What is the best concussion assessment and management protocol for an athletic trainer to follow?

For a certified athletic trainer (AT), the gold standard for concussion assessment and management aligns with the international consensus framework (such as the Concussion in Sport Group Consensus Statement ) and guidelines established by the National Athletic Trainers' Association (NATA).

The protocol relies on a multimodal, objective, and conservative approach summarized across the key phases of care:

1. Recognition and Immediate Removal ("When in Doubt, Sit Them Out")

• Immediate Removal: If a concussion is suspected—either through observed mechanism, visible signs (e.g., blank stare, ataxia, tonic posturing), or reported symptoms—the athlete must be immediately removed from play and not returned that day.
• Red Flag Evaluation: Screen immediately for emergency indicators (spine injury, worsening confusion, repeated vomiting, deteriorating conscious state) to activate the Emergency Action Plan (EAP).

2. Acute Sideline Assessment (First 72 Hours)

Move the athlete to a quiet area off-field away from game pressure to conduct a 10–15 minute multimodal evaluation. Utilize the updated Sport Concussion Assessment Tool (SCAT6) or Concussion Recognition Tool (CRT6) depending on medical credentials. A comprehensive acute assessment includes:

• Symptom Graded Checklist: Rate severity across 22 distinct symptoms (headache, dizziness, fog, etc.).
• Cognitive Screening: Assess orientation, immediate recall, and concentration/digits backward.
• Balance & Coordination: Evaluate postural stability using tests like the Balance Error Scoring System (BESS) or tandem gait.
• Neurological Screen: Check cranial nerves, ocular movements, and gross motor/sensory function.

3. Subacute Management & Referral (72 Hours to Weeks)

• Physician Referral: Coordinate a formal evaluation with a team physician or a healthcare provider experienced in concussion management. For serial tracking in a clinic or athletic training room past the initial 72 hours, utilize the Sport Concussion Office Assessment Tool (SCOAT6).
• Relative Rest vs. Active Recovery: Advise relative physical and cognitive rest for only the initial 24 ÷ 48 hours. Strict, prolonged cocooning is discouraged; light, symptom-limited physical activity (like walking) and controlled cognitive tasks can be introduced early if kept below a threshold that exacerbates symptoms (1–2 point increase on a 10-point scale).

4. Graduated Stepwise Progression

Do not start a formal progression until the athlete is completely asymptomatic and cleared by a physician (where state or institutional law requires).

• Return-to-Learn (RTL) First: Academic accommodations and gradual integration back into the classroom must precede heavy athletic exertion.
• Return-to-Sport (RTS) Progression: Advance through the monitored, multi-stage protocol (light aerobic exercise → sport-specific exercise → non-contact drills → full-contact practice → unrestricted return). Each step should take a minimum of 24 hours, dropping back a step if symptoms recur.

Would you like me to detail the specific stages of the Return-to-Sport/Return-to-Learn progression or break down how to interpret baseline vs. post-injury test metrics?

The current best-practice protocol for an athletic trainer is based on the 2022 Amsterdam International Consensus Statement on Concussion in Sport, along with guidance from the National Athletic Trainers' Association (NATA) and sport governing bodies (e.g., NCAA, NFHS). The emphasis has shifted from prolonged rest to early recognition, immediate removal from play, multimodal assessment, early symptom-limited activity, and a graduated return-to-learn (RTL) and return-to-sport (RTS) progression.

1. Immediate On-Field Recognition

If concussion is suspected:

• Remove the athlete from play immediately.
• "When in doubt, sit them out."
• Never allow same-day return to play after a suspected concussion.
• Activate emergency action protocols if red flags are present.

Red Flags (EMS Activation)

• Declining level of consciousness
• Repeated vomiting
• Seizure
• Increasing confusion or agitation
• Neck pain or suspected cervical spine injury
• Focal neurological deficits
• Severe worsening headache
• Loss of consciousness with persistent symptoms

These require emergency medical evaluation rather than routine concussion management.

---

2. Sideline Assessment

Primary Survey

• Airway
• Breathing
• Circulation
• Cervical spine stabilization if indicated

Initial Neurologic Screen

Assess:

• Orientation
• Speech
• Cranial nerve abnormalities
• Motor function
• Balance
• Eye tracking
• Visible signs

If concussion remains suspected:

Do not return the athlete to participation.

---

3. Perform SCAT6

The SCAT6 is now the preferred standardized sideline assessment for healthcare professionals.

It includes:

• Symptom evaluation
• Cognitive screening
• Immediate memory
• Concentration
• Neurological screen
• Balance testing
• Delayed recall

The SCAT6 is most useful within the first 72 hours (and up to one week) after injury. It should take approximately 10–15 minutes and be performed in a quiet environment.

---

4. Additional Vestibular/Ocular Assessment

Many athletic trainers also include:

• Vestibular/Ocular Motor Screening (VOMS)
• Near-point convergence
• Smooth pursuits
• Saccades
• Vestibulo-ocular reflex
• Visual motion sensitivity

These help identify vestibular and ocular impairments that may benefit from targeted rehabilitation.

---

5. Serial Reassessment

Symptoms evolve.

Reassess:

• 15–30 minutes later (if appropriate)
• Later that day
• 24–48 hours
• Daily thereafter

Serial examinations are more informative than a single assessment.

---

6. Referral

Refer promptly if:

• Symptoms worsen
• Red flags develop
• Symptoms persist
• Multiple prior concussions
• Significant neurologic findings
• Academic or psychological concerns
• Pediatric athlete with prolonged symptoms

---

7. Initial Management

Older recommendations for strict "cocoon therapy" have changed.

Current recommendations:

• Relative physical and cognitive rest for 24–48 hours
• Avoid activities that significantly worsen symptoms
• Encourage light activities of daily living
• Reduce (rather than eliminate) screen time initially

After 24–48 hours:

Begin light symptom-limited aerobic activity if tolerated. Early, controlled exercise is associated with improved recovery compared with prolonged inactivity.

---

8. Return-to-Learn (RTL)

Academic recovery should generally precede unrestricted sport participation.

Typical progression:

1. Relative cognitive rest
2. Light schoolwork at home
3. Partial school attendance
4. Full school with accommodations
5. Full academics without accommodations

---

9. Graduated Return-to-Sport (RTS)

Each stage generally lasts at least 24 hours, and the athlete should remain symptom-free before progressing.

If symptoms recur:

• Stop activity.
• Return to the previous asymptomatic stage after symptoms resolve.

---

10. Persistent Symptoms (>10–14 Days in Adults or >4 Weeks Overall)

Evaluate for:

• Vestibular dysfunction
• Cervical spine impairment
• Migraine
• Anxiety/depression
• Sleep disturbance
• Oculomotor dysfunction

Management may include:

• Vestibular rehabilitation
• Cervical physical therapy
• Vision therapy
• Graded aerobic exercise
• Behavioral health support
• Multidisciplinary referral when appropriate

---

Best Documentation for Athletic Trainers

Document:

• Mechanism of injury
• Witness reports
• Observable signs
• Symptom scores
• SCAT6 findings
• Neurological examination
• Balance assessment
• VOMS findings (if used)
• Parent/guardian notification
• Physician communication
• Daily symptom progression
• Return-to-learn progress
• Return-to-sport stage
• Final medical clearance

---

Baseline Testing

Preseason baseline testing (e.g., cognitive or balance tests) can provide helpful comparison data for some athletes, but it should not be used in isolation to diagnose or clear a concussion. Clinical judgment and a multimodal assessment remain the standard.

Bottom line

For most athletic trainers, an evidence-based concussion protocol is:

1. Recognize and remove from play immediately.
2. Rule out emergencies and cervical spine injury.
3. Perform a multimodal assessment using SCAT6 (and VOMS if available).
4. No same-day return to play.
5. Reassess serially over the next several days.
6. Begin relative rest for 24–48 hours, then early symptom-limited activity.
7. Progress through structured return-to-learn and six-stage return-to-sport protocols.
8. Refer for specialized care if recovery is prolonged or atypical.

This approach aligns with the latest international consensus and current sports medicine practice.

For an athletic trainer (AT), the gold standard for concussion assessment and management combines the guidelines from the International Concussion in Sport Group (CISG) Consensus Statement and the National Athletic Trainers’ Association (NATA) Position and Bridge Statements.

A best-practice protocol relies on a multimodal, objective, and individualized approach rather than any single test. The protocol is structured across four primary phases:

1. Recognition and Immediate Removal (Sideline Assessment)

• Mandatory Removal: Any athlete with actual or suspected signs of a concussion (loss of consciousness, tonic posturing, impact seizure, ataxia, blank stare, or confusion) must be immediately removed from play . Same-day return to play is strictly prohibited.
• Off-Field Evaluation: Move the athlete to a quiet area away from the pressure of the match. Allow at least 10--15 minutes for a thorough initial screening.
• Sideline Tools: Utilize the Sport Concussion Assessment Tool (SCAT6 or Child SCAT6) if within the acute 72-hour window, evaluating symptoms, cognitive function (immmediate memory, digits backward), balance, and delayed recall. Use the Concussion Recognition Tool (CRT6) to educate coaches and auxiliary staff on initial recognition.

2. Acute Management and Rest (First 24--48 Hours)

• Modified Rest: Strict, prolonged cocoon-style rest in a dark room is no longer recommended. Instead, encourage relative physical and cognitive rest for the first 24--48 hours, limiting screen time and activities that significantly exacerbate symptoms.
• Sub-Symptom Exertion: Early, light-intensity physical activity (such as walking or light stationary cycling) that does not provoke or worsen symptoms is now encouraged to facilitate recovery.
• Home-Care Instructions: Provide a standardized Concussion Home-Care Instruction Sheet to the athlete and their parents/roommates, restricting them from non-acetaminophen medications (like NSAIDs or aspirin during the acute bleeding-risk window) and alcohol.

3. Serial Evaluations and Multidisciplinary Care

• Daily Monitoring: Conduct daily focused clinical evaluations tracking symptom scores, sleep, and mood.
• Office & Subacute Tools: For evaluations past 72 hours or serial monitoring in a clinic/athletic training room, transition to the Sport Concussion Office Assessment Tool (SCOAT6). Incorporate vestibulo-ocular (vestibular/oculomotor) and cervical spine screenings, as neck and visual symptoms frequently overlap.
• Return-to-Learn (RTL) Prioritization: Coordinate with academic counselors and school nurses. Academic accommodations and a gradual return to the classroom must always precede the full return-to-sport progression.

4. Graduated Return-to-Sport (RTS) Progression

Once the athlete is completely asymptomatic (and returned to baseline cognitive/balance measures), advance them through the step-by-step RTS protocol. Each step should take a minimum of 24 hours:

1. Symptom-limited activity: Daily activities that do not provoke symptoms.
2. Light aerobic exercise: Walking or stationary cycling at 70% maximum heart rate; no resistance training.
3. Sport-specific exercise: Running or skating drills; no head impact activities.
4. Non-contact training drills: Harder drills, passing sequences; may start progressive resistance training.
5. Full-contact practice: Following medical clearance, participate in normal training activities.
6. Return to sport: Normal game/competition play.

If symptoms recur at any step, the athlete must drop back to the previous asymptomatic level before attempting to progress again.

If you'd like to narrow this down, let me know:

• Is your setting high school, collegiate, or clinical/outpatient?
• Do you have access to baseline computerized neurocognitive testing (such as ImPACT or HeadCheck) or force-plate balance systems?

I can tailor the specific documentation or referral criteria to your exact workflow.

The current best practice for an athletic trainer is based on the Amsterdam 2022 International Consensus Statement on Concussion in Sport (published 2023), which updated the SCAT and return-to-play guidelines. Rather than relying on a single test, the recommended approach is a multimodal assessment combined with serial follow-up and a graduated return-to-learn and return-to-sport progression.

1. Immediate on-field assessment

Recognize and remove

• Suspect concussion after any direct or indirect blow to the head.
• Immediately remove the athlete from play.
• When in doubt, sit them out.
• The athlete should not return to play the same day if concussion is suspected.

Screen for red flags

Activate EMS immediately if any of the following are present:

• Deteriorating level of consciousness
• Repeated vomiting
• Seizure
• Neck pain or cervical spine concern
• Increasing confusion or agitation
• Focal neurological deficits
• Severe or worsening headache
• Unequal pupils
• Loss of consciousness with persistent altered mental status

Manage airway, breathing, circulation, and cervical spine according to emergency protocols.

---

2. Sideline evaluation

The preferred sideline tool is the SCAT6 (or Child SCAT6 for ages 8–12).

A comprehensive evaluation includes:

• Symptom checklist
• Orientation
• Immediate memory
• Concentration
• Neurological screening
• Balance assessment (modified BESS)
• Delayed recall

The evaluation should occur in a quiet environment and generally takes 10–15 minutes. No single component should determine diagnosis by itself.

---

3. Clinical diagnosis

Diagnosis is based on:

• Mechanism of injury
• Observable signs
• Reported symptoms
• Cognitive findings
• Balance findings
• Clinical judgment

Normal computerized neurocognitive testing or balance testing does not rule out concussion.

Baseline testing can be helpful but is not required for diagnosis.

---

4. Initial management (first 24–48 hours)

Current recommendations no longer support prolonged "cocoon therapy."

Instead:

• Relative physical and cognitive rest for the first 24–48 hours
• Activities of daily living are encouraged
• Limit activities that substantially worsen symptoms
• Maintain hydration, sleep, and nutrition
• Avoid alcohol and high-risk activities

After 24–48 hours:

• Begin light symptom-limited aerobic exercise if tolerated.

---

5. Follow-up evaluation

Reassess within 24–48 hours.

Monitor:

• Symptom progression
• Cognitive function
• Balance
• Vestibular and ocular function
• Sleep
• Emotional symptoms
• School performance

If symptoms persist beyond the acute phase, the SCOAT6 is recommended for office-based serial assessment.

---

6. Return-to-learn

Students should return to school as soon as tolerated.

Recommendations include:

• Shortened school days if needed
• Academic accommodations
• Breaks during class
• Reduced screen time if symptoms worsen
• Gradual increase in workload

Complete symptom resolution is not required before returning to school.

---

7. Graduated return-to-sport

Each stage should generally last at least 24 hours. If symptoms recur, the athlete returns to the previous asymptomatic stage.

The Amsterdam consensus added a clearance step before non-contact drills, requiring symptom resolution (including after exertion) and normalization of cognitive findings before progressing.

---

8. Persistent symptoms (>2–4 weeks)

Refer for multidisciplinary evaluation if symptoms persist.

Potential referrals include:

• Sports medicine physician
• Neurologist
• Vestibular rehabilitation
• Neuropsychology
• Vision therapy
• Physical therapy
• Mental health services

Targeted rehabilitation should address the specific impairments (e.g., vestibular dysfunction, cervical issues, migraine, mood symptoms).

Practical protocol for athletic trainers

Many athletic trainers use a workflow like this:

1. Remove athlete from play immediately.
2. Assess for cervical spine injury and emergency red flags.
3. Perform a multimodal sideline assessment (SCAT6/Child SCAT6).
4. Notify parents/guardians (if applicable), coaches, and the supervising physician according to protocol.
5. Provide written concussion instructions.
6. Reassess within 24–48 hours.
7. Coordinate return-to-learn.
8. Begin symptom-limited aerobic exercise after 24–48 hours if appropriate.
9. Progress through the graduated return-to-sport protocol.
10. Document each assessment and progression step thoroughly.

This approach aligns with the latest international consensus and is widely regarded as the current evidence-based standard for athletic trainers managing sport-related concussion.

The current best-practice protocol for an athletic trainer is based on the 2022 Amsterdam International Consensus Statement on Concussion in Sport, which underpins the most up-to-date concussion tools (SCAT6, Child SCAT6, CRT6, and SCOAT6). Athletic trainers should also follow their state practice act, school or organization policies, and applicable physician standing orders.

Evidence-based concussion assessment protocol

1. Recognize and remove immediately

If an athlete has a suspected concussion:

• Remove them from play immediately.
• Do not allow same-day return to play.
• Assume concussion until proven otherwise.
• Monitor closely because symptoms can evolve over several hours.

2. Rule out emergency conditions

Immediately activate emergency medical services if the athlete develops any red flags, including:

• Declining level of consciousness
• Repeated vomiting
• Increasing confusion or agitation
• Seizure
• Focal neurological deficits
• Unequal pupils
• Severe or worsening headache
• Suspected cervical spine injury
• Significant neck pain
• Persistent unconsciousness

Maintain cervical spine precautions whenever the mechanism or symptoms suggest possible spinal injury.

3. Perform a sideline assessment

The current preferred assessment includes:

• Symptom evaluation
• Observable signs
• Glasgow Coma Scale
• Cervical spine examination
• Cranial nerve screening
• Orientation and memory testing
• Concentration testing
• Balance assessment
• Coordination testing
• Neurological screening

The recommended tools are:

• SCAT6 (ages ≥13)
• Child SCAT6 (ages 8–12)
• CRT6 for initial recognition by non-medical personnel

The SCAT6 is most useful within the first 72 hours (and up to about one week) after injury.

4. Document thoroughly

Documentation should include:

• Mechanism of injury
• Immediate symptoms
• Witness reports
• Neurological findings
• SCAT6 findings
• Balance results
• Memory testing
• Vital signs if obtained
• Communication with parents, coaches, physicians, or guardians
• Return precautions

Early management

Relative rest—not strict bed rest

Current evidence no longer recommends complete physical and cognitive rest.

Instead:

• Relative rest for the first 24–48 hours
• Activities of daily living as tolerated
• Reduced screen time initially
• Avoid activities with risk of another head impact

Light walking is appropriate if symptoms do not significantly worsen.

Medical referral

Refer for physician evaluation when:

• Symptoms are severe or worsening
• Neurological deficits are present
• Symptoms persist
• There is uncertainty regarding diagnosis
• School or state regulations require physician involvement

Return-to-learn

Before full return to sport:

• Gradually resume school participation
• Allow symptom-limited cognitive activity
• Use accommodations if necessary:
  • Reduced workload
  • Frequent breaks
  • Extra testing time
  • Reduced screen exposure

Return-to-learn and return-to-sport should progress together.

Graduated return-to-sport progression

Each stage should take at least 24 hours, and the athlete should return to the previous successful stage if symptoms recur.

Progression to stages involving head-impact risk should occur only after complete symptom resolution, a normal clinical examination, and clearance according to organizational or legal requirements.

Persistent symptoms (>2–4 weeks)

Athletes with prolonged recovery may benefit from:

• Vestibular rehabilitation
• Cervical spine assessment and treatment
• Vision or oculomotor therapy
• Supervised subsymptom aerobic exercise
• Neuropsychological evaluation when indicated
• Referral to a multidisciplinary concussion specialist

Persistent symptoms should not be managed with prolonged inactivity alone.

Practical athletic trainer checklist

• ✓ Remove athlete immediately after suspected concussion.
• ✓ No same-day return to play.
• ✓ Rule out cervical spine injury and emergency red flags.
• ✓ Perform SCAT6 or Child SCAT6.
• ✓ Document findings carefully.
• ✓ Educate athlete and family about warning signs.
• ✓ Recommend relative rest for 24–48 hours.
• ✓ Begin symptom-limited activity, then early light aerobic exercise as tolerated.
• ✓ Guide return-to-learn.
• ✓ Supervise the graduated return-to-sport progression.
• ✓ Refer appropriately if symptoms persist or worsen.

For most athletic trainers working in secondary schools, colleges, or sports medicine clinics, this protocol reflects the current international standard of care and aligns well with guidance from organizations such as the Concussion in Sport Group and contemporary sports medicine practice.

The best concussion assessment and management protocol for an athletic trainer (AT) is a multifaceted, evidence-based approach that emphasizes immediate removal from play, objective assessment (including baseline comparisons), a gradual return-to-learn and return-to-play (RTP) progression, and, when necessary, a multidisciplinary team approach.

Following the 6th International Conference on Concussion in Sport (Amsterdam, 2022) , which often underpins current NATA position statements, the protocol is structured as follows:

1. Recognition and Immediate Action (Sideline)

• Recognize, Remove, Refer: If a concussion is suspected, the athlete must be removed from play immediately ("When in doubt, sit them out").
• Initial Assessment: Use the Sport Concussion Assessment Tool (SCAT6 or child SCAT6) , which includes Maddocks questions , Glasgow Coma Scale (GCS), and symptom evaluation.
• Emergency Check: Look for "red flags" (deteriorating consciousness, increasing confusion, neck pain) requiring immediate emergency referral.

2. Acute Management (First 24–48 Hours)

• Initial Rest: A brief period of relative rest (24-48 hours) is recommended, avoiding physical or mental exertion that worsens symptoms.
• Avoid Total "Cocooning": Active rest (e.g., light walking) is preferred over strict bed rest.
• Documentation: Record the injury time and symptom severity to monitor recovery progress.

3. Assessment and Diagnostic Tools

• Multifaceted Assessment: A best-practice assessment includes a 3-domain minimum: symptoms, cognition (e.g., memory), and balance.
• Baseline Testing: Conduct pre-season baseline testing (cognitive and balance) on athletes, especially in high-risk sports, to compare against post-injury results.
• Vestibular-Ocular Screening: Include assessment of vestibular-ocular function (e.g., VOMS tool) to identify specific dizziness or visual symptoms.

4. Management and Treatment

• Referral: All athletes with a suspected concussion must be evaluated by a physician or other licensed healthcare professional.
• Sub-symptom Activity: Initiate sub-symptom threshold activity (e.g., light exercise) once the initial 24–48 hour rest period passes, if symptoms allow.
• Academic Accommodations: Coordinate with schools for a "return-to-learn" protocol, reducing cognitive load if needed.

5. Return-to-Play (RTP) Protocol

• Stepwise Progression: Utilize a gradual 6-step progression, moving to the next step only if the previous step is completed without symptom exacerbation:
  1. Symptom-limited activity: Daily activities that don't increase symptoms.
  2. Light aerobic exercise: Walking, stationary bike.
  3. Sport-specific exercise: Running, dribbling.
  4. Non-contact training drills: Harder training, passing drills.
  5. Full-contact practice: Following medical clearance.
  6. Return to sport: Full competition.
• Clearance: The final return to full contact must be approved by a physician.

6. Key Considerations

• Compliance: Always comply with state laws (e.g., Lystedt Law ) and organizational policies (e.g., NCAA or high school association).
• Documentation: Meticulously document all assessments and the, RTP process.
• Education: Educate coaches, athletes, and parents on symptoms and the importance of reporting injuries.

Would you like me to provide the specific, in-depth components of the SCAT6 tool or a sample return-to-learn academic accommodation plan?

The best protocol for an athletic trainer (AT) is one that combines the latest international consensus recommendations, current athletic training guidance, and any state or governing body requirements (e.g., NCAA, NFHS, state concussion laws). The current gold standard is based on the 2022 Amsterdam International Consensus Statement, which introduced the SCAT6, Child SCAT6, CRT6, and SCOAT6, together with updated return-to-learn and return-to-sport recommendations.

A practical protocol looks like this:

1. Immediate On-Field Recognition

Any athlete with a suspected concussion should be managed as though they have one until proven otherwise.

Immediately:

• Remove the athlete from participation.
• Do not allow same-day return to play if concussion is suspected.
• Evaluate for emergency conditions.

Red flags requiring EMS activation

• Declining level of consciousness
• Repeated vomiting
• Seizure
• Worsening headache
• Unequal pupils
• Neck pain with neurological deficits
• Significant weakness or numbness
• Suspected cervical spine injury

2. Sideline Assessment

After life-threatening injuries are excluded:

Perform a multimodal assessment using:

• CRT6 for recognition by coaches or first responders.
• SCAT6 (or Child SCAT6 for ages 8–12) when performed by a trained healthcare professional.
• Cervical spine examination
• Cranial nerve screen
• Symptom evaluation
• Cognitive assessment
• Balance testing
• Coordination testing
• Memory testing

The SCAT6 is most useful within the first 72 hours and up to one week after injury. It should not be used as the sole determinant of return to play.

3. Initial Management (First 24–48 Hours)

Provide:

• Relative physical rest
• Relative cognitive rest
• Hydration
• Adequate sleep
• Avoid alcohol and recreational drugs
• Limit activities that markedly worsen symptoms

Current recommendations do not support prolonged "dark room" or strict bed rest. Light daily activities are encouraged as tolerated after the first 24–48 hours.

4. Serial Reassessment

Reassess:

• Symptoms
• Neurological status
• Balance
• Cognition
• Vestibular and ocular function
• Exertional tolerance

Consider additional testing when indicated:

• Vestibular/Ocular Motor Screening (VOMS)
• Neurocognitive testing (e.g., ImPACT or similar) as an adjunct—not a stand-alone clearance tool
• SCOAT6 after 72 hours if symptoms persist

5. Return-to-Learn

Student-athletes should gradually resume academics before full athletic participation.

Progression:

1. Home activities
2. Partial school attendance
3. Full school attendance with accommodations
4. Full academic participation

Temporary accommodations may include:

• Reduced screen time
• Extra time for assignments/tests
• Rest breaks
• Reduced homework
• Modified class schedule

6. Graduated Return-to-Sport

Once symptoms are resolving and the athlete has medical clearance to begin progression:

Key points:

• Minimum 24 hours between stages.
• If symptoms recur, stop activity, allow symptoms to settle, and resume at the previous successful stage.
• Progression is individualized and often takes more than one week.

7. Clearance Criteria

Before unrestricted competition, the athlete should have:

• No concussion symptoms at rest
• No symptoms with maximal exertion
• Normal neurological examination
• Normal balance and vestibular findings
• Cognitive function returned to baseline or age-appropriate norms
• Successful completion of the graduated return-to-sport protocol
• Clearance according to state law and team physician or designated qualified healthcare provider requirements.

8. Referral

Refer promptly if:

• Symptoms persist beyond approximately 2–4 weeks
• Vestibular dysfunction
• Ocular dysfunction
• Significant migraine symptoms
• Cervical dysfunction
• Mood changes
• Sleep disorders
• Multiple prior concussions
• Learning disabilities or other complex recovery factors

Referral may involve sports medicine physicians, neurologists, neuropsychologists, vestibular therapists, or vision specialists.

Documentation Best Practices

Athletic trainers should document:

• Mechanism of injury
• Witnessed signs
• Initial symptoms
• SCAT6 findings
• Neurological examination
• Balance assessment
• Communication with parents, coaches, and physicians
• Daily symptom scores
• Return-to-learn progression
• Return-to-sport progression
• Final medical clearance

Key Principles

• When in doubt, sit them out.
• No same-day return to play after a suspected concussion.
• Use a multimodal assessment rather than relying on a single test.
• Encourage early, symptom-limited activity after the initial 24–48 hours instead of prolonged strict rest.
• Return-to-learn and return-to-sport should occur in parallel, with medical oversight.
• Individualize management based on symptoms, examination findings, and recovery trajectory.

The best concussion assessment and management protocol for an athletic trainer (AT) is a multi-faceted, objective, and evidence-based approach that emphasizes immediate removal from play, rapid evaluation, and a staged, symptom-guided return to learn and play.

Following the NATA Position Statement and international consensus (such as the 6th International Conference in Amsterdam), the following protocol is considered best practice:

1. Immediate Action (Sideline Assessment)

• Recognize and Remove: If a concussion is suspected, the athlete must be removed from play immediately ("When in doubt, sit them out").
• Initial Assessment (Sideline): Use a tool like the SCAT6 (Sport Concussion Assessment Tool) (or child version for under 12) which includes symptom checklists, cognitive screening (Maddocks questions), and balance assessments.
• Evaluate "Red Flags": Immediate referral to emergency care for red flags (e.g., loss of consciousness, worsening headache, seizure, focal neurologic deficits).

2. Acute Evaluation (Within 24-48 Hours)

• Clinical Examination: Perform a comprehensive evaluation, including:
  • Symptom Checklist: Document symptoms (headache, dizziness, nausea, etc.).
  • Cognitive Function: Test memory, attention, and concentration.
  • Vestibular-Ocular Screening: Assess for eye-tracking issues, dizziness, or fogginess (e.g., VOMS testing).
  • Balance Evaluation: Perform postural stability tests (e.g., BESS test).
• Compare to Baseline: Compare results against pre-season baseline tests (if available).

3. Management and Recovery

• Referral: All concussions should be evaluated by a physician or qualified healthcare professional.
• Relative Rest (24-48 hours): The first 24–48 hours should involve limited physical and cognitive activity (no "cocoon therapy" in a dark room, but rather light, low-intensity activity).
• Stepwise "Return to Learn": Initiate a graduated return to classroom activity (e.g., part-time, then full-time with accommodations) before returning to heavy physical activity.
• Individualized Approach: Management should be tailored to the individual's specific symptoms (e.g., addressing vestibular-ocular, migraine, or anxiety aspects).

4. Return to Participation (RTP) Protocol

• Asymptomatic State: The athlete must be asymptomatic at rest and off medication before starting the return-to-play progression.
• 6-Step Progression:
  1. Step 1: Symptom-limited activity: Daily activities that don't provoke symptoms.
  2. Step 2: Light aerobic exercise: Walking, stationary biking (5–10 mins).
  3. Step 3: Sport-specific exercise: Running drills, no head impact activities.
  4. Step 4: Non-contact training drills: Harder drills, passing, cognitive training.
  5. Step 5: Full-contact practice: Following medical clearance.
  6. Step 6: Return to competition.
• Monitoring: The AT must supervise each step; if symptoms return, the athlete drops back to the previous step for at least 24 hours.

Best Practices Checklist

• Document Everything: Meticulously document all evaluations, symptoms, and progression steps.
• Multidisciplinary Team: Collaborate with team physicians, school nurses, and neuropsychologists.
• Annual Review: Review concussion protocols, policies, and education annually.

Would you like more information on the 6-step return to play protocol , specific vestibular rehabilitation techniques , or how to implement baseline testing in a high school setting?

The current best-practice protocol for an athletic trainer is based on the 2022 Amsterdam International Consensus Statement (published in 2023), integrated with established recommendations from the CDC and the National Athletic Trainers' Association (NATA). This approach emphasizes early recognition, immediate removal from play, a multimodal assessment, relative rest (not prolonged complete rest), and a graduated return-to-learn and return-to-sport progression.

1. Immediate Sideline Assessment

Any athlete with a suspected concussion should be removed from play immediately.

Immediate "red flag" signs requiring emergency activation (EMS):

• Declining level of consciousness
• Repeated vomiting
• Seizure
• Neck pain or suspected cervical spine injury
• Focal neurological deficits
• Worsening headache
• Significant confusion or agitation
• Unequal pupils
• Persistent loss of consciousness

Maintain cervical spine precautions when indicated.

Do not allow same-day return to play if concussion is suspected.

---

2. Sideline Evaluation

Primary survey

• Airway
• Breathing
• Circulation
• Cervical spine

Observe for visible signs

• Blank or vacant stare
• Disorientation
• Poor balance
• Slow responses
• Motor incoordination
• Behavioral change
• Amnesia

Use standardized tools

The preferred tools are:

• SCAT6 (ages ≥13)
• Child SCAT6 (ages 8–12)
• CRT6 for initial recognition by non-medical personnel

The SCAT6 includes:

• Symptom evaluation
• Orientation
• Immediate memory
• Concentration
• Neurological screen
• Balance testing
• Delayed recall

These tools are most useful during the first 72 hours (and up to one week) after injury.

---

3. Clinical Examination

Document:

• Mechanism of injury
• Previous concussion history
• Loss of consciousness
• Amnesia
• Symptom severity
• Cranial nerve screening
• Cervical spine examination
• Balance and gait
• Vestibular/ocular findings
• Cognitive function

Many athletic trainers also perform:

• Vestibular/Ocular Motor Screening (VOMS)
• Near point convergence
• Tandem gait
• King-Devick test (if part of institutional protocol)

These complement—but do not replace—a clinical examination.

---

4. Initial Management (First 24–48 Hours)

Current recommendations have shifted away from "complete brain rest."

Instead:

Relative Rest

Allow:

• Walking
• Normal activities of daily living
• Light cognitive activity as tolerated

Avoid:

• Contact sports
• Heavy lifting
• Vigorous exercise
• Activities that substantially worsen symptoms

Research supports early, symptom-limited activity rather than prolonged inactivity.

---

5. Daily Monitoring

Monitor:

• Symptom scores
• Sleep
• Headache severity
• Balance
• Cognitive status
• School participation
• Vestibular symptoms

Serial reassessments are recommended, particularly during the first several days after injury.

---

6. Return-to-Learn

School should return before unrestricted sport.

Typical progression:

1. Relative cognitive rest
2. Light schoolwork at home
3. Partial school attendance
4. Full school attendance with accommodations if needed
5. Full academic participation

Most athletes do not need prolonged absence from school.

---

7. Graduated Return-to-Sport (RTS)

Each step should take at least 24 hours, and the athlete should only advance if symptoms do not worsen. If symptoms recur, stop the activity and resume at the previous successful stage after symptoms have settled.

---

8. Clearance Criteria

Before full return to contact sport, the athlete should have:

• No concussion symptoms at rest
• No symptoms with exertion
• Normal neurological examination
• Normal balance
• Normal cognition relative to baseline or expected norms
• Completion of the graduated RTS progression
• Clearance according to state law and team/physician protocols where applicable

---

9. Documentation

Document:

• Injury mechanism
• Witness statements
• Initial symptoms
• SCAT6 findings
• Neurological examination
• Balance assessment
• Parent/guardian communication
• Physician referral
• Daily symptom progression
• Return-to-learn progression
• Return-to-sport progression
• Final clearance

Comprehensive documentation is both a clinical and legal best practice.

Practical "gold standard" workflow for an athletic trainer

1. Suspect concussion → remove from play immediately.
2. Assess ABCs and cervical spine; identify emergency red flags.
3. Perform a multimodal assessment (SCAT6/Child SCAT6, symptom inventory, neurological exam, balance, cognition, and vestibular/ocular screening as appropriate).
4. No same-day return to play if concussion is suspected.
5. Provide written home care instructions and refer for medical evaluation when indicated.
6. Recommend 24–48 hours of relative rest, then begin symptom-limited physical and cognitive activity.
7. Reassess regularly, using serial symptom and clinical evaluations.
8. Guide return-to-learn alongside recovery.
9. Progress through the six-step return-to-sport protocol, advancing no faster than one stage every 24 hours if symptom-free.
10. Return to unrestricted play only after clinical recovery, successful completion of the progression, and appropriate medical clearance.

This protocol reflects the current international consensus and is the approach most commonly recommended for athletic trainers working in secondary schools, colleges, and sports medicine settings.

The best concussion assessment and management protocol for athletic trainers is a multidimensional, individualized, and staged approach anchored in the consensus guidelines from the 6th International Conference on Concussion in Sport (Amsterdam, 2022) and the National Athletic Trainers’ Association (NATA) Position Statement.

A best-practice protocol consists of these five pillars:

1. Preparation (Baseline Testing)

2. Recognition & Immediate Removal ("When in doubt, sit them out")

3. Acute Assessment (Sideline Evaluation)

4. Management & Rehabilitation (Recovery Phase)

5. Graduated Return-to-Learn and Return-to-Play

6. Preparation: Annual Baseline Testing

Establish an athlete's normal brain function before the season, ideally every two years.

• Components: Symptom checklist, cognitive testing (e.g., ImPACT ), and postural stability/balance testing (e.g., BESS or Sway apps).
• Assessment: Include neurocognitive and ocular-motor screenings.

2. Immediate Removal (The 3 R's)

Recognize, Remove, and Refer.

• Policy: Anyone suspected of having a concussion must be immediately removed from play and cannot return the same day, regardless of whether symptoms improve.
• Action: Evaluate on the sideline using the SCAT6 (Sport Concussion Assessment Tool) (the current standard).

3. Acute Assessment (Sideline & 24-48 hours)

• Clinical Examination: Perform a comprehensive evaluation including symptom score, cognitive function, and postural stability.
• Key Tools: SCAT6 or Child SCAT6 (for ages 12 and under), Maddocks questions, and vestibular-ocular reflex (VOR) testing.
• Documentation: Meticulously document all signs/symptoms, and repeat assessments 24–48 hours post-injury to track progress.

4. Management & Rehabilitation

• Initial Rest: A brief period of rest (24–48 hours) is beneficial, but "cocooning" (long-term dark room rest) is harmful.
• Active Recovery: After 48 hours, introduce sub-symptom-threshold, light physical activity (e.g., walking, stationary biking).
• Multidisciplinary Care: If symptoms persist beyond 4 weeks, refer to specialists for vestibular, ocular, or cervicogenic rehabilitation.

5. Graduated Return-to-Play (RTP) Protocol

The athlete must be fully asymptomatic without the aid of medication before starting the 6-stage protocol.

1. Symptom-limited activity: Daily activities that do not provoke symptoms.
2. Light aerobic exercise: Walking or stationary cycling (no resistance training).
3. Sport-specific exercise: Running drills, no head impact.
4. Non-contact training drills: Harder training, passing drills.
5. Full-contact practice: Following medical clearance.
6. Return to competition.

• Note: If symptoms return, stop, rest, and resume at the previous asymptomatic step after 24 hours.

6. Return-to-Learn (RTL) Protocol

RTL should precede full RTP. This includes academic accommodations (e.g., reduced screen time, frequent breaks, reduced workload) in collaboration with school staff.

Key Takeaways for Athletic Trainers:

• Objective Data: Use tools like ImPACT and balance apps, but trust your clinical judgment.
• Physician Clearance: Mandatory before returning to contact sports.
• Follow Up: Ensure proper documentation of all symptoms and tests.

Would you like to discuss the specific differences between the SCAT5 and SCAT6 , or perhaps see a sample school-based return-to-learn plan?