Professor Michael Molloy:

Chairman, thank you for inviting me. I am going to start with a definition of concussion and mild traumatic brain injury. I think I share this view with many others that perhaps it would be more effective if this was called mild traumatic brain injury. There is a strong view that it is mild traumatic brain injury regardless of whether there are long-term consequences. This is something that has not been completely evaluated or accepted.

I was going to list how one deals with the issue in practice. The cause is trauma to the head, neck and body. In the management of concussion, the Zurich consensus statement on concussion in sport is used. It is an acceptable document and used worldwide. Concussion is a brain injury and is defined as a complex patho-physiological process affecting the brain induced by mechanical forces. It can be a trauma to the head, neck or body transmitted to the brain, in other words, shaking the brain.

The diagnosis - there are on either side of me people who have dealt with this on the sideline regularly and still do so and I have a lot of experience of it myself - needs to be immediate. Other speakers will mention how they make sure they are aware of it and the significance of the impact or the contact. That should result in the individual being removed from the field of play. That the diagnosis is made urgently and the individual - I am talking about contact sports at all levels - is removed from the field of play is perhaps the most important part of the whole process.

The second most important part is that the individuals concerned are not allowed back to play the same day. This is something that has come from the NFL in America where there was a concern about concussion and long-term consequences including traumatic encephalopathy. The US Government introduced a regulation stating that if a person had a diagnosis of concussion he or she had to come off the field of play and could not go back to play or train again until passed fit by a different - independent - medical person. The clinical decision here is the gold standard. Others have published an article on this some years ago. The concussion statement points out that it is a clinical concussion.

There are many questionnaires available. One can ask the individual questions to determine whether he or she has concussion. It is a clinical diagnosis because it is a changing and evolving situation. A person who is concussed may well sound reasonable and sensible initially but then a minute later he or she is confused.

Next is the on-field or sideline assessment which is very important. We have issued the relevant guidance documents to the committee, known as Sport Concussion Assessment Tool, SCAT 3 and Child SCAT. There is also a pocket SCAT. The SCAT 3 document is very good. Members can imagine the fun involved in going through that list in the middle of a game. A clinical decision must be made first and then on the sideline someone must do the evaluation which involves repeated neuro-psychological questions. All of the questions have been validated. Child SCAT is very important because children are very susceptible to head injury and are at higher risk. In certain sports like horse riding and rugby, for example, one must exclude a neck injury. When an individual is on the ground, one has an obligation to make sure that he or she does not have a significant neck injury. Once a neck injury has been discounted or dealt with, if necessary, then one is dealing with an evolving injury, namely concussion. The good news is that 80% to 90% of concussed people recover in seven to ten days although it can take longer for children and adolescents to fully recover. It is important to remember that point because too often concussion is considered to be a trivial event.

If an individual has been knocked unconscious or there has been a more serious event, he or she can be referred to hospital for an X-ray and-or scan. Unless there is a fracture, CT scans and MRI scans will not pick up anything in pure concussion. However, if there is a brain injury - a bleed for instance - a CT scan will pick that up. The most accurate test of all is a functional MRI scan but there is only one such scanner in this country. It can pick up changes in the brain immediately following the injury. We must go down the road of providing more functional MRI scanners to evaluate the injuries properly and to enhance research in this area.

The neuro-psychological assessment is a very important part of the evaluation process and particularly so with children. Children also have to be treated differently. They should be kept out of school, not allowed to play games on their telephones and allowed to rest. This is taken very seriously in most countries, particularly in the US. Children must be evaluated slowly and it must be remembered that they take longer to recover. They are at a greater risk than adults because frequently they bleed from the injury. In that way, they are a special group. In the recovery phase they are also a special group and should be monitored very carefully. It is generally accepted that neuro-psychologists are in short supply in this country but most of the larger hospitals have one attached to the psychiatric unit.

The return-to-play protocol is very clear. Individuals are assessed daily over a six-day period. They are assessed on the first day and if all is well, they are allowed to do some exercise the next day. If they are fine the next day, following an evaluation by medical personnel, they are allowed to do more exercise and so forth. It is possible, therefore, under the return to play protocol, for an individual to return to play within a week. Players go through a very rigorous, careful evaluation before they are allowed back to play. Before they go back, however, they must be given medical clearance. This is quite easy to manage in professional sport but with amateur sport it is a major headache. In previous times, when rugby was an amateur sport, for example, players took a three-week break. In a sense, three weeks is a necessary safety net for amateur sports because the necessary medical expertise is not readily available.

There have been many articles in respected journals detailing the possible long-term consequences of concussion. It has been suggested that there is a higher risk of dementia from repetitive head injury. It has also been suggested in numerous papers in the US that chronic traumatic encephalopathy can be a consequence of concussion. Cases of repetitive head injury causing early onset dementia or chronic traumatic encephalopathy have been reported in the US among American football players. One case has been reported here of chronic traumatic encephalopathy in a rugby player. In America, most of the cases reported are among American football players, with no cases reported in other sports such as ice hockey or Australian rules football but that may simply be because information was not being collected.

The most important issue in all of this is prevention. It is essential to minimise the risk of head injury to make sport safer. It is vital that players protect their heads and necks. The aim should be to prevent head trauma in all sport and the sporting bodies need to do more work in this regard. Education is also critical for all age groups and teachers, coaches and referees have an important role to play in this regard. In New Zealand, for example, referees must have a first aid certificate before they can referee a game at any level and that certificate must be re-validated every two years. In my opinion, coaches should also be required to have a first aid qualification. This is particularly true at the lower levels of sport, where medical expertise is not on hand all of the time. Coaches, referees and other officials at the touch-line should have first aid training, should be aware of concussion and know what action to take.

In all sports, but particularly in rugby, if a player is concussed but refuses to come off the pitch, the referee should send him or her off. Many times at international level, I have told a referee to send a player off. Referees must look out for signs of concussion in players. A number of years ago an Irish referee sent a player off during a match between Scotland and Wales. The fact that the player had been injured was not spotted by anybody else but the referee saw the player vomiting and sent him off immediately. At all levels of the sport, referees have a role to play, as do coaches. The coaches also have a role to play in the context of prevention, particularly in sports where there is a possibility of a lot of head contact. Coaches should aim to minimise if not avoid such contact.

There are excellent education programmes in many countries. In ice hockey in Canada and America, for example, there are specialised programmes for players as young as seven. While seven might seem a little young to start playing, those of us who support hurling here will know that if children do not start playing at aged five or six, they will probably never be really good at the game.

I have given the committee an overview of where the problems lie, as I see them. It is an ongoing and evolving situation, with research being carried out continuously. We intend to get involved in one or two studies here which will be very significant and which will involve the use of functional MRI scanners as well as neuro-psychological evaluation post-concussion.