Canadian Guideline On Concussion In Sport
Canadian Guidelineon Concussion in Sport
Canadian Guideline on Concussion in SportJuly 2017Funding provided by:Public Health Agency of CanadaThe views expressed herein do not necessarily represent the views of the Public Health Agencyof Canada.Suggested citation:Parachute. (2017). Canadian Guideline on Concussion in Sport. Toronto: Parachute. Parachute – Leaders in Injury Prevention, 2017
ContentsEXPERT ADVISORY COMMITTEE ON CONCUSSIONS5ADDITIONAL REVIEW AND FEEDBACK6PARACHUTE PROJECT TEAM6OVERVIEW7PURPOSE7APPLICATION TO NON-SPORT RELATED CONCUSSION7WHO SHOULD USE THIS GUIDELINE?7HOW TO READ THIS GUIDELINE8ROLE OF CLINICAL JUDGMENT8KEY TERM DEFINITIONS8GUIDELINE RECOMMENDATIONS111. PRE-SEASON EDUCATION122. HEAD INJURY RECOGNITION133. ONSITE MEDICAL ASSESSMENT144. MEDICAL ASSESSMENT165. CONCUSSION MANAGEMENT176. MULTIDISCIPLINARY CONCUSSION CARE207. RETURN TO SPORT21CANADIAN SPORT CONCUSSION PATHWAY23GUIDELINE DEVELOPMENT PROCESS25EVIDENCE25STAKEHOLDER CONSULTATION25UPDATES TO THIS GUIDELINE26APPENDIX: DOCUMENTS & TOOLS27PRE-SEASON CONCUSSION EDUCATION SHEET29MEDICAL ASSESSMENT LETTER31
MEDICAL CLEARANCE LETTER33CONCUSSION RECOGNITION TOOL – 5TH EDITION (CRT5)35SPORT CONCUSSION ASSESSMENT TOOL – 5TH EDITION (SCAT5)37CHILD SPORT CONCUSSION ASSESSMENT TOOL – 5TH EDITION (CHILD SCAT5)45
ContributorsExpert Advisory Committee on ConcussionsDr. Charles Tator, Co-Chair, MD, PhD, FRCSC, FACSProfessor of Neurosurgery, University of TorontoDivision of Neurosurgery and Canadian Concussion Centre, Toronto Western HospitalDr. Michael Ellis, Co-Chair, BSc, MD, FRCSCMedical Director, Pan Am Concussion ProgramDept. of Surgery and Pediatrics and Section of Neurosurgery, University of ManitobaScientist, Children’s Hospital Research Institute of ManitobaCo-director, Canada North Concussion NetworkDr. Shelina Babul, B.Sc., PhDAssociate Director, Sports Injury Specialist, BC Injury Research & Prevention Unit, BC Children'sHospitalInvestigator, Djavad Mowafaghian Center for Brain Health, UBCClinical Associate Professor, Dept. of Pediatrics/Pathology & Laboratory Medicine, UBCDr. Shannon Bauman, MD, CCFP (SEM), Dip. Sport MedMedical Director, Concussion NorthDept. of Family Medicine, Dept. of Surgery, Royal Victoria Regional Health CentreDr. Michael Cusimano, MD, MHPE, FRCS, DABNS, PhD, FACSDivision of Neurosurgery, St. Michael's HospitalProfessor of Neurosurgery, Education and Public Health, University of TorontoDr. Carolyn Emery, BScPT, PhDAssociate Dean Research and Associate Professor, Faculty of KinesiologyCo-chair, Sport Injury Prevention Research Centre, Faculty of KinesiologyPediatrics and Community Health Sciences, Faculty of Medicine, University of CalgaryDr. Pierre Frémont, MD, PhD, FCMFFull Professor, Faculty of Medicine, Laval UniversityDr. Claude Goulet, PhDFull Professor, Faculty of Education, Department of Physical Education, Laval UniversityLouise Logan, BA (Hons), JDPresident, Logan & AssociatesPARACHUTE Canadian Guideline on Concussion in Sporti5
Dr. Alison Macpherson, PhDAssociate Professor, Faculty of Health, School of Kinesiology & Health Science, York UniversityAdjunct Scientist, Institute for Clinical Evaluative SciencesDr. Nick Reed, PhD, MScOT, OT Reg (Ont)Clinician Scientist, Bloorview Research InstituteCo-Director, Concussion Centre, Holland Bloorview Kids Rehabilitation HospitalAssistant Professor, Dept. of Occupational Science and Occupational Therapy, University ofTorontoDr. Kathryn Schneider, PT, PhD, DipManipPTAssistant Professor, Clinician Scientist, Faculty of Kinesiology, University of CalgaryAlberta Children’s Hospital Research InstituteClinical Specialist–Musculoskeletal PhysiotherapyDr. Ash Singhal, BSc, MSc, MD, FRCSCPediatric Neurosurgeon, BC Children’s HospitalMedical Director, BC Pediatric Trauma ProgramClinical Assistant Professor, UBCDr. Michael Vassilyadi, MD, CM, MSc, FRCS (C), FACS, FAAPAssociate Professor of Surgery, University of OttawaDivision of Neurosurgery,CHEODr. Roger Zemek, MD, FRCPCAssociate Professor, Dept of Pediatrics and Emergency MedicineClinical Research Chair in Pediatric Concussion, University of OttawaDirector, Clinical Research Unit, CHEOAdditional review and feedbackDr. Jack Taunton, MSc, MD, DIPL Sports Med (CASEM), FACSMFederal-Provincial/Territorial Work Group on Concussions in SportParachute Project TeamPamela Fuselli, VP, Knowledge Transfer & Stakeholder RelationsValerie Smith, Director, SolutionsStephanie Cowle, Project Manager, SolutionsPARACHUTE Canadian Guideline on Concussion in Sporti6
OverviewPurposeThis guideline covers pre-season education and the recognition, medical diagnosis, andmanagement of athletes who sustain a suspected concussion during a sport activity. It aims toensure that athletes with a suspected concussion receive timely and appropriate care, andproper management to allow them to return to their sport. This guideline may not addressevery possible clinical scenario that can occur but is intended as a general overview thatincludes critical elements based on the latest evidence and current expert consensus.Application to non-sport related concussionThis guideline has been developed based on a review of the current scientific evidence andexpert consensus on best practices for the evaluation and management of Canadian athleteswho sustain a concussion during a sport activity. However, the management principlesdescribed in this guideline should also be applied to children, adolescents and adults whosustain a concussion outside of a sporting environment and are returning to activity (in school,in the workplace, and so on).Certain terminology has been used to make this guideline as specific as possible and to directlyreflect the International Consensus Statement on Concussion in Sport. These terms may be newto some readers and two examples are worth noting. A Return-to-School Strategy isrecommended to address the process commonly known as “return to learn”. The Return-toSchool Strategy focuses on the individual returning to a formal, structured learning environmentrather that engaging more broadly in cognitive day-to-day activities. A Return-to-Sport Strategyis recommended to address the process known as “return to play”. The Return-to-Sport Strategyfocuses on individuals returning to training, practice, and competition in organized sport, notunstructured day-to-day activity or play. For further information on terminology used in thisguideline, please see the “Key Term Definitions” section.Who should use this guideline?This guideline is intended for use by all stakeholders who interact with athletes inside andoutside the context of school and non-school based organized sports activity, including athletes,parents, coaches, officials, teachers, trainers, and licensed healthcare professionals.PARACHUTE Canadian Guideline on Concussion in Sporti7
How to read this guidelineThis guideline addresses 7 areas in the prevention, recognition, diagnosis, and management ofsport-related concussion:1. Pre-season education2. Head injury recognition3. Onsite medical assessment4. Medical assessment5. Concussion management6. Multidisciplinary concussion care7. Return to sportFor each area, recommendations are provided, along with:‣Who: Who are the people that play a key role to implement the recommendations inthis area.‣How: What are the key tools and documents people can use to implement therecommendations in this area. All tools are included directly in this guideline.Role of clinical judgmentSeveral recommendations in this guideline are aimed at licensed healthcare professionals withthe aim of helping them make informed decisions about their patients. However, this guidelineis not intended to take the place of clinical judgment in diagnosing and treating concussion.Healthcare professionals must make their own decisions about care after consultation with theirpatients, using their clinical judgement, knowledge and expertise.Key Term DefinitionsConcussion: A form of traumatic brain injury induced by biomechanical forces that result insigns and symptoms that typically resolve spontaneously within 1-4 weeks of injury.1Athlete: Any youth or adult participating in a school or non-school based sport activity,competing at any level of play (amateur or national team). This term refers to all sportparticipants and players. The most appropriate term will vary across different sports andsettings.Youth or youth athlete: An athlete or sport participant who is less than 18 years of age.et al. (2017). Consensus statement on concussion in sport – the 5th international conference onconcussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51(11), 838-847.1McCroryPARACHUTE Canadian Guideline on Concussion in Sporti8
Sport or sport activity: A school or non-school based physical activity that can be played as anindividual or a team including games and practices.Recognition: The detection of an event (i.e. a suspected concussion) occurring during sports ora sport activity.Exercise: Any physical activity that requires bodily movement including resistance training aswell as aerobic and anaerobic exercise or training.Persistent symptoms: Concussion symptoms that last longer than 2 weeks after injury in adultsand longer than 4 weeks after injury in youth.Licensed healthcare professional: A healthcare provider who is licensed by a nationalprofessional regulatory body to provide concussion-related healthcare services that fall withintheir licensed scope of practice. Examples include medical doctors, nurses, physiotherapists,and athletic therapists.Among licensed healthcare professionals, only medical doctors and nurse practitioners arequalified to conduct a comprehensive medical assessment and provide a concussion diagnosisin Canada. The types of medical doctors qualified to do such an evaluation are: pediatricians;family medicine, sports medicine, emergency department and rehabilitation (physiatrists)physicians; neurologists; and neurosurgeons.Medical Assessment: The evaluation of an individual by a licensed healthcare professional todetermine the presence or absence of a medical condition or disorder, such as a concussion.Treatment: An intervention provided by a licensed healthcare professional to address adiagnosed medical condition/disorder or its associated symptoms, such as physical therapy.Multidisciplinary concussion clinic: A facility or network of licensed healthcare professionalsthat provide assessment and treatment of concussion patients and are supervised by aphysician with training and experience in concussion.Tool: A standardized instrument or device that can be used to help recognize an event (i.e. asuspected concussion) or assess an individual with a suspected medical diagnosis (i.e. SportConcussion Assessment Tool 5).Document: A standardized written letter or form that can help facilitate communicationbetween sport stakeholders.Concussion Recognition Tool – 5th Edition (CRT5): A tool intended to be used for theidentification of suspected concussion in children, youth, and adults. Published in 2017 by theConcussion in Sport Group, the CRT5 replaces the previous Pocket Concussion Recognition Toolfrom 2013.PARACHUTE Canadian Guideline on Concussion in Sporti9
Sport Concussion Assessment Tool – 5th Edition (SCAT5): A standardized tool for evaluatingconcussions in individuals aged 13 years or older, designed for use by physicians and licensedhealthcare professionals. Published in 2017 by the Concussion in Sport Group, the SCAT5replaces the previous SCAT3 from 2013.Child Sport Concussion Assessment Tool – 5th Edition (Child SCAT5): A standardized tool forevaluating concussions in individuals aged 5 to 12 years, designed for use by physicians andlicensed healthcare professionals. Published in 2017 by the Concussion in Sport Group, the ChildSCAT5 replaces the previous Child SCAT3 from 2013.Return-to-School Strategy: A graduated stepwise strategy for the process of recovery andreturn to academic activities after a concussion. The broader process of returning to cognitiveactivities has commonly been referred to as “return to learn”.Return-to-Sport Strategy: A graduated stepwise strategy for the process of recovery and thenreturn to sport participation after a concussion. The broader process of returning tounstructured and structured physical activity has commonly been referred to as “return to play”.PARACHUTE Canadian Guideline on Concussion in Sporti10
Guideline RecommendationsPARACHUTE Canadian Guideline on Concussion in Sporti11
1.1.Pre-SeasonPre-SeasonEducationEducationDespite recent increased attention focusing on concussion there is a continued need to improveconcussion education and awareness. Optimizing the prevention and management ofconcussion depends highly on annual education of all sport stakeholders (athletes, parents,coaches, officials, teachers, trainers, and licensed healthcare professionals) on evidenceinformed approaches that can prevent concussion and more serious forms of head injury andhelp identify and manage an athlete with a suspected concussion.Concussion education should include information on: the definition of concussion, possible mechanisms of injury, common signs and symptoms, steps that can be taken to prevent concussions and other injuries from occurring in sport, what to do when an athlete has suffered a suspected concussion or more serious headinjury, what measures should be taken to ensure proper medical assessment including Return-toSchool and Return-to-Sport Strategies, and Return-to-sport medical clearance requirements.As an example, this education could be provided using an education sheet that is reviewed andsigned by all stakeholders at the time of sport registration or before the beginning of eachsports season to confirm that the key information has been received by all participants.In addition to reviewing information on concussion, it is also important that all sportstakeholders have a clear understanding of the concussion protocol and policies for their sportand sport setting at the beginning of each sport season. For example, this can be accomplishedthrough pre-season in-person orientation sessions for athletes, parents, coaches and othersport stakeholders.‣Who: Athletes, parents, coaches, officials, teachers, and trainers, licensed healthcareprofessionals‣How: Pre-season Concussion Education SheetPARACHUTE Canadian Guideline on Concussion in Sporti12
ough the formal diagnosis of concussion should be made following a medical assessment,all sport stakeholders including athletes, parents, coaches, officials, teachers, trainers, andlicensed healthcare professionals are responsible for the recognition and reporting of athleteswho demonstrate visual signs of a head injury or who report concussion symptoms. This isparticularly important because many sport and recreation venues will not have access to on-sitelicensed healthcare professionals.A concussion should be suspected in any athlete who sustains a significant impact to the head,face, neck, or body and demonstrates ANY of the visual signs of a suspected concussion orreports ANY symptoms of a suspected concussion as detailed in the Concussion Recognition Tool5. A concussion should also be suspected if a player reports ANY concussion symptoms to oneof their peers, parents, teachers, or coaches or if anyone witnesses an athlete exhibiting any ofthe visual signs of concussion.In some cases, an athlete may demonstrate signs or symptoms of a more severe head or spineinjury including convulsions, worsening headaches, vomiting or neck pain. If an athletedemonstrates any of the ‘Red Flags’ indicated by the Concussion Recognition Tool 5, a moresevere head or spine injury should be suspected, and Emergency Medical Assessment should bepursued (see 3a. Emergency Medical Assessment).‣Who: Athletes, parents, coaches, officials, teachers, trainers, and licensed healthcareprofessionals‣How: Concussion Recognition Tool - 5th Edition (CRT5)PARACHUTE Canadian Guideline on Concussion in Sporti13
Depending on the suspected severity of the injury and access to medical services, an initialassessment may be completed by emergency medical professionals or by an on-site licensedhealth professional where available. In cases where an athlete loses consciousness or it issuspected an athlete might have a more severe head or spine injury, Emergency MedicalAssessment by emergency medical professionals should take place (see 3a below). If a moresevere injury is not suspected, the athlete should undergo Sideline Medical Assessment orMedical Assessment, depending on if there is a licensed healthcare professional present (see 3bbelow).3a. Emergency Medical AssessmentIf an athlete is suspected of sustaining a more severe head or spine injury during a game orpractice, an ambulance should be called immediately to transfer the patient to the nearestemergency department for further Medical Assessment.Coaches, parents, trainers and sports officials should not make any effort to remove equipmentor move the athlete until an ambulance has arrived and the athlete should not be left aloneuntil the ambulance arrives. After the emergency medical services staff has completed theEmergency Medical Assessment, the athlete should be transferred to the nearest hospital forMedical Assessment. In the case of youth (under 18 years of age), the athlete’s parents or legalguardian should be contacted immediately to inform them of the athlete’s injury. For athletesover 18 years of age, their emergency contact person should be contacted if one has beenprovided.‣Who: Emergency medical professionals3b. Sideline Medical AssessmentIf an athlete is suspected of sustaining a concussion and there is no concern for a more serioushead or spine injury, the player should be immediately removed from the field of play.Scenario 1: If a licensed healthcare professional is presentThe athlete should be taken to a quiet area and undergo Sideline Medical Assessment using theSport Concussion Assessment Tool 5 (SCAT5) or the Child SCAT5. The SCAT5 and Child SCAT5 areclinical tools that should only be used by a licensed medical professional that has experienceusing these tools. It is important to note that the results of SCAT5 and Child SCAT5 testing canbe normal in the setting of acute concussion. As such, these tools can be used by licensedhealthcare professionals to document initial neurological status but should not be used to makesideline return-to-sport decisions in youth athletes. Any youth athlete who is suspected ofhaving sustained a concussion must not return to the game or practice and should be referredfor Medical Assessment.PARACHUTE Canadian Guideline on Concussion in Sporti14
If a youth athlete is removed from play following a significant impact and has undergoneSideline Medical Assessment, but there are NO visual signs of a concussion and the athletereports NO concussion symptoms then the athlete can be returned to play but should bemonitored for delayed symptoms.In the case of national team-affiliated athletes (age 18 years and older) who have been removedfrom play following a suspected concussion, an experienced certified athletic therapist,physiotherapist or medical doctor providing medical coverage for the sporting event may makethe determination that a concussion has not occurred based on the results of the SidelineMedical Assessment. In these cases, the athlete may be returned to the practice or gamewithout a Medical Clearance Letter but this should be clearly communicated to the coachingstaff. Players that have been cleared to return to games or practices should be monitored fordelayed symptoms by the licensed healthcare professional. If the athlete develops any delayedsymptoms the athlete should be removed from play and undergo
3. onsite medical assessment 14 4. medical assessment 16 5. concussion management 17 6. multidisciplinary concussion care 20 7. return to sport 21. canadian sport concussion pathway 23 guideline development process . evidence stakeholder consultation updates to this guideline. appendix: documen
concussion test is a tool or device used to check a What is a concussion test? person's level of functioning after a suspected concussion. There are several types of concussion tests, including neurocognitive, balance, vestibular ocular, motion sensors, and more. These tests do not diagnose concussion, but rather note deficits in
This policy is aligned with the Canadian Guideline on Concussion in Sport. . the 5th International conference on concussion in sport held in Berlin, Oct 2016. British Journal of Sports Medicine 2017 0:1-10. This policy is aligned with the Canadian Guideline on Concussion in Sport. . medical
suspected of having sustained a concussion/mTBI (mild traumatic brain injury). This guideline is not intended for use with patients or clients under the age of 18 years. This guideline is not intended for use by people who have sustained or are suspected of having sustained a concussion/mTBI for any self-diagnosis or treatment. Patients
Consensus Statement on Concussion in Sport . The detailed clinical assessment of concussion is outlined in the SCAT2 form, which is an appendix to this document. The suspected diagnosis of concussion can include one . psychological test batteries that assess attention and memory
used in the evaluation of concussion; however, none is specifically validated for such use.31–41 SCAT2 includes one such symptom evaluation scheme.7 Increasing evidence suggests that concussion rating scales based on athlete self-report of multiple symptoms are a more reliable and practical way of detecting concussion
Furthermore, a detailed concussion his-tory is an important part of the evalua-tion both in the injured athlete and when conducting a pre-participation examina-tion. The detailed clinical assessment of concussion is outlined in the SCAT2 form (see p 85). The suspected diagnosis of concussion can include one or more of the following clinical .
The risk of concussion is 4 times higher in a previously concussed player than in a player who has never sustained a concussion. Concussion (Mild Traumatic Brain Injury) Structural damage with loss of brain cells does occur with some concussions Repeated concussions additive – slower/ less complete recovery Second Impact Syndrome – 100%
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