Elsevier

World Neurosurgery

Volume 83, Issue 6, June 2015, Pages 1098-1113
World Neurosurgery

Peer-Review Report
Functional and Structural Traumatic Brain Injury in Equestrian Sports: A Review of the Literature

https://doi.org/10.1016/j.wneu.2014.12.030Get rights and content

Objective

Sports-related concussions and traumatic brain injury (TBI) represent a growing public health concern. We reviewed the literature regarding equestrian-related brain injury, ranging from concussion to severe TBI.

Methods

A literature review was performed to address the epidemiology of sports-related concussion and TBI in equestrian-related sports. MEDLINE and PUBMED databases were searched to identify all studies pertaining to brain injury in equestrian-related sports. We included two broad types of brain injury using a distinction established in the literature: 1) TBI with functional impairment, including concussion, or mild TBI, with negative imaging findings; and 2) TBI with structural impairment, with positive imaging and at least one of the following pathologies identified: subdural hemorrhage, epidural hemorrhage, subarachnoid hemorrhage, intraparenchymal hemorrhage, cerebral contusions, and skull fractures.

Results

Our literature search yielded 199 results. We found 26 studies describing functional TBI and 25 mentioning structural TBI, and 8 including both. Of all modern sporting activities, equestrian sports were found to cause some of the highest rates of total bodily injury, severe brain injury, and mortality. Concussions comprise 9.7%–15% of all equestrian-related injuries brought to hospitals for evaluation. Structural TBI was rare, and documentation of these injuries was poor. Although demographic risk factors like age and sex are minimally discussed in the literature, two studies identified a protective effect of increasing rider experience on all forms of bodily injury. However, it remains unclear whether increasing rider experience protects specifically against head injury. Finally, rates of helmet use in horseback riding remain dismally low—ranging from 9%–25%, depending on the activity. These low rates have persisted over time, despite evidence in this literature that helmets lead to an absolute risk reduction for head injury of 40%–50% in equestrian sports.

Conclusions

Equestrian-related functional and structural TBI represent a significant public health burden. Rider and horse characteristics make the sport uniquely dangerous, as the athlete has limited control over an animal weighing a thousand pounds. Helmet use rates remain very low despite clear evidence of risk reduction. Health care providers are strongly urged to lobby professional and governmental organizations for mandatory helmet use in all equestrian sports.

Introduction

The Centers for Disease Control estimate that 1.7 to 3.8 million traumatic brain injuries (TBI) occur in the United States each year, more than 300,000 of which are due to sports and recreational activities 28, 42. Sports-related concussions (SRC) represent a major public health concern, comprising 9% of all athletic injuries and affecting athletes across all ages and genders (32). From 1997 to 2007, rates of SRC increased 4.2-fold, with an annual increase of 16% (45). In a recent study of more than 1,900 high school athletes, most sports-related head injuries occurred in football, followed by girls' soccer, boys' wrestling, and girls' basketball (48). Although less prevalent, equestrian-related brain injury (ERBI) is a significant source of trauma, ranging from mild concussion to severe structural brain injury.

The scope of equestrian activities is wide, including polo, racing, rodeo, jumping, and simply recreation (39). Horseback riding is typically practiced in amateur settings, often separate from school-sponsored activities. Although often considered a leisure sport, equestrian activities have a higher hospital admission rate than motorcycle riding (0.49 vs. 0.14 admissions for every 1000 hours of activity) 15, 67. Furthermore, horseback riding has the highest mortality of all sports and results in higher rates of severe brain and total body injuries than skiing, football, rugby, and automobile racing combined 15, 43, 47, 58, 60, 67. ERBI ranges from benign, self-limiting concussions to catastrophic structural injuries, requiring neurosurgical intervention and carrying the risk of permanent neurological deficit or death (55).

We conducted a literature review of equestrian-related functional and structural brain injuries. Our review is designed to critically appraise and provide a detailed summary of existing reports of TBI in equestrian-related sports, as well as examine the mechanisms, types of riding, and protective headgear implicated in ERBIs.

Section snippets

Methods

MEDLINE and PUBMED records were searched to identify all studies pertaining to ERBI throughout the past half-decade. We performed a search using the following medical subject heading terms and text words: sport-related head injury, concussion, catastrophic head injury, subdural hemorrhage, epidural hemorrhage, subarachnoid hemorrhage, cerebral contusion, skull fracture, equestrian, horseback riding, and horse racing.

Using a distinction established in the literature for framing discussions of

Results

Several studies commented on all injuries pertaining to equestrian-related activities. These references were included, but only the reports mentioning brain injury were used. We excluded all non-English language references and those reporting studies in which no specification of brain injury was mentioned.

The search returned 199 entries. The reference lists of these articles were examined to identify additional relevant research. After exclusion of references that were not pertinent to the goal

Epidemiology

Most reported data regarding ERBI come from isolated case reports and retrospective observational studies. Few prospective studies exist. The anecdotal nature of the data reflects the decentralized manner in which equestrian sports are practiced. Centralized governing bodies exist such as USA Equestrian and FEI (Federation Equestrian Internationale). Furthermore, these groups collect robust injury statistics. However, despite international popularity, no central national or international body

Conclusion

The goal of our literature review was to summarize and appraise existing reports of functional and structural TBI in equestrian-related sports. Our review yielded 43 studies describing brain injury in equestrian sports, with a range of methodologies including prospective studies, retrospective case series, and isolated case reports. Concussions comprise 9.7%–15% of all equestrian injuries and structural TBI is a much rarer event, with documentation of these severe injuries being poor at best.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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