The risk of concussion in horse riding can be considerable and comparable with high-impact sports such as football and auto racing. But eventers are a hardy bunch! Falling is par for the course — Princess Anne, daughter of Queen Elizabeth, fell and suffered a concussion in Bromont, Canada, at the 1976 Summer Games with Goodwill, famously remounting and completing the course but not remembering much of the experience afterwards.
According to the UK’s National Health Service, concussion is a type of minor traumatic brain injury, described as a sudden, short-lived loss of mental function that occurs after a blow or other injury to the head. However, concussions cannot be captured on any imaging devices; they are diagnosed based on clinical symptoms. Information published by the U.S. National Library of Medicine in 2014 shows that head and brain injuries are responsible for the majority of serious equestrian injuries and deaths, with the rate of concussion estimated to be between 3% and 91%.
“Education of riders, parents, and horse trainers is needed to raise awareness of concussions and reduce the likelihood of subsequent injuries,” one study reports.
Sports concussion has a wide field of research. Researchers have for example recently found measurable brain changes in children after a single season of playing youth football, while the UK’s Guardian newspaper recently reported on another football study that tracked changes in each player’s brain using MRI scans. Researchers concluded that rest is required to allow the brain to heal after impacts, advice that is transferable to all dangerous sports.
Do we rest sufficiently after a fall?
As safety becomes increasingly important for equestrian influences and organisers, today competitive riders are bound by post-fall guidelines that help us to stay safer. But are we doing enough to safeguard our most valuable assets–our heads–in the course of our riding, and do we rest sufficiently after a fall?
Our helmets may be up-to-standard and technologically advanced, but they cannot provide the rest that may be the key to us safe-guarding our brain health. Concussion is a common consequence of eventing-related injuries, according to Dr. Judith Johnson, a member of British Eventing (BE)’s Risk Management Committee. “It is very easy to think that because we are overtly uninjured, that we are undamaged in any way. But we should consider brain damage–even in a minor form–to be more common than is formally diagnosed,” she advises.
Under British Eventing (BE) rules, all concussed eventing competitors must be assessed by a medical practitioner (doctor or consultant) as fit to ride, including after the mandatory 21 days’ suspension that allows them to recuperate. (There are some exceptions, subject to medical assessment.)
Under FEI rules, riders with suspected concussion are seen by an examining medical officer, and a ‘Concussion Recognition Tool’ is used. If concussion is identified, the athlete may not ride a horse nor return to competition/training for the remainder of the day, and must be assessed at a hospital, before being reassessed to ride the next day.
“I was written off for several weeks of competition”
Bonnie Fishburn is a UK-based amateur eventer. She is currently fit and well, with recent successes including second place at Somerford Park International Horse Trials, and ninth at Gatcombe International Horse Trials, both in the novice sections, riding Mr. Precision.
However, in the space of three years, she has had two potentially serious falls. The first was three years ago when Bonnie suffered a rotational fall while competing at a BE Intermediate horse trials, where she was knocked unconscious for several minutes. It is now apparent that her erratic behaviour after her fall made Bonnie make questionable decisions.
“I was sedated and airlifted to hospital suffering a dislocated collarbone, fractured shoulder, bruised lungs, fractured skull and a bruised brain,” she tells EN. “This wrote me off for several weeks of competition, but I was actually back on a horse only five days later, doing a little bit of schooling and hacking. Six weeks later we were part of the British Riding Clubs Open Show Jumping winning team.”
The manufacturer of Bonnie’s riding helmet reported that the ‘high energy impact’ had reduced the shock absorbing polystyrene liner from 20mm to 15mm in thickness, although the glass reinforced outer shell was intact. So does she feel, given her injuries, that she rushed back to the saddle?
“I have very little memory from the time after my fall, and people tell me that for the couple of weeks that followed my fall, I was a pain in the backside! I wouldn’t listen to anything people told me and went against everyone’s advice to rest,” Bonnie said. “When I was in hospital, I would just leave the building and then phone random friends and tell them I’d escaped and to come and collect me. Then when I was discharged after four days I took off my sling and went straight to the horses and tacked one up to ride, as I was due to ride at the British Riding Clubs Horse Trials National Championships and I was determined not to let my club down. I do sort of remember that actually it really hurt to ride, and sitting on my bottom was really painful.”
Bonnie was lucky, as she says there are no obvious long-term mental effects due the fact that she rode too quickly. “Everything seemed to heal eventually, although I do have a dent that’s been left in my skull, which hat manufacturers Patey discovered when I had my head measured for my wedding top hat, which I wore to ride to church on my big day. I was gobsmacked when I saw the template–I didn’t know [the dent] was there.”
“The confusion was the worst…”
Incredibly, just over a year after this fall, Bonnie’s horse slipped and she fell out of the side door and was again knocked out for several minutes. “Luckily, a friend’s mother was nearby and came to help me. Once again I was angry and uncooperative because I wasn’t really ‘with it’–this confusion is said to be a common issue after suffering from a head injury,” Bonnie said.
She was taken to hospital by road ambulance, however after a head scan and observation, she was discharged. “This time I was concussed. I was sick, dizzy, confused and basically felt like I had a really bad hangover,” she recalls. “The confusion was the worst, I couldn’t understand what had happened or why I was there. It’s a really horrible feeling.”
Bonnie now says that in hindsight, removing her sling and riding with her injuries after the first fall was not the best idea. “I may also think twice about riding just four days afterwards,” she muses, with trademark eventer’s grit.
Look out for the symptoms
Mick Carter, a British Critical Care Paramedic, says that it is important to look out for the common symptoms of concussion after a riding fall or blow to the head, which include a brief loss of consciousness after the head injury; any periods of memory loss; disturbances in vision, such as ‘seeing stars’ or blurry vision; any periods of confusion; a blank expression, or a delay in answering questions immediately after the head injury. He advises anyone present at the incident to use questioning to help – e.g. “where are we,” “what’s the horse’s name?” If there’s any doubt to the person’s health status, then they need to see a healthcare professional for assessment.
FEI Medical Officer and Team GBR’s Chief Medical Officer, Dr. Peter Whitehead, has said that concussion is serious, whatever the symptoms. “Anyone suffering from concussion should cease competition to prevent repetition of the injury and be followed up until all symptoms have resolved,” he says.
He has reported that in America, 3.8 million sports concussions are reported to team doctors annually, with many more going unreported, and in an FEI ‘sports concussion’ presentation he recommended practices including the use of an electronic database for medical armband production, more accurate injury surveillance in eventing contests, and widespread control of medical suspension, especially for concussion cases. (USEF events require medical bracelets or medical armbands to be worn; they’re optional under BE-run events.)
Concussion is serious
Fortunately, only 3% of riders in British Eventing contests suffer what is described as ‘serious’ injuries, a category that includes hospital admission for concussion. (Source: BE’s ‘Summary Of XC Falls 2014/15’). (NB, BE uses different assessment criteria to the FEI). This figure showed a dramatic reduction against the previous season.
Dr. Judith Johnson, also BE’s Chief Medical Officer, explains the effects of concussion on the brain and performance here. “The old advice of ‘lying in a darkened room’ is good advice for initial brain recovery. Brain rest [after concussion] is important and ‘screen time’ should be limited to under two hours a day,” she says.
“Rehabilitation time and speed varies enormously from individual to individual and bears little correlation to the perceived severity of initial symptoms. Whilst we may feel intuitively that a period of unconsciousness is likely to represent severe concussion and a bit of confusion and balance problems a minor form, this is not necessarily true.”
Go eventing (safely)!