I'll call this meeting to order. It's great to have everybody back.
This is the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee on Health.
Today we have, from the College of Family Physicians of Canada, Pierre Frémont, chair of the sport and exercise medicine committee. From the Canadian Academy of Sport and Exercise Medicine, we have Elisabeth Hobden, president-elect.
We're going to have an opportunity to hear from our witnesses now. For all those who may be following these proceedings, through our portal there is also an opportunity to make submissions to our committee.
We look forward to hearing from our witnesses. Witnesses, you're going to make your statements. Then we will hear questions from the members. We'll do this in a rotational manner, so you'll hear from all parties.
We will start with Mr. Frémont.
On behalf of the College of Family Physicians of Canada, I would like to thank you for the privilege and opportunity to present the family medicine perspective around concussion.
I would also like to acknowledge the close collaboration of the Canadian Academy of Sport and Exercise Medicine and the Canadian Medical Association in developing the brief that was jointly submitted to this committee.
First, I would like to explain my experience with concussion from a broad spectrum of perspectives.
Personally, I have sustained three concussions in alpine skiing, soccer and playing water polo. I also have a bunch of kids who have sustained quite a number of concussions.
As a sport medicine team physician, I was involved in concussion management from the international level of competition all the way down to varsity and grassroots-level sports. I am also involved in a number of current initiatives around concussion, including the Canadian Concussion Collaborative and the Sport Canada working group on concussion.
As an academic, I have been studying the implementation of concussion management protocol in high school-level sports programs. I've also been involved in the use of an innovative strategy, namely massive open online courses, to disseminate the good way to deal with concussions and to support sports in school settings in the implementation of protocols.
Finally, as a physician, I have seen patients with concussions from all causes, in all age groups and at all stages of this injury.
Now, before I can discuss the potential contribution of family medicine to address this issue, I would like to remind you of some key background information.
First of all, the simple principles of initial concussion management are clearly within the scope of family practice.
Second, these simple principles, which are removal from danger, initial rest and gradual return to cognitive and physical activity, allow the vast majority, that is, 80% to 90% of concussion patients, to evolve favourably within seven to 10 days. That's a very good reason to start with primary care. As well, over 85% of Canadians have access to a family physician. That's not a perfect score, but that's a pretty good one.
The question is this: Can family physicians play such a role?
Over the last decade, with increasing awareness around concussion, there have been constant medical education opportunities about concussion for family physicians. There was a rapid increase.
Again, it's not perfect but it's available and expertise is increasing to deal with the aspects of early concussion management. These are the initial assessment and diagnosis associated with the standard initial recommendations, which I alluded to. Then there is the decision, once things are going well, about returning to an activity at risk for concussion. Finally, there is assessment in the presence of persistent symptoms. That can involve referral, at this point, if you get out of any given physician's expertise with concussions.
The bottom line message here is to not be afraid to build strategies with a central primary care role for family physicians.
Another key aspect of how we can address the issue of concussion is empowerment. In the joint statement from the Canadian Academy of Sports Medicine and the College of Family Physicians, we state that key aspects of concussion prevention, detection and management occur prior to as well as after the medical encounter, namely, in sports and school settings. Therefore, we need to develop public health strategies that aim to support and empower school and sports settings in dealing with the day-to-day management of concussion. Sport medicine physicians and family physicians can play a role in supporting the implementation of such strategies.
Also, as a family physician, I want to emphasize that Canadians of all age groups suffer from concussions that occur in contexts often unrelated to organized sports, such as leisure, work or car accidents. These Canadians should also be considered in the way we address this issue.
In conclusion, I'd like to leave you with three key messages. The first one is that now that high-level sports and national sports organizations have received significant support to do better about concussions, the next steps should aim to improve concussion by prevention and management at every level of sport participation all the way to the grassroots level. Also, we should consider concussion occurring in every context and age group. Finally, don't forget that family physicians can and should play a key role.
Thank you very much.
I would like to thank you for having me here today to speak before the committee.
I'm a sport and exercise medicine physician. We're uniquely qualified and experienced in concussion management.
Sport and exercise medicine physicians have been founding members of the Canadian Concussion Collaborative. They've played key roles in the international consensus statement on concussion in sport. This is an international gold standard that physicians look towards when they're looking to treat a sport-related concussion or return a patient to play. They are also experts in the design and implementation of medical systems and protocols for sporting events. A diploma in sport medicine is granted after examination ensuring competence.
Unfortunately, there are still many barriers for Canadians who have a concussion. I see too many patients like the following one: a young girl who was required to travel over an hour to see me. Her expectation and her mother's expectation was that she was simply going to walk in, get a note saying she could return to hockey for the weekend, play her playoff game and head back home. A concussion assessment takes 45 minutes or more. During this assessment, we discovered that this young lady, who is very intelligent and was expecting a scholarship from MIT to become an engineer, was unable to subtract seven from 100 and get the right answer. She really had no idea of her deficit, nor did her family.
Sport and exercise medicine and family physicians are able to safely manage most concussions like this one because they do indeed get better. What these patients do need is time. They need time to understand their injury and they need extra support that we often don't see with other patients because they have a brain injury, which means they can miss appointments or they can have difficulty coordinating their care. That puts an extra burden on physicians who are trying to manage a full waiting room and have the financial reality of the increasing burden of overhead.
Qualified, multidisciplinary treatment in their own area is extremely effective for these patients because the burden of travelling can actually increase concussion symptoms, so it's very important that they have treatment that's close to home.
Appropriately designed community-based clinics with evidence-based care could help to alleviate many of these barriers. However, the reality is that there are only 531 physicians in Canada with a sport and exercise medicine diploma, but all Canadians can benefit from their expertise through a public health-style approach. There's no doubt that community sport medicine and family physicians are excellent resources for patients with concussions. However, using the integration of sport and exercise medicine physicians in the planning of sport events can empower people to have prevention, detection and management of concussion at all levels. We've done a fairly good job at the elite level, so that's coming along, but most of our participants are at a recreational level. Some of our pediatrics, or our children, are at the most risk from concussions, so it's important that we hit all levels.
The legislated requirements of medical expertise in concussions for the planning of sporting events and protocols at all levels would greatly benefit the health and safety of all Canadians.
I recall a young patient that I had who suffered a tackle in a community football league. At the time, he didn't know he was concussed; his teammates didn't know he was concussed and there was no protocol in place to address this within his context. I saw him several weeks later, after his academic performance had started to decline and he'd been suffering from headaches and feeling dazed and confused for several weeks. Unfortunately, this is all too common to see in my practice.
The reality is that sport culture changes slowly and it often does not include medical considerations. It's important that we bring this to light at all levels of sport in Canada. The medical involvement in planning gives credibility to change within the sport and to sporting bodies or community bodies to say, “Do you know what? We know we haven't done things this way in the past, but this is why we feel it's important to make these changes.”
I want to make it very clear that I believe participation in sports should not be discouraged. It should be encouraged. It's important for Canadians' health. Any requirements should not create an undue burden so that people are unable to participate in organized sport. Canadians need to be active. They need to know that they are safe being active and that if they should suffer an injury, they can get the best possible care.
Thank you for your attention. I look forward to the discussion.
Thank you very much, Dr. Hobden and Dr. Frémont.
We're going to have an opportunity now to hear some questions from the members.
Members, we're going to have a vote later this evening, and bells should start ringing at about 6:05 p.m. I understand there is a consensus that we will stay here until about five minutes before the vote. Then we'll just scoot up, vote and come back down to committee.
I see everybody is in the affirmative. That's great.
We are going to start our questions with the Liberals and Dr. Eyolfson.
Thank you to both witnesses for coming. It's nice to be among my peeps. I was an emergency physician for 20 years before doing this.
You made a great point about the number of concussions that happen in non-sport settings, but we often tend to forget that. We use the word “concussion”, for the most part, only when someone comes in injured from a sporting event. When someone comes in having been knocked over the head and had their wallet taken or having fallen and broken their hip at home, we don't tend to think about concussion, but it is a consideration. Although this is about sports-related concussions, I think there's much that's applicable to the overall treatment of concussion.
Do you know if there are any public health approaches to concussions that are not related to sports? Has there been any concerted effort to get that out there, or is the science still concentrating on the sports-related concussions?
There are two solitudes that we are trying to connect at this point. T
here's the world of mild traumatic brain injury, which is often the term used to describe those concussions that occur in non-sport contexts. The definition of that is linked to some objective criteria, such as loss of memory, loss of consciousness, things like that. It's a challenge to get people comfortable with the management of that kind of injury, the recognition of it, in non-sport contexts as much as it is in sports-related contexts. There's a lot of work to do. We often see people who get a hip injury, and the concussion that comes with it is not identified. We need to do better with all of those cases.
There is no scientific indication that the physiopathology of the injury is different if you get hit by a soccer ball or you fall on the ice. It's the same problem, and we need to do better on both fronts. I'm not aware that there is specifically a strategy to address that as a public health issue, but there certainly are grounds, in the numbers I gave you, for addressing it in a stepwise manner, starting with primary care. In so many of those cases, if you do the basic simple stuff, they will heal, just by keeping them safe and having them gradually resume their activities.
That can be the basis.
What is the state of knowledge on these head injury guidelines among primary care physicians? That would include family doctors, emergency physicians. Would you say that throughout Canada, there is a reasonably consistent level of knowledge from the physicians' point of view?
Do we have a long way to go in making sure that all physicians understand when a primary physician says they can manage this, or no, they need to refer that one?
Dr. Frémont, you might want to chime in on this as well.
Thank you both for being here. I appreciate it.
Dr. Hobden, you talked about protocols and the issue.... I think it's important that we address that because the reality is that when we're looking at people knowing the level they're at, they may not see that concussion come in until four or five days after the event, and they may have forgotten about the event. We see that all the time in practice, whether it's a sport or an everyday concussion.
What would you tell us that the sporting bodies need to do?
I come from a regulatory background, so I would look to see how we regulate these bodies to make certain they put in these protocols. I'm wondering if you could expand on that.
Okay, I'll let you come back to that.
One of the things we see, for example, the CAHA came out with mandatory trainers for every team, so we have them on the benches. The reality is that training program sometimes doesn't provide more than basic first aid. That's a challenge when you're asking somebody who doesn't have the medical background or any type of health care background to all of a sudden assess someone who's been injured on the ice and make that decision. Granted, usually the statement is they should see their family doctor.
As I've mentioned to you earlier, I come from rural Saskatchewan, and we don't have access to those doctors. As you mentioned, all of a sudden, they call you up because they can't run this program because they need a doctor there. Those are big challenges for rural Canada, so we want to make certain that when we talk about things here, we encompass not only the urban settings but also the rural settings.
About that, I'd like to loop back to the previous question.
The CCC made a recommendation about that. The CCC cannot make laws, but we made a clear recommendation that was published. If you organize an activity at risk for concussion, you should implement a way to manage concussion, in the same way you should have a security and prevention strategy in general.
You should consider your resources and ask, “How can I do as best as is possible for concussion?” Those levels of resources will not be the same. Suppose you are on the world cup tour in alpine skiing or at a little ski club on the mountain by the city. You will have a doctor and an expert physiotherapist on the world cup tour and you will not have any health care providers at the little ski club. But you can still do very well. You can implement awareness. You can find a way to consider...if the kid was able to return to school prior to returning to sport.... There's a way you can address every aspect and ask, with consideration for the resources of any setting, “How well can I do?” I think that's the process we are looking for.
We will never be able to have sport therapists and even fewer physicians present everywhere a sport event is occurring and there's a risk for concussion.
Going back to your organization, it's collaborative. Tell me what your experience has shown where we need, as a government, to facilitate more the evidence gathering or the data sharing so that you have effective regulations even down the road.
We've had various testimony already. One group, Parachute, for example, did the guideline for concussion.
That information, that evidence, is evolving all the time. Then you have these silos. Then you have which stakeholders should be included. When you set regulations, I know that everyone is most comfortable when they are evidence based.
Where do you think we could be facilitating that data gathering, data sharing and evidence sharing? Where are there opportunities?
What was initiated with the Canadian concussion protocol harmonization project, which was led by Parachute with funding from the Public Health Agency of Canada, was the start of creating a centralized, validated and hopefully continuously updated hub of information. Hopefully there will be more federal funding to keep that going and keep that updated.
What we used to have before that was the international consensus, which is updated every four years. The next one will be in Paris in 2020. Then we need Parachute to have the resources to work with the experts and contextualize the new updated recommendation at that point and maintain that central hub.
The next challenge you have is transfer of that information and contextualization to a broad spectrum of contexts that go from the very resourceful elite sports to the non-resourceful grassroots sports. They still can do well if they are supported to do the best they can with the resources they have.
The next challenge is knowledge transfer and implementation while keeping support for the harmonization project which I think made big progress towards avoiding the problem of googling “concussion” and getting 2,000 results and you didn't know what was good or bad.
I'm sorry that I missed the witnesses' opening remarks. I hope that my questions won't force them to repeat themselves, since that's not my intention.
Here in the subcommittee, we're trying to determine what we can do and suggest, as members of Parliament and legislators, to ensure that the government can support all the initiatives under way and work with the provinces. I gather that the issue is complex, and that both the federal and provincial governments must play a role.
I know that you've already proposed some ideas. Since we're in the final round of discussions, I'd like you to say what you think that we, as legislators, should do. You specifically talked about the need to increase funding, and I want to hear what you haven't had the chance to tell us yet.
Mr. Frémont, you may begin.
Thank you, Mr. Chair. Doctors, thank you for coming today to present.
I'll start with you, Dr. Hobden, on a comment you made in your presentation of a young man who got hurt and didn't know he was concussed. Of course, his academics declined, and his headaches and confusion were evident.
An individual nowadays has that avenue. Back in my day, in the late 1970s and early 1980s.... I know for a fact that I've been concussed numerous times, maybe not as many as you, Dr. Frémont. I don't know whether or not I was dealt a concussion, but I was certainly knocked out.
Being someone who assesses patients—again, this is my first time at this committee so other committee members have probably heard this before but I have not—how do you assess whether someone has had a concussion or not? Being knocked out does not necessarily mean you've had a concussion, correct?
The SCAT5 is the sport concussion assessment tool. It's not actually the fifth version, but they call it the SCAT5 for other reasons.
The document comes out of the international consensus statement on concussion in sport. There's a narrative that you can read with evidence behind it and all that kind of thing, but the SCAT is what we as physicians use to assess a sporting concussion.
It starts out with very simple things: What's your name? What's the date? What sport were you playing? What's the score? What quarter are you in? It moves on to more complex things like asking you to do some tests of short-term and long-term memory. It asks you to do some balance tests to see how your balance is affected, because that is very often affected in concussion. Then there are some concentration aspects where you ask them to subtract seven from 100, and keep going. Lots of people have difficulty doing that with a concussion, or saying the months of the year backwards. When you've tested this, you can test some of their movement as well.
Essentially you come up with a score. The score doesn't tell you whether or not you have a concussion, but it can help me as a physician.
Another thing that's part of it is that the patient rates their symptoms. As a physician, I can say that overall, I think things are improving. It's designed really only for the initial assessment to see where you're at. But certainly the self-reporting of symptoms is important as you go along.
You both made an important point that no one concussion is (a) the same, (b) treated the same, and (c) comes out with the same results. I appreciate those comments, because that's an awareness thing that we need to know, and that we need to get out for the sporting bodies to understand that as well, because they extrapolate that all into saying....
In my day, when I had my concussion, they'd say, “Your bell was rung. Get back out there. It's a long way from the heart.” Today, we need to be very well aware of that aspect of it because of the implications of it, and no one ever recovers exactly the same way. I was the victim of a hit-and-run when I was 16. I was riding a bicycle and was hit by a drunk driver. I was unconscious for 10 days. The reality is that I've come back from it but it took time. You see everyone recovering on those aspects.
When we deal with children, they're reliant upon the people around them to make decisions for them. That goes back to, as you talked about earlier, recreational sporting before they get to that elite level. As they get to the elite level, they usually have a lot more professional help that's providing that for them.
What can we say to those who might be listening today, the parents who might be listening today, as to how they approach that aspect? A lot of parents will panic and maybe overdiagnose it themselves because they read it on the Internet, or they may not do anything. I'd like some suggestions from you, if possible.
If I understand your question correctly, it is what does the mom do who has a child participating in a sport and is worried about the risk of concussion.
The first thing I'd suggest is for her to talk to the sporting organization, talk to the coach, about what education the coach has. There are free online courses that sporting organizations give. Does the coach have anything? I think that's a good place to start.
The second thing is there's a lot of good information for parents on the Internet from groups like Parachute about concussions, how to recognize them and what's going on. The reality is, if you're concerned about the health of your child, if you're concerned about a concussion, we always say that when in doubt, sit them out until you can get a proper assessment to understand what their health status really is.
I think that notion of a central hub of information with tools to support every type of setting in the implementation of those recommendations is the key here. Implementing formal expectations, whether it's through regulation or legislation, those are different means, and I'm not the one who will choose.
I think it's okay, for example, for Sport Canada to associate funding.... They do it for harassment. If you don't have a harassment policy, you don't get the funding. Why not do it with concussions? Why couldn't we say that if they want to organize a sport at risk for concussions, they must have a rule or they will not get that type of support?
There are different ways to reach that, but this has to come with the support to meet the expectations, which is often a problem. If you just pass a law and you don't support people in meeting the requirements of the law and you don't have the resources to verify the application of the law, then you just have a sword of Damocles hanging there to be able to say someone is guilty when a kid dies, which is not right. If you implement an expectation, you need to have the support.
I'm glad everybody is back. I apologize for that break for the vote.
We are back now with our second panel of witnesses. From the Canadian Concussion Centre, University Health Network, Toronto Western Hospital, we have Dr. Charles Tator. We also have with us, from the University of Ottawa Brain and Mind Research Institute, Shawn Marshall, division head, physical medicine and rehabilitation. From the Centre for Rehabilitation Research and Development, we have Dorothyann Curran, who is research associate at the Ottawa Hospital.
We are going to start with Dr. Charles Tator. Just in case something happens with our video conference, we want to ensure that we get Dr. Tator's statement and testimony here for the members to hear. Then we'll move to our other witnesses. Then we'll have questions from the members.
Dr. Charles Tator, the floor is yours.
Thank you, Mr. Fonseca.
I'd like to thank the committee for inviting me to speak. I'm very pleased, in fact, that this committee of Parliament is putting so much energy into the field of concussion.
I've been focusing on this field in my practice and research for the past 20 years. I think it's great that our country feels that this is a major concern. It has been my view for a long time that concussions are a major public health issue in our country, for a number of reasons. We generate a lot of concussions because of the way we live. We drive quickly. We play a lot of high-risk sports. In fact, we generate about 200,000 concussions annually. I can tell you that our research shows that about 20% do not recover within the usual time of about a month. In fact, some never recover.
We've learned quite a bit about concussions. We're impressed with the fact that they are often followed by significant issues, such as major mental health disorders. In fact, some end up with brain degeneration, as I'm sure you are aware.
I think it's important for this committee to have a perspective. I'm probably the oldest person who is going to speak to you, and from my perspective, a lot really has gone on in the last 20 years. I welcome this committee to the team to deal with concussions, but I really feel that it's important for you to be aware of this perspective.
In about 2000, the Canadian Academy of Sport and Exercise Medicine—you just heard from representatives of that committee—put out one of the first concussion guidelines of any country, so Canada was really quite forward in saying in the year 2000, for example, that every concussed athlete should be removed from the game or practice and should see a medical doctor. In the following year, and for about the next 10 years, there were concussion road shows that went across the country and visited all the major cities. They were sponsored by a number of organizations, including Hockey Canada and ThinkFirst.
In about 2010, we opened what I think is Canada's first comprehensive concussion centre focusing on concussion care and concussion research. There are now several others across the country in major cities and even in some smaller cities such as Barrie, Ontario. From 2011 until 2019, the present time, CASEM has had a Canadian concussion collaboration with a number of organizations, which now includes Parachute Canada, Canada's injury prevention agency.
In 2012, in the Ontario legislature, for the first time a concussion law was given first reading, but it did not pass. To put that into perspective, by 2014 all 50 states in the U.S. had already enacted some form of concussion legislation.
Next, 2013 was an important year, because the first Canadian cases of CTE, the dreaded brain degeneration related to repetitive concussions, was first reported in Canada. That same year, in 2013, Rowan Stringer died in Ottawa from concussion-induced second impact syndrome following concussions in school-based rugby.
In 2014, the following year, the Ontario Ministry of Education enacted PPM No. 158, which was a concussion policy procedure for school-based sports. It only covered school-based sports, but it was very important to do that.
In 2015, sent mandate letters to the federal ministers of health and sport, and , respectively, to support a national strategy to raise awareness for parents, coaches and athletes on concussion management. It was a very important initiative. That same year, the Rowan Stringer inquest was held and established that that was a concussion-related death. The jury recommended 49 measures to prevent further deaths in sports.
In the following years the Public Health Agency of Canada awarded Parachute Canada a contract to harmonize concussion education and guidelines for our country. From 2016 to 2019 the federal Ministry of Sport's working group on concussions, headed by Jocelyn East and Michel Fafard, began its work. That has been an excellent committee with representatives from sport, health, education and prevention, with great committee work on harmonization and dissemination of guidelines.
In 2017, the Rowan Stringer committee formally called for concussion legislation, and I'm very pleased to say that was ultimately enacted in 2018 in Ontario. That's very recent, and now we are aware of other provinces, especially Manitoba, that are moving in that direction.
Parachute Canada and PHAC introduced these excellent guidelines so we now have guidelines written by Canadians for Canadians for all sports. It is important for your committee to know and appreciate that.
Thank you, Dr. Tator, that was a great presentation and history.
While I think Dr. Tator precedes me in age, I'm also of a similar ilk. I think we predate concussion being a concern. Early on in our careers when we started off, concussion wasn't identified.
What I want to focus on in my presentation is that I think the emphasis has been on identification and prevention of concussion. Where we have come into the fold and where we've done a lot of our work is on, I think, something very important mentioned by Dr. Tator, which is the management of a concussion after it's occurred.
There's acute management, and there's that minority of persons who had a sport-related concussion or a concussion outside of that. Generally it's 15% to 20% in a study for pediatrics, and it exceeds 30% if we go longer than 30 days. If we go beyond six months, it's probably 15% to 20% of the population. Again, sport concussion is a subset of concussion. I think concussion affects everyone in their daily lives.
The tack I take from it is that we as clinicians were recognizing that people were having concussion, and these individuals weren't necessarily completely recovering, which is what the expectation was: complete recovery. My main area has been moderate and severe brain injury. We were in rehabilitation and finding that these patients were not completely recovering.
Akin to guidelines that talk about management of concussions, or concussions more clearly, Canada has been a lead. Another area that we have focused on has been the management of symptoms following that, to try to standardize practice for how we manage people who have ongoing symptoms following concussion, primarily focusing on those with persistent post-concussion symptoms.
Through the work of the Ontario Neurotrauma Foundation, there have been two sets of guidelines created, one for pediatric, ages 18 and under, and another for adults. These have been published nationally and internationally. They have been presented as such and are recognized as very solid guidelines. We're currently in the third edition for the adult concussion guidelines. The aim of this is to standardize practice to provide care. As Dr. Tator mentioned, 200,000 Canadians per year sustain concussions. If 20% are not better after 30 days, then we're looking at people who need help and support. This needs to be improved in care and where we're focusing our research.
The other thing I will comment on specifically is that there have been initiatives that, to date, have not been successful, but have tried to harness the expertise here nationally in the country. Led in Calgary by Keith Yeates, there was an application for a national centre of excellence for concussion management through the University of Calgary. It was not successful in the letter of intent stage, but it harnessed experts throughout the country to focus on sport-related concussion and concussion in general, both pediatric and adult.
Another initiative that has been successful, but has not received full funding through the Ontario government, is the Ontario Brain Institute in relation to the Connect group studying concussion from all elements, from pre-concussion to concussion, looking at even chronic encephalopathy through all stages, including acute management and post-concussion management.
These are things that should be pursued further to standardize practice of care. Clearly, Canada and Ontario are leading in this area in trying to set these standards, and this has been well recognized internationally.
I believe that support on setting those guidelines and standards and allowing for further research will help us better serve our patients.
Concussion, in particular, sport concussion, has become very topical in terms of public awareness over the last 15 years. Both physicians alluded to that.
Research on concussion has also risen exponentially. In doing a literature review for the 2012 adult version of “Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms”, about 18,000 abstracts were reviewed. When the third version of the guidelines was created in 2018, over 38,000 abstracts were reviewed.
There are different types of research targeting different aspects of concussion. There's research on identifying concussion conclusively and quickly. Not everyone who experiences an impact to the head develops a concussion. How do we identify those people who actually do end up with brain damage? There's research that looks at proper healing timelines, and there are guidelines for adults, children and adolescents, designed to advise people on getting back to work, school or play. A lot of research has been done looking at attempts to speed recovery during concussion, in the subacute phase, to address specific symptoms, such as headaches, cognitive issues and vestibular issues. People want to get back to their day-to-day activities as quickly as possible.
Some research on persisting symptoms has also been done. How do we identify people who might develop persisting symptoms? We know, for example, that women tend to have persisting symptoms more frequently than men do. What can we offer these people, in terms of rehabilitation? What therapies and treatments might offer optimal management for these persisting symptoms in the long run?
There's also research that looks at extrinsic and intrinsic factors that might contribute to persisting symptoms. There's a concern about the effects of multiple concussions that may translate into persistent symptoms. There's gender, age and mechanism of injury which could contribute to persisting symptoms as well.
Some athletes are working in jobs that can increase their likelihood of having concussions. It's known that people who experience a concussion are more likely to have another one, which is also a danger for athletes, especially those in contact sports.
It's generally accepted, as Shawn and Dr. Tator mentioned, that about 15% of people who experience a concussion may go on to have persisting symptoms. It's becoming a little more clear that it could actually be a higher number; maybe 20% of people end up with persisting symptoms following a concussion. Symptoms that remain beyond three months are considered persisting symptoms. People who fall into the persistent symptoms category are at a great disadvantage. Their symptoms interfere with work, return to play, social activities and family obligations.
In terms of avenues for future research, which is more where my focus is, augmented reality and virtual reality are definitely gaining interest, in terms of assessment and treatments for concussion. There are different types of goggles with analytic software emerging for use in sports. They are very portable, and may be able to assist in the diagnosis of concussions. Virtual reality that uses larger, more immersive systems can also measure range of motion and centre of balance. They have good potential, although they'd only be available at health care centres. The newer gaming platforms make simulation interfaces more visually engaging, which could improve compliance with treatment.
The advantages of the use of VR for assessment and therapy are that we can program virtual reality very specifically, to elicit responses based on increment, difficulty or intensity, and we can measure responses to stimuli. It's also a great distraction, and, obviously, the entertainment feature is high.
In terms of the disadvantages, we don't know what long-term exposure to virtual reality can do. Virtual reality is also not the real world. Human responses are not the same in virtual reality. If we want to rehabilitate people into the real world, there are some things we simply want them to do in the real world. If we want them to stack blocks in virtual reality, they might as well stack blocks in the real world.
Overall, there's a lot of research being done on concussion. At this point, the literature, in my opinion, needs to be evaluated. Studies need to be evaluated by people with clinical and research experience using reporting guidelines that will help to qualify the research. The new research that is going to be done needs to be driven by what gaps exist that we know about now.
Thank you, everyone, for coming.
I was explaining to the last panel that I'm a physician, so it's kind of nice being back with people from my field. I feel like we're getting the band back together.
I'd like to start with Dr. Tator. At your centre, they're studying deterioration of brain function. I think you mentioned chronic traumatic encephalopathy in your remarks. Has your research found any correlation with other identifiable neurologic conditions like dementia, Parkinson's disease, MS, or anything like that?
Thank you to all of you for being here and for bearing with us on a day like today.
It's great to have researchers here. It's piqued my interest on a number of questions and aspects that I'd like to hear about. I'm trying to figure out where I want to start.
A number of you talked about brain degeneration, and some of the side effects that we might see, with mental health issues or possible CTE, etc.
I'm wondering whether there is research out there now compared to my day, and I go back to the days when I was.... I could talk about my undergraduate degree. I studied under Dr. Pat Bishop at the University of Waterloo. He was a mentor of mine. We did research where we were dropping hockey helmets, ancient contraptions.
Dr. Tator, I can see you smiling. I know you're very well aware of this information.
Nowadays, we're seeing a lot more new information. Ms. Curran, you mentioned about virtual imaging. These are all interesting aspects that I haven't kept up with, and I'd love to hear a little more about it. For example, on the issue of looking at this protein, the tau, obviously this is a new study. It's obviously done when someone has passed away. We can't look for that product today. It's after the fact.
How do you take all of that information and correlate that with a sports concussion?
I'll throw the question out to Dr. Tator first and then go from there.
That's a great question, a tough question. I will try to answer it.
By the way, I interacted with Pat Bishop for a long time. There is no doubt that he was a great Canadian researcher on head injuries.
With respect to your question about tau and the fact that we can see it at an autopsy, the good news that's starting to appear is that research has shown us a way to identify it in the living. We're not ready to be able to apply it to an individual patient who is suffering, let's say, with dementia, and you want to know whether it's regular Alzheimer's disease or CTE. We're not ready for that, but I think that is coming down the pike. We will be able to identify it in the living.
One of the hottest areas of research right now in this condition is the use of PET scanning, which can identify deposits of this abnormal protein. We use a radioactive tracer that's labelled with fluorine-18. We inject it and then do PET scanning, and we can see deposits of tau in the brains of some of those living athletes.
We've had a very good relationship with the CFL Alumni Association. They have sent along a number of their alumni for examination with this technique, and we can identify deposits of tau in the brains of people who are living.
I think that's a very important first step in trying to develop a treatment for this. We don't want to just be able to diagnose it. We want to be able to do something about those deposits of tau.
I think we're talking a little bit about different things too. There's the one goal of identifying CTE, which is a chronic sequela, presumed due to multiple concussions. I think the research is certainly going off in that range. We're learning more and more each day, and I think those things are very important.
I think the other area, which is in high-intensity research, looking probably more at the sport level and the acute concussion level, is the immediate diagnosis of concussion. It relates to what you're saying about PTSD, so often associated with injury, more often outside of sport than inside of sport. There's an emotional reaction that we often talk about, PTSD, and some of the symptoms can be similar to those of a concussion.
The other thing is that we're looking for markers—or biomarkers, if you will—that would suggest you've actually had resolution of your concussion. When is it safe to return? A case in point would be an example like Rowan Stringer. Clearly, she was a person who had evidence of concussion, when they went through and looked at the record, and yet continued to play. Now through prevention and other strategies in this day and age, we would identify it, first of all. That's probably one of the many failures in the system that occurred, which Dr. Tator is referring to, and we need to remedy, but it would be ideal to identify those who actually had a concussion urgent injury.
There are experimental imaging techniques. Conventional imaging such as a CT or MRI generally shows normal, and we consider it actually a more severe brain injury if it's not normal. However, we do know certain MRI protocols, like diffusion tensor imaging and other types of protocols like SWI, can show concussions acutely. The problem is that it can't be used diagnostically at this point in time. But these things need to be explored. There are also biomarkers such as SB100 which, if it's in more severe cases, is a better pickup, but when it's in the milder cases won't pick up. So I think for the acute markers—
If you wanted to leverage, I think things are at the point where we've identified as a priority some very important areas. I think research is where to go.
The truth is that you have a lot of great researchers in this country who have actually come together. This is unique, compared to other countries, working in collaboration, a national centre of excellence, as I mentioned earlier. I think through big data, for instance, through the Ontario Brain Institute, our being able to examine these large populations, and coming together, we should be able to identify technologies that can diagnose concussion and actually monitor progression, so we know who are at risk. I think this is going to be key to our being successful, helping to solve the diagnostics and then actually treatment. I think these collaborations to foster those and foster that research here in our country would be huge.
I think what Dr. Marshall just said is very important. I would like the House of Commons committee on health to put some teeth into what has been done to date. For example, I feel very strongly that every province should enact concussion laws, because that's one way to be sure we are all on the same page with concern about concussion. The concussion laws should apply to not only school-based sports, but also all the non-school based sports, for example, all of those that are organized by Hockey Canada, the Canadian Soccer Association, etc. All of those folks should be subject to the concussion laws.
What do the concussion laws say? They say that everybody should be educated about concussion. They should know how to recognize concussion. That goes for parents, coaches, teachers, players. Even the referees have to be clued in about concussion. We simply have to prevent people like Rowan Stringer from ending up dead.
We need accurate surveillance data. I've heard other speakers recommend that to your committee. We do have the machinery in Canada to make that happen. We have CIHI, PHAC, ICES, with all their methods of data management. We have to collect data about what is happening in every sport in the country. We simply don't have that information and we should. From the annual coroners' reports we should know how many people die. Those take three or four years to finish, but we should be compiling that data.
There was recently a death in P.E.I. of another rugby player. Who's adding up all those catastrophic injuries? That should be a national effort. We've heard about good resources that are available, for example, the one I held up, the “Canadian Guideline on Concussion in Sport”. This should be in the hands of every family, every coach, every referee. I would like to see your committee do something about the distribution of what is already available. I think Canadians have done a very good job of preparing a menu of opportunities for your committee to distribute and emphasize.
I would encourage you to use what's available, rather than—
I'm going to share my time with Dr. Eyolfson.
You answered part of my question, Dr. Tator. I know that a few years ago there was a concern about brain tumours, and doctors had no information about what was going on in other locations. There was no brain tumour registry.
We passed a bill in Parliament to establish a brain tumour registry so that if there was a cluster of brain tumours in one location, they could compare the circumstances to see if there was some common denominator. It sounds as though that's what's needed here, in terms of concussions, so that there is a registry and studies done that researchers can compare to see if there is common ground or a common denominator.
Would you recommend that?
For many years I dealt with sports, in my time as a trainer, in my private practice, and then when I was one of the team doctors for our junior hockey team, so basically for 25 years. I reflect back today, and although I treated a lot of concussions over the years, it did not seem to be the same.... When I was ending my practice, the longevity of the injury seemed to be greater in my last couple of years of practice versus in my early years of practice. I'd like to think that in my early years of practice, fresh out of school, I was on top of it and everything.
I'm wondering, from the research, can you tell us why we're seeing more situations where concussions seem to be lasting longer than 30 days? Is there any research to suggest that?
I'll start with the researcher, Ms. Curran.
Do you have any comments?
It's a great question. The quick answer is I don't know.
What do I think? I think you're asking the question now if they had a concussion. I think we're old enough to know that previously, concussions were dismissed, and it wasn't even conceivable that people could actually have persisting symptoms. I think that now that we ask, we see them.
I think society has also changed. I think people are on board all the time with thinking of these sorts of things, with regard to technology and these sorts of things that can perpetuate symptoms.
I think it's because we're more aware of it. We're actually asking the question, whereas you were almost vilified before if you actually said you had symptoms afterwards. It was almost blaming the patient for saying they had ongoing symptoms, because no one would ever believe them. We have many examples of this through health care and through the insurance industry trying to minimize these things.
First of all, I'm not sure if the committee has interviewed Dr. Angela Colantonio, but she actually has a CIHR grant to look at gender differences in brain injury and concussions in particular. She's an expert and an excellent resource.
I can definitely say that in my clinic, two-thirds or 70% of patients who have persisting symptoms are women. Their injuries are different. They're managed differently. I also think we have to consider a lot of psychosocial implications of this.
I can also comment that my clinic isn't just related to sport concussions. I see a lot of concussions outside of sport.
If I had one message, particularly if we're looking at adolescents, people in university and that sort of thing, sport has done so much for concussion, but there are people who have concussions because they are active, and concussion affects people who are active. People who aren't active don't get concussions. The truth is that you can even get one through recreation, through things that we don't consider sports, rock climbing and other things that aren't organized sport but people can get concussions. I think we have to ensure that this awareness occurs. People playing on the playground get concussions.
Certainly, the focus on gender needs to be researched. Women absolutely behave differently in relation to their response and in the treatment of their concussion.