Appendix E1: Concussion Management – Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) Plan
Student’s Name: _______________________________ Date: ___________________
This form is to be used by parent(s)/guardian(s) to track and to communicate to the school the student’s progress through the stages of the Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) Plan following a diagnosed concussion.
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Background Information on the Concussion Recovery Process
A student with a diagnosed concussion needs to follow an individualized and gradual Return to School Plan (RTS) and Return to Physical Activity Plan (RTPA). In developing the Plan, the RTS process is individualized to meet the particular needs of the student as there is not a pre-set plan of strategies and/or approaches to assist a student returning to their learning activities. In contract the RTA Plan follows an internationally recognized graduated approach,
The management of a student concussion is a shared responsibility, requiring regular communication between the Collaborative Team* and outside sports team (where appropriate).
· The Collaborative Team consists of the student, parents/guardians, staff and volunteers working with the student with consultation from the student’s medical doctor or nurse practitioner and/or licensed healthcare providers (for example, nurses. Physiotherapists, chiropractors and athletic therapists).
There are two parts to a student’s RTS and RTPA Plan. The first part of the plan occurs at home (refer to the Concussion Management – Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) Plan (Appendix E1) and prepares the student for the second part which occurs at school (refer to the School Concussion Management – Return to School (RTS) and Return to Physical Activity (RTPA) Plan (Appendix E2).
General Procedures for Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) Plan
· This Plan does not replace medical advice .
1. The home part of the plan begins with the Parent/Guardian communicating the diagnosis to the school principal. Reporting to non-school related concussion as well.
2. The school principal or designate will communicate information on the stages of RTS and RTPA plan that occur at home.
3. The stages of the plan occur at home under the supervision of the parent/guardian in consultation with the medical doctor/nurse practitioner and/or other licensed healthcare providers.
4. A student moves forward to the next stage when activities at the current stage are tolerated and the student has not exhibited or reported a return of symptoms, new symptoms, or worsening symptoms.
5. If symptoms return , or new symptoms appear at any stage in the Home Preparation for RTS and RTPA Plan, the student returns to previous stage for a minimum of 24 hours and only participates in activities that can be tolerated.
6. If at any time symptoms worsen , the student/parent/guardian contacts medical doctor/nurse practitioner or seeks medical help immediately.
7. While the RTS and RTA stages are inter-related they are not interdependent. Students do not have to go through the same stages of RTS and RTPA at the same time.
8. A student must not return to vigorous or organized physical activities where the risk of re-injury is possible, until they have successfully completed all stages of the Return to School Plan. Early introduction of some low intensity physical activity in controlled and predictable environment with no risk of re-injury is appropriate.
9. Progression through the Plan is individual; timelines and activities may vary.
10. Prior to the student returning to school the principal will identify and inform members of the collaborative team and designate a staff member to serve as the main point of contact for the student and the collaborative team.
INSTRUCTIONS
· Review the activities (permitted and not permitted) at each stage prior to beginning the Plan.
· Check ( ✔ ) the boxes at the completion of each stage to record student’s progress through the
stages.
· A student may progress through the RTS stages at a faster or slower rate than the RTPA stages.
· When the student has successfully completed all stages of the Home Preparation for RTS and RTPA Plan, parent(s)/guardian(s) must sign and date this form.
· Communicate to the school principal/designate that the student is ready to begin the school portion of the RTS and RTPA Plan (Appendix E2).
Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) Plan
To be completed by the Parent while student is at home
| Home Preparation for Return to School (RTS) Stages | Home Preparation for Return to Physical Activity (RTPA) Stages |
| Each stage must last a minimum of 24 hours | Each stage must last a minimum of 24 hours |
| RTS – Initial Rest
24 – 48 hours of relative cognitive rest (sample activities below): Sample activities permitted if tolerated by student
Activities that are not permitted at this stage
| RTPA – Initial Rest
24 – 48 hours of relative physical rest (sample activities below): Sample activities permitted if tolerated by student
Activities that are not permitted at this stage
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| Student moves to RTS Stage 1 when:
Symptoms start to improve or after resting 2 days maximum, or whichever occurs first. | Student moves to RTPA Stage 1 when:
Symptoms start to improve or after resting 2 days maximum, or whichever occurs first. |
Stage 1
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| RTS – Stage 1
Light cognitive (thinking / memory / knowledge) activities (as per activities permitted listed below: Gradually increase cognitive activity up to 30 minutes. Take frequent breaks.
Activities permitted if tolerated by student
Activities that are not permitted at this stage
| RTPA – Stage 1
Light physical activities (as per activities permitted listed below) 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
Activities that are not permitted at this stage
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| Student moves to RTS Stage 2 when:
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. Student has completed a minimum of 24 hours at RTS – Stage 1 | Student moves to RPTA Stage 2a when:
Student tolerates light physical activities (completes both activities above) and has not exhibited or reported a return of symptoms, new symptoms or worsening symptoms. Student has completed a minimum of 24 hours at RTPA – Stage 1
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| Student has exhibited or reported a return of symptoms and must return to the previous stage for a minimum of 24 hours.
Student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner. | Student has exhibited or reported a return of symptoms and must return to the previous stage for a minimum of 24 hours.
Student has exhibited or reported a worsening of symptoms and must return to medical doctor or nurse practitioner. |
Stage 2
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| RTS -Stage 2
Gradually add cognitive activity (as per activities permitted listed below). When light cognitive activity is tolerated, introduce school work (at home and facilitated by the school). Activities permitted if tolerated by student
· Crosswords, word puzzles, Sudoku, word search · Limited device use (for example, computer, laptop, tablet, iPad)/cell phone (for example, texting / games /photography) starting with shorter periods and building up as tolerated Activities that are not permitted at this stage
| RTPA –Stage 2a
Daily activities that do not provoke symptoms. Add additional movements that do not increase breathing and heart rate or break a sweat. Activities permitted if tolerated by student
· Light physical activity for example, use of stairs · 10 – 15 minute slow walking 1 – 2x per day inside and outside (weather permitting) Activities that are not permitted at this stage
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| Student moves to RTS Stage 3a when:
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. Student has completed a minimum of 24 hours at RTS – Stage 2 | Student moves to RTPA Stage 2b when:
Student tolerates daily physical activities (completes activities permitted listed above) and has not exhibited or reported a return of symptoms, new symptoms or worsening symptoms. Student has completed a minimum of 24 hours at RTPA – Stage 2a |
| Student has exhibited or reported a return of symptoms, or new symptoms and must return to the previous stage for a minimum of 24 hours. | Student has exhibited or reported a return of symptoms, or new symptoms and must return to the previous stage for a minimum of 24 hours. |
| Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. | Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. |
| RTPA – Stage 2b
Light aerobic activity Activities permitted if tolerated by student
Activities that are not permitted at this stage
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| Student moves to RTPA Stage 3 when:
Student tolerates light aerobic activities (completes activities above) and has not exhibited or reported a return of symptoms, new symptoms or worsening symptoms. Student has completed a minimum of 24 hours at RTPA – Stage 2b | |
| Student has exhibited or reported a return of symptoms, or new symptoms and must return to the previous stage for a minimum of 24 hours. | |
| Student has exhibited or reported a worsening of symptoms and must return to a medical doctor or nurse practitioner. |
Parent/Guardian communicates to school principal (by completing the following information on this form) that the student has completed RTS Stage 2 and RTPA Stage 2b and is ready to return to school and begin the school part of the Return to School and Return to Physical Activity Plan.
· My child has successfully completed all of the stages of the Home Preparation for Return to School (RTS) and Return to Physical Activity (RTPA) and is ready to return to school.
Parent/Guardian Signature: ______________________________ Date: _____________
Comments: ______________________________________________________________
The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulation. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be utilized only for the purpose of managing student learning and well-being. Access to this information will be limited to those who have an administrative need, to the student to whom the information relates and the parent(s)/guardian(s) of a student who is under 18 years of age. Any questions with respect to this information should be directed to the school principal.
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The school part of the Return to School Plan and the Return to Physical Activity Plan is now ready to begin. The plan begins with:
· Communication from the principal or designate to the Parent(s)/Guardian(s) to provide information on:
o The school part of the RTS and RTPA Plan (Appendix E2)
o Collaborative Team participants and parent(s)/guardian(s) role on the team.
· A Student assessment to determine possible strategies and/or approaches for student learning.
In accordance with the Municipal Freedom of Information and Protection of Privacy Act this information will be used solely to assess the student’s Return to Learn and Return to Physical Activity. It will be retained in the Ontario Student Record (OSR) for one year after the student graduates or transfers out of the school. The Ministry of Education may also request school reports on concussion activity. If you have any questions or concerns about the collection of information on this form, please contact the school principal.
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Reproduced and adapted with permission form Ophea, (Ontario Physical Education Safety Guidelines, 2018.