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

Juniper Publishers- Journal of Physical Fitness, Medicine & Treatment in Sports


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).


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.



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

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 (X2 1 = -0.165, p = 0.114). A highly significant association was found between years of riding and pain (X2 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.


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 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 [24-27]. 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 [35-37], 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 [35-37,39]. 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 [40-96].


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.


The authors would like to acknowledge those who kindly took the time to participate in the study.

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Weaning Pattern Characteristics, Based on Simplified Acute Physiology Score 3, of Critically Ill Patients Requiring Ventilator Care-Juniper Publishers

Background: The Simplified Acute Physiology Score 3 (SAPS 3) scoring system was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. The present study focuses on how outcomes, according to SAPS 3 score, differ in patients receiving or not receiving mechanical ventilation.
Methods: We retrospectively reviewed electronic medical records of patients admitted to the surgical or medical ICU from October to December 2014. The SAPS 3 model scores were evaluated for all patients, and for subgroups of patients receiving mechanical ventilation (MV group) or not (Non-MV group). The MV group was further subdivided into two groups, based on the ventilator weaning (simple [MV-SW] and others [MV-Others]), to compare patient characteristics and mortality, based on SAPS 3 scores.
Results: The SAPS 3 score and mortality were significantly higher, and the length of ICU stay was significantly longer in the mechanical ventilation group (p = 0.004, p < 0.001, and p = 0.007, respectively) compared to the non-mechanical ventilation group. The MV-SW group included patients requiring significantly more postoperative care, while the MV-Others group had more patients intubated due to hypoxemia (p < 0.001). The AUC value, indicating discrimination, was 0.871.
Conclusion: The present study, conducted using the SAPS 3 score, showed good discrimination. It is believed that this method will be useful in predicting weaning difficulties and mortalities of patients requiring mechanical ventilation.
Keywords: Intensive care unit; Mechanical ventilation; Mortality; SAPS 3; Ventilator weaning


Severity scoring systems are used to predict and compare outcomes, to help guide the allocation of limited resources and to evaluate the process of care in intensive care units (ICU). In critically ill patients, several scoring systems have been developed over the last three decades [1,2]. The Acute Physiology and Chronic Health Evaluation (APACHE) and the Simplified Acute Physiology Score (SAPS) are the most widely used scoring systems in ICUs. Recently, the SAPS 3 was developed through a worldwide prospective study to predict hospital mortality in critically ill patients. It is based on 20 different variables, that are easily measured at patient admission, and dissociating patient status from the quality of care in the ICU [3-7]. There has, however, been no investigation into how outcomes differ in patients receiving or not receiving mechanical ventilation.
The aim of this study was to evaluate the epidemiology and prognostic performance of the SAPS 3 in a retrospective electric chart review, and to describe the weaning pattern characteristics of patients receiving mechanical ventilation.

Material and Methods

The study protocol was approved by the institutional review board.

Patient population

All patients admitted to the surgical or medical ICU from October to December 2014 were included in the present study. In addition, patients who were admitted to the ICU with serious medical or surgical postoperative complications were also included. Pediatric patients (<18 years of age), patients with an ICU stay < 24 h, and patients who were readmitted after an initial ICU discharge were excluded.

Data Collection

One individual retrospectively reviewed the electronic medical records. These records provided all of the data required to predict the mortality rate using the SAPS 3 model. The SAPS 3 score was obtained from the most severe laboratory findings 1 h before or after ICU admission. Predicted hospital mortality rate (PMR) was calculated using the following equation; where score means SAPS 3 admission score [6].
The performance of the model was evaluated in all patients, as well as, in two subgroups of patients who had received mechanical ventilation (MV group) or not (Non-MV group). Based on the ventilator weaning pattern, the MV group was further subdivided into two groups to compare the characteristics and prolonged, or chronic mechanical ventilation weaning.

Statistical Analysis

Statistical analyses were performed using IBM SPSS Statistics 21 for Windows. Data were reported as means ± standard deviation (SD) or medians with 25th and 75th quartiles for continuous variables, and percentages for quantitative variables. Student's t-test, chi-squared test, or Fisher's exact test were used depending on whether the variables were continuous or categorical. P-values less than 0.05 were used to indicate statistical significance. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to measure discrimination for hospital mortality.


MV: patients who received mechanical ventilation; Non-MV: patients who did not received mechanical ventilation; OR: operating room; PACU: postanesthetic unit; eR: emergency room; ICU: intensive care unit; IM: internal medicine; GS: general surgery; NS: neurosurgery; TS: Thoracic surgery; OS: orthopedic surgery; PS: plastic surgery; UR: urosurgery; NR: neurology; SAPS: Simplified Acute Physiology Score; IQR: Interquartile range.
Of the 154 patients admitted to the ICU between October and December 2014, 2 pediatric patients, 4 readmissions, and 7 patients with missing data, mostly due to ICU length of stay < 24 h, were excluded. The study group, therefore, comprised 141 patients: 76 males (53.9%) and mean age 67.7 yr. The characteristics of the study group are shown in (Table 1). There were no significant differences in demographic characteristics between patients in the MV group and the Non-MV group. The SAPS 3 score and ICU mortality were significantly higher in the MV group (p = 0.004 and p < 0.001, respectively). In addition, length of ICU stay was significantly longer (p = 0.007) for the MV group.
MV-SW: patients who received mechanical ventilation and simple weaning; MV-Others: patients who received mechanical ventilation and all other weaning groups; SAPS: Simplified Acute Physiology Score; IQR: inter-quartile range.
The MV group (n = 43; excluding 2 patients with missing weaning protocol data) was subdivided based on weaning pattern. When the reason for the intubation was compared between subgroups, the MV-SW group included patients requiring significantly more postoperative care, while the MV-Other group had significantly more intubations due to hypoxemia (p = 0.001). Observed mortality, SAPS 3 score, and predicted mortality were significantly higher in the MV-Other group (Table 2), and observed mortality (60.0%) was higher than the predicted mortality (39.4%).
Hospital mortality was considerably greater in patients with higher SAPS 3 scores. The highest hospital mortality rate was observed in patients with a SAPS 3 score greater than 90 (Figure 1). Discrimination, as measured by the AUC, was good (AUCs = 0.871), (Figure 2).


In the present study, the mean SAPS 3 score of all patients was 46.1; the score was 10 points higher for the group requiring mechanical ventilation compared to the group without. Although there were no significant differences in gender, age, route of admission, and department between the groups, the group requiring mechanical ventilation exhibited longer ICU stays and higher mortality. Among members of the MV group, those capable of simple weaning showed lower severity scores and mortality.
Many previous studies have shown that SAPS 3 is a scoring system model with good discrimination but poor calibration [5,8-10]. In the present study, the AUC value, which indicates discrimination, was 0.871; this is similar to previous studies (0.8-0.89) and indicates favorable discrimination [5,11]. While there were no in-hospital mortalities in patients with SAPS 3 scores of <40 points, patients with scores of 41-90 points had a mortality rate under 50%, and the mortality rate increased rapidly for patients with scores >90.
Unlike previous SAPS 3 studies that compared discrimination or calibration to outcomes from other scoring models or investigated regional variations [10,12-14], the present study focused on how outcomes differed in patients receiving or not receiving mechanical ventilation. This is because, among various factors affecting SAPS 3, the effect of applying mechanical ventilation on the score is minimal; however, a significant number of patients in the ICU receive ventilator care and applying mechanical ventilation has a clinically significant impact on the clinical course of critically ill patients.
The patient group requiring mechanical ventilation was divided into two subgroups based on the weaning pattern. The simple weaning (MV-SW) group included patients with successful 1st extubation after the 1st SBT. The other (MV-Other) group included all other weaning groups: Difficult weaning (failed 1st SBT trial, but succeeded within the 3rd SBT trials or successful weaning within 7 days after the 1st SBT); prolonged weaning (failed weaning on the 3rd SBT trial or required more than 7 days on the 1st SBT); and chronic mechanical ventilation weaning (the same as tracheostomy) [15,16].
The majority of patients from our hospital had chronic mechanical ventilation weaning when simple weaning failed; for this reason, we consolidated the three groups into one. Since most of the patients who had simple weaning were those who underwent extubation after maintaining mechanical ventilation for postoperative care due to old age, prolonged operation time, or underlying diseases (19 subjects, 82.6%), they not only showed lower SAPS 3 scores, but also lower mortality rates compared to the MV-Other group. Conversely, most ofthe patients within the MV-Other group were intubated for mechanical ventilation because of hypoxemia caused by impairment of normal ventilation function (17 subjects, 85%), which may have manifested as an increase in the severity of weaning.
The mean length of hospital stay for the MV-Other group, whose conditions were more severe, was not significantly different from the MV-SW group; this may be attributed to a shortened overall length of hospital stay due to the larger number of "do not resuscitates" (DNRs) and patients who passed away in this group. Moreover, it can be surmised that the observed mortality rate (60.0%) in this group was higher than the predicted mortality (39.4%) because of the influence limited proactive management for patients who were expected to have unfavorable prognosis and had effectuated DNRs in advance.
The limitations of this study include having a small number of participants, which resulted in a low number of patients in the ventilated group and corresponding subgroups. In addition, at the time of data collection, the hospital did not have a standard weaning protocol; weaning was carried out either by applying a T-piece or a pressure support ventilation (PSV) mode after the SBT and the protocol used was determined by the doctor in charge of the department. Consequently, the reason for a patient not having been placed into a weaning subgroup may not have been due to the patient's condition.
Furthermore, while all charts were reviewed by a single person responsible for the ICU, the SAPS 3 scores were inputted by different doctors who were in charge of the department at the time of admission; for this reason, individual evaluator errors cannot be eliminated. We plan to perform future studies with a larger number of patients; furthermore, the hospital plans to implement a standard SBT protocol, therefore data obtained after the protocol is applied may be compared to the results presented to allow the mechanical ventilation subgroups to be more clearly defined to determine any differences.


In conclusion, in the present study, conducted on patients who were hospitalized in the surgical or internal medicine ICU, SAPS 3 score assisted-evaluations showed good discrimination. It is believed that this will be a useful method for predicting weaning difficulties and mortalities in patients requiring mechanical ventilation.


This work was supported by a research grant from Jeju National University Hospital in 2015.
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