Head and Spinal Injuries in Equestrian Sports: Update on Epidemiology, Clinical Outcomes, and Injury Prevention

CNS and Thorax Injury and Associated Risks Factors in Equestrian Sports

CONTEXT

Equestrian sports continue to gain popularity in the United States and are associated with a high injury rate, especially involving the central nervous system and thorax. Due to this high rate of injury and the potential for long-term consequences associated with participation, an understanding of the unique risks of this sport is needed.

OBJECTIVE

To describe severe injury in equestrian sports and review the role that protective gear plays in injury mitigation.

DATA SOURCES

The PubMed Database was searched using the search terms "equestrian" and "horse" combined with "spinal cord injury," "head injury," "traumatic brain injury," "experience levels," and "demographics."

STUDY SELECTION

A total of 53 papers were selected based on their relevance of epidemiology, risk factors, and management of injuries sustained during equestrian activities. Case studies, randomized controlled trials, prospective studies, and retrospective studies were all included for further review.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

None.

RESULTS

Injuries to the thorax, including fractures, pneumothoraces, internal organ contusions, and crush injuries, have been cited in multiple national and international trauma registries as the most prevalent injury location in equestrians; however, head and neck injuries, high cervical spine fractures, and closed head injuries are reported to be associated with the highest rates of mortality. Helmets provide protection against skull fracture and traumatic brain injury. Vests were not associated with diminished rates of spinal cord injuries; however, they may provide protection to the thorax. Riding experience also plays a role in reducing the prevalence of injury.

CONCLUSION

Equestrian-related activities are associated with a high risk of injury despite protective measures. Protective gear can mitigate some injury risk but does not protect against spinal injury. Continued investigation into improving protective equipment, rider education, and preventative strategies to mitigate this risk is needed.

A novel equestrian helmet testing method: helmet liner performance in highly realistic simulation

OBJECTIVE

Employ a novel testing method to assess Multi Directional Impact Protection System (MIPS) helmet technology on rotational velocity and acceleration during head impact.

METHODS

An optimization study was completed utilizing a 50th percentile male Hybrid III anthropomorphic test device (ATD). Helmets included expanded polystyrene foam (EPS) and two different MIPS helmets (MIPS 1, MIPS 2). A 24.38-m-long elevated track with rails and a motorized sled was utilized to replicate a fall from approximately 2.13 m. The sled was set to a speed of 20.92 kph, where a tripping mechanism induced rotation in the ATD from the sled and onto a sand surface. During impact of the ATD with the sand surface, head kinematics were measured using resultant acceleration (peak G's), duration of impact (ms), and rotational velocity (rad/s).

RESULTS

A total of three trials for each helmet did not demonstrate a significant difference between the EPS vs. MIPS 1 group with, peak (G's) for resultant acceleration (p = 0.100), duration (ms) for resultant acceleration, (p = 0.100), peak (G's) for rotational velocity, (p = 0.700), and duration (ms) for rotational velocity (p = 0.700). Similarly, the EPS vs. MIPS 2 testing demonstrated no significant differences between the MIPS 2 helmet compared to the EPS helmet, with resultant acceleration (p = 0.400), duration acceleration (p = 0.200), rotational velocity (p = 0.400) and duration velocity (p = 0.400). However, when the MIPS helmet data were pooled, and the EPS helmet data were compared, a statistically significant difference in the duration of acceleration was found (p = 0.048).

CONCLUSIONS

Current testing uses a helmeted head form which is dropped or rolled from a prescribed height. These methods discount the loading placed on the neck and head through the angular momentum of the body. Our novel testing method did not find significant differences between the helmet types in diminishing peak rotational forces to the brain; however, our data suggests that MIPS helmet liners may reduce duration of impact. The reduction of acceleration duration could indicate less rotation of the neck, due to the dampening of these forces by the MIPS liners.

Neurosurgical Injuries Associated with Recreational Horseback Riding: A 6-year Retrospective Analysis

INTRODUCTION

Horseback riding can cause severe brain and spinal injuries. This study aimed to identify the spectrum of neurosurgical injuries related to recreational horseback riding.

METHODS

A retrospective study was performed utilizing the University of Puerto Rico neurosurgery database to identify patients who were consulted to the neurosurgery service between 2018 and 2023 after a horse fall during recreational activities. The outcome upon discharge using the modified Rankin scale (mRS) was documented. Descriptive statistics were used to report frequency and median values.

RESULTS

The neurosurgery service evaluated and managed 112 patients with a horseback riding fall-related injury during 6 years. Ninety-eight (87.5%) patients were male. The patients' median age was 31.5 (IQR 22-40). There were 89 head injuries (79.5%), 19 spinal injuries (17%), and 4 combined head/spine injuries (3.5%). Forty percent of the patients were admitted to inpatient care with a median length of stay of 7 days (IQR 3-17). Twenty-four patients (21%) required surgery. Upon discharge, 86.6% of the patients had an mRS grade of 0-2, 3.6% had a grade of 3, 1.8% had a grade of 4, and 1.8% had a grade of 5. Seven patients (6%) died (mRS grade 6).

CONCLUSIONS

Most neurologic injuries involve isolated trauma to the head. Fifteen percent of the riders' falls were caused after the horse was impacted by a motor vehicle. Forty percent of the patients require admission and 21% undergo surgery. Ten percent of the patients had a poor mRS grade of 4- to 6 when discharged.

Epidemiology of horse trauma: a literature review

PURPOSE

Horses are used for many recreational and occupational activities. They are large, strong, temperamental, and unpredictable animals and people involved with them are at risk for injuries, from minor abrasions to severe injuries that may lead to death. This review reports on horse trauma in relation to the characteristics of injured equestrians, characteristics of horse trauma, and clinical outcomes.

METHODS

A literature search was conducted from health-related electronic databases to identify studies from 2018 to 2023. The search returned 115 relevant full-text articles but after screening and assessment for eligibility, 39 were included in this review for a detailed examination of horse trauma epidemiology. Most studies were undertaken in the USA and the most used method was a retrospective review of hospital or trauma registry data.

RESULTS

There have only been very slight changes in horse trauma numbers and outcomes over the past 5 years. Most injuries often follow falls and kicks. Females in their late-20 s to mid-30 s who are recreational equestrians are the group most represented in the data. The commonest injuries include fractures, and head, thoracic, and abdominal trauma. Most individuals with horse trauma were treated in the Emergency Department and discharged. For the equestrians who were admitted to hospital, around one-third required surgery. Mortality rates are very low.

CONCLUSION

The popularity of occupational and recreational horse activities does not seem to wane and horse trauma continues to represent a significant concern for the health system. Health care workers need to be cognizant of the scope of trauma presentations as the mechanisms of injury can be complicated putting the equestrian at a high risk of associated injuries that may be life-threatening.

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study

BACKGROUND

Helicopter Emergency Medical Services (HEMS) may be tasked to equestrian related incidents. Previous studies have suggested that majority of patients do not require HEMS specific interventions. No data has been published since 2015 so this article aims to establish the current incidence of equestrian incidents attended by one UK HEMS and identify trends that would aid the dispatch of HEMS to the patients who most need it.

METHODS

A retrospective review of the computerised record system for one UK HEMS was performed between 1st January 2015-30th June 2022. Demographic data, timings, suspected injury pattern and HEMS specific intervention details were extracted. The 20 patients with the highest confirmed injury burden were reviewed in detail.

RESULTS

257 patients (229 female) were treated by HEMS (0.02% of all HEMS dispatches). Of those 124 dispatches were due to interrogation of the 999 calls by a clinician on the dispatch desk. Only 52% were conveyed to hospital by the HEMS team; 51% had no HEMS specific intervention. Of the 20 most severely injured patients their pathology included splenic, liver, spinal cord and traumatic brain injuries.

CONCLUSION

Whilst HEMS dispatches to equestrian incidents remain a small percentage, there are four mechanisms that may benefit due to potential injury burden: fall onto head with suggestion of hyper-extension or hyper-flexion injury; kick to the torso; horse fallen or repetitively rolled onto patient and, no movement of patient since incident. In addition, age >50 years should be considered as higher risk.

Investigating the Market Value of Brumbies (Equus caballus) in the Australian Riding Horse Market

Feral horses, also known as brumbies, are widely distributed across Australia with some populations being managed largely by human intervention. Rehoming of suitable feral horses following passive trapping has wide community acceptance as a management tool. However, there is little information about the number and relative economic value of feral horses compared with cohorts in the riding horse market. We examined 15,404 advertisements of horses for sale in 53 editions of Horse Deals, published from February 2017 to July 2022. Despite the considerable media attention and public scrutiny surrounding feral horse management, rehomed feral horses represented only a tiny fraction of the horse market in the current study. Of the 15,404 advertisements examined, only 128 (0.0083%) were for feral horses. We recorded phrases used to describe behavioural characteristics and other variables. The following variables were found to be not independent: Ridden Status, Height, Age, Sex, Colour, and Warning terms/more work. Using descriptive statistics to describe basic features of the data, the average price for feral horses ($1408) was lower than that for domestic horses ($1790) with the maximum price for a domestic horse being nearly twice the maximum for a feral horse. Univariate analysis showed feral horses were over-represented among "Unbroken" horses and underrepresented among "Ridden", "Broodmare" and "Harness" horses compared with domestic bred horses (p < 0.001). Feral horses appeared over-represented at shorter heights, among younger age groups (3 years or younger and 3.1 to 6 years) (p < 0.001) and in the dilute colour category (p = 0.008). The multivariable mixed model on price revealed that for domestic horses, the highest estimated marginal mean price averaged across the colour categories was for ridden horses aged 6.1-10-year-old at $1657.04 (95% CI $1320.56-$2074.66). In contrast, for feral horses, the multivariable mixed model demonstrated the similar highest estimated marginal mean averaged was for green broken 3-6-year-old horses that have undergone foundation training under saddle at $2526.97 (95% CI $1505.63-$4208.27). Australian feral horses were valued differently tfromsimilar domestic horses in the recreational riding horse market and further research is warranted to determine appropriate target markets and boost the sustainability of rehoming as a feral horse management tool.

Horseback Riding-Related Injuries in Portugal and Prevention Strategies

CONTEXT

Horse riding (HR) has gain popularity in Portugal, thereby increasing the number of related injuries. This study identifies frequently occurring injuries in Portuguese riders, the conditions under which they occur, and preventive measures.

DESIGN

A retrospective cohort study.

METHODS

We included 216 Portuguese riders practicing HR at the time of the study with ≥1 year of experience. Data were obtained from a questionnaire that characterized first and second rider injuries; we opted for a systematic method to assess the riders' injuries, in a temporal order. Questions regarding demographic data, sports-related background, systematic training workload, number and characteristics of the first 2 injuries, and the need for treatment were included in the questionnaire.

RESULTS

Most first and second injuries were musculoskeletal, occurred from falling off the horse during training, and primarily affected the lower limb. Rehabilitation was required in almost 50% of all cases. The occurrence of injury was significantly associated with the number of days of training per week, years of experience, height and weight of the rider, and practice of another sport. Riding different horses was also significantly associated with the number of injuries.

CONCLUSIONS

The most frequently occurring injuries during HR are musculoskeletal and in the extremities. Injury prevention is essential in HR, as most riders have at least one injury while practicing. Rehabilitation should involve a physiatrist and core strengthening exercises.

A retrospective study of helmet use and head injury in severe equestrian trauma

Objectives

The aim of the study was to examine helmet use, incidence of injury, and patient outcomes in a rural cohort of equestrian accidents.

Material and Methods

EHR records of patients admitted to a Level II ACS trauma center in the North-west United States were reviewed for helmet use. Injuries were categorized according to International Classification of Diseases-9/10 code.

Results

Of 53 identified cases, helmets only reduced superficial injury (χ2 (1) = 4.837, P = 0.028). Intracranial injury rates were not different between those with and without helmets (P > 0.05).

Conclusion

In equine related injury, helmets protect against superficial injury but not intracranial injury in Western riders. More investigation is needed to assess why this is the case and determine ways to decrease intracranial injury.

Analysis of Injuries in Competitive Equestrian Events

OBJECTIVE

Current equestrian sport-related acute injury research is sparse. The goal of this study is to explore equestrian injury types stratified by population and equestrian discipline.

DESIGN

Injury reports from the US Equestrian Federation (USEF) were compiled from 2015 through 2019, and the prevalence of different injury types within the main equestrian disciplines was calculated.

SETTING

Retrospective cohort study from USEF accident report data.

PARTICIPANTS

Athletes competing at USEF sanctioned equestrian events.

INDEPENDENT VARIABLES

Equestrian participant's age group, sex, and equestrian event type are the independent variables.

MAIN OUTCOME MEASURES

Frequency of types of injuries in equestrian events stratified by equestrian discipline, age (junior vs senior), and sex.

RESULTS

Three thousand four hundred thirty equestrian athletes injured from 441 816 total athlete exposures during 2015 to 2019 were analyzed showing an injury rate between 0.06% and 1.18% for each discipline with an overall injury rate of 780 per 100 000 athlete exposures. Hunter-jumper and 3-day eventing had the highest injury rates. Head injuries and bone injuries were the most common types. No clinically significant differences in injury rates were observed between males and females or junior and senior equestrian athletes.

CONCLUSIONS

Equestrian sports have an overall injury rate of 780 per 100 000 athlete exposures in the certified competition setting. Hunter-jumper and 3-day eventing have an increased injury rate compared with nonjumping disciplines. These data should help equestrian event clinicians to anticipate the types of injuries and help outpatient clinicians make preparticipation medical eligibility and assist in counseling for equestrian sports.

Development of a video analysis protocol and assessment of fall characteristics in equestrian cross-country eventing

Cross-country eventing is one of the highest-risk sporting activities for serious injury outcomes. This study investigated relationships between fall characteristics and high-risk falls at jumps in cross-country eventing. A video analysis protocol was systematically developed to analyze 87 video recordings of high-risk rider falls; defined as when the rider's head impacted the ground and/or where there was potential horse impact with the rider. Falls were classified according to competition type, jump type, horse-related, and rider-related factors. At least one high-risk fall characteristic was observed in 45 of 87 examined falls. Multivariable best subsets regression identified five independent variables explaining 38.4% of the variance in the number of high-risk falls. Increased likelihood of high-risk falls was associated with continuation of horse direction or speed upon rider ground impact, higher jump approach speed, changes in rider body posture upon landing, rider air jacket usage, and reduced rider fall time. The Eventing Fall Assessment Instrument (EFAI) video analysis protocol (attached as supplementary material) facilitated systematic examination of multiple characteristics associated with high-risk falls and identified likely influential characteristics. Based on EFAI and subsequent data analyses, findings suggest optimized approach speed for correct striding and take-off; jump design to enable run-out; and rider training could help reduce the occurrence of high-risk falls. Air jacket usage and their design characteristics warrant further investigation.

Helmet use in equestrian athletes: opportunities for intervention

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.