University of Vermont AAHS
AMEA

November 1997, Vol. VIII, Number 3

 Table of Contents
 15-year Study of Rodeo Injuries
 News of the AMEA
 Safety Equipment Institute
 Safety Summit
 Development of Equestrian Sports Medicine
 Helmet Life Span
 Park Service Stable Concessionaries Survey
 Horse-related Deaths
 Sports-related Recurrent Brain Injuries
 Management of Concussion

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JUSTIN SPORTSMEDICINE PROGRAM
15-YEAR PRCA STUDY OF RODEO INJURIES

The Justin Sportsmedicine Program was initiated at the National Finals Rodeo in December of 1980. The next year the program covered 10 of the major Professional Rodeo Cowboys Association (PRCA) Rodeos and the first full season of sports medicine coverage of ProRodeo began.

During the 15 years ending in 1995 the Justin Sportsmedicine Program increased involvement in the PRCA from 10 (1.6%) of the 641 rodeos in 1981 to 79 (10.7%) of the 739 events in 1995. The number of performances that were covered by the Justin Sportsmedicine Program increased during that same time frame from 110 (5.6%) of 1,941 performances in 1981 to 426 (19.2%) of the 2,217 performances in 1995.

The events with the most injuries remained bull riding, bareback bronc and saddle bronc riding in that order over the 15 years. Rodeo clowns/bullfighters were, as could be expected, the most frequently injured non-contestants (77.4%). When combined with rodeo events, clowns and bullfighters, which account for less that 1% of the professional rodeo membership, account for almost 10% of the injuries received.

The most injured sites were constant during the 15 year period with the spine, knee and shoulder ranking, 1,2,3. However, concussion remained the most frequent major injury from 1981 to 1995. The concussion injury rate increased from 2.3% in 1981-1985 to 3.5% in 1991-1995 while the injury rate for all other major injuries declined from 8.2% to 4.4%.

Justin Sportsmedicine Program Report data was collected under the direction of J. Pat Evans, MD, and Tandy Freeman, MD, Medical Directors and assembled by Hayden Younggren, Systems Manager and Mary Ann Brasher, Operations Manager, at the Justin Sports Medicine Program office in Grapevine, Texas. The report was analyzed by Robert Vaughan, Ph.D., Exercise Physiologist at the Tom Landry Sports Medicine and Research Center and prepared by Marnie Hill and Michele Alvarado.

The staff members of the Justin Sportmedicine Program would like to express their appreciate to the Professional Rodeo Cowboys Association and the Justin Boot Company for their continued support of this unique medical service program to the most dedicated group of athletes in the world.

The Justin Sportsmedicine Program would also like to thank sincerely Jack Weakley, Director, Sports Medicine Group with Johnson and Johnson Consumer Products, Inc. for their considerable contributions to the rodeo athlete and this comprehensive injury study.

Justin Pro Rodeo Fifteen Year Ranking
INJURY
PERCENT
Concussion
38.00
Chest/Rib Fracture/Lung Injury
9.43
Shoulder Fracture/Dislocation
8.86
Knee Ligaments
6.57
Ankle Fracture
6.57
Cervical Spine (neck) possible Fracture
5.14
Wrist Fracture/Dislocation
4.86
Tibia/Fibula (lower leg) Fracture
4.29
Elbow Dislocation/Fracture
2.57
Abdominal/Spleen/Liver
2.29
Facial/Jaw Fracture
2.00
Hand Fracture/Laceration
1.71
Humerus (upper arm) Fracture
1.43
Foot Fracture
1.14
Femur (thigh) Fracture
0.86
Lumbar (lower back) Fracture
0.86
Clavicle (collar bone) Fracture
0.86
Ulna/Radius (forearm) Fracture
0.57
Hip Fracture
0.57
Scapula (shoulder blade) Fracture
0.29
Chest Injury Fatal
0.29
Head Injury Fatal
0.29
Gastric Rupture
0.29
Thumb Amputation
0.29
TOTAL
350
 

Editorial note:  Rodeo Injuries
The members of the AMEA will note with concern the high number of concussions in the major injuries.  Don Andrews, Executive Director, states:  "This is concern of our program primarily because of post concussive syndrome."

Mr. Andrews points out the position on the use of helmets in professional rodeo, "We do not endorse a mandate of helmet usage for professional rodeo athletes because adequate research and testing has not been completed to ensure that the use of helmets will not increase the potential for cervical spine injury.  We welcome any qualified organization who would be willing to undertake the testing of current or future models of head protection that would release their findings to us and other interested organizations and individuals."

Equestrian sport physicians and schools are challenged to undertake this study to give the equestrian community findings to answer the concerns of the professional prorodeo organization.

Doris Bixby Hammett, MD, Editor

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NEWS OF THE AMERICAN MEDICAL EQUESTRIAN ASSOCIATION
 

American Medical Equestrian Association Annual Meeting October 24-25, 1997
The report of years accomplishments included:

1. development of the brochure "No Accident" by Dr. Julie Ballard and Dr. David McLain. The brochure is being used in new helmets and is available for duplication by members of the horse community for distribution.

2. the video tape Equestrian Safety produced by Dr. William Lee. This tape is available for sale at $17.95 plus handling and postage. His address is William Lee, MD, Desert Foothills Medical Center, PO Box 2150, Carefree, AZ 65277. Phone 602/488-9220. (See article in the NEWS.)

3. AMEA on the Web: Articles from the AMEA NEWS and announcements can be seen at: www.law.utexas.edu/dawson/

4. the AMEA has six new organization members

5. AMEA NEWS: quarterly newsletter continues to provide information of interest to the horse community.

6 AMEA annual meeting: always outstanding

NEW BUSINESS

The Board of Directors contracted with Michael Nolan to be Executive Secretary beginning January 1, 1998. His remarks:

PLANS FOR 1998:

Safety Summit during Equitana in Louisville, KY, June 18-21. Michael Nolan, organizer, stated that this was to be a forum to discuss issues of equestrian safety. (See article in the NEWS.)

Annual meeting 1998: Raleigh/Durham North Carolina. Maureane Hoffman chair.  5408 Sunny Ridge Drive, Durham, NC, 27705, phone 919/286-6925 e-mail maureane@med.unc.edu

Report of nominating Committee:

Election of Officers: Above slate elected by acclimation.

Doris Bixby Hammett, MD, will continue as editor and Pat Hammett will continue to design the AMEA NEWS.

Doris Bixby Hammett, MD Secretary

New Executive Secretary AMEA January 1998
Mike Nolan comes to the AMEA with a broad and varied background with horses. Since learning to ride at Rock Creek, one of the premier saddle seat facilities in Louisville, KY, he has owned Tennessee Walkers, Quarter Horses, Thoroughbreds, Arabs and Paints. "Now I am strictly a Western rider on the trails around our farm," Nolan reported, "but I still enjoy nearly every type of horse sport."

In addition to riding, serving as a volunteer official at 3 day events, service on the boards of a number of horse-related organizations, and earlier ownership of money losing Thoroughbred broodmares, Nolan's experience with horses also includes many professional positions. His first jobs were at various race tracks in Kentucky while in high school and college. After serving as an officer in the Navy during the Viet Nam War, Nolan returned briefly to racing, then joined the staff of the American Horse Council in Washington, DC in 1972.

While at the AHC, he was at various times the chief staff person for their Horse Show Committee, Land Use Committee, and Health and Regulatory Committee. He also worked closely with the AHC's state affiliates, organizing the annual state horse council conferences. During this period, Nolan was elected president of the National Trails Council, where he worked closely with one of the NTC's key director's Dr. Doris Bixby Hammett.

After fifteen years at the American Horse Council, Nolan became the executive director of the American Association of Equine Practitioners, and moved back to his home state of Kentucky to oversee the AAEP's Lexington office. During his tenure at AAEP, Nolan totally revamped their ponderous committee system, expanded membership, increased the size and profitability of the convention and trade show, and significantly improved their financial situation.

Since departing from AAEP, Nolan has operated his own association management firm which works with small companies and associations to provide such services as meeting planning, business planning, membership promotion and public relations. Concurrently he spent five years at the University of Louisville's Equine Industry Program, where he taught students about the business side of the industry, and assisted in research and public relations projects.

He and his wife, Ellen, live on a farm with three horses and too many dogs and cats. They have two grown children and a new grandson.

His address is 4715 Switzer Road, Frankfort, KY 40601, phone/FAX 502/695-8940; e- mail mnolan@mis.com

Editorial note: The American Medical Equestrian Association has grown sufficiently in members, activities, studies, challenges and opportunities that an executive secretary is needed. Volunteer enthusiasm is not sufficient to serve the AMEA adequately. Beginning in January 1, Mike Nolan will serve the AMEA in the new position of Executive Secretary. Mike Nolan will serve as chairman of the planned SAFETY SUMMIT during Equitana 1998.

The by-laws require that the officers be members of the AMEA and physicians. I will continue in name as the Secretary/Treasurer, and in fact as Editor of the AMEA NEWS for 1998. We look forward to this new era of the American Medical Equestrian Association.

Rider Safety Video
Rider safety is discussed by international leaders of the horse community in a 56 minutes video, Rider Safety Video, just released by the American Medical Equestrian Association.

The tape is divided into three parts for easier use with audiences. The first part covers the numbers involved in injuries and rider safety. The second part addresses rider skill, mounting, rope injuries, heat and alcohol problems, the five deadly sins, warm up and trail riding. The third part concludes by describing selecting a horse, safe horse handling and final summary.

The tape was funded by the late Neil Ayer and produced by William Lee, MD and is available from the American Medical Equestrian Association, using the address, William Lee, MD, Desert Foothills Medical Center, PO Box 2150. Carefree. AZ 85377. 602/466- 9220, FAX 602/488-7014 at a cost of $17.95 plus $3.00 for postage and handling.

David McLain Receives Award from AMEA
David McLain was honored at the annual meeting by an award from the American Medical Equestrian Association for his leadership in chairing the annual meeting and contributions to the horse community. This award was presented by retiring president, William Byrd, and was a Waterford crystal horse.

World Equestrian Games
The American Medical Equestrian Association is considering a meeting with medical colleagues from other nations to be held in conjunction with the World Equestrian Games scheduled for Rome, Italy, from September 27 through October 11, 1998. This International Medical Equestrian Association meeting would be held in Rome October 3- 4. The proposed dates are between the first week of eventing, driving and vaulting, and the second week of jumping and dressage. If you are interested in attending or want additional information, please contact David McLain, MD, 6225 Cahaba Valley Road, Birmingham AL 35242. FAX 205/877-2790, phone 205/877-2555.

AMEA Represented at Biltmore Estate Rides
The American Medical Equestrian Association had a exhibit table at the North American Trail Ride Conference ride August 15-17 and the American Endurance Ride Conference ride September 26-28 at the Biltmore Estate in North Carolina. The Biltmore Estate requires protective helmets on all mounted riders using the trails on the estate. Every participant wore a protective helmet during the rides. Managing the exhibit was Doris Bixby Hammett, MD, AMEA, and visiting the exhibit was Kris Bulas, MD, AMEA, and her three children.

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SAFETY EQUIPMENT INSTITUTE

The Safety Equipment Institute is a private nonprofit organization established in 1981 to administer the first non-government third-party certification program to test and certify a broad range of safety and protective products. SEI's certification program is accredited by the American National Standards Institute (ANSI) in accordance with the Standard ANSI Z34.1-1993.

The purpose of the SEI's certification program is to assist government agencies along with users and manufacturers of safety equipment in meeting their mutual goal of protecting consumers with safety equipment in keeping with recognized standards and the current state of the art.

SEI certification programs are voluntary and available to any manufacturer of safety equipment seeking to have product models certified by SEI. Participation in SEI's program is open to all manufacturers.

SEI certification programs include on-going product testing and quality assurance audits which qualify a product model for SEI certification. SEI will certify the manufacturer's product model and grant the right to use the SEI certification label when (1) the testing laboratory has determined that the product model has been tested and successfully meets the appropriate product standard, and (2) the quality assurance auditor has determined that the manufacturer complies with SEI quality assurance requirement.

All product model testing is conducted in accordance with the selected voluntary, government or other standards available for the product. Current standards are promulgated for various products by such organizations as the American National Standards Institute (ANSI), American Society for Testing and Materials (ASTM) and National Fire Protection Association (NFPA).

Both compliance testing and quality assurance audits are repeated at regular intervals to maintain certification. The manufacturers submits to on-going scrutiny of products and processes by independent third-parties and agrees to recall non-conforming products.

Another important benefit of SEI certification is the additional assurance granted to purchasers and users of these safety products. It means products bearing the SEI label have been manufactured to meet the level of quality and performance of the most current comprehensive standards existing for the product. While SEI does not assume responsibility for product performance, SEI's certification label indicates that the manufacturer is concerned and responsible, and that the model for that product has met the recognized standards for testing and quality assurance.

Thomas A. Augherton, Executive Director, Safety Equipment Institute, 1307 Dolley Madison Blvd. Suite 3A, McLean, VA 22101  www.seinet.org [http://www.seinet.org].

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SAFETY SUMMIT JUNE 17-18, 1998

Dr. William Lee, newly elected President of the American Medical Equestrian Association, has announced plans for a Safety Summit to be held June 17 and 18, 1998, in Louisville, KY. The Summit will involve invited representatives from breed registries, show and event sanctioning organizations, manufacturers, distributors and retailers of equine products, liability insurance underwriters, lawyers and equine-related trade publications.

The purpose of the Summit will be to identify methods of increasing the safety of riders and other involved with horses through improved equipment, rule changes, and education. The event was scheduled to coincide with Equitana, an event which attracts a wide spectrum of horse sports and disciplines. It will be arranged by the American Medical Equestrian Association. The AMEA is a organization of physicians and health care professionals who are engaged in the prevention of equine-related injuries and in the treatment of injuries which do occur.

Further details on the Summit will be available from the AMEA office, Doris Bixby Hammett, MD, Secretary, AMEA, 103 Surrey Road, Waynesville, NC, 28786.

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THE DEVELOPMENT OF EQUESTRIAN SPORTS MEDICINE

The field of Sports Medicine has existed for over 2000 years with a medical manuscript of ancient India, dating from between 800 and 1000 B.C., recommending exercise and massage as therapies for chronic rheumatism. Beginning in 776 B.C., contests were held every four years at Mount Olympus to honor Zeus. Prospective competitors in these ancient Olympic Games were required to devote themselves to intensive training under supervision for a period of ten months during the year in which the quadrennial renewal took place. This training was carried out under the supervision of a physician interested in all phases of the athlete's training.

During the Greek period, Philostratus, writing in the third century A.D., warned athletes of the danger of the combination of high temperature and high humidity. (The same concern raised by the USCTA Equine Physiology study for the Atlanta Olympics). He warned athletes to be cautious in their training when "the southern winds are humid, sluggish, and oppressive beyond measure and are more likely to exhaust than stimulate." He was also aware that persons who are fat and stocky are less well able to radiate heat and should keep out of the sun, while those who are slender may tolerate exposure very well. (This rings true for the breeds of horses that are competitive at upper level eventing with the thoroughbreds being over represented and warmbloods under represented, probably for the same reason.) In the first reference to Equestrian Sports Medicine, it was noted that a number of deaths took place in the chariot races.

Little is recorded of Equestrian Sports Medicine during the remainder of the Greek Period, Roman Period (although chariot races continued), from the Byzantine and Muslim cultures, during the Renaissance, and up to the present. Of course, medicine made major advances through these periods.

Sports medicine in the U.S. began with Edward Hitchcock, M.D. who became, in 1854, the first physical education instructor at Amherst College. He is considered the father of American physical education, first sports medicine physician, and the first team physician. What may have been the first English publication in sports medicine appeared in 1898 as a section on first aid in "The Encyclopedia of Sport" written by Byles and Osborn. In this chapter they described emergency treatment for hemorrhage, wounds, bites, bruises, fractures, dislocations, strains and head injuries, and transportation for the injured. (This is similar to many of our present day concerns with Equestrian safety.)

In 1905, the U.S. government considered abolishing football because of its high injury and fatality rate. Four years later the rules had been changed and further study revealed that the new rules lowered the injury and mortality rate. (Rules in equestrian sport also promote safety and many have been formulated with safety in mind. Sometimes a specific incident will trigger a new rule.)

In preparation for the 1928 winter Olympics in St. Moritz, European physicians held a congress on Sports Medicine. At the 1928 summer games in Amsterdam, an international sports congress convened, out of which developed the Federation Internationale of Medicine in Sports (FIMS). The Federation exists today as the international organization for sports medicine physicians. It holds meetings before the winter and summer Olympic games and publishes The Journal of Sports Medicine and Physical Fitness.

In contrast to our colleagues in other sports, the field of Equestrian Sports Medicine has been slow in development. The first jockey hat was developed in England in 1963 to replace the hunt caps made of beetle juice. Not until the 1970's did medical studies begin to appear regarding equestrian related injuries including head injuries in jump jockeys. The first studies appeared in British and Scandinavian medical journals in 1973 and in medical journals in the United States in 1975. In 1976, USCTA News was in the forefront when it published a safety study conducted by medical researchers Mahaley and Seaber in cooperation with USCTA riders and Neil Ayer. Their findings were presented at the 18th AMA Conference on the Medical Aspects of Sports in 1976 in Dallas.

In 1978, the United States Pony Club established the ad hoc helmet committee which developed the United States Pony Club protective standard for helmets. This committee then became the safety committee in 1980 and participated in the Berhang Winslett study of the AHSA. The fifteen year study (to be published) began in 1982. The USPC was involved in the development of the present ASTM standard and the certification by SEI. The USPC has always required a hard hat, a USPC standard protective hat since 1983 and an ASTM SEI helmet since January 1,1990. The USPC Safety Committee represents one of the few in horse sports in the United States that is actively functioning. information ?

The USCTA was founded in 1959 at the Pan American Games in Chicago. The present articles of incorporation, adopted in 1981, mention safety in 5 different sections. Neil Ayer realized the importance of safety to the continued growth of the sport. Under his guidance a Safety Committee was established and represents another one of the few in horse sports in the United States that is actively functioning. The USCTA Safety Committee continues to evaluate accident statistics and to strive to make the sport safer for all competitors.

Protective vests were developed in 1974 when a leading British steeplechase jockey and the medical officer of the jockey club met in a pub to discuss ways in which jump jockeys could get back into racing more quickly after a fall. A modified flak jacket was produced to cushion falls of the rider and minimize soft tissue injuries.

The Medical Equestrian Association was founded in England in 1984 at the Royal Society of Medicine following news that in 1982-3 there were 19 horse related deaths (compared with 7 in motor sports). It was felt that a need existed to have better knowledge of the causes, circumstances, and outcomes of these incidents in all equestrian pursuits. In the United States, the American Medical Equestrian Association (AMEA) was founded in 1986 as a section of the American Medical Athletic Association and was incorporated as an independent organization in 1990. This year's meeting represents the 8th Annual Meeting of the AMEA.

David McLain, M.D., FACP, FACR, 6225 Cahaba Valley Road, Birmingham, AL 35242

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HELMET LIFE SPAN

Our helmet manufacturers use five years as a rule of thumb for replacement. But what about the helmet which spends its first three years on a tack shop shelf in a dark box because it is an odd size which didn't sell? Nobody can tell us whether such treatment extends its useable life.

We now have a helmet with a polypropylene liner which has a certain amount of recovery from a blow, and can probably withstand being dropped on the tackroom floor without the weight of a head in it several times -- but we don't know how many! A heavy fall still requires this helmet to be checked by the manufacturer, since so much serious damage can be invisible until the helmet is taken apart for inspection.

We have told our Pony Clubbers "Your first ASTM/SEI helmet should not be expected to follow you through your entire riding lifetime. Plastics used in riding helmets can be affected by heat, cold, ultraviolet light, and even the air in your barn. If your or your pony use your helmet for a soccer ball (with or without your head inside it) it will need to be inspected by the manufacturer or destroyed and replaced. Serious damage cannot always be seen or felt."

I have been told that the ultraviolet aging test being done by the Europeans proves absolutely nothing. Perhaps it is possible to write one which does, but the engineers I have asked about it are not optimistic.

Some of the signs of hard use are the following.

1. Harness pulling loose from helmet
2. Squeeze clips with broken teeth
3. White helmet turning yellow
4. Black velvet helmet turning beige
5. Surface cracks, holes or dents
6. Chunks missing from the liner
7. Liner squashed down in places
8. Shell or liner cracked through

These are the signs USPC Horse Management Judges are asked to look for at helmet inspection before a child is allowed to ride in a lesson or competition. They are also asked to check the date of manufacture on the label and inspect the helmet especially carefully if the helmet is older than five years. The above list was developed after consultation with our manufacturers. It is meant to be meaningful when looking at ultra-lightweight helmets as well as more conventional models.

In this county football helmets are required to be inspected and reconditioned every few years of service. Auto racing helmets were not permitted on the tracks after the age of five years; the racing secretary confiscated them if they were older and the driver was required to buy a new one before racing. I have been told that this is not done any longer because the drivers were educated to the necessity to replace the helmet every five years. These are the only rules I have been able to find relating to helmet age, and they are required by the rules making bodies, not as part of the standards process. By default age checking is being done here in the U.S. with equestrian helmets only by USPC.

Drusilla Malavase, Chairman, Subcommittee Equestrian Helmets, ASTM 2270 County Road #39. Bloomfield, NY 14469

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NATIONAL PARK SERVICE STABLE CONCESSIONAIRES SURVEYED
Yosemite Concession Service Corporation surveyed 28 National Park Systems stable concession owners/managers by telephone as to size, safety procedures, insurance coverage, accident and litigation problems.  This information was printed in the North American Horsemen's Association 1996 Yearbook of News.  This is the report.
 
 
Question
Response
Respondents
How long in business? 1-10 years 
11-20 years 
21-30 years 
31-50 years 
51+ years
3
6
10
4
5
State offers liability protection? yes 
no 
don't know
6
0
4
Does/could legislated protection 
benefit?
yes 
no 
don't know
19
18
9
Pre-ride orientation? yes 
no
26
2
Who gives orientation? Human 
Video
25
1
Helmets required? 

Required footware?

yes 
no 
yes 
no
3
14
8
20
English only yes 
no
12
16
Age limit? 5 years 
6 years 
7 years 
8 years 
13 years 
15 years
5
13
1
3
1
1
Weight limit? 200 lbs 
225 lbs 
250 lbs 
275 lbs 
No limit 
Discretionary
5
5
8
1
6
3
Offer Tapaderos? yes 
no
12
16
Clothing requirement? yes 
no
5
23
How many animals? 1-20 
21-40 
41-80 
81-100 
101+
5
8
5
3
7
Cinch check? yes
28
Who is insurance carrier? knew 
didn't know 
would not tell
10
17
1
What is your deductible? $0 
$500 
$1,000 
Above $1,000 
Didn't know
0
4
4
1
19
Accidents/litigation a problem? no 
somewhat 
major
24
3
1
How many serious accidents 
per year?
none 
.5 
1-4
23
1
4
Insurance legal cost threaten 
operation?
yes 
no 
possibly
8
12
8
Type of terrain? flat 
hilly 
rugged 
water 
combination
0
0
3
0
25
How many riders per guide? 5 riders 
6 riders 
7 riders 
8 riders 
9 riders 
10 riders 
12 riders 
2-3 guides per 11 riders
2
8
4
5
2
5
1
1
Length of ride? 3/4 hour to 1 hour 
1 hour to 1 1/2 hour 
2 hours to 4 hours 
3 hours to 4 hours 
1/2 day
16
17
18
11
1
How many riders on ride? 1-8 
9-12 
13-15 
16-30
9
10
5
4
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VITAL STATISTICS OF THE UNITED STATES
HORSE RELATED DEATHS

The National Center for Health Statistics (NCHS), the nations principal health statistics agency, mission is to provide statistical information to guide actions and policies to improve the health of the American people. Some idea of horse related deaths can be obtained from its data base. Access via the internet for morbidity figures is available through the address  wonder.cdc.gov [http://wonder.cdc.gov]. There is no inclusive figures for horse related deaths. The chief classification is E828 "animal being ridden". Other animals are ridden: bulls in rodeo and elephants for example. Animal drawn vehicle, E827, are mostly horses, but again bovine, dogs, elephants and other animals can draw a vehicle. Motor vehicles causing deaths of riders of animals and animal drawn vehicle occupant are included in E813.5. "Other injuries caused by animals." is the last category included in the figures below (E906.8). This includes death from kicks, crushing, bites not only from horses, but bites of snakes, dogs, and other animals. These figures will never provide an accurate count of horse related deaths. Accurate figures must be obtained from the state medical examiner who can provide all horse related deaths which will include horse related deaths rather than the categories in the National Center for Health Statistics animal figures.

Using the NCHS figures for gender, the two categories: Motor vehicle involving Animal being ridden/animal drawn vehicle, Animal Drawn vehicle show but few percents difference in the male deaths (59.5%, 58.%, and 55.3%) outnumbering female deaths (40.5%, 42.%, and 44.7%). However, in the category "Other injury cause by animal," the predominance of male over female is 76.4% male 23.6% female.

Using on the category "Animal Being Ridden" (E828) during the years 1983 to 1989 55.6% were males and 44.4% females. This can be compared with the last 5 years in which 54.7% males and 45.3% females died, very little change in the percent. Males animal ridden related deaths continue to out number female deaths..
 
 

94 93 92 91 90 89 88 87 86 85 84 83
Total
Death/Year
Motor vehicle collision 
with ridden animal or 
animal-drawn vehicle 
Male
Female
6
5
1
8
5
3
7
5
2
12
7
5
3
2
1
6
4
2
2
1
1
3
3
0
10
6
4
4
1
3
9
5
4
4
0
4
74 
44   59.5% 
30   40.5%
6
 
Animal-drawn vehicle 
Male
Female
6
5
1
7
1
6
8
6
2
2
1
1
6
2
4
8
5
3
5
4
1
9
7
2
4
3
1
8
4
4
2
1
1
 
4
1
3
69 
40  58.0% 
29  42.0%
6
Animal being ridden 
Male
Female
98
57
41
 
66
35
31
109
60
49
95
48
47
109
61
48
106
59
47
94
46
48
112
67
45
116
62
54
108
61
47
100
54
46
105
63
42
1218 
673 55.3% 
545 44.7% 
102
Other injury caused 
by animal 
Male
Female
 
64
48
16
87
68
19
106
84
22
68
46
22
67
49
18
63
47
16
60
46
14
74
63
11
68
53
15
67
46
21
58
43
15
70 
58 
12
852 
651 76.4% 
201 23.6%
71
 

Editors note:
Studies have shown that approximately 20% of horse related injuries are not riding injuries but occur on the ground in horse management, cleaning the stalls, grooming, saddling, foot care and farrier activities, vetting, and spectators around a horse. (AMEA NEWS May 1997 Vol. VIII Number 1) If this figure is correct, we can estimate 123 horse related deaths a year of which 20 deaths a year are not in riding. This may be accurate, as 6 deaths a year occur by motorist hitting a rider or the occupant of a animal drawn vehicle and 6 deaths a year to occupants of a animal drawn vehicle leaving 8 deaths by kicking or crushing by horses from the category "other injury caused by animal."

In 1984 finding no number of horse related deaths, I contact the ten states which had a state medical examiner system, and which at that time had their records on data base (DE, ME, MD, MT, NM, NC, UT, VT, VA, WV). I obtained the horse related deaths for the past 10 years or as many years as on their data base, using an average of these deaths a year, projected the annual death rate for the nation upon human populations (217 deaths a year) and upon horse population (257 deaths a year). I felt the human population was more accurate. Using the figures from NCHS these figures are high. As stated above, the proper check would be again to survey the state medical examiners, of which many for are now on data base, and develop new figures using this method. It is the hope of the American Medical Equestrian Association members that real progress has been made in the horse related deaths.

We are indebted to Alan Hoskins, Statistics Department, National Safety Council, 111 Spring Lake Drive, Itasca, IL 60143, for his patient guidance and direction in finding these figures from the National Center for Health Statistics.
Doris Bixby Hammett, MD

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SPORTS-RELATED RECURRENT BRAIN INJURIES
MMWR 1997;46:224-227

An estimated 300,000 sports-related traumatic brain injuries (TBIs) of mild to moderate severity, most of which can be classified as concussions (i.e., conditions of temporarily altered mental status as a result of head trauma), occur in the United States each year. The proportion of these concussions that are repeat injuries is unknown; however, there is an increased risk for subsequent TBI among persons who have had at least one previous TBI. Repeated mild brain injuries occurring over an extended period (i.e., months or years) can result in cumulative neurologic and cognitive deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days or weeks) can be catastrophic or fatal. The latter [phenomenon, termed "second impact syndrome," has been reported more frequently since it was first characterized in 1984. The article gives two cases of second impact syndrome resulting in death occurring in football.

Editorial note: The risk for catastrophic effects from successive, seemingly mild concussions sustained within a short period is not yet widely recognized. Second impact syndrome results from acute, usually fatal, brain swelling that occurs when a second concussion is sustained before complete recovery from a pervious concussion. Brain swelling apparently results from a failure of autoregulation of cerebral circulation that causes vascular congestion and increased intracranial pressure, which may be difficult or impossible to control.

The risk for second impact syndrome should be considered in a variety of sport associated with likelihood of blows to the head, including boxing, football, ice or roller hockey, soccer, baseball, basketball, and snow skiing (horseback riding should be included.) The American Academy of Neurology has proposed recommendations for the management of concussion in sport that are designed to prevent second impact syndrome and to reduce the frequency of other cumulative brain injuries related to sports. (See article on Concussion Management). These recommendations define symptoms and signs of concussion of varying severity and indicate intervals during which athletes should refrain from sports activity following a concussion. Following head impact, athletes with any alteration of mental status, including transient confusion or amnesia with or without loss of consciousness, should not return to activity until examined by a health care provider familiar with these guidelines.

The popularity of contact sports in the United states exposes a large number of participants to risk from brain injury. Recurrent brain injuries can be serious or fatal and may not respond to medical treatment. However, recurrent brain injuries and second impact syndrome are highly preventable. Physicians, health and physical education instructors, athletic coaches and trainers, parents of children participating in contact sports, and the general public should become familiar with these recommendations.

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SUMMARY OF RECOMMENDATIONS FOR
MANAGEMENT OF CONCUSSION IN SPORTS

A concussion is defined as head-trauma-induced alteration in mental status that may or may not involve loss of consciousness. Concussions are graded in three categories. Definitions and treatment recommendations for each category are presented below.

Grade 1 Concussion
 Definition: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities of < 15 minutes.

 Management: The athlete should be removed from sports activity, examined immediately and at 5 minute intervals, and allowed to return that day to the sports activity only if postconcussion symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 1 week.

Grade 2 Concussion
 Definition: Transient confusion, no loss of consciousness, and a duration of mental status abnormalities of > 15 minutes.

 Management: The athlete should be removed from sports activity and examined frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for > 1 week. The athlete should return to sports activity only after asymptompatic for 1 full week. Any athlete who incurs a Grade 2 concussions subsequent ot a Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 2 weeks.

Grade 3 Concussion
 Definition: Loss of consciousness, either brief (seconds) or prolonged (minutes or longer).

 The athlete should be removed from sports activity for 1 full week without symptoms if the loss of consciousness is brief or 2 full weeks without symptoms if the loss of consciousness is prolonged. If still unconscious or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department. An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 2 months. Any athlete with an abnormality on computed tomography or magnetic resonance imaging brain scan consistent with braih swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports.

Source: Quality Standards Subcommittee, American Academy of Neurology.
Editor's note: See AMEA NEWS VII; May 1996:12-13. Grading scale for concussions in sports. Colorado Medical Society.

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