Concussion Assessment and Managemen… AI recommendations | Parse
What is the best concussion assessment and management protocol for an athletic trainer to follow?
Data as of Sep 26, 2026 · Based on 338 AI responses from ChatGPT Search and Google AI Mode · See how Parse measures this
Effective concussion management for athletic trainers relies on using validated sideline assessment tools like the SCAT-5/SCAT-6, supplemented by standardized symptom inventories and Vestibular/Ocular Motor Screening (VOMS) for multidimensional evaluation. Trainers should also utilize professional educational resources such as CDC HEADS UP to stay updated on management protocols and recovery processes like Return-to-Learn and Return-to-Play steps.
National Athletic Trainers' Association Position Statement: Management of Sport Concussion - PMChttps://pmc.ncbi.nlm.nih.gov/articles/PMC3975780/
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CONCUSSION MANAGEMENT PROTOCOL - University of Houston Athleticshttps://uhcougars.com/sports/2018/6/12/ot-sportsmed-concussion-html
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Responding to a Sports-related Concussion | HEADS UP | CDChttps://www.cdc.gov/heads-up/response/index.html
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Role of Athletic Trainers for Concussion Carehttps://impacttest.com/why-athletic-trainer-concussion-infographic/
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Management of Sport Concussion - NATAhttps://www.nata.org/sites/default/files/2025-08/management_of_sport_concussion.pdf
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National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion - PMChttps://pmc.ncbi.nlm.nih.gov/articles/PMC522153/
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Athletic Trainers' Concussion-Assessment and Concussion-Management Practices: An Update - PMChttps://pmc.ncbi.nlm.nih.gov/articles/PMC6961637/
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Athletic Trainers Role in Concussion Management | HEADCHECK Healthhttps://www.headcheckhealth.com/athletic-trainers-concussion-management/
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Checking your browser - reCAPTCHAhttps://pmc.ncbi.nlm.nih.gov/articles/PMC3445181/
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Concussion Protocol - St. Charles Health Systemhttps://stcharleshealthcare.org/services/center-orthopedics-and-neurosurgery/concussion-center/concussion-protocol
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Question: What is the best concussion assessment and management protocol for an athletic trainer to follow?
For an athletic trainer, I’d structure the protocol around the Amsterdam 2022 International Consensus Statement and the CDC’s current HEADS UP guidance. The key principle is: recognize → remove → rule out serious injury → assess → monitor → rehabilitate → graduated return to learn/sport.
1. Recognize and remove
If concussion is suspected:
Remove the athlete from play immediately.
Do not allow same-day return to play when a concussion is suspected.
Perform an immediate primary survey: airway, breathing, circulation, cervical-spine concerns, and level of consciousness.
Look for obvious neurological deterioration or another potentially serious injury.
If the athlete has a concerning mechanism or symptoms/signs suggesting a more serious brain or cervical-spine injury, activate emergency medical services.
Important red flags requiring emergency evaluation include worsening/severe headache, repeated vomiting, seizure, deteriorating consciousness, increasing confusion/agitation, focal neurological deficit, unequal pupils, significant neck pain/tenderness, or other signs of serious intracranial or cervical-spine injury.
The athlete should be serially reassessed, because concussion signs and symptoms can evolve over minutes, hours, or days.
For an athletic trainer (AT), the gold standard for concussion assessment and management is guided by the Amsterdam 2022 International Consensus Statement on Concussion in Sport and foundational frameworks like the NATA Management of Sport Concussion Guidelines.
Question: What is the best concussion assessment and management protocol for an athletic trainer to follow?
The best concussion assessment and management protocol for an athletic trainer (AT) is a multimodal, stepwise clinical protocol based on current concussion consensus guidelines—not reliance on a single test or score. The AT should combine clinical judgment, symptom evaluation, neurologic assessment, vestibular/ocular screening, balance testing, and a graduated return-to-learn/return-to-sport process. The 2024 National Athletic Trainers’ Association (NATA) Bridge Statement is one of the most directly relevant resources for AT practice.
Question: What is the best concussion assessment and management protocol for an athletic trainer to follow?
The gold standard framework for an athletic trainer (AT) to follow is a multidimensional concussion protocol grounded in the consensus guidelines from the International Conference on Concussion in Sport (currently utilizing the SCAT6 / Child SCAT6 frameworks) alongside the National Athletic Trainers' Association (NATA) Position Statement.
Question: What is the best concussion assessment and management protocol for an athletic trainer to follow?
For an acute suspected concussion, use the SCAT6 (or Child SCAT6 for the appropriate pediatric population) as part of a multimodal assessment.
Assess:
Observable signs
Orientation
Immediate memory
Concentration
Delayed recall
Self-reported symptoms
Neurological status
Balance
Coordination
Cervical spine
Vestibular/ocular findings as appropriate
Clinical response over time
The SCAT6 is most useful during the acute period—particularly the first 72 hours and up to approximately 5–7 days. It should not be treated as a stand-alone diagnostic test or clearance tool.
Computerized neurocognitive testing can provide additional information, but it should never be used in isolation to diagnose concussion or determine return to play.
3. Refer for medical evaluation
The athletic trainer should follow the team's emergency action plan and local/state requirements for medical referral.
The athlete should receive appropriate evaluation by a qualified healthcare professional when concussion is suspected. The trainer's assessment should be communicated to the treating clinician, including:
Mechanism and timing of injury
Immediate symptoms/signs
Loss of consciousness, if any
Amnesia
Seizure
Previous concussion history
Serial examination findings
SCAT6 findings
Any symptom changes
Documentation is particularly important.
4. First 24–48 hours: relative rest, not "cocooning"
Current evidence has moved away from prescribing complete physical and cognitive rest.
For approximately the first 24–48 hours:
Permit activities of daily living as tolerated.
Reduce activities that substantially aggravate symptoms.
Limit excessive screen time.
Encourage good sleep.
Light physical activity such as walking can be appropriate if it causes no more than mild, brief symptom exacerbation.
Avoid activities with risk of another head impact, collision, or fall.
Strict isolation and complete rest until every symptom disappears are not recommended.
5. Subacute reassessment
After the acute period, use serial clinical assessment rather than repeatedly relying on the acute SCAT6.
The SCOAT6 is designed for assessment beginning around 72 hours after injury and through the following weeks. It incorporates a broader multimodal examination, including symptoms, cognition, neurological examination, orthostatic measurements, cervical examination, balance/gait and other relevant domains.
Particularly assess symptom patterns involving:
Headache
Dizziness
Balance
Vestibular/ocular function
Neck pain
Exercise intolerance
Sleep
Cognitive function
Mood/behavior
School/work performance
6. Begin active rehabilitation
Once the athlete has tolerated the initial relative-rest period, progressively introduce activity.
The Amsterdam consensus supports early physical activity and subsymptom-threshold aerobic exercise rather than prolonged inactivity. Exercise should remain below the threshold that produces more than mild, brief symptom exacerbation.
For persistent problems, treatment should be targeted to the clinical profile—for example:
Cervicovestibular rehabilitation for appropriate dizziness/neck/headache presentations
Vestibular rehabilitation for vestibular/balance problems
Aerobic exercise rehabilitation for exercise intolerance
Appropriate headache management
Academic accommodations for cognitive symptoms
Persistent symptoms beyond approximately 4 weeks warrant multimodal reassessment and consideration of referral to clinicians with concussion-specific expertise.
7. Return-to-learn
For student-athletes, return to academics should occur alongside physical recovery.
Rather than requiring complete cognitive rest, gradually restore:
Normal daily activities
School attendance as tolerated
Increasing academic workload
Normal academic workload without accommodations
Potential temporary accommodations include reduced screen exposure, rest breaks, modified attendance, additional assignment time, and postponement of major tests.
Return-to-learn and return-to-sport should be coordinated rather than treated as completely separate processes.
8. Graduated return-to-sport
A practical framework is:
Stage
Activity
1
Symptom-limited daily activity
2A
Light aerobic exercise
2B
Moderate aerobic exercise
3
Individual sport-specific exercise
4
Non-contact training, higher intensity
5
Full-contact practice/training after medical authorization
6
Unrestricted return to sport
Each stage generally requires at least 24 hours. If symptoms recur, the athlete should stop, allow symptoms to return to their previous baseline, and resume at the preceding tolerated level rather than simply pushing through.
Crucially, the later stages involving risk of head impact should occur only after the athlete has achieved appropriate clinical recovery and received the required healthcare-professional authorization.
9. Clearance
Before unrestricted competition, the athlete should have:
No concussion-related symptoms at rest
No symptoms with cognitive exertion
No symptoms with physical exertion
Appropriate clinical examination findings
Successfully completed the graduated progression
Appropriate medical clearance under applicable law, school/organizational policy, and sport regulations
The Amsterdam consensus defines return to sport as completion of the progression without symptoms or clinical findings associated with the concussion at rest or with maximal physical exertion.
A practical athletic-trainer algorithm
Suspected concussion → Remove from play → Primary survey/red flags → Emergency referral if indicated → SCAT6/multimodal assessment → No same-day return → Medical evaluation → 24–48 h relative rest → Early tolerated activity → Serial reassessment/SCOAT6 → Individualized rehabilitation → Return-to-learn → Graduated RTS → Medical authorization for contact-risk activity → Full return
One particularly important point: SCAT6 is an assessment tool, not a "pass/fail" concussion test, and a normal SCAT6 does not by itself clear an athlete. The diagnosis and progression should be based on the whole clinical picture.
For implementation, the CDC also has a dedicated HEADS UP training course for athletic trainers, developed with the National Athletic Trainers' Association, covering evaluation, management, return-to-school/play, and documentation.
If you're developing an actual high-school/college athletic training concussion protocol, I can also lay this out as a one-page sideline algorithm/checklist that an AT could print and keep in the medical kit.
The gold standard protocol for concussion assessment and management is the multimodal evaluation framework outlined in the Concussion in Sport Group (CISG) Consensus Statement (Amsterdam, 2022) combined with standardized tools like the Sport Concussion Assessment Tool (SCAT6) and baseline neurocognitive testing.
Athletic trainers (ATs) must never rely on a single test; instead, they should implement a comprehensive, multi-domain approach from the moment of injury through the final return-to-play (RTP) progression.
Phase 1: Immediate Recognition and Sideline Evaluation
When a concussion is suspected, the primary directive is immediate removal from play—no athlete diagnosed or suspected of a concussion should return to activity on the same day.
Immediate Removal: Pull the athlete from participation immediately upon any suspected impact or symptom presentation.
Emergency Assessment: Check the ABCs (airway, breathing, circulation) and stabilize the cervical spine if a severe or catastrophic brain or neck injury is suspected.
Sideline Assessment Tools: Administer the SCAT6 (or Child SCAT6 for younger athletes) alongside rapid mobile or computerized neurocognitive tools (e.g., ImPACT or Sway Medical ) if baseline tests are available.
Vestibular-Ocular Screening (VOMS): Perform baseline balance (BESS test) and ocular-vestibular checks to catch functional deficits.
Phase 2: Post-Injury Management and Rest
Physical and Cognitive Rest: Recommend a brief period (24–48 hours) of relative physical and cognitive rest before initiating a gradual, symptom-limited return to activity. Complete cocoon therapy (strict isolation in dark rooms) is no longer recommended.
Physician Referral: Coordinate prompt evaluation by a supervising team physician, neurologist, or specialized concussion healthcare provider.
Daily Monitoring: Track symptom scores and daily progression or regression. Monitor for any "red flags" (worsening headache, repeated vomiting, slurred speech, increasing confusion, or unequal pupils) requiring emergency room referral.
Phase 3: Graduated Return-to-Play (RTP) Protocol
Once the athlete is completely symptom-free at rest and has returned to their regular academic/work baseline without symptom exacerbation, the AT should guide them through a step-by-step graduated exertion protocol. Each step takes a minimum of 24 hours:
Symptom-limited activity: Daily activities that do not provoke symptoms.
Light aerobic exercise: Walking or stationary cycling at slow-to-medium pace; no resistance training.
Sport-specific exercise: Running or skating drills; no head impact activities.
Non-contact training drills: Harder drills, passing drills, and progressive resistance training.
Full contact practice: Following medical clearance, participate in normal training activities.
Return to play: Normal game play.
Note: If symptoms recur during any step, the athlete must drop back to the previous symptom-free level and wait another 24 hours before attempting to progress again.
If you'd like, let me know:
What setting or sport level you are working with (youth, high school, collegiate)
Whether you have access to baseline computerized testing
I can help tailor specific documentation templates or referral workflows for your program.
A comprehensive, multi-modal protocol follows a structured progression from immediate sideline recognition to full return-to-play.
1. Acute Recognition and Sideline Evaluation (First 0–72 Hours)
Removal from Play: Any athlete suspected of sustaining a concussion must be immediately removed from play and evaluated by a qualified healthcare professional. They should not be left unattended.
Use Standardized Tools: Utilize the Concussion Recognition Tool-6 (CRT6) for quick sideline identification by coaches/non-medics, and the Sport Concussion Assessment Tool-6 (SCAT6) or Child SCAT6 for comprehensive sideline/acute evaluation by the AT or team physician.
Multimodal Battery: Assess symptom severity scores, cognitive function (orientation, immediate memory, concentration), and balance (modified Balance Error Scoring System - mBESS or similar).
Red Flags Check: Continuously monitor for emergency signs (e.g., deteriorating conscious state, increasing or severe headache, repeated vomiting, slurred speech) that necessitate immediate referral to an emergency department.
2. Initial Management and Early Rest (First 24–48 Hours)
Relative Rest: Advise a brief period (24–48 hours) of relative physical and cognitive rest. Strict, prolonged cocooning/dark-room isolation is no longer recommended, as it can heighten anxiety and prolong symptoms.
Early Sub-Threshold Aerobic Exercise: Current evidence supports initiating controlled, light-intensity aerobic exercise (e.g., stationary cycling) early in the recovery phase (within 48 hours) as long as it does not significantly exacerbate symptoms.
Individualized Education: Provide reassurance and structured education to the athlete, parents, and teachers regarding symptom expectations.
3. Progressive Rehabilitation and Targeted Interventions
Targeted Rehabilitation: If recovery stalls or specific deficits appear, implement a targeted approach. This includes cervicovestibular rehabilitation for athletes experiencing persistent dizziness, neck pain, balance difficulties, or headaches, as well as vision therapy if oculomotor dysfunction is present.
Graduated Return-to-Learn (RTL) and Return-to-Play (RTP): Progress the athlete through standardized, step-wise protocols only when they are back to their baseline. Each step generally takes a minimum of 24 hours:
Step 1: Symptom-limited activity (daily activities that do not provoke symptoms).
Step 3: Sport-specific exercise (running/drifting drills, no head impact activities).
Step 4: Non-contact training drills (progressing to more complex coordination and passing drills).
Step 5: Full contact practice (following medical clearance).
Step 6: Return to unrestricted sport/competition.
4. Clearance and Documentation
Physician-Led Clearance: Final clearance for unrestricted return-to-play must be granted by a physician or designated medical director with specific training in concussion management.
Comprehensive Documentation: Maintain rigorous records of the initial injury mechanism, serial SCAT6/neurocognitive test scores, symptom progression logs, and communication with academic and medical teams for legal and continuity-of-care protection.
Would you like to explore specific SCAT6 modifications , or do you need help structuring a Return-to-Learn / Return-to-Play school accommodation template for an athlete?
For an athletic trainer, the most defensible approach is a multimodal, serial concussion protocol built around the 2022 Amsterdam International Consensus Statement, SCAT6/SCOAT6, and your state's/school's governing rules. The key principle is: suspected concussion → immediate removal → emergency screening → structured assessment → no same-day return → supervised recovery → graduated return-to-sport with medical clearance.
1. Before the season: have the system ready
An athletic program should have:
A written concussion-management plan and Emergency Action Plan.
Clearly identified healthcare providers responsible for concussion diagnosis/clearance.
A process for notifying parents/guardians, coaches, school personnel, and the athlete.
Baseline information when appropriate, including concussion history and relevant symptom/cognitive information. Baseline testing should not be treated as a pass/fail diagnostic test.
Access to the CRT6, SCAT6/Child SCAT6, and SCOAT6.
A documentation system for injury mechanism, signs/symptoms, examinations, serial assessments, instructions, referrals, and progression.
An established return-to-learn process as well as return-to-sport.
The Amsterdam consensus specifically emphasizes that computerized neurocognitive testing should be interpreted as part of the broader clinical picture—not used alone to diagnose concussion or determine clearance.
2. Suspected concussion: remove immediately
If an athlete has a mechanism consistent with concussion plus a concerning symptom, sign, or observable change:
Remove from play immediately.
Do not allow the athlete to "shake it off," return for a brief trial, or return later the same day. CDC guidance specifically recommends removal when concussion is suspected and keeping the athlete out on the day of injury until evaluated and cleared by an appropriate healthcare provider.
Immediate red flags
Activate emergency medical care for findings such as:
Deteriorating level of consciousness
Repeated vomiting
Increasingly severe or worsening headache
Seizure
Neck pain/tenderness with concern for cervical injury
Focal neurological deficit
Increasing confusion/agitation
Weakness, numbness, or significant sensory changes
Slurred speech
Significant deterioration in neurologic status
Suspicion of a serious intracranial or cervical injury
The athlete should not be left alone while awaiting further evaluation.
3. Acute sideline assessment
Once immediate life-threatening problems and cervical-spine concerns have been addressed, perform a structured multimodal assessment.
The SCAT6 is designed for healthcare professionals and has its greatest utility during approximately the first 72 hours and up to 1 week after injury. The consensus recommends that the acute assessment incorporate multiple domains rather than relying on a single symptom checklist or cognitive test.
Assess/document:
Mechanism
What happened?
Direct head impact or indirect force?
Rotation/acceleration/deceleration?
Loss of consciousness?
Amnesia?
Symptoms
Headache
Dizziness
Nausea
Balance problems
Visual symptoms
Sensitivity to light/noise
Cognitive symptoms
Emotional changes
Sleep/fatigue symptoms
Observable signs
Vacant/dazed appearance
Motor incoordination
Ataxia
Abnormal behavior
Delayed responses
Seizure/tonic posturing
Falling without protective action
Cognition
Orientation
Immediate memory
Concentration
Delayed recall
Neurologic examination
Pupils/cranial nerves as appropriate
Motor function
Sensation
Coordination
Neurologic status
Balance/gait
Balance testing
Tandem gait/dual-task gait as appropriate
Cervical spine
Pain/tenderness
ROM
Neurologic findings
Mechanism suggesting cervical injury
A multimodal evaluation generally requires 10–15 minutes or more, and the Amsterdam group recommends performing it away from the pressure and distractions of competition when possible.
4. Make the disposition decision
If concussion is suspected:
No same-day return to competition.
The athlete should be referred to an appropriate healthcare professional for diagnosis and management. The athletic trainer should communicate the findings, mechanism, examination results, symptom evolution, and relevant history.
Also remember that a normal sideline test does not automatically rule out concussion. Symptoms and signs can evolve over minutes, hours, or days, so serial reassessment is important.
5. First 24–48 hours: relative rest, not "cocooning"
Current guidance has moved away from strict dark-room/bed rest until symptoms disappear.
Instead:
Allow normal activities of daily living as tolerated.
Reduce activities that substantially aggravate symptoms.
Limit excessive screen exposure initially.
Encourage light physical activity such as walking when tolerated.
Avoid activities carrying a risk of contact, collision, or falling.
Begin appropriate symptom-limited aerobic activity relatively early rather than prescribing prolonged complete rest.
The Amsterdam consensus recommends relative rest for approximately 24–48 hours, followed by gradual increases in physical and cognitive activity as tolerated.
6. Return-to-learn comes alongside return-to-sport
The athlete shouldn't be managed solely around athletics.
Coordinate with parents/guardians, school personnel, teachers, and the healthcare provider to determine whether temporary accommodations are needed, such as:
Reduced workload
Rest breaks
Reduced screen exposure
Temporary reduction in testing
Additional time
Gradual increase in academic demands
Return-to-learn and return-to-sport should progress together, with the athlete ultimately returning to normal academic function as recovery permits.
7. Use a graduated return-to-sport progression
A practical six-step progression is:
Step
Activity
1. Regular activities
Normal daily activities/school; healthcare-provider authorization to begin progression
2. Light aerobic
~5–10 min walking, stationary bike, or light jogging
3. Moderate
Moderate running/biking and moderate resistance exercise
Controlled practice and full contact when appropriate
Each step generally requires at least 24 hours. If symptoms recur, stop the progression, allow recovery, and return to the previous tolerated stage rather than pushing through symptoms.
Importantly, the later stages involving potential head impact should occur only after the athlete has recovered and received the appropriate healthcare-provider authorization.
8. Reassess rather than relying on one test
For the subacute period—roughly 72 hours onward—the SCOAT6 is designed to provide a more extensive multimodal framework for serial assessment.
It can incorporate:
Symptom assessment
Cognitive testing
Orthostatic measurements
Cervical examination
Neurologic examination
Tandem/dual-task gait
Vestibular/oculomotor considerations
Physical-exertion response
Relevant concussion history
The important concept is serial clinical assessment, not simply obtaining one "normal" test result.
9. Persistent symptoms need targeted rehabilitation
If symptoms aren't progressively resolving, don't simply continue repeating the same concussion checklist.
The Amsterdam consensus recommends multimodal evaluation and consideration of targeted rehabilitation when symptoms persist. For example:
Cognitive or psychological symptoms: appropriate specialist involvement
Symptoms persisting beyond 4 weeks warrant a more comprehensive multimodal assessment and consideration of referral to clinicians experienced in concussion management.
A concise athletic-trainer algorithm
Suspected concussion
↓
Remove from play
↓
Primary survey + cervical/neurologic/emergency assessment
↓
Identify danger signs → EMS/ED if present
↓
SCAT6/multimodal assessment
↓
No same-day return
↓
Healthcare-provider evaluation + parent/guardian notification as appropriate
↓
24–48 h relative rest / symptom-limited activity
↓
Return-to-learn + gradual physical activity
↓
Serial reassessment
↓
Graduated RTS, ≥24 h per stage
↓
Medical clearance before unrestricted/contact-risk participation
↓
Full competition
One important distinction
An athletic trainer's exact scope of practice varies by jurisdiction and employment setting. The clinical protocol should therefore be paired with your state's athletic-training regulations, school/league concussion policy, and the supervising/team physician's protocol. The CDC also has a dedicated HEADS UP training course for athletic trainers, developed with NATA, covering evaluation, management, return-to-school/play, and documentation.
If you're building an actual athletic-department concussion protocol, I can also lay this out as a one-page sideline flowchart/checklist for an AT, including exact assessment fields, red flags, documentation, parent instructions, and a return-to-play table.
For an athletic trainer, the best current approach is a written, team-based concussion protocol built around immediate removal, emergency screening, multimodal assessment, individualized recovery, and graduated return-to-learn/return-to-sport. The 2024 NATA Bridge Statement and current CDC HEADS UP guidance are strong foundations.
Suspect concussion → remove immediately. No same-day return to play.
Rule out emergency injury: assess ABCs, cervical spine, consciousness, neurologic status, and red flags (worsening headache, repeated vomiting, seizure, deteriorating consciousness, focal neurologic deficit, unequal pupils, etc.). Activate EMS when indicated.
Perform multimodal assessment: mechanism/history, symptoms, cognition, neurologic/ocular examination, balance/motor control, and cervical/vestibular assessment. Use an age-appropriate standardized tool (e.g., SCAT6/Child SCAT6) as an aid—not a stand-alone diagnostic test.
Refer for medical evaluation/diagnosis. Document findings, serial reassessments, medications, prior concussions, and communication with the athlete, family, physician, and school.
First 24–48 hours: relative rest rather than strict “cocooning.” Reduce activities that substantially worsen symptoms, while allowing light daily activity as tolerated.
Return to learn: gradually restore academics with accommodations when necessary before unrestricted sport.
Active rehabilitation: individualized aerobic exercise and targeted vestibular/cervical or other rehabilitation when indicated; persistent symptoms warrant appropriate specialty referral.
Return to sport: progress through the CDC's 6-step graduated protocol, generally with ≥24 hours between stages. If symptoms recur, stop, allow recovery, and resume at the previous tolerated stage.
Medical clearance before unrestricted competition according to applicable state law, school/league policy, and your supervising physician's protocol. CDC guidance emphasizes healthcare-provider approval before return.
For an actual athletic-training program, I would base the written policy on the 2024 NATA Bridge Statement, current CDC HEADS UP materials, and your state's concussion law rather than an older SCAT-only protocol.
For an athletic trainer (AT), the gold standard for concussion assessment and management relies on a multidimensional, evidence-based protocol aligned with guidelines from the Concussion in Sport Group (CISG) Amsterdam Consensus Statement and the National Athletic Trainers’ Association (NATA) Position Statement on Management of Sport Concussion.
Because a concussion is a functional rather than structural injury, no single test can diagnose or manage it alone. A comprehensive protocol spans four distinct phases:
Phase 1: Pre-Season Baseline Testing
Before the season starts, high-risk or contact-sport athletes should complete a baseline assessment. This provides a personal benchmark for comparison if an injury occurs.
If a concussion is suspected due to a mechanism of impact or observable signs (e.g., loss of consciousness, motor instability, blank stare, confusion):
Immediate Removal: The athlete must be pulled from play immediately . Under no circumstances should an athlete return to play on the day of injury.
Emergency Assessment: Rule out cervical spine trauma, skull fractures, or intracranial bleeding (ABCDEs, vital signs, neurological red flags).
Use Standardized Tools: Utilize the Concussion Recognition Tool 6 (CRT6) on the sideline if needed, and follow up with the comprehensive Sport Concussion Assessment Tool 6 (SCAT6) within the acute window (first 72 hours).
Multimodal Clinical Exam: Assess symptoms, orientation, immediate/delayed memory, concentration, and balance. (Note: A normal SCAT6 score does not rule out a concussion).
Phase 3: Subacute Monitoring & Rest (Days 3–14)
Limited Rest: Contemporary guidelines recommend a brief period (24–48 hours) of relative physical and cognitive rest, followed by symptom-limited activity rather than strict prolonged cocooning.
Daily Tracking: Monitor symptom score evolution, sleep quality, and mood changes. Referral to specialists (neuropsychologists, vestibular physical therapists, or concussion-trained physicians) is recommended for complex or prolonged recoveries (> 2 weeks).
Phase 4: Graduated Return-to-Learn and Return-to-Play (RTP)
An athlete should only begin a physical exertion progression after a clinical examination is normal, symptoms have completely resolved, and neurocognitive/balance scores have returned to baseline.
Step 1: Symptom-limited activity (Daily activities that do not provoke symptoms).
Step 2: Light aerobic exercise (Walking or stationary cycling; no resistance training).
Step 3: Sport-specific exercise (Running drills; no head-impact activities).
Step 4: Non-contact training drills (More complex coordination and passing drills; progressive resistance training).
Step 5: Full-contact practice (Following medical clearance by a physician or designated healthcare provider).
Step 6: Return to unrestricted sport/competition.
Rule of thumb: Each step should take a minimum of 24 hours . If symptoms recur, the athlete drops back to the previous asymptomatic step.
Would you like to focus on a specific aspect of this protocol, such as choosing baseline neurocognitive tools, managing vestibular/ocular symptoms , or coordinating return-to-learn accommodations with an academic institution?
For an athletic trainer (AT), the gold standard for concussion assessment and management aligns with the joint framework provided by the National Athletic Trainers' Association (NATA) via their foundational position and bridge statements, alongside the international consensus from the Concussion in Sport Group (Amsterdam Consensus Statement).
A best-practice protocol follows a sequential, multimodal framework divided into key phases:
Immediate Recognition and Emergency Evaluation
Action on Site: Assess the scene and rule out catastrophic cervical spine injury or life-threatening intracranial pathology.
Removal from Play: Any athlete suspected of sustaining a concussion must be immediately removed from participation and not returned to play on the day of injury.
Tool Use: Utilize standardized sideline assessment tools like the Sport Concussion Assessment Tool (SCAT6) or Child-SCAT6 to document acute signs, observable-only features, and Glasgow Coma Scale scores.
Comprehensive Multimodal Clinical Assessment
Symptom Scale: Quantify symptom severity and frequency using graded checklists (e.g., Post-Concussion Symptom Scale).
Neurocognitive Testing: Compare post-injury performance against baseline measures (using tools like ImPACT or computerized/paper batteries).
Integrate tandem walking, modified Balance Error Scoring System (mBESS), and targeted vestibular/oculomotor screens (VOR, near-point convergence).
Would you like me to dive deeper into a specific phase, such as sideline tool selection (SCAT6) , or outline a graduated return-to-learn/return-to-sport matrix?
Establish a written concussion management plan approved by the medical team and administration.
Educate: - Athletes
Coaches
Parents/guardians (especially in youth sports)
School/team personnel
Document: - Prior concussions
Migraine history
Mental health history
Learning disabilities/ADHD
Sleep issues
Previous neurologic injuries
Baseline testing may be useful when resources allow, but it is not mandatory for every athlete and should not replace clinical evaluation.
Acute sideline concussion protocol
Step 1: Recognize and remove
Immediately remove the athlete from play if concussion is suspected.
Automatic removal signs include:
Loss of consciousness
Seizure or convulsive movements
Tonic posturing
Significant confusion
Ataxia (poor coordination)
Gross balance problems
Amnesia
Clearly observed concussion signs
The athlete should not return to play the same day if concussion is diagnosed or strongly suspected.
Step 2: Rule out emergency conditions
Perform an emergency evaluation:
Check:
Airway, breathing, circulation
Cervical spine concerns
Level of consciousness
Neurologic status
Refer urgently for medical evaluation if there are red flags such as:
Worsening severe headache
Repeated vomiting
Increasing confusion/agitation
Weakness or numbness
Unequal pupils
Seizure
Declining consciousness
Neck pain with neurologic symptoms
3. Initial concussion assessment
A complete evaluation should include:
A. Symptom assessment
Document:
Headache
Dizziness
Nausea
Light/noise sensitivity
Fatigue
Fogginess
Memory problems
Emotional symptoms
Sleep changes
Use a standardized symptom inventory when available.
B. Cognitive/mental status evaluation
Assess:
Orientation
Attention
Concentration
Immediate and delayed recall
Ability to answer questions appropriately
Tools such as the SCAT6 may assist assessment in appropriate age groups, but no tool should replace clinical judgment.
C. Neurologic examination
Assess:
Cranial nerves
Pupillary response
Speech
Motor strength
Sensation
Coordination
Gait
D. Balance and motor control
Evaluate:
Tandem gait
Single-leg stance
Balance errors
E. Vestibular and ocular assessment
Include:
Smooth pursuits
Saccades
Near-point convergence
Vestibulo-ocular reflex testing
Visual motion sensitivity
Current recommendations emphasize visual/vestibular assessment as an important concussion domain.
F. Cervical spine evaluation
Assess:
Neck pain
Range of motion
Strength
Cervical contributions to symptoms
4. Early management (first 24–48 hours)
Activity
Avoid:
Contact sports
Risk of another head impact
Heavy exertion
However, prolonged strict rest is no longer recommended. After a brief period of relative rest, athletes can begin gradual, symptom-limited activity. Controlled aerobic exercise can often begin within 1–2 days if symptoms are stable and not worsening.
Provide instructions
Give athlete and family:
Written home-care instructions
Warning signs requiring emergency care
Sleep recommendations
Activity restrictions
Follow-up plan
5. Follow-up management
Reassess regularly:
Symptoms
Neurologic status
Vestibular/ocular findings
Balance
Exercise tolerance
Academic function
Mental health factors
Avoid making decisions based solely on symptom scores or computerized cognitive testing. The diagnosis and recovery assessment remain clinical decisions.
6. Return-to-learn progression
A typical progression:
Relative rest (first 24–48 hours)
Light cognitive activity
Increased school workload with accommodations
Full academics without symptom exacerbation
Examples of accommodations:
Reduced workload
Breaks
Extra time
Reduced screen exposure
Quiet testing environment
7. Graduated return-to-sport (RTS)
Advance only if symptoms do not worsen.
Step 1: Symptom-limited activity
Daily activities
Walking
Step 2: Light aerobic exercise
Stationary bike
Light jogging
Step 3: Sport-specific exercise
Running drills
Non-contact skills
Step 4: Non-contact training with resistance
More intense drills
Strength training
Step 5: Full-contact practice
Only after medical clearance
Step 6: Return to competition
If symptoms return:
Drop back one stage
Resume progression after improvement
8. Persistent symptoms (>2–4 weeks)
Consider referral for targeted care:
Vestibular therapy
Cervical rehabilitation
Vision therapy when indicated
Exercise rehabilitation
Neuropsychology
Mental health support
Persistent concussion symptoms are often multifactorial and may require a team approach.
Practical AT concussion checklist
Suspected concussion →
Remove from play
Screen for emergency signs
Evaluate symptoms + neurologic status
Assess balance + vestibular/ocular function
Document findings
Notify physician/medical team
Provide written instructions
Begin individualized recovery plan
Monitor daily/regularly
Progress through return-to-learn and return-to-sport stages
The strongest modern approach is a patient-centered, multimodal protocol with early active rehabilitation and individualized progression, rather than a “wait until symptom-free, then test” model.
An effective protocol relies on objective clinical assessment tools combined with standard clinical examinations rather than a single standalone test.
Pre-Season Baseline Testing
Before activity begins, establish individual baselines to measure against if an injury occurs.
Medical History: Record previous concussions, learning disabilities (e.g., ADHD), and history of migraines or mental health disorders.
Symptom Checklist: Complete a standard 22-item symptom evaluation scale.
Cognitive & Balance Metrics: Establish baselines using the SCAT6 cognitive screen (e.g., immediate memory, digits backwards) and the Balance Error Scoring System (BESS).
Neurocognitive Testing: Utilize computerized tools like ImPACT Testing to establish baseline reaction times and verbal/visual memory.
Acute Sideline Evaluation
If a concussion is suspected, the athlete must be removed from play immediately and cannot return to activity the same day.
Check for "Red Flags": Look for neck pain, double vision, weakness/tingling in the arms or legs, severe or increasing headache, seizure, repeated vomiting, or deteriorating consciousness. If present, activate EMS immediately.
Standardized Assessment: Administer the SCAT6 (Sport Concussion Assessment Tool 6) . This includes the Maddocks Questions for orientation, immediate memory checks, and a brief neurological screen.
Medical Referral: Refer the athlete to a physician or sports medicine specialist for formal diagnosis, as mandated by most state laws.
Home Instructions: Provide parents or guardians with written take-home monitoring instructions, highlighting emergency "red flags".
Serial Monitoring: Administer daily or serial symptom checklists to track progress.
Stepwise Recovery Frameworks
Recovery must prioritize a Return-to-Learn (RTL) protocol before transitioning to a Return-to-Sport (RTS) protocol. Progress to the next step only if the athlete remains completely symptom-free for at least 24 hours at the current step.
[Return-to-Learn] ──> [Return-to-Sport Stepwise Pathway]
Step 1: Symptom-limited activity (Rest & short walks)
Step 2: Light aerobic exercise (Stationary cycling, no resistance)
Step 3: Sport-specific exercise (Running drills, no head impact)
Step 4: Non-contact training drills (Passing, progressive resistance)
Step 5: Full-contact practice (Requires formal medical clearance)
Step 6: Return to play / Match competition
Step
Activity Type
Functional Objective
1. Symptom-limited
Daily activities that do not provoke symptoms (e.g., short walks).
Gradual reintroduction of light activity.
2. Light aerobic
Walking, stationary cycling at slow/medium pace; no resistance training.
Increase heart rate slightly.
3. Sport-specific
Running or skating drills; no head-impact activities.
Add movement variety.
4. Non-contact drills
Harder training drills (e.g., passing); progressive resistance training.
Exercise, coordination, and cognitive load.
5. Full-contact practice
Normal training activities following medical clearance.
Restore confidence; assess functional skills.
6. Return-to-Sport
Full, unrestricted game play.
Safe, final return to competition.
If you are currently updating your program's specific documents, let me know:
What setting you work in (e.g., high school, NCAA, or professional sports)?
The specific state regulations governing your practice?
What computerized neurocognitive tools (if any) your clinic uses?
I can provide a tailored policy template that aligns with your specific organizational requirements.
A high-quality concussion protocol for an athletic trainer (AT) should be evidence-based, team-physician supported, and built around immediate recognition, removal from play, multimodal assessment, symptom-guided management, and a graduated return-to-sport process. Current best practice is based largely on the Concussion in Sport Group Amsterdam 2022 consensus and updated athletic training guidance from the National Athletic Trainers' Association.
1. Preseason preparation
Before the season begins:
Establish a written concussion management plan approved by the medical director/team physician.
Educate: - Athletes
Parents/guardians (especially for minors)
Coaches
Officials and administrators
Define: - Who can remove an athlete from play
Who can clear an athlete for return
Communication procedures
Emergency referral procedures
Baseline testing may be useful in selected situations, but it should not be the sole determinant of diagnosis or return-to-play decisions. A concussion diagnosis remains a clinical diagnosis based on history and examination.
2. Immediate sideline recognition and removal
When concussion is suspected:
Remove the athlete from play immediately.
Do not allow same-day return if concussion is suspected.
Assess for emergency conditions.
Red flags requiring emergency evaluation
Activate emergency procedures for signs such as:
Loss of consciousness
Repeated vomiting
Increasing confusion or agitation
Seizure activity
Neck pain with neurologic symptoms
Weakness, numbness, or deteriorating neurologic status
Worsening headache
Unequal pupils
Increasing drowsiness or inability to awaken
Visible signs that strongly suggest concussion include:
Ataxia (poor coordination)
Tonic posturing
Impact seizure
Falling without protective response
Clearly altered mental status or a vacant/dazed appearance
3. Acute sideline assessment
Perform the evaluation in a quiet environment away from competition pressure.
A good sideline assessment includes:
A. Injury history
Document:
Mechanism of injury
Force/direction of impact
Immediate symptoms
Loss of consciousness (duration)
Post-traumatic amnesia
Previous concussion history
Relevant medical history (migraine, ADHD, mood disorders, sleep issues, etc.)
B. Symptom evaluation
Assess symptoms such as:
Headache
Dizziness
Nausea
Light/noise sensitivity
Balance problems
Fatigue
Sleep disturbance
Cognitive difficulty
Emotional changes
C. Neurologic examination
Include:
Orientation
Memory
Concentration
Cranial nerve screening
Motor strength
Coordination
Cervical spine evaluation when indicated
D. Balance and vestibular/ocular assessment
Consider:
Balance testing
Tandem gait
Vestibular-ocular screening
Visual tracking and convergence
The current approach emphasizes a multimodal assessment, rather than relying on one test score.
4. Use of concussion assessment tools
Common tools:
Sport Concussion Assessment Tool 6 — useful in the acute period (approximately first 72 hours and up to about 1 week).
Sport Concussion Office Assessment Tool 6 — designed for office-based serial evaluations after the acute period.
Computerized neurocognitive testing can provide additional information but should not be used alone to diagnose concussion or determine return-to-play status.
5. First 24–48 hours after concussion
Management should focus on:
Relative rest (avoid symptom-provoking activity)
Good sleep hygiene
Hydration and nutrition
Symptom monitoring
Early follow-up assessment
Strict rest and complete inactivity are no longer recommended as the primary strategy. Early, symptom-limited activity is generally favored when tolerated.
Provide written instructions to the athlete and a responsible adult covering:
Expected symptoms
Warning signs
Activity restrictions
Follow-up plan
Emergency contact instructions
6. Follow-up evaluation and treatment
The AT should monitor:
Symptom progression
School/work tolerance
Sleep
Mood
Exercise tolerance
Vestibular symptoms
Cervical symptoms
Persistent symptoms may require targeted rehabilitation:
Vestibular therapy
Cervical spine therapy
Subsymptom aerobic exercise
Vision therapy when indicated
Psychological support when appropriate
A biopsychosocial approach is recommended because concussion recovery is influenced by physical, cognitive, emotional, and social factors.
7. Return-to-learn protocol
Before full athletic return, athletes should demonstrate increasing tolerance to academic demands.
Typical progression:
Daily activities that do not provoke symptoms
School activities with accommodations
Increased academic workload
Full academic participation
Return-to-learn and return-to-sport plans should occur together rather than treating school as secondary.
8. Graduated return-to-sport progression
Each step should take at least 24 hours, and progression occurs only if symptoms do not worsen.
Step 1: Symptom-limited activity
Normal daily activities
Light movement
Step 2: Light aerobic exercise
Walking
Stationary bike
Easy cardiovascular work
Step 3: Moderate activity
Increased intensity
Sport-specific movement without contact
Step 4: Non-contact training
More complex drills
Resistance training
Step 5: Full-contact practice
Only after medical clearance and appropriate recovery
Step 6: Return to competition
If symptoms return, drop back to the previous tolerated stage.
9. Documentation requirements
An AT should document:
Injury mechanism
Initial symptoms
Examination findings
Assessment tools used
Communication with physicians/parents/coaches
Treatment provided
Return-to-learn progression
Return-to-sport progression
Clearance decisions
Practical “AT sideline algorithm”
Suspected concussion → Remove from play → Screen for emergency signs → Perform multimodal evaluation → Document → Provide instructions → Follow up within 24–48 hours → Begin individualized recovery plan → Progress return-to-learn → Progress return-to-sport → Medical clearance → Return to competition
This framework should be adapted to the sport, age group, governing body requirements, state laws, and the supervising physician’s policies.
Holistic Factors: Screen concurrently for sleep disturbances, mental health variables (anxiety/depression flags), and academic/scholastic impacts.
Rest and Subacute Management
Individualized Approach: Avoid strict, prolonged cocoon-style physical and cognitive rest. Instead, advocate for a brief initial relative rest period (24\unicode{x2013}48 hours) followed by symptom-limited sub-maximal physical and cognitive activity.
Return to Academics/Work First: Prioritize a graduated return-to-learn or return-to-school strategy before heavy athletic exertion. Accommodations may include reduced screen time, modified workloads, and rest breaks.
Graded Exertion and Return-to-Sport (RTS) Progression
Prerequisites: Progression should only begin after the athlete is completely asymptomatic, has returned to baseline neurocognitive and motor control scores, and has a normal clinical exam.
Stepwise Protocol: Advance through monitored, progressive stages (light aerobic exercise → sport-specific exercise → non-contact drills → full-contact practice → unrestricted return to play). Each step should take a minimum of 24 hours; if symptoms return, drop back to the previous asymptomatic level.
Physician Clearance and Documentation
Final Authority: No athlete should return to unrestricted contact or physical activity without formal evaluation and clearance from a physician (or their designated medical lead trained in concussion management).
Meticulous Records: Ensure proper legal and clinical documentation of initial evaluations, daily symptom tracking, stepwise exertion logs, and ongoing communications with supervising physicians.
