Subcommittee on Sports-Related Concussions in Canada Committee on April 10th, 2019

[The Chair, Liberal, Peter Fonseca]

Welcome, everybody. We're delighted you're here.

This is the health subcommittee on sports-related concussions. Pursuant to the motion by the standing committee that was adopted on October 4, 2018, we started our proceedings and we have heard from many witnesses. We commenced with Ken Dryden, who has done extensive work on concussions, and listened to parents, coaches, experts and everybody in between. It has been quite eye-opening for us.

Today we have the federal-provincial-territorial concussion working group. I think they can tie it all together for us in terms of the pan-Canadian work they've done. With us today are Jocelyn East and Greg Guenther.

As well, from the Canadian Standards Association, we have Nancy Bestic and Dr. Patrick Bishop.

Before I turn over the floor, I will ask the members for unanimous consent, which I think I have gotten before, to continue through the bells if they start ringing, as we might have votes up in the House. We'll run up, get our votes done, and come back down to hear from the witnesses.

Thank you.

You now have the floor. We'll start with Nancy and we'll go across. I don't know if everybody has a statement to make.

[Nancy Bestic, Director, Health and Safety Standards, Canadian Standards Association]

Thank you, Mr. Chair and honourable members. We appreciate the opportunity to address the subcommittee today. We would like to express our support for your work in studying sports-related concussions.

My name is Nancy Bestic, and I am Director of Health and Safety Standards at Canadian Standards Association, operating as CSA Group. With me is a CSA Group volunteer member, Dr. Patrick Bishop. Dr. Bishop, a professor emeritus at the University of Waterloo, serves as chair of the CSA technical committee on equipment for ice hockey. He will provide his own perspectives on the topic of concussions, not necessarily those of CSA Group.

In our remarks, we would like to highlight the following key points. First, we will provide some background on CSA Group. Second, we will summarize our activities regarding protective sport equipment and the concern for concussion intervention. Finally, we will identify some future concerns and offer recommendations that may help guide this subcommittee's work.

CSA Group was established 100 years ago, in 1919, and it continues to be Canada's largest accredited standards development organization. We're a member-based association serving business, government and consumers with over 3,000 published standards and codes in more than 50 subject areas, including health care and well-being, public safety and worker safety. Our mission is to enhance the lives of Canadians through the advancement of standards in the public and private sectors. The technical and management standards developed with our 10,000 members help improve safety, health, the environment and economic efficiency in Canada and beyond.

Specifically related to sport and injury prevention, CSA has developed standards since the 1970s to help protect against head and face injury for hockey and other sports, such as lacrosse, ringette, skiing and snowboarding. A series of four standards address helmets and face protectors for their ability to withstand impact trauma to the head, to fit properly, to avoid penetration by pucks and sticks, and to stay on the head during play. These standards, which are systematically reviewed and updated, are referenced in Canadian legislation. Hockey Canada has mandated the use of helmets and face protectors certified to the CSA standards for use in hockey under its jurisdiction. Such certified products have been most successful in reducing the risk of catastrophic head injury and reducing eye injuries. We are now revisiting the helmet standard to address the concussion issue—more specifically, to determine whether we can find a way to help mitigate the problem.

[Dr. Patrick Bishop, Volunteer, Canadian Standards Association]

Thank you, Mr. Chair and honourable members.

I, too, would like to highlight a few key points as they relate to head trauma in sport.

As you already know, concussion is a complex injury caused by rotational motion of the brain. In hockey, there are four ways in which a player can be concussed by these rotational forces, namely, a shoulder or an elbow to the head, a collision with the boards, a collision with the ice or a puck to the head. I will return to this in a few minutes.

Concussion is not a new injury in sport. In the early days of head injury research, studies were concerned with what were then called “closed head injuries” sustained mainly in assaults and auto accidents. The injuries involved loss of consciousness without skull injury and the patient usually survived. These were concussions, and plenty of athletes sustained such injuries.

Today, concussion is defined by symptoms other than loss of consciousness, such as headaches, memory loss, motor dysfunction and other related signs and symptoms.

Because hockey players wear helmets to protect against catastrophic injury such as skull fracture, subdural hematoma and so on, there's an expectation that helmets should also play a role to protect against concussion. However, concussion in hockey—unlike in football—has many mechanisms, as I mentioned earlier. Reducing injury risk against all of these mechanisms is indeed a challenge.

CSA Group members have been working diligently to try to determine whether helmets and helmet standards can be modified to mitigate the concussive risk. This is not a trivial pursuit, as the conditions that cause concussion—namely, trauma induced by rotational motion of the head and the ensuing strain on the brain—are difficult to reproduce in a testing laboratory and are difficult to quantify as a safety metric. Work to find possible test conditions that are suitable for testing such injury-causing situations is ongoing.

For example, CSA Group, in collaboration with the University of Ottawa, undertook a research project to examine test protocols to help limit head rotation in hockey. After a full year of work, it was determined that although much was learned in regard to the different types of concussion-causing events, additional research is needed to learn more about mitigation and the ways to offer protection.

There are certainly opportunities to investigate improvement of the protective value of such equipment, especially with the study of these rotational forces and their role in concussions. We recommend that this research be continued and expanded.

Goaltenders are another group that has experienced an increase in concussion, and we recommend that research should be undertaken on this group's unique protective needs as well.

CSA Group is an established and experienced standards development organization with a history of developing important standards on protective equipment for various sports. These have helped reduce catastrophic head and eye injuries, but the complexities of concussion require more research to determine a role for such equipment.

We welcome the opportunity to work with members of this subcommittee, particularly where standards may be needed, to find a solution that leverages the work we have undertaken with the mandate of this committee.

Thank you, Mr. Chair and honourable members, for the opportunity to address you today. We will be happy to attempt to answer any questions you might have.

[The Chair, Liberal, Peter Fonseca]

Thank you.

Now we're going to have an opportunity to hear from the FPT working group.

[Jocelyn East, Co-Chair, Federal-Provincial-Territorial Concussion Working Group]

Good afternoon, everyone.

My name is Jocelyn East.

I will do my introduction in French, and I will be happy to answer questions in the two official languages.

Mr. Chair and members of the Subcommittee on Sports-Related Concussions in Canada, good afternoon.

I'm Jocelyn East, and I am the manager of the new international unit on safety and integrity in sport at Sport Canada. My duties include co-chairing the Federal-Provincial-Territorial Concussion Working Group on concussions in sport. I have been doing that since the group was created in 2015.

On behalf of the working group, my colleague Mr. Guenther and I want to thank you for this invitation to come share with you, in all humility, accomplishments stemming from the hard work and dedication of members, to shed some light on your work.

It is a true privilege to be here and to have been co-chairing that working group since 2015. I feel fortunate to have contact with frontline experts and truly passionate leaders in this field who work tirelessly to make sport safer.

I would like to commend the work and dedication of all current and former members, including Michel Fafard, who was our first co-chair. I also want to pay tribute to all the victims of concussion and their families, as well as the researchers who have educated us about taking action in this area.

Since we started our work, seven members of our working group have testified before you. Their appearances show the expertise and diversity of our group and the inclusion of various sectors, such as education, health and governments, including Sport Canada, the Public Health Agency of Canada, six provinces and one territory. That is a unique situation for this type of a working group.

It is important to point out that concussions are a complex problem and a public health issue—I believe you have heard this a number of times. Concussions are not unique to sport, but sport is in the hot seat because of repeated exposure to risk. It is on that premise that the working group began its work in 2015.

In 2014, the Federal-Provincial/Territorial Sport Committee, to which we report, wondered whether governments had a role to play in this area, given the many existing initiatives.

With the help of Sport Canada, in 2015, we invited those in charge of the national sport community, health and governments to a workshop here, in Ottawa, to answer that question. The answer came very quickly: yes, governments have a role to play, and it is one of harmonizing initiatives, protocols and key messages.

Sport organizations clearly told us two things at that workshop. First, they asked us to tell them what to do and said they would do it. Second, they said they needed support from all levels of government, so that their message and the information on their activities and their policies would get to clubs and families.

As a working group, we have a mandate to provide recommendations to the ministers responsible for sport, physical activity and recreation, and we have done so on three occasions: in 2016, in 2017 and recently in 2019, in Red Deer. Our objective is clear: support the harmonization of tools to ensure that Canadians have them and know how to use them, as concussions are a collective responsibility. In all, we have provided 16 recommendations to ministers since 2016. They have all been accepted by the provinces and territories.

Of course, the greatest accomplishment is still the acceptance of a harmonized Canada-wide approach, which includes awareness, prevention, detection, management and oversight components. That harmonized approach is our strategy and remains at the heart of our actions.

We have also developed a framework for action, so that all the provinces and territories, regardless of their approach—a piece of legislation, a framework for action, a strategy—would have the essential and minimum components for moving forward and having concerted action.

In 2019, in Red Deer, following a recommendation from the working group, the provinces and territories all accepted to dedicate one day a year to concussion awareness and to develop an action plan to facilitate tool dissemination.

Through our expertise, we have supported other important projects, including the Governor General's conference on concussions in sport in 2016, Parachute Canada's Canadian guidelines, which you have heard about frequently, and the national campaign “Headstrong Canada”, which we could talk about later.

That was an overview of what the working group has done so far. You will find more details in a support document that will be submitted to you.

In closing, allow me to specify that, at the request of federal, provincial and territorial ministers responsible for sport, our working group will focus on two essential elements by 2021. First, we will work on tracking the implementation of the recommendations accepted since 2016 in order to continue to support governments in their advances, including when it comes to the Canadian guidelines, the framework for action and concussion awareness days. Second, we will work on making recommendations and implementing prevention measures by and for sport communities in order to combat this scourge.

It is with great pleasure that I yield the floor to my co-chair, Mr. Guenther, who will talk about the reality of the provinces and territories in relation to the implementation of these recommendations. Afterwards, we will be pleased to answer any questions you may have.

Thank you Mr. Chair and members of the subcommittee.

[The Chair, Liberal, Peter Fonseca]

Thank you.

Greg.

[Greg Guenther, Co-Chair, Federal-Provincial-Territorial Concussion Working Group]

Thank you, Mr. East.

Thank you for the opportunity to present.

Jocelyn has been doing great work since 2015. I've been fortunate to join the national working group more recently as it's a portfolio I hold in the province of Manitoba.

My presentation will focus a little more on the provincial-territorial perspective to give you an understanding of how some of this work is supporting what we do.

The Red Deer recommendations, the six recommendations that came forward from Red Deer endorsed by the ministers, are a tremendous opportunity for provinces and territories to continue the good work that's been done to date in the area of concussion prevention, education, awareness and management. Some of those good things that have been done are certainly the Canadian concussion guidelines. It's a key tool that we and other provinces and territories have used as a chance for us to ensure we standardize the pan-Canadian work that we're doing. The national sport organizations are also beginning to do good work in the area of increased coach education, athlete training and prevention methods. They are starting to look more at the rules, and how rules of the game need to be altered to ensure we have a safer sport experience.

Absolutely, the work on prevention needs to continue, and sport needs to take a leadership role in this area. It's really important in increasing the ongoing network of coach training, rule changes, equipment adaptations and facility management that make sure the sport environment is safe. The national sport bodies, NSOs, have a big role to play there.

In terms of the enhanced awareness, the leadership and work being done in the PT jurisdictions, many of the provinces and territories are now looking at the protocols that have been developed nationally and we're starting to see more provinces and territories come on board to adopt them. That is tremendous news because it ensures we're all singing from the same songbook.

Parachute is leading the work with the national sport organizations and has done a great job in the last year in making progress in that area. Jocelyn mentioned the national “We Are Headstrong” campaign. It is available to all the national, provincial and territorial sport bodies, and the messages of recognize, remove, refer and return are really important messages we need to get to everyone in the sport community. We've often heard, “When in doubt, sit them out”. But once they sit out, where do we go from there? That's really important.

We're starting to see the concept of the creation of provincial-territorial sports-specific concussion working groups fall into place. Specific to my experience in Manitoba, we have created a working group. It includes sport medicine practitioners, physician expertise, provincial education representatives and experienced sport administrative staff. It has allowed us to make significant progress with our provincial sport governing bodies in the area of adopting concussion protocols.

The other thing the FPT working group has provided is the opportunity to share best practices and the opportunity to learn from good things that are happening from one province to another. It is a tremendous achievement that we can be proud of.

It's important to note that the work being done at the national level does help provinces and territories in moving toward a consistent harmonized approach, and again that we're all using the same tools.

One of the challenges we face at a provincial-territorial level is ensuring collaboration among sport, education and health. I think everyone can appreciate those portfolios reside in each province and territory, so it's really important that the communication is open and collaborative.

The other thing is that parents and athletes need help in navigating the health care system when they need care. That is an area we need to work on.

Many valuable tools have been developed around education and awareness. If you think about a national team, a university or a provincial team program, where they have access to comprehensive care through an integrated support team and medical practitioners, many tools can be used, but those models don't work at the community level.

The reality of a community sport team or a community-level coach is very different from someone who has access to a physician, physio, AT and so on. We need to keep that in mind. As has been mentioned here before, drilling down to the community level, it is really a challenge, because we rely heavily on a volunteer sector to deliver community-level sport.

It's really important to end on a positive note, though. How far we've come in such a short time is really something we should be proud of in terms of some of the recommendations that have come forward. It's a tremendous opportunity to work with all the sectors, including education and health, towards the issue of prevention. Many folks have said, “We've talked about what we do when it happens, but how can we stop it from happening?”

There are good examples in terms of a number of national sport bodies—rugby, basketball, volleyball and hockey, just to name a few—that are already doing good work in this area of addressing how they might be able to ensure prevention is looked at.

The endgame has to be active for life; that's what we want for Canadians. We need to be smart and practical in our approach, because community sport is large, complex, and again, functions with a high number of volunteers. I speak from my own perspective, but in what we think sometimes is possible from our office, we always need to remember how we can implement in a realistic and cost-effective manner. We have lots of great conversations in my shop, but we always need to think about how we're going to do this in terms of delivery.

Thank you very much. I'm happy to answer any questions during the question period.

[The Chair, Liberal, Peter Fonseca]

Thank you.

To the witnesses, thank you for your statements, your work and your service. I know the members are eager to ask you questions. We're going to move right to questions now.

To be able to get as many members as we can through, we will be holding questions to five minutes per party.

We'll start with Dr. Eyolfson from the Liberals.

[Doug Eyolfson, Charleswood—St. James—Assiniboia—Headingley, Lib.]

Thank you all for coming and for your valuable testimony.

Dr. Bishop, you were talking about helmets. I want to confirm: did you say in regard to hockey helmets that there has been a demonstrated decrease in concussions?

[Dr. Patrick Bishop]

No, I'm sorry, I don't think I said that.

[Doug Eyolfson]

I wasn't sure, so I wanted to double-check.

[Dr. Patrick Bishop]

The decrease is in traumatic brain injury such as skull fractures, subdural hematomas, and I didn't mention death.

[Doug Eyolfson]

Okay, so it was head injuries. Is this in comparison from pre-1973 when these were made mandatory?

[Dr. Patrick Bishop]

Yes.

[Doug Eyolfson]

However, you said there was no data really on concussions per se, on concussions prevented.

[Dr. Patrick Bishop]

We know there's a concussion problem. We do know that, and we do know what's happening to players who are wearing helmets. The question is, why is it happening, and is there a way in which the helmet can mitigate against these things?

My own personal approach to this is that there are two types of concussions: There are those that are unwarranted and those that are accidental. The unwarranted ones are intentional, really, caused when one player strikes another about the head. The accidental ones are when the youngsters fall and strike the ice or the boards with their heads unintentionally.

[Doug Eyolfson]

When we talk about standards for hockey helmets, I know there are a number of different tests they'll do to see how they withstand a force. When I was playing in the 1970s as a teenager, I was told that they were dropped from six feet with a 10-pound weight in them, or something such as that.

When they test them, is it testing the damage to the helmet, or are there more sophisticated ways now of testing what type of force is transmitted or not transmitted through the helmet?

[Dr. Patrick Bishop]

The original tests were a 10-pound block of wood dropped onto a helmeted head form. Now we drop the head form. The sensors that are used now are three-dimensional accelerometers, so we measure the acceleration experienced by the head in striking the ground. That measure of acceleration has been linked with skull fracture, and that has really been our measure over the many years.

As I said, we have virtually eliminated that type of injury. The only time a skull fracture happens really is if the person loses their helmet.

[Doug Eyolfson]

How often are these standards for helmets reviewed or revised?

[Dr. Patrick Bishop]

It's every five years.

[Doug Eyolfson]

You mentioned something interesting. You said that the incidence of concussion in goaltenders is increasing. Is that correct?

[Dr. Patrick Bishop]

Yes. Well, it's increasing at the pro level. In fact, just recently the NHL board of governors or general managers had a meeting in Florida, where that was one thing on their agenda, the number of goaltenders who had concussions this year and were out for a long time.

We haven't a good grip on that in amateur or minor hockey. We've asked Hockey Canada to see if it has data. Certainly at our next technical committee, which is next week, we plan to have a discussion, at least, on the rarity of the strikes on the head of the goaltender—that's either pucks or striking the goalpost.

[Doug Eyolfson]

Okay. Thank you.

[The Chair, Liberal, Peter Fonseca]

We're moving over to the Conservatives.

Dr. Kitchen.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you all for being here.

Dr. Bishop, it's just like it was back in 1976-81, when I learned from you back then. I appreciate your being here. It's good to see you. This time I think I get to ask the questions. I won't be grading you on this one, by the way.

I want to follow up a little bit more on what Doug was talking about, especially in dealing with goalies. We had a young hockey player here; his name was Carter Phair. He played junior hockey and sustained a number of concussions. He's still having issues. He's been having good days and bad days. I know the family fairly well. I'm interested a little bit more as to whether you've extrapolated or looked into the NHL occurrences with goalies versus going down into lower levels.