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Assessing the sport-specific and functional characteristics of back pain in horse riders

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  • Hartpury University
  • Hartpury University

Abstract and Figures

Currently, no standardised screening tools nor established interventions are available to address the characteristics of back pain (BP) specifically in horse riders. Therefore, the aim of this case-control study is to explore sport-specific and functional characteristics of BP in horse riders. 16 professional and 16 amateur riders (25±7 years) participated in two questionnaires (a sport-specific questionnaire and the Oswestry Disability Index questionnaire) and were examined via the physical functional movement screening (FMS) and Luomajoki’s motor control (MC) screening. The lifetime prevalence of BP was as high as 81%, and spinal discomfort in horse riders was mainly located in the lumbar spine. Professional riders revealed significantly higher prevalence of BP in the last month before assessment (P=0.014) than amateur riders. Compared to horse riders using dressage or multiple saddle types, show jumping riders (n=10) who only use jumping saddles (P=0.027) also revealed higher BP prevalence. Horse riders with lower scores on the FMS and MC screening, and thereby with more movement dysfunctions, were found to experience higher levels of pain (r=-0.582, P=0.001; r=-0.404, P=0.024, respectively) and disability caused by BP (r=-0.688; P<0.001; r=-0.474; P=0.006, respectively). Both physical screening tools are found to be clinically relevant enabling investigators to identify objective functional characteristics related to BP in horse riders. The high prevalence of BP in riders is a clinically important finding that should be explored further to elucidate the causes and subsequently guide occupational health in horse riders.
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COMPARATIVE
EXERCISE
PHYSIOLOGY
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1. Introduction
Equestrian-related injuries are relatively severe compared
with injuries incurred in other popular sports (Van Balen
et al., 2019). A substantial proportion of these equestrian
injuries are acute. Evidence suggests that these can lead to
long-term chronic dysfunction (Ball et al., 2009). Physical
overloading can also result in chronic pains (Kraft et al.,
2009; Lewis and Baldwin, 2018; Lewis and Kennerley, 2017)
and overuse injuries account for almost half of the injuries
in eventing riders (Ekberg et al., 2011). One of the most
common areas of pain in the equestrian population is back
pain (BP), with a reported prevalence of 71-100% compared
to 33% in non-riders (Kraft et al., 2009; Lewis and Baldwin,
2018). Previous stated possible origins of spinal discomfort
in horse riders across different equestrian disciplines
include the repetitive nature of riding (Lewis et al., 2019),
acute traumas, postural defects, asymmetry (Hobbs et al.,
2014; Nevison and Timmis, 2013), an insufficient recovery
period following a fall and insufficient rehabilitation of
previous injuries and monotonous training routines (Ekberg
et al., 2011). Furthermore, the level of riding (Hobbs et
al., 2014) and the type of saddle (Quinn and Bird, 1996)
are stated to possibly be related with BP development and
continuity as well.
Equestrian sports science is an emerging field, but evidence-
based data on the use of sport-specific screening and their
outcomes are still limited in riders. Current research in
other non-equestrian sport disciplines, such as football,
Assessing the sport-specific and functional characteristics of back pain in horse riders
I. Deckers1,2*, C. De Bruyne1, N.A. Roussel1, S. Truijen1, P. Minguet3, V. Lewis5, C. Wilkins2 and E. Van Breda1*
1
Department of Rehabilitation Sciences and Physiotherapy (REVAKI), Faculty of Medicine and Health Sciences, University of Antwerp,
Universiteitsplein 1, 2610 Wilrijk, Belgium; 2Equestrian Performance Research and Knowledge Exchange Department, Hartpury University,
GL19 3BE, United Kingdom;
3
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Movement and Rehabilitation Sciences,
Catholic University of Leuven, Tervuursevest 101, 3001 Leuven, Belgium; isabeau.deckers@hotmail.com; isabeau.deckers2@hartpury.ac.uk;
eric.vanbreda@uantwerpen.be
Received: 23 November 2019 / Accepted: 9 April 2020
© 2020 Wageningen Academic Publishers
RESEARCH ARTICLE
Abstract
Currently, no standardised screening tools nor established interventions are available to address the characteristics
of back pain (BP) specifically in horse riders. Therefore, the aim of this case-control study is to explore sport-specific
and functional characteristics of BP in horse riders. 16 professional and 16 amateur riders (25±7 years) participated
in two questionnaires (a sport-specific questionnaire and the Oswestry Disability Index questionnaire) and were
examined via the physical functional movement screening (FMS) and Luomajoki’s motor control (MC) screening.
The lifetime prevalence of BP was as high as 81%, and spinal discomfort in horse riders was mainly located in the
lumbar spine. Professional riders revealed significantly higher prevalence of BP in the last month before assessment
(P=0.014) than amateur riders. Compared to horse riders using dressage or multiple saddle types, show jumping
riders (n=10) who only use jumping saddles (P=0.027) also revealed higher BP prevalence. Horse riders with lower
scores on the FMS and MC screening, and thereby with more movement dysfunctions, were found to experience
higher levels of pain (r=-0.582, P=0.001; r=-0.404, P=0.024, respectively) and disability caused by BP (r=-0.688;
P<0.001; r=-0.474; P=0.006, respectively). Both physical screening tools are found to be clinically relevant enabling
investigators to identify objective functional characteristics related to BP in horse riders. The high prevalence of BP
in riders is a clinically important finding that should be explored further to elucidate the causes and subsequently
guide occupational health in horse riders.
Keywords: horse riding, motor control, functional movement screen, back pain, sports performance
I. Deckers et al.
8 Comparative Exercise Physiology 17 (1)
basketball, running, rowing and cycling, already recommend
physical screening of athletes prior to athletic participation
(Sanders et al., 2013; Wingfield et al., 2004). The general aim
of physical screening is to detect conditions that predispose
the athlete to injury or illness and consequently to adapt
their training programs accordingly to maximise their
health and safety (Mirabelli et al., 2015). Two popular
and simple physical screening tools used in many sport
disciplines, both with moderate-to-excellent inter- and
intra-rater agreement (Cook et al., 2014; Luomajoki et
al., 2007), are the Functional Movement Screening (FMS)
and the Luomajoki’s motor control (MC) screening. The
FMS, which has been reported to correlate with injury risk
(Cook et al., 2014; Kiesel et al., 2007; Moran et al., 2017),
aims to assess the quality of a person’s basic functional
movements, muscle flexibility, strength, neuromuscular
coordination, proprioception, core stability, imbalances and
general movement proficiency (Cook et al., 2014). The MC
screening was developed to assess movement dysfunctions
of the lower back and the quality of a person’s movement
control of the lumbopelvic complex (Luomajoki et al., 2008)
and it is used to distinguish individuals with and without
BP (Luomajoki and Moseley, 2011). These screening tools
seem suitable for riders, as they assess the characteristics
that possibly relate to injury development or continuity
in horse riders, such as strength of the core and lower
body musculature, balance, quick hand-eye coordination,
flexibility, pelvic stability and the control to dissociate lower
limb movement and trunk movement (Douglas, 2017).
In other sports, dynamic and functional capacities such
as muscle strength, mobility, stability and neuromuscular
control of the spine are related to the prevalence and
intensity of BP and the grade of disability caused by BP
(Roussel et al., 2012; Stuber et al., 2014; Tayrose et al., 2015;
Van Dieën et al., 2019). Some evidence in riders suggests the
same (Douglas et al., 2012; Hampson and Randle, 2015). The
aim of this study was to assess sport-specific and functional
capacities related to BP in riders. It was hypothesised that
the FMS and MC scores are indicative of BP in riders,
and that BP is associated with competition level, riding
discipline, and the hours of riding per day.
2. Materials and methods
Study design
A case-control study was used to assess the relationship
between BP and sport-specific and physical functional
characteristics in riders. All participants completed two
questionnaires and were examined using two physical
performance screening tools. The experimental protocols
received Institutional Ethics Committee Approval at the
University of Antwerp and informed written consent was
obtained from all participants.
Study participants
32 riders (10 men, 22 women) average age of 25 (±7)
years were recruited by the use of social media and a local
advertisement at a national and regional competition of the
LRV (Federation of competitive Belgian horse riders). Only
riders between 18 and 60 years old, competing within the
dressage, show jumping, eventing and/ or Icelandic riding
disciplines and without BP or with non-specific BP were
included. Non-specific BP can be defined as low BP not
attributable to a recognisable and known specific pathology
(Balagué et al., 2012). Riders with a known cause for BP,
i.e. specific BP, such as previous surgery concerning the
spine, congenital scoliosis or scoliosis >25° and BP with
a known anatomical cause, were excluded. By excluding
participants with specific BP, the non-specific character
of the BP under investigation was maintained and risk of
selection bias was minimised.
Riding level was defined as per Williams and Tabor (2017):
professionals were those whose career was related to their
competitive profile and amateurs were those competing at
affiliated level at regional competitions. The demographic
information of the participants can be found in Table 1.
Testing procedure
A survey was constructed using the principles reported
by Diem (2002): it was designed to take no longer than 10
minutes to complete, contained 20 closed-response (e.g.
yes/no and Likert scale) and open-response items and a
pain Visual Analogue Scale (VAS) score (Jensen, 2003). The
survey comprised two sections: the Oswestry Low Back Pain
Disability Questionnaire and a self-designed, sport-specific
questionnaire. The Oswestry Disability Index (ODI) is a
validated patient-reported parameter that measures and
categorises the impact of low BP on everyday life by its
Table 1. The general characteristics of the participants.
Horse riders (n=32)
Gender Female 22
Male 10
Discipline Jumping 12
Dressage 10
Jumping and dressage 7
Eventing 2
Icelandic riding 1
Level Professional 9
National competition 7
Competitive level 16
Age (years) 25±7
Years of riding 17±7
Hours of riding/day 3±3
Back pain in horse riders
Comparative Exercise Physiology 17 (1) 9
severity on a scale from 0 (no disability caused by BP at
all) to 100 (bed-bound due to BP) (Chiarotto et al., 2016;
Davidson and Keating, 2002; Van Hooff et al., 2015). The
self-designed sport-specific questionnaire contained 10
topics: demographic data (age and gender), profession,
level of riding, years of riding, the average amount of
hours riding per day, discipline, saddle type, incidence
of BP, location of pain and the severity of their BP (VAS).
This questionnaire was self-designed based on the lack of
standardised demographic questionnaires in this population
and developed in agreement with both equine professionals
and the supervisors of this study with the aim to provide
valid and reliable data.
Participants were screened using 14 clinical tests, divided
in two sections. The first section was the seven-point
FMS protocol, including the deep squat to assess bilateral,
symmetrical, and functional mobility of the hips, knees
and ankles; the hurdle step to examine the body’s stride
mechanics during the asymmetrical pattern of a stepping
motion; the in-line lunge to assess hip and trunk mobility
and stability, quadriceps flexibility, and ankle and knee
stability; the shoulder mobility test to assess bilateral
shoulder range of motion, scapular mobility, and thoracic
spine extension; the active straight leg raise to determine
active hamstring and gastroc-soleus flexibility while
maintaining a stable pelvis; the trunk stability push-up
to examine trunk stability while a symmetrical upper-
extremity motion is performed; and the rotary stability
test to assess multi-plane trunk stability while the upper
and lower extremities are in combined motion. Each FMS
movement was scored (0-3 point FMS score) independently
by two 5
th
-year-MSc Physiotherapy and Rehabilitation
Science students from the University of Antwerp. After the
seven different movements were evaluated, a cumulative
score out of 21 was recorded, as per the method described
by Cook et al. (2014) where 21 is the highest score possible.
The second section of the physical screening reported the
seven clinical tests of the MC screening, including the
waiter’s bow, to assess hip flexion and hamstring length
with a neutral lumbopelvic complex; pelvic posterior tilt,
to examine lumbopelvic flexion; the one leg stance, to
assess the lumbopelvic rotation; the sitting knee extension
to assess the lower limb extension and hamstring length
with a neutral lumbopelvic complex; rocking backward
and forward to examine the hip movement with a neutral
lumbopelvic complex; and the prone knee flexion to assess
the lower limb movement with a neutral lumbopelvic
complex. After each MC movement, two scores (0-1 point
scale) were independently given to the movement based on
specific MC criteria by the same two assessors. After the
seven different movements were evaluated, a cumulative
score out of seven was recorded, as per the method
described by Luomajoki et al. (2007) where 0 indicates
the highest level of altered MC and 7 the highest level of
functional MC skills.
All screenings and questionnaires were obtained on the
same day and none of the riders were familiar with the
applied screenings, neither with the questionnaires. The
assessors remained blinded for BP and for each other’s
scores throughout the study procedure.
Statistical analysis
Statistical analyses were conducted using SPSS Statistics
24 (IBM Corp., Armonk, NY, USA). Inter-rater agreement
was calculated for both the FMS and MC scores prior to
analysis by Kappa correlation. The normality of the data was
assessed with the Kolmogorov-Smirnov normality test. As
the data were not normally distributed, the Mann-Whitney
U test was used to test for differences between the different
subcategories of riders. The Pearson’s, Spearman’s and
Chi-Square analyses were used to determine associations
between the FMS tests, MC tests, the BP parameters,
and the demographic and sport-specific parameters. The
significance level was set at 0.05, odd levels of significance
are mentioned explicitly.
3. Results
22 women (69%) and 10 men (31%) participated in the study.
Subjects had been horse riding for an average of 17±7 years
and rode 3±3 hours a day on average.
Pain parameters
81% of riders had experienced BP at some time in their life
and 35% had experienced BP in the last month before the
assessment. Of all riders with spinal discomfort(s), 83%
located the discomfort in the lumbar spine, 26% in the
thoracic spine and 9% in the cervical spine. The appointed
spinal pain localisations are demonstrated in a body chart
(Figure 1). Based on the VAS, the intensity of the pain in
the riders ranged from no pain to moderate pain (min.
VAS=0.00/10; max. VAS=5.70/10; µ=1.91±1.67). The results
of the ODI revealed that the average rider experienced no
or minimal disability on the day of testing as a result of BP
(min. ODI=0.00%; max. ODI=25%; µ=4.59±4.78), meaning
the average rider continued their normal lifestyle despite
experiencing BP.
Sport-specific parameters
88% of professional riders had experienced BP at some time
in their life and 56% in the last month, which was higher
compared to 73% (χ
2
=0.963; P>0.05) and 13% (χ
2
=6.028;
P=0.014) in the amateur riders. The jumping riders who
solely used jumping saddles were more prone to have had
BP within the last month before the assessment (60%)
compared to the dressage riders (18%) or jumping riders
who also used dressage saddles (0%) (χ2=4.894; P=0.027).
No significant differences were found in the intensity of BP
I. Deckers et al.
10 Comparative Exercise Physiology 17 (1)
or the disability caused by BP between the different levels
and disciplines of riding (P>0.05). Parameters that did not
influence the pain parameters (the prevalence and intensity
of BP and the grade of disability caused by BP) were gender,
age, years of riding and hours of riding per day.
Functional physical characteristics
Cohen’s Kappa values for inter-rater reliability between
the two scorers were 0.982 and 0.981 for the FMS and
MC scores, respectively. A significant relationship was
found between the experience of BP in the last month or in
the lifetime and the in-line lunge test (r=-0.410; P=0.022);
rotary stability test (r=-0.372; P=0.040); and rocking
backwards (r=-0.438; P=0.014) and forwards (r=-0.416;
P=0.020). This relationship is presented in Figure 2. The
mean cumulative FMS score in all riders was 16.30±2.02
(min. FMS score = 12.00; max. FMS score = 19.00) and
15.41±2.78 (min. FMS score = 9.00; max. FMS score =
19.00) in the riders that experienced BP within the last
month, while the mean cumulative MC score across all
riders equalled 4.75±1.81 (min. MC score = 1.00; max. MC
score = 7.00) and 4.14±1.82 (min. MC score = 2.00; max.
MC score = 7.00) in the riders that experienced BP within
the last month (Table 2). Riders with lower scores on the
MC screening and/ or on the FMS, were found to experience
higher levels of pain (r=-0.582, P=0.001; r=-0.404, P=0.024),
to be seen in Figure 3. The ODI was negatively correlated
with the results of the MC testing (r=-0.474; P=0.006) and
the FMS (r=-0.688; P<0.001), indicating that scoring low
on the FMS or MC screening, encountered relatively more
limitations during their activities of daily living (Figure
4). No significant differences were found in the FMS and
MC results between the different levels and disciplines of
riding, although a trend was seen in lower scores on the
MC screening in the professional riders 3.67±1.52 (min.
MC score = 1.00; max. MC score = 6.00) compared to the
amateur riders 4.98±1.84 (min. MC score = 1.00; max. MC
score = 7.00) (U=59.50; P=0.061).
Figure 1. Body chart of the pain location. This figure shows the
locations of spinal pain mentioned by horse riders. The darker
areas indicate a higher prevalence of pain.
Table 2. A comparison of FMS and MC composite scores between professional and amateur horse riders and between horse riders
with back pain (BP) experience within the last month and horse riders without BP experience within the last month.1
Number of
riders (n)
Cumulative
MC score
Standard
deviation
Range of
scores
Number of
scores ≤6
Number of
scores >6
MC screening Higher level 16 4.22 ±1.69 1.5-7 14 (87.4%) 2 (12.6%)
Lower level 16 5.00 ±1.93 1-7 11 (68.7%) 5 (31.3%)
BP last month 11 4.24 ±1.79 1-7 10 (90.9%) 1 (9.1%)
No BP last month 20 5.75 ±1.41 4-7 15 (75%) 5 (25%)
Number of
scores ≤ 14
Number of
scores >14
FMS Higher level 16 15.97 ±1.77 13-19 3 (18.8%) 13 (81.2%)
Lower level 16 16.13 ±2.80 9-19 3 (18.8%) 13 (81.2%)
BP last month 11 15.41 ±2.78 9-19 3 (27.3%) 8 (72.7%)
No BP last month 20 16.30 ±2.02 12-19 3 (15%) 17 (85%)
1 FMS = functional movement screening; MC = Luomajoki’s motor control.
Back pain in horse riders
Comparative Exercise Physiology 17 (1) 11
4.0
3.0
2.0
1.0
0.0 Experience with BP
this month
No experience with BP
this month
Mean
RotationLunge
A
**
4.0
3.0
2.0
1.0
0.0 Experience with BPNo experience with BP
Mean
Rocking forwardsRocking backwards
B
**
Figure 2. Clustered bar-graph showing the scores of the functional movement screening (FMS) and Luomajoki’s motor control
(MC) screen components with significant correlation to the incidence of back pain (BP). Scores of horse riders who did not and
who did experience BP (A) within the last month before the examination of this study, and (B) within their lifetime are represented.
The Y-axis depicts the scores on the FMS-subtests (0-3/3) and the MC-subtests (0-1/1). The components included from the FMS
were the in-line lunge test and the rotation test. For the MC screening, these were the rocking forwards and backwards tests.
Error bars represent 95% confidence interval. * P<0.05.
A B
VAS
6.05.04.03.02.01.00.0
FMS
20.0
18.0
16.0
14.0
12.0
10.0
8.0
16.89 – 0.47x
VAS
6.05.04.03.02.01.00.0
MC
7.0
6.0
5.0
4.0
3.0
2.0
1.0
5.55 – 0.53x
Figure 3. Scatterplot-graphs showing the relation between the visual analogue (VAS)-score and (A) the functional movement
screening (FMS) score (r=-0.582; P=0.001) and (B) the Luomajoki’s motor control (MC) score (r=-0.404; P=0.024).
ODI (%)
2520151050
FMS
20.0
18.0
16.0
14.0
12.0
10.0
8.0
17.18 – 0.25x
ODI (%)
2520151050
MC
7.0
6.0
5.0
4.0
3.0
2.0
1.0
5.23 – 0.14x
A B
Figure 4. Scatterplot-graphs showing the relation between the Oswestry Disability Index (ODI)-score and (A) the the functional
movement screening (FMS) score (r=-0.688; P<0.001) and (B) the Luomajoki’s motor control (MC) score r=-0.474; P=0.006).
I. Deckers et al.
12 Comparative Exercise Physiology 17 (1)
4. Discussion
The aim of this study was to assess sport-specific and
functional capacities related to BP in riders. The pain
parameters prevalence and intensity of BP and the grade
of disability caused by BP showed several significant
correlations with the FMS and MC screening scores, as
well as the riding level and discipline parameters.
A high incidence of BP was found among riders in this
study, particularly in the lumbar back, which is consistent
with other studies within this population (Kraft et al., 2009;
Lewis and Baldwin, 2018). Similar to the results reported
by Kraft et al. (2007), this study found no significant
correlation between gender, intensity of riding and the
pain parameters. However, this study found significant
differences in the incidence of BP and intensity of BP
between professional and the amateur riders. Hobbs et al.
(2014) similarly postulated that the development of BP was
related to postural defects and asymmetry in riders and is
more likely with an increasing level of horse riding. Due to
the repetitive nature of equestrian training (Ekberg et al.,
2011), or long-term repeated application of asymmetrical
forces in both horse and rider (Kraft et al., 2009; Quinn
and Bird, 1996), it is possible that the riding mechanisms
might contribute to the increased prevalence of BP in higher
level riders.
In contrast with previous research (Kraft et al., 2007),
this study found a significant difference in BP parameters
between the show jumping riders, the dressage riders and
the riders who combine dressage and show jumping in
their riding sessions, meaning riding with both jumping
and dressage saddle regularly. These results confirm that
the type of saddle might be associated with BP in riders,
as stated by Quinn and Bird (1996). The saddle seat depth,
difference in stirrup length, saddle cushioning, additional
support and postural position in the saddle are reported
to play a role in the continuity of BP (Quinn and Bird,
1996). However, this study did not control for the riding
activities differing when riding with the different saddle
types and only small sample sizes interdisciplinary were
presented. Because of the small amount of Icelandic riding
and eventing riders, no statistics could be performed to
analyse the differences between these disciplines. Further
research is required to investigate the influence of the riding
discipline and/or the type of saddle on BP.
Despite the high methodological quality of the ODI, it is
arguable as to whether the questionnaire is sensitive enough
or whether an adapted classification of the disability caused
by BP should be recommended for this active population
(Chiarotto et al., 2016; Davidson and Keating, 2002). Given
that all riders in the selected population were competitive, it
might be considered that these athletes work through their
pain and aim to prevent the pain to interfere with their daily
life or competition commitments and thereby score false
negatively on the grading of BP interference (ODI). This
consideration is verified by Lewis and colleagues (Lewis and
Baldwin, 2018; Lewis and Kennerly, 2017) who reported
that most riders continue competing with BP, although
71% of the riders with pain felt that their performance
was negatively affected through fatigue, decreased range
of motion, asymmetry, anxiety and irritability (Lewis et
al., 2016).
The results of this study support the utilisation of the FMS
and MC screening to predict the susceptibility to BP in
riders (Bonazza et al., 2017; Ko et al., 2016; Luomajoki et
al., 2007; Moran et al., 2017). Previously, the cut-off value
for injury prediction of the FMS was set at ≤14 (Bonazza et
al., 2017). The average FMS score in the population of this
study was 16 which is above the cut-off value and thereby
indicates that the average rider can perform adequate
functional movement patterns. As only two of the riders
in this study reported clinically relevant BP, based on their
ODI score, on the day of the assessment and no other
current injuries were reported, this result can be verified.
However, on average, riders who experienced BP within
the last month before the assessment (n=11) scored 15 on
the FMS which indicates a higher level of dysfunctional
movement patterns which is related to a higher likelihood
of injury development compared to those with higher scores
(Bonazza et al., 2017). Furthermore, the findings in this
study confirm the association between the MC scores and
BP (Salvioli et al., 2019) and the cut-off value of 5.5./7 for BP
presence found by Luomajoki et al. (2008). As the average
score of riders without BP in the last month was 5.8/7
compared to 4.4/7 in riders with BP in the last month, the
results of this study agree with the cut-off value of 5.5/7.
Out of the 14 clinical tests implemented in the FMS and
MC screening, four had a significant relationship with the
experience of BP: the in-line lunge test, rocking backward
and forward, and the rotary stability test. These specific
tests evaluate the dynamics of the hip and pelvis, which
are crucial elements for riders. The two lowest scored FMS
tests were the push-up and the active straight leg raise.
The push-up test screens the symmetric trunk stability
in the sagittal plane during a symmetric upper extremity
movement and the ability to transfer force symmetrically
from the upper extremities to the lower extremities and
vice versa (Cook et al., 2014). The active straight leg raise
assesses the functional hamstring, gluteal, and iliotibial
band flexibility, adequate hip mobility of the opposite leg
and pelvic and core stability (Cook et al., 2014). These
findings agree with previous findings of low hamstring
flexibility, and pelvic and ankle stability in riders (Douglas,
2017). The two lowest scoring tests within the MC screening
were the rocking forward and the waiter’s bow test. This
indicates that riders have difficulty in hip and lumbopelvic
dissociation, which indicate a low neuromotor control skills
(Luomajoki et al., 2007). The findings of the FMS and MC
Back pain in horse riders
Comparative Exercise Physiology 17 (1) 13
screening agree with previously published research that
found an association between the dynamics of the hip and
pelvis, and hip muscle characteristics and BP (Fasuyi et al.,
2017; Ingber, 1989; Sajko and Stuber, 2009).
The cumulative FMS scores seen in this study are slightly
higher than those found in female collegiate horse riders
(Lewis et al., 2019), semi-professional rugby players
(Attwood et al., 2019), healthy adults aged 20-39 years
(Perry and Koehle, 2013) and long-distance runners
(Loudon et al., 2014), similar to the cumulative FMS score
seen in young active females of 18-40 years old (Schneiders
et al., 2011) and in Gaelic field sports athletes (Attwood
et al., 2019), but lower than these of healthy professional
football players (Kiesel et al., 2007). This indicates an
adequate quality of basic movement functionality in riders.
No assumptions can be made between the FMS scores and
performance levels in riders based on current evidence
and the non-significant difference found in this study in
the FMS scores between the amateur and professional
riders. However, it can be hypothesised that the MC
scores have a negative association with performance level
as stated by Roussel et al. (2012) in dancers, as a trend
is seen in this study for professional riders to have more
MC deficits in comparison with amateur riders. Also, in
elite soccer players, MC deficits and a high prevalence of
BP is prominent and related (Grosdent et al., 2016). It is
widely recognised that athletes benefit from training various
physical capacities and that physical adaptations are likely
to improve performance and decrease the risk of injury
(Lauersen et al., 2014; Sajko and Stuber, 2009; Tayrose et
al., 2015). These findings support the recommendation for
unmounted training of riders, including motor control and
core stability exercises (Douglas et al., 2012; Hampson and
Randle, 2015; Wilson and Collis, 2016).
The results of this study should be interpreted in light
of some methodological concerns. First, the sample size
of this study was relatively small. Second, functional
asymmetries were not assessed although the relevance
of this horse-riding related characteristic is emphasised
in current research. Finally, the ODI was applied as a BP-
specified questionnaire but did not seem to be sensitive
enough for this athletic population. Due to these limitations,
further research is necessary to investigate the relationships
between the functional physical characteristics, as such in
the FMS and Luomajoki’s MC screening, and BP in riders.
5. Conclusions
The high prevalence of BP in riders is confirmed by this
study. Significant differences in the prevalence of BP
between professional and amateur riders and show jumping
and dressage riders were demonstrated, as well as significant
correlations between the prevalence and incidence of and
disability caused by BP and the FMS and Luomajoki’s
MC screening. Both screening tools were found clinically
relevant and can therefore be used to objectively measure
functional characteristics related to BP in riders. The results
of this study can be taken into consideration in the physical
management of the rider. Additional research is required
to confirm the reported correlations and to determine the
sport-specific needs of riders to contribute to their welfare
and performance.
Acknowledgements
We would like to thank B. Fierens from the Department
Physiotherapy and Rehabilitation Science at the University
of Antwerp, and Lisa Deckers MSc, Linguistics and
Literature (Dutch and English), for their input in this
manuscript and the LRV (union of competitive Belgian
riders) for their contribution in recruiting riders willing
to participate in this study. The Equestrian Performance
team at the University of Hartpury are also thanked for
their input.
Conflict of interest
The authors declare no conflict of interest.
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Evidence supporting use of the Functional Movement Screen (FMSTM) to identify athletes’ risk of injury is equivocal. Furthermore, few studies account for exposure to risk during analysis. This study investigated the association of FMSTM performance with incidence and burden of match-injuries in adult community rugby players. 277 players performed the FMSTM during pre-season and in-season time-loss injuries and match exposure were recorded. The associations between FMSTM score, pain, and movement-pattern asymmetries with match-injury incidence (≥8-days time-loss/1000hours), severe match-injury incidence (>28-days time-loss/1000hours), and match-injury burden (total time-loss days/1000hours for ≥8-days match-injuries) were analysed using Poisson regression. Multivariate analysis indicated players with pain and movement-pattern asymmetry during pre-season had 2.9 times higher severe match-injury incidence (RR, 90%CI = 2.9, 0.9–9.7) and match-injury burden (RR, 90%CI = 2.9, 1.3–6.6). Players with a typically low FMSTM score (mean – 1SD threshold) were estimated to have a 50% greater match-injury burden compared to players with a typically high FMSTM score (mean + 1SD threshold) as match-injury burden was 10% lower per 1-unit increase in FMSTM score. As the strongest association with injury outcome was found for players with pain and asymmetry, when implementing the FMSTM it is advisable to prioritise these players for further assessment and subsequent treatment.
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The functional movement screen (FMS) is an easily administered and non-invasive tool to identify areas of weakness and asymmetry during specific exercises. FMS is a common method of athlete screening in many sports and is used to ascertain injury risk, but has to be used within an equestrian population. The aim of this study was to establish FMS scores for female collegiate age (18-26 years) riders, to inform a normative data set of FMS scores in horse riders in the future. Thirteen female collegiate horse riders (mean ± standard deviation (sd); age 21.5±1.4 years, height 167.2±5.76 cm, mass 60.69±5.3 kg) and 13 female collegiate non-riders (mean ± sd; age 22.5±2.1 years, height 166.5±5.7 cm, mass 61.5±4.9 kg) were assessed based on their performance on a 7-point FMS (deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability and rotary stability). The mean composite FMS scores (± sd) for the rider group was 14.15±1.9 and for the non-riders was 13.15±1.77. There was no statistically significant difference in median FMS composite scores between the rider and non-rider groups (Mann-Whitney U test, z=-1.249, P=0.223). However, 46% of riders and 69% of non-riders scored ≤14, indicating that a non-rider is 1.5 times (odds ratio) more likely to be at increased risk of injury compared to riders. Collegiate female riders scored higher than the non-rider population, but lower than seen in other sports suggesting some riders may be at risk of injury. Riders’ FMS scores demonstrated asymmetric movement patterns potentially limiting left lateral movement. Asymmetry has a potential impact on equestrian performance, limiting riders’ ability to apply the correct cues to the horse. The findings of such screening could inform the development of axillary training programmes to correct asymmetry pattern and target injury prevention.
Article
The aim of the study was to investigate the prevalence of riders at the international levels in eventing, competing with pain, the location of their pain, factors affecting their pain and whether they perceived this pain to have an effect on their performance. 331 questionnaires were completed by international event riders (FEI CCI*, CCI**, CIC***) at the Hartpury International Horse Trials, UK, to establish the prevalence of riders competing with pain. 96% of international event riders competed while experiencing pain, 76% of riders stated that this pain was in the neck, upper back or shoulders. All female riders reported pain, giving a significant correlation between gender and pain (X=-0.479, P=0.006). 55% of riders felt their pain affected their riding performance, giving an odds ratio of 1.14, compared to those riders who felt their pain did not effect their performance. Pain was perceived to influence performance by affecting fatigue, their concentration, and anxiety levels. 96% of riders reporting pain used medication to alleviate their symptoms. This high incidence of international event riders who compete with pain, particularly back pain, could be problematic given the longevity of a rider's career, which can span over four decades and could potentially increase the risk of a serious or fatal fall in the cross-country phase. This research reports rider's perceptions and self-reported pain and management options, which may affect the data. Further research is needed to establish the causes of back pain and appropriate management strategies.
Article
Synopsis: Compared to healthy individuals, patients with low back pain demonstrate differences in all aspects of trunk motor control that are most often studied as differences in muscle activity and kinematics. However, differences in these aspects of motor control are largely inconsistent. We propose that this may reflect the existence of 2 phenotypes or possibly the ends of a spectrum, with "tight control" over trunk movement at one end and "loose control" at the other. Both may have beneficial effects, with tight control protecting against large tissue strains from uncontrolled movement and loose control protecting against high muscle forces and resulting spinal compression. Both may also have long-term negative consequences. For example, whereas tight control may cause high compressive loading on the spine and sustained muscle activity, loose control may cause excessive tensile strains of tissues. Moreover, both phenotypes could be the result of either an adaptation process aimed at protecting the low back or direct interference of low back pain and related changes with trunk motor control. The existence of such phenotypes would suggest different motor control exercise interventions. Although some promising data supporting these phenotypes have been reported, it remains to be shown whether these phenotypes are valid, how treatment can be targeted to these phenotypes, and whether this targeting yields superior clinical outcomes. J Orthop Sports Phys Ther 2019;49(6):370-379. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7917.
Article
Background: Equestrian-related injuries (ERIs) are relatively severe compared with injuries in other popular sports. Previous studies on epidemiology of ERIs vary widely and mainly focus on incidence instead of severity of the injury. Purpose: The aim of this study was to determine incidence, mechanisms and severity of ERIs in two Dutch hospitals (level 1 and level 2 trauma centers) over a 5-year period. Patients and methods: All patients with ERIs who visited the emergency departments of VieCuri Medical Centre in Venlo and Maastricht University Medical Centre+ in Maastricht, The Netherlands, between July 2010 and June 2015 were retrospectively included. Clinical data were extracted from medical records. Results: Most ERIs occurred in mounted riders (646 events; 68%); 94.9% of which involved a fall. Being kicked (42.5%) or trapped (30.1%) was the most common cause of injury in unmounted riders. Most frequently injured body parts were the upper extremities (43.8%) in mounted riders and lower extremities (40.5%) in the unmounted group. A relatively high percentage of facial injuries (9.7%) were found in the unmounted group. Seventeen per cent of all ERIs required admission. The median Injury Severity Score was 5 in the admitted population and 1 in the total population. Conclusion: Horseback riding is a risky activity. Prior studies particularly studied admitted patients in level 1 trauma centers outside of Europe and demonstrated a high risk of significant injury. However, our study demonstrates that these studies in selected groups might have overestimated the severity of ERIs in the general population.
Article
Equestrianism is more dangerous than many sports including motorcycle riding, skiing, football, and rugby with one in five equestrians seriously injured during their riding career. Current research has focused on acute riding injuries but as seen in other sports over-use injuries, repetitive strain and lifestyle could aggravate symptoms causing chronic pain. An elite rider suffering from pain may still choose to compete with pain due to the pressures from sponsors and owners and the need for competition success. The aim of the study was to investigate the prevalence of riders at the elite level competing with pain, and whether they perceived this pain to have a negative effect on their performance. A quantitative approach was used due to the experimental nature of the study. Fifty questionnaires were distributed to elite dressage riders (British Dressage Group 3 and above) at the Festival of Dressage, Hartpury College to establish the prevalence of riders competing with pain. 74% of elite dressage riders competed while experiencing pain, 62% of this pain was classed as chronic and 76% of riders stated that this pain was in the low back. Over half (51%) relieved the symptoms of pain by using over the counter pain medication. There was a highly significant relationship between riders competing with pain and the perception that this pain affecting negatively on performance (Χ²=16.216a, df=1, P=0.001). This high incidence of elite dressage riders who compete with pain, particularly lower back pain (LBP), could be problematic given the longevity of a rider's career which can span over four decades. This research reports rider's perceptions and self-reported pain and management options, which may affect the data. Further research is needed to establish the causes of back pain and appropriate management strategies.
Article
In horseback riding, the physical influence of the rider is increasingly being recognized as an important contributor to equine back pain. Asymmetrical loading, in particular, can be detrimental to performance. The aim of this study was to investigate the left-to-right differences in mean pressure distribution, and other parameters, on the equine back at Week 0 and Week 8 of an unmounted equestrian core fitness program. Ten healthy dressage horse and rider pairs (horse age 12.30 ± 4.64 years, rider age 41.5 ± 14.83 years) performed two ridden tests at sitting trot, before and after participating in an 8-week program. The regime was a sport-specific, 20-minute core fitness program, performed three times weekly. Horses and riders each wore four reflective markers. A Pliance™ electronic saddle mat (60Hz sampling rate) and Casio™ high speed camera (240 frames per second) with Quintic™ biomechanical software were used to record all trials. All subjects (n=10) showed a significant decrease in left-right mean pressure differential of 0.368 ± 0.361kPa. Maximum overall force (F = ma) had a non-significant increase of 2.36 ± 3.36N/kg (p=0.05), normalized to rider body mass. Mean stride length (m) increased by 8.4%. This study demonstrates that participating in a rider core fitness program can have a significant effect on rider symmetry and consequently provide an important method for reducing asymmetrical loading and improving both human and equine performance.
Article
Aim: This paper aims to systematically review studies investigating the strength of association between FMS composite scores and subsequent risk of injury, taking into account both methodological quality and clinical and methodological diversity. Design: Systematic review with meta-analysis. Data sources: A systematic search of electronic databases was conducted for the period between their inception and 3 March 2016 using PubMed, Medline, Google Scholar, Scopus, Academic Search Complete, AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Health Source and SPORTDiscus. Eligibility criteria for selecting studies: Inclusion criteria: (1) English language, (2) observational prospective cohort design, (3) original and peer-reviewed data, (4) composite FMS score, used to define exposure and non-exposure groups and (5) musculoskeletal injury, reported as the outcome. Exclusion criteria: (1) data reported in conference abstracts or non-peer-reviewed literature, including theses, and (2) studies employing cross-sectional or retrospective study designs. Results: 24 studies were appraised using the Quality of Cohort Studies assessment tool. In male military personnel, there was 'strong' evidence that the strength of association between FMS composite score (cut-point ?14/21) and subsequent injury was 'small' (pooled risk ratio=1.47, 95% CI 1.22 to 1.77, p<0.0001, I(2)=57%). There was 'moderate' evidence to recommend against the use of FMS composite score as an injury prediction test in football (soccer). For other populations (including American football, college athletes, basketball, ice hockey, running, police and firefighters), the evidence was 'limited' or 'conflicting'. Conclusion: The strength of association between FMS composite scores and subsequent injury does not support its use as an injury prediction tool. Trial registration number: PROSPERO registration number CRD42015025575.