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Horseback-Riding-Associated Traumatic Brain Injuries -- Oklahoma, 1992-1994

MMWR 45(10);209-211

Publication date: 03/15/1996

Table of Contents


Editorial Note




Each year, traumatic brain injury * (TBI) is associated with 52,000 deaths and accounts for one third of all injury deaths in the United States (2); in addition, approximately 80,000 persons who survive TBI incur some loss of function, residual disability, and increased medical-care needs because of these injuries (3). Major causes of TBI are motor-vehicle crashes, falls, assaults, and sports and recreational activities (3,4). During 1992-1993 in Oklahoma, horseback riding was the leading cause of sports-related TBI (5). To further characterize horseback-riding-associated TBIs, the Oklahoma State Department of Health (OSDH) and CDC analyzed these injuries for 1992-1994. This report summarizes the findings of this analysis.

In 1992, the OSDH established surveillance statewide in Oklahoma for all cases of TBI resulting in death or hospitalization. A case is defined as a TBI recorded on a medical examiner report or coded on a hospital discharge report as specified by International Classification of Diseases, Ninth Revision, codes N800.0-801.9, N803.0-804.9, and N850.0-854.1. Medical records of persons with TBI are reviewed by state injury-prevention service personnel at all 125 hospitals in the state either one, two, or four times per year (frequency depends on the size of the hospital). A standardized data-collection form is completed for each case. Information for all fatal cases is provided by the state Office of the Chief Medical Examiner, which investigates all trauma deaths. Horseback riding and other causes of injury are specified in the narrative of the medical record or medical examiner report.

During 1992-1994, a total of 9409 TBIs occurred in Oklahoma, of which 109 (1.2%), including three deaths, were associated with horseback riding; 23 other TBIs were attributable to horses but were not riding-associated. The numbers of these injuries were nearly equal among females (55) and males (54), and riders ranged in age from 3 years to 71 years (median: 30 years). Cases occurred more commonly during the spring (38) and summer (34) than winter (19) and autumn (18). Nearly one half (48%) of the riding-associated TBIs occurred on a Saturday or Sunday. Of 93 cases for which time of injury was known, 64 (69%) occurred between noon and 8 p.m. Of the 105 cases for which the mechanism of injury was specified, 100 (95%) involved riders who struck their heads either on the ground or a nearby object after falling from the horse, four (4%) who were kicked or rolled on by the horse after falling from the horse, and one (1%) who fell to the ground after his head struck a pole while riding. Of the 96 persons for whom information on type of activity was available, most (86 {90%}) were associated with recreational activity, and 10 (10%) were work-associated. A total of 107 persons were hospitalized (two persons died at the scene) and accounted for 388 hospital days (median duration of stay: 2 days). Among the 106 survivors of riding-associated TBIs, 84 (79%) had one or more indicators of brain injury severity: 67 (63%) had loss of consciousness, 49 (46%) had posttraumatic amnesia, and 14 (13%) had persistent neurologic sequelae on discharge from the hospital (e.g., seizures or cognitive, hearing, vision, speech, and/or motor impairment). Among those hospitalized, the Abbreviated Injury Severity (AIS) scores ** for the head region ranged from two (moderate) (64% of cases) to five (critical) (5% of cases). TBI was listed as the first (of a maximum of 10) discharge diagnosis for 90% of the hospitalized cases and as the first or second diagnosis for 99%.

Among the 23 TBIs attributable to horses not identified as riding-associated, 21 (91%) resulted from a direct kick to the head by a horse; one person died, and two others required cardiopulmonary resuscitation. Thirteen (57%) of these occurred among children aged less than or equal to 10 years. Of the 19 cases for which place of injury was specified, 15 occurred on a farm.

Reported by: P Archer, MPH, S Mallonee, MPH, S Lantis, MPH, Oklahoma State Dept of Health. Div of Acute Care, Rehabilitation Research, and Disability Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: Even though only 1% of the TBIs in Oklahoma were associated with horseback riding, the medical burden of these injuries is substantial as reflected by the adverse neurologic outcomes and number of hospitalization days. In addition, the horseback-riding-associated TBIs described in this report probably underestimate the total number of all such injuries receiving medical care. For example, during 1991, 66% of persons in the United States who received medical care for TBIs were not hospitalized (4), and 79% of regular (i.e., six or more times per year) horseback riders who incurred a concussion or other nonfacial head injury were not hospitalized (6; CDC, unpublished data, 1995). In Oklahoma, only persons with TBIs who are hospitalized are identified by the surveillance system.

In Oklahoma, during 1992-1994, bicycle riding accounted for more than twice the number of TBIs as horseback riding (234 versus 109). However, the risk for injury during horseback riding probably was substantially greater than for bicycle riding: during 1989-1991, the rate of horseback-riding injury sufficiently severe to require hospital-based emergency care was an estimated 28 per 100,000 riding hours (6), while the rate for bicycle-associated injuries was 3.7 per 100,000 riding hours (7). The occurrence of most horseback-riding-associated TBIs during warm weather months, on weekends, and in the afternoon probably reflects greater ridership during those times. The high proportion of nonriding horse-related TBIs among children underscores the need for reducing the risk for direct contact with horses and the importance of using protective head gear for children who cannot be continuously supervised when near horses.

Horseback-riding-associated TBIs can be prevented by wearing protective helmets that meet the American Society of Testing and Materials (ASTM) standards (8). This measure is based on the documented effectiveness of helmet use for preventing bicycle-associated TBI by 88% (9). OSDH has included a recommendation for helmet use in the state's Strategic Plan for Injury Prevention and Control to promote helmet use among horseback riding clubs and organizations in Oklahoma. Additional efforts to prevent this problem should include direct assessment of the effectiveness of helmet use during horseback-riding activities, characterization of the biomechanics of horseback-riding-associated injury, educational programs in safe grooming and riding of horses, and careful matching of horses and supervision to the skill level of the rider.



1. Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines for surveillance of central nervous system injury. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1995.

2. Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury, 1979 through 1992. JAMA 1995;273:1778-80.

3. Kraus JF. Epidemiology of head injury. In: Cooper PR, ed. Head injury. 3rd ed. Baltimore, Maryland: Williams and Wilkins, 1993:1-25.

4. Sosin DM, Sniezek JS, Thurman DJ. Incidence of mild and moderate brain injury in the United States, 1991. Brain Injury 1996;10:47-54.

5. Lantis S. Horseback riding-related traumatic brain injuries. In: Injury Prevention Service. Injury update. Oklahoma City, Oklahoma: Oklahoma State Department of Health, Injury Prevention Service, April 1994.

6. Nelson DE, Rivara FP, Condie C, Smith SM. Injuries in equestrian sports. The Physician and Sportsmedicine 1992;22:53-60.

7. Rodgers GB, Tinsworth DK, Polen C, et al. Bicycle use and hazard patterns in the United States. Washington, DC: US Consumer Product Safety Commission, 1994.

8. American Academy of Pediatrics Committee on Sports Medicine and Fitness. Horseback riding and head injuries. Pediatrics 1992;89:512.

9. Thompson RS, Rivara FP, Thompson DC. A case-control study of the effectiveness of bicycle safety helmets. N Engl J Med 1989;320:1361-7.

* Either 1) an injury to the head that is documented in a medical record, with one or more of the following conditions attributed to head injury: observed or self-reported decreased level of consciousness, amnesia, skull fracture, objective neurologic or neuropsychologic abnormality, or diagnosed intracranial lesion; or 2) death resulting from trauma, with head injury listed in the sequence of conditions that resulted in death on the death certificate, autopsy report, or medical examiner's report (1).

** AIS is an anatomic injury-severity scale ranging from one for minor injury to six for maximum injury.


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