Evidence of meeting #7 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 physician.
A video is available from Parliament.
6:05 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Thank you.
We'll move over to the Liberals with Dr. Eyolfson.
Dr. Eyolfson, you have about three minutes. Then we will have to run out for a vote.
6:05 p.m.
Doug Eyolfson Charleswood—St. James—Assiniboia—Headingley, Lib.
Thank you, Mr. Chair.
Thanks to both of you for coming.
Dr. Schneider, we've talked about prevention. You talked about certain rules that have changed, such as no running under the net in volleyball, changing the ages at which you can bodycheck in hockey, and these sorts of things. There has been some controversy about certain sports that should be entirely avoided below certain ages.
In your experience, are there any sports in which you should say that people below a certain age should not engage?
6:05 p.m.
Assistant Professor, Integrated Concussion Research Program, University of Calgary, As an Individual
That's an interesting question. Not that I think of off the top of my head, but—
6:05 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Let's pull a sport out of the air, just as an example: tackle football.
Would you say there's a certain age below which someone should not start it or engage in it?
6:10 p.m.
Assistant Professor, Integrated Concussion Research Program, University of Calgary, As an Individual
I think a lot more research needs to be done to really understand some of the risks in different sports at different ages. One thing we have seen in some of the hockey work our group has done over the last number of years is that we actually do see a spike in the risk of concussion in the 11- and 12-year-old age group. The rates of concussion would be very high, almost similar to what you'd see at a professional level, and then that rate comes back down again. Potentially, then, that's a vulnerable age for those kids.
Ultimately, we do see that decrease in risk in terms of absolutely not playing. I think that's an interesting question, but it would be interesting to look at some of the different rules around risk. I know that a lot of the sports are doing some evaluation to look at that—i.e., around tackling and limiting contact at practices. There is evaluation going on to look at some of those. It will be interesting to see what some of that research shows.
6:10 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Thank you.
We also talked about equipment. I know that people sometimes take a very simplistic view of protective equipment, particularly helmets. We know that helmets are not the panacea to completely prevent head injuries.
In addition to restrictions in rules of play, have you been able to make any recommendations in changes to the types of equipment or standards of protective equipment used in different sports?
6:10 p.m.
Assistant Professor, Integrated Concussion Research Program, University of Calgary, As an Individual
That's another really good question. We often look at prevention in terms of rules of the game, equipment and then intrinsic risk factors. These are factors that change risks that are internal to that person. Some of the intrinsic risk factors would be related to their awareness of space, coordination, head and neck control, and that kind of thing.
Then, of course, there's the equipment and the rules of the game. We do some evaluation in that area. There's been some work done in the area of looking at mouthguards and risk in youth ice hockey. Our systematic review from Berlin showed potentially a non-significant protective risk of about 19%, with a need for further research. We've actually been able to compare that, because in Alberta, because of the lack of literature, there wasn't necessarily rule enforcement around the wearing of mouthguards. Within our youth concussion studies, we've been able to study the kids who have and who have not worn mouthguards. You can stay tuned for the results of that.
6:10 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
On behalf of the committee, Dr. Schneider and Dr. Marshall, thank you for being with us. We apologize, but we have to suspend in order to go and vote. Please give to our analysts any reports or anything you would like to provide, beyond your testimony, that would inform our report. The report should be done by the end of spring. It will be tabled in the House of Commons.
Thank you very much.
6:10 p.m.
Assistant Professor, Integrated Concussion Research Program, University of Calgary, As an Individual
Thank you.
6:40 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
We'll reconvene. This is the Subcommittee on Sports-Related Concussions in Canada of the Standing Committee on Health.
For our second round of witnesses today, we have from Concussion North, Dr. Shannon Bauman, medical director and lead physician. She's coming to us via video conference from Barrie, Ontario. Welcome, Dr. Bauman.
From Hockey Canada, we have Dr. Mark Aubry, chief medical officer, as well as Todd Jackson, the director of insurance and risk management.
We are going to start with Dr. Bauman, just in case we lose the video feed. This is your opportunity to make a statement.
6:45 p.m.
Dr. Shannon Bauman Medical Director, Lead Physician, Concussion North
Thank you, Mr. Chair.
Respected members of the House, I am honoured to be here with you this evening. Thank you for the invitation to be a witness, and thank you to the committee and subcommittee for giving attention to such an important topic.
I will briefly introduce myself. My name is Dr. Shannon Bauman. I'm a primary care sports medicine physician and have a dedicated practice to the care of athletes of all ages and all ranges of participation, from recreational level to professional athletes. I've been a team physician for lacrosse, hockey and sledge hockey. I currently hold medical privileges within the department of family medicine and department of surgery at the Royal Victoria Regional Health Centre in Barrie, Ontario, and I am associated with the University of Toronto.
I am the medical director and founder of Concussion North, a physician-led interdisciplinary team dedicated to the medical management and rehabilitation of sports- and exercise-related concussions. Concussion North has been recognized as a world leader in the management of concussions, and I've been asked to present at various meetings, such as in Berlin, in Croatia and across the United States, on our model and our research in the recovery of sports-related concussions. We see Olympic athletes, world junior hockey players, professional athletes, as well as local athletes and those who travel far distances across Canada and the United States to receive care at our clinic.
Most recently, Concussion North has been recognized provincially on the Minister's Medal honour roll for our dedication to excellence in concussion care in Ontario.
I'm proud to be an expert adviser and committee member at Parachute Canada, Ontario Neurotrauma Foundation, the Canadian Concussion Collaborative and MomsTeam, working with the NCAA and U.S. Department of Defense. Through my work on these committees, I've also co-authored five of our leading provincial and federal guidelines on concussion, including the “Canadian Guideline on Concussion in Sport”, our “Statement on Concussion Baseline Testing in Canada”, and Ontario Neurotrauma Foundation's provincial “Standards for Post-Concussion Care”.
First and foremost, I'm a clinician who provides care to my patients in the focused area of sports-related concussions. I'm also a clinician scientist. My area of research is in the management of concussion within an interdisciplinary team model, the recovery of sports-related concussions and factors contributing to the risk of prolonged recovery, and sex differences in the recovery of concussion.
Based on my professional experience in concussions, I have two primary recommendations that can inform this subcommittee's work.
The first is national uptake and implementation of the best practice guidelines. Through the leadership of our federal government and the Public Health Agency of Canada, as well as the work of our nationally recognized researchers, expert clinicians, knowledge translation specialists in Parachute Canada and the Ontario Neurotrauma Foundation, we've produced strong guidelines that set a high standard of care for concussions, both provincially and nationally.
Working with the majority of Canada's national sports organizations, these guidelines have now been translated into harmonized sport-specific concussion protocols that allow all sports stakeholders to work together to optimize the recognition and management of concussion in Canada. However, we need all health care professional organizations, provincial and municipal sports organizations, as well as school divisions to widely adopt these protocols to ensure the messaging is consistent across all school and sports settings. This isn't happening currently across all provinces in Canada and we're often confronted by the mixed messages that sport and school stakeholders are receiving from other sources outside of our guidelines.
Second, we need the government to fund and support physician-led interdisciplinary concussion centres of excellence across Canada. These centres need to be geographically located and funded appropriately to ensure everyone has access to the interdisciplinary expertise needed to successfully treat concussions.
We know that most individuals recover from concussions within two weeks of injury, but for those 25% of individuals who continue to experience prolonged symptoms, finding clinics that uphold the current stated standard of care for persistent symptoms is a challenge.
Our federal guidelines are clear in stating that people suffering a concussion require assessment by a physician and some may require a multidisciplinary clinic with a physician with extra experience in concussion care, together with an interdisciplinary team of health care professionals.
Caring for athletes and patients with persistent symptoms of concussion is challenging. As a physician, my licensing and training enables me to assess the complex medical issues, including migraine, sleep, cognitive difficulties, depression and exacerbation of other co-existing medical conditions that all need to be recognized by the physician providing an initial assessment. Only physicians can provide this type of care.
These conditions such as concussion are becoming more common. There are also aspects that will require rehabilitation by allied health care professionals with experience in managing the nuances of this injury, which may include physiotherapy, athletic therapy, occupational therapy, neuropsychology and optometry, all of which exist in clinics under one roof.
Unfortunately, we need to be wary of large concussion businesses that are falsely promoting expertise and are falling short of providing the necessary standard of care that we see in our guidelines. Despite marketing or certification of concussion expertise, it's a challenge when these clinics are not meeting their current guidelines.
Like conditions such as cancer that are medically complex, concussion care requires physicians in addition to other allied health providers to work collaboratively in an interdisciplinary fashion. In short, we need to establish regional centres of excellence that are able to uphold the high standard of multidisciplinary care set out by our guidelines.
We currently do this at Concussion North. I am quite confident that with federal support and funding, we will be able to offer this high standard of care in centres across Canada.
Thank you very much. I look forward to your questions.
6:50 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Thank you, Dr. Bauman.
We'll move now over to Hockey Canada and Dr. Aubry.
February 26th, 2019 / 6:50 p.m.
Dr. Mark Aubry Chief Medical Officer, Hockey Canada
Mr. Chair and members of the subcommittee, thank you very much for inviting Todd and I to give you a report.
I'd like to take the opportunity to introduce myself before the committee. I am a sport medicine physician who is a co-director of the Ottawa Sport Medicine Centre. We see athletes with concussions on a daily basis. I'm also the chief medical officer of Hockey Canada and the International Ice Hockey Federation. I've been involved in the world of concussion for the last 20 years, having treated numerous professional and amateur athletes with this terrible injury.
The International Ice Hockey Federation, in co-operation with other international groups such as the IOC, FIFA, World Rugby, and now the FEI, the Fédération Équestre Internationale, have organized five international symposia on concussion in sport, with the resulting consensus on concussion, which has appeared in medical journals and provides the guidelines on issues surrounding concussion, based on scientific evidence. The last symposium was held in Berlin in 2016, and we are now preparing for the 2020 6th international symposium in Paris. The symposium brings together the worldwide experts on concussion. Following a two-day symposium, an expert panel develops a consensus on the evidence presented during those two days and publishes the guidelines in those medical journals.
In conjunction with the symposia, we have also developed a sport concussion assessment tool, now called the SCAT5; the child sport concussion assessment tool, the child SCAT5; and the concussion recognition tool, CRT5, for non-medical people who are involved in sport. These tools have been translated into several languages, including French, with the help of Hockey Canada and other experts across the country.
I would like to speak briefly on the work of Hockey Canada, which has worked diligently for many years on the issue of concussion in its sport. I'm joined by Todd Jackson, who is director of insurance and risk management at Hockey Canada. He has directed the safety program for many years. He'll certainly give you a lot of the details on the different programs that Hockey Canada has for concussion.
Since the late 1990s Hockey Canada has produced player safety information to the Hockey Canada safety program. It has delivered in-person and online training sessions, and it's worked with its provincial members to provide tools to all stakeholders to make the game safer. These tools include an online resource centre, a concussion app and an online educational stream for coaches, trainers, parents and administrators, all in the name of player safety.
In 2011 Hockey Canada introduced the zero-tolerance head contact rule. Minor penalties, double minor and major penalties are now assessed for any head contact, including incidental head contact. In 2013 the rules and regulations were changed to remove bodychecking from the game for kids aged 12 and under. Today, approximately 85% of games played under the Hockey Canada umbrella are played without bodychecking.
Hockey Canada, through its members, delivers information to coaches and parents, using an online educational platform called “Respect in Sport”, which deals with many topics including concussion awareness. Education and skill development are also provided to players as they go through the system, to improve their ability to keep themselves and their opponents safe during play.
Among the many safety measures, Hockey Canada calls for a safety person to be present for all minor hockey teams across the country. The safety person is educated to recognize all types of injuries, including the signs and symptoms of concussions. It also has a strict concussion protocol in place that calls for the removal of any player who shows signs and symptoms of a suspected concussion. The established return-to-play protocol has a series of steps in place, including medical clearance from a physician to ensure that they no longer have any symptoms and that the athlete is safe to return to play.
Hockey Canada continues to work in partnership with the sport injury prevention research centre at the University of Calgary—and you heard from Dr. Kathryn Schneider. Through its research, the centre has provided much of the evidence on the issues surrounding concussion, and Hockey Canada has used that research to guide its injury prevention efforts, including applicable rules and regulations.
Finally, we feel that it is crucial to have an active and healthy society. For this we need families to feel safe to have their children participate in sport. We also feel that we need to have ongoing education and continued research on the issue of athlete safety, which does include concussion safety.
Thank you.
6:55 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Thank you, Mr. Aubry.
Mr. Jackson.
6:55 p.m.
Todd Jackson Director, Insurance and Risk Management, Hockey Canada
That statement was one we put together in conjunction with each other. I'd just add that I think the networking we have done has been crucial, and certainly the sport injury prevention research centre is an example of it—Parachute Canada is another—and it has led to the effective tools and the ongoing information we've received to help us make important decisions around safety internally as an organization.
6:55 p.m.
Mr. Peter Fonseca (Mississauga East—Cooksville, Lib.)
Thank you.
Now we're going to have an opportunity to hear some questions from our members that you'll have an opportunity to answer.
We're going to start with the Liberals and Dr. Eyolfson.
6:55 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Thank you, Mr. Chair.
Thank you all for coming and giving your testimony.
Dr. Bauman, I'm an emergency physician, so I understand the challenges of knowledge translation to primary care providers.
Guidelines of all sorts for all treatments change from time to time, and there are always efforts to get them out there. For some issues, it's often a challenge even to get things into the curriculum at the medical school level.
Are you involved in getting training out to physicians at the early levels of training so that they have consistent knowledge of how to apply these assessment guidelines?
6:55 p.m.
Medical Director, Lead Physician, Concussion North
Yes, I've been involved with some work through Parachute Canada whereby we've created an online platform for education, which has received medical education credit, designed for family physicians and pediatricians as well as medical students. It is a rolled-out course that we were able to prepare, which I assisted with.
When we have information like this coming out, it's great to have it get to the physicians and to put these tools in their hands. Tools developed by physicians for physicians and for other health care practitioners are really essential.
I've also been involved at local levels with giving presentations to family physicians and I teach medical residents through the University of Toronto. We have a department of family medicine program here in Barrie, Ontario, where they come though our clinic and work with me first-hand seeing patients.
I feel that if we can get the information into the generation of new family physicians, residents and medical students, we will have an ability in our capacities as family physicians to initially assess concussions as they come into the office, and we will also have a better understanding of the guidelines that are out, because it's our opportunity to practice these guidelines in our clinical world.
7 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Great. Thank you.
Have you been approaching the colleges to make this a mandatory part of the curriculum, such as the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons? Has there been dialogue with them to include it in the standardized curriculum for residents?
7 p.m.
Medical Director, Lead Physician, Concussion North
I know some of my predecessors who have spoken to the committee previously, such as Dr. Pierre Frémont and Dr. Charles Tator, are individuals who have been spearheading some of these different aspects within the medical school. I haven't directly been involved with the medical schools myself, but I know there are some great leaders in the field working on such efforts whom you guys have heard from previously.
7 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Thank you.
Dr. Aubry, I want to switch gears here.
Mr. Jackson, you might be able to help me out with this.
One issue that has come up and about which we've heard some testimony is the issue of fighting in hockey. We know that it's against the rules at all levels. It's absolutely forbidden and not tolerated at all at the junior levels, but at the professional level, particularly in the National Hockey League, although against the rules, it is, depending on who you talk to, either tolerated or, if you listen to certain sportscasters with loud shirts, encouraged.
7 p.m.
Charleswood—St. James—Assiniboia—Headingley, Lib.
Exactly.
Has Hockey Canada taken any stance to aggressively message the NHL, saying, “I don't care what would happen to your ratings. You need to get the fighting out of professional hockey”?