Parent's Guide to Parachute Concussion in Sport Guideline All Ages 2024

Parachute lists these signs and symptoms:

• Physical: headache, head pressure, dizziness, nausea or vomiting, blurred vision, sensitivity to light or sound, ringing in the ears, balance problems, tiredness or low energy, drowsiness, and feeling that you "don't feel right".
• Cognitive: not thinking clearly, feeling slowed down or "in a fog", trouble concentrating, and memory problems.
• Emotional: easily upset or angered, sadness, nervousness or anxiety, and feeling more emotional.
• Sleep: sleeping more or less than usual, and difficulty falling asleep.

The guideline says a concussion should be suspected if an athlete has an impact to the head, face, neck or body and shows one or more observable signs, or reports one or more symptoms, of suspected concussion (as detailed in the Concussion Recognition Tool 6, CRT6). This includes cases where nobody saw the impact. A diagnosis is made only after a medical assessment.

Sources: https://parachute.ca/en/injury-topic/concussion/ and https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

Parachute lists these emergency danger signs. Call an ambulance right away if any are present:

• neck pain or tenderness
• double vision
• weakness or tingling in the arms or legs
• severe or increasing headache
• seizure or convulsion
• loss of consciousness
• deteriorating conscious state
• vomiting more than once
• increasing restlessness, agitation or combativeness
• growing confusion

The guideline says that with any red flag a more severe head or spine injury should be suspected and first aid principles followed. Coaches, parents/caregivers, trainers and officials should not try to remove equipment or move the athlete, and the athlete should not be left alone until the ambulance arrives. For a youth athlete, their parents or legal guardian should be contacted immediately.

Sources: https://parachute.ca/en/injury-topic/concussion/ and https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

The medical assessment decides whether an athlete has a concussion. In Canada, the licensed healthcare professionals whose scope of practice matches the guideline's requirements are medical doctors and nurse practitioners. In rural, remote or northern regions with limited access to them, a nurse with pre-arranged access to a medical doctor or nurse practitioner can facilitate this role.

Provincial differences the guideline notes: in Manitoba, physician assistants can diagnose concussion; in Quebec, nurse practitioners cannot diagnose concussion.

The assessment must rule out more serious brain and spine injuries and other conditions with concussion-like symptoms.

You will be given a Medical Assessment Letter:

• If no concussion is diagnosed, the letter says so and the athlete can return to school, work and sport without restriction.
• If a concussion is diagnosed, the letter says so and the athlete must follow a gradual return to school, work and sport.

The letter contains personal health information, so it is the athlete's or parent/legal guardian's responsibility to give it to the athlete's coaches, teachers or employers.

Source: Parachute, Canadian Guideline on Concussion in Sport, 2nd edition: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

1. Activities of daily living and relative rest (first 24 to 48 hours). Typical home activities (preparing meals, social interactions, light walking) that do not cause more than mild and brief worsening of symptoms, with minimal screen time. After a maximum of 24 to 48 hours, move to step 2.
2. School activities with encouragement to return to school (as tolerated). Homework, reading or other light cognitive activities at school or home; take breaks and adapt activities if symptoms worsen more than mildly and briefly; gradually resume screen time.
3. Part-time or full days at school with accommodations (as needed). Gradually reintroduce schoolwork, build tolerance to the classroom over time (part-time days with breaks and other accommodations may be needed), then gradually reduce accommodations and increase workload.
4. Return to school full-time. Full days and academic activities without concussion-related accommodations.

Also from the guideline:

• Students do not need to be symptom-free to return to school, and a complete absence from school of more than one week is not recommended.
• Medical clearance is not required to return to school, except for full participation in school-based sport and physical activity (including physical education class), which follows the Return-to-Sport Strategy.
• The strategy is a recommendation and does not replace medical advice.

Source: Parachute, Canadian Guideline on Concussion in Sport, 2nd edition (Table 1): https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

Each step takes at least 24 hours. The strategy begins at the same time as return to school, and the two can happen at the same time.

1. Activities of daily living and relative rest (first 24 to 48 hours). Typical home activities such as preparing meals, social interactions and light walking, with minimal screen time.
2. Aerobic exercise. 2A: light effort, such as stationary cycling or walking at a slow to medium pace (up to about 55% of maximum heart rate); light resistance training may begin. 2B: moderate effort, such as brisk walking or stationary cycling (up to about 70% of maximum heart rate).
3. Individual sport-specific activities without risk of inadvertent head impact. For example running, changing direction and individual drills, supervised by a teacher, parent/caregiver or coach, until the athlete is free of concussion-related symptoms even when exercising.
   Medical clearance is required before step 4.
4. Non-contact training drills and activities. High-intensity exercises with no body contact, such as passing drills, multi-athlete training and practices.
5. Return to all non-competitive activities, full-contact practice and physical education activities. No competitive gameplay yet.
6. Return to sport. Unrestricted sport and physical activity.

The guideline calls this a guideline that does not replace medical advice; with direction from a healthcare professional, timelines and activities may vary.

Source: Parachute, Canadian Guideline on Concussion in Sport, 2nd edition (Table 2): https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

Yes, a slight worsening is expected as long as it is mild and brief:

• Mild: symptoms worsen by only one to two points on a zero-to-10 scale (the guideline's sample scale runs from "feel great, no symptoms" to "worst I have ever felt").
• Brief: symptoms settle back down to pre-activity levels within an hour.

If symptoms worsen more than this, the athlete should stop the activity and try again the next day at the same step. For return to school, the student should pause and adapt activities as needed.

Source: Parachute, Canadian Guideline on Concussion in Sport, 2nd edition: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

A medical doctor or nurse practitioner. The final decision is based on their clinical judgment, taking into account the athlete's past medical history, clinical history, physical examination findings and the results of other tests and consultations where indicated.

• To progress to step 4 of the Return-to-Sport Strategy, the athlete must give their coach a Medical Clearance Letter stating that a medical doctor or nurse practitioner has personally evaluated them and cleared them to return to sport.
• Before step 4 the athlete must also have successfully completed all steps of the Return-to-School Strategy (if applicable) and steps 1 to 3 of the Return-to-Sport Strategy.
• In rural, remote or northern regions with limited access to medical doctors, a licensed healthcare professional such as a nurse with pre-arranged access to a medical doctor or nurse practitioner can provide this documentation.
• The athlete or coach should also give the information to sport organization administrators responsible for injury reporting and concussion surveillance, where applicable.

Source: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf

If the athlete has any new concussion-like symptoms during steps 4 to 6 of the Return-to-Sport Strategy (after medical clearance), they should stop the activity and return to step 3 so the symptoms fully resolve. Medical clearance is required again before they progress to step 4.

Parachute's handout adds: if symptoms return after medical clearance, follow up with a doctor for re-assessment, and never return to activities with risk of contact until cleared by a doctor.

If the athlete has a new suspected concussion, the guideline's recommendations start again from the beginning.

Sources: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf and https://parachute.ca/wp-content/uploads/2019/06/Return-to-Sport-Strategy.pdf

The guideline says most athletes who have a concussion in sport make a complete recovery, and return to full school without concussion-related accommodations and full sport without restrictions, within four weeks of injury. Approximately 15 to 30 per cent of people have symptoms that last longer.

• Symptoms lasting longer than four weeks are called persisting symptoms. The athlete may benefit from referral to specialized interdisciplinary concussion care.
• Parachute's Return-to-Sport Strategy handout says each step takes a minimum of 24 hours but could take longer, that people progress at different rates, and that someone who has had a concussion before may take longer to heal the next time.
• If symptoms last longer than four weeks, the handout says the doctor should consider referring the athlete to a licensed healthcare professional who is an expert in concussion management.

Sources: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf and https://parachute.ca/wp-content/uploads/2019/06/Return-to-Sport-Strategy.pdf

The Canadian Guideline on Concussion in Sport (2nd edition, March 2024) says everyone with a role in the sport community, including athletes and parents/caregivers, should receive concussion education every year.

The education should cover:

• the definition of concussion
• possible mechanisms of injury
• common signs and symptoms
• steps to prevent concussions and other injuries (including the sport's code of conduct, if there is one)
• what to do when an athlete has a suspected concussion or more serious head injury
• the medical assessment needed, including the Return-to-School and Return-to-Sport Strategies
• return-to-sport medical clearance requirements

The guideline gives the example of an education sheet (the Pre-season Concussion Education Sheet) that everyone reviews and signs at registration or before each season. It also suggests pre-season in-person orientation sessions on the sport's concussion protocol and code of conduct.

Source: Parachute, Canadian Guideline on Concussion in Sport, 2nd edition: https://parachute.ca/wp-content/uploads/2019/06/Concussion-Guideline-2024.pdf