Evidence of meeting #6 for Subcommittee on Sports-Related Concussions in Canada in the 42nd Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was concussion.
A video is available from Parliament.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
We are moving over to the Conservatives now, and Dr. Kitchen for five minutes.
Souris—Moose Mountain, CPC
Thank you to all of you for being here and for bearing with us on a day like today.
It's great to have researchers here. It's piqued my interest on a number of questions and aspects that I'd like to hear about. I'm trying to figure out where I want to start.
A number of you talked about brain degeneration, and some of the side effects that we might see, with mental health issues or possible CTE, etc.
I'm wondering whether there is research out there now compared to my day, and I go back to the days when I was.... I could talk about my undergraduate degree. I studied under Dr. Pat Bishop at the University of Waterloo. He was a mentor of mine. We did research where we were dropping hockey helmets, ancient contraptions.
Dr. Tator, I can see you smiling. I know you're very well aware of this information.
Nowadays, we're seeing a lot more new information. Ms. Curran, you mentioned about virtual imaging. These are all interesting aspects that I haven't kept up with, and I'd love to hear a little more about it. For example, on the issue of looking at this protein, the tau, obviously this is a new study. It's obviously done when someone has passed away. We can't look for that product today. It's after the fact.
How do you take all of that information and correlate that with a sports concussion?
I'll throw the question out to Dr. Tator first and then go from there.
Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital
That's a great question, a tough question. I will try to answer it.
By the way, I interacted with Pat Bishop for a long time. There is no doubt that he was a great Canadian researcher on head injuries.
With respect to your question about tau and the fact that we can see it at an autopsy, the good news that's starting to appear is that research has shown us a way to identify it in the living. We're not ready to be able to apply it to an individual patient who is suffering, let's say, with dementia, and you want to know whether it's regular Alzheimer's disease or CTE. We're not ready for that, but I think that is coming down the pike. We will be able to identify it in the living.
One of the hottest areas of research right now in this condition is the use of PET scanning, which can identify deposits of this abnormal protein. We use a radioactive tracer that's labelled with fluorine-18. We inject it and then do PET scanning, and we can see deposits of tau in the brains of some of those living athletes.
We've had a very good relationship with the CFL Alumni Association. They have sent along a number of their alumni for examination with this technique, and we can identify deposits of tau in the brains of people who are living.
I think that's a very important first step in trying to develop a treatment for this. We don't want to just be able to diagnose it. We want to be able to do something about those deposits of tau.
Souris—Moose Mountain, CPC
Thank you.
I know at the University of Ottawa they have a scanner that's been used in looking at PTSD aspects in veterans. There's some early research on that.
Perhaps, Dr. Marshall. you might have some information that would correlate with this.
Division Head, Physical Medicine and Rehabilitation, University of Ottawa Brain & Mind Research Institute
I think we're talking a little bit about different things too. There's the one goal of identifying CTE, which is a chronic sequela, presumed due to multiple concussions. I think the research is certainly going off in that range. We're learning more and more each day, and I think those things are very important.
I think the other area, which is in high-intensity research, looking probably more at the sport level and the acute concussion level, is the immediate diagnosis of concussion. It relates to what you're saying about PTSD, so often associated with injury, more often outside of sport than inside of sport. There's an emotional reaction that we often talk about, PTSD, and some of the symptoms can be similar to those of a concussion.
The other thing is that we're looking for markers—or biomarkers, if you will—that would suggest you've actually had resolution of your concussion. When is it safe to return? A case in point would be an example like Rowan Stringer. Clearly, she was a person who had evidence of concussion, when they went through and looked at the record, and yet continued to play. Now through prevention and other strategies in this day and age, we would identify it, first of all. That's probably one of the many failures in the system that occurred, which Dr. Tator is referring to, and we need to remedy, but it would be ideal to identify those who actually had a concussion urgent injury.
There are experimental imaging techniques. Conventional imaging such as a CT or MRI generally shows normal, and we consider it actually a more severe brain injury if it's not normal. However, we do know certain MRI protocols, like diffusion tensor imaging and other types of protocols like SWI, can show concussions acutely. The problem is that it can't be used diagnostically at this point in time. But these things need to be explored. There are also biomarkers such as SB100 which, if it's in more severe cases, is a better pickup, but when it's in the milder cases won't pick up. So I think for the acute markers—
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Thank you, Dr. Marshall.
We're going to be moving over to the NDP and Ms. Hardcastle, for five minutes.
Windsor—Tecumseh, NDP
Thank you, Mr. Chair.
Actually, I would love to hear you continue, Dr. Marshall, with regard to how we sort out and monitor the progress that's been made for diagnosis and treatment, and then move on to the more long-term effects that Dr. Tator was talking about, the intensity of that kind of research.
Looking at it from the mandate of this committee—and we're not really clear on what is going to manifest itself from the testimony and the report and the recommendations—how can we be facilitating not just advances in research but also in the protocols that are needed and the standards and all of it?
Division Head, Physical Medicine and Rehabilitation, University of Ottawa Brain & Mind Research Institute
It's a large topic and I realize there's a time limitation.
In relation to concussion, and the fact that we're focusing on sport concussion, I think we have to first compliment the Canadians who Dr. Tator was referring to earlier, who actually led the guidelines for, first of all, identifying it and for return-to-play protocols, because you're saying how do you do it. We're all looking for—
February 20th, 2019 / 7:25 p.m.
Windsor—Tecumseh, NDP
To be clear, because our time is limited, how about sharing where the best places would be for us to look at how we leverage what you've already done to move forward, and how we can facilitate that.
Division Head, Physical Medicine and Rehabilitation, University of Ottawa Brain & Mind Research Institute
If you wanted to leverage, I think things are at the point where we've identified as a priority some very important areas. I think research is where to go.
The truth is that you have a lot of great researchers in this country who have actually come together. This is unique, compared to other countries, working in collaboration, a national centre of excellence, as I mentioned earlier. I think through big data, for instance, through the Ontario Brain Institute, our being able to examine these large populations, and coming together, we should be able to identify technologies that can diagnose concussion and actually monitor progression, so we know who are at risk. I think this is going to be key to our being successful, helping to solve the diagnostics and then actually treatment. I think these collaborations to foster those and foster that research here in our country would be huge.
Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital
I think what Dr. Marshall just said is very important. I would like the House of Commons committee on health to put some teeth into what has been done to date. For example, I feel very strongly that every province should enact concussion laws, because that's one way to be sure we are all on the same page with concern about concussion. The concussion laws should apply to not only school-based sports, but also all the non-school based sports, for example, all of those that are organized by Hockey Canada, the Canadian Soccer Association, etc. All of those folks should be subject to the concussion laws.
What do the concussion laws say? They say that everybody should be educated about concussion. They should know how to recognize concussion. That goes for parents, coaches, teachers, players. Even the referees have to be clued in about concussion. We simply have to prevent people like Rowan Stringer from ending up dead.
We need accurate surveillance data. I've heard other speakers recommend that to your committee. We do have the machinery in Canada to make that happen. We have CIHI, PHAC, ICES, with all their methods of data management. We have to collect data about what is happening in every sport in the country. We simply don't have that information and we should. From the annual coroners' reports we should know how many people die. Those take three or four years to finish, but we should be compiling that data.
There was recently a death in P.E.I. of another rugby player. Who's adding up all those catastrophic injuries? That should be a national effort. We've heard about good resources that are available, for example, the one I held up, the “Canadian Guideline on Concussion in Sport”. This should be in the hands of every family, every coach, every referee. I would like to see your committee do something about the distribution of what is already available. I think Canadians have done a very good job of preparing a menu of opportunities for your committee to distribute and emphasize.
I would encourage you to use what's available, rather than—
Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital
Yes.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
We're going to be moving now to the Liberals.
We're fortunate that we have Mr. Casey, the chair of the Standing Committee on Health, with us today.
Thank you for launching this subcommittee, Mr. Casey. The floor is yours for the next three minutes. I understand you may be sharing your time.
Liberal
Bill Casey Liberal Cumberland—Colchester, NS
I'm going to share my time with Dr. Eyolfson.
You answered part of my question, Dr. Tator. I know that a few years ago there was a concern about brain tumours, and doctors had no information about what was going on in other locations. There was no brain tumour registry.
We passed a bill in Parliament to establish a brain tumour registry so that if there was a cluster of brain tumours in one location, they could compare the circumstances to see if there was some common denominator. It sounds as though that's what's needed here, in terms of concussions, so that there is a registry and studies done that researchers can compare to see if there is common ground or a common denominator.
Would you recommend that?
Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital
Absolutely. It really makes sense to me that we document carefully all the concussions that are occurring in the country, especially in sports and recreation. We can do that. We have the organizational ability to do it. We have CIHI, ICES, PHAC. We have all of those great opportunities available to do the math and count up how many are occurring in rugby, in hockey, in soccer. Then we'd find out how important heading the ball is in soccer. We really suspect that it's an important cause of brain injury in some people. This would be the way to make sure we get early warning in our country.
We want kids to play sports, but we do want them to play safely, and that will keep them playing forever. That's the moto of Parachute Canada—play safely; play forever.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Dr. Eyolfson, you have about 45 seconds.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Okay. I have a very quick question.
We were talking before, Dr. Tator, about the studies you've done on brains. I know your sample size is not really large, but have you found any cases of athletes who had had a number of concussions but who had no symptoms? There are people who recover. They'll have multiple concussions but no long-term clinical presentations. Was there any correlation you found where you'd have less of these tau proteins in the people who had less symptoms, or more? Did you see some of these in people who really had no long-term symptoms?
Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital
You know, those are all great questions, and we can't answer any of them accurately with our small sample. We said before that we need about 200 brains in order to answer those questions. There are some big gaps in our knowledge. For example, we just received the first woman's brain. All 44 of the other brains we have accumulated over the past 10 years have been male, and that's the same with most registries: there's a real lack of women's brains. We put out a big advertising campaign to try to get women to donate their brains, ultimately, when they're finished with them, to give them to us for science.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
On that note, we're going to move over to the Conservatives. Thank you.
Dr. Kitchen.
Souris—Moose Mountain, CPC
Thank you.
For many years I dealt with sports, in my time as a trainer, in my private practice, and then when I was one of the team doctors for our junior hockey team, so basically for 25 years. I reflect back today, and although I treated a lot of concussions over the years, it did not seem to be the same.... When I was ending my practice, the longevity of the injury seemed to be greater in my last couple of years of practice versus in my early years of practice. I'd like to think that in my early years of practice, fresh out of school, I was on top of it and everything.
I'm wondering, from the research, can you tell us why we're seeing more situations where concussions seem to be lasting longer than 30 days? Is there any research to suggest that?
I'll start with the researcher, Ms. Curran.
Do you have any comments?
Research Associate, The Ottawa Hospital, Centre for Rehabilitation Research and Development
As I mentioned, we definitely do know that more people have persisting symptoms than we initially thought, symptoms like headaches, vestibular issues, which are going beyond the usual—quote, unquote—“recovery time” of a couple of weeks. It's unclear whether that is simply because people are more comfortable reporting it and they don't hide it as much as they may have previously, or whether there is some other factor, extrinsic or intrinsic, that is emerging. That is definitely something on which more research needs to be done.
We do know that women do present with persisting symptoms more frequently than men do, so the fact that Dr. Tator has received only one woman's brain for his research is very interesting. It would be very interesting to see more female brains.
In terms of how long symptoms last, when people end up with persisting symptoms, they can become chronic. That's a huge issue in terms of managing the people in that 15% to 20% who end up with a concussion that has persisting symptoms. That impacts people's lives thereafter. The research we really need is to figure out what sorts of things we can do for those people and what kind of evidence we can find in the research to support people like Dr. Marshall who do rehabilitation with people with persisting symptoms.