University of Vermont AAHS

AMEA

May 1996, Vol. VI, Number 2

Table of Contents

Vaulting Safety and the Use of Protective Headgear
Peripheral Vision and Helmets
1995 U.S. Pony Club Accident Study
More on Deer Whistles
N.M. Equestrian Helmet Training Project
Grading Scale for Concussion in Sports
NAHA Bodily Injury Damage Statistics Report

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Vaulting Safety and the Use of Protective Headgear

Vaulting is defined as the performance of gymnastic and acrobatic exercises on a moving horse. This sport requires teamwork by the horse, the vaulter and the longeur who controls the horse in a circle.

In individual vaulting youth and young adults may demonstrate their individual abilities and skills in the gymnastics or skating, and by their own Kur or freestyle routines. In team vaulting all vaulters perform their compulsory exercises together with up to three vaulters on the horse at a time Their combined weight does net exceed 400 pounds on the horse.

Vaulting is one of the oldest known sports. In early Roman times the annual games consisted of chariot and horse racing as well as acrobatic displays on cantering horses. Vaulting, along with riding; fencing, archery and several other sports, was a permanent part of the educational program of young Romans of high social standing, During the middle ages knights practiced jumping onto horses and performing elegant exercises on horseback while in armor. During the Renaissance, vaulting was a preparatory exercise for equestrian disciplines but also evolved into an independent discipline in which the horse was replaced by a wooden model. It is at this point that exercises were developed which formed the basis of modern gymnastics.

Modern vaulting as it is practiced today, was first developed in Germany in the late 1940's with the first official rules being published in 1964. The first world championships were held in 1986 in Switzerland and in 1990 the sport was first included in the World Equestrian Games in Stockholm. The American Vaulting Association (AVA) was founded in 1969.

Vaulting is a hybrid sport involving a blend of the skills and discipline of the involved sports as well as blend of their safety standards. Although most of the activities would be familiar to gymnasts or dancers, like all other equestrian sports they must be adjusted to the movement and the rhythm of the horse. The horse is not a lifeless bit of gymnastic apparatus and no individual or team exercise can be performed satisfactorily unless it is done with consideration and in harmony with the horse.

Safety has been a major concern of modern vaulting. As safety standards have been developed for the sport, helmet use has been an issue which has been repeatedly reviewed by the Federation Equestre Internationale (FEI) in Europe. Helmet use in vaulting in the United States was. initially reviewed by the U. S, Pony Clubs (USPC) 15 years ago. Several groups in the United States including the American Medical Equestrian Association, United States Pony Club and the American Riders Instructor Certification Program (ARICP) have questioned again the possible need for protective headgear.

Essentially all United States vaulters are members of the 60 teams comprising the American Vaulting Association (AVA) or are coached by AVA affiliated coaches. The annual safety reports of this organization as well as the reported injuries have been reviewed. Unfortunately injuries appear to have been recorded only for the national competition or for recognized events for most years. Although types of injuries were noted, it was not possible to tell which injuries occurred on the practice barrel as opposed to the horse and what injuries may have occurred in practice as opposed to competition. -A standardized reporting form has not, to this point, been utilized. Most injury categories report such low numbers, usually less than five each year, it is difficult to identify trend, calculate percentage incidence, etc. Standardized forms developed by the AVA safety committee for reporting vaulting injuries will hopefully come into wide-spread use this year.

In the absence of adequate statistical data, it has been necessary- to fall back on information from retrospective surveys. An effort has been made in this study to evaluate the advisability of requiring the use of some variety of helmet for vaulting.

I was able to interview the coaches or managers for 40 of the 60 United States vaulting teams including almost all of the larger teams. They were asked about head injuries, either of their team or others in the past five years that required medical attention. While they could not be expected to remember every sprained ankle, it was felt that they could probably remember every significant head injury with which they had been involved.

The AVA statistics did not report any head injuries. In my interviews I was able to find only two head injuries occurring in the past five years. One injury occurred when a horse shied and a vaulter fell, striking her head art the ground. She developed a subcutaneous hematoma, but no medical attention was required and there was no evidence of neurologic injury. The other injury occurred in practice when a child fell from a horse and landed in a sitting position. Although the child's head never touched the horse or the ground, she did experience amnesia and confusion for the rest of the day and was diagnosed as having a concussion. It is doubtful if any helmet would have been helpful in this case.

While the United States has only about 500 active vaulters, Germany registers 40,000 vaulting competitors each year. I was able to interview Ulrike Rieder, president of the German Equestrian Federation's vaulting committee. She was aware of only one significant head injury in the past several years. This occurred when the vaulter's head struck a horse's hoof in a fall.

I was also able to interview vaulting coaches from Sweden and Denmark. They reported a similar absence of head injuries in their countries. It is of interest that Sweden and England did require helmets for vaulting for several years. Both countries decided that helmets did not contribute to the safety of their vaulters and discontinued their use.

United States and European vaulters have joined their gymnastic colleagues in taking the position that helmets are a hazard to their sport. Potentially, they adversely affect balance and can interfere with peripheral vision. An additional consideration in vaulting is that in many of the up side down positions, the vaulter's head is pressed against the horse's back or side in order to stabilize the vaulter while the horse is cantering. Any potentially movable object between the vaulter's head and the horse could be unsafe for the rider. I was able to find no one in the vaulting community who supports the use of helmets.

While some may wonder if vaulting can really have as low an injury rate, particularly head injuries, as its leaders claim, it is well to remember that this is a sport that has been very conscious of safety. Vaulting standards specifically related to safety, while not universally adhered to, have been developed by the FEI and the AVA and are as extensive as those available to any equestrian discipline. Education and enforcement of safety standards is improving in the United States.

Young horses are not permitted in competition (minimum age six years) and a horse that gives any evidence of being out of control is immediately eliminated from competition. The horse is controlled from the ground by a longeur who keeps the horse in a controlled 13 meter circle. This vaulting circle produces sufficient centrifugal force to ensure that an unstable vaulter will usually land well away from the horse. The environment is controlled by using deeper footing than is usually desirable for any other equestrian sport and by permitting no fences or other solid objects in the vicinity of the vaulting circle. Finally the vaulter is trained from the beginning how to dismount from a moving horse, either intentionally or unintentionally, in a controlled and safe manner. Additionally, vaulters are required to stay in good physical condition. Dismounts are practiced and falls critiqued as a routine part of training.

After reviewing several hundred hours of videos of equestrian competitions range from backyard horse shows to major international events, it is the author's impression that no equestrian discipline gives much attention to techniques for safety dismounting a moving horse except vaulting. This may ultimately be vaulting's greatest contribution to equestrian safety. Even beginner vaulters, when they have a serious loss of balance or stability, are taught not to attempt to recover or hold on to horse or tack. They push away from the horse and accept a rolling controlled fall.

Although it may seem that the vaulter is at significant risk of head injury because of the height of the horse's back, it is probably worth noting that, by comparison, the higher of the gymnast's uneven bars is placed at 40 inches and the rings are at 105 inches. In the language of horses that would be the equivalent of 22 and 26 hands. The control of environmental hazards is quite similar in the two sports. It is interesting that equestrian disciples, even at the level of international competition, have generally not taken the seemingly obvious step of objectively measuring the shock absorbency of various footing and reported this in some standard recognizable form for the benefit of competitors, coaches and ring or course designers. This might be a useful engineering pursuit for vaulting or some other group.

In the National Horseback Riding Injury Survey reported by the National Center for Injury Prevention and Control at the Centers far Disease Control, and the Harborview Injury Prevention and Research Center, 33% of the injuries occurring in riders under age 25 were head injuries. In the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Safety Commission report for 1995 head injuries are involved in 11.3% of emergency room treated injuries occurring in horse related activities.

My survey of vaulting injuries shares the limitation of all retrospective surveys and involved quite small numbers. It does have the advantage of involving reports on a majority of United States vaulters and a comparison with the much greater European vaulting communities and their experience

Head injuries have been quite rare in the modern vaulting experience in the United States and Europe. In both areas injuries have been primarily lower extremity injuries and have been comparable to the injuries usually seen in gymnastics and skating. It is the author's impression from talking to numerous coaches that the incidence of upper extremity injuries, and especially spine injuries, has been much less than is the case for gymnastics. It is hoped that more complete injury statistics will be available in the next few years permitting a clearer picture of the actual incidence of various injuries and the circumstances under which they occur.

While it is tempting to assume that helmets should contribute to the safety of vaulters it may be well to remember how often seemingly reasonable assumptions in medicine have been finally proven to be wrong. A current example is the long standing assumption that beta carotene supplements should reduce the risk of cancer. Finally at the completion of the Harvard Physician's Health Study in 1995 almost everybody was surprised and disappointed to find no significant evidence of any benefit from beta carotene supplements. Even more surprising, the multicenter Beta : Carotene and Retinol Efficiency Trail (CARET) revealed a 28% increase in lung cancer and a 17% increase in mortality in the group taking the vitamins. Because of obvious ethical considerations, the study was discontinued 21 months before it was scheduled to be completed.

Although we might believe that vaulters would benefit from the use of helmets, there is at this point no evidence of the existence of a head injury problem in vaulting. It is perhaps instructive to note that in the two countries with a trial of helmet use each independently decided to discontinue their use. As was mentioned earlier vaulting is a hybrid sport. While the equestrian community has been moving toward requiring more body armor for its participants and establishing standards for headgear, vests and boots, the gymnastic community has resisted the use of any impact protectors attached to the participant. It may well be that the gymnasts and vaulters are correct in their assertion that helmets would not contribute to safety and could be a safety hazard. Hopefully, adequate data will be available in the next few years to determine with more certainty whether there is a significant head injury hazard for the modern vaulter

Robert Faulkner, MD
Newton Professional Court
North Hill Street
Covington, GA 30209

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Peripheral Vision and Helmets

Peripheral Vision and ASTM/SEI Equestrian Helmets

Some of the equestrian community repeat the nostrum that riding helmets reduce the peripheral vision of riders, an argument used not to use helmets. These helmets we know are clearly helpful in preventing serious head injuries.

To investigate peripheral vision we did a threshold visual field testing with and without helmets. Test instrument was a Humphrey auto field analyzer, the most commonly used and the standard of most eye care professionals in determining visual field restriction and abnormalities.

The patient was a 47 years old equestrian who was first tested with no helmet to determine the degree of peripheral vision present. The test was then repeated with a Lexington model L5300 helmet. We did not remove the visor. This helmet was manufactured December 7, 1995.

The equestrian had no obstruction to visual field in any direction while wearing the helmet One would suspect that if a helmet was to cause obstruction it would cause upgaze obstruction more than anywhere else cause of the present of the visor. However, the results with and without the helmet were identical.

Most helmets are similarly designed and often have even larger visors. Upgaze restriction would not be a problem even had we found it. The importance of helmets is that they protect the head from serious injury and this test shows clearly that there is no obstruction to straight ahead, side, or downgaze in any manner,

John J. Nerney, MD
Diplomate American Board of Ophthalmology
Mountain Eye Associates PA
116 Hospital Drive
Clyde, NC 28721

Visual Fields

I have done two studies of peripheral visual fields with and without helmets and have found there to he no significant difference that would impair peripheral vision whilst wearing a protective helmet. The visual field studies were done without a visor using a TROXEL lightweight SEI riding helmet. The instrument used was a Humphrey Field Analyzer, and visual field changes are extremely minimal. From my own personal experience I have found absolutely no reduction or interference with my peripheral field either jumping or working on the flat.

M.M. Porias, DO, FOCOO
North Loop Eye Center
2030 North Loop West
Houston, TX 77018

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1995 U.S. Pony Club Accident Study

At the end of a day of riding competition, a Pony Clubber still has enough energy left to turn cartwheels in the grass. She punctures the palm of one hand. After the awards ceremony at a Knowdown competition held in an elementary school, one of the participants can not resist the playground equipment. She dislocates her shoulder. While riding a bicycle on Steeplechase Road at the USPC Festival, a Pony Clubber falls and is injured.

Once again in 1995 our members have managed to find new ways to injure themselves. This year's report, a record 167 of them, showed twelve "not directly related to the horse" accidents. Four of them could, however, be classified as "horseplay without a horse." The others were., 1 physical illness, 2 heat illness, 2 barn accidents, 1 trailer accident, 1 car accident without an injury, and 1 emotional illness suffered by a close friend of one of the people killed in the tragic fatal crash near the Horse Park. That accident was not officially reported, and was not counted in our totals, but it certainly reminds us that our members, parents and volunteers are vulnerable to uncontrollable circumstances at any time.

Because this update is of interest to the rest of the horse world outside USPC, the Safety Committee needs to give a brief explanation of the on going accident study and its background. Since 1982, we have collected riding accident and injury in formation from the District Commissioners of our member clubs, which have close to 13,000 members. In 1995 we added an optional "short form" report to our longer standard form. Of the total returned, in 74 most of them reported incidents which resulted in no actual injuries. Of the total 167 reports, 143 were to current active members of USPC. We compile the reports on non-members separately and do not count them in the total. The report: covers every- aspect of USPC, mounted and unmounted.

The 1995 reports show that 89% of the incidents described happened to female members, The rating levels of members showed a significant change from 1994. Both years showed Unrated accidents as slightly under 7%,. In 1994, 73.3% were D's but in 19$5 the percentage de creased to 50.8%. C accidents went from 18.3% in 1994 to 41.7% in 1995. The B figure decreased from 1.67% to 0.76%, and there were no accidents to HA or A member. By far the largest number of accidents occurred to riders with 4 years of riding experience, 55.7% in 1995.

As usual, the interpretation of the changes presents an interesting challenge. Are we concentrating on the safety of our D members, and giving them better supervision and/or instruction? Or ate we looking at figures skewed by the fact that the 1995 Championships/Festival included mainly C level members, and represented 23.6% of the reported accidents?

Mounted accidents accounted for 78.8% of the reports, last year this figure was 84.6%. Unmounted accidents were 12..1% and 9% were not horse related. Leading the horse was the most dangerous unmounted activity; 62.5% of the 1995 accidents included horses which kicked, pushed, pulled, and stepped on their handlers. Perhaps it is time for all clubs to emphasize safe leading and handling techniques to members of every level, since there were also grooming, feeding, bandaging, saddling and loading accidents reported. Good manners in horses also needs to be encouraged in our teaching.

What are the most dangerous supervised activities for Pony Clubbers? Lessons with 35.6%, Camp with 24.6% and Rallies (all kinds) with 15,1%. Testing were 7.6%, Prep and Combined Training Clinics were 1.6%, Competitions were 7.6% and Trail Riding 2.6%. There were two new categories in 1995, Drill Team Demonstration and Prep and Parade, with one accident each. Happily there were no Driving Tetrathlon, Polo or Vaulting accidents this year. However, there is less exposure in these activities.

What are the worst sins committed by Pony Club horses? Refusing jumps and falling or slipping tied for first place. Bucking was next, followed by shying or jumping too big. Kicking or biting came next. Falling into jumps and rearing were also mentioned. The "other" category showed the excellent command of English of our reporting D.C.'s and included Bolted, Popped, Puffed, Reared, Rolled on, Swerved, Veered, and Tossed Head into child's face.

What were the three in jury areas seen most often in 1995? The head, 12'%; Wrist/ Hand, 10.1%; and Ankle/Foot 9.4% But the good news here is that only three accidents required hospitalization. None of these was for a head injury, although a child hospitalized for a bruised kidney also had a suspected mild concussion. The other hospital admissions were for an abdominal kick which caused internal injuries and a lower leg fracture. The most common type of injury is bruise/abrasion, 42.7%; closed fractures were next, 12.5%; and third was concussion with 11.9%.

Because the USPC has required the use of ASTM/SEI riding helmets for its members since 1990, head injury reports are always followed closely We have the strictest interpretation of concussions of any group studying the subject; we include momentary confusion as well as the more usual memory loss, headache, or loss of consciousness. The baseline study we use for comparison showed that head injuries to children under 14 years of age were 43.1% of riding injuries and 40.5% for riders under 18 years of age. Dr. Hammett's tea year study showed a USPC head injury percentage of 24.2%. The six years of ASTM/SEI helmets reduced this number to 12.4%. None of the 1995 reported head injuries were serious. Eight of the twelve came from direct blows to the helmet, and four involved facial impacts. Five riders reported headache. One had vision problems, and another reported a bump on the head. The one head injured rider with loss of consciousness was released from the Emergency Room within two and a half hours

All the mounted accidents reported were to riders wearing ASTM/SEI helmets. One helmet fell off before impact, but the rider hit with her back first and had no head injury. However, this rare occurrence points out the need to check on the fit of helmets before every mounted lesson and activity, not just before competition.

Two of the head injuries were sustained while leading horses. In one case, the horse tossed its head and hit the handler. In the other, the handler received a kick above the eye.. Of the mounted head injuries, one happened during a victory gallop, one because of a slipping saddle in competition, and another when the horse tossed his head into the rider's face. Of concern was an injury to a young unrated rider on the longe line, who, with her mother's permission, was allowed to canter.

There was several non-head injuries reported to D1 and unrated riders while jumping. perhaps a gentle reminder from the Safety Committee is in order. Our instructors need to be especially careful with our newest riders and should be very familiar with the D1 and D2 standards to be sure they are not being overfaced, even when they are begging to do more.

The reporting response was excellent this year, for which the Safety Committee thanks the D.C.'s and R.S.'s responsible. The information we receive is unique in the horse world, and once again we want to promise that there will be no repercussions to clubs or individuals as a result of honest reporting. Many of our safety practices have been improved as a result of our improved knowledge.

The 1995 report from the Festival and Championship organizers related in many ways to safety, and this information will be gassed on to future organizers. Some of it is relevant for clubs who run much smaller activities, For example, golf carts may not be lighted, and even a taped on flashlight would be helpful when they are used after dusk. Riding by non-competitors needs to be con trolled and monitored. Emergency procedures need to be developed for weather extremes, such as extreme heat and severe storms. The use of safety belts in cars transporting competitors, parents, and coaches should be emphasized.

The 1995 reports on our over-age-21 parents, other friends and officials covered several amazing accidents. A Show Secretary was hit in the head by a falling tent. An innocent parent walking past a trailer was kicked on the knee by a tied horse. While getting out of a car, a parent closed the door on her head. An official was following a truck on foot. It reversed, and the trailer hitch hit her in the knee. A volunteer was picking up flags and numbers, jumped out of the back of the truck and broke both a tibia and a kneecap. A parent slipped on wet grass and broke an ankle. But the report which was a first for the Safety Committee was one which involved a parent who had such a heated argument with another parent that she developed radiating chest pain and an anxiety attack. Our D. C.'s may have neglected to report such problems in the past, but all of us know they happen locally as well as nationally especially to sleep-deprived chaperons. Without making any value judgments, the Safety Committee hopes that we can all make safety a priority, and that we can also be granted the patience to be civil and kind to one another

Drusilla E. Malavase
USPC Safety Committee
2270 County Road 39 RD 2
Bloomfield, NY 14469 716-657-7053

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More on Deer Whistles

Several companies manufacture deer whistles that are designated to protect vehicles by emitting ultrasonic and/or audible sounds intended to frighten deer and other animals. Deer whistle manufacturers claim that sounds ranging from 16 to 20 kHz will frighten deer, but there is no published research indicating these frequencies will elicit a flight response in deer at other ungulates, such as cows and horses.

Research done by Mary Bomford and Peter O'Brien at Cornell University, Georgia Game and Fish personnel University of Georgia, Timothy Lawhern at University of Wisconsin, Laura Roman and Larry Dalton from Utah Division of Wildlife Resources, Major D. A. Mack, Ohio State University, indicate that deer whistles are not effective for deer and thus would not be a hazard to horseback riders or drivers.

The February 1996 issue of AMEA News contains a longer discussion of deer whistles and their possible hazards for mounted horsemen.

Doris Bixby Hammett, MD
702 Surrey Road
Waynesville, NC 28786

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New Mexico Equestrian Helmet and Safety Training Project

Equestrian Helmet Safety Training Project purpose was to educate 4-H Club Leaders and Youth Leaders about the value of ASTM/SEI equestrian helmets during horse riding activities and to promote the use of approved helmets among riders. Given the facts about equestrian safety and helmet use, it was believed that participants in the training project would have a greater chance of changing both their attitudes and behaviors about the use of ASTM/SEI approved equestrian helmets. The steps to accomplish these goals were.

1. Distribute an Equestrian Helmet Survey to 4-H Horse Clubs statewide to solicit current knowledge and attitudes about equestrian safety helmets..

2. Conduct a one day Equestrian and Helmet Safety Workshop to encourage 4-H club and youth leaders to conduct additional training an helmets.

3. Conduct a fellow-up survey (Past) to measure "be- fore" and "after" attitudes of the training.

4. Provide follow-up support and technical assistance to clubs that participated in the training, and that have agreed to provide a similar training in their own communities.

THE SURVEY

An Equestrian Helmet Survey and materials packet was sent to over one hundred 4-H Horse Clubs in the state. The packet included a letter which gave a brief over view of the project including information that any club attending the training would be required to conduct two presentations in their area and distribute material locally. Those who agreed to these conditions would be eligible for a S150.00 stipend. Included in the packet were articles on equestrian safety and helmet use; discount coupons to purchase ASTM/ SEI approved helmets, and copies of an equestrian helmet survey for individual club members to complete and return in a self addressed stamped envelope. Initial response to the surveys was low. Follow-up phone contacts were made to clubs, and Extension Agents throughout the state were briefed on the protect. At the end of 5 months, a total of seven clubs and thirteen leaders had responded.

THE WORKSHOP

After polling leaders and checking calendars, a date and a location at a rural setting in a horse arena was chosen. With an audience of youth and adults, the training had to be fun, fast paced and diverse. For those participants who had not previously filled out a mailed survey, one was completed at the beginning of the workshop. The agenda included a range of topics, speakers and activities with promotional items including horse brushes, a variety of styles of ASTM/SEI equestrian safety helmets, and a copy of the video "Every Time, Every Ride" for each club that attended. A presentation by a panel of survivors of horse-related injuries was particularly powerful.

EVALUATION

(Post Test)

Due to the low response to initial surveys, the post-test evaluation was canceled. In its place, a workshop report card was developed to evaluate the multiple sessions during the one-day training. Clearly, those attending the workshop were more safety conscious in general and wore approved equestrian helmets more of the time.

FOLLOW-UP WITH COMMUNITY TRAINING

Each participant of the one-day training received "Community Training Guidelines" with specific suggestions on how to make their community workshops successful. Two additional contacts will be made after the training: the first within two months to club representatives requesting an update on their project activities and an inquiry regarding any change in patterns of helmet use since the beginning. The second will be done four months after the initial training with community trainers.

As a result of our public awareness activities and one-day training, the following barriers, solutions and recommendations for future strategies were developed.

BARRIERS AND SOLUTIONS

Barrier:

Low response rate from 4-H Clubs

1. Club activities tend to be nominal during the summer which prevented clubs from completing the survey.

2. Both leaders and children changed 4-H activities or left clubs. As a result, same clubs changed their focus or activities.

3. Hesitation in getting involved with a potentially controversial subject.

4. Unclear expectations or reluctance regarding required helmet safety training.

.Solution:

1. Open the invitation to a wider audience of horse clubs. Use exiting mailing list of statewide newsletter.

2. Include county extensions agents, program.

3. Follow hip with phone calls.

Barrier

The greatest barrier is the subject matter itself: Wearing a helmet during horseback riding.

1.. General lack of education about the subject.

2. Breaking of old stereotypes and images (e.g., it is not fashionable to wear safety helmets on a horse; real cowboys wear cowboy hats, etc.)

3. Insular feeling, "An injury can not happen to me.

4. Mindset that helmet use is ineffective, and feeling that in some instances a helmet could cause a great injury.

Solution:

1. Find the causes of these barriers and solve through education.

2. Find a notable spokesperson or survivor of a horse-related injury to help convey message.

RECOMMENDATIONS

Training

1. Plan training on a more frequent, regionalized basis, rather than one large training covering clubs from across the state.

2. Extend training beyond 4-H clubs to neighborhood clubs, pony clubs, horse associations, private stables, Future Farmers of America, etc.

.3. ; Hold training in a location or with an organization that is supportive of the content of the training, preferable in a horse arena.

4. Hold training in a facility accessible to participants.

5. Affiliate with key representative in the equestrian community and incorporate them into training activities.

6. Keep evaluations brief and at a minimum.

7. Take caution to schedule training apart from any major horse shows unless the training is to be an actual part of the larger event,

8, Show a wide range of helmets to display various usage.

9. Make material/announcements or preconditions mailed to clubs simple and user friendly. Be specific about any requirements or preconditions that need to be met in order to participate in the training.

AWARENESS/OUTREACH

1. Use existing communications networks to get the word out about the training, i.e., newsletters, horse shows, mailouts to clubs, etc.

2. Promote helmet use as a part of a comprehensive equestrian safety program for riders, young and old.

a, Determine if the state's trauma registry measures helmet use during its data gathering and disseminates specific data to relevant equestrians.

4. Contact representative in Washington State where an equestrian helmet rule has been implemented for 4-H clubs. Has membership in the 4-H Horse Clubs declined? Have there been fewer injuries since the rule went into effect? Has there been any problem enforcing the rule on private land? Do riders comply now that helmet use is a rule> As an educational organization. what is our state 4-H currently teaching in regards to safety practices?

5. Meet with representative of the US Pony Clubs or other groups that require ASTM/SEI helmet use. What suggestions can they offer to promote a positive image of helmet use?

CONCLUSION

While the use of equestrian safety helmets during horse activities is still a new and debated topic, a core group of people believe that helmets are a necessary safety precaution and must be worn during horse related activities. These people can become effective advocates of helmet use due to personal experience getting injured themselves or having some- one close to them injured. The videos, materials and data support their beliefs in promoting helmet use. Training to this group, while preaching to the choir, is very productive.

On the other hand, there are those who resist and resent -what is perceived as bureaucratic intervention in their personal affairs. In addition, equestrians tend to be pioneer spirited people who believe that their existing tradition must be preserved. Many believe that the risk involved in the equestrian riding is obvious and knowingly taken. Still others believe that it is still too soon to make conclusions about the long term effectiveness of wearing equestrian helmets. These equestrians are critical of what they see as oversimplified approach to horse safety.

The fact remains that 6000 head injuries are reported each year in the United States from horse riding accidents. Half of these injuries require hospitalization. There does need to be improved collection of accurate statistics an horse-related injuries, including information on whether or not approved equestrian helmets are involved. While it is indisputable that scores of lives have been spared due to the use of a helmet while horseback riding, many people unfortunately remain unaware that ASTM/SEI equestrian safety helmets are available and becoming more affordable and comfortable. Education, exposure, familiarity, peer pressure and political changes all can influence attitudes and behaviors that can save lives, The results of one training program in New Mexico show that some people can change their minds about helmet use. If only one person goes forth to convince another, the cycle has begun.

It is said that every journey begins with a first step. The New Mexico Disability Prevention Program has taken that initial step, toward public awareness of equestrian helmet use. Lessons learned in this first round of activities will make the next step a little easier.

Nancy Pieters
Disability Prevention Program
Health Promotion Bureau
Department of Health
1190 St. Francis Drive
Room N-1308
Santa Fe NM 87502

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Grading Scale for Concussion in Sports
Colorado Medical Society (Revised May 1991)

Concussion is the most common consequence of head injury in contact sports. Head and neck injuries are the most frequent catastrophic sports problem. While these injuries can occur in any athletic activity, they are must common in football, boxing, horseback riding, swimming, diving, cycling, ice hockey, gymnastics, martial arts, sky driving, rugby and motorized vehicle racing. Current information regarding head injuries must bring new respect for what is frequently dismissed as an athlete having suffered a "ding" injury. Several observations call in question the very concept of "minor" head injury

1. Brain injury in sports can result from any rotational (angular) or translational (linear) force applied to the head. Frequently both forces act in combination. Rotational forces more commonly cause loss of consciousness associated with deep shearing injuries of nerve fibers (diffuse axonal injury or DAI). Translational forces are less likely to cause unconsciousness but more commonly lead to skull fractures, intracranial hematomas and cerebral contusions.

2. Central nervous system axons are more vulnerable to the shearing forces of mild head injury than the surrounding glia and vascular tissues.

3. It has long been recognized, although underappreciated, that confusion and amnesia can result from concussion even without loss of consciousness.

4. Current neuroimaging techniques of magnetic resonance imaging (MRI) and computerized tomography (CT) frequently detect intracranial lesions following mild head trauma, even without loss of consciousness. MRI has proven to be more sensitive than CT in detecting intracranial pathology, especially the non-hemorrhagic lesions of DAI prevalent in closed head injury.

5. Neuropsychological deficits may be evident even when there are no abnormalities detected on thorough neurological examination.

6. Information processing ability can be reduced following concussions. Twenty-five percent of athletes with three minor head injuries, 33% of those with four minor head injuries, and 40% of those with five minor head injuries showed persistent abnormalities on neuropsychological testing at 6 months after in- jury.

7. Repeated concussions appear to impart cumulative damage, resulting in increasing severity and duration with each incident.

8. In football, the chance of having a second concussion is four times greater than the chance of sustaining a first concussion.

9. Amnesia following mild head injury frequently takes several minutes to appear, suggesting that some neuropathological process evolves slowly over time after the mechanical blow.

10. The Second Impact Syndrome, although rare, can result in catastrophic brain swelling which may occur following a second minor head injury in individuals who are still symptomatic from a prior concussion.

While several scales for grading head trauma have been published, we propose a simple and practical system for the classification and management of sports related concussions. This scale is intended to he sensitive to subtle neurological deficits which could be overlooked using existing methods.

While these guidelines cannot replace the sound clinical judgment of the treating physician, it is hoped that this report will be useful to coaches, athletic trainers and emergency personnel, as well as team physicians and other medical professionals.

GRADE 1

Confusion without amnesia
No loss of consciousness
Remove from event pending onsite evaluation prior to return

This is the most common yet the most difficult form of concussions to recognize. The athlete is not rendered unconscious and suffers only momentary confusion. The majority of concussions in sports are of this type, and players commonly refer to it as having been "dinged" or - having their "bell rung." All athletes with Grade 1 concussions should be removed form the game and evaluated before reentering the contest.

Return to Play Following Grade 1 Concussion

Following a Grade 1 concussion, if the athlete has no symptoms at test or exertion return to the game may he permissible after at least 20 minutes observation.

In every instance, when the athlete is symptomatic, removal from the game is mandatory. All symptoms (headache, dizziness, impaired orientation, impaired concentration, memory dysfunction) first at rest and then with exertional provocation testing before return to competition. Return is allowed only if the athlete is asymptomatic during rest and exertion for at least 20 minutes. A second Grade 1 concussion in the same contest eliminates the player from competition that day. CT scanning or MRI scanning is recommended in all instances in which headache or other associated symptoms either worsen or persist longer than one week. It is recommended that three Grade 1 concussions terminate a player's season. No further contact sports are permitted for at least 3 months, and then only if asymptomatic at rest and exertion.

GRADE 2

Confusion with amnesia
No loss of consciousness
Remove from event and disallow return

With a Grade 2 concussion, the athlete is not rendered unconscious but exhibits confusion and has amnesia for the events following the impact (post-traumatic amnesia). After a Grade 2 concussion the athlete should be removed from the game and should be evaluated frequently over the next 24 hours for signs of evolving intracranial pathology by direct medical observation with explicit, written instructions given to the family

Return to play following Grade 2 concussion

Return to competition after a first concussion may be as soon as one week after the athlete is asymptomatic at rest and exertion. A neurological exam should be performed by a physician prior to return to practice. CT scanning or MRI scanning is recommended in all instances in which headache or other associated symptoms either worsen or persist longer than one week. Return to contact play should be deferred for at least one month after a second Grade 2 concussion, and termination of the season should be considered. Terminating the season for that player is mandated by three Grade 2 concussions, as would any abnormality on CT or MRI scan consistent with brain contusion or other intracranial pathology.

GRADE 3

Loss of consciousness
Remove from event
Transport to appropriate medical facility

It is usually quite easy to recognize a Grade 3 concussion. This level of head in- jury applies to any athlete who is rendered unconscious for any period time. Initial treatment includes transport to the nearest hospital by ambulance (with cervical spine immobilization if indicated). A thorough neurological evaluation should he performed emergently, including CT scan or MRI scan when appropriate. Hospital confinement is indicated if any signs of pathology are detected or if the mental status of the athlete remains abnormal. If findings are normal, explicit written instructions may be given to the family far overnight observation. Neurological status should be assessed dairy thereafter until all symptoms have resolved.

Prolonged unconsciousness, persistent mental status alterations, worsening post-concussion symptoms, or abnormalities on neurological exam require urgent neurosurgical consultation or transfer to a trauma center.

Return to play following Grade 3 concussion

One month is the typical period the athlete should be held from contact sports after a Grade 3 Concussion Return to play after one month is allowed only if the athlete has been asymptomatic at rest for at least 2 week. CT or MRI scanning is recommended in all instances in which headache or other associated symptoms either worsen or persist longer than one week. If asymptomatic, conditioning drills may be resumed prior to one month. A season is terminated by two Grade 3 concussions or by any abnormality on CT or MRI consistent with brain contusion or intracranial pathology. Return to any contact sport should be seriously discouraged in discussions with the athlete.

In most instances when an athlete has suffered a head injury which requires intracranial surgery, return to contact sports is contraindicated. However, the final determination as to when an athlete may return to competition is the team physicians' clinical decision.

Side Line Evaluation

MENTAL STATUS TESTING

Orientation:
Tune, Place, Person and Situation (circumstance of injury)

Concentration:
Digits backward. 3-1-7; 4-6-8-2; 5-9-3-7-4; Months of year in reverse order

Memory:
Names of teams in prior contest; President, Governor Mayor, Recent newsworthy events; 3 words and 3 objects at O and 5 minutes. Details of contest (Plays, moves, strategies, etc.)

EXERTION PROVOCATIVE TESTS

40 yard sprint, 5 push-up, 5 sit-ups, 5 knee bends Any appearance of associated symptoms is abnormal, e.g. headache, dizziness, nausea unsteadiness, photophobia, blurred or double vision, emotional lability or mental status changes.

NEUROLOGICAL TESTS

Pupils: Symmetry and reaction

Coordination: Finger-nose-finger and tandem

Sensation: Finger-nose (eyes closed) and Romberg

Guidelines for the Management of Concussion in Sports
Sports Medicine Committee
Colorado Medical Society

PO Box 17550
Denver CO 80217-0550
303-779-5455

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North American Horsemen's Association

Bodily Injury Damage Statistics Report
January 1, 1992 through December 31, 1995

Total Insurance Polices Involved: 3,576

Bodily Injuries Incidents 90%

Death 1 Person

Back.................6%
Arm - R..............8%
Elbow - R. Less than 1%
Hand-R...............1%
Wrist- R.............3%
Finger - R Hand......1%
Arm - L..............4%
Elbow -L.............1%
Wrist- L.............1%
Fingers-L Hand.......1%
Both Arms Less than..1%
Ribs.................4%
Face.................7%
Head.................4%
Clavicle.............1%
Eyes Less than.......1%
Neck.................1%
Shoulder-R...........1%
Abdomen Less than....1%
Wrists Less than.....1%
Allergy Less than....1%

TOTAL UPPER BODY....51%

Hip/Pelvis...........6%
Leg-R................4%
Leg-L................2%
Ankle-R..............1%
Angle-L..............1%
Knee - R.............1%
Knee-L...............1%
Foot Less than.......1%
Both Knees Less than.1%
Tailbone.............1%

TOTAL LOWER BODY....19%


Examined and No or
No Known Injury.....30%

BODILY INJURY TYPES

Fracture............26%
Bruise..............18%
Laceration..........10%
Concussion...........1%
Sprain...............1%
Amputation (finger)..1%
Sore................10%
Dislocation..........1%
Bee Sting............1%
Torn Ligaments.......1%
No known Injury.....30%

HORSE RELATED CAUSES

Horse Related Budily Injury Only
Fall of Rider.......81%
Kicked...............6%
Bite.................3%
Knocked Down.........2%
Lost control.........1%
Dragged Less than....1%
Stepped on...........1%
Jummped off..........1%
Horse fell...........1%
Dismounting..........1%
Collision............1%
Emergency Dismount...1%

TOTAL..............100%

ACTION OF THE HORSE

Horse Related Claims Only

No action - Rider Lost Balance...41%
Shied, Spooked, Side-Stepped,
Ran forward.....................21%
Jumped/Bucked.....................9%
Kicked............................8%
Stumbled..........................6%
Bit...............................3%
Reared............................2%
Bolted............................2%
Equipment Failure.................2%
Horse Fell........................1%
Sudden Stop.......................1%
Rider Lost Control of Horse.......1%
Threw Head........................1%
Stepped On........................1%
Turned Sharply Less than..........1%
Worse Threw Shoe Less than........1%
Horse Laid Down to Roll Less than 1%

TOTAL...........................100%


EDITORIAL NOTES

Bodily injuries have not changed significantly (See AMEA NEWS November 1992 Volume II # 4). The changes or points to be noted are listed below.

Head injuries lowered from 7% to only 4%.

One head injury involved no horse activity: a camp had an airplane throw candy suckers out of a plane into a field. The children were to go into the held and look for the candy suckers after the plane passed over. One wayward sucker landed on a child's head resulting in a laceratian which required stitches.

One head injury due to dragging in a horse-leading incident resulted in the one noted death.

One head injury was the result of a young rider getting a foot caught in the stirrup and being dragged. This resulted in a laceration to the head which required stitching (ASTM helmets had been offered, but refused.)

Facial injuries were up - from 1% to 7%
These mostly related to falls from a horse where the face was scratched or the nose bumped, however, involving only minor injuries.

Finger amputations
For the first time our statistics included three partial finger amputations. Two children experienced loss at the first knuckle, and one adult at the second knuckle, dug to horses biting.

Out of 403 incidents two involved dragging, one while leading a horse and another due to the foot becoming caught in a stirrup.

Action of the horse involving only horse related incidents, showed two significant changes.

The number involving a simple loss of balance and fall from a horse rose from 23% to 41%

Stumbling of a horse decreased from 11% to 5%.

Linda Liestman, President
North American Horsemen's Association
PO Box 22
Paynesville, MN 56362

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