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

[Dr. Pierre Frémont]

I probably had the chance to be quite well informed as a physician, except maybe for the one I had when I was younger, playing water polo. I don't remember any consequence of that. I was probably able to heal. I had the chance not to get reinjured after that first injury. The two subsequent concussions just healed because I made sure that I didn't get reinjured and I rested and then I gradually resumed activities. I don't feel that I have sequelae from the three concussions.

[Bill Casey, Liberal, Cumberland—Colchester, NS]

Thanks very much. That's good.

[The Chair]

Thank you, Bill.

We will now move to the Conservatives and Dr. Kitchen.

[Robert Kitchen]

Thank you.

I appreciate your comments regarding the questions from Mr. Webber and Mr. Casey. I think a lot of times on this committee there are a lot of people who don't understand how we walk ourselves through the injuries and what we see. While Dr. Eyolfson and I might have some experience in that avenue, a lot of our colleagues don't, so I appreciate those comments.

As we roll with that—I want to keep on that subject—one of the things that we see in sports now is the aspect that we're dealing with the SCAT5 and the child SCAT5. While I may understand it, I would ask if you could relay to my colleagues your approach to the SCAT5 and the child SCAT5.

[Dr. Elisabeth Hobden]

The SCAT5 is the sport concussion assessment tool. It's not actually the fifth version, but they call it the SCAT5 for other reasons.

The document comes out of the international consensus statement on concussion in sport. There's a narrative that you can read with evidence behind it and all that kind of thing, but the SCAT is what we as physicians use to assess a sporting concussion.

It starts out with very simple things: What's your name? What's the date? What sport were you playing? What's the score? What quarter are you in? It moves on to more complex things like asking you to do some tests of short-term and long-term memory. It asks you to do some balance tests to see how your balance is affected, because that is very often affected in concussion. Then there are some concentration aspects where you ask them to subtract seven from 100, and keep going. Lots of people have difficulty doing that with a concussion, or saying the months of the year backwards. When you've tested this, you can test some of their movement as well.

Essentially you come up with a score. The score doesn't tell you whether or not you have a concussion, but it can help me as a physician.

Another thing that's part of it is that the patient rates their symptoms. As a physician, I can say that overall, I think things are improving. It's designed really only for the initial assessment to see where you're at. But certainly the self-reporting of symptoms is important as you go along.

[Robert Kitchen]

Thank you.

You both made an important point that no one concussion is (a) the same, (b) treated the same, and (c) comes out with the same results. I appreciate those comments, because that's an awareness thing that we need to know, and that we need to get out for the sporting bodies to understand that as well, because they extrapolate that all into saying....

In my day, when I had my concussion, they'd say, “Your bell was rung. Get back out there. It's a long way from the heart.” Today, we need to be very well aware of that aspect of it because of the implications of it, and no one ever recovers exactly the same way. I was the victim of a hit-and-run when I was 16. I was riding a bicycle and was hit by a drunk driver. I was unconscious for 10 days. The reality is that I've come back from it but it took time. You see everyone recovering on those aspects.

When we deal with children, they're reliant upon the people around them to make decisions for them. That goes back to, as you talked about earlier, recreational sporting before they get to that elite level. As they get to the elite level, they usually have a lot more professional help that's providing that for them.

What can we say to those who might be listening today, the parents who might be listening today, as to how they approach that aspect? A lot of parents will panic and maybe overdiagnose it themselves because they read it on the Internet, or they may not do anything. I'd like some suggestions from you, if possible.

[Dr. Elisabeth Hobden]

If I understand your question correctly, it is what does the mom do who has a child participating in a sport and is worried about the risk of concussion.

The first thing I'd suggest is for her to talk to the sporting organization, talk to the coach, about what education the coach has. There are free online courses that sporting organizations give. Does the coach have anything? I think that's a good place to start.

The second thing is there's a lot of good information for parents on the Internet from groups like Parachute about concussions, how to recognize them and what's going on. The reality is, if you're concerned about the health of your child, if you're concerned about a concussion, we always say that when in doubt, sit them out until you can get a proper assessment to understand what their health status really is.

[The Chair]

Thank you.

We're going to be moving over to the New Democrats for about two minutes or so before we take a little break and scoot out for votes and that will conclude our first witnesses.

Ms. Hardcastle.

[Cheryl Hardcastle]

We have a Canadian standards organization that has the authority to constantly monitor and to regulate or to set standards.

Do you think we need to be exploring that kind of concept of monitoring or assessing, I don't know, at some point down the road...? Are you concerned that the more you learn and the more you...? There are a lot of silos. How do we bring this together? Do you think maybe we should be looking at a central organization or something? Just finish up with your thoughts on where you think this really needs to go.

[Dr. Pierre Frémont]

I think that notion of a central hub of information with tools to support every type of setting in the implementation of those recommendations is the key here. Implementing formal expectations, whether it's through regulation or legislation, those are different means, and I'm not the one who will choose.

I think it's okay, for example, for Sport Canada to associate funding.... They do it for harassment. If you don't have a harassment policy, you don't get the funding. Why not do it with concussions? Why couldn't we say that if they want to organize a sport at risk for concussions, they must have a rule or they will not get that type of support?

There are different ways to reach that, but this has to come with the support to meet the expectations, which is often a problem. If you just pass a law and you don't support people in meeting the requirements of the law and you don't have the resources to verify the application of the law, then you just have a sword of Damocles hanging there to be able to say someone is guilty when a kid dies, which is not right. If you implement an expectation, you need to have the support.

[Dr. Elisabeth Hobden]

I think that's important too, because Canadians aren't active enough. What you don't want to see happen is that regulations are put in place that people can't meet and then there is less participation in sport. They really have to have the support so that they can achieve these goals.

[The Chair]

Excellent. Thank you for the questions and thank you for the answers and recommendations from our witnesses.

We want to thank Dr. Frémont and Dr. Hobden for being with us today. We are looking to have this report ready to be tabled by the end of spring.

We thank you for appearing here and for your testimony.

We're going to break now for about 20 minutes.

[The Chair]

I'm glad everybody is back. I apologize for that break for the vote.

We are back now with our second panel of witnesses. From the Canadian Concussion Centre, University Health Network, Toronto Western Hospital, we have Dr. Charles Tator. We also have with us, from the University of Ottawa Brain and Mind Research Institute, Shawn Marshall, division head, physical medicine and rehabilitation. From the Centre for Rehabilitation Research and Development, we have Dorothyann Curran, who is research associate at the Ottawa Hospital.

We are going to start with Dr. Charles Tator. Just in case something happens with our video conference, we want to ensure that we get Dr. Tator's statement and testimony here for the members to hear. Then we'll move to our other witnesses. Then we'll have questions from the members.

Dr. Charles Tator, the floor is yours.

[Dr. Charles Tator, Director, Canadian Concussion Centre - University Health Network, Toronto Western Hospital]

Thank you, Mr. Fonseca.

I'd like to thank the committee for inviting me to speak. I'm very pleased, in fact, that this committee of Parliament is putting so much energy into the field of concussion.

I've been focusing on this field in my practice and research for the past 20 years. I think it's great that our country feels that this is a major concern. It has been my view for a long time that concussions are a major public health issue in our country, for a number of reasons. We generate a lot of concussions because of the way we live. We drive quickly. We play a lot of high-risk sports. In fact, we generate about 200,000 concussions annually. I can tell you that our research shows that about 20% do not recover within the usual time of about a month. In fact, some never recover.

We've learned quite a bit about concussions. We're impressed with the fact that they are often followed by significant issues, such as major mental health disorders. In fact, some end up with brain degeneration, as I'm sure you are aware.

I think it's important for this committee to have a perspective. I'm probably the oldest person who is going to speak to you, and from my perspective, a lot really has gone on in the last 20 years. I welcome this committee to the team to deal with concussions, but I really feel that it's important for you to be aware of this perspective.

In about 2000, the Canadian Academy of Sport and Exercise Medicine—you just heard from representatives of that committee—put out one of the first concussion guidelines of any country, so Canada was really quite forward in saying in the year 2000, for example, that every concussed athlete should be removed from the game or practice and should see a medical doctor. In the following year, and for about the next 10 years, there were concussion road shows that went across the country and visited all the major cities. They were sponsored by a number of organizations, including Hockey Canada and ThinkFirst.

In about 2010, we opened what I think is Canada's first comprehensive concussion centre focusing on concussion care and concussion research. There are now several others across the country in major cities and even in some smaller cities such as Barrie, Ontario. From 2011 until 2019, the present time, CASEM has had a Canadian concussion collaboration with a number of organizations, which now includes Parachute Canada, Canada's injury prevention agency.

In 2012, in the Ontario legislature, for the first time a concussion law was given first reading, but it did not pass. To put that into perspective, by 2014 all 50 states in the U.S. had already enacted some form of concussion legislation.

Next, 2013 was an important year, because the first Canadian cases of CTE, the dreaded brain degeneration related to repetitive concussions, was first reported in Canada. That same year, in 2013, Rowan Stringer died in Ottawa from concussion-induced second impact syndrome following concussions in school-based rugby.

In 2014, the following year, the Ontario Ministry of Education enacted PPM No. 158, which was a concussion policy procedure for school-based sports. It only covered school-based sports, but it was very important to do that.

In 2015, Prime Minister Trudeau sent mandate letters to the federal ministers of health and sport, Jane Philpott and Carla Qualtrough, respectively, to support a national strategy to raise awareness for parents, coaches and athletes on concussion management. It was a very important initiative. That same year, the Rowan Stringer inquest was held and established that that was a concussion-related death. The jury recommended 49 measures to prevent further deaths in sports.

In the following years the Public Health Agency of Canada awarded Parachute Canada a contract to harmonize concussion education and guidelines for our country. From 2016 to 2019 the federal Ministry of Sport's working group on concussions, headed by Jocelyn East and Michel Fafard, began its work. That has been an excellent committee with representatives from sport, health, education and prevention, with great committee work on harmonization and dissemination of guidelines.

In 2017, the Rowan Stringer committee formally called for concussion legislation, and I'm very pleased to say that was ultimately enacted in 2018 in Ontario. That's very recent, and now we are aware of other provinces, especially Manitoba, that are moving in that direction.

Parachute Canada and PHAC introduced these excellent guidelines so we now have guidelines written by Canadians for Canadians for all sports. It is important for your committee to know and appreciate that.

[The Chair]

Thank you, Dr. Tator.

We have come a long way over 20 years, but we still have much work to do, as we know from the witnesses we've heard on this committee.

We're going to move to Dr. Marshall for five minutes.

[Dr. Shawn Marshall, Division Head, Physical Medicine and Rehabilitation, University of Ottawa Brain & Mind Research Institute]

Thank you, Dr. Tator, that was a great presentation and history.

While I think Dr. Tator precedes me in age, I'm also of a similar ilk. I think we predate concussion being a concern. Early on in our careers when we started off, concussion wasn't identified.

What I want to focus on in my presentation is that I think the emphasis has been on identification and prevention of concussion. Where we have come into the fold and where we've done a lot of our work is on, I think, something very important mentioned by Dr. Tator, which is the management of a concussion after it's occurred.

There's acute management, and there's that minority of persons who had a sport-related concussion or a concussion outside of that. Generally it's 15% to 20% in a study for pediatrics, and it exceeds 30% if we go longer than 30 days. If we go beyond six months, it's probably 15% to 20% of the population. Again, sport concussion is a subset of concussion. I think concussion affects everyone in their daily lives.

The tack I take from it is that we as clinicians were recognizing that people were having concussion, and these individuals weren't necessarily completely recovering, which is what the expectation was: complete recovery. My main area has been moderate and severe brain injury. We were in rehabilitation and finding that these patients were not completely recovering.

Akin to guidelines that talk about management of concussions, or concussions more clearly, Canada has been a lead. Another area that we have focused on has been the management of symptoms following that, to try to standardize practice for how we manage people who have ongoing symptoms following concussion, primarily focusing on those with persistent post-concussion symptoms.

Through the work of the Ontario Neurotrauma Foundation, there have been two sets of guidelines created, one for pediatric, ages 18 and under, and another for adults. These have been published nationally and internationally. They have been presented as such and are recognized as very solid guidelines. We're currently in the third edition for the adult concussion guidelines. The aim of this is to standardize practice to provide care. As Dr. Tator mentioned, 200,000 Canadians per year sustain concussions. If 20% are not better after 30 days, then we're looking at people who need help and support. This needs to be improved in care and where we're focusing our research.

The other thing I will comment on specifically is that there have been initiatives that, to date, have not been successful, but have tried to harness the expertise here nationally in the country. Led in Calgary by Keith Yeates, there was an application for a national centre of excellence for concussion management through the University of Calgary. It was not successful in the letter of intent stage, but it harnessed experts throughout the country to focus on sport-related concussion and concussion in general, both pediatric and adult.

Another initiative that has been successful, but has not received full funding through the Ontario government, is the Ontario Brain Institute in relation to the Connect group studying concussion from all elements, from pre-concussion to concussion, looking at even chronic encephalopathy through all stages, including acute management and post-concussion management.

These are things that should be pursued further to standardize practice of care. Clearly, Canada and Ontario are leading in this area in trying to set these standards, and this has been well recognized internationally.

I believe that support on setting those guidelines and standards and allowing for further research will help us better serve our patients.

Thank you.

[The Chair]

Thank you, Dr. Marshall.

Dr. Tator, I'm not sure if we cut you off at one point, but if you do have more to your opening statement, you can submit that. We will distribute that to the committee members, and it will be made public.

Thank you.

[Dr. Charles Tator]

Thank you.

[The Chair]

Now we're moving to Ms. Dorothyann Curran.

[Dorothyann Curran, Research Associate, The Ottawa Hospital, Centre for Rehabilitation Research and Development]

Concussion, in particular, sport concussion, has become very topical in terms of public awareness over the last 15 years. Both physicians alluded to that.

Research on concussion has also risen exponentially. In doing a literature review for the 2012 adult version of “Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms”, about 18,000 abstracts were reviewed. When the third version of the guidelines was created in 2018, over 38,000 abstracts were reviewed.

There are different types of research targeting different aspects of concussion. There's research on identifying concussion conclusively and quickly. Not everyone who experiences an impact to the head develops a concussion. How do we identify those people who actually do end up with brain damage? There's research that looks at proper healing timelines, and there are guidelines for adults, children and adolescents, designed to advise people on getting back to work, school or play. A lot of research has been done looking at attempts to speed recovery during concussion, in the subacute phase, to address specific symptoms, such as headaches, cognitive issues and vestibular issues. People want to get back to their day-to-day activities as quickly as possible.

Some research on persisting symptoms has also been done. How do we identify people who might develop persisting symptoms? We know, for example, that women tend to have persisting symptoms more frequently than men do. What can we offer these people, in terms of rehabilitation? What therapies and treatments might offer optimal management for these persisting symptoms in the long run?

There's also research that looks at extrinsic and intrinsic factors that might contribute to persisting symptoms. There's a concern about the effects of multiple concussions that may translate into persistent symptoms. There's gender, age and mechanism of injury which could contribute to persisting symptoms as well.

Some athletes are working in jobs that can increase their likelihood of having concussions. It's known that people who experience a concussion are more likely to have another one, which is also a danger for athletes, especially those in contact sports.

It's generally accepted, as Shawn and Dr. Tator mentioned, that about 15% of people who experience a concussion may go on to have persisting symptoms. It's becoming a little more clear that it could actually be a higher number; maybe 20% of people end up with persisting symptoms following a concussion. Symptoms that remain beyond three months are considered persisting symptoms. People who fall into the persistent symptoms category are at a great disadvantage. Their symptoms interfere with work, return to play, social activities and family obligations.

In terms of avenues for future research, which is more where my focus is, augmented reality and virtual reality are definitely gaining interest, in terms of assessment and treatments for concussion. There are different types of goggles with analytic software emerging for use in sports. They are very portable, and may be able to assist in the diagnosis of concussions. Virtual reality that uses larger, more immersive systems can also measure range of motion and centre of balance. They have good potential, although they'd only be available at health care centres. The newer gaming platforms make simulation interfaces more visually engaging, which could improve compliance with treatment.

The advantages of the use of VR for assessment and therapy are that we can program virtual reality very specifically, to elicit responses based on increment, difficulty or intensity, and we can measure responses to stimuli. It's also a great distraction, and, obviously, the entertainment feature is high.

In terms of the disadvantages, we don't know what long-term exposure to virtual reality can do. Virtual reality is also not the real world. Human responses are not the same in virtual reality. If we want to rehabilitate people into the real world, there are some things we simply want them to do in the real world. If we want them to stack blocks in virtual reality, they might as well stack blocks in the real world.

Overall, there's a lot of research being done on concussion. At this point, the literature, in my opinion, needs to be evaluated. Studies need to be evaluated by people with clinical and research experience using reporting guidelines that will help to qualify the research. The new research that is going to be done needs to be driven by what gaps exist that we know about now.

[The Chair]

Thank you, Ms. Curran.

I know that the members are eager to ask all of you many questions to tap into your expertise and your knowledge.

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

[Doug Eyolfson]

Thank you, Mr. Chair.

Thank you, everyone, for coming.

I was explaining to the last panel that I'm a physician, so it's kind of nice being back with people from my field. I feel like we're getting the band back together.

I'd like to start with Dr. Tator. At your centre, they're studying deterioration of brain function. I think you mentioned chronic traumatic encephalopathy in your remarks. Has your research found any correlation with other identifiable neurologic conditions like dementia, Parkinson's disease, MS, or anything like that?

[Dr. Charles Tator]

Yes. That's a very good question, because there is a real connection between all of the neurodegenerative disorders, and patients may end up having more than one. For example, in the brains we have examined of athletes who have had multiple concussions, we have found other conditions present, like Parkinson's disease, or small strokes or a loss of blood supply to the brain. That's why very careful analysis has to be done of people who are suffering from symptoms like dementia and other brain degenerations to figure out exactly what caused it.

We're at a very early stage of this. In our centre, we've examined about 45 brains now that have been donated to us by the loved ones of people who have passed on where something of that sort was suspected. In about one-third of those people, we do find evidence of CTE. It's not as common as has been reported in other centres. Some were saying that up to 95% of brains donated to them concerning patients who have passed on with those degenerative conditions have shown CTE, but that hasn't been the case for us. I think that's just indicative that this is a growing field. We're just scratching the surface, really, but we have made some gains. I would hope that one of the objectives of your committee will be to advance further research as just indicated by Dr. Curran.

[Doug Eyolfson]

Further to the examination of brain tissue, you've described how in these patients you find things like Parkinson's disease. In the absence of any of these diagnoses in the brains you've examined, are there any specific changes to the brain that you've seen that are unique to concussion that don't fit any other diagnostic criteria like Parkinson's or something like that?

[Dr. Charles Tator]

Yes, very definitely. The diagnosis of CTE, chronic traumatic encephalopathy, has definite criteria. For example, you have to see deposits of this abnormal protein called phosphorylated tau. It's quite easy to identify that protein because it stains a dark brown if the brain is prepared with the appropriate stain according to now-established techniques. Yes, we can identify brains that have that problem specifically.

For example, you may know the name Steve Montador. He played for six NHL teams during his career. We went over his records very carefully, and I personally counted that he had had 19 documented concussions. He was a very aggressive player. When he died unexpectedly at the age of 35, his brain had lots of deposits of this abnormal protein, which is very specifically located in areas that are characteristic of CTE.

The answer is yes. There are some people, even young people of 35 years of age, who are showing this abnormality after multiple concussions.