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Topic:Rehabilitation

Rehabilitation for horses refers to the process of restoring physical function and performance following injury, illness, or surgery. This process often involves a combination of veterinary care, physical therapy, and specialized training techniques. Rehabilitation aims to promote healing, improve mobility, and prevent further injury. Common methods used in equine rehabilitation include controlled exercise programs, hydrotherapy, and the use of therapeutic modalities such as laser therapy and ultrasound. The effectiveness of these methods is evaluated through clinical assessments and performance metrics. This page compiles peer-reviewed research studies and scholarly articles that explore the methodologies, outcomes, and advancements in the field of equine rehabilitation.
Advances in Imaging Techniques to Guide Therapies and Monitor Response to the Treatment of Musculoskeletal Injuries.
The Veterinary clinics of North America. Equine practice    July 21, 2023   doi: 10.1016/j.cveq.2023.06.001
Horne CR, Tufts S.Continual advancements in diagnostic imaging have allowed for more accurate and complete diagnoses of injuries in the performance horse. The use of several different imaging tools has further allowed the equine sports medicine clinician to more carefully direct treatment options, monitor response to therapy and guide rehabilitation recommendations. The advancements in diagnostic imaging and novel treatment options have led to the improvement in the overall prognosis of many injuries that affect the horse and their performance. The purpose of this section is to review the advancements made in d...
Equine tendon mechanical behaviour: Prospects for repair and regeneration applications.
Veterinary medicine and science    July 20, 2023   doi: 10.1002/vms3.1205
Shojaee A.Tendons are dense connective tissues that play an important role in the biomechanical function of the musculoskeletal system. The mechanical forces have been implicated in every aspect of tendon biology. Tendon injuries are frequently occurring and their response to treatments is often unsatisfactory. A better understanding of tendon biomechanics and mechanobiology can help develop treatment options to improve clinical outcomes. Recently, tendon tissue engineering has gained more attention as an alternative treatment due to its potential to overcome the limitations of current treatments. This ...
Flexor Tendon Lacerations
   June 20, 2023  
Stevens KA, Caruso JC, Fallahi AKM, Patiño JM.Since initial reports suggesting primary tendon repair as possible and even desirable emerged in the 1960s, significant advancements in the understanding of flexor tendon anatomy, biology, mechanisms of response to injury, and methods of repair, have been made. Recent research highlights enhanced improvements in operative techniques and rehabilitative care that have made primary flexor tendon repair a preferred operative approach for lacerations and can successfully achieve a reliable flexor tendon repair site, optimizing digital motion. The formative goals of surgical treatment for lacerated ...
Restoration of function following traumatic superior eyelid avulsion in a horse treated with advancement flap blepharoplasty (H-plasty) and subdermal hyaluronic acid filler.
Veterinary ophthalmology    June 19, 2023   Volume 27, Issue 1 90-94 doi: 10.1111/vop.13122
Lamkin I, Pugliese B, Nystrom J, Fubini SL, Knickelbein KE.To describe the successful restoration of superior eyelid function in a horse following traumatic avulsion using an advancement flap blepharoplasty and subdermal hyaluronic acid filler. Methods: A 21-year-old American Paint Horse stallion who was attacked by a fellow stallion resulting in numerous traumatic injuries including avulsion of approximately 75% of the left superior eyelid. Methods: With standing sedation and locoregional anesthesia, the superior eyelid wound was debrided and an advancement flap blepharoplasty (H-plasty) and temporary tarsorrhaphy were performed. Routine healing of t...
The Effect of Radial Extracorporeal Shock Wave Therapy (rESWT) on the Skin Surface Temperature of the Longissimus Dorsi Muscle in Clinically Healthy Racing Thoroughbreds: A Preliminary Study.
Animals : an open access journal from MDPI    June 18, 2023   Volume 13, Issue 12 doi: 10.3390/ani13122028
Śniegucka K, Soroko-Dubrovina M, Zielińska P, Dudek K, Žuffová K.Radial extracorporeal shock wave therapy (rESWT) is increasingly being used to treat musculoskeletal injuries in horses. The aim of this study was to assess the influence of rESWT on the skin surface temperature of the longissimus dorsi muscle in clinically healthy racing horses. A total of 24 thoroughbreds were divided into a study group (n = 12) and an rESWT-sham group (n = 12). The study group underwent rESWT, whereas the rESWT-sham group had rESWT without probe activation in the treated area. Both groups underwent thermographic examination before and just after rESWT to determine and compa...
Osteochondral allograft transplantation for treating medial femoral condyle subchondral bone cyst in a 14-year-old standardbred horse: a case report.
Journal of veterinary science    June 5, 2023   Volume 24, Issue 3 e31 doi: 10.4142/jvs.22239
Pál Z, Bodó G.Allograft arthroplasty is a promising cartilage-resurfacing technique. A 14-year-old horse was diagnosed with a medial femoral condyle subchondral bone cyst. Allografts were harvested from a young donor animal and implanted to fill the cyst cavity. A visual assessment of the surgical site was possible during follow-up arthroscopy. In addition to a desirable gliding surface and a good adaptation of the grafts, fibrillation of the cranial ligament of the medial meniscus was noted and debrided. The recipient horse became sound four months after follow-up surgery with a high level of owner satisfa...
Effect of speed and leading or trailing limbs on surface muscle activities during canter in Thoroughbred horses.
PloS one    May 26, 2023   Volume 18, Issue 5 e0286409 doi: 10.1371/journal.pone.0286409
Takahashi Y, Takahashi T, Mukai K, Ebisuda Y, Ohmura H.Given that Thoroughbred horses' canter is an asymmetric gait, not only speed but also leading or trailing limbs could affect muscle activities. However, the muscle activity during a canter remains poorly understood. Hence, we aimed to investigate speed and lead-side (leading or trailing) effects on surface electromyography (sEMG) during a canter. The sEMG data were recorded from left Musculus brachiocephalicus (Br), M. infraspinatus (Inf), long head of M. triceps brachii (TB), M. gluteus medius (GM), M. semitendinosus (ST), and M. flexor digitorum longus of seven Thoroughbreds with hoof-strain...
Electrohydraulic Shockwave for Treatment of Forelimb Superficial Digital Flexor Tendinitis and Proximal Suspensory Desmitis in Horses.
Journal of equine veterinary science    April 27, 2023   Volume 127 104504 doi: 10.1016/j.jevs.2023.104504
Khairoun A, Hawkins JF, Moore GE, Lescun TB, Adams SB.Superficial digital flexor tendinitis (SDFT) and proximal suspensory desmitis (PSD) are common causes of lameness in horses. Current treatment options include rest, controlled exercise, administration of anti-inflammatories, intralesional injections, surgery, and electrohydraulic shock wave therapy (ESWT). ESWT is safe, noninvasive, and is used to treat a variety of musculoskeletal abnormalities. Medical records between 2010 and 2021 were reviewed. Horses were separated into two categories: (group 1: ≥ 3 ESWT treatments; group 2: < 3 ESWT treatments). Our objective was to examine the effe...
Effect of hippotherapy on balance, functional mobility, and functional independence in children with Down syndrome: randomized controlled trial.
European journal of pediatrics    April 26, 2023   Volume 182, Issue 7 3147-3155 doi: 10.1007/s00431-023-04959-5
Kaya Y, Saka S, Tuncer D.Impaired muscle strength, proprioceptive and vestibular deficits, and orthopedic dysfunction are common disorders associated with Down syndrome (DS). Hippotherapy uses the horses' multidimensional movement to improve posture, balance, and overall function, both motor and sensory. Research evidence supports hippotherapy as an effective, medically recognized intervention for the rehabilitation of gross motor skills. The aim of this study was to determine the effect of hippotherapy on balance, functional mobility, and functional independence in children with DS. Thirty-four children with DS were ...
The Surgical Repair of a Salter-Harris Type-2 Physeal Fracture of the Proximal Phalanx in a Foal.
Journal of equine veterinary science    April 25, 2023   Volume 126 104500 doi: 10.1016/j.jevs.2023.104500
Breen LJ, Coleridge MOD, O'Brien T.A 6-month-old thoroughbred colt foal was referred to a private equine referral hospital for evaluation of an acute onset, left hind limb lameness. On arrival the foal was 4/5 lame on the left hind at walk and there was diffuse swelling of the left hind pastern and fetlock region. The physical exam was otherwise unremarkable. Digital radiographs of the left hind pastern identified a Salter-Harris type-2 physeal fracture of the proximal phalanx. The fracture was initially treated conservatively using a cast, but the immobilization was not sufficient at achieving adequate reduction. As a result, ...
Skills for future equine sports rehabilitation careers.
Translational animal science    April 24, 2023   Volume 7, Issue 1 txad042 doi: 10.1093/tas/txad042
Reed SA, Streff LN.The field of equine sports medicine and rehabilitation provides a career opportunity for students interested in remaining in the horse industry but not focused on a career as a veterinarian. However, throughout the United States, there are limited educational opportunities for undergraduate students to prepare for this career. The objective of this work was to determine what skills and theoretical knowledge professionals in the equine rehabilitation industry deemed most useful for employment in the equine rehabilitation industry, and, using that information, develop a curriculum to meet these ...
Conservative management of equine tarsal collateral ligament injuries may allow return to normal performance.
Journal of the American Veterinary Medical Association    April 11, 2023   Volume 261, Issue 7 995-1003 doi: 10.2460/javma.22.12.0597
Fraschetto C, Dancot M, Vandersmissen M, Denoix JM, Coudry V.To describe type and distribution of tarsal collateral ligament (CL) injuries and to assess the long-term outcome in horses treated conservatively. Methods: 78 horses (median age, 7 years [IQR, 4 to 9.75 years]) of different breeds and disciplines. Methods: Retrospective analysis (2000 through 2020) of horses with tarsal CL lesions diagnosed on ultrasound. The resting time, ability to return to work, and performance level after the injury were compared between horses having a single ligament (group S) or multiple ligaments (group M) affected and according to the case severity. Results: Most of...
The impact on physical performance, pain and psychological wellbeing of chronic low back pain patients during 12-weeks of equine- facilitated therapy intervention.
Frontiers in veterinary science    March 14, 2023   Volume 10 1085768 doi: 10.3389/fvets.2023.1085768
Mattila-Rautiainen S, Venojärvi M, Rautiainen H, Keski-Valkama A.Equine - Facilitated Therapy (EFT), an equine environment, and horses themselves can meet many physical and mental health needs beyond diagnostic categories. The horse's ability to produce a walk-like movement and the participant's ability to connect to non-judgemental living creatures, both of which can benefit participation and construct a positive self-image for chronic pain patients. The objective of this study is to evaluate the impact of EFT on perceived physical performance, level of pain, pain acceptance, depression and anxiety, and quality of life within a 12-week intervention for chr...
Correlation of Arthroscopic Grading and Optical Coherence Tomography as Markers of Early Repair and Predictors of Later Healing Evident on MRI and Histomorphometric Assessment of Cartilage Defects Implanted with Chondrocytes Overexpressing IGF-I.
Cartilage    March 2, 2023   Volume 14, Issue 2 210-219 doi: 10.1177/19476035231154508
Ciamillo SA, Pownder SL, Potter HG, Stefanovski D, Nixon AJ, Ortved KF.Injury of articular cartilage is common, and due to the poor intrinsic capabilities of chondrocytes, it can precipitate joint degradation and osteoarthritis (OA). Implantation of autologous chondrocytes into cartilaginous defects has been used to bolster repair. Accurate assessment of the quality of repair tissue remains challenging. This study aimed to investigate the utility of noninvasive imaging modalities, including arthroscopic grading and optical coherence tomography (OCT) for assessment of early cartilage repair (8 weeks), and MRI to determine long-term healing (8 months). Large (15 mm...
Approaches to standardising the magnetic resonance image analysis of equine tendon lesions.
Veterinary record open    February 23, 2023   Volume 10, Issue 1 e257 doi: 10.1002/vro2.57
Doll CU, Bohner M, Berner D, Buettner K, Horstmeier C, Winter K, Burk J.Low-field magnetic resonance imaging (MRI) has gained increasing importance to monitor equine tendon lesions. Comparing results between studies and cases is hampered, because image analysis approaches vary strongly. This study aimed to improve reliability, comparability and time efficiency of quantitative MRI image analysis. Unassigned: Induced tendon lesions were studied over a 24-week period with 10 follow-up MRI examinations. Signal intensities (SIs) of tendons, tendon lesions, cortical bone and background, as well as lesion cross-sectional areas (CSAs) were measured. Lesion SI standardisat...
A Preliminary Study of the Influence of High Intensity Laser Therapy (HILT) on Skin Surface Temperature and Longissimus Dorsi Muscle Tone Changes in Thoroughbred Racehorses with Back Pain.
Animals : an open access journal from MDPI    February 22, 2023   Volume 13, Issue 5 doi: 10.3390/ani13050794
Zielińska P, Soroko-Dubrovina M, Dudek K, Ruzhanova-Gospodinova IS.The reason for undertaking this study was to investigate soft tissue response to high-intensity laser therapy (HILT) by measuring changes in skin surface temperature and longissimus dorsi muscle tone in the thoracolumbar back area in Thoroughbreds with back pain and diagnosed with and without Kissing Spines Syndrome (KSS). Thoroughbreds aged 3-4 years with clinically presented back pain underwent a radiological examination (to assess a lack or presence of KSS) and longissimus dorsi muscle palpation (to assess muscle tone and pain degree). The subjects were divided into two groups, those with K...
Breast Cancer: How Hippotherapy Bridges the Gap between Healing and Recovery-A Randomized Controlled Clinical Trial.
Cancers    February 19, 2023   Volume 15, Issue 4 1317 doi: 10.3390/cancers15041317
Viruega H, Galy C, Loriette C, Jacquot S, Houpeau JL, Gaviria M.Breast cancer is the most diagnosed women's cancer, and has a high survival rate. Despite great progress in detection and treatment, life reconstruction requires comprehensive cross-sectoral approaches between different disciplines and deeper consideration of the patient's challenges. Hippotherapy is an emerging specialized rehabilitation approach, performed by accredited health professionals and equine specialists, on specially trained horses via their movement, activating major paths for physical, mental, psychic and social reinforcement, and is synergistic to rehabilitative and supportive c...
Severe equinus cavo-varus correction through triplanar tarsectomy and posterior tibial tendon transfer based on 3D-printed biomodel.
Foot (Edinburgh, Scotland)    February 11, 2023   Volume 54 101976 doi: 10.1016/j.foot.2023.101976
Chans-Veres J, Albiñana-Cunningham J, Quintela JM, Pereira E, Tejero S.Surgery for severe equine cavo-varus is complex and must be individualized. The interindividual phenotypic variability demands a personalized planning of each foot to be operated. The study's primary goal was to evaluate the function and satisfaction of a series of patients with severe equinus cavo-varus deformity who underwent a triplanar tarsectomy and transposition of the posterior tibial tendon in a single stage surgery after a patient specific 3D biomodel planning. A series of 12 feet (5 patients bilaterally) operated with this technique was analyzed. The cohort comprised 2 females (28.5 ...
Reattachment of Osteochondritis Dissecans Lesions in the Lateral Femoral Trochlear Ridge With Bioabsorbable Screws in 4 Yearling Standardbreds.
Journal of equine veterinary science    February 10, 2023   Volume 123 104242 doi: 10.1016/j.jevs.2023.104242
Bertuglia A, Pallante M, Pillon G, Valle D, Pagliara E, Riccio B.This case series describes an alternative surgical technique to obtain reattachment of osteochondritis dissecans (OCD) lesions in the lateral trochlear ridge of the femur (LTRF) as well as the clinical and radiological outcome of treated cases. Four Standardbred yearlings (6 lesions in total) underwent surgical fixation of large OCD defects in the LTRF under arthroscopic guidance. Reattachment of the OCD lesions was obtained using 3.0/3.7 mm headless bio-compression and absorbable poly-l-lactic acid (PLLA) screws, inserted perpendicularly to the cartilage surface through the lesion. All horse...
Horseback Riding-Related Injuries in Portugal and Prevention Strategies.
Journal of sport rehabilitation    January 23, 2023   Volume 32, Issue 4 409-414 doi: 10.1123/jsr.2022-0101
Pinto LV, Gouveia FC, Ramalho JF, Silva SR, Silva JR.Horse riding (HR) has gain popularity in Portugal, thereby increasing the number of related injuries. This study identifies frequently occurring injuries in Portuguese riders, the conditions under which they occur, and preventive measures. Methods: A retrospective cohort study. Methods: We included 216 Portuguese riders practicing HR at the time of the study with ≥1 year of experience. Data were obtained from a questionnaire that characterized first and second rider injuries; we opted for a systematic method to assess the riders' injuries, in a temporal order. Questions regarding demographi...
Treatment of racehorse superficial digital flexor tendonitis: A comparison of stem cell treatments to controlled exercise rehabilitation in 213 cases.
Equine veterinary journal    January 16, 2023   Volume 55, Issue 6 979-987 doi: 10.1111/evj.13922
Salz RO, Elliott CRB, Zuffa T, Bennet ED, Ahern BJ.Overstrain of the superficial digital flexor tendon (SDFT) is a common Thoroughbred racehorse limb injury requiring treatment. Objective: To determine whether treatment of SDFT lesions in flat Thoroughbred racehorses with autologous bone marrow-derived mesenchymal stem cells (BM-MSCs) or allogenic adipose-derived mesenchymal stem cells (A-MSCs) is associated with improved likelihood of returning to racing, when compared to racehorses managed with a controlled exercise rehabilitation program (CERP) alone. Methods: Retrospective cohort study combining clinical treatment records with race records...
No correlation found between palpation and ultrasound for evaluation of effusion in the medial femorotibial and femoropatellar joint compartments of horses.
Journal of the American Veterinary Medical Association    January 5, 2023   1-5 doi: 10.2460/javma.23.10.0582
Ruff JH, Tufts S, Robertson J, Horne C, Schnabel LV, Jacobs C.To compare palpation and ultrasound scores of effusion of the medial femorotibial and femoropatellar joints of horses. Methods: 40 horses (80 stifles) were evaluated over a 12-week period. Methods: Horses > 1 year of age without history of stifle disease were enrolled from September to December 2022. Palpation of right and left medial femorotibial and femoropatellar joint compartments was performed. Amount of effusion was scored by a board-certified large animal surgeon, a third-year large animal surgery resident, and an equine sports medicine intern. Effusion of right and left medial femoroti...
Equine blood flow restriction training: Safety validation.
Equine veterinary journal    January 4, 2023   Volume 55, Issue 5 872-883 doi: 10.1111/evj.13904
Johnson SA, Frisbie DD, Griffenhagen GM, King MR.Blood flow restriction (BFR) has become a key rehabilitative tool for human orthopaedic conditions. With modernised technology and evolution of clinical application, patient-specific delivery of occlusion percentages is now considered the standard of care in human patients due to improved therapeutic outcomes and minimised safety risks. Safety validation and limb occlusion pressure (LOP) data for horses, however, are lacking. Objective: (1) To determine if BFR exposure resulted in forelimb biomechanical gait dysfunction as safety validation and (2) to investigate inter-horse and inter-limb LOP...
A pilot observational study of horsemanship skills training for veterans with posttraumatic stress disorder.
Complementary therapies in medicine    December 16, 2022   Volume 72 102910 doi: 10.1016/j.ctim.2022.102910
Marchand WR, Smith J, Hoopes KH, Osborne M, Andersen SJ, Bell K, Nazarenko E, Macneill R, Joubert K.Pilot assessment of an equine-assisted services intervention for Veterans with posttraumatic stress disorder. Methods: Prospective cohort. Methods: A large Veterans Administration healthcare system. Methods: Two sessions of instruction in horsemanship skills and two sessions of trail rides. Methods: Safety and feasibility of recruitment, retention, providing the intervention, and measuring outcomes, as well as acceptability of the intervention to the population studied were the main outcome measures. Results: There were no injuries among the 18 participants, 6 staff, or 11 equines over the 3 m...
Equine-assisted services for individuals with substance use disorders: a scoping review.
Substance abuse treatment, prevention, and policy    December 14, 2022   Volume 17, Issue 1 81 doi: 10.1186/s13011-022-00506-x
Diaz L, Gormley MA, Coleman A, Sepanski A, Corley H, Perez A, Litwin AH.The implementation of equine-assisted services (EAS) during treatment for psychological disorders has been frequently documented; however, little is known about the effect of EAS on outcomes for populations with substance use disorder (SUD). The purpose of this scoping review was to synthesize existing literature reporting the effects of EAS when incorporated into SUD treatment. This review followed guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for scoping reviews. A search of four databases (MEDLINE/PubMed, PsycINFO, the Cumulative Ind...
A Case Series of 11 Horses Diagnosed with Bone Spavin Treated with High Intensity Laser Therapy (HILT).
Journal of equine veterinary science    December 2, 2022   Volume 120 104188 doi: 10.1016/j.jevs.2022.104188
Zielińska P, Śniegucka K, Kiełbowicz Z.The aim of this work was to characterize and describe the effect of High Intensity Laser Therapy (HILT) used in the treatment of chronic osteoarthritis in horses. Over a 2 year period, 11 horses with diagnosed bone spavin were treated with HILT as a monotherapy. The horses chosen for this report presented hind limb lameness, were positive in a spavin flexion test and showed improvement after intra-articular anesthesia of the tarsometatarsal joint. Additionally, all the horses presented radiological signs of tarsus osteoarthritis and had not been treated for bone spavin for a minimum of 6 month...
Free Swimming and Exercise-Induced Pulmonary Hemorrhage in Endurance Horses: A Preliminary Study.
Journal of equine veterinary science    December 2, 2022   Volume 120 104182 doi: 10.1016/j.jevs.2022.104182
Vinardell T, David F, Galezowski AM, Ali M, Qasim M, Massie SL, McCrae P, Filho S, Leguillette R.Swimming is used for rehabilitation of musculoskeletal injuries and for conditioning to improve equine fitness. However, there are anecdotal reports that suggest that tethered swimming can induce epistaxis, likely secondary to exercise-induced pulmonary hemorrhage (EIPH). The objective of this observational, prospective study was to investigate if EIPH occurs during intensive free-swimming training sessions (5 × 70m) using 15 endurance horses. On tracheo-bronchoscopic evaluations following swimming, low grade mucus scores were observed, but no tracheal blood was observed. Bronchoalveolar la...
Interaction during equine-facilitated rehabilitation from the rehabilitees’ perspective – A phenomenological study.
Physiotherapy theory and practice    November 27, 2022   1-12 doi: 10.1080/09593985.2022.2151332
Mattila M, Honkanen S, Sjögren T, Piirainen A, Aartolahti E.Interaction has a multidimensional role in equine-facilitated rehabilitation. Unassigned: The aim of this study was to understand rehabilitees' experiences of interaction during equine-facilitated rehabilitation. Unassigned: Six children and four adults with individual diagnoses or reasons to participate in equine-facilitated rehabilitation were included in this qualitative study. Data were collected by interviewing individually the rehabilitees. A phenomenological Spiegelberg's seven-phase meaning analysis was performed to reveal the meanings. Unassigned: Seven meanings were identified: 1) Tr...
Modified toggle pin technique combined with prosthetic capsular reconstruction for surgical stabilization of coxofemoral luxation in a Shetland pony.
Veterinary surgery : VS    November 21, 2022   Volume 52, Issue 2 221-228 doi: 10.1111/vsu.13915
Müller EMT, Ehrle A, Pozzi A, Lasarzik de Ascurra J, Lischer CJ, Kümmerle JM.To describe open reduction and surgical stabilization of a coxofemoral luxation in a pony using a modified toggle pin technique and prosthetic joint capsule reconstruction without osteotomy of the greater trochanter. Methods: A 2-year-old Shetland pony with a bodyweight of 167 kg. Methods: Case report. Methods: Radiographic examination confirmed craniodorsal luxation of the left coxofemoral joint. An open reduction with the aid of a pulley system was performed. A toggle pin was inserted through a bone tunnel extending from the level of the femoral shaft through the femoral head and the cente...
Systematic Review of Complementary and Alternative Veterinary Medicine in Sport and Companion Animals: Extracorporeal Shockwave Therapy.
Animals : an open access journal from MDPI    November 12, 2022   Volume 12, Issue 22 doi: 10.3390/ani12223124
Boström A, Bergh A, Hyytiäinen H, Asplund K.Extracorporeal shockwave therapy (ECSWT) is increasingly used to treat different types of musculoskeletal conditions in sport and companion animals. To explore the scientific basis for the treatment, we conducted a systematic review of the literature on ECSWT used in horses, dogs, and cats. Methods: Relevant articles published in 1980-2020 were identified from three major databases. Each article was assessed for risk of bias. Results: The review identified 27 relevant articles on the effects of ECSWT in horses, nine in dogs, but none in cats. Typically, ECSWT involved one to three treatment se...