Subcommittee on Sports-Related Concussions in Canada Committee on Feb. 26th, 2019

[Dr. Mark Aubry]

First of all, from a minor hockey perspective, I think Hockey Canada's role is certainly minor hockey. I'm not sure it's up to Hockey Canada to tell the NHL what it should or shouldn't do. I do feel strongly, though, that fighting should not be allowed. We've provided that message not only to Hockey Canada but certainly across all levels of our sport.

I think that the NHL has changed tremendously. I think the fighting is down considerably, and eventually it will probably just wear itself out. A lot of pressure has been brought, not only by members of the hockey community but also by the media. I think they've heard the message loud and clear, and I think it's changing.

We had a summit at the Mayo Clinic involving experts from around North America. Certainly one of the published statements that came out of the summit was to abolish fighting at all levels of hockey.

Todd, do you want to add to that?

[Todd Jackson]

The role, from Hockey Canada's standpoint, is to make sure that we are influencing our culture at the amateur level and, as you said, spreading the message that fighting is against the rules, we don't want to see fighting, and it's not tolerated. If we can start to influence that right when the kids are at a young age, all the way up through the levels, then we are going to reduce and bring down the amount of fighting at the amateur level, in the amateur hockey game.

[The Chair]

We're going to be moving over to the Conservatives and Dr. Kitchen for seven minutes.

[Robert Kitchen]

Thank you, Mr. Chair, and thank you all for being here today. We greatly appreciate it. Thank you also for tolerating our little interruptions beforehand. I appreciate your staying here.

Dr. Bauman, I missed a bit at the beginning. You are a family physician and a specialist in sports injuries. Is that correct?

[Dr. Shannon Bauman]

Yes, I'm a family physician with a diploma in sports medicine through our Canadian academy of sports medicine.

[Robert Kitchen]

Okay. Thank you.

You've been involved with the parachute organization, I understand. Is that correct?

[Dr. Shannon Bauman]

Yes. I'm one of their expert advisers on their various subcommittees.

[Robert Kitchen]

You did specialized training after medical school in a diploma program.

[Dr. Shannon Bauman]

I did family medicine through Queen's University. Then I did a fellowship in sports medicine through McMaster University. Then I received an additional certificate of competency through the Canadian academy of sports medicine for sports medicine practice, and I've had a dedicated practice in sports injuries for the past 12 years.

[Robert Kitchen]

I appreciate that because that's where I'm leading to now.

You're a clinician and I'm a hockey parent, a hockey coach and so on. I've been involved in the sport for many years. I won't tell you how long it's been, but 1976 was when I got my coaching certification. We won't go that far.

Let's say I believe that my daughter has a concussion, I've heard about your credentials and I'm going to come see you. Walk me through how that would work.

[Dr. Shannon Bauman]

Your daughter has a concussion. There has probably already been someone on the ice with your daughter who has identified a possible concussion. That person's job is to recognize and remove your daughter from play. Depending on the severity of the symptom she has, meaning if there are any red flags that there's a cervical spine injury or some neurologic signs, it might be recommended that she go to the emergency department for immediate assessment. If she seems stable, the recommendation would be to follow up with her family physician. Ideally she should see a physician, whether it's through the emergency room, a family physician, a walk-in clinic or urgent care within probably about 48 hours.

At that point, there will be a medical assessment conducted by that physician, determining whether there has been a diagnosis of concussion, ruling out some of the medical red flags, determining if there's any imaging that needs to be ordered and giving some early education and recommendations about how to manage the initial signs of concussion and symptoms, how to gradually be reintroduced to school, how to go about their day and some guidance on how they're going to gradually become active.

There should be an additional follow-up after that point. This could be the role of a primary care physician. Luckily, with most concussions, 80% of patients are only going to need care under their primary care physician. There will be a follow-up within about two weeks, where that physician can then see how the transition is going in terms of returning to school and, day to day, how they're recovering in terms of symptoms.

If the physician at this two-week appointment identifies that there is something that's making it difficult for your daughter to continue to learn at school, if she's having some visual symptoms, headaches, difficulty with learning or they're getting worse during a school day, something such as that might suggest that the physician will make a referral to a specialist like me who has had additional experience in concussion care. It could be a primary care sports medicine physician, a pediatrician, a physiatrist, a neurosurgeon or a neurologist.

That physician's role is to make a referral directly to a physician who can do some further medical assessments, to pick up some of those subtle nuances that might end up giving your daughter a prolonged recovery. That would be the role I play. I see patients every day in my clinic—

[Robert Kitchen]

Let's say we got to that stage with my daughter and I've been referred to you, your clinic specifically.

When my daughter comes in that door, who is seeing her right off the bat?

[Dr. Shannon Bauman]

That would be me.

[Robert Kitchen]

You would see that person right off the bat. There wouldn't be any other referrals or assessments beforehand by anyone in your clinic.

[Dr. Shannon Bauman]

No, it would be me. I'm referred by another physician, the family physician. That person directly comes to me. My job is to spend about an hour to an hour and a half with your daughter. I do a very detailed history, medical assessment and examination, and we discuss some of the features we've identified of her concussion, which could be sleep issues, migraine, visual issues or vestibular issues. It could be mood exacerbations or other things, but this is all individualized.

Depending what I see, within my team under my roof, I have an occupational therapist with a Ph.D. in cognitive rehab and I am then referring to her care, and she's going to do a more detailed school assessment and provide some of that education. I also have an athletic therapist in my clinic who will help with some of the exercise piece if I feel that we need to put your daughter through some treadmill testing, some of our testing that we can do in-house under a supervised program. I have physical therapists in my clinic who work with neck and jaw and have competency-based training in vestibular rehab. If that's what's needed, I can refer to that individual.

The thing that's different and unique about our clinic is that this is a medically supervised clinic. I'm there first and foremost seeing your daughter. I will also be overseeing the rehabilitation under my centre, and I'll also be the one clearing your daughter back to sport, making decisions about return to school and providing the documentation they need when those decisions are made. The difference in our clinic is that I would be seeing your daughter all the way through and I would be the one ultimately discharging her and communicating back everything that has been done for your daughter to the physician who referred.

[Robert Kitchen]

I come from rural Saskatchewan and we don't have access to that. In fact, we have doctors who come from countries that don't even know what hockey is. It's not just in rural Saskatchewan, but throughout rural Canada that we have that access. It's a big challenge when we don't have the people who have those skills. There are other professions out there that have those skills and have done the post-graduate training to provide those skills and that information.

We need to look at that aspect of how it is for all of Canada. Not everyone is just in the central part of the big cities, in Barrie, or wherever it may be.

What would you say for those rural areas?

[The Chair]

Dr. Kitchen, we're going to have to hold that for, perhaps, your next round.

We're moving over to the NDP and Ms. Hardcastle.

[Cheryl Hardcastle]

Welcome. Thank you very much for contributing to our report and ultimately to our recommendations.

I'm making that term clear because previously when I asked a question of one of the witnesses, they didn't really understand the link when I asked what the government's role should be. They said, it shouldn't have any, but I'd like to see us have something articulated in a recommendation as necessary. That's the reason for my questions.

I'd like to start with you, Dr. Bauman.

With regard to your expertise that contributed to the Parachute Canada guidelines and your role with.... Is it Concussion North?

[Dr. Shannon Bauman]

Yes.

[Cheryl Hardcastle]

Does Concussion North apply all of the Parachute Canada guidelines?

[Dr. Shannon Bauman]

Yes, we do.

[Cheryl Hardcastle]

Is the way that the Parachute Canada guidelines are designed...? I don't want to say designed, I don't think. In anticipation of what my colleague Dr. Kitchen was just mentioning—the geographic realities and the availability of doctors—how realistic are these guidelines right now?

[Dr. Shannon Bauman]

In the guidelines we've created through Parachute Canada, we are setting a gold standard for what we want the care to be in Canada. We are looking at best practices. We are looking at what needs to happen to provide care so that each person—my daughter, your daughter, your son—has access to the best care we know. Our guidelines have been an example of what we feel is the best care available. Just because we don't meet that standard across all regions right now doesn't mean we shouldn't achieve a high standard of care.

For example, if you have a knee injury, if you sprained your knee and needed an MRI, an X-ray wouldn't cut it. If you need that MRI, you could see your family physician, have a medical assessment and be referred to a place to get the test you need. Just because we have access to X-rays doesn't necessarily mean they're the best test out there.

What I'm saying is that we need government support. My recommendation is that with government support, provincial support, we have the ability to uphold these guidelines, but we need the support financially to do so.

I believe that like cancer care, this is a complex medical issue that has a physician with an interdisciplinary team of professionals working together. We don't have a cancer care regional centre in every city, but what we do have is front-line physicians, such as primary care physicians and emergency room physicians, who can do a lot of the initial assessments.

Eighty per cent of people will be managed by their primary care physician or a physician. When we need referral to a specialty clinic—we're talking about 25% of these high-risk, persistent-symptom patients—just as with cancer care, we should have regional clinics that we can identify, which are accessible to all, depending on the geographic area. I truly believe this is achievable.

With clinics such as mine—Concussion North in Barrie, Ontario—or the Pan Am Clinic in Manitoba, or clinics in Ottawa under Dr. Shawn Marshall and clinics out in Calgary, we already have some great examples of people doing this work and following what we've set out in our Parachute Canada guidelines and our Ontario Neurotrauma Foundation provincial standards in Ontario.

We need more examples of these, but we also need the funding to do this. With funding, I believe we can be successful. I'm happy to help with this and show government how to do it fast.

[Cheryl Hardcastle]

Thank you.

Dr. Aubry, I know about your involvement—I think it's 22 years—with the Rough Riders. Can you tell us a bit about how you have seen our approach to concussions evolve, what you think some of the milestones or the best practices are and how we should be moving forward?

[Dr. Mark Aubry]

Concussion knowledge has changed our course of action over the last 20 years. I can go back to 2001, when we published the first consensus. It really wasn't until 2012 that the consensus said we could return athletes back to play in the same game, if they didn't have symptoms.

I think now we're all in agreement that concussion is a serious problem, a serious injury, and that if there is any suspicion, we need to remove the player from play and then go through a stepwise protocol and process to get him back. I can say that, even speaking in terms of professional athletes, who include CFL and NHL athletes, we have seen that approach: removing players from play even on suspicion, and not having them go back until they've gone through the stepwise process.

If we look at the CFL and the NHL—I'm speaking for professional athletes—the time frame before we've allowed them to go back and play has increased, just because now we're more concerned with safety than with allowing players to go back with the risk of getting another concussion or of endangering their health.

I think it's changing and is going to continue to change. Referring back to the guidelines and where people are in different parts of the country, the consensus provides very simple guidelines and can be enacted by all medical people in various parts of the country. It's really pretty simple.

The biggest thing is that we want them removed from play and we want them rested, but not rested in the sense that they have to not do anything—we allow them to do daily activities in the stepwise process—and there is educating them on symptoms, and certainly no going back until they are free from symptoms and, from our perspective in hockey and from the professional perspective, until they get the clearance from their physician.