Concussion Assessment, Management, and Return to Play Guidelines
The following policy and procedures on neurocognitive baseline testing and subsequent assessment and
management of concussions as well as return to play guidelines has been developed in accordance with the goal
of the Athletic Training Department at Plymouth State University (PSU) to provide quality healthcare services
and assure the well-being of each student-athlete at PSU.
Purpose
The Plymouth State University Athletic Training Department recognizes that sport related concussion pose a
significant health risk for PSU student-athletes. Therefore the Athletic Training Department has implemented
policies and procedures to deal with the assessment, management, and return to play (RTP) considerations for
student-athletes who have sustained a concussive episode. In addition the Athletic Training Department also
recognizes the importance of baseline testing on student-athletes who participate in sports which are recognized
as contact or collision and/or who have a history of concussions upon entering athletic participation at PSU.
Baseline concussion testing will consist of neurocognitive testing and balance testing, this information will be
extremely useful in RTP decisions. The baseline data along with physical exam, diagnostic testing, symptom
scaling, follow up testing and a gradual RTP protocol will all be used in conjunction with sound clinical
judgment and on an individualized basis to determine when it is safe for an athlete to return to competition.
Definition
Concussion - A complex pathophysiological process affecting the brain, induced by traumatic
biomechanical forces.
 Direct blow or impulsive forces transmitted to the head
 Typically results in rapid onset of neurological impairments
 Functional injury: Not a structural injury
 May or may not include loss of consciousness (LOC)
 Not identifiable on standard imaging (CT, MRI)
Mild Traumatic Brain Injury (mTBI) – All concussions are a form of mTBI, however not all
mTBI's are concussions. The terms mTBI and concussion
should NOT be used interchangeably.
Post Concussion Syndrome – A set of symptoms which may last for weeks, months, or years
following a concussion
Second Impact Syndrome – Rare condition when an athlete sustains a second head injury before
symptoms from the first have resolved, often fatal
Signs and Symptoms of Concussion
Certified athletic trainers and athletic training students need to be aware of the potential signs and symptoms of
concussion in order to properly diagnosis the injury and begin formal management. Symptoms can take seconds
to hours to develop following a concussive injury.
Physical
Headache
Fatigue
Dizziness
Photophobia
Sensitivity to noise
Nausea
Balance problems
LOC
Vision difficulty
Cognitive
Difficulty remembering
Difficulty concentrating
Feeling slowed down
Feeling in a fog
Slowed reaction times
Altered attention
Amnesia
Emotional
Behavioral changes
Irritability
Sadness
Feeling emotional
Nervousness
Anxiety
Sleep
Sleep more than usual
Sleep less than usual
Drowsiness
Trouble falling asleep
Baseline Assessment
All incoming Freshmen or those first time entering PSU student-athletes who are participating in those sports
identified as collision or contact and/or who have had previous concussions identified by their health history will
have a baseline neurocognitive test and baseline Modified Balance Error Scoring System (BESS) test performed
as part of their athletic medical screening. Currently the PSU Athletic Training Department utilizes the
ImPACT™ concussion management system (impacttest.com). The ImPACT™ system is a user friendly
computer based program with 10 modules which are designed to test multiple aspects of cognitive functioning.
The Modified BESS test consists of three total 20 second balance trials utilizing a double leg stance, single leg
stance and tandem stance. Each stance is performed once on a firm flat surface for 20 seconds. Errors are
scored based on the athlete’s positioning and toe touches during the test.
The sports which currently undergo baseline testing include:
Football
M & W Basketball
Diving
M & W Lacrosse
Field Hockey
Cheerleading
Wrestling
M & W Soccer
M & W Ice Hockey
Baseball
Volleyball
M & W Skiing
Softball
Management
In any circumstance where a concussion is suspected, the athlete will not be allowed to return to play that day.
In the event of immediate concerns regarding the athlete’s mental state, the athletic trainer will err on the side of
caution until further evaluations can be obtained and/or the athlete is examined by a physician.
The recommendations in this document for the management of concussion are based on a review of the medical
literature including, but not limited to, Consensus Statement on Concussion in Sport – The 4th International
Conference on Concussion in Sport held in Zurich (2012), The National Athletic Trainers’ Association Position
Statement: Management of Sport-related Concussion, The 6th Annual Sports-Related Conference on Concussion
and Spine Injury and NCAA Sports Medicine Handbook.
On Field / Sideline Evaluation
1) In all cases in which a concussion is suspected the athlete will be removed from athletic
participation and a formal evaluation will take place. The athlete will NOT be allowed further
participation on the day of the injury.
a) Athlete removed from field utilizing c-spine precautions and transported to
emergency department if presents with:
i) Prolonged LOC and/or
ii) Focal neurologic defect and/or
iii) Significant alteration or deterioration in mental status.
b) Athlete conscious and alert will be removed to sideline for evaluation
2) Sideline evaluation
a) SCAT3 will be perfomed:
i.
Injury history (Hx), date/time, previous concussion Hx recorded, etc.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
Verbal symptom checklist
Neurologic exam
Cranial Nerve Assessment
Upper and lower quarter screening
Neurocognitive test – Standardized Assessment of Concussion (SAC)
Modified BESS test
Coordination examination
Finger to nose task
Gait coordination
Tandem walk
b) Following the sideline evaluation, continue serial monitoring every 5 minutes until
symptoms stabilize, improve, or a determination is made that the athlete should be referred to the
hospital. Hold helmet (if applicable).
PSU ATR Clinic Evaluation
1) Any PSU athlete who has sustained a concussion will be required to report to the PSU
Athletic Training Room (ATR) or equivalent if traveling for more formal evaluation
2) Clinic evaluation will consist of:
a) PSU Initial Clinic Evaluation form
b) SCAT3
3) The athlete will be scheduled for ImPACT testing between 24-48 hours after the injury
4) If warranted, physician evaluation will also be scheduled within 48 hours of the injury
5) Prior to leaving the ATR the athlete will be given a home instructions sheet, and given
instructions on what to do should their condition deteriorate
Treatment / Rehabilitation
1) PSU athletes who sustain a concussion will be instructed to rest, meaning total rest:
a) Physical rest
i) No athletic participation
ii) No recreational exercise
b) Cognitive rest
i) Limit academic work
ii) Limit video games
iii) Limit text messaging
c) When warranted, notification will be sent to the athlete’s professors and the Dean of
Undergraduate Studies requesting the student be granted academic accommodations as needed
during their recovery.
Credentialed ImPACT Consultant (CIC)
Dr. Stuart Glassman, MD of Granite Physiatry in Concord, NH will serve as our CIC. Dr. Glassman will
review all ImPACTs (baseline and post-injury) completed by a PSU athlete and determine if they are valid
and/or within normal values.
An athlete should not begin a RTP progression until the athletic training staff has received email, phone,
or text notification from Dr. Glassman directly, indicating the athlete has returned to baseline.
Follow up Evaluation(s)
1) PSU athletes who have sustained a concussion will be required to follow up with their
team athletic trainer daily until cleared by a medical professional
2) Follow up evaluation will consist of completing the PSU Management Follow up Form
a) Graded symptom check list
b) Neurologic exam
c) Modified BESS test
3) Once the athlete is asymptomatic and has returned to baseline values with the modified
BESS test, they should then be tested on ImPACT (2nd time since onset of injury)
4) Once the athlete is symptom free and back to baseline values with the modified BESS test
and the ImPACT score they may begin a supervised graduated RTP protocol
Grading
The grading of concussions prior to their resolution is not appropriate and therefore concussions will not be
given a grade or number until the concussion has completely resolved. Many of the factors in grading a
concussion depend on the severity of symptoms and duration which cannot be known until the athlete is
asymptomatic both at rest and with exertion.
Special Considerations
Medications – Are usually not needed but in some cases may be needed when considering sleep and headaches.
If the athletic trainer or physician allows the athlete to take medication, only Tylenol (acetaminophen) should be
used. Aspirin and NSAIDs should NOT be used by the athlete.
*note that the athlete should not be using medication when assessing symptoms and RTP.
Physician / Neurologist Clearance – Will be required for the following situations prior to RTP:
 Multiple Concussions, in season and/or career
 Duration of symptoms greater than 10 days
 LOC greater than 1 minute
 Convulsions
 Two concussive episodes close together, and/or recent TBI
 Athlete suffering from migraine, depression, ADHD, sleep disorder, or other mental health issue
 Athlete currently taking psychoactive drugs, anticoagulants
*note: if an athlete needs to be seen by a neurologist/physiatrist for any of the above reasons and does not
have a preference as to who evaluates them, the athletic training staff can set up an appointment with Dr.
Glassman’s office at:
Granite Physiatry, PLLC
60 Commercial St., Suite 303
Concord, NH 03301
(603)223-8145
(603)223-8146 (fax)
www.granitephysiatry.com
Return to Play Considerations
RTP protocol following a concussion follows a stepwise progression. The athlete must be symptom free and
returned to baseline values before beginning this progression. The athlete will complete each level and progress
to the next only if they remain asymptomatic both at rest, during and following provocative exercise for 24
hours. Each step will take 24 hours. Should the athlete become symptomatic during the progression, they will
drop back to the previous asymptomatic level and try to progress after a 24 hour period of rest has passed and a
follow up ImPACT test completed (3rd from time of injury).
Level 1 – Light aerobic exercise = increase heart rate (walking, stationary bike, sit ups, etc.)
Level 2 – Sport specific exercises (ex: skating, running, cutting, jumping)
Level 3 – Non-contact drills (complex training drills, passing, catching, resistance training)
Level 4 – Full contact practice (full medical clearance)
Level 5 – Return to play (game)
Continued post-concussive symptoms, prior concussion history and any diagnostic testing results along with
neurocognitve testing and physical exam, will be utilized by the team physician and athletic trainer in
establishing a timeline for an athlete's return to activity. It is important to note that this timeline could last over a
period of days to weeks or months, or potential medical disqualification from Plymouth State University
athletics. All cases will be handled on an individualized basis. The decision by the Team Physician for all cases
of an athlete's return to activity is final.
Summary
The Plymouth State University Athletic Training Department is proactive in the prevention, recognition, and
management of concussion in order to limit the risks of concussions associated with athletics as well as to limit
the potential catastrophic and long term risks associated with sustaining a concussion. The management and
return to play decisions will remain in the realm of clinical judgment on an individualized basis by both the
certified athletic trainer and the team physician.
PSU Initial Clinic Concussion Evaluation
Name: ___________________________________________ Sport: _______ YOG: __________
Date of Injury: ________________ Time of Injury: ________________
Date of Exam: ________________ Time of Exam: _________________
Mechanism of Injury: ______________________________________________________________
Does patient have a history of prior concussion:
Current Symptom
No / Yes, When _________________________
None
Headache
Nausea
Vomiting
Dizziness
Drowsiness
Numbness / Tingling
Feeling “slowed down”
Feeling like “in a fog”
Difficulty concentrating
Difficulty remembering
Visual changes (blurry, double)
Ringing in the ears
Sensitivity to light
Sensitivity to noise
Sadness
Irritability
Emotional
Nervous / Anxious
Fatigue
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Mild
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Moderate
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Severe
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Total Symptom Score: __________
Loss of consciousness: No / Yes, Duration __________
Amnesia: Pre Injury: No / Yes, Duration __________ Post Injury: No / Yes, Duration __________
Pupils equal: No / Yes
Pupils reactive: No / Yes
Cranial Nerve Exam: Normal / Abnormal, Findings _______________________________________
Motor screening: Normal / Abnormal, Findings ___________________________________________
Sensory screening: Normal / Abnormal, Findings __________________________________________
Deep Tendon Reflex: Normal / Abnormal, Findings ________________________________________
Modified BESS test: # Errors ________
Coordination: Normal / Abnormal
PSU Management Follow Up Form
Name: _____________________________________________ Date of Injury: _____________________
Today’s Date: _______________
Current Time of Day: _______________
Please complete the following scale based on how you currently feel:
Current Symptom
Headache
Nausea
Vomiting
Dizziness
Drowsiness
Numbness / Tingling
Feeling “slowed down”
Feeling like “in a fog”
Difficulty concentrating
Difficulty remembering
Visual changes (blurry, double)
Ringing in the ears
Sensitivity to light
Sensitivity to noise
Sadness
Irritability
Emotional
Nervous / Anxious
Fatigue
None
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Mild
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Moderate
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Severe
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Total Symptom Score: __________
Repeat ImPACT test needed: No / Yes, Date: __________
Today’s Neurologic Exam:
Cranial Nerve Exam: Normal / Abnormal, Findings _______________________________________
Motor screening: Normal / Abnormal, Findings ___________________________________________
Sensory screening: Normal / Abnormal, Findings __________________________________________
Deep Tendon Reflex: Normal / Abnormal, Findings ________________________________________
Balance:
Modified BESS test: # Errors ________
PSU Home Instructions for Concussion
_______________________ has received a head injury, commonly called a concussion while participating in a
colligate athletic event. The following are instructions for this person’s care over the next few days.






Do not drink alcohol
Do not drive a vehicle
Rest, No physical activity
Limit texting and video games
Do not take Aspirin or Ibuprofen (Advil, Motrin)
Tylenol (acetaminophen) may be acceptable if authorized by you certified athletic trainer or
Physician
 You may sleep, but should be checked on periodically if exhibiting moderate to severe
symptoms
Signs and symptoms of a closed head injury do not always present until hours after the initial trauma. Do to
this fact; you should be aware of possible signs and symptoms that indicate a significant head injury.
If any of the following occur call an ambulance or take the athlete to the hospital ER.








Persistent or repeated vomiting
Convulsions/seizure
Difficulty seeing, any peculiar movements of the eyes, or one pupil is larger than the other
Restless, irritability, or drastic changes in emotional control
Difficulty walking
Difficulty speaking or slurred speech
Progressive or sudden impairment of consciousness
Bleeding or drainage of fluid from the nose or ears
Emergency Phone Numbers
Plymouth Rescue - 911
Campus Police - 535-2330
Speare Memorial Hospital - 238-2239
PSU Athletic Training Room - 535-2757
If any signs and symptoms from the list above become apparent, do not delay seeking medical attention