Dr. Sean Moffatt:

Concussion is a brain injury which the GAA believes must be treated seriously to protect players in the acute and long-term periods following this important injury. By definition, it is a complex pathophysiological process in which forces are transmitted to the brain and result in temporary impairment of brain function. In considering this definition of concussion, there are four key strands to be considered. Concussion can be caused by either a direct or indirect blow to the face, head, neck or elsewhere in the body with forces transmitted to the head. Concussion typically results in a rapid onslaught of short-lived impairment of brain function that resolves spontaneously. In some cases, symptoms can take longer to develop. Typically, concussion is a functional disturbance rather than a structural disturbance. Therefore, typically, on neuroimaging such as CAT scan or MRI, there will be no abnormality detected. Contrary to popular belief prior to an increased awareness of concussion, a person does not need to lose consciousness to have a concussive injury.

Since 2007, the GAA has focused on raising awareness on concussion in three key areas. These are education and knowledge transfer to our players, coaches, managers, team doctors and physiotherapists, highlighting, in particular, the diagnosis and on-field management of concussion, and the ongoing management of concussion and safe return to play. In terms of diagnosing concussion, an index of suspicion is required. The team doctor needs to closely monitor play, in particular collisions. It is necessary to be able to recognise the symptoms and signs of concussion which can vary from the very obvious to the subtle and hence the difficulties sometimes in diagnosing concussion. The typical symptoms and signs range from balance difficulties, such as dizziness, to headaches, drowsiness, confusion, irritability, noise and light sensitivity and the more obvious signs and symptoms, such as loss of consciousness or concussive seizure.

It is the GAA’s position stand that if there were a detection of any one of these symptoms or signs, a player must be safely removed from play following medical evaluation. The player should be brought to the side-line, serially monitored by the team doctor or responsible adult. If no team doctor is available, they should be brought for immediate medical attention, whether at an accident and emergency department, GP or out-of-hours services.

The GAA has advised that while the use of concussive assessment tools such as SCAT 3, sport concussion assessment tool, are useful in making the diagnosis of concussions and assessing their initial severity, the assessment of the symptoms, neuro-cognition and balance should be done after a 15-minute rest period, therefore excluding the effects of exertion and fatigue. However, it remains a clinical judgment for a medical doctor. There is no other diagnosis tool, bar a doctor’s medical knowledge. Hence, the drive by the GAA to educate our playing population, coaching staff, team doctors and physiotherapists.

With regard to return to play, the cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve. Typically in uncomplicated cases, the acute symptoms resolve after a rest period of 24 to 48 hours. Our protocol following a concussion follows a step-wise process where a player should only continue to proceed to the next level if asymptomatic at the current level. Generally, each step would take 24 hours.

The GAA has taken on board the consensus expert opinion on concussion and the advice from our medical opinion to advocate and adopt a much more conservative return to play in our child and adolescent population where the emphasis is on return to learn and safe schooling. For the five to 12 year old cohort of players, we have adopted a minimum rest period of two weeks and the child SCAT 3 as an assessment and management tool for concussion.

Other modifying issues that we have discussed at length and at education meetings with our team doctors that may predict longer return to play are more serious or persistent concussion symptoms, players who suffer recurrent concussion injuries, players who have suffered a loss of consciousness for greater than one minute as part of their concussion injury, concussion injuries that occur repeatedly with less traumatic force and being aware of the comorbidities of players who suffer from migraine, depression or children with attention deficit disorder or learning disabilities.

The GAA has adopted and advocated a comprehensive educational tool since 2007 that is in keeping with best practice internationally and we continually review for players, managers and team doctors.