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QUALITY IMPROVEMENT REPORTS 

 

17 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 4 – Issue 3 – November 2021 
 

A Proposed Return-to-Ride Protocol for United States Jockeys 
Following Concussion   
Carolina Quintana, PhD, ATC*; Kimberly I. Tumlin, PhD, MS, MPH†; Matthew C. Hoch, PhD, ATC†; Nicholas 
R. Heebner, PhD, ATC†; Bianca L. Grimshaw‡, MS, ATC, OTC; Carl G. Mattacola, PhD, ATC**  
*California State University, Fresno, Fresno, CA; †University of Kentucky, Lexington, KY; ‡University of Louisville Health Sports 
Medicine Institute, Louisville, KY; **University of North Carolina Greensboro, Greensboro, NC  
 

 
ABSTRACT 

Professional horse racing jockeys participate in a high-risk 
sport, however there is limited research and policies 
regarding welfare and safety. Despite the high incidence 
and risk of concussions, there are not standardized protocols 
for returning these unique athletes to participation following 
concussion. A return-to-ride concussion protocol for 
thoroughbred horse racing athletes must take into account the 
unique considerations and practices of the sport. Current 
concussion management strategies suggest removal from 
riding and activity when a concussion is suspected. This is 
followed by further evaluation for diagnosis, a period of 
both cognitive and physical rest before a gradual return-to-
activity prior to full medical clearance and a return to 
previous levels of activity and competition. The proposed 
protocol follows suggested strategies while tailoring the 
graduated return-to-activity to meet the needs of the US 
jockey population. This protocol may be used following injury 
to ensure an adequate recovery and safe return-to-activity 
and is outlined such that it can be followed by an individual 
athlete and provides descriptions for each activity and stage.  
 
Key Phrases 
Concussion; policy and procedure development; risk 
management and mitigation 

Correspondence 
Dr. Carolina Quintana Department of Kinesiology, California 
State University, Fresno, 5275 N. Campus Dr. M/S SG28 
Fresno, CA 93740-8018. 
E-mail:  carolinaquintana@mail.fresnostate.edu  
Twitter: @cquintanaatc 

Full Citation 
Quiutana C, Tumlin KI, Hoch MC, Heebner NR, Grinshaw BL, 
Mattacola CG. A proposed return-to-ride protocol for 
United States jockeys following concussion. Clin Pract Athl 
Train. 2021;4(3):17-27. 
https://doi.org/10.31622/2020/0004.3.4.  
  
Submitted: February 25, 2021 Accepted: June 15, 2021 

INTRODUCTION 

Concussions have been cited as one of the most 
frequently occurring injuries in professional horse 
racing jockeys around the world.1,2 The Centers 
for Disease Control and Prevention defines a 

concussion as a type of traumatic brain injury (TBI) 
that is “caused by a bump, blow, or jolt to the 
head or by a hit to the body that causes the head 
and brain to move rapidly back and forth.”3 These 
injuries may result in a disruption of brain function 
including, but not limited to,  loss of consciousness, 
memory loss, disorientation or confusion, and other 
functional deficits.4 It is well documented that the 
majority of injuries that jockeys sustain are a result 
of falls.1,2,5-11 Hitchens et. al. reported that of 360 
reported falls during thoroughbred races, 184 
injuries occurred indicating that 51% of falls 
resulted in injury.8 Additionally there were 1.99 
falls reported per 1000 rides.8 Concussions have 
represented a higher percentage of overall 
injuries in jockeys,  as high as 13% in a four month 
time frame.10 Despite concussions representing a 
large proportion of injuries in jockeys very few 
policies and procedures are in place throughout 
the United States that require adequate 
documentation and record keeping surrounding 
this type of injury. As a result, the actual injury 
prevalence in this population remains 
undocumented. While it is clear there is both high 
risk and high incidence of these injuries, there are 
many factors specific to horse racing that need to 
be considered to impose the healthcare of 
jockeys. 

Despite concussion being recognized as the most 
frequently occurring injury among jockeys,10,12 it 
has been reported in other sports that many head 
injuries go unrecognized, unreported, or 
undiagnosed,13,14 therefore, it may be assumed 
that the estimates  of the true number of racing-
related concussions are skewed or inaccurate. 
Reasons for not reporting concussions have been 
attributed to overall lack of access to medical 

mailto:carolinaquintana@mail.fresnostate.edu
https://doi.org/10.31622/2020/0004.3.4


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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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professionals when an injury occurs,  education 
regarding the injury risks, signs and symptoms, 
and sport-specific guidelines to return athletes to 
competition, the importance of treating these 
injuries appropriately.15 Recent literature from 
amateur and professional jockeys in Ireland also 
cite not considering a concussion to be serious, risk 
of losing a ride and therefore wages, and seeing 
the injury as a sign of weakness as additional 
reasons riders would not report a concussion and 
continue to ride.16 The overwhelming lack of 
resources and education is especially apparent 
within the thoroughbred horse racing industry in 
the United States, as availability of onsite 
healthcare or resources at the racetrack is 
inconsistent and procedures used are not 
universally adopted. While other racing 
jurisdictions such as the British Horseracing 
Authority have implemented concussion protocols 
to manage concussions,17 the United States has yet 
to implement or adopt protocols unique to the 
needs of riders in the United States.  

In the United States, equestrian sports remain 
some of the only organized competitive activities 
that have not adopted national and 
comprehensive concussion management protocols 
or guidelines. While significant progress has been 
made to improve the management of concussions 
in horse racing and other equestrian sports,18-24 a 
gap continues to exist on contextually-
appropriate return-to-sport protocols.25 At this 
time, there is no consistent healthcare 
management or practices from track to track 
across the country. Additionally, there is a lack of 
standardized baseline concussion protocols and 
tracks and jurisdictions are left to make their own 
protocols, policies and procedures. While 
information may be circulated or provided, there 
are not standard guidelines or recommendations 
for the racing community.  

Non-racing equestrian24 and professional rodeo 
have established concussion return-to-ride 

guidelines,23 but these do not consider the unique 
qualities of time pressures to resume racing, need 
for comprehensive medical oversight, and lack of 
training protocol for personnel on concussion 
management at all racing tracks. Therefore, the 
uniqueness of thoroughbred horse racing and the 
occupational demands placed upon race-riding 
jockeys warrant contextually appropriate 
protocols for concussion management in this sport 
that can be implemented regardless of resources 
or healthcare personnel available.   

Generic return-to-sport guidelines have been 
developed by groups such as the Concussion in 
Sport Group26 and the American Academy of 
Neurology;27 however, these guidelines do not 
reflect the sport-specific needs of the United 
States jockey population to ensure the best 
standard of care and practice. Despite clear need 
for concussion education for jockeys, the lack of a 
systems-wide support to decrease perceived 
negative connotations of addressing concussion 
still exists.16 As such, addressing the need for a 
jockey-specific return-to-ride guideline following 
concussion injury which considers the racing 
environment, physiological demands, and 
potential health disparities is not only 
necessitated, but required to advance safety in 
these athletes.  Therefore, the proposed return-to-
ride progression protocol is based on other sport 
protocols but is specific to the needs and demands 
of race riding. The proposed protocol is similar to 
Wicklund et al.23 who created a protocol for the 
rodeo athlete, and Serrano and Wu’s24 
management policy for Collegiate Hunter/Jumper 
Equestrian Athletes, is an adaptation of the widely 
accepted graduated return-to-sport strategy 
suggested by the Concussion in Sport Group,26. It 
must be acknowledged that while concussion 
management is being addressed in international 
racing jurisdictions the diversity of needs and 
practices within US horse racing sport necessitates 
the proposed protocol.   



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CURRENT MODEL 

Protocol Description  

Existing standards for horse racing injury 
management include having at least one medical 
professional at a racetrack during both morning 
workouts and live racing. The medical 
professional, such as a physician or licensed 
medical professional, must be trained to diagnose 
concussion and clear riders for additional riding 
post-fall.28 Although the sport lags behind other 
organizations in the development and practice of 
concussion management guidelines, it is important 
that any suggested protocols stay current with 
recommendations in other sports. Thus, current 
recommendations are moving away from the idea 
of complete rest, dark rooms and isolation from 
stimulation, the suggested protocol promotes an 
active recovery and expedites exposure to 
physical, mental, and social activity.29,30 To create 
a riding specific protocol, existing live racing data 
were analyzed and compared to data collected 
using a riding simulator.31 A Racewood Racing 
Simulator (Racewood Equestrian Simulators, 
Cheshire, UK) was utilized so that heart rate data 
of race-riders of various professional levels could 
be monitored in simulated racing conditions.31 
Utilizing a racehorse simulator and removing the 
live horse provides a much safer environment for 
the rider to increase physical exertion and 
gradually return-to-riding without the risk of injury 
from a fall from an unpredictable event. The 
proposed protocol focuses on a gradual increase 
in intensity as monitored by percent heart rate, 
and exercise demands (repetitions) until sport-
specific intensity has been reached. Mean heart 
rates measure during live and simulated racing 
were used to set parameters for each stage. One 
standard deviation above and below the target 
heart rates, derived from the mean heart rates, 
were identified and compared to previously set 
standards for validity for each stage.26 

Simulated races were used to mimic a physical 
situation close to what a jockey would encounter 
in a live race. A previous study31 investigating 
heart rate during live and simulated rides  
demonstrated that although there is not a 
significant difference in peak heart rate between 
the two, there was a nearly 15% gap in achieved 
peak heart rate during the simulated ride when 
compared to the peak heart rate during live 
racing. Although horse simulators have not been 
compared to treadmill exercise, prior research 
indicating that heart rate at 80% of heart rate 
achieved at symptom exacerbation using the 
Buffalo Concussion Treadmill Test is an acceptable 
level. Given the work comparing live racing and 
simulation and the Buffalo Concussion Treadmill 
Test,32  it is concluded that a goal of achieving 
85% of the maximum peak heart rate during live 
racing was selected as the final exertion stage for 
simulated riding in our return protocol is 
appropriate to prevent symptom exacerbation.31 
From there, a reversed approach was then taken 
to graduate heart rates from the 85% maximum; 
equivalent to return of racing while mounted on a 
live horse. Through this process, average peak 
heart rate during live racing was used to create a 
range of target heart rates for each stage moving 
at 10% from the prior state. The suggested heart 
rate zones are expected to be achieved and 
maintained during an exercise bout lasting at 
least two minutes, the duration of an average 
horse race in the United States. This step also 
mimics the intensity and timing of workouts and 
training bouts on the horse, as workout lengths 
typically range between 2 to 8 furlongs while 
race lengths range from 5 to 12 furlongs. 
Furthermore, use of peak heart rate to inform 
stage thresholds is contextually simplistic to use 
and implement in the jockey community, thus 
enhancing a culture of acceptance during post-
concussion recovery (Table 1). This approach is 
advantageous to ensuring reduction of risk moving 
through the first three stages of the protocol  



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ensuring the jockey has reached cardiovascular 
exertion without exacerbating prior injury.  

As in the guidelines outlined by McCroy et al.,26 if 
at any point during the return-to-ride graduated 
protocol the individual experiences a return or 
provocation of concussion symptoms, the athlete 
should return to the previous asymptomatic level 
and work to progress from that stage forward 
after a 24-hour period without concussion-related 
symptoms at that level.  Monitoring the 
progression of the protocol and advancing riders 
to the next step should be done by licensed 
healthcare professionals. Athletic trainers are 
keenly suited for this role due to their knowledge  

 

and experience managing these injuries.  As an 
additional consideration, riders should strive to 
maintain good nutrition, hydration and sleep, to 
promote good health and recovery, such as those 
described in the American College of Sports 
Medicine Joint Position Statement: Nutrition and 
Athletic Performance.33 

Stage 1: Light Activity  

In Stage 1, the aim is to gradually reintroduce 
light activity that does not aggravate post-
concussion symptoms (e.g., headache, dizziness, 
nausea). Riders should only participate Stage 1 
once they have been deemed asymptomatic by a 

Table 1: Proposed Return-to-Ride Protocol by Activity Stage and with Target Heart Rate Progression 

Objective Target Heart Rate 
Zone 

Criteria to Progress to Next Stage  

Stage 1: Light Activity 
Gradually reintroduce light activity and activities 
of daily living that do not aggravate symptoms 
or place individual at risk for secondary impact 
or fall 

≤100 BPM 
 

Participate in activities in daily 
living without an increase in 

symptoms for 24 hours 

Stage 2: Light Aerobic Activity 
Introduce light aerobic cardiovascular effort while 
minimizing secondary fall or impact by doing 
activities away from a horse that do not present 
a high risk  

98-111 BPM 
OR 

≤ 60-70% of 
maximum heart rate 

Maintenance of heart rate within 
target heart rate zone for ten, two-

minute simulated rides on a race 
horse simulator 

Stage 3: Sport-Specific Exercise 
Work to increase heart rate to 75% of maximum 
heart rate as the goal of the cardiovascular 
fitness levels in ways other than riding a live 
horse, incorporating race horse simulator 

112-151 bpm 
OR 

≤ 75% of maximum 
heart rate 

Maintenance of heart rate within 
target heart rate zone for ten, two-

minute simulated rides on a race 
horse simulator 

Stage 4: High Intensity Sport-Specific Exercise 
Simulated rides should be continued with the 
intention of increased heart rate greater than 
85% of the peak heart rate experienced during 
live racing. 

151-171 BPM 
OR 

≤ 85% of maximum 
heart rate 

Maintenance of heart rate within 
target heart rate zone for ten, two-

minute simulated rides on a race 
horse simulator 

Stage 5: Return to Live Horse 

Reintroduce live horse and begin to restore riding 
performance and confidence 

151-171 BPM or 
above 

 

Confidence on live horse and 
ability to maintain composure and 

fitness during workouts 
Stage 6: Full Participation 
Return to race related activities and full 
competition -  -  

BPM=beats per minutes 



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licensed healthcare professional. These activities 
may include activities of daily living that do not 
place the individual at risk for secondary injury or 
provocation of symptoms (e.g., walking, bathing, 
doing household chores). These activities should be 
initiated after a period of at least 24 hours of 
physical and cognitive rest. Encouraging the rider 
to stay involved in everyday activities outside of 
riding may promote motivation and positively 
affect mood and general emotional and mental 
well-being while they are unable to participate in 
riding. To graduate from Stage 1 the rider, at a 
minimum, should be able to participate in activities 
of daily living without an increase in symptoms but 
should be guided by a clinician. 

Stage 2: Light Aerobic Activity 

Stage 2 of the progression places an emphasis on 
light aerobic cardiovascular activity while 
minimizing secondary fall or impact by doing 
activities away from a horse that do not present a 
high fall risk. This stage should begin 24-hours 
after the successful completion of Stage 1 with no 
return of symptoms. Riders gradually begin light 
aerobic activities that may be done at the 
racetrack, in a gym or anywhere they may be 
able to walk, jog or complete other light activities 
with minimal risk of falling or impact to the head. 
Successful completion of this stage will depend 
heavily on whether or not the increased intensity 
of activity causes a return of symptoms. Riders 
should be monitored before, during, and following 
activity to detect any potential symptom return. 
The intensity and duration of light aerobic activity 
in Stage 2 should demonstrate a marked increase 
from Stage 1 before progressing to the next 
stage. Additionally, progression should only occur 
when riders are able to complete the activity 
without complications or a provocation of 
symptoms.  Graduation from this stage requires 
the maintenance of heart rate within the target 
heart rate zone (98- 111 beats per minute or 
≤ 65% of maximum heart rate) for ten, two-

minute simulated rides on a racehorse simulator. If 
the rider is able to complete these exercise bouts 
without a provocation of symptoms, as monitored 
by a licensed medical professional who is 
managing their care, they may move onto Stage 
3.  

Stage 3: Sport-Specific Exercise  

The goal of Stage 3 is to have the rider increase 
their heart rate to 75% of maximum heart rate in 
ways other than riding a live horse. Based on 
previously reported physiological heart rate data 
during live racing,31 increasing heart rate to a 
percentage (<75%) of the jockey’s maximum 
heart rate is appropriate in this stage. As 
indicated previously, this value is based on the 
overall target heart rate of 85% of the jockey’s 
maximum heart rate31 and working backwards to 
create attainable and meaningful heart rate 
targets and based on prior research indicating 
that exercise intolerance post-concussion is 
achieved at 85-90% of heart rate.32 Use of a 
self-propelled racehorse simulator like the 
Racewood RaceTrainer RT (Racewood LTD, 
Tarporley, England) (Figure 1), Equicizer 
(Equicizer, Norwalk, OH), or fully mechanized and 
computer integrated simulator such as MK10 
RACEHORSE SIMULATOR (Racewood LTD) is 
frequently part of United States jockeys’ training 
regime and is appropriate in this stage (Figure 1).  

On these simulators, arm motions are increased 
during practices to simulate “chasing” or 
motivation of the live horse. Arm cranking in other 
port results in higher heart rate, heart rate 
variability, increase in sympathetic outflow.34-36 If 
a racehorse simulator is not available for any or 
all of the steps in the return-to-ride progression, 
other activities with a cardiac demand, with low 
risk of reinjury, i.e. elliptical or treadmill, may be 
utilized to achieve the target heart rate.  



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Utilizing a racehorse simulator allows the ability 
to mimic racing through a sport-specific activity 
with limited risk of secondary impact or falls. 
Additionally, to better prepare for the return-to-
riding and racing, riders should consider 
incorporating dynamic balance activities into their 
exercise routines. Dynamic balance is a crucial 
component to riding and balance dysfunction is a 
common consequence of concussion. The BOSU® 
PRO Balance Trainer provides a method for 
training balance and stability and can be 
adapted to create a sport-specific training 
environment. Riders can progress through basic 
balance exercises such as single leg stance to 
holding a low squat or “riding stance” on a foam 
pad and progress to using the BOSU® PRO 
Balance Trainer for longer periods of time, 
mimicking a race.  

In order to warrant progression to the next step, 
riders should be able to attain 75% of their 
maximum heart rate and maintain a heart rate 
within the zone using a racehorse simulator for ten, 
two-minute bouts. Additionally, the rider should be 
able to demonstrate acceptable levels of 
balance. Maintaining upright balance on the 
BOSU® PRO Balance Trainer for a minute and a 
half to two minutes would provide evidence of 
acceptable balance as the time would be 
equivalent to the duration of most thoroughbred 
horse races (Figure 2). This can be done in double 
limb standing stance and progressing in difficulty 
from standing, to squatting to in a crouching 
position, closer mimicking the riding stance with 

both feet on the flat side of the BOSU® PRO 
Balance Trainer. Added perturbations to the 
balancing riding stance would better assess 
dynamic balance while also replicating the 
outside influences on riding during live races. 
Similarly to the simulated ride, this should be 
completed a total of ten rounds, to better 
demonstrate the ability to maintain repeated 
exercise bouts. In addition, light aerobic activity 
may be completed in Stage 3 to increase 
endurance and maintain a baseline level of 
fitness.   

Stage 4: High Intensity Sport-Specific Exercise 

During the Stage 4, simulated rides should 
continue with the intention of increasing the heart 
rate to greater than 85% of the peak heart rate 
experienced during live racing. When returning 
athletes from concussions, increasing 
cardiovascular demands without symptom 
provocation continues to be the standard. Thus, 
more challenging and sports-specific training 
should be added such as decision-making tasks 
during a simulated ride, challenges of reaction 
time, and continued balance training/exercises 
while also increasing the heart rate. This may be 
done through the implementation of cognitive 
tasks that require the rider to provide a “correct” 

Figure 1. Examples of Racehorse Simulators 

Figure 2. BOSU® PRO Balance Trainer Balance Exercise 



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answer based on a provided stimulus or catching 
a ball or object thrown that they are unable to 
anticipate at varied speeds. Successful 
progression from Stage 4 should only occur if the 
rider is able to maintain the heart rate zone 
during another set of 2-minute riding bouts without 
symptoms.  

Stage 5: Return to Live Horse   

Following medical clearance to return-to-riding by 
an appropriate licensed medical professional 
(i.e., MD, DO, ATs, the return to live horse stage is 
the first stage in which the rider is reintroduced to 
the live horse. Before returning to full race riding, 
the rider should gradually progress from breezing 
horses to breaking from the gate before 
competing in a full race, over the course of 
consecutive days. Breezing is the term used for a 
“workout in which a horse is easily running under 
a hold without encouragement from the rider.”37 
At this point, there is not a limit on the activity. It is 
important that the rider has restored confidence 
on the horse and functional skills before returning 
to pre-injury activity levels. This may be 
completed during morning workouts or at a 
training center, galloping and/or breezing horses. 
Track conditions listed at least as “good” for dirt 
or “firm” for turf are recommended. Through a 
gradual reintroduction to race riding, without a 
return of symptoms and regained confidence, 
riders may return to full competition.  

Stage 6: Full Participation  

When athletes successfully complete the 
reintroduction to race riding without a provocation 
of symptoms or other unforeseen issues, it is then 
safe for the jockey to return to race related 
activities and participation in full races. In 
accordance with The Association of Racing 
Commissioners International’s Model Rules of 
Racing,28 the jockey must be cleared by a 
physician or licensed medical professional before 
returning to racing.  

DISCUSSION  

Policies that protect the jockey profession are 
minimal in the United States, including the lack of 
standardized protocols to manage injury. 
Concussion experts and groups have developed 
guidelines and protocols to return athletes to sport 
following concussion; however, these guidelines do 
not provide directed goals based on the 
physiological and biomechanical demands and 
unique nature of the sport of horse racing. The 
proposed protocol provides specific heart rate 
metrics and guidance on progressive activities to 
achieve a gradual, safe return-to-sport for horse 
racing jockeys. Professional horse racing is a high-
risk sport with unique considerations and physical 
demands for its athletes. With high inherent risk of 
injury, and documented high rates of concussions, 
it is imperative that professional jockeys have 
guidelines designed for athletes to achieve high 
levels of athletic activity necessary to safely 
compete and perform at pre-injury levels. Injury 
management protocols not only protect the injured 
rider but improve the overall safety of the other 
horses and riders by removing riders that are not 
fit to ride from the field.  These recommendations 
are consistent with the protocols of major sports 
organizations such as the National Football 
League (NFL), National Collegiate Athletic 
Association (NCAA), and other professional and 
collegiate sports. This alignment is important in 
making strides towards recognition that the jockey 
has the access to and similar protections as other 
sport’s athletes.  

Previous return-to-sport progressions included 
graduated progressions, increasing exercise 
intensity, incorporating sports-specific exercise to 
gradually and safely return athletes to sport. 
Metrics that are easy-to-understand and 
implement into practice will facilitate compliance 
to various post-injury policies for United States 
jockeys. Intentionally, this protocol was designed 
to build on existing protocols and consider athletic 



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performance requirements. Progression through 
the protocol, similar to other return-to sport 
protocols, includes a period of rest, as suggested, 
immediately following concussion injury, 
monitoring of self-reported symptoms, and the use 
of other assessment tools to objectively assess 
function.26 Progression through the proposed 
protocol should be monitored closely and 
managed by a healthcare professional such as 
athletic trainer or sports medicine physician; 
adoption of this protocol highlights the importance 
of having these professionals available to jockeys 
during workouts and live racing. The presence of 
an athletic trainer at the racetrack presents many 
benefits for the racing community including the 
management of concussions and safely returning 
jockeys to sport. The versatility, skill and training 
position athletic trainers to be ideal and dynamic 
healthcare professionals suited to serve the horse 
racing community.  

This protocol sets the groundwork for putting 
United States jockey health at the forefront of 
return-to-sport considerations, limiting the risk of 
premature return-to-participation, and providing 
benchmarks through progression as well as 
exercises specific to the population. Current 
literature on NCAA athletes suggests the time to 
return to play and time that to the symptom free 
window have increased over time. These data 
should be investigated in this population and kept 
in mind for clinical decision making moving 
forward.38 Return-to-sport guidelines are only one 
piece to the concussion management puzzle and 
should be backed by standards and accrediting 
criteria to ensure proper implementation and 
practices. Additionally, this protocol does not 
minimize the risk of concussion injury in sport, but 
rather provides an opportunity for improved 
clinical practice following concussion injury.  

In this protocol, heart rate as a measure of 
physiological demands was evaluated in 
racehorse jockeys during live racing in a cohort of 

professional jockeys, predominately male (n=29, 
2 female).31 Peak heart rate was documented at 
187±11  beats per minute with an overall 
average peak heart rate of 169±10 beats per 
minute, demonstrating a high cardiovascular 
demand.31 These data support that in addition to 
resolution of injuries sustained in return-to-sport 
protocol, demonstration of high cardiovascular 
fitness is necessary for a safe return. Heart rate is 
integral to assess the brain’s ability to maintain 
pressure changes due to increased activity, 
without a return or exacerbation of symptoms. 
Exercise post-concussion is an effective strategy if 
heart rate is monitored to ensure that 
exacerbation of symptoms is not achieved.32,39 An 
increase in symptoms may occur with an increased 
heart rate because as severity of brain injuries 
increases, the autonomic nervous and 
cardiovascular systems become increasingly 
uncoupled.40 Therefore blood flow regulations 
and adaptations to the disruption from concussion 
may explain why symptoms reappear or worsen 
with physical exertion or other stressors that 
increase blood pressure.30 

This protocol is the first of this kind specific to the 
sport of horse racing, however limitations are 
based on lack of data at the population level. 
Building on existing protocols from other sports, 
the recommendations for each stage are clearly 
linked to progression in cardiovascular exertion 
measured by heart rate. Despite being evidence-
based on live heart rate collected during 
competition, the sample size is small and may not 
be representative of all jockeys by experience 
level and age.  We did not control the impact of 
social behaviors; however the potential impact 
should not be overlooked. The impact of social 
behaviors on heart rate such as weight reduction 
methods including intentional dehydration will 
alter cardiovascular output. As such, this protocol 
sets guidelines for optimal performance, and 
individual health behaviors will need to be 
considered in use of the guidelines. Additionally, 



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other factors may influence the recovery 
timeframe including the various concussion 
pathways such as vestibular involvement or sleep 
difficulties.  

The recommended protocol meets many of the 
needs and fills current gaps in the thoroughbred 
horse racing industry and improves the safety and 
welfare of professional jockeys. However, the 
suggested protocol is not without limitations. While 
the authors have proposed a protocol that utilizes 
licensed medical professionals to monitor the 
progress through the stages and the safe return-
to-riding , not all riders have access to the 
proposed level of healthcare. To better meet the 
needs of this unique population, racetracks should 
consider employing athletic trainers to provide 
quality healthcare to the riders and manage 
injuries. An additional limitation is the potential 
lack of access to a racehorse simulator as 
suggested throughout. Activities that place similar 
demands on the body such as running or riding a 
stationary bike may be used in a similar way to 
reach the target heartrate for each stage when a 
simulator is not available.  

The suggested protocol serves as a starting point, 
continued efforts should work to improve and 
build on the work suggested to ensure the best 
possible protocols and practices in the sport. 
Future iterations should examine scores on 
neurocognitive tests, objective balance tests, 
vestibular and oculomotor tests, and mental health 
assessments to provide a more robust evaluation 
and data driven return to ride criteria.  

CLINICAL BOTTOM LINE 

Current concussion guidelines recommend sport-
specific intensity through three stages of return-to-
sport following concussion. This research is 
important because it initiates the  implementation 
of a graduated return-to-sport protocol, a 
comprehensive understanding of the recovery 
process, and intervention for a safe return-to-ride 

for professional jockeys.39 A riding simulator adds 
controlled, sport-specific exercise when returning 
a jockey to athletic performance that is based on 
the percentage of peak heart rate values 
previously established. These recommendations 
may also be suitable for other equine sports 
including but not limited to polo, show jumping, 
and eventing, but further evidence is necessary to 
establish maximal sport-specific exertion of these 
disciplines or other criteria that may be critical to 
clinical decision-making following concussion. 

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