Dr. Alan Byrne:

I echo much of what Dr. McGoldrick said and, regarding rehabilitation at professional and semi-professional levels in football, doctors and physiotherapists play a very important role. I agree with Dr. McGoldrick, as will anyone working in professional or amateur sport, that the difficulty is concussion symptoms in adolescents and young adults can go on for months and it is very difficult to access a neurologist or a neuropsychologist. If a family does not have the necessary financial resources, it may not get such access for some time, and this is an important issue.

There has been much talk of education, but coaches, players, referees and parents attend all matches. I agree with Dr. McGoldrick that doctors must be educated in the management of concussion, and in an ideal world there would be a medical professional at all training sessions and matches, but I do not think this is practical, nor am I sure it is essential. Coaches, players, referees and parents should become more aware of concussion. It is very difficult for doctors to diagnose concussion, and this arose in the World Cup final, although I do not wish to highlight the highly experienced doctor involved, whom I know well. Concussion is a difficult clinical diagnosis that evolves, so we should try to focus on people at grassroots level who may be in a position to take an affected child to a GP. The GP will usually know such a child and can make a judgment. If a referral is required, it can be done, although difficulty of access to a neurologist has been mentioned. We can work towards educating GPs through the Irish College of General Practitioners and the faculty of sports and exercise medicine, but I feel this matter applies most to those who attend matches. There is a significant voluntary element to sport at this level in Ireland and we must not discourage people from taking part. The benefits we accrue as a society from sport are great. I believe in the people who put up nets and wash the gear. We can only raise awareness of concussion. If people suspect concussion, they must seek appropriate medical attention.

Schools are an area on which attention should be focused. Many teachers are also coaches and all children must attend school, so this presents a great opportunity for it to be used as a forum where players can learn about concussion and teachers can be trained. The SCAT3, the ChildSCAT3 and the pocket recognition tool were referred to. The SCAT3 and the ChildSCAT3 are for use by medical professionals, and this is an important point. They are good tools but they are quite complex and could put pressure on coaches. The pocket recognition tool for concussion has the Maddocks questions to which Dr. McGoldrick referred. The Maddocks questions form a series of questions to which everyone should know the answer such as, "Where are we playing today? What is the score? What was the score last week?" and so on. These questions may raise the suspicion of concussion and the next step is to remove the player from the field of play and not allow him or her back on. The player is handed over to a parent, guardian or responsible adult to seek medical advice. The Maddocks questions form a simple tool. I took a player off the pitch in the 1996 FAI cup final after 22 minutes and it was a straightforward case of concussion, but on other occasions one may not be sure. A player may have received a kick in the head and may be bleeding. One might ask him whether he wants to go back on the pitch.

I have not met a player yet who does not want to play. One is fighting against that, and Mr. MacAuley mentioned that.

It is a difficult diagnosis. We cannot diagnose 100% of concussions. Education starts at grassroots level, by disseminating information. We recently sent our revised concussion guidelines to all our clubs and coaches, along with a short video. That is the way to keep that message out there. It is very difficult for one body to do that. We work closely with our colleagues in rugby and in the GAA and outside of the medical profession also. The focus should be on grassroots level.

Like Dr. McGoldrick, I do not think legislation is a good idea at the moment. We have a lot of work to do before we get to that. FIFA governs and makes the rules for football. I am not saying legislation would not be a good idea down the road but it might be a difficult marriage at the moment. To be fair, FIFA is reviewing what happened at the World Cup and has issued some comments. It has empowered referees to empower doctors in a more significant way from now on in regard to professional sport, of course. Initially, a referee would seek the advice of the doctor as to whether the player is concussed and needs to be removed from the pitch. However, we should really focus our attention on grassroots level.