What is a concussion?

If we are to talk about preventing and managing concussions, it is important to ensure we understand what we mean. There are many definitions of concussion, and some are highly technical and medical in nature. Perhaps one of the most helpful to the lay person is the definition used by the Canadian injury prevention organization, Parachute:

A concussion is a common form of head and brain injury, and can be caused by a direct or indirect hit to the head or body (for example, a car crash, fall or sport injury). This causes a change in brain function, which results in a variety of symptoms. With a concussion there is no visible injury to the structure of the brain, meaning that tests like MRI or CT scans usually appear normal footnote 1.

Throughout the report, a distinction is made between head injuries and concussions. In this context, “head injury” would include everything from minor injuries, such as a bruise or cut without a concussion, to very severe injuries such as a skull fracture or bleeding in the brain. Not all head injuries are concussions; and not all concussions are caused by injuries directly to the head.

International Consensus Statement on Concussion in Sport

The coroner’s inquest jury recommended that Ontario adopt the International Consensus Statement on Concussion in Sport. These international consensus statements were first established at a conference in Vienna, Austria in 2001. They are refreshed periodically, most recently at the Fifth International Consensus Conference on Concussion in Sport, which was held in Berlin, Germany in October, 2016. Two of our committee members, Dr. Charles Tator and Warren Hoshizaki, attended the conference, and Dr. Tator presented at the conference and co-authored the consensus statement.

Broadly, these statements focus on improving the education of athletes, coaches and parents, ensuring that athletes are removed from the field of play if a concussion is even suspected, and mandating that they not be permitted to return to play until they have been medically cleared to do so. If they are diagnosed with a concussion, they progress through a step by step return-to-learn and return-to-play process, using evidence-based guidelines under the supervision of trained professionals.

Canada

Currently there is no common approach in Canada for addressing concussions across the many sports settings in which they can occur, including schools, fields of play, and recreation centres. This, however, is beginning to change.

In November, 2015, the Right Honourable Prime Minister Justin Trudeau included in his mandate letters to the Minister of Health and the Minister of Sport and Persons with Disabilities the development of "a national strategy to raise awareness for parents, coaches and athletes on concussion treatment".

In March 2016, the federal budget committed $1.4 million over two years to the Public Health Agency of Canada (PHAC) to work with the provinces and territories on the harmonization of concussion management guidelines, with a focus on athlete and student return-to-learn and return-toplay protocols. The goal of harmonizing concussion guidelines is to provide caregivers, including parents, and front-line professionals, including teachers, coaches, and health professionals, with consistent and evidence-based information.

At the June, 2016 conference of the Federal, Provincial and Territorial (F-P/T) Ministers responsible for sport, physical activity and recreation, there was unanimous acknowledgment that concussions are an important public health issue.

On December 6, 2016, His Excellency David Johnston convened the Governor General’s Conference on Concussion in Sport: We Can Do Better. This one-day conference assembled leaders in sport, health and public policy at Rideau Hall, and challenged all of us to make this issue a priority in order to advance the safe participation in sport for all Canadians. Five members of the Rowan’s Law Advisory Committee attended and participated in this inspiring event.

PHAC directed funding to Parachute, a leading Canadian not-for-profit injury prevention organization formed in 2012, to develop a Canadian concussion guideline, based on the Berlin Consensus Statement, that achieves the same goals while reflecting the Canadian reality. An Expert Advisory Committee was created to lead this work. The Canadian Guideline on Concussion in Sport was released by Parachute in July 2017.

Parachute is also working with national sport organizations to review their sportspecific concussion protocols. A Concussion Protocol Harmonization Event was held in Ottawa on May 8, 2017, with Parachute and the national sport community discussing the shaping of protocol development. The guidelines and protocols will focus on children, youth and older athletes in sport and recreational settings, and are expected to be complete by the Fall of 2017.

In addition, the Canadian Institutes of Health Research is currently funding 19 research projects on mild traumatic brain injuries, with a focus on improving the prevention, diagnosis and treatment for populations most at risk of suffering from these injuries, including children and youth, athletes and seniors.

On May 29, 2017, the Manitoba Government introduced Bill 37, The Concussion in Youth Sport Act. At the time of this report, Bill 37 has received first reading, and is expected to proceed through public consultation in the Fall of 2017.

Ontario

Ontario is considered to be the leading jurisdiction in Canada when it comes to concussion management. We are the first province to pass any form of concussion-related legislation, thanks to the Rowan's Law Advisory Committee Act, 2016. In addition, our province has Policy/Program Memorandum 158 (PPM 158), “School Board Policies on Concussion”. This memorandum was issued in 2014, and mandates school boards across the province to develop and implement concussion policies that include strategies to raise awareness of concussions, as well as strategies for the prevention and identification of concussions, and training for board and school staff.

Notably, PPM 158 requires school boards to implement concussion management procedures (return to learn and return to physical activity) for students with diagnosed concussions. The Ontario Physical and Health Education Association (Ophea) developed a concussion protocol as part of their Ontario Physical Education Safety Guidelines. This protocol was considered the minimum standard for all school boards in Ontario when implementing PPM 158. All 72 publicly funded school boards in Ontario now have a concussion policy in place, and while this is an important step forward, similar requirements do not exist for private or First Nations schools, or for amateur sports taking place outside of schools.

It is the view of this Committee that while Ontario should take pride in having taken the lead on concussion management in Canada, we have a lot work still to do. What follows in this report is our advice to government for getting started on that work, and making Rowan’s Law a reality in this province, and a model for this country.

Making progress

Since the Rowan Stringer coroner’s inquest, Ontario has already implemented several of the jury’s recommendations:

Recommendation #4

The Ontario Ministry of Tourism, Culture and Sport should acquire and make available information and resources to support parent, coach, player, referee and trainer education using resources from Parachute Canada, Ontario Physical and Health Education Association (Ophea), the Canadian Concussion Collaborative and the U.S. Centre for Disease Control.

Response: Addressed through the Ontario.ca Concussion Web Portal. It will be enhanced through Action Item 13 in this report.

Recommendation #10

The Ontario Ministry of Education should provide funding to school districts to support the full implementation of PPM 158. This should include funding to cover the costs associated with proposed changes to the Ontario Safety Guidelines (OSG) effective September 2016 re: certifications and requirements for coaching and first aid.

Response: Funding has been provided.

Recommendation #13

The Ontario Ministry of Education should facilitate the implementation of PPM 158 to support the unique needs of families whose first language is other than English or French by making resources available to school districts, such as a concussion identification tool, in multiple languages.

Response: Resources have already been translated into nine different languages and are available on the Ontario.ca Concussion Web Portal.

Recommendation #17

When implementing PPM 158, all school boards in Ontario should adopt the International Concussion Consensus Guidelines (Zurich) on Management of Concussion in Sport as the standard of practice for concussion management.

Response: The latest International Concussion Consensus Guidelines (Berlin, which updated Zurich) are used as the standard of practice for concussion management.

Recommendation #19

When implementing Policy/Program Memorandum No. 158 (PPM 158) all school boards in Ontario should acquire and make available information and resources to support education by using resources from Parachute Canada, Ontario Physical and Health Education Association (Ophea), the Canadian Concussion Collaborative and the US Centre for Disease Control.

Response: Addressed through the ontario.ca Concussion Portal. It will be enhanced through Action 13 in this report.

Recommendation #28

When implementing PPM 158, all school boards in Ontario should ensure that all First Aid kits in schools contain an appropriate Concussion Recognition Tool.

Response: Recommendation will be fully implemented in September 2017, when the updated concussion recognition tool from the Berlin Conference is available.

Recommendation #46

The Canadian Red Cross Society, St. John Ambulance, and the Lifesaving Society should ensure concussion awareness and management is included in all First Aid training. This should include the signs and symptoms of concussion, potential catastrophic results of improper concussion management and the use of the International Concussion Consensus Guidelines (Zurich).

Response: Recommendation has already been implemented.

Footnotes