Presentation to the Oireachtas Joint
Committee on Health and Children
2nd. October 2014
Dr. Adrian Mc Goldrick
Senior Medical Officer
Irish Turf Club
Representing Irish Turf Club and Irish Jockeys Association
Background
Concussion 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
Definition
Concussion 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.
Incidence
It 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 Syndrome
Second 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
Injuries
284
264
376
344
217
273
2014
(To
date)
?
Concussions
29
48
32
29
16
15
23
10.2%
18.2%
8.5%
8.4%
7.4%
5.5%
?
1.03%
1.95%
1.35%
1.24%
0.86%
0.75%
?
As
percentage
of injuries
As
percentage
of falls
2009
2010
2011
2012
2013
Comparative Data
Country
U.K.
Ireland
Number of rides
1,904,400
267,638
Number of
concussions
Concussions per
ride
1,635
0.086
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
GUIDELINES
st
2001 VIENNA - 1 . INTERNATIONAL SYMPOSIUM ON
CONCUSSION IN SPORT
2004-N.A.T.A. POSITION STATEMENT : MANAGEMENT
OF SPORTS RELATED CONCUSSION
nd.
2004 PRAGUE - 2 INTERNATIONAL SYMPOSIUM ON
CONCUSSION IN SPORT
A.C.S.M. 2006 –CONCUSSION AND THE TEAM
PHYSICIAN – A CONSENSUS STATEMENT
rd.
2008 ZURICH – 3 INTERNATIONAL SYMPOSIUM ON
CONCUSSION IN SPORT
A.C.S.M. 2011 UPDATE–CONCUSSION AND THE TEAM
PHYSICIAN – A CONSENSUS STATEMENT
th
2012 ZURICH– 4 . 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
UPDATE
2013 : 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 Neuropsychologists 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 Physician
or 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 neuropsychological 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.
00353-872424404
amcgold@indigo.ie
August 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
A FACT SHEET FOR TRAINERS
CONCUSSION – THE FACTS
 A concussion is a brain injury.
 All concussions are serious.
 Can occur from blows to the body as well
as to the head.
 Riders may not report their symptoms for
fear of losing a ride.
 Recognition and proper response to
concussions when they first occur can
help prevent further injury or even death.
 Can occur while riding out as well as on
the racecourse.
 Can happen even without loss of
consciousness.
HOW CAN YOU REDUCE THE LIKELYHOOD OF
CONCUSSION?
Basic steps you can take to protect your rider:
 Make sure they wear all appropriate
P.P.E. (Personal Protective Equipment) –
i.e. helmet, goggles, safety vest and riding
boots at all times when riding out at home
or on the gallops.
 Make sure they make weight safely by
appropriate dieting and exercise.
SIGNS AND SYMPTOMS OF CONCUSSION
SIGNS YOU MAY OBSERVE IN YOUR RIDER:







Appears dazed or stunned.
Loses consciousness –even briefly.
Answers questions slowly.
Can’t recall events before the fall.
Can’t recall events after the fall.
Is unsteady on their feet.
Shows behaviour or personality changes.
SYMPTOMS REPORTED BY RIDER:











“Don’t feel right”
Difficulty paying attention.
Confusion.
Headache or “pressure” in head.
Loss of consciousness.
Balance problems or dizziness.
Double or fuzzy vision.
Nausea (feeling that they might vomit).
Feeling sluggish, foggy or groggy.
Sensitivity to noise or light.
Feeling unusually irritable.
WHAT SHOULD YOU DO IF YOU THINK A RIDER HAS HAD A CONCUSSION?
Refer the rider for a medical check-up. Your G.P. can tell you if your rider has had a concussion. If he/she
has had a concussion, inform the Turf Club and they 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 (0872-424404).
The brain needs time to heal. While the brain is healing a rider is more likely to have another concussion
if they suffer a blow to the head or body. In rare cases, repeat concussions can cause permanent brain
damage. Severe brain injury can change their 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 article
Knowledge 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
2.
2Department
3.
3The
for Healthy and Safe Sport, University of Ballarat, Ballarat, Victoria, Australia
of Marketing, Peninsula Campus, Monash University, Frankston, Victoria, Australia
Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre—Austin Campus, Heidelberg,
Victoria, Australia
4.
1.
4Centre
for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand
Professor Caroline F Finch, Centre for Healthy and Safe Sport, University of Ballarat, Ballarat, Victoria
Correspondence to
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
Abstract
Aim 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.