Subcommittee on Sports-Related Concussions in Canada Committee on Feb. 20th, 2019

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

I'll call this meeting to order. It's great to have everybody back.

This is the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee on Health.

Today we have, from the College of Family Physicians of Canada, Pierre Frémont, chair of the sport and exercise medicine committee. From the Canadian Academy of Sport and Exercise Medicine, we have Elisabeth Hobden, president-elect.

We're going to have an opportunity to hear from our witnesses now. For all those who may be following these proceedings, through our portal there is also an opportunity to make submissions to our committee.

We look forward to hearing from our witnesses. Witnesses, you're going to make your statements. Then we will hear questions from the members. We'll do this in a rotational manner, so you'll hear from all parties.

We will start with Mr. Frémont.

[Dr. Pierre Frémont, Chair of the Sport and Exercise Medicine Committee, College of Family Physicians of Canada]

Thank you very much.

On behalf of the College of Family Physicians of Canada, I would like to thank you for the privilege and opportunity to present the family medicine perspective around concussion.

I would also like to acknowledge the close collaboration of the Canadian Academy of Sport and Exercise Medicine and the Canadian Medical Association in developing the brief that was jointly submitted to this committee.

First, I would like to explain my experience with concussion from a broad spectrum of perspectives.

Personally, I have sustained three concussions in alpine skiing, soccer and playing water polo. I also have a bunch of kids who have sustained quite a number of concussions.

As a sport medicine team physician, I was involved in concussion management from the international level of competition all the way down to varsity and grassroots-level sports. I am also involved in a number of current initiatives around concussion, including the Canadian Concussion Collaborative and the Sport Canada working group on concussion.

As an academic, I have been studying the implementation of concussion management protocol in high school-level sports programs. I've also been involved in the use of an innovative strategy, namely massive open online courses, to disseminate the good way to deal with concussions and to support sports in school settings in the implementation of protocols.

Finally, as a physician, I have seen patients with concussions from all causes, in all age groups and at all stages of this injury.

Now, before I can discuss the potential contribution of family medicine to address this issue, I would like to remind you of some key background information.

First of all, the simple principles of initial concussion management are clearly within the scope of family practice.

Second, these simple principles, which are removal from danger, initial rest and gradual return to cognitive and physical activity, allow the vast majority, that is, 80% to 90% of concussion patients, to evolve favourably within seven to 10 days. That's a very good reason to start with primary care. As well, over 85% of Canadians have access to a family physician. That's not a perfect score, but that's a pretty good one.

The question is this: Can family physicians play such a role?

Over the last decade, with increasing awareness around concussion, there have been constant medical education opportunities about concussion for family physicians. There was a rapid increase.

Again, it's not perfect but it's available and expertise is increasing to deal with the aspects of early concussion management. These are the initial assessment and diagnosis associated with the standard initial recommendations, which I alluded to. Then there is the decision, once things are going well, about returning to an activity at risk for concussion. Finally, there is assessment in the presence of persistent symptoms. That can involve referral, at this point, if you get out of any given physician's expertise with concussions.

The bottom line message here is to not be afraid to build strategies with a central primary care role for family physicians.

Another key aspect of how we can address the issue of concussion is empowerment. In the joint statement from the Canadian Academy of Sports Medicine and the College of Family Physicians, we state that key aspects of concussion prevention, detection and management occur prior to as well as after the medical encounter, namely, in sports and school settings. Therefore, we need to develop public health strategies that aim to support and empower school and sports settings in dealing with the day-to-day management of concussion. Sport medicine physicians and family physicians can play a role in supporting the implementation of such strategies.

Also, as a family physician, I want to emphasize that Canadians of all age groups suffer from concussions that occur in contexts often unrelated to organized sports, such as leisure, work or car accidents. These Canadians should also be considered in the way we address this issue.

In conclusion, I'd like to leave you with three key messages. The first one is that now that high-level sports and national sports organizations have received significant support to do better about concussions, the next steps should aim to improve concussion by prevention and management at every level of sport participation all the way to the grassroots level. Also, we should consider concussion occurring in every context and age group. Finally, don't forget that family physicians can and should play a key role.

Thank you very much.

[The Chair]

Thank you, Dr. Frémont.

Now, we're going to hear from Ms. Hobden.

[Dr. Elisabeth Hobden, President Elect, Canadian Academy of Sport and Exercise Medicine]

I would like to thank you for having me here today to speak before the committee.

I'm a sport and exercise medicine physician. We're uniquely qualified and experienced in concussion management.

Sport and exercise medicine physicians have been founding members of the Canadian Concussion Collaborative. They've played key roles in the international consensus statement on concussion in sport. This is an international gold standard that physicians look towards when they're looking to treat a sport-related concussion or return a patient to play. They are also experts in the design and implementation of medical systems and protocols for sporting events. A diploma in sport medicine is granted after examination ensuring competence.

Unfortunately, there are still many barriers for Canadians who have a concussion. I see too many patients like the following one: a young girl who was required to travel over an hour to see me. Her expectation and her mother's expectation was that she was simply going to walk in, get a note saying she could return to hockey for the weekend, play her playoff game and head back home. A concussion assessment takes 45 minutes or more. During this assessment, we discovered that this young lady, who is very intelligent and was expecting a scholarship from MIT to become an engineer, was unable to subtract seven from 100 and get the right answer. She really had no idea of her deficit, nor did her family.

Sport and exercise medicine and family physicians are able to safely manage most concussions like this one because they do indeed get better. What these patients do need is time. They need time to understand their injury and they need extra support that we often don't see with other patients because they have a brain injury, which means they can miss appointments or they can have difficulty coordinating their care. That puts an extra burden on physicians who are trying to manage a full waiting room and have the financial reality of the increasing burden of overhead.

Qualified, multidisciplinary treatment in their own area is extremely effective for these patients because the burden of travelling can actually increase concussion symptoms, so it's very important that they have treatment that's close to home.

Appropriately designed community-based clinics with evidence-based care could help to alleviate many of these barriers. However, the reality is that there are only 531 physicians in Canada with a sport and exercise medicine diploma, but all Canadians can benefit from their expertise through a public health-style approach. There's no doubt that community sport medicine and family physicians are excellent resources for patients with concussions. However, using the integration of sport and exercise medicine physicians in the planning of sport events can empower people to have prevention, detection and management of concussion at all levels. We've done a fairly good job at the elite level, so that's coming along, but most of our participants are at a recreational level. Some of our pediatrics, or our children, are at the most risk from concussions, so it's important that we hit all levels.

The legislated requirements of medical expertise in concussions for the planning of sporting events and protocols at all levels would greatly benefit the health and safety of all Canadians.

I recall a young patient that I had who suffered a tackle in a community football league. At the time, he didn't know he was concussed; his teammates didn't know he was concussed and there was no protocol in place to address this within his context. I saw him several weeks later, after his academic performance had started to decline and he'd been suffering from headaches and feeling dazed and confused for several weeks. Unfortunately, this is all too common to see in my practice.

The reality is that sport culture changes slowly and it often does not include medical considerations. It's important that we bring this to light at all levels of sport in Canada. The medical involvement in planning gives credibility to change within the sport and to sporting bodies or community bodies to say, “Do you know what? We know we haven't done things this way in the past, but this is why we feel it's important to make these changes.”

I want to make it very clear that I believe participation in sports should not be discouraged. It should be encouraged. It's important for Canadians' health. Any requirements should not create an undue burden so that people are unable to participate in organized sport. Canadians need to be active. They need to know that they are safe being active and that if they should suffer an injury, they can get the best possible care.

Thank you for your attention. I look forward to the discussion.

[The Chair]

Thank you very much, Dr. Hobden and Dr. Frémont.

We're going to have an opportunity now to hear some questions from the members.

Members, we're going to have a vote later this evening, and bells should start ringing at about 6:05 p.m. I understand there is a consensus that we will stay here until about five minutes before the vote. Then we'll just scoot up, vote and come back down to committee.

I see everybody is in the affirmative. That's great.

We are going to start our questions with the Liberals and Dr. Eyolfson.

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

Thank you, Chair.

Thank you to both witnesses for coming. It's nice to be among my peeps. I was an emergency physician for 20 years before doing this.

You made a great point about the number of concussions that happen in non-sport settings, but we often tend to forget that. We use the word “concussion”, for the most part, only when someone comes in injured from a sporting event. When someone comes in having been knocked over the head and had their wallet taken or having fallen and broken their hip at home, we don't tend to think about concussion, but it is a consideration. Although this is about sports-related concussions, I think there's much that's applicable to the overall treatment of concussion.

Do you know if there are any public health approaches to concussions that are not related to sports? Has there been any concerted effort to get that out there, or is the science still concentrating on the sports-related concussions?

[Dr. Pierre Frémont]

There are two solitudes that we are trying to connect at this point. T

here's the world of mild traumatic brain injury, which is often the term used to describe those concussions that occur in non-sport contexts. The definition of that is linked to some objective criteria, such as loss of memory, loss of consciousness, things like that. It's a challenge to get people comfortable with the management of that kind of injury, the recognition of it, in non-sport contexts as much as it is in sports-related contexts. There's a lot of work to do. We often see people who get a hip injury, and the concussion that comes with it is not identified. We need to do better with all of those cases.

There is no scientific indication that the physiopathology of the injury is different if you get hit by a soccer ball or you fall on the ice. It's the same problem, and we need to do better on both fronts. I'm not aware that there is specifically a strategy to address that as a public health issue, but there certainly are grounds, in the numbers I gave you, for addressing it in a stepwise manner, starting with primary care. In so many of those cases, if you do the basic simple stuff, they will heal, just by keeping them safe and having them gradually resume their activities.

That can be the basis.

[Doug Eyolfson]

Dr. Hobden, I know there's a lot of communication that goes from sports medicine physicians to places where sports are done, whether it's in community athletic clubs, semi-professional teams, professional teams, or schools.

What would you say is the current level of knowledge in the sporting community among the clubs? Is their knowledge good generally? Would you say it's poor? What's the general trend?

[Dr. Elisabeth Hobden]

I think it's very sport- and club-specific, to be honest with you. There are some pockets where people have adopted it. They've looked at what they can do to prevent concussion. But there are a lot—I hesitate to say "most"—that probably don't address it; it doesn't even cross their radar. It's not unusual for me to get an email asking if I can cover an event because it can't be run without a doctor, and it's the first anybody has thought of medical...or concussion. These clubs don't have anything in place, and unfortunately, that's really not uncommon.

At the elite level, we're getting there. Where the national sporting organizations have their policies, it is filtering down. One of the difficulties is that even if you have a national sporting organization, let's say for volleyball, not every volleyball tournament is sanctioned by the national sporting organization. They would fall outside of that and wouldn't get that education. I think our schools are in that hole as well. They don't necessarily get that information coming to them.

[Doug Eyolfson]

Okay, that's good.

What is the state of knowledge on these head injury guidelines among primary care physicians? That would include family doctors, emergency physicians. Would you say that throughout Canada, there is a reasonably consistent level of knowledge from the physicians' point of view?

Do we have a long way to go in making sure that all physicians understand when a primary physician says they can manage this, or no, they need to refer that one?

Dr. Frémont, you might want to chime in on this as well.

[Dr. Elisabeth Hobden]

I'll speak from the emergency medicine perspective because I am an emergency physician also. I'll let Pierre speak to family medicine.

We're getting there. I think the challenge in emergency medicine is most of the doctors have the knowledge and the ability to initially manage a concussion. It's not complicated. It's to make sure nothing worse is going on and then advise about rest and follow-up.

The challenge in emergency medicine is what Pierre alluded to, that it's often forgotten. They come in with a primary injury. It's very obvious they have a broken hip, and it doesn't come to light until later that they're having headaches because they may not have them right away. So we're missing people there.

[Doug Eyolfson]

Thank you.

[The Chair]

We feel very safe in the committee here and with the witnesses. We have many doctors here with us today.

We're moving to our next resident doctor, and that's Dr. Kitchen from the Conservatives.

You have seven minutes.

[Robert Kitchen, Souris—Moose Mountain, CPC]

Thank you, Mr. Chair.

Thank you both for being here. I appreciate it.

Dr. Hobden, you talked about protocols and the issue.... I think it's important that we address that because the reality is that when we're looking at people knowing the level they're at, they may not see that concussion come in until four or five days after the event, and they may have forgotten about the event. We see that all the time in practice, whether it's a sport or an everyday concussion.

What would you tell us that the sporting bodies need to do?

I come from a regulatory background, so I would look to see how we regulate these bodies to make certain they put in these protocols. I'm wondering if you could expand on that.

[Dr. Elisabeth Hobden]

I think they need to have a hard look at their own sport and look where the injuries are happening and what rules can be changed. I think where sport and exercise medicine physicians can add to that is looking to help with education: What do we do when we think we have a concussion? What is our policy for following that?

As I said, the reality is a lot of sporting organizations don't have medicine at the top of their thoughts, and then all of a sudden, they come up with a policy or a protocol that has had no input from anybody with expertise in concussion.

Pierre, I don't know if you wanted to add to that.

[Robert Kitchen]

Dr. Frémont.

[Dr. Pierre Frémont]

Sorry, go ahead.

[Robert Kitchen]

Okay, I'll let you come back to that.

One of the things we see, for example, the CAHA came out with mandatory trainers for every team, so we have them on the benches. The reality is that training program sometimes doesn't provide more than basic first aid. That's a challenge when you're asking somebody who doesn't have the medical background or any type of health care background to all of a sudden assess someone who's been injured on the ice and make that decision. Granted, usually the statement is they should see their family doctor.

As I've mentioned to you earlier, I come from rural Saskatchewan, and we don't have access to those doctors. As you mentioned, all of a sudden, they call you up because they can't run this program because they need a doctor there. Those are big challenges for rural Canada, so we want to make certain that when we talk about things here, we encompass not only the urban settings but also the rural settings.

[Dr. Pierre Frémont]

About that, I'd like to loop back to the previous question.

The CCC made a recommendation about that. The CCC cannot make laws, but we made a clear recommendation that was published. If you organize an activity at risk for concussion, you should implement a way to manage concussion, in the same way you should have a security and prevention strategy in general.

You should consider your resources and ask, “How can I do as best as is possible for concussion?” Those levels of resources will not be the same. Suppose you are on the world cup tour in alpine skiing or at a little ski club on the mountain by the city. You will have a doctor and an expert physiotherapist on the world cup tour and you will not have any health care providers at the little ski club. But you can still do very well. You can implement awareness. You can find a way to consider...if the kid was able to return to school prior to returning to sport.... There's a way you can address every aspect and ask, with consideration for the resources of any setting, “How well can I do?” I think that's the process we are looking for.

We will never be able to have sport therapists and even fewer physicians present everywhere a sport event is occurring and there's a risk for concussion.

[Robert Kitchen]

We have a lot of primary health care practitioners—and we chatted a bit earlier about this—who set up programs and specialties within those primary health care programs. They recognize that aspect, for example, for sports injuries, in particular, when we deal with concussions, etc., not only in the assessment process but also in the treatment and the return to play process. For a lot of those, unfortunately, we're finding today, we don't have the data to say how many injuries, how we are affecting it.

As we move forward with this, would you not agree that we need to recognize there are professions that do have those specializations? Should they also regulate within their bodies to make certain that those people are the ones being discussed and brought into the fold?

[Dr. Pierre Frémont]

If we were able to screen from the whole denominator of all concussions that occur, the 10% to 20% who will evolve with persistent symptoms, we would focus on those efficiently, right after two weeks, to make sure that before they make it to three weeks or a month, they are seen by those specialists, those with expertise, whether they are physiotherapists with vestibular and cervical expertise, chiropractors.... We need to have a multidisciplinary team who will provide the individualized treatment that people need at this point.

What we are suggesting is to have a stepwise process, where we screen for those who are not doing well. We make a good decision at the right time to return to play those who are doing well. But we need to improve access to the experts. We need to safeguard access to these experts by not overloading them with a whole bunch of concussion cases. There are not enough such experts. There will never be.

[Dr. Elisabeth Hobden]

I would like to add to that. I agree with what you said, Pierre, completely. We have to look at the reality that many Canadians don't have coverage for some of these allied health professionals, who are invaluable, and that is a barrier, for sure.

[The Chair]

Thank you.

We're going to be moving over to the NDP and Ms. Hardcastle for seven minutes.

[Cheryl Hardcastle, Windsor—Tecumseh, NDP]

Thank you very much.

Can you elaborate, Dr. Hobden, on the kinds of things that are being recognized as perhaps a standard of care for people with concussion, certain specialities that are not covered but that you can see as emerging?

[Dr. Elisabeth Hobden]

As Pierre said, at the beginning, rest and then gradual return to activity is good for about 90% of patients, but there is about 10% who, after two weeks, still have symptoms. There are chiropractors, physiotherapists, occupational therapists, athletic therapists—am I missing anyone, Pierre?—who all have great expertise in specific areas of concussion and know how to help people with specific problems, whether it be that they're having trouble with memory, with balance, or with their neck. They have the expertise to deal with that.

As a physician, I do not give very many complicated exercises for balance. I can give simple ones, but when you fail that first two weeks, you need something a bit more. Unless you have a private insurance plan, often that's not covered.