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Emilie was an avid rider, but one fall from her horse drastically changed her life. She sustained a concussion. For months afterward, she grappled with headaches, dizziness and brain fog. Emilie gave up riding and struggled to complete her schooling. Although many years have passed since her injury, she still experiences symptoms. She can only manage part-time work and worries that she will have to give up her dream of becoming a teacher.

Unfortunately, Emilie’s story is not rare or even unusual. We all know that riding poses a relatively high risk for head injury when compared to other sports. The horse is a large animal, equestrian competition often involves great speed, and accidents can happen when we least expect them. What’s more, any mishap involving the head has the potential to cause concussion. Health care professionals warn that some of the subtler effects of brain injury can be difficult to recognize and may linger in ways that can affect mental health and overall well-being for years afterward.

“Most people are aware of the major symptoms of concussion, including headache, confusion and balance problems,” says Ansley Grimes Stanfill, PhD, RN, FAAN, of the University of Tennessee Health Science Center. “But many are likely to shrug off some of the symptoms that may arise later, such as feeling sluggish or ‘blue,’ sensitivity to light or sound, or difficulty sleeping. Concentration problems are also common and many find that computer work or other screen time exacerbate their post-concussion symptoms.”

How equestrian sports are unique

Much of what we know about equestrian head injuries comes from research into other sports. “Concussion has received increasing attention both within academic research and the media,” says Hannah Butler-Coyne, BSc (Hons), MSc (Psych. Child Develop), MSc (Sport & Exercise Psych), DClinPsy. “However, the majority of academic studies tend to involve contact sports such as football and rugby.”

Still, a growing body of research has advanced understanding of the types of head injuries equestrians typically sustain, as well as the prevalence of mental health challenges that may complicate healing. 

Several specific stress factors are intrinsic to equestrian sports, says Butler-Coyne. Not only must riders manage the financial requirements and the life-shaping training regimens required for any elite athletic performance, but they also shoulder the burdens of horse ownership. In addition to worrying about their own physical well-being, riders in high-stakes equestrian sports must deal with the emotional strain of putting their horse’s safety at risk.

All of these factors can make concussions more difficult to manage for equestrians as compared to other athletes. “Navigating these often-relentless pressures can lead to stress and increased vulnerability to mental health difficulties, alongside the dilemma of what to do and how to cope—all of which impact riding ability, decision making, the horse-rider relationship, psychological well-being and, ultimately, performance,” Butler-Coyne says. “Research findings offer a unique holistic understanding of the experiences of equestrian sportspeople and the potential factors contributing to mental health and well-being, not only within equestrian sport, but also more widely in consideration of involvement in sport in general.”

A whole new dimension

Head injury—or, more specifically, traumatic brain injury—adds another dimension to the already formidable challenges riders face. This type of trauma can alter brain structure, damage neural circuits, change cerebral blood flow and trigger biochemical changes. All of this can have far reaching effects.

Sport and exercise psychology coach Annika McGivern, MSc, herself a rider, has studied the effects that concussion can have on the mental health of equestrians. With Stephen Shannon, PhD, and Gavin Breslin, PhD, at Northern Ireland’s Ulster University, McGivern co-authored the paper “Resilience, well-being, depression symptoms and concussion levels in equestrian athletes,” which was based on a survey of equestrian athletes in Canada, Ireland, the United Kingdom, Australia and the United States.

In addition to collecting data on the respondents’ horse-related activities, the survey asked them to describe injuries they had sustained as well as their outlook on the future and their perceptions of their own well-being.

McGivern says the survey results suggested a link between incidents of concussion and depression. For example, equestrians who sustained multiple concussions were 2.4 times more likely to struggle with depression than were those who had not been injured. Beyond the statistics, though, McGivern says the research revealed widespread concern that the needs of many equestrians are unacknowledged or ignored.

A large response

“I think my biggest take-away from this study was the large response, which to me indicated that equestrians felt this was an important topic that warranted more research and discussion,” she says. “Although I knew concussions were common in the sport, it was still surprising to see the very high numbers that many participants reported. I was also surprised by how many of the participants felt they had not received adequate support following concussion(s).”

In addition, McGivern found a correlation between concussion and increased symptoms of Major Depressive Disorder, similar to findings in other sports.

“I believe the major call to action is to develop awareness of mental health within equestrian sport so that riders feel they can ask for support when needed,” she says. “The more we can talk about it and bring it into the open, the more we can normalize asking for help and supporting one another to get the help and support needed to cope with the pressure of the sport and the challenging injuries we can incur while doing it.”    

Of the riders from all disciplines who participated in the survey, 27 percent reported symptoms of severe depressive illness. The signs were most common among the upper-level riders.

Helmet use and knowledge gaps

These statistics point to the importance of measures to prevent head injuries, namely wearing helmets. A 2020 University of Tennessee Health Science Center study, spearheaded by Stanfill, shows progress has been made in the area but more needs to be done.

In a survey of nearly 2,600 adult riders conducted through social media, the researchers sought to better understand attitudes toward helmet use and concussion awareness among equestrians. While 76 percent of respondents reported that they always wear helmets when riding, about 15 percent indicated that they never wore a helmet. Equestrians in the latter group listed various reasons: While 49 percent of those respondents cited poor fit as the reason they skipped helmet use, others said helmets were too hot (44 percent) or caused general discomfort (38 percent). About 41 percent said they simply chose not to wear a helmet.

Stanfill, herself an amateur dressage rider, was surprised to see riders still cite discomfort and poor ventilation as deterrents to helmet use. “With all of the technological advancements over the past several years, we are a far cry from the velveteen ‘mushroom hats’ of my time as a teenager and young adult,” she says.  “My own helmets are so lightweight and well-ventilated that I hardly notice they are on, even when training in steamy Memphis summers.”

Hardship and resilience

Another striking result: the number of write-in responses describing the hardships resulting from riding-related brain injuries. “The majority of these people had been through—or had loved ones affected by—traumatic brain injury,” Stanfill notes. “Some of the responses became quite lengthy as they told the story, and it became clear to me that these individuals were really looking for an opportunity to share their experiences with others.”

Overall, she says, the research points to the need for greater awareness of the concussion risks posed by equestrian sports and the readily available means for mitigating them.

“Traumatic brain injury (TBI) is all too common in equestrians, and some studies have even demonstrated that equestrians are more likely to have a TBI than combat veterans,” Stanfill explains. “The proper use of an ASTM/SEI-certified helmet can greatly reduce that risk, especially if the helmet has Multidirectional Impact Protection System (MIPS) technology.” 

Education is key

For nearly four decades, equestrian organizations have been working to educate their members about the risks of concussion while promoting the use of helmets. And innovations in headgear technology have greatly increased the number of riders who take this vital precaution to protect against head injury. Now, however, revelations of the potential lingering effects of concussion/traumatic brain injury and the possibility that riders are uniquely susceptible to related mental health challenges brings new urgency to these discussions. 

There is clearly a “compelling need for education, promotion of sharing experiences, facilitation of specialist professional training and intervention—as well as a review of regulations from equestrian governing bodies,” Butler-Coyne says. As for her own research, it “… offered essential opportunity to consider ways forward in how best to support the psychological well-being and mental health of our equestrian sportspeople.”