HOUSTON – In 2011, the National Football League developed the NFL Game Day Concussion Diagnosis and Management Protocol.
The protocol was developed by the NFL Head, Neck and Spine Committee, which is made up of a board of independent and NFL-affiliated physicians and scientists along with advisors for the NFL Players Association.
Each year, the protocol is reviewed to "ensure players are receiving care that reflects the most up-to-date medical consensus on the identification, diagnosis and treatment of concussions."
Here's a look at the NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol:
What is a concussion?
The diagnosis and management of concussions are complicated by the difficulty in identifying the injury as well as the complexity of managing the injury, according to the protocol.
The league classifies a sports-related concussion as "a traumatic brain injury induced by biomechanical forces."
How do you define a concussion?
- SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
- SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
- SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
- SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases, symptoms may be prolonged.
What are the visual signs of potential concussion?
- Any loss of consciousness
- Slow to get up following a hit to the head (“hit to the head” may include secondary contact with the playing surface)
- Motor coordination/balance problems (stumbles, trips/falls, slow/labored movement)
- Blank or vacant look
- Disorientation (e.g., unsure of where he is on the field or location of bench)
- Amnesia, both anterograde and retrograde
- Clutching of head after contact
- Visible facial injury in combination with any of the above
What are some potential concussion symptoms?
- Headache
- Dizziness
- Balance or coordination difficulties
- Nausea
- Amnesia, both anterograde and retrograde
- Cognitive slowness
- Light/sound sensitivity
- Disorientation
- Visual disturbance
- Tinnitus
Each team is required to develop, write, discuss, practice and review an emergency action plan for all practice and game venues.
Each EAP is required to establish the protocols that the medical staff is to follow in the event of a significant injury.
Each EAP must include a list of spotters and a list of certified and approved emergency room physicians to serve as medical liaisons for visiting teams.
The EAP must be approved by an expert and sent to the visiting club's medical team in advance of all games.
During the preseason, players and club personnel review educational material regarding concussion.
Players are encouraged to report concussion signs to the team's medical staff.
Preseason assessment:
Physical exam - Each team physician is required to use the preseason physical to review and answer questions about a player's previous concussions and to discuss the importance of reporting signs and symptoms, according to the protocol.
Neuropsychological testing - Each player is given a baseline physical that includes a traditional neurological exam.
Game day concussion diagnosis and management:
During games, each team is assigned an unaffiliated neurotrauma consultant by the committee. The UNC is a physician who is "impartial and independent from any Club, is board certified or board eligible in neurology, neurological surgery, emergency medicine, physical medicine and rehabilitation, or any primary care CAQ sports medicine certified physician and has documented competence and experience in the treatment of acute head injuries (as evidenced by no less than monthly treatment of such patients)."
The UNC is on the sideline of every game and is focused on identifying symptoms of a concussion that warrant evaluation, working with the team's head physician to implement the concussion protocol and is present to observe (and collaborate) with the team physician to implement the concussion evaluation and management protocol on the sideline and in the locker room.
The UNC is also available to assist in transportation to an appropriate facility for more evaluation.
According to the protocol, the responsibility for the diagnosis of concussion and the decision to return a player to a game remains exclusively within the professional judgment of the Head Team Physician or the team physician assigned to managing traumatic brain injuries.
Spotters
Two certified athletic trainers are assigned to a stadium booth to spot concussions. They have access to multiple views of video and replay to aid in the recognition of injuries.
The spotters are trained to follow the NFL Concussion Protocol and are in charge of monitoring the game, both live and via video feed, to identify players who may need additional medical evaluation.
The booth spotters, UNC, and the team physician must be in communication through radio, according to the protocol. The booth spotters are also connected to the on-field game officials through radio.
When the spotter sees a player who is clearly unstable or shows signs of a concussion, the spotter will contact the team physician and UNC via radio to ensure a concussion evaluation takes place on the sideline.
The club medical staff will then verify to the booth spotter that the evaluation has been performed.
The spotter notes the time of the initial contact with the club medical staff and also the time the evaluation was performed. If the spotter sees a player who was flagged for medical evaluation return to the game before receiving an evaluation, the spotter can call a medical timeout.
Spotters file reports of their activity following each game. The reports are reviewed by the NFL Chief Medical Officer and the NFLPA Medical Director.
"No-go" signs and symptoms:
If a player exhibits any of the following symptoms of concussion, he must be removed from the field immediately and taken to the locker room. The player may not return to participation on the same day under any circumstances:
- Loss of consciousness
- Confusion
- Amnesia
NFL Sideline Concussion Assessment (Sideline Survey):
If a player exhibits a sign or symptom of concussion, or a concern is raised by any game day medical personnel, the player must be removed from the field and must undergo the entire NFL Sideline Concussion Assessment, which at the minimum, must consist of the following:
- A review of the “No-Go” criteria reviewed above (Loss of Consciousness, Confusion, and Amnesia), which, if present, requires the player to be brought to the locker room immediately and he shall not return to play
- Inquiry regarding the history of the event
- Review of concussion signs and symptoms
- Maddock’s questions
- Video Review of the injury
- Focused Neurological Exam, inclusive of the following:
- Cervical Spine Examination (including range of motion and pain)
- Evaluation of speech
- Observations of gait
- Eye Movements and Pupillary Exam
The sideline exam is conducted inside the medical evaluation tent on the sideline.
If upon completing the Sideline Survey, the medical staff concludes that the player did not sustain a concussion, then the player may return to play.
If any elements of the assessment are positive, inconclusive or suspicious for the presence of a concussion, the player must be taken to the locker room immediately to complete the NFL Locker Room Comprehensive Concussion Assessment.
NFL Locker Room Comprehensive Concussion Assessment (Locker Room Exam):
"The NFL Locker Room Comprehensive Concussion Assessment is the standardized acute evaluation that has been developed by the NFL’s Head Neck and Spine Committee to be used by teams’ medical staffs and designated Unaffiliated Neurotrauma Consultant to evaluate potential concussions during practices and on game day."
The locker room assessment is used to aid in the diagnosis of concussion even if there is a delayed onset of symptoms.
The use of the locker room assessment in conjunction with the preseason baseline testing gives medical personnel a comprehensive and detailed picture of each athlete's injury and recovery course.
Each team keeps a copy of the locker room assessments. A copy is also given to each player and the team medical staff.
The team physician is responsible for determining the concussion diagnosis.
When a booth spotter has clear evidence that a player has suffered a concussion and it appears that the player will remain in the game and not be attended by the medical staff, the spotter can call a medical timeout.
The spotter will contact the side judge using the radio to identify the player by his team and number, according to the protocol.
The spotter will also contact the medical staff of the player involved and advise that the player appears to need medical attention, the protocol says.
The spotter will remain in contact with the medical staff until an evaluation has occurred or is underway. It is the spotter's responsibility to confirm that a concussion evaluation has occurred before the player returns to play.
If the spotter sees a player returning to the game without receiving confirmation of an evaluation, the spotter is to signal to the official for a medical timeout.
After the player is removed from the field, the team medical staff will conduct an evaluation before making any decision regarding the player's return to play. In no instance will this evaluation period last less than one play, unless there is an extended delay unrelated to the player's removal from the game. An injury time out is not charged to a team who has a player removed during this process.
The Madden Rule says that any player diagnosed with a concussion on game day must be removed from the field and observed in the locker room by qualified medical personnel. Once a player is diagnosed with a suspected concussion, he is not permitted to meet or talk to the press until he is medically cleared.
NFL concussion game day checklist:
Since each concussion is unique, there is no set timeframe for return to participation or for the progression through the steps of the graduated exercise program.
The decision to return a player to participation relies on the professional judgment of the team's head physician or team physician designated for concussion evaluation and treatment.
All decisions are to be confirmed by the Independent Neurological Consultant.
After a player is diagnosed with a concussion, he must be monitored daily through the Return-to-Participation Protocol.
The player must progress through the following protocol to return to participation. A player-patient may proceed to the next step in the protocol only after he has demonstrated tolerance of all activities in his current step without recurrence of signs or symptoms of concussion being observed or reported. Depending on the severity of the concussion and the time required for return to baseline, the progression through the steps may be accelerated, according to the protocol.
The Return-To-Participation Protocol:
Step One: Rest and Recovery
This is the physical and relative cognitive rest step. The player is prescribed rest, limiting or, if necessary, avoiding activities (both physical and cognitive) which increase or aggravate symptoms until his signs and symptoms and neurologic examination, including cognitive and balance tests, return to baseline status. During this step, the player-patient may engage in limited stretching and balance activity as tolerated at the discretion of the medical staff. Should additional issues present, the team physician should consider external consultation or additional diagnostic examinations.
Once the player-patient is at his baseline level of signs and symptoms and neurological examination, he may be cleared to proceed to the next step.
Neurocognitive testing is administered to assess the player/patient’s level of cognitive function and identify any acute/subacute deficits that would affect his ability to resume normal activities. Neurocognitive testing can be introduced any time after completing Step One, or during Steps Two or Three, as long as it is completed prior to the initiation of contact activities. The timing of neurocognitive testing is up to the team physician with consultation from the team’s neuropsychology consultant. All neurocognitive tests are to be interpreted by the team’s neuropsychology consultant, with the results communicated to the team physician.
Step Two: Light Aerobic Exercise
Step Two involves the initiation of a graduated exercise program. Under the direct oversight of the team’s medical staff, the player-patient should begin graduated cardiovascular exercise (e.g., stationary bicycle, treadmill) and may also engage in dynamic stretching and balance training. The duration and intensity of all activity may be gradually increased so long as the player-patient remains at baseline while performing the activity and for a reasonable period thereafter. If there is a recurrence of signs or symptoms the activity should be discontinued. He may attend regular team meetings and engage in film study.
If neurocognitive testing was not administered during Step One, it should be administered during Step Two or Three. If a player/patient’s initial neurocognitive testing is not interpreted as back to baseline by the consulting team neuropsychologist, the tests will be repeated at a time interval agreed upon by the team physician and consulting team neuropsychologist (typically 48 hours). Additionally, a comprehensive evaluation of potential non-injury related causes of a noted neuropsychological decrement should be performed by the team physician. An athlete may be allowed to participate in non-contact activities even if their neurocognitive testing is interpreted as abnormal. The player-patient should not proceed to contact activities until their neurocognitive testing is interpreted as having returned to their baseline level by the consulting team neuropsychologist or, if a decrement persists, until the team physician has determined that this is not due to the concussion. The need and time interval for additional testing will be determined by the team physician, in consultation with the team’s neuropsychology consultant, based on the clinical status of the player/patient.
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Once the player-patient has demonstrated his ability to engage in cardiovascular exercise without recurrence of signs or symptoms, he may proceed to the next step.
Step Three: Continued Aerobic Exercise & Introduction of Strength Training
The player/patient continues with supervised cardiovascular exercises that are increased and may mimic sport-specific activities, and supervised strength training is introduced. Some may consider this step as a continuation of Step Two. If neurocognitive testing was not administered after Step One, or during Step Two, it should be administered during Step Three. If a player/patient’s initial neurocognitive testing is not interpreted as back to baseline by the consulting team neuropsychologist, the tests will be repeated at a time interval agreed upon by the team physician and consulting team neuropsychologist (typically 48 hours). A player/patient may be allowed to participate in non-contact activities even if his neurocognitive testing is interpreted as abnormal. The player-patient should not proceed to contact activities until their neurocognitive testing is interpreted as back to their baseline level by the consulting team neuropsychologist or, if a decrement is still present, until the team physician has determined a non-concussion related cause. The determination of when to proceed with contact activities is ultimately made by the team physician.
Once the player-patient has demonstrated his ability to engage in cardiovascular exercise and supervised strength training without recurrence of signs or symptoms, he may proceed to the next step.
Step Four: Football Specific Activities
The player-patient may continue cardiovascular conditioning, strength and balance training and participate in non-contact football activities such as throwing, catching, running and other position-specific activities. All activities at this step remain non-contact. (e.g., no contact with other players or objects, such as tackling dummies or sleds).
If the player-patient is able to tolerate all football specific activity without a recurrence of signs or symptoms of concussion and his neurocognitive testing has returned to baseline, he may be moved to the next step in the sequence.
Step Five: Full Football Activity/Clearance
After the player-patient has established his ability to participate in non-contact football activity including team meetings, conditioning and non-contact practice without recurrence of signs and symptoms and his neurocognitive testing is back to baseline, the team physician may clear him for full football activity involving contact. Once cleared by the team physician, the player-patient may participate in all aspects of practice. If the player/patient tolerates full participation practice and contact without signs or symptoms and the team physician concludes that the player/patient’s concussion has resolved, he may clear the player-patient to return to full participation. Upon clearance by the team physician, the player must be examined by the INC assigned to his Club. The INC must be provided a copy of all relevant reports and tests, including the player/patient’s neurocognitive tests and interpretations. If the INC confirms the team physician’s conclusion that the player-patient’s concussion has resolved, the player-patient is considered cleared and may participate in his Club’s next game or practice.