title: Functional and Structural Traumatic Brain Injury in Equestrian Sports: A Review of the Literature.
abstract: 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.
authors.affiliation: Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA. Electronic address: scott.zuckerman@vanderbilt.edu.
authors.forename: Scott L
authors.initials: SL
authors.lastname: Zuckerman
authors.affiliation: Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: Clinton D
authors.initials: CD
authors.lastname: Morgan
authors.affiliation: Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Burks
authors.affiliation: Department of Neurological Surgery, David Grant Medical Center, Travis Air Force Base, Fairfield, California, USA.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Forbes
authors.affiliation: Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: Lola B
authors.initials: LB
authors.lastname: Chambless
authors.affiliation: Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: Gary S
authors.initials: GS
authors.lastname: Solomon
authors.affiliation: Department of Neurological Surgery, Vanderbilt Sports Concussion Center, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
authors.forename: Allen K
authors.initials: AK
authors.lastname: Sills
mesh_terms: D000818:Animals; D001265:Athletic Injuries / Q000473:pathology / Q000503:physiopathology; D001696:Biomechanical Phenomena; D001924:Brain Concussion / Q000209:etiology / Q000473:pathology / Q000503:physiopathology; D001930:Brain Injuries / Q000473:pathology* / Q000503:physiopathology*; D050723:Fractures, Bone / Q000209:etiology; D006260:Head Protective Devices / Q000706:statistics & numerical data*; D006736:Horses; D006801:Humans; D013177:Sports
keywords: Brain concussion; Head protective devices; Intracranial epidural hematoma; Recreation; Sports; Subdural hematoma; TBI (traumatic brain injury)