Sample Home Concussion Management Form (Return to School Plan)

The Return to Learning (RTL) and Return to Physical Activity (RTPA) Plans have been developed in partnership with Parachute and are based on the most recent research and recommendations of the expert scientific community on concussion, that is the Canadian Guidelines on Concussion in Sport, July 2017 and the Berlin Consensus Statement on Concussion in Sport, October 2016.

The RTL and RTPA plans are inter-related however, they are not interdependent. A student’s progress through the stages of RTL is independent from their progression through the RTPA stages. Different students will progress at different rates.

Before using the Home Concussion Management Form (Return to School Plan), consult the General Procedures and the Instructions for the Home Concussion Management Form (Return to School Plan).

The Sample Home Concussion Management Form (Return to School Plan) derives from the stage of Initial Rest to Stage 2 of the Concussion Return to School Plan for Return to Learning and the stages of Initial Rest to Stage 2b of the Concussion Return to School Plan for Return to Physical Activity.

Student Name:
Date:

Return to Learning (RTL)

Each stage must last a minimum of 24 hours.

Initial Rest

  • 24 – 48 hours of relative cognitive rest:
    • Sample activities permitted if tolerated by student:
      • Short board/card games
      • Short phone calls
      • Photography (with camera)
      • Crafts
    • Activities that are not permitted at this stage:
      • TV
      • Technology use (for example, computer, laptop, tablet, iPad)/cell phone (for example, texting/games/photography)
      • Video games
      • Reading
      • Attendance at school or school-type work
  • The student moves to Stage 1 when:
    • Symptoms start to improve or after resting 2 days maximum (whichever occurs first).

Stage 1

  • Light cognitive (thinking/memory/ knowledge) activities
  • Gradually increase cognitive activity up to 30 minutes. Take frequent breaks.
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • Easy reading (for example, books, magazines, newspaper)
      • Limited TV
      • Limited cellphone conversations
      • Drawing/building blocks/puzzles
      • Some contact with friends
    • Activities that are not permitted at this stage:
      • Technology use (for example, computer, laptop, tablet, cell phone (for example, texting/games/photography))
      • Attendance at school or school-type work
  • The student moves to Stage 2 when:
    • the student tolerates 30 minutes of light cognitive activity (for example a student should be able to complete 3-4 of the permitted activities listed above) and has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
    • The student has completed a minimum of 24 hours at Stage 1.
  • However:
    • The student must return to the previous stage for a minimum of 24 hours when they have exhibited or reported a return of symptoms, or new symptoms.
    • The student must return to a medical doctor or nurse practitioner when they have exhibited or reported a worsening of symptoms.

Stage 2

  • Gradually add cognitive activity (as per activities permitted). When light cognitive activity is tolerated, introduce school work (at home and facilitated by the school).
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • School-type work in 30-minute increments
      • Crosswords, word puzzles, Sudoku, word search
      • Limited technology use (for example, computer, laptop, tablet, cell phone (for example, texting/games/photography)) starting with shorter periods and building up as tolerated.
    • Activities that are not permitted at this stage:
      • School attendance
  • The student moves to Stage 3a when:
    • The student tolerates the additional cognitive activity (for example a student should be able to complete 3-4 of the activities permitted) and has not exhibited or reported a return of symptoms, new symptoms or worsening symptoms.
    • The student has completed a minimum of 24 hours at Stage 2.
  • However:
    • The student must return to the previous stage for a minimum of 24 hours when they have exhibited or reported a return of symptoms, or new symptoms.
    • The student must return to a medical doctor or nurse practitioner when they have exhibited or reported a worsening of symptoms.

Return to Physical Activity (RTPA)

Each stage must last a minimum of 24 hours.

Initial Rest

  • 24 – 48 hours of relative physical rest
    • Sample activities permitted if tolerated by student:
      • Limited movement that does not increase heart rate or break a sweat
      • Moving to various locations in the home
      • Daily hygiene activities
    • Activities that are not permitted at this stage:
      • Physical exertion (increases breathing and heart rate and sweating)
      • Stair climbing other than to move locations throughout the home
      • Sports/sporting activity
  • The student moves to Stage 1 when:
    • Symptoms start to improve or after resting 2 days maximum (whichever occurs first).

Stage 1

  • Light physical activities (as per activities permitted) that do not provoke symptoms.
  • Movements that can be done with little effort (do not increase breathing and/or heart rate or break a sweat).
    • Activities permitted if tolerated by student:
      • Daily household tasks (for example, bed-making, dishes, feeding pets, meal preparation)
      • Slow walking for short time
    • Activities that are not permitted at this stage:
      • Physical exertion (increases breathing and heart rate and sweating)
      • Sports/sporting activity
      • Stair climbing, other than to move locations throughout the home
  • The student moves to Stage 2a when:
    • The student tolerates light physical activities (completes both activities permitted from Stage 1) and has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
    • The student has completed a minimum of 24 hours at Stage 1.
  • However:
    • The student must return to the previous stage for a minimum of 24 hours when they have exhibited or reported a return of symptoms, or new symptoms.
    • The student must return to a medical doctor or nurse practitioner when they have exhibited or reported a worsening of symptoms.

Stage 2a

  • Daily activities that do not provoke symptoms.
  • Add additional movements that do not increase breathing and/or heart rate or break a sweat.
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • Light physical activity (for example, use of stairs)
      • 10-15 minutes slow walking 1-2x per day inside and outside (weather permitting)
    • Activities that are not permitted at this stage:
      • Physical exertion (increases breathing and/or heart rate and sweating)
      • Sports
      • Sporting activities
  • The student moves to Stage 2b when:
    • The student tolerates daily physical activities (completes activities permitted in Stage 2a) and has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
    • The student has completed a minimum of 24 hours at Stage 2a
  • However:
    • The student must return to the previous stage for a minimum of 24 hours when they have exhibited or reported a return of symptoms, or new symptoms.
    • The student must return to a medical doctor or nurse practitioner when they have exhibited or reported a worsening of symptoms.

Stage 2b

  • Light aerobic activity
    • Activities permitted if tolerated by student:
      • Activities from previous stage
      • 20-30 minutes walking/stationary cycling/recreational (that is, at a pace that causes some increase in breathing/heart rate but not enough to prevent a student from carrying on a conversation comfortably)
    • Activities that are not permitted at this stage:
      • Resistance or weight training
      • Physical activities with others
      • Physical activities using equipment
  • The student moves to Stage 3 when:
    • The student tolerates light aerobic activities (completes activities permitted in Stage 2b) and has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms
    • The student has completed a minimum of 24 hours at Stage 2b.
  • However:
    • The student must return to the previous stage for a minimum of 24 hours when they have exhibited or reported a return of symptoms, or new symptoms.
    • The student must return to a medical doctor or nurse practitioner when they have exhibited or reported a worsening of symptoms.

Parent/Guardian

My child/ward has successfully completed the stages of Initial Rest to Stage 2 of the Concussion Management Plan for Return to School and the stages of Initial Rest to Stage 2b of the Concussion Management Plan for Return to Physical Activity and is ready to return to school.
Signature
Date:
Comments: