When I was a kid, no one paid all that much attention to concussions. Heck, we were lucky if we were wearing helmets that offered even a modicum of protection. Most of us got up, sat down again if we saw stars, and were probably back riding within a day or two. But, let’s face it: when you fall off a horse, especially if you’re traveling at speed, you can easily suffer from at least a mild concussion.

Medical knowledge about Traumatic Brain Injury (TBI), which includes concussion, has improved significantly over the past 40 years. Today, most of us wear vastly more protective helmets, and we know more about the cumulative effects of concussion. Today, doctors understand that the brain needs time and rest to ensure recovery. Since many symptoms of concussion are fleeting or mild, it’s easy to dismiss them and not provide adequate time for recovery.

Almost every concussion causes some damage to the brain; additional concussions are more severe, especially if they occur within a year of the first because the brain is more susceptible to injury when it has not fully recovered from the first injury. In fact, someone who sustains a brain injury is 3 times as likely to sustain a second brain injury; people who sustain a second brain injury are 8 times more likely to sustain a third brain injury. (Source: The Center for Brain Injury Services). Repeat concussions, even when mild, can increase the risk of post-concussive symptoms (PCS) such as headaches, memory loss, difficulty concentrating, etc. Chances of PCS are even more increased if the second injury occurs too soon, before recovery from the first has taken place. The higher the rate of concussions, the higher the risk of long-term cognitive dysfunction.

While there is some disagreement among experts about the exact distinction among grades of concussions, the distinctions and recommendations provided by the American Academy of Neurology provide a good example:

A concussion is defined a head-trauma-induced alteration in mental status that may or may not involve loss of consciousness. Concussions are graded in three categories. Definitions and treatment recommendations for each category are presented below. 

Grade 1 Concussion: 

Definition: Transient Confusion, no loss of consciousness, and a duration of mental status abnormalities of less than 15 minutes. 

Management: The athlete should be removed from sports activity, examined immediately and at 5 minute intervals, and allowed to return that day to the sports activity only if post concussive symptoms resolve within 15 minutes. Any athlete who incurs a second Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 1 week.

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Grade 2 Concussion: 

Definition: Transient confusion, no loss of consciousness, and a furation of mental status abnormalities of more than 15 minutes. 

Management: The athlete should be removed from sports activity, examined immediately and frequently to assess the evolution of symptoms, with more extensive diagnostic evaluation if the symptoms worsen or persist for more than 1 week. The should return to sports activity only after asymptomatic for 1 full week. Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed from sports activity until asymptomatic for 2 weeks.

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Grade 3 Concussion: 

Definition: Loss of consciousness, either brief (seconds) or prolonged (minutes or longer). 

Management: The athlete should be removed from sports activity for 1 full week without symptoms if the loss of consciousness is brief, or 2 full weeks without symptoms if the loss of consciousness is prolong. If still unconscious, or if abnormal neurologic signs are present at the time of initial evaluation, the athlete should be transported by ambulance to the nearest hospital emergency department. An athlete who suffers a second Grade 3 concussion should be removed from sports activity until asymptomatic for 1 month. Any athlete with an abnormality on computed tomography or magnetic resonance imaging brain scan consistent with brain swelling, contusion, or other intracranial pathology should be removed from sports activities for the season and discouraged from future return to participation in contact sports.

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Features of Concussion Frequently Observed: 

1. Vacant stare (befuddled facial expression) 
2. Delayed verbal and motor responses (slow to answer questions or follow instructions) 
3. Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities) 
4. Disorientation (walling in the wrong direction; unaware of time, date and place) 
5. Slurred or incoherent speech (making disjointed or incomprehensible statements) 
6. Gross observable incoordination (stumbling, inability to walk tandem/straight line) 
7. Emotions out of proportion to circumstances (distraught, crying for no apparent reason) 
8. Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorize and recall 3 of 3 words, or 3 of 3 objects in 5 minutes) 
9. Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal) 

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What does all of this mean for equestrians? There’s been discussion recently on one of the equestrian forums about a professional rider that is about to begin competing about five months after suffering a level 3 concussion. There is concern that lingering effects from the initial TBI may have impaired the rider’s judgement about the wisdom of putting themselves at risk to suffer a second brain injury on the heels of the first, especially when that injury may still cause them to be disoriented, or prevent them from making the split second decisions that can come up during a cross country course.

None of us can know what that rider’s current state of healing might be. And few of us are professional equestrians, whose livelihood depends on competition. Personally, if I fall off my horse, I am now much more conscious (so to speak) to check for any subtle signs that I might have a concussion. If I’m at all concerned, I telephone my doctor.

I always wear an approved helmet, but if I hit my head at all while wearing it, I buy a new one. In fact, I replace my schooling helmet about every three years as a matter of course. 

I haven’t had a concussion for many years, but I am now mature enough and wise enough to take time off if I need it.