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Concussion History and Knowledge Base in Competitive Equestrian Athletes
Abstract
Head injuries are responsible for the majority of serious equestrian sports injuries and deaths. Because of significant health risks to equestrians, education regarding the prevention of head and brain injuries is essential.
A significant number of riders have experienced a concussion, and few have knowledge of concussion.
Cross-sectional study.
Level 2.
Ninety-four riders competing, riding, or attending equestrian events at the Palm Beach International Equestrian Center in Wellington, Florida, from January to April 2010 were surveyed. Measures of central tendency were utilized to evaluate response patterns.
Almost half of equestrian riders (44%) experienced concussions during their careers. Those riders who suffered a brain injury were likely to return to riding without seeking medical clearance. Almost 40% of riders were never educated regarding concussions, while 15% received education from their trainers.
Education of riders, parents, and horse trainers is needed to raise awareness of concussions and reduce the likelihood of subsequent injuries.
... [3][4][5] Under-reporting, low awareness of concussion, premature return to activity, prior injury and lack of appropriate management can lead to increased symptoms, delayed recovery and risk of re-injury. 1,[6][7][8] The economic costs of providing health care and productivity loss for unresolved concussions are high. 9 Reducing the burden of TBI involves both preventing injuries from occurring and ensuring effective recognition and management. 2 To be effective, health promotion initiatives require accurate data on injury mechanisms, knowledge, awareness and behaviour (in members of the public, athletes, trainers and clinicians) to identify gaps and misunderstandings that can then be addressed with well-designed initiatives. ...
... The prevalence of concussion was higher than reported in a previous study of equestrian athletes attending a competitive venue (44%). 6 Differences in prevalence between the two studies may reflect an increased awareness of concussion over the last five years and therefore greater reporting. 6 The findings may also reflect differences between the two samples and study methodologies, with the current study using an anonymous online survey and the comparative study surveying a smaller number people, in person, at competitive events. ...
... 6 Differences in prevalence between the two studies may reflect an increased awareness of concussion over the last five years and therefore greater reporting. 6 The findings may also reflect differences between the two samples and study methodologies, with the current study using an anonymous online survey and the comparative study surveying a smaller number people, in person, at competitive events. Previous reviews on the epidemiology of sports concussion in contact sports, such as rugby and football, have shown that the prevalence of concussion varies by type and level of sport, forces exposed to (e.g. ...
Objective
To determine knowledge, attitudes and behaviour towards concussion in adult equestrian athletes.
Design
Nationwide, cross-sectional, questionnaire.
Methods
Participants were recruited via advertisements circulated through social media, community presentations and equestrian organisations. Participants were sent a web link to an online questionnaire previously designed for high school athletes and modified to ensure relevance to equestrian activities. The percentage of correct responses per item and a total knowledge score were calculated. Differences in concussion knowledge by age, sex, level of experience and previous history of concussion were explored using t-tests, 95% confidence intervals (CI) and effect sizes.
Results
The questionnaire was completed by 1486 participants (Mean age = 39.1 ± 15.4). Knowledge of what concussion was, how to recognise it and key symptoms (except poor sleep) was high (>80%). In contrast, awareness of guidelines was moderate (56%) and inability of helmets to prevent concussion was low (12%). Significantly higher levels of knowledge of concussion were identified in females compared with males (t=-6.55 p < 0.001, 95%CI=-3.26 to -1.75). The majority (87%) of participants reported that a helmet should be replaced after a fall, yet 46% reported re-using a helmet following a hit to the head.
Conclusions
Knowledge of and attitudes towards concussion were positive. However, there were knowledge gaps and discrepancies between some attitudes and behaviour on some aspects of concussion. Targeted campaigns to promote awareness of concussion and improve recognition and onward management are needed. Education related to equestrian activities such as helmet use and injury mechanisms is needed to change behaviour and minimise the risk of injury.
... Similarly, in non-contact sports like equestrian sports, concussion can equally lead to serious long-term effects [76][77][78][79] but many professional equestrian riders are not aware of the consequences. Almost half of the equestrian riders in Kuhl's [40] study that received a self-reported concussion were likely to return to training or competing without seeking medical clearance. After experiencing concussion symptoms, more than 30% of riders thought that they could get back on a horse on the same day [40]. ...
... Almost half of the equestrian riders in Kuhl's [40] study that received a self-reported concussion were likely to return to training or competing without seeking medical clearance. After experiencing concussion symptoms, more than 30% of riders thought that they could get back on a horse on the same day [40]. ...
... Though the culture may vary within different sports, the attitudes towards pain and injury are not confined to one sport or one cohort of athletes. In non-contact sports such as equestrian sports, riders are still encouraged to get back onto their horses immediately following a fall [40]. Furthermore, Paralympic athletes with spinal injuries intentionally induce autonomic dysreflexia for better performance, ignoring its risk [31]. ...
Professional athletes involved in high-performance sport are at a high injury risk, which may lead to long-term health consequences. Professional athletes often expose themselves to risky behaviours, resulting in a higher acceptance level of occupational risk compared to other occupations. To date, many studies have focused on elite athletes’ specific injury prevention techniques. The objective of this narrative review is to (1) summarise elite athletes’ attitudes towards important occupational safety and health (OSH) practices, including injury reporting, medicine usage and personal protective equipment (PPE) usage, and (2) explore factors that may influence elite athletes’ injury awareness. If injury awareness were given a similar weighting in elite sports as in any other highly physical occupation, the potential benefits to elite athletes and their long-term health could be highly significant. This review identifies that most elite athletes are not aware that sporting injuries are occupational injuries requiring behaviours determined by OSH rules. All the 39 studies identified met the moderate methodological quality criteria according to the Mixed Methods Appraisal Tool (MMAT). The factors impeding athletes’ injury awareness from achieving occupational health standards are discussed from three safety management perspectives: organisational, societal and individual. This review contributes to a better understanding of how to build a positive safety culture, one that could reduce elite athletes’ injury rate and improve their long-term wellbeing. Further research is required to develop a quantitative measurement instrument to evaluate occupational health awareness in the sport context. Based on the papers reviewed, the study population was categorised as elite, professional, high-performance amateur and student-athletes.
... Persistent neurologic symptoms occurred in 13% of those riders following discharge [6]. Moreover, injuries are common among equestrian athletes with 44% suffering from a concussion during their career and many reporting neck pain, headaches, dizziness, poor balance, poor concentration, fatigue, and irritability [7]. Many athletes may return to riding without proper medical assessment [7], thereby putting them at risk of a secondary neurologic injury that may result in cognitive, behavioral, mood, or motor symptoms [8]. ...
... Moreover, injuries are common among equestrian athletes with 44% suffering from a concussion during their career and many reporting neck pain, headaches, dizziness, poor balance, poor concentration, fatigue, and irritability [7]. Many athletes may return to riding without proper medical assessment [7], thereby putting them at risk of a secondary neurologic injury that may result in cognitive, behavioral, mood, or motor symptoms [8]. ...
... Others have suggested that the wider public may not be knowledgeable of equestrian related risk. Kuhl and colleagues [7] reported that less than 40% of equestrian riders had any education about TBI. Increased awareness of TBI risk may be one method to improve helmet utilization. ...
Purpose:
Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report underutilization of safety equipment and rates of operative intervention as high as 33%.
Methods:
We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4.
Results:
Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p<0.01), TBI (32.4% vs. 55.3%, p=0.03), and ICU admission (10.7% vs. 29%, p=0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1-6.3).
Conclusion:
Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities.
Level of evidence:
Retrospective comparative study, Level III.
... The FEI requires that athletes wear properly fastened protective helmets when riding on the showgrounds at international events (44). There are policies that vary for whether helmets are mandatory when riding to and from the horse stables or other places on the competition premises (39,41,45). The United States Equestrian Federation (USEF) has required helmet usage in sanctioned jumping competitions since 1964 (46). ...
... Given that equestrians who sustain multiple falls are at a higher risk for neurological deficits (12), equestrian education on concussions is warranted. Currently, 40% of equestrians report never receiving education on concussions (45), with 15% garnering information from their trainers. Educating both the equestrians themselves as well as their trainers/ coaches could help prevent injuries and ensure an informed return to sport after a concussive injury. ...
Equestrian sports represent a variety of activities involving a horse and rider. Due to the unpredictable nature of horses, their height, and potential high speeds involved, equestrian athletes are at risk of head and spinal injuries. This review describes the epidemiology, injury mechanisms, and risk factors for equestrian sports-related head and spinal injuries. Traumatic brain injuries, including concussions, are more common than spinal injuries. Both injury types are most commonly related to a rider fall from a horse. Spinal injuries are less common but are associated with potentially significant neurological morbidity when spinal cord injury occurs. An improved understanding of preventable injury mechanisms, increased certified helmet use, improved helmet technologies, and educational outreach may help to address the risk of head and spinal injuries in equestrian sports.
... Injuries and pain are considered inherent in sports-especially in elite and professional levels-as trauma injuries from impact are an inevitable element of contact sports, whilst chronic injuries from overuse are potential unwanted outcomes of the gruelling training and competition regimes that athletes' bodies endure (Kuhl et al. 2014;Malone and Gloyer 2013). Central ethical issues in sports medicine involve the conflicts of interests within clinical practice and decision-making, where the athlete's performance is often in conflict with their health and welfare. ...
In the world of elite sport, pain and suffering are inherent. In exploring return-to-play treatments and decision-making in sports medicine, two overarching areas seem to dominate the existing literature: (i) the autonomy of the injured athlete and (ii) the conflicts of interests faced by the sport medical practitioner. Today, these two ethical issues are further exacerbated by innovations in biomedical technologies. An in-depth analysis will be conducted on how novel and emerging biomedical technologies in modern sports medicine affect—and further perpetuate—the pre-existing bioethical issues, using the case study of platelet-rich plasma therapy used by elite athletes. Attitudes towards novel technologies will be further explored, comparing both the faith-like commitments and the rejection of novel technologies with areas in religious epistemology. A pluralistic approach to clinical practice will be suggested, to begin resolving some of the bioethical issues present.
... Knowledge of signs of concussion including confusion, dizziness, headache, and loss of consciousness were higher than found in previous studies in rugby players and equestrian athletes (17,21). Although other symptoms such as seizure, tonic posturing, and poor sleep were less well known. ...
Objective
To determine knowledge, attitudes, and behavior toward concussion in cyclists and to identify predictors of concussion knowledge.
Methods
Cycling organizations sent members a web link to online information about the study and a questionnaire. Anyone aged >16 years, living in New Zealand and engaged in a cycling activity was invited to participate. The 36-item questionnaire included sociodemographics, knowledge about concussion, helmet use, and personal concussion history. Data were collected between 15/05/19 and 30/06/19. A multiple linear regression model identified factors associated with levels of concussion knowledge.
Results
The questionnaire was completed by 672 participants aged between 16 and 82 years (x̄ = 48.6 years). Knowledge of concussion was high. However, knowledge that helmets are not able to prevent concussion was low and time to return to sport after injury was variable. Knowledge did not always translate to seeking of medical attention or replacement of helmet behavior. Younger age and having sustained at least one prior concussion were associated with higher levels of concussion knowledge F(df = 3) = 8.81, p < .001.
Conclusions
Knowledge and attitudes toward concussion were positive. However, knowledge gaps and discrepancies between attitudes and behavior were identified. Consistent, clear messages are needed around return to sport timeframes.
... Additionally, inconsistencies have been reported in putting evidence-based recommendations for physical (Stoller et al., 2014;Zemek, Eady, et al., 2014) and cognitive rest (Lebrun et al., 2013, Stoller et al., 2014Zemek, Eady, et al., 2014) into practice, which contribute to poor uptake and confusion over best evidence within the medical community. In the athletic community, athletes have found to be misinformed about concussion (Kuhl, Ritchie, Taveira-Dick, Hoefling, & Russo, 2014), and lack the appropriate knowledge of (Broglio et al., 2010;Cournoyer & Tripp, 2014) or have a misunderstanding as it relates to concussion signs and symptoms (McAllister-Deitrick, Covassin, & Gould, 2014). Coaches have been shown to have misconceptions about concussion as it relates to terminology (Saunders, Burdette, Metzler, Joyner, & Buckley, 2013) and do not necessarily follow best practices related to return-to-play (Mrazik, Bawani, & Krol, 2011). ...
Knowledge gaps exist regarding how to best educate audiences about concussion. Knowledge translation (KT) plays a critical role in how information is shared. In the field of concussion, infographics are becoming a popular KT strategy for synthesising and sharing information. Study objectives were to explore how infographics enhance concussion knowledge, infographic use and preferences across various stakeholders, and to determine their utility as a KT strategy. Six infographics were created to provide concussion information in a user-friendly and accessible format. A prospective design using a self-developed survey was conducted. Data were collected from youth (n = 78) and adults (n = 88) including students, teachers and healthcare professionals. Descriptive statistics exored perceived knowledge acquisition and infographic use. Thematic analysis of written feedback provided insight on participant responses. Participants identified that the infographics met their knowledge needs (91%) and provided them with new knowledge (87%). Participants also identified that they intend to use the infographics to build their knowledge (89%) and educate others (55%). Enhancement opportunities included incorporating graphics that appeal to different audiences and sharing the lived experiences of individuals who have a concussion. This study demonstrates the potential impact of infographics as a KT strategy that meets the knowledge needs of many audiences.
... 27,43 Rates of concussion range from 10% to 45% of all equestrian-related injuries. 22,27,38,43,50 These estimates are conservative, as rates of concussion in equestrian sports are likely underreported. 14,27 Typically, individuals experience symptom resolution within 10 to 14 days post concussion 32 ; however, 10% to 30% of individuals report persistent symptoms beyond this time frame. ...
Background:
Equestrian riding is a sport with a high risk of concussion. Currently, the literature guiding rehabilitation for concussions in equestrian athletes is limited, especially for directing return to sport.
Case description:
In this case report, a 14-year-old female equestrian athlete presented to physical therapy following her third concussion in 3 years. Her primary complaints were headaches, dizziness, difficulty concentrating, light sensitivity, and neck pain. On examination, the patient demonstrated reproduction of symptoms during testing of the vestibular-ocular reflex, showed a 3-line symptomatic loss on the dynamic visual acuity test, and had impairments in the joint position error test (1/5 correct on the left, 4/5 correct on the right) and a Balance Error Scoring System (BESS) score of 38/60 errors. A return-to-riding protocol was adapted from general return-to-sport guidelines and tailored to meet the unique demands of the patient's equestrian sport. The protocol included phased progression through no activity, light aerobic activity, moderate aerobic activity, sport-specific nonjumping skills, sport-specific jumping skills, full practice, and return to competition. During the protocol, the patient participated in 8 physical therapy sessions over 4 weeks for vestibular training, aerobic conditioning, and cervical and core exercises, as well as equestrian exercises at her stables.
Outcomes:
At the final evaluation, the patient reported no symptoms at rest, with exercise, or when testing vestibular-ocular reflex. Improvements were noted in the dynamic visual acuity test, joint position error, and BESS, with changes in the BESS exceeding minimal detectable change. The patient completed the full return-to-riding protocol in 8 weeks and was able to return to equestrian competition without complaints.
Discussion:
This case report describes the physical therapy management of an adapted return-to-sport protocol for an equestrian athlete with a history of multiple sport-related concussions.
Level of evidence:
Therapy, level 5. J Orthop Sports Phys Ther 2018;48(12):934-942. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8214.
... As sex may influence post-concussive symptoms [7,67], studies must include representative female samples and explore potential sex effects. In particular, equestrian sports may be a fertile avenue for concussion research given the high prevalence of concussion in this population [68] and the relative balance of males and females who participate [61]. ...
Background:
Elite athletes can experience a diverse range of symptoms following post-concussive injury. The impact of sport-related concussion on specific mental health outcomes is unclear in this population.
Objective:
The aim was to appraise the evidence base regarding the association between sport-related concussion and mental health outcomes in athletes competing at elite and professional levels.
Methods:
A systematic search of PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane, and Cinahl databases was conducted.
Results:
A total of 27 studies met inclusion criteria for review. Most of the included studies (67%, n = 18) were published in 2014 or later. Study methodology and reporting varied markedly. The extant research has been conducted predominantly in North America (USA, n = 23 studies; Canada, n = 3), often in male only (44.4%, n = 12) and college (70.4%, n = 19) samples. Depression is the most commonly studied mental health outcome (70.4%, n = 19 studies). Cross-sectional retrospective studies and studies including a control comparison tend to support an association between concussion exposure and depression symptoms, although several studies report that these symptoms resolved in the medium term (i.e. 1 month) post-concussion. Evidence for anxiety is mixed. There are insufficient studies to draw conclusions for other mental health domains.
Conclusion:
Consistent with current recommendations to assess mood disturbance in post-concussive examinations, current evidence suggests a link between sports-related concussion and depression symptoms in elite athletes. Causation cannot be determined at this stage of enquiry because of the lack of well-designed, prospective studies. More research is required that considers a range of mental health outcomes in diverse samples of elite athletes/sports.
Objectives:
Equestrians have a high risk of concussions per hospital records. However, most concussions occur in private settings where concussions are not tracked. We determined concussion incidence by self-report, expressed per 1000 h of exposure, and determined helmet usage and concussion knowledge.
Design:
Descriptive epidemiological study.
Methods:
Equestrians were recruited using a snowball method of sampling in which enrolled participants recruited more equestrians. Participants completed a survey of equestrian experience and history of concussion, symptoms and provided estimates of hours spent in various equestrian activities. From these data, incidences of concussions were calculated. In addition, they answered questions regarding helmet usage and willingness to take risks when concussed.
Results:
210 participants (203 women) reported 27 ± 14 years of equine experience and 728 concussions, 3.47 ± 5.34 per person (0-55). Incidence while riding was 0.19/1000 h which was greater than the incidence while driving (0.02/1000 h) or handling horses (0.03/1000 h). Riders were helmeted at the time of injury 85% of the time. While concussion knowledge was high, most reported willingness to risk permanent injury by continuing to work with horses while injured.
Conclusions:
To our knowledge this is the first study to document incidence of concussions in equestrians: incidence is higher while riding than during football or rugby training. Helmets were far more commonly worn at the time of concussion than reported in hospital data, suggesting that helmets effectively reduce concussions severe enough to warrant urgent medical care.
Purpose
This paper aims to conduct the first cross-sectional survey on depression, Resilience, well-being, depression symptoms and concussion levels in equestrian athletes and to assess whether past concussion rates were associated with depression, resilience and well-being.
Design/methodology/approach
In total, 511 participants from Canada, Republic of Ireland, UK, Australia and USA took part in an international cross-sectional, online survey evaluating concussion history, depression symptoms, resilience and well-being.
Findings
In total, 27.1% of athletes met clinically relevant symptoms of major depressive disorder. Significant differences were shown in the well-being and resilience scores between countries. Significant relationships were observed between reported history of concussion and both high depression scores and low well-being scores.
Practical implications
Findings highlight the need for mental health promotion and support in equestrian sport.
Social implications
Results support previous research suggesting a need for enhanced mental health support for equestrians. There is reason to believe that mental illness could still be present in riders with normal levels of resilience and well-being.
Originality/value
This study examined an understudied athlete group: equestrian athletes and presents important findings with implications for the physical and mental health of this population.
Background:
Equestrian athletes (horse riders) are at high risk for head injury, including concussions.
Materials & methods:
Adults riders were recruited via social media posting to complete a branching survey collecting data on demographics, riding experience, helmet use, injury history and concussion symptom knowledge. Results are reported as frequencies and percentages, with associations tested using chi-square with significance level p < 0.05.
Results:
Of the 2598 subjects, about 75% reported always wearing a helmet. Of those who did not, the most common reasons were that helmets are unnecessary (57.4%) or do not fit well (48.6%). Many indicated improper storage conditions and/or did not follow manufacturer's replacement recommendations. Most (75.4%) reported a high level of comfort with recognizing concussion signs, with half experiencing a prior head injury.
Conclusion:
This information suggests opportunities for intervention to improve helmet use through increased fit, while the responses indicate a need for further education on proper helmet use.
Horseback riding and related activities bring risks for serious injury. Extant literature focuses largely on moderate to severe horse-related injuries resulting in a need for medical care. Yet incidents deemed as less severe are also important, with potential to impact subsequent safety precautions and behaviors of parents and children. The study objectives were to gather preliminary information about: (1) the prevalence of a range of horse-related painful incidents experienced by children, (2) children's helmet use and supervision, and (3) the subsequent impact of horse-related painful incidents. The methodological approach was based on a questionnaire.
One hundred and twenty four child (120 Female; Mage: 11.82 years; rangeage: 8–18; SDage: 2.26) and parent (103 mothers; 16 fathers; 5 other legal guardians) dyads completed a brief 5 minute researcher-generated questionnaire. The results show, that painful incidents are common for children when handling and riding horses, with the majority of children having experienced these incidents more than once. Helmet use and supervision (typically by parents and coaches) were reported to occur consistently during riding, but less commonly during handling (e.g., grooming). Despite the high prevalence of painful incidents, these incidents largely do not impact children's ability to participate in other activities, result in access to specialized medical attention, or alter children's perceptions or behavior around horses. Findings may have implications for safety and education initiatives.
Management implications
Findings from this work suggest several implications. First, in acknowledging the range and frequency of incidents that occur during horse-related activities, educational initiatives should target a broad range of incident types when teaching about horse safety and injury prevention. Second, in recognizing primary caregivers and riding coaches as the most common supervisors of horse-related activities, they should also be targeted in educational initiatives (e.g., horse and safety knowledge, first aid, supervision guidelines). Finally, in developing and implementing targeted safety and injury prevention initiatives, reported benefits of the sport (e.g., improved problem-solving skills) could be used and supported in safety programming.
A retrospective study of horse riding injuries in Berkshire was undertaken over a one year period from November 1983. The information was obtained from the Ambulance Service, the Jockey Club and the St. John Ambulance Brigade. There was a total of 103 injured persons with no deaths. Information from the Jockey Club was compared with the other two groups, the former sustaining more limb injuries and the latter more head injuries. A questionnaire was sent to all 42 ambulance patients. Thirty-eight had radiographs taken, 16 of which showed a fracture. Forty-one were wearing some form of hard hat, but if a safety strap was available it was attached in 24 cases. The dangers of riding are highlighted and the importance of adequate protective clothing emphasised.
Although the risk of serious head injury for horse riders is higher than for most other sports, few equestrians regularly wear protective headgear. This study indicates that riders are well informed about the need for helmets and that the main reason for nonuse is inadequate helmet design. In particular, riders perceive that existing helmets are uncomfortable, expensive, and inappropriate for some riding styles. Based on these findings, the authors developed strategies to increase usage and incorporated them into a successful program. These strategies included working with manufacturers to develop a low-cost, versatile helmet; efficiently distributing educational literature among the horse riding community; and encouraging individual clubs and equestrian organizations to mandate a helmet policy.
A 3-year chart survey and questionnaire was conducted of equestrian-injured patients at a regional trauma center to determine patterns and consequences of injury and rate of recidivism. Ninety-two patients (95 encounters) were treated; most were young (mean age, 27 +/- 11 years) women (84%) riders sustaining falls (80%). Most injuries were orthopedic (47%); 19 per cent of patients required hospital admission. There was one death. Helmet use was documented in only 34 per cent. Eighty-one per cent of patients responded to a follow-up telephone survey; 36 per cent recounted additional accidents (mean, 1.4 +/- 0.5). Mean time lost from work was 3 weeks, with 19 per cent reporting chronic disability. Mean annual hospital charges for the cohort were $88,925.00. Recidivism is common in equestrian trauma. Hospital charges are significant. Lost time from work is considerable, with one in five patients reporting long-term disability. Given the cost and disability incurred with equestrian trauma, efforts at injury prevention appear warranted.
To describe the demographics and nature of injuries occurring on or around horses, to examine the nature of protective clothing in relation to these injuries, and to compare our data with previously published work in this area.
Patients were identified using the term "sports injury-horse riding" from the departmental database for one calendar year from February 2000. Data were collected regarding demographics, injuries, protective clothing, and outcome. The data were then analysed and compared with the previously published literature.
260 patients' records were analysed. The patients were mostly young (median age 26) and female (84.6%). The majority of patients had a single injury (88.8%). Seventeen per cent had an isolated head injury, all of which proved to be minor. Multiple injuries including the head accounted for 8.5% of all injuries. These again proved minor, bar one fatality where the helmet came off before impact. Upper limb injuries accounted for 29.2% of all injuries of which 61.8% sustained a fracture of which 36.2% were to the wrist. When compared with previous work the incidence and severity of head injury continues to decline while the relative number and severity of upper limb injuries increases.
The majority of head injured riders are wearing approved helmets and sustaining only minor injury. There is currently no protective gear recommended for the upper limb and more specifically the wrist. This paper identifies the potential need for research and development of such protection.
In brief The authors surveyed equestrians to determine an injury profile. Based on responses from 2,195 frequent riders, the study confirms previous findings regarding injury rates, injury sites, and helmet use. New findings include a large number of neck and back injuries and a likelihood of injured riders to be between 15 and 44 years of age, ride English style, and have less than 10 years of riding experience. Data also show that many horseback-riding injuries are treated in physicians' offices. The high percentage of injured patients who suffered prolonged disability underscores the need for physicians to counsel horseback-riding patients about hazards and safety measures-especially helmet use.
The authors surveyed equestrians to determine an injury profile. Based on responses from 2,195 frequent riders, the study confirms previous findings regarding injury rates, injury sites, and helmet use. New findings include a large number of neck and back injuries and a likelihood of injured riders to be between 15 and 44 years of age, ride English style, and have less than 10 years of riding experience. Data also show that many horseback-riding injuries are treated in physicians' offices. The high percentage of injured patients who suffered prolonged disability underscores the need for physicians to counsel horseback-riding patients about hazards and safety measures - especially helmet use.
To assess the frequency, nature, and severity of injuries to participants in equestrian sports, a review of the world literature was performed. Up to 90% of injuries occur in those riders less than 21 years of age, with 70% being female. Furthermore, ~70% of accidents occur to amateur riders during unsupervised recreational riding. Injury during instruction in a riding school is rare (4%). Approximately 75% of injuries are due to a fall from a horse while 15% are due to a kick. Overall, the most common injury is to the upper extremity (fracture, sprain, or dislocation) consistent with a fall onto the outstretched arm. However, the most common injury necessitating hospitalization is to the head. It is the most common cause of death or disability to the rider. In those riders with serious head injury, the lack of an appropriate protective helmet is almost universal. Only 1-2% of those with neurologic injury wear adequate headgear: the majority wear either no helmet, an inadequate hat, or a helmet that is not secured to the head. Clearly, in this potentially hazardous sport, preventative measures, including the habitual use of an approved helmet, are to be emphasized.
(C) Lippincott-Raven Publishers.
We reviewed the English language scientific literature about equestrian injuries among children and young adults. All studies showed that more females than males were injured, with falls from horses being the most common cause of injury. Fractures were common, and head injuries were associated with the vast majority of deaths (72% to 78%) and hospitalizations (55% to 100%). Although the overall injury rate was low, equestrian athletes are at risk for serious injuries. Pediatricians should know the medical contraindications for participation in equestrian sports and encourage riders to obtain horse safety training and use protective headgear (helmets) approved by the American Society for Testing Materials when riding or working around horses. Pediatricians can play an active role in increasing public awareness of equestrian injuries and in reducing risk of injury.
The most common location of horse-related injuries is the upper extremity (24% to 61%) with injuries to the lower extremity second in frequency (36% to 40%). The head and face sustain 20% of horse-related injuries. The most common type of injury is a soft tissue injury (92% to 1%), followed by a fracture (57% to 3%). Concussion is the third most common type of injury (63% to 2%). The most frequent cause of hospitalisation is concussion (38% to 4%) with fracture second. The most common injury which leaves residual impairment is injury to the central nervous system.
The age at which most injury occurred is less than 21 years. In the latest NEISS report (1987–1988), injuries have decreased in the younger riders, but have increased in the older riders (above 24 years). More women are injured than men, but over the age of 44 years more men are injured than women, with the difference more marked in the 1987–1988 NEISS report. Previous horse-related injuries are reported frequently (37% to 25%).
In mortality studies from Australia and the United States, head injuries caused the majority of deaths (78% and 60%), followed by chest injuries (9%). In the Australian study each sex had 50% of the deaths. In the United States, 60% were male, 40% female. Above the age of 24 years male deaths increasingly predominate, being 15 male deaths to 1 female above the age of 64.
Concussion is divided into 3 divisions of severity which require different medical evaluation and treatment: mild in which rider is stunned or disoriented for a brief period; moderate in which there is loss of consciousness for less than 5 minutes; and severe in which there is a loss of consciousness for more than 5 minutes.
Investigative need is cited in the areas of previous horse-related injury, lessons, experience vs knowledge, epilepsy, drowning, gender, deaths, safety helmets, stirrups, and body protectors.
No horse is a safe horse; some are safer than others but the horse is a potentially lethal animal. Prevention of accidents and injuries is dependent upon using knowledge previously obtained from studying horse activities. Much more information is available than in the past through the medical studies that have been done and the recommendations made by these investigators. The medical community has a responsibility to educate the horse riding public and to participate in investigations requested by the horse organizations.
The foremost requirement for riders is that secured certified protective headgear secured by a chin strap or harness be worn by all riders at all times when mounted.
All horse-related injuries presenting to an Accident Service over a two-year period were investigated. 237 patients presented. The injuries were not considerable in absolute number but were in severity. There was a high morbidity with 22% of all patients requiring admission to hospital, 50% of all admissions because of head injuries. At least seven life-threatening injuries were identified and there were other severe pelvic and spinal injuries. The wearing of protective head gear remains the most important safety measure.
Of 1900 head injuries serious enough to be admitted to the neurosurgical unit in Glasgow over a five year period, 52 (2.7%) were due to "sport." Golf, horse-riding, and Association football were the sports most commonly linked with serious head injury. Golfing injuries were all compound depressed fractures, and all these patients made a good recovery; horse-riding produced more severe injuries, three of the eight patients being left with residual disability. Much attention has been directed to preventing repeated minor head injury in boxing, but this study emphasises the need for preventing both the primary head injury and secondary complications associated with other sports.
To determine patterns of helmet use and attitudes toward helmets among horseback riders, we analyzed a subset of data (n = 1,834) from a cross-sectional mail survey of horseback riders conducted from July to December 1991. Riders were randomly selected from the mailing list of a national mail-order company that sells horseback-riding equipment. Of 900 English-style riders, 517 (57.5%) wore helmets on their last ride, compared with only 81 of 684 (11.8%) Western-style riders. Among 546 riders who did not own helmets, their most commonly cited reasons included believing that helmets were unnecessary (43.8%) or uncomfortable (29.9%). Of the 1,263 helmet owners, nearly 62% had one or more complaints about helmets, but 41.1% of owners reported that their helmet had prevented at least one head injury. Increasing helmet use will require major educational efforts with horseback riders and design changes by manufacturers.
A retrospective chart review was conducted to define the demographic and injury patterns of patients presenting to the emergency department (ED). The setting is a rural/small urban tertiary care center with approximately 40,000 visits per year. All patients presenting to the ED from January 1986 through December 1990 with equestrian-related injuries were enrolled in the study. Measurements included age, sex, mechanism of injury, injury or injuries diagnosed, admission to the hospital, morbidity, and mortality. A total of 142 patients met the inclusion criteria. The majority of injuries occurred when the patient fell from a horse. There were also a large number of injuries associated with handling the horse. Most injuries were minor, but 15% required hospital admission. There were no deaths. In conclusion, equestrian activities are associated with a risk of serious injury to both riders and handlers of horses. Education of both the public and primary care physicians should focus on injury prevention.
Horse riding is a dangerous pastime with more accidents occurring per hour than during motor-cycling. Since a prospective survey of horse-related injuries conducted at a major centre in 1971-1972, equestrian groups and the medical profession have encouraged improvements in training and protective riding wear. By conducting a similar study at the same centre 20 years later we hoped to assess the effects of these measures on the pattern of injuries resulting from contact with horses. Patient and injury details were recorded prospectively for all those presenting to the Accident Service at Oxford during the whole of 1991. Total admissions fell by 46 per cent on average. Most of the decrease was due to a near fivefold fall in those admitted with head injuries (P < 0.001). A reduction in the severity of such injuries was associated with an increased use of riding helmets. However, the most commonly injured group remained amateur young female riders suggesting the need for increasing awareness and training of this group. In seven cases, severe digital injuries were caused by the habit of entwining reins around the fingers. This practice should be discouraged. Up to 12 per cent of all injuries might have been prevented if adequate footwear had been worn.
The medical and sports literature databases were searched for equestrian sports-related injury published in English since 1980, together with conference abstracts and discussions with equestrian sporting bodies. This literature was critically reviewed, with emphasis on measures to prevent or control injury i.e. countermeasures. While there is considerable literature available on the epidemiology of injury incurred in most equestrian sports, there is little on the prevention of these injuries. Case-control or other studies evaluating the effectiveness of the countermeasures suggested by authors do not seem to exist. There is a good body of epidemiology that supports the proper use of approved helmets as a means of preventing injury in these sports. However, protective helmets do not always prevent injury as expected, and many riders do not choose to wear them because of perceived poor design. The search for the ideal equestrian helmet should continue. Ideally the effectiveness of helmets should be assessed scientifically. Among the other countermeasures discussed are the use of rules and regulations for conduct of events, knowledge of horse behaviour, well-conducted lessons, contraindicated medical conditions, public education, rider education, appropriate equipment and clothing, the riding environment, rider experience, safety stirrups, body protectors, falling techniques, and first aid measures. Even though the injury rate for equestrians is relatively low when compared with other sports, the injuries that are incurred are usually severe. prevention is often difficult because the behaviour of the horse is unpredictable. Countermeasures used for prevention should be evaluated for the effectiveness to reduce the frequency and severity of injuries to equestrians.
Thirty million Americans ride horses; 50,000 of these riders are treated in emergency rooms annually. Equestrian activities are uniquely dangerous because the participant is unrestrained, often helmetless, and riding large, unpredictable animals capable of 40-mph speeds and kicking with up to 1 ton of force. Neurologic injuries in equestrians constitute the majority of severe injuries and fatalities. We prospectively studied all patients admitted to the University of Kentucky Medical Center with equine-related neurosurgical trauma from July 1992 to January 1996. Eighteen of 30 patients were male. Age ranged from 3 to 64 years. Five patients died (17%), and two suffered permanent paralysis. There were 24 head injuries (80%) and 9 spinal injuries (30%). The majority of injuries (60%) were caused by ejection or fall from the horse. Twelve patients (40%) were kicked by a horse, and four patients sustained crush injuries. Six patients underwent craniotomy, three had operative spinal stabilization, and five required ventriculostomy. Eleven patients (37%) were professional riders. Twenty-four patients (80%) were not wearing helmets, including all fatalities and craniotomy patients. Our data show that equine-related neurosurgical injuries can be severe and fatal because of the significant size, force, and unpredictability of these animals as well as the lack of proper headgear. We recommend that helmets be worn at all times around horses because a significant number of our patients (33%) were injured as bystanders. Risk of serious injury appears to be a function of cumulative exposure to horses, not level of expertise. Experience is not protective; helmets are.
Horseback riding is an increasingly popular activity among today's youth, providing them with the opportunity to learn responsibility and respect for animals. However, it can also be associated with severe injury, of which many physicians are unaware. In 2002, there were an estimated 13,400 emergency department visits nationwide for horse-related injuries among children younger than 15 years. When using a severity score to compare it with other childhood injuries, equestrian-related injury ranked second only to pedestrians being struck by a car, and had a higher score than all terrain vehicle, bicycle, and passenger motor vehicle crash injuries. Most serious injuries occur when a rider is thrown from a horse, which is often accompanied by being dragged or crushed by the horse. However, hoof kick injuries to an unmounted child represent about 30% of horse-related injuries and may result in more severe injury. Head injury is the injury most likely to result in hospitalization or death. The effectiveness of helmets in preventing serious head injury in horse-related accidents has been very well established. Recommendations for the prevention of horse-related injury include requiring helmet use on and near a horse, use of safety stirrups to prevent drag injury, matching rider skill with the appropriate horse, and providing close adult supervision.
This chapter reviews the current evidence for the epidemiology of pediatric equestrian injuries.
The relevant literature was searched through the use of MEDLINE (1966-2004) and SPORT DISCUS (1975-2004) searches, hand searches of journals and reference lists and discussions with experts and sporting organizations worldwide. Keywords and Mesh headings used in all searches included horse racing, children, pediatric injuries, sports injuries, equestrian injuries and sports trauma.
Limited data exist on the epidemiology of pediatric equestrian injuries. Most studies note the high preponderance of females with a peak incidence at approximately 14 years of age. This is likely to reflect the higher rate of female riders. The two most common horse riding-related injuries are long bone fractures and head injury. Although most injuries occur during recreational riding, approximately 15% of injuries occur in nonriding activities such as feeding, handling, shoeing and saddling.
While there is little knowledge of injury demographics or the efficacy of prevention countermeasures in this field, it is likely that injuries will continue to occur. The major challenge in reducing pediatric equestrian injuries is the formal scientific demonstration that the various proposed injury prevention measures are effective. With the majority of equestrian injuries happening during unsupervised leisure riding, the prospect of injury prevention is limited.
Horseback riding is more dangerous than motorcycle riding, skiing, football, and rugby. The purpose of this study was to identify the incidence and injury patterns, as well as risk factors associated with severe equestrian trauma.
All patients with major equestrian injuries (injury severity score > or = 12) admitted between 1995 and 2005 were reviewed. A 46-question survey outlining potential rider, animal, and environmental risk factors was administered.
Among 7941 trauma patients, 151 (2%) were injured on horseback (mean injury severity score, 20; mortality rate, 7%). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Forty-five percent required surgery. Survey results (55%) indicated that riders and horses were well trained, with a 47% recidivism rate. Only 9% of patients wore helmets, however, 64% believed the accident was preventable.
Chest trauma previously has been underappreciated. This injury pattern may be a result of significant rider experience. Helmet and vest use will be targeted in future injury prevention strategies.
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