Concussion Assessment Protocol
A comprehensive concussion assessment requires a standardized approach using validated tools that evaluate symptoms, cognitive function, and balance to accurately diagnose and guide return-to-play decisions. 1
Initial Recognition and Sideline Assessment
Signs and Symptoms to Identify
Concussion should be suspected if any of the following are present after a head impact:
Physical Signs:
- Loss of consciousness/impaired conscious state
- Poor coordination or balance
- Concussive convulsion/impact seizure
- Gait unsteadiness
- Vacant stare/glassy eyed
- Slurred speech
- Nausea/vomiting 1
Reported Symptoms:
- Headache
- Dizziness
- Nausea
- Unsteadiness/loss of balance
- Feeling "dinged," stunned, or dazed
- Visual disturbances (seeing stars, flashing lights)
- Ringing in the ears
- Double vision 1
Cognitive/Emotional Signs:
- Slow to answer questions or follow directions
- Poor concentration
- Unusual emotions (laughing, crying)
- Personality changes
- Inappropriate playing behavior
- Decreased playing ability 1
Immediate Assessment Tools
Standardized Assessment of Concussion (SAC) - Tests orientation, immediate memory, concentration, and delayed recall 1
Balance Error Scoring System (BESS) - Evaluates postural stability 1
Symptom Checklist - Document presence and severity of symptoms 1
Maddock's Questions - Memory assessment more reliable than standard orientation questions 1
Comprehensive Evaluation
Neuropsychological Assessment
- Baseline testing recommended for high-risk athletes 1
- Assess cognitive domains including:
- Information processing
- Planning
- Memory
- Mental set switching 1
- Computer-based or paper-pencil testing options available 1
Physical Examination
- Assess cervical spine and cranial nerves to identify potential cervical spine or vascular intracerebral injuries 1
- Monitor vital signs and level of consciousness every 5 minutes until condition improves 1
Monitoring and Management
Serial Assessment
- Document time of initial injury 1
- Perform serial assessments noting presence/absence of signs and symptoms 1
- Monitor for delayed signs and symptoms for several days post-injury 1
Return to Play Protocol
- Complete symptom resolution - Athlete must be asymptomatic at rest and with exertion 1
- Cognitive and balance testing - Return to baseline or normal function 1
- Gradual activity progression:
- Light aerobic exercise
- Sport-specific training
- Non-contact training drills
- Full contact training (after medical clearance)
- Return to full participation 2
Important: Never return an athlete to play on the same day of concussion, even if symptoms resolve 1
Special Considerations
Sleep Disturbances
- Establish consistent sleep schedule and practice good sleep hygiene 2
- Consider non-pharmacological interventions like Cognitive Behavioral Therapy for Insomnia (CBT-I) 2
- Melatonin may be considered for sleep disorders with minimal side effects 2
Pediatric and Adolescent Athletes
- Recovery course is typically longer than for college/professional athletes 1
- More conservative approach to return to play is warranted 1
- School accommodations may be necessary during recovery 1
Common Pitfalls to Avoid
Using the term "ding" - This diminishes the seriousness of the injury 1
Relying solely on loss of consciousness - LOC is uncommon in concussion and not required for diagnosis 1
Using standard orientation questions - Time, place, person questions are less reliable than memory assessment 1
Single test diagnosis - No single test should determine recovery or return to play 1
Premature return to play - Athletes should never return while symptomatic, as this increases risk of repeat concussion and prolonged recovery 1
Ignoring sleep disturbances - Sleep problems should be addressed early to promote recovery 2
Neglecting baseline testing - Without baseline data, it's difficult to determine when an athlete has returned to normal function 1