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The NFL concussion protocol cannot save football

NFL players are going to try to fake the concussion protocol, no matter how good it is.

Herm Edwards may love football more than anyone on Earth has ever loved football. He played 10 seasons, coached for 22, and now resides in television sets, from which he tells people all about football. And he admits that, as a football lover, he would absolutely try to fake the NFL concussion protocol if he were playing today.

“Yeah. Sure. If I could function and it don't hurt the team,” Edwards told SB Nation. “If you're injured, you can't play. Hurt? The only guys who don't hurt in football are the guys who don't play.”

Last October, Seattle Seahawks wide receiver Doug Baldwin went on Bill Simmons’ Any Given Wednesday and claimed that NFL players fake the concussion protocol. He had taken a big hit from New York Jets safety Calvin Pryor the weekend before and was screened for a concussion on the sideline. Baldwin said that he didn’t try to cheat the protocol but that he could have if he had wanted to, and that the ability to cheat is “relatively known around the league.”

“Guys — we know the protocol, so if you are cognitively there somewhat then you can cheat the system,” Baldwin said. “Honestly, I don’t know what’s a better way to do it. We’re waiting for that. We’re waiting for that information.”

There is no consensus among players that faking the concussion protocol is as prolific as Baldwin suggests. The one thing most would seem to agree on is that there is motivation to try. The tests used to screen concussions are inexact and need to be interpreted by a qualified medical professional. There is financial incentive for players to try to skew that interpretation and team goals that can encourage lax oversight. In short: The NFL environment is ripe for players to try to fake.

The concussion protocol is the NFL’s best defense against perhaps its biggest existential threat. Youth participation in football has declined precipitously since 2010 — 27.7 percent among players aged 6-14. There was a slight uptick from 2014 to 2015, the most recent figures available, but that is little headway for a sport that was once much more robust. Since 2009, youth touch and tackle football participation has declined at a greater rate than all other sports other than court volleyball and wrestling.

The decline coincides with growing awareness of the long-term effects of repeated brain injuries. Former Denver Broncos and Arizona Cardinals safety Hamza Abdullah is one of several players who have criticized the NFL for the treatment they received for concussions. In 2013, a little less than two years after he retired, he alleged, in a Twitter rant, that team doctors covered up his concussions, and he confessed that he had struggled with suicidal thoughts since leaving football.

Abdullah only played one season under the NFL’s formalized sideline concussion assessment protocol, however, which was implemented with the new collective bargaining agreement in 2011 and has since been refined. Few, if anyone, would argue that the protocol hasn’t helped. Abdullah’s younger brother, Husain, in fact, has lauded the Kansas City Chiefs and how they guided him back from a concussion over the last month of his final regular season in 2015.

Last year at age 30, the same age Hamza was when he ranted against the league, Husain explained his decision to retire in a story for The Players’ Tribune. In it, he praised the protocol, specifically:

When I was with the Chiefs and I suffered my fifth concussion, it was completely different. They went above and beyond to try to diagnose the concussion, and to try and rehabilitate me. There was a protocol — different steps you had to complete and benchmarks you had to reach before you could step back on the field. It wasn’t just, When you’re good, you’re good.

That seems like progress from what Edwards describes, an acknowledgment that even when you feel “good” you may not be good at all. The NFL concussion protocol works well at monitoring and rehabilitating athletes, giving them follow-up assessments and defined steps that determine when a player is ready to play again.

The protocol is still not good at spotting concussions, however. It depends on medical professionals being able to see concussive hits when they occur, even when large bodies pile up on one another on a football field. When players are then pulled off the field, the screening process relies on them to be forthcoming about mild symptoms.

The first sideline test administered to players is often a modified version of the Maddocks questions, five questions — like “What venue are you playing at today?” and “Did your team win last week?” — that should reveal whether a serious concussion has occurred. Those questions are often easy, recycled, and can be practiced.

“Passing the concussion test was cake because I already knew everything,” Husain told SB Nation. He said that he never tried to fake the test, but he knew the screening questions before trainers asked him, and so did his teammates.

“And they go back through the same thing. He'd ask me the date. He would ask me who was the vice president. He would ask me to count backwards by seven from 100. The first time it's like, 'OK, by seven backwards. OK. Yeah, 100, 93, 86 — ’"

The NFL concussion protocol has made life better for players, but it can be inadequate when it comes to screening, and it’s not clear that it can actually improve much at this moment in time. Its foundation rests on three pillars — science, players, and observant medical professionals — that are flawed.

The NFL in many ways encourages players to stay on the field however they can, and perhaps none more significant than non-guaranteed contracts. A player with no dead money left on his deal can be cut at a second’s notice and, in theory, never make another dime in the league if he has lost his utility to teams. Those contracts may make owners and general managers happy, but they may also be hastening the league’s demise by incentivizing players to squeeze everything they can out of their short and brutish careers.

From an early age, players have been told that they need to stay on the field to survive; that there is always someone right behind them. For pros, that person may also be much younger and cheaper. They also learn that pain is normal, even extreme pain.

The NFL Players Association is trying to undo that hard coding.

“It's one of those things where if you're prepared for it, or your mind's in overdrive, then you might be able to fake,” NFLPA president Eric Winston told SB Nation. “But the one thing we stress on our educational level is that, hey, injuries happen, and that you're actually doing yourself a disservice, and you're actually doing your team a disservice by going out there.”

No one should play through a concussion the way they might play through the mild pain of a sprained ankle. A concussion is more than an ache. Sometimes it isn’t an ache at all. Mild concussive symptoms make players more susceptible to severe concussions, and thus long-term neurological problems. “Hurt” with a concussion is hard to qualify, because symptoms like blurred vision and disorientation aren’t painful. And without pain, the players play.

“And people are wondering, 'Well, why would they do that?' That's just what you do,” Edwards said. “And I used to tell guys, 'Whatever you can do, do it as long as you can. Because when it's gone, man, it's gone.’”

Kansas City Chiefs v San Diego Chargers Photo by Sean M. Haffey/Getty Images

“I called them the '70 percenters,' I was one of those guys who could be terminated. So we didn't have that luxury of safety. We didn't have the luxury of, 'OK, some doctor wants to protect our brain.' And that's as honest as I can be when it comes to that.”

I was talking to a former NFL player. Here’s what I can tell you about him: He played fullback and special teams for franchises in the NFC West and South, and he played before and after the concussion protocol was enhanced in 2011. He doesn’t want to reveal more about himself than that because he is part of the concussion lawsuit that is still being settled.

“The back end of the NFL is just a nasty place, man,” the player said. “They want to protect their money, they think everything is theirs, we're just meat to them, and people really do have issues once they leave that game. And it wasn't caused from anything else but football.”

The NFL has fostered an Us-vs.-Them relationship with players in a lot of ways. The players union is the weakest among the big four American professional sports — it’s the only one with non-guaranteed contracts, for example — and the league has become increasingly fine-happy about self-expression on and off the field.

That sense of Us vs. Them extends to concussions and the football field. The former pro said players protected one another from doctors during games, especially after 2011 when NFL teams began making better efforts to spot concussions. He recalled how a teammate helped him stay on the field during a game in which he was “walking knocked out” — playing more than two-and-a-half quarters of football that he can’t remember.

“My buddy, who wasn't playing, actually due to a concussion, he wrote down all my assignments on my glove. So not only was it a culture of abuse for coaches vs. the players, because the coaches always wanted you to play, but it was also players know how important it is to people and other players that you're playing.”

The former player’s experience differs from Husain Abdullah’s, but that doesn’t mean that either is skirting the truth. Abdullah emphasized that how well a player is treated for a concussion can vary greatly on a team-by-team basis, and even within teams depending on a player’s importance.

“How J.J. Watt is treated different from Husain Abdullah, is treated different from a guy on practice squad,” Abdullah said. “It's all relative to the individual, the way the trainers cared for me and the way they looked out for me could be different from the way they cared for another person, could be different in Denver, could be different in Seattle, could be different in Miami.”

Certain team cultures, especially those struggling with disunity, may be conducive to faking the protocol. Winston said that faking the concussion protocol “probably” occurs in the NFL, but that he hasn’t personally noticed the phenomenon across his career with the Texans, Chiefs, Cardinals, Seahawks, and Bengals, in large part because those teams have strong core leadership.

“And when I say that everybody is on board, that's what I mean: Everybody has got to be on board,” Winston said. “It literally has to be the whole team. Because if it's not, a lot of those problems come up even more than they already are.”

According to the former player, teammates who suffered chronic concussions were called “sissies” where he played — “Which is bad, I know” — but the pejorative shielded players in a way. Getting labeled as “concussion prone” would’ve been worse, potentially triggering the downfall of a player’s career.

Herm Edwards said the same thing.

“Here's the problem,” Edwards said. “If you're a young player and you play a sport, and you've been concussed at a young age — let's just say in high school you had one or two, and then college you had three or four — well if you're player, you don't really want people to know that, to be quite honest. Because that might deny you the ability to play in the league.”

Edwards will readily admit that that mentality is still seen as essential in great football players. At the NFL level, it’s impossible not to be tough. Being able to stay on the field is looked at not as a factor of luck or health, but as one of the most valuable skills a player can have. Edwards calls it a “talent” in itself — being able to grit the symptoms and cheat the system.

Kansas City Chiefs v Houston Texans Photo by Chris Graythen/Getty Images

“I'm impressed by how well it works,” Dr. Barry Jordan told me. Jordan is an unaffiliated neurotrauma consultant (UNC) for the New York Giants. “I think it's probably the gold standard right now for concussion evaluation in sports.”

Jordan specializes in sports neurology as the director of neurorehabilitation at Burke Rehabilitation Hospital in White Plains, N.Y. He is also a team physician for USA Boxing and served 13 years as the chief medical officer of the New York State Athletic Commission. He has, in his words, “witnessed more concussions than probably most physicians in the world.”

The NFL made a significant improvement to the concussion protocol by adding a UNC like Jordan for each team. UNCs stand on catty-corner 25-yard lines during NFL games, watching for possible concussions and assisting team physicians in evaluating players. The NFL also added an independently certified athletic trainer to the booth as a spotter who can stop play, which makes for a minimum of 29 medical professionals at every NFL game.

Those trainers, doctors, consultants, and spotters are all looking for observable concussion symptoms: things like clumsy movement, loss of consciousness, or the fencing response, which is when a player involuntarily extends his arms straight out after suffering a brain injury. Having a lot of eyeballs is important because concussions are incredibly difficult to spot from the sidelines, especially when they occur in the trenches.

That’s a fundamental issue with constructing a concussion protocol: Unless a player displays an overt sign of a concussion, you can’t actually see one. A bum ankle or shoulder? An untrained eye can pick up on a limp or some gingerness. A mild concussion requires close examination from a trained medical professional to diagnose. From a distance, a concussed man in a helmet and pads looks like any healthy football player.

For sideline evaluation, the NFL relies on a modified version of the most recent Sports Concussion Assessment Tool, or SCAT, a step-by-step diagnostic that was developed by international consensus and is used in sports leagues around the world. The latest version is the SCAT3, which includes sections for observable concussion symptoms, cognitives assessments (like reading a series of digits backward or recalling a list of words), and balance testing.

The SCAT3 also asks players to describe the severity of their own symptoms, which is a significant flaw when there are athletes who would like to subvert the test. That’s the one thing you should really know about the NFL concussion protocol: that whether you think it’s doing its job or not — and there are a lot of opinions — it is a process that depends on individuals. There is no feasible way to objectively diagnose a concussion on a football sideline at this point in time.

“That's what people have to understand, there's no test that's going to replace the clinical diagnosis,” Jordan said. “There's things that may assist in helping you make the diagnosis. The SCAT3 doesn't make the diagnosis, it helps you.”

Doctors still miss a lot. A 2014 study by Harvard University and Boston University found that college football players, on average, suspected that they sustained six concussions for every one concussion that was actually diagnosed. For offensive linemen, that ratio was nearly 8 to 1.

Scientists and engineers are working to design a holy grail: an objective measure of a concussion, just like a doctor might do a blood test to determine your illness. A small study conducted at Northwestern University found that a hearing test, by measuring the brain’s electrical response to speech sounds, could identify concussions in children. Cleveland Clinic developed a concussion assessment app called C3 Logix that, in addition to a battery of cognition and vision tests, uses the iPad’s gyroscopic capabilities to test balance.

The King-Devick tests vision in a nominally objective way by giving potentially concussed players a series of numbers to read — left to right, top to bottom — as fast as they can. It doesn’t rely on the word of athletes or trainers to gauge the severity of the injury. Rather, the speed with which players read through the numbers is compared to a baseline test they took before the season when they were healthy. If their post-injury time is worse than their baseline, it may signal that a concussion has occurred.

Unfortunately, baseline testing is yet another way that players may be able to fake the concussion protocol. If players are aware of the relationship between the tests, they can tank the baseline so that they will almost certainly pass the test later in the season. According to the former player, the practice was common in the locker rooms he was in. Husain Abdullah said he had never heard of teammates doing it, but that he wouldn’t doubt that tanking occurred.

“Human beings, right? Someone makes a law, we find a loophole,” Abdullah said. “That's been in the nature of mankind for our entire existence.”

Dr. Gillian Hotz has seen the same phenomenon at the high school level. Hotz is a research professor and neuroscientist at the University of Miami. She heads a youth concussion program that serves South Florida high schools. In Miami-Dade County, every high school athlete who plays a contact sport is baseline tested.

“They'll throw them,” Hotz says. “Yeah I've seen that a lot, when we put 20 kids in a lab and their scores come up less than 1 percentile, and you go, ‘Wait a minute, this is an A student. How did that happen?’”

Hotz’s lab is trying to develop a panacea. A team of Miami researchers headed by Michael Hoffer is developing goggles that use cameras to track eye movement, which would be near impossible for a concussed athlete to fake. But Hotz says that the research is still too nascent for the NFL’s purposes.

The league is looking at supplements to the SCAT3. It partnered with the Canadian Football League to study the effectiveness of the King-Devick test during the 2015 CFL season. There is still no replacement for a good clinician, however, and until there is, fakery will remain an extant issue for the NFL.

“Is the [NFL] protocol good? Yeah it's good,” Hotz said. “Could they be doing more? I don't really know what more to do right now because the science hasn't gone there. We're trying to get the science out.”

Wild Card Round - Miami Dolphins v Pittsburgh Steelers Photo by Justin K. Aller/Getty Images

NFL legislation is trying to address its concussion problem. Helmet-to-helmet hits have been a point of emphasis since 2010 when the NFL expanded its definition of a “defenseless” player. This year, the league introduced fines for teams that get caught violating the concussion protocol.

There were four investigations into concussion protocol violations during the 2016 season. One of the most jarring was the hit that Miami Dolphins quarterback Matt Moore took from Steelers pass rusher Bud Dupree during the AFC Wild Card round, leaving the quarterback writhing on the ground.

That play demonstrated the protocol’s shortcomings. A team physician and a UNC both cleared him for return. The physician reportedly looked at Moore’s eyes. The turnaround of the all-clear — Moore sat out just one play before trotting back out onto the field and never went to the locker room — was disturbing to even untrained observers. Moore was never diagnosed with a concussion, but it was easy to see that the speed of the screening didn’t allow for much thoroughness.

The NFL found that the Dolphins failed to follow protocol but didn’t punish the team, determining that though the Dolphins “did not recognize that Mr. Moore presented a documented symptom, bleeding from the mouth … There is no indication that competitive issues had an impact on the care that Mr. Moore received.” Essentially, it couldn’t determine that the Dolphins had intended to do anything wrong.

“When they told me he was coming back in, I started talking to him and he was good,” Dolphins head coach Adam Gase said. “They went through the league’s deal and then our trainers; he cleared everything.”

There is nothing in the concussion protocol that stipulates that a player needs to miss a certain amount of time or number of plays to return to field. His return is always at the discretion of the team physician, and that has never changed. It is nearly impossible to tell the difference between a player who is actively subverting the system and another who slipped through the cracks.

And yet, the Moore situation was a sign of progress.

“I do think that even their recognition that there was a violation is good,” Winston said. “That's the first step towards fixing something, right? It's admitting that there was a mistake that was being made.”

* * *

Few people want to see football die. The former player calls the sport a “maker of men,” one that his kids will play. Hamza Abdullah says he loves football and recalls how he used to religiously watch the Jacked Up segment on ESPN, even if it was an example of “the way that they treat players as products instead of people.”

On that point, Husain Abdullah agrees with his brother.

“[Players] are walking around and they look like trophies, you know what I mean?” Husain said. “We like violence, whether we want to admit it or not, so we applaud that kind of stuff: 'Oh, this guy's tough. Oh this guy's a this, he's a that.'

“The reality is, that guy's a broken human being.”

Both Hamza and Husain Abdullah pause once each while I talk to them to apologize for losing track of the question they were trying to answer or for forgetting words. Both are certain they’ve suffered long-term damage as a result of concussions.

“Thankfully it's not as much memory, my memory is OK,” Hamza said. “But I have a hard time reaching for words — simple words — like I have a word bank in my head, that I know the word to choose, but for some reason I can't choose it.”

The secret to success in the NFL today is the same as when Edwards played. You can’t be good at football without being reckless. You can’t be reckless without exposing yourself to a lifetime of health problems — the deterioration of the brain perhaps chief among them. What players and fans like about the sport is also slowly dismantling it.

Playing football requires willful ignorance. Players now have a better idea of the risks of football than any generation has ever had. But for those who are anticipating two- or three-year careers, there are only two choices: forgo a dream or suspend your worry and accept that the consequences may be subtle, latent, and potentially dire.

“What's weird is that you don't know,” the former player said. “I don't know if I was supposed to be smarter than this.”

The NFL’s concussion protocol is improving, and it may truly be the best the league can do within the parameters of science and football. It is entirely overmatched for the job, however, and its fundamental flaw is human nature. The NFL concussion protocol is broken, just like the people who enforce it and the people it is meant to protect.