Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members, witnesses and those in the Visitors Gallery to please ensure their mobile telephones are switched off for the duration of our meeting as they interfere with the broadcasting of proceedings. It also causes interference for the members of staff. I thank everyone for being here this morning. Apologies have been received from Deputies Catherine Byrne, Regina Doherty, Peter Fitzpatrick, Ciara Conway, Eamonn Moloney and Senator Colm Burke. Deputy Catherine Byrne and Senator Imelda Henry had to leave us this morning.

We are beginning our first in a series of meetings dealing with the issue of concussion in sport. With sport increasingly becoming played at a faster speed and with greater physical intensity at both professional and amateur level, the number of concussions appears to have increased and the issue has become very prominent with many of the sporting and medical boards expressing concern. For most of us, concussion is something to be associated with elite sports people and involves physical contact. The reality is concussion can affect anyone who undertakes any type of physical activity. It is an issue that is relevant to everyone from those in the school yard, to the recreational walker, to the person who plays five-a-side, to the club player and to the elite sports person.

Unfortunately, head injury awareness is limited. It is important to bring attention and focus to the issue, so that the focus is not just on high profile incidents but across the spectrum of society. I welcome the committee's deliberations and wish to inform people that at the end of our hearings we will produce a report. We will meet with a wide variety of medical professionals and a range of stakeholders, including athletes and sporting organisations, to explore the various issues around concussion. At the end of the process, which I hope will be rewarding and in keeping with the tradition of this committee, we will hopefully have an increasing awareness of concussion.

I welcome Professor Michael Molloy who I have known for almost 30 years. I first met him as a student working as a porter in University College Cork hospital. Professor Molloy is an eminent consultant rheumatologist and is chair of the concussion advisory group at the Faculty of Sports & Exercise Medicine at the Royal College of Surgeons in Ireland and the Royal College of Physicians of Ireland. He is a former chief medical officer to the Irish Rugby Board and a former Irish rugby international player. Dr. Padraig Sheeran is dean of the Faculty of Sports & Exercise Medicine at the Royal College of Surgeons in Ireland and the Royal College of Physicians of Ireland. Professor John Ryan is the consultant in emergency medicine in St. Vincent's University Hospital and the team doctor with the Leinster rugby team. Dr. Michael Farrell is the consultant neuropathologist from Beaumont Hospital. Dr. Éanna Falvey is director of Sports and Exercise Medicine at the Sports Surgery Clinic and also works with the Irish rugby team. You are all very welcome and I thank you for being here. This is the first of two meetings this morning.

Before we begin, to remind people on privilege, witnesses are protected by absolute privilege in respect of the evidence you are to give to the committee. However, if you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to do so, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice that where possible you should not comment on, criticise or make charges against any person or entity by name or in such a way as to make them identifiable and members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that members shall not comment on, criticise or make charges against any person outside the House or an official either by name or in such a way as to make him identifiable.

This is the first of two meetings. I am hoping with the co-operation of all that this meeting will conclude between 11.15 a.m. and 11.20 a.m. to allow people time to change the tapes for recording of the next session, which will begin at 11.30 a.m. and which must end at 2 p.m.

I call on Professor Molloy to make his opening remarks.

Professor Michael Molloy:

Chairman, thank you for inviting me. I am going to start with a definition of concussion and mild traumatic brain injury. I think I share this view with many others that perhaps it would be more effective if this was called mild traumatic brain injury. There is a strong view that it is mild traumatic brain injury regardless of whether there are long-term consequences. This is something that has not been completely evaluated or accepted.

I was going to list how one deals with the issue in practice. The cause is trauma to the head, neck and body. In the management of concussion, the Zurich consensus statement on concussion in sport is used. It is an acceptable document and used worldwide. Concussion is a brain injury and is defined as a complex patho-physiological process affecting the brain induced by mechanical forces. It can be a trauma to the head, neck or body transmitted to the brain, in other words, shaking the brain.

The diagnosis - there are on either side of me people who have dealt with this on the sideline regularly and still do so and I have a lot of experience of it myself - needs to be immediate. Other speakers will mention how they make sure they are aware of it and the significance of the impact or the contact. That should result in the individual being removed from the field of play. That the diagnosis is made urgently and the individual - I am talking about contact sports at all levels - is removed from the field of play is perhaps the most important part of the whole process.

The second most important part is that the individuals concerned are not allowed back to play the same day. This is something that has come from the NFL in America where there was a concern about concussion and long-term consequences including traumatic encephalopathy. The US Government introduced a regulation stating that if a person had a diagnosis of concussion he or she had to come off the field of play and could not go back to play or train again until passed fit by a different - independent - medical person. The clinical decision here is the gold standard. Others have published an article on this some years ago. The concussion statement points out that it is a clinical concussion.

There are many questionnaires available. One can ask the individual questions to determine whether he or she has concussion. It is a clinical diagnosis because it is a changing and evolving situation. A person who is concussed may well sound reasonable and sensible initially but then a minute later he or she is confused.

Next is the on-field or sideline assessment which is very important. We have issued the relevant guidance documents to the committee, known as Sport Concussion Assessment Tool, SCAT 3 and Child SCAT. There is also a pocket SCAT. The SCAT 3 document is very good. Members can imagine the fun involved in going through that list in the middle of a game. A clinical decision must be made first and then on the sideline someone must do the evaluation which involves repeated neuro-psychological questions. All of the questions have been validated. Child SCAT is very important because children are very susceptible to head injury and are at higher risk. In certain sports like horse riding and rugby, for example, one must exclude a neck injury. When an individual is on the ground, one has an obligation to make sure that he or she does not have a significant neck injury. Once a neck injury has been discounted or dealt with, if necessary, then one is dealing with an evolving injury, namely concussion. The good news is that 80% to 90% of concussed people recover in seven to ten days although it can take longer for children and adolescents to fully recover. It is important to remember that point because too often concussion is considered to be a trivial event.

If an individual has been knocked unconscious or there has been a more serious event, he or she can be referred to hospital for an X-ray and-or scan. Unless there is a fracture, CT scans and MRI scans will not pick up anything in pure concussion. However, if there is a brain injury - a bleed for instance - a CT scan will pick that up. The most accurate test of all is a functional MRI scan but there is only one such scanner in this country. It can pick up changes in the brain immediately following the injury. We must go down the road of providing more functional MRI scanners to evaluate the injuries properly and to enhance research in this area.

The neuro-psychological assessment is a very important part of the evaluation process and particularly so with children. Children also have to be treated differently. They should be kept out of school, not allowed to play games on their telephones and allowed to rest. This is taken very seriously in most countries, particularly in the US. Children must be evaluated slowly and it must be remembered that they take longer to recover. They are at a greater risk than adults because frequently they bleed from the injury. In that way, they are a special group. In the recovery phase they are also a special group and should be monitored very carefully. It is generally accepted that neuro-psychologists are in short supply in this country but most of the larger hospitals have one attached to the psychiatric unit.

The return-to-play protocol is very clear. Individuals are assessed daily over a six-day period. They are assessed on the first day and if all is well, they are allowed to do some exercise the next day. If they are fine the next day, following an evaluation by medical personnel, they are allowed to do more exercise and so forth. It is possible, therefore, under the return to play protocol, for an individual to return to play within a week. Players go through a very rigorous, careful evaluation before they are allowed back to play. Before they go back, however, they must be given medical clearance. This is quite easy to manage in professional sport but with amateur sport it is a major headache. In previous times, when rugby was an amateur sport, for example, players took a three-week break. In a sense, three weeks is a necessary safety net for amateur sports because the necessary medical expertise is not readily available.

There have been many articles in respected journals detailing the possible long-term consequences of concussion. It has been suggested that there is a higher risk of dementia from repetitive head injury. It has also been suggested in numerous papers in the US that chronic traumatic encephalopathy can be a consequence of concussion. Cases of repetitive head injury causing early onset dementia or chronic traumatic encephalopathy have been reported in the US among American football players. One case has been reported here of chronic traumatic encephalopathy in a rugby player. In America, most of the cases reported are among American football players, with no cases reported in other sports such as ice hockey or Australian rules football but that may simply be because information was not being collected.

The most important issue in all of this is prevention. It is essential to minimise the risk of head injury to make sport safer. It is vital that players protect their heads and necks. The aim should be to prevent head trauma in all sport and the sporting bodies need to do more work in this regard. Education is also critical for all age groups and teachers, coaches and referees have an important role to play in this regard. In New Zealand, for example, referees must have a first aid certificate before they can referee a game at any level and that certificate must be re-validated every two years. In my opinion, coaches should also be required to have a first aid qualification. This is particularly true at the lower levels of sport, where medical expertise is not on hand all of the time. Coaches, referees and other officials at the touch-line should have first aid training, should be aware of concussion and know what action to take.

In all sports, but particularly in rugby, if a player is concussed but refuses to come off the pitch, the referee should send him or her off. Many times at international level, I have told a referee to send a player off. Referees must look out for signs of concussion in players. A number of years ago an Irish referee sent a player off during a match between Scotland and Wales. The fact that the player had been injured was not spotted by anybody else but the referee saw the player vomiting and sent him off immediately. At all levels of the sport, referees have a role to play, as do coaches. The coaches also have a role to play in the context of prevention, particularly in sports where there is a possibility of a lot of head contact. Coaches should aim to minimise if not avoid such contact.

There are excellent education programmes in many countries. In ice hockey in Canada and America, for example, there are specialised programmes for players as young as seven. While seven might seem a little young to start playing, those of us who support hurling here will know that if children do not start playing at aged five or six, they will probably never be really good at the game.

I have given the committee an overview of where the problems lie, as I see them. It is an ongoing and evolving situation, with research being carried out continuously. We intend to get involved in one or two studies here which will be very significant and which will involve the use of functional MRI scanners as well as neuro-psychological evaluation post-concussion.

Professor John Ryan:

I thank the Chairman for inviting me to speak and also thank Professor Molloy for his eloquent opening statement. He has set the scene regarding concussion very well. I am sure many of the other speakers here will echo the points made by Professor Molloy.

I wish to speak on this issue from the perspective of emergency medicine. At a national level we have a poor amount of data on the volume of concussion here. We know that concussions are occurring at club level which are not reported to general practitioners, primary care teams or accident and emergency departments. This means it is very difficult to know what the true incidence of concussion is in Ireland. This is an issue which must be addressed going forward and it underpins one of my key points, which is the need for research.

We need some basic research on the incidence of concussion in Ireland. The top sports involved are rugby, GAA, soccer, equestrian and, increasingly, cycling, which has taken off in the past few years. People are presenting at emergency departments with head injuries and concussions, along with other injuries. We need to improve our awareness of the incidence and try to get some statistical evaluation of increases and decreases in particular sports and an understanding of the mechanisms involved.

Professor Molloy has covered what concussion is very well, and I will not repeat that. It does not have to incur loss of consciousness or amnesia or involve a blow to the head. A transmitted force or whiplash type of injury can be enough to cause concussion. Part of the educational process necessary for the public and the medical, nursing and other allied professions involved with injured athletes, is to get the message across of what concussion is, how to recognise it on the field of play and in emergency departments, and how to manage it.

The two main issues arising in emergency medicine are education and the need for us to get a better handle on it through research. It is unfortunate that much of our time in undergraduate education is spent on the severity of injuries and illnesses. I do not wish to denigrate that in any way. The management of patients with multiple injuries and major head injuries is very important but there is no doubt that junior doctors mostly see people at the lower end of the spectrum, which Professor Molloy spoke about, the mild traumatic brain injury group. We spend a lot of time teaching undergraduates about the severity of severe injuries and head injuries associated with major trauma. We desperately need to focus on undergraduate education and the volume of injuries at the lower end of the spectrum. At postgraduate level too our emphasis is on taking people through courses such as the advanced trauma life support course for managing patients with major injury and multiple injuries. We are not so good at teaching our postgraduate doctors how to deal with the consequences of mild traumatic brain injuries which will constitute the largest volume of what they will treat in emergency departments.

The issue around chronic traumatic encephalopathy has been elucidated. I am sure Dr. Farrell will speak about it too. It has helped in some ways because it has led to greater public awareness of traumatic brain injuries and concussion. Parents, players, coaches, managers and, increasingly, junior and emergency medicine doctors are becoming aware of concussion, of its significance and the need to deal with it. While there is a desperate need to have longitudinal clinical pathological studies on, and evaluating, chronic traumatic encephalopathy that discussion is helping to drive greater awareness of concussion. The Irish Rugby Football Union, IRFU, has done some great work in the past year or 18 months on developing safe rugby courses for coaches, medics and physiotherapists involved with players who sustain injuries on the pitch and their assessment and safe management. That is very welcome. The faculty has been seminal in leading courses on the management of concussion through its sports course as well as half day courses.

The International Rugby Board, IRB, is studying what was previously known as a pitch side concussion assessment trial, now a head injury assessment trial to try to gain some information on the outcome for players. The non-governmental organisation, NGO, Acquired Brain Injury Ireland held a very successful meeting last year drawing attention to this. We are starting to see that in emergency medicine. We did a study in St. Vincent's Hospital of the number of head injuries in sport presenting in the 2012-13 season compared with the 2013-14 season. There has been a significant increase in the number presenting. I do not think that is because more people are playing but because there is a greater recognition of the need to seek help. The greatest rise has been in the adolescent group. There has been a 41% increase in adolescents presenting at the emergency department with concussion. In response we have developed a process out of which we hope to develop research findings that could be reproduced in, and transferred to, other emergency departments around the country.

Our policy now is to admit our patients to a clinical decision unit for a period of observation and effectively education too, for the parents and the injured athlete, to reassess and re-evaluate during that period. Concussion is a disorder of function rather than structure and CT scans and MRI scans are usually normal. Given a period of rest in a quiet ward area in most cases that is not necessary. What is necessary is the instruction to have a two-week period of complete rest followed by a graduated return to play. Following discharge we give the patient an appointment to return to a dedicated concussion clinic for an evaluation and further instruction about returning to play. That works now. It is labour intensive and needs more research. It would be great to see support and funding for that type of initiative to enable us to get some hard data. If successful it could then be transferred to, and reproduced in, other emergency departments. My main points in regard to emergency medicine are the need for more information through research, for support for the public awareness campaigns and undergraduate and postgraduate education, particularly within emergency medicine.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Professor Ryan and invite Dr. Michael Farrell to make his opening remarks.

Dr. Michael Farrell:

I am a brain pathologist at Beaumont Hospital where I have worked since the hospital opened. I have spent much of my life examining the consequences of head injury in patients who have been unfortunate enough to die.

At the far end of the spectrum is chronic traumatic encephalopathy. This condition has been around for over 100 years. It was recognised in the 1920s in boxers when its pathology was described. It has received enormous publicity recently because it has been recognised in a group of American professional football players. There have been other individual cases described in a rugby player and individuals from other sports. The pathology is one of progressive loss or death of nerve cells in the brain and the accumulation of a particular protein called tau. The filaments in the nerve cells are like fingers of asparagus tied in a bunch with string. They move down along the nerve cell over time. The string is known as tau. In patients with chronic traumatic encephalopathy the tau becomes abnormal. It changes shape, accumulates phosphate molecules and the process of supplying the far end of the nerve cell fails. The patient then develops a dementia which is progressive over time, characterised by behavioural changes, impulsivity, suicidality and so on. The diagnosis can be confirmed only at autopsy. The key question concerning all these sport-related concussions is whether repeated concussions over multiple periods of time result in chronic traumatic encephalopathy.

The scientific evidence is entirely anecdotal. There have been no prospective longitudinal studies conducted on players with established baselines before they become concussed and examined afterwards with a variety of different biomarkers and followed long enough to see whether they develop this condition. That is where we are at. Nobody has been able to come up with a study. We tried to design one ourselves involving the rugby football unions from a number of countries. The study would be enormously expensive but it is doable. It is doable because of the willingness of the rugby football unions and other sporting bodies to support the study. It requires new biomarkers of concussion to see how long an individual patient takes to return from concussion. We have all the return to play guidelines but we do not have really good biomarkers either in the blood, radiological or otherwise that would allow us to say one's brain has completely returned to normal and one is free to return.

We know there are individuals who are genetically or otherwise prone to concussion and that there are individuals who never get concussed. One hears people talk about boxers who have a glass chin, one blow and he is down. There are all these individual variations from person to person in one's susceptibility or resistance to concussion and that may or may not have a bearing on whether, in the long term, one gets chronic traumatic encephalopathy. From my point of view the condition exists, it is interesting, it is difficult to diagnose even pathologically with a brain in front of one, because one can never be sure that the patient did not have a gene that was disregulated, the code for tau, that perhaps this patient who got repeated blows was genetically predisposed to get a dementia related to tau, of which there are many. The science is dirty, the data is dirty, there is no data, there is no scientific data, all we have is anecdote and, unfortunately, that is the way it will continue.

The upside of all of this is that the publicity attended to chronic traumatic encephalopathy has resulted in all of the sporting bodies paying increased attention to concussion in its diagnosis and management. That can only be a good thing for players who now realise it is not natural to go back on the pitch having had a concussion, or to hide one's concussion symptoms. One is not doing one's team any favour, one must stay off the pitch and wait until one is better. That is filtered down to all levels to schools and so on. Yes, more can and will be done but in respect of the dramatic outcome in some footballers and some Rugby players there is no scientific evidence available and studies need to be done.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Farrell and welcome Dr. Éanna Falvey. I apologise to Dr. Falvey and members as there was an issue with the transfer of the presentation in terms of the opening of the file that could not be replicated.

Dr. Éanna Falvey:

Thank you Chairman. As I had some visuals for the committee that is the reason it would not transfer, so my apologies.

I have been invited to appear before the committee as director of sports and exercise medicine at the Sports Surgery Clinic but I have my feet in a number of camps with regard to concussion. I represented Ireland internationally in boxing and would have been one the people mentioned earlier with the glass chin. From a professional perspective I look after the Irish senior rugby team and the Irish Amateur Boxing high performance unit, both sports have been linked and will continue to be linked to concussion. In my day job at the Sports Surgery Clinic, we look after some of the jockeys for Dr. Adrian McGoldrick's excellent programme which manages concussion for the turf club. We look after three groups and the general public on concussion.

I wish to speak on concussion and echo my fellow speakers who have made excellent presentations, which are well thought out with moderated approaches which, unfortunately, in the debate around concussion is not always the case. Any publicity on this topic is good. We will take the good with the bad. Raising public awareness and making parents, athletes and coaches more aware of issues around concussion is always positive. We need to do our best to keep this topic in the limelight. I commend the committee on having such an in-depth look at the process over the next couple of sessions.

Concussion is a multi-sport global issue. It is not an Irish problem, a rugby problem or a boxing problem, it is in many sports all over the world. It is an emotive health concern and, as Dr. Michael Farrell said, the science is of a very poor quality. We have serious causal difficulties in what we say in and around areas such as chronic traumatic encephalopathy. I echo the point in respect of tau protein. Tau protein as well as being present in CTE is a natural protein that is seen in aging. Anybody who is over 50 years of age will probably have some tau protein in their brain on autopsy, thankfully I am not there just yet.

We have to know where we can differentiate out between what is a natural process and what is a traumatic process. The only way we can do that is to structure proper longitudinal studies. To date we have not been able to do that and it is something we need to progress towards. We have to ask ourselves a number of questions around concussion. We do not know more than we know in and around concussion. We do not even know the parts of the brain that are affected. Professor Michael Molloy mentioned functional MRI. Thankfully, things have moved on slightly more. There is now diffusion weighted scanning and also connectivity scanning which shows the traps in the brain that are affected when there is a concussion and allows us to look at people in real time and, nowadays, tell some information in and around the concussion. It remains a clinical diagnosis but we have some better imaging that we can look at nowadays that we did not have previously.

Similarly, it is vital to create a number of screening programmes where we take baselines in targeted populations in, say, the population of boxers, the population of Rugby players, the population of non-contact athletes, and follow this group longitudinally over a period, looking at their psychometric analysis and biomarkers. Biomarkers are an interesting area in that their blood tests will potentially show injury to cells in the brain and something we can follow up. The work in that area is evolving. Therefore, the work here would be in and around longitudinally following a group but taking blood samples from that group on a yearly basis and storing those samples so that in five or six years' time if something shows up that is a biomarker that may be of use, we have the serology available to go back and revisit that to see if it is present. If we have something that is gradually increasing over time, this may be a useful marker for us to use but we must have the samples to do that.

Similarly, we need to look at biomechanics. The biomechanics of how head injury occurs is still poorly understood. We need to look at impact biomechanics, for example, the use of helmets, protective equipment and so on. We also need to look at detection strategies such as genetics susceptibility, the APOE gene. There is a group of people in society who will have a concussion with a much lower head contact than people without. Screening for that at the moment is a slightly problematic area but I imagine it will be done in the future, where we can advise people on their risk of developing concussion. There is a unique possibility here in regard to research as there is good data to show that university based research takes about 15 years to get from the university to the patient. There is a big delay in how that happens. There are a number of reasons for that but where there is expertise in terms of research one does not have patients. Generally, where there are patients, as Professor John Ryan said they are very busy and, therefore, it is very difficult to conduct research, but busy clinicians are the people who can ask the hard questions in and around dealing with injuries and illnesses.

I work at the Sports Surgery Clinic in Dublin, Ireland's largest private orthopaedic facility. Since its inception in 2007, more than 150,000 patients have been through the premises. We have a very large sports medicine department with five sports physicians working there. It is the largest of its kind in the country. We look after a number of groups who are prone to these problems. Due to the throughput of patients and our interest in looking at this, we are launching a research foundation at the facility aimed at answering some of the hard clinical questions. The reason it is important to look at this is that concussion is a global problem.

With regard to research in the clinical issues around the world, it has been highlighted that many small groups are undertaking small projects. Pulling it all together becomes quite difficult. International collaboration is the way forward in terms of big problems like this where we need to gather proper longitudinal data. It is difficult to gather this kind of data where a small group in a small population is involved. It becomes very expensive and very difficult. If you have groups from around the world working together, pooling their resources, pooling their information, big numbers would be quickly gathered. Similarly, Dr. Farrell mentioned looking at all the rugby unions. Spreading this beyond rugby - if other countries and groups were also included - would be one of the ways forward. The research foundation being set up will look at a group of areas, one of which is brain health. The programme on brain health would gather a group of internationally recognised experts in the area. We have invited a scientific board who will attend in November. Among those invited is Professor Paul McCrory who would have been involved in the publication of many of the papers circulated to the board today. He has over 400 publications on concussion. Steven Blair who works for the centre for disease control in the States will also attend. He has over 600 publications on the epidemiology of injury. Lars Engebretsen from the International Olympic Committee will also attend. He has over 400 publications. These are world leaders in cutting-edge concussion research who are working in large groups and pulling all the information together. Rather than reinventing the wheel, we are hoping to plug into information already available and expand upon work already done.

Further on from what was stated by Professor Ryan, we would like to look at developing proper concussion clinics where patients with concussion attend and are not only diagnosed but are rehabilitated. One of the issues raised at the recent Faculty of Sports Medicine & Exercise meeting was that concussion is one of the only injuries where we tell patients simply to rest. There are very few injuries where we tell the patients to rest and do not do anything else to help make them better. At the moment, we have very few tools to help people get better. In the US, dealing with concussion is a big industry . People are out of work and so forth because of this. Methods to improve the situation - there are some methods - need to be researched and examined properly. A centre which conducts high level research is a perfect tool to educate. We need to educate clinicians. This can be seen on a regular basis. We need to educate doctors, physiotherapists, team trainers, coaches and individuals on this issue.

A centre of excellence gives a focus point for much of that. It provides a focus point to develop a screening programme and proper neuro-imaging. This would allow us to move on from functional MRI to fusion tensor imaging and mapping, or connectivity, where the tracks in the brain are viewed live and differences or changes in these can be seen. This is prospective work which needs to be done in a healthy population and then in an unhealthy population. One of the issues - which is difficult to separate from the research available - is headlines which state, for example, 20 American football players have developed CT. We have no idea how much of the normal population has this problem. If 2,000 people in the normal population were sampled, we do not know if some of them would have similar problems. Until we get proper baseline data, we cannot make a comparison. We run the risk of jumping to conclusions. It is, as Dr. Farrell stated, poor science. Anything that raises the profile of concussion is good but we need to do it in a scientific fashion. We do not want to draw false conclusions. Similarly, looking at impact, I have a video clip of the Honda laboratory in America which I had hoped to show. Honda are researching how to protect pedestrians when they are struck by cars. They have crumple zones in the cars. If a person is struck by a car at less than 30 km/h, the person has a chance of surviving. A crash test dummy is struck by the car and is thrown 10 m when hit by the car at 30 km/h.

I would show a video alongside that of a collision in Australian rules football where one footballer runs into another at 54 km/h. The player who is impacted is on the ground and is having a post-concussive seizure. The other player gets up and runs off. These are real problems. These are major traumas. We need to look at the impact of that. Professor Andrew Macintosh in the University of New South Wales has experimented with crash test dummies. He uses these to test, for example, helmets in boxing and American football. It is a Hybrid III concussion bio-mechanics model. This is very useful. We are looking to engage with Professor Macintosh so that we can use this information rather than trying to recreate it. We hope to tap into what the information he already has and to house some of his material and equipment and do some prospective work ourselves.

To recap, our primary goal in terms of concussion has to be education. We need to use any publicity available including opportunities like that available today - it is good to see members of the press here today - to highlight the problem and make people more aware of it. We need to set up an international centre of excellence and tap into people and a scientific advisory board with more than 2,500 PubMed citations and more than 1,500 publications on concussion alone. These are the types of people we need to engage to push this issue forward. We need to examine longitudinal population studies and follow groups over a long period of time. This needs to be done in a fashion where we can gather as much information as possible so that, down the line, when we need to draw inferences we are drawing them safely. It would be worthwhile looking into impact bio-mechanics and seeing if there is anything we can do to protect people who are getting these contacts. Gene-type analysis is an area of serious growth. So is the area of biomarkers. These are blood tests which, in the future, may help us to track someone's recovery from an injury. Advanced neuro-imaging, which we mentioned earlier, will be an area where we are going to see advances in the near future. We are working with the Hotchkiss Brain Institute in Calgary, Canada and the Florida institute in Melbourne, two of the world-leading concussion research centres.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you Dr. Falvey. We now move to questions from members. I call on Deputy Billy Kelleher.

Billy Kelleher (Cork North Central, Fianna Fail)
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Thank you, Chairman. I welcome the witnesses and note that the session was very informative. At the outset, there are two real issues. One is what happens on a local pitch, basketball court, American football pitch or ice-hockey pitch. Then there is the broader issue of how we collate all our data and statistics to have a long-term strategy on this issue. The biggest problem is to take action without having any detailed research. It may lead to conclusions that may not be correct. This could damage the sport itself. People participating in sport and parents may be anxious about a potential threat to their families or children playing sports. It is important to keep things in perspective and to act with the proper research and science.

I have played a little hurling and football. I never had a concussion. I would try to stay away from the physical activity as much as I could and let the other players get involved in the messy side of it. There is huge pressure on team doctors and the local coach. They are looking into the eyes of the best player and the player is a bit starry-eyed but he might run it off after five minutes. There is huge pressure at local level. At a professional level, it is obviously very different. The local team doctor will have an emotional involvement in the issue as well. He is probably the local everything. That is a key issue. A clinician makes a decision in the interest of the patient. However, he may also be taking into account the interests of the team. I am wondering if that is an area where we might need a stronger focus in terms of giving people the confidence to say concussion is an issue that can have prolonged implications on a person's health. It is not just for five or ten minutes while the player is running around the pitch running off that particular concussion. That is something that happens on a daily basis.

The broader issue raised by the speakers concerns prevention. Nowadays watching an All-Ireland hurling match, it is hard to believe that there was a time 30 people would take to the pitch without a helmet between them and it was permitted. Is there detailed research - perhaps in American football which would be a very high impact contact sport - on helmets? Where do we draw the line? People will argue that impact collisions are equally as high for people wearing helmets.

At what point do we have to drill down through the simplistic assessment that one can avoid concussion by wearing a helmet?

On the longitudinal studies, it is difficult for a small country like Ireland, with a population of just over 4 million, to gather data at the scale required for detailed analysis. I realise there is a considerable throughput at Dr. Farrell's sports clinic but we also need to collaborate internationally. The best way to do this is through medical organisations but it can also be done at governmental level. It does not always work to get governments involved in matters but the populations of countries like Australia, the United States and New Zealand are strongly committed to sports, and could offer opportunities for collaborative approaches. This could also be done at EU level. I imagine that considerable co-operation would be required to complete longitudinal studies because they would be logistically difficult without a commitment at some other level to assist in the studies.

We should be careful to avoid discouraging people from taking up sports when we discuss these issues. One often hears people say, for example, that they do not want their sons to play Rugby or to play in certain positions. Clear training programmes should be developed for coaches and even clinicians at local level. Every Saturday and Sunday in the parishes of this country, injured players are going back onto pitches pretending that they are not seeing stars and the local coach or GP might say they can run it off in three or four minutes. Perhaps sporting organisations need to given the confidence to encourage coaches and GPs to tell players they cannot play when they are concussed.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I support Dr. Falvey's appeal to the media covering the business of the Houses of the Oireachtas to report on these hearings. We need continuous and ever increasing attention to the issues we are discussing, and I hope they will help us in that regard. We are meeting the witnesses in our role as legislators. Do they believe there is any legislation that we should consider or are there specific steps that the Houses of the Oireachtas could take to enhance standards, adherence and other matters? I do not know if they have given consideration to that issue but it would be helpful if there were particular actions they asked us to consider. In regard to safety improvements or measures, do they believe further improvements could be made in terms of the standards of safety equipment and other instructions that could be introduced to participants across a wide discipline of sporting activities? A question that immediately comes to mind in is whether they believe satisfactory standards apply to headgear across the various sporting activities, such as hurling, cycling, football, boxing and horse racing. What is the situation regarding compulsion in these sporting activities? Is compulsion the order of the day for the sporting bodies overseeing these activities and is this something in which we might have a role to play as legislators? Are there particular areas of resistance to the commonsense advice that the witnesses in their collective professional experience would give? Is there resistance from the sporting bodies and, even, individual players? One can understand why there may be resistance in the heat of a game or a contest.

I beg the witnesses' pardon if I missed their comments on the issue of repeat concussion, the consequences of which can be serious. Do we have statistics on the incidence of concussions across the various sporting disciplines? It can and, all to sadly, does happen, with serious consequences. In regard to special awareness and care for children and adolescents, Professor Molloy highlighted the benefits of rest for brain development and concentration. If one is lying back on the couch, one may still be exercising one's brain with a video game or other technology. This is a message that should go out. Lying back does not mean one's brain functions are resting. Dr. Ryan recommended a return to school first for children and adolescents, with sporting activity to follow later. Are there rules of thumb in regard to the period of time that should govern the programmed return to full and normal activity? Can we demonstrate that not only for the medical profession but also for parents who are keen to know more about how they can support their children? I am not familiar with SCAT3 and welcome that Dr. Ryan referred to it. Is this hospital based equipment and are comparable sideline tools available to confirm concussion while play continues? Where are we in terms of technological advances across that area? I thank the witnesses for their contributions and assure them this committee is anxious to play its part in imparting the critical information they have shared with us.

Jillian van Turnhout (Independent)
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I thank the witnesses for their interesting presentations on concussion in sport. I had my own experience of concussion approximately ten years ago, although it happened through a simple slip on the bathroom floor rather than being connected to sports. I went about my business for the day without realising what had happened but over the following ten days I became aware of the seriousness of concussion. I was surprised at how much one could be thrown by it. This was brought home to me again as I was reading documents in preparation for this meeting.

Several speakers noted that we cannot draw conclusions which are not there and that we need to learn more about the issue. I understand that but, in preparing for the meeting I read about the experience of the NFL in the United States, which appears to be ahead of us in this discussion, particularly when it comes to protocols. In Ireland the team doctor seems to be responsible but in the US it is necessary to have somebody independent make the clinical decision. Deputy Kelleher spoke about the emotional connection and the difference between a clinical decision and an emotional one. I appreciate this is an evolving area in which we need to do further research.

However, I wonder whether things could be done to see how we could make changes. This was brought home to me when I was researching for today's meeting and looking at experiences. Brian O'Driscoll, who I am sure is a great hero to many of us, gave a quote last November when Dr. Éanna Falvey made the decision that he should come off. He tweeted that he definitely would have tried to go back on but that was why the decision must be taken out of the players' hands. I thought that tweet was highly honourable and it engenders a culture. Several speakers have spoken of the importance of sport but for me, there is importance both in playing the sport and being honourable about making such a decision. Moreover, there is nothing wrong with that decision to take off a player and perhaps more must be done to engender such a culture, whereby it is not a case of a player failing his or her team but is the reality of the situation in which he or she is and that the player's health must be put first.

In preparing for this meeting, I also encountered an issue that has not yet been mentioned. I do not know whether there is a correlation or if it is a contributing factor but I am concerned about the bulking-up of players and of the greater use of the tactics of barging through. This has been seen in rugby with professionalism but it also is evident in the GAA. My colleague, Deputy McLellan, will undoubtedly raise several issues in that regard. However, if one considers the increased reliance on putting on weight, I am concerned in particular about the promotion of protein products, such as creatine and so on, to those under 18 years of age in particular. I must state I am both angry and annoyed that a province I support, namely, Leinster, is clearly associated with one such protein product in a leading sports shop. This is telling children that it is good for sport and I have an issue with that because I wonder whether it is a contributing factor, through the type of play, which I have seen change. I mentioned Brian O'Driscoll, who went on to state the current professional rugby players are guinea pigs for the current study and being those guinea pigs for that study is not a good place in which to be. Is it necessary to talk sometimes about the nature of the change of play? Is this a matter that should be discussed or perhaps it is completely unrelated?

However, having looked at sports and having spoken to many people in preparation for today's meeting, I believe there is a correlation that must be discussed. I wish to hear a little more about this subject to ascertain whether members should be doing something about it or whether they should be raising awareness of it. While it is necessary to have awareness at all levels, there is a particular role for the professional sports and the leading amateur sports to set the standards and best practice. They should set out what is the ethos and culture when dealing with mild traumatic brain injuries and concussion. They set the tone and the children pick it up from there. I completely agree that education and training are needed but the children will look to what their role models will say. In international rugby, for example, a culture almost has been promoted in which players are expected to shake it off after five minutes. This should not be the case but I reiterate what Brian O'Driscoll and other rugby players have said, which is that this issue must be taken seriously and this is the way to do it. More and more is being learned about concussion and I understand the need for longitudinal studies. However, like my colleague, I ask whether there is a way which we can co-operate with other countries to ensure we have sufficient data to make it representative and that we are not using our players as guinea pigs for too long? It is far too serious an issue. Equally however, as Deputy Kelleher noted, we want young people to be playing sports. Although we want them out there, I do not want them to have these protein products either. I want them playing sports in the way it was intended.

Dan Neville (Limerick, Fine Gael)
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I thank the witnesses, who left very few questions for members to ask because their presentation was very comprehensive. What is the status in training or first-aid courses regarding awareness of identifying concussion and awareness of what to do when it is identified? In many instances it will be the first-aid person, rather than a qualified medic, who will make many such decisions. While there is a growing awareness of the whole subject of concussion, this is coming from a position in which there was not sufficient awareness of it. How well has first-aid training moved in respect of having a level of skill in identifying concussion and knowing how to respond to it?

Sandra McLellan (Cork East, Sinn Fein)
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I take this opportunity to welcome the witnesses and to thank them for their highly comprehensive presentations. This was not something about which I had thought in depth but having spent several hours going over the presentations last night, they certainly provided food for thought. They made me think about many issues pertaining to concussion about which I had never really thought previously. The presentations make it obvious that clear protocols are needed to adhere to best practice. I noted from the presentations issues such as the lack of neurosurgeons, the lack of science and funding, the need for further education and the science to recognise concussion, as well as how it should be treated. In his presentation earlier, Dr. Falvey stated that proper concussion clinics were needed and that it would be necessary to set up an international centre of excellence. This certainly is something towards which we must work. America was mentioned quite a lot throughout the presentations. Is it the model of best practice or should Ireland be looking towards another country? It also struck me that although we have no national database of concussions in sport, I have to hand a table setting out Ireland's concussion rate per thousand playing hours, which goes from horse racing down to American football. How are those data collated in the absence of such a national database? Were such a database to be established, who would be in charge of it? Who must ensure that these changes are made? As for education, I note that Scotland has been to the fore by providing leaflets at school and club levels. The leaflet advises coaches, teachers and parents on how to identify the signs of concussion and what actions to take. It states, "If in doubt, sit them out". Is this the type of education practice to which we should be adhering here in Ireland?

I will turn to the recent all-Ireland football final at which, near the end of the match, there was a heavy collision with perhaps 20 minutes to go. One player came off the pitch while the other remained on and played for approximately 20 minutes while concussed. Reference was made to the sport concussion assessment tool, SCAT 3, and my question is, did anyone use it with this player? Whose decision was it that he should remain on the pitch? I ask this because from reading the presentations, I gather that somebody who is concussed is not the best person to make such a decision. Should the referee have made that decision, should it have been the coaching staff or perhaps a qualified medic was available because it was an all-Ireland final? However, if one then moves to football and hurling at a lower level or to weekday matches in which seven, eight, ten or 12-year-olds are playing, sometimes one might have a referee for the match but there will be no sideline officials. It may merely be a parent who is taking charge and must such a parent have first-aid training? Who should identify whether a child is hurt? Whose responsibility is it if the child insists he or she is grand and wishes to play on? Is it necessary to put into legislation the decision of whose responsibility it is? I have one further point to make on rugby's five-minute concussion rule, which some people have stated is discredited. Do the witnesses have an opinion in this regard and if so, perhaps they could expand on it?

Jerry Buttimer (Cork South Central, Fine Gael)
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I will start with Dr. Farrell and work backwards. I am conscious that we must conclude by 11.20 a.m., which hopefully will give us ample time.

Dr. Michael Farrell:

I do not work on the sidelines but would point out that in American football where the players are genuinely considerably bigger than are the players in rugby, there are two issues. One is the wearing of a helmet, which can be used as an offensive weapon. In other words, one leads into a head to knock out or injure the other player. Second, there are off-the-ball tackles in rugby which are not allowed in football. An unsuspecting player can be gang-tackled by two or three people and one does not need to have one's head hit to be concussed; the mere rapid acceleration or deceleration associated with a tackle, for which one is not prepared, is what separates American football, in many ways, from rugby, football and other sports. The first issue is that the helmet is used as an offensive weapon and the second issue is third-man-tackle or the off-the-ball tackle by one or two other players on an unsuspected player.

Professor John Ryan:

A number of points have been made and there is some overlap, so I will touch on some of them and other colleagues will touch on others. The evidence, particularly in the sport of rugby, around scrum caps shows that they will protect the scalp but not the brain. There is anxiety in some circles that it may give younger children a false sense of security, allowing them to lead with the head and use it as a weapon because it is now protected. The structure one wants to protect is the brain inside of it, but what one is protecting is the scalp. In some sports the weight of a heavier helmet may put an abnormal torque on the neck and even put the neck at risk. There are studies evaluating the true benefits of protective head gear in sport.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does that cover the measurement of the protectiveness of the headgear-----

Professor John Ryan:

Pardon me.

Jerry Buttimer (Cork South Central, Fine Gael)
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-----in terms of its evolution, similar to the hurling helmet? Will the scientific evidence show that it should not be considered a safeguard which some young people think it is?

Professor John Ryan:

There is that false realisation that it will protect the brain but that is not the case. It is the scalp that is being protected, not the brain. The need for improvement in this area and greater awareness at pitch side is necessary. We must realise that the majority of people getting head injuries in sport occur among a group of weekend warriors and school children for which this country does not have the capacity to provide a medic or even a paramedic or an allied health carer. We need to drill down that education to coach and parental levels. That is certainly the case in the sport of rugby.

A Deputy mentioned that Scotland has produced leaflets. The work done under the SAFE Rugby programme by the IRFU is fantastic. They have gone out to the clubs and schools. I know that even this year one school had 45 members of its coaching and teaching staff attend a weekend course on the management of pitch side injuries, including concussion. That has made a difference particularly during the past 18 months. As a consequence of that we have seen in our emergency department a greater awareness by parents in terms of the people presenting with those injuries needing to be assessed. We are seeing that but more needs to be done. We are aware of the legislation around child abuse, the need for Garda clearance and so on, and rightly so, and perhaps the legislative route is a way to make sure that parents and those coaches who are involved are up to date with, as Deputy Neville said, the-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Does Professor Ryan believe that if we take a legislative approach that the legislation could encompass a different policy perspective for adults and children?

Professor John Ryan:

Anybody who will give advice and be in charge should be properly educated in that area. I am a little nervous that a concern about the consequences of the introduction of legislation might result in the withdrawal of volunteerism upon which sport in this based. We have seen a shrinking in the level of volunteerism in the past decade and we need to be careful we do not do further damage in that regard. Legislation is certainly one option.

Jerry Buttimer (Cork South Central, Fine Gael)
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To develop Deputy Kelleher's point in terms of the helmet in hurling - bearing in mind that ten years ago when I played junior hurling badly, the players never wore a helmet but today we would not allow anyone to go out on a field without a helmet - can that non-binding legislative approach, even though it is within the rules of the GAA, be applied across the sporting bodies? I am not referring only to the IRFU. Professor Molloy touched on the point that the IRFU should be commended on the way in which this year in particular it has involved the referees in this respect. I have met a few referees who have spoken about how they have been asked to become more aware of this.

Professor John Ryan:

Certainly the sporting bodies would need to be involved in the legislation and information gathering. There is the issue of how we can get the statistics for those with head injuries. That data are collected by individual sporting bodies and they need to make the reporting of injuries sustained to players mandatory and collate the data that way. Having a central database collection from all the sporting bodies would give us true national figures of where we are at with head injuries.

Professor Michael Molloy:

Prevention is the most important part of this, preventing the injury from occurring. If there is a situation one can envisage that increases the risk of the injury, then one has to consider that. First, there is the sporting bodies and if they do not take it on, then somebody else needs to, but the sporting bodies have a major role to play. I was involved in the past with the International Rugby Board, IRB, and I was one of the signatories to the concussion statement issued in 2008. The IRB then had a responsibility. It took two years to draw up the documentation and it took ages to get consensus because there were many differing views on it, but eventually the IRB put together a package that all the other countries use and it was translated into seven languages at the time. The biggest users of it were the Chinese and they do not play much rugby.

There is a need for the sporting bodies, for example, in a sport like rugby where there is a good deal of head contact, to give this issue serious consideration. Perhaps we should add to that the question on the bulking. That is the problem. The bigger the players are, the bigger the collision, and the wearing of helmets comes into that. Helmets do not protect players from concussion, that is for sure. Even in American football where they have specially adapted helmets, it does not work, but it does prevent, as Professor John Ryan said, injury to the face and fractures. I think equipment in the helmet is now used to measure the contact force. Dr. Éanna Falvey will mention this when he speaks shortly but the contact force on the head can be measured by using equipment in the helmet. It does not protect one but gives a false sense of security and for children in particular, it should be outlawed. In rugby it does protect the player's ears. I know from my experience that if one did not wear it in the forward position one's ears would look like those of Dr. Spock.

The other question raised was on who decides in this regard. The medical person on the day has to make the decision. I would go further, and my colleagues would agree with me, by saying that it has to be a decision that is made instantly, without dependence on the sports concussion assessment tool, SCAT. We have copies of the SCAT if members want it.

Sandra McLellan (Cork East, Sinn Fein)
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We have a copy of it.

Professor Michael Molloy:

That is written for lay people. I was part of the original group that set that up. This is an updated version. It is critical that the person makes the decision quickly and that the player comes off the pitch. This is only for professional sport, and that is the majority. There is a need to train people in first aid, and this is where we have a major responsibility. First aid courses are available. The faculty has a special emergency care programme for doctors, physiotherapists and others, which Dr. Padraig Sheeran will speak about shortly, where the participants go through a programme and are then certified. There must be certification. If we take New Zealand as an example, as others did, it has specific requirements. The Government in New Zealand is the insurance company also. Even when it hosted the Rugby World Cup it had to insure that event. The coaches, the referees and the teachers have to be certified in first aid every few years. That is necessary. If any legislation or direction comes forward here, that is on what it should be focused.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask Professor Molloy to leave aside his rugby hat for a moment and I refer to the child who goes into a playground in Ballyphehane or Templeogue on a Saturday morning, falls off a swing and bangs his or her head.

Professor Michael Molloy:

When it comes to regulated sport, the responsibility lies with the sport's governing body. Helmets work well in hurling because heads are protected from cuts and so on. Dr. Falvey and I were involved in publishing a paper on this some years ago and he might speak to that. They work but they do not protect people from concussion.

When it comes to recreational sport, it is everybody's responsibility. For example, we asked the people at the desk on the way in how often the defibrillator has been used because things get a bit hot in here sometimes. It has never been used but it is important to have people trained in its use. The Department of Education and Skills decided some years ago that everybody doing a gap year in secondary school should do first aid training. I gather that is happening and the HSE has pushed that. That is important in order that everybody has that skill.

My experience of playing amateur rugby in the UK, which goes back too many years to mention, was that the game could not start unless there was a first aider on the sideline. My wife ended up doing it because she happened to be medically trained. Somebody trained in this regard had to be present before the game started and we need to adopt that.

The sideline concussion assessment tool, SCAT, works exactly the same way for recreational activities and it has been written specifically for lay people. The child SCAT is for children because they are a particularly vulnerable group.

The bulking problem is a worry. We are conducting studies on protein, exercise and health in the general population and protein is an important part of that. We are not talking about the people dosing themselves with large amounts but protein, exercise and well-being is a well established combination. Dr. Falvey is involved with us in the study. We have shown this combination both in professional and amateur sport but bulking is a worry. Some years ago, patients got the Irish Sports Council to drug check some of the children because they were concerned about them. That is happening and it is a protection.

Senator van Turnhout asked about compulsion but it is difficult to answer that. All the sporting bodies should be specific about having trained personnel available. The officials, in particular, should be trained because that covers a large number.

Professor Ryan referred to volunteering and he is right that volunteers are needed but the well-being of the athletes surpasses anything else and most people approached to take on the responsibility are happy to learn first aid. It is a good skill.

Dr. Padraig Sheeran:

One area that every Member has touched is the management of concussion in children. As a consultant in the children's hospital in Crumlin, my main area of concern is management of concussion or evolving brain injury and major injury in schools. Every parent wants to know that his or her child is as safe as he or she can be and parents want to know that their child has the right to suitable advice, equipment and medical support if something goes wrong. Currently, there are no national structures or guidelines in our schools. Concussion is difficult to detect in adults and because of differences in anatomy and physiology, it is even harder to detect in children. We have had initial meetings with Dr. Miriam Owens in the Department of Health and Mr. Seanie McGrath in the Department of Education and Skills to initiate protocols and guidelines which will have to be compulsorily placed in schools and if we can do this, we hope there will be a positive effect on children's GAA and mini-rugby on Saturdays and Sundays. If we can have firm guidelines in schools, they will, hopefully, have a knock-on effect in clubs and that will involve the sporting bodies.

We do not have to reinvent the wheel. For example, South Africa's guidelines - BokSmart - involve two people being consistently present to address playing field injuries and they are referees and school teachers.

Dr. Éanna Falvey:

I thank everyone for their questions. Deputy Kelleher asked about the longitudinal studies. Even though it is a small country, Ireland has an ideal set up for performing this research. We are a small country and our geography allows us to gather data on groups reasonably well. We are well set up in that we do not have many centres spread out all over the country. We have a number of centres to gather data. I agree we need to collaborate with international groups and if possible it would be better again to do so at governmental level, if this was possible. One wants to pool as much data as one can as early as one can to gather the information quickly and I echo that fully.

With regard to helmets, the concept is risk compensation. We all have an acceptable level of risk and if we do something that makes us feel less at risk, we will undertake more risky behaviour. This is an established fact. If one puts a helmet on a child, he or she will feel there is less risk involved and, therefore, they will go for a ball in hurling or into a tackle in rugby. There is, therefore, a side effect. We need to be extremely careful in legislating for safety equipment to ensure, first, it is doing its job and, second, it is not causing unexpected consequences. We must be careful that the standards relating to the equipment are met. There are stringent guidelines for that. Dr. Paddy Crowley has done the research on the micro helmet and he has shown the evolution of head injuries in hurling as a result of helmet use. However, strict guidelines have to be adhered to in the manufacture of helmets as a result.

Good studies have been done on protective helmets. In Australia, the use of bicycle helmets in cycling was analysed and over a ten-year period during which extensive money was spent on education and advising people on health risks, the use of helmets increased from 20% to 32%. Legislation was introduced and helmets became mandatory. Helmet use increased from 32% to 95% in one year. There is, therefore, definitely a role for legislation; it just needs to be directed and informed. We need to be careful of jumping in with legislation but doing the right stuff with the strength of legislation behind it could be powerful.

I echo Professor Ryan's comments on compulsion. Making it compulsory to do anything means we could potentially lose volunteers but there is a gap for a body such as the faculty of sports medicine to step in and help to provide a basic first aid set up that can be delivered. This is usually done by sports and rugby is doing a good job at the moment. Referees are all indoctrinated now in concussion management while all coaches involved in the AIL this year have to partake in the course before being allowed to be involved. That is obviously at a higher level but significant education is not needed for this to filter down to the grassroots. The SCAT tree can be used on the sideline. If one not is medically trained, this tool will help one decide whether one should sit the person out. If one is medically trained, one can make the call but if one is not, this tool can be used if one is worried about a player. It is easy to use and we could educate people about it easily if there was an initiative and support. Perhaps this could be legislated for. If one is involved in a team, it is important that one, for example, takes an online module. I urge members to go the IRB's website because it contains a good module on how to complete the SCAT tree for non-medical people. One reads it and then one is asked a few questions to make sure one has read it. That could easily be done.

It is low cost and with some support it could be very effective. We need to not just educate the players and the coaches, but, to echo Dr. Sheeran's point, if we start at the bottom in schools, the change will become a fact. I was cycling recently with my daughter and she asked me why someone was not wearing a helmet. I struggle to wear a bicycle helmet because I did not use one growing up. She takes it for granted that one does not get on one's bike without using a bicycle helmet. If we start at the bottom, we will see change. The schools' initiative is a really big one.

With regard to protocols, the doctor must be independent. One of the biggest struggles when one is involved in a team is not being a fan but one is a person as well. It is hard not to be a fan but one must try to be as impersonal as one can. The nice thing about protocols is that much of the time it takes the situation out of one's hands. If one follows the protocol and one is honest about it, then the protocol will do the work. If one is worried about someone and one asks the questions such as whether the person is oriented in time and place or if he or she steady on their feet, one will remove the person if the situation dictates. If one follows the protocol, it helps one to be as professional as one can be. We need to see a cultural change.

In response to Senator van Turnhout’s question about players feeling like guinea pigs, it is important that research takes place. It must happen in a professional setting as the required group of people are available. The current players are guinea pigs in the sense that they have seen a dramatic change in rugby in the course of their playing careers. The average forward is 10 kg heavier and the average back is 8 kg heavier than when they started to play rugby. That is why there is a big change. The protein supplement companies would be delighted to hear Senator van Turnhout’s comments. If it were true that just taking a protein supplement made one bigger, they would be really happy. What is happening is that athletes are training much harder now. Taking supplements help the process but if one just took a protein supplement without putting in any effort, nothing would happen.

Jillian van Turnhout (Independent)
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One sees large jars of protein supplements on sale.

Dr. Éanna Falvey:

Yes, the companies sell it but the problem is not the protein. That is too simplistic a way of looking at the issue. That is marketing. The companies would love to hear that it is the protein that is causing the players to get bigger. The reason children get bigger is that from the age of 15 on players are involved in structured weight programmes. In fact, there is good evidence to show that if one has a well-balanced diet with proper protein intake, that is every bit as good for getting big as taking a protein supplement.

Jerry Buttimer (Cork South Central, Fine Gael)
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That does not come across.

Dr. Éanna Falvey:

Of course not.

Jerry Buttimer (Cork South Central, Fine Gael)
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Senator van Turnhout is saying that for someone involved in sport one associates the product with bulk.

Dr. Éanna Falvey:

I could not agree more.

Jillian van Turnhout (Independent)
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One also sees sporting stars lining up to promote the product.

Dr. Éanna Falvey:

The companies would be delighted to hear the conversation we are having.

Jerry Buttimer (Cork South Central, Fine Gael)
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What Dr. Falvey said is 100% clear.

Jillian van Turnhout (Independent)
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It is a clear message.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is there an obligation on the organisation not to get involved in product endorsement? It is a bit like the high-performance drinks that we see endorsed.

Jillian van Turnhout (Independent)
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They should not be associated with such products.

Dr. Éanna Falvey:

Yes, sugary drinks should not be endorsed. That is not a point for me to argue. It is difficult to know where to draw the line. For example, one can question whether wearing a certain type of boot makes one kick the ball over the bar. You are correct, Chairman, about how the message is portrayed.

Professor Michael Molloy:

The sporting bodies endorse the products they know are real and safe. One can buy anything one wants at the counter but the sporting bodies are involved in promoting health, well-being and nutrition.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is a fair point.

Dr. Éanna Falvey:

The courses available from both the faculty of sports medicine and the various sporting organisations are much more readily available. People have access to courses, whereas they did not have it in the past. That is a huge positive in terms of what has happened in recent years. I thank the committee.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Falvey. I also thank Dr. Farrell, Professor Ryan, Professor Molloy and Dr. Sheeran for attending this morning and giving of their expertise. The meeting has been a useful one and is the first in a series of meetings.

I acknowledge the presence in the gallery of Dr. Miriam Owens and Dr. Ronan Twomey, from the health and well-being programme in the Department of Health. They are most welcome also.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have received apologies from Deputy Kelleher and Deputy Ó Caoláin, who could not be present for this session. I remind members and witnesses to ensure that their mobile telephones are switched off or put on flight mode for the duration of this meeting, as they interfere with broadcasting equipment.

This is the second session of the meeting the Joint Committee on Health and Children has convened to examine the issue of concussion in sport in Ireland. I welcome to our second session Dr. Adrian McGoldrick, senior medical officer at the Turf Club and the Irish Jockeys Association; Mr. Ruud Dokter, high performance director with the FAI; Dr. Alan Byrne, Irish senior soccer team medical specialist with the FAI; Ms Barbara O'Connell, CEO of Acquired Brain Injury Ireland; Ms Karen O'Boyle, communications manager with Acquired Brain Injury Ireland; and Mr. Michael Darragh Macauley, Acquired Brain Injury Ireland champion and prominent inter-county footballer. I thank the witnesses for their attendance at this meeting. As I said at the beginning of our last session, this is part of a series of work being carried out by the committee on the issue of concussion, which we hope will lead to a report from the committee on the issue.

I call on Ms Barbara O'Connell to make her opening remarks.

Ms Barbara O'Connell:

I thank the joint committee and the Chairman for inviting Acquired Brain Injury Ireland to present at this hearing today. I am the chief executive and co-founder of Acquired Brain Injury Ireland. We set up the organisation 14 years ago to fill the gap in the provision of neuro-rehabilitation for people with a brain injury and their families. Ms. O'Boyle has been responsible for our education and awareness programmes on concussion and is here to answer any questions the committee might have. Mr. Macauley is our all-star ambassador and role model for our concussion campaigns.

We are pleased to be recognised as a significant player in the high-profile debate on concussion that is currently taking place. As stated in our written submission, we have to date carried out a number of activities and collaborations to raise much-needed awareness on the issue of concussion. Only 10% of people who experience a concussion are actually knocked out. That leaves 90% of concussions to be reported by the player, observed by the coach or the team doctor. How can people observe something that they do not understand or do not recognise? If one asks a player whether they have ever been concussed, most will say that they have not. If one asks players whether they have seen stars, most will say that this has happened many times. Players will admit to having thrown up after a match or having felt dizzy, but do not always relate that to the fact that they may have had a concussion. That is why we need education and to implement agreed protocols to ensure that concussion is managed correctly on every playing pitch across Ireland and at every level, from grass roots to elite.

Concussion campaigners call for change in concussion education and guidelines, along with increased awareness among young players, coaches and parents in order to protect the safety and well-being of our sportspeople. Acquired Brain Injury Ireland's concussion awareness and education campaign was driven from a grass-roots level at a local sports club, where it became evident that nobody knew what to do when a bang to the head happened. It is that basic. Knowledge, education and awareness of how to respond when a concussion happens should be available to all parents, coaches, and players in any sport. We argue that it should be mandatory but unfortunately that is not the case, so concussion continues to be mismanaged or not managed at all, which puts our children and families at risk. It is a manageable injury, but when it is not dealt with correctly it can be fatal. Think of Ben Robinson. He had a repeat concussion before the first concussion had healed. This is seriously dangerous and often fatal. We call for players to be removed from play if a concussion is suspected to prevent the possibility of second impact syndrome.

I want to say a few words on concussion care pathways. The abnormality of concussion is the same as with any brain injury, so we must start linking concussion with mild brain injury, making the role of a healthcare professional essential in monitoring a player through the rehabilitation process. Players are being concussed every weekend of the year throughout the country but there are no specialist services available. Dr. Ryan stated earlier that they have some concussion clinics scattered around the country but these services are not readily available and GP awareness is not there. Concussion care pathways services should be available nationally in the public health service to anyone in need of a mild brain injury rehab following a brain injury. No concussion is the same, so each one should be treated individually and cared for specifically.

Children require a particular mention because they are not small versions of adults; they are physiologically different. What we call "return to play" guidelines for adults we call "return to learn" guidelines for children. These must be implemented in schools for parents and teachers. Return to learn should be facilitated by inter-disciplinary teams, made up of the coach, the teacher, the family member and the clinician. I recently came across a young boy who returned to school the day after a concussion and was dribbling in class, completely disorientated. He became a spectacle for his peers, who were laughing and joking at him, when really this boy was clinically suffering from a concussion.

We carried out a research project that found that 42% of GAA players who sustained a concussion reported that they had played on and did not remember any of the rest of the game. These players are putting themselves at risk and must be educated about the dangers. As we have called for in our written submission, a sustained national collaborative concussion campaign is required to bring together all involved bodies to outline best practice, education, messaging and protocols. The sporting bodies have the information, but it is not enough for this information to be on a website or in a booklet. It must systematically be put into protocols so that people are trained. The Acquired Brain Injury Ireland ambassador and role model, Mr. Macauley, knows only too well what it means to be concussed, so I will hand over to him.

Mr. Michael Darragh MacAuley:

I have worked as an ambassador with Acquired Brain Injury Ireland for the past three years. As a Gaelic player at both club and county level, I have suffered my fair share of concussions. I know first-hand what it feels like. I have both been knocked out cold and suffered concussions that left me dizzy and off-balance. The reality is that one is no good to anyone on the field in that condition, yet sometimes players feel they know differently. Players are their own worst enemies when it comes to handling concussion. I am no stranger to injuries, as demonstrated by the fact that my arm is in a cast, and I knew last Saturday that it was time to come off when I could see my thumb was broken.

However, brain injury is different. We think that because we cannot see it it will be grand and we will stay on the pitch, even though we know inside that something is not right. This comes down to the wire ethos within many sports, including the GAA. It should be more than acceptable, it should be admirable to sit out after receiving a concussion. A concussed player has impaired decision-making capacities and is in no fit state to make a judgement call on whether or not to remain on the pitch. The coach or the management team must make the decision for the player to sit out. It cannot be left in the hands of the player because as well as being impaired cognitively we are emotionally involved. All any player wants to do is to finish the game to the final whistle, preferably on the winning team. Do not leave the decision up to us; take us out of the game.

Dr. Adrian McGoldrick:

I thank the Chairman and the committee members for their kind invitation to this hearing on concussion, an area in which I have a particular interest. Before I start, Deputy McLellan earlier asked what country could be seen as a role model and I would recommend South Africa. Twenty years ago Sports Concussion South Africa was set up by Dr. Jon Patricios and Dr. Ryan Kohler, who have now renamed it BokSmart. This is a Third World country, yet every child in South Africa playing rugby has baseline concussion assessment. Their website would be an ideal model for this committee to look at in drawing up their recommendations. Having watched what has happened in the US over many years, as I attend the American college on an annual basis, it is my belief that we in Europe are at least ten years behind. However, Irish different sporting bodies are not very far, if at all, behind their European counterparts. There is still much more to do and I will address this at the end of my presentation.

Concussion in sport has been the hottest topic in sports medicine for the last ten years, with more peer-reviewed articles published on concussion than on all other topics in sports medicine. Some 90% of concussions occur in young athletes and recreational sportspeople, rather than elite athletes, so it is very important that we not concentrate on elite athletes; we must look at young athletes in particular and recreational sportspeople.

The Irish Turf Club and the Irish National Hunt Steeplechase Committee view concussion extremely seriously. We follow the most current evidence based, internationally accepted, best practice standards of prevention, identification, treatment and management of riders suspected of, or having been diagnosed with, concussion. The presentation we have submitted to the committee touches on second-impact syndrome and chronic traumatic encephalopathy. I think those aspects of the matter were dealt with adequately at an earlier stage of this meeting.

I would like to comment briefly on the incidence of concussion in sport. We know from American figures that as many as 3.8 million concussions occurred in the US in 2012 during competitive sport and recreation activities. This is twice the number of concussions reported in that country in 2002. It is reckoned that as many as 50% of concussions may go unreported. Given that the US has a population of 317 million, it is probable that between 2% and 2.5% of Americans suffer concussion on an annual basis. Currently, there are no statistics available for the rate of concussion in sports and recreational activities in Ireland.

With respect to racing, I must point out that I am possibly unique in this area in so far as I am dealing with a very defined cohort of athletes - approximately 170 professional flat and national hunt riders and approximately 450 amateur riders, all of whom must be licensed on an annual basis. Additional criteria in respect of baseline concussion assessment have been in place since 2010. On race days, races take place every 30 minutes, on average. This means we have more time to assess concussions than those involved with rapidly moving sports like Gaelic games, soccer and rugby. There is a 15% fall rate in point-to-point racing and a 5% fall rate in national hunt racing. This means there can be multiple fallers - perhaps ten or 12 - during each race. We have to assess these riders quickly. One of the conditions written into our rule book is that riders can be stood down for as long as it takes to assess them for concussions. As a result, our doctors have to assess riders for concussions on a daily basis. This leads to improvements in their skills.

The number of participants in racing has fallen in line with the decline in the economy. We currently have approximately 40,000 runners per annum, with approximately 2,200 fallers over approximately 450 meetings. We have approximately 290 recorded injuries per annum, of which 10% are concussions. Therefore, approximately 1% of falls result in concussions. My predecessor, Dr. Walter Halley, introduced concussion guidelines in 1991 in conjunction with Professor Jack Phillips of the department of neurosurgery at Beaumont Hospital. The 1991 guidelines, which were based on the current knowledge of that time, provided that a rider with a concussion of a minor nature was stood down for two days, a rider with a brief loss of consciousness was stood down for seven days and a rider with significant loss of consciousness and amnesia was referred to hospital and stood down for 21 days.

Jerry Buttimer (Cork South Central, Fine Gael)
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I would like to draw the attention of Senators to the vote that has been called in the Seanad.

Jillian van Turnhout (Independent)
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We have paired.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is fine.

Jillian van Turnhout (Independent)
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I apologise to Senator Colm Burke.

Marc MacSharry (Fianna Fail)
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I would say Senator Burke's side has the numbers to allow him to stay here.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am conscious of the mathematical permutations in the Seanad.

Jillian van Turnhout (Independent)
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We realised what was happening so we agreed to pair.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask Dr. McGoldrick to resume.

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.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. McGoldrick for his interesting presentation. I call on Dr. Alan Byrne, medical director at the Football Association of Ireland, FAI.

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.

Marc MacSharry (Fianna Fail)
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What is specifically meant by rehabilitation services after concussion? What are the next steps for ABII on the educational awareness side? Who funds the organisation? How much of Ms O'Connell and Ms Boyle's time is dedicated to fund-raising? This is not specifically related to the issue at hand but I am curious to know how much time is wasted, so to speak, keeping the lights on rather than doing the work?

For the witnesses in the football and sports medicine side, I was at an under-10s training session for the GAA recently, watching parents scolding children for crying when injured. I did not know if there was a doctor around, although there were perhaps 200 or 300 children there on that Saturday morning. Is there any onus on the GAA or the FAI to have a doctor present when training is taking place or, for the younger age groups, when a blitz rather than a one-off match is taking place? Are there any existing regulations which insist on this, or ought there to be ones? I do not think there are. We seem to have defibrillators everywhere now, thankfully. Do we need to have a physician present every time we are playing any kind of contact sport, whether it is children or adults? As Dr. Byrne mentioned, the League of Ireland has to have Civil Defence or Order of Malta on hand with an ambulance and personnel. Does that need to be done? I apologise that I will have to excuse myself after those answers.

Sandra McLellan (Cork East, Sinn Fein)
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I thank the witnesses for their informative presentations, which have demonstrated that we need clear protocols to adhere to best practice. I was struck by the fact that we have no national database for concussion. How would this information be collated and who would be in charge of it? Most sporting activity in Ireland is not supported by medical or paramedic expertise. How can we change this? Education is key, but who should be responsible for rolling out the awareness and education campaigns? Should it be external organisations, the sporting bodies, the Department of Health or the Department of Education and Skills?

Did Mr. Macauley, who said he himself played while suffering from concussion, take the SCAT3 test when he had concussion? I refer again to the all-Ireland football final, when there was a serious collision between Jonny Cooper and Rory O'Carroll 16 or 20 minutes before the end of the game. Johnny Cooper came off but Rory O'Carroll played on for the 20 minutes. There is no doubt that a concussed player's decision-making is impaired. Should a player be forced to leave the pitch? Who is responsible for making this happen? Should it be the referee, a medic or a coach? Should all referees, coaches and volunteers have first aid training? On most weeks throughout the country it is coaches and volunteers who are taking part in under-age matches. There will not be any medics in sight. When it comes to these matches, the decisions are left to the coaches and maybe the referee. Do they all know about SCAT3 and should it be mandatory?

Jillian van Turnhout (Independent)
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I will pick up where Deputy McLellan left off. We have learned quite a lot about the child SCAT3 in this discussion. Is this in use and is it applicable to all the sports and sporting bodies we are talking to? We have heard about the need for greater pitchside and trackside awareness. We need to have a training programme for this. We heard some references to different sporting bodies having a training programme. Under the Healthy Ireland initiative, ABII suggested one training programme for all sports, especially for schools and school-age players. I would like to hear more about the witnesses' views on this. We heard about an example from South Africa called Boksmart which offers good guidelines to schools.

When we are drawing conclusions based on these hearings, one conclusion should be about raising awareness, but we should also make sure we are not sending conflicting or separate messages. My background is in youth work and girl guides, and we do a standardised first aid course along with other youth workers, because we are doing activities with young people. In New Zealand there is certification for these types of courses. Is that something we should consider? I am trying to put on my hat as a policy-maker, legislator and influencer to try to see what we can do. We have a role as legislators but we do not want to produce any unintended consequences in what we do. On the issue of helmets, we see that in certain sports, mandatory helmets can lead to risk compensation whereby young people think they are invincible because they have a helmet. This can lead to more injuries because they have this weapon.

Do the witnesses have any pointers for us? Are there areas where legislation is needed? What are their views on having a combined training programme or certification level that would be available to all schools, coaches, parents who are actively involved and other youth workers and organisations, such as has been suggested by ABII under the Healthy Ireland initiative?

Colm Burke (Fine Gael)
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I apologise if I am going back over old ground. Do the witnesses believe adequate training is being provided by the people who are coaching younger people, in particular in school? Is enough done to prepare the people involved in sporting activities in schools? Where do the witnesses see the more serious deficiencies? Although we have raised great awareness of farm accidents, there have been far more tragedies and deaths in that area this year than in any other year.

Are we doing enough on this with regard to sport and where are the greatest deficiencies? Is training provided to coaches in schools and clubs?

Dr. Adrian McGoldrick:

I thank Senator MacSharry for his queries. Rehabilitation after concussion is relatively easily dealt with in racing because those involved form a contained group of professionals and amateurs who all come under the auspices of the Turf Club. A designated medical professional like me oversees them, but problems arise with those involved at a recreational level. There is a massive deficiency in Ireland when it comes to neurologists, especially neuropsychologists, and if this committee could make representations to the Department of Health on this, it could be a major step forward. One of the great problems facing people is access to a neurologist or, in particular, a neuropsychologist. Assessment is almost impossible.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is there a window of time relating to referral for accurate diagnosis?

Dr. Adrian McGoldrick:

It is more of an issue in complicated cases. Concussions can be dealt with by people like me but in complicated cases, the Turf Club pays for riders to be assessed privately by a neuropsychologist, and not everyone can afford this. The vast majority of concussions, some 99%, occur at the amateur level, and this is the area that needs to be addressed.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is Dr. McGoldrick referring to point-to-point racing?

Dr. Adrian McGoldrick:

No, I am just referring to the general public. The vast majority of concussions in equestrian sports occur in the recreational area, and this is of major concern. Regarding the presence of doctors, I cannot simply turn up to oversee a race meeting or GAA match. I must inform my medical indemnifier that I am doing so. This is mandatory or I will not be insured. A doctor in such circumstances also must be trained to a level sufficient to cover the risks he or she is undertaking. For example, in horse racing, doctors must undertake a one-day course every three years. I was concerned when I heard recently that the Medical Council is considering mandating a three-day course for all doctors participating in sports activities. If this goes ahead, there will be a risk that many sports will not be able to get general practitioners to oversee them. Perhaps this committee could suggest to the Medical Council that a one-day course is more than adequate. Most GPs cannot afford to take three days off in order that they can cover one or two point-to-point race meetings or GAA matches. There must be a balance between what is appropriate and what is feasible.

Doctors must be trained and must inform their indemnifiers, which is not as easy as one might think. In terms of education, one small body cannot do everything. The Departments of Health and Education and Skills and the sporting bodies have roles to play, and all are working together on education. It is important to inform the public on concussion issues, but it is as important or more important that we educate the medical personnel who must diagnose and treat these injuries. Educating the public and professionals must be done hand in hand. There is no point in taking a child to a GP with concussion if he or she does not know how to diagnose and treat it.

I agree with Deputy McLellan on the need for a database and that we require a survey that examines schools. A model can be drawn up on what should be done using accident and emergency departments. The suggestion relating to first aid training would be impossible for one body. The Order of Malta, St. John Ambulance and other bodies do great work and I suggest we allow them to continue doing so.

Senator van Turnhout mentioned legislation, and I have referred to this. In the current climate we should not take this route first because we are a long way behind. We must roll out an education programme on a voluntary basis and, if it is felt in two or three years that we did not succeed in this, legislation could be considered. The laws introduced in the United States vary greatly and are not all adhered to, so I do not think legislation is the way to go.

Senator Burke mentioned young players and education is the key to this as there is a massive information deficit on concussion and its management.

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.

Jerry Buttimer (Cork South Central, Fine Gael)
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How would Dr. Byrne assess the current approaches to the assessment and the diagnosis? Are they adequate? Would Dr. Byrne change anything?

Dr. Alan Byrne:

In terms of the assessment?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Dr. Alan Byrne:

From a medical or a non-medical viewpoint?

Jerry Buttimer (Cork South Central, Fine Gael)
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Both.

Dr. Alan Byrne:

We have much work to do, although a lot has been done. I work in general practice as well as in sports medicine. Unfortunately, one needs to experience a few concussions to manage it. Someone has to visit a doctor with a medical problem in order for the doctor to learn how to manage it. One has to experience concussion. There is a necessity to work in the area also but I think the Irish College of General Practitioners can play a huge role from the medical end of things.

A lot of people put the pocket concussion recognition tool together. I would not say there is one thing we should do differently. We have plenty to do at the moment with what we have. We could increase the resources we have as doctors, where we can send on our difficult cases of concussion. A child or an adolescent may not be able to sit his or her junior certificate because he or she has been concussed, has had symptoms for the past six months and has been unable to go to school. If we could get those difficult cases to the appropriate professionals, while at the same time educate those people who are at the coalface to raise the suspicion of concussion, we can then look to the next step. However, we have plenty of work ahead of us.

Ms Barbara O'Connell:

We took a very pragmatic and practical approach. I was asked what rehabilitation services actually entail but I would like to bring members back to what a concussion is. One can experience headaches and dizziness and people can get very depressed. We are coming across many players who have sustained a number of concussions over time. The rehabilitation services are for people who say they are forgetting things, they are disorganised and they are really moody. We have heard players say they are sitting in dark rooms, due to light sensitivity. Relationships are breaking down at home. We need a multidisciplinary team to deal with that.

Dr. Byrne mentioned the child who cannot go to school. Acquired Brain Injury Ireland has the ability and knowledge to deal with those cases but not the resources to roll them out. That is what is needed so that when people are experiencing those things, they have someone to help them. A player who recently retired, and then spoke about his concussions, had difficulty going back to college because he could not organise his college notes and could not turn up to appointments on time. A very practical and pragmatic approach is required which does not always require a neurologist or a neuropsychologist but which needs clinical input around counselling and occupational therapy. It is not always about the physios or the medics; it is about the allied health professionals who are very pragmatic, the activities of daily living which people can no longer do as a result of repeat concussions, and social withdrawal and how that affects people's lives. To answer the question on what we see as rehabilitation, it must go the whole way down the track.

A member mentioned they fell and knocked their head. If they suddenly thought they were not themselves and asked who would they go to, I would advise that they go to Acquired Brian Injury Ireland. We do not have the resources but we have the knowledge. I was asked what we can do. There is a role for an organisation like ours to add on to the care pathway, following the clinical diagnosis and when it becomes a non-medical issue. That is what a person who has experienced a concussion is looking for. Specialist services, including psychology, behavioural therapy and family support, are needed. If an elite player is not himself anymore and has become depressed, it affects the whole family, including the kids, so that help is needed for everybody.

On the question about how Acquired Brain Injury Ireland could play a part, one area of our expertise is that we provide neuro-rehabilitation. We are prepared to take a leadership role in assisting the Department of Health. Our experience has been tremendous. We deal with all of the sporting bodies. We have been very successful in bringing everybody together and in pulling together the expertise. I heard somebody ask at what country should we look. I got really annoyed about that because we have the expertise here. We know what to do. That is why we have identified the Department of Health and the Department of Education and Skills to say we are going to pull everybody together. It is not a one-size-fits-all but a series of agreed protocols and policies which would be rolled out and which people would know.

We need to take in the added value of educating our children that trips and falls also cause concussion. There is an added value there in training kids to recognise what a concussion is at a very young age, namely, that they are dizzy because they just fell.

We are producing very simple cards because people do not like carrying around little booklets and they are never there when they need them. Basically, something very small which fits into one's wallet is required and which has some of the questions mentioned to hand if one is at the side of a pitch. We have produced a number of easy things and we will launch an app next month, which will be accessible to parents and coaches. It will have clinical guidelines, questions and answers for clinicians. We have an expert group, of which Dr. McGoldrick is part. An international expert group has helped us also. Acquired Brain Injury Ireland can play a leadership role in assisting the roll out of that education and awareness.

On a very practical level, a member spoke about the girl guides and the Order of Malta. They all have really good training programmes. Let us use what people have and just add on to it. People will say they have another class to go to but information should be readily available and practical. We are really teaching people to signpost. One may be taking one's son home in the car and notice he is not really himself and he will say he does not feel well. It is usually mums and dads who will identify something is not right and will ask what they should do. It follows on that general practitioners need to be educated. The care pathway needs to be in place. We should start at grassroots level and make this something people know.

As I said, we asked players who said they got sick after the match, if they knew it was a concussion. They said "No" but that they did not feel right for a couple of days. We are starting at that very basic level.

Jerry Buttimer (Cork South Central, Fine Gael)
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I remind Senators that there is a vote in the Seanad.

Ms Barbara O'Connell:

Should I be quiet?

Jerry Buttimer (Cork South Central, Fine Gael)
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God no. If Ms O'Connell finishes, I can invite the other two speakers to contribute so that Senators might be able to vote.

Ms Barbara O'Connell:

We had to engage in innovative fund-raising. Coca Cola sponsored a video, of which Mr. MacAuley was a part, that we made in conjunction with the GAA. Covidien has sponsored our app. We are at that level, so we need to be resourced properly. It is ridiculous that we must ask outside companies for €10,000 to do something. We do not even have the necessary resources to send the approved material to people.

Jerry Buttimer (Cork South Central, Fine Gael)
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In terms of this meeting's output, we might discuss that as an action point.

Ms Karen O'Boyle:

The question of who should roll this out was asked. It is a cross-departmental issue. As Dr. Byrne stated, it must start in schools, so it is an issue for the Department of Education and Skills, but it is also an issue for the Departments of Health, and Children and Youth Affairs. I have been working on this campaign for four years, so we have a great deal of material and do not need to reinvent the wheel. With combined expertise, supporting bodies and Departments, we can be successful.

Mr. Michael Darragh MacAuley:

A Senator asked whether I had completed the SCAT3 test. I did not when I got concussed with three minutes to go while playing in a county final with my club. The celebrations started, but I did not know where I was. The problem is that the situation at club level is not the same as at county level. Lads on our team who have been concussed this year underwent the SCAT3 test and were taken out of games. It is a question of rolling the tests out from club to younger levels and ensuring that everyone can access the same facilities.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it the case that, working together, the GPA and GAA have done that at inter-county level, but not at club junior football or hurling level where one does not necessarily receive the same level of medical attention as one does at a senior match?

Mr. Michael Darragh MacAuley:

Yes. Acquired Brain Injury Ireland has been working with the GPA on this matter. In terms of the GAA, we saw the Rory O'Carroll incident in the All-Ireland final. Obviously, he was in no state to play. He could have been on a beach in Spain and he would not have known the difference. There were no substitutes left, though, so he could not leave the pitch. He was left to wander around it and was of no use to anyone. Like blood substitutes, perhaps there should be something like a brain injury substitute. It is not a matter for this committee, but perhaps the GAA should consider it.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is a good idea. With that, I thank all of our witnesses for their participation and attendance. I also thank Mr. MacAuley for being the ambassador. It is good that we have a high-profile sports person to be that voice and face.

We will adjourn. The select committee will meet on Tuesday at 5.30 p.m. and the joint committee will adjourn until next Thursday at 9.30 a.m.