Dr. Alan Byrne:

I thank the committee for the opportunity to contribute to its deliberations on the important topic of concussion. I have been medical director at the FAI since 2006 and have been working in football medicine for over 20 years at all levels. Mr. Ruud Dokter, who is accompanying me today, is the high performance director at the FAI.
Concussion is a brain injury and in its simplest form can be described as a disturbance of brain function. It may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, the clinical picture may evolve over several minutes to hours. This is a very important factor in how we manage concussion pitch side. Concussion results in a graded set of clinical symptoms that may or may not involve a loss of consciousness.
The majority, 80% to 90%, of concussions resolve in a short time over seven to ten days, although the recovery time may be longer in children and adolescents. All contact sports have some risk of concussion injury. Sport offers so many benefits to society but we do have an obligation to participants. The most important aspect of the medical management of concussion, once diagnosed, is the timing of the return to play decision.
There have been four international concussion consensus conferences held since 2001. FIFA, Fédération Internationale de Football Association, our world governing body, along with the International Ice Hockey Federation and the International Olympic Committee, were the initial signatories to the conferences and subsequent consensus statements. The most recent conference in 2012 further developed several side-line tools for use by medical professionals such as SCAT 3, sport concussion assessment tool, child SCAT 3 for ages 5-12 years and the pocket concussion recognition tool for non-medical people.
Concussion is a clinical diagnosis and presents with a collection of symptoms and signs such as headache, dizziness, loss of balance, disorientation, confusion and memory loss. If an athlete sustains a concussion or is suspected of sustaining a concussion they should be removed safely from the field of play and not be allowed to return to play on the day of the injury. That is a key point to all involved in this area. The final decision regarding a definitive diagnosis of concussion and/or the timeframe for a return to training or playing is a medical decision based on clinical judgment. Concussion is ultimately a clinical diagnosis.
It is worth noting conventional neuro-imaging, CT, computed tomography, or MRI, magnetic resonance imaging, is typically normal in concussive injury. The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded programme of exertion prior to medical clearance and return to play. Progress through the graded return to play is contingent on the athlete being asymptomatic as they move along the stages. It is worth restating that no return to play should be allowed on the day of a concussive injury. In the child or adolescent, it is recommended that no return to sport or activity should occur before the child or adolescent has returned to school successfully.
There are no figures for concussion, not just for football but for amateur sport in Ireland. UEFA, the Union of European Football Associations, has been actively involved in the whole area of sports injury research since 2001 involving 1,400 players and 26 professional football clubs. It published the data from this study in the Clinical Journal of Sports Medicinein 2013. It found there were 0.06 concussions per 1000 hours and head and neck injuries accounted for 2.2% of all injuries. In the study, a 25-player squad would suffer an average of 0.4 concussions per season. Accordingly, one can say football is a safe game.
However, there is an important obligation on the players to obey the rules of the game and for referees to enforce them. For the FIFA World Cup in 2006, a deliberate elbow was sanctioned with a straight red card resulting in a three-match ban. This had a significant impact on head and neck injuries when compared to the 2002 World Cup. Adherence to the rules by players and strict enforcement of the rules by referees may be an important aspect in the prevention of head injuries and subsequent concussions.
The FAI considers all aspects of player health and safety to be of the utmost importance. It first published guidelines on concussion in January 2010. The most recent copy of summary guidelines approved by the FAI medical committee is included at the end of the written submission. Our international team doctors and chartered physiotherapists, at all levels from under-15 boys and under-16 girls through to the senior teams, attend an annual medical seminar which includes the management of on-field emergencies including spinal injuries and the management of concussion. Our League of Ireland team doctors and physiotherapists are now required, under the club licensing agreement, to attend an annual medical seminar which includes the management of on-field emergencies including the assessment, diagnosis and management of concussion injury or suspected concussion injury. Under League of Ireland club licensing regulations, team doctors and physiotherapists are required at all games, along with the presence of an ambulance and crew.
The FAI has a detailed child welfare policy which specifies that the health, safety and welfare of children is of paramount importance with each club having a designated child welfare officer. The policy recommends that first aid should be available for all training sessions and matches. Referees at all levels abide by the FIFA laws of the game. The referee is empowered to stop the match if, in his opinion, a player is seriously injured, such as with a head injury, concussion, and ensures the player is removed from the field of play.
It is goes without question that prevention is better than cure. Recognising or suspecting a player has concussion is of paramount importance. This requires education of all the stakeholders involved in the game. Players have a significant role in the prevention of concussion by adherence to the rules of the game. Coaches, likewise, have a role in the prevention of concussion too, as the style of play they choose for their team may influence the likelihood of a player sustaining a concussive type injury. That is more a footballing matter and maybe an area I should avoid.

At the core of the prevention, recognition and management of concussion is education and awareness. All the stakeholders - players, coaches, team medics, referees, parents and administrators - need to be reminded to think with their heads and not with their hearts when making decisions on the medical fitness of a player who is suspected of or has sustained a concussion injury.

Concussion is not a common injury in football. It is a very important injury, however, and requires recognition and appropriate management. A lot of work has been done by the FAI on player welfare over recent years. This work is ongoing, and the cornerstone of any further work in this area should be an ongoing education programme.