Dr. Adrian McGoldrick:

No problem. I reviewed the 1991 guidelines following my appointment as senior medical officer in 2008. Over the following 18 months, I introduced a new protocol based on certain documents, from the 1997 guidelines of the American Academy of Neurology up to and including the most recent consensus statement issued following the fourth international consensus conference on concussion in sport, which took place in Zurich in 2012.

Our current concussion protocol involves baseline neuropsychological testing being carried out on all riders. This is evaluated by one of a team of neuropsychologists retained by the Irish Turf Club. When a rider has a fall, he or she is assessed by one of the doctors in attendance at the race meeting. This assessment takes place not less than ten minutes after the injury is sustained, assuming no other more serious injuries have been sustained. This guideline has been provided for on the basis that concussion is an evolving injury and cannot be diagnosed immediately following the fall. The assessment involves six screening questions - the modified Maddocks questions - which are scientifically accepted as providing good baseline guidance with respect to concussion.

If a rider fails to answer one or more questions, he or she then undergoes a detailed assessment using the third sport concussion assessment tool and a full neurological examination. The doctor is then required to make a definitive diagnosis of whether the rider has suffered a concussion. If the answer is "Yes", he or she is stood down for a six-day period. Following this period, he or she undergoes a repeat neuropsychological assessment and an examination by a sports physician. The neuropsychological assessment is compared to his or her baseline by our neuropsychologist, who then advises me accordingly, as does the sports physician. If the rider fails either of these assessments, he or she is stood down for a further 14 days, after which he or she undergoes the same procedure again.

At any time, I may seek a neurosurgical, neurological or neuropsychological assessment to assist me in making a decision on the management of the rider. Baseline testing is done on all professional riders every two years and on all amateur riders every five years. This is based on recommendations from our panel of neuropsychologists. In the UK racing industry, only professional riders have baseline assessment testing carried out at present. Since we introduced our protocol four years ago, we have had riders sidelined with concussion for periods varying from six to 12 months.

The researchers spoke earlier in the discussion about what needs to be done in their area. Work has certainly been ongoing in this regard. I would like to stress that Professor Michael Gilchrist of University College Dublin is one of the leading biomechanical engineers in this field. Nine years ago, the Irish Turf Club gave him funding to carry out instrumented helmet research on our riders. I was glad to hear recently that he has received EU funding to continue his research along with Dr. Peter Helding from Copenhagen.

With regard to racing, the current European helmet standard – EN 1384 (2012) - is a 1996 standard with the date updated. Nothing happened to it in the interim. There may be anecdotal evidence that helmets reduce concussion, but there is no scientific basis to support this hypothesis. A new higher standard for equestrian helmets – EN 14572 - was introduced in 2005. No helmets to this standard were ever produced, most likely because manufacturers did not try to do so. After the standard was withdrawn in 2010, at Ireland's request, the fifth CEN working group on helmets for horse riders was directed to rewrite EN 1384. Ireland took over the secretariat of the working group at that stage. I commend the work of Ms Elizabeth O'Ferrall of the National Standards Authority of Ireland, who was the secretary of the working group. She has done outstanding work with me, in my capacity as convenor of the group, over the last three years.

It was agreed that a two-stage rewrite of EN 1384 would take place. The initial stage involved an increase in the current requirements. This was followed by the drawing up of a test for tangential impact. This test was devised by the eleventh of the 12 CEN working groups that worked in the area of equestrian helmets. We focused on the tangential impact test because most concussions occur from such impacts, rather than from direct impacts. It is hoped to have this test completed within the next two years so it can be incorporated into the new standard. This will, for the first time, provide a helmet standard that will have the potential to reduce concussion. In the interim, the Irish Turf Club increased the minimum helmet standard with effect from 1 January last. As a result, all helmets now have to meet the joint standards of PAS015 (2011), which is a much higher standard produced by the British Standards Institution, and EN 1384. The British Horseracing Authority has agreed to do likewise and this took effect yesterday.

I would like the joint committee to recommend that the minimum equestrian helmet standard used by those involved in other equestrian sports and by recreational riders should be raised to the standard we now use in horse racing. I am not sure whether that can be mandated, but I would certainly like to see it recommended. In racing, riders participate in a controlled environment in the presence of a minimum of two doctors and two ambulances with paramedical personnel. By contrast, the vast majority of people participating in equestrian sports do not have any back-up.

Education is the cornerstone of the general approach we must take with regard to concussion. It is essential that education is provided to undergraduates and, more importantly, to doctors who diagnose and treat concussion. I refer particularly to GPs, sports physicians and emergency medicine physicians. This is being done through the faculty of sports and exercise medicine and the Irish College of General Practitioners. Education of the general public, particularly coaches, parents and those participating in sports, is also essential. This is being provided by the Departments of Health and Education and Skills, with input from sports physicians and Acquired Brain Injury Ireland.

Reference was made earlier to what is happening in England and Scotland. My personal feeling is that there is no point in educating coaches, parents and teachers unless we educate the doctors who take care of concussions. Currently, the vast majority of GPs cannot diagnose or treat concussions. We do not have the educational skills. We are in the very early stages of the learning process. It is important for this committee to send a clear message to the training bodies for general practice, which are at the forefront of concussion treatment, that they have an important role in educating GPs in this area. The faculty of sports and exercise medicine has been very proactive in this approach and has held many seminars on this topic. As I have said, we are in the early stages and much more needs to be done.

Legislation was mentioned earlier. We are all aware of the Zackery Lystedt law, which was introduced in Washington State in 2008 with respect to concussion in youth athletes. Since then, all 50 states in the US have introduced variations on this theme.

It has three basic tenets: a mechanism to inform and educate youth athletes and their parents-guardians about concussion; provisions to remove a youth athlete who appears to have suffered a concussion; and a requirement that a youth athlete must be cleared by a licensed health care professional trained in the evaluation and management of concussions before returning to practice or play. While we would like to see this done on a voluntary basis, we should not rule out the need for legislation in the future if all of us fail to get our message through. I would like to see the committee actively review this aspect in one to two years.