Concussion Management


The Collegiate Water Polo Association (CWPA) follows the concussion guidelines, policies and protocols designated by the National Collegiate Athletic Association (NCAA) for men’s and women’s varsity competition.

These guidelines are recommendations for the league’s (CWPA) Collegiate Club programs. It is the decision of the individual member institutions which currently offer collegiate club opportunities to determine to what extent they follow these recommendations.

The following guidelines are provided by the NCAA and directed towards collegiate varsity programs. Any policies and protocols required of NCAA recognized varsity programs are considered recommendations for the collegiate club level:


A concussion is a serious injury, so proper reporting, diagnosis and treatment are crucial. Student-athlete wellbeing is a priority for the NCAA and has been a key component of our mission for more than 100 years. The NCAA is a leader in evaluating the impact of concussions in sport and has produced research and best practices to mitigate the potential effects of head injuries.

NCAA member schools are a critical component of these efforts. Our campuses recognize the responsibility they have to care for their student-athletes. To empower campus personnel and others with the most up-to-date information on concussions, the NCAA provides detailed recommendations in its Sports Medicine Handbook—an annual publication that is available to every NCAA member school.  The NCAA also provides resources to raise awareness of concussions among student-athletes.

In addition to playing rules aimed at providing a safer playing environment, such as prohibiting helmet-to-helmet contact, the NCAA requires each member school to have a concussion management plan in place. These plans detail when a player should be removed from practice or competition and give guidelines for evaluation by a health care provider before returning to play. If a student-athlete shows signs of a concussion, he or she is not permitted to return to play the same day of the injury.

This document from the NCAA addresses diagnosis and management of sport-related concussion in the collegiate setting for all sports.


There are more than 42 consensus-based definitions of concussion.  A recently published, evidence-based definition of concussion follows.1

Concussion is:

  • a change in brain function,
  • following a force to the head, which
  • may be accompanied by temporary loss of consciousness, but is
  • identified in awake individuals, with
  • measures of neurologic and cognitive dysfunction.

Diagnosis and management of sport-related concussion is a clinical diagnosis based on the judgment of the student-athlete’s health care providers.2 The diagnosis and management of sport-related concussion is challenging for many reasons:

  • The physical and cognitive examinations are often normal, and additional tests such as brain computerized tomography (CT), brain MRI, electroencephalogram and blood tests are also commonly normal. Although comprehensive neuropsychological tests may be a useful adjunctive tool supporting the diagnosis of sport-related concussion, there remains controversy regarding interpretation and utility as a clinical tool.
  • The clinical effects of sport-related concussion are often subtle and difficult to detect with existing sport-related concussion assessment tools.
  • The symptoms of sport-related concussion are not specific to concussion and it is challenging to evaluate a student-athlete who presents non-specific symptoms that may be related to other conditions.
  • Sport-related concussion may manifest with immediate or delayed-onset symptoms.  Symptom manifestation can vary between individuals and in the same individual who has suffered a repeat concussion.
  • Modifying factors and co-morbidities­ — such as attention deficit hyperactivity disorder, migraine and other headache disorders, learning disabilities and mood disorders — should be considered in making the diagnosis, in providing a management plan, and in making both return-to-play and return-to-learn recommendations.3-7
  • “Signal detection” on clinical measures (e.g., cognitive and balance testing) often quickly diminishes in the acute setting of early recovery.  Although cognitive function and balance assessed within 24 hours with various sideline tests (Standardized Assessment of Concussion [SAC] and Balance Error Scoring System, respectively) have been shown to be useful in diagnosing concussion, these tests often normalize within a few days and cannot be used to make a definitive diagnosis.
  • Student-athletes may underreport symptoms and inflate their level of recovery in hopes of being rapidly cleared for return to competition. 8,9
  • Clinical assessment of sport-related concussion is a surrogate index of recovery and not a direct measure of brain structure and functional integrity after concussion.

In summary, the natural history of concussion remains poorly defined, diagnosis can be difficult, there are often few objective findings for diagnosis or physiological recovery that exist for clinical use, and there often remains a significant reliance on self-report of symptoms from the student-athlete.

The NCAA Concussion Policy and Legislation mandates that institutions implement the following:10

  1. An annual process that ensures student-athletes are educated about the signs and symptoms of concussion;
  2. A process that ensures a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from athletics activities and evaluated by a medical staff member with experience in the evaluation and management of concussion;
  3. A policy that precludes a student-athlete diagnosed with a concussion from returning to athletic activity for at least the remainder of that calendar day; and
  4. A policy that requires medical clearance for a student-athlete diagnosed with a concussion to return to athletics activity as determined by a physician or the physician’s designee.


The goals of developing guidelines for the diagnosis and management of sport-related concussion are: (1) helping athletic health care providers to diagnose and manage sport-related concussion; (2) developing prevention strategies for sport-related concussions and repeat sport-related concussion; (3) promoting sport-related concussion injury resolution; (4) minimizing factors that contribute to prolonged or recurrent symptoms of sport-related concussion; and (5) preventing or minimizing complications of other co-morbidities that may accompany sport-related concussion (e.g., ADHD, migraine and other headache disorders, learning disabilities and mood disorders).

Concussion Management Plan:

Institutions should make their concussion management plan publically available, either through printed material, their website, or both. Guideline components of a concussion management plan are:

  1. Education: Institutions should provide applicable NCAA concussion fact sheets or other applicable educational material annually to student-athletes, coaches, team physicians, athletic trainers, and athletics directors.  There should be a signed acknowledgement that all parties have read and understand these concussion facts and their institution’s concussion management plan.
  2. Pre-participation assessment: A one-time, pre-participation baseline concussion assessment for all varsity student-athletes should include, but not necessarily be limited to:
    • A brain injury/concussion history;
    • Symptom evaluation;
    • Cognitive assessment; and
    • Balance evaluation.

    The team physician should determine pre-participation clearance and/or the need for additional consultation or testing.11

  3. Recognition and diagnosis of concussion: All student-athletes who are experiencing signs, symptoms or behaviors consistent with a sport-related concussion, at rest or with exertion, must be removed from practice or competition and referred to an athletic trainer or team physician with experience in concussion management.  A student-athlete’s health care provider experienced in the diagnosis and management of concussion should conduct and document serial clinical evaluation inclusive of symptom inventory and evaluation of cognition and balance.  A student-athlete diagnosed with sport-related concussion should not be allowed to return to play in the current game or practice and should be withheld from athletic activity for the remainder of the day.  Disposition decisions for more serious injuries such as cervical spine trauma, skull fracture or intracranial bleed, should be made at the time of presentation.
  4. Post-concussion management: The foundation of sport-related concussion management is initial physical and relative cognitive rest as part of an individualized treatment plan.2. Initial management of sport-related concussion is based on individual serial clinical assessments, taking a concussion history, modifying factors, and taking specific needs of the student-athlete into consideration.  Such management includes, but is not limited to:
    • Clinical evaluation at the time of injury. When the rapid assessment of concussion is necessary (e.g., during competition), symptom assessment, physical and neurological exam, and balance exam should be performed.  Brief concussion-evaluation tools such as the Standardized Concussion Assessment Tool 3 (SCAT3), which includes the Standardized Assessment of Concussion (SAC), provide standardized methods and can be compared to a baseline evaluation.12
    • Assessment for head and cervical spine injury at time of injury and implementation of the emergency action plan, as warranted.
    • Transportation to the nearest hospital if any of following signs and symptoms are present: Glasgow Coma score less than 13; prolonged period of loss of consciousness (longer than 1 minute); focal neurological deficit; repetitive emesis; persistently diminished or worsening mental status or other neurological signs or symptoms; and potential spine injury.
    • Serial evaluation and monitoring for deterioration following injury. Upon discharge from medical care, both oral and written instructions for home care should be given to the student-athlete and to a responsible adult (e.g., parent or roommate) who should continue to monitor and supervise the student-athlete during the acute phase of sport-related concussion.12

Return to activity:

Sport-related concussion is a challenging injury for student-athletes and, unlike other injuries, the timeline for return to full activity (including return-to-play and return-to-learn) is often difficult to project. The psychological response to injury is also unpredictable.  Sometimes, student-athletes who are kept out of their sport for a prolonged period of time experience emotional distress related to being unable to participate in sport. 13 It is important that health care providers remain alert to the signs and symptoms of depression and other emotional responses to injury that can be particularly challenging following concussive injury. 13  A student-athlete’s health care providers should verify the diagnosis instead of assuming that the student-athlete has prolonged concussion symptoms.  These symptoms may represent post-concussion syndrome, sleep dysfunction, migraine or other headache disorders, or co-morbid mood disorders such as anxiety and depression.7  Passive management, such as prolonged physical and cognitive rest, may be counter-productive in these scenarios.


Once a student-athlete has returned to his/her baseline, the return-to-play decision is based on a protocol of a stepwise increase in physical activity that includes both an incremental increase in physical demands and contact risk supervised by a physician or physician-designee.12  Most return-to-play protocols are similar to those in the Consensus Statement on Concussion in Sport guidelines,2 which outline a progressive increase in physical activity if the individual is at baseline before starting the protocol and remains at baseline throughout each step of the protocol.  It is noteworthy that all return-to-play guidelines are consensus-based and have not been validated by evidence-based studies.14-15  McCrea and colleagues16 have reported that a symptom-free waiting period is not predictive of either clinical recovery or risk of a repeat concussion.  Further, student-athletes have variable understanding of the importance of reporting possible concussion symptoms.8-9  In summary, it should be recognized that current  return-to-play guidelines are based on expert consensus.

There is emerging evidence that focused exercise or recovery techniques may be utilized before full recovery has occurred, but more study is needed.  Given the paucity of scientific evidence regarding return-to-play and expert consensus documents that have been published, adherence to consensus guidelines is recommended.  However, it is important to stress an individualized approach for return-to-play.  Some student-athletes may have minimal concussive symptomatology with minimal symptom duration and no modifiers (conditions that may prolong recovery such as prior concussion, migraine, ADHD, depression/anxiety).  In scenarios of this nature, and with experienced clinicians in a highly select setting, the return-to-play protocol may be modified.17  In contrast, if a student-athlete has a concussion history, increased symptom burden or duration, or has symptoms for three to four weeks with other concussion modifiers, then the return-to-play progression should proceed more cautiously and each stage may take more than a day.12

Distinctive neurological deficits, such as vestibular or oculo-motor dysfunction, should be specifically addressed to avoid prolonged return-to-play.  For example, if a student-athlete suffers from vestibular dysfunction as a manifestation of sport-related concussion, and is unable to progress in the return-to-play protocol, it is important to address the specific vestibular dysfunction rather than to simply return the student-athlete to the previous level of return-to-play progression. 7  In other words, ‘rest’ can sometimes lead to adverse outcomes if an accurate diagnosis based on neurological dysfunction is not made.  The guidelines presented herein serve as a general guide and are not meant to be prescriptive.

Stepwise progression:

The initial management of sport-related concussion is relative physical and cognitive rest.  Athletes diagnosed with sport-related concussion must be removed from play and must not return to sport-related activity for at least one calendar day and are to be evaluated by a health care provider with expertise in sport-related concussion.   Once a concussed student-athlete has returned to baseline level of symptoms, cognitive function and balance, then the return-to-play progression can be initiated, as follows in this general outline:

  1. Light aerobic exercise such as walking, swimming or riding a stationary bike. No resistance training.  If asymptomatic with light aerobic exercise, then;
  2. Mode, duration and intensity-dependent exercise based upon sport. If asymptomatic with such exertion, then;
  3. Sport-specific activity with no head impact.  If asymptomatic with sport-specific activity, then;
  4. Non-contact sport drills and resumption of progressive resistance training.  If asymptomatic with non-contact drills and resistance training, then;
  5. Full-contact practice.  If asymptomatic with full-contact practice, then;
  6. Return-to-play.  Medical clearance will be determined by the team physician/physician designee, or athletic trainer in consultation with a team physician.

At any point, if the student-athlete becomes symptomatic (i.e., more symptomatic than baseline), or scores on clinical/cognitive measures decline, the team physician should be notified and the student-athlete should be returned to the previous level of activity. Final determination of return-to-play ultimately resides with the team physician/physician designee.

Return to academics:

Return to academics (return-to-learn) is a parallel concept to return-to-play,6,18-20 but has received less scientific evaluation.  Return-to-learn guidelines assume that both physical and cognitive activities require brain energy utilization, and that after a sport-related concussion, brain energy may not be available for physical and cognitive exertion because of a brain energy crisis.3 Return-to-learn should be managed in a stepwise program that fits the needs of the individual, within the context of a multi-disciplinary team that includes physicians, athletic trainers, coaches, psychologists/counselors, neuropsychologists, administrators as well as academic (e.g. professors, deans, academic advisors) and office of disability services representatives.  The return-to-learn recommendations outlined below are based on expert consensus.  Like return-to-play, it is difficult to provide prescriptive recommendations for return-to-learn.  The student-athlete may appear physically normal but may be unable to perform as expected due to concussive symptomatology.

Stepwise progression:

As with return-to-play, the first step of return-to-learn is relative physical and cognitive rest.  Relative cognitive rest involves minimizing potential cognitive stressors, such as school work, video games, reading, texting and watching television.  Data from small studies suggest a beneficial effect of cognitive rest on concussion recovery. 20  For the college student-athlete, consideration should be given to avoiding the classroom for at least the same day as the sport-related concussion.  The period of time needed to avoid class or homework should be individualized.  The gradual return to academics should be based on the absence of concussion symptoms following cognitive exposure.  The consensus to date includes:3,19

  1. If the student-athlete cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall.
  2. Once the student-athlete can tolerate cognitive activity without return of symptoms, he/she should return to the classroom, often in graduated increments.

At any point, if the student-athlete becomes symptomatic (i.e., more symptomatic than baseline), or scores on clinical/cognitive measures decline, the team physician should be notified and the student-athlete’s cognitive activity reassessed.

The extent of academic adjustments needed should be decided by a multi-disciplinary team that may include the team physician, athletic trainer, faculty athletics representative or other faculty representative, coach, individual teachers, neuropsychologist and psychologist/counselor.  The level of multi-disciplinary involvement will vary on a case-by-case basis.  The majority of student-athletes who are concussed will not need a detailed return-to-learn program because full recovery typically occurs within two weeks.  For the student-athlete whose academic schedule requires some minor modification in the first one to two weeks following a sport-related concussion, adjustments can often be made without requiring meaningful curriculum or testing alterations.

For those student-athletes whose symptoms persist for longer than two weeks, there are differing ways to access academic adjustment or accommodations. The student-athlete may need a change in his or her class schedule; special arrangements may be required for extended absences, tests, term papers and projects.  Many institutions offer “provisional or temporary” accommodations for individuals who have impairments that are short-term in nature – six months or less (such as a broken arm or concussion).  Such accommodations are often accessed through the disability services office.

A more difficult scenario occurs when the student-athlete experiences prolonged cognitive difficulties.  In this case, considerations should include neuropsychological evaluation to: (a) determine the nature and severity of cognitive impairment, and (b) identify the extent to which psychological issues may be present and may be interacting with the cognitive processes.  Institutions can develop a detailed academic plan that specifies the support services available for that student-athlete. The student-athlete can also choose to disclose the documentation to the disability office in order to seek long-term accommodations or academic adjustments. The disability office will verify if the impairment is limiting a major life activity per the Americans with Disabilities Act. Accommodations or academic adjustments are often provided in order to ‘level the playing field’ for the student-athlete with prolonged cognitive difficulties resulting from a concussion.  A detailed academic plan coupled with accommodations can provide the needed support for a student-athlete as he or she returns to learning after a concussion.

The successful implementation of return-to-learn depends on several variables:

  • Recognition that concussion symptoms vary widely among student-athletes, and even within the same individual who may be suffering a repeat concussion.
  • Identification of a point person or case manager for the student-athlete who can navigate the dual obligations of academics and athletics.
  • Identification of co-morbid conditions that may impair recovery, such as migraine or other headache conditions, attention-deficit hyperactivity disorder, anxiety and depression, or other mood disorders.
  • Identification of campus resources that can help assure that student-athletes are provided their full rights during this transition period.

Campus resources vary, and may include the following:

  • Learning specialists. Many college campuses have certified learning specialists who have specialized knowledge of medical conditions such as concussion and post-concussion syndrome.  They usually work directly with the disability office.
  • Office of disability services. Most campuses have a disability office that is responsible for verifying each student’s impairment under the Americans with Disabilities Act Amendments Act (ADAAA).  Sometimes there is a separate disability office and ADAAA office.  In this case the first resource is the campus disability office.  Concussion and mild traumatic brain injury are covered under ADAAA.

It is advisable for the concussed student-athlete’s medical team to identify an academic point person and to be certain this academician is interwoven into the medical management plan.  Because return-to-learn is often under-managed and under-recognized, there should also be broad discussions of this important paradigm with athletics departments across the country, engaging organizations such as the National Association of Academic Advisors for Athletics, the American College Personnel Association, NASPA, Student Affairs Administrators in Higher Education, the Coalition on Intercollegiate Athletics, National Athletic Trainers Association, College Athletic Trainers Society, American Medical Society for Sports Medicine and other allied organizations.  Student-athletes are more likely to return successfully to full classroom activity in the setting of a proactive and well-integrated management plan.


  1. Carney N, Ghajar J, Jagoda A et al. Concussion Guidelines Part 1: Systematic review of prevalent indicators.  Neurosurgery, accepted in press.
  2. McCrory P et al.  Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br J Sports Med 2013; 47:250-258.
  3. NCAA Sport Science Institute Newsletter, Vol 1, Issue 2, 2013.
  4. NCAA Sport Science Institute Newsletter, Vol 1, Issue 4, 2013.
  5. NCAA Sport Science Institute Newsletter, Vol 1, Issue 6, 2013.
  6. NCAA Sport Science Institute Newsletter, Vol 1, Issue 7, 2013.
  7. NCAA Sport Science Institute Newsletter, Vol 2, Issue 3, 2014.
  8. Torres DM et al. Sports-related concussion: anonymous survey of a collegiate cohort. Neurol Clin Pract 2013; 3:279-287.
  9. Kroshus E et al. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports       Med 2013; 48:135-140.
  10. 2013-14 NCAA Sports Medicine Handbook.
  11. Makdissi et al.  Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups.  Br J Sports Med 2013; 47:314-320.
  12. Broglio SP et al.  National Athletic Trainers’ Association position statement: management of sport concussion.  J Athl Train 2014; 49:245-265.
  13. Putukian M.  Psychological response to injury: mental health issues.  Presented at NCAA Mental Health Task Force, November 2013.
  14. Harmon KG et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013; 47:15-26.
  15. Giza CC et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports. Neurology 2013; 80:2250-2257.
  16. McCrea M et al. Effects of a symptom-free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery 2009; 65:876-883.
  17. Guskiewicz K, Putukian M.  Standardized assessment and return to play. Safety in College Football Summit.  Presented January 23, 2014, Atlanta, GA.
  18. Centers for Disease Control and Prevention: Returning to school after a concussion: a fact sheet for school professionals.
  19. Halstead ME et al:  Returning to learning following a concussion.  Pediatrics 2013; 132:948-957.
  20. Moser RS et al.  Efficacy of immediate and delayed cognitive and physical for treatment of sports-related concussion.  J Pediatr2012; 161:922-926.

This Consensus Best Practice, Diagnosis and Management of Sport-Related Concussion, has been endorsed by:

  • American Academy of Neurology
  • American College of Sports Medicine
  • American Association of Neurological Surgeons
  • American Medical Society for Sports Medicine
  • American Orthopaedic Society for Sports Medicine
  • American Osteopathic Academy for Sports Medicine
  • College Athletic Trainers’ Society
  • Congress of Neurological Surgeons
  • National Athletic Trainers’ Association
  • NCAA Concussion Task Force
  • Sports Neuropsychological Society


This document addresses independent medical care for college student-athletes in all sports.


Diagnosis, management, and return to play determinations for the college student-athlete are the responsibility of the institution’s athletic trainer (working under the supervision of a physician) and the team physician.  Even though some have cited a potential tension between health and safety in athletics,1,2 collegiate athletics endeavor to conduct programs in a manner designed to address the physical well-being of college student-athletes (i.e., to balance health and performance).3,4  In the interest of the health and welfare of collegiate student-athletes, a student-athlete’s health care providers must have clear authority for student-athlete care.  The foundational approach for independent medical care is to assume an “athlete-centered care” approach, which is similar to the more general “patient-centered care,” which refers to the delivery of health care services that are focused only on the individual patient’s needs and concerns.5  The following 10 guiding principles, listed in the Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges,5 are paraphrased below to provide an example of policies that can be adopted that help to assure independent, objective medical care for college student-athletes:

  1. The physical and psychosocial welfare of the individual student-athlete should always be the highest priority of the athletic trainer and the team physician.
  2. Any program that delivers athletic training services to student-athletes should always have a designated medical director.
  3. Sports medicine physicians and athletic trainers should always practice in a manner that integrates the best current research evidence within the preferences and values of each student-athlete.
  4. The clinical responsibilities of an athletic trainer should always be performed in a manner that is consistent with the written or verbal instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated medical director.
  5. Decisions that affect the current or future health status of a student-athlete who has an injury or illness should only be made by a properly credentialed health professional (e.g., a physician or an athletic trainer who has a physician’s authorization to make the decision).
  6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual student-athlete’s injury management or sports participation status, all aspects of the care process and changes in the student-athlete’s disposition should be thoroughly documented.
  7. Coaches must not be allowed to impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional organizations.
  8. An athletic trainer’s role delineation and employment status should be determined through a formal administrative role for a physician who provides medical direction.
  9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who lack health care expertise, particularly in the context of hiring, promotion, and termination decisions.
  10.  Member institutions should adopt an administrative structure for delivery of integrated sports medicine and athletic training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of student-athletes.

Team physician authority becomes the linchpin for independent medical care of student-athletes.  Six preeminent sports physicians associations agree with respect to “… athletic trainers and other members of the athletic care network report to the team physician on medical issues.”6 Consensus aside, a medical-legal authority is a matter of law in 48 states that require athletic trainers to report to a physician in their medical practice. The NCAA Sports Medicine Handbook’s Guideline 1B opens with a charge to athletics and institutional leadership to “create an administrative system where athletics health care professionals – team physicians and athletic trainers – are able to make medical decisions with only the best interests of student-athletes at the forefront.”7 Multiple models exist for collegiate sports medicine. Athletic health care professionals commonly work for the athletics department, student health services, private medical practice, or a combination thereof.  Irrespective of model, the answer for the college student-athlete is established independence for appointed athletics health care providers.8


Institutional medical line of authority should be established independently of a coach, and in the sole interest of student-athlete health and welfare. Medical line of authority should be transparent and evident in athletics departments, and organizational structure should establish collaborative interactions with the medical director and primary athletics health care providers (defined as all institutional team physicians and athletic trainers) so that the safety, excellence and wellness of student-athletes are evident in all aspects of athletics and are student-athlete centered.

Institutions should, at a minimum, designate a licensed physician (M.D. or D.O.) to serve as medical director, and that medical director should oversee the medical tasks of all primary athletics health care providers.  Institutions should consider a board certified physician, if available. The medical director may also serve as team physician.  All athletic trainers should be directed and supervised for medical tasks by a team physician and/or the medical director.  The medical director and primary athletics health care providers should be empowered with unchallengeable autonomous authority to determine medical management and return-to-play decisions of student-athletes.


  1. Matheson GO. Maintaining professionalism in the athletic environment. Phys Sportsmed. 2001 Feb;29(2)
  2. Wolverton B. (2013, September 2) Coach makes the call. The Chronicle of Higher Education. [Available online]
  3.  NCAA Bylaw (Div. I and Div. II; (Div. III).
  4. National Collegiate Athletic Association. (2013). 2013-14 NCAA Division I Manual. Indianapolis, IN: NCAA.
  5. Courson R et al.  Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges.  J Athletic Training 2014; 49:128-137.
  6. Herring SA, Kibler WB, Putukian M. Team Physician Consensus Statement: 2013 update. Med Sci Sports Exerc. 2013 Aug;45(8):1618-22.
  7. National Collegiate Athletic Association. (2013). 2013-14 NCAA Sports Medicine Handbook. Indianapolis, IN: NCAA.
  8. Delany J, Goodson P, Makeoff R, Perko A, Rawlings H [Chair]. Rawlings panel on intercollegiate athletics at the University of North Carolina at Chapel Hill. Aug 29 ‘13. [Available online]

*This Consensus Best Practice, Independent Medical Care for College Student-Athletes, has been endorsed by:

  • American Academy of Neurology
  • American College of Sports Medicine
  • American Association of Neurological Surgeons
  • American Medical Society for Sports Medicine
  • American Orthopaedic Society for Sports Medicine
  • American Osteopathic Academy for Sports Medicine
  • College Athletic Trainers’ Society
  • Congress of Neurological Surgeons
  • National Athletic Trainers’ Association
  • NCAA Concussion Task Force
  • Sports Neuropsychological Society


What is a Concussion?
A concussion is a brain injury that:
• Is caused by a blow to the head or body from contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball.
• Can change the way your brain normally works.
• Can range from mild to severe.
• Presents itself differently for each athlete.
• Can occur during practice or competition in ANY sport.
•Can happen even if you do not lose consciousness.

How can I prevent a Concussion?
Basic steps you can take to protect yourself from concussion:
• Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet.
• Avoid striking an opponent in the head. Undercutting, flyingelbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions.
• Follow your athletics department’s rules for safety and the rules of the sport.
• Practice good sportsmanship at all times.
• Practice and perfect the skills of the sport.

What are the symptoms of a Concussion?
You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury.

Concussion symptoms include:

• Amnesia.
• Confusion.
• Headache.
• Loss of consciousness.
• Balance problems or dizziness.
• Double or fuzzy vision.
• Sensitivity to light or noise.
• Nausea (feeling that you might vomit).
• Feeling sluggish, foggy or groggy.
• Feeling unusually irritable.
• Concentration or memory problems (forgetting game plays, facts, meeting times).
• Slowed reaction time.

Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse.

Recognizing a Concussion:
To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices:
1. A forceful blow to the head or body that results in rapid movement of the head;
2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms)

Signs & Symptons:

Signs Observed By Coaching Staff
• Appears dazed or stunned.
• Is confused about assignment or position.
• Forgets plays.
• Is unsure of game, score or opponent.
• Moves clumsily.
• Answers questions slowly.
• Loses consciousness (even briefly).
• Shows behavior or personality changes.
• Can’t recall events before hit or fall.
• Can’t recall events after hit or fall.
Symptoms Reported By Student-Athlete
• Headache or “pressure” in head.
• Nausea or vomiting.
• Balance problems or dizziness.
• Double or blurry vision.
• Sensitivity to light.
• Sensitivity to noise.
• Feeling sluggish, hazy, foggy or groggy.
• Concentration or memory problems.
• Confusion.
• Does not “feel right.”

What do I do if I think I have a Concussion?

  • Don’t hide it: Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out.
  • Report it: Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play.
  • Get checked out: Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance.
  • Take time to recover: If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life.

Coaches Prevention & Preparation

As a coach, you play a key role in preventing concussions and responding to them properly when they occur.

Here are some steps you can take to ensure the best outcome for your student-athletes:

• Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play.
– Review and practice your emergency action plan for your facility.
– Know when you will have sideline medical care and when you will not, both at home and away.
– Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly.
– Review the Concussion Fact Sheet for Student-Athletes with your teamto help them recognize the signs of a concussion.
– Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete.
• Insist that safety comes first.
– Teach student-athletes safe-play techniques and encourage them to follow the rules of play.
– Encourage student-athletes to practice good sportsmanship at all times.
– Encourage student-athletes to immediately report symptoms of concussion.
• Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death.

If you think a student-athlete has sustained a Concussion:

Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion.

An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional.

Sports have injury timeouts and player substitutions so that student-athletes can get checked out.

If a Concussion is suspected:

1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently.

2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the student-athlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management.

3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact.

4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change.



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Information courtesy NCAA Concussion Facts Sheets for Coaches & Student-Athletes
Collegiate Water Polo Association