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Concussion in the Collegiate Equestrian Athlete

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Concussion in the Collegiate Equestrian Athlete

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Concussion in the Collegiate Equestrian Athlete
thesportjournal.org/article/concussion-in-the-collegiate-equestrian-athlete/

U.S. Sports Academy February 7,

2020

Authors: Tasneem Zahira PhD, Timothy Henry PhD ATC,

Michael L. Pilato MS ATC

Corresponding Author:
Michael L. Pilato MS ATC
1000 East Henrietta Road, Rochester, NY 14623
mikep316@yahoo.com
585-329-6463

Michael L. Pilato is an athletic trainer with Monroe Community College in Rochester, N.Y. He
has been researching sports medicine for the equestrian athlete since 2003 and has been
published in peer and non-peer reviewed journals.

Tasneem Zaihra PhD.

Department of Mathematics State University New York College at Brockport
350 New Campus Dr, Brockport, NY 14420
tzahira@brockport.edu
585-3952075

Tasneem Zaihra is an assistant professor of statistics in the department of mathematics,

SUNY Brockport. She has many presentations and publications in peer-reviewed journals, to
her credit.

Timothy Henry PhD. ATC

Department of HPERD State University New York College at Brockport
350 New Campus Dr, Brockport, NY 14420
thenry@borckport.edu
585-395-5357

Timothy Henry is director of the athletic training program at SUNY Brockport. He is also a
reviewer for The Journal of Sport Rehabilitation and The Journal of Athletic Training.

Concussion in the Collegiate Equestrian Athlete

ABSTRACT
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Equestrian sports, in general, pose a significant risk of concussion. Minimizing the risk of
concussion has been a focal point in recent years. The purpose of this paper is to describe
concussion and explore potential association(s) between groups of musculoskeletal injuries
and Body Mass Index (BMI) on the risk and odds of concussion in the collegiate equestrian
athlete. Forty-three schools, ranging from DI to DIII, from the Eastern United States were
selected from the NCAA and Intercollegiate Horse Show Association’s websites. Self-
reported injury and demographic data was collected through an online survey created in
Mach Forms. Seventy-three participants completed the online survey (women n=71, men=2).
Aggregate descriptive data is reported on all subjects. After removing data on 2 men, and a
single female with incomplete data, the data from 70 females with complete data was
analyzed using chi-squared and Fisher’s exact tests and ordinal logistic regression. Pearson’s
chi-squared as well as Fisher’s exact test (p-value =.0288 and.0297 respectively) indicates the
risk of having concussion with 0 UE injury is not the same as with 1 or 2+ injuries. The
average number of injuries per athlete increased from 0 to 2(+) concussions. Concussion is a
commonly reported injury. Upper extremity injury is identified as having the strongest
association with concussion risk in the equestrian athlete. Knowing UE injury status could be
useful in gaging the risk and odds of concussion in equestrian athletes.

Keywords: Equestrian concussion, Equestrian athlete, Concussion, Equestrian injury

INTRODUCTION

Female participants dominate the approximately 10,000 athletes competing in U.S.

collegiate equestrian sports (6,23). While not as well researched as other female collegiate
sports (e.g. soccer), equestrian sports, in general, are otherwise widely recognized by
researchers as dangerous (16). In a 2002 data analysis, it was noted “horse-riders can expect
a serious accident once in every 350 hours of participation, which is twenty times more
dangerous than motor cycling” (Silver 264). The head was the most commonly injured body
part amongst riders 19-49, with upper extremity fractures just ahead of concussion (16.6 vs.
15.2%) in riders age 0-18 (2). Data compiled from the National Electronic Injury Surveillance
System (NEISS) for the years 1997-2015 showed an average of 24.19% of all equestrian
injuries came from the sport setting, with injuries to the head making up an average of
20.07% of all injuries; Concussion made up an average 5.01% of all injuries(19). Winkler
(2016) noted 45.2% of the over all population and 21% of those aged 18–29 years old sports-
related traumatic brain injury (TBI) were from equestrian and related sports. In an
Australian population, equestrian activities accounted for the second highest level of mean
participation-adjusted rates of hospitalization for concussion over a 9-year period
(130.3/100 000)(8). Falls have been shown to be responsible for 51%- 82% of the injuries that
occur in equestrian sports (2,4,5,14,20). Indicative fall times,(i.e. time it takes to contact the
ground) based on rider center of mass height, from four to ten feet have been calculated
and range from 505-782ms (20).

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Non-collegiate sources were utilized to estimate the rate of falling from the horse as data
regarding the rate of falling in collegiate competition is not available. The rate of falling, as
reported in the 2010 United States Eventing Association Cross Country Competition Safety
Report, for each starter is 1 in 42 and the probability of a fall for each jump is 1 in 879 (24).
Despite the limited data, the mechanism creates a fall is consistent across disciplines and
skill levels. There is a loss of Center of Mass (CoM) control and position as it relates to
movement of the horse. This can be intentional (e.g. bucking, rapid stop) or unintentional
(e.g. rider error) and most often associated with an obstacle (e.g. fence) (10, 24).

The high incidence of injury has led to increased attention on reducing the risks associated
with falling as a way to decrease the number of injuries, especially concussions. Continuing
efforts include improving personal protective equipment for the athlete, designing safer
competition obstacles and teaching an emergency dismount to help athletes escape from
the horse under certain situations. Prior to 1970, gymnastic style tuck and roll training was
also taught as part of the Pony Club curriculum and as such, widely accepted as a way to
minimize the risk of injury should the rider fall from the horse (16). This type of training has
been revived on an extremely limited basis and is presently not part of the equestrian’s
standard training or curriculum.

Research indicates that concussion, musculoskeletal injury and body mass index (BMI) can
influence injury and re-injury risk in subjects, secondary to increased demands on postural
control (3,7,9,11-13,15,17). While equestrians accept the high risk of falling as well as the
association between falling from the horse and concussion, the risk and odds of concussion
that can be associated with musculoskeletal injury and BMI is unknown in female collegiate
equestrians.

The purpose of this paper is to present a description of concussion in collegiate equestrian

athletes and to explore further potential association(s) between lower extremity (LE), upper
extremity (UE) and spinal (SP) injuries, and body mass index (BMI), on the risk and odds of
concussion in the female collegiate equestrian athlete.

METHODS

This study was approved by the institution’s IRB. An online survey instrument was
developed in Mach Forms to gather demographic and self-reported, whole body, injury data
from the respondents. Concussion history was self-reported as a separate category.
Consent was assumed upon voluntary completion and submission of the survey. Anonymity
was assured to all participants. The form reduced mailing costs and encouraged
participation in an uncomplicated manner. An outside expert in the field of equestrian
reviewed the survey instrument for appropriateness of the content, content validity and also
provided feedback relative to the format of the questionnaire. A link to the survey was sent
to 43 equestrian teams, representing 10 percent of the total number of teams, randomly
selected from the National Collegiate Athletic Association and Intercollegiate Horse Show
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Association’s websites. Seventy-three athletes (male=2, female=71) completed and
submitted the survey. We report descriptive data on the entire group of 73 athletes. The
data from the two male subjects was removed to avoid potential gender bias and one
female with incomplete data was also removed, resulting in 70 total subjects for further
analysis (mean age of age = 20.3 years +1.90yrs, mean weight=62.15kg +9.42kg, mean
height+8.2cm).

For the purpose of analysis, concussion was organized into 0, 1 and 2 or more (2+),
categories. Independent risk factors were total number of SP, LE and UE injuries. The data
was analyzed using Chi-squared and Fishers Exact tests.

RESULTS

Aggregate total number of concussion are reported in Table 1. The 32 individuals reporting
concussion represent 44.5% of the population. There were 61 total concussions (ave. appx 2
per individual reporting concussion). Concussion represents 11% of the 568 total number of
injuries (which includes concussion) reported. The no concussion group accounted for 39%
(221/568)of injuries; while the concussion group accounted for 61% (347/568) of injuries.

Table 1. Aggregate Number of Concussions

1 2 3 4 0

No. of Athletes 17(22.9%) 5(2.7%) 10(13.5%) 1(1.3%) 40(44.5)

We then homogenized the group into four concussion categories x body part (head, neck, R.
shoulder, etc). The zero concussion group contained 39 athletes, totaled 155 affected body
parts and appx. 4 inj/athlete); Single concussion (N=15, Total 62 body parts affected, appx
4inj/athlete); Two concussions (N=5, Total 27 body parts affected, appx. 5 inj/athlete) and
more than two concussions (N=11, Total 96 body parts affected, appx. 9 inj/athlete).

For BMI, values ranged from16.31 to 30.18. Mean BMI was 22.57. According to standard BMI
interpretation, 1subject was graded as obese, 11 overweight, 4 underweight and 55 normal
weight. The discussion regarding BMI is limited as after further analysis demonstrating the
association between BMI and concussion was not significant for our data.

The three tables below report the distribution of athletes categorized by concussions and
number of injuries.

Table 2. Athlete Distribution by Concussions and UE Injuries Categorized into 0, 1 and 2+

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 No Conc 1 Conc 2+Conc

0 25 8 6

1 8 1 1

2+ 6 6 9

Table 3. Subject Distribution by Concussions and LE injuries

No Conc 1 Conc 2+Conc

0 11 6 2

1 4 0 0

2+ 24 9 14

Table 4. Subject Distribution by Concussions and Spinal Injuries

No Conc 1 Conc 2+Conc

0 19 8 6

1 5 0 1

2+ 15 7 9

The chi-squared test indicates the risk of having a concussion with 0 UE injuries is not the
same as with 1 or 2+ injuries (p-value=.0288). Since, some of the cells are sparse (less than 5
subjects) we also used Fisher’s exact test to study association between concussions and UE,
LE and Spinal injuries. Fisher’s exact test also showed a significant association (Fishers
p=.0297) between Concussions and UE but not the other two (LE, Fisher’s exact p=0.205 and
Spinal, Fisher’s exact p=0.568). Thus, an association between incidence of concussions and
UE injuries was indicated by chi-squared test as well as the Fisher’s exact test. However,
BMI, Spinal injury and LE injury did not show any association with concussion occurrence.

DISCUSSION

Our finding of 11% of all injuries being concussion is more than double than the cumulative
NEISS average of 5% from 1997-2014 and within the range (9.7-15%) of all injuries reported
by Zuckerman (2015). While no data to compare collegiate concussion rates is available, in a
survey of concussion and concussion symptoms in equestrian athletes registered with the

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United States Equestrian Federation, Buetow (2016) found 71.6% of the population reported
concussion symptoms, with 40.9% being officially diagnosed with a concussion. While we
did not ask about concussion symptoms, the 45% of our population reporting at least one
concussion is comparable. Only motor vehicle-based sports are consistently reported as
having higher TBI rates (8, 21, 26).

Perhaps more importantly, in a study of Swedish equestrians, the head was reported as the
most frequently injured region and the most commonly injured region associated with a
fatality (18).

Helmet use is chronically emphasized as a way to reduce concussion in equestrians. While

helmet use is mandatory during competition (25), and perhaps the most easily modifiable
factor in terms of reducing head injury/concussion, it’s overall use is chronically low (27). So
while important to continue to emphasize overall helmet use among equestrians and
improve helmet function, it is perhaps necessary to expand industry focus to include
complementary modes of protection.

The average difference in number of body parts injured between zero and one concussion
is negligible (3.97 vs. 3.87) and in fact, one concussion having a lower average is interesting.
While we cannot suggest a scientific reason for the lower value, it is possible that athletes
are taking extra precautions to minimize the risk of a second concussion. The 20% increase
from 0/1 to 2 concussion (4 vs 5) and then almost doubling (5 vs. 9) in injuries per body part
when more than 2 concussions occurs is a revealing, but not surprising finding. The
interaction of concussion and the variables that influence postural control is not fully
understood; yet it is clear postural control (Howell 2018) and or neurocognitive
performance (Herman 2015) is negatively affected, hence influencing injury risk. In riding
athletes, this would be an especially critical problem, as they would be falling from height
and often at significantly higher speeds than other athlete’s experience.

We would however suggest that, as it relates to equestrians, the pathway proposed by

Herman (2015) would be circular vs. linear. The hypothesis being, as the effects of
concussion compound, the athlete’s ability and capacity to minimize the risk of falling and
hence the risk of injury decrease. Thus more injury leads to greater risk of falling and more
injury.

While no association between LE and concussion was found in our data, a short discussion
of the potential interplay of these variables as it relates to equestrians is warranted as this is
a noted finding in other sports (Herman 2017). Equestrians accept falling off as an inevitable
part of riding. However, they rely on the strength of “their seat”, which is commonly
understood as the interaction between the LE, saddle, stirrup and movement of the horse,
to minimize the risk of falling off. Equestrian athletes are not traditional foot on the ground
athletes; unlike as an example, soccer players. The lack of stable ground under foot provides

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fewer options to the athlete to maintain body position and postural control compared to
more traditional athletes. Hypothetically then, a LE that is compromised by (multiple)
injuries could increase the risk of falling and hence head injury and or concussion.

The use of the UE to protect the head is instinctual (e.g. attempting to catch/deflect a
projectile thrown at the head). However the concepts of when and how to use the UE to
protect the head first, when a fall is inevitable, is not taught as a primary part of riding
education. Traditional riding education teaches athletes to stay on the horse if at all
possible. Riders are taught the UE’s primary use is to maintain a connection with the horses
head through the reins. Athletes learn by feel and experience when their “seat” will no
longer keep them in the saddle and a fall is inevitable. In this situation, they are instructed
to grab the pommel of the saddle, neck or mane of the horse or tighten up on the reins to
stay on the horse. By attempting to ride out the dangerous situation instead of dismounting
when the situation is less dangerous, the athletes can place themselves in a position where
an injury could be more likely to happen, as opposed to dismounting when their position
could allow for less risk of injury.

For example, the fall time for an athlete falling from a horse is typically measured in
milliseconds (20). In this extremely small amount of time, he or she has to decide they are in
danger, plot an escape and generate a movement pattern. This is not likely enough time to
place the UE in a position to protect effectively the head. The overall poorer body position
and lack of time to properly position the UE, likely compromises the UE’s ability and capacity
to spread out the increased ground contact forces, allowing for increased chance of head
contact with the ground (think darting into the ground vs. tucking and rolling through the
fall). When the above scenario is considered, the model results of UE injuries having the
strongest association with concussion appears plausible. Anecdotally, a 1997-2013 trend in
the NEISS data demonstrates an overall increase in concussion and flat trend of overall UE
injuries, which could indicate anyone of the above scenarios (19).

The thought to ride out the dangerous situation may be due to how falling is treated in
equestrian. While equestrian sports do air on the side of caution, generically, if an athlete is
separated from the horse or touches the ground, and requires assistance to get back into
the saddle, he or she is can be penalized either time or points. In the situation where a
concussion could be suspected, the athlete is removed from competition until cleared by a
physician (25).

We fitted an ordinal logistic regression model to explore the association of MS injury while
adjusting for BMI. Although the odds of 2+ vs 0 or 1 concussions were almost three-times
greater going from 0 to 5+ UE injuries (OR=1.250 and 3.051 respectively), while adjusting for
BMI but despite large effect size the results were not statistically significant. While a larger
sample size is needed for further exploration and to reach stronger conclusions, the results
are worth a short discussion. BMI presents an interesting challenge for equestrian athletes.
Horses are taught to move at a given pace during competition irrespective of the load it is
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carrying. Physics dictate athletes having larger BMI’s moving at like pace, compared to
athlete’s with lower BMI’s, are subject to not only larger destabilizing forces that challenge
body position, but larger ground contact forces. During the fall, the forces generated by the
horse and imparted on the rider can often place the rider in a head down position or turn
the rider into a head-first projectile. As such, the athlete must now manage his or her body
weight with the UE, which does not have the same physical capacity as the LE to dissipate
the ground contact forces. When the above scenario is considered, the model results, albeit
inconclusive, appears reasonable.

CONCLUSION

Concussion is a common injury in equestrian sports. This investigation is the first to report
potential associations between concussion and categories of musculoskeletal injury in
collegiate equestrian athletes. Our findings of UE injuries having stronger associations, than
LE and SP injury, as well as an increasing average number of injuries per athlete going from
0 to 2(+) concussions is unique. While focusing on improving obstacles and personal
protective equipment to decrease injury risk should continue, our findings provide a starting
point from which to consider athlete specific factors (i.e. musculoskeletal injury, BMI) that
influence the risk and odds of concussion in the collegiate equestrian athlete.

Applications in Sport

Despite the large number of participants and teams in collegiate equestrian sports, the
frequency of concussion and potential interaction(s) with musculoskeletal injury on the
athletes who participate in them are not well understood by the people charged with their
care. Concussion, and their co-factors, pose as significant a problem in this group of
athletes, as in any other group of athletes. Our findings indicate concussion is common,
average number of injuries per athlete increased with increased concussions and upper
extremity injuries potentially increase risk and odds of concussion. These findings provide a
rationale to explore potential injury prevention programs beyond the present focus of
improving personal protective equipment and obstacle design.

ACKNOWLEDGMENTS

We declare no financial or non-financial gains nor funding used in creation of this paper.

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