Equestrian Traumatic Brain Injury – Opportunities to Acknowledge, Educate and Guide

ann-hsAnn R. Stroink, MD, FAANS
Central Illinois Neuro Health Science
Bloomington, IL

The fall season soon approaches with exhilarating thoughts of crisp air, bonfires and outdoor sports! It is also the season when the media will focus on concussions in professional football players. This draws attention to the potential hazards of football, with needed public reminders about traumatic brain injury (TBI) and prevention. This is particularly poignant as parents sign up over 1.2 million American youths for tackle football this year.

Receiving much less attention are the competitive and non-competitive equestrian athletes of the horse sports industry which account for more sports-related TBIs than football and other sports. In 2009, 14,446 emergency room visits were attributed to equestrian brain injuries in riders with 26.3 percent requiring hospital admission. This past spring, a ten-year retrospective analysis from the National Sample Program of the National Trauma Data Bank on adult (>18 years of age) sports-related TBIs, published in Neurosurgical Focus, revealed key information. Data indicated that equestrian sports were the largest contributor to sports-related TBI in adults accounting for 45.2 percent of all brain injuries, followed distantly by contact sports (20.35), roller sports (19%), skiing/snowboarding (12%) and aquatic sports (3.5%).

The turnout for the carriage, the horses and harness and for the whip and passengers is strict according to the type of driving event being undertaken. While competition driving requires modern lightweight carriages for fast maneuvering around obstacles and helmet and body protection for participants, pleasure driving, on the other hand, such as the invitational Big Bend Drive through the Brandywine Valley to the Winterthur Point-to-Point Races, as shown in the photo, requires antique or traditional style carriages and formal dress with stylish hats, rather than helmets that would distract from the historical integrity expected from the event.

The turnout for the carriage, the horses and harness and for the whip and passengers is strict according to the type of driving event being undertaken. While competition driving requires modern lightweight carriages for fast maneuvering around obstacles and helmet and body protection for participants, pleasure driving, on the other hand, such as the invitational Big Bend Drive through the Brandywine Valley to the Winterthur Point-to-Point Races, as shown in the photo, requires antique or traditional style carriages and formal dress with stylish hats, rather than helmets that would distract from the historical integrity expected from the event.

In the United States alone, approximately 30 million Americans ride horses each year for both recreational and competitive sports. Equestrian athletes, particularly prone to TBIs, ride competitively in events that vary both in the types of competitions and geographic locations of where these events typically occur — as many horse sports activities are tied to local customs, culture and tradition. The recent summer Olympic Games in Rio drew attention to the equine disciplines of dressage, eventing, show jumping and driving, which represents only a small slice of the horse sport industry. Equestrian sport covers a broad spectrum of horse related activities not only for equine athletes but also for the providers who care for these animals. Equestrian competition encompasses a vast sports industry in horse-specific racing, English and Western riding, rodeo and stock handling, driving in harness as well as team sports like polo and horseball.

The horse adds a significant dimension to the complexity of the injury risk. Although these animals are highly trained and disciplined, their behavior can be unpredictable to the rider. Other factors that also contribute to higher rates of injuries associated with equine activities include:

  • Rider experience;
  • Body posture;
  • Riding surface;
  • Environmental variations;
  • Weather conditions; and
  • Equipment failure.

While there is little concussions or head injury risk difference between Western and English style riding, the risk does increase when the competitions involve polo, horse racing and eventing. Current estimations indicate that 75-80 percent of head injuries occur while the rider is seated on the horse. Sadly, there remain head injuries that also occur during the care and maintenance of horses during:

  • Veterinarian checks;
  • Stall cleaning;
  • Feeding;
  • Grooming; and
  • Farrier care.

Spectators have also been injured from runaways, close but not vigilant observation and an unpredictable horse. Whether athletes are mounted in competition or unmounted in driving or preparing a horse for events, they are still at risk for TBIs.

helmetGiven these statistics, what can be done? Helmets, like in other sports, seem one important step so why is there still debate regarding these at equestrian competitions? Currently, in the U.S., less than one in eight riders use helmets. New York and Florida have passed legislation that requires helmets to be worn by riders under the age of 16 while the remainder of states have remained silent on this initiative. Organizations overseeing polo and horse racing do require helmets for riders. The United States Equestrian Federation mandates helmets on mounted riders anywhere on the showgrounds and requires the helmets be ASTM International (ASTM) certified. The ASTM establishes criteria for horseback riding helmets that is universally recognized in the U.S. horse industry. In the world of Western horse competition, helmets are not required in most events, although some participants and venues have recently adopted voluntary use. The aversion to embracing the safety requirements set up by other horse organizations is driven by the tradition of wearing a conventional style of hat worn by peers, such as cowboy hats in western venues, fedoras or bowlers in English. This then stands in the way of safety. For others, it’s the perceived discomfort in wearing a riding helmet and not getting the shade offered by the brim of the conventional hat.

Concussions remain the leading cause of disability for equestrians. A recent study reported in Sports Health concluded that equestrian athletes were misinformed and unaware of the potential negative consequences of concussions and timing for return to competition as a result of receiving little, if any, education in head injuries. This is despite all the attention given to concussions in other sports and the media.

The science of helmets offering protection for the athlete is evident, but not accepted by all equine sport activities, and the evidence is clear that equestrian TBIs far outweigh in frequency any other sport-related head injuries — including football. It’s prime time to put more effort into addressing the deficiencies in safety for our equestrians. Neurosurgery will continue to lead the way to emphasize, educate and guide the media and the equestrian sport industry to promote awareness for head injury prevention in this large vulnerable group.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #ConcussionFacts.

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