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Brain Injuries and Therapeutic
Riding
Reprinted from NARHA
Strides magazine, April 1996 (Vol. 2, No. 2)
Traumatic brain injury
(TBI) is defined as an insult to the brain caused by an external physical force
that may produce a diminished or altered state of consciousness. This results
in an impairment of cognitive abilities and/or physical functioning. The term
TBI does not apply to brain injuries that are congenital or degenerative, or
brain injuries induced by birth trauma.
The cognitive effects
of TBI may include: short and long term memory loss; difficulties with
concentration, judgment, communication and planning; and spatial
disorientation. Physical effects may include: seizures; muscle spasticity;
vision, hearing, smell and taste loss; speech impairment; headaches; and
reduced endurance. Psychosocial, behavioral and emotional effects may include:
anxiety and depression; mood swings; denial; sexual difficulties; unstable
emotions; egocentricity; impulsivity; agitation; and isolation.
TBI is responsible for
the majority of injury-related deaths of Americans under 45 years of age. It is
estimated that TBI claims more than 56,000 American
lives annually. Each year, approximately 373,000
Americans are hospitalized as a result of TBI. Of these, 99,000
individuals sustain moderate to severe brain injuries resulting in lifelong
disabling conditions. Vehicle crashes are the leading cause of TBI (50% of all
injuries), followed by falls (21%), firearms (12%), and sports/recreation
(10%).
After one traumatic
brain injury, the risk for a second injury is three times greater; and after a
second TBI, the risk for a third injury is eight times greater.
From
Traumatic Brain Injury Fact Sheets, Brain Injury Association, Inc., (202) 296-6443
Medical
Considerations for Therapeutic Riding
By Liz Baker, PT,
NARHA Medical Committee Chairman
For therapeutic riding
programs, the opportunity to serve a person who has had a traumatic brain
injury is a tremendously rewarding challenge. A team approach to evaluation and
program planning is essential. The rider's impairments help determine which
health professionals and inputs are needed. As always, the riding instructor is
the key member, often the leader, of the team.
Besides those listed
above, people with TBI may also have the following conditions:
ˇ
Physical
problems, including lack of automatic and volitional, spontaneous movement;
difficulty with balance and coordination; diminished, altered or slow response
to sensory input.
ˇ
Other
communication problems include difficulty retrieving words from memory
(anomia); poor understanding of sequential information; difficulty processing
auditory input; expressive aphasia (using sentences with complete appropriate
grammar and vocabulary); good social language but poor comprehension of the
content; and poor articulation and voice quality.
Difficulty with
communication can have physical, cognitive or mental health causes. Age is also
an issue; pediatric head injuries are the leading cause of disability in
children, with 5-10% of those injured having temporary or permanent problems
afterwards.
Prolonged lack of
exercise after TBI contributes to poor endurance, deconditioning and easy
fatigue. The person may have had other injuries such as broken bones in the
extremities or spine, or internal injuries. Vision is also often affected,
causing blurred or double vision, poor depth perception, poor visual tracking
and poor recognition of body parts by vision. therapeutic riding programs often
see a change in behavior -- at times inappropriate behavior -- in the person.
Most people progress along a continuum of behavior as they recover, but may
have varying degrees of confusion, agitation, aggression and difficulty with
stress. Lack of internal motivation is also common. The riding program needs to
know what is normal behavior for that person at this time, and how to best
respond.
Initially after the
injury, the person with TBI is stabilized in the hospital and transferred to a
rehabilitation facility to continue recovery. There, the focus is to become as
independent as possible and to return to home as soon as possible. Some rehab
facilities have their own therapeutic riding programs or refer to one nearby;
thus the patient may start therapeutic riding quite soon. However, most people
with TBI contact a therapeutic riding center after they are discharged from
rehab. At that point, due to the TBI, major changes have occurred in the
person's life. The person may be quite physically/cognitively/commicatively
impaired and no longer able to live independently. Persons with TBI and their
families will still be adjusting to these significant changes. The therapeutic
riding center will need to be sensitive and supportive while planning a
program.
Since recovery can
continue for years, and since the horse can promote improvement in many
impaired skill areas, therapeutic riding can be of tremendous help to the
person with TBI. It can be a lifelong activity for enjoyment, recreation and
sport, with ongoing therapeutic benefits to the body and mind. Initially, the
instructor should evaluate the rider with a physical, occupational or speech
therapist, as well as with a mental health professional (this depends on the
person's abilities and impairments). The riding team's evaluation should
include on- and off-horse components; a decision to accept the rider should not
be made until the evaluation is done. By visiting the center before the
evaluation, the prospective rider will adjust to the setting, which may make the
evaluation easier for all concerned.
The PT will assess the
person's joint mobility (ROM), head and trunk control, balance, functional
mobility, adapted equipment and ambulation abilities if appropriate. The OT
will add a focus on the client's upper extremity control, sensory processing,
sensation, perception and any upper extremity splint or adapted equipment use.
There is an overlap of skills between PT's and OT's; both will recommend the
type of therapy or therapeutic program, equipment and horse. A speech-language
pathologist is invaluable when the prospective rider has difficulty with
speech, communication and/or oral control. The SLP can evaluate the rider in
these areas, as well as swallowing/drooling and language. The rider may already
have an adapted method of communication such as sign language or an electronic
communication device. An immediate concern is to have a way to communicate
simple concepts with the rider such as "yes," "no,"
"halt," "walk on," and discomfort and fatigue. This will
prevent frustration for the client and staff. Since the riding session is
excellent for working on communication goals of all kinds, the SLP should
recommend strategies for a) communicating with the rider, and b) activities for
the instructor, other therapists and staff to use to improve the rider's
communication skills.
A health professional
specializing in psychology and behavior may be needed. People post-TBI can have
trouble controlling their behavior; they may have injury-related changes in
their emotional state, difficulty dealing with frustration and stress or be
depressed. The sensory input to the brain experienced during riding may trigger
the brain's limbic system, causing emotional responses such as inappropriate
laughing, crying or anger. The amount of stimulation from the horse may need to
be graded to avoid or diminish these outbursts. Riders may also have a specific
behavioral management plan that all staff need to know. Psychologists,
psychiatrists, psychotherapists, psychiatric social workers, psychiatric nurses
or the OT specializing in this area can provide direct treatment or
consultation; efforts may include training staff and tailoring the program to
help improve appropriate behavioral responses.
Other concerns include
the following. The rider should be at least at the Ranchos Los Amigos Scale of
Cognitive Functioning Level Six; that is, the rider may be confused but
appropriate; with good directed behavior, but needing cueing; able to relearn
old skills such as activities of daily living; may have serious memory
problems; some awareness of self and others. Medical problems that may need
assessment and further investigation (see NARHA Precautions and
Contraindications) include seizures, presence of a shunt, abnormal bone
structure or missing bone in the head s/p surgery; and problems with the
regulation of autonomic nervous system functions such as blood pressure,
sweating/body temperature regulation, and abnormal bone formation (myositis). A
ventilated helmet helps with excessive sweating of the head; also, avoiding
fatigue is helpful.
Immediately following
the session, have a chair available for the rider to rest. This concept of
resting after riding does not just rest muscles; while riding, the rider with
TBI takes in large quantities of sensory input in all the sensory systems, and
the brain is constantly trying to process that input and create a functional
outcome, such as maintaining an upright posture and turning the horse. For a
person with TBI, this is fatiguing even while it is therapeutic. A rest period
after riding decreases stress, allows a recovery and may help the person retain
the beneficial effects of the riding session.
TBI can cause problems
with alignment, posture, mobility and balance. It is not unusual for a person
with TBI to have a sacral-sitting posture on the horse, with pelvis tilted back
and the legs extended, feet out in front of the knees. In this posture, or any
abnormal alignment, teaching specific riding skills without correcting
alignment will only reinforce poor alignment. Before teaching riding skills,
the instructor and therapist should search to find the horse and saddle or
surcingle combination, coupled with program activities that achieve a more
normal riding posture. In a correct alignment, if it is possible, the horse's
movement can begin to mobilize and activate the rider's trunk and postural
control, which may have become compromised due to the effects of the TBI. Slow
and patient work here will pay off in the long run; working toward good posture
and balance control on the horse before superimposing riding skills on that
control, will result in a safer, more physically competent rider. Balance
skills should be "background" skills; one should not have to think
about balancing oneself, but should be able to maintain upright posture and
good balance while doing something else, such as using reins. However, it is
exactly these skills that are the most difficult for the rider post-TBI.
Vision is also an
important component of balance; the person may seem more unstable in a crowded,
busy environment with other riders present because the visual component of
balance is over stressed. In essence, the rider's posture, alignment and
balance should be of first concern, with riding skills gradually taught at the
rider's rate of progression. Consideration should be given to overall amount of
stimulation, particularly visual, in the riding environment. Also, careful task
analysis of each new skill will be helpful.
The rider with TBI
might be described as an individual who can often perform individual tasks, but
when those tasks must be integrated together, the brain does not perform as
efficiently. Although therapeutic riding tasks must be structured and broken
down so as not to overload, the activity of riding actually provides an
excellent means of slowly re-integrating the brain's abilities in "system
processing" (somewhat similar to computer multitasking). Slowly
progressing the rider, adjusting the stimulation to challenge but not
overwhelm, allowing ample time to safely make mistakes and correct them, in (at
least initially) a quiet low-stress environment, is a helpful approach.
Given all these
considerations, what is it about therapeutic riding that is so helpful to
people with TBI? As always in therapeutic riding, it is the unique problems
faced by the person post-TBI, not the diagnosis itself, which may be improved
through the use of the horse. In spite of their balance, movement, posture,
communication and behavioral problems, horses can provide a strong motivating,
consistent, multisensory input that appears to help the rider's brain organize
itself. Gradual recovery from TBI can continue for years, making therapeutic
riding a source of stimulation to continue that recovery over a long period of
time. A well-planned, carefully implemented riding program can not only
facilitate the rider's recovery from TBI, but also provide a much-needed source
of pleasure, risk and self-esteem to a person who really needs it. The attraction
of and bonding with the horse can be a positive and stabilizing experience in
that person's life; it also can be an activity in which the whole family can
participate. Helping people with TBI to help themselves, through the unique
qualities of the horse, is rewarding for everyone.
References:
Contemporary Management of Motor Control Problems. 1991. Chapters 24-25.
Foundation for Physical Therapy, 1111 N. Fairfax St.,
Alexandria, VA 22314
Neurologic
Rehabiliation. Darcy Umphred, PhD, PT, ed. 1990. Chapter 13. CV Mosby, 11830
Westline Industrial Dr., St. Louis, MO 63146
Contributor: Ruth
Dismuke-Blakely, CCC-SLP, NARHA Medical Committee
A Review of Relevant
Literature
Dr. J. Warren Evans,
Research Committee Chairman
Since about 1975, a
number of papers have been published about horseback riding or equestrian
events and related injuries. Conclusions by some of the authors or their
findings are as follows:
Dr. Bixby-Hammett
reported that there were 42,000 horse-related
accidents in the U.S. from 1979-1982 resulting in hospital emergency room
treatment. Accidents resulting in death, no treatment, treatment at site of
accident or treatment in a physician's office were not included. During this
time period, 62% of horse-related deaths resulted from head injury. (Reference:
Horseback Riding in North Carolina. North Carolina Medical Journal 47 (11):530-533, 1986.)
In 1987, Dr.
Bixby-Hammett reported additional data from the United States Pony Club, Inc.
From 1982-1986, there were 130 accidents while horses were being ridden and 30
other horse-related accidents in a membership of 46,351.
The most frequently injured area of the body was the head and face (22% of the
injuries). Bruises and abrasions (29%) and closed fracture (22%) were the most
common type of injury. In 76% of the accidents, the horse threw the rider,
failed to take a jump or slipped and fell. One very interesting statistic was
that within three months of the first horse-related injury, 10% are injured in
a second horse-related accident. (Reference: Accidents in Equestrian Sports.
American Family Practitioner 36(3):209-214, 1987.)
In 1990, Bixby-Hammett
wrote an excellent review of the subject with additional data regarding
mortality. Head injuries caused 60 and 78% of the deaths respectively in the
U.S. and Australia and chest injuries were responsible for 9%. (Reference:
Common Injuries in Horseback Riding - A Review. Sports Medicine 9(1):36-47, 1990.) Her papers are an excellent source of
references for other papers on the subject.
In the Journal of
Family Practice 39(2):148-152, 1994, horseback riding
injuries were reported for New Zealand. Their findings from a
large survey were: 6% of riders had been hospitalized at least once; 27.5% of
those riders had been treated by a physician within previous two years of last
injury; an injury occurred about every 2,000 riding hours; 42% of the injured
had sprains or strains; 40% had lacerations or bruises; 33% had fractures or
dislocations; and 27.5% had sustained concussions or other head injuries.