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Horseback riding-related injuries treated in emergency departments: Risk factors and prevention strategies
Journal of Safety Research 71 (2019) 251–257
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Horseback riding-related injuries treated in emergency departments: Risk factors and prevention strategies Nicole Asa a, Alison Newton a, Lindsay Sullivan a, Junxin Shi a, Krista Wheeler a, Gary A. Smith a,b, Jingzhen Yang a,b,⇑ a b
Center for Injury Research and Policy at The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, United States Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, United States
a r t i c l e
i n f o
Article history: Received 30 April 2019 Received in revised form 20 August 2019 Accepted 28 September 2019 Available online 20 November 2019 Keywords: Epidemiology Qualitative research Recreation/Sports Risk perception
a b s t r a c t Introduction: Despite inherit dangers of horseback riding (HBR), research on HBR-related injuries is sparse. This study used both quantitative and qualitative methods to (1) examine HBR-related injuries treated in emergency departments (EDs) and associated risk factors and (2) explore HBR-related injury experiences and recommendations for prevention strategies from the perspective of riders. Method: We retrospectively analyzed data from the Nationwide Emergency Department Sample (NEDS), identifying HBR-related ED visits between 2010 and 2014. Additionally, we conducted 10 phone interviews with active horseback riders to understand their experiences and perspectives regarding HBR-related injuries and recommendations for prevention measures. Results: A total of 21,899 ED visits for HBR-related injuries were identified. When weighted, these represented 100,964 ED visits in the United States. Females had a consistently higher proportion of ED visits compared to males across the study period, with the proportion of ED visits being highest in females aged 15–19. Most injuries (85.9%) were treated and released from the ED. Three primary themes were identified as key to the prevention of HBR-related injuries: (1) rider safety (e.g., use of protective equipment), (2) external factors (e.g., awareness of environment), and (3) rider and horse interactions (e.g., matching skill level of the rider to the horse). Conclusions: Results indicate that HBR-related injuries treated in EDs are prevalent, with female riders aged 15–19 years having the highest proportion of injuries treated in EDs. Practical Applications: There is a critical need for injury prevention programs that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices. Ó 2019 National Safety Council and Elsevier Ltd. All rights reserved.
1. Introduction Each year, approximately 20 million people aged 16 years and older in the United States participate in competitive or recreational horseback riding (HBR)-related sports. (Foundation, 2017; Thomas, Annest, Gilchrist, & Bixby-Hammett, 2006) HBR generates many positive physical health benefits, (Altgarde, Redeen, Hilding, & Drott, 2014; O’Connor, Hitchens, & Fortington, 2018) such as enhancing balance, motor function, and muscle strength. (Ohtani, Kitagawa, & Mikami, 2017) Riding and caring for horses can also help relieve anxiety, reduce hyperactivity, enhance self-esteem, (Alfonso, Alfonso, Llabre, & Fernandez, 2015) and promote relaxation, (Ohtani et al., 2017) thus improving mental health. However, ⇑ Corresponding author at: Center for Injury Research and Policy at Nationwide Children’s Hospital, 700 Children’s Drive – RBIII, Columbus, OH 43205, United States. E-mail address: [email protected] (J. Yang). https://doi.org/10.1016/j.jsr.2019.09.004 0022-4375/Ó 2019 National Safety Council and Elsevier Ltd. All rights reserved.
HBR poses an inherent risk for injury and has one of the highest mortality rates among sports. (Lemoine, Tate, Lacombe, & Hood, 2017; Zuckerman, Morgan, & Burks, 2015) Previous studies suggest that the increased risk of injuries in HBR-related sports as compared to other sports is largely a result of the rider sitting three meters above the ground and the potential to reach speeds of 65–75 km/h. (Ball, Ball, Mulloy, Datta, & Kirkpatrick, 2009; Van Balen, Barten, & Janssen, 2017) The location and severity of HBRrelated injuries also varies considerably due to the difficult-topredict and yet powerful nature of horses. (Ball et al., 2009; Sandiford, Buckle, Alao, Davidson, & Ritchie, 2013) Most studies note a predominance of injuries to female riders, (Lemoine et al., 2017) with female teen riders who ride recreationally without a helmet being the most frequently injured group. (Altgarde et al., 2014; Lemoine et al., 2017; Sandiford et al., 2013; Van Balen et al., 2017; Zuckerman et al., 2015) This sex difference in HBR-related injury rates may reflect the riding population, as HBR sports are female-dominated. While some
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HBR-related injuries are a result of unexpected events, Ball et al. (Ball et al., 2009) found that 64% of riders believed their injuries were preventable. Horseback riders who wear safety equipment, such as helmets, lower their risk of injury and injury severity. (Sandiford et al., 2013; Van Balen et al., 2017) Additional evidence suggests that injuries can be prevented by pairing the rider with a horse that matches their experience and capability levels. (Lemoine et al., 2017) Few epidemiological studies, however, have examined the demographic and injury characteristics of HBRrelated injuries treated in emergency departments (EDs) using national data. (Thomas et al., 2006) No study to date has used qualitative methods to examine HBR-related injuries and recommendations for prevention strategies from the perspective of riders. This study aimed to (1) examine the characteristics and associated risk factors of HBR-related injuries treated in EDs between 2010 and 2014, using the Nationwide Emergency Department Sample (NEDS) and (2) explore HBR-related injury experiences and recommendations for prevention strategies from active horseback riders’ perspectives via in-depth phone interviews. Understanding factors contributing to HBR-related injuries using both quantitative and qualitative approaches will help fill critical knowledge gaps and inform the development of injury prevention programs. 2. Materials and methods 2.1. Study design This study used both quantitative and qualitative approaches. Specifically, using a quantitative approach, we retrospectively analyzed data derived from NEDS to identify HBR-related injuries treated in EDs during the years 2010 through 2014, evaluating associated demographic and injury risk factors. Using a qualitative approach, we interviewed 10 active horseback riders to learn about their HBR-related injury experiences and recommendations for injury prevention strategies. 2.2. Data and study population 2.2.1. NEDS data NEDS is the largest all-payer ED database in the US sponsored by the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project. (Healthcare Cost and Utilization Project (HCUP), 2018) The de-identified and publicly available data from NEDS can be used to produce national estimates of hospital-based ED visits. Each year, NEDS contains over 30 million ED visits from a sample of more than 900 hospital EDs in the US. In this study, we used five years (2010–2014) of NEDS data. HBR-related injuries were identified using the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9-CM and ICD-10-CM, respectively) E-code E006.1 (Horseback riding). Although the year 2015 data were available, we did not include them in this study due to both ICD-9-CM and ICD-10-CM being used, resulting in a drop in external cause of injury completeness. (Slavova et al., 2018) Thus, a sample of 21,899 injuries including patients of all ages who visited the ED from 2010 through 2014 were identified and analyzed. The variables of interest included rider demographics: rider’s sex, age, median household income, and primary expected payer (Medicare/ Medicaid, private insurance); injury characteristics: place of injury (home or farm vs place for recreation and sport), injury severity score (ISS), body location of injury, and type of injury; and ED visit characteristics: visit year, type of event (treated and released, admitted to same hospital), hospital region of the country (North-
east, Midwest, South, West), and teaching status of the hospital (metropolitan non-teaching, metropolitan teaching, and nonmetropolitan).
2.2.2. Telephone interviews We conducted semi-structured interviews with a convenience sample of active horseback riders to understand their experiences with HBR-related injuries. Participants were recruited through a large public university’s equestrian club team in the Midwest region. An individual was eligible if he or she 1) was an active horseback rider aged 18 years at time of interview; 2) had at least 12 months of HBR experience; and 3) had at least one HBR-related injury that either prevented him or her from practicing or required medical attention. A total of 10 riders were interviewed following screening for eligibility. Participants provided verbal consent and authorized audio recording of the interview. On average, the phone interviews lasted 30-min. This study was approved by the Institutional Review Board at the authors’ primary institution.
2.2.2.1. Interview guide development and pilot test. The interview guide was developed based on the Health Belief Model (Rosenstock, Strecher, & Becker, 1988) and injury prevention literature, (Altgarde et al., 2014; Sandiford et al., 2013; Thomas et al., 2006; van Wilgen & Verhagen, 2012; Zuckerman et al., 2015) guiding questions around risk factors of injury and injury prevention strategies. The interview guide was pilot tested on three riders for length and appropriateness of questions. Modifications were made by the research team before the interview questions were finalized. Participants were asked about their experiences and perceptions regarding five key topics with multiple probe questions: (i) HBR experience, (ii) HBR-related injury (or injuries) experience (s), (iii) impact of the injury (or injuries) on their overall health, (iv) perception of risk associated with horses and HBR (e.g., ‘‘How has your injury affected how you perceive risk around horses?”), and (v) practices related to injury prevention, including questions about general safety measures used around horses. The open ended questions allowed the participants to explain their experiences with horses without being restricted to specific answers. All of the telephone interviews were conducted by the first author and took place between June 2018 and July 2018.
2.3. Statistical analysis National estimates were generated using the weights provided in the NEDS datasets. Weighted percentages along with 95% confidence intervals (CIs) for HBR-related injuries treated in EDs were calculated by age group, sex, median household income by zip code, primary expected payer, type of ED event, hospital region, trauma level designation, location of injury, and type of injury. Incidence rates of injuries per 10,000 persons, using bridged-race population estimates, (Centers for Disease Control and Prevention. Bridged-Race Population Estimates, 2014) were calculated by sex and age. Data analyses were conducted using SAS version 9.4 (SAS Institute, Inc. Cary, NC). All audio-tape recorded interviews were transcribed verbatim. Using a thematic analysis approach, the transcripts were first reviewed independently by four authors to identify a set of preliminary themes. The identified themes were then compared and discussed before a final set of themes was produced once consensus was reached among all four authors. The final themes, along with supporting quotes that captured the perceptions and experiences of the 10 participants, are reported.
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3. Results 3.1. Patient and injury characteristics in the NEDS sample From 2010 through 2014, a total of 21,899 HBR-related injuries that were treated in an ED were identified. When weighted, these represented 100,964 HBR-related injuries treated in an ED from 2010 through 2014, averaging 20,193 injuries annually. Trends in HBR-related injuries treated in EDs remained relatively unchanged
during the study period. Thus, averages of the annual estimates are reported in Table 1. The majority of injuries were sustained by females (68.5%, 95% CI: 67.2–69.8). A high proportion of injuries were sustained by adolescents aged 15–19 years old (13.6%, 95% CI: 13.1–14.2) (Table 1). Nearly 2.5% of injuries had an ISS 16, while 7.9% of injuries had an ISS between 9 and 15. Most (85.7%) injuries were treated in the ED and released (95% CI: 85.7–86.6). Only 43.5% of the injuries had a known place of injury, the majority of which occurred at home
Table 1 Characteristics of injuries treated in the Emergency Department (ED). N in sample
Annual National Estimatesa
%
95% CI
Total
21,899
20,193
100.0
(100.0–100.0)
Sex Male Female
6839 15,053
6363 13,823
31.5 68.5
(30.2–32.8) (67.2–69.8)
Age 0–4 years 5–9 years 10–14 years 15–19 years 20–24 years 25–29 years 30–34 years 35–39 years 40–44 years 45–49 years 50–54 years 55–59 years 60 years
268 936 2504 2985 2046 1483 1426 1302 1550 1726 1802 1606 2265
261 890 2344 2749 1889 1365 1292 1206 1402 1584 1630 1465 2116
1.3 4.4 11.6 13.6 9.4 6.8 6.4 6.0 6.9 7.8 8.1 7.3 10.5
(1.1–1.5) (4.0–4.8) (10.9–12.3) (13.1–14.2) (8.9–9.8) (6.4–7.1) (6.0–6.8) (5.6–6.3) (6.6–7.3) (7.5–8.2) (7.6–8.5) (6.9–7.7) (9.9–11.1)
Place of injury Home or farm Recreation and sport Street and highway Public building, residential institution or industrial location Other specified places Unspecified place/unknown
3296 3136 166 214 2690 12,397
3054 2896 158 203 2486 11,395
15.1 14.3 0.8 1.0 12.3 56.4
(13.6–16.6) (13.1–15.6) (0.6–1.0) (0.8–1.2) (11.2–13.4) (53.9–58.9)
Injury Severity Score ISS 1-8 ISS 9-15 ISS 16-24 ISS 25-75
18,857 1637 425 86
17,368 1528 401 81
89.6 7.9 2.1 0.4
(88.9–90.3) (7.4–8.4) (1.8–2.3) (0.3–0.5)
4351 5194 5439 6147
3946 4936 5136 5499
20.3 25.4 26.4 28.0
(18.7–21.9) (23.8–26.9) (24.8–28.0) (25.5–30.4)
Primary expected payer Medicare/Medicaid Private insurance including HMO Self-pay Other
4408 13,203 2985 1411
4018 12,117 2694 1297
20.0 60.2 13.4 6.4
(19.0–20.9) (58.9–61.5) (12.6–14.1) (5.8–7.0)
Type of ED event Treated and released Admitted to the same hospital Transferred to a short-term hospital Died in the ED Not admitted, destination unknown
18,810 2348 715 11 15
17,299 2182 683 13 17
85.7 10.8 3.4 0.1 0.1
(84.7–86.6) (9.9–11.7) (3.0–3.7) (0.0–0.1) (0.0–0.1)
Hospital region Northeast Midwest South West
2190 3874 6672 9163
2112 4045 5491 8545
10.5 20.0 27.2 42.3
(8.5–12.4) (17.8–22.3) (24.7–29.7) (39.2–28.5)
Teaching status of hospital Metropolitan non-teaching Metropolitan teaching Non-metropolitan
10,340 6246 5313
8959 5942 5292
44.4 29.4 26.2
(41.2–47.5) (26.6–32.3) (23.9–28.5)
Medium household income 0%–25% 25%–50% 50%–75% 75%–100%
b
ED, Emergency Department; HMO, Health maintenance organization; ISS, Injury Severity Score. a Annual estimates were calculated by adjusting the weight divided by 5. b Median household income is based on national quartile for patient ZIP Code.
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or on a farm (n = 3296, 15.1%, 95% CI: 13.6–16.6), followed by a place for recreation and sport (n = 3136, 14.3%, 95% CI: 13.1–15.6). Of the 21,899 HBR-related injuries, 28.0% occurred among patients who resided in zip codes with the highest quartile of median household income (95% CI: 25.5–30.4), while 20.3% were in the lowest income quartile (95% CI: 18.7–21.9). Private insurance providers, including Health Maintenance Organizations, were the most common primary expected payer (60.2%, 95% CI: 58.9–61.5), followed by Medicare/Medicaid (20.0%, 95% CI: 19.0–20.9) (Table 1). Approximately one-third of injuries were fractures (32.8%), while 22.3% of injuries were superficial/contusions (Fig. 1A). The most common location of injury was the upper extremity (25.5%), followed by the lower extremity (20.3%), and the torso (19.8%). Head injuries accounted for 22.7% of the injuries, with 10.4% of these injuries being traumatic brain injuries (Fig. 1B). 3.2. Incidence rate of HBR-related injuries The overall incidence of HBR-related injuries treated in an ED was 0.64 per 10,000 persons (95% CI: 0.60–0.68, data not shown elsewhere). Females (0.89 per 10,000 persons) had a higher incidence rate than males (0.40 per 10,000 persons). The age group 15–19 years (1.28 per 10,000 persons) had a higher incidence rate than the other age groups. Females had consistently higher incidence rates than males across all age groups except for ages 0–4 years and 65–69 years (Fig. 2). Females aged 15–19 years
(2.08 per 10,000 persons; p < 0.05) had a significantly higher incidence rate as compared to any other age and sex combination. The West region had the highest incidence rate per 10,000 persons (1.16), followed by the Midwest (0.60), South, (0.47), and Northeast (0.38) (data not shown). 3.3. Patient and injury characteristics in the interview sample Of the 10 active horseback riders who completed the phone interview, nine were female, with an average age of 28 years (ranging from 19 to 50 years). All participants rode English discipline, and one participant also rode Western style. Most participants began riding at around eight years old, and had over 16 years of riding experience. Among the 10 interviewees, there were a total of 29 injuries with an average of three injuries per participant (range = 1–6), and an average of six months off from riding due to the injury (range = 1 week to 9 months). The most common type of injury was bone fractures (e.g., legs, arms, noses, collar bones), followed by sprains, shoulder dislocations, torn anterior cruciate ligaments, and concussions. 3.4. Common themes on HBR safety The three common themes identified from the interviews were (1) Rider Safety, (2) External Factors, and (3) Rider and Horse Interactions.
10.8% 32.8%
Fracture (32.8%) Dislocation (2.4%) Sprains & Strains (14.6%)
22.3%
Internal Organ (11.8%) Open Wounds (5.2%) 2.4%
Superficial/Contusion (22.3%) Unspecified/Other (10.8)
5.2% 11.8%
14.6%
Fig. 1A. Nature of injury among patients, Nationwide Emergency Department Sample (2010–2014).
1.9
10.4
Truamatic Brain Injury (10.4%)
20.3 12.4
Other Head, Face, Neck (12.4%) Spine and Back (9.7%) Torso (19.8%)
9.7
Upper Extremity (25.5%) Lower Extremity (20.3%)
25.5 19.8
Unclassifiable by Site (1.9%)
(2010-2014). Fig. 1B. Location of injury among patients, Nationwide Emergency Department Sample (2010–2014).
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Rider safety encompassed things that a rider could do for himself/herself to stay safe while riding or around horses and to protect against injury. Rider safety included the three subthemes of staying fit, using safety equipment, and not riding alone (Table 2). Being fit entailed being physically strong, and also included mastery of the skills and positioning required to be an effective horseback rider. Participants indicated that wearing protective gear (e.g., helmet, gloves, boots) was vital to injury prevention, with most participants reporting that wearing safety equipment prevented or lessened the severity of an injury. Lastly, participants stressed the importance of riding with someone in case something happened to the horse or to the rider. External Factors such as the horse and the environment emerged as another risk factor of HBR-related injuries (Table 2). Participants noted that riders need to be aware of the horse at all times to avoid injury as horses are big, powerful, and their behavior is sometimes difficult to predict. Several participants mentioned that environmental factors, such as the wind, rain, bad ground, and riding location, are additional factors that contributed to HBR-related injuries. Rider and horse interactions occurred when riding, grooming, and spending time around horses. Participants stated that in order for riders to stay safe around horses, they need to be aware of the horse’s body at all times, especially their legs, in order to prevent getting stepped on or kicked. The skill level of the rider also needs to match the horse. For example, participants indicated that if a rider was unable to handle the horse with which he/she was working with, it could result in injury. Participants also stressed that the rider and the horse needed to be in the right mindset prior to riding (Table 2). If a rider was nervous or hesitant, the horse could sense it, which could potentially lead to injury. Similarly, if a horse was too energetic and not focused, riding that horse could be dangerous and subsequently result in an injury. 4. Discussion This study described HBR-related injuries treated in EDs from 2010 through 2014, and explored recommendations for prevention strategies from the perspective of active horseback riders. Results
of this study revealed that the proportion of HBR-related injuries treated in EDs was consistently higher in females compared to males across all ages except for ages 0–4 years and ages 65 years, with female riders aged 15–19 years having the highest proportion of ED visits. The number of HBR-related injuries treated in EDs did not change over time during the study period. More than 10% of these injuries had an ISS 9 (range 9–75). Many of these injuries had a potentially severe diagnosis, such as bone fracture or concussion. The findings from the qualitative interviews suggest that while risk of HBR-related injuries may be high due to poorly handled interactions between the rider, the environment, and the horse, many of these injuries are largely preventable if the rider takes effective action. The results of this study have important implications for the development of injury prevention programs that aim to minimize the number and severity of HBR-related injuries. Consistent with previous literature, (Altgarde et al., 2014; Havlik, 2010) we found that females aged 15–19 years had the highest proportion of HBR-related injuries treated in EDs compared to males and other age groups. One potential explanation for this finding is that HBR is more common among youth and the female sex, (Altgarde et al., 2014; Carmichael, Davenport, Kearney, & Bernard, 2014; Lemoine et al., 2017) thus greater risk exposure in this group. Our study also found that the Western region had a higher incidence of injury than other US regions. This could be due to the Western riding culture, which does not require riders to use protective equipment such as helmets. Our findings highlight the need for injury prevention programs that target adolescent female horseback riders and riders in the Western region. Further studies are also needed to better estimate the incidence rate of HBR-related injuries by using the horseback rider population as the denominator when calculating incidence rates as opposed to using the general population. Similar to previous research, (Altgarde et al., 2014) we found that the most common type of injuries in our population were fractures, followed by superficial/contusions, and sprains and strains. This finding was supported by the results of the phone interviews where fractures, dislocations, and concussions were the most common injuries reported by the riders. Our results revealed that while
2.50 Male 2.09
Incidence, per 10,000 people
Female
1.92
2.00
1.50 1.21 0.97 1.00
0.82
0.96
0.86 0.74
0.75
0.50
0.47
0.92 0.68
0.65 0.51 0.50
0.38 0.15
0.23
0.48
0.45
0.48
0.49
0.48
0.48
0.43
0.48 0.29 0.45
0.13
0.11 0.00 0-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Age, years
Fig. 2. Incidence of horseback riding-related injuries, Nationwide Emergency Department Sample (2010–2014).
70-
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Table 2 Summary of the Qualitative Findings. Theme/ Subthemes Rider Safety Fitness
Safety Equipment
Don’t ride alone
External Factors Horse as source of injury
Environmental factors
Quotes
‘‘You need to have enough physical strength and endurance” ‘‘I should have done more no stirrup work and have a stronger leg, if I had a stronger seat I wouldn’t have just tipped over” ‘‘If you want to be a good rider you have to stay in shape and stay healthy, the older I get the more I realize that” ‘‘Wear a helmet as much as possible, even when on the ground” ‘‘I’ve gotten two concussions with a helmet so I can’t imagine what would have happened if I didn’t wear one” ‘‘I try not to ride unless someone is with me because that would have been bad if I would have hurt myself worse” ‘‘You should always have someone with you when you’re riding, don’t ride by yourself” ‘‘Don’t take for granted that you know the horse because anything can happen” ‘‘The biggest risk are things out of our control, the most dangerous ones we don’t see coming” ‘‘You need to know who and what is around your horse and how they might behave and if they will freak out” ‘‘Environmental factors such as footing in the ring, distractions that could spook the horse, and appropriate jump level are all risks” ‘‘Riding outside of the arena is a risk because there’s more that could spook the horse”
Horse/Rider Interaction Be aware of ‘‘You need to pay attention to what they’re looking so horse’s body you can sense what they’re feeling and be prepared to move out of the way if you think something might spook them” ‘‘Be aware of where their feet are at all times because they could step on you or kick you” Match skill level ‘‘A lot has to do with the capability of the rider and how hard the horse is to ride, you’re going to get hurt if you’re an inexperienced rider dealing with a horse that’s hard to manage” ‘‘You need to make sure your ability matches with the horse’s ability” Be confident ‘‘Don’t be careless, but don’t be so cautious that you’re nervous because the horses can sense it” ‘‘If you have a hesitant rider you need to be aware of that because the horse can sense that” Exercise horse ‘‘My trainer thought the horse could do things that it before riding could not” ‘‘Your horse will tell you when they’re upset, so pay attention to them, if you don’t listen to your horse you’re going to get hurt”
most injuries were not severe injuries, 7.9% of the injuries were relatively severe (ISS between 9 and 15) and 2.5% of the injuries were major traumas (16). These findings are supported by Ball and colleagues (Ball et al., 2009) who reported that HBR was one of the top three sporting activities that was most likely to result in injuries leading to a long term disability. Previous studies also found that HBR and equestrian sports resulted in more severe injuries than football, motorcycle riding, wrestling, skiing, and rugby. (Havlik, 2010; Lemoine et al., 2017; Zuckerman et al., 2015) HBR-related injuries are often difficult to prevent due to horse-related risk factors. Our study, in line with others, (Carmichael et al., 2014; Lemoine et al., 2017) highlights the importance of educating horseback riders about the importance of adopting safe riding practices, including the use of protective equipment (e.g., helmet, gloves, safety vest), in order to prevent and minimize the severity of HBR-related injuries.
Our qualitative interviews revealed that horses represent an important risk factor for injury. More specifically, participants discussed how interactions between the rider and the horse may lead to injury, stating that these interactions were often poorly handled and therefore resulted in the horse losing control. Participants acknowledged that interactions between the horse and the environment were another risk factor for injury. These findings are consistent with previous literature, which suggests that the difficult-to-predict and yet powerful nature of horses (Ball et al., 2009; Sandiford et al., 2013) as well as the characteristics of horses (e.g., age, training level, breed, weekly activity) can lead to injury. (Zuckerman et al., 2015) Thus, effective injury prevention programs need to educate riders on proper horse handling strategies. 4.1. Limitations This study had several limitations. First, the HBR-related injuries included in this study were only those treated in the ED. HBR-related injuries treated elsewhere or untreated were not included. Second, the denominators used for the calculation of incidence rates of HBR-related injuries were based on the general population, not the HBR population, therefore the incidence rates reported in this study are likely to be underestimated. Third, we relied on an Ecode to define our injury cases. While E-codes are very specific, we may have missed some HBR-related injuries if the E-code was missing. Fourth, most of the interviewees were female and rode English; thus, the riders’ experiences described in this study may not reflect male riders and riders from other disciplines. 5. Conclusions Based on the results obtained from this study, the authors have reached the following recommendations for the prevention of HBR-related injuries: (1) Adopt safe riding practices. Riders should always use protective equipment such as a helmet, safety vest, and gloves, in order to prevent injury and minimize injury severity. (2) Be aware of the environment. Riders should be knowledgeable about the horse’s response(s) to various environmental conditions (e.g., weather, distractions, and riding inside vs. outside) in order to prepare and handle the horse accordingly. (3) Be aware of the horse at all times. Riders should know where the horse’s head and legs are at all times and should ensure that the horse is in a good mental mindset before riding. Future research that identifies strategies to implement these recommendations is warranted. Prevention programs, especially targeted at females aged 15–19 years, that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices should be developed, implemented, and evaluated. 6. Contributors NA designed the study in collaboration with AN, LS, and JY; acquired qualitative data; performed analysis and interpretation of results; drafted the manuscript; and critically reviewed and revised the manuscript. AN helped design the study in collaboration with NA, LS and JY; substantially contributed to data analysis and interpretation of results; and critically reviewed and revised the manuscript. LS helped design the study in collaboration with NA, AN, and JY; substantially contributed to qualitative data analysis and interpretation of results; and critically reviewed and
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revised the manuscript. JS developed the quantitative data analysis plan in collaboration with JY; conducted all quantitative data analyses; assisted in the interpretation of quantitative results; and critically reviewed and revised the manuscript. KW assisted in the interpretation of results, and critically reviewed and revised the manuscript. GS assisted in the interpretation of results, and critically reviewed and revised the manuscript. JY developed the concept in collaboration with NA, AN, and LS; developed the study design and analysis plan; supervised study implementation; assisted in the interpretation of results; and critically reviewed and revised the manuscript. All authors approved the final version of the manuscript as submitted. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements None. Funding This research was partially supported by the National Student Injury Research Training Program at the Center for Injury Research and Policy at the Abigail Wexner Research Institute at Nationwide Children’s Hospital. References Alfonso, S. V., Alfonso, L. A., Llabre, M. M., & Fernandez, M. I. (2015). Project stride: An equine-assisted intervention to reduce symptoms of social anxiety in young women. Explore: The Journal of Science & Healing, 11, 461–467. https://doi.org/ 10.1016/j.explore.2015.08.003. Altgarde, J., Redeen, S., Hilding, N., & Drott, P. (2014). Horse-related trauma in children and adults during a two year period. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22, 40. https://doi.org/10.1186/s13049014-0040-8. American Horse Council Foundation (2017). Economic Impact Study of the U.S. Horse Industry; 2017. Accessed 26.07.19. Havlik, H. S. (2010). Equestrian sport-related injuries: A review of current literature. Current Sports Medicine Reports, 9, 299–302. https://doi.org/10.1249/JSR.0b013e 3181f32056.
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Healthcare Cost and Utilization Project (HCUP). Overview of the National Emergency Department Sample (NEDS). (2018).. Lemoine, D. S., Tate, B. J., Lacombe, J. A., & Hood, T. C. (2017). A retrospective cohort study of traumatic brain injury and usage of protective headgear during equestrian activities. Journal of Trauma Nursing, 24, 251–257. https://doi.org/ 10.1097/jtn.0000000000000300. O’Connor, S., Hitchens, P. L., & Fortington, L. V. (2018). Hospital-treated injuries from horse riding in Victoria, Australia: Time to refocus on injury prevention? e000321 BMJ Open Sport & Exercise Medicine, 4. https://doi.org/10.1136/ bmjsem-2017-000321. Ohtani, N., Kitagawa, K., Mikami, K., et al. (2017). Horseback riding improves the ability to cause the appropriate action (go reaction) and the appropriate selfcontrol (no-go reaction) in children. Frontiers in Public Health, 5, 8. https://doi. org/10.3389/fpubh.2017.00008. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15, 175–183. Sandiford, N., Buckle, C., Alao, U., Davidson, J., & Ritchie, J. (2013). Injuries associated with recreational horse riding and changes over the last 20 years: a review. JRSM Short Reports, 4. https://doi.org/10.1177/2042533313476688. 2042533313476688. Slavova, S., Costich, J. F., Luu, H., Fields, J., Gabella, B. A., Tarima, S., et al. (2018). Interrupted time series design to evaluate the effect of the ICD-9-CM to ICD-10CM coding transition on injury hospitalization trends. Injury Epidemiology, 5(1), 36. https://doi.org/10.1186/s40621-018-0165-8. Thomas, K. E., Annest, J. L., Gilchrist, J., & Bixby-Hammett, D. M. (2006). Non-fatal horse related injuries treated in emergency departments in the United States, 2001–2003. British Journal of Sports Medicine, 40, 619–626. https://doi.org/ 10.1136/bjsm.2006.025858. Van Balen, P. J., Barten, D. G., Janssen, L., et al. (2017). Beware of the force of the horse: Mechanisms and severity of equestrian-related injuries. European Journal of Trauma and Emergency Surgery. https://doi.org/10.1097/mej.00000000 00000511. van Wilgen, C. P., & Verhagen, E. A. (2012). A qualitative study on overuse injuries: The beliefs of athletes and coaches. Journal of Science and Medicine in Sport, 15, 116–121. https://doi.org/10.1016/j.jsams.2011.11.253. 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, 1098–1113. https://doi.org/10.1016/j.wneu.2014.12.030. Nicole Asa is a Research Aide at the Center for Injury Research and Policy at the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio. Alison Newton is a Research Associate at the Center for Injury Research and Policy at the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio. Dr. Lindsay Sullivan is a Postdoctoral Research Scientist at the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio. Dr. Junxin Shi is a Biostatistician at the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio. Krista Wheeler is a Research Manager at the Center for Injury Research and Policy at Nationwide Children’s Hospital in Columbus, Ohio. Dr. Gary Smith is a Professor of Pediatrics, Emergency Medicine, and Epidemiology at The Ohio State University, and is the director of the Center for Injury Research and Policy of the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio. Dr. Jingzhen Yang is a Principal Investigator at the Center for Injury Research and Policy at Nationwide Children’s Hospital and is an Associate Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University College of Medicine.
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Journal of Safety Research journal homepage: www.elsevier.com/locate/jsr
Horseback riding-related injuries treated in emergency departments: Risk factors and prevention strategies Nicole Asa a, Alison Newton a, Lindsay Sullivan a, Junxin Shi a, Krista Wheeler a, Gary A. Smith a,b, Jingzhen Yang a,b,⇑ a b
Center for Injury Research and Policy at The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, United States Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, United States
a r t i c l e
i n f o
Article history: Received 30 April 2019 Received in revised form 20 August 2019 Accepted 28 September 2019 Available online 20 November 2019 Keywords: Epidemiology Qualitative research Recreation/Sports Risk perception
a b s t r a c t Introduction: Despite inherit dangers of horseback riding (HBR), research on HBR-related injuries is sparse. This study used both quantitative and qualitative methods to (1) examine HBR-related injuries treated in emergency departments (EDs) and associated risk factors and (2) explore HBR-related injury experiences and recommendations for prevention strategies from the perspective of riders. Method: We retrospectively analyzed data from the Nationwide Emergency Department Sample (NEDS), identifying HBR-related ED visits between 2010 and 2014. Additionally, we conducted 10 phone interviews with active horseback riders to understand their experiences and perspectives regarding HBR-related injuries and recommendations for prevention measures. Results: A total of 21,899 ED visits for HBR-related injuries were identified. When weighted, these represented 100,964 ED visits in the United States. Females had a consistently higher proportion of ED visits compared to males across the study period, with the proportion of ED visits being highest in females aged 15–19. Most injuries (85.9%) were treated and released from the ED. Three primary themes were identified as key to the prevention of HBR-related injuries: (1) rider safety (e.g., use of protective equipment), (2) external factors (e.g., awareness of environment), and (3) rider and horse interactions (e.g., matching skill level of the rider to the horse). Conclusions: Results indicate that HBR-related injuries treated in EDs are prevalent, with female riders aged 15–19 years having the highest proportion of injuries treated in EDs. Practical Applications: There is a critical need for injury prevention programs that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices. Ó 2019 National Safety Council and Elsevier Ltd. All rights reserved.
1. Introduction Each year, approximately 20 million people aged 16 years and older in the United States participate in competitive or recreational horseback riding (HBR)-related sports. (Foundation, 2017; Thomas, Annest, Gilchrist, & Bixby-Hammett, 2006) HBR generates many positive physical health benefits, (Altgarde, Redeen, Hilding, & Drott, 2014; O’Connor, Hitchens, & Fortington, 2018) such as enhancing balance, motor function, and muscle strength. (Ohtani, Kitagawa, & Mikami, 2017) Riding and caring for horses can also help relieve anxiety, reduce hyperactivity, enhance self-esteem, (Alfonso, Alfonso, Llabre, & Fernandez, 2015) and promote relaxation, (Ohtani et al., 2017) thus improving mental health. However, ⇑ Corresponding author at: Center for Injury Research and Policy at Nationwide Children’s Hospital, 700 Children’s Drive – RBIII, Columbus, OH 43205, United States. E-mail address: [email protected] (J. Yang). https://doi.org/10.1016/j.jsr.2019.09.004 0022-4375/Ó 2019 National Safety Council and Elsevier Ltd. All rights reserved.
HBR poses an inherent risk for injury and has one of the highest mortality rates among sports. (Lemoine, Tate, Lacombe, & Hood, 2017; Zuckerman, Morgan, & Burks, 2015) Previous studies suggest that the increased risk of injuries in HBR-related sports as compared to other sports is largely a result of the rider sitting three meters above the ground and the potential to reach speeds of 65–75 km/h. (Ball, Ball, Mulloy, Datta, & Kirkpatrick, 2009; Van Balen, Barten, & Janssen, 2017) The location and severity of HBRrelated injuries also varies considerably due to the difficult-topredict and yet powerful nature of horses. (Ball et al., 2009; Sandiford, Buckle, Alao, Davidson, & Ritchie, 2013) Most studies note a predominance of injuries to female riders, (Lemoine et al., 2017) with female teen riders who ride recreationally without a helmet being the most frequently injured group. (Altgarde et al., 2014; Lemoine et al., 2017; Sandiford et al., 2013; Van Balen et al., 2017; Zuckerman et al., 2015) This sex difference in HBR-related injury rates may reflect the riding population, as HBR sports are female-dominated. While some
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HBR-related injuries are a result of unexpected events, Ball et al. (Ball et al., 2009) found that 64% of riders believed their injuries were preventable. Horseback riders who wear safety equipment, such as helmets, lower their risk of injury and injury severity. (Sandiford et al., 2013; Van Balen et al., 2017) Additional evidence suggests that injuries can be prevented by pairing the rider with a horse that matches their experience and capability levels. (Lemoine et al., 2017) Few epidemiological studies, however, have examined the demographic and injury characteristics of HBRrelated injuries treated in emergency departments (EDs) using national data. (Thomas et al., 2006) No study to date has used qualitative methods to examine HBR-related injuries and recommendations for prevention strategies from the perspective of riders. This study aimed to (1) examine the characteristics and associated risk factors of HBR-related injuries treated in EDs between 2010 and 2014, using the Nationwide Emergency Department Sample (NEDS) and (2) explore HBR-related injury experiences and recommendations for prevention strategies from active horseback riders’ perspectives via in-depth phone interviews. Understanding factors contributing to HBR-related injuries using both quantitative and qualitative approaches will help fill critical knowledge gaps and inform the development of injury prevention programs. 2. Materials and methods 2.1. Study design This study used both quantitative and qualitative approaches. Specifically, using a quantitative approach, we retrospectively analyzed data derived from NEDS to identify HBR-related injuries treated in EDs during the years 2010 through 2014, evaluating associated demographic and injury risk factors. Using a qualitative approach, we interviewed 10 active horseback riders to learn about their HBR-related injury experiences and recommendations for injury prevention strategies. 2.2. Data and study population 2.2.1. NEDS data NEDS is the largest all-payer ED database in the US sponsored by the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project. (Healthcare Cost and Utilization Project (HCUP), 2018) The de-identified and publicly available data from NEDS can be used to produce national estimates of hospital-based ED visits. Each year, NEDS contains over 30 million ED visits from a sample of more than 900 hospital EDs in the US. In this study, we used five years (2010–2014) of NEDS data. HBR-related injuries were identified using the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9-CM and ICD-10-CM, respectively) E-code E006.1 (Horseback riding). Although the year 2015 data were available, we did not include them in this study due to both ICD-9-CM and ICD-10-CM being used, resulting in a drop in external cause of injury completeness. (Slavova et al., 2018) Thus, a sample of 21,899 injuries including patients of all ages who visited the ED from 2010 through 2014 were identified and analyzed. The variables of interest included rider demographics: rider’s sex, age, median household income, and primary expected payer (Medicare/ Medicaid, private insurance); injury characteristics: place of injury (home or farm vs place for recreation and sport), injury severity score (ISS), body location of injury, and type of injury; and ED visit characteristics: visit year, type of event (treated and released, admitted to same hospital), hospital region of the country (North-
east, Midwest, South, West), and teaching status of the hospital (metropolitan non-teaching, metropolitan teaching, and nonmetropolitan).
2.2.2. Telephone interviews We conducted semi-structured interviews with a convenience sample of active horseback riders to understand their experiences with HBR-related injuries. Participants were recruited through a large public university’s equestrian club team in the Midwest region. An individual was eligible if he or she 1) was an active horseback rider aged 18 years at time of interview; 2) had at least 12 months of HBR experience; and 3) had at least one HBR-related injury that either prevented him or her from practicing or required medical attention. A total of 10 riders were interviewed following screening for eligibility. Participants provided verbal consent and authorized audio recording of the interview. On average, the phone interviews lasted 30-min. This study was approved by the Institutional Review Board at the authors’ primary institution.
2.2.2.1. Interview guide development and pilot test. The interview guide was developed based on the Health Belief Model (Rosenstock, Strecher, & Becker, 1988) and injury prevention literature, (Altgarde et al., 2014; Sandiford et al., 2013; Thomas et al., 2006; van Wilgen & Verhagen, 2012; Zuckerman et al., 2015) guiding questions around risk factors of injury and injury prevention strategies. The interview guide was pilot tested on three riders for length and appropriateness of questions. Modifications were made by the research team before the interview questions were finalized. Participants were asked about their experiences and perceptions regarding five key topics with multiple probe questions: (i) HBR experience, (ii) HBR-related injury (or injuries) experience (s), (iii) impact of the injury (or injuries) on their overall health, (iv) perception of risk associated with horses and HBR (e.g., ‘‘How has your injury affected how you perceive risk around horses?”), and (v) practices related to injury prevention, including questions about general safety measures used around horses. The open ended questions allowed the participants to explain their experiences with horses without being restricted to specific answers. All of the telephone interviews were conducted by the first author and took place between June 2018 and July 2018.
2.3. Statistical analysis National estimates were generated using the weights provided in the NEDS datasets. Weighted percentages along with 95% confidence intervals (CIs) for HBR-related injuries treated in EDs were calculated by age group, sex, median household income by zip code, primary expected payer, type of ED event, hospital region, trauma level designation, location of injury, and type of injury. Incidence rates of injuries per 10,000 persons, using bridged-race population estimates, (Centers for Disease Control and Prevention. Bridged-Race Population Estimates, 2014) were calculated by sex and age. Data analyses were conducted using SAS version 9.4 (SAS Institute, Inc. Cary, NC). All audio-tape recorded interviews were transcribed verbatim. Using a thematic analysis approach, the transcripts were first reviewed independently by four authors to identify a set of preliminary themes. The identified themes were then compared and discussed before a final set of themes was produced once consensus was reached among all four authors. The final themes, along with supporting quotes that captured the perceptions and experiences of the 10 participants, are reported.
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3. Results 3.1. Patient and injury characteristics in the NEDS sample From 2010 through 2014, a total of 21,899 HBR-related injuries that were treated in an ED were identified. When weighted, these represented 100,964 HBR-related injuries treated in an ED from 2010 through 2014, averaging 20,193 injuries annually. Trends in HBR-related injuries treated in EDs remained relatively unchanged
during the study period. Thus, averages of the annual estimates are reported in Table 1. The majority of injuries were sustained by females (68.5%, 95% CI: 67.2–69.8). A high proportion of injuries were sustained by adolescents aged 15–19 years old (13.6%, 95% CI: 13.1–14.2) (Table 1). Nearly 2.5% of injuries had an ISS 16, while 7.9% of injuries had an ISS between 9 and 15. Most (85.7%) injuries were treated in the ED and released (95% CI: 85.7–86.6). Only 43.5% of the injuries had a known place of injury, the majority of which occurred at home
Table 1 Characteristics of injuries treated in the Emergency Department (ED). N in sample
Annual National Estimatesa
%
95% CI
Total
21,899
20,193
100.0
(100.0–100.0)
Sex Male Female
6839 15,053
6363 13,823
31.5 68.5
(30.2–32.8) (67.2–69.8)
Age 0–4 years 5–9 years 10–14 years 15–19 years 20–24 years 25–29 years 30–34 years 35–39 years 40–44 years 45–49 years 50–54 years 55–59 years 60 years
268 936 2504 2985 2046 1483 1426 1302 1550 1726 1802 1606 2265
261 890 2344 2749 1889 1365 1292 1206 1402 1584 1630 1465 2116
1.3 4.4 11.6 13.6 9.4 6.8 6.4 6.0 6.9 7.8 8.1 7.3 10.5
(1.1–1.5) (4.0–4.8) (10.9–12.3) (13.1–14.2) (8.9–9.8) (6.4–7.1) (6.0–6.8) (5.6–6.3) (6.6–7.3) (7.5–8.2) (7.6–8.5) (6.9–7.7) (9.9–11.1)
Place of injury Home or farm Recreation and sport Street and highway Public building, residential institution or industrial location Other specified places Unspecified place/unknown
3296 3136 166 214 2690 12,397
3054 2896 158 203 2486 11,395
15.1 14.3 0.8 1.0 12.3 56.4
(13.6–16.6) (13.1–15.6) (0.6–1.0) (0.8–1.2) (11.2–13.4) (53.9–58.9)
Injury Severity Score ISS 1-8 ISS 9-15 ISS 16-24 ISS 25-75
18,857 1637 425 86
17,368 1528 401 81
89.6 7.9 2.1 0.4
(88.9–90.3) (7.4–8.4) (1.8–2.3) (0.3–0.5)
4351 5194 5439 6147
3946 4936 5136 5499
20.3 25.4 26.4 28.0
(18.7–21.9) (23.8–26.9) (24.8–28.0) (25.5–30.4)
Primary expected payer Medicare/Medicaid Private insurance including HMO Self-pay Other
4408 13,203 2985 1411
4018 12,117 2694 1297
20.0 60.2 13.4 6.4
(19.0–20.9) (58.9–61.5) (12.6–14.1) (5.8–7.0)
Type of ED event Treated and released Admitted to the same hospital Transferred to a short-term hospital Died in the ED Not admitted, destination unknown
18,810 2348 715 11 15
17,299 2182 683 13 17
85.7 10.8 3.4 0.1 0.1
(84.7–86.6) (9.9–11.7) (3.0–3.7) (0.0–0.1) (0.0–0.1)
Hospital region Northeast Midwest South West
2190 3874 6672 9163
2112 4045 5491 8545
10.5 20.0 27.2 42.3
(8.5–12.4) (17.8–22.3) (24.7–29.7) (39.2–28.5)
Teaching status of hospital Metropolitan non-teaching Metropolitan teaching Non-metropolitan
10,340 6246 5313
8959 5942 5292
44.4 29.4 26.2
(41.2–47.5) (26.6–32.3) (23.9–28.5)
Medium household income 0%–25% 25%–50% 50%–75% 75%–100%
b
ED, Emergency Department; HMO, Health maintenance organization; ISS, Injury Severity Score. a Annual estimates were calculated by adjusting the weight divided by 5. b Median household income is based on national quartile for patient ZIP Code.
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or on a farm (n = 3296, 15.1%, 95% CI: 13.6–16.6), followed by a place for recreation and sport (n = 3136, 14.3%, 95% CI: 13.1–15.6). Of the 21,899 HBR-related injuries, 28.0% occurred among patients who resided in zip codes with the highest quartile of median household income (95% CI: 25.5–30.4), while 20.3% were in the lowest income quartile (95% CI: 18.7–21.9). Private insurance providers, including Health Maintenance Organizations, were the most common primary expected payer (60.2%, 95% CI: 58.9–61.5), followed by Medicare/Medicaid (20.0%, 95% CI: 19.0–20.9) (Table 1). Approximately one-third of injuries were fractures (32.8%), while 22.3% of injuries were superficial/contusions (Fig. 1A). The most common location of injury was the upper extremity (25.5%), followed by the lower extremity (20.3%), and the torso (19.8%). Head injuries accounted for 22.7% of the injuries, with 10.4% of these injuries being traumatic brain injuries (Fig. 1B). 3.2. Incidence rate of HBR-related injuries The overall incidence of HBR-related injuries treated in an ED was 0.64 per 10,000 persons (95% CI: 0.60–0.68, data not shown elsewhere). Females (0.89 per 10,000 persons) had a higher incidence rate than males (0.40 per 10,000 persons). The age group 15–19 years (1.28 per 10,000 persons) had a higher incidence rate than the other age groups. Females had consistently higher incidence rates than males across all age groups except for ages 0–4 years and 65–69 years (Fig. 2). Females aged 15–19 years
(2.08 per 10,000 persons; p < 0.05) had a significantly higher incidence rate as compared to any other age and sex combination. The West region had the highest incidence rate per 10,000 persons (1.16), followed by the Midwest (0.60), South, (0.47), and Northeast (0.38) (data not shown). 3.3. Patient and injury characteristics in the interview sample Of the 10 active horseback riders who completed the phone interview, nine were female, with an average age of 28 years (ranging from 19 to 50 years). All participants rode English discipline, and one participant also rode Western style. Most participants began riding at around eight years old, and had over 16 years of riding experience. Among the 10 interviewees, there were a total of 29 injuries with an average of three injuries per participant (range = 1–6), and an average of six months off from riding due to the injury (range = 1 week to 9 months). The most common type of injury was bone fractures (e.g., legs, arms, noses, collar bones), followed by sprains, shoulder dislocations, torn anterior cruciate ligaments, and concussions. 3.4. Common themes on HBR safety The three common themes identified from the interviews were (1) Rider Safety, (2) External Factors, and (3) Rider and Horse Interactions.
10.8% 32.8%
Fracture (32.8%) Dislocation (2.4%) Sprains & Strains (14.6%)
22.3%
Internal Organ (11.8%) Open Wounds (5.2%) 2.4%
Superficial/Contusion (22.3%) Unspecified/Other (10.8)
5.2% 11.8%
14.6%
Fig. 1A. Nature of injury among patients, Nationwide Emergency Department Sample (2010–2014).
1.9
10.4
Truamatic Brain Injury (10.4%)
20.3 12.4
Other Head, Face, Neck (12.4%) Spine and Back (9.7%) Torso (19.8%)
9.7
Upper Extremity (25.5%) Lower Extremity (20.3%)
25.5 19.8
Unclassifiable by Site (1.9%)
(2010-2014). Fig. 1B. Location of injury among patients, Nationwide Emergency Department Sample (2010–2014).
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Rider safety encompassed things that a rider could do for himself/herself to stay safe while riding or around horses and to protect against injury. Rider safety included the three subthemes of staying fit, using safety equipment, and not riding alone (Table 2). Being fit entailed being physically strong, and also included mastery of the skills and positioning required to be an effective horseback rider. Participants indicated that wearing protective gear (e.g., helmet, gloves, boots) was vital to injury prevention, with most participants reporting that wearing safety equipment prevented or lessened the severity of an injury. Lastly, participants stressed the importance of riding with someone in case something happened to the horse or to the rider. External Factors such as the horse and the environment emerged as another risk factor of HBR-related injuries (Table 2). Participants noted that riders need to be aware of the horse at all times to avoid injury as horses are big, powerful, and their behavior is sometimes difficult to predict. Several participants mentioned that environmental factors, such as the wind, rain, bad ground, and riding location, are additional factors that contributed to HBR-related injuries. Rider and horse interactions occurred when riding, grooming, and spending time around horses. Participants stated that in order for riders to stay safe around horses, they need to be aware of the horse’s body at all times, especially their legs, in order to prevent getting stepped on or kicked. The skill level of the rider also needs to match the horse. For example, participants indicated that if a rider was unable to handle the horse with which he/she was working with, it could result in injury. Participants also stressed that the rider and the horse needed to be in the right mindset prior to riding (Table 2). If a rider was nervous or hesitant, the horse could sense it, which could potentially lead to injury. Similarly, if a horse was too energetic and not focused, riding that horse could be dangerous and subsequently result in an injury. 4. Discussion This study described HBR-related injuries treated in EDs from 2010 through 2014, and explored recommendations for prevention strategies from the perspective of active horseback riders. Results
of this study revealed that the proportion of HBR-related injuries treated in EDs was consistently higher in females compared to males across all ages except for ages 0–4 years and ages 65 years, with female riders aged 15–19 years having the highest proportion of ED visits. The number of HBR-related injuries treated in EDs did not change over time during the study period. More than 10% of these injuries had an ISS 9 (range 9–75). Many of these injuries had a potentially severe diagnosis, such as bone fracture or concussion. The findings from the qualitative interviews suggest that while risk of HBR-related injuries may be high due to poorly handled interactions between the rider, the environment, and the horse, many of these injuries are largely preventable if the rider takes effective action. The results of this study have important implications for the development of injury prevention programs that aim to minimize the number and severity of HBR-related injuries. Consistent with previous literature, (Altgarde et al., 2014; Havlik, 2010) we found that females aged 15–19 years had the highest proportion of HBR-related injuries treated in EDs compared to males and other age groups. One potential explanation for this finding is that HBR is more common among youth and the female sex, (Altgarde et al., 2014; Carmichael, Davenport, Kearney, & Bernard, 2014; Lemoine et al., 2017) thus greater risk exposure in this group. Our study also found that the Western region had a higher incidence of injury than other US regions. This could be due to the Western riding culture, which does not require riders to use protective equipment such as helmets. Our findings highlight the need for injury prevention programs that target adolescent female horseback riders and riders in the Western region. Further studies are also needed to better estimate the incidence rate of HBR-related injuries by using the horseback rider population as the denominator when calculating incidence rates as opposed to using the general population. Similar to previous research, (Altgarde et al., 2014) we found that the most common type of injuries in our population were fractures, followed by superficial/contusions, and sprains and strains. This finding was supported by the results of the phone interviews where fractures, dislocations, and concussions were the most common injuries reported by the riders. Our results revealed that while
2.50 Male 2.09
Incidence, per 10,000 people
Female
1.92
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1.50 1.21 0.97 1.00
0.82
0.96
0.86 0.74
0.75
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0.47
0.92 0.68
0.65 0.51 0.50
0.38 0.15
0.23
0.48
0.45
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0.49
0.48
0.48
0.43
0.48 0.29 0.45
0.13
0.11 0.00 0-4
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10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 Age, years
Fig. 2. Incidence of horseback riding-related injuries, Nationwide Emergency Department Sample (2010–2014).
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Table 2 Summary of the Qualitative Findings. Theme/ Subthemes Rider Safety Fitness
Safety Equipment
Don’t ride alone
External Factors Horse as source of injury
Environmental factors
Quotes
‘‘You need to have enough physical strength and endurance” ‘‘I should have done more no stirrup work and have a stronger leg, if I had a stronger seat I wouldn’t have just tipped over” ‘‘If you want to be a good rider you have to stay in shape and stay healthy, the older I get the more I realize that” ‘‘Wear a helmet as much as possible, even when on the ground” ‘‘I’ve gotten two concussions with a helmet so I can’t imagine what would have happened if I didn’t wear one” ‘‘I try not to ride unless someone is with me because that would have been bad if I would have hurt myself worse” ‘‘You should always have someone with you when you’re riding, don’t ride by yourself” ‘‘Don’t take for granted that you know the horse because anything can happen” ‘‘The biggest risk are things out of our control, the most dangerous ones we don’t see coming” ‘‘You need to know who and what is around your horse and how they might behave and if they will freak out” ‘‘Environmental factors such as footing in the ring, distractions that could spook the horse, and appropriate jump level are all risks” ‘‘Riding outside of the arena is a risk because there’s more that could spook the horse”
Horse/Rider Interaction Be aware of ‘‘You need to pay attention to what they’re looking so horse’s body you can sense what they’re feeling and be prepared to move out of the way if you think something might spook them” ‘‘Be aware of where their feet are at all times because they could step on you or kick you” Match skill level ‘‘A lot has to do with the capability of the rider and how hard the horse is to ride, you’re going to get hurt if you’re an inexperienced rider dealing with a horse that’s hard to manage” ‘‘You need to make sure your ability matches with the horse’s ability” Be confident ‘‘Don’t be careless, but don’t be so cautious that you’re nervous because the horses can sense it” ‘‘If you have a hesitant rider you need to be aware of that because the horse can sense that” Exercise horse ‘‘My trainer thought the horse could do things that it before riding could not” ‘‘Your horse will tell you when they’re upset, so pay attention to them, if you don’t listen to your horse you’re going to get hurt”
most injuries were not severe injuries, 7.9% of the injuries were relatively severe (ISS between 9 and 15) and 2.5% of the injuries were major traumas (16). These findings are supported by Ball and colleagues (Ball et al., 2009) who reported that HBR was one of the top three sporting activities that was most likely to result in injuries leading to a long term disability. Previous studies also found that HBR and equestrian sports resulted in more severe injuries than football, motorcycle riding, wrestling, skiing, and rugby. (Havlik, 2010; Lemoine et al., 2017; Zuckerman et al., 2015) HBR-related injuries are often difficult to prevent due to horse-related risk factors. Our study, in line with others, (Carmichael et al., 2014; Lemoine et al., 2017) highlights the importance of educating horseback riders about the importance of adopting safe riding practices, including the use of protective equipment (e.g., helmet, gloves, safety vest), in order to prevent and minimize the severity of HBR-related injuries.
Our qualitative interviews revealed that horses represent an important risk factor for injury. More specifically, participants discussed how interactions between the rider and the horse may lead to injury, stating that these interactions were often poorly handled and therefore resulted in the horse losing control. Participants acknowledged that interactions between the horse and the environment were another risk factor for injury. These findings are consistent with previous literature, which suggests that the difficult-to-predict and yet powerful nature of horses (Ball et al., 2009; Sandiford et al., 2013) as well as the characteristics of horses (e.g., age, training level, breed, weekly activity) can lead to injury. (Zuckerman et al., 2015) Thus, effective injury prevention programs need to educate riders on proper horse handling strategies. 4.1. Limitations This study had several limitations. First, the HBR-related injuries included in this study were only those treated in the ED. HBR-related injuries treated elsewhere or untreated were not included. Second, the denominators used for the calculation of incidence rates of HBR-related injuries were based on the general population, not the HBR population, therefore the incidence rates reported in this study are likely to be underestimated. Third, we relied on an Ecode to define our injury cases. While E-codes are very specific, we may have missed some HBR-related injuries if the E-code was missing. Fourth, most of the interviewees were female and rode English; thus, the riders’ experiences described in this study may not reflect male riders and riders from other disciplines. 5. Conclusions Based on the results obtained from this study, the authors have reached the following recommendations for the prevention of HBR-related injuries: (1) Adopt safe riding practices. Riders should always use protective equipment such as a helmet, safety vest, and gloves, in order to prevent injury and minimize injury severity. (2) Be aware of the environment. Riders should be knowledgeable about the horse’s response(s) to various environmental conditions (e.g., weather, distractions, and riding inside vs. outside) in order to prepare and handle the horse accordingly. (3) Be aware of the horse at all times. Riders should know where the horse’s head and legs are at all times and should ensure that the horse is in a good mental mindset before riding. Future research that identifies strategies to implement these recommendations is warranted. Prevention programs, especially targeted at females aged 15–19 years, that not only promote the use of protective equipment, but that also educate horseback riders on horse behavior, the proper handling of horses, and safe riding practices should be developed, implemented, and evaluated. 6. Contributors NA designed the study in collaboration with AN, LS, and JY; acquired qualitative data; performed analysis and interpretation of results; drafted the manuscript; and critically reviewed and revised the manuscript. AN helped design the study in collaboration with NA, LS and JY; substantially contributed to data analysis and interpretation of results; and critically reviewed and revised the manuscript. LS helped design the study in collaboration with NA, AN, and JY; substantially contributed to qualitative data analysis and interpretation of results; and critically reviewed and
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revised the manuscript. JS developed the quantitative data analysis plan in collaboration with JY; conducted all quantitative data analyses; assisted in the interpretation of quantitative results; and critically reviewed and revised the manuscript. KW assisted in the interpretation of results, and critically reviewed and revised the manuscript. GS assisted in the interpretation of results, and critically reviewed and revised the manuscript. JY developed the concept in collaboration with NA, AN, and LS; developed the study design and analysis plan; supervised study implementation; assisted in the interpretation of results; and critically reviewed and revised the manuscript. All authors approved the final version of the manuscript as submitted. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgements None. Funding This research was partially supported by the National Student Injury Research Training Program at the Center for Injury Research and Policy at the Abigail Wexner Research Institute at Nationwide Children’s Hospital. References Alfonso, S. V., Alfonso, L. A., Llabre, M. M., & Fernandez, M. I. (2015). Project stride: An equine-assisted intervention to reduce symptoms of social anxiety in young women. Explore: The Journal of Science & Healing, 11, 461–467. https://doi.org/ 10.1016/j.explore.2015.08.003. Altgarde, J., Redeen, S., Hilding, N., & Drott, P. (2014). Horse-related trauma in children and adults during a two year period. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22, 40. https://doi.org/10.1186/s13049014-0040-8. American Horse Council Foundation (2017). Economic Impact Study of the U.S. Horse Industry; 2017
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Healthcare Cost and Utilization Project (HCUP). Overview of the National Emergency Department Sample (NEDS). (2018).