Jan 29, 2015
Upgrading Protocols

The standard of care for treating an athlete with a concussion is advancing at lightning speed. In this article, a Hall of Fame athletic trainer takes us inside his upgraded protocols.

By Phil Hossler

Phil Hossler, MS, ATC, is Head Athletic Trainer at East Brunswick (N.J.) High School. He was inducted into the NATA Hall of Fame in 1999 and is a former President of the Eastern Athletic Trainers’ Association. The author of four books, two of which are on concussions, he can be reached at: [email protected].

These days, it is rare for a week to pass without seeing a headline about concussions. There are stories about the steps sport governing bodies are taking to prevent concussions. There are articles on legislation being implemented in various states across the country. And there are reports on new research findings.

There are also heartbreaking stories documenting what happens when a concussion leaves lasting scars or leads to a tragic outcome. We are hearing about how athletes who have suffered multiple concussions now struggle with cognitive issues. And each new case of chronic traumatic encephalopathy (CTE) is reported in detail.

As athletic trainers, we have known about the dangers of concussions far longer than most people. However, we aren’t the only ones worrying about the issue anymore.

In response to the heightened amount of attention currently focused on the issue, it is critical for athletic trainers to upgrade their policies and procedures for dealing with this injury. It is no longer acceptable to simply record, evaluate, and monitor a concussed athlete. We must now develop a “portfolio” mentality when handling concussions, which entails a more collaborative and documented approach.


The media’s focus on concussions is a very positive change for student-athlete welfare. It is leading to more funding for research on concussions, is helping everyone understand the dangers of the injury, and will hopefully allow the public to better appreciate the importance of athletic trainers in all settings. But it has also changed the landscape for us in three major ways that we must address.

Public Interest: Due to increased media attention, parents now know more about the dangers of concussions and many of them have questions about the issue. We need to be prepared for their questions and welcome them. Better yet, we should be proactive about educating parents and have educational materials ready and waiting for those who want more information.

To start, speak at preseason parents meetings about concussions and how you handle them at your school. Offer a handout to parents marked “Retain This Page For Your Records” with basic information on concussions, and include a statement about concussions as a part of the Informed Consent portion of pre-participation examination forms.

Then, be sure your athletic training room is viewed as a trusted source for more information on concussions. As a reminder of the seriousness of the injury, hang posters in your facility that depict signs and symptoms of concussions. Have easily accessible handouts with in-depth information–for example, a sheet detailing signs and symptoms. If possible, create a page on the school Web site with downloadable files and links to more information for parents and athletes to explore. (Many good resources are available from the Centers for Disease Conrol at: www.cdc.gov/Concussion.) In addition, speak to your coaches and teams about noteworthy indicators of possible concussions.

New Laws: Several states have or are in the process of implementing legislation to prevent athletes from returning to play too soon after a concussion by requiring a doctor to clear the athlete. This is a great help in convincing coaches and athletes about the importance of making a full recovery from a concussion. But it also means we need to take a collaborative approach with local physicians on establishing and adhering to return-to-play criteria.

It is very difficult for a doctor to determine an athlete’s readiness to go back on the field during a 15-minute office visit. A physician needs a full report on the athlete’s progress in order to make an informed decision, and it becomes our duty to provide that through careful documentation.

Continued Research: The amount of research being conducted on concussions is growing exponentially. This is fantastic, but the ever-increasing amount of information can be difficult to keep up with and sort through. However, it does require that we keep up on the topic. As the leaders of activity healthcare, we need to attend meetings, search the Internet, seek learning opportunities, and explore new avenues of information acquisition.

Due to these three major changes, a larger box of tools is needed to handle all the aspects of a concussion. To make sure I always have my bases covered, I created the Concussion Assessment and Management Portfolio (CAMP). When you were getting ready to go to summer camp as a youngster, you were given a list of things you needed to pack. When working with concussed athletes, CAMP provides a list to ensure I am thoroughly prepared for handling any concussion situation. It includes tools for initial evaluations, tracking progress, more thorough diagnostic tests, communicating, and handling return-to-play decisions.

Just as important, CAMP also allows for thorough documentation. The process enables me to efficiently document all signs and symptoms, test results, and feedback from the concussed athlete. I can then easily produce an individualized portfolio to track progress and share with the athlete’s other healthcare providers and parents. I will detail how it works in the following sections.


The first component of CAMP is a list of options for the initial evaluation. Anytime a concussion is suspected, an assessment should be performed on the athlete immediately.

As recently as a few years ago, athletes were re-entering games after a hit to the head as soon as they passed a quick sideline test. We now know that assessing a concussion is not so simple.

To start, athletes with concussions exhibit varying symptoms. While one athlete might briefly lose consciousness, another might not. One athlete might act confused and slur their speech, yet another may act and speak clearly. The list of possible signs and symptoms is lengthy and must be understood by the assessing athletic trainer to ensure that he or she doesn’t miss or underestimate a concussion.

Secondly, no one test has proven 100 percent effective in assessing the severity of a concussion. The American College of Sports Medicine has concluded that while multiple symptom scales and assessment tools are available, no single tool has proven superior. In fact, many common tests are based more on opinion than rigorous scientific evaluation.

That’s why the latest recommendations on assessing concussions call for a multi-pronged approach. The NATA position statement on concussions states, “a combination of tests for cognition, postural stability, and self-reported symptoms” should be used.

Deciding which assessment tools to employ may depend on your specific situation and resources. (See “First Step” for a list of assessment tests.) Keep in mind that you want evaluations which allow you to:

• Record signs and symptoms • Record findings at varying time lengths • Conduct mental and physical dexterity tests • Conduct immediate and delayed memory tests • Track progress in order to collaborate with others.

Along with determining whether a concussion has occurred, the initial evaluation is the starting point of its treatment. A key element of caring for a concussed athlete is watching their progress using follow-up evaluations that can be compared to the initial assessment.


The next step of CAMP entails monitoring the injured athlete. Along with encouraging complete physical and mental rest, athletic trainers should closely watch concussed student-athletes on a daily basis. School nurses, coaches, teachers, and parents can help do this as well. During this early recovery stage, look for any changes in personality, problems with school work, behavior, or memory, sensitivity to light and noise, headaches, and other symptoms related to neurocognitive function.

To help keep track of such symptoms, I use two forms: the Post-Concussion 7-Day Symptom Scale and the Post-Concussion 8-Week Checklist (see note at the end of this article for how to access these lists). These forms provide an easy way to record any symptoms the athlete has, such as headaches, trouble sleeping, or behavioral changes. I give these forms to the athlete’s parents and ask them to use the list of symptoms to identify and monitor changes in their child. Involving the athlete’s parents has the benefit of recording symptoms that may be present outside of school and helps the parents feel they are a part of the recovery process.

Concussed athletes report to me every day. They perform a self-assessment of their signs and symptoms each visit for a minimum of seven days. In addition, during subsequent days, I may perform a repeat neurocognitive test or a vestibular (balance) test.

I also explain to the athlete why this careful monitoring is necessary. They must understand that any symptoms, including changes in their personality, schoolwork, behavior, or memory, need to be reported and recorded. One way to ensure athletes understand the significance of their injury is to have easy-to-understand educational tools in the athletic training room. These can include videos, books and pamphlets, or whatever you feel will work for your student-athletes. In our athletic training room, I have a dedicated computer equipped with headphones on which student-athletes can view a PowerPoint presentation I created with my own voice narration.

Even after they have been released from daily monitoring, athletes should continue to be checked frequently. Cleared cannot mean forgotten. Ask about and validate changes in symptoms to avoid unforeseen and tragic possibilities. Educate the athlete that changes can occur even if they feel better–they should know that their condition can actually worsen over time.

It’s also important to not rely on the student-athlete alone to report symptoms, since an athlete’s desire to return to activity may overrule common sense. Research demonstrates that athletes often underreport their condition in order to get back to competition, so be sure to also use tests not controlled by the athlete, such as computer assessment and balance protocols.


A study conducted about 10 years ago found that athletes were returning to play after a concussion far too early. It showed that 30 percent of all high school and collegiate football players who sustained concussions returned to competition on the same day of the injury, and the remaining 70 percent averaged just four days of rest before playing again.

Many return-to-play guidelines call for the athletes to be symptom free for at least seven days after a concussion before returning to participation. But even the seven-day recommendation should be viewed only as a guideline. It is much better for all parties to follow a process that carefully monitors progress, instead of simply waiting a certain number of days before allowing the athlete to play again.

Usually, concussed athletes start to recover rapidly once the feelings of fogginess disappear. When they have no headaches or other concussion symptoms for a predetermined number of days, they can begin a graduated return-to-play exercise program under the care of an athletic trainer or physician. Recommended at the 2008 Zurich Concussion Conference, return-to-play programs should include the following stages:

No Activity: Complete physical and cognitive (mental) rest with the objective of recovery.

Light Aerobic Exercise: Walking, swimming, or use of a stationary bicycle, keeping intensity under 70 percent of maximum predicted heart rate. The goal is to increase the heart rate to assess how the athlete reacts to this small amount of exertion.

Sport-Specific Exercise: This can include any simple movement activities that don’t involve the risk of head impact like skating drills in ice hockey or running drills in soccer to assess the athlete’s response.

Non-Contact Training Drills: The athlete progresses to more complex training drills, such as passing drills in football and ice hockey. Here, we are assessing if the athlete can coordinate movements during exercise, which tests brain function coupled with the sport activity.

Full-Contact Practice: Following medical clearance, the athlete participates in normal training activities. The goal here is to restore confidence and allow the coaching staff to assess functional skills.

Return to Play: Normal play is allowed, with close monitoring for any symptoms.

During this process, it is important to remember that if headaches or other symptoms occur at any step, the activity needs to be stopped. The athlete should then wait 24 hours and restart at the previous symptom-free level.

You should also monitor recovery through assessment testing. Currently, the gold standard is baseline neurocognitive testing, which evaluates the athlete’s decision-making ability, reaction time, attention, and memory. Neurocognitive tests should be performed on all athletes during the preseason to establish a baseline score. In the event that an athlete sustains a concussion, the multi-component test can be administered again and the findings compared to the athlete’s baseline result.

In addition to neurocognitive testing, the Balance Error Scoring System (BESS) provides a portable, cost-effective, and objective method of assessing static postural stability, and takes approximately 10 minutes to conduct. The athlete is timed and scored as they hold single-leg, double-leg, and tandem stances on two different surfaces, one stable and one unstable, for 20 seconds. Each of the tests is scored by counting the athlete’s errors or deviations from the proper stance.


This leads us to what may be the most critical aspect of CAMP: documentation. Whether new laws in your state require a doctor to clear an athlete before return to play or not, it’s a good idea to do so, which means you need to document and share all assessments and forms with the athlete’s physician.

Therefore, it is key that testing and monitoring be recorded systematically and in a way that is easily interpreted by a physician. To accomplish this, I use an evaluation log, which records all tests and their results for the entire duration of the episode. Each entry includes the date, evaluation tool used, and results. The results area also has room for notes, such as “copy of symptom scale and checklist sent home with parents.”

Before giving this log to a physician, I summarize all the results from the multiple assessment tools. It can also be helpful to make an introductory call to the athlete’s physician and explain the assessment and documentation procedures you’ll be using.

In addition, I have found it immensely helpful to keep two additional logs. One is a communication log. Consistent communication about a concussed athlete is critical and should occur among everyone working with the athlete. This log includes the date, whom I spoke with, and an area for notes. The second is a return-to-play log, which records steps, dates, and the athlete’s reactions as he or she goes through the systematic return-to-play criteria.

Tracking all conversations, therapy sessions, evaluation tools, dates, and athlete reactions will allow the physician to make a much more informed decision. It may also be legally prudent. Documentation of actions may prove invaluable should legal action be taken.


While concussion awareness among the general public has greatly increased in recent years, there are still many parents who do not understand the seriousness of the injury. Some may remember their own playing days when people referred to “getting their bell rung” while others may not understand why their child has to sit out when they appear to be healthy and able to play.

In addition to having educational resources available for parents, I try to communicate directly and frequently with them after their child suffers a concussion. One main topic is why it is critical to not allow an athlete to continue to play. There are three talking points I use during this discussion:

Complete Rest is Needed: I explain, first of all, that recovery from a concussion requires complete rest. If an athlete continues to participate in a sport, his or her head is being put through vigorous exercise that it is not ready for. In fact, new research suggests student-athletes who are too active not just on the field, but at home and school, may be hindering their recovery. The brain uses glucose as a fuel for activity and recovery. If the brain is busy reading, watching videos, texting, and so forth, the glucose stores will not be available for recovery.

Second-Impact Syndrome: An even more important reason to keep players off the field is to ensure that a second concussion is not sustained while the brain is healing. Although still not completely understood, second-impact syndrome appears to occur when an athlete suffers a second concussion before symptoms from the first have disappeared. Second-impact syndrome is associated with severe injury to the brain, including death. The risk is considered highest among people 20 years old or younger.

Recurrent Concussions: Even after symptoms of a concussion have gone away, athletes may face a greater risk of suffering subsequent concussions. There is also some indication that symptoms may be more severe than the first occurrence. One study found that athletes with three or more concussions were nine times more likely to have more severe concussion symptoms than players with no prior history of concussion.

Multiple concussions are also connected to increased risk for depression and early dementia. Brain autopsies have found that athletes who suffered numerous concussions can develop CTE, which is linked with cognitive impairment and depression.

The goal is not to scare parents, but to make them partners in the recovery process. Their input about how the athlete is acting at home, including sleeping patterns, can be very helpful. To keep them involved in the process, I take the time to share test results, concerns, and a recovery plan.

Today, there are many more tools available to help us assess and treat concussions than ever before. In order to ensure the safety of our athletes, we must implement these resources into our protocols. If we don’t, the long-term ramifications can be devastating for all involved.

A version of this article has appeared in Athletic Management magazine, a sister publication to Training & Conditioning.

To access forms, sample logs, and references for this article, enter “Upgrading Protocols: Bonus Materials” into the article search window at: www.Training-Conditioning.com.


The following are evaluation forms that may be used for initial concussion assessment.

Graded Symptom Checklist: The NATA recommends using this checklist. It includes scales that allow a Likert-type rating of concussion-related symptoms, permitting the quantification of severity and/or duration.

Acute Concussion Evaluation: The ACE includes a myriad of components such as injury characteristics, a symptom checklist, risk factors for protracted recovery, and a list of red flags for acute emergency management along with detailed explanations. It is available from the Centers for Disease Control and Prevention.

Standardized Assessment of Concussion: The SAC was designed to assess orientation, immediate memory, concentration, and delayed memory recall. Also included are exertional maneuvers as well as three different versions to allow follow-up testing.

Sport Concussion Assessment Tool: The SCAT provides broad explanations of signs and symptoms the athlete may experience, including post-concussive areas, signs to look for 24 to 48 hours post-injury, and a symptom checklist. Sport Concussion Assessment Tool 2: The SCAT2 combines features from the SAC, Glasgow Coma Scale, Maddock sideline assessment questions, and balance assessments. It includes an informational sheet to give to the athlete and provides immediate diagnosis as well as follow-up parameters.

CDC Checklist: Included within its recently released guidelines, Heads Up to Schools–Know Your Concussion ABCs, the CDC offers this grading chart. The checklist provides nine observed signs, nine physical symptoms, five cognitive symptoms, and four emotional symptoms to be reviewed immediately after a possible concussion and again in 5 minutes, 30 minutes, and at later intervals.


Recovery from a concussion requires complete rest from physical activity. Equally important, but not as widely known, is the need for mental rest. When a student suffers a concussion, his or her teachers should be notified. You can provide them with these tips:

• Mental rest is critical. Have the athlete take “brain breaks.” • Reduce time spent in school as needed. Rebuild it slowly. • Reduce assignments and workload. • Encourage a “study buddy” to be there when needed. • Give assignments in written format rather than orally. • Use step-by-step assignment sheets. • Work cooperatively with and report any unusual behavior to the school nurse, athletic trainer, parents, and physician.


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