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How does the NFL's concussion protocol work?

The NFL implemented the concussion protocol in 2009 and has adjusted it in the last seven years.

Rob Carr/Getty Images

Head injuries in the NFL are not new, but with more spotlight on their long-term effects to player health, the league has instituted protocol to address the diagnosis and management of concussions.

The NFL made changes to the protocol after completing investigations into the way two teams handled head injuries to players during the 2017 season. The Seahawks were fined $100,000 when the league found they did not follow the protocol with quarterback Russell Wilson. The Texans were cleared by the league regarding their process with quarterback Tom Savage, but those two investigations pushed the league to refine the protocol to better protect players.

After the Seahawks investigation concluded, the league added a rule that requires teammates, coaches, or officials to take the player directly to a member of the medical team for evaluation. The changes after the Savage investigation were more sweeping. Among other things, the NFL has added an additional unaffiliated neurotrauma consultant to each postseason game, including the Super Bowl, to identify, monitor, and evaluate players for head injuries. Players also must be removed from the field of play and taken to the locker room for evaluation after the update.

In September 2016, the NFL announced the initiative "Play Smart. Play Safe." to continue to strive for a healthier game:

"Rightfully, much of the public discussion is about concussions — how they happen, how they can be prevented and treated and what is known about their long-term impact," NFL commissioner Roger Goodell wrote in a letter addressed to fans. "The NFL has been a leader on health and safety in many ways, and we’ve made some real strides in recent years. But when it comes to addressing head injuries in our game, I’m not satisfied, and neither are the owners of the NFL’s 32 clubs. We can and will do better."

The "NFL Game Day Concussion Protocol" was first implemented in 2009, adjusted in 2011 and tweaked in the last five years, including the introduction of disciplinary action in 2016 for teams that do not adhere properly.

In the league’s opener for the 2016 season, multiple hits delivered to reigning MVP Cam Newton raised questions and the NFL Players Association launched an official investigation to see if protocol was violated. A week later, Buffalo Bills quarterback Tyrod Taylor was personally escorted off the field by referee Ed Hochuli to receive evaluation.

Concussion protocol

In addition to the team medical staff and an unaffiliated neurological consultant, the league employs two medical spotters in the booth who watch the game with binoculars and video replay to identify injuries that others missed. The league added a rule in 2015 allowing for the medical spotters to stop the game with a medical timeout to remove an injured player.

"Observable symptoms"

There are seven observable symptoms used to identify players with concussions. Those are:

  • 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)
  • Clutching of head after contact
  • Visible facial injury in combination with any of the above

When spotters or other medical personnel see those signs, that’s when the protocol goes into effect.

Return to play process

In addition to the in-game protocol, there is also a "Return-to-Participation Protocol" that can keep players out of action for more practices or games until they pass through and are cleared to return.

It is a five-step process without any set timeline for a full return from a concussion:

  1. Rest and recovery: Until a player returns to the "baseline level of signs and symptoms and neurological examination," only limited stretching and balance activities are recommended. Electronics, social media and team meetings are all to be avoided.
  2. Light aerobic exercise: The NFL recommends 10-20 minutes on a stationary bike or treadmill without resistance training or weight training. The cardiovascular activity is monitored by an athletic trainer to "determine if there are any recurrent concussion signs or symptoms."
  3. Continued aerobic exercise and introduction of strength training: Increased duration and intensity of aerobic exercise with strength training added. An athletic trainer will supervise to watch for recurrent concussions signs or symptoms.
  4. Football specific activities: The cognitive load of playing football will be added and players will participate in non-contact activities for the typical duration of a full practice.
  5. Full football activity/clearance: A player returns to full participation in practice, including contact without restriction.

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During the offseason this year, the NFL added a measure that would punish teams that failed to properly enforce the concussion protocols. Any violation — either in-game or return-to-participation — could cost a team fines or even the forfeiture of draft picks.

As you can see, the league has a thorough process for handling concussions, but as with most NFL rules, it’s a matter of consistent enforcement.