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Impact of helmet use in equestrian-related traumatic brain injury: a matched-pairs analysis
Abstract
Purpose:
Traumatic brain injury is an important health concern in equestrian sports. Nevertheless, the use of safety helmets, especially in recreational riding, is reported to be rare. The purpose of this study was to perform the first matched-pairs analysis of traumatic brain injury with regard to the use of helmets.
Materials and methods:
In a multicenter retrospective database analysis 40 patients (mean age: 35 ± 17.13 years; 34 female & 6 male) were combined in 20 matched pairs based on age group, gender and trauma mechanism. Admission trauma computed tomography was qualitatively analyzed for the presence or absence of fractures or intracranial hemorrhage. Quantitatively, in patients with intracranial hemorrhage dedicated volumetry of the blood volume was performed. Odds ratio and relative risk were calculated for the endpoints fractures and intracranial hemorrhage. Crude risk ratio and lesion volume differences between helmeted and unhelmeted riders were compared.
Results:
Concerning skull fractures, in this cohort 6 patients (85.7% of all patients with fractures) did not wear a helmet and only one (14.3%) wore a helmet (p = .068).and fractures were considered more complex in the unhelmeted subgroup. Intracranial hemorrhage occurred significantly more often in the unhelmeted subgroup (10 vs. 2; p = .008). Moreover, the total lesion volume with 19.31 ± 23.93ml in the unhelmeted subgroup, presenting with intracranial hemorrhage, was significantly higher than in the control group (0.65 ± 0.35ml; p = .002). Odds ratios were 9 for intracranial hemorrhage (p = .014) and 8.14 for skull fractures without helmet (p = .09). Altogether, the relative risk for intracranial bleeding for unhelmeted riders was 5-fold higher and the relative risk reduction was 96% by wearing a safety helmet.
Conclusions:
Under consideration of comparable trauma mechanisms, horseback riders that do not wear a safety helmet are at risk to suffer significantly more severe brain injury than helmeted riders. Therefore, safety helmets are recommendable for all horseback riders.
... 30 Despite the increased risk of TBIs without the use of helmets, rates of consistent helmet use in all forms of skating and horseback riding in children remain low. [29][30][31][32] Helmet Effectiveness ...
... Intracranial hemorrhage was reported to be more common in unhelmeted children (OR: 9.0; 95% CI: 1.64 to49.45). The authors concluded that the relative risk reduction of intracranial bleeding by wearing a safety helmet was 96%.32 ...
Bicycling, snow sports, and other recreational activities and sports are important activities to keep children and youth active as part of a healthy lifestyle. These activities can be associated with serious and fatal head and facial injuries. Helmets, when worn correctly, are effective in decreasing head injuries and fatalities related to these activities. Legislation for helmet use is effective in increasing helmet use in children and, ultimately, in decreasing deaths and head and facial injuries. A multipronged strategy employing legislation, enforcement of laws, and medical clinicians and community programs is important for increasing helmet use to decrease deaths and injuries from recreational sports.
... [10][11][12][13][14] Despite the strong evidence for the effectiveness of helmets in decreasing head and facial injuries, their use is not consistent among sports participants. 10,[15][16][17][18][19][20] Helmet use is also cost-effective in the prevention of head injuries. 21,22 To increase helmet use, a multipronged approach including legislation, [23][24][25] enforcement of laws and rules, 26 public educational campaigns, 27 child education programs, 28,29 anticipatory guidance from clinicians, 30,31 and equitable access to helmets will be required. ...
Recreational activities and sports are a common and popular way for youth to enjoy physical activity; however, there are risks related to physical injury. Injuries can potentially result in death and long-term disability, especially from traumatic brain injury. Helmet use can significantly decrease the risk of fatal and nonfatal head injury, including severe traumatic brain injury and facial injuries when participating in recreational sports. The most robust evidence of helmet effectiveness has been demonstrated with bicycling and snow sports (eg, skiing, snowboarding). Despite this evidence, helmets are not worn consistently with all recreational sports. A multipronged approach is necessary to increase helmet use by children and youth participating in recreational sports. This approach includes legislation and enforcement, public educational campaigns, child education programs, and anticipatory guidance from clinicians. This policy statement guides clinicians, public health advocates, and policymakers on best practices for increasing helmet use in recreational sports, including bicycling and snow sports.
... A similar study to ours found that there was low awareness among equestrians of the inability of helmets to protect against concussion [12]. While helmets can greatly improve outcomes after falls [13], current safety inspections and helmet-testing occur through impact with hard, flat surfaces as opposed to 'real-world' injuries that often occur with a rotational component to the fall [14]. The recent advancements in helmet technology (such as the MIPS system) are promising in laboratory testing, which may help to protect riders more completely in such falls and could be better marketed to demonstrate the advancements in injury protection they may offer for riders [15]. ...
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.
Objective:
Little information exists about horse-related injury admissions to Level 1 trauma centres in the Western United States. This study describes injury patterns in this population, to reveal potential areas for injury prevention initiatives.
Methods:
A retrospective database review of 512 non-fatal equine-related injuries over a 15-year period was conducted, using a Level 1 hospital trauma registry. To determine patterns of injury, patients injured by riding or being near a horse were classified according to age, sex, helmet use, abbreviated injury score, anatomical region injured, and length of stay.
Results:
Equine-related injury was more frequent among females than males, the anatomical region most at risk among adults was the lower extremity (including pelvis), and among children and youth, the head. 75% of head-injured patients were not wearing a helmet at the time of injury and those with the most severe head injuries were least likely to be wearing a helmet.
Conclusion:
Preventable equine-related injuries occur across all ages, are more frequent among females, and affect all regions of the body. Despite head-injury risks associated with horse activities, helmet use was not common among most of the injured. Decreasing the risk of these injuries requires use of appropriate protective equipment and enhanced education campaigns aimed at those in the horse industry and the general public.
Introduction/Objecive
There are very few studies that have investigated equestrian-related maxillofacial injuries. A retrospective review was performed to investigate maxillofacial horse trauma at a Level 1 Trauma Centre at the Royal Stoke Hospital over the last 10 years between 2010 and 2020.
Study Design/Methods
Search of the hospital’s major trauma database as well as ED records showed 51 patients who sustained maxillofacial injuries related to horses. Statistical analysis was performed using Chi Squared tests.
Results
41 patients were female and the remaining 10 were male. 43% of patients were female and aged 30 and under. Kicks from horses accounted for 64.4% of equine-related maxillofacial injuries. A total of 90 injuries were recorded. Hard tissue injuries which include all fractures accounted for 66.3% of injuries sustained. 70.5% patients sustained isolated maxillofacial trauma. There was an association between patients sustaining non-isolated maxillofacial trauma and hard tissue maxillofacial injuries ( P = 0.04). 65.6% of injuries were managed operatively. Patients aged 30 and under were more likely to be managed operatively ( P = 0.03).
Conclusion
Equestrian related maxillofacial trauma represents a proportion of trauma workload. The safety aspect of horse riding should be considered and education in safe riding and the use of appropriate safety equipment is vital.
Introduction
: Large animal-related injuries (LARI) are relatively uncommon, but, nevertheless, a public hazard. The objective of this study was to better understand LARI injury patterns and outcomes.
Materials and Methods
We performed a retrospective review of the 2016 National Trauma Data Bank and used ICD-10 codes to identify patients injured by a large animal. The primary outcome was severe injury pattern, while secondary outcomes included mortality, hospital length of stay, ICU admission, and mechanical ventilation usage.
Results
: There were 6,662 LARI included in our analysis. Most LARI (66%) occurred while riding the animal, and the most common type of LARI was fall from horse (63%). The median ISS was 9 and the most severe injuries (AIS ≥ 3) were to the chest (19%), head (10%), and lower extremities (10%). The overall mortality was low at 0.8%. Compared to non-riders, riders sustained more severe injuries to the chest (21% vs. 16%, p<0.001) and spine (4% vs. 2%, p<0.001). Compared to motor vehicle collisions (MVC), riders sustained fewer severe injuries to the head (10% vs. 12%, p<0.001) and lower extremity (10% vs. 12%, p=0.01). Compared to auto-pedestrian accidents, non-riders sustained fewer severe injuries to the head (11% vs. 19%, p<0.001) and lower extremity (10% vs. 20%, p<0.001).
Conclusion
: Patients involved in a LARI are moderately injured with more complex injuries occurring in the chest, head, and lower extremities. Fall from horse was the most common LARI mechanism. Overall mortality was low. Compared to non-riders, riders were more likely to sustain severe injuries to the chest and spine. Severe injury patterns were similar when comparing riders to MVC and, given that most LARI are riding injuries, we recommend trauma teams approach LARI as they would an MVC.
Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.
This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.
Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.
As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.
Zusammenfassung
Reiten ist eine hoch koordinative Sportart mit nur geringer kardio-pulmonaler Ausdauerkomponente. Dabei können Kinder schon frühzeitig mit dem Pferd in Kontakt gebracht werden und besonders Voltigieren stellt für sie eine gute Möglichkeit dar, unter kontrollierten Bedingungen den Zugang zum Pferd zu finden.
Voraussetzung ist die sichere Stabilisierung der Wirbelsäule und Kontrolle des Kopfes, wobei die dreidimensionale Übertragung des Schwingungsimpulses vom Pferderücken auf den Reiterrücken positive Effekte aufweist und Überlastungsschäden dabei nicht zu erwarten sind.
Der Pferdesport geht mit einem erhöhten Unfallrisiko einher, besonders auch in der Altersgruppe der unter 18-Jährigen. Die meisten Verletzungen ereignen sich beim Reiten selbst, aber auch beim Umgang mit dem Pferd. Neben Verletzungen der oberen und unteren Extremitäten machen Kopfverletzungen bereits im Kindes- und Jugendalter einen erheblichen Anteil aus.
Die beste Unfallprävention ist eine gute Ausbildung, die nicht nur das Reiten selbst, sondern auch den Umgang mit dem Pferd und eine korrekte Selbsteinschätzung der eigenen reiterlichen Fähigkeiten beinhaltet. Der wichtigste Ausrüstungsgegenstand ist ein gut passender Reithelm.
Simple
Equitation science describes an approach to horse training and riding that focuses on embracing the cognitive abilities of horses, their natural behaviour, and how human riders can use signalling and rewards to best effect. This approach is concerned with both horse welfare and rider safety, and this review discusses how equitation science can minimise risk to humans around horses and enhance horse welfare.
Equitation science is an evidence-based approach to horse training and riding that focuses on a thorough understanding of both equine ethology and learning theory. This combination leads to more effective horse training, but also plays a role in keeping horse riders and trainers safe around horses. Equitation science underpins ethical equitation, and recognises the limits of the horse’s cognitive and physical abilities. Equitation is an ancient practice that has benefited from a rich tradition that sees it flourishing in contemporary sporting pursuits. Despite its history, horse-riding is an activity for which neither horses nor humans evolved, and it brings with it significant risks to the safety of both species. This review outlines the reasons horses may behave in ways that endanger humans and how training choices can exacerbate this. It then discusses the recently introduced 10 Principles of Equitation Science and explains how following these principles can minimise horse-related risk to humans and enhance horse welfare.
Objectives
Equestrian sports can result in a variety of injuries to the nervous system due to many factors. We describe our series of 80 patients with injuries sustained during participation in equestrian sports.
Methods and Results
All patients seen at the regional trauma center with injuries associated with equestrian sports between 2003 and 2011 were reviewed; 80 patients were identified. Fifty-four per cent were female and the average age was 37 years (2·2–79·3). The mean injury severity score (ISS) was 9·9 ± 0·7. Only two patients had documented helmet use. Glasgow coma score (GCS) was 15 in 93% of patients. The most common neurosurgical injuries were to the cranial vault (28%), including concussions, intracranial hematomas and hemorrhages, and skull, facial, and spine fractures (10%), with the majority (63%) being transverse process fractures. The mechanisms of injury varied: 55% were kicked or stepped on, 28% were thrown or fell off, and 21% were injured by the horse falling on them. The causes ranged from carelessness and lack of attention to animal factors including inadequate training of horses and animal fear. Fourteen per cent required surgery. There were no mortalities and average length of stay was 3·7 ± 0·35 days. All patients were discharged home with 95% requiring no services.
Discussion
Equestrian sports convey special risks for its participants. With proper protection and precautions, a decrease in the incidence of central nervous system injuries may be achieved. Neurosurgeons can play key roles in advocating for neurologic safety in equestrian sports.
In Switzerland there are about 150,000 equestrians. Horse related injuries, including head and spinal injuries, are frequently treated at our level I trauma centre.
To analyse injury patterns, protective factors, and risk factors related to horse riding, and to define groups of safer riders and those at greater risk
We present a retrospective and a case-control survey at conducted a tertiary trauma centre in Bern, Switzerland.Injured equestrians from July 2000 - June 2006 were retrospectively classified by injury pattern and neurological symptoms. Injured equestrians from July-December 2008 were prospectively collected using a questionnaire with 17 variables. The same questionnaire was applied in non-injured controls. Multiple logistic regression was performed, and combined risk factors were calculated using inference trees.
RETROSPECTIVE SURVEY: A total of 528 injuries occured in 365 patients. The injury pattern revealed as follows: extremities (32%: upper 17%, lower 15%), head (24%), spine (14%), thorax (9%), face (9%), pelvis (7%) and abdomen (2%). Two injuries were fatal. One case resulted in quadriplegia, one in paraplegia. CASE-CONTROL SURVEY: 61 patients and 102 controls (patients: 72% female, 28% male; controls: 63% female, 37% male) were included. Falls were most frequent (65%), followed by horse kicks (19%) and horse bites (2%). Variables statistically significant for the controls were: Older age (p = 0.015), male gender (p = 0.04) and holding a diploma in horse riding (p = 0.004). Inference trees revealed typical groups less and more likely to suffer injury.
Experience with riding and having passed a diploma in horse riding seem to be protective factors. Educational levels and injury risk should be graded within an educational level-injury risk index.
Jockey head injuries, especially concussions, are common in horse racing. Current helmets do help to reduce the severity and incidences of head injury, but the high concussion incidence rates suggest that there may be scope to improve the performance of equestrian helmets. Finite element simulations in ABAQUS/Explicit were used to model a realistic helmet model during standard helmeted rigid headform impacts and helmeted head model University College Dublin Brain Trauma Model (UCDBTM) impacts. Current helmet standards for impact determine helmet performance based solely on linear acceleration. Brain injury-related values (stress and strain) from the UCDBTM showed that a performance improvement based on linear acceleration does not imply the same improvement in head injury-related brain tissue loads. It is recommended that angular kinematics be considered in future equestrian helmet standards, as angular acceleration was seen to correlate with stress and strain in the brain.
OBJECTIVE: Sports-related traumatic brain injury (TBI) is an important public health concern estimated to affect 300,000 to 3.8 million people annually in the United States. Although injuries to professional athletes dominate the media, this group represents only a small proportion of the overall population. Here, the authors characterize the demographics of sports-related TBI in adults from a community-based trauma population and identify predictors of prolonged hospitalization and increased morbidity and mortality rates.
METHODS: Utilizing the National Sample Program of the National Trauma Data Bank (NTDB), the authors retrospectively analyzed sports-related TBI data from adults (age ≥ 18 years) across 5 sporting categories-fall or interpersonal contact (FIC), roller sports, skiing/snowboarding, equestrian sports, and aquatic sports. Multivariable regression analysis was used to identify predictors of prolonged hospital length of stay (LOS), medical complications, inpatient mortality rates, and hospital discharge disposition. Statistical significance was assessed at α < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis.
RESULTS: From 2003 to 2012, in total, 4788 adult sports-related TBIs were documented in the NTDB, which represented 18,310 incidents nationally. Equestrian sports were the greatest contributors to sports-related TBI (45.2%). Mild TBI represented nearly 86% of injuries overall. Mean (± SEM) LOSs in the hospital or intensive care unit (ICU) were 4.25 ± 0.09 days and 1.60 ± 0.06 days, respectively. The mortality rate was 3.0% across all patients, but was statistically higher in TBI from roller sports (4.1%) and aquatic sports (7.7%). Age, hypotension on admission to the emergency department (ED), and the severity of head and extracranial injuries were statistically significant predictors of prolonged hospital and ICU LOSs, medical complications, failure to discharge to home, and death. Traumatic brain injury during aquatic sports was similarly associated with prolonged ICU and hospital LOSs, medical complications, and failure to be discharged to home.
CONCLUSIONS: Age, hypotension on ED admission, severity of head and extracranial injuries, and sports mechanism of injury are important prognostic variables in adult sports-related TBI. Increasing TBI awareness and helmet use-particularly in equestrian and roller sports-are critical elements for decreasing sports-related TBI events in adults.
Sports-related concussions (SRC) and traumatic brain injury (TBI) represent a growing public health concern. We reviewed the literature regarding equestrian-related brain injury (ERBI), ranging from concussion to severe TBI.
A literature review was performed to address the epidemiology of SRC and TBI in equestrian-related sports. MEDLINE and PUBMED databases were searched to identify all studies pertaining to brain injury in equestrian-related sports. We included two broad types of brain injury using a distinction established in the literature: 1) TBI with functional impairment, including concussion, or mild TBI, with negative imaging findings; 2) TBI with structural impairment, with positive imaging and at least one of the following pathologies identified: subdural hemorrhage (SDH), epidural hemorrhage (EDH), subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), cerebral contusions, and skull fractures.
Our literature search yielded 199 results. We found 26 studies describing functional TBI and 25 mentioning structural TBI, and 8 including both. Of all modern sporting activities, equestrian sports were found to cause some of the highest rates of total bodily injury, severe brain injury, and mortality. Concussions comprise approximately 9.7-15% of all equestrian-related injuries brought to hospitals for evaluation. Structural TBI was rare, and documentation of these injuries was poor. While demographic risk factors like age and sex are minimally discussed in the literature, two studies identified a protective effect of increasing rider experience on all forms of bodily injury. However it remains unclear if increasing rider experience protects specifically against head injury. Finally, rates of helmet use in horseback riding remain dismally low - ranging from 9-25%, depending on the activity. These low rates have persisted over time, despite evidence in this literature that helmets lead to an absolute risk reduction for head injury of 40-50% in equestrian sports.
Equestrian-related functional and structural TBI, represents a significant public health burden. Rider and horse characteristics make the sport uniquely dangerous, as the athlete has limited control over an animal weighing over a thousand pounds. Helmet use rates remain very low despite clear evidence of risk reduction. Healthcare providers are strongly urged to lobby professional and governmental organizations for mandatory helmet use in all equestrian sports.
Copyright © 2014 Elsevier Inc. All rights reserved.
Patients with equestrian injuries were identified in the trauma registry from 2004 to 2007. We a priori divided patients into three groups: 0 to 18 years, 19 to 49 years, and 50 years old or older. There were 284 patients identified with equestrian-related trauma. Injury Severity Score for the three major age categories 0 to 18 years, 19 to 49 years, and 50 years or older, were 3.47, 5.09, and 6.27, respectively. The most common body region injured among all patients was the head (26.1%). The most common injuries by age group were: 0 to 18 years, upper extremity fractures; 19 to 49 year olds, concussions; and 50 years or older, rib fractures. Significant differences were observed among the three age groups in terms of percent of patients with rib fractures: percent of patients with rib fractures was 2, 8, and 22 per cent in age groups 0 to 18, 19 to 49, and 50 years or older, respectively. We found different patterns of injuries associated with equestrian accidents by age. Head injuries were commonly seen among participants in equestrian activities and helmet use should be promoted to minimize the severity of closed head injuries. Injury patterns also seem to vary among the various age groups that ride horses. This information could be used to better target injury prevention efforts among these patients.
Using a cross-sectional survey design, this study sought to determine usage rates and barriers to the use of protective equipment in roughstock athletes. Between 2004 and 2006, amateur, collegiate, and professional roughstock athletes were surveyed using national organizational mailing lists. Findings revealed that during competition, 69% never wore a helmet. Barriers were a negative effect on performance and sport persona. Conversely, 88% always wore a vest. The perception that vest usage was required encouraged roughstock athletes to wear them. Mouthpiece use results were mixed; 58% always used and 21% never used a mouthpiece. Barriers were discomfort and frequent forgetfulness. Reported injury rate was high, with users noting fewer injuries to head and ribs than nonusers, and riders agreed that protective equipment prevented injury to the head, ribs, and mouth. However, equipment usage rates varied widely by type and seemed to be underutilized because the equipment affected performance, was uncomfortable, and "not cowboy."
Equestrian sports continue to grow in popularity in the Unites States and abroad, with an estimated 30 million people riding horses annually in the United States alone. Approximately one in five of these riders will suffer a serious injury during their riding career, requiring medical care and potentially hospitalization. Riding carries with it an implicit risk of injury associated with the unpredictability of the animals, the rider's head being positioned approximately 9 feet off the ground, and traveling unrestrained at speeds up to 40 mph. This article reviews common equestrian injuries, epidemiology, mechanism of injury, risk factors, and prevention strategies, with an emphasis on the more dangerous aspects of the sport.
It was the purpose of this study to review equestrian-related injuries using a large nation wide database and analyze predictors of significant injury.
The National Electronic Surveillance System database was queried for equestrian injuries from 2002 to 2004. The presence of a fracture, dislocation, traumatic brain injury, musculoskeletal injury, orthopedic injury, and spinal injury, as well as injury mechanism, geographical location, and emergency room disposition were noted. Bivariate, cosinor seasonal, and multiple logistic regression analyses were performed. p < 0.01 was considered significant.
Emergency room visits because of equestrian-related injuries from 2002 to 2004 from the NEISS database were reviewed; there were 5,033 visits during this time span. The average age was 30.0 +/- 17.0 years; 66% were women. The injuries occurred at home (36%), recreation/sporting facility (30%), on a farm (19%), and other public property (12%). The injury was due to a fall (59%), thrown/bucked from the horse (22.0%), and while riding the horse (9%). The most common injuries were contusion/abrasions (31%), fractures (28%), sprain/strains (18%), traumatic brain injuries (12%), and lacerations (6%). The body area injured was the head and neck (24%), trunk (29%), upper extremity (30%), lower extremity (16%), and multiple locations (1%). Most injuries occurred in the summer. Predictors of hospital admission were age >18 years, traumatic brain injury, fracture, or occurrence on other public property (odds ratios 1.4, 6.25, 7.7, and 1.5, respectively).
The largest number of equestrian injuries occur in white females in the 2nd, 4th, and 5th decades of life. Serious injuries are due to falling or being bucked off a horse and most commonly occur at home or at a recreational/sporting facility. Prevention strategies (educational and passive protection equipment) should be especially targeted to this high risk group.