Wet applications that included both the 40
distal limb and foot (Fig 3c) resulted in a similar marked reduction in Control
median HWST from 2–8 h: 5.2°C (4.8–7.8°C) for the fluid bag and 2.7°C Ambient
Temperature (°C)

(2.4–3.4°C) for the ice boot; however the wet application (ice boot) that 30
Ice pack, foot and
included the distal limb only (but not the foot) resulted in median HWST of distal limb
25.7°C (20.6–27.2°C) for the same period. 20 Perfused cuff

10
Discussion
0
Marked differences in HWST were achieved over an 8 h experimental 0 1 2 3 4 5 6 7 8
period with a variety of different cooling methods that are currently used in Time (h)
clinical practice. Data collected using cooling methods that incorporated at
c) Wet applications
least a portion of the distal limb in addition to the foot tended to have the
lowest HWST and wet applications (ice water immersion) appeared to be 40
superior to applications with dry skin contact, with the exception of the Control
Ambient
Temperature (°C)

perfused cuff prototype. This is consistent with an important role for 30

cooling both the hoof itself as well as a portion of the arterial supply to the Ice boot, distal limb
foot (i.e. the palmar/plantar digital arteries) and also supports the only
20 Ice boot, foot and
proposition that superior conduction is achieved when water is in direct
contact with the haired distal limb [6]. The HWST results for the 5 l fluid bag distal limb
filled with ice and water were similar to those previously reported for this 10 Fluid bag with ice
method [9] and it appears that there is little difference, in terms of HWST,
when the application is extended more proximally than the fetlock region. 0
Dry application methods (ice packs) that lack any mechanism for 0 1 2 3 4 5 6 7 8
continuously circulating the portion of the cooling medium that is in direct Time (h)
contact with the limb performed poorly, whereas the perfused cuff
prototype (which constantly recirculates the cooling medium) resulted in Fig 3: Hoof wall surface temperatures in the treated and untreated (control) feet of 4
HWST comparable to the wet application methods. The ice boot that healthy, mature horses during the 8 h application of 7 different methods for cooling
the foot. Dry applications that included the foot only (a) or the distal limb and the foot
incorporated the distal limb but not the foot (Jack’s Ice Boot) was least
(b) were relatively ineffective with the exception of the perfused cuff prototype. The
effective in reducing HWST. HWST is affected by the ambient temperature ice and water immersion methods (c) that included the foot and a portion of the distal
surrounding the hoof, as well as the underlying lamellar tissue perfusion limb (ice boot and fluid bag with ice) were most effective; however, the ice boot that
and metabolic rate [10], therefore it is possible that HWST measured in the did not include the foot was least effective in reducing hoof wall surface temperature.
current study, rather than internal (stratum medium) hoof temperature Data points and bars represent median ± range.

122 Equine Veterinary Journal 48 (2016) 120–124 © 2015 EVJ Ltd

A. W. van Eps and J. A. Orsini
tested in this study, which represent methods commonly used in clinical
practice, do not achieve HWST <10°C; however, it is not known whether
even small decreases in lamellar temperature might still provide some
benefit during the developmental or early acute phases of laminitis. Human
medical research indicates that lowering tissue temperature by even 5°C
(i.e. 5°C below normal body temperature) can be helpful in clinical disease
states, particularly sepsis [11–14]. In rodent models of sepsis, mild to
moderate whole body hypothermia (6–8°C below normal) had survival
benefits and reduced acute lung and liver injury [15–17]. Therefore, even
the least effective methods tested in this study, which caused a minimum
5–10°C decrease in HWST, may have some prophylactic or therapeutic
effect.
In the only clinical study of cryotherapy for laminitis prophylaxis, Kullman
et al. [7] showed that horses with colitis were 10 times less likely to develop
laminitis when the limbs were cooled continuously for 48 h or more using
the 5 l fluid bag method, with ice replenished every 2 h. Although this
method is inexpensive and allows the horse some limited ambulation in a
stall environment, it is highly labour intensive and probably not practical
outside a hospital environment. Although there were no complications
reported in that study, there are anecdotal reports of complications
associated with particularly longer term (>5 days) continuous cryotherapy
in horses using wet application methods. Prolonged exposure to cold and
moisture (days to weeks) is associated with the development of ‘immersion
foot’ and ‘trench foot’ in human patients [18]. Local swelling and pain are
features of these conditions, which may progress to blistering of the skin,
nerve damage and gangrene [19]. Although the ungulate foot and skin are
anatomically and physiologically very different from those of the human,
there are anecdotal reports of a similar phenomenon in horses being
treated with digital hypothermia, specifically with the application of ice
cubes directly to skin (without a sufficient water interface). Although
dermatitis of the pastern and maceration of the coronary band can occur
with prolonged therapy (unpublished data), the risks associated with
therapy are likely to be outweighed by benefit to the horse at risk of
developing laminitis. However, the future development of an ideal cooling
device for long-term use incorporating a dry interface may be preferable.
In the current study, the HWST achieved by the dry-sleeve perfused cuff
prototype was comparable to ice and water immersion, and such a device
has the potential benefit of being less labour intensive and providing more
accurate temperature control, which could enhance efficacy and safety in
the clinical environment. A similar device was used in a previous study
examining flexor tendon cooling in horses [20]. It should be emphasised
that until further data are available, the use of methods that achieve
consistent HWST <10°C is advisable in clinical patients for laminitis
prevention and treatment.
Limitations of the current study include the small number of replicates
and the relatively short testing period (8 h). Although it lacked the number
of replicates required for robust formal statistical comparisons, this study
was conducted in a cross-over design with consistent ambient conditions
and therefore presents useful data on which further studies comparing
cooling methods can be formulated. Although it is recommended in horses
at risk of laminitis that digital hypothermia is maintained for at least 48 h
[6], the 8 h study period was chosen for the current study because in
previous experiments there has been little variation in hoof temperature
after the first 2–4 h after initiation of cooling [1–5].
In conclusion, the current data indicate that the ice-water immersion
methods that included the foot and a portion of the distal limb (wader boot
and 5 l fluid bag) and a prototype perfused cuff were effective in reducing
HWST to <10°C for an 8 h study period. These methods cooled both the
hoof and the blood flowing into the hoof (they extended from the ground
surface to at least the fetlock) and either had a water interface or used a
pressure mechanism to maximise contact and therefore conduction
between the limb and the coolant. Further studies are required to
determine the optimum systems and protocols for limb cooling in horses
for the prevention and treatment of laminitis.
Authors’ declaration of interests
Funding for evaluation of the dry-sleeve prototype and the device itself
was provided by CoolSystems, Inc.
Equine Veterinary Journal 48 (2016) 120–124 © 2015 EVJ Ltd
Seven methods for continuous therapeutic cooling of the equine digit
Ethical animal research
This study was approved by the IACUC Committee of the University of
Pennsylvania.
Sources of funding
Support for this research were provided by the Spot Castle Fund and Game
Ready Equine.
Acknowledgements
The authors thank Emily Schaefer and Amanda Ziegler for technical
assistance in completing this study.
Authorship
A. van Eps and J. Orsini designed, executed, interpreted, prepared and
approved the manuscript as colleagues and co-authors.
Manufacturers’ addresses
a
Baxter Healthcare Corp., Deerfield, Illinois, USA.
b
Abbott Laboratories, North Chicago, Illinois, USA.
c
Gemini Data Loggers (UK) Ltd, Chichester, West Sussex, UK.
d
VET ONE/MWI, Meridian, Idaho, USA.
e
Medichest, Inc., Charlotte, North Carolina, USA.
f
Jack’s Inc., Washington Court House, Ohio, USA.
g
CoolSystems, Inc., Concord, California, USA.
h
GraphPad Software, San Diego, California, USA.
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