Concussion Management in the NFL: The Return to Play Protocol

In the second of a multi-part series on concussion management in the NFL, find out more about the league's return to play protocol and why it's not as regulated as you might expect.

This is the first of a multi-part series. With the assistance of multiple sources with knowledge of the league's gameday and sideline concussion protocols, I'm going to take you inside the day-to-day management of head injuries in the NFL.

In the first installment, I wrote about the NFL's process of evaluating and managing head injuries on gameday and why players might still fall through the cracks. Today, I'll look at the league's Return to Play protocol and highlight where the NFL does things differently than other levels of football. I'll also address the most common misconceptions on head injuries and how the league's approach to concussions may evolve in future seasons.

how does the NFL clear players to return to contact?

It's a Friday afternoon in Philadelphia.

Eagles' head athletic trainer Rick Burkholder is updating the media on the condition of LeSean McCoy and Michael Vick. Both players have been out for more than a week with concussion symptoms. ESPN's Dan Graziano is one of the assembled reporters getting an unusually detailed briefing on how the Eagles clear players to return after a concussion.

Burkholder sent McCoy to Pittsburgh to be examined by the University of Pittsburgh's concussion specialists because he "just didn't like the way things were adding up. I didn't like how he was getting symptoms at night and not during the day."

He said those tests yielded nothing alarming but did convince Burkholder to change McCoy's rehabilitation protocol.

Burkholder said Vick and McCoy both remain in stage four of the Eagles' five-phase concussion recovery program and said neither has passed the league-mandated ImPACT test. He said results of their latest tests, taken Friday, were not available.

"We're waiting to go to phase five, and phase five is contact," Burkholder said. "I'm just waiting until they get less symptoms and a little bit better on their reaction time before I move them into that phase."

Fast forward to the Oakland Raiders' press room last week and another Friday post-practice press conference, where head coach Dennis Allen is taking questions on the status of Terrelle Pryor.

Q: With the Pryor situation, you said there’s one more test that you’re going to do but it's not something you have to do?

Coach Allen: He’s been cleared. It’s not something that has to be done. It’s something that we want to do. I want to make sure that we’re making the right decision for this kid.

These press conferences are becoming more commonplace around the league. More and more details are emerging about the NFL's protocols for returning a player to contact after he has suffered a concussion. Many of these news items include details about a five stage testing and evaluation process. Others suggest that certain teams choose to add additional testing, possibly for some players and not others.

None of them are specific about the timeframes for each stage or precisely state the hurdles a player must clear to be deemed ready for contact.

The NFL has made some strides in the transparency of how it diagnoses and treats concussions. There has been an effort to increase oversight of concussion management by asking providers and experts unaffiliated with teams to be involved -- when asked -- in the evaluation and clearance process. 

But the return to play protocols seem unnecessarily vague and mysterious.

Mike Sando wrote late last season of his failed attempts to track down a concussion-protocol checklist. I've attempted to get specific details from multiple sources over the years, both to inform my writing on NFL players returning from concussion and to learn how the NFL might use its available resources to provide care to its elite athletes that sideline providers at lower levels of play cannot. I have yet to hear a clear answer on protocol specifics.

After obtaining documents from a source involved in the Unaffiliated Neurotrauma Consultant (UNTC) program detailing how the league manages head injuries on gameday and in the days after a head injury, it has become clear why a specific protocol has yet to be reported.

There isn't one. There are no "regulations" or "protocols" that every team must follow when returning a player to contact after concussion. As the source told me, "All of this falls under the discretion of the team physician."

zurich graduated return to play protocol

The five stage or phase return process we commonly hear referenced in cases of NFL players rehabilitating from a recent concussion is based on a guideline recommended by the 2012 Zurich Consensus Statement on Concussion in Sport. The guideline was written by a group of authors that included Dr. Robert Cantu, a senior adviser to the NFL's Head, Neck and Spine committee, and Dr. Margot Putakian, who also serves on the committee and was involved in the development of the sideline assessment protocols.

The Zurich protocol has replaced older guidelines that were based on grading a concussion in the minutes after the injury. Depending on the severity of certain symptoms (headache, amnesia, confusion, etc.) and the length of any loss of consciousness, some players were able to return to play on the same day. Others were head out for one or more weeks.

The Zurich guidelines confirmed a seismic shift that was already gaining favor in the management of head injuries in athletes.

No longer are we "grading" concussions as mild, moderate or severe. Now, players are treated on symptoms alone. No two athletes with a concussion are to be treated alike. 

In that sense, the lack of a clear set of regulations for NFL teams to follow when returning players to contact seems reasonable. However, the NFL allows for more discretion than the Zurich recommendations.

where the nfl differs from the zurich guideline

According to the graduated Zurich protocol, athletes:

...should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any postconcussion symptoms occur while in the stepwise programme, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed.

However, last week, an illuminating feature in the Houston Chronicle on the recovery of Andre Johnson from a concussion included an interview with Dr. Kenneth Podell, a neuropsychologist and consultant for the Houston Texans. Though the Zurich protocols suggest 24 hour intervals and a 5-6 day return to play goal if there no are no setbacks during the recovery process, Dr. Podell told the Chronicle that the NFL allows team physicians to move players through exercise stages more quickly than the Zurich guideline recommends.

“It’s a gradual increase in exercise intensity,” Dr. Podell said. “We start with cardio, advance to intense cardio with weight lifting and position-specific drills. If athletes continue to be symptom-free, they advance to the next stage.”

NFL regulations, he said, allow a player to complete up to two stages each day. A player might be allowed light cardio activity in the morning, for example, and moderate activity that afternoon.

I've now been able to confirm with multiple sources that the NFL is comfortable advancing its players through the protocol at intervals shorter than 24 hours. As one source told me, "There is no explicit rule regarding one stage per day."

Undoubtedly, sideline providers have the best interests of each player in mind. Some athletes are likely able to progress through the early exercise stages more quickly than others and do so without symptoms. And studies show that younger athletes have a more difficult time progressing as quickly through the exercise stages than adult athletes. Two sources told me that the age factor is significant. One specifically expressed that "younger athletes should have at least 24 hours per stage."

But studies also show that a significant percentage of adult athletes exhibit a mismatch in symptoms and test results. The NFL shared research with its prospective UNTCs that 15-30% of athletes may continue to have abnormalities in neurocognitive testing after their concussion symptoms have resolved while 10-25% may be able to pass neurocognitive tests despite still having symptoms of concussion.

Those findings underscore the importance of the NFL's mantra to "know your player." Andre Johnson successfully returned to play after an accelerated exercise protocol. An examination of last year's Frontline data shows at least four players were cleared to play on Thursday night after a Sunday concussion. None of those players missed additional games later in the season.

But, sometimes, knowing your player isn't enough.

According to Dennis Allen, Terrelle Pryor was cleared to play on Friday (after a Monday Night game and admitting to symptoms of amnesia) before having additional symptoms. NFL teams have the ability to track symptoms on an hour-to-hour rather than day-to-day basis. But there's a clear disconnect here for a league that's accelerating its players more quickly than a guideline recommended by members of its own specialist committees.

additional elements of the return to play process

The Zurich stages aren't the only stages of the process to return an NFL athlete to contact. 

Every player must take the same battery of tests (the NFL's versions of the ImPACT, BESS, SCAT, etc) and prove that he is back to his already-established pre-injury baseline in reaction time, memory, balance. He must self-report that he is symptom-free. Though based on the best available evidence, the testing and symptoms are both subjective and non-specific pieces of data.

As Dr. Podell told the Chronicle:

"Once symptoms have subsided, players submit once again to the standard baseline testing, plus the 30-45 minutes required to complete more advanced versions. Sometimes there is additional testing with the neuropsychologist. Even then, there are no pass-fail grades, only additional data for doctors to interpret."

If a player shows progress on his tests, he can be cleared for return to physical activity.

That's still more confirmation that each team physician can advance players through the process at his / her discretion. 

The NFL also mandates that the player be examined by an independent neurologist and cleared before returning to full contact practice and games. Although those specialists aren't affiliated with the team and they are sometimes involved -- as with McCoy above -- in the care of a player not yet ready for a clearance exam, they have participated in clearing players earlier than the Zurich protocol recommends.

To be clear, I'm not suggesting that the league's sideline providers and medical staffs do not have the best interests of their players in mind. But I do think it is important to the transparency of the process that the NFL continue to share more details about the process of returning its players to play. The debate should include discussion on where and why the process may differ from the recommendations of their own committee members, especially when the accelerated process seems to veer from the gameday recommendation to err on the side of conservative care.

Follow on Twitter @JeneBramel for more discussion on concussions, the league's management of head injuries, and for commentary and analysis of injuries around the NFL.

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