diving plongeon canada concussion protocol · concussion include: pediatricians; family medicine,...
TRANSCRIPT
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
2
TableofContents1.Introduction...........................................................................................................................3
2.Pre-seasonEducation.............................................................................................................3
3.HeadInjuryRecognition.........................................................................................................4
4.OnsiteMedicalAssessment....................................................................................................54a.EmergencyMedicalAssessment.....................................................................................................54b.SidelineMedicalAssessment.........................................................................................................6
5.MedicalAssessment...............................................................................................................6
6.ConcussionManagement.......................................................................................................76a.Return-to-SchoolStrategy..............................................................................................................86b.Return-to-DivingStrategy..............................................................................................................9
TableofStepstoReturntoPostConcussionTraining...........................................................................10RulesforImplementingtheTableofStepstoReturntoPostConcussionTraining..............................11ConcussionManagementProtocolforCoaches....................................................................................13
7.MultidisciplinaryConcussionCare........................................................................................15
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
3
1.IntroductionTheDivingPlongeonCanadaConcussionProtocolhasbeendevelopedtohelpguidethemanagementofathleteswhomayhaveasuspectedconcussionasaresultofparticipationinDivingPlongeonCanadaactivities.Thisprotocolcontainstheinformationtoconveyatthestartofeveryseason,aswellastheidentificaiton,medicaldiagnosisandmanagementofathleteswhomayhavesustainedaconcussionduringasportactivity.ItaimstoensurethatathleteswhomayhavesustainedaconcussionreceivetimelyandappropriatecareandthattheinjurybeproperlymanagedtoallowasafereturntotheirsportingactivitiesThisprotocolmaynotaddresseverypossibleclinicalscenariobutwascreatedtoactasastartingpointwhichincludesthelatestcriticalevidenced-basedelementsandmostcurrentexpertconsensus.Thisprotocolisintendedforusebyallindividualswhointeractwithathletesinsideandoutsidethecontextofschoolandnon-schoolbasedorganizedsportsactivity,includingathletes,parents,coaches,officials,teachers,trainersandlicensedhealthcareprofessionals.
ForasummaryoftheDivingPlongeonCanadaConcussionProtocolpleaserefertotheDivingPlongeonCanadaSportConcussionPathwayattheendofthisdocument.
2.Pre-seasonEducationDespiterecentincreasedattentionfocusingonconcussionthereisacontinuedneedtoimproveconcussioneducationandawareness.Optimizingthepreventionandmanagementofconcussioniscloselylinkedtotheyearlyeducationofallstakeholders(athletes,parents,coaches,officials,teachers,trainersandlicensedhealthcareprofessionals).Thiseducationisbasedononcurrentevidence-informedapproachesthatcanhelppreventconcussionsandmoreseriousformsofheadinjuryandhelpidentifyandmanageanathletewithasuspectedconcussion.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
4
Concussioneducationshouldincludeinformationon:• thedefinitionofconcussion;• possiblemechanismslinkedtoinjury;• commonsignsandsymptoms;• stepsthatcanbetakentopreventconcussionsandotherinjuriesfromoccurringinsport;• whattodowhenanathletehassufferedapossibleconcussionormoreserioushead
injury;• whatmeasuresshouldbetakentoensurepropermedicalassessment;• Return-to-SchoolandReturn-to-DivingStrategies,and;• returntosportmedicalclearancerequirements
AllparentsandathletesarerequiredtoreadandsubmitasignedcopyofthePre-seasonConcussionEducationSheettotheircoachpriortothefirstpracticeoftheseason.Inadditiontoreviewingtheinformationonconcussion,itisalsoimportantthatallsportstakeholdershaveaclearunderstandingoftheDivingPlongeonCanadaConcussionProtocol.Tothisend,apre-seasonin-personorientationsessionsforathletes,parents,coachesandothersportstakeholderscanbeplanned.
AnexampleofPre-seasonConcussionEducationSheetcanbefoundattheendofthisdocument.
3.HeadInjuryRecognitionAlthoughtheformaldiagnosisofconcussionshouldonlybemadefollowingamedicalassessment,allsportstakeholdersincludingathletes,parents,teachers,coaches,teachers,officialsandlicensedhealthcareprofessionalsareresponsiblefortheidentificationandreportingofathleteswhomaydemonstratevisualsignsofaheadinjuryorwhoreportconcussion-relatedsymptoms.Thisisparticularlyimportantgiventthatthevastmajorityofsportandrecreationvenueswillnothaveaccesstoon-sitelicensedhealthcareprofessionals.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
5
Aconcussionshouldbesuspected:
• inanyathletewhosustainsasignificantimpacttothehead,face,backoftheneckorbodyanddemonstratesANYofthevisualsignsofasuspectedconcussionorreportsANYsymptomsofasuspectedconcussionasdetailedintheConcussionRecognitionTool5(CRT5)
• ifadiverreportsANYconcussionsymptomstooneoftheirpeers,parents,teachersorcoachesorifanyonewitnessesanathleteexhibitinganyofthevisualsignsofconcussion.
• Insomecases,anathletemaydemonstratesignsorsymptomsofamoresevereheadorspineinjuryincludingconvulsions,worseningheadaches,vomitingorneckpain.Ifanathletedemonstratesanyofthe‘REDFLAGS’indicatedintheConcussionRecognitionTool5(CRT5),amoresevereheadorspineinjuryshouldbesuspected,andEmergencyMedicalAssessmentshouldbepursued.
4.OnsiteMedicalAssesmentDependingonthesuspectedseverityoftheinjury,aninitialassessmentmaybecompletedbyemergencymedicalprofessionalsorbyanon-sitelicensedhealthcareprofessionalwhereavailable.Incaseswhereanathletelosesconsciousnessoritissuspectedanathletemighthaveamoresevereheadorspineinjury,EmergencyMedicalAssessmentbyemergencymedicalprofessionalsshouldtakeplace(see4abelow).Ifamoresevereinjuryisnotsuspected,theathleteshouldundergoSidelineMedicalAssessmentorMedicalAssessment,dependingonifthereisalicensedhealthcareprofessionalpresent(see4bbelow).
4a.EmergencyMedicalAssesmentIfanathleteissuspectedofsustainingamoresevereheadorspineinjuryduringagameorpractice,anambulanceshouldbecalledimmediatelytotransferthepatienttothenearestemergencydepartmentforfurtherMedicalAssessment.Coaches,parents,teachers,trainersandofficialsshouldnotmakeanyefforttoremoveequipmentormovetheathleteandwaituntiltheambulancearrives.AftertheemergencymedicalservicesstaffhascompletedtheEmergencyMedicalAssessment,theathleteshouldbetransferredtothenearesthospitalforaMedicalAssessment.Inthecaseofyouthunder18yearsofage,theathlete’sparentsshouldbecontactedimmediatelytoinformthemoftheirchild’sinjury.Forathletesover18yearsofage,theiremergencycontactpersonshouldbecontactedifonehasbeenprovided.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
6
4b.SidelineMedicalAssesmentIfanathleteissuspectedofsustainingaconcussionandthereisnoconcernforamoreseriousheadorspineinjury,theplayershouldbeimmediatelyremovedfromthefieldofplay.Scenario1:IfalicensedhealthcareprofessionalispresentTheathleteshouldbetakentoaquietareaandundergoSidelineMedicalAssessmentusingtheSportConcussionAssessmentTool5(SCAT5)ortheChildSportConcussionAssessmentTool5(ChildSCAT5).TheSCAT5andChildSCAT5areclinicaltoolsthatshouldonlybeusedbyalicensedhealthcareprofessionalexperiencedintheiruse.ItisimportanttonotethattheresultsofSCAT5andChildSCAT5testingcanbenormalinthecaseofanacuteconcussion.Assuch,thesetoolscanbeusedbylicensedhealthcareprofessionalstodocumentinitialneurologicalstatusbutshouldnotbeusedtomakesidelinereturn-to-sportdecisionsinyoungathletes.AnyyoungathletewhoissuspectedofhavingsustainedaconcussionmustnotreturntotrainingorcompetitionandmustbereferredforMedicalAssessment.Ifayoungathleteisremovedfromcompetitionortrainingfollowingasignificantimpactandhasundergoneassessmentbyalicensedhealthcareprofessional,butthereareNOvisiblesignsofaconcussion,theathletecanthenreturntotrainingorcompetitionbutshouldbemonitoredfordelayedsymptoms.Inthecaseofnationalteam-affiliatedathletesremovedfromcompetitionortrainingduetoasuspectedconcussion,thetherapist,licensedsportphysiotherapistormedicaldoctorprovidingmedicalcoverageforthesportingeventmaymakethedeterminationthataconcussionhasnotoccurredbasedontheresultsofaMedicalAssessment.Inthesecases,theathletemaybereturnedtothecompetitionorpracticewithoutaMedicalClearanceLetterfromalicensedphysician,butthissituationshouldbeclearlycommunicatedtothecoachingstaff.Athletesclearedtoreturntotrainingorcompetitionshouldbemonitoredfordelayedsymptoms.Iftheathletedevelopsanydelayedsymptomstheathleteshouldberemovedandundergomedicalassessmentbyamedicaldoctorornursepractitioner.Scenario2:IfthereisnolicensedhealthcareprofessionalpresentTheathleteshouldbereferredimmediatelyformedicalassessmentbyamedicaldoctorornursepractitioner,andtheathletemaynotreturntotrainingorcompetitionuntilmedicalclearanceisobtained.
5.MedicalAssesmentInordertoprovideacomprehensiveevaluationofathleteswithasuspectedconcussion,themedicalassessmentmustruleoutmoreseriousformsoftraumaticbrainandspineinjuries,mustruleoutmedicalandneurologicalconditionsthatcanpresentconcussion-likesymptoms,andmustmakethediagnosisofconcussionbasedonfindingsoftheclinicalhistoryandphysicalexaminationandtheevidence-baseduseofadjunctivetestsasindicated(i.eCTscan).Inaddition
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
7
tonursepractitioners,medicaldoctors1thatarequalifiedtoevaluatepatientswithasuspectedconcussioninclude:pediatricians;familymedicine,sportsmedicine,emergencydepartment,internalmedicine,andrehabilitation(physiatrists)physicians,neurologistsandneurosurgeons.IngeographicregionsofCanadawithlimitedaccesstomedicaldoctors(i.e.ruralornortherncommunities),alicensedhealthcareprofessional(i.e.nurse)withpre-arrangedaccesstoamedicaldoctorornursepractitionercanfacilitatethisrole.Themedicalassessmentcandeterminewhethertheathletehassufferedaconcussionornot.AthleteswithadiagnosedconcussionshouldbeprovidedwithaMedicalAssessmentLetterconfirmingtheconcussiondiagnosis.Athletesthataredeterminedtonothavesustainedaconcussionwillbeallowedtoresumetheirsportbutmustobtainadoctor’snoteallowingthemtoreturntheirsportingactivities,includingtrainingandcompetitions.
AnexampleofMedicalAssessmentLettercanbefoundattheendofthisdocument.
6.ConcussionManagementWhenanathletehasbeendiagnosedwithaconcussion,itisimportantthattheathlete’sparent/legalguardianorpartnerisinformed.AllathletesdiagnosedwithaconcussionmustbeprovidedwithastandardizedMedicalAssessmentLetterthatnotifiestheathleteandtheirparents/legalguardians/spousethattheyhavebeendiagnosedwithaconcussionandmaynotreturntoanyactivitieswithariskofconcussionuntilmedicallyclearedtodosobyamedicaldoctorornursepractitioner.BecausetheMedicalAssessmentLettercontainspersonalhealthinformation,itistheresponsibilityoftheathleteortheirparent/legalguardiantoprovidethisdocumentationtotheathlete’scoaches,teachers,oremployers.Itisalsoimportantfortheathletetoprovidethisinformationtosportorganizationofficialsthatareresponsibleforinjuryreportingandconcussionsurveillancewhereapplicable.Athletesdiagnosedwithaconcussionshouldbeprovidedwitheducationaboutthesignsandsymptomsofconcussion,strategiesabouthowtomanagetheirsymptoms,therisksofreturningtosportwithoutmedicalclearanceandrecommendationsregardingagradualreturntoschoolandsportactivities.AthletesdiagnosedwithaconcussionaretobemanagedaccordingtotheirReturn-to-SchoolandReturn-to-DivingStrategyunderthesupervisionofamedicaldoctorornursepractitioner.Whenavailable,athletesshouldbeencouragedtoworkwiththeteamathletictherapistorphysiotherapisttooptimizeprogressionthroughtheirReturn-to-DivingStrategy.OncetheathletehascompletedtheirReturn-to-SchoolandReturn-to-DivingStrategyandare1MedicaldoctorsandnursepractitionersaretheonlyhealthcareprofessionalsinCanadawithlicensedtrainingandexpertisetomeettheseneeds;thereforeallathleteswithasuspectedconcussionshouldundergoevaluationbyoneoftheseprofessionals.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
8
deemedtobeclinicallyrecoveredfromtheirconcussion,themedicaldoctorornursepractitionercanpreparetheathleteforafullreturntosportsandschoolactivitiesandissueaMedicalClearanceLetter.ThestepwiseprogressionsforReturn-to-SchoolandReturn-to-DivingStrategiesareoutlinedbelow.Asindicatedinstage1oftheReturn-to-DivingStrategy,reintroductionofdaily,school,andworkactivitiesusingtheReturn-to-SchoolStrategymustprecedereturntosportparticipation.
AnexampleofMedicalClearanceLetteraswellasaSymptomFollow-upSheetcanbefoundattheendofthisdocument.
6a.Return-to-SchoolStrategyThefollowingisanoutlineoftheReturn-to-SchoolStrategythatshouldbeusedtohelpstudent-athletes,parentsandteacherstocollaborateinallowingtheathletetomakeagradualreturntoschoolactivities.Dependingontheseverityandtypeofthesymptomspresent,student-athleteswillprogressthroughthefollowingstagesatdifferentrates.Ifthestudent-athleteexperiencesnewsymptomsorworseningsymptomsatanystage,theyshouldgobacktothepreviousstage.Athletesshouldalsobeencouragedtoasktheirschooliftheyhaveaschool-specificReturn-to-LearnPrograminplacetohelpstudent-athletesmakeagradualreturntoschool.
Childrenandteensshouldreturntoschoolactivitiesverygraduallyandattheirownpace.SeeRecommendationsforchildrenandyouthregardingconcussiononp.23ofthisdocument.
Stage Activity Goalofeachstep1 Dailyactivitiesat
homethatdonotgivethestudent-athletesymptoms
Typicalactivitiesduringthedayaslongastheydonotincreasesymptoms(i.e.reading,texting,screentime).Startat5-15minutesatatimeandgraduallybuildup.
Gradualreturntotypicalactivities
2 Schoolactivities Homework,readingorothercognitiveactivitiesoutsideoftheclassroom.
Increasetolerancetocognitivework
3 Returntoschoolpart-time
Gradualintroductionofschoolwork.Mayneedtostartwithapartialschooldayorwithincreasedbreaksduringtheday.
Increaseacademicactivities
4 Returntoschoolfull-time
Graduallyprogress Returntofullacademicactivitiesandcatchuponmissedschoolwork
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
9
6b.Return-to-DivingStrategyThefollowingisanoutlineoftheReturn-to-DivingStrategythatshouldbeusedtohelpathletes,coaches,trainersandmedicalprofessionalstopartnerinallowingtheathletetomakeagradualreturntosportactivities.Aninitialperiodof24-48hoursofrestisrecommendedbeforestartinganyconcussionprotocol.Itisimportantthatyouthandadultstudent-athletesreturntofull-timeschoolactivitiesbeforeprogressingtoReturn-to-DivingStrategy.ItisalsoimportantthatallathletesprovidetheircoachwithaMedicalClearanceLetterpriortoreturningtoresumingtraining.TheTableofStepstoReturntoPostConcussionTraining(onthenextpage)needstobeappliedinconjuctionwiththeRulesforImplementingtheTabletoReturntoPostConcussionandwiththeConcussionManagementProtocolforTrainers.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
10
TableofStepstoReturntoPostConcussionTrainingDesignedbyMarie-ClaudeSaint-Amour,Pht,dip.Physioofsport,FCAMPT(Version3-1)
Day Physical preparation Dry land Dry board and Trampo Pool deck and in the water
1 meter 3 meters Tower
1 Rest Rest Rest Rest Rest Rest Rest 2 Stationary bike (low intensity) Stretching
Core/stabilization training Proprioceptive exercises (low intensity)
3 Stationary bike (moderate intensity)
Swimming (low intensity 20 minutes) Muscle training (low intensity)
Stretching/core exercises
Proprioceptive exes on balance boards/ground Simulations (no jump)
4 Warm up (out of water) Progress muscle training
Armstand against the wall Jumps (Intensity: 50-75%) Simulations (no jump)
Vestibular stimulation (twist on the floor, rolls) Coordination exercises (agility ladder, etc)
Head down postion in water Torpedo in the water
5 Warm up (out of water) Normal muscle training
Armstand Jumps (Intensity: 100%) Hurdle Simulations with jump
Vestibular (twist floor/standing, cartwheel, rolls)
Coordination exercises (agility ladder, etc)
Dry board: 100/200 (no hurdle or approach) 100/200 with hurdle/approach
Trampo: 100 (non continuous)
100 with approach
No hurdle jump Front/back fall Head down in deep water
No hurdle jump Front/back fall
No hurdle jump 100/200 3m/5m
6 Armstand (done repeatedly)
Continuous jumps (Intensity: 100%) without rest More complex vestibular/coordination exercises
Trampo: continuous jumps
Dry board: 100 with multiple bounce
101/201/301/401 101/201/301/401
(without hurdle and with hurdle) 100/200 with hurdle/approach Front/back fall
Front/back fall 3m/5m 100/200 7m/10m
7 102-202-302-402 102-202-302-402 without and with hurdle/approach
102-202-302-402 610-621 small tower
102-202-302-402 101/201/301/401 no hurdle 101/201/301/401 3m/5m Front/back fall 7m
8 Dryland repetitive twists X01 and X03 (landing on the back) 5122-5221
5201-5101 103-203-403-303 101/201/301/401 (without hurdle and with hurdle)
101/201/301/401 7m Front/back fall 10m
9 104-204-304-404 520X-510X 104-204-304-404 103-203-403-303 103-203-403-303 5m/7m
611-621 3m/5m 101/201/301/401 7m/10m
10 10X-20X-30X-40X
5122-5221-5321
105-205-305-405 105-205-305-405 5m/7m
612-622 3m/5m 103-203-403-303 7m/10m
11 51XX-52XX-53XX 5132-5231-5331 10X-20X-30X-40X
105-205-305-405 7m/10m 6XX 3m/5m 612-622 7m/10m 5122-5221-5321 3m 5132-5231-5331 3m/5m
12 51XX-52XX-53XX 10X-20X-30X-40X 7m/10m 5132-5231-5331 7m-10m 51XX-52XX-53XX 3m/5m
13 6XX 7m/10m 61XX-62XX 3m/5m 51XX-52XX-53XX 7m/10m
14 61XX-62XX 7m/10m
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
11
RulesforImplementingtheTableofStepstoReturntoPostConcussionTrainingDesignedbyMarie-ClaudeSaint-Amour,Pht,dip.Physioofsport,FCAMPTVersion3,2018
I. Acompleterestperiodof24-48haftertheinjuryoccurredisrecommended.Ifsymptomsaregettingbetteraftertheinitialrestperiod,theathletecanthenstarttheReturn-to-SchoolStrategywhilecloselymonitoringandkeepingsymptomsundercontrol(activitiesshouldnotbringonorworsentheirsymptoms).Oncesymptomsareundercontrol,theathletecanstarttheReturn-to-DivingStrategy.
II. Gettheapprovalfromtheteamphysician(orotherphysician)beforeresumingtraining.
III. Neverstartstep#2whentherearestillsomesymptoms,whatevertheyare.
IV. Monitortheathletetomakesurethereisnorecurrenceofsymptomsduringmovements/exercisesandduringthefirst24hr
followingtraining.
V. Ifduringasteptheathletehassymptomsthatreoccur,he/shemuststoptrainingrightawayandrestfor24hrstartingwhen
symptomswillhavedisappeared.Then,he/shewillbeallowedtoresumetheprotocolatthesteppriortowheresymptoms
occurredandgoonwhentherearenosymptoms.
VI. Ineachstepoftheprotocol,whenstartingnewmovements,onlytrytodo3or4repetitions.Wewantagradualexposureto
increasedstressonthebrain.Theitemswhichwerepermittedinthepriorstepcanbedonewithoutanyrestriction.
VII. Withchildrenandyouth/teenagers(<18yearold),theReturn-to-SchoolStrategyshouldbeverygradualandmaybelonger(seepoint6aofthisdocumentforrecommendations)whichmeanstheperiodoftimebeforegoingbacktosportspecificactivitiesmaybelongerthanwithadults.Oncethechildisclearedtogobacktophysicalactivities,eachstepoftheReturn-to-DivingStrategycanlastbetween2and4days,insteadof24hrecommendedforadults(atthephysician’sdiscretion).Childrenandteenagersshoulddefinitelynotreturntosportuntiltheyhavesuccessfullyreturnedtoschool.Earlyintroductionofsymptom-limitedphysicalactivityisrecommended.
VIII. Ifanathletesuffersfromasecondorthirdconcussion,returntodivingusingtheprotocolshouldbeevenmoregradualthanfora
firstconcussion.Eachstepoftheprotocolshouldthenlastbetween2and4days,ratherthan24hrs.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
12
Theprotocoltoreturntodivingisnotbasedonthedifficultyofthediveitself.Itismostlybasedontheamountofstressputonthebrainduringtheexecutionofthedive.Therefore,itispossiblethatduringtheprotocol,sometechnicallyeasierdiveswillbepermittedlaterintheprocesseveniftheyaremoresimpletoexecute.Itissimplythattheamountofstressputonthebrainisgreaterorthatthemotorcommandinthosedives(ex:armstands)ismorecomplex.Glossary
Warm-up Themaingoalistoincreasethebodytemperaturebydoingexercise
Fall Nohurdleornojumpwhileenteringwaterheadfirst
Headdownpositioninwater
Fullbodyimmersioninthewaterwithheadfacingdown(theathletemustnotdivetotakethatposition,he/shemustassumethispositiondirectlyinthewater)
Hurdle/Approach Walkonthespringboard/platform
Simulations Sequenceofdivingmotiononthefloor(armmovement,opening...)withmentalvisualization
Torpedo Fullbodyimmersioninthewater.Theathleteisthenaskedtopushoffthewallofthepooltopropelhimself/herself(onthestomachandback)
Muscletraining Muscle training will progress will taking exercise intensity, volume and complexity intoconsideration.Forexample,instep3oftheprotocol,theathletecanbeginlightmuscletraining.Inthatcase,theweightsmustbeadaptedtolimitintensity,volumeandcomplexityoftheeffort.If one of these elements needs to be increased,we need to lessen the two others. So, if thecomplexityoftheexerciseincreases,intensityandvolumeshallbedecreasedtocompensate.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 13
ConcussionManagementProtocolforCoachesDesignedbyMarie-ClaudeSaint-Amour,Pht,dip.Physioofsport,FCAMPT,2018Herearethedifferentstepscoachesshouldfollow:I. Whenanathletecomplainsofheadache,dizziness,nauseaorofanyothersymptomorthat
he/shemissedadive(flat),removetheathletefromtraining/competition.II. Askhim/heraboutthedifferentsymptomshe/sheisexperiencing(headache,dizziness,
nausea,dazzling,ringingintheears,feelingofbeinginafog,etc…).III. Ifanysymptomispresent,removefromtrainingorcompetition.IV. Iftheteamphysiotherapist/physicianispresentonpooldeckornearby,askhim/hertosee
theathlete.V. Explaintotheathletethathe/shemustberestingCOGNITIVELY(nocomputer,noreading,
nothingdemandingconcentration)andPHYSICALLYuntilhe/sheseestheteamphysician.Atemporaryschoolbreakmaybenecessaryforadequatebrainrest.
VI. Makeanappointmentwiththeteamphysicianassoonaspossibleforamoredetailedevaluation.Iftheteamphysicianisnotavailablethenextday,askthedivertoseetheteamphysiotherapist.He/shewillbeabletocommunicatewiththeteamphysiciantotransmithis/herdetailedevaluation.
VII. Explaintofamilymemberswhathappenedandgivethemgeneraladvicefollowingaconcussion.
VIII. Followingtheall-clearfromthephysicianforareturntodiving,theathletewillbeallowedtoreturngraduallytotrainingaccordingtothestepsintheconcussionprotocol.Durationofeachstepwilldependontheathlete’sage,previoushistoryofconcussionandhowtheathleterespondswhileontheprotocol.
IX. Aneuropsychologicaltestmaybeconsideredwhentheathletereachesstep3or4.Generaladvicefollowingaconcussion:
• Neverleavetheathletealoneduringthefirst24hrsfollowingtheincident.• Itisrecommendedthattheathleteremainsawakeforafewhoursfollowingthe
incident(butitisnotnecessarytowakehimupduringthenight).• Thereisnomedicationprovenbeneficialtominimizesymptomsortreatconcussions
morequickly.• Theathletemustrestcognitivelyandphysically,it’stheonlywaytoheal!Ifneeded,
theathletecouldtemporarilyberemovedfromschool.• Theathleteshouldtrytosleepbetween12to14hrsadaytoallowhis/herbrainto
rest(includingnaps).• Theathleteshouldnotusedrugsoralcoholinthedaysfollowingtheincident.
Whenshouldtheathletegototheemergencyroom,evenifhe/shehasalreadyseenaphysician?
• Increasingheadache• Increasingdrowsiness
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 14
• Increasingconfusion(incoherentspeech,disorientation…)• Twosessionsofvomitingormore(3ifachild)inthe24hrsfollowingaconcussion• Bleedingorliquiddrippingfromnoseorears• Convulsions/epilepsy• Anynewneurologicalsymptom(weaknessintheleg/arm,lossofbalance,double
vision,speechtrouble…)• Excessivecrying(child)
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
15
7.MultidisciplinaryConcussionCare Mostathleteswhosustainaconcussionwhileparticipatinginsportwillmakeacompleterecoveryandbeabletoreturntotheirfullschoolandsportschedulewithin1to4weeksofinjury.However,approximately15-30%ofindividualswillexperiencesymptomsthatpersistbeyondthistimeframe.Ifpossible,individualswhoexperiencepersistentpost-concussionsymptoms(>4weeksforyoungathletes,>2weeksforadultathletes)maybenefitfromareferraltoamedicallysupervisedmultidisciplinaryconcussionclinicthathasaccesstoprofessionalswithlicensedtrainingintraumaticbraininjurythatmayincludeexpertsinsportmedicine,neuropsychology,physiotherapy,occupationaltherapy,neurology,neurosurgery,andrehabilitationmedicine.Referraltoamultidisciplinaryclinicforassessmentshouldbemadeonanindividualizedbasisatthediscretionofanathlete’smedicaldoctorornursepractitioner.Ifaccesstoamultidisciplinaryconcussionclinicisnotavailable,areferraltoamedicaldoctorwithclinicaltrainingandexperienceinconcussion(e.g.asportmedicinephysician,neurologist,orrehabilitationmedicinephysician)shouldbeconsideredforthepurposesofdevelopinganindividualizedtreatmentplan.Dependingontheclinicalpresentationoftheindividual,thistreatmentplanmayinvolveavarietyofhealthcareprofessionalswithareasofexpertisethataddressthespecificneedsoftheathletebasedontheassessmentfindings.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 16
!
!
Was$a$concussion!diagnosed?!
‣ Who:!Athletes,!parents,!coaches,!officials,!trainers,!teachers,!healthcare!professionals!‣ How:!Pre4season!Education!Sheet!
1.$Pre4Season$Education$
Impact$to$the$head,$face,$neck$or$body$
Head$injury$is$suspected$
2.$Head$Injury$Recognition$‣ Who:!Athletes,!parents,!coaches,!officials,!trainers,!teachers,!healthcare!professionals!‣ How:!Concussion!Recognition!Tool!5!(CRT5)!
Is$a$more$serious$head$or$spine$injury$suspected?$
!NO$
3A.$Emergency$Medical$Assessment$‣ Who:!Emergency!medical!personnel!!
Is$a$licensed$healthcare$professional$present?$
!NO$ !YES$
4.$Medical$Assessment$
‣ Who:!Medical!doctor,!nurse!practitioner!‣ How:!Medical!Assessment!Letter!!
Is$a$concussion$suspected?$
‣ Who:!Athletic!therapist,!physiotherapist,!medical!doctor!
‣ How:!SCAT5,!Child!SCAT5!
3B.$Sideline$Assessment$
5.$Concussion$Management$‣ Who:!Medical!doctor,!nurse!practitioner,!and!team!athletic!therapist!or!
physiotherapist!‣ How:!Return4to4School!Strategy,!Sport4Specific!Return4to4Sport!Strategy!!
Does$the$athlete$have$persistent$symptoms?*$
6.$Multidisciplinary$Concussion$Care$
‣ Who:!Multidisciplinary!medical!team,!medical!doctor!with!clinical!training!and!experience!in!concussion,!licensed!healthcare!professionals!
Return$$to$Sport$
7.$Return$to$Sport$Medical$Clearance$
‣ Who:!Medical!doctor,!nurse!practitioner!‣ How:!Medical!Clearance!Letter!!
!YES$
!YES$ !NO$
!NO$!YES$
*Persistent$symptoms:$lasting$>!4!weeks!in!children!&!youth!or!>!2!weeks!in!adults$
!
Remove$from$play$
YES$ NO$
DivingPlongeonCanadaConcussionPathway
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
17
Pre-SeasonConcussionEducationSheet
WHATISACONCUSSION?Aconcussionisabraininjurythatcan’tbeseenonx-rays,CTorMRIscans.Itaffectsthewayanathletethinksandcancauseavarietyofsymptoms.
WHATCAUSESACONCUSSION?Anyblowtothehead,faceorneck,orsomewhereelseonthebodythatcausesasuddenjarringoftheheadmaycauseaconcussion.Examplesincludegettingbody-checkedinhockeyorhittingone’sheadontheflooringymclass.
WHENSHOULDISUSPECTACONCUSSION?Aconcussionshouldbesuspectedinanyathletewhosustainsasignificantimpacttothehead,face,neck,orbodyandreportsANYsymptomsordemonstratesANYvisualsignsofaconcussion.
AconcussionshouldalsobesuspectedifanathletereportsANYconcussionsymptomstooneoftheirpeers,parents,teachers,trainersorcoachesorifanyonewitnessesanathleteexhibitingANYofthevisualsignsofconcussion.Someathleteswilldevelopsymptomsimmediatelywhileotherswilldevelopdelayedsymptoms(beginning24-48hoursaftertheinjury).
WHATARETHESYMPTOMSOFACONCUSSION?Apersondoesnotneedtobeknockedout(loseconsciousness)tohavehadaconcussion.Commonsymptomsinclude:! Headachesorheadpressure! Dizziness! Nauseaandvomiting! Blurredorfuzzyvision! Sensitivitytolightorsound! Balanceproblems
! Feelingtiredorhavingnoenergy! Notthinkingclearly! Feelingsloweddown! Easilyupsetorangered! Sadness! Nervousnessoranxiety
! Feelingmoreemotional! Sleepingmoreorsleepingless! Havingahardtimefallingasleep! Difficultyworkingonacomputer! Difficultyreading! Difficultylearningnewinformation
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 18
WHATARETHEVISUALSIGNSOFACONCUSSION?Visualsignsofaconcussionmayinclude:! Lyingmotionlessontheplayingsurface! Slowtogetupafteradirectorindirecthitto
thehead! Clutchinghead
! Blankorvacantstare! Balance,gaitdifficulties,motorincoordination,
stumbling,slowlaboredmovements
! Facialinjuryafterheadtrauma! Disorientationorconfusionorinabilityto
respondappropriatelytoquestions
WHATSHOULDIDOIFISUSPECTACONCUSSION?Ifanyathleteissuspectedofsustainingaconcussionduringsportstheyshouldbeimmediatelyremovedfromtrainingorcompetition.Anyathletewhoissuspectedofhavingsustainedaconcussionduringsportsmustnotbeallowedtoreturntothesameeventorpractice.ItisimportantthatALLathleteswithasuspectedconcussionundergomedicalassessmentbyamedicaldoctorornursepractitioner,assoonaspossible.ItisalsoimportantthatALLathleteswithasuspectedconcussionreceivewrittenmedicalclearancefromamedicaldoctorornursepractitionerbeforereturningtosportactivities.
WHENCANTHEATHLETERETURNTOSCHOOLANDSPORTS?Itisimportantthatallathletesdiagnosedwithaconcussionfollowastep-wisereturntoschoolandsports-relatedactivitiesthatincludesthefollowingReturn-to-SchoolandReturn-to-SportStrategies.Itisimportantthatyouthandadultstudent-athletesreturntofull-timeschoolactivitiesbeforeprogressingtotheReturn-to-DivingStrategy.
Return-to-SchoolStrategyStage Activity Goalofeachstep1 Dailyactivitiesathomethatdonot
givethestudent-athletesymptomsTypicalactivitiesduringthedayaslongastheydonotincreasesymptoms(i.e.reading,texting,screentime).Startat5-15minutesatatimeandgraduallybuildup.
Gradualreturntotypicalactivities
2 Schoolactivities Homework,readingorothercognitiveactivitiesoutsideoftheclassroom.
Increasetolerancetocognitivework
3 Returntoschoolpart-time Gradualintroductionofschoolwork.Mayneedtostartwithapartialschooldayorwithincreasedbreaksduringtheday.
Increaseacademicactivities
4 Returntoschoolfull-time Graduallyprogress Returntofullacademicactivitiesandcatchuponmissedschoolwork
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 19
Return-to-DivingStrategyDesignedbyMarie-ClaudeSaint-Amour,Pht,dip.Physioofsport,FCAMPTVersion3-1,January2016
*SeethecompleteReturn-to-DivingStrategyonpoint6bofDivingPlongeonCanada'sConcussionManagementdocument*
Day Physical preparation Dry land Dry board and Trampo Pool deck and in the water
1 meter 3 meters Tower
1 Rest Rest Rest Rest Rest Rest Rest 2 Stationary bike (low intensity) Stretching
Core/stabilization training Proprioceptive exercises (low intensity)
3 Stationary bike (moderate intensity)
Swimming (low intensity 20 minutes) Muscle training (low intensity)
Stretching/core exercises
Proprioceptive exes on balance boards/ground Simulations (no jump)
4 Warm up (out of water) Progress muscle training
Armstand against the wall Jumps (Intensity: 50-75%) Simulations (no jump)
Vestibular stimulation (twist on the floor, rolls) Coordination exercises (agility ladder, etc)
Head down postion in water Torpedo in the water
5 Warm up (out of water) Normal muscle training
Armstand Jumps (Intensity: 100%) Hurdle Simulations with jump
Vestibular (twist floor/standing, cartwheel, rolls)
Coordination exercises (agility ladder, etc)
Dry board: 100/200 (no hurdle or approach) 100/200 with hurdle/approach
Trampo: 100 (non continuous)
100 with approach
No hurdle jump Front/back fall Head down in deep water
No hurdle jump Front/back fall
No hurdle jump 100/200 3m/5m
6 Armstand (done repeatedly)
Continuous jumps (Intensity: 100%) without rest More complex vestibular/coordination exercises
Trampo: continuous jumps
Dry board: 100 with multiple bounce
101/201/301/401 101/201/301/401
(without hurdle and with hurdle) 100/200 with hurdle/approach Front/back fall
Front/back fall 3m/5m 100/200 7m/10m
7 102-202-302-402 102-202-302-402 without and with hurdle/approach
102-202-302-402 610-621 small tower
102-202-302-402 101/201/301/401 no hurdle 101/201/301/401 3m/5m Front/back fall 7m
8 Dryland repetitive twists X01 and X03 (landing on the back) 5122-5221
5201-5101 103-203-403-303 101/201/301/401 (without hurdle and with hurdle)
101/201/301/401 7m Front/back fall 10m
9 104-204-304-404 520X-510X 104-204-304-404 103-203-403-303 103-203-403-303 5m/7m
611-621 3m/5m 101/201/301/401 7m/10m
10 10X-20X-30X-40X
5122-5221-5321
105-205-305-405 105-205-305-405 5m/7m
612-622 3m/5m 103-203-403-303 7m/10m
11 51XX-52XX-53XX 5132-5231-5331 10X-20X-30X-40X
105-205-305-405 7m/10m 6XX 3m/5m 612-622 7m/10m 5122-5221-5321 3m 5132-5231-5331 3m/5m
12 51XX-52XX-53XX 10X-20X-30X-40X 7m/10m 5132-5231-5331 7m-10m 51XX-52XX-53XX 3m/5m
13 6XX 7m/10m 61XX-62XX 3m/5m 51XX-52XX-53XX 7m/10m
14 61XX-62XX 7m/10m
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 20
HOWLONGWILLITTAKEFORTHEATHLETETORECOVER?Mostathleteswhosustainaconcussionwillmakeacompleterecoverywithin1-2weekswhilemostyouthathleteswillrecoverwithin1-4weeks.Approximately15-30%ofpatientswillexperiencepersistentsymptoms(>2weeksforadults;>4weeksforyouth)thatmayrequireadditionalmedicalassessmentandmanagement.
HOWCANIHELPPREVENTCONCUSSIONSANDTHEIRCONSEQUENCES?Concussionprevention,recognitionandmanagementrequireathletestofollowtherulesandregulationsoftheirsport,respecttheiropponents,avoidheadcontact,andreportsuspectedconcussions.
TOLEARNMOREABOUTCONCUSSIONSPLEASEVISIT:ParachuteCanada:www.parachutecanada.org/concussionSIGNATURES(OPTIONAL):Thefollowingsignaturescertifythattheathleteandhis/herparentorlegalguardianhavereviewedtheaboveinformationrelatedtoconcussion.
______________________________________PrintedNameofAthlete
_____________________________________Signatureofathlete
_________________Date
______________________________________PrintedNameofParent
_____________________________________Signatureofparent
_________________Date
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL
21
MedicalAssessmentLetter
NameofAthlete:__________________________________Date:____________
Towhomitmayconcern,AthleteswhosustainasuspectedconcussionshouldbemanagedaccordingtotheCanadianGuidelineonConcussioninSport.Accordingly,IhavepersonallycompletedaMedicalAssessmentonthispatient.
ResultsofMedicalAssessment
! Thispatienthasnotbeendiagnosedwithaconcussionandcanresumefullparticipationinschool,work,andsportactivitieswithoutrestriction.
! Thispatienthasnotbeendiagnosedwithaconcussionbuttheassessmentledtothefollowing
diagnosisandrecommendations:______________________________________________________________________________________________________________________________________________________
! Thispatienthasbeendiagnosedwithaconcussion.
Thegoalofconcussionmanagementistoallowcompleterecoveryofthepatient’sconcussionbypromotingasafeandgradualreturntoschoolandsportactivities.Thepatienthasbeeninstructedtoavoidallrecreationalandorganizedsportsoractivitiesthatcouldpotentiallyplacethematriskofanotherconcussionorheadinjury.Startingon___________________(date),Iwouldaskthatthepatientbeallowedtoparticipateinschoolandlow-riskphysicalactivitiesastoleratedandonlyatalevelthatdoesnotbringonorworsentheirconcussionsymptoms.TheabovepatientshouldnotreturntoanyfullcontactpracticesorgamesuntilthecoachhasbeenprovidedwithaMedicalClearanceLetterprovidedbyamedicaldoctorornursepractitionerinaccordancewiththeCanadianGuidelineonConcussioninSport.
OtherComments:____________________________________________________________________________________________________________________________________________________________
Thank-youverymuchinadvanceforyourunderstanding.YoursSincerely
Signature/print___________________________________M.D./N.P.(circleappropriatedesignation)**Inruralornorthernregions,theMedicalAssessmentLettermaybecompletedbyanursewithpre-arrangedaccesstoamedicaldoctorornursepractitioner.Formscompletedbyotherlicensedhealthcareprofessionalsshouldnototherwisebeaccepted.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 22
MedicalClearanceLetter
NameofAthlete:__________________________________Date:____________
Towhomitmayconcern,
AthleteswhoarediagnosedwithaconcussionshouldbemanagedaccordingtotheCanadianGuidelineonConcussioninSportincludingtheReturn-to-SchoolandReturn-to-SportStrategies(seepage2ofthisletter).Accordingly,theaboveathletehasbeenmedicallyclearedtoparticipateinthefollowingactivitiesastoleratedeffectivethedatestatedabove(pleasecheckallthatapply):
! Symptom-limitingactivity(cognitiveandphysicalactivitiesthatdon’tprovokesymptoms)! Lightaerobicactivity(Walkingorstationarycyclingatslowtomediumpace.Noresistancetraining)! Sport-specificexercise(Runningorskatingdrills.Noheadimpactactivities)! Non-contactpractice(Hardertrainingdrills,e.g.passingdrills.Maystartprogressiveresistance
training.Includinggymclassactivitieswithoutariskofcontact,e.g.tennis,running,swimming)! Full-contactpractice(Includinggymclassactivitieswithriskofcontactandheadimpact,e.g.soccer,
dodgeball,basketball)! Fullgameplay
Whatifsymptomsrecur?Anyathletewhohasbeenclearedforphysicalactivities,gymclassornon-contactpractice,andwhohasarecurrenceofsymptoms,shouldimmediatelyremovehimselforherselffromtheactivityandinformtheteacherorcoach.Ifthesymptomssubside,theathletemaycontinuetoparticipateintheseactivitiesastolerated.Athleteswhohavebeenclearedforfullcontactpracticeorgameplaymustbeabletoparticipateinfull-timeschool(ornormalcognitiveactivity)aswellashighintensityresistanceandenduranceexercise(includingnon-contactpractice)withoutsymptomrecurrence.Anyathletewhohasbeenclearedforfull-contactpracticeorfullgameplayandhasarecurrenceofsymptoms,shouldimmediatelyremovehimselforherselffromplay,informtheirteacherorcoach,andundergoMedicalAssessmentbyamedicaldoctorornursepractitionerbeforereturningtofull-contactpracticeorgames.AnyathletewhoreturnstopracticesorgamesandsustainsanewsuspectedconcussionshouldbemanagedaccordingtotheCanadianGuidelineonConcussioninSport.
Othercomments:____________________________________________________________________________________________________________________________________________________________________________
Thank-youverymuchinadvanceforyourunderstanding.YoursSincerely,
Signature/print_____________________________________________M.D./N.P.(circleappropriatedesignation)**Inruralornorthernregions,theMedicalClearanceLettermaybecompletedbyanursewithpre-arrangedaccesstoamedicaldoctorornursepractitioner.Formscompletedbyotherlicensedhealthcareprofessionalsshouldnototherwisebeaccepted.
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 23
SymptomFollow-UpSheet
DesignedbyMarie-ClaudeSaint-Amour,Pht,dip.Physioofsport,FCAMPT
NameofAthlete:_________________________________________________________Date:_____________________Examiner:__________________________________
Name :______________________________________________________________________ Date :__________________________ Examiner :____________________
Scale of assessment of post-traumatic cranio-cerebral symptoms
None Moderate Severe 0 1 2 3 4 5 6 0 1 2 3 4 5 6
0 1 2 3 4 5 6 0 1 2 3 4 5 6
0 1 2 3 4 5 6 0 1 2 3 4 5 6
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Dizziness
Headache
Nausea
Vomiting
Balance problems 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Difficulty falling asleep 0 1 2 3 4 5 6
Emotional Liability
Irritability
Sadness
Nervousness
Numbness
Feeling Slowed Down 0 1 2 3 4 5 6
Falling asleep earlier than usual
2 3 4 5 6 Feeling dazed and confused
0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6 Difficulty focusing 1 2 3 4 5 6
0 1 2 3 4 5 6 Loss of memory 0 1 2 3 4 5 6 Sensivity to light
Sensitivity to sound 0 1 2 3 4 5 6 Others 0 1 2 3 4 5 6
Post-MTBI Symptoms. Check with the diver the list of symptoms below. Ask the athlete to rate the severity of each symptom using the 0 to 6 severity scale.
None Moderate Severe
0 1
0
⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL 24
AdditionalOnlineResourcesGuidelinesforChildrenandYouthregardingconcussionhttps://www.thechildren.com/departments-andstaff/departments/department-of-concussionsCanadianGuidelinesonConcussioninSports(Parachute)http://www.parachutecanada.org/downloads/injurytopics/Canadian_Guideline_on_Concussion_in_Sport-Parachute.pdf
ConcussionRecognitionTool5(CRT5)http://www.parachutecanada.org/downloads/resources/CRT5.pdf
SportConcussionAssessmentTool(SCAT5)http://www.parachutecanada.org/downloads/injurytopics/SCAT_5.pdf
ChildSportConcussionAssessmentTool(ChildSCAT5;childaged5-12yearsold)http://www.parachutecanada.org/downloads/injurytopics/Child_SCAT5.pdf
EducationSummarySheets
forCoacheshttp://www.parachutecanada.org/downloads/resources/Concussion-Coaches.pdfforAthleteshttp://www.parachutecanada.org/downloads/resources/Concussion-Athletes.pdfforParentsandCaregivershttp://www.parachutecanada.org/downloads/resources/Concussion-Parents-Caregivers.pdf
OnlineTrainingandLearningOpportunities
ConcussionEducationApplication(forApple,AndroidandWebversion)http://www.parachutecanada.org/concussion/whattodoMakingHeadWayConcussionE-Learninghttps://www.coach.ca/-p153487ConcussionAwarenessTrainingTool-https://cattonline.com/