I call the meeting to order. It's great to have everybody here. This is the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee on Health.
Today we have limited time. There may be votes coming up in the House. We have asked the members for consent that we would all leave to go and vote five minutes before the vote. This will give our witnesses as much time as possible.
Joining us today is Ms. Kathryn Schneider, an assistant professor with the integrated concussion research program at the University of Calgary, and Dr. Cameron Marshall, the founder and president of Complete Concussion Management Inc.
Welcome to both of you. We appreciate it.
Ms. Schneider, you have time to make your opening statement, followed by Dr. Marshall. Then we'll go right into questioning from the members.
Thanks so much for the invitation to present to the group today on behalf of the integrated concussion research program at the University of Calgary.
Concussion is one of the most common injuries suffered by children, adolescents and young adults, with an estimated 250,000 concussions occurring each year in Canada. While the majority of individuals recover in the days to weeks following concussion, up to 30% suffer symptoms and functional difficulties that last for more than one month.
Concussion can lead to reduced participation in sport and recreational activities, increase the risk of overweight and obesity, and ultimately increase the risk of chronic disease. Alternatively, staying physically active across the lifespan has many known benefits. Ultimately, the collaborative aim of our program is to minimize the public health impact of concussion across the lifespan through scientific discovery and evidence-informed practice and policy regarding concussion.
The ICRP is a university-wide initiative at the University of Calgary that includes experts from kinesiology, arts and the Cumming School of Medicine, with support from the Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute. Concussion is a heterogeneous injury, and an interdisciplinary approach is imperative. For example, we we have many different researchers and clinicians who work together, each of whom have different areas of expertise as part of our collaborative team. Many of our researchers are also clinicians and collaborate to answer critical questions, thus creating a very unique environment and leading to groundbreaking research and clinical work.
The research success and impact at the University of Calgary is also a testament to our strong and sustained clinical, community, industry, education and sport partnerships; national and international collaboration; and our robust training and education programs for the generation of researchers in concussion. The ICRP addresses concussion across the spectrum of injury and includes critical research questions related to prevention, diagnosis, prognosis, mechanism of injury and rehabilitation. I will share with you a couple of highlights of our research program.
With regard to prevention, ultimately, if we can prevent concussions from happening in the first place, we will decrease the public health burden from concussion. Over a decade of concussion prevention research and sustained partnerships with the hockey community—including Hockey Canada, Hockey Calgary, B.C. Hockey and others—has characterized the work of my colleague Dr. Carolyn Emery, chair of the sport injury prevention research centre at the University of Calgary.
As a result of her work, an evidence-informed bodychecking policy change occurred nationally in 2013. A 70% reduction in the risk of concussion was found following a national bodychecking policy change disallowing bodychecking in the peewee age group, which is 11- and 12-year-olds. This translates to an estimated reduction per year of 580 concussions in Alberta and 4,800 concussions in Canada among 11- and 12-year-olds alone. She was also the lead author on the systematic review evaluating the prevention of concussion that informed the fifth international consensus on concussion in sport.
Another example of policy change that's been informed by our research was also presented at the fifth international consensus conference on concussion in sport in the sport of volleyball. One of my undergraduate students, Derek Meeuwisse, worked with Volleyball Canada on a survey that showed that 15% of concussions were actually happening in the warm-up, when players ran under the net to go and get the ball. Volleyball Alberta made a rule change to no longer allow players to run under the net. That was subsequently instituted by Volleyball Canada at the youth national championships last year and will be done again this year. That's the largest youth sport competition, with over 10,000 volleyball athletes.
Speaking more recently, Dr. Emery is the lead principal investigator on a pan-Canadian research program funded by the NFL scientific advisory board. Collaborating with 17 ICRP researchers at the University of Calgary, 25 researchers from nine other Canadian universities, sport organizations, educators and multidisciplinary clinical teams at each site, we will complete a research program entitled “SHRED concussions”, or surveillance in high school to reduce concussions and their consequences. The pan-Canadian research program will enrol 6,000 students participating in high-risk concussion sports in 60 high schools from five provinces across Canada, and will follow them for three years. The research will target the prevention, detection, diagnosis, prognosis and management of sport concussion in youth.
On diagnosis, researchers at the University of Calgary are evaluating new tools to diagnose concussion, including novel neuroimaging, robotics and fluid biomarkers.
On prognosis, a multidisciplinary research team is working to identify factors that will predict prolonged recovery following concussion in children to inform targeted treatment strategies that will reduce the consequences of concussion. Dr. Yeates leads that program, an A-CAP study.
On mechanism, there are many innovations across animal and human models that will inform mechanisms of concussion and recovery.
On rehabilitation, our group works collaboratively to identify and optimize the management of concussion. Some of the research I have led has shown that youth and young adults who are treated with a combination of treating the neck and the balance systems were 10 times more likely to get medically cleared to return to sport within an eight-week time period compared with the people who weren't treated.
Other examples include evaluation of physical activity and sleep therapies to assist with recovery from concussion. We have a number of different studies looking at combinations of treatment as well.
I led the research for the systematic review on the effects of rest and treatment that informed the 5th consensus on concussion in sport.
We're also working with Alberta Health Services' strategic clinical networks, with funding through Alberta Health Services and Brain Canada, and with Dr. Keith Yeates, who leads our integrated concussion research program and is testing the effectiveness of a clinical pathway for pediatric concussion in the emergency department. The pathway includes a novel web portal that families can use to obtain evidence-based information about concussion and to track recovery.
Other highlights include leading the development of a massive, open online course in concussion. I checked on my way here today. We have over 4,200 people registered so far. We also have a number of our program group who were involved in the 5th international consensus on concussion in sport. I was part of the scientific committee, and we'll be doing so again for the 6th consensus. Dr. Emery and I led two of the systematic reviews and we've been involved in tools that were outputs from the meeting, such as the concussion recognition tool and the SCAT5.
I want to say what an honour and privilege it is to be here today. I would also like to thank the committee for the opportunity to speak with you today on a topic that is both my passion and my life's work.
My name is Dr. Cameron Marshall. I'm a practising sports specialist chiropractor from Oakville, Ontario. I'm also a published concussion researcher, executive board member of Brain Injury Canada and the founder and president of Complete Concussion Management, a network of specially trained staff in over 250 concussion treatment and rehabilitation clinics across Canada. I'm also a former athlete, playing both junior hockey and lacrosse for Western University.
The very fact that this committee exists speaks well of the Government of Canada's understanding of the importance of concussions as a risk factor for the health and well-being of Canadians. Continuing efforts on the part of government officials, coaches, teachers and health care professionals are succeeding in raising awareness about the importance of concussions.
Founded more than five years ago, Complete Concussion Management is currently the largest single provider of concussion care in Canada. We now see more than twice as many concussions each year as the top 11 pediatric and emergency departments combined. Each day, more than 100 Canadians visit one of our partner clinics for concussion-related issues. This year, CCMI will treat close to 7,000 concussions, and since our care is covered by secondary health insurance, we'll save our provincial health care systems $30 million in 2019 alone.
We also collect, store and analyze this data through our secure electronic database system. This Canadian-built universal EMR system, specially designed for concussion care, is currently, if not the largest, one of the largest concussion databases in the world and is currently being used to conduct research with five Canadian universities.
Seventy-one per cent of the concussion patients we see are under the age of 25, and 57% of their injuries are related to organized sport. Complete Concussion Management currently works with more than 300 youth sports organizations across Canada and are the preferred concussion care providers for more than 50,000 youth athletes.
Yes, there's an app for that, too. The concussion tracker smartphone application walks a coach or sideline therapist through a brief injury-reporting form, instructing them on key things to look for. Once the injury report is complete, notifications are sent to every other sport, team, coach, teacher and trainer associated with that athlete. Medical clearance letters are scanned by the app and shared with all stakeholders associated with the athlete. Constant and automated communication is paired with appropriate documentation and tracking so that nothing falls through the cracks.
A few weeks ago, Mr. Paul Hunter from Rugby Canada stated to this panel that if there were an app that could report injuries across sports, it would be an absolute deal maker. The CCMI concussion tracker app does exactly this, and we have now made it free for all schools and sports programs in Canada.
A few weeks ago, Dr. Roger Zemek reported to the committee that the number of people with concussions presenting to Ontario physicians' offices and emergency departments has quadrupled in the past 10 years. According to the Ontario Neurotrauma Foundation, the average wait time to see a physician in Ontario is 18 days and to see a neurologist, 250 days. These results demonstrate some inherent limitations of our health care system to deal with this rapidly growing problem.
As such, Complete Concussion Management went about tackling this problem a little differently. We trained licensed physiotherapists and chiropractors to work alongside family physicians for co-management and to improve patient accessibility. Physiotherapists and chiropractors are licensed and regulated health care professionals who have concussion diagnosis and management within their licensed scope of practice.
Over the past seven years the scientific evidence has pointed towards the use of physical exertion testing as a way of establishing physiologic recovery from concussion and preventing premature return to play. As we now know, it is the repeated concussions that ultimately do the most damage and are the single biggest issue in sports-related concussions. Specially trained physiotherapists and chiropractors have the skills, time and equipment to run these necessary tests and assist with the safe return to sport.
As a result, 30% of our patients are now directly referred from family physicians and emergency departments who don't have the equipment or time necessary to run these essential tests. In our experience, the formation of local collaborative multidisciplinary networks of trained health care professionals supports the provision of a high standard of evidence-based best practices concussion care in both urban and rural areas of Canada.
Once again, I am honoured to be able to address you today and I look forward to answering any questions you may have so that we can continue to work together to improve concussion care in this country.
It has always been free, but it has been tied to our clinics. We have a network of 250 clinics and they work with the local sporting group.
Originally the way the app worked was that if an injury was reported, it automatically notified the other sport that the person is involved in, because we found that the communication lines were getting dropped. If an injury happens in hockey, the soccer coach doesn't find out about it. We've heard that concern raised in this committee throughout the process.
The app that we developed originally was just tied into our clinics, because we had no other way, really. If they go to their family doctor or a different clinic, we don't know what's going on at that point.
Just this past year, we've revamped it now to include that, so if a patient comes into one of our clinics and wants to utilize that avenue, the app will communicate with them each step along the way. If they happen to go to a different health care provider who may not be within our network, let's say a family or sports medicine physician, that health care professional can manage that case.
When the athlete comes back with their clearance letter to return to sport, the coach can scan a copy of it, using the app, and then share that letter with every other coach and trainer so that everyone now has a copy of it and everyone knows what's going on with this particular athlete. They can't lie to their coach. They can't sneak on.
I'm going to stay on this topic, because it's one that has piqued my interest.
Dr. Marshall, thank you very much for being here today.
As you mentioned, we've discussed throughout how to take the information from one sport and put it to another. It sounds from your testimony as though we could entail all of that here, also because it goes from community-based minor hockey and minor soccer all the way up to junior levels. I know your organization is involved across the country with junior hockey teams, in particular one of my own junior hockey teams, for which I was team doctor for many years.
With that said and my putting on my doctor hat, can you explain to the committee how the issue of privacy is contained within your app so that we have assurances of that protection?
Privacy is something we've taken extremely seriously since the genesis of our entire system.
The way the app works is by having one file for one athlete. Some of the other technologies out there might have different set-ups for different sports, and that's why they don't communicate. We've done one file for one athlete.
The way it works is that when they register for our system, they get a number. They're de-identified right from the get-go. If a coach goes to add that athlete, they don't know them by name. They have to add their number. The only way they can get that number is by the athlete's handing it to them. It's almost like a credit card-type of transaction. Once the coach adds that athlete, the athlete has to confirm and accept that the coach may see some of their information.
The only medical information that is passed is their current injury status. We don't know what happened during their medical examination. We don't know what happened even when the injury was reported. The only person who knows that is the person who filed the report. The other coaches will know that there has been a report filed, but they can't access that report.
The only thing that is shared—and only by consent from the athlete, which they or their guardian can remove at any time—is purely their injury status. It's either injured and not yet allowed to return to practice, injured and allowed to return to non-contact practice, or fully cleared and ready to go.
That's a great question.
There is an option to have a certificate, but there's a nominal administrative fee. Everything else about the course is free, but there's a nominal fee for the certification of completion, and there is an evaluation component they have to complete so that we know that they've actually covered the material.
There are also other courses. The concussion awareness training tool gives you a certificate. It's of shorter duration, but then that can automatically go to specific organizations. It's meant for different professionals in different areas. The Coaching Association of Canada also has the “Making Head Way” program.
We cover all these different pieces within the MOOC, so that people are aware of them. I think depending on the needs of the individual there's a capacity to look at some of these different training modules in different environments.
I think that's a great question.
Unfortunately, I don't think there's a really simple answer to it, which makes it a challenging area. It's very much a clinical diagnosis based on a trauma, followed by the onset of symptoms and clinical findings. Typically there are no findings on any type of neuroimaging.
In a lot of the research work that we're doing, because there are so many different areas that can be affected from a concussion, we want to look at them all together, so we have people with expertise in multiple different areas all working together. We just finished a five-year cohort study with just over 3,000 youth ice hockey players, where we looked at a bunch of different tests in different areas, looking at cognition, balance, dizziness, neck involvement, some of the mood and other factors, and how those associate with one another. We're actually in the process of analyzing some of that data right now.
We'll build on the SHRED concussions more, where there are also biomarkers, neuroimaging, robotics. There's going to be even greater depth so that we can help better understand what we're actually seeing following concussion to better measure it, which can then help inform that diagnosis piece.
The literature has really evolved over the last few years and is continuing to do so, but because there are so many different components, different areas of the body that can be affected from a concussion, it's certainly an ongoing process that we need to further evaluate.
We'll reconvene. This is the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee on Health.
For our second round of witnesses today, we have from Concussion North, Dr. Shannon Bauman, medical director and lead physician. She's coming to us via video conference from Barrie, Ontario. Welcome, Dr. Bauman.
From Hockey Canada, we have Dr. Mark Aubry, chief medical officer, as well as Todd Jackson, the director of insurance and risk management.
We are going to start with Dr. Bauman, just in case we lose the video feed. This is your opportunity to make a statement.
Respected members of the House, I am honoured to be here with you this evening. Thank you for the invitation to be a witness, and thank you to the committee and subcommittee for giving attention to such an important topic.
I will briefly introduce myself. My name is Dr. Shannon Bauman. I'm a primary care sports medicine physician and have a dedicated practice to the care of athletes of all ages and all ranges of participation, from recreational level to professional athletes. I've been a team physician for lacrosse, hockey and sledge hockey. I currently hold medical privileges within the department of family medicine and department of surgery at the Royal Victoria Regional Health Centre in Barrie, Ontario, and I am associated with the University of Toronto.
I am the medical director and founder of Concussion North, a physician-led interdisciplinary team dedicated to the medical management and rehabilitation of sports- and exercise-related concussions. Concussion North has been recognized as a world leader in the management of concussions, and I've been asked to present at various meetings, such as in Berlin, in Croatia and across the United States, on our model and our research in the recovery of sports-related concussions. We see Olympic athletes, world junior hockey players, professional athletes, as well as local athletes and those who travel far distances across Canada and the United States to receive care at our clinic.
Most recently, Concussion North has been recognized provincially on the Minister's Medal honour roll for our dedication to excellence in concussion care in Ontario.
I'm proud to be an expert adviser and committee member at Parachute Canada, Ontario Neurotrauma Foundation, the Canadian Concussion Collaborative and MomsTeam, working with the NCAA and U.S. Department of Defense. Through my work on these committees, I've also co-authored five of our leading provincial and federal guidelines on concussion, including the “Canadian Guideline on Concussion in Sport”, our “Statement on Concussion Baseline Testing in Canada”, and Ontario Neurotrauma Foundation's provincial “Standards for Post-Concussion Care”.
First and foremost, I'm a clinician who provides care to my patients in the focused area of sports-related concussions. I'm also a clinician scientist. My area of research is in the management of concussion within an interdisciplinary team model, the recovery of sports-related concussions and factors contributing to the risk of prolonged recovery, and sex differences in the recovery of concussion.
Based on my professional experience in concussions, I have two primary recommendations that can inform this subcommittee's work.
The first is national uptake and implementation of the best practice guidelines. Through the leadership of our federal government and the Public Health Agency of Canada, as well as the work of our nationally recognized researchers, expert clinicians, knowledge translation specialists in Parachute Canada and the Ontario Neurotrauma Foundation, we've produced strong guidelines that set a high standard of care for concussions, both provincially and nationally.
Working with the majority of Canada's national sports organizations, these guidelines have now been translated into harmonized sport-specific concussion protocols that allow all sports stakeholders to work together to optimize the recognition and management of concussion in Canada. However, we need all health care professional organizations, provincial and municipal sports organizations, as well as school divisions to widely adopt these protocols to ensure the messaging is consistent across all school and sports settings. This isn't happening currently across all provinces in Canada and we're often confronted by the mixed messages that sport and school stakeholders are receiving from other sources outside of our guidelines.
Second, we need the government to fund and support physician-led interdisciplinary concussion centres of excellence across Canada. These centres need to be geographically located and funded appropriately to ensure everyone has access to the interdisciplinary expertise needed to successfully treat concussions.
We know that most individuals recover from concussions within two weeks of injury, but for those 25% of individuals who continue to experience prolonged symptoms, finding clinics that uphold the current stated standard of care for persistent symptoms is a challenge.
Our federal guidelines are clear in stating that people suffering a concussion require assessment by a physician and some may require a multidisciplinary clinic with a physician with extra experience in concussion care, together with an interdisciplinary team of health care professionals.
Caring for athletes and patients with persistent symptoms of concussion is challenging. As a physician, my licensing and training enables me to assess the complex medical issues, including migraine, sleep, cognitive difficulties, depression and exacerbation of other co-existing medical conditions that all need to be recognized by the physician providing an initial assessment. Only physicians can provide this type of care.
These conditions such as concussion are becoming more common. There are also aspects that will require rehabilitation by allied health care professionals with experience in managing the nuances of this injury, which may include physiotherapy, athletic therapy, occupational therapy, neuropsychology and optometry, all of which exist in clinics under one roof.
Unfortunately, we need to be wary of large concussion businesses that are falsely promoting expertise and are falling short of providing the necessary standard of care that we see in our guidelines. Despite marketing or certification of concussion expertise, it's a challenge when these clinics are not meeting their current guidelines.
Like conditions such as cancer that are medically complex, concussion care requires physicians in addition to other allied health providers to work collaboratively in an interdisciplinary fashion. In short, we need to establish regional centres of excellence that are able to uphold the high standard of multidisciplinary care set out by our guidelines.
We currently do this at Concussion North. I am quite confident that with federal support and funding, we will be able to offer this high standard of care in centres across Canada.
Thank you very much. I look forward to your questions.
Mr. Chair and members of the subcommittee, thank you very much for inviting Todd and I to give you a report.
I'd like to take the opportunity to introduce myself before the committee. I am a sport medicine physician who is a co-director of the Ottawa Sport Medicine Centre. We see athletes with concussions on a daily basis. I'm also the chief medical officer of Hockey Canada and the International Ice Hockey Federation. I've been involved in the world of concussion for the last 20 years, having treated numerous professional and amateur athletes with this terrible injury.
The International Ice Hockey Federation, in co-operation with other international groups such as the IOC, FIFA, World Rugby, and now the FEI, the Fédération Équestre Internationale, have organized five international symposia on concussion in sport, with the resulting consensus on concussion, which has appeared in medical journals and provides the guidelines on issues surrounding concussion, based on scientific evidence. The last symposium was held in Berlin in 2016, and we are now preparing for the 2020 6th international symposium in Paris. The symposium brings together the worldwide experts on concussion. Following a two-day symposium, an expert panel develops a consensus on the evidence presented during those two days and publishes the guidelines in those medical journals.
In conjunction with the symposia, we have also developed a sport concussion assessment tool, now called the SCAT5; the child sport concussion assessment tool, the child SCAT5; and the concussion recognition tool, CRT5, for non-medical people who are involved in sport. These tools have been translated into several languages, including French, with the help of Hockey Canada and other experts across the country.
I would like to speak briefly on the work of Hockey Canada, which has worked diligently for many years on the issue of concussion in its sport. I'm joined by Todd Jackson, who is director of insurance and risk management at Hockey Canada. He has directed the safety program for many years. He'll certainly give you a lot of the details on the different programs that Hockey Canada has for concussion.
Since the late 1990s Hockey Canada has produced player safety information to the Hockey Canada safety program. It has delivered in-person and online training sessions, and it's worked with its provincial members to provide tools to all stakeholders to make the game safer. These tools include an online resource centre, a concussion app and an online educational stream for coaches, trainers, parents and administrators, all in the name of player safety.
In 2011 Hockey Canada introduced the zero-tolerance head contact rule. Minor penalties, double minor and major penalties are now assessed for any head contact, including incidental head contact. In 2013 the rules and regulations were changed to remove bodychecking from the game for kids aged 12 and under. Today, approximately 85% of games played under the Hockey Canada umbrella are played without bodychecking.
Hockey Canada, through its members, delivers information to coaches and parents, using an online educational platform called “Respect in Sport”, which deals with many topics including concussion awareness. Education and skill development are also provided to players as they go through the system, to improve their ability to keep themselves and their opponents safe during play.
Among the many safety measures, Hockey Canada calls for a safety person to be present for all minor hockey teams across the country. The safety person is educated to recognize all types of injuries, including the signs and symptoms of concussions. It also has a strict concussion protocol in place that calls for the removal of any player who shows signs and symptoms of a suspected concussion. The established return-to-play protocol has a series of steps in place, including medical clearance from a physician to ensure that they no longer have any symptoms and that the athlete is safe to return to play.
Hockey Canada continues to work in partnership with the sport injury prevention research centre at the University of Calgary—and you heard from Dr. Kathryn Schneider. Through its research, the centre has provided much of the evidence on the issues surrounding concussion, and Hockey Canada has used that research to guide its injury prevention efforts, including applicable rules and regulations.
Finally, we feel that it is crucial to have an active and healthy society. For this we need families to feel safe to have their children participate in sport. We also feel that we need to have ongoing education and continued research on the issue of athlete safety, which does include concussion safety.
Yes, I've been involved with some work through Parachute Canada whereby we've created an online platform for education, which has received medical education credit, designed for family physicians and pediatricians as well as medical students. It is a rolled-out course that we were able to prepare, which I assisted with.
When we have information like this coming out, it's great to have it get to the physicians and to put these tools in their hands. Tools developed by physicians for physicians and for other health care practitioners are really essential.
I've also been involved at local levels with giving presentations to family physicians and I teach medical residents through the University of Toronto. We have a department of family medicine program here in Barrie, Ontario, where they come though our clinic and work with me first-hand seeing patients.
I feel that if we can get the information into the generation of new family physicians, residents and medical students, we will have an ability in our capacities as family physicians to initially assess concussions as they come into the office, and we will also have a better understanding of the guidelines that are out, because it's our opportunity to practice these guidelines in our clinical world.
Dr. Aubry, I want to switch gears here.
Mr. Jackson, you might be able to help me out with this.
One issue that has come up and about which we've heard some testimony is the issue of fighting in hockey. We know that it's against the rules at all levels. It's absolutely forbidden and not tolerated at all at the junior levels, but at the professional level, particularly in the National Hockey League, although against the rules, it is, depending on who you talk to, either tolerated or, if you listen to certain sportscasters with loud shirts, encouraged.
Your daughter has a concussion. There has probably already been someone on the ice with your daughter who has identified a possible concussion. That person's job is to recognize and remove your daughter from play. Depending on the severity of the symptom she has, meaning if there are any red flags that there's a cervical spine injury or some neurologic signs, it might be recommended that she go to the emergency department for immediate assessment. If she seems stable, the recommendation would be to follow up with her family physician. Ideally she should see a physician, whether it's through the emergency room, a family physician, a walk-in clinic or urgent care within probably about 48 hours.
At that point, there will be a medical assessment conducted by that physician, determining whether there has been a diagnosis of concussion, ruling out some of the medical red flags, determining if there's any imaging that needs to be ordered and giving some early education and recommendations about how to manage the initial signs of concussion and symptoms, how to gradually be reintroduced to school, how to go about their day and some guidance on how they're going to gradually become active.
There should be an additional follow-up after that point. This could be the role of a primary care physician. Luckily, with most concussions, 80% of patients are only going to need care under their primary care physician. There will be a follow-up within about two weeks, where that physician can then see how the transition is going in terms of returning to school and, day to day, how they're recovering in terms of symptoms.
If the physician at this two-week appointment identifies that there is something that's making it difficult for your daughter to continue to learn at school, if she's having some visual symptoms, headaches, difficulty with learning or they're getting worse during a school day, something such as that might suggest that the physician will make a referral to a specialist like me who has had additional experience in concussion care. It could be a primary care sports medicine physician, a pediatrician, a physiatrist, a neurosurgeon or a neurologist.
That physician's role is to make a referral directly to a physician who can do some further medical assessments, to pick up some of those subtle nuances that might end up giving your daughter a prolonged recovery. That would be the role I play. I see patients every day in my clinic—
In the guidelines we've created through Parachute Canada, we are setting a gold standard for what we want the care to be in Canada. We are looking at best practices. We are looking at what needs to happen to provide care so that each person—my daughter, your daughter, your son—has access to the best care we know. Our guidelines have been an example of what we feel is the best care available. Just because we don't meet that standard across all regions right now doesn't mean we shouldn't achieve a high standard of care.
For example, if you have a knee injury, if you sprained your knee and needed an MRI, an X-ray wouldn't cut it. If you need that MRI, you could see your family physician, have a medical assessment and be referred to a place to get the test you need. Just because we have access to X-rays doesn't necessarily mean they're the best test out there.
What I'm saying is that we need government support. My recommendation is that with government support, provincial support, we have the ability to uphold these guidelines, but we need the support financially to do so.
I believe that like cancer care, this is a complex medical issue that has a physician with an interdisciplinary team of professionals working together. We don't have a cancer care regional centre in every city, but what we do have is front-line physicians, such as primary care physicians and emergency room physicians, who can do a lot of the initial assessments.
Eighty per cent of people will be managed by their primary care physician or a physician. When we need referral to a specialty clinic—we're talking about 25% of these high-risk, persistent-symptom patients—just as with cancer care, we should have regional clinics that we can identify, which are accessible to all, depending on the geographic area. I truly believe this is achievable.
With clinics such as mine—Concussion North in Barrie, Ontario—or the Pan Am Clinic in Manitoba, or clinics in Ottawa under Dr. Shawn Marshall and clinics out in Calgary, we already have some great examples of people doing this work and following what we've set out in our Parachute Canada guidelines and our Ontario Neurotrauma Foundation provincial standards in Ontario.
We need more examples of these, but we also need the funding to do this. With funding, I believe we can be successful. I'm happy to help with this and show government how to do it fast.
Concussion knowledge has changed our course of action over the last 20 years. I can go back to 2001, when we published the first consensus. It really wasn't until 2012 that the consensus said we could return athletes back to play in the same game, if they didn't have symptoms.
I think now we're all in agreement that concussion is a serious problem, a serious injury, and that if there is any suspicion, we need to remove the player from play and then go through a stepwise protocol and process to get him back. I can say that, even speaking in terms of professional athletes, who include CFL and NHL athletes, we have seen that approach: removing players from play even on suspicion, and not having them go back until they've gone through the stepwise process.
If we look at the CFL and the NHL—I'm speaking for professional athletes—the time frame before we've allowed them to go back and play has increased, just because now we're more concerned with safety than with allowing players to go back with the risk of getting another concussion or of endangering their health.
I think it's changing and is going to continue to change. Referring back to the guidelines and where people are in different parts of the country, the consensus provides very simple guidelines and can be enacted by all medical people in various parts of the country. It's really pretty simple.
The biggest thing is that we want them removed from play and we want them rested, but not rested in the sense that they have to not do anything—we allow them to do daily activities in the stepwise process—and there is educating them on symptoms, and certainly no going back until they are free from symptoms and, from our perspective in hockey and from the professional perspective, until they get the clearance from their physician.
If you could stop me at five minutes, as a common courtesy I'd like to give the last two minutes to Mr. Nathaniel Erskine-Smith. Thank you.
Thank you all very much for being here. I apologize for the fact that we had to step out and are going to have a shortened time frame here, so that I'm not going to get to ask you all the things I want to ask you.
One of the pre-eminent concussion advocates is Ken Dryden. We had him here at our committee. He has said:
We need only to penalize all hits to the head, because whether a blow is from a stick, an elbow, a shoulder or a fist, whether it's done intentionally or accidentally, whether it's legal or illegal, the brain doesn't distinguish. The damage is the same.
That was his personal plea to the NHL and to Gary Bettman. I know that Hockey Canada does not speak to the NHL or the NHL Players Association in that way, but you have zero tolerance.
Now, I don't know whether zero tolerance speaks exactly to what Ken said there. I'm a father of, starting tonight in his first game ever, a junior B hockey player. You can get a kid in peewee who is six foot one and a kid in peewee who is four foot eleven, and you have a head shot when that six-foot guy hits the four-foot-eleven guy regardless of whether there was intent or not. That's fine. It's not a terrible rule. Zero tolerance is a good thing.
Does it speak to the things that Ken wants it to speak to, and do you envision in the future zero tolerance at the minor hockey level through Hockey Canada organizations filtering up to the NHL level, whereby we will one day see what Ken wanted to see?
Guidelines such as our Parachute Canada guidelines were done in conjunction with the federal government and our Public Health Agency of Canada. We developed a really strong guideline.
The challenge I see as a clinician is that I have young athletes coming into my clinic every day from various sporting organizations in our different local leagues across Ontario, and many of them have never seen our Parachute Canada guidelines. It's a very strong, well-documented guideline. We've been using it with some of our national sports organizations. My challenge is that, when I present this to the patient, I would like them to be able to take it to their sporting organizations across our province. Locally, in Barrie, this isn't happening.
What I would like to see is that this guideline we developed with federal funding gets support at the provincial level that trickles, for example, in Barrie, to our Barrie Minor Hockey Association. I would like them to use it. We could have one guideline supported across all of Canada, to which every organization would have access.
This guideline has medical assessment forms in it, medical clearance forms. It has a protocol that is a very good protocol for coaches and parents. It includes pre-season education. It outlines what to do when your son or daughter has a concussion, who they need to see at various steps of their injury and when they should be referred to a multidisciplinary concussion centre.
If we had this, and if everyone were using the same form, we wouldn't have confusion. What's happening is that individual clinics are developing their own guidelines. They're developing statements, and then these organizations don't know which ones to use. Unfortunately, our federally funded one isn't getting into the hands of the athletes who need it.
I've been fortunate enough in Oro-Medonte to use the guideline developed by Parachute Canada.
The consensus is actually an international document that is produced by experts around the world following the two-day symposium. They give a consensus on the evidence that is presented.
For example, in the last 2016 Berlin consensus, over 64,000 articles were reviewed, and from that, then, there is a consensus, which is based on scientific evidence.
Those guidelines are so related to scientific evidence they provide the current status of what we know in concussion. They really form the basis of other groups, such as Parachute and Hockey Canada, giving their guidelines, because they will usually follow the consensus, which becomes what I would say is the leading document in the field so that different groups can then look at it and adopt it, or adopt some parts of it.