NFL Concussion Protocol and Return to Practice Process

[NanceUSMC]

So after the game this weekend, I started to wonder what exactly it takes to move from stage to stage in the NFL Concussion Protocol...  Don't know if it's been posted before, but I figured I'd share my findings...

NFL Head, Neck and Spine Committee's Protocols Regarding Diagnosis and Management of Concussion (PDF)
Includes: Definition, Signs, Symptoms, Emergency Action Plan, Practice and Game Day Management, and Return to Practice Process

Initial Diagnosis

NFL Sideline Test (PDF)
Includes: In-Depth screening questions used to diagnose potential concussion, scoring system, player self-assessment

ON THE FIELD

To assist the medical teams on game day, there is now an "eye in the sky" a certified athletic trainer sitting in a stadium box who watches the game and television replays to scan the field and look for players with a potential head injury who may require assessment by the medical staff.

Players who are suspected of suffering a concussion are assessed by their teams medical staff. The team physician first reviews a six-item checklist outlining findings that necessitate a player's immediate removal from the game. This checklist includes the more obvious symptoms of concussion: loss of consciousness, unresponsiveness, confusion, amnesia and other concerning symptoms. The team doctor then administers the rest of the sideline concussion assessment tool in order to further assess for concussion. This sideline test includes the same tests performed as part of the pre-season baseline concussion assessment, as well as some additional questions. Like the preseason evaluation, the test measures, memory, concentration and balance. as well as measuring how quickly and thoroughly the player recalls words given to them at least five minutes earlier. As in the preseason examination, the team doctor asks players to name the month, date, day of week, year and time. The additional questions include specific sideline orientation questions that ask players to identify the venue, quarter of game, who scored most recently, the team's previous opponent and whether the team won or lost its most recent game. This process takes about 8-12 minutes.

Beginning this year, a neuro-trauma expert physician unaffiliated with an NFL team will be available on the sideline as an extra set of eyes. He can be consulted by the NFL medical team or NFL player.

NFL regulations require a player diagnosed with a possible concussion to leave the field for the locker room. Medical personnel remain with the player for the remainder of the game. Team physicians determine whether the player's condition is stable enough to send him home -- with instructions that include physical and cognitive rest, avoiding certain medications and alcohol, and a plan for follow up care including phone numbers to call if there are any questions or concerns.

Further Assessment

DAYS FOLLOWING THE CONCUSSION

The initial treatment is rest, and the team doctors and athletic trainers begin monitoring to see when a player appears to have returned to baseline functioning. Do symptoms return when a player watches practice or when he watches film? Is there return of symptoms with physical activity?

Once symptoms have completely subsided, the player again performs more comprehensive neuropsychological tests interpreted by the team neuropsychologist. There are no pass-fail grades, only additional data for physicians to consider.

If the player is progressing, he would be become eligible for increased physical activity. The workouts would ramp up over a few days if no symptoms occur.

A player feeling normal one day after the game might pass cognitive testing Tuesday and begin a light exercise program, intensify their exercise routine Wednesday, participate in non-contact aspects of practice on Thursday and return to full practice Friday. But if a player has a history of concussions or isn't progressing as quickly as planned, the process moves accordingly.

The medical team increases the exercise regimen to full speed as the player proves he can handle the escalation without incident. Some teams stage controlled contact drills featuring, for example, one lineman blocking another the way they would in an unpadded practice.

"The thing that I think is important here is you don't manage concussions by a calendar," Dr. Herring said. "Some guys may come back in a week. Some guys may come back in six weeks. These steps don't have an expiration date on them. The player's history of injury and other issues come into play."

Once a team doctor signs off on a player's return, the player is evaluated in person by an unaffiliated concussion expert physician approved by both the NFL and NFL Players Association. This unaffiliated expert also must sign off on the player's health before he is allowed to return to play.

"The thinking is that we have done our best work, but an automatic second opinion is built in," Herring said. "We've never had a disagreement, but I would welcome it if we did because we could learn from it. This is a trust issue. We need assurances there is no rush to return to play for any reason."


Return to Practice Process

After a concussion has occurred in practice or play, the concussed player must be examined and monitored in the training room on a daily basis or as decided by the medical staff. Components of the NFL Sideline Concussion Assessment can be utilized to check for symptoms as well as continue to monitor the other aspects of the examination. The following measures must occur in order for a

player to return to play:

a. A player returns to baseline status of symptoms and neurologic exam, including cognitive and balance functions.

• i. Repeat neuropsychological evaluation is performed before return to practice or play with interpretation of the data by the team neuropsychology consultant. The team neuropsychology consultant reports the findings back to the team physician.

b. A graduated exercise challenge, followed by a gradual return to practice and play, is initiated when the player returns to baseline status. The RTP protocol following a concussion follows a stepwise process to be outlined in the NFL Head, Neck and Spine Committee’s Return to Participation Protocol.

c. Prior to return to practice or play, not only must the team physician clear the player, but the Independent Neurological Consultant with expertise in concussion must also evaluate and clear the player for return to practice and play.

d. A player may be considered for return to practice and play only after the player has returned to baseline status with rest and exertion, has repeat neuropsychological testing which is interpreted by the team neuropsychology consultant as back to baseline levels of functioning, and has completed the Return to Participation Protocol referenced above and is cleared by the Team Physician and the Independent Neurological Consultant.

Further Defined:

For those seeking a better understanding of what the NFL concussion protocol requires, here’s a look at its five steps:
Rest and recovery. Players may stretch and work on their balance, but they don’t work out beyond that. In addition, they’re advised against spending time on computers, any electronic device and social media. They don’t take part in team meetings.
Light aerobic exercise. Under supervision of the team’s medical staff, the player can start cardiovascular exercise, such as riding a stationary bike and using a treadmill, and work on more dynamic stretching and balancing. The workload is increased gradually and halted entirely if concussion-related symptoms recur. Players can attend team meetings and study film.
Continued aerobic exercise, introduction of strength training.Building gradually on the work of step 2, the player can start weight training.
Football-specific work. The player adds non-contact football drills, such as throwing, catching and running to his repertoire of exercise. No contact allowed with other players, tackling dummies or sleds.
Full football activity, full clearance. The player resumes practicing with the team, with no limitations. Once the team physician clears him to complete, the player is examined by the independent neurological consultant, who also reviews any relevant neurological tests.

 

Sources
http://www.nfl.com/news/story/0ap2000000253716/article/nfls-2013-protocol-for-players-with-concussions
https://www.washingtonpost.com/news/football-insider/wp/2015/08/29/explaining-nfl-concussion-protocol-the-five-step-map-for-rgiiis-return/
http://espn.go.com/blog/nflnation/post/_/id/108223/what-exactly-is-the-concussion-protocol
http://blogs.nfl.com/2009/12/02/league-announces-stricter-concussion-guidelines/

 

[AceBoogie]

Good research man

[Keith Moons Liver]

Dude should retire. Probably already has at least mild brain damage, like virtually every NFL player. 

[arbnranger]

Thanks for that. I was wondering what the steps of the protocol were as well. Seems pretty straight forward in the sense that it's all based on the players progression. If Luke is doing well, playing on Sunday is an option. 

[Ivan The Awesome]

So he's likely out for this coming game?

[DeeJay]

he passed stage 1 that's all ive seen so far

[UpstatePanther]

So he's likely out for this coming game?

so... youre saying theres a chance?!

[imminent rogaine]

Even if he passes everything, I'd still be fine if they sat him on Sunday. He is worth way too much in the long-run and Klein is a serviceable back-up in the short term. Plus we are going against a team with an inexperienced QB and a back-up rb.

[2jakefansinva]

Guess some Huddlers can now understand why Klein has a roster spot.

[GRWatcher]

I am more than fine with Luke sitting this week. A week before a game is all about preparation. That's what Luke thrives on. If he's doing as he is supposed to while in the protocol, and I'm positive he is, all the extra film study is off the table. Rest, baby, rest. Yeah, he's the better athlete than AJ but I believe AJ will be better prepared for this game and with TD next to him, he's more than just efficient. Even if he is active on Sunday, I don't think Luke will be in on every play, sharing time with AJ. If he doesn't suit up, he'll still be on the sideline as McDermott's mini-me.

[SOJA]

ok if both Luke and Star sit this week 

[Kevin Greene]

Sit Luke, with the contract just signed, Panthers need to think long term. 

[CRA]

I'd be fine if they sit him even if he technically cleared.  Luke seemed gone hitting harder than his previous years.  He ain't worth gambling with

[Dave Gettleman's Shorts]

I bet Luke is going through withdrawals from not watching film which is like a drug for him