Dr. Mary Flannery:

As honorary medical officer to Horse Sport Ireland, I thank the Chairman and the committee for inviting me to present on concussion in equestrian sport. In 2006, I was appointed to first medical committee of the Fédération Equestre Internationale, FEI, the international equestrian federation based in Lausanne which oversees all equestrian sports across the world. This committee was chaired by the late Craig Ferrall, who had a particular interest in concussion, and during my term of office it became very aware, from evidence-based medicine, that all concussion is serious and the terms "mild" or "moderate" concussion are no longer acceptable in medical circles. As a result, we introduced legislation with a mandatory suspension following any diagnosis of concussion and also making wearing of protective head gear compulsory. This has gone through right across the world in the various countries subject to the FEI. Horse Sport Ireland is unique in this sporting sphere, in that it encompasses many different disciplines of equestrian sport. It involves somewhere between 9,000 and 10,000 competing individuals on an annual basis, but with an enormous range of age, capabilities and experience. We have four year old children on lead rein ponies and we have people up to 100 years of age breeding horses for competition. It also embraces those who do not compete and who are involved with horses for leisure, pleasure, or commerce.

The FEI has advised on risk-management policy. Helmets are mandatory at all times and fortunately we have adopted a standard, which Dr. Adrian McGoldrick last week said he aspired to for all racing people, kite-marks on competitors' helmets, so that they are checked regularly. Cross-country competitors must wear medical armbands. These armbands show not only the individual rider's name, contact number and next of kin, but also their previous medical history, in particular any history of concussion or falls, any medications they are taking and any allergies they might have. If a horse or rider falls, they must leave the field of competition - hopefully walking and not on a stretcher - and they are not allowed to re-mount until seen by a medical officer. All falls are recorded in a medical book at events and a record of these falls is maintained by the individual disciplines within the sport. Competitors and horses are monitored regularly by stewards at competitions to ensure that they are competing at a level for which they are qualified and capable. Stewards are advised that they may tell people, parents or individual competitors that they should be downgraded if necessary for their own safety. Tack and saddlery must be of a safe standard and are inspected regularly. The field of competition and courses are also checked by stewards and must be passed safe for competition.

Diagnosis of concussion has also been dealt with very specifically by various medical professionals, both this morning and in the last session, but it is important to get through to competitors, riders and members that concussion is an alteration in brain function secondary to trauma. It is not structural damage and may not be obvious. We use the SCAT tools, which were very eloquently dealt with in last week's meeting. This SCAT tool is not an expensive piece of medical equipment, but rather a sensible series of questions put to the patient - for example what horse they were riding, which fence they fell at, etc. - and clinical observations. We have put a copy of this in the cover of the more recent medical books, so that medical officers and paramedics can refer to it. The importance of diagnosing concussion cannot be stressed enough because the real problem is ensuring that patients or riders have a sufficient recovery-rest period. An interesting North American study has shown that those who suffer brain injury and concussion and are undiagnosed and not allowed to rest are three times more likely to have a second episode within a year. Those who have a second episode are eight times more likely to sustain a third during that period.

Return to sport is therefore very important. Competitors sustaining concussion are given printed information on head injuries. Most doctors acting at an event will carry these, but in case they do not have them we are now putting them into the medical books which go around from one event to another. Those who have sustained a concussion are not allowed to ride on the day of diagnosis because suspension for 21 days is mandatory. This suspension can be amended to ten days if the rider is asymptomatic and is passed fit by a qualified medical practitioner. The suspension can be reduced to seven days if the rider has had previous neurogenic or psychometric testing and attains that level. Unfortunately, very few - in fact, none that I know of - in Irish sport have actually had psychometric testing. This is because of both the cost and the difficulty in having it done. All suspensions are recorded in a rider's medical armband and repeated episodes of concussion must be reviewed by a consultant neurologist.

Education, as my colleagues said earlier, is of the utmost importance. We must educate riders, handlers, parents, trainers, coaches and medical officers of the significance of concussion. Our coaches must undergo an equine-related first aid session before qualification as coaches, and this entails a module on concussion. We must ensure that our medical officers and paramedics are always in attendance and that medical records are kept in date. This is something to which we very seriously aspire in Horse Sport Ireland.