Presentation to the Oireachtas Joint Committee on Health and Children

2 nd . October 2014

Dr. Adrian Mc Goldrick

Senior Medical Officer

Irish Turf Club

Representing Irish Turf Club and Irish Jockeys Association

BackgroundConcussion is derived from the Latin word concussus, which means to shake violently. It was first described in the 16th century. Despite its ancient recognition, attempts to understand the pathophysiology of concussion are comparatively recent and date back not much further than the Renaissance. By the end of the 18th century enough information had been amassed on the nature of concussion to allow a now classic definition to be formulated. This was written in 1787 by Benjamin Bell, a neurosurgeon at the Edinburgh Infirmary. According to Bell “every affection of the head attended with stupefaction, when it appears as the immediate consequence of external violence, and when no mark or injury is discovered, is in general supposed to proceed from commotion or concussion of the brain, by which is meant such a derangement of this organ as obstructs its natural functions, without producing such obvious effects on it as to render it capable of having its real nature ascertained by dissection”. During the 19th century, neurologists were concerned with attempting to reconcile how the seemingly severe paralysis of neural function associated with concussion could occur with no obvious visible damage.

During the first part of the 20th century there was continuing development of animal models of mechanical brain injury and an associated development of a variety of theories of concussion such as molecular, vascular, mechanical and humoral hypotheses. There was also an upsurge of interest into the previously rather neglected area of traumatic amnesia and its possible prognostic role in determining the severity of concussion.

The modern era in the study of concussion is usually assumed to have started in the 1940s when a series of very significant papers were published. Among the most significant was one by Denny-Brown and Russell at Oxford which emphasised the importance of head movements in the elicitation of concussion. Shortly afterwards Holbourn (1943;1945), another Oxford investigator, defined more precisely the biomechanics of cerebral damage using a wax skull filled with coloured gelatin as a model. He reasoned that angular acceleration or deceleration of the head set up rotational movements within the easily distorted brain, generating shear strain injuries and probably concussion. Thirty years later the basic tenets of Holbourn’s theory were more or less confirmed using animals rather than physical models (Ommaya & Gennarelli 1974).

Over the last 30 years there has been an exponential growth in the development and employment of animal models of concussion and more recently the use on finite element (computerised) models.

Medical Implications of Concussion in Sport

DefinitionConcussion is a brain injury caused by trauma that is transmitted to the brain, either directly or indirectly, and results in impairment of brain function. The majority of people who suffer concussion do not lose consciousness. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms may evolve over a number of minutes to hours.

Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

Animal and human studies support the concept of post concussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell.

Experimental evidence suggests the concussed brain is less responsive to usual neural activation, and when premature cognitive or physical activity occurs before full recovery, the brain may be vulnerable to prolonged dysfunction.

It has received much attention in the medical literature over the last 20 years but particularly in the last 10 years where there have been more publications on concussion than on all other sports related topics.

The Irish Turf Club and Irish National Hunt Steeplechase Committee view concussion extremely seriously and 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.

IncidenceIt is estimated that as many as 3.8 million concussions occur in the U.S. per year during competitive sports and recreational activities (2012). This is double the number of concussions reported in 2002; however as many as 50% of concussions may go un-reported - (U.S. population 317m).

Currently there are no statistics available for the rate of concussion in sports and recreational activities in Ireland.

Second Impact SyndromeSecond Impact Syndrome has become a very topical subject in recent years due to the deaths of 2 young rugby players on this island.

It was first described in 1984 following the deaths of 3 athletes from massive brain swelling after a minor concussion. In all 3 cases there had been an antecedent concussion from which they were still symptomatic.

However it is a very uncommon occurrence and should not deflect us from getting the message out that all concussions are potentially dangerous.

C.T.E. (Chronic Traumatic Encephalopathy)

Likewise CTE has received significant media coverage following the attempted settlement by the NFL of a legal action against them. “The media focus has been positive in that it has raised public awareness of concussion, but the same media focus could have negative consequences by forcing sports to adopt hastily developed and evidence deficient risk management strategies. The risk of long-term neurodegenerative illness following head injury is unknown. This uncertainty is the fuel that fires the public debate. What we do not know is:

Is there a link between concussion and neurodegenerative disease? At what level of repetitive head injury do these long-term neurological

sequelae become evident? Also unknown – what is the impact of individual susceptibility, mental

illness, alcohol or substance misuse in the development of neurodegenerative complications following head injury?.” (Dr. Martin Rafferty, BJSM Oct 2013).

In another paper published last year in the BJSM 158 published case studies of CTE were reviewed (Gardner et al). 85 were pure athletes and detailed review showed only 20% to have pure neuropathology associated with CTE.

“Currently it can only be diagnosed at post mortem. What is required is a large scale prospective longitudinal clinicopathological study to answer some of the current unresolved issues associated with CTE” (Gardner BJSM 2013).

CONCUSSION IN IRISH RACING 2008-2014

2008 2009 2010 2011 2012 2013 2014(To date)

Injuries 284 264 376 344 217 273 ?

Concussions

29 48 32 29 16 15 23

As percentage of injuries

10.2% 18.2% 8.5% 8.4% 7.4% 5.5% ?

As percentage of falls

1.03% 1.95% 1.35% 1.24% 0.86% 0.75% ?

Comparative Data

Country Number of rides Number of concussions

Concussions per ride

U.K. 1,904,400 1,635 0.086

Ireland 267,638 231 0.086

Concussion in Irish Racing

In 1991 my predecessor Dr. Walter Halley in conjunction with Prof. Jack Philips from the Department of Neurosurgery at Beaumont Hospital introduced concussion guidelines:

Concussion of a minor nature – rider stood down for 2 days.

Brief loss of consciousness – rider stood down for 7 days.

Significant loss of consciousness and has amnesia – refer rider to hospital and rider stood down for 21 days.

Following my appointment as Senior Medical Officer in 2008 I reviewed the Guidelines and in 2010 introduced a new protocol based on the following documents. The diagnostic / management protocol was updated in 2013 following the 4th. International Consensus Conference on Concussion in Sport Zurich 2012 –Guidelines published in 2013.

BACKGROUND –SPORTS RELATED CONCUSSION

1997 – AMERICAN ACADEMY OF NEUROLOGY GUIDELINES2001 VIENNA - 1st. INTERNATIONAL SYMPOSIUM ON CONCUSSION IN SPORT2004-N.A.T.A. POSITION STATEMENT : MANAGEMENT OF SPORTS RELATED CONCUSSION2004 PRAGUE - 2nd. INTERNATIONAL SYMPOSIUM ON CONCUSSION IN SPORT A.C.S.M. 2006 –CONCUSSION AND THE TEAM PHYSICIAN – A CONSENSUS STATEMENT2008 ZURICH – 3rd. INTERNATIONAL SYMPOSIUM ON CONCUSSION IN SPORT A.C.S.M. 2011 UPDATE–CONCUSSION AND THE TEAM PHYSICIAN – A CONSENSUS STATEMENT 2012 ZURICH– 4th. INTERNATIONAL SYMPOSIUM ON CONCUSSION IN SPORT - CONSENSUS STATEMENT PUBLISHED IN APRIL 2013.A.C.S.M. : THE TEAM PHYSICIAN AND THE RETURN TO PLAY DECISION : A CONSENSUS STATEMENT – 2012 UPDATE2013 : AMERICAN MEDICAL SOCIETY FOR SPORTS MEDICINE POSITION STATEMENT : CONCUSSION IN SPORT

IRISH TURF CLUB CONCUSSION ASSESSMENT PROTOCOL (From January 2010)

Neuro-psychological (NP) testing

This will take place at one of 3 regional centres. These centres will be located in private (independent) clinics or G.P. surgeries and trained nurses at each location will carry out the NP testing on behalf of The Turf Club. Each jockey/rider will be required to complete a computerised test (CogSport) - http://cogsport.com and a series of pen and paper tests (SCOLP, Digit Span, SDMT:Symbol Digit Modalities Test, Colour Trails, STROOP) – the whole process will take about 60 minutes to complete.The various tests will then be evaluated by one of a team of Clinical Neuro-psychologists retained by The Turf Club.

Standard Assessment of Concussion (post event, on-course) - Irish Turf Club Concussion Assessment Tool.

Whenever a jockey/rider suffers a fall, the doctor in attendance at the racecourse/ point to point will carry out a standardised medical assessment. This will involve a set of screening questions and a more detailed neurological evaluation for those who are considered to be concussed. The jockey/rider considered to be concussed will be stood down from race riding until the evaluation has been carried out.In every case, the doctor will be required to make a definitive diagnosis in regard to concussion – YES / NO. If a diagnosis of concussion is made the jockey/rider will be stood down for a minimum of 6 days.

Post-concussion evaluation (fitness to return to race riding)Any jockey/rider who is diagnosed as having suffered concussion will be required to undergo a two part evaluation before being allowed to return to race riding:

(a) Repeat NP testing.(b) Examination by a Sport Physicianor Neurologist / Neurosurgeon where indicated. This 45 – 60 minute consultation will usually take place at the same Regional Centre as the NP testing or at a Neurological centre.

The reports from both of these examinations will be sent to the Turf Club Senior Medical Officer who will then be responsible for deciding if the jockey/rider can safely be allowed to return to race riding, or if a further period of rest is required.

If the NP tests are judged by the psychologist to be abnormal (i.e. a failure to return to baseline levels in those with a baseline test, or a significant deviation from age – and education – related norms in those without a baseline test), or if the jockey /rider

fails the Sports Physician assessment, he/ she will be stood down for a further 14 days, after which repeat post-concussion evaluation will take place (NP testing +/- Sports Physician review). This process will be repeated until it is deemed safe for the jockey/rider to return to race riding or the SMO may at any time opt to request a Neurosurgical / Neurological / Neuropsychological opinion.

All jockeys/riders will be subjected to the same concussion assessment at the time of injury and to the same post-concussion evaluation to determine when they are ready to return to race riding. However the timing and requirements for baseline neuro-psychological testing will vary across different categories as follows:Professional Jockeys and Category C Qualified Riders – 2010 –All Jockeys / Riders to be tested by the end of February and licence stamped accordingly. Flat jockeys working abroad will be required to have completed testing within 2 weeks of their return and their licence stamped accordingly.Category A and B Qualified Riders –start of 2011.Professional Jockeys-baseline testing every two years or at the start of the following season after any concussion.Qualified Riders-baseline testing every five years or at the start of the following season after any concussion.

Dr. Adrian Mc Goldrick,Senior Medical Officer,The Turf Club,The Curragh,Co. Kildare.00353-872424404amcgold@indigo.ieAugust 2009.

COGSPORT

Psychomotor Function / Speed of processing.

Visual attention / Vigilance. Visual learning and memory.

PEN AND PAPER TESTS

COLOUR TRAILS – Measures sustained attention and sequencing.

STROOP – Test of mental vitality and flexibility.

SYMBOL-DIGIT - Screens for organic cerebral dysfunction.

SCOLP – Speed and capability of language processing test measures the slowing in cognitive processes that can be experienced by individuals with brain damage.

DIGIT SPAN – Measure of short term memory.

CONCUSSION

A FACT SHEET FOR RIDERS

WHAT IS A CONCUSSION? A concussion is a brain injury that:

Is caused by a blow to the head or body. Can change the way your brain normally

works. Can range from mild to severe. Can present itself differently for each rider. Can occur while riding out as well as on the

racecourse. Can happen even if you do not lose

consciousness. HOW CAN I REDUCE THE LIKELYHOOD OF

CONCUSSION? Basic steps you can take to protect yourself: Wear all appropriate P.P.E. (Personal

Protective Equipment) –i.e. helmet, goggles, safety vest and riding boots at all times when riding – whether riding out at home, on the gallops or on the racecourse.

Make weight safely by appropriate dieting and exercise.

Avoid rapid fluid loss prior to riding. Practice and perfect the skills of riding. Practice good sportsmanship.

WHAT ARE THE SYMPTOMS OF CONCUSSION? You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. You might notice one or more of the symptoms listed below or that you “don’t feel right”:

Memory problems. Difficulty paying attention. Confusion. Headache or “pressure” in head. Loss of consciousness. Balance problems or dizziness. Double or fuzzy vision. Nausea (feeling that you might vomit). Feeling sluggish, foggy or groggy. Sensitivity to noise or light. Feeling unusually irritable. Slowed reaction time.

Exercise or activities that involve a lot of concentration, such as playing video games, may cause concussion symptoms to reappear or get worse.

WHAT SHOULD I DO IF I THINK I HAVE A CONCUSSION? Don’t hide it. Tell your trainer, agent and family. Never ignore a bump or blow to the head even if you feel fine. Also tell your trainer right away if you think one of your fellow jockeys might have a concussion. Get a medical check-up. Your Turf Club Medical Officer, Racecourse Medical Officer or G.P. can tell you if you have a concussion. You will then be assessed through the Turf Club and advised when it is safe to return to race riding. (If in doubt ring the Senior Medical Officer - Dr. Adrian Mc Goldrick (087-2424404). Your brain needs time to heal. While your brain is healing you are more likely to have another concussion if you suffer a blow to the head or body. In rare cases, repeat concussions can cause permanent brain damage. Severe brain injury can change your whole life.

IT IS BETTER TO MISS ONE RACE MEETING THAN THE WHOLE SEASON.

Concussion Information Poster

Concussion Information Poster in Jockeys’ Weighroom

WHAT NEEDS TO BE DONE?

Specific to racing The current European helmet standard – EN1384:2012 is in fact a 1996 standard with the date updated. While there may be anecdotal evidence that some higher standard helmets reduce concussion, there is no scientific evidence to date to support this hypothesis.

In 2005 a new higher standard for equestrian helmets was introduced –EN14572. However no helmets to this standard were ever produced – most likely because manufacturers didn’t try.

In 2010 at Ireland’s request the standard was withdrawn and WG5 of CEN (Working Group 5 – Helmets for Horse Riders - of CEN - the European Standards Body) was directed to rewrite EN1384.

Ireland took over the Secretariat of WG5 with Ms. Elizabeth O’Ferrall of NSAI as Secretary and I was appointed Convenor.

It was agreed that a 2 stage rewrite would take place with an initial increase in the current requirements while a test for tangential impact was devised by WG11 of CEN. It is hoped to have this test completed within the next 2 years and to have it incorporated into the new standard. This will, for the first time, provide a helmet standard that potentially will reduce concussion.

Over the last 4 years we have had many meetings –with much opposition from manufacturers of helmets to any increase in the standard.

However a final draft of the first stage rewrite has been completed and has been forwarded to CEN Headquarters in Brussels to be sent out to all European countries for enquiry.

In the interim The Irish Turf Club, with effect from January 1st 2014 increased the minimum helmet standard so that all helmets have to meet the joint standards of PAS015:2011 and EN1384. PAS015:2011 is a much higher standard produced by BSI.

The British Horseracing Authority have agreed to do likewise with effect from October 1st 2014.

Other Equestrian Sports and recreational riders

I would like to see the minimum equestrian helmet standard raised to the standard used in racing.

In racing, riders participate in a controlled environment where a minimum of 2 doctors and 2 ambulances with paramedical personnel are present.

General

Education

It is essential that education is provided to doctors diagnosing and treating concussion i.e. G.Ps, Sports Physicians and Emergency Medicine physicians.This is underway via the Faculty of Sports and Exercise Medicine and the Irish College of General Practitioners.Education of the general public but in particular coaches, parents and those participating in sports. This is underway via the Departments of Health and Education with input from Sports Physicians and Acquired Brain Injury Ireland.However we are In the early stages and much still needs to be done.

Br J Sports Med 2014;48:119-124 doi:10.1136/bjsports-2013-092785

Original articleKnowledge about sports-related concussion: is the message getting through to coaches and trainers?

1. Peta E White1, 

2. Joshua D Newton2, 

3. Michael Makdissi3, 

4. S John Sullivan4, 

5. Gavin Davis3,

6. Paul McCrory3, 

7. Alex Donaldson1, 

8. Michael T Ewing2, 

9. Caroline F Finch1

+Author Affiliations

1. 1Centre for Healthy and Safe Sport, University of Ballarat, Ballarat, Victoria, Australia

2. 2Department of Marketing, Peninsula Campus, Monash University, Frankston, Victoria,

Australia

3. 3The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre—Austin

Campus, Heidelberg, Victoria, Australia

4. 4Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New

Zealand

1. Correspondence toProfessor Caroline F Finch, Centre for Healthy and Safe Sport, University of Ballarat, Ballarat,

Victoria 3353, Australia; c.finch@ballarat.edu.au

Received 20 June 2013

Revised 6 August 2013

Accepted 21 August 2013

Published Online First 16 September 2013

AbstractAim The need for accurate diagnosis and appropriate return-to-play decisions following aconcussion in sports

has prompted the dissemination of guidelines to assist managing this condition. This study aimed to assess

whether key messages within these guidelines are reflected in the knowledge of coaches and sports trainers

involved in community sport.

Methods An online knowledge survey was widely promoted across Australia in May–August 2012 targeting

community Australian Football (AF) and Rugby League (RL) coaches and sports trainers. 260 AF coaches, 161

AF sports trainers, 267 RL coaches and 228 RL sports trainers completed the survey. Knowledge scores were

constructed from Likert scales and compared across football codes and respondent groups.

Results General concussion knowledge did not differ across codes but sports trainers had higher levels than

did coaches. There were no significant differences in either concussionsymptoms

or concussion management knowledge across codes or team roles. Over 90% of respondents correctly

identified five of the eight key signs or symptoms of concussion. Fewer than 50% recognised the increased

risk of another concussion following an initial concussion. Most incorrectly believed or were uncertain that

scans typically show damage to the brain after a concussion occurs. Fewer than 25% recognised, and >40%

were uncertain that younger players typically take longer to recover from concussion than adults.

Conclusions The key messages from published concussion management guidelines have not reached

community sports coaches and sports trainers. This needs to be redressed to maximise the safety of all of those

involved in community sport.