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

[The Chair]

We're going to start with Dr. Roger Zemek from CHEO.

[Dr. Roger Zemek, Director, Clinical Research, Children's Hospital of Eastern Ontario]

Thank you.

As the previous speakers did, I want to thank the committee and the subcommittee for giving attention to such an important topic.

First, I want to say that I am a recipient of competitive grants from numerous organizations, including the CIHR, Ontario Neurotrauma Foundation, Ontario Brain Institute, Brain Canada, Physicians' Services Incorporated, and the NFL, but I don't believe any of these poses a conflict of interest.

I want to introduce myself. My name is Roger Zemek. I'm a pediatric emergency physician in the Department of Pediatrics at the University of Ottawa. I'm a senior scientist at the clinical research unit and I lead the evidence to practice program at CHEO. I have a clinical research chair at the University of Ottawa in pediatric concussion through the Ottawa Brain and Mind Research Institute and I am the vice-chair of Pediatric Emergency Research Canada.

As for my own area of research in addition to being a clinician in the emergency department, my research focus is on the generation, application and knowledge translation of the best available evidence for concussion, bringing that evidence to the bedside as well. I have gotten more than than $4.3 million as the lead investigator on research and as a team member for more than $34 million in total concussion research funding.

One thing I'm very proud of is having been able to lead the team that has done the largest concussion study to date in the world. We did nine centres across Canada, with more than 3,000 children enrolled in the study. This study was the 5P study: Predicting Persistent Postconcussive Problems in Pediatrics.

I also have studied the epidemiology of concussion to examine the trends over the past decade. I lead a provincial randomized controlled trial of early physical activity, as mentioned in the Berlin guidelines—versus the previous guidelines of Zurich—to see which of those two rest protocols is more effective. I also led the first comprehensive concussion guidelines, through the ONF, for pediatrics. That had not only a health care provider version but was also the first to introduce a coach and teacher as well as a parent version.

I am part of Pam's team as a parachute content expert. As well, I was on the Berlin panel as one of the pediatric experts and was on one of the other teams also. I have presented to the National Institutes of Health in the United States, at Bethesda, sitting on some of their expert panels.

I am very proud to say that Canada is a world leader in concussion research. Of the 10 most-cited universities across the world with regard to concussion, Canada is home to four of these top 10. We truly are groundbreaking. If you were looking at the panel of scientists who presented at that Berlin meeting and who led many of those committees, Canada was definitely hitting above its punching weight.

I want to quickly highlight a few things with regard to my own research. Then I'm happy to delve into more detail on questions.

One thing is epidemiology. We've shown that in Ontario the number of emergency department and office visits for concussion has quadrupled over the last decade. That increase is most significant in adolescents, which showed a more than five-and-a-half-fold increase.

My study was of 3,000 patients across emergency departments in Canada. This was really getting children at their most acute times of injury. The average child was enrolled in less than three hours from the time of their injury to when they got into the study. We followed those children for more than three months. What we found was, and the good news is—there is good news—that most kids get better. About 30%, however, continue to have symptoms that persist beyond one month. I've gone over some of those factors that are predictive. I won't go into the details now.

We also know that while sport is an important cause of concussion, about 25% of all concussions and potentially even up to a third happen unrelated to sport. That is very important to keep in mind, because our athletes can still slip on the ice, can still have collisions in the hallways at school and be involved in motor vehicle collisions, and this can then affect their sport afterwards.

One thing our team did was talk about return to play and how those things have evolved. I'm proud to have led the team that found that early physical activity actually did lead to improved recovery over time. The concept of home jail, in which families interpreted “rest until asymptomatic” as keeping their children in dark rooms for periods of time, may actually have caused more potential harm than good. I'd be happy to talk later about finding the correct Goldilocks balances—not too hot, not too cold—and our finding the “just right” balance.

Last, one of the studies we did looked at the quality of life of children with concussion. While children with concussion improve in many aspects of quality of life, one of the things that remain very impactful compared to the average child is the impact on school. As a pediatrician, this is such an important factor. Even in those kids who have recovered, the school quality of life factors remained significantly decreased from healthy children for months on end, and that extends beyond three months.

I'm happy to have this opportunity to talk to the panel about something I am so passionate about trying to get to some answers for.

[The Chair]

Thank you, Dr. Zemek.

Now we're going to Parachute Canada and Ms. Pamela Fuselli.

[Pamela Fuselli, Vice-President, Knowledge Transfer and Stakeholder Relations, Parachute Canada]

Thank you. Good evening.

As you said, my name is Pamela Fuselli. I'm the Vice-President at Parachute Canada, Canada's national charity dedicated to injury prevention. Thank you for inviting me to speak to the committee on this important topic.

The purpose of this subcommittee aligns well with Parachute's vision to ensure Canadians live long lives to the fullest. As we reduce the incidence and long-term impact of concussions, Canadians can get back to participation in sport in their day-to-day lives.

Parachute acts as a bridge between research and policy-makers, the public, professionals and industry, translating research into key messages, tools, strategies and policies—basically, who needs to know what, how, where and when.

We also have topic experience. We've been undertaking targeted work at the national level, supported by federal funding from the Public Health Agency of Canada, in collaboration with our partners from Sport Canada, in education, health, government and in consultation with our concussion expert advisory committee that comprises internationally recognized clinical and research professionals.

What are our recommendations that can inform this subcommittee's work?

The first is national uptake and implementation of best practice guidelines and tools. We've already made excellent advances to improve concussion education, recognition, prevention and management in Canada. We have strong foundational documents for a harmonized national approach based on the international consensus statement on concussion in sport, such as Parachute's Canadian guideline on concussion in sport and our harmonized concussion protocol template.

In addition to being evidence-based, it's critical that this approach be comprehensive, that it emphasize pre-season education and prevention, and that it be embraced within the culture of a sport organization. Since 2017 these documents have been adopted by over 40 national sport organizations as well as a number of provincial organizations and schools. We don't need to reinvent the wheel, but we do need collective support to ensure the use of these expert-informed best practice resources by everyone.

Second is training for medical and health care professionals. Concussion education for health care professionals is required. It's essential for them to be knowledgeable of the most current clinical practice recommendations, for example, proper assessment and guidance regarding gradual return to activities. Parachute is sharing the latest and best information through the concussion awareness training tool for medical professionals, a free, online accredited training course that ensures information gets into the hands of experts. The potential implications of missed or poorly managed concussions makes proper assessment and management essential.

Third is education and awareness. The public is both focused on and confused with concussions. There are myths that are still perpetuated as well as a sense of fear that every concussion will be life-altering. Youth and their parents need current and credible information with clear actions that they can take themselves.

Parachute developed a suite of concussion fact sheets and a mobile app called Concussion Ed to help families understand the signs and symptoms, identify red flags that require immediate urgent medical attention, and steps to help manage a concussion. There are also tools, such as the Canadian Concussion Collaborative's four characteristics of a good concussion clinic to help families assess where they are obtaining care from. This education needs to be addressed to many audiences. It needs to be sustained and ongoing, contain relevant facts and actions, and ensure that the information sticks.

Fourth is research and evaluation. Knowledge about concussion has increased, but there is still much we don't know, especially about prevention. Canada is a leader internationally in the field of concussion and increased, long-term funding to support research will help our leadership to continue. Many of the interventions currently being implemented do not have adequately resourced evaluation plans to understand the impact, or not, of the interventions and how to best meet the needs of various audiences.

Fifth is beyond sport. While much attention has been on concussion in sport across all age groups in Canada, the majority of concussions are sustained through falls, motor vehicle crashes and daily living. Individuals who suffer concussions outside of sport participation also need guidance in their recovery, but may not receive attention because of the focus on concussion in sport. We need to bring greater attention to populations that we rarely talk about and those who live in rural and northern communities to ensure that they are receiving timely, equitable, qualified and cost-effective medical care.

These recommendations apply across the country in every province and territory. There is a significant need to strategize to reduce the fragmentation where some jurisdictions have been quite successful in developing standardized sport and school protocols as well as clinical pathways that ensure patients are receiving the highest standard of medical care, while other jurisdictions have not.

I believe and hope that this information will be valuable to inform the subcommittee's final recommendations.

Thank you.

[The Chair]

Thank you, Ms. Fuselli.

Now we're going to move to questions, commencing with Mr. Darren Fisher from the Liberals.

[Darren Fisher]

Thank you very much.

Thank you so much, folks, for being here.

Pamela, you spoke so quickly that I was scribbling things down as fast as I possibly could.

[Pamela Fuselli]

I'm sorry.

[Darren Fisher]

That's okay. You had such a wealth of information that you wanted to get out in a short period of time.

Tell me about this bridge. You talk about Parachute as a bridge between research and policy. How does that work? Can you give us an example of what that looks like?

[Pamela Fuselli]

Knowledge translation is founded in theories and principles about asking who needs to know information, and how, when and where they need to receive it. One of the roles we play as that bridge is to turn language and findings from research that is not accessible to all audiences into either lay language or strategies that can be used with various audiences, whether that's to inform what a policy looks like or that in some cases is an industry change that needs to be made, or key messages or actions to parents. Not everyone is going to read published manuscripts of research, so our job, or my job in particular, is to understand what the research is telling us, what the leaders in Canada and internationally are saying about concussion, and to make sure that gets translated into action.

For example, Dr. Zemek talked about the changes in terms of activity levels. We want to make sure that information gets into the hands of parents and medical professionals who speak to parents. Some of our role is to arm an intermediary, whether that's a health care professional or a policy-maker, in terms of what they're communicating to the people who really are the ones we are trying to impact with that research.

[Darren Fisher]

You talked about the importance of uptake of best practices. I assume those are best practices for identifying and preventing and for the treatment.

I know I'm going to run out of time, but you mentioned “poorly managed concussions”. Maybe you can tell us a little about the success of uptake of best practices and talk about what a poorly managed concussion would look like.

I'm sticking with sport. I was surprised and amazed by your point that most concussions happen outside of sport. I always associated them with sport.

[Pamela Fuselli]

For youth, sport is the leading cause of concussion. For the rest of us, it is other things and factors. We're seeing an uptick in concussions from seniors falling, but that's a discussion for another day.

In terms of a poorly managed concussion, I may defer to the physician. However, in terms of best practices, it's talking about what will make the best impact on that individual, the information we know about activity levels, the amount of rest that's needed, the amount of screen time or no screen time, and how to return to activity but not particular sporting activities. It's making sure that concussions, once they happen, are managed appropriately, meaning employing the best information we have for the best outcome, so that we have the majority of people who have suffered a concussion recover within a period of two to four weeks, depending on how old they are, versus having the longer-term concussion symptoms.

[Darren Fisher]

Is there good uptake on best practices?

[Pamela Fuselli]

It's certainly getting better.

In terms of the difference in the last five years in how we are talking about concussion, Dr. Zemek talked about the increase in concussion reporting. Some of that is that there aren't more concussions happening but more people are aware of the fact that concussion is a big issue and that they need to seek medical attention. In some cases, those increased numbers are good news for us, because that indicates that the information is getting to the right people.

[Darren Fisher]

You said that youth and parents need to have good quality information, but youth and parents probably don't know very much about concussions until they get one, or they get another one. They probably go right to the Internet. They probably start searching and panicking, asking “Is this a concussion?”

You talk about working with medical and health care professionals. How do we get to the point where someone in Atom B hockey in Dartmouth-Cole Harbour has the ability to get that good-quality information when the first thing they do is go to Google and look up “concussion” and get God knows what?

[Pamela Fuselli]

We're actually working on that in terms of the Google search engine—I am not a technical expert by any means—and how the information that is most credible comes up in the Google searches so that, number one, if they go to Google, they find good-quality and credible information.

I think it's multipronged. Unfortunately, there's never one magic solution. I think it's a time issue as well. We know from other public health issues that it takes a while for this information to get down to all levels in the country, but a sustained multipronged approach, I think, is what is most effective. It's about working with our partners, such as the coaches association, the different NSOs, the provincial organizations, the schools, the provincial and territorial governments and health care professionals, and just getting it out there.

One of the roles of Parachute is to talk to the media and the public at large. We do a lot of work on social media on various channels, targeting that message to the people who are on those channels in particular. Facebook would look very different from a tweet and so forth. It's about multiple channels and multiple layers, and it's sustained over time. I think that's the most important thing. It's to see that everyone is armed with the most credible and current information so that they can be those conduits out to everyone.

[Darren Fisher]

That's fabulous. Thank you very much.

[The Chair]

We will be moving over to the Conservatives now, with Mr. Kitchen for seven minutes.

[Robert Kitchen]

Thank you, Mr. Chair.

Dr. Zemek and Ms. Fuselli, thank you very much for coming here today. We appreciate it.

I'm going to follow up on what Mr. Fisher was mentioning about the reality of rural Canada and where we deal with that. Some of the greatest hockey players in Canada came from Saskatchewan. I will defer to him on one of the greatest; I'll give him that. They're both good. That said, it's an argument for a later day.

A lot of times what we're seeing in rural Canada is practitioners who aren't trained and don't have the skill set to make the diagnosis and do the assessment. Just because I graduated from chiropractic college or medical school or came from physical therapy and put “doctor” or whatever in front of my name does not mean that I'm an expert in this area. A lot of these professions do have certifications that recognize those aspects within themselves, and they regulate themselves along those lines.

I've spent 30 years in practice, and it is a big challenge when somebody comes in and says to me, “I have a concussion.” As a physician, you ask the question: “Do you really have a concussion?” Ultimately you ask them to describe it. They say they went into the boards and therefore they have a concussion, but no one asks them the question about how they went into the boards. When you say, “I fell at the blue line, slid feet first into the boards and snapped my head”, it doesn't necessarily mean that you have a concussion. You have symptoms that are very similar to a concussion, but more than likely you might have whiplash, as opposed to a concussion.

That's a big challenge. How do we help Canadians in rural Canada where we don't have those skills? We might, but we don't. How do we help so that our constituents and our population are being looked at, whether it's rugby, hockey or whatever the sport may be?

[Dr. Roger Zemek]

That's an excellent question. Thank you very much. It's one that all of us who are diagnosticians.... That's what I do in emergency medicine. I come in with someone who doesn't yet have a label, who says “I have this”, and we have to come up with that. It's an issue that we face every day on all of these diseases we see, including concussion.

I'm going to answer your question in two ways: first on what we can do now and, second, on what we can do in the future to help this.

On what we can do now, again, this is where it's so important that we have high-quality, evidence-informing guidelines that then get into the hands of the people who need to do this. As part of the Berlin, the Parachute or the pediatric-specific Ontario Neurotrauma Foundation guidelines, all of them have sections on how to make the diagnosis. As the speakers prior to our group alluded to, some of the roles sometimes are for people within their scope of practice to suspect concussion, and then some of this is to make the diagnosis.

I think that for some of the concussions, they're going to be clear. There is a definite concussion. There was a witnessed loss of consciousness. The brain was definitely involved.

In children—as a pediatrician, I see this all the time—what happens to that two-year-old or three-year-old who is skating for the first time, fell, hit their head and now has a goose egg? We know that they've hit their head, but did it affect their brain? Some of the tools we use are not necessarily valid in that age group. The communication skills may not be best in order for that child to even communicate. It's the same with the elderly.

I know that the goal for today is to focus on sport, but this certainly happens in.... I'm sure you watch sporting events on TV. There's a collision and a player goes down. From watching it on TV we know that the person hit their head, but did it affect their brain? That's what you need for concussion. It must be a brain injury. You don't always have to hit your head; the collision can be to elsewhere in the body and the energy can be transmitted in that whiplash-type motion.

With regard to that and saying that it is definite, possible or probable, these are all things you can think about, but in terms of a lack of better evidence to help us differentiate those, the management for concussion at this point is still the same. It's conservative, being to prevent, with no harm first, do no harm.... You don't want that person going back to an activity where they're going to reinjure themselves. I think the first and foremost thing, whether it's still possible or definite, is to make sure they do not engage in another risky behaviour within a period while the brain has not recovered, to prevent the tragic outcome of what happened to Rowan Stringer, as we discussed earlier. That's number one in the management.

With regard to further diagnosis and clarification, again, those are all things where there are concussion tools that exist, such as the CAT tool we talked about earlier on how to train. There are guidelines that these providers can use. Those are all things that we need to make sure are part of the regular maintenance of certification.

The second part of my answer, not to take up too much time, though, is that we still are lacking that objective biomarker. There is no blood test, no saliva test, no picture test or even no eye-tracking, pupil size or balance test. None exists yet that on its own can objectively diagnose concussion.

This is something that many people are desperate for, especially outside of sport, such as the military. There's a blast, someone is thrown and now they're having symptoms. Well, was it a concussion or is it PTSD? The symptoms are very overlapping with regard to that. That can happen in concussion. Children who had a bad collision and a bad concussion can still have symptoms months and weeks on. Again, which are from the concussion and which are the other types of related sequelae of having an injury?

One of the things we need is more research to find these objective biomarkers. I know that there is a global effort among many groups to come up with that blood test, picture or other sort of validated measure that can accurately distinguish those two groups. That's something where as scientists we have more work to do.

[The Chair]

Thank you.

We're going to be moving now to Ms. Hardcastle from the NDP.

[Cheryl Hardcastle]

Thank you very much, Mr. Chair.

Thank you very much, both of you, for your very meaningful input here.

I want to start with you, Dr. Zemek. I'm sure you've had a chance to read some of the other testimony.

Over the Christmas break, I saw that a race car driver by the name of Dale Earnhardt Jr. had released a book in the fall called Racing to the Finish. It specifically addresses the fact he didn't have a traditional concussion, but that his brain swished around, so to speak. This latest book that he did is dedicated to mental health.

Some of the testimony was about the gaps between physical health and mental health when you're seeking treatment. I wonder if you see some of what we would call strengths, weaknesses and opportunities, and what our role and our recommendations might be able to focus on.

[Dr. Roger Zemek]

Thank you again, especially today, on Let's Talk Day; it's so important to recognize the mental health implications of concussion. They are there, and it is something that we've continued to study to better understand.

I think we have to be very careful about how we use the word “cause”. We have to use the word “association” at this point, because we don't know yet which is chicken and which is egg. Is it the fact that people who are predisposed to, or who would later in life go on to have, such mental health-related illnesses as anxiety, depression or other associated mental health problems are more likely to have ongoing mental health symptoms after their injury? We do have research indicating that there may be an association, not with regard to their physical symptoms but with regard to their ongoing mental health symptoms. Is it the fact that the concussion has now triggered and exposed this? For many things in life, an exposure changes your DNA. You can have your DNA changed by exposures. That's what causes many illnesses. Is there something with regard to the injury that has changed the brain, either through DNA or blood flow, etc.? That's something we still need to work on. I think that's an opportunity to study.

Did you have a follow-up question?

[Cheryl Hardcastle]

I just wanted to clarify and maybe be a bit more practical about what is happening right now. In some of the testimony, we heard about a patient seeking treatment for an alleviation of symptoms that are physical, that are mental, and that could or could not be linked. When you're in pediatrics, it's dealt with one way. Then when people reach a certain age, it's dealt with another way.

I thought maybe you'd be able to give us a little bit about the practical areas we could be focusing some of our attention on for the future.

[Dr. Roger Zemek]

My area of expertise is in pediatrics. I can't really comment too much on how the adult patients are managed. I can say, though, as a scientist, that we still have so much to understand with regard to the actual science. That's how I'll answer your question: through the science. As a science, we still don't know what the true physiological recovery time is. That is so important in terms of helping our patients who have a concussion. If we had a better understanding, we could say, with an objective picture, yes, the concussion part of your injury is over; now all that remains is this other process. Or it could be, we have the picture that shows us that, yes, the parts of your brain that got changed with the concussion are still there three months, six months, or one year later. That can then help us say if the treatment has to differ.

At this point, there is no evidence to say that a child's ongoing mental health problems from a concussion, be it anxiety or depression, have to be treated differently from those of a child without a concussion. Currently the medications and the treatments are the same. What's important is the recognition of where the child is at and the recognition that concussion may be associated with an increased risk.

[Cheryl Hardcastle]

With that, we know that a lot of research still needs to be done. You also heard from the previous testimony that we need to address data collection as well. Do you think there might be some opportunities there that we should be meaningfully exploring? If there is a federal or a government role, do you see how that could be orchestrated?

Let's go to Ms. Fuselli first.