Dr. Roger Zemek
Associate Professor, Dept. of Pediatrics and Emergency Medicine Clinical Research Chair in Pediatric Concussion, University of Ottawa Director, Clinical Research Unit, Children’s Hospital of Eastern Ontario Physician, Children’s Hospital of Eastern Ontario Emergency Department
Q&A With Dr. Roger Zamek
What Is the Most Satisfying Part of Your Work as a Researcher?
I see myself as a clinician- researcher, one role is not independent of the other for me. The questions raised through my clinical work in the Emergency Department at CHEO guide my research. I am very motivated to find answers to the questions asked by families whose children have experienced concussion. So, in my case, the clinician in me who is frustrated by the lack of evidence-based treatments for concussion has helped me focus my research in order to find the best answers for families.
The 5P Study Which You Led Has Been an Important Base for Discussion about the Recognition, Care and Treatment of Concussions. Building on the Evidence You Have Gathered and Analyzed for 5P What Do You See as the next Step in Terms of Research on the Subject?
The 5P study is a starting point and its strength was the massive cohort of patients – more than 3000 children who had been diagnosed with concussions from across Canada. Data from these patients were captured in a similar care setting (the emergency department) in the acute phase of their injury. This has provided an excellent baseline. The next phase of this research will be to identify and analyze the key predictors to better understand which treatments, including return to physical activity, have been effective.
The real future after the 5P study is to examine the potential treatments and gaining a better understanding of the ideal recovery regimen that includes a balance between engaging in activity and cognitive tasks and moves the patient towards recovery as quickly as possible. Evidence is already leading to a new approach that encourages appropriate physical activity and return to the tasks of daiy life. Gone are the days when someone is left in a dark room and told to move as little as possible. There has been a lot of attention given to concussions, particularly relating to children and youth in sports and other activities of childhood (playgrounds, etc.). This appears to have panicked some parents who may now be more reluctant to allow their children to experience formal and informal sports and play activities.
What Do You Believe Health Care Professionals and Researchers Can Do and Say to Help Parents and Caregiver Take a More “Informed but Concerned” Position When Making Decisions?
As an emergency physician I don’t have the opportunity to counsel families and patients in the same way that a family doctor does, but as a pediatrician and researcher I am very engaged in guideline development for pediatric concussion. It is all about finding the best balance for each individual in terms of risks and benefits of physical activity. Sports offer much to kids and with the risks of obesity due to the lack of physical activity becoming a greater concern, we need to find that balance.
Children need to be involved and engaged in the world around them and we need to work on making the games and activities that children participate in as safe as possible without going overboard. If the standards appear too high, no amount of activity will appear to be safe and we don’t want that. Living a concussion-free life is not a reasonable or practical goal. As clinicians and researchers we need to ask questions such as: What are the best choices for individual patients? What are the alternatives to some physical activities that can be considered? Can we change rules and policies around sports that could lead to safer play?
Ensuring Patients Young and Old Receive the Most Appropriate and Timely Diagnosis, Care and Treatment for a Concussion Can Vary by Region. Based on Your Experience, What Changes Would You like to See at the Systems Level to Ensure Consistency in Care and Outcomes for All Patients?
There is currently no effective way to offer a definitive concussion diagnosis for some people who experience a concussion. For instance, loss of consciousness may be criteria – in some cases – to indicate severity of injury and guide the course of treatment. In other cases, no cognitive changes could lead a clinician to believe the injury is not serious only to have cognitive symptoms appear later when there are no physical symptoms. These cases do not mean the diagnosis has been missed but rather there may be another reason such as in the case of post traumatic stress disorder when the physical symptoms are healed but the psychological symptoms related to the injury emerge later.
So how do we tackle this? Treatment guidelines are critical to ensure a consistent approach to assessing and diagnosing concussion. Making sure guidelines have reached and are being used by the target audience is critical especially since guidelines support research by providing a common language for clinicians. Currently there is an element of interpretation or subjectivity in the diagnosis and treatment process. Clinicians should be encouraged and supported to make evidence-based treatment decisions.
And finally, developing a fool-proof bio-marker such as a blood or serum test, EEG monitoring or MRI techniques is the ultimate solution in terms of both diagnosis and understanding when the treatment is complete. Currently there no way to tell why recovery takes longer in some people than others. Biomarkers would also address this – knowing when the brain is better.
Dr. Nick Reed (Toronto) and Yourself Are Leading the Project to Revise and Update the Pediatric Concussion Guidelines for the Ontario Neurotrauma Foundation. What Changes or Revisions Are Likely to Make the Most Positive Difference in Supporting Those Involved in Caring for Children and Youth with Concussions?
The most important recommendations will be those that support people to get back to their life as soon as they feel comfortable – no more “bedroom jail” approach. I believe recent evidence focused on physical rehab as early as possible – starting with appropriate activity level – will make a significant change in the lives of the patients. It will be interesting to see how healthcare providers and families will react to them.
Another feature of the revised Pediatric Guidelines will be a focus on using digital communication tools to share them broadly. Keeping pace with the digital world ensures these guidelines get to those who can use them. Reaching the target audience using modern communication methods sends an important and positive message supporting the up-to-date approaches to diagnosis and treatment.