DIVING PLONGEON CANADA CONCUSSION PROTOCOL · concussion include: pediatricians; family medicine, sports medicine, emergency department, internal medicine, and rehabilitation (physiatrists)

⎪ DIVINGPLONGEONCANADACONCUSSIONPROTOCOL

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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


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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.


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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.


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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.

http://www.parachutecanada.org/downloads/resources/CRT5.pdf

http://www.parachutecanada.org/downloads/resources/CRT5.pdf


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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

http://www.parachutecanada.org/downloads/injurytopics/SCAT_5.pdf

http://www.parachutecanada.org/downloads/injurytopics/Child_SCAT5.pdf


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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.


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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


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6b.Return-to-DivingStrategyThefollowingisanoutlineoftheReturn-to-DivingStrategythatshouldbeusedtohelpathletes,coaches,trainersandmedicalprofessionalstopartnerinallowingtheathletetomakeagradualreturntosportactivities.Aninitialperiodof24-48hoursofrestisrecommendedbeforestartinganyconcussionprotocol.Itisimportantthatyouthandadultstudent-athletesreturntofull-timeschoolactivitiesbeforeprogressingtoReturn-to-DivingStrategy.ItisalsoimportantthatallathletesprovidetheircoachwithaMedicalClearanceLetterpriortoreturningtoresumingtraining.TheTableofStepstoReturntoPostConcussionTraining(onthenextpage)needstobeappliedinconjuctionwiththeRulesforImplementingtheTabletoReturntoPostConcussionandwiththeConcussionManagementProtocolforTrainers.


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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


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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.


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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


• Increasingconfusion(incoherentspeech,disorientation…)• Twosessionsofvomitingormore(3ifachild)inthe24hrsfollowingaconcussion• Bleedingorliquiddrippingfromnoseorears• Convulsions/epilepsy• Anynewneurologicalsymptom(weaknessintheleg/arm,lossofbalance,double

vision,speechtrouble…)• Excessivecrying(child)


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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.


!

!

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


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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


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


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


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


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.


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.


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


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/

DIVING PLONGEON CANADA CONCUSSION PROTOCOL · concussion include: pediatricians; family medicine, sports medicine, emergency department, internal medicine, and rehabilitation (physiatrists)

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