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Down Syndrome and Therapeutic Riding
Reprinted from NARHA
Strides magazine, October 1996 (Vol. 2, No. 4)
Down Syndrome is the
most common and readily identifiable chromosomal condition associated with
mental retardation. It is caused by a chromosomal abnormality: for some
unexplained reason, an accident in cell development results in 47 instead of
the usual 46 chromosomes. The extra genes cause certain characteristics known
as Down Syndrome. Individuals with Down Syndrome also have all the other genes
given to them by their parents. As a result, they have a combination of
features typical of Down Syndrome on top of the individual features from their
parents. This includes some degree of mental retardation, or cognitive
disability and other developmental delays. The extra chromosome changes the
orderly development of the body and brain. In most cases, the diagnosis of Down
Syndrome is made according to results from a chromosome test administered
shortly after birth.
Approximately 4,000 children with Down Syndrome are born in the U.S. each
year, or about one in every 800 to 1,000 live births.
Although parents of any age may have a child with Down Syndrome, the incidence
is higher for women over 35.
There are more than 50
clinical signs of Down Syndrome, but it is rare to find all or even most of
them in one person. Common characteristics include: poor muscle
tone; slanting eyes with folds of skin at the inner corners (epicanthal folds);
hyperflexibility (excessive ability to extend the joints); short, broad hands
with a single crease across the palm on one or both hands; broad feet with
short toes; flat bridge of the nose; short, low-set ears; short neck; small
head; small oral cavity; and/or short, high-pitched cries in infancy.
Individuals with Down
Syndrome are usually smaller than their peers without disabilities, and their
physical as well as intellectual development is slower.
Besides having a
distinct physical appearance, children with Down Syndrome frequently have
specific health-related problems. A lowered resistance to infection makes these
children more prone to respiratory problems. Visual problems such as crossed
eyes and far- or near-sightedness are higher in individuals with Down Syndrome,
as are mild to moderate hearing loss and speech difficulty.
Some people with Down
Syndrome also may have a condition known as Atlantoaxial Instability -- a
misalignment of the top two vertebrae of the neck. This condition makes these
individuals more prone to injury if they participate in activities that
overextend or flex the neck. Parents are urged to have their child examined by
a physician to determine whether or not their child should be restricted from
sports and activities that place stress on the neck.* Although this
misalignment is a potentially serious condition, proper diagnosis can help
prevent serious injury.
* NARHA Standards
require all NARHA operating centers to have their riders with Down Syndrome
examined annually by a physician for Atlantoaxial Instability.
From Down Syndrome Fact
Sheet, National Information Center for Children and Youth with Disabilities,
1-800-695-0285.
Medical Considerations
for Therapeutic Riding
By Liz Baker, PT,
Medical Committee Chairman
Serving people with
Down Syndrome in the therapeutic horseback riding setting can be a source of
great joy and satisfaction to riders, instructors, therapists and volunteers.
These riders are often among the most talented and competitive a program may
ever serve. It is helpful to be familiar with a few characteristics of Down
Syndrome which will influence the operating center's decisions as to how to
best serve this population.
People with Down
Syndrome are more likely than most people to have Atlantoaxial Instability.
This is a condition in which the first two vertebrae of the spine, the atlas
and the axis (C-1 and C-2), are loosely connected by the corresponding
ligaments that are supposed to hold the vertebrae together. This results in
dislocation of the C1-C2 joint, placing pressure on and even completely
disrupting the spinal cord at that level.
It is presumed to be a
result of the generally low muscle tone and lax ligaments commonly found in
people with Down Syndrome. AAI is potentially life-threatening. A person with
Down Syndrome with AAI may or may not demonstrate neurological symptoms.
The following is quoted
from the NARHA Precautions and Contraindications, found in the NARHA Guide and
the NARHA Operating Center Standards & Accreditation Manual: "Specific
x-rays are needed to rule out this instability before riding is permitted. This
condition can occur in adults with Down Syndrome even though previous x-rays
during or after childhood may have been interpreted as negative. At present, it
is not known how often adults with Down Syndrome should be tested to rule out
atlantoaxial instability. Operating centers should not rely on x-rays taken
before the age of 2 and 1/2 to 3 years, as [this area of the spine] has not
[become fully formed bone] at this early age. A set of films taken just prior
to riding is advisable."
Given that a fall from
a horse (or even excessive motion to the neck from the movement of the horse)
could be life-threatening to a person with Down Syndrome-related AAI, it is
imperative that all programs serving these individuals be completely familiar
with this section of the Precautions and Contraindications. In short:
If the individual is
younger than 2 and 1/2 to 3 years, it is impossible to tell whether AAI is present;
(thus it is inappropriate to allow children with Down Syndrome to ride until
AAI can be definitively ruled out). |
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Once past this age,
this area of the spine has become fully formed bone and the x-ray is
reliable. |
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Once the x-ray has
been read as negative for AAI by a physician experienced in this problem,
research suggests it is unlikely that the individual will develop AAI.
However, current research has not gone on long enough to make this a
"sure thing" (hence the recommendation for an x-ray before
beginning riding). |
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Research suggests
that certain symptoms (which can be tested for by the physician annually) are
enough to document that AAI is not present. Thus, when the operating center
updates medical forms on its riders annually, there is
no need for another set of x-rays. You can simply request the physician to
again give the date of the last x-ray and its result, and indicate that the
symptoms of AAI are not present. |
In the Operating Center
Standards and Accreditation Manual, the current form entitled "Rider's Medical
History and Physician's Statement" allows the physician to indicate the
positive or negative status and the date of the last x-ray taken for AAI. An
upcoming modification of this form will allow the physician to simply indicate
the continued lack of symptoms of AAI.
For the benefit of
operating center staff, these symptoms are detailed in the NARHA Precautions
and Contraindications. Instructors, volunteers and therapists are sometimes the
first to notice a change in the rider and may recognize these symptoms, which
include:
ˇ
Loss
of head control--head tilt, stiff neck, torticollus
ˇ
Loss
of hand control--fisting, change of dominant hand, progressive weakness, tremor
ˇ
Change
in gait--toe walking, scissoring(walking with the
knees close together or crossing one over the other), progressive clumsiness,
posturing abnormally
ˇ
Loss
of bowel and bladder control
The presence of
antlantoaxial instability (that is, a positive x-ray and/or the presence of
signs and symptoms of this condition) are an absolute contraindication to
participation in riding at a NARHA Operating Center. It has not been
established that this is a contraindication to therapeutic driving; it is
generally not considered a contraindication to stable management and horse care
activities, although good judgment should be used by the riding instructor
and/or therapist as to the level of risk to the participant.
People with Down
Syndrome may also have a greater tendency to degenerative "wear and
tear" of the spine, resulting in a form of arthritis. This also may
produce neurologic symptoms such as those encountered when atlantoaxial
instability is present, or the arthritis may be a problem in the lower spine.
This can result in pain or instability in the spine wherever the degeneration
occurs. It is helpful to remember that the observations of the person's
abilities and function at the operating center, and changes in function, are
useful information to the physician and parent/guardian; the program staff
again may be the first to detect a change that can be diagnosed and treated.
Additionally, people
with Down Syndrome may have related problems such as learning disabilities,
mental retardation, congenital heart defects, premature aging, deafness, and
the development of Alzheimer-like changes in the brain later in life. Make sure
the physician, parent/guardian and rider understand the physical activity and
risk of horseback riding.
In most instances
operating centers will be able to accept and serve individuals with Down
Syndrome in a wide variety of equestrian activities. However, it is appropriate
to give some thought to the concepts of just what therapeutic riding is, and
what "inclusion" is. Many people providing services under the
umbrella of "therapeutic riding" would agree that a person with a
disability should be able to go to a public stable that offers safe, quality
riding instruction, with appropriate accommodations for their physical
impairments, and participate in whatever level of riding or equestrian
activities are desired and most enjoyable. After all, we would certainly agree
that individuals with disabilities who wish to play tennis should be able to go
to a public tennis court and play, whether they play with disabled or
non-disabled peers!
However, our realization
of both the tremendous therapeutic benefits of equestrian activities, in all
areas, and our concurrent understanding of the risks involved in riding,
particularly at a public stable have led to the establishment of therapeutic
riding centers. Our centers provide a safer, more therapeutic setting for most
riders. But we should also work toward inclusion of our riders, whenever safe
and appropriate, into a "normal" riding setting. It is our
responsibility, however futuristic, to promote the integration of riders with
disabilities into non-disabled riding settings. Thus, an operating center
serving a capable and independent rider with Down Syndrome can look at whether
this rider could participate equally well in equestrian activities at the
"non-therapeutic" public riding stable down the road; or whether it
should integrate people with a wider variety of abilities and disabilities into
its own sessions.
Liability insurance
should not be the driving force which compels capable independent riders with
disabilities to ride at NARHA centers rather than public stables! Inclusion and
community integration are more than concepts--they are methods by which NARHA
Operating Centers and staff continually look for the best way to bring the joy
of the horse to the person with Down Syndrome.