Subcommittee on Sports-Related Concussions in Canada Committee on Jan. 30th, 2019

[The Chair, Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)]

We're going to get started. Welcome, everyone, to 2019 and these new halls for us. To our witnesses who are here with us today, this is our first week back.

In October 2018, the House of Commons Standing Committee on Health struck a subcommittee. This is the subcommittee.

We're looking at sports-related concussions and the opportunity to make our playing fields safer for our kids, making sure that coaches and all those involved in sport are aware of the different protocols and guidelines that are out there and looking at ways we can make them even better, so best practices.

We had the opportunity before the new year to hear from a lot of athletes who have experienced concussion, amateur athletes as well as their parents. Through their stories we were able to learn a lot.

Today, all the members here, from coast to coast to coast, many of whom have a great deal of experience in sport and in medicine, will be asking questions of the witnesses.

We have, as witnesses, Rugby Canada, which we've heard a lot about. Mr. Paul Hunter will be representing them here today. He's the Director of National Rugby Development. From the Coaching Association of Canada, we have Peter Niedre, the Director of Education Partnerships.

For the witnesses, the questioning will be in rotation. You'll hear from the Liberals, the Conservatives and the NDP. Each member will have an opportunity to ask you a number of questions and you'll be able to answer. We will have to cut you off when each member's time for questioning is up, but we will go around a number of times, so you will get another opportunity.

We're going to start with the Liberals and Mr. Doug Eyolfson.

[Mona Fortier, Ottawa—Vanier, Lib.]

The witnesses present first.

[The Chair]

Sorry. That's right.

[Mona Fortier]

You wanted to see if we were ready.

[The Chair]

I'm a little rusty after the holidays.

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

What did you have for lunch?

[The Chair]

We can start with Mr. Peter Niedre.

[Peter Niedre, Director of Education Partnerships, Coaching Association of Canada]

Thank you.

I want to thank the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee of Health for the invitation for us to be here to present. It's an honour to have the Coaching Association of Canada here.

I also want to start by thanking the Public Health Agency of Canada for its initial support to help us develop our current national coaching certification program's concussion management e-learning module, Making Head Way in Sport, and Sport Canada for its continued support in making sure that we're able to keep our content in the Making Head Way module current.

I will start with a brief introduction of what we do. Coaches are a part of our entire sports system of technical leaders and administrators who work to develop and protect our athletes and participants in sport. The Coaching Association of Canada's mandate, recognized by all federal, provincial and territorial ministers, is to lead ethically sound coaching and sport leader training, delivery and promotion, in association with other stakeholders, through our national coaching certification program. We work in partnership with 66 national sports organizations, like Rugby Canada, and 13 provincial-territorial representatives as the primary partnership organizations responsible and accountable for national and provincial-territorial coaching and sport leader development and delivery of our education.

I think we all know that training and education are widely recognized as enabling social change. Education and training through the NCCP is widely noted in the research as having a significant impact in changing coaching behaviours in all sports contexts: community, competitive and instructional.

Through our partnership, over 60,000 new coaches enter the national coaching certification program on an annual basis, and the highest percentage of our coaches taking the national coaching certification program training are engaged at a community or competition introduction level. Coaches will coach across multiple sports, stages of athlete development, age groups and skill levels. They're working on the ground with participants in practice and competition environments on a daily basis, where concussions are always a risk.

It is also important to understand that although there are sports that may have a higher prevalence of concussions, no sport precludes the risk of concussion—there's not one that does. Additionally, all coaches, teachers and instructors may encounter participants who risk concussion, whether it's on the playground, at municipal facilities or in the school gym. As concussions are not exclusive to any sport in particular, regardless of high or low risk, the entire sports system, from community to high performance, is responsible for concussion prevention, detection and management.

With the support of the Public Health Agency of Canada, the national coaching certification program's Making Head Way in Sport e-learning module was developed in 2013 as a tool to better equip and enable coaches to manage concussion through prevention, detection and recovery. The online training was created with the expertise of leading experts Dr. Charles Tator, Dr. James Kissick, Dr. Pierre Frémont, Dr. Karen Johnston, Dr. Laura Purcell, Dr. Mark Aubry and Dr. David Ellenberg, and in partnership with Parachute Canada.

Making Head Way was recently revised in 2017, following the 2016 Concussion in Sport Group's international conference on concussion in sport held in Berlin, Germany. The NCCP Making Head Way module contents are closely aligned with Parachute Canada on return-to-play and return-to-learn protocols. With respect to baseline testing, the CAC's NCCP Making Head Way module recognizes the recommendations of the federal, provincial and territorial working group, the international Concussion in Sport Group and Parachute Canada in our educational material and education of coaches as we work towards a harmonized approach to concussion management.

We've worked closely with Parachute and the federal, provincial and territorial groups to ensure a harmonized approach in the prevention, detection and recovery and return to play from concussions. Provincial and territorial jurisdictions play an extremely important role in enhancing the national harmonized approach protocol within their jurisdictions. Two specific examples that significantly enhance a harmonized approach include Ontario, with the development and implementation of Rowan's law, and in Quebec with an enhanced return-to-play protocol.

Since its launch in 2013, approximately 52,000 coaches have taken NCCP Making Head Way. We have seen an 87% increase in the number of coaches who have engaged on an annual basis since 2015. Of these coaches, over 90% are coaching at the community and introduction to competition contexts.

Through our survey that we do post e-learning, 88% of those who have been surveyed have indicated that they are more confident in handling concussions with their athletes and managing concussions after having taken NCCP Making Head Way.

In closing, I've had the incredible opportunity in my career to work in the school and sport system for over 20 years. As a curriculum development and delivery specialist and practitioner, I spent over 10 years in the school system at both the secondary and post-secondary levels. I have worked over 20 years in the sport system as a coach at all levels, a coach educator, and a technical leader responsible for coach education curriculum development and delivery at a national sport organization and at the Coaching Association of Canada.

I can't emphasize enough the importance of prevention of concussions through training and education of our coaches working on the ground. Education is the number one tool for enabling behaviour change in our coaches.

In closing, I'd like to make two recommendations.

The first is that the entire Canadian sports system—national sport organizations, provincial and territorial sport organizations, including school sport, from community to high performance—need to legislate concussion management training through the NCCP Making Head Way or other partner resources to better enable our coaches. We already have 14 of our NSOs, national sport organizations, that have it as part of their training and certification pathway for their coaches.

The second is that all levels of government, in addition to safe sport, need to have concussion management training as a priority because it's a public health issue.

[The Chair]

Thank you, Mr. Niedre.

Now we're going to hear from Mr. Paul Hunter, with Rugby Canada.

[Paul Hunter, Director of National Rugby Development, Rugby Canada]

I usually start off with an apology because of the accent, so I'm happy to repeat, should I need to.

[Voices]

Oh, oh!

[Mona Fortier]

Don't.

[Paul Hunter]

It's the worrying faces on the translators as they kind of start wondering, “Is my microphone working or not?” I can't do anything about it, I'm afraid.

I would like to share an overview of Rugby Canada.

Since 2016, Rugby Canada has implemented a player welfare program which targets all the pillars involved in sport, from players to coaches to parents to administrators to match officials, and tries to create an understanding that we all have a responsibility around player welfare in our sport.

Rugby Canada, like many sports, has developed guidelines. What has been critical in developing these guidelines is that they are not being done in isolation. We've developed our guidelines, or looked to harmonize our guidelines, in partnership with Parachute Canada through its harmonization program. We're also very fortunate that World Rugby is one of the five organizing partners of the international concussion event, so we're able to access the research that comes from that event. That does influence how our guidelines are created.

Rugby Canada and its 10 provincial unions must do concussion management training. That's an online module. Not just that, but we also have a rugby-specific module. We've been able to identify that in rugby there are five areas of concern where we can increase the likelihood of a concussion. There is training around the awareness of a concussion, the management and what to do to report a concussion, but it's also important that people are educated in how we prevent concussions as well.

They are two very different pieces. Along with our coaches, who have a direct influence with our athletes, we also focus on our match officials who have to manage the games. They have to be able to identify and know what to do in a game should an incident happen. Those are our two primary focus areas, although we do understand and are looking at how we support the parents and players as well, and not just work in isolation.

In rugby, we've also looked at the prevention piece and identified, through research and our evidence from injuries, that the tackle is where we see the largest number of concussion-related injuries. We've now developed a resource that looks at the introduction of tackling to young kids. In Ontario we'll be rolling out our tackle technique resource. Again, it's a prevention strategy that supports coaches as well as players on the introduction to tackling.

Another piece that we've implemented is a zero tolerance approach to contact to the head. There is zero tolerance at all levels of the game, from the professional and international end of the game to the community and domestic end of the game. Should contact happen to the head, there are sanctions. Should repeated contact happen to the head, there are more severe sanctions that take place as well, both on the field as well as off the field.

Because we're a large country, that face-to-face contact is very difficult, so we also provide webinars where we look to have ongoing education. This has been a primary focus for our referees on how to manage those dangerous tackles. Seeing examples of dangerous tackles and knowing how to manage those dangerous tackles is a way for us to provide them with the resources to support them in making those decisions in a game as well.

Along with the partnership with the Coaching Association of Canada, we have concussion training around the incidence and likelihood of concussion in the game at all levels of our training and education. That means that a two-hour slot in all of our courses is focused on the tackle, ruck, maul, scrum and jumping in the line-out. These are the five areas of the game where we see an increased likelihood of concussion-related injuries. When coaches leave any of our coaching courses, they have had the opportunity to practically try to coach in those areas.

The course I talked about previously that they have to do, the rugby readiness-specific, is the online learning piece. Before they go on the course, they must have done the online learning piece. Then, when they come on the course, there's the opportunity to practically apply that, as well as create professional development workshops around this area.

Another thing that we have is a free app that helps with the identification of signs and symptoms, and what to do should a coach suspect a concussion. It's available in a bilingual format—in multiple languages, actually—because we're fortunate to use World Rugby on multiple platforms. We know that players play a critical part. We know they're quite technology savvy, so we are trying to get something into their hands that can help give them some very accurate information around concussions.

We've also looked at promoting the provincial health lines. Often there are parents and players looking for somebody to speak to, and they're not sure whom to speak to, so we try to promote the provincial health lines as a point of contact. They can phone 24-7, 365 days a year, and there will be someone who can provide some help as well.

As an organization, we wouldn't ask our members to do something that we're not willing to do, so at all our AGMs and mid-term AGMs, as a player welfare piece, we have had speakers come in to educate our board as well as our provincial union executives. We have had Gord Stringer, the father of Rowan Stringer. We've had Parachute Canada come in as well, along with some neurologists and so on. We're just trying to increase the awareness of the decision-makers in our organization to make sure they do make player welfare a priority. Education is important right across the board.

We're also fortunate that we were the only national sport organization to be sitting on the Rowan's law advisory committee. Obviously, Rowan was involved in rugby, and we feel we have a lot to learn and share from that experience. We've been fortunate enough to speak at many conferences, including education conferences and World Rugby's medical conference. The focus on concussions in Canada most certainly has global attention, and collaboration has been key for us to develop the resources that we have.

On that point, I'm happy to take any questions or repeat it all again, whichever comes first.

[Voices]

Oh, oh!

[The Chair]

We love the accent.

Thank you, Mr. Hunter and Mr. Niedre.

Now we're going to have the opportunity to have questions from our members.

We're going to start with the Liberals. It will be for seven minutes.

Doug Eyolfson will commence.

[Doug Eyolfson]

Thank you, Mr. Chair.

Thank you to both of you for coming.

I'm very excited to be part of this study. I practised medicine for almost 20 years. I was an emergency doctor. Actually, my first job was in an area of town where rugby was quite popular, so I really got to hone my orthopaedic skills.

One of the things I was curious about with rugby.... As you say, there are things like tackling techniques that have been helpful. Have there been any changes in any protective gear in rugby that have had any impact on concussions?

[Paul Hunter]

That's a great question. No would be the answer. From our understanding, there's not a lot of evidence to suggest that the wearing of equipment can reduce the number of concussion-related injuries.

Two areas we believe very strongly can reduce concussion-related injuries are changing the laws of the game, for example, tackle height—zero tolerance—and also a cultural change. To look at equipment alone, we find that people will manipulate equipment and use it more as a weapon, potentially. Equipment in isolation, from our understanding, hasn't reduced the number of concussion-related injuries, but we do see education and influencing that culture as two key areas to reducing concussion-related injuries.

We are seeing an increase in the number of organizations and companies that are selling the answer to concussions as various different garments or helmets and so on. We just don't see the evidence there at this point. Whether or not that evolves in the future, at this point there's no requirement for a rugby player to be wearing a piece of equipment that would reduce the likelihood of a concussion-related injury.

[Doug Eyolfson]

Have there been any changes in the last few years regarding the overall rules of the game, such as international standards that have changed to reflect the increasing knowledge of concussions?

[Paul Hunter]

Yes, absolutely. We've just seen piloted last year an initiative to reduce the height at which contact can happen, and that's correlated across other sports. We have seen a reduction in concussion-related injuries since hockey made changes to their game, so we are going to be looking to implement a tackle height and reducing the tackle height. We have seen that being effective in other sports. Through global research, we have seen that concussion-related injuries increase when the height of the tackle is up at around the shoulder and head area.

Where we introduce tackling, which at our U11 level, that's going to be below the waist. How we coach that area and introduce tackling is to make sure that the body height comes down. We have seen that if you make changes to the laws or the rules of your game, that can reduce the likelihood of concussion-related injuries. The other one is zero tolerance for contact to the head, zero tolerance meaning zero tolerance, and the sanctions have seen a reduction in contact to the head.

[Doug Eyolfson]

You had mentioned, as well, that people of different ages are playing this in your jurisdiction. I do know that in other sports, different things are allowed for different ages. For instance, in hockey, there's no contact or body checking below a certain age. I don't imagine there's such as thing as touch rugby, but—

[Robert Kitchen, Souris—Moose Mountain, CPC]

Actually, there is.

[Doug Eyolfson]

There is? What I was wondering is whether there is an age at which certain things are allowed and not at another. How is that set up?

[Paul Hunter]

Absolutely. We introduce tackle technique or contact at U11. Prior to that, it's a non-contact version of the game, so it's tag and it's flag as well. U11 is where we're looking to introduce contact by lowering the tackle height to be at the waist, but for all ages and levels of the game, from international to professional, there is no contact to the head, at any point. We take a zero tolerance approach to that.

Yes, we do have a gradual introduction to tackling. Through our education, we send strong messages to our coaches not to put somebody in a game if they're not prepared physically and emotionally to be in that game. It's not a case of throwing them in to try as well. That's where that education and culture piece comes down to us. Yes, there is a gradual approach to introducing people to the game of rugby.

[Doug Eyolfson]

Thank you.

Mr. Niedre, you talked about your e-learning module on concussions, and it sounds like you have a very good, comprehensive list of people who have helped developed it. I know that part of this is return-to-play guidelines. Those were developed a while ago and they're always being revised. Is there any stage of it or have they incorporated any requirement at some level of concussion where there has to be a formal medical evaluation before they can return to play?

[Peter Niedre]

Absolutely. Again, it's part of the protocol. It's guiding coaches, the athletes and the parents of the participants to seek medical attention. Part of that is managing the concussion. When they suspect there's a concussion, the next step is to seek medical attention. We do guide them that way. The return-to-play protocol comes after the medical expert has issued the release. Then we have another long protocol that aligns with what Parachute Canada has said about how the coach manages that and the return-to-play protocol to bring the athlete right back into the field of play.