Understanding the NFL’s Five-Step Return-to-Play Protocol for Concussion

Not long ago, concussions weren’t a major talking point in the NFL. Players who were hit hard were sent back into the game, and problems that arose after the season was over were blamed on factors outside the sport.

In today’s NFL, these players are taken much more seriously. Players who are hit hard or appear to have a head injury are taken off the field and evaluated immediately for a concussion. If team officials believe the player is seriously injured or at risk of a concussion, he will be removed from the game.

The league’s concussion protocol is a complex process. Enrolling in and activating the protocol requires several steps.

THE Jugo Mobile reviews the NFL’s concussion protocol: what it is, how players are placed in it, and how they are removed from it.

What is the NFL’s concussion protocol?

The NFL’s concussion protocol is a series of five steps players must follow to return to play after sustaining a concussion.

How does the NFL concussion protocol work?

If a player exhibits symptoms of a concussion, the protocol will be initiated by the person who spotted him. The player is taken to the sideline and assessed for a concussion. He will be evaluated for any so-called “ban” symptoms — loss of consciousness, gross motor instability, confusion, amnesia, fencing reaction, impact seizure — history of concussions, any other symptoms or targeted neurological examination. Following the findings of the investigation into the management of Tua Tagovailoa’s injury in 2022, ataxia, defined as an abnormality of balance/stability, motor coordination or speech dysfunction caused by a neurological condition, has been added to the banned list. If a ban is found, the player is not permitted to return to the field.

If there is concern that a player has suffered a concussion, he or she must be examined by a team physician, neurotrauma consultant, or unaffiliated athletic trainer. The protocol will be put in place if examiners believe a player has suffered a concussion. The protocol includes a follow-up neurological examination and periodic evaluation by the medical team. Players are not permitted to return to play during this time.

How long is the NFL concussion protocol?

Players must go through several stages before being cleared to play by a doctor. Since each phase can take a different amount of time depending on the severity of the concussion, the timeline can vary greatly depending on the player.

Here are the steps players must follow to exit concussion protocol:

Symptom of limited activity

During this phase, players are asked not to engage in excessive physical activity. They are expected to rest during this time and limit anything that could aggravate their symptoms. Afterward, players will be allowed to do limited stretching and light aerobic exercise, provided the team’s training staff supervises them.

Aerobic exercise

Players will begin working on cardio exercises, stretching and training, under the supervision of the team’s medical staff. After this phase, players will be able to begin working on balance tests.

Football Specific Exercise

In the third stage, players can participate in football-specific drills and begin working with the team for up to 30 minutes under supervision. Players can also increase their cardio workload.

Non-contact training exercises in the club

Players who reach stage four can begin throwing, catching, running, and participating in more position-specific activities. They can also continue to intensify their drills and training. By the end of this phase, players must have completed neurocognitive and balance testing.

Full football activity/authorization

The player must be cleared by the club doctor and the independent neurologist to return to full activity.

When did the NFL concussion protocol begin?

The league’s concussion protocol was developed in 2011 by the Head, Neck and Spine Committee. The committee is comprised of independent and league-affiliated physicians and scientists as well as advisors from the NFL Players Association.

History of NFL Concussion Protocols

Football has long been recognized as a dangerous sport, but it took a long time for the league to begin considering concussions as part of player health and safety.

The NFL didn’t begin measuring concussions until 1994, according to PBSwhen Commissioner Paul Tagliabue appointed Dr. Elliot Pellman to chair the Mild Traumatic Brain Injury (MTBI) Committee. Pellman, however, lacked experience in the field. Later that year, Tagliabue described concussions as a “pack journalism problem.”

• In 1997, the American Academy of Neurology issued guidelines stating that players should be removed from games if they exhibit concussion-like symptoms within 15 minutes of an injury, because of the risk of further brain damage. Three years later, MTBI members criticized the report, saying it lacked research.

Mike Webster, a center who was inducted into the NFL Hall of Fame and retired from the NFL in 1990, claimed in 1999 that his football career had caused dementia. A year later, the NFL’s retirement board ruled that his playing the sport had left him “totally and permanently” disabled. Webster died of a heart attack at age 50 in 2002.

Dr. Bennet Omalu examined Webster’s brain shortly after his death and discovered early signs of chronic traumatic encephalopathy (CTE). In 2003, Dr. Kevin Guskiewicz warned in an article that repeated concussions could slow the recovery of neurological function. At the same time, Pellman, who was the Jets’ team physician, sent wide receiver Wayne Chrebet back into a game after he was knocked unconscious.

The MTBI committee stated in a 2004 paper that 92% of players with concussions returned to practice within seven days, in an attempt to downplay the severity of concussions. That same year, the committee criticized Guskiewicz’s research and said his study did not support its conclusions. The committee later published another paper stating that NFL players are less likely to suffer brain injuries than the general population.

• In 2005, the committee released another report and stated that players who return to play after sustaining a concussion are at no greater potential risk of injury than those who are removed from play after a concussion. Omalu published his findings on Webster that year.

After Omalu’s report was published, one MTBI committee member called it “spurious reasoning.” Others called for the paper to be retracted. Instead, Omalu published a second paper in 2006. This time, he claimed to have discovered an ETC in the brain of former Steelers lineman Terry Long.

• In 2007, the league began to question the process for returning players to the field. Commissioner Roger Goodell said he was concerned about players returning after a concussion. Later that year, Pellman resigned from the MTBI committee and Goodell organized a concussion summit. The league sent out a brochure calling the research on concussions inconclusive.

After some shuffling within the MTBI committee and new research being published, the NFL finally acknowledged in December 2009 that concussions can have long-term health impacts on players. It issued return-to-play guidelines that instructed players with concussion-like symptoms not to return to play.

The NFL designated Dr. Ann McKee’s Center for the Study of Traumatic Encephalopathy at Boston University as its brain bank. The center would study brain injuries in deceased NFL players. The league continued to fund research as more was learned about concussions. The center discovered CTE in Owen Thomas, a 21-year-old Penn player, and former Bears safety Dave Duerson, both of whom committed suicide.

• In 2011, former Falcons safety Ray Easterling sued the NFL for “deception and denial” of concussion science. Two years later, the NFL settled the lawsuit for $765 million but admitted no wrongdoing. That year, the league introduced its game-day concussion diagnosis and management protocol.

As new research on concussions and CTE continues to be published, the NFL has increased its investment in research and announced rule changes and new measures. Independent neurologists have been added to NFL teams.

• In 2014, Boston University reported finding evidence of ETC in 76 of 79 brains of deceased former NFL players. Studies have continued to reveal high rates of ETC in players.

• In 2018, the league’s protocol was expanded to include a third, unaffiliated neurotrauma consultant to monitor game broadcasts and alert on-field consultants of possible head, neck or spinal injuries. The league also said that if players experience an impact seizure or exhibit the fencing reaction, they are considered “no-gos,” meaning they cannot return to play.

Additionally, if a player trips or falls to the ground, they must be evaluated to determine the cause of the fall. If someone is evaluated for a concussion during the game, they must undergo a second evaluation the following day.