Head Injuries in Equestrian Sports

Synopsis: Background: Concussion, a type of mild traumatic brain injury (mTBI) is the number one injury risk in contact, noncontact and collision sports such as boxing, martial arts, rugby, soccer, ice hockey and horse riding (Musumeci, Ravalli, Amorini, & Lazzarino, 2019; Zuckerman et al., 2015). Concussions can be caused by direct trauma to the head, such as from falling, getting hit or being in an accident. They can also occur as a result of rapid acceleration-deceleration of the head, such as in whiplash injuries. The assumption that concussions involve a loss of consciousness is not true and in many cases, those with a concussion never lose consciousness. In recent years, sport-related concussion (SRC) has become a primary issue of discussion among sports medicine professionals, athletes, media, and sports sponsors concerning athletes' return to play, after a concussion (Musumeci et al., 2019). SRC is often an evolving injury, and signs and symptoms may be delayed, thus, erring on the side of caution (i.e., keeping an athlete out of participation when there is any suspicion of injury) is important (Paul, Willem, et al., 2017). The 5th International Conference on Concussion in Sport was held in Berlin in 2016. This consensus statement on concussion was developed for physicians and healthcare providers involved in recreational, elite, or professional athlete care. At this conference, the Sport Concussion Assessment Tool 5 (SCAT-5, Child SCAT5), an improvement on the previous concussion tools, was also developed (Paul, Willem, et al., 2017). The 6th International Conference on Concussion in Sport was held in Amsterdam in 2022 where the recommendations for SRC’S were updated through an evidence-informed consensus methodology (Patricios et al., 2023). At the conference, Return to Sport and Return to Learning recommendations were updated and existing tools, were revised. The consensus process also highlighted the need for more awareness and research on clinical recommendations for the para-athlete, as well as the need for inclusivity and interdisciplinary collaboration together with taking into account the athlete’s perspective, concussion-specific medical ethics, as well as matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease (Patricios et al., 2023). Over the years, several sports have improved their safety guidelines by introducing compulsory baseline testing tools such as SCAT-5 and Child SCAT5. This widely used clinical test for concussion which has been implemented by many professional bodies such as the International Association Football Federation (FIFA), and World Rugby (Harry et al., 2023). However, ongoing education and awareness are still required, especially in sports, such as equestrian sports, where helmet use in adult equestrians is reported to be as low as 9% despite the high risk for head injuries (Stanfill et al., 2020; Zuckerman et al., 2015). Equestrian sports comprise all sports involving horses. These sports include show jumping, dressage, cross country, endurance riding, polo, carriage driving, and saddle seat to name a few. Horse riders or equestrians can participate at competition level, recreational or leisure riding or a combination of these. The unpredictable nature of horses, together with their size and speed, presents a significant risk for injury in all equine-related activities (Davidson, Blostein, Schrotenboer, Sloffer, & VandenBerg, 2015). Both rider and horse characteristics make equestrian sport uniquely dangerous, as the athlete has limited control over quite a sizeable animal (Zuckerman et al., 2015). Despite clear evidence of risk reduction, the use of helmets in equestrian sports remains low (Zuckerman et al., 2015). Continued improvement in the prevention and management of concussion in athletes and the extensive interdisciplinary research that focusses on both prevention and management of concussion to ensure the safe return of athletes to their sport, has changed the way contact sports like rugby, soccer, American football, and ice hockey manage concussion injuries both on and off the field. When it comes to equestrian sports, however, it is evident that a regulatory framework for the management of concussion exists at Federation Equestre International and Olympic level, but this seems to be reserved for use by medical officers and healthcare professionals. The United States Equestrian Federation and British Equestrian have also improved awareness and education around concussion injuries in equestrian sports and have implemented training programmes for coaches and parents. It is evident, from reviewing the policy documents on the South African Equestrian Federation’s (SAEF) website (www.saef.org.za), that this regulatory framework has not filtered down to member countries such as SA and that programmes to improve awareness and education around concussion as well as return to ride and return to learning protocols are severely lacking in equestrian sports in SA. Aim: Based on the outcomes of the study, the overarching aim is to design and implement return to play and return to learning protocols following a horse-riding related head injury. Objectives: - To establish the prevalence and correlates of head injuries in equestrian sports in South Africa (SA) - To establish the knowledge, attitudes, beliefs, and practices of South African coaches, riding school instructors, umpires, show-holding bodies, and judges with regards to head injuries - To establish subsequent management or healthcare post-head injury Methodology: Two separate cross-sectional surveys will be conducted at the same time. A survey (Study A) will be conducted among adult equestrians in SA to establish the prevalence of head injuries and knowledge surrounding concussion. A second survey, Study B, will be conducted among professionals in the South African equestrian industry to establish the knowledge, attitudes, beliefs, and practices surrounding head injuries and return to riding after a confirmed concussion injury. As a background to the study, a systematic review of the literature will be conducted to determine the prevalence of head injuries in equestrian sports as well as the knowledge, attitudes, beliefs, and practices of professionals involved in equestrian sports surrounding head injuries and return to riding after a confirmed concussion. Both surveys will be created using Microsoft Forms and will include a consent form, a demographic questionnaire, a head injury prevalence questionnaire, a concussion knowledge questionnaire as well as an attitudes and beliefs and practices questionnaire. The sample for the head injury survey will include adult equestrians over 18 years old, currently participating in equestrian sports in SA at a competitive and recreational level. The sample for the knowledge, attitudes, beliefs, and practices questionnaire will include adults over 18 years old currently working in the equestrian industry as coaches, riding school instructors, show holding body representatives, umpires, and judges. Ethical approval to conduct this study will be sought from the University of Cape Town’s Faculty of Health Sciences Human Research Ethics Committee (HREC) and the SAEF. Members of the SAEF and affiliated equestrian clubs and disciplines will be invited to participate in our study via an advertisement on their Facebook pages as well as in their electronic newsletters. The advertisement will include an online link that will take the participants to the relevant Microsoft Forms survey when clicked. Informed consent will then be explained, and a tick box must be selected before the participant can proceed. Once informed consent has been provided, the relevant questionnaire can then be accessed and completed. Participants will also be informed that they can withdraw from the study at any point without consequence. Once we have obtained ethical approval for our study, 10 known equestrians will be asked to pilot the head injury surveillance questionnaire. The same procedure will be undertaken for the knowledge, attitudes and beliefs questionnaire aimed at coaches, riding school instructors, umpires, show holding body representatives, and judges. The questionnaires will be emailed to these known equestrians, and they will then be excluded from participating in the study. The data obtained will be analysed using descriptive statistics to report on how well the questionnaires worked, whether the questions were relevant and understandable, as well as the time taken to complete the questionnaires. Information obtained from the pilot studies will be used to make any adjustments before finally rolling out the questionnaire. The questionnaires will be made available online for a period of 3 months. The proposed study will adhere to the ethical values of non-maleficence, beneficence, justice, autonomy, confidentiality, and informed consent as set out in the declaration of Helsinki (World Medical, 2013). This is a low-risk study with minimal risk to participants. As an incentive to recruit participants, we will secure vouchers from those equestrian tack and supply stores with an online shopping platform. This will enable participants to use those vouchers regardless of where they are located nationally. Results: In line with the study protocol and from previous literature reviewed, the outcomes are expected to offer substantial support for the hypothesis that the prevalence of head injuries in equestrian sports is high in South Africa and that the knowledge, attitudes, beliefs, and practices of coaches, riding school instructors, judges, umpires, and show holding bodies is lacking when it comes to the management of suspected and or confirmed concussion injuries. Conclusion: This study will contribute to the existing body of literature by closing the gap in the current literature in the field of head injuries among equestrians by reporting on the prevalence of head injuries among adult South African equestrians as well as by reporting on the knowledge, attitudes, beliefs, and practices of those involved in the sport. The results of our study will better inform us on the current practices in equestrian sports in South Africa with regards to return to riding and return to learning after a suspected or confirmed concussion injury, and thereby assist us in designing and implementing return to riding and return to learning protocols, or by improving upon current protocols, should these already exist. Synopsis: Background: Concussion, a type of mild traumatic brain injury (mTBI) is the number one injury risk in contact, noncontact and collision sports such as boxing, martial arts, rugby, soccer, ice hockey and horse riding (Musumeci, Ravalli, Amorini, & Lazzarino, 2019; Zuckerman et al., 2015). Concussions can be caused by direct trauma to the head, such as from falling, getting hit or being in an accident. They can also occur as a result of rapid acceleration-deceleration of the head, such as in whiplash injuries. The assumption that concussions involve a loss of consciousness is not true and in many cases, those with a concussion never lose consciousness. In recent years, sport-related concussion (SRC) has become a primary issue of discussion among sports medicine professionals, athletes, media, and sports sponsors concerning athletes' return to play, after a concussion (Musumeci et al., 2019). SRC is often an evolving injury, and signs and symptoms may be delayed, thus, erring on the side of caution (i.e., keeping an athlete out of participation when there is any suspicion of injury) is important (Paul, Willem, et al., 2017). The 5th International Conference on Concussion in Sport was held in Berlin in 2016. This consensus statement on concussion was developed for physicians and healthcare providers involved in recreational, elite, or professional athlete care. At this conference, the Sport Concussion Assessment Tool 5 (SCAT-5, Child SCAT5), an improvement on the previous concussion tools, was also developed (Paul, Willem, et al., 2017). The 6th International Conference on Concussion in Sport was held in Amsterdam in 2022 where the recommendations for SRC’S were updated through an evidence-informed consensus methodology (Patricios et al., 2023). At the conference, Return to Sport and Return to Learning recommendations were updated and existing tools, were revised. The consensus process also highlighted the need for more awareness and research on clinical recommendations for the para-athlete, as well as the need for inclusivity and interdisciplinary collaboration together with taking into account the athlete’s perspective, concussion-specific medical ethics, as well as matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease (Patricios et al., 2023). Over the years, several sports have improved their safety guidelines by introducing compulsory baseline testing tools such as SCAT-5 and Child SCAT5. This widely used clinical test for concussion which has been implemented by many professional bodies such as the International Association Football Federation (FIFA), and World Rugby (Harry et al., 2023). However, ongoing education and awareness are still required, especially in sports, such as equestrian sports, where helmet use in adult equestrians is reported to be as low as 9% despite the high risk for head injuries (Stanfill et al., 2020; Zuckerman et al., 2015). Equestrian sports comprise all sports involving horses. These sports include show jumping, dressage, cross country, endurance riding, polo, carriage driving, and saddle seat to name a few. Horse riders or equestrians can participate at competition level, recreational or leisure riding or a combination of these. The unpredictable nature of horses, together with their size and speed, presents a significant risk for injury in all equine-related activities (Davidson, Blostein, Schrotenboer, Sloffer, & VandenBerg, 2015). Both rider and horse characteristics make equestrian sport uniquely dangerous, as the athlete has limited control over quite a sizeable animal (Zuckerman et al., 2015). Despite clear evidence of risk reduction, the use of helmets in equestrian sports remains low (Zuckerman et al., 2015). Continued improvement in the prevention and management of concussion in athletes and the extensive interdisciplinary research that focusses on both prevention and management of concussion to ensure the safe return of athletes to their sport, has changed the way contact sports like rugby, soccer, American football, and ice hockey manage concussion injuries both on and off the field. When it comes to equestrian sports, however, it is evident that a regulatory framework for the management of concussion exists at Federation Equestre International and Olympic level, but this seems to be reserved for use by medical officers and healthcare professionals. The United States Equestrian Federation and British Equestrian have also improved awareness and education around concussion injuries in equestrian sports and have implemented training programmes for coaches and parents. It is evident, from reviewing the policy documents on the South African Equestrian Federation’s (SAEF) website (www.saef.org.za), that this regulatory framework has not filtered down to member countries such as SA and that programmes to improve awareness and education around concussion as well as return to ride and return to learning protocols are severely lacking in equestrian sports in SA. Aim: Based on the outcomes of the study, the overarching aim is to design and implement return to play and return to learning protocols following a horse-riding related head injury. Objectives: - To establish the prevalence and correlates of head injuries in equestrian sports in South Africa (SA) - To establish the knowledge, attitudes, beliefs, and practices of South African coaches, riding school instructors, umpires, show-holding bodies, and judges with regards to head injuries - To establish subsequent management or healthcare post-head injury Methodology: Two separate cross-sectional surveys will be conducted at the same time. A survey (Study A) will be conducted among adult equestrians in SA to establish the prevalence of head injuries and knowledge surrounding concussion. A second survey, Study B, will be conducted among professionals in the South African equestrian industry to establish the knowledge, attitudes, beliefs, and practices surrounding head injuries and return to riding after a confirmed concussion injury. As a background to the study, a systematic review of the literature will be conducted to determine the prevalence of head injuries in equestrian sports as well as the knowledge, attitudes, beliefs, and practices of professionals involved in equestrian sports surrounding head injuries and return to riding after a confirmed concussion. Both surveys will be created using Microsoft Forms and will include a consent form, a demographic questionnaire, a head injury prevalence questionnaire, a concussion knowledge questionnaire as well as an attitudes and beliefs and practices questionnaire. The sample for the head injury survey will include adult equestrians over 18 years old, currently participating in equestrian sports in SA at a competitive and recreational level. The sample for the knowledge, attitudes, beliefs, and practices questionnaire will include adults over 18 years old currently working in the equestrian industry as coaches, riding school instructors, show holding body representatives, umpires, and judges. Ethical approval to conduct this study will be sought from the University of Cape Town’s Faculty of Health Sciences Human Research Ethics Committee (HREC) and the SAEF. Members of the SAEF and affiliated equestrian clubs and disciplines will be invited to participate in our study via an advertisement on their Facebook pages as well as in their electronic newsletters. The advertisement will include an online link that will take the participants to the relevant Microsoft Forms survey when clicked. Informed consent will then be explained, and a tick box must be selected before the participant can proceed. Once informed consent has been provided, the relevant questionnaire can then be accessed and completed. Participants will also be informed that they can withdraw from the study at any point without consequence. Once we have obtained ethical approval for our study, 10 known equestrians will be asked to pilot the head injury surveillance questionnaire. The same procedure will be undertaken for the knowledge, attitudes and beliefs questionnaire aimed at coaches, riding school instructors, umpires, show holding body representatives, and judges. The questionnaires will be emailed to these known equestrians, and they will then be excluded from participating in the study. The data obtained will be analysed using descriptive statistics to report on how well the questionnaires worked, whether the questions were relevant and understandable, as well as the time taken to complete the questionnaires. Information obtained from the pilot studies will be used to make any adjustments before finally rolling out the questionnaire. The questionnaires will be made available online for a period of 3 months. The proposed study will adhere to the ethical values of non-maleficence, beneficence, justice, autonomy, confidentiality, and informed consent as set out in the declaration of Helsinki (World Medical, 2013). This is a low-risk study with minimal risk to participants. As an incentive to recruit participants, we will secure vouchers from those equestrian tack and supply stores with an online shopping platform. This will enable participants to use those vouchers regardless of where they are located nationally. Results: In line with the study protocol and from previous literature reviewed, the outcomes are expected to offer substantial support for the hypothesis that the prevalence of head injuries in equestrian sports is high in South Africa and that the knowledge, attitudes, beliefs, and practices of coaches, riding school instructors, judges, umpires, and show holding bodies is lacking when it comes to the management of suspected and or confirmed concussion injuries. Conclusion: This study will contribute to the existing body of literature by closing the gap in the current literature in the field of head injuries among equestrians by reporting on the prevalence of head injuries among adult South African equestrians as well as by reporting on the knowledge, attitudes, beliefs, and practices of those involved in the sport. The results of our study will better inform us on the current practices in equestrian sports in South Africa with regards to return to riding and return to learning after a suspected or confirmed concussion injury, and thereby assist us in designing and implementing return to riding and return to learning protocols, or by improving upon current protocols, should these already exist.