A Preliminary Study to Investigate the Prevalence of Pain in Competitive Showjumping Equestrian Athletes

Due to the unpredictable nature of a 500kg animal capable of travelling at speeds of 65-75kmh-1 [1] horse riding has a high injury risk; arguably making it one of the most dangerous sporting activities to participate in [2,3]. The hospitalisation rate for equestrian activity is 49 hospital visits for every 1000hours of riding compared to rugby that has a hospital rate of 93 per 1000hours [4]. Most injuries occur as a result of falling off the horse whilst riding [1,5] and the more severe injuries often occur during a fall whilst jumping fences [6,7]. There have been sixty reported deaths occurring during jumping competitions between 1993 and 2017 which has encouraged the governing bodies of equestrian sports to work to improve safety standards [8,9].


Introduction
Due to the unpredictable nature of a 500kg animal capable of travelling at speeds of 65-75kmh -1 [1] horse riding has a high injury risk; arguably making it one of the most dangerous sporting activities to participate in [2,3]. The hospitalisation rate for equestrian activity is 49 hospital visits for every 1000hours of riding compared to rugby that has a hospital rate of 93 per 1000hours [4]. Most injuries occur as a result of falling off the horse whilst riding [1,5] and the more severe injuries often occur during a fall whilst jumping fences [6,7]. There have been sixty reported deaths occurring during jumping competitions between 1993 and 2017 which has encouraged the governing bodies of equestrian sports to work to improve safety standards [8,9].
Ball et al. [10] identified that over half of riders that had been hospitalized due to an acute riding injury, experienced chronic physical difficulties following their accident including chronic pain, weakness, decreased balance, headaches, limited use of limbs, decreased memory and mood changes. Whilst acute injuries resulting from horse riding have been documented, evidence is mainly anecdotal suggesting that musculoskeletal injuries arising from overuse could result in riders experiencing chronic pain. Horse riders are at a greater risk of experiencing chronic pain particularly back pain that the non-equestrian population [11,12]. This may be due to the repetitive nature of riding and/or as a longer-term consequence of an acute riding injury.
Research has examined the chronic pain experience by equestrian athletes competing in Dressage [12] and Elite Eventing [13] but to date there have been no published studies investigating pain experienced by equestrian athletes competing in showjumping. The demands placed on the rider do differ between disciplines both in terms of physiological demands and biomechanical skill [14]. The aim of the study was to investigate the prevalence of competitive showjumping athletes who experience pain, the location of their pain, factors affecting their pain and whether they perceive this pain to effect on their riding performance.

Materials and Methods
A six part 34 question on-line survey (Survey monkey) was made available to equestrian athletes who competed in showjumping, and who were aged eighteen years and over following full institutional ethical approval. The on-line survey was accessible for a 1 month period and no incentive was offered to participants. An online survey was chosen as they reduce time, cost and potential error arising from the transcription of paper questionnaires, in addition to allowing participants to respond at their convenience [15]. Volunteer participants were recruited from personal contacts via email and number of specialist equestrian social media sites (such as the Horse & Hound forum) was identified and a link to the survey was posted on these sites. A snowball sampling technique was employed where those receiving an email regarding the survey were asked to send on the email to other female horse riders that they knew. Due to the anonymity of the survey, completion of the form was considered as consent to take part in the study (as explained to them in the participant information sheet preceding the survey).

Measure
A survey was constructed using the principles put forward by Diem [16]. The survey containing twenty questions was developed containing a mixture of closed -response (e.g. Yes/ no and Likert scale) and open-response items designed to take no longer than 10 minutes to complete. Section 1 asked respondents to state their eventing competition level. Section 2 asked questions related to previous injury and self reported level of pain (adapted from validated questions taken from shortform McGill Pain Questionnaire [17], location and cause of this pain. Section 3 was specific to the perceived impact this pain had on their performance. Section 4 asked what factors contributed to increased levels of pain when riding (e.g. saddle, movement of the horse, cold weather, yard work). Information related to the participants management strategies for dealing with this pain (e.g. over the counter pain medication, prescription pain medication, manual therapy such as physical therapy, chiropractic treatment and other strategies) was also gathered. The final section (5) was modified for equestrian athletes from the Oswestry pain questionnaire [18] to assess the impact their pain has on their general life and wellbeing. Validity evidence for the instrument was provided by reviewing the questionnaire for: (1) clarity of wording, (2) use of standard English and spelling (3) reliance of items, (4) absence of biased words and phrases, (5) formatting of items, and (6) clarity of instructions [19]. Two faculty senior academics experienced in survey design, were asked to use these guidelines to review the instrument. Based on the reviewers' comments the instrument was revised and as a pilot study the questionnaire was distributed to 10 riders before further revisions were made prior to final administration.

Data Analysis
In total there were 110 survey responses; however of these only 91 identified that showjumping was their main riding discipline. Eleven participants did not complete the survey fully. As such, the data for the remaining 80 participants met the inclusion criteria for data analysis and the remaining 30 responses were discounted. Data from the Survey monkey  package were downloaded into a Microsoft Excel (2010) spreadsheet. Descriptive statistics were used to report frequencies and percentages within data. The Chi-squared test and odds ratios were utilized to assess prevalence of pain experienced by showjumping riders. An alpha value was set at p<0.05 (confidence interval 95%) throughout unless otherwise stated. Data were analysed using SPSS for Windows version 24. Figure 1: The self-reported pain experienced by Showjumpers.

Journal of Physical Fitness, Medicine & Treatment in Sports
The 80 showjumping participants had a median age of 23 years (Interquartile range from 20 to 31 years). The majority of participants (89 %) were female and only 11 % were male. The majority of participants (70 %) self-described as amateur competitive riders, with 12.5 % described as recreational riders and 17.5 % self-described as professional riders. Figure  1 describes the pain reported by the participants, with a participant being 1.42 times more likely to experience pain than to be pain free.

Participants Self-Reporting Pain
A participant was twice as likely (2.0 times) to be experiencing chronic pain (67%) as acute pain (33%). If they solely competed in showjumping this odds ratio increased to 2.2 times more likely to be experiencing chronic pain than acute pain. Participants who competed in other disciplines as well as showjumping were 1.5 times more likely to be experiencing chronic pain compared to acute pain.
Of the participants reporting pain, 85% reported experiencing neck and back pain. The majority of these experienced lower back pain. 66% of participants reported experiencing pain in other regions of the body, with the knee being the most common. Table 1 displays the location and level of pain experienced by participants. The majority of pain was described as being mild, however participants experiencing hip and upper back pain had median levels of moderate pain. Some participants did report severe pain. The median durations of pain experienced all exceeded two years, with participants reporting neck, elbow, head and wrist pain reporting median durations of four to five years. Only 15% of those reporting pain had had a medical diagnosis. Only 15% of those reporting pain said that it has prevented them from riding, for durations ranging from the occasional day periodically to a whole year. 85% of participants reported that their experience of pain did not stop them riding.
30% of participants with pain did not report any method of management or treatment. The majority, 70% reported that they did try to manage or treat their pain. The most common method participants reported using to manage or treat their pain was over the counter medication. 67% of those using a management or treatment method used over the counter medication with only 9% using prescription medication. 47% reported using a manipulative therapy to manage or treat the pain, most commonly physiotherapy. 25% utilised an exercise programme to manage or treat the pain.
There was no association between age and report of pain (X 2 1 = -0.165, p = 0.114). A highly significant association was found between years of riding and pain (X 2 1 = -294, p = 0.004). 85% percent of riders perceived their pain to impact on their riding performance. Most commonly they believed that it affected their postural asymmetry (45%), followed by reducing their range of motion (36%), causing fatigue (24%), affecting mood by increasing anxiety and irritability (21%), and reducing concentration (19%). Only 14% of participants directly reported it affecting the horse by causing asymmetry.

Discussion
This is a preliminary and exploratory study, using a purposeful sample. The study identified that 61% of competitive showjumpers competing at the novice to sub-elite level were experiencing pain. This was lower than was seen in elite dressage riders [12] and elite event riders [13]. Chronic injury is a common cause of early retirement from sport [20,21], however there is little evidence to suggest this is a problem within the sport of showjumping. As with other equestrian sports, showjumping is considered an early start, late maturation sport [22], where the mean age of British Olympic showjumping riders in the twenty-first century is forty four years old [23]. It appears that many showjumping riders, such as Olympic Gold Medallist Nick Skelton, who won the gold medal at Rio at the age of sixty despite being in chronic pain after several serious injuries including a broken neck, continue to ride and compete. Lewis & Kennerley [12] and Lewis & Baldwin [13] found a significant relationship between elite equestrian athletes' pain and their perception that this pain effected their riding performance. Douglas et al. [14], suggested that riders often do not consider

Journal of Physical Fitness, Medicine & Treatment in Sports
themselves as the athlete within the unique dyad relationship that they have with their horse and if the horse is not injured then pain they experience is not a reason for rest, rehabilitation or even retirement from the sport.
In this current study eighty-five percent of riders believed that the pain affected negatively on their riding performance by effecting their posture, increasing fatigue, reducing their range of movement and effecting their concentration. Posture is a key element in any equestrian discipline where the rider aims to maintain a straight line running through the ear-shoulderhip-heel whilst moving in rhythm and harmony with the horse's movement [24][25][26][27]. To maintain this position requires stabilization and isometric contraction of the core muscles [28] are needed to enable the trunk to return to equilibrium after perturbation. In order to control the horse the rider must be able to apply individual hand and leg 'aids' or signals by disassociation movements of the arms and legs. Injury or damage to the 'core' muscle groups can result in chronic lower back pain. 86% of riders in this study reported lower back pain suggesting that the cyclic nature of riding may damage these soft tissue structures [11] and that pain in these structures may have and impact of postural control whist riding. The activity of jumping requires the rider to alter or adjust their position by adopting a forward seat in order to cope with the increased mechanical forces involved. During jumping, the rider closes the hip and thigh angle and moves the trunk into a more forward position. In order to maintain their balance through the jumping phase the rider's weight is absorbed by the legs, as opposed to pelvis and legs as seen in the regular riding position [14,29,30]. This adjustment in position requires a great deal of control of the body segments as the rider has to deal with acceleration forces from the horse particularly on landing [30]. Any restriction in the rider's range of movement as a result of pain will effect their position over the fence and will impact on the performance of the horse. Riders also stated that the pain effected their levels of fatigue. Nadler [31]; Kankaanpaa et al., [32] and McGill [33] identified poor endurance in hip extensor muscles (Gluteus maximus) and hip abductors (Gluteus medius), key muscles used to maintain an effective riding position, in individuals that had chronic LBP, suggesting a link between fatigue in these muscle groups and pain.
Participants also noted that the pain affected their concentration. In showjumping riders are required to ride from memory a set pattern of fences of up to 15 obstacles, some with multiple jumping elements, usually with several changes of direction. Failure to jump the fences in the correct order results in an elimination [34]. Equestrian athletes must also process many variables from the horse and environment including speed, stride length, straightness, quality of the gait, ground conditions, type of fence, height of fence etc. in order to position the horse in the optimal take off zone to jump the fence cleanly. Failure to process this information and to make correct decision could result in the horse knocking the fence down (4 faults) or refusing to jump the fence (4 faults) Therefore, any disturbance to the rider's concentration caused by pain may effect performance and safety of horse or rider.
The majority of showjumpers in the study employed pain management strategies. The most common strategy was the use of over-the-counter (OTC) non-steroid anti-inflammatory drugs (NSAIDs) such as aspirin, paracetamol and ibuprofen. Only 9% of showjumping riders used prescription, which is consent with results found in dressage and event riders [12,13]. NSAIDs are widely used in other [35][36][37], in part due to the ease, cost and accessibility of these drugs. Berglund and Sundgot-Borgen [38], exterminated that sporting athletes use NSAIDs six to ten times more often than the general population, this puts sports people at the potential risk of over mediating or over reliance on pain medication to continue training or competing. The use of self-medicating NSAIDs puts the rider showjumping rider at risk of non-compliance with the World Anti-Doping Agency (WADA) regulations and also the potential risk of side effects of these drugs. Frequent use of NSAID can cause damage to the cardiovascular system, gastro intestines (GI), kidneys and liver [35][36][37]39]. Following one month regular use of NSAIDs users have a higher relative risk of bleeding in the upper GI tract, other side effects include dyspepsia, nausea, ulcers .

Conclusion
This study using a small sample of equestrian athletes established that there is a high incidence of showjumpers who compete with pain, particularly back and neck pain. This is of some concern giving how long a showjumper can participate in the sport, which can span several decades. Participants reported that this pain effected their posture whilst riding, reduced their range of motion, caused fatigue, effecting mood by increasing anxiety and irritability, and reducing their concentration, all of which is likely to impact on both performance and safety. Despite pain experienced and effect on performance a large number of equestrian athletes continued to compete. Athletes self-medicating using NSAIDs could be putting themselves at an increased risk of long-term health issues. This research reports athlete's perceptions and self-reported pain and management options, which may affect the data. Further research is needed to establish the causes of pain and appropriate management strategies.