CONCUSSION PROTOCOL

MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL SUMMARY

The following is a summary of the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL.

1.) All athletes participating in the Manitoba Major Junior Hockey League and their parents are encouraged to review the Pre-season Concussion Education Sheet prior to the first practice of the season. In addition to reviewing information on concussion, it is also important that all sport stakeholders have a clear understanding of the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL.

2.) In the event that a Manitoba Major Junior Hockey League (MMJHL) athlete is suspected to have sustained a head injury or concussion the following procedures must be followed:
a) If any athlete is suspected of sustaining a severe head or spine injury during a MMJHL activity, an ambulance should be called immediately to transfer the athlete to the emergency department of the appropriate hospital.
b) If the athlete is suspected of sustaining a concussion during a hockey game or practice, they must be immediately removed from play and evaluated in the emergency department of the nearest hospital.
c) If the athlete develops delayed concussion symptoms several hours later, the athlete should be evaluated immediately in the emergency department of the nearest hospital. If the athlete develops delayed and non life-threatening concussion symptoms that are identified during regular office hours (9:00am-4:00pm) on weekdays (Monday-Friday) they should be evaluated at the Pan Am Concussion Program.

All MMJHL athletes who have been initially assessed at a hospital must undergo follow-up care at the Pan Am Concussion Program. To arrange an appointment, it is recommended that athletes (18 years and older) or the parent/guardian of the athlete contact the clinic at 204-927-2766 during regular office hours to arrange an appointment.

All MMJHL athletes with a suspected concussion must provide their coach with a Medical Assessment or Medical Clearance Letter signed by a physician from the Pan Am Concussion Program before returning to any MMJHL activities. All MMJHL athletes who have sustained a suspected concussion outside of MMJHL activities are also required to provide their coach with a Medical Assessment or Medical Clearance Letter signed by a physician from the Pan Am Concussion Program before returning to MMJHL activities

For more information on the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL please see below for outline of the complete protocol.

For more information on concussion please visit https://parachute.ca/en/injury-topic/concussion/
 


MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL

The Manitoba Major Junior Hockey League (MMJHL) has developed the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL to help guide the management of athletes who may have a suspected head injury or concussion.

Purpose

This protocol covers the recognition, medical diagnosis, and management of athletes who may sustain a suspected concussion during a sport activity. It aims to ensure that athletes with a suspected concussion receive timely and appropriate care and proper management to allow them to return to their sport safely. This protocol may not address every possible clinical scenario that can occur during MMJHL activities but includes critical elements based on the latest evidence and current expert consensus.

Application to non-sport related concussionThis guideline has been adapted from the Canadian Guideline on Concussion in Sport for the management of MMJHL athletes who sustain a concussion during sport. However, the management principles described in these guidelines should also be applied to children and adolescents who sustain a concussion outside of a sporting activity and are returning to MMJHL activities including practices and games.

Who should use this protocol?
This guideline is intended for use by all individuals who interact with athletes inside and outside the context of the MMJHL, including athletes, parents, coaches, officials, teachers, trainers, and licensed healthcare professionals.

Recommendations

1. Pre-Season Education

 
Despite recent increased attention focusing on concussion there is a continued need to improve concussion education and awareness. Optimizing the prevention and management of concussion depends highly on annual education of all sport stakeholders (students, parents, coaches, officials, teachers, trainers, licensed healthcare professionals) on current evidence-informed approaches that can prevent concussion and more serious forms of head injury and help 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 head injury,
what measures should be taken to ensure proper medical assessment,
 
Return-to-School and Return-to-Sport Strategies, and
Return-to-Sport medical clearance requirements

Who: Athletes, parents, coaches, officials, teachers, and trainers, licensed healthcare professionals.

How:  
Pre-season Concussion Education Sheet

(https://www.sportmanitoba.ca/wp- content/uploads/2019/09/Concussion-PreSeason-Education-Sheet_SportMB.pdf)

All MMJHL athletes and their parents are encouraged to review the Pre-season Concussion Education Sheet prior to the first practice of the season. In addition to reviewing information on concussion, it is also important that all sport stakeholders have a clear understanding of the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL.

2. Head Injury Recognition

Although the formal diagnosis of concussion should be made following a medical assessment, all sport stakeholders including students, parents, coaches, teachers, officials, and licensed healthcare professionals are responsible for the recognition of MMJHL athletes who may demonstrate visual signs of a head injury or who report concussion-related symptoms. This is particularly important because some sport and recreation venues will not have access to on-site licensed healthcare professionals.

A concussion should be suspected:
in any MMJHL athlete who sustains a significant impact to the head, face, neck, or body and demonstrates ANY of the visual signs of a suspected concussion or reports ANY symptoms of a suspected concussion as detailed in the Concussion Recognition Tool 5.
if a MMJHL athlete reports ANY concussion symptoms to one of their peers, parents, teachers, coaches, therapsists or if anyone witnesses an athlete exhibiting any of the visual signs of concussion.

In some cases, an athlete may demonstrate signs or symptoms of a more severe head or spine injury including convulsions, worsening headaches, vomiting or neck pain. If an athlete demonstrates any of the ‘Red Flags’ indicated by the Concussion Recognition Tool 5, a more severe head or spine injury should be suspected.

Who: Athletes, parents, coaches, officials, teachers, trainers, and licensed healthcare professionals.

How: Concussion Recognition Tool 5 (See below)

3. Onsite Medical Assessment


Depending on the suspected severity of the injury, an initial assessment may be completed by emergency medical professionals or by an on-site licensed health professional (e.g. team therapists or physicians) where available.

3a. Emergency Medical Assessment

If a MMJHL athlete is suspected of sustaining a more severe head or spine injury during a game or practice, an ambulance should be called immediately to transfer the athlete to the emergency department at the appropriate hospital for further Medical Assessment. Coaches, parents, teachers, trainers and officials should not make any effort to remove equipment or move the athlete until an ambulance has arrived and the athlete should not be left alone until the ambulance arrives. After the emergency medical services staff has completed the Emergency Medical Assessment, the athlete should be transferred to the nearest hospital for Medical Assessment. In addition, the athlete’s parents should be contacted immediately to inform them of the student’s injury. After initial assessment at the hospital, it is recommended athletes (18 years and older) or the parent/guardian of the athlete contact the clinic at 204- 927-2766 during regular office hours to arrange a follow-up appointment.

Who: Emergency medical professionals

3b. Sideline Medical Assessment

If a MMJHL athlete is suspected of sustaining a concussion and there is no concern for a more serious head or spine injury, the athlete should be immediately removed from the field of play. If a licensed healthcare professional (e,g team therapist or physician) is present, the athlete should be taken to a quiet area and undergo Sideline Medical Assessment using the Sport Concussion Assessment Tool-5 (SCAT5) or the Child SCAT5. The SCAT5 and Child SCAT5 are clinical tools that should only be used by a licensed medical professional that has experience using these tools. It is important to note that the results of SCAT5 and Child SCAT5 testing can be normal in the setting of acute concussion. As such, these tools can be used by licensed healthcare professionals to document initial neurological status but should not be used to make sideline return-to-sport decisions in MMJHL athletes. Any athlete who is suspected of having sustained a concussion must not return to the game or practice and must be referred for Medical Assessment.

If an athlete is removed from play following a significant impact but there are NO visual signs of a concussion and the athlete reports NO concussion symptoms then the athlete can be returned to play but should be monitored for delayed symptoms.

Who: Athletic therapists, physiotherapists, medical doctor.

How: Sport Concussion Assessment Tool 5 (SCAT5), Child Sport Concussion Assessment Tool 5 (Child SCAT5)(See below)
 
4. Medical Assessment

In order to provide comprehensive evaluation of athletes with a suspected concussion, the Medical Assessment must rule out more serious forms of traumatic brain and spine injuries, must rule out medical and neurological conditions that can present with concussion-like symptoms, and must make the diagnosis of concussion based on findings of the clinical history and physical examination and the evidence-based use of adjunctive tests as indicated (i.e. CT scan). The Medical Assessment is responsible for determining whether the athlete has been diagnosed with a concussion or not.

In the case of MMJHL athletes with a suspected concussion, the following procedures should taken:

1.) If the athlete is suspected of sustaining a concussion during a hockey game or practice, they must be immediately removed from play and evaluated in the emergency department of the nearest hospital. Following initial medical assessment, athletes should arrange a follow-up appointment at the Pan Am Concussion Program.

2.) If the athlete develops delayed and non life-threatening concussion symptoms several hours later, the athlete should be evaluated immediately in the emergency department of the nearest hospital. If the athlete develops delayed and non life-threatening concussion symptoms that are identified during regular office hours (9:00am-4:00pm) on weekdays (Monday-Friday) they should be evaluated at the Pan Am Concussion Program.

Athletes with a diagnosed concussion should be provided with a Medical Assessment or Clearance Letter indicating a concussion has been diagnosed and what activities the athlete is cleared to return to. Athletes that are determined to have not sustained a concussion must be provided with a Medical Assessment Letter indicating a concussion has not been diagnosed and the athlete can return to school, work, and sports activities without restriction.

Who:
Medical doctor, nurse practitioner, nurse.

How: Medical Assessment Letter

5. Concussion Management

When an athlete has been diagnosed with a concussion, it is important that the athlete’s parent/legal guardian is informed. All MMJHL athletes diagnosed with a concussion must be provided with a standardized Medical Assessment or Clearance Letter that notifies the athlete and their parents/legal guardians/spouse that they have been diagnosed with a concussion and what activities they are cleared to return to. Because these resources contain personal health information, it is the responsibility of the athlete or their parent/legal guardian to provide this documentation to the athlete’s coaches.
 
MMJHL athletes diagnosed with a concussion should be provided with education about the signs and symptoms of concussion, strategies about how to manage their symptoms, the risks of returning to sport without medical clearance and recommendations regarding a gradual return to school and sport activities. Athletes diagnosed with a concussion are to be managed according to their Return-to-School and Sport-Specific Return-to-Sport Strategy under the supervision of the Pan Am Concussion Program. When available, athletes should be encouraged to work with the team athletic therapist or physiotherapist to optimize progression through their Sport-Specific Return-to-Sport Strategy. Once the athlete has completed their Return-to-School and Sport-Specific Return-to-Sport Strategy and are deemed to be clinically recovered from their concussion, the Pan Am Concussion Program will consider the athlete for a return to full MMJHL activities.

Return-to-School Strategy

The following is an outline of the Return-to-School Strategy that should be used to help athletes, parents, and teachers to collaborate in allowing the athlete to make a gradual return to school activities. Depending on the severity and type of symptoms present athletes will progress through the following stages at different rates. If the athlete experiences new symptoms or worsening symptoms at any stage, they should go back to the previous stage.

Stage 1


AIM: Daily activities at home that do not give the student-athlete symptoms

ACTIVITY: Typical activities of the child during the day as long as they do not increase symptoms (i.e. reading, texting, screen time). Start at 5-15 minutes at a time and gradually build up

GOAL: Gradual return to typical activities

Stage 2

AIM: School activities

ACTIVITY: Homework, reading or other cognitive activities outside of the classroom

GOAL: Increase tolerance to cognitive work

Stage 3

AIM: Return to school part- time

ACTIVITY: Gradual introduction of schoolwork. May need to start with a partial school day or with increased breaks during the day

GOAL: Increase academic activities

Stage 4

AIM: Return to school full- time

ACTIVITY: Gradually progress

GOAL: Return to full academic activities and catch up on missed school work


Return-to-Sport Strategy


The following is an outline of the Return-to-Sport Strategy that should be used to help athletes, coaches, trainers, teachers and medical professionals to partner in allowing the athlete to make a gradual return to sport activities. An initial period of 24-48 hours of rest is recommended before starting the Sport-Specific Return-to-Sport Strategy. If the athlete
 
experiences new symptoms or worsening symptoms at any stage, they should go back to the previous stage. It is important that athletes return to full-time school activities before progressing to stage 5 and 6 of the Sport-Specific Return-to-Sport Strategy. It is also important that all athletes provide their coach/teacher with a Medical Clearance Letter prior to returning to any sport activities.

Stage 1

AIM: Symptom-limiting activity

ACTIVITY: Daily activities that do not provoke symptoms

GOAL: Gradual re-introduction of work/school activities

Stage 2    

AIM: Light aerobic activity  

ACTIVITY: Walking or stationary cycling at slow to medium pace. No resistance training

GOAL: Increase heart rate

Stage 3

AIM: Sport-specific exercise

ACTIVITY: Running or skating drills. No head impact activities

GOAL: Add movement

Stage 4

AIM: Non-contact training drills

ACTIVITY: Harder training drills, i.e. passing drills. May start progressive resistance training

GOAL: Exercise, coordination and increased thinking

Stage 5

AIM: Full contact practice

ACTIVITY: Following medical clearance

GOAL: Restore confidence and assess functional skills by coaching staff

Stage 6

AIM: Return to sport

ACTIVITY: Normal game play

Who: Medical doctor, nurse practitioner and team athletic therapist or physiotherapist (where available).

How: Return-to-Learn Strategy, Sport-Specific Return-to Sport Strategy, Medical Assessment Letter


6. Multidisciplinary Concussion Care

Most athletes who sustain a concussion while participating in sport will make a complete recovery and be able to return to full school and sport activities within 1-4 weeks of injury. However, approximately 15-30% of individuals will experience symptoms that persist beyond this time frame. If not already done so, athletes who experience persistent post-concussion symptoms (>4 weeks) should have their family doctor or pediatrician make a referral to the Pan Am Concussion Program, a medically-supervised multi-disciplinary concussion clinic that has access to professionals with licensed training in traumatic brain injury that include experts in neurosurgery, sport medicine, neuropsychology, exercise science, physiotherapy, and neurology.

Who: Multidisciplinary medical team, medical doctor with clinical training and experience in concussion (e.g. a sports medicine physician, neurologist, or rehabilitation medicine physician), licensed healthcare professionals.
 
7. Return to Sport

MMJHL athletes who have been determined to have not sustained a concussion and those that have been diagnosed with a concussion and have successfully completed their Return- to-School and Sport-Specific Return-to-Sport Strategy can be considered for return to full sports activities. The final decision to medically clear a athlete to return to full game activity should be based on the clinical judgment of the medical doctor taking into account the athlete’s past medical history, clinical history, physical examination findings and the results of other tests and clinical consultations where indicated (i.e. neuropsychological testing, diagnostic imaging). Prior to returning to any MMJHL-related activities, athletes that have been diagnosed with a concussion must provide their coach with a standardized Medical Clearance Letter that specifies that a medical doctor at the Pan Am Concussion Program has personally assessed the athlete and has cleared the athlete to return to sports.


Athletes who have been provided final medical clearance to return to full-contact practices and games will be provided with a Medical Clearance Letter. If the athlete experiences any new concussion-like symptoms while returning to play, they should be instructed to stop playing immediately, notify their parents, coaches, or trainer and undergo follow-up Medical Assessment. In the event that the athlete sustains a new suspected concussion, the MANITOBA MAJOR JUNIOR HOCKEY LEAGUE CONCUSSION PROTOCOL should be followed as outlined here.

Who: Medical doctor, nurse practitioner

Document: Medical Clearance Letter


For more information on concussion and how to download the Concussion Recognition Tool 5, SCAT5 & Child SCAT5 please visit:


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