Sport concussion assessment tool

Davis GA, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097506SCAT5

To download a clean version of the SCAT tools please visit the journal online (http://dx.doi.org/10.1136/bjsports-2017-097506SCAT5)

SCAT5 © Concussion in Sport Group 2017

SCAT5©

WHAT IS THE SCAT5?

The SCAT5 is a standardized tool for evaluating concussions

designed for use by physicians and licensed healthcare

professionals

. The SCAT5 cannot be performed correctly

in less than 10 minutes.

If you are not a physician or licensed healthcare professional,

please use the Concussion Recognition Tool 5 (CRT5). The

SCAT5 is to be used for evaluating athletes aged 13 years

and older. For children aged 12 years or younger, please

use the Child SCAT5.

Preseason SCAT5 baseline testing can be useful for

interpreting post-injury test scores, but is not required for

that purpose.Detailed instructions for use of the SCAT5 are

provided on page 7. Please read through these instructions

carefully before testing the athlete. Brief verbal instructions

for each test are given in italics. The only equipment required

for the tester is a watch or timer.

This tool may be freely copied in its current form for dis-

tribution to individuals, teams, groups and organizations.

It should not be altered in any way, re-branded or sold for

commercial gain. Any revision, translation or reproduction

in a digital form requires specic approval by the Concus-

sion in Sport Group.

Recognise and Remove

A head impact by either a direct blow or indirect transmission

of force can be associated with a serious and potentially fatal

brain injury. If there are signicant concerns, including any

of the red ags listed in Box 1, then activation of emergency

procedures and urgent transport to the nearest hospital

should be arranged.

Patient details

Name:

DOB:

Address:

ID number:

Examiner:

Date of Injury: Time:

Key points

•

Any athlete with suspected concussion should be REMOVED

FROM PLAY, medically assessed and monitored for

deterioration. No athlete diagnosed with concussion

should be returned to play on the day of injury.

•

If an athlete is suspected of having a concussion and

medical personnel are not immediately available, the

athlete should be referred to a medical facility for urgent

assessment.

•

Athletes with suspected concussion should not drink

alcohol, use recreational drugs and should not drive a motor

vehicle until cleared to do so by a medical professional.

• Concussion signs and symptoms evolve over time and it

is important to consider repeat evaluation in the assess-

ment of concussion.

•

The diagnosis of a concussion is a clinical judgment,

made by a medical professional. The SCAT5 should NOT

be used by itself to make, or exclude, the diagnosis of

concussion. An athlete may have a concussion even if

their SCAT5 is “normal”.

Remember:

•

The basic principles of rst aid (danger, response, airway,

breathing, circulation) should be followed.

•

Do not attempt to move the athlete (other than that required

for airway management) unless trained to do so.

•

Assessment for a spinal cord injury is a critical part of the

initial on-eld assessment.

•

Do not remove a helmet or any other equipment unless

trained to do so safely.

SPORT CONCUSSION ASSESSMENT TOOL — 5TH EDITION

DEVELOPED BY THE CONCUSSION IN SPORT GROUP

FOR USE BY MEDICAL PROFESSIONALS ONLY

supported by

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SCAT5 © Concussion in Sport Group 2017 2

IMMEDIATE OR ON-FIELD ASSESSMENT

The following elements should be assessed for all athletes who

are suspected of having a concussion prior to proceeding to the

neurocognitive assessment and ideally should be done on-eld after

the rst rst aid / emergency care priorities are completed.

If any of the “Red Flags“ or observable signs are noted after a direct

or indirect blow to the head, the athlete should be immediately and

safely removed from participation and evaluated by a physician or

licensed healthcare professional.

Consideration of transportation to a medical facility should be at

the discretion of the physician or licensed healthcare professional.

The GCS is important as a standard measure for all patients and can

be done serially if necessary in the event of deterioration in conscious

state. The Maddocks questions and cervical spine exam are critical

steps of the immediate assessment; however, these do not need to

be done serially.

STEP 1: RED FLAGS

STEP 2: OBSERVABLE SIGNS

Witnessed  Observed on Video 

Lying motionless on the playing surface Y N

Balance / gait difculties / motor incoordination: stumbling, slow /

laboured movements

Y N

Disorientation or confusion, or an inability to respond appropriately

to questions

Y N

Blank or vacant look Y N

Facial injury after head trauma Y N

STEP 3: MEMORY ASSESSMENT

MADDOCKS QUESTIONS

“I am going to ask you a few questions, please listen carefully and

give your best effort. First, tell me what happened?”

Mark Y for correct answer / N for incorrect

What venue are we at today? Y N

Which half is it now? Y N

Who scored last in this match? Y N

What team did you play last week / game? Y N

Did your team win the last game? Y N

Note: Appropriate sport-specific questions may be substituted.

STEP 4: EXAMINATION

GLASGOW COMA SCALE (GCS)

Time of assessment

Date of assessment

Best eye response (E)

No eye opening 1 1 1

Eye opening in response to pain 2 2 2

Eye opening to speech 3 3 3

Eyes opening spontaneously 4 4 4

Best verbal response (V)

No verbal response 1 1 1

Incomprehensible sounds 2 2 2

Inappropriate words 3 3 3

Confused 4 4 4

Oriented 5 5 5

Best motor response (M)

No motor response 1 1 1

Extension to pain 2 2 2

Abnormal exion to pain 3 3 3

Flexion / Withdrawal to pain 4 4 4

Localizes to pain 5 5 5

Obeys commands 6 6 6

Glasgow Coma score (E + V + M)

CERVICAL SPINE ASSESSMENT

Does the athlete report that their neck is pain free at rest?

Y N

If there is NO neck pain at rest, does the athlete have a full

range of ACTIVE pain free movement?

Y N

Is the limb strength and sensation normal? Y N

In a patient who is not lucid or fully

conscious, a cervical spine injury should

be assumed until proven otherwise.

RED FLAGS:

• Neck pain or

tenderness

• Double vision

• Weakness or tingling/

burning in arms or legs

• Severe or increasing

headache

• Seizure or convulsion

• Loss of consciousness

• Deteriorating

conscious state

• Vomiting

• Increasingly restless,

agitated or combative

Name:

DOB:

Address:

ID number:

Examiner:

Date:

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Davis GA, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097506SCAT5

Name:

DOB:

Address:

ID number:

Examiner:

Date:

SCAT5 © Concussion in Sport Group 2017 3

OFFICE OR OFF-FIELD ASSESSMENT

Please note that the neurocognitive assessment should be done in a

distraction-free environment with the athlete in a resting state.

STEP 1: ATHLETE BACKGROUND

Sport / team / school:

Date / time of injury:

Years of education completed:

Age:

Gender: M / F / Other

Dominant hand: left / neither / right

How many diagnosed concussions has the

athlete had in the past?:

When was the most recent concussion?:

How long was the recovery (time to being cleared to play)

from the most recent concussion?: (days)

Has the athlete ever been:

Hospitalized for a head injury? Yes No

Diagnosed / treated for headache disorder or migraines? Yes No

Diagnosed with a learning disability / dyslexia? Yes No

Diagnosed with ADD / ADHD? Yes No

Diagnosed with depression, anxiety

or other psychiatric disorder?

Yes No

Current medications? If yes, please list:

STEP 2: SYMPTOM EVALUATION

The athlete should be given the symptom form and asked to read this instruction

paragraph out loud then complete the symptom scale. For the baseline assessment,

the athlete should rate his/her symptoms based on how he/she typically feels and for

the post injury assessment the athlete should rate their symptoms at this point in time.

Please Check:  Baseline  Post-Injury

Please hand the form to the athlete

none mild moderate severe

Headache

0 1 2 3 4 5 6

“Pressure in head” 0 1 2 3 4 5 6

Neck Pain 0 1 2 3 4 5 6

Nausea or vomiting 0 1 2 3 4 5 6

Dizziness 0 1 2 3 4 5 6

Blurred vision 0 1 2 3 4 5 6

Balance problems 0 1 2 3 4 5 6

Sensitivity to light 0 1 2 3 4 5 6

Sensitivity to noise 0 1 2 3 4 5 6

Feeling slowed down 0 1 2 3 4 5 6

Feeling like “in a fog“ 0 1 2 3 4 5 6

“Don’t feel right” 0 1 2 3 4 5 6

Difculty concentrating 0 1 2 3 4 5 6

Difculty remembering 0 1 2 3 4 5 6

Fatigue or low energy 0 1 2 3 4 5 6

Confusion 0 1 2 3 4 5 6

Drowsiness 0 1 2 3 4 5 6

More emotional 0 1 2 3 4 5 6

Irritability 0 1 2 3 4 5 6

Sadness 0 1 2 3 4 5 6

Nervous or Anxious 0 1 2 3 4 5 6

Trouble falling asleep

(if applicable)

0 1 2 3 4 5 6

Total number of symptoms:

of 22

Symptom severity score: of 132

Do your symptoms get worse with physical activity? Y N

Do your symptoms get worse with mental activity? Y N

If 100% is feeling perfectly normal, what

percent of normal do you feel?

If not 100%, why?

Please hand form back to examiner

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SCAT5 © Concussion in Sport Group 2017 4

STEP 3: COGNITIVE SCREENING

Standardised Assessment of Concussion (SAC)

ORIENTATION

What month is it? 0 1

What is the date today? 0 1

What is the day of the week? 0 1

What year is it? 0 1

What time is it right now? (within 1 hour) 0 1

Orientation score of 5

IMMEDIATE MEMORY

The Immediate Memory component can be completed using the

traditional 5-word per trial list or optionally using 10-words per trial

to minimise any ceiling effect. All 3 trials must be administered irre-

spective of the number correct on the rst trial. Administer at the rate

of one word per second.

Please choose EITHER the 5 or 10 word list groups and circle the specic word list chosen

for this test.

I am going to test your memory. I will read you a list of words and when I am done, repeat

back as many words as you can remember, in any order. For Trials 2 & 3: I am going to repeat

the same list again. Repeat back as many words as you can remember in any order, even if

you said the word before.

List Alternate 5 word lists

Score (of 5)

Trial 1 Trial 2 Trial 3

A Finger Penny Blanket Lemon Insect

B Candle Paper Sugar Sandwich Wagon

C Baby Monkey Perfume Sunset Iron

D Elbow Apple Carpet Saddle Bubble

E Jacket Arrow Pepper Cotton Movie

F Dollar Honey Mirror Saddle Anchor

Immediate Memory Score of 15

Time that last trial was completed

List Alternate 10 word lists

Score (of 10)

Trial 1 Trial 2 Trial 3

Finger

Candle

Penny

Paper

Blanket

Sugar

Lemon

Sandwich

Insect

Wagon

Baby

Elbow

Monkey

Apple

Perfume

Carpet

Sunset

Saddle

Iron

Bubble

Jacket

Dollar

Arrow

Honey

Pepper

Mirror

Cotton

Saddle

Movie

Anchor

Immediate Memory Score of 30

Time that last trial was completed

CONCENTRATION

DIGITS BACKWARDS

Please circle the Digit list chosen (A, B, C, D, E, F). Administer at the

rate of one digit per second reading DOWN the selected column.

I am going to read a string of numbers and when I am done, you repeat them back to me

in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.

Concentration Number Lists (circle one)

List A List B List C

4-9-3 5-2-6 1-4-2 Y N

6-2-9 4-1-5 6-5-8 Y N

3-8-1-4 1-7-9-5 6-8-3-1 Y N

3-2-7-9 4-9-6-8 3-4-8-1 Y N

6-2-9-7-1 4-8-5-2-7 4-9-1-5-3 Y N

1-5-2-8-6 6-1-8-4-3 6-8-2-5-1 Y N

7-1-8-4-6-2 8-3-1-9-6-4 3-7-6-5-1-9 Y N

5-3-9-1-4-8 7-2-4-8-5-6 9-2-6-5-1-4 Y N

List D List E List F

7-8-2 3-8-2 2-7-1 Y N

9-2-6 5-1-8 4-7-9 Y N

4-1-8-3 2-7-9-3 1-6-8-3 Y N

9-7-2-3 2-1-6-9 3-9-2-4 Y N

1-7-9-2-6 4-1-8-6-9 2-4-7-5-8 Y N

4-1-7-5-2 9-4-1-7-5 8-3-9-6-4 Y N

2-6-4-8-1-7 6-9-7-3-8-2 5-8-6-2-4-9 Y N

8-4-1-9-3-5 4-2-7-9-3-8 3-1-7-8-2-6 Y N

Digits Score: of 4

MONTHS IN REVERSE ORDER

Now tell me the months of the year in reverse order. Start with the last month and go backward.

So you’ll say December, November. Go ahead.

Dec - Nov - Oct - Sept - Aug - Jul - Jun - May - Apr - Mar - Feb - Jan 0 1

Months Score of 1

Concentration Total Score (Digits + Months) of 5

Name:

DOB:

Address:

ID number:

Examiner:

Date:

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Davis GA, et al. Br J Sports Med 2017;0:1–8. doi:10.1136/bjsports-2017-097506SCAT5

Name:

DOB:

Address:

ID number:

Examiner:

Date:

SCAT5 © Concussion in Sport Group 2017 5

STEP 4: NEUROLOGICAL SCREEN

See the instruction sheet (page 7) for details of

test administration and scoring of the tests.

Can the patient read aloud (e.g. symptom check-

list) and follow instructions without difculty?

Y N

Does the patient have a full range of pain-

free PASSIVE cervical spine movement?

Y N

Without moving their head or neck, can the patient look

side-to-side and up-and-down without double vision?

Y N

Can the patient perform the nger nose

coordination test normally?

Y N

Can the patient perform tandem gait normally? Y N

BALANCE EXAMINATION

Modified Balance Error Scoring System (mBESS) testing

Which foot was tested

(i.e. which is the non-dominant foot)

 Left

 Right

Testing surface (hard oor, eld, etc.)

Footwear (shoes, barefoot, braces, tape, etc.)

Condition Errors

Double leg stance of 10

Single leg stance (non-dominant foot) of 10

Tandem stance (non-dominant foot at the back) of 10

Total Errors of 30

STEP 5: DELAYED RECALL:

The delayed recall should be performed after 5 minutes have

elapsed since the end of the Immediate Recall section. Score 1

pt. for each correct response.

Do you remember that list of words I read a few times earlier? Tell me as many words

from the list as you can remember in any order.

Time Started

Please record each word correctly recalled. Total score equals number of words recalled.

Total number of words recalled accurately: of 5 or of 10

STEP 6: DECISION

Domain

Date & time of assessment:

Symptom

number (of 22)

Symptom severity

score (of 132)

Orientation (of 5)

Immediate memory

of 15

of 30

of 15

of 30

of 15

of 30

Concentration (of 5)

Neuro exam

Normal

Abnormal

Normal

Abnormal

Normal

Abnormal

Balance errors (of 30)

Delayed Recall

of 5

of 10

of 5

of 10

of 5

of 10

Date and time of injury:

If the athlete is known to you prior to their injury, are they different from their usual self?

 Yes  No  Unsure  Not Applicable

(If different, describe why in the clinical notes section)

Concussion Diagnosed?

 Yes  No  Unsure  Not Applicable

If re-testing, has the athlete improved?

 Yes  No  Unsure  Not Applicable

I am a physician or licensed healthcare professional and I have personally

administered or supervised the administration of this SCAT5.

Signature:

Name:

Title:

Registration number (if applicable):

Date:

SCORING ON THE SCAT5 SHOULD NOT BE USED AS A STAND-ALONE

METHOD TO DIAGNOSE CONCUSSION, MEASURE RECOVERY OR

MAKE DECISIONS ABOUT AN ATHLETE’S READINESS TO RETURN TO

COMPETITION AFTER CONCUSSION.

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SCAT5 © Concussion in Sport Group 2017 6

CLINICAL NOTES:

Name:

DOB:

Address:

ID number:

Examiner:

Date:

CONCUSSION INJURY ADVICE

(To be given to the person monitoring the concussed athlete)

This patient has received an injury to the head. A careful medical

examination has been carried out and no sign of any serious

complications has been found. Recovery time is variable across

individuals and the patient will need monitoring for a further pe-

riod by a responsible adult. Your treating physician will provide

guidance as to this timeframe.

If you notice any change in behaviour, vomiting, worsening head-

ache, double vision or excessive drowsiness, please telephone

your doctor or the nearest hospital emergency department

immediately.

Other important points:

Initial rest: Limit physical activity to routine daily activities (avoid

exercise, training, sports) and limit activities such as school,

work, and screen time to a level that does not worsen symptoms.

1) Avoid alcohol

2) Avoid prescription or non-prescription drugs

without medical supervision. Specically:

a) Avoid sleeping tablets

b) Do not use aspirin, anti-inammatory medication

or stronger pain medications such as narcotics

3) Do not drive until cleared by a healthcare professional.

4) Return to play/sport requires clearance

by a healthcare professional.

Clinic phone number:

Patient’s name:

Date / time of injury:

Date / time of medical review:

Healthcare Provider:

Contact details or stamp

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SCAT5 © Concussion in Sport Group 2017 7

INSTRUCTIONS

Words in Italics throughout the SCAT5 are the instructions given to the athlete by the clinician

Symptom Scale

The time frame for symptoms should be based on the type of test being admin-

istered. At baseline it is advantageous to assess how an athlete “typically” feels

whereas during the acute/post-acute stage it is best to ask how the athlete feels

at the time of testing.

The symptom scale should be completed by the athlete, not by the examiner. In

situations where the symptom scale is being completed after exercise, it should

be done in a resting state, generally by approximating his/her resting heart rate.

For total number of symptoms, maximum possible is 22 except immediately post

injury, if sleep item is omitted, which then creates a maximum of 21.

For Symptom severity score, add all scores in table, maximum possible is 22 x 6

= 132, except immediately post injury if sleep item is omitted, which then creates

a maximum of 21x6=126.

Immediate Memory

The Immediate Memory component can be completed using the traditional 5-word

per trial list or, optionally, using 10-words per trial. The literature suggests that

the Immediate Memory has a notable ceiling effect when a 5-word list is used. In

settings where this ceiling is prominent, the examiner may wish to make the task

more difcult by incorporating two 5–word groups for a total of 10 words per trial.

In this case, the maximum score per trial is 10 with a total trial maximum of 30.

Choose one of the word lists (either 5 or 10). Then perform 3 trials of immediate

memory using this list.

Complete all 3 trials regardless of score on previous trials.

“I am going to test your memory. I will read you a list of words and when I am done,

repeat back as many words as you can remember, in any order.” The words must be

read at a rate of one word per second.

Trials 2 & 3 MUST be completed regardless of score on trial 1 & 2.

Trials 2 & 3:

“I am going to repeat the same list again. Repeat back as many words as you can

remember in any order, even if you said the word before.“

Score 1 pt. for each correct response. Total score equals sum across all 3 trials.

Do NOT inform the athlete that delayed recall will be tested.

Concentration

Digits backward

Choose one column of digits from lists A, B, C, D, E or F and administer those digits

as follows:

Say: “I am going to read a string of numbers and when I am done, you repeat them

back to me in reverse order of how I read them to you. For example, if I say 7-1-9,

you would say 9-1-7.”

Begin with rst 3 digit string.

If correct, circle “Y” for correct and go to next string length. If incorrect, circle “N” for

the rst string length and read trial 2 in the same string length. One point possible

for each string length. Stop after incorrect on both trials (2 N’s) in a string length.

The digits should be read at the rate of one per second.

Months in reverse order

“Now tell me the months of the year in reverse order. Start with the last month and

go backward. So you’ll say December, November ... Go ahead”

1 pt. for entire sequence correct

Delayed Recall

The delayed recall should be performed after 5 minutes have elapsed since the end

of the Immediate Recall section.

“Do you remember that list of words I read a few times earlier? Tell me as many words

from the list as you can remember in any order.“

Score 1 pt. for each correct response

Modied Balance Error Scoring System (mBESS)

testing

This balance testing is based on a modied version of the Balance Error Scoring

System (BESS)

. A timing device is required for this testing.

Each of 20-second trial/stance is scored by counting the number of errors. The

examiner will begin counting errors only after the athlete has assumed the proper

start position. The modied BESS is calculated by adding one error point for each

error during the three 20-second tests. The maximum number of errors for any

single condition is 10. If the athlete commits multiple errors simultaneously, only

one error is recorded but the athlete should quickly return to the testing position, and

counting should resume once the athlete is set. Athletes that are unable to maintain

the testing procedure for a minimum of ve seconds at the start are assigned the

highest possible score, ten, for that testing condition.

OPTION: For further assessment, the same 3 stances can be performed on a surface

of medium density foam (e.g., approximately 50cm x 40cm x 6cm).

Balance testing – types of errors

1. Hands lifted off

iliac crest

2. Opening eyes

3. Step, stumble, or fall

4. Moving hip into > 30

degrees abduction

5. Lifting forefoot or heel

6. Remaining out of test

position > 5 sec

“I am now going to test your balance. Please take your shoes off (if applicable), roll up

your pant legs above ankle (if applicable), and remove any ankle taping (if applicable).

This test will consist of three twenty second tests with different stances.“

(a) Double leg stance:

“The rst stance is standing with your feet together with your hands on your hips

and with your eyes closed. You should try to maintain stability in that position for 20

seconds. I will be counting the number of times you move out of this position. I will

start timing when you are set and have closed your eyes.“

(b) Single leg stance:

“If you were to kick a ball, which foot would you use? [This will be the dominant

foot] Now stand on your non-dominant foot. The dominant leg should be held in

approximately 30 degrees of hip exion and 45 degrees of knee exion. Again, you

should try to maintain stability for 20 seconds with your hands on your hips and your

eyes closed. I will be counting the number of times you move out of this position. If

you stumble out of this position, open your eyes and return to the start position and

continue balancing. I will start timing when you are set and have closed your eyes.“

“Now stand heel-to-toe with your non-dominant foot in back. Your weight should be

evenly distributed across both feet. Again, you should try to maintain stability for 20

seconds with your hands on your hips and your eyes closed. I will be counting the

number of times you move out of this position. If you stumble out of this position,

open your eyes and return to the start position and continue balancing. I will start

timing when you are set and have closed your eyes.”

Tandem Gait

Participants are instructed to stand with their feet together behind a starting line

(the test is best done with footwear removed). Then, they walk in a forward direction

as quickly and as accurately as possible along a 38mm wide (sports tape), 3 metre

line with an alternate foot heel-to-toe gait ensuring that they approximate their heel

and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees

and return to the starting point using the same gait. Athletes fail the test if they

step off the line, have a separation between their heel and toe, or if they touch or

grab the examiner or an object.

Finger to Nose

“I am going to test your coordination now. Please sit comfortably on the chair with

your eyes open and your arm (either right or left) outstretched (shoulder exed to

90 degrees and elbow and ngers extended), pointing in front of you. When I give

a start signal, I would like you to perform ve successive nger to nose repetitions

using your index nger to touch the tip of the nose, and then return to the starting

position, as quickly and as accurately as possible.”

References

McCrory et al. Consensus Statement On Concussion In Sport – The 5th

International Conference On Concussion In Sport Held In Berlin, October 2016.

British Journal of Sports Medicine 2017 (available at www.bjsm.bmj.com)

Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following

concussion in athletes. Clinical Journal of Sport Medicine 1995; 5: 32-33

3. Jennett, B., Bond, M. Assessment of outcome after severe brain damage: a

practical scale. Lancet 1975; i: 480-484

McCrea M. Standardized mental status testing of acute concussion. Clinical

Journal of Sport Medicine. 2001; 11: 176-181

Guskiewicz KM. Assessment of postural stability following sport-related

concussion. Current Sports Medicine Reports. 2003; 2: 24-30

on September 17, 2024 by guest. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2017-097506SCAT5 on 26 April 2017. Downloaded from

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CONCUSSION INFORMATION

Any athlete suspected of having a concussion should be removed from

play and seek medical evaluation.

Signs to watch for

Problems could arise over the rst 24-48 hours. The athlete should not be

left alone and must go to a hospital at once if they experience:

• Worsening

headache

• Drowsiness or

inability to be

awakened

• Inability to

recognize people

or places

• Repeated vomiting

• Unusual behaviour

or confusion

or irritable

• Seizures (arms

and legs jerk

uncontrollably)

• Weakness or

numbness in

arms or legs

• Unsteadiness

on their feet.

• Slurred speech

Consult your physician or licensed healthcare professional after a sus-

pected concussion. Remember, it is better to be safe.

Rest & Rehabilitation

After a concussion, the athlete should have physical rest and relative

cognitive rest for a few days to allow their symptoms to improve. In most

cases, after no more than a few days of rest, the athlete should gradually

increase their daily activity level as long as their symptoms do not worsen.

Once the athlete is able to complete their usual daily activities without

concussion-related symptoms, the second step of the return to play/sport

progression can be started. The athlete should not return to play/sport

until their concussion-related symptoms have resolved and the athlete

has successfully returned to full school/learning activities.

When returning to play/sport, the athlete should follow a stepwise,

medically managed exercise progression, with increasing amounts of

exercise. For example:

Graduated Return to Sport Strategy

Exercise step

Functional exercise

at each step

Goal of each step

1. Symptom-

limited activity

Daily activities that do

not provoke symptoms.

Gradual reintroduc-

tion of work/school

activities.

2. Light aerobic

exercise

Walking or stationary

cycling at slow to medium

pace. No resistance

training.

Increase heart rate.

3. Sport-specic

exercise

Running or skating drills.

No head impact activities.

Add movement.

4. Non-contact

training drills

Harder training drills, e.g.,

passing drills. May start

progressive resistance

training.

Exercise, coor-

dination, and

increased thinking.

5. Full contact

practice

Following medical clear-

ance, participate in normal

training activities.

Restore con-

dence and assess

functional skills by

coaching staff.

6. Return to

play/sport

Normal game play.

In this example, it would be typical to have 24 hours (or longer) for each

step of the progression. If any symptoms worsen while exercising, the

athlete should go back to the previous step. Resistance training should

be added only in the later stages (Stage 3 or 4 at the earliest).

Written clearance should be provided by a healthcare professional before

return to play/sport as directed by local laws and regulations.

Graduated Return to School Strategy

Concussion may affect the ability to learn at school. The athlete may

need to miss a few days of school after a concussion. When going back

to school, some athletes may need to go back gradually and may need to

have some changes made to their schedule so that concussion symptoms

do not get worse. If a particular activity makes symptoms worse, then the

athlete should stop that activity and rest until symptoms get better. To

make sure that the athlete can get back to school without problems, it is

important that the healthcare provider, parents, caregivers and teachers

talk to each other so that everyone knows what the plan is for the athlete

to go back to school.

Note: If mental activity does not cause any symptoms, the athlete may

be able to skip step 2 and return to school part-time before doing school

activities at home rst.

Mental Activity Activity at each step

Goal of

each step

1. Daily activities

that do

not give

the athlete

symptoms

Typical activities that the athlete

does during the day as long as

they do not increase symptoms

(e.g. reading, texting, screen

time). Start with 5-15 minutes at

a time and gradually build up.

Gradual

return to

typical

activities.

2. School

activities

Homework, reading or other

cognitive activities outside of

the classroom.

Increase

tolerance

to cognitive

work.

3. Return to

school

part-time

Gradual introduction of school-

work. May need to start with

a partial school day or with

increased breaks during the day.

Increase

academic

activities.

4. Return to

school

full-time

Gradually progress school

activities until a full day can be

tolerated.

Return to full

academic

activities and

catch up on

missed work.

If the athlete continues to have symptoms with mental activity, some

other accomodations that can help with return to school may include:

• Starting school later, only

going for half days, or going

only to certain classes

• More time to nish

assignments/tests

• Quiet room to nish

assignments/tests

• Not going to noisy areas

like the cafeteria, assembly

halls, sporting events, music

class, shop class, etc.

• Taking lots of breaks during

class, homework, tests

• No more than one exam/day

• Shorter assignments

• Repetition/memory cues

• Use of a student helper/tutor

• Reassurance from teachers

that the child will be supported

while getting better

The athlete should not go back to sports until they are back to school/

learning, without symptoms getting signicantly worse and no longer

needing any changes to their schedule.

on September 17, 2024 by guest. Protected by copyright.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2017-097506SCAT5 on 26 April 2017. Downloaded from