Concussions have become a hot-button topic in the NFL world over the last decade-plus, with hits to the head—and both their short- and long-term effects—having been proven to have a significant impact on players’ health and safety.
As such, the league has worked to put together a robust protocol in recent years, giving both players and teams a framework to determine when a player is allowed to step back on the field. The idea being that their concussion fully heals prior to their return to play, which in turn will decrease the chances of them getting another.
But how does the protocol work? I’m glad you asked. Here’s a look at how players are evaluated, and cleared from, concussions in the NFL.
How are players evaluated for concussions in the NFL?
Each NFL game is staffed with three Unaffiliated Neurotrauma Consultants (UNC): one on each team's sideline and a third that is assigned to a stadium booth with multiple camera angles of the game.
These UNCs are certified physicians who are impartial and independent from any club. They work to identify signs or symptoms of concussions in players, and also consult with, work with, and observe team physicians during concussion evaluations and protocol.
Additionally, each game is also staffed with two Booth Certified Athletic Trainer Spotters (Booth AT Spotter) assigned to each team. They are also positioned in a stadium booth and charged with monitoring the game—both live and via video feed—to identify players that may require medical evaluation.
If a player either exhibits or reports signs or symptoms of a concussion, they must be immediately removed from the game and undergo the NFL’s Sideline Concussion Assessment (which can be read, in full, on page 7, here.)
If a player is deemed to have suffered a concussion, they are then placed in the NFL’s concussion Return to Participation Protocol.
What is the NFL's five-step concussion protocol?
In order to return to the field, players must progress through the NFL’s Return to Participation protocol. Said protocol includes the following five phases:
Symptom Limited ActivityAerobic ExerciseFootball Specific ExerciseClub-based Non-contact Training DrillsFull Football Activity/Clearance
Here’s a look at each:
Phase One: symptom limited activity
During Phase One of concussion protocol, players are assigned to rest and limit both physical and cognitive activities. They may be permitted to limited stretching, light aerobic activity and if tolerable, attend meetings.
If a player does not experience an increase in symptoms, they are then cleared to move on to Phase Two.
Phase Two: aerobic exercise
Phase Two of concussion protocol involves a graduation to an exercise program overseen by the club’s medical staff. Said exercises may include work on a stationary bike or treadmill, dynamic stretching and balance training—all of which are gradually lengthened and intensified. Players are also permitted to attend meetings in Phase Two.
A player should be back at his baseline level of symptoms in Phase Two and, if they don't experience an increase while performing said aerobic exercise, they are permitted to proceed to Phase Three.
Phase Three: football specific exercise
Phase Three of the NFL’s return-to-participation protocol includes the permission to perform sport-specific activities and strength training. Said activity is monitored by the team’s medical staff and shall only last 30 minutes or less.
Additionally, if neurocognitive testing was not administered to the player after Phase Two, it should be administered during Phase Three. If said testing is, “interpreted by the NPC as being indicative of residual cognitive impairment(s) due to the concussion, the tests will be repeated at a time interval agreed upon by the Club physician and NPC (typically 48 hours).” The player-patient is then not permitted to advance to Phase Four until their testing returns to baseline (or, “if a decrement is still present, until the Club physician has determined a non-concussion related cause.”)
Once a player shows the ability to engage in the above exercise without an increase or aggravation in symptoms, they can then proceed to Phase Four.
Phase Four: club-based non-contact training drills
Phase Four of the return-to-participation protocol adds team-based, sport-specific exercise to the players' plate, should it be non-contact.
If the player continues to tolerate this football-specific activity without a recurrence of symptoms—and continues to maintain their baseline of neurocognitive testing—they can then proceed to Phase Five.
Phase Five: full football activity/clearance
Phase Five adds to the clearance of full football activity, including contact, by the club physician. To return to game action, a player must tolerate “full participation practice and contact without signs or symptoms,” and must also be formally cleared by the club physician before being eligible to return to play.
The league adds that, the avoidance of doubt, “if a player-patient cannot participate in
practice or full contact with other players due to the time of year and/or rules imposed by the
Collective Bargaining Agreement, simulated contact activity will suffice to satisfy this Phase.”
Upon being cleared, the player must then be examined by an Independent Neurological Consultant (INC) who is assigned to their club. The INC makes the final decision to formally clear the player for the team's next game or practice.
How long does it take for a player to return from a concussion?
While the guidelines for how a player returns to the field after a concussion are set in stone, the timeline for how long it takes is not.
As explained by the league, each player and each concussion is unique, and as such, there is no set timeframe for return to play. Recovery time will vary from player to player, and the decision to allow their return “remains within the professional judgment of the Head Club Physician or Club physician designated for concussion evaluation and treatment.”
