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Traumatic brain injuries in equestrian athletes. Lola B. Chambless, MD Department of Neurosurgery Vanderbilt University. Overview. Definitions Incidence data Mechanisms of Injury Symptoms Diagnostic tools Outcome Prevention. Definitions. TBI = traumatic brain injury

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Traumatic brain injuries in equestrian athletes

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Traumatic brain injuries in equestrian athletes

Traumatic brain injuries in equestrian athletes

Lola B. Chambless, MD

Department of Neurosurgery

Vanderbilt University



  • Definitions

  • Incidence data

  • Mechanisms of Injury

  • Symptoms

  • Diagnostic tools

  • Outcome

  • Prevention



  • TBI = traumatic brain injury

    • Any injury to the brain which produces structural or functional alterations

    • May be “mild” – concussion

    • Severe cases cause coma and death

  • Concussion = transient trauma-induced alteration in brain function

    • Does NOT require loss of consciousness

  • CTE = chronic traumatic encephalopathy

    • Slowly progressive loss of global neurologic function in athletes with history of multiple concussions

Scope of the problem

Scope of the problem

  • Between 2 and 3.8 million cases of TBI reported annually in the US

    • 500,000 – 760,000 are sports-related

  • 50,000 deaths/year

  • 70,000 – 90,000 permanently disabled/year

  • Highest incidence: ages 15-24

Scope of the problem1

Scope of the problem

  • Concussion in athletes:

    • Duration of symptoms is highly variable

    • 15% of these patients will continue to have symptoms one year after the injury

    • An athlete who sustains a concussion is 4-6 times more likely to sustain a second concussion

Scope of the problem2

Scope of the problem

  • Horseback riding causes 11.7% of all TBIs among recreational sports

    • Highest percentage of any recreational sport

  • In 2009 there were over 14000 ER visits for brain injuries among riders

Major traumatic brain injury

Major traumatic brain injury

  • REMEMBER: in the unconscious patient ALWAYS assume an associated spine injury

  • ABC’s

    • Emergency airway

    • Hyperventilation

Types of tbi

Types of TBI

  • Skull fractures

  • Intracranial hematomas

  • Concussions

Skull fractures

Skull fractures

Skull fractures diagnosis and management

Skull fractures – diagnosis and management

  • CANNOT reliably diagnose these lesions by palpation

    • Significant individual variability in baseline contours of skull

  • Does not always have an associated scalp laceration

  • May occur even with mild brain injury

  • If suspected – refer for CT

    • X-ray useless

Basilar skull fracture

Basilar skull fracture

  • Can present in delayed fashion

  • Symptoms:

    • Hearing loss, severe dysequilibrium

    • CSF rhinorrhea or otorrhea

    • Loss of smell or taste

  • Signs:

    • “racoon eyes”

    • Battle sign (bruising over mastoid)

Intracranial hematomas in sports

Intracranial hematomas in sports

  • Suspected from symptoms and course

    • Severe headache with vomiting

    • Lethargy

    • Pupil asymmetry (with above)

    • Lateralizing neuro signs

    • Beware the “lucid interval”

      • Initial mild symptoms, then rapid deterioration

      • Usually occurs within 6 hours

Valadka AB (2004). "Injury to the cranium". in Moore EJ, Feliciano DV, Mattox KL. Trauma. New York: McGraw-Hill, Medical Pub. Division. pp. 385–406.

Basic science studies

Basic Science Studies

  • Current knowledge limited due to available models

    • There is no existing animal or experimental model that accurately reflects a sporting concussive injury

How do we diagnose a concussion

How do we diagnose a concussion?

  • Mostly a clinical diagnosis based on reported symptoms, observation of the athlete’s behavior and function and examination of specific brain function

  • Inherent problem of truthful symptom reporting

  • Requires on site assessment by personnel trained to identify brain injury

Signs and symptoms of concussion




Balance problems or dizziness  

Double vision   

Sensitivity to light or noise   

Feeling sluggish   

Feeling “foggy”    

Concentration or memory problems   

Change in sleep pattern (appears later)   

Feeling fatigued

Signs and Symptoms of Concussion


  • Appears dazed or stunned

  • Confused about assignment

  • Forgets plays

  • Is unsure of game, score, or opponent

  • Moves clumsily

  • Answers questions slowly

  • Loses consciousness

  • Shows behavior or personality change

  • Forgets events prior to play (retrograde amnesia)

  • Forgets events after hit (anterograde amnesia)

From powell et al neurosurg 54 1 2004

From Powell et al. Neurosurg 54(1) 2004

  • Three most common symptoms:

    • Headaches (55%)

    • Dizziness (42%)

    • Blurred vision (16.3)

  • 45.9% experienced either cognitive or memory problems

  • 9.3% had loss of consciousness

Maddocks questions

Maddocks’ Questions

  • Which field are we at?

  • Which team are we playing?

  • Who is your opponent at present?

  • Which quarter (period) is it?

  • Which side scored the last point?

  • Which team did we play last week?

  • Did we win last week?

Clinical Journal of Sports Medicine, 1995

Concussion grading scales

Concussion grading scales

  • Several grading scales have been used as an attempt to classify severity of concussions based on presenting symptoms (grade1, 2, and 3)

    • No standardized definitions

    • No correlation with outcome

    • Arbitrary return to play guidelines

    • Becoming obsolete

Concussion classification modern thoughts

Concussion classification – modern thoughts

  • Each concussion is assessed independently based upon:

    • Nature and duration of symptoms and signs

    • Patient’s age

    • Patient’s previous concussion history

Traumatic brain injuries in equestrian athletes

Note: in the overwhelming majority of cases both CT and MRI imaging modalities will be normal. This does NOT rule out a very serious brain injury, since CT and MRI are tests of structure and not brain function




Time course of recovery guskiewicz et al jama 2003

Time course of recoveryGuskiewicz et al. JAMA 2003

  • Average duration of symptoms is 3.5 days

  • 88% of athletes have full recovery at 1 week

Second impact syndrome

Second Impact Syndrome

  • Initially described by Schneider 1973

    • 3 cases moderate impact caused almost immediate death

  • Coined by Saunders and Harbaugh 1984

    • Described college FB player who was in a fight week before then sustained minor trauma and died

  • “….an athlete who has sustained an initial head injury, most often a concussion, sustains a second head injury before symptoms associated with the first have fully cleared.”

Second impact syndrome1

Second Impact Syndrome

  • Pathophysiology

    • Loss of autoregulation of brain’s blood supply

    • Leads to vascular engorgement with resultant cerebral edema

    • Increasing ICP and herniation

  • 50% mortality

  • 100% morbidity

    Cantu RC. Second-Impact Syndrome. Clinics in Sports Medicine. 17 (1) 38-44, 1998.

Delayed worsening of symptoms

Delayed worsening of symptoms

  • Delayed Symptoms:

    • Division 1 College Football:

      • 33% of players who returned to play prior to resolution of symptoms experienced delayed onset of additional symptoms vs 12.6% that did not return

        • Guskiewicz. JAMA. 2003

Why are individual neurocognitive baselines useful in assessment of sports related concussions

Why are individual neurocognitive baselines useful in assessment of sports-related concussions?

What is computerized cognitive testing

What is computerized cognitive testing?

  • Concussion will produce transient alterations in objective measures of visual attention, concentration, visual, verbal and spatial memory, and reaction time

  • Measurement of these functions has historically required a paper and pencil battery of tests administered by a neuropsychologist

    • Expensive, time-consuming, and subject to the limited availability of qualified practitioners who understand the unique time sensitivity of athletic team schedules

  • A computerized test can provide a quick, reproducible assessment of these parameters

    • Eliminates reliance on honesty of athlete’s reporting of symptoms

Traumatic brain injuries in equestrian athletes


  •  Demographic/Concussion History Questionnaire

  •  Concussion Symptom Scale

    • - 21 Item Likert scale (e.g. headache, dizziness, nausea, etc)

  •  Eight Neurocognitive Measures

    • - Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores

  •  Detailed Clinical Report

    • - Automatically computer scored

    • - Outlines demographic, symptom, neurocognitive data

Impact memory composite control vs concussed athletes

ImPACT MEMORY COMPOSITEControl vs. Concussed Athletes


difference between

groups out to

at least 8 days








*Lower score indicates poorer performance

Collins MW, Lovell MR, Maroon et al. Medicine and Science in Sports Exercise, 34:5;2002

Current impact test users

Current ImPACT test users

  • All NFL teams

  • All NHL teams

  • 31 Major League baseball teams

  • 7 NBA teams

  • All MLS teams

  • Formula One and IRL auto racing

  • USA Olympic teams – soccer, hockey, skiing, boxing

  • Over 100 major US universities

The bottom line

The Bottom Line:

  • Policies in place within the NCAA, NFL, NHL and all published practice parameters for medical professionals support neurocognitive testing as the standard of care for athletes with sports-related concussion.

Rtp same game 2010 ncaa guidelines

RTP same game – 2010 NCAA guidelines

  • “Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan.”

Step wise return to play

Step-wise return to play

  • No activity until asymptomatic

  • Light aerobic exercise

  • Sport specific training

  • Non-contact drills

  • Full-contact drills

  • Game action

Traumatic brain injuries in equestrian athletes

What is the maximum number of “safe” concussions?

Traumatic brain injuries in equestrian athletes


(but probably zero)

Strategies for concussion prevention

Strategies for concussion prevention


    • Reduce risk of severe brain injury in all sports where used (including non-contact)

    • Multiple examples worldwide where mandatory helmet laws have reduced severe brain injuries and neurologic deaths from sports and leisure activities

2010 nfl nflpa study

2010 NFL/NFLPA study

  • The results of an independent study commissioned by the NFL and the players’ union show modern helmets meet all national safety standards, though it stressed that no helmet can prevent concussions and more studies are necessary.

Rule changes and technique

Rule changes and technique

Rule changes

Rule changes

  • NFL

    • No helmet–to–helmet hits

    • “defenseless quarterback”

  • MLB

    • Automatic ejection for pitch aimed at head

  • NHL

    • More frequent penalties for high sticks or checks above shoulders

Recent equestrian developments

Recent Equestrian Developments

  • US Eventing Assoc. required that paticipants wear ASTM-approved helmets at all times when mounted

  • US Dressage Assoc. adopts similar rule for non-FEI levels

  • US Polo Assoc. to require that participants in sanctioned events wear NOCSAE-approved helmets (Jan 2012?)

Traumatic brain injuries in equestrian athletes

1997 NAYRC CCI**



  • Management of sports concussions is under ever increasing scrutiny from regulatory bodies, media, and others

  • RTP decisions should be based on standard assessment tools which include self-reported symptoms, standardized scales, balance testing, and neurocognitive testing of some form

    • Data from each of these components must not be considered in isolation



  • Long term effects of multiple sports concussions remain to be elucidated

  • Lifetime number of “safe” concussions remains unknown, though repeated traumatic brain injuries can clearly produce delayed cognitive deficits

  • Proper equipment, technique, and avoidance of exposure to another head impact while recuperating from previous concussion are all important prevention strategies

Opportunities for improvement

Opportunities for Improvement

  • Get professionals behind the use of proper helmets whenever mounted

  • Institute a formal system of sideline evaluation of injured players

  • Create formal return-to-play guidelines

  • Use a Comprehensive Concussion Center to evaluate high-risk athletes


Thank you

Thank You!

  • US Polo Association

  • Allen Sills, MD

  • Craig Ferrell, MD

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