Concussion Protocols: Where We Stand Now

October 26, 2022

Miami Dolphins QB Tua Tagovailoa returned to play this past Sunday night, several weeks after absorbing blows to the head that sparked a national conversation about concussions in the NFL. This much-needed dialogue has raised important questions and commentary in the media and has also led to some confusion and misrepresentation. I want to clear up some of these issues.

What is the NFL and the NFLPA’s role when it comes to the protocols?

It is the obligation of the NFL to provide the safest possible working environment for our players. As the union, it is our role to advocate for the highest possible standards and then hold management accountable to those standards and agreements. Everyone -- from our Medical Director, Dr. Thom Mayer, and union staff, to the team physicians, to the unaffiliated neurotrauma consultants (UNCs) and all the way to the NFL’s Chief Medical Officer, Dr. Allen Sills -- must focus on players as patients first. They serve us; not the game, not the owners and not the business.

What is the origin story of the concussion protocols?

In 2009, the NFLPA began advocating for better health and safety standards as part of a looming lockout by the NFL owners. The NFL had long denied the impact of concussions on our players, and the NFLPA leadership set a course for both acknowledging the risks and pushing aggressively for change.

New standards for concussion care were ushered in by 2011, and the union later fought for even more advanced protocols by pushing for independent concussion experts on the sideline (the first UNCs), which were adopted ahead of the 2014-2015 season.

It is important to note that these protocols were not always popular with some of our players because it was a stark culture shift from our desire as players to return to play, potentially harming ourselves in the process.

We just implemented another change in the protocols; what is the actual difference?

At the start of the 2022-23 season, this is how the concussion protocol was set to play out:

Scenario 1:

- A player takes a blow to the head but shows no visible symptom of a concussion:

• The player would be evaluated on the sideline.
• If the player continued to show no signs of a concussion and passed his evaluation, he would be allowed to re-enter the game.
• If the player begins to show symptoms of a concussion, a full examination in the locker room is performed and the player is prohibited from returning to the game.

Scenario 2:

- A player takes a blow to the head and displays one of the four “no-go” symptoms of a concussion (loss of consciousness, gross motor instability, confusion, and/or amnesia):

• That player is to be removed from the game and further evaluated in the locker room.
• Even if that player passed his concussion test in the locker room, he would still not be allowed to re-enter the game because he had already presented one or more symptoms of a concussion. It is important to note that cognitive impairment from head trauma can present itself in many different ways. Even the same player-patient may experience different symptoms during his recovery and from one injury to the next.

So, in short:

• If a player shows no symptom of a concussion and passes his concussion examination, he would be allowed to re-enter the game.
• If a player does not have a symptom, but fails his concussion test, he would be ruled out.
• If a player has a no-go symptom, regardless of whether he passes a concussion test, he would be ruled out. That should be straightforward. However, in the protocols to start the season, there was an additional caveat within the “no-go” symptom of gross motor instability.

The caveat, or “loophole,” to the conservative approach we were all aiming for – and this is what happened in Tua’s case – was if the player passed his concussion exam and the team doctor believed, considering the player’s relevant medical history, that gross motor instability (a no-go sign) was caused by an orthopedic injury, then the player would be allowed to re-enter the game. This “loophole” remained in place because of situations like the one we saw with Cam Newton in 2017, when he was deemed to suffer a knee injury and not a head injury.

But here is the problem:

What happened during the Dolphins/Bills game?

We all saw the video of Tua falling back and hitting his head on the ground – which our data shows is the number one impact injury of a concussion for the quarterback position. He was pulled out of the game because he presented a no-go symptom of gross motor instability and was taken to the locker room for a concussion examination. He passed the concussion exam, but as I explained above, he still had a no-go symptom, so he would not have been cleared to return to play EXCEPT for the club doctor deeming that his injury was a result of his back not his head. However, as we detailed in our joint statement with the league, the doctors performing the concussion evaluation never even examined his back when attributing his gross motor instability to that injury.

So the concussion protocol was followed?

If we are using the concussion protocols as a checklist and path to return players back into the game, then yes, each step was followed. But that approach takes us all the way back to the problems we faced before 2011, and the culture we had of return to work at all costs. This is the culture and practice we have worked so hard to change for so long. Our union does not care about checklists; our concern is for player care.

The decision to allow a player who displayed a “no-go” symptom to re-enter the game was to only happen if the doctor was CERTAIN that the symptom was a result of a separate injury.Again, upon our joint review, it was disclosed that Tua was not examined for his back during the concussion test in the locker room. We also know that he was tested for concussion symptoms every day following the game against the Bills heading into that Thursday night game against the Bengals. Which begs the question whether a reasonable person could make the determination that gross motor instability was caused by an orthopedic injury when they never checked his orthopedic injury and were still checking to see if he had a concussion afterwards. That seems to point to a level of uncertainty and is why we initiated the investigation into his care on September 25 in the first place.

So what changed from that incident?

We have changed the symptom from “gross motor instability” to “ataxia.” Ataxia is defined as abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue. The term is well-documented in medical literature, understood in the medical profession and should eliminate any ambiguity. It also removes the orthopedic loophole that inherently prioritizes returning a player to the field over conservative care.

We saw Teddy Bridgewater removed from the game. Is this a result of the protocol change?

In short, no. Nothing that happened in Teddy’s case would have been treated differently than before the protocol change. The ATC spotter saw unsteadiness when he stood up and there was a brief pause in the game, which allowed both spotters and the booth UNC to rewatch the video of the previous play. All three agreed to call down to the club medical staff and he was removed from the game for having a no-go symptom.

What if a player gets hit hard in the legs, rolls his ankle, etc. and gets up and is wobbly? Does that mean he is pulled out for a concussion?

No, the concussion protocol is only triggered by significant contact to the head/neck. Limping from a leg injury or having the wind knocked out of you and being slow to get up will not trigger the concussion protocol. It is up to the spotters and sideline medical staff to see and review the incident to look for that contact.

We saw Russell Wilson get hit in the head on an interception return and be evaluated for a concussion, but he returned to play. Will that be handled differently under these new changes?

No, Russell did not display any of the four no-go signs and he passed his concussion test. He was examined for a concussion because of a blow to the head that was seen by the spotters.

Do you see any additional concussion protocol changes being necessary?

Over the course of the long term, yes, we do. For example, we want to ensure that all of our medical professionals not only adhere to the protocols as written, but also understand that they serve the players as patients. We review the protocols regularly. Since their inception, the protocols have been routinely changed to better protect the players. That will always continue.That’s good medicine and results in the best care for our player-patients.

What should be our takeaways as players and fans of the NFL?

There is a constant undercurrent from some in the media that continues to imply competitive and financial considerations should supersede the health and safety of players. We believe, based on the last decade, quite the opposite: the growth of our game and our business has been directly enhanced by putting player safety first.

The vast improvements our union fought for – especially when it comes to concussions and head injuries – are a standard every sport should aspire to. Our union will continue to follow the data when it comes to this serious issue, especially when we know that in many cases, the true impact on players may not be realized for years down the road. Our goal is not to stoke fear, but rather to do everything we can to limit the risk to our membership and make our game as safe as possible.

The integrity of our game depends on everyone committing to the key principle that health and safety always overrides competitive considerations. This culture change is most evident with how far our players have come to appreciate this, as more than 50% of concussions are diagnosed based on some form of self-reported symptoms. We should be proud of the advancements we have made in our game and should look to do everything we can to adjust and adapt as we learn more.