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

[Pamela Fuselli]

I think it's a challenge across injury issues, but certainly for concussion and the way that data is collected, we always see the tip of the iceberg. At the FPT working group, we have talked a lot about what systems already exist that could be leveraged to collect the data that is out there. What are sport organizations collecting and how can we access that or not? What are the barriers and facilitators to that?

It is a challenge across the board. I don't think any country has solved this issue around access to get a clear picture about the number and severity and, as Dr. Zemek said, the period of time concussion can take, in order to understand the real picture of the burden of concussions in Canada. I would say that as part of that research and evaluation, this is an essential component that we are missing in terms of understanding the data very clearly.

Now, data will tell us one thing. It will tell us how many. In prevention, what we also need to know are the contextual pieces of information to understand how the injury occurred. By knowing that, we can direct the prevention strategies so that we are not looking for solutions that aren't even part of the problem.

I would encourage both the numbers collection, in terms of absolute numbers, and also the contextual information, so that we can understand what solutions can be put into place.

[The Chair]

Thank you.

We're going to be moving now to Madam Fortier for the Liberals.

[Mona Fortier]

Thank you, Mr. Chair.

Mr. Zemek and Ms. Fuselli, I very much appreciate Ms. Hardcastle's question, and I would like to echo her concerns. I'll give you the opportunity to keep providing guidance on the role that the federal government could play when it comes to analyses or on the recommendations and other items that the subcommittee could study.

[Dr. Roger Zemek]

Thank you for the question.

With regard to how we can better measure, I think it's so important that we have an opportunity to better link all of our distinct provinces and territories. People will ask me how common concussions are in Canada, and I have to say, “Well, they're this common in Ontario, this common in Alberta and this common in this province.” I am jealous of countries such as Australia, where they have a national insurance number, and where all the billings and all the information for health care visits for the country are on a national level, whereas in terms all of our numbers, we have OHIP for Ontario, RAMQ for Quebec, etc.

As scientists, we don't know if there are differences across jurisdictions. If I had a magic wand, that would be one way; I would love to do that. As Pam said, it would be great to detect those, but that would help us to detect those through the ways that we can detect. One of our panellists has many years of chiropractic. We don't have an ability as scientists to see how many of those visits are covered or to see those with physical therapists, occupational therapists or athletic trainers, which are also such important partners in this interdisciplinary care we provide. Those numbers aren't tracked because they are not part of a provincial billing record. That would be another magic wand: to see if there is a way to systemically track those who don't go through the traditional emergency department or family medicine first.

With regard to other things we can study, there are so many. In terms of a priority for study, as the first thing, I'm a pragmatic person, an emergency physician, and I would love to know what is the best treatment. We still have no treatment for concussion. What are the promising pharmacological and non-pharmacological treatments? I say “pharmacological” meaning what medicines we can give to address the mental health, the headaches and the dizziness, but what are the non-pharmacological treatments?

We talked earlier about the care that may not be good. This is a bit of the wild west and a bit of snake oil salesmen at times, who are sometimes purporting therapies that have not been evidence based, be it through lasers or hyperbaric oxygen chambers, and who are taking money from people who are desperate. We've learned of all these people who are desperate to get better. If they think there's a chance that these would work, people may be spending their money on something that is as good as snake oil.

I would love to have evidence to show what works, and also to prove what things don't work so that people don't waste their hard-earned money on things that aren't going to get their child better. That will allow them to focus on the things that do work and to recognize that not all of them have to be pills. It can be physical therapy or other avenues such as mental health care, etc., which may lead to a better recovery.

[Mona Fortier]

Thank you, Mr. Zemek.

Ms. Fuselli, do you have anything to add?

[Pamela Fuselli]

I would only add that the clinics that we see as being very effective have, as Dr. Zemek said, that multidisciplinary approach. Are there models that work, that have that multidisciplinary approach or framework, that can be replicated, whether that be physically located in the same area and in the same space or that the patients have access to? I think that is one of the promising practices we're seeing in a couple of areas. There's Concussion North in Barrie and the Pan Am concussion program out in Winnipeg.

It would be looking at some of those, but it would also be looking holistically at concussion as a whole. It doesn't really matter, once you have a concussion, where it came from. Whether it's from sport or something else, the treatment and the return to your daily activities, including sport, are the same. I would encourage putting a framework around concussion as a whole. How do we approach it so that we don't leave out those who have sustained a concussion in ways other than sport, but who want to return to sport, and we give them access to that medical information and care? We hear anecdotally that they don't see a sport concussion clinic as somewhere they can go for care or be accepted as a patient because they are truly just focused on the sport piece.

[Mona Fortier]

Ms. Fuselli, you referred earlier to the Canadian Intergovernmental Conference Secretariat in connection with the idea of aligning the initiatives with the guidelines. Do you know whether the provinces and territories are in the process of implementing this recommendation?

[Pamela Fuselli]

Is that in terms of adopting the guideline and protocols?

[Mona Fortier]

Yes.

[Pamela Fuselli]

Some are. Sport Manitoba has required that all of their provincial-level sport organizations build a concussion strategy and protocol around the guideline and protocol template we developed for the national level. One of the goals for us, even though we were working with the NSOs at the national level, was that any tools we produced could be used by any level of sport. We saw that uptake in Manitoba. Ontario is currently pursuing doing the same. They have a bid out right now to create some resources, using the guideline as one of the appendices that anyone who does the work on the bid must use. We are seeing that uptake.

[Mona Fortier]

Okay.

Thank you.

[The Chair]

Thank you.

We'll move over to the Conservatives.

Dr. Kitchen, you're up.

[Robert Kitchen]

Thank you.

Thank you for your comments. I agree that in the perfect world, health care would be attached to one....and particularly in sport. We heard that from our coaches as well as sport-specific...where you could track that. We see how in rugby someone with a head injury will then play hockey in the wintertime, and there's no tracking of that. Even when the sporting organizations ask them that question when they sign up, nine times out of 10 it's purely a formality. That piece of paper is put somewhere.

I'm not a data-collecting or computer type of guy, but I realize there are people who have the skills to come up with that.

Ms. Fuselli, I understand that Parachute has an app. Correct me if I'm wrong here, but to my understanding, the app is more of an educational app than actually a tracking app.

[Pamela Fuselli]

In fact, the purpose of the app was very specific to be what we called an “on the go” app, with access to quick, short pieces of information that can be accessed from a mobile platform at a time when that information is needed. It's not to track the injury, because our expertise is not in medical tracking or any of that kind of data. We also did not want to have to house and protect personal data. The concept of the app is that it's on the go, at the point when you need that information. It's key information about prevention, about signs and symptoms, and about red flags, when you need to seek urgent medical care. It can be used by coaches and parents and educators.

There is what we call a calendaring option. A parent can assess on a day-to-day basis, based on the symptoms of the concussion, how good or bad those symptoms are within a scale or a range so that when they talk to the physicians or their medical professionals, they can report, “This seems to be getting better”, or “This new symptom came up four days ago.” It's more of a calendaring tool versus a tracking tool.

[Robert Kitchen]

I'm a big believer in education. I believe the more we can get out there to our parents, to our coaches, to our trainers such that they're aware of that.... The risk you have is that, as practitioners have seen, you'll get someone who walks in your door, and they've gone on the Internet, and they've seen something, and they have that symptom because they saw it on the Internet or their next door neighbour had the same symptoms. Oftentimes, while Fred next door may have it, that doesn't necessarily mean that you have it.

With that said, Dr. Zemek, I'm so happy to see you talk about injuries. I think you said 25% of concussions are actually outside of the sports realm, which is good, because we need to recognize that for the general population as well. I'll throw my wife under the bus here, because she tripped over the blue line and hit her head when we were in one of our practices with our kids, and she didn't have a helmet on. You do see that, and unfortunately for her, she suffered a concussion, and it had a huge impact on her for a good three or four months.

Those are big challenges that we have, and you mentioned that the good news is that people are getting better. You talked about a three-month time frame if I remember correctly. Do we know what percentages go past those three months?

[Dr. Roger Zemek]

I'm an expert in pediatrics, so I'll focus my comments on pediatrics, because I'm not as familiar with the adult literature.

We recently published a study in JAMA Pediatrics which looked at the natural progression of recovery from concussion. Again, we're using our cohort of children who had their injury within a few hours. The good news is that most kids, depending on their ages—there are two factors: their age and their sex—recover in the first week or two following their concussions with the exception of teenage girls. Teenage girls take about four weeks. Most of the recovery that is going to happen for them is going to happen in four weeks. Beyond that, unfortunately, it seems as though the recovery fairly plateaus. We know that one-third, or 30%, of children are still symptomatic at one month. About 20% or so of people are still symptomatic at three months.

The recovery curve, although it went very quickly down in that first week or two weeks depending on your age and so on, does flatten out over time. That's when we need to come up with these better ways to figure out how best to treat them. Is it, again, through interdisciplinary manners, or is it focused on their symptoms, or are there ways for us to better detect what we are treating?

[The Chair]

Thank you.

Our last questioner is going to be Dr. Eyolfson for the Liberals for five minutes.

[Doug Eyolfson]

Thank you very much.

Thank you both for coming.

Dr. Zemek, I liked hearing your perspective. You were here when I was in the early part. Much of my career was in a community hospital that saw children and adults. The last eight years I was at a teaching hospital that saw exclusively adults.

You made a good point about the number of concussions that are not sport-related. In our practice, I'll admit, whenever we thought of concussion we thought sports. We worked in the inner city, and we saw all sorts of blunt trauma assaults. When we were treating them, we were not thinking of concussion when someone had been robbed of their wallet. It's a good point, and I think medical education needs to really step up in recognizing this.

I was also disappointed—not in you—when you said there's no magic bullet imaging. I was hoping you'd say that you now have a magic imaging bullet that can say, “Yeah, this is concussion,” but there still isn't one and it's still elusive.

One of the things about imaging, something that's starting to come up now, is that we do know there's a lot of imaging that is not useful, but we also know that in the early days of the CT scanner, we did it a lot, and we didn't think there was any harm to it. It wasn't until later studies in radiation that we realized there probably is an effect, and 30 years out, a lot of clinicians are biting their nails over what's going to start sprouting from these CT scans 30 years ago. Have you been tracking any data with concussion in regard to those who have been inappropriately imaged over time, and are you seeing any trends into more responsible or conservative imaging?

[Dr. Roger Zemek]

That's such an important question because, again, as you talked about earlier, you don't want to do harm.

[Doug Eyolfson]

Exactly.

[Dr. Roger Zemek]

We do know that radiation can potentially increase your risk of harm of future malignancy, and in the growing brain, potentially even have effects on IQ. The good news is that in Canada, as compared to our neighbours to the south, because of the type of medicine that's practised and less risk of litigation and less defensive medicine, we are doing very well with reducing the number of unnecessary CT scans.

There are studies which have shown that the number of CTs that have been done has significantly decreased up to the point that, for our study, the rate was only approximately 1%, which is a very, very low rate of CT scans. Some of them are certainly indicated. With regard to CT imaging, which has the worrisome radiation, that is one thing on which we can say we've made great progress. That is one thing we address in our comprehensive concussion guidelines. We include recommendations on when a CT scan should be done, or not.

MRI is a different type of picture that does not use radiation. An MRI is done by magnets, with no risk of those X-ray or radiation effects. Unfortunately, MRIs do not show routine changes with concussion. One caveat is that there are now some experimental protocols. I'm involved in some research that is undertaking some of those studies as well, so full disclosure. There are some advanced MRIs that are looking at the way—without getting too technical—water moves through the brain, etc. Terms like ASL, DTI and the whole alphabet soup are ways to see if there are ways to better see how the brain changes with concussion.

What we're doing is also comparing to kids who either are normal or have had other types of injuries, like ankle injuries or others. There may be some promising ways to do that, using those advanced techniques, but they're experimental. If you were to go to your community hospital tomorrow and say, “I want that scan”, first, they wouldn't have written the code to program the computer to do it, and second, there wouldn't be a radiologist who has the expertise on how to interpret it because it's not a clinical test yet. It would be a neuroscientist who has studied those and who would do those.

My hope is that in time we may have some opportunities to use imaging, either through advanced MRI or other even more novel things, for example, fNIRS, which is functional near-infrared spectroscopy, which is just little probes looking at infrared light, without even having to be in a scanner. Are there other things we can use to better detect the brain changes that we can't see or test on our physical exam?

[Doug Eyolfson]

Thank you very much.

[The Chair]

Dr. Zemek from CHEO and Ms. Fuselli from Parachute Canada, thank you for your insight and for helping inform this committee and the analysts, who will be putting a report together for later this spring.

Also, for those who may be following these proceedings online or over the television, we have had a number of sports organizations that have participated and have been here as witnesses, but there are so many others that may want to make a submission. You could do that through our web portal. You're able to make a submission to this committee, to help as we put our report together.

Thank you, everybody.

That will conclude our hearings for today.

The meeting is adjourned.