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.
For an athletic trainer, the best-supported approach is a recognize → remove → evaluate → refer → monitor → rehabilitate → graduated return-to-learn/return-to-sport pathway, using the Amsterdam 2022 International Consensus and the current NATA 2024 Bridge Statement as the core framework.
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.
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.
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.
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. [](]()]()
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.
1. Preseason preparation
Before the season:
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Step 5: Full contact practice: Following medical clearance, participate in normal training activities.
Step 6: Return to sport: Normal game play/competition.
Note: Each step generally takes a minimum of 24 hours. If symptoms recur, drop back to the previous asymptomatic level before attempting to progress again.
Are you looking for protocols tailored to a specific age group (e.g., youth/high school vs. collegiate) , or do you need help setting up a baseline testing and documentation workflow?
Cognitive symptom: fogginess, slowed thinking, memory or concentration difficulty
Emotional symptom: irritability, sadness, anxiety
Sleep disturbance
Balance/coordination abnormality
Oculomotor/vestibular abnormality
Observable behavioral or mental-status change
When in doubt, take the athlete out. An athlete with suspected concussion should not return to play the same day. Athletic trainers should have authority to remove and withhold an athlete from participation when concussion is suspected.
2. Immediately rule out a more serious injury
Before concentrating on concussion testing, perform an appropriate primary survey and assess for cervical-spine injury and other potentially life-threatening trauma.
Activate emergency medical services/urgent physician evaluation for concerning findings such as:
Loss of consciousness with concerning features
Deteriorating mental status
Repeated vomiting
Seizure
Increasing/worsening severe headache
Focal neurologic deficit
Unequal pupils or other concerning neurologic findings
Significant neck pain/tenderness
Increasing confusion or agitation
Weakness/numbness
Suspected skull fracture
Any clinical deterioration
Don't let a "normal concussion test" override concerning clinical findings.
3. Perform the acute assessment
For the first 72 hours and generally up to 1 week, the SCAT6 is the standardized acute assessment tool recommended by the Amsterdam consensus. For children, use the Child SCAT6.
Your assessment should include, as clinically appropriate:
Mechanism and injury history
Immediate symptoms and symptom evolution
Red-flag screening
Mental status/orientation
Memory
Neurologic examination
Balance/coordination
Oculomotor/vestibular function
Cervical-spine assessment
Symptom inventory/severity
Relevant concussion history and modifying factors
A useful principle is multimodal assessment rather than relying on one score. Computerized neurocognitive testing can provide useful information, but it should not be used by itself to diagnose concussion or determine return to play.
After approximately 72 hours, particularly when serial assessments are needed, the SCOAT6 is designed for office/clinical evaluation.
4. Document a clinical baseline
Ideally, have preseason/baseline information available, including:
Prior concussion history
Current health/medication history
Symptom profile
Relevant neurologic/vestibular findings
Academic considerations
Individual risk modifiers
But don't require a baseline test to diagnose concussion. A baseline is a reference point, not a pass/fail diagnostic standard.
5. Refer and establish medical follow-up
The athlete should be evaluated by an appropriately qualified healthcare professional according to your state law, school/organization policy, and medical-director protocol.
Particularly consider referral to clinicians with concussion expertise when:
Symptoms are severe or worsening
Recovery is not progressing normally
Significant vestibular/ocular/cervical symptoms are present
There are substantial academic difficulties
Symptoms persist beyond the expected recovery period
There are multiple complicating factors
The Amsterdam consensus recommends multimodal evaluation and targeted rehabilitation for athletes with persistent symptoms, particularly those lasting more than 4 weeks.
6. Avoid "cocooning"
One important change from older concussion protocols is that strict physical and cognitive rest until completely symptom-free is no longer recommended.
For approximately the first 24–48 hours, use relative rest:
Normal activities of daily living as tolerated
Reduce activities that substantially aggravate symptoms
Limit excessive screen time
Avoid contact/collision and activities with fall risk
After that, introduce light physical activity as tolerated. Evidence supports early, symptom-limited activity rather than prolonged complete rest.
7. Start return-to-learn alongside recovery
Return-to-school/learning should occur in parallel with, rather than after, return-to-sport.
Potential temporary accommodations include:
Reduced workload
Extra time for assignments/tests
Breaks
Reduced screen exposure
Quiet environment
Temporary postponement of nonessential testing
The goal is progressive restoration of normal cognitive activity while monitoring symptoms.
8. Use a graduated return-to-sport progression
The current framework has six stages, with each stage generally requiring at least 24 hours.
Stage
Activity
1. Symptom-limited activity
Normal daily activities; relative rest initially
2A. Light aerobic
Walking, easy cycling; approximately 55% max HR
2B. Moderate aerobic
Moderate aerobic exercise; approximately 70% max HR
3. Individual sport-specific
Sport-specific activity, progressively more complex
4. Non-contact training
High-intensity exercise, drills, resistance training
5. Full-contact practice
Normal controlled practice after medical clearance
6. Competition
Full return to competition
The Amsterdam protocol actually separates aerobic rehabilitation into 2A and 2B, giving clinicians a more gradual progression.
Critical rule
If symptoms worsen beyond a mild/transient level or new symptoms appear, stop or reduce the activity, allow recovery, and resume at an appropriately tolerated level rather than simply pushing through.
Before activities involving meaningful risk of head impact, the athlete should have resolved concussion-related symptoms and relevant clinical abnormalities, including symptoms with/after exertion, and appropriate medical authorization should be obtained.
9. Treat the clinical profile—not just the diagnosis
Modern concussion management is increasingly targeted rehabilitation rather than "wait until symptom-free."
Persistent symptoms: multidisciplinary concussion care
The Amsterdam consensus specifically supports early aerobic exercise and cervicovestibular rehabilitation when indicated.
10. Reassess continuously
At each follow-up, reassess more than symptoms alone:
Symptoms + cognition + neurologic status + balance + vestibular/ocular function + exertional response + school/function + clinical examination.
The ultimate endpoint isn't simply "symptom score = 0." The athlete should have returned to normal function and have no concussion-related symptoms or clinical findings at rest and with maximal physical exertion before unrestricted return.
A practical athletic-trainer algorithm
Suspected concussion → Remove from play → Primary survey/red flags → SCAT6/multimodal evaluation → Emergency referral if indicated → Medical evaluation → Relative rest 24–48 h → Return-to-learn + early symptom-limited activity → Targeted rehabilitation → Graduated RTS → Medical clearance before contact risk → Full practice → Competition → Continued monitoring
One particularly important point: SCAT6 is an assessment tool, not a "clearance test." The return-to-play decision should be based on the entire clinical picture.
For implementation, I'd use the 2024 NATA Bridge Statement + Amsterdam Consensus/SCAT6 + CDC HEADS UP as the foundation of the athletic program's written concussion protocol. The CDC's current guidance also emphasizes that athletes should progress under healthcare-provider supervision and that each stage generally takes at least 24 hours.
If you're an athletic trainer building an actual sideline protocol, I can also lay this out as a one-page concussion assessment/management flowchart with SCAT6 components, red flags, documentation requirements, and a day-by-day return-to-play progression.
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.
2. Acute sideline assessment
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.
Emergency Assessment: Check the ABCs (airway, breathing, circulation) and stabilize the cervical spine if a severe or catastrophic brain or neck injury is suspected.
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.
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.[](https://bjsm.bmj.com/content/57/11/695)
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.
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).
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?
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
6. Competition
Return to competition
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.
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.
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:
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). [](https://pmc.ncbi.nlm.nih.gov/articles/PMC3975780/)
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. [](https://pmc.ncbi.nlm.nih.gov/articles/PMC3975780/)
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).
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?
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. [](https://pmc.ncbi.nlm.nih.gov/articles/PMC3975780/)
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).
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.
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. [](https://pmc.ncbi.nlm.nih.gov/articles/PMC3975780/)
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).
