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A Preliminary Study to Investigate the Prevalence of Pain in Competitive Showjumping Equestrian Athletes- Juniper Publishers
Ball et al.  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  and Elite Eventing  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 . 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.
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.
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  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  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 . 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 ; Kankaanpaa et al.,  and McGill  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 . 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 , 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].
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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
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.
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.
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).
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.
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