University of Vermont AAHS
AMEA

February, 1994, Vol. IV, Number 1

Table of Contents

Health Care and the Horse Industry
Eastern Competitive Trail Ride Association Institutes Mandatory ASTM/SEI Helmet Rule
Thoughts on Conducting Horseback Riding Injury Surveillance
Answers to Common Questions on Stinging Insect Allergy
Osteoporosis and Equestriennes
NEISS Summary 1993
Editorial Comments Regarding NEISS
Sports Injury Research


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Health Care and the Horse Industry

The horse has been an integral part of our American heritage as well as a part of the advancement of civilization for thousands of years. They- have served as a source of power and labor and have fulfilled transportation needs. They have been equally important for civilian and military purposes. Additionally, the horse has been a participant in man's recreational pursuits.

The tractor and the automobile generate far more horsepower than the animal and, consequently the horse has largely became obsolete. Their role in competitive and recreational venues remains. Were it not for this role, the horse would primarily be resigned to fending for itself; running -wild on the range or existing in zoos.

As the last bastion for justifying the existence of the horse outside of its natural habitat recreational and competitive uses of the horse have come under increasing scrutiny The welfare of the animal is everyone's social concern. The horse industry as a whole has demonstrated a proactive approach to this philosophy. One need only look at the modern high tech equine research facilities to appreciate the millions of dollars spent studying and emphasizing the health of the horse.

However, one must remember that the unique nature of equestrian competition is that it is a team sport comprised of members of two different species. They are intimately dependent upon one another, both for success as well as safety. With regards to health and welfare, the human is usually the forgotten member of the team.

At the elite levels, the rider is usually well looked after. However, there are many equestrian scenes where the riders are more passive participants or more poorly prepared for the potential hazards of the sport. Children left to their own devices certainly represent the most clear example of this. However, even in professional racing, there are many jockeys and handlers living from one pay check to the next who will accept inordinate risks or, at the very least have no input into what constitutes a safe environment.

It is paramount that the horse industry police itself with regards to emphasizing safety in all aspects in order to prevent others from dictating this, such as through inappropriate legislation. As physicians and health care professionals active in the equestrian world, our interest is primarily the rider. This interest is expressed through three directions. First is research to better define injury patterns and occurrences. Second is equipment and rules changes for better protection. Thirdly is education and preparation to emphasize safe participation.

Short of abolishment of all horse related sports, there will always be some risks associated with these activities. The key for the rider is the recognition and acceptance of these risks, making all efforts to minimize their occurrence and having appropriate systems in place to handle injuries that occur. The horse, obviously, has less choice in participation. However, eliminating the recreational and competitive use of the horse resigns it to rare commercial needs and returns it to living in the wild or in zoos.

Again, the horse industry commits millions of dollars toward the welfare of the horse. physicians, health care professionals and the American Medical Equestrian Association attempt to show a similar commitment to the rider but with considerably fewer resources.

J.W. Thomas Byrd, MD
President, American Medical Equestrian Association

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Eastern Competitive Trail Ride Association Institutes Mandatory ASTM SEI Helmet Rule

The Eastern Competitive Trail Ride Association Board of Directors now requires ASTM/SEI approved helmets for all competitors on ECTRA events, both rides and drives. Passengers and grooms in carriages are also required to wear protective helmets. ECTRA believes it is the first large regional trail organization in the United States to require helmets.

In a recent survey of ECTRA members, 173 replies were received of which 74.7% approved a ASTM/SEI helmet requirement for all riders, and 96% felt all juniors should be required to wear ASTM/SEI helmets on ECTRA events. Members who already owned ASTM/SEI helmets were 93.1%, of which 86.1% reported they always wore them, and 53.2% felt they had prevented them from injury.

The American Medical Equestrian Association commends the Eastern Competitive Trail Ride Association for this decision and its leadership for the horse community.

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Thoughts on Conducting Horseback Riding Injury Surveillance

Collecting data tends to be expensive and time-consuming. There is an ongoing challenge between developing simple collection forms (e.g., one page) vs. the desire to gather as much information as possible. It is important to recognize the difference between routine data collected on a regular basis and specific studies through which more extensive data can be obtained.

My general suggestion is to try to limit data collection to these items that will help with decision making. For example, if a riding organization was considering a ban on recreational riding if there was snow on the ground, then it would be useful to ask a question about ground conditions at the time of injury- (e.g., was the ground covered with snow?); however, if the organization already has a recommendation: "Do not ride when there is snow on the ground" and there was no interest or move afoot to change this, information on the presence of snow at the time of injury would not really be very useful. In contrast, information on helmet use at time of injury would be useful since some people doubt the effectiveness of helmet use in preventing injury.

The second general suggestion I have is to present data as rates, especially to a scientifically oriented audience. So-called "numerator" data (e.g. the Pony Club had 20 head injuries in 1985, 25 in 1987, and 19 in 1990) is difficult to interpret. We cannot make conclusions about the extent of the problem without denominators. As an example, think about information on motor vehicle injuries in Wyoming vs. California. Although the total number of injuries is much higher in California, the injury rate (injuries per million miles driven) is substantially higher in Wyoming.

Ideally, one would like to have some estimate of riding hours, but more realistically. you may want to use membership numbers. Data could then be presented as: the John Doe Pony Club had 4.2 injuries per 1,000 members in 1985, 3.1 per 1,000 members in 1986, 3.1 per 1,000 members in 1987, etc. It would also be helpful to have membership information both by gender and age groups; this would allow comparisons across these groups (e.g. 5.5 injuries per 1,000 members aged 5-9; 1.3 injuries per 1,000 female members, etc.).

MINIMUM DATA SET FOR INJURY SURVEILLANCE

Person Give age, gender, race, and place of residence of person injured

Location Specify place where injury occurred: home, work, farm, school.

Mounted/unmounted Note whether injured was mounted on the horse or unmounted at time of injury.

Time List day and time when injury occurred.

Nature of Injury Identify part of body injured, such as arm, head.

Type of Injury Identify type of injury, such as bruise, laceration, fracture.

Cause of Injury Describe how and why the injury occurred: if possible use E-code.

Diagnosis Specify the diagnosis using N-codes.

Treatment First aid, outpatient emergency care (Doctors office/free standing/hospital), hospitalized.

Outcome No loss of work or school, temporary or permanent loss of function, death.

Other factors Indicate helmet use/secured-loss/SEI certified; drug use, blood alcohol level

For the purpose of the study, define injury and concussion.

(Injury: A condition treated by a health professional. Concussion: A neurological injury involving the brain.)

If a researcher would like editorial suggestions on collection forms or questionnaires, please contact me.

David E. Nelson, MD, M.P.H.
Medical Epidemiologist
Oregon Health Division
800 NE Oregon Street
Suite 215
Portland, OR 97232
503/731-4084
FAX 503/731-4084

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Answers to Common Questions on Stinging Insect Allergy

Allergy and Asthma Medical Group and Research Center

Equestrians, due to the outdoor nature of their sport, can have increased exposure to stinging insects. In those people with a history of insect allergy, this can lead to some understandable concern and worry about safety. Unfortunately, there are some common myths about this problem that can further increase the anxiety already held by a sting- sensitive person. The following are some answers to common questions about stinging insect allergy that may help dispel some of these myths.

Q What is the most common cause of serious allergic reactions in insect stings?
A The most common is a honey bee sting. Stings from wasps, yellow jackets, hornets, and fire ants can also result in serious allergic reactions with the frequency depending on the location of the country in which you live. House flies, mosquitoes fleas, and ticks can bite and cause nuisance localized reactions but never result in any type of significant life- threatening problems.

Q What kind of reactions do people get when they are allergic to insect stings?
A Non-allergic people who get stung either have no reaction, or have local pain, mild swelling, and redness for a few hours and then symptoms resolve.

The most common type of allergic reaction to an insect sting is a large local reaction. The area becomes quite swollen in the area of the sting with the peak of the reaction occurring one to two days later. The other type of reaction which is more concerning, and fortunately not as common, is a systemic reaction, or anaphylaxis. This is a generalized or whole body allergic reaction. Symptoms may include itchy skin, hives, swelling of the lips, eyelids and/or throat, difficulty breathing, wheezing, vascular collapse (shock), and potentially, death. A less severe systemic-type reaction is one where the individual has hives all over the body without any throat swelling or breathing problems.

Q How common is it for someone to have anaphylaxis, i.e., the serious type of reaction?
A Very uncommon. Less than 0.1% of people stung will have anaphylaxis.

Q How often does death occur from a sting reaction?
A Very rarely. It is estimated that about 100 deaths per year in the whole United States result from insect stings.

Q My son once had bee sting with a large local reaction and we took him to the emergency room. They told us we better be careful because the next sting was likely to cause an even bigger reaction. Is this true?
A No. It is not true that every subsequent sting is going to result in a larger reaction. Most re-stings result in either no reaction, or one that is not any greater than the previous one. Therefore, it is inaccurate and unnecessarily alarming to tell someone that sting reactions "build and build" with repeated stings. Moreover, it is true that people who have had a major anaphylactic reaction in the past are more susceptible to having another anaphylactic reaction if re-stung.

Q How can you tell if you were stung by a bee, a wasp, or something else?
A Most people are stung by bees, since it is the most common stinging insect. You can almost always tell if you are stung by a bee because only bees leave their stinger behind. The other stinging insects do not.

Q If I have other types of allergy problems, like hay fever, asthma or drug reactions, do I have a higher risk of having insect sting allergy?
A Probably not. Insect sting allergy seems to be a unique problem and not strongly related to other types of allergy conditions.

Q My father had severe bee sting reactions - does that mean I am likely to have problems? Is insect sting allergy a familial condition?
A No, insect sting allergy does not "run in the family.

Q What should someone do if they are stung by a bee and feel like they are having a major reaction?
A Here are a few items or suggestions to follow:

Try to be calm.
Immediately go to a location where other people are present.
Flick or scrape out any residual stingers as soon as possible. Don't squeeze it.
Observe yourself for any feelings of a reaction occurring away from where the sting occurred.
Take an antihistamine if available.
Seek immediate medical help in an emergency room if you are having symptoms of anaphylaxis (e.g. throat closure, difficulty breathing, faint feeling, nausea, vomiting).
Consider calling 911.

Q If someone has a serious allergy to an insect sting, can anything be done about if? Is help available?
A Yes. You should talk with your physician who can determine if you need further evaluation. You can then be referred to a board certified allergist who will work out a treatment program for your problem.

Q What kind of treatment can an allergist offer?
A An allergist can perform allergy skin testing to determine your specific stinging insect allergy. The allergist will go over what measures should be taken if you are stung again. He/she will alert you to the symptoms and signs of anaphylaxis. Together you will decide whether you should regularly carry indictable epinephrine, which is used to treat anaphylaxis. Immuno-therapy (i.e. desensitization, "allergy shots") will also be discussed and if appropriate, offered to you as a preventative form of therapy.

Q Are allergy shots for insect sting allergy available? Do they give good protection?
A Yes, venom immune therapy is highly effective, and if done properly, can give very good protection against future insect sting reactions.

Q What is venom immuno- therapy? How does it work?
A An allergic individual is given gradually increasing doses of venom by injection into the arm, injections are initially given one to two times a week. Later, the interim period between injections is lengthened. When the "maintenance" dose is reached, injections are given one a month. Venom immuno-therapy provides protection in part by the individual developing a "blocking" antibody that combines with the insect venom, reducing the chance of a reaction occurring from the interaction of the allergy antibody with the venom.

Michael J. Welch, MD
9610 Granite Ridge Drive
Suite B
San Diego, CA 92123.

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Osteoporosis and Equestriennes

Bone responds favorably to weight-bearing exercise. Since horseback riding is not, in general, a weight-bearing activity, it would not be considered useful for building or maintaining bone density. The exception would be riding English, which may have some spinal benefit due to the action of posting. However since the National Osteoporosis Foundation recommends exercise and fitness activities beyond their bone building qualities, the fact that horseback riding is not technically a weight-bearing exercise should not be a deterrent. Certainly it is a useful activity with both physical and emotional benefits.

Studies have shown that individuals with low bone density have a greater risk for fracture. For them, falling off a horse, or even a jolt while riding (such as when the posting rhythm is interrupted), can result in a fracture of the spine, or in the case of a fall, the hip, wrist, spine, or other bones. Also, for individuals with spinal osteoporosis, the action of swinging a heavy saddle from below the knees onto the horse could be dangerous. This action is equal to that of swinging a golf club or tossing a bowling ball. The stress of the weight and twisting motion on a severely weakened spine could result in a compression fracture of one or more vertebrae

There is no way of knowing for sure if an equestrienne with low bone density will fracture if she hoists a saddle or falls from a horse. A bone density test provides information about an individual's bone density.. The fracture threshold for spinal bone density is believed to be .965 g/cm2, with 1.20g/cm2 considered normal for healthy young women. Another way of looking at bone density readings is standard deviations (SD). Most physicians consider 1 SD below the mean to signify that you are at increased risk of developing osteoporosis; 2 SD signifies that therapeutic intervention is needed, and 3 SD is considered dangerously low-bone density.

Should all post-menopausal equestriennes have bone density tests? National Osteoporosis Foundation does not recommend bone densities for all women. Rather, if the information supplied by a bone density test will help a woman make decisions about medication use or dose, life-style choices, or other intervention, the bone density test should be ordered. Since women who ride horseback are engaging in an inherently "risky" activity, a bone density test for those concerned may be a good idea. Equestriennes should definitely discuss osteoporosis and bone density testing with their physicians. The physician will provide information and guidance on the best course of action for the individual. Estrogen replacement therapy is an option that may be discussed. Estrogen therapy has been shown to prevent bone loss in estrogen-deficient women. For women who already have osteoporosis, estrogen, as well as calcitonin is FDA-approved to halt further bone loss. Adequate calcium and weight-bearing exercise are necessary as well.

The woman who has already had an osteoporotic fracture and wants to continue horseback riding faces a dilemma. To lower the chances of fracturing again she must give up an activity she loves. As this is a personal choice, only the individual patient and her doctor can arrive at a recommended solution.

From
Laurie Gibson Lindberg
Director, Patient Information and Education
from information supplied by
Gail P. Dalsky, Ph.D.
Research Exercise Physiologist

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NEISS Summary 1993

The figures used are from a compilation of information derived from horse associated injuries treated in hospital emergency rooms participating in the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Product Safety Commission. The NEISS estimates are calculated from a sample of hospitals which are statistically representative of institutions with emergency treatment departments located within the United States and its territories. NEISS warns small figures in their statistics have a high margin of error and may not have significance.

TOTAL FIGURES:

NEISS figures are based on estimates so the total may vary slightly. I have omitted "Unknown" in several tables for clarification.


YEAR/NUMBER INJURED

YEAR TOTAL YEAR TOTAL YEAR TOTAL 1979 29,438 1987 48,542 1990 74,349 1980 42,643 1988 43,820 1991 71,490 1981 50,708 1989 46,929 1992 73,685 1982 44,825

TOTAL 526,429

The participating hospitals were increased in 1990. NEISS did not record the horse related injuries in the years 1983 to 1986, but restarted in 1887.


AGE

YEARS 79-82 % 87-89 % 90-93 %

O-4 3318 2.0 2850 2.0 4158 1.9 5-14 45504 27.1 29397 21.1 46533 21.l 15-24 56185 33.5 36043 25.9 51590 23.4 25-44 49570 29.6 55325 39.7 89814 40.8 45-64 11422 6.8 13218 9.5 23984 10.9 65+ 1685 1.0 2455 1.8 4058 1.8

TOTAL 167,683 134,242 220,251

The older ages in the horse community are having an increase in the percent of injuries with the greatest increase in the ages 25-44. The ages 15-24 years have shown a decrease.

The changes in the demographics may be: a. Youth are increasingly aware of safety, whereas the older rider has not changed riding habits, b. increasing numbers of older persons have more leisure and are involved in horse activities, c. a decreasing number of youth are involved with horses related to increased urbanization and other interests and avenues for recreational activities for youth.


BODY PART

Body part 79-82 % 87-89 % 90-92 %

LowerTrunk 19892 11.9 16146 11.6 28408 12.9 Head 18957 11.3 14668 10.5 23228 10.6 UpperTrunk 13938 8.3 13776 9.9 22416 10.2 Wrist 12248 7.3 10160 7.3 17479 8.0 Ankle 10438 6.2 7431 5.3 12984 5.9 LowerArm 10349 6.2 6349 4.6 12838 5.8 Shoulder 10315 6.2 9586 6.9 16095 7.3 Face 9845 5.9 9025 6.5 13003 5.9 Finger 8405 5.0 5314 3.8 8638 3.9 Knee 8312 5.0 6246 4.5 10054 4.6 Foot 8206 4.9 5663 4.1 9220 4.2 LowerLeg 7808 4.7 7464 5.4 9948 4.5 Elbow 6227 3.7 4186 3.0 6443 2.9 Hand 5337 3.2 3581 2.6 5146 2.3 UpperLeg 4824 2.9 3747 2.7 4725 2.2 UpperArm 3562 2.1 3687 2.6 4928 2.2 Neck 3230 1.9 1427 1.0 4034 1.8 Toe 2363 1.4 1124 0.8 1753 0.8 Mouth 1131 0.7 1076 0.8 1215 0.6 Eyeball 765 0.5 242 0.2 1016 0.5 PubicRegion 674 0.4 1108 0.8 1097 0.5 25-50% Body 454 0.3 6580 4.7 3047 1.4 Ear 332 0.2 387 0.3 485 0.2 AllPartsBody 74 0.0 398 0.3 1048 0.5 NotStated/Unk 276 0.1 TOTAL 167,686 139,371 219,524

Body part 79-82 % 87-89 % 90-92 %

HEAD 31030 18.5 25156 18.0 37931 17.3 Head,Face,Mouth,Ear,Eyeball

UPPER EXTREMITY 35779 21.3 26928 19.3 42634 19.4 Upper/LowerArm, Elbow, Finger, Hand, Wrist

LOWER EXTREMITY 41951 25.0 31675 22.7 48684 22.2 Lower/UpperLeg, Knee, Ankle, Foot, Toe

TRUNK 44819 26.7 40616 29.1 68016 31.0 Upper/LowerTrunk, Shoulder, PubicRegion

The percentage of all injuries that occur to the head, upper and lower extremities have changed very little, although there seems to be a small decrease. Injuries to the trunk appear to be increasing.

An increase in the number of injuries involving multiple parts of the body are being seen. The increase in the year 1988-1989 of injury to 25-50% of the body cannot be explained except by aberration of the data. One of the causes of the increase in multiple injuries may be a foot caught in the stirrup and the rider being dragged. Continued evaluation of the quick release stirrup or the safety stirrup, its development and use may be a solution to decreasing these injuries.


TYPE OF INJURY

YEAR 79-82 % 87-84 % 90-92 % Type/Injury

CONTUSION/ ABRAS 69441 37.9 43993 31.6 71553 32.6 FRACTURE 47382 25.9 36633 26.3 65935 30.0 STRAIN/SPRAIN 29338 16.0 24557 17.6 35824 16.3 LACERATION 16998 9.3 15624 11.2 16809 7.7 CONCUSSION 6775 3.7 5444 3.9 7296 3.3 INTERNAL INJURY 1852 1.0 3448 2.5 7393 3.4 DISLOCATION 3102 1.7 2895 2.1 4454 2.0 OTHER 2592 1.4 2455 1.8 4253 1.9 HEMATOMA 2246 1.2 1297 0.9 2778 1.3 PUNCTURE 635 0.3 858 0.6 720 0.3 UNKNOWN 1125 0.6 102 0.1 564 0.3 AVULSION 592 0.3 792 0.6 310 0.1 CRUSHING 81 0.0 826 0.6 420 0.2 FOREIGN BODY 421 0.2 84 0.1 152 0.1 DERMA/CONJUNCT 125 0.1 0 0.0 339 0.2 AMPUTATION 107 0.1 0 0.0 350 0.2 BURN 30 0.0 102 0.1 222 0.1 SUBMERSION 0 0.0 0 0.0 112 0.1

TOTAL 183,142 139,293 219,524

Concussion has decreased slightly over the 1979-1982 figures. The percentage of injuries that result in fractures and internal injuries have increased. Internal injury increase is consistent with the increase of trunk injuries. Older persons when they have an accident are more likely to have fractures, internal injuries, and multiple injuries. This may explain the percentage increase in these types of injuries. Horse related submersion injuries do not appear to a significant degree, although drownings continue to occur in Medical Examiner figures. They do not appear in Emergency Rooms.


GENDER

GENDER 1979-82 % 1987-89 % 90-92 %

FEMALE 102614 61.2 73383 52.7 134423 61.2 MALE 64964 38.8 65908 47.3 85055 38.8

TOTAL 167,578 139,291 219,478

More women have horse related accidents than men, but this percentage does not appear to have changed from 1979-1982.


SEVERITY

YEARS 79-82 % 87-89 % 90-92 % Severity

ZERO 1920 1.1 2099 1.5 4028 1.8 ONE 28278 16.9 20621 14.8 33102 15.1 TWO 45089 26.9 33001 23.7 50483 23.0 THREE 52225 31.1 37983 27.3 66822 34.4 FOUR 19933 11.9 17968 12.5 24171 11.0 FIVE 11449 6.8 13454 9.7 26467 12.1 SIX 8244 4.9 13890 10.0 13731 6.3 SEVEN 126 0.1 796 0.6 680 0.3 EIGHT 418 0.2 81 0.1 40 0.0

TOTAL 167,682 139,293 219,524

NEISS explanation of severity rating is thus:
ONE: mild injuries to small areas; example bruise, abrasion
TWO: contusion to lower trunk, dislocation elbow
THREE: fracture arm, strain neck
FOUR: crush finger, head laceration
FIVE: concussion, fracture neck without nerve damage
SIX: amputation, arm crushing
SEVEN: all hospitalized patients
EIGHT: death

These figures show no pattern. The years 1987-1989 showed an increased in the severe six and seven injuries, but these are down in the years 1990-1992, although above the figures of 1979-1982. We know the horse related death figures are low. Many do not get to the emergency rooms.


                         LOCATION

Year 79-82 % 87-89 % 90-92 % Location SPORTS 47129 35.0 20449 21.3 33215 28.0 SCHOOL 1764 1.3 408 0.4 442 0.4 PUBLIC 8478 6.3 12340 12.8 10761 9.1 INDUST 3096 2.3 - - APART - - 112 0.1 STREET 5222 3.9 2712 2.8 2409 2.0 FARM 28240 21.0 25821 26.9 14195 12.0 HOME 40557 30.2 34346 35.7 57250 48.3 KNOWN 134486 96076 118434 UNKNOWN 33183 43216 101290

TOTAL 167669 139292 219724

Injuries in sports and on the farm have decreased for different reasons. Sport activities are increasingly aware of safety and some have made rules and regulations to increase safety in their activities. In those sports in which the governing body has not made changes, a larger proportion of the persons participating are aware of their personal responsibility for safety and are wearing protective hats and taking other measures for reduction of the risk of injury.

Farm injuries have decreased because of the continuing loss of land used for farming and the decrease in use of the horse in farming activities.

In contrast the percent of injuries at the home have increased over this time period. Recreation and leisure activities account for a large majority of horse related injuries. It is this part of the horse community that is least likely to be aware of the need of safety procedures in all of the mounted activities. It is this part of the horse community that must be reached by education, leadership and example by the members of the organized horse community.


                            TREATMENT

Year 79-82 % 87-89 % 90-92 % TR/REL 144009 85.9 122826 88.2 195707 89.2 TN/REL 6331 3.8 2503 1.8 5824 2.7 TN/HOSP 2586 1.5 1997 1.4 2473 1.1 HOSP 14234 8.5 11886 8.5 15436 7.0 DOA 418 0.2 81 0.1 40 0.0

UNK 102 0.1 0 43 0.0 KNOWN 167578 139293 219480 TOTAL 167680 139293 219523

TR/REL: Released with or without treatment
TN/REL: Transferred for further treatment but not hospitalized
TN/HOSP: Treated, transferred and hospitalized
HOSP: Admitted for hospitalization
UNK: Disposition unknown
DOA: Died in the emergency department, dead on arrival

The percent of injuries treated and released has increased. This may be an indication the seriousness of horse related injuries have decreased, but it also may indicate change of hospital admission requirements during these years.

The next category of patients, those transferred for further treatment, has decreased which may be an indication the injuries are not of the serious nature to require further treatment (as in trauma centers) but also may indicate the improved facilities at emergency rooms during these years.

The next two percent figures, treated and hospitalized and hospitalized directly, have decreased. This decrease may be that the seriousness of the accidents has lessened and the patients do not require hospitalization, but it also may indicate more home treatment and less hospitalizations for the same level of injury.

CONCLUSION

NEISS gives the horse community an opportunity to study the injuries in its activities. NEISS warns repeatedly these figures are approximations and small numbers may be inaccurate. However, they are available for study and evaluation so those who are concerned and feel we can reduce these injuries can use NEISS figures to show areas that need evaluation, changes that are occurring, and indicate steps the horse community needs to take to reduce these injuries in our activities.

These figures do not give causes. The horse community must provide these. Nor do they give recommendations. These recommendations must he provided by the leaders of the horse community: the shows, activities, clinics, instructors, state horse extension agents, clubs, breed and other horse related organizations.

NEISS
U.S. CONSUMER PRODUCT SAFETY COMMISSION
National Injury Information Clearing House
Washington, DC 20207
Reported by Doris Bixby Hammett, MD
103 Surrey Road, Waynesville, NC 28786

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Editorial Comments

I have reviewed the information on the NEISS Summary 1993. If the American Medical Equestrian Association wants to develop an injury surveillance system, it will need commitment of time and finances. However, if important decisions need to be based on the these data, it may be something to consider.

TOTAL FIGURES:

I would like to see from NEISS a formal definition of injury and a statement that this definition did not change over the three time periods monitored. If this is not the case, then these data are not comparable. All other comments are made assuming that there was a consistent formal injury definition and that the data was reported consistently by the same method over all three time periods.

AGE:

These data are helpful only if you know that the number of riders in each age category was consistent across each time frame. Otherwise, you do not know if more people are injured due to the same skill factor or the percent is higher or lower just because the number of people in the age category changed. I would not recommend reporting these data unless you have accurate participation figures for each age group for each time category.

BODY PART:

The percent and the absolute numbers are very different in the three age periods. I do not understand the category of 25-50% of the body injured.

TYPE OF INJURY:

I am not sure that if you ran a Chi square analysis on concussion that 3.7%, 3.9%, and 3.3% are significantly different from a statistical sense. For the statement "Older persons when they have an accidents are more likely to have fractures, internal injuries and multiple injuries" you should cite a reference.

GENDER:

The information that "More women have horse related accidents than men" may be very deceiving or even wrong unless you have an idea of the total number of participants in each gender.

SEVERITY:

The figures shown are small and subject to error, and therefore limit the amount of useful information that one can derive from these numbers.

FINAL SUMMARY:

There are significant limitations in these data. My suggestions.

1. Evaluate the important questions that you the horse community want answered. Work with NEISS to have these (potentially) more specific questions answered.

2. Develop some method of estimating the number of participants in horse riding.

3. Have a statistical consultant review these data, the NEISS System, your participation pool, and then determine what needs to be done to give more validity to these numbers. Injury rates are probably the better measure.

Randall W. Dick
Assistant Director of Sport Sciences
The National Collegiate Athletic Association
6201 College Boulevard
Overland Park, KS 66211-2422

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Sports Injury Research

Sports medicine research should be approached epidemiologically. Epidemiology is the study of frequency and determinants of trauma (or disease); its goal is preventive medicine. The study of sports injuries (sports traumatology) combines epidemiology and clinical medicine to analyze the frequency and determinants of injuries sustained by athletes, to prevent injuries, or to alter patterns of participation which contribute to injury.

The AOSSM [American Orthopaedic Society for Sports Medicine] Committee asked the questions 1) what type of studies currently appear in the sports medicine literature and 2) what problems can be identified in these studies. The committee determined that the person conducting a sports injury analysis is interested in a specific injury causal factors of the injury, treatment of the injury, or analysis of a series of studies. Reports on all of these topics appear in the current literature, but the majority of them have flaws in study design and are seriously remiss in appreciating epidemiologic criteria- For example,

A specific injury

Commonly the following questions are not answered in sufficient clarity in the currently published studies: What is the specific injury? Is the definition of an injury clear without ambiguity? Does it mean the same degree of severity and potential outcome to every investigator? Is the injury described adequately in correct anatomical terms as well as in terms indicating severity and potential outcome?

Cause of the Injury

Commonly, the highly specific experimental protocol and question formats required for data collection were not developed before the study was initiated. Data did not provide consistent answers to the following questions:

What are the causal factors related to the injury-? How did it occur; what factors led to it occurrence? What- steps can be taken to prevent the injury? Does the sports medicine team understand thoroughly all the conditions associated with the injury, specifically, the causal factors which lead directly to such an injury?

Analysis of a series of studies

Currently a number of barriers are apparent in the sports traumatology literature that prevent a meaningful analysis of the causal factors related to sports injuries. There are differences in study design and methodology that limit application and comparison. The methods or data from which the researcher tried to draw conclusions are not presented in detail or a statistical analysis is meager or not present. The following points are examples of barriers to analyses of sports injury studies:

Definition of injury is not precise. If two studies on equestrian injury conducted by competent investigators showed marked differences in incidence rates of injuries, the reader would ask why. Does the reader also ask "Do the two investigators define injury and are the definition the same?" If the definition of injury are not the same, does the reader recognize that the two studies cannot be compared? In its review of the literature, the Committee found many studies in which either the definition of injury was not given or that definitions of two studies "compared" were different. For example, in a "comparison," one study included all injuries no matter how trivial and the other study included only those injuries which required treatment at a medical facility. Because no universal definition of what constitutes an injury exists, the definition of "an injury" must be stated in each study. Only studies with the same definition of injury should be compared.

Population-at-risk is not predetermined. Many current studies on sports injuries include the total population which "walks through the door to be treated." The Committee's review of the literature determined that the majority of current sports injury studies report only the type of injury (numerator) without assessing the entire population-at-risk (denominator). When the population-at-risk is not predetermined, investigators cannot report the true incidence rate of injuries.

Exact method of patient selection/exclusions is not stated. The definition of injury and the population-at-risk, as discussed, are two methods of formulating inclusionary and exclusionary criteria for patient selection. When procedures are not stated in the study design, investigators have an inherent problem which cannot he resolved by data collection. If the criteria of selection are given in an ambiguous fashion in the report, the reader is unable to assess the profile of the population and compare results of two reports. More questions may be raised than solutions found.

Perhaps more than any other type of medical research, sports injury research requires a team working together to complete the project. The quality of the research and the validity of the conclusions are only as good as the weakest link in the investigative chain. Design requires forethought and application of sound methodology. Execution demands the successful interaction between the investigator and those collecting data. Methods for collecting and use of the data collection instrument (DCI, i.e. the form) must be consistent to produce reliable data. Final analysis and interpretation of the data demand the skills of clinician, epideminologist, and biostatistician to present a meaningful valid product.

Sports injury research teams should be headed by the physician. Trainers play a vital role in the project. The selection criteria for the study population, including the control populations of athletes, patients, and potential patients, are critical to the worthiness of the study. The public, vulnerable to misleading suggestions of entrepreneurs and irresponsible people selling products or "explaining" cause of injuries to team heroes, has the power to handle valid research effectively and to misuse invalid salesmanship.

Team physicians are research team leaders. They must establish themselves as the reliable (sought-after) source for current knowledge about conditioning and safety practices. They must be able to communicate to the audience--parents, administrators, general public-- results of research in terms of health, safety, and costs.

Epideminologists are the members of the research team who assist in formulating the study design, interpreting the results of analyses, and helping athletes prevent injury by recommending changes in protective equipment. They also recommend exercise and conditioning programs, changing behavior of athletics or changes in rules of the game.

Biostatisticians are concerned with the statistical methods in the study design and the statistical analysis of the data. Their ability to draw inferences from the data becomes the foundation for the epidemiologists. Biostatisticians have experience with medical and biological applications of statistics in contrast to statisticians who concentrate on economics and psychological interpretations of data.

No sports injury study is possible without reliable, consistent data collectors.

Challenges for the Future

What is the future of sports injuries research?

First, we need common nomenclature. The readers must be able to distinguish the similarities or the differences in the definition of a sports injury. We do not have a common nomenclature whereby we can code injuries into a computer format. The coding of injuries must be highly specific and much more encompassing than in the past. Computer assistance is required to sort through all the different types and severities of injuries.

We need adequate computer software for injury documentation and analysis. A comprehensive and commercially available software program which the clinician can use to perform sports injury analysis dues not exist.

We need to recognize the unique problems of each sport and study these problems separately.

We need interested and trained clinicians to conduct sports traumatology research and to work closely with a team. We need to improve study designs, utilize objective measuring systems, define patient populations accurately, utilize well-established statistical and epidemiologic methods, and to acquire more critical, unbiased reporting of study results.

Perhaps the largest barrier to conducting sports injury analyses relates to the time required of the clinician. A special commitment is required of the physician who is already busy with patient care. Sports medicine research requires hours and hours to design a valid study protocol, obtain funding, carry out the research, analyze the data, report the results of the study, and to submit the paper for peer review.

Perhaps the second largest barrier to sports injury research is money. It is ironic that the medical field with the highest current public visibility is one where its practitioners remain inexperienced in the essentials of epideminological methodology.

We promote the concept of critical thinking. Critical thinking is essential to designing one's own research and in analyzing research results reported by others. Critical thinking implies the ability of one investigator to challenge the results of another without emotional factors acting as barriers to this process. Medical disciplines that have a healthy bit -of skepticism and critical thinking among their members usually make greater gains and advances in the specialty than those where results and treatment outcomes are readily accepted or taken at face value.

From Frank R. Noyes, MD, and John P. Albright, MD.
American Orthopaedic Society
for Sports Medicine
Supplement Issue: American Journal of Sports Medicine 1988

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