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.