Recognising Concussion: Concussion in any sport is common and presents a significant public health issue, yet it remains poorly understood and is frequently undiagnosed or misdiagnosed. So what do riders need to know? Recognizing concussion is the first step.
Equestrian sports present one of the highest risks for concussion when considering the injury incidence in proportion to the number of participants in a sport. Dealing with horses in any way inherently involves accepting a degree of danger. For some riders, that very risk is part of the appeal however, there is immense scope for improvement in the education, prevention, and management of concussion in horse sports.
This article outlines the key findings and recommendations of the International Consensus Statement for Concussion in Sport (1) released in 2012, and represents the latest in medical recommendations for the diagnosis and management of concussion in sport.
Editor’s Note: Sinc the article was first published, the International Consensus Statement for Concussion in Sport (2017) has been updated and can be read HERE.
What is concussion?
Concussion is an injury to the brain and does not necessarily involve a direct external blow to the head. Our brain floats in fluid, within our skull, therefore a rapid deceleration, from a kick, fall, or whiplash-type movement, can cause the brain to be damaged against the inside of the skull.
Physical symptoms such as a loss of consciousness and amnesia (memory loss), make the concussion diagnosis more obvious, but concussion can also occur without a loss of consciousness.
Symptoms vary from person to person so there is no single diagnostic checklist.
A suspected diagnosis can include cognitive symptoms (e.g. confusion, forgetfulness, slowed reaction time), somatic symptoms (e.g. headache), emotional symptoms (e.g. lability, irritability), or sleep disturbance. These symptoms evolve over time and are not always obvious immediately following the injury.
Fortunately, the symptoms of most concussions are short-lived, and resolve spontaneously. This is where correct injury management becomes critical. A second injury, before recovery from the first, can have a disproportional effect.
Recurrent concussions can result in persistent cognitive deficits and have been implicated in progressive deterioration in brain function and generally poorer outcomes (2).
What do we do once we suspect a concussion?
What is universally agreed is that no return to sport should occur on the day of the concussion, and if in doubt, sit them out.
Once a concussion is suspected it is important the person is not left alone, and monitoring for deterioration should continue at intervals over the following few hours.
The treatment for concussion is essentially rest. Decisions about return to sport should only be made by a medical doctor. Concussion can effect work and social activities and it is recommended that return to these occur before a return to sport.
After a concussion, all activities should be approached in a stepwise manner, increasing gradually as tolerance allows, and reducing to a lighter level if symptoms become aggravated. A rider should be symptom free, that is, all symptoms completely resolved without the use of medication, before returning to riding. A more conservative management approach is required for children and adolescents, as well as riders who have sustained previous concussions.
How do we prevent concussion?
A formal review of the research on brain injury in equestrian sports established that helmet use results in reduction of risk of head injury in general, yet rates of helmet use among riders remains dismally low (4).
You need a fitted helmet, and you need to wear it with the harness secured. Regularly check the date of manufacture on your helmet. Most helmet manufacturers recommend replacement after approximately 5 years or immediately after the helmet has sustained a heavy impact.
A substantial proportion of concussions in equestrian sports occur from kicks which are not necessarily sustained while riding, so it is good practice to put your helmet on before you catch the horse, and leave it on whenever you are working around the horses.
Lack of attention and carelessness have been identified as causes of concussion so it would be wise to approach riding and horse handling as you would driving, for example, making sure you are alert and sober, and acting within your capabilities. Some clubs offer training in falling techniques, although the degree to which this reduces concussion or general injury is unknown.
Horses have their own self-protection mechanisms, many of which cause our injuries in the first place – that refusal at the water jump or spook at the hedge – but with rider education and basic behaviour change, a reduction in injury in equestrian sports can be achieved.
Current recommendations (Updated July 2019)
Equestrian Australia is placing a renewed emphasis on concussion – both how they identify and manage suspected cases. They circulated the following advice (26th July 2019):
Officials and Organising Committees (OCs) are working hard to ensure that any suspected concussions are recognised as soon as they happen, and that appropriate action and medical care is taken.
Concussion is a serious condition.
If you are suspected of having a concussion by the medical service at the event, you will be provided with an advice card as shown HERE. The provisions of which include:
- Being monitored by another adult for a period between 4 and 24 hours; and
- Not being able to drive or operate machinery until receiving medical clearance.
If you are suspected of having a concussion, please co-operate with our OCs who will facilitate these arrangements for you. The OCs will also facilitate alternate transport arrangements for you and your horses in the same way as they would if you were incapacitated through another injury.
In the event a friend or travelling companion will be able to drive you and your horses back home – please let the OC know to save them arranging alternate logistics. To assist the OCs, please ensure your emergency contact details on your entry forms are up to date.
If you have any questions, please contact our NSO via firstname.lastname@example.org
TIP: Download the Pocket Concussion Recognition Tool, the recommended tool for non-medically trained people to use (coaches, other players/riders etc) here: http://bjsm.bmj.com/content/47/5/267.full.pdf
- McCrory, P., Meeuwisse, W.H., Aubry, M., et al. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine, 47, 250-258.
- Makdissi, M., Davis, G., McCrory, P. (2014). Updated guidelines for the management of sports-related concussion in general practice. Australian Family Physician, 43(3), 94-9.
- Srinivasan, V., Pierre, C., Plog, B. et al. (2014). Straight from the horse’s mouth: neurological injury in equestrian sports. Neurological Research, 36(10), 873-7.
- Zuckerman, S.L., Morgan, C.D., Burks, S. et al. (2015). Functional and structural traumatic brain injury in equestrian sports: a review of the literature. World Neurosurgery, 83, 1098-113.