University of Vermont AAHS
AMEA

May 1994, Vol. IV, Number 2

Table of Contents

Mouth and Tooth Protectors for Equestrians
Editorial Comment
The USCTA Safety Committee
The Development of Equestrian Helmet Standards
Unied States Pony Clubs: 1993 Accident Summary
Vigorous Head Nodding by a Rider During the Sitting Trot in a Therapeutic Riding Program
Author's Comments


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Mouth and Tooth Protectors for Equestrians: An Overlooked Area of Preventive Sports Medicine

A survey of members of the American Medical Equestrian Association and a review of the scientific literature reveal that few, in any carefully designed studies have been conducted to determine the incidence of dental injuries in equestrian sports.

Extensive data do exist relating to various types of injuries that accompany horse-riding, but the closest applicable information to injuries to the teeth and adjoining structures relates to "the face." Careful review of that data, and the epidemiological criteria for collecting that data, indicate little relationship to dental structures, per se.

It is hoped that this paper will stimulate interest on the part of equestrian epidemiologists to review the basic criteria for data collection and, specifically, include separate reference to "injuries to the teeth, gums, and lips," with sub-categories that specify the type and extent of such injuries.

Anecdotal information reveals interest in the subject of this paper. Everyone seems to know someone who rides who had a blow to the mouth or teeth that resulted, at least, in a visit to a dentist's office. Among those members of the AMEA surveyed, one had a fourteen year-old daughter who sustained a fractured jaw, three had a daughter who chipped or fractured front teeth, two reported visits to root canal specialists as a result of riding incidents, and the author of this paper spent two hours a few months ago in the emergency room of a local hospital while an emergency physician placed fourteen stitches in his daughter's upper lip and replaced two loosened and chipped teeth in their sockets, prior to a visit to a dentist the next day.

Review of the Literature

Hill et al, in a study of 130 patients with dental and facial injuries following sports accidents, observed that "miniature motor cycling and horse-riding are the most dangerous individual sports." The same authors report that "the highest risk of injury in an individual sport is associated with horseriding, as a result of falls or kicks. This sport is also said to carry the highest risk of mortality per participant." "Considering the numbers participating, horseriding and miniature motor cycling are higher risk individual sports," according to the same authors. They concluded that "protective measures ... need ... be considered...for horse riders." [FN1]

Hickey et al, in a 1967 study of the use of mouth protectors to reduce intracranial pressure, found that there was a "decided reduction in the amplitude of the intracranial pressure wave when the mouth protector was in place." [FN 2]

A study by Stenger et al in 1964 demonstrated that the use of mouthguards "dramatically reduces the incidence of head and neck injuries."[FN 3]

In the first wide scale "evaluation of mouth protectors used by high school football players," conducted under the auspices of the American Dental Association in 1964, there was overwhelming receptivity by the players for custom-made devices, accompanied by the self-assurance that they would protect their teeth from injuries' [FN 4]

The bureau of Health Education of the American Dental Association in 1984 laid down the guidelines for an ideal mouth protector: it "must be easy to fabricate, comfortable, able to accommodate the needs of an individual's dentition, durable, easily held in place, and able to provide protection to the teeth, jaws and cranial structures." [FN 5]

Finally in 1993 Oikarinen et al concluded that "intra-oral mouth protectors...not only protect the teeth, but they also prevent soft-tissue lacerations as direct contact with the oral mucosa and teeth is prevented" and that "intracranial pressure in indirect traumas is reduced." They also observed that "a player with a removable prosthesis should replace it with a mouth protector, and those with orthodontic appliances ... should also pay more attention to infra-oral protection of the teeth, as forceful contacts between the teeth and mucosal tissues can cause large lacerations and wounds if labial brackets are in position." [FN 6]

Observations and Discussion

It is generally agreed that people in the "equestrian industry" tend to move slowly and cautiously before making changes in the rules that govern the conduct and behavior of horse riders.

The use of helmets and chin straps did not occur without some stresses and strains within the rule-making bodies of the sport; therefore, encouraging these same people to do the obvious-and that is, at a minimum, to encourage the use of tooth and mouth protectors, at least by teenagers--will not lead to positive results without pressure from the parents of those most susceptible to mouth, tooth, and related injuries, as well as the instructors who instruct them.

It is relatively simple and inexpensive to make a custom-made tooth and mouth protector. Most dentists are equipped to make them; and individual barns can literally hire a dentist to come to the barn to make impressions on site, and to return a week later with the final products in hand.

The making of custom-made tooth and mouth protectors has been greatly simplified by the disposable impression trays. Table-top vacuum-former machines are readily available at reasonable prices to fabricate plastic tooth and mouth protectors, a streamlined program could easily be adapted to most horse barns, where the entire process could be conducted on-site, as many high school and college football teams have done.

Recommendations

1. Tooth and mouth protectors should be made available to all horseriders, especially young and inexperienced ones.

2. Individual barns should arrange with a local dentist to make such tooth and mouth protectors on-site at fair fees.

3. Individual barns should set standards that require use of tooth and mouth protectors by younger riders, and encourage their use by older riders, as well.

Presented at the annual meeting of the American Medical Equestrian Association, San Diego, CA, November 6, 1993.

Brace L. Douglas, DDS, MPH,
Professor of Public Health, University of Illinois School of Public Health
Diplomate, American Board of Oral & Maxillofacial Surgery
2401 Duffy Lane
Riverwood, IL 60015

Steven P Rempas, DDS
Dental Practitioner
Webster Dental Affiliation
Chicago, Illinois

REFERENCES

[1] Hill, C. M. et al, Dental and Facial Injuries Following Sports Accidents: A Study of 130 Patients, British Journal of Oral and Maxillofacial Surgery (1985) 23, 268-274.

[2] Hickey J, C, et al, The Relation of Mouth Protectors to Cranial Pressure and Deformation. JADA (March 1967), 74:4, 735-740.

[3] Stenger. J. M. et al, Mouthguards: Protection Against Shock to Head, Neck, and Teeth (Sept. 1964) 68:3, 273-281.

[4] Douglas, B. L. et al, Evaluation of Mouth Protectors Used by High School Football Players, JADA (March 1964). 68:3, 430-442.

[5] Powers, J. M. et al. Mouth Protectors and Sports Team Dentist, JADA (July 1984) 109:1, 84-87.

[6] Oikarinen, K. S. et al, Endodontics and Dental Traumatology, 1993:9, 115-119.

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Mouth and Tooth Protectors for Equestrians
Editorial Comment

To find if the recommendations of Dr. Douglas would apply to a community and its horse activities, a survey was done of the dentists of Haywood County, a rural community in Southern Appalachia with 4-H and United States Pony Club members, two trail riders organizations, a horsemen's association working with the county fair, a NATRC sanctioned 100 mile ride, several tourist ranches and camps, and individuals who show in English and Western classes.

The dental survey was sent to the 19 dentists in the county with a request the survey be returned by a two week deadline. Of the dentists, eight replied (41.1%). All recommended mouth protectors in sport activity with all recommending its use in football, 75% in soccer, 62.5% in wrestling, horseriding and basketball, and 50% in baseball. Only one dentist- considered age a factor in the recommendation and he recommended guards up to the age of 12 years, and only two (25%) considered braces or bridges a factor in their recommendations for mouth guards.

Buying mouth protectors at health or sport stores was recommended by 89.5% of the dentists who said any guard was better than none, 62.5% agreed it was simple and easy to make a custom-made mouth protector, 87.5% reported they had impression trays, with 71.4% owning vacuum former machines to fabricate plastic mouth protectors. Only 57.1% said these machines were readily available at reasonable prices with the price range from $250 to $1,200. Cost for mouth protectors made in the office varied from a low of $25.00 to a high of $75.00. No dentist stated he would come to a barn or stable, with only 2 (25%) willing to set aside time in the office for a club or group to come for taking impressions for the mouth protector The minimum number in such a group was ten, and the anticipated cost for each guard would be $25.00.

Four (50%) of the dentists gave additional comments, from one stating the new mouth guards purchased at health stores were very good and easily molded in hot water which made it available without having a prohibitive cost, to a comment asking how liability would be handled followed by a statement that the group approach was short sighted. If cost was a factor, one should go to Wal-Mart. Custom fabricated tooth guards made by the dentist were the best.

The local health supply store has guards available for $1.59 and $2.79. Wal-Mart has sport mouth guards for $0.97.

Although most riders are dependent upon their personal dentists recommendations relative to mouth/tooth guards, medical recommendations are that all children wear mouth guards when mounted on their horse. These guards can be attached to the chin strap of the protective helmet, so that the guard is always available. Adult use is recommended especially with risky activities, hazardous environments, and when riding untrained horses.

Doris Bixby Hammett, MD
103 Surrey Road
Waynesville, NC 2:8786

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The USCTA Safety Committee

Combined training, like many equestrian sports, is considered a "risk sport". There are fatalities in combined training or eventing, but statistics reveal many lesser injuries such as shoulder separations and fractures as more frequent causes of injury. The charter of the United States Combined Training Association (USCTA), the parent organization for eventing in the U.S., mentions safety in no less than four out of seven paragraphs in its articles of incorporation. It states that one of the purposes of the USCTA shall be "providing instruction regarding (i) safety precautions applicable to participants and the public generally in connection with equestrian combined training, and (ii) methods for the hazards in course construction and otherwise, so as to limit frequency and extent of injuries to riders, horses, and ponies." And paragraph 3 also reiterates "knowledge of safety precautions to prevent injury" and paragraph 4 "encouraging the proper education and instruction of the organizers of equestrian combined training competitions so as to foster the proper and safe conduct of equestrian combined training competitions." Safety is again mentioned in paragraph 6. Safety is a concern of the Safety Committee of which I chair, but is also a concern of the Equine Research and Welfare and Education committees. Cross-country schooling days, rule making, cross country course building seminars, and the course advisor program all have safety implications.

The Safety Committee of the USCTA concerns itself mainly with rider safety. A member of the Executive Committee asked if I would be Chairman of the committee. at the time, I had just joined the USCTA Board of Governors. Most committee chairmen in the USCTA are board members, although there is no stipulation to that effect. I was aware at the time I was appointed that there had been controversy during the previous chairman's stint with regards to the decision to mandate ASTM/SEI helmets. The helmets were mandated and then within several months the mandate was withdrawn. The problem had been with the fit of the helmets and the outcry from our active Riders (riders competing at the highest levels of eventing--intermediate and advanced) that the helmets were falling in their eyes on the approach to fences. One of the difficulties with administering a sport through a global organization, such as the USCTA, is that all levels and skills are covered--from children through professionals. If you look at other sports, such as baseball, you have various administrators from T-ball to little league to high school/pony league to NCAA to minor league to Major League Baseball. Most equestrian sports have a fairly limited number of participants (the USCTA has 10,000 members nationwide), not making it cost efficient to subdivide the administration in the way that other sports are able to. This leaves the administrators having the same rules for all members from professionals to children. The US Pony Clubs, on the other hand, have a homogeneous membership in that all members are children or young adults. It is perhaps easier to mandate rules on a group like this, just as it would be easier to mandate rules if all members were professionals and could come to a consensus.

With this in mind I tried to explain the base of the safety committee. The committee had traditionally been made up of physicians, a lawyer, perhaps an official, but few Active Riders. The Active Riders that I contacted were happy to join the committee and have been some of the most helpful committee members. Present members include two former Olympians (Phyllis Dawson and Dorothy Trapp) and an international competitor USTCA judge, and technical delegate Jim Graham. Committee members also include a lawyer, a safety engineer, a USCTA technical delegate, a cross country course designer and event organizer (and husband of an Active Rider), a USCTA judge and USCTA board member, and an emergency room physician and AMEA board member Julie Ballard, M.D.). Two of the committee members are confidants of two of the most influential people in the sport of combined training worldwide (Phyllis Dawson with Bruce Davidson and Ritch Temple with Captain Mark Phillips). By having a committee with broad interests in the sport, specialized talents, and political clout, decisions made by the committee can have more credibility to the USCTA membership at large. If and when we attempt to have the USCTA Board of Governors vote on safety issues such as helmet mandates or the need for protective vests, having a strong committee with recognizable individuals will- help allay fears that the committee is pushing an agenda without adequate input.

Since becoming chairman of the safety committee, I have surveyed committee members on various topics to get a consensus of what issues we should tackle. When I assumed the chairmanship, various projects were under way. These included the development of a medical card for riders to carry when they went across country and the development of a safety officer concept. Besides these ideas, I consulted our officials and active riders at events for their ideas on safety. I also wrote the sport administrators in Canada and the United Kingdom. From these discussions, twelve different ideas were presented to the committee in written form for their comment. The results of the poll lead to several ideas being formalized and brought before the USCTA Board of Governors. One of the ideas, a meeting of several active riders the day before cross country to discuss any problems with the cross country course (a so-called "Ski Captain's meeting, so named because of a similar meeting held before ski races) was adopted independent of safety committee action. A safety handout to jump judges listing what to do in the event of a rider fall was incorporated into a larger handout to jump judges that also lists information on scoring. The safety aspects of this handout were developed with safety committee input and give a step-by-step approach that the jump judge (usually a volunteer of varying degrees of knowledge of the sport) can take from stopping the next rider, summoning safety personnel, and attending to the fallen rider in the minutes before medical help arrives, and preventing remounting if the rides appears confused.

The medical card to be carried on the rider listing personal and medical information, who is to contact, and a release (if the rider was a minor) was approved by the USCTA Board as a recommendation but not a mandatory item. (The cards are mandatory in England). Implementation has been delayed. We had first suggested placing the card in the helmet. This was opposed by Dr. Bill Brooks because removal of the helmet by well-meaning individuals might lead to potential spinal cord injury. The British had been using a helmet card but switched to an arm band for this very reason. Trying to find an alternative means of carrying the card has lead to delays. Various means have been evaluated and cost has been a consideration. Hopefully a mechanism will be approved soon.

Other ideas that have been brought before the USCTA Board include a USCTA Yellow Card concept and the idea of a Safety Check before cross country. The Yellow Card was a concept taken from the FEI that was to be a mechanism to warn a competitor that was acting in an unsafe, inhumane, or belligerent manner. This was to have been an educational and not a punitive action. This was approved by the USCTA Board only to be withdrawn after it was determined that this was viewed as a disciplinary procedure that should be under the guise of the AHSA. The USCTA is an educational organization that has no disciplinary function. That function is administered by the AHSA. (Not all USCTA events are AHSA recognized but all run under AHSA rules. Whether those rules can be enforced at non-AHSA recognized events on non-AHSA members is a question that is debated.) While developing the Yellow Card concept here in the U.S. we kept our friends in Canada informed and they (the Canadian Combined Training Association) approved of this concept and have since implemented it.

The concept of a Safety Check before cross country where the competitors' girth and tack would be checked was not approved by- the board. The Canadians have this tack check before each phase. When brought before the USCTA board, the feeling of some of the more vocal members was that a tack check would open up the organizers to liability in the event that a girth broke and the organizer had "approved" of the rider to leave the start box. Lawyers I consulted stated that there probably was no increased liability since approval may already be implied by allowing the competitor to ride at the event. Both of these well-intentioned ideas went down to defeat because of concern over liability. Safety and liability (at least in the U.S.) often seem to have an unpleasant interface.

Other ideas have been more controversial. The Safety Committee was quite divided on the issue of mandating ASTM/SEI helmets at USCTA events. Several of the Active Riders felt that the ASTM/SEI helmets had not progressed in design enough to recommend their use. One rider referred to the previous helmet flip-flop as a "fiasco" and stated "I cannot believe they are considering going through that again." Other committee members such as Dr. Bill Brooks, strongly supported the mandate. Several factors are in the works that are helping solve this dilemma. First is the improvement in the ASTM/SEI helmets themselves. Several new versions with improved fit and lighter weight are in the offing. Second, there is concern in England that the British Jockey standard is not sufficient. Eventing is centered in the world in Great Britain. American riders look to the U.K. for leadership in the sport. The biggest event in the world is Badminton, a British event. Most Active Riders in the U.S. wear British helmets. The Mark Davies Injured Riders Fund in England sponsored a study of British helmets. Their study concluded that the British helmet standard was not strict enough. Subsequently, based on this study it appears that ASTM helmets will be allowed to be worn in BHS events. (Hew can they disallow someone wanting superior protection?) This development is very positive from my standpoint at the USCTA Safety Committee. The Safety Committee strongly endorses the use of ASTM/SEI helmets and has so stated this in articles in the USCTA News, but their use is not mandated at present.

A second area of controversy is protective vests. Protective vests are mandatory in eventing in England and they have recently been mandated by the New York Board of Racing. The committee voted against making them mandatory for the USCTA. Various reasons were given for opposition including lack of scientific data of their effectiveness and their cost (particularly for entry level riders. There are only two manufacturers in the U.S. and vests are generally more expensive here than in England.). Some of the committee members that strongly favored ASTM helmets, strongly opposed vests and vice versa. There does seem to be a tendency in the USCTA statistics and in Dr. Brooks' study of vests to suggest that they may protect the back. Vests are also undergoing further refinement and improvement and perhaps the USCTA Safety Committee will visit this area again.

Other ideas that received mixed or negative reviews were the safety officer concept for all events (too costly, already covered by the officials, organizers already strapped with costs), making USCTA membership mandatory to compete (discourage participation by new riders, no guarantee that they will be better educated), and the grading of cross country courses (too expensive). The cross country course grading concept was approved by the USET, AHSA, and USCTA at the higher levels (independent of the safety committee) with the appointment of a "course advisor" and the USCTA is planning on implementing this at the lower levels. The concept is to make sure that cross country courses are safe and consistent for the level advertised.

The Safety Committee was asked to provide a column for the nationally distributed USCTA News on safety. The title "Safety Savvy" was chosen. Columns have covered helmets, eventer fatalities, USCTA accident statistics, and protective vests. A column for the January-February, 1994 issue was entitled "Tips from the Experts for a Safer Event Season" and received feature billing. It featured many of the ideas I had heard from officials and Active Riders on safety from being "unmounted" to being "at home" to being "at the event" to "on course". An article in the most recent issue was written by 1992 Olympic team member Todd Trewin and was entitled "Without my helmet and body protector...I might not be here!" This article recounted Todd's unexpected and freak accident not directly related to a jump where his foot caught a tree while galloping and he hit his head and shoulder on subsequent trees. He was helicoptered to a trauma center and lived to recount this story to other eventers because of his protective equipment. In my experience, anecdotes "sell" better than scientific facts and hopefully this column will encourage helmet use. The USCTA Safety Committee also gathers accident statistics based on technical delegate reports from events. These incidents are entered into a computer data base and further refinements have been added. In our latest statistics, the type of cross country fence at the site of the accident is identified.

Finally, during 1993 I discovered that Christopher Reeve, star of one of the highest grossing motion pictures in history was an event rider. It occurred to me that "Even HE needs and wears a helmet." With the help of the AMEA, Harborview, Horse Trials Canada, the Mark Davies Injured Riders Fund (UK), and Think First Canada, Mr. Reeve was convinced to participate in an ad campaign to encourage the use of helmets by all, not just "super" stars. (He also agreed to narrate a video on helmet use being developed by 4-H). As we know from statistics, 60% of equestrian injuries are from recreational riding. Most riders do not belong to any equestrian organization. Their only contact with the "Horse Community" is their local tack shop, local barn, and equestrian magazines. It is this group that is most in need of the message that helmets need to be worn for "every ride." Hopefully this project will receive financial backing.

Since becoming chairman of the safety committee of the USCTA, I have found that promotion of safety is not easy. I think I know how those who distribute condoms must feel. There are those who feel that whatever you do is too much. There are others that feel that whatever you do is too little. There are personalities to deal with at all levels, among "friends" and "foes", and sometimes it is hard to tell which is which. I think that as in advertising, to promote safety we must first get our audience's attention and we have to change perceptions. There was a two page advertisement in USA Today last summer that depicted two race car drivers face to face, one on each page with their black leather jackets on and their arms resting on their helmets. They were facing off in a future race. Having their arms an their helmets made then appear as if they were courageous warriors. In the equestrian world, helmets are thought of by many of our professionals as a sign of weakness. They (I'm thinking of the jumpers, particularly) would prefer an almost unprotective hunt cap without harness to an ASTM/SEI helmet with harness. Like the race drivers, maybe we just need to change the perception. Perhaps protecting oneself in the face of danger should be seen as a sign of strength and not weakness, like armor worn into battle. Who would think of jousting in their underwear?!

David A. McLain, MD
7325 Cahaba Valley Road
Birmingham AL 35242-6302

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The Development of Equestrian Helmet Standards

The tremendous success of the ASTM Equestrian Standard utilized by the United States Pony Clubs, has been a big step forward in the field of head protection.

Statistics have shown head injuries have dropped dramatically since the Pony Clubs required helmets passing ASTM and the Safety Equipment Institute requirement. Many hours of work by many people led to the final standard. However, the helmets resulting from the standard follow basic head protection formulas, a load spreading shell, an energy attenuating liner, and a good retention system.

I have mentioned many times in my talks and articles that when there is trauma to the brain, it doesn't know if you fell from a horse, bicycle, or were struck by a baseball. The basic principles of head protection are needed. The key difference in helmet design is dictated by the anticipated or possible impacts. Football helmets must protect against hundreds of repeated low energy impacts while most other activities, in addition to low energy impacts, many times see high velocity, high energy impacts.

Most of today's helmets borrow from information obtained in developing early day auto racing helmets. From the historic Barney Oldfield aviator caps, helmet: makers developed shells made of many materials.

The British were pioneers in shell development, but it was not until the fifties that helmets with energy absorbing liners began to appear. Prior to this helmet, interiors were generally fitted with webbing systems as were most equestrian helmets. Unfortunately, there are many old helmets of this type still being worn. A major breakthrough in head protection occurred when professors Lobard and Roth of the University of Southern California invented non-resilient expanded polystyrene (EPS) liners for use in helmets.

This patented process owned by Bell helmets is the basis for 95% of all helmets produced in the world today. The effectiveness of the EPS liner is demonstrated by the fact that many light sports helmets produced today do not have an exterior hard shell.

Following World War II, professional and amateur motorsport racing boomed and with it, helmet use. It soon became evident that many subpar helmets were being sold in the market. It was not until 1958 that with the death of Peter Snell, an amateur sports car driver, wearing a poorly designed and manufactured helmet, that action was taken by a group of engineers and doctors who raced with Snell. The Snell Foundation was formed headed by the late Dr. George Snively. The Foundation built a test laboratory, developed a standard, and began to certify helmets.

Today there are standards for many activities. The standards are developed by the American Society for Testing and Materials (ASTM), the Snell Memorial Foundation (SMF), and the American National Standards Institute (ANS).

Football and baseball helmets are currently manufactured to the NOCSEA standards developed by Dr. Voight Hodgson of Wayne State University. ASTM also has a football standard.

The British, again were pioneers in helmet testing equipment. The early swingaway impact system was developed in Britain. The Europeans for many years tested helmets by impacting them on the top with a flat anvil and measuring the force transmitted through the neck of a head form. This was done on the theory that helmets could break necks, a theory long since disproved.

Due to considerable work on the part of some United States representatives, both the swingaway and the transmitted force methods of testing gave way to the rigid anvil falling head form system currently in use.

A change toward better helmets in the equestrian field began in 1984 when I was contacted by Ron Dancer who headed a safety committee for the United States Trotting Association. There had been two unfortunate deaths from head injuries in trotting racing, and there was concern about the capabilities of helmets being worn.

After meeting with Ron Dancer's group, I tested eight different helmets being sold as trotting helmets and found them to be very poor in head protection. I was then asked by the safety committee to develop what I thought would be a suitable helmet for the sport. To do this, I visited six tracks around the United States, photographed and logged the many hazards encountered in a race, and talked to drivers, owners, and track operators.

After a final meeting at the Meadowlands in New Jersey with fifty-five representatives in the industry, I constructed three prototypes helmets which I labeled good, better, and best. I presented these three helmets and described their capabilities at the Trotting Association's annual meeting in Columbus, Ohio. The large group present chose the middle or "better" helmet and from this the Snell Memorial Foundation developed a standard. Unfortunately, due to many reasons, most of them political, a major controversy developed and the trotting industry was slow to adopt the new helmets.

Other equestrian groups became interested in better helmets, and under the guidance of Dru Malavase of the United States Pony Clubs, an ASTM Equestrian Standard was developed which has demonstrated its effectiveness.

Again, unfortunately, politics and vanity have hindered the growth of the standard into other equestrian areas. I would strongly recommend that these groups take a lesson from the Pony Clubs and seriously consider better head protection.

Although I work for a helmet company, we do not manufacture equestrian helmets, so I have no ulterior motive, only hopefully to prevent unnecessary injuries.

Dean Fisher
Senior Vice President
Bell Sports
13875 Cerritos Corporate Dr.
Cerritos, CA 90701

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United States Pony Clubs: 1993 Accident Summary

United States Pony Clubs (USPC) study of accidents occurring in its activities has completed its twelfth year. Although the data we collect has been of great interest to other organizations, our emphasis is to determine the causes of accidents to our own members, and to suggest ways to reduce the number and severity of these accidents. We encourage club District Commissioners (DCs) to file a report of any incident of concern to members, instructors, leaders, parents, or outside competitors at Pony Club sponsored activities. We acknowledge that there are many non-injury incidents which are not reported and that we receive multiple reports from especially conscientious DCs, who will probably only be rewarded in heaven.

In the interest of keeping the summary at a manageable size, we have chosen figures of particular interest and significance. The Pony Club activities include dressage, stadium and cross county jumping, trail riding, gymkhana, vaulting, tetrathlon and horse management, with the upper levels involved in teaching other Pony Clubbers, as well as judging and evaluating the training of a horse.

The total reports filed were 56 from 12,089 Pony Club members. Of these, 52, or 92.9%, were incidents which resulted in injury. The ten year study (1982-1991) shows 93.5% during that time period. Four injury reports were to non-members of Pony Club, and were not included in the totals, although their contents were noted.

Of the injury accidents, the ten year study showed the head as the site most often injured: 14.4%. The breakdown of that percentage, computed both before and after 1990, when the ASTM/SEI helmet was required by the USPC rules remains significant. During 1982- 1989, the percentage of head injuries was 24.2%. In 1993 it was 14.6%, a decrease from 15.4% in 1992. All riders reported wearing ASTM/SEI headgear; one helmet slipped slightly on the head at impact, but was not lost. Another took a major blow in a dragging accident; the brim was lost off the hat, and the rider had a small laceration which needed no sutures.

Two of the head injury accidents were more serious than a mild concussion. One involved a horse which shied; the rider was hospitalized for 24 hour observation and recovered quickly. The other occurred to a non-member student of a DC helping at a fund raiser, who was holding a pony at the food booth. She was kicked in the forehead and sustained a serious skull fracture which required surgery. This accident is not reflected in the totals, but is mentioned because it underscores the continuing need to consider the safety of non-members at Pony Club activities.

In 1992 facial injuries were 12.1%; in 1993 this decreased to 5.6%. In 1992 all the face injuries were superficial; in 1993 this was also true. The most serious injury was to a rider walking down a barn aisle; a horse reached out and bit her ear which required one suture.

The second most frequently injured site was ankle/foot/toes, with 9%, up from 7.7% in 1992. Tied for third were the forearm and dorsal/lumber spine areas, with 7.9% each. In 1992 the knee was second, the face and wrist/hand areas tied for third.

The most common type of injury was bruise/abrasion, 26.1%, down from 35.6% in 1992, including both primary and secondary injuries. The ten year average was 35.1%. The second most common was closed fracture, with 15.9%, up from 14.9% in 1992. The third most common was sprain/muscle pull, 13% up from 12.6%. Fourth was laceration, no sutures, with 11.6%; fifth was concussion/unconscious, 8.7% down from the 10.3% in 1992. Concussion was defined to include any momentary "seeing stars", confusion, or memory loss. All the concussions were mild, with one occurring to a rider bending over to put on her chaps while holding her horse; she had not yet put on her helmet. She was kicked in the head.

Those reporting a previous injury in a horse-related accident were 13.5%, down from 33.7% in 1992. We hope that this reflects caution on the part of DCs, instructors, and parents in observing previously injured riders, since the USPC study has shown that past accidents are a possible indicator for future accidents. This year only one rider reported two separate injuries. The second injury occurred in the swimming pool at camp the day after a mild riding accident.

The figure for hospitalization after injury was 8.6% in 1993, down from 11.4% in 1992. Physician office or hospital visits where riders were treated and released continued to increase, although they remain below the level of the ten year study. Of these riders 8.6% returned to ride an the same day; 48.3% were unable to return but were released on the same day.

Of concern is the fact that 74% of those injured were at the "D" level 26% at the "C"; none at "B"; 4% "HA". The largest number of injuries occurred to those with 5 or more years of riding experience; the second largest were those with 2 to 4 years. Mounted riders were involved in 66.7% of the accidents, 25% were not mounted and 8.3% were not horse related. All but one of the reports were associated with supervised activities. The most common activity was the mounted meeting or lesson; second was camp, and third was the competitive rally. Of the activities, taking a lesson was most common, jumping was second, and cross county was third. The most common location was the arena, second the cross country course, and third an outside ring.

Of the horse actions causing accidents, the most common were falling/slipping and bucking, followed by refusing a jump. Common rider errors were losing control of the horse, or being out of position. Of the non-riding accidents, 35.7% involved the horse stepping on the injured party; tied for second most common were kicking, pushing, or pulling back or away from the handler.

Of the accidents which were not horse related, there were no obvious patterns of activity. A dog bit a child--"unprovoked" the DC assures us. A drag scraper was dropped on a non-member worker's foot. At a work day, a standard being painted broke, dropping a nail through the Pony Clubber's foot. One child was stung by a hornet while at camp. Another child at camp stood up after singing around the campfire, fell in a hole and suffered an ankle injury. A District Commissioner received a serious back injury while riding along a road.

It is interesting to note that it appears to be more dangerous to patronize a Pony Club food stand than it is to hit an indoor ring wall head first while wearing an ASTM/SEI helmet.

The United States Pony Club members and those adults who take their welfare seriously continue to produce an excellent safety record.

For further information:
Dru Malavase, member
USPC Safety Committee
2270 County Road 39 RD 2
Bloomfield, NY 14469

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Vigorous Head Nodding by a Rider During the Sitting Trot in a Therapeutic Riding Program

D. Riede in 1986 measured two rider's spines at the seventh cervical vertebra and the lumbar spine as the horse walked, trotted, and cantered. These measurements revealed that the vibration from riding is not sufficient to cause damage to the rider's spine.

Stenosis of the cervical spine was reported by Reese et al in individuals with spastic cerebral palsy. Strong neck extension used by their subjects to right their heads from flexion may have contributed to their developing stenosis of the cervical spine. In 1987 Fuji et al found that athetoid mavemen t were associated with cervical stenosis in individuals who had athetoid cerebral palsy. Cervical spinal stenosis should be considered when an individual complains of neck pain and/or exhibits neurological symptoms, such as hypertonia, paresis, paresthesia, sustained clonus and/or asymmetry of mavement and/or strength.

Individuals who have athetoid cerebral palsy have been found to be at risk for developing premature cervical spondylosis as a result of dystonic-athetoid movement. These studies report the C3-C4 level to be the most frequent site of this premature spondylosis. Candidates for mounted equestrian activities who have athetosis should be carefully evaluated to rule out degenerative cervical changes prior to riding. No mounted equestrian activities should be undertaken until the individual has been examined by a physician.

Spinal instability, which may be the result of cervical trauma, neurofibromatosis, rheumatoid arthritis, secondary carcinoma, or atlantoaxial instability is a contraindication to riding. Repeated head movements by individuals with spastic or athetoid cerebral palsy may lead to cervical stenosis, spondylosis or problems in these diagnostic groups.

The results of our study suggest the sitting trot may be used to strengthen cervical muscles in riders who have been diagnosed with spastic quadriplegia and cerebral palsy. If the individual uses excessively strong neck extension to right his head from flexion, then profound weakness or hypotonia of cervical and upper thoracic musculature exists; therefore, trotting is not indicated. Other therapeutic mounted activities may better serve this rider, such as carefully graded walk-halt-walk, walk-halt-back-walk transitions and stridelength changes within the walk. Head nodding that includes neck extension or hyperextension within the arc of excursion may be more likely to produce cervical microtrauma than head nodding that occurs within a cervical flexion-to-neutral excursion. Head and neck postural alignment and arc of head nodding excursion need to be evaluated on an individual ongoing basis if the rider is going to ride with the horse moving at a trot.

The duration of the horse's trotting interval should be considered when using the movement to strengthen the rider's cervical musculature. Providing a visual target will give the rider a stationary point upon which to fix his gaze; this will assist him/her in maintaining a steadier head position. Over a prolonged period of time, vigorous head nodding may cause damage to the cervical structures of riders with spastic or athetoid cerebral palsy. If the sitting trot is being used to strengthen cervical muscles, it should not he used for longer than a few weeks.

The amount of external stabilization that is used by the rider will impact the amount of head nodding that will occur. Grasping the saddle with both hands is likely to increase tone, cause the shoulders to elevate and the thoracic region of the spine to become kyphotic. As a result, the spinal movement in the lumbar and thoracic regions will be blocked and in the cervical region it will he increased. Stabilization with one hand should allow greater lumber and thoracic movement, thus dampening head nodding. If the rider does not hold onto the saddle, provided spinal fusion or hypomobility are not present, the movement will be taken up throughout the spine, although the distribution will vary segment-to-segment and region-to-region.

No available research has proven the sitting trot will strengthen cervical muscles. Dr. Riede reported the movement of the horse may activate automatic responses influencing control over spinal movement and provide training in coordination and balance. The rhythmic movement of the horse's back as it walks and trots may strengthen the head and neck musculature. As the strength of cervical muscles and the impact of the sitting trot can be measured objectively, a pre-test, interval, post-test design could be developed to research the impact of a sitting trot intervention on cervical muscle strength. Such a study would be it beneficial contribution to the documentation available on therapeutic riding.

This study suggests that the sitting trot may be used to strengthen cervical muscles in riders with spastic quadriplegic and cerebral palsy who have mild cervical weakness. Extreme caution must be taken when considering the application of the sitting trot to riders who have other diagnoses.

Elizabeth Haartz, PT
Beech Spring Farm
125 West Bare Hill Road
Harvard, MA 01451-1626

REFERENCE LISTS

Fuji, T, Yonenobu, K,, Fujiwara, K., Yamashita, K., Ebara, S, Kono, K, and Okada, K., (1987) Cervical radiculopathy or myelopathy secondary to atheroid cerebral palsy. The Journal of Bone and Joint Surgery, 69-A, 815-821.

Glasow, B. L. (1985), Principles of NDT and normal development applied to progressions in hippotherapy. In Proceedings of the Fifth International Congress on Therapeutic Riding, Milan, Italy: Italian National Association of Equestrian Rehabilitation and Recreative Horseriding for the Handicapped.

Glasow, B, L. (1993). "HippotherapyThe Next Step" Workshop. Winslow Therapeutic Riding Unlimited, Inc. Warwick, New York, December 4-5.

Hirose, C. and Kadoya, S. (1984) Cervical spondylotic radiculomeyelopathy in patients with athetoid-dystonic cerebral palsy: clinical evaluation and surgical treatment, Journal of Neurology, Neurosurgery and Psychiatry, 47:775-780.

Nishihara, N., Tanabe, G., Nakahara, S., Imai, T., and Murakawa, H. (1984) Surgical treatment of cervical spondylotic myelopathy complicating athetoid cerebral palsy. Journal of Bone and Joint Surgery, 66-B, 504-508.

North American Riding for the Handicapped Association (1992). precautions and contraindications. The NARHA GUIDE, Denver, Colorado.

Reese, M.E., Msall, M,E., Owen, S., Pictor, S.P. and Paroski, M.W. (1991) Acquired cervical spine impairment in young adults with cerebral palsy. Developmental Medicine and Child Neurology. 33:153-58.

Riede, D. (1988) Aspects of Therapeutic Horseback Riding. (J. F. Allen Jr. Trans.) Riderwood, Maryland, Therapeutic Riding Services, Inc.

Riede, D. (1988), Physiotherapy on the Horse. (A.C. Dusenbury, Trans.) Renton, Washington. The Delta Society. (Original work published in 1986.)

Tebay, J.M. and Schlesinger, K.S.(1985). Riding therapy as a contraindication for Down syndrome individuals with atlantoaxial instability. In Proceedings of the Fifth International Congress on Therapeutic Riding, Milan, Italy: Italian National Association of Equestrian Rehabilitation and Recreative Horseriding for the Handicapped.

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Author's Comments

Little information exists on the effects of riding horseback on disabled and non-disabled individuals that is published in English. While some of the references do not pertain directly to the cervical region of the spine, they do refer to studies that have been done on the rider's spine, and thus, are related.

Therapeutic riding programs usually do not have substantial budgets and person-power; thus true scientific research is out of many programs' reach. Still in our field we encourage efforts to answer questions. While I agree that mine is not a scientific study, it is a start that has created an awareness and has prompted dialog. I pray that the interest I have created within the membership of the American Medical Equestrian Association will not die, as I am unable to carry this investigation any further.

The American Medical Equestrian Association appears to be equipped with the expertise and resources needed to investigate this topic and I implore its members to do so. Therapeutic riding programs need to know the answer to the question: Could the vigorous headnodding produced by the sitting trot be injurious or useful as a treatment application to strengthen weak cervical muscles?

I would like to thank the American Medical Equestrian Association for its support of this project.

Elizabeth Haartz, PT
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