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  • Writer's pictureRandon Hall, MD

Understanding the Entire Concussion Protocol

What does mean to be put on the concussion protocol?

When an athlete is diagnosed or suspected to have a concussion the professional leagues require that the athlete is evaluated in a standard fashion which is referred to as the concussion protocol. The athlete is removed from play and is required to be evaluated by a healthcare professional typically the team physician or the athletic trainer. The evaluation generally consists of a physical evaluation checking nerve function, strength, balance, coordination and vision. Additionally, the athlete will undergo some type of assessment of cognitive ability including orientation, short-term memory, concentration and long-term memory. A key provision is that even if the athlete is NOT diagnosed with a concussion they still have to be evaluated again within 24 hours to confirm they did not develop symptoms over time. Interestingly, this implies that if an athlete is removed for even a suspected concussion they are not going to be returned back to play that day. Once the athlete has recovered from a concussion they then need to undergo several steps of increasing exertion with no return of symptoms. The protocol is clear to state that their is no predetermined time frame for this process, one athlete may take a few days and another may take weeks.

What is a "concussion test"?

The cognitive assessment can be anything from basic set of questions to a computerized assessment, which many people refer to as a "concussion test". A brief digression: The computer based test is not a pass or fail "concussion test"; it is a cognitive assessment that can help a medical provider understand the entire clinical picture. As I mentioned in my post about initial evaluation of a concussion, if the athlete is clearly disoriented and concussed it doesn't quite make sense to put them through the cognitive testing at the time of injury. On the other hand, it is quite helpful if the athlete is showing very mild symptoms which may not be clear on the physical evaluation. The NBA uses a modified version of the Sports Concussion Assessment Tool - Version 3 (SCAT 3) as the initial assessment for suspected concussion injuries (see below).

How doeS return to play work?

The return to participation protocol involves gradual progression of increasing physical activity (see below). With each step, a player must be symptom free to move to the next step. If a player develops symptoms, they will go back to resting until they are symptom free and begin again at the level of activity they were able to perform without symptoms.

SCAT 3 Assessment


Return to Play Protocol

Step 1: Light aerobic activity The Goal: Only to increase an athlete’s heart rate. The Time: 5 to 10 minutes. The Activities: Exercise bike, walking, or light jogging. Absolutely no weight lifting, jumping or hard running.

Step 2: Moderate activity The Goal: Limited body and head movement. The Time: Reduced from typical routine. The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting

Step 3: Heavy, non-contact activity The Goal: More intense but non-contact The Time: Close to typical routine The Activities: Running, high-intensity stationary biking, the player’s regular weightlifting routine, and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Practice & full contact The Goal: Reintegrate in full contact practice.

Step 5: Competition The Goal: Return to competition.


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