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.