According to the Equestrian Medical Safety Association (EMSA), head injuries are the most common reason for equestrian-related deaths and hospitalization. And 2009 statistics out of the United States indicate that riders are more likely to suffer traumatic brain injury (ranging from concussion to life-threatening) than athletes who play rugby, football, boxing or soccer, or even race motorcycles – high-impact sports in their own rights, each with extremely high concussion rates. That makes equestrian sport the most dangerous sport per participation.
Consider how often you’ve fallen off a horse. Then count the number of times you’ve fallen off and either suffered a blow to the head or a severe body jolt. If you’ve been riding for any length of time, it’s likely in excess of five instances.
It stands to reason that being flung off an animal, sometimes from three or more metres above the ground, and landing on your head, face or neck would create excessive forces on the brain. The EMSA states that a fall from 60 cm can cause permanent brain damage and a human skull can be shattered by an impact of only 7-10 km/hour… and horses are able to gallop at speeds up to 65 km/hour. Bear in mind too, that athletes who have suffered a single head injury are 40 per cent more likely to suffer subsequent head injuries.
Now, the kicker: research increasingly indicates that repetitive blows to the head are likely precursors to debilitating, progressive degenerative brain diseases similar to Alzheimer’s, other dementias, Parkinson’s or Lou Gehrig’s. Taking into account that equestrians have more likelihood of traumatic brain injury than even athletes who participate in high impact sports, and that they can sustain multiple brain injuries – no matter how slight – during their riding career, does this mean equestrians are at as much, if not more, risk than other athletes for long-term brain disease?
“It is a high-risk sport and people do hurt their brains and spinal cords, unfortunately,” says Dr. Charles Tator, a concussion expert and founder of the Sports Concussion Project at the Krembil Neuroscience Centre at Toronto Western Hospital. The group is “focused on examining the possible correlation between repeated concussions and late deterioration of brain function.”
The topic of traumatic brain injury has been brought to the fore in the past couple of years, largely due to the injury that forced hockey superstar Sidney Crosby to sit out the better part of two seasons. Most horse incident-related brain injuries are concussions, which, according to ThinkFirst, a Canadian non-profit organization dedicated to the prevention of brain and spinal cord injuries, are “caused by excessive, rapid movement of the brain inside the skull. This movement causes damage that changes how brain cells function, leading to symptoms that can be physical (headaches, dizziness), cognitive (problems remembering or concentrating), or emotional (feeling depressed).”
Although concussions are considered temporary, mild traumatic head injuries, they do have the potential to set the foundation for more serious conditions. One such condition, post-concussion syndrome, occurs when the temporary symptoms of a mild brain injury become more permanent. PCS often occurs when the athlete returns to intense activity before the brain has fully healed. Those with PCS can experience short-term memory loss, difficulty concentrating, irritability, depression and trouble sleeping, as well as headaches, dizziness, light and noise sensitivity and visual disturbances. Symptoms can last longer than three to six months, with recovery usually occurring within a year. If they persist beyond that time, however, the condition is likely permanent.
Athletes are also at increased risk for ‘second impact’ syndrome. Although rare, this condition occurs when the athlete receives a secondary blow – even minor – resulting in severe brain swelling, brain damage and death.
The current buzzword in the traumatic brain injury realm is chronic traumatic encephalopathy (CTE), which has been found during the brain autopsies of several former NFL football players and other athletes involved in high-impact sports. CTE is a slowly progressive, eventually debilitating, neurologic condition that is believed to be caused by repeated concussions; however, the direct relationship between concussions and CTE is not yet known.
Formerly called “punch drunk” or dementia pugilistica, CTE has been associated with boxers since the 1920s. In many ways, CTE presents itself similarly to certain dementias and Alzheimer’s disease with memory loss, confusion, disorientation and difficulty concentrating. Eventually, impaired speech, motor skill difficulties, loss of balance and dementia occur. The condition is also associated with psychological problems such as paranoia, aggression, impulse control issues, impaired judgment, violence, depression, suicide, drug and alcohol use.
CTE is characterized by a buildup of an abnormal protein called tau, and brain atrophy, and can only be diagnosed by a brain exam at autopsy. It appears to take years, even decades, for these changes to occur after the athlete has left the sport.
“I don’t think any cases of CTE have been identified in riders. We are worried about riding, because it is one of those sports with repetitive concussions. And that’s the thing that leads to CTE,” says Tator. “I think sooner rather than later we’re going to see our first case.” His Canadian Sports Concussion Project’s research team, comprised of neurosurgeons, neurologists, neuropathologists, neuroradiologists, neuropsychologists, specialists in genetics and molecular biology and psychiatrists investigates CTE by performing autopsies on brains donated so far by professional football players. They are also seeking donated brains from other athletes – including riders.
“We would like to examine the brains of riders who have had repeated concussions,” says Tator. “When you go, your brain will be of no use to you, but it will be of use to science and potentially other people who will benefit from the research. People shouldn’t just squirrel away their brains afterwards, they should send them to us.”
The team also assesses those who are currently suffering the effects of concussion. “I saw a young lady this week who is continuing to suffer the effects from her last concussion she sustained riding. I forget how many concussions she’s had, but she’s remaining symptomatic,” said Tator.
EDUCATING – AND TESTING – RIDERS
In January 2012, the third Helmet Safety Symposium was held in Wellington, FL, organized by Riders4Helmets, a group created to educate equestrians on the benefits of wearing proper helmets. On the Riders4Helmets website, the group has posted a video of a symposium presentation by Dr. Allen Sills, associate professor of Neurological Surgery at Vanderbilt Medical Center in Nashville, TN.
“The bottom line,” says Sills. “If you have a mild concussion similar to what we see in sports concussions, it doesn’t appear to cause you to have a great risk to develop dementia later in life. However, there may be a relationship between multiple concussions and late-life dementia once you pass a certain threshold. We just don’t know what that threshold is yet.”
So, taking the subject of traumatic brain injury away from the research labs and into the day-to-day equestrian arena, what can be done to mitigate any kind of brain injury? One way is to provide cognitive testing of riders. These tests – which a 2006 study published in the American Journal of Sports Medicine, called the “cornerstone of concussion management” – are designed to measure problem-solving, memory, concentration, impulse control and reaction time following a concussion, as well as in baseline tests prior to injury.
Because concussions are very difficult to diagnose, and MRIs and CT scans of concussion sufferers usually appear normal, the tests (some paper/pencil, others on computer/online) can provide important information about a potential brain injury, rather than simply providing a diagnosis based primarily on clinical signs.
The United States Equestrian Federation (USEF) has given most of its elite riders free baseline “ImPACT” testing, a program used by many professional sports teams in the NFL, NHL and NBA as well as elementary, high school and college athletic programs. ImPACT tests an athlete at the beginning of the season and if the athlete sustains a concussion, researchers can measure how long it takes for the brain to go back to its baseline.
Contact sports, from grassroots up to professional levels, use “return-to-play” protocols involving neurological tests such as ImPACT and screening to determine if an athlete who has suffered a concussion is ready to get back in the game. And, in 2009, the USEF established its own return-to-play regulations, as have other organizations such as the British Equestrian Federation, which has very specific rules pertaining to riders returning to competitive action.
The return-to-play concept is contrary to the old way of thinking that a rider should get right back on after a fall. The rider shouldn’t be allowed to re-mount if a concussion is suspected. Their judgment and motor skills could be compromised. The rider should consult a physician and not return to riding until all the symptoms have resolved. Returning to riding should be a gradual process, depending on the suspected level of injury, as guided by the physician.
BRAIN BUCKET TRUTHS
What role do approved ASTM/SEI helmets play in preventing concussions? “People think, ‘Oh I’ll just put the helmet on my head and I’ll be protected,’” says Tator. “But, unfortunately, it isn’t that easy.”
Helmets don’t protect against concussion, something Tator says is hard for the public to understand. What they do very well, however, is protect against catastrophic brain injury such as tearing, blood clots, bruising and skull fractures.
The consensus statement of the 2008 International Conference on Concussion in Sport backs this up: “Helmets show reduction in biomechanical forces, but have not translated to a reduction in concussion incidence … Helmets reduce other forms of injury (e.g. fracture), in cycling, equestrian and motor sports.”
Tator likens the brain to Jello. “When you fall off your horse and whack your head, your brain jiggles. It’s that jiggle that causes concussion. So no matter how many helmets you pile on your head, it’s not going to prevent the jiggle.” Rather than depending entirely on helmets to prevent concussion, Tator suggests that riders, particularly women, strengthen their neck muscles to mitigate the jiggle effect of the brain.
Traumatic brain injury is so prevalent in sport, but nevertheless remains very much a mystery. Tools on the imminent horizon, however, will aid in diagnosing, preventing and treating all levels of brain damage. New imaging technologies such as advanced MRIs will be able to provide better diagnoses. Genetic research indicates that it could be possible to ascertain an athlete’s predisposition to brain injury, while other work suggests proteins called serum biochemical markers can help to determine phases of brain injury via blood test.
Despite the risk, however, Tator says he doesn’t want to see people become couch potatoes and not participate in activities such as riding. “But we do want them to be aware.”