Written by KBIS veterinary advisor Annie Bevins MA Vet MB MRCVS 
Horses unlike human patients do not always realise when they have to take it easy so it is unfortunately inevitable that when they are injured they will have to be confined on Box Rest.
This can be a stressful time for both owner and horse alike especially if your horse was competition fit and “full of beans” when he sustained the injury. Even if he is a pleasure horse and is used to a routine he will not be too pleased at enforced imprisonment. In my experience though, the first few weeks are the worst and after this time the horse will get used to it and accept his fate.
It is well known that a change it any routine can be stressful to horses and stress in itself can cause stomach changes such as glandular disease (ulcers). Any change in the horse’s diet should always be done slowly, allowing the microflora in the hind gut to adjust accordingly. However, should your horse be 3 day event fit and then has a tendon injury you obviously cannot feed high energy carbohydrate whilst he is on rest! The feed companies are very useful for advice in these situations, but as a general rule you should substitute for a lower energy mix or nut initially, and then reduce the volume over a few days to a week or thereabouts. In most situations ad lib good quality forage supplemented by a forage balancer should be sufficient for horses on long term box rest. The aim is to supply enough energy for maintenance of the body condition as well as tissue repair and to replicate “normal” grazing behaviour as far as possible. Horses are trickle feeders and will eat for about 17 hours a day in the wild, moving about as they do so which aids digestion.
A common problem of box rest is impacted colic where the horse gets bunged up, usually at the U bend in the gut; the pelvic flexure, as the ingesta passing through is drier than the norm. This is especially true where horses have had access to pasture and are getting moisture from the grass. Horses on box rest quite often do not drink sufficiently to make up for this so steamed or soaked forage as well as wetting any hard feed is useful. Some horses will readily drink a slightly warm “soup” of soaked pony or grass nuts in preference to water and a couple of apples sliced into the drinking water can make it more appealing.
When grazing horses slowly move from place to place as they eat with their heads down which is important for their respiratory health as well as stretching the top line. Horses are not giraffes- they will browse the hedge occasionally but are not designed to eat from the trees all the time. We tend to use haynets for our convenience, (not that of the horse) to save wastage and keep the stable tidy. Haynets have two major disadvantages 1: The forage is at nose height and any spores of bacteria are released as a cloud into the air when the horse pulls at the hay and these contaminants then get inhaled. Therefore if the horse is unable to remove contaminants by drainage he will develop some degree of inflammatory airway disease whilst inside. Feeding steamed forage is very important in preventing this- but it should still be fed at floor level. There are now available some nets which have small holes and are designed for low level feeding. In order to replicate natural behaviour as far as possible and to encourage the horse to move a little it can be helpful to position alternative forage, such as a little alfalfa or dried grass around the stable. Scattering a few grass nuts about can help too.
2: Eating from a net with the head up will also affect the spine and back muscles as the horse will tend to hollow as it pulls the hay from the net, which can lead to muscle stiffness. Remember when the head is down the top line is stretched, the dorsal spinal ligament is engaged and the spinous processes move away from each other slightly. Another problem of standing in will be to lose some muscle condition and top line as these muscles are not being exercised. The horse may also develop a bit of a belly as he is not working with an engaged core. These changes cannot be stopped completely but may be mitigated with massage and stretches which are easily done at home once your physiotherapist has shown you how. Your physiotherapist may also show you how to passively manipulate any joints that might have a tendency to stiffness as well as any specific post-operative or rehabilitation exercises required.
You might initially see some lower limb filling when the horse starts on box rest. This is especially true if he has been on a relatively high protein diet and in hard work. It is quite normal and is due to the imbalance between the osmotic pressures in the blood and tissues. It will normally rectify once the diet is sorted but stable bandages may have to be used initially. This is especially important if there is a wound as the “pool” of fluid is a good medium for bacteria and, if infection occurs, can lead to cellulitis or lymphangitis which are serious in their own right. Most vets nowadays will recommend box rest with a little controlled exercise and you may be advised to have your horse out of the stable for a few minutes every hour or so. This walking is beneficial in increasing the circulation and so prevents swelling. Remember that if your horse is in the box and moving around on a concrete floor all the time there is less shock adsorption than he would get out at pasture. For this reason I would advise the use of rubber mats or flooring to ease the stresses on his joints and this also has the benefit of saving on the amount of bedding used.
If he is allowed out for a while then mucking out should be done at this time. It is important that the stable is kept clean and dry as standing in the wet can cause the feet to soften and can lead to thrush even if the feet are regularly picked out. Another advantage is that any fungal spores released from the bedding will not be inhaled by the horse. Stable designs very rarely have adequate ventilation and hence there is insufficient air movement to remove spores and dust from the air space. If your horse is to be in for a prolonged period I would remove the little window from the back of the stable completely, or create a hole if there is not one.
As herd animals and creatures of routine one of the biggest problems encountered when starting a period of box rest is the psychological adjustment of the patient to his confinement. He will find it extremely stressful if all his friends go out in the field without him! Where feasible I would advise leaving a friend in with him. It might be possible to let a small companion pony wander around an enclosed yard so that they can “talk” over the box door. Some owners find stable mirrors a good solution as the horse feels he has company (or admires his own reflection-who can tell?!). If the horse absolutely will not settle sedation may be necessary in order to prevent re injury. A fit horse on box rest can canter round the stable, buck and even try to jump out. I have personally kept a horse sedated for six weeks on acepromazine and it had no long term effects and was infinitely preferable to rupturing an already damaged tendon. Most owners do not like the idea of sedation but as mentioned before horses do usually become accustomed to being in after a few weeks.
It is also important to consider the mental well-being of your confined horse. If he is working, competing or turned out he will have a lot of stimulation which is absent from the stable environment. It is easier on a busy yard where there is a lot going on and if your horse is a laid back type. Vices or stereotypies are often blamed on box rest and will certainly show up if the horse has developed one. Nowadays we know that these behaviours are a way of self-pacifying and advice is not to prevent the behaviour as prevention leads to increased stress. Rather give your crib biter a rubber surface to use and give your box walker and weaver something else to do. Stable mirrors have again been useful here as are treat balls and homemade treats such as” kebabs” of carrots and apples on a string. Ad lib forage has also been shown to be useful in several studies (and he should be on that anyway.) The old trainers used to cut a” turf “of grass about 30 cm square for the race horses and they would play with this and eventually eat including the roots. This might not be practical in a livery yard situation though! Some horses like to have the radio on if in on their own. Talk stations were shown to have a greater calming effect in one study; the theory being that they think someone is about, but pop music is regularly used. Your massage and stretches will also provide some stimulation as will individual attention. The horse will not need a thorough grooming on rest but a brush over will help the circulation and aid the human horse bond.
Frustrating as it is to have a horse on box rest, this time can be made easier with a little input from the owner and could eventually lead to a better relationship between horse and rider.
