Subcommittee on Sports-Related Concussions in Canada Committee on April 3rd, 2019

[The Chair, Liberal, Peter Fonseca]

We're going to be moving over to the Conservatives now.

Dr. Kitchen, you have five minutes. This is our second round.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Mr. Chair.

Thank you again. It's great information. I appreciate it.

I'll try to make sure I get both of you involved in the questioning. You talked about—and we've heard this before as well—how in soccer, women have a 50% higher proportion of concussions than men. There's been some research that talks about neck strength and the value of that, definitely at the younger age. Although one assumes that it's been looked at at the Olympic and Paralympic level, it may not be.

Quickly, from both of you, could I get a response to that?

I'll start with Dr. Gordon.

[Dr. Kevin Gordon]

The neck strength thing has.... First off, data. If you do a cross-sectional study of high school athletes, neck strength will predict the likelihood of concussion in the following year. That's an older study now, and we were all enthused when it came out because we thought the trials would be under way to prove that neck strengthening can prevent concussion. They had a lead time on the exercise trials. We have no data yet on neck strengthening having any effect for subsequent concussion. We're all still waiting.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Dr. McCormack, do you have a response?

[Dr. Robert McCormack]

It's the same. There's lots of research here. People are doing trials looking at neck strengthening with all kinds of fancy gizmos, and the data is just not there yet.

If I may, I will come back to one other comment that was made earlier from the NDP member about baseline testing. Not only is there the changing baseline in children but I think the problem is actually much simpler at the grassroots level. We really just need to get that out, that when in doubt, sit them out.

The reason we do these enhanced things with athletes is that they're in the middle of the playoffs, or the Olympics are coming up and it's once every four years or once in a lifetime for them. We're trying to see how quickly we can get them back and when it is safe. However, when we're talking about a child's brain, we don't need neuropsychological tests to assess them, because we shouldn't be pushing the envelope to get them back to high-risk situations.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

One of the things we've heard throughout our study has been on data collection, how sparse it is and how hard it is to do it. We've heard from a couple of organizations that actually have apps that collect data. Some are free; some are costly.

The challenge we have is that we want to collect that data so that we can get the research, but also we want to collect that data so that it can be shared at the same time as protecting the privacy of the athlete and the family.

There is such a program that will collect that data without sharing the personal information. For example, if a soccer player gets a concussion during the soccer season and goes into hockey, the data that there's a concussion can be accessed by the coach or the organization the person is moving into without sacrificing that.... How valuable is that, and what steps have you seen going forward on this?

Dr. McCormack.

[Dr. Robert McCormack]

Always more data is useful. It's the question really of the quality of the data. You really have to make sure the numerator and denominator actually are valid to be able to make some judgment off of it. That's sometimes a challenge.

What I think I heard you say was that we need something with which, when athletes change sports, we can pick up their previous history, which can be relevant. That may actually be different from a database of all concussions.

That may be a questionnaire when the people start a new sport that asks if they have had a previous concussion. At the professional level that's what we do. We ask: Have you ever had a previous concussion? How many? When was the last one? How much time did you miss? That's useful information for us to assess and manage the risks.

I think there are two separate issues there. One is a research tool to look at incidents and the effect of treatment. Registries like that aren't always perfect data. Then the second question is how we protect athletes who go between sports.

[The Chair, Liberal, Peter Fonseca]

We're moving over to the Liberals now.

Mr. Bossio, you have five minutes.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

This question is for Mr. McCormack.

You have a ton of experience both on the Olympic side and with a number of other professional sports. What rule changes do you see should be implemented that would lead to fewer concussions in the first place? Once again, prevention is, I think, the number one goal we all have to look towards.

Also, are you finding there's a lot of push-back from professional sports whereby, if it weren't there, you could see that change would occur to the rules?

[Dr. Robert McCormack]

I would agree with the comments Dr. Gordon made earlier that rules are in place and virtually every sport has had changes in rules. The automatic red card for an elbow in soccer is one that comes to mind with me. That changed the incidence of concussions in that sport.

Every sport has rules. It's a question of enforcement. That is a challenge. Referees are under a lot of stress.

We still have Hockey Night in Canada and the NFL opening up with these massive hits. I can say sitting on the sidelines that there still is the culture in a collision sport that when a player makes a significant hit, there is enthusiasm and almost pride in it on the sidelines, which is going to take time to change.

Also, one of the challenges is the glorifying of these hits in the media all the time and personalities putting out tapes that just are a collection of these hellacious hits. When the pros actually take pride in it, there's a trickle-down effect to the grassroots.

Part of it is going to be changing the culture.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

You know that a lot of that culture.... We've evolved a long way. It was 45 years ago when I had my first concussion. I had multiple concussions playing multiple different sports because I loved to play sports. I'm so grateful that things have changed since that time because there was virtually no protocol. You sat out a couple of games, and then you were right back in there. It has evolved quite a bit.

What changes do you think could be made? As far as the culture goes, of course, we have to continue, but it's through those rule changes that we actually see an improvement in the sport that is then making the cultural changes occur as a result of the rule changes. I think most people now would agree that in hockey the fact that we have far less fighting, far less of those big hits, has actually improved the game tremendously in terms of speed and agility and the free movement that happens in the game now.

Are there any rules though that you could see...? Once again, yes, I know that change is different for every single sport, but is there anything that you know would make a difference in sport if you had it?

[Dr. Robert McCormack]

It does vary from sport to sport, but a few things come to mind. I think there is a move away from having full contact at the minor levels for collision sports, whether it be football or rugby. Part of the challenge is the traditions of the sport. I remember all the challenges we had, despite having solid data, to convince Hockey Canada to remove body checking at the younger ages. Eventually, through a lot of pressure, they came around.

The most vulnerable group are those who are young. I'm of course speaking more at the high performance level, but I see in my clinical practice that it's the young athletes who are the ones we are most worried about. It's about avoiding unnecessary exposures for them, and with rule changes.... Perhaps the type of sport they are in.... If they play flag football instead of tackle football, they can learn the skills. They can be active, and then later, when they have better neck strength, better balance, better proprioception and a more developed brain, they can decide on their own if they want to add higher-risk things like the collision sports.

I think that every sport is looking at what they are doing. Again, working in the CFL, every year there are rule changes, and the majority of them are actually based on how we can make the game safer. Every sport is doing that and trying to determine what they need to do to address this epidemic of sport concussion.

Then you have to overcome the traditions of the sport. Sometimes, it's a little tough to sell. Once it's in place, you have to get the referees that are going to enforce it, and you have to have the public that is going to accept it. All those are barriers, I would suggest.

[The Chair, Liberal, Peter Fonseca]

Thank you, Dr. McCormack. Thank you, Mr. Bossio.

Before we move over to the NDP, I have one quick question, if you would give me the liberty.

Dr. Gordon, you brought up that female soccer players are disproportionately exposed to this injury, with injury rates as much as 50% higher when compared to male soccer players. What is the root cause? Have you found the root cause of that?

[Dr. Kevin Gordon]

We all wish we knew. We don't.

Certainly, concussion within females is one of the hottest subgenres of concussion research at the present time. We are all looking for answers to that question. We certainly know that females, across many athletic injuries, are at higher risk. This is distressing in terms of what the issue is for females in particular, because the rates in soccer approach those in hockey. I'm sorry, I'm not supposed to complain about the other guy's sport, but our female soccer players have pretty high rates of concussion. Why is that? I think other researchers are working in this field. Certainly my Twitter feed blows up regularly on females and concussions.

[The Chair, Liberal, Peter Fonseca]

Thank you.

I want to impress on both of you, as leaders and influencers, that as this committee looks into sport-related concussion, we are looking to expand the number of participants in sport in Canada. We believe and we know—the numbers show us—that in sports that have high concussion rates, the numbers are dropping, and dropping significantly in some sports. For the viability of those sports, for them to continue to be able to change direction and grow, this is very important, and your advocacy can help that happen, so I thank you.

We're going to move over now to the NDP and Ms. Hardcastle.

[Cheryl Hardcastle, NDP, Windsor—Tecumseh, ON]

Thank you, Mr. Chair.

I agree, and your comments are really intriguing. That's part of what we're doing here. Some of it seems almost like a culture change and a little more of a philosophical approach to sport, like not glorifying certain things.

Other aspects of the study are more logistical, like about data collection. Who should be doing data collection? Is it something that should be done by team and sport organizations, or do you think that's something that should be for the doctor, the medical professional who is issuing the clearance, or both? How do you do it right now? How about you both tell me how you do it right now? How does it work?

[Dr. Kevin Gordon]

I think Bob really hit the nail on the head. Take the history at the beginning of the season. I was struck when he was talking about that patient, one of mine, a girl who came in with a history of two superimposed concussions who had actually had four of them superimposed. When she was told she could no longer play hockey, she said, “That's okay; it's rugby season next week.” I throw that back, because that was 15 years ago. I have not heard anything that egregious in my clinic in the past five years.

The kids are aware of this injury. I think everyone is aware of this injury. In fact, from the comments earlier today, we may be a bit too aware of this injury, because we're fearing this injury and maybe fearing it more than it needs to be feared. I think kids are safer now than they've ever been because of some of the changes that have been put in place over the last couple of decades.

The concussion of our kids today is not the concussion of 20 years ago. Those were largely ignored, and you would get up, dust yourself off and use smelling salts. My word. Now, you're out of the game, you're under an observation period, and do you know what? You're a kid. This is not professional sport. We don't need you back in the game today. We're going to assess you, and we're going to watch you for the next 24 to 48 hours if we need to, and we're only going to allow you to go back in when it's absolutely safe for you to do that.

That alone makes the injury much different from what it used to be. Sometimes you get caught up in the entire field, but that is the fundamental truth. These are different injuries now than they were before, and we have to watch that we don't apply what we're finding about yesterday's concussions to today's concussions. They're being reported at rates that are up to 250 times what they were 20 years ago. We're not having more concussions; we're just reporting concussions, and they're being reported at subtler concussions than they were previously. It's crazy thinking that, at one stage, one of the definitions was that you had to be knocked unconscious before people would agree you had a concussion. That's outrageous today, so things are changing.

As for the medical record, this is a tricky one, because we do want people to go from sport to sport, so we really need almost a passport system to keep people safe. However, on the receiving end, it's the culture. If we have a culture of disclosure, everyone knows that hiding concussions is dangerous. I think that, increasingly, the message for our kids is not to hide the concussion. Declare the concussion. Get better from the concussion and play your sport.

[The Chair, Liberal, Peter Fonseca]

Thank you, Dr. Gordon.

Thank you, Dr. McCormack.

It's been a pleasure having you here and hearing from you. We want to thank you for your commitment to sport as well as to health.

If there is something that we didn't ask you, you have an opportunity to present any report or any submission that you would like to our analyst before April 12 so that we can get it into our report, as we would like to get a report and recommendations together to be tabled in the House of Commons by the late spring.

We thank you again on behalf of all the committee members as well as the Canadian Olympic Committee and the Canadian Soccer Association. Thank you.

That concludes our meeting.