How RMTs Use This Reference
Reading the rest of this article through one of these four lenses will make it most useful:
- Interpreting client charts and referral letters. Numbers and acronyms in medical documentation are not decorative. A GCS of 13 vs. 15 is the difference between mild and at-risk presentation. A SCAT6 noted as "stage 3" tells you the client is in the controlled-aerobic-activity phase of return-to-sport.
- Deciding whether to treat today. A client in the acute symptomatic phase of concussion (24–72 hours post-injury) is generally not appropriate for treatment beyond gentle cervical work or postural support. Knowing what the SCAT6 protocol expects helps you align with their physician's recovery plan rather than disrupting it.
- Identifying when to refer. A client whose post-concussion symptoms are worsening — headache intensifying, new vomiting, increasing confusion, weakness — is presenting with red flags that warrant immediate ER referral. RMTs who can articulate the change in terms of these tools ("the headache has gone from 4 out of 10 yesterday to 8 today, and they're more confused than at intake") communicate more effectively with physicians than a vague "they don't seem right."
- Working in inter-professional settings. RMTs in sports clinics, physiotherapy practices, and team-based environments routinely see these tools in shared client charts. Knowing the basics keeps you part of the conversation.
Glasgow Coma Scale (GCS)
The most widely used tool in the world for grading consciousness after head injury, used by paramedics, ER physicians, ICU staff, and neurosurgeons. Originally published by Teasdale and Jennett in 1974 and refined as the Standardized GCS in 2014. GCS is administered serially — at the scene, on arrival to the ER, and repeatedly throughout admission — to detect deterioration.
What It Tests
Three independent neurological domains scored separately, then summed for a total:
| Component | Score Range | What It Assesses |
|---|---|---|
| Eye opening (E) | 1–4 | Arousal — does the patient open their eyes spontaneously, to voice, to pain, or not at all |
| Verbal response (V) | 1–5 | Cortical function — orientation, content of speech |
| Motor response (M) | 1–6 | Brainstem and cortical motor function — does the patient obey commands, localize pain, withdraw, posture abnormally, or not respond |
Total range: 3–15. A score of 3 means no response in any domain (deep coma); a score of 15 means fully alert and oriented.
Detailed Scoring
Eye opening (E):
| Score | Response |
|---|---|
| 4 | Spontaneous |
| 3 | To voice |
| 2 | To pain (sternal rub, supraorbital pressure) |
| 1 | None |
| NT | Not testable (e.g., periorbital swelling) |
Verbal response (V):
| Score | Response |
|---|---|
| 5 | Oriented (knows name, place, date) |
| 4 | Confused conversation (responds but disoriented) |
| 3 | Inappropriate words (random speech, no conversation) |
| 2 | Incomprehensible sounds (moans, groans) |
| 1 | None |
| NT | Not testable (e.g., intubated, denoted "T") |
Motor response (M):
| Score | Response |
|---|---|
| 6 | Obeys commands ("squeeze my hand twice") |
| 5 | Localizes pain (purposeful movement toward stimulus) |
| 4 | Withdraws from pain (pulls away, non-purposeful) |
| 3 | Decorticate posturing (flexion, arms across chest) — severe brain injury |
| 2 | Decerebrate posturing (extension, arms straight, internally rotated) — very severe brain injury |
| 1 | None |
| NT | Not testable (e.g., paralyzed, sedated) |
Documentation format: GCS 14 (E4 V4 M6) — total followed by component breakdown. The components matter more than the sum because two patients with the same total can have very different injuries.
Score Categories
| Total Score | Severity | Typical Disposition |
|---|---|---|
| 13–15 | Mild TBI / concussion | Observation, possible discharge if neuroimaging clear |
| 9–12 | Moderate TBI | Hospital admission, neurosurgery consult |
| 3–8 | Severe TBI | Intubation indicated (GCS ≤8 = "intubate"), ICU admission |
A drop of 2 or more points on serial GCS is a neurosurgical emergency — it suggests expanding hemorrhage or worsening cerebral edema and may indicate need for immediate intervention.
Pediatric GCS
For children under 5 (and especially infants), verbal and motor scoring are modified because the standard scale assumes language and command-following ability the child doesn't have yet. The Pediatric GCS uses age-appropriate alternatives (e.g., for V: "smiles, oriented to sound, follows objects" for infants instead of "oriented" for adults).
Limitations
- Cannot be scored reliably in intubated patients (V scored as "T" or 1)
- Affected by alcohol intoxication, sedation, and language barriers
- Periorbital swelling may make E untestable
- Spinal cord injury may make M unreliable for limb assessment
What GCS Means for MT Practice
A client tells you they had a GCS of 13 at the ER three days ago.
- Translation: They had a mild TBI but were on the lower end — close to the moderate threshold. They were likely admitted for observation or had imaging to rule out hemorrhage.
- Implication for treatment: This is not a "headache after a knock" — this is a documented brain injury. Expect a longer symptomatic phase (often 2–4 weeks vs. 7–10 days for an uncomplicated concussion). Defer aggressive cervical work, deep tissue, and any stimulating modalities until cleared by their physician.
A client tells you their GCS dropped from 15 to 13 between two ER assessments yesterday.
- Translation: They deteriorated. This is significant — even a 2-point drop in mild range warrants neurosurgical attention.
- Implication: Ensure they have a follow-up appointment scheduled. If they describe new or worsening symptoms (headache intensification, repeated vomiting, increasing confusion, weakness, drowsiness), refer them back to ER immediately. Do not treat.
Sport Concussion Assessment Tool 6 (SCAT6)
The SCAT6 was published in 2023 (replacing SCAT5) by the Concussion in Sport Group as the standard sideline and clinical assessment tool for sport-related concussion. It is administered by team physicians, athletic therapists, certified athletic trainers, and other appropriately trained healthcare professionals — not by coaches, parents, or RMTs.
The SCAT6 has three companion documents:
- SCAT6 — for athletes 13 years and older
- Child SCAT6 — for athletes 5–12 years
- SCOAT6 (Sport Concussion Office Assessment Tool) — for ongoing follow-up beyond the first 72 hours
What It Tests
The SCAT6 is a multi-stage protocol covering immediate sideline assessment through delayed clinical evaluation. It includes:
| Component | What It Tests | Approximate Duration |
|---|---|---|
| Immediate observable signs | Loss of consciousness, motor incoordination, vacant look, impact seizure, tonic posturing | 30 seconds |
| Glasgow Coma Scale | Consciousness — see above | 1 minute |
| Maddocks questions | Immediate orientation/memory (5 questions) | 1 minute |
| Cervical spine assessment | Pain, ROM, neurological screen — to clear cervical injury before further testing | 2 minutes |
| Symptom checklist (22 symptoms) | Severity 0–6 for each: headache, nausea, dizziness, balance, vision, fogginess, fatigue, sleep, emotional, cognitive | 3 minutes |
| Cognitive screening | Orientation (5 items), immediate memory (5-word list, 3 trials), digits backward, months reverse order, delayed recall | 5–7 minutes |
| Neurological screen | Cranial nerves, double vision, finger-nose, tandem gait, single-leg stance | 3 minutes |
| Modified BESS (balance) | 3 stances on firm surface (see BESS section below) | 5 minutes |
| Tandem gait + dual-task (new in SCAT6) | Walking heel-to-toe while performing a cognitive task | 2 minutes |
| Reaction time (new in SCAT6) | Drop-stick test or computerized | 2 minutes |
| Neck strength assessment (new in SCAT6) | Isometric strength testing in 4 directions | 3 minutes |
Total time for full SCAT6: approximately 25–35 minutes.
What's New in SCAT6 (vs. SCAT5)
- Tandem gait + dual-task — adds cognitive load to balance assessment, more sensitive to subtle deficits
- Reaction time — added because reaction-time impairment correlates strongly with concussion-related performance decline
- Neck strength — added based on evidence that lower neck strength is a risk factor for concussion and may also be impaired post-injury
- Removed SAC (Standardized Assessment of Concussion) as a separate component — its elements (orientation, immediate memory, concentration, delayed recall) are now distributed throughout the cognitive screening section
Baseline vs. Post-Injury Comparison
A best-practice SCAT6 application is baseline testing in the pre-season, then re-testing after a suspected concussion. The post-injury score is compared to the athlete's individual baseline rather than to population norms — this is more sensitive because some athletes are naturally faster, slower, more or less symptomatic at baseline. Without baseline, the SCAT6 is still useful but less sensitive.
Return-to-Sport (RTS) Protocol
Following a SCAT6-confirmed concussion, athletes progress through a 6-stage graduated return-to-sport protocol, with at least 24 hours at each stage and physician sign-off between stages:
| Stage | Activity | Goal |
|---|---|---|
| 1. Symptom-limited activity | Daily activities that don't worsen symptoms | Gradual reintroduction of work, school, and screen time |
| 2. Light aerobic exercise | Walking, stationary cycling at low intensity | Increase heart rate without symptom provocation |
| 3. Sport-specific exercise | Running drills (no head impact risk) | Add movement complexity |
| 4. Non-contact training drills | Passing drills, complex training (no contact) | Coordination, cognitive load |
| 5. Full-contact practice | Normal training activities (after physician clearance) | Restore confidence, assessment by coaching staff |
| 6. Return to sport | Normal game play | Return to competition |
If symptoms recur at any stage, the athlete returns to the previous stage after 24+ hours of rest.
What SCAT6 Means for MT Practice
A client mentions they're on day 5 of the return-to-sport protocol after a concussion 2 weeks ago.
- Translation: They've completed the worst of their acute symptoms but are still in graduated return. They are NOT cleared for full contact and are NOT fully recovered.
- Implication for treatment: Light, relaxation-focused massage is generally appropriate. Avoid:
- Deep cervical work (still vulnerable)
- Vigorous mobilization
- Anything that aggravates headache, dizziness, or fatigue
- Useful question to ask: "Has anything we just did worsened your symptoms? On a scale of 0 to 6 (the SCAT6 scale), how is your headache, dizziness, fatigue?" This communicates clinical credibility AND gives you usable feedback.
A client says they had a SCAT6 at the sideline and were "cleared to play."
- Translation: The SCAT6 was negative — no signs or symptoms of concussion at the time of assessment.
- Caveat: SCAT6 is not 100% sensitive. Symptoms can develop 24–48 hours after impact (delayed presentation). If the client is now reporting headache, dizziness, fogginess, or fatigue that wasn't present at sideline assessment, refer them back to their physician.
Maddocks Questions
A 5-question rapid orientation screen used at the immediate point of impact. Originally developed by Maddocks et al. (1995) for sideline assessment of Australian rules football players, now embedded in the SCAT6 protocol.
The Questions
The questions are sport-specific and time-anchored:
- What venue are we at today?
- Which half is it now?
- Who scored last in this game?
- What team did you play last week?
- Did your team win the last game?
Score: 1 point per correct answer. A score below 5 (any incorrect answer) suggests possible concussion and warrants removal from play and full SCAT6 assessment.
Why These Specific Questions?
The questions test immediate, recent, and short-term episodic memory — exactly the cognitive domains most affected by acute concussion. Importantly, they are NOT general orientation questions (name, date, place) — those are too easy and not sensitive to subtle impairment in athletes who routinely perform under pressure.
What Maddocks Means for MT Practice
You will rarely see Maddocks scores in clinic charts because the questions are administered immediately at the sideline and the result triggers either "removed from play" or "cleared to continue." The result that matters to RMTs is the downstream decision (was the athlete pulled? did they continue and develop delayed symptoms?), not the score itself.
If a client mentions their athletic therapist used the Maddocks questions on them, you know the AT was using a structured screening tool — that's a signal of clinical rigor in the team's concussion management.
Balance Error Scoring System (BESS)
A clinical balance test originally developed at the University of North Carolina, now embedded in the SCAT6 protocol but also used as a standalone tool. Developed because the cerebellar/vestibular systems are commonly affected in concussion, and balance impairment is one of the most objectively measurable post-concussion deficits.
How It's Performed
The athlete performs 3 stances, each held for 20 seconds with eyes closed and hands on hips:
- Double-leg stance — feet together
- Single-leg stance — non-dominant leg, dominant leg held in 30° flexion at the hip and 45° at the knee
- Tandem stance — heel of one foot directly in front of toes of the other (non-dominant in front)
Each stance is performed on two surfaces: a firm surface and a foam pad. Total: 6 trials.
(The modified BESS in the SCAT6 omits the foam-pad trials because foam pads are rarely available on the sideline — only the 3 firm-surface trials are used.)
Scoring — Counting Errors
The examiner counts the number of times the athlete commits any of these errors during each 20-second trial:
| Error | Description |
|---|---|
| 1 | Lifting hands off iliac crests |
| 2 | Opening eyes |
| 3 | Stepping, stumbling, or falling |
| 4 | Moving the hip into more than 30° abduction or flexion |
| 5 | Lifting the forefoot or heel |
| 6 | Remaining out of test position for more than 5 seconds |
Maximum 10 errors per trial. Errors are added across trials. Higher score = worse balance.
Score Interpretation
There is no single universal cutoff because BESS scores are normally distributed and affected by age, surface, fatigue, and footwear. Typical interpretive guidelines:
- Modified BESS (firm surface only, 3 trials = 30 max errors): a post-injury score 3+ errors above baseline suggests balance deficit consistent with concussion
- Full BESS (6 trials = 60 max errors): a post-injury score 5–6+ errors above baseline is suggestive
Without baseline, post-injury BESS is interpreted in the context of the broader SCAT6 examination, not in isolation.
Limitations
- Practice effects: Repeated BESS testing produces lower error scores even without injury. Re-testing closer than 7 days apart is unreliable.
- Examiner training matters: Inter-rater reliability is moderate at best when examiners aren't well-trained. Standardized training improves consistency.
- Fatigue effects: Post-exercise BESS scores are worse than rested BESS — important for sideline interpretation immediately after a play.
- Footwear and ankle pathology: Ankle injuries, footwear differences, or tight calves can produce errors unrelated to concussion.
What BESS Means for MT Practice
A client says their athletic therapist scored them at "8 errors above baseline" on the modified BESS after a head impact.
- Translation: Significant balance impairment relative to their own pre-season baseline. Strongly suggestive of concussion-related cerebellar/vestibular involvement.
- Implication for treatment: Cervical work should be conservative, and head movement (rotation, extension) should be limited until they're cleared. Vestibular components of concussion can be aggravated by head positioning changes. Position the client carefully and keep movement gradual.
King-Devick Test (K-D)
A 1-minute eye-tracking and rapid-naming test used as an adjunct to SCAT6. Originally developed in the 1970s for reading-disorder assessment in children, repurposed in the 2000s as a concussion screening tool. Not part of the official SCAT6 protocol but widely used alongside it.
How It's Performed
The athlete reads aloud the numbers on a series of test cards as quickly and accurately as possible. Time and errors are recorded.
- Test card setup: A demonstration card followed by 3 test cards of progressively spaced numbers
- Total time: approximately 60 seconds for the test cards
- Score: total time + number of errors
A baseline is established pre-season. Post-injury, the test is re-administered. Any worsening of time (or any new errors) is flagged as a positive screen for concussion.
What It Assesses
The K-D test loads multiple neurological systems simultaneously:
- Saccadic eye movements (rapid shifts between numbers)
- Visual processing speed (number recognition)
- Cognitive processing (rapid sequential reading)
- Attention (sustained focus over 60 seconds)
Concussion impairs all of these to varying degrees. Because the K-D test loads all of them simultaneously, it is highly sensitive to subtle post-concussion impairment that other tests may miss.
Strengths and Limitations
Strengths: - Brief (60 seconds) - Easy to administer with minimal training - Sensitive to subtle deficits - Computerized iPad version available with standardized timing and scoring
Limitations: - Requires baseline for meaningful interpretation - Affected by visual conditions (uncorrected refractive error, dyslexia, ADHD) - Practice effects with frequent retesting
What K-D Means for MT Practice
A client mentions their AT used the King-Devick test and they were 5 seconds slower than baseline.
- Translation: Subtle visual/cognitive impairment consistent with concussion, even if other SCAT6 components were borderline.
- Implication: This is corroborating evidence that the brain hasn't fully recovered. Continue conservative treatment until cleared by their physician. Avoid anything that demands sustained visual focus or rapid head movement (which they'll likely report as fatiguing or symptom-aggravating).
Tools Comparison Table
| Tool | Used By | Time | What It Adds | RMT Familiarity Need |
|---|---|---|---|---|
| GCS | Paramedics, ER, ICU | 2 min | Severity grading of consciousness in any TBI | High — appears in every TBI chart |
| SCAT6 | Team physicians, athletic therapists | 25–35 min | Comprehensive sport concussion assessment | Moderate — common in sports medicine charts |
| Maddocks | Athletic therapists, sideline staff | 1 min | Immediate sideline orientation screen | Low — rarely seen in charts |
| BESS | Athletic therapists, physiotherapists | 5–10 min | Objective balance measurement | Moderate — common in concussion follow-up |
| King-Devick | Athletic therapists, optometrists | 1 min | Sensitive screen for subtle visual/cognitive deficit | Low — supplement to other tools |
What These Tools Mean for MT Practice — Decision Framework
Use this table when you encounter a post-concussion or post-TBI client to decide whether and how to treat:
| Status | Treatment Decision |
|---|---|
| Acute symptomatic phase (0–72 hours post-injury) | Defer treatment beyond gentle reassurance and basic comfort positioning. No deep work, no vigorous cervical mobilization, no stimulating modalities. |
| GCS dropped 2+ points on serial assessment | Refer to ER immediately. Do not treat. |
| Currently mid-RTS protocol (stages 2–5) | Light, relaxation-focused massage is generally appropriate. Avoid deep cervical, head positioning changes, vigorous mobilization. Match treatment intensity to the stage they're at. |
| Cleared from RTS but ongoing symptoms | Conservative full treatment with continuous symptom monitoring. Use the SCAT6 0–6 scale to track. |
| Persistent post-concussion symptoms (PPCS, beyond 4 weeks) | Treat the cervicogenic component (commonly the actual driver of persistent headaches and dizziness). Coordinate with their primary care physician and ideally a vestibular physiotherapist or concussion clinic. |
| Worsening symptoms during your treatment | Stop the technique, reassess, and consider whether to refer. New or worsening headache, vomiting, drowsiness, weakness, or confusion are red flags for ER. |
Common Misinterpretations RMTs Should Avoid
- "Cleared to play" ≠ "fully recovered." RTS protocol clearance means symptoms are absent on the day of clearance — recovery is still ongoing for weeks to months in some cases.
- "GCS 15" doesn't mean "no concussion." Most concussions present with GCS 15 because the test is too crude to detect mild cognitive disruption. A negative GCS does not rule out concussion.
- Normal SCAT6 doesn't rule out concussion. Symptoms can be delayed 24–72 hours. A sideline-cleared athlete who develops headache the next day still had a concussion.
- Headache + cervical injury is common, not separate. The same biomechanical force that injures the brain almost always injures the cervical spine. Cervicogenic contribution is a major component of "persistent post-concussion symptoms" and is something MT can directly address — but only after acute clearance.
- BESS errors don't equal concussion alone. Ankle pathology, fatigue, and footwear can all increase BESS errors. Don't interpret BESS in isolation.
Where to Find the Official Forms
The SCAT6, Maddocks Questions, BESS protocol, and Child SCAT6 are all freely available from the British Journal of Sports Medicine, which publishes them as open-access resources following each Concussion in Sport Group consensus meeting:
- SCAT6 and SCOAT6 — published in BJSM (Patricios et al., 2023). Free PDF download. Required attribution if reproducing.
- GCS — published in The Lancet (Teasdale & Jennett, 1974). The Standardized Glasgow Coma Scale chart is available from the Glasgow Coma Scale website (glasgowcomascale.org).
- King-Devick Test — proprietary, available at kingdevicktest.com (requires purchase or institutional access).
RMTs should NOT reproduce these forms in their clinic intake materials or use them to make clinical decisions — that is outside scope of practice. The references above are for understanding what the documents look like when they appear in client charts.
Key Takeaways
- These tools are administered by physicians, athletic therapists, and emergency providers — not RMTs. The RMT role is recognition and interpretation, not administration.
- GCS grades consciousness in any TBI: 13–15 mild, 9–12 moderate, ≤8 severe (intubation indicated).
- SCAT6 is the comprehensive sport concussion protocol: immediate sideline through 6-stage return-to-sport. New in SCAT6: tandem gait + dual-task, reaction time, neck strength.
- Maddocks Questions are the 5-question sideline orientation screen embedded in SCAT6.
- BESS is an objective balance test embedded in SCAT6: 3 stances × 20 seconds, count errors. Modified BESS (firm surface only) is the SCAT6 version.
- King-Devick is a 1-minute rapid-naming test sensitive to subtle visual/cognitive impairment, used as a SCAT6 adjunct.
- A drop of 2+ points on serial GCS, or worsening symptoms during MT treatment, are red flags requiring immediate ER referral.
- Most "persistent post-concussion symptoms" (PPCS) have a major cervicogenic component — this is the part MT can directly treat, but only after acute clearance.
- Cleared-from-RTS does not mean fully recovered. Monitor symptoms during treatment using the SCAT6 0–6 severity scale and adjust accordingly.
Sources
- Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75(Suppl 4), S24–S33.
- Maddocks, D. L., Dicker, G. D., & Saling, M. M. (1995). The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine, 5(1), 32–35.
- Patricios, J. S., Schneider, K. J., Dvořák, J., Ahmed, O. H., Blauwet, C., Cantu, R. C., Davis, G. A., Echemendia, R. J., Makdissi, M., McNamee, M., Broglio, S., Emery, C. A., Feddermann-Demont, N., Fuller, G. W., Giza, C. C., Guskiewicz, K. M., Hainline, B., Iverson, G. L., Kutcher, J. S., ... Meeuwisse, W. (2023). Consensus statement on concussion in sport: The 6th International Conference on Concussion in Sport — Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695–711.
- Riemann, B. L., & Guskiewicz, K. M. (2000). Effects of mild head injury on postural stability as measured through clinical balance testing. Journal of Athletic Training, 35(1), 19–25.
- Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical scale. The Lancet, 304(7872), 81–84.
- Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2014). The Glasgow Coma Scale at 40 years: Standing the test of time. The Lancet Neurology, 13(8), 844–854.
- Galetta, K. M., Brandes, L. E., Maki, K., Dziemianowicz, M. S., Laudano, E., Allen, M., Lawler, K., Sennett, B., Wiebe, D., Devick, S., Messner, L. V., Galetta, S. L., & Balcer, L. J. (2011). The King-Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort. Journal of the Neurological Sciences, 309(1–2), 34–39.
- College of Massage Therapists of Ontario. (2024). Standards of practice — Scope of practice and clinical communication. CMTO.