The National Football League’s concussion management is again under a microscope after the 2016-2017 season. Even though the concussion protocol was improved prior to the start of this season, its failures have been glaring since the season kicked off.
NFL Concussion Protocol: A Background
A concussion protocol was first introduced in 2009 by the NFL’s Head, Neck and Spine Committee in an effort to improve concussion detection. After updating in 2013, the protocol defined what a concussion is, as well as listed a number of symptoms. Also included in the protocol were concussion assessments for the sidelines of games and practices, and baseline testing. The protocol instructed the players and clubs to review educational materials, in addition to examining and testing the players prior to the start of the season. The 2013 protocol also required dedicated personnel to spot potential concussions throughout games and evaluate those who are injured.
The protocol has evolved over the years to improve upon the League’s treatment of concussions. As of 2016, 29 medical officials––including physicians, concussion spotters, athletic trainers, and unaffiliated neurological consultants (UNC)––are present at every game. There is one UNC on each sideline at every game, assigned to work with a team’s medical staff in identifying and evaluating potentially concussed players. Ideally, the unaffiliated consultant will not consider the player’s influence on the game when deciding whether or not to remove the player for medical purposes.
Concussion spotters are athletic trainers hired by the League to identify players that should be removed from the game for evaluation. Spotters are stationed at booths within the stadium, with access to video replay and direct communication to a team’s medical staff to alert the team of a suspected concussion.
In 2015, spotters were given the authority to use a medical timeout to halt play and remove a player for concussion evaluation. In order to stop play, a spotter must have clear visual evidence of the following criteria outlined by the NFL, “1. A player who displays obvious signs of disorientation or is clearly unstable; and 2. If it becomes apparent that the player is attempting to remain in the game and not be attended to by the club’s medical or athletic training staff.”
Prior to the 2016-2017 season, the NFL added additional elements to its concussion policy to ensure enforcement of the protocol, namely disciplining those teams that violate the required procedures. The NFL and NFL Players Association designated a representative to monitor team’s’ adherence to the protocol and investigate possible violations. Disciplinary actions imposed by the NFL and NFLPA include remedial education, fines, and the forfeit of draft picks. Additionally, the NFL elaborated that teams cannot be motivated by competitive advantage when deciding whether or not to remove a player for the concussion protocol.
Although the NFL has an established concussion protocol and has strengthened its enforcement, there were still issues this season––starting with the season opener.
The Concussion Protocol in Practice: The 2016-2017 Season
Carolina Panthers’ quarterback Cam Newton suffered multiple helmet-to-helmet hits during the season opener against the Denver Broncos. These hits were so severe that the NFL fined two Broncos defenders for them. However, even after facing a number of vicious hits, most notably one in the final 37 seconds of the game, Newton was not removed from the game for evaluation.
The Broncos went at Cam Newton’s head all night: https://t.co/4HxmQLA88m pic.twitter.com/gQPsnraOFJ
— Deadspin (@Deadspin) September 9, 2016
Beyond the issue that the Broncos did not face any discipline during the game for the hits to Newton’s head, the medical staff on the sideline or the spotter should have pulled Newtown from play regardless of the Panthers’ score.
The NFL says its spotters saw "no indications of a concussion" for Cam Newton: https://t.co/2DVhLPnkVL pic.twitter.com/Xx5zMPBpZs
— SB Nation (@SBNation) September 9, 2016
The NFL and NFLPA independently investigated whether the Panthers adhered to the protocol; neither found a violation. According to the League, the sideline staff asked the spotter for a replay of the hit on Newton, which was delayed by a technical issue. Once the medical personnel contacts the spotter, the spotter loses the ability to call a medical time out. The League found that this inability played a role in this case. After that incident, the NFL amended the rule, now requiring the spotter “to remain in contact with the club medical team and provide video support until the medical team confirms that a concussion evaluation has occurred.”
This incident with Cam Newton was not the only failure of the concussion protocol during the 2016-2017 season. Miami Dolphins quarterback Matt Moore was obliterated by Pittsburgh Steelers’ Bud Dupree during the AFC Wild Card game. Dupree’s helmet hit Moore in the chin, and Moore hit the turf. Trainers tended to Moore on the turf until he got up to walk to the sideline. Backup quarterback T.J. Yates entered the game and ran one play while the Dolphin’s doctor and the UNC evaluated Moore on the bench. After Yates’ play, Moore somehow was cleared to return.
Matt Moore is dead. He has died. https://t.co/SB9PjSUjoG
— Barstool Sports (@barstooltweetss) January 8, 2017
It was determined that Moore did not have a concussion in the short time that he was evaluated. Although he was luckily not later diagnosed with a concussion, since symptoms may not develop immediately, that short time was certainly not enough time to determine whether Moore could safely return to the game.
The following day, NFL announced that the Dolphins’ compliance with the concussion protocol would be reviewed. In addition, the League announced that it fined Dupree for the hit on Moore. The NFL and NFLPA’s joint review found that the Dolphins did not “strictly follow” the League’s concussion protocol. Despite finding that the Dolphins did not adequately adhere to the protocol, the NFL did not discipline the club because there was “no indication that competitive issues had an impact on the care that Mr. Moore received, nor did Mr. Moore demonstrate any concussion symptoms either during or at any time following the game,” even though the UNC and team doctor both did not adequately address the fact “that Mr. Moore presented a documented symptom, bleeding from the mouth, that required further evaluation in the locker room under the protocol.” Instead, the Dolphins’ were left with a warning that another violation “may result” in punishment.
Two weeks later, during the AFC Divisional Round, the Pittsburgh Steelers visited the Kansas City Chiefs. During that game, Chiefs’ receiver Chris Conley was hit in the head by Steelers’ defensive back Sean Davis. Conley was tended to on the field and then evaluated on the sidelines––only missing one play, similar to the incident involving Matt Moore. The NFLPA is currently reviewing whether the Chiefs violated the protocol in a similar way to the Dolphins.
Moving Forward With Concussion Management
Enhancing the protocol to strengthen enforcement seemed like a wise move from the NFL. However, if teams are not going to face penalties for poor concussion management, it raises serious questions about the League’s intentions in making these changes.
The League’s history with concussion management is already so fraught, and while the NFL has appeared to make positive efforts in their handling of concussions, these situations only suggest the League has regressed. The protocol should have been enforced since its institution, but it wasn’t. It should have been followed since disciplinary action was put in place to avoid these situations, but it wasn’t. And the League should have disciplined teams for violating the protocol to set a precedent and strengthen their policy, but they didn’t.
The NFL has released injury data from the 2016-2017 pre-season and regular season. Combining this data, the number of reported concussions decreased by 11.3 percent from last season. While this may appear on its face to be a marked improvement, this is a decrease against the previous season, which saw the highest number of diagnosed concussions (275) in the past five years.
Having a loosely followed concussion protocol clearly is not enough. The NFL should be more invested in the well-being of its players, the League’s biggest assets. The NFL should be contributing to the research without creating controversy and studying the brain to better understand what happens when players are hit.
The League could also help further research into football helmets. Companies like Vicis are trying to create a safer helmet, as is Bill Gates in conjunction with Intellectual Ventures. But having the NFL as resource would likely help facilitate progress.
Additionally, the League could theoretically use sensors to track how hard players are being hit during games. With trainers and researchers having an indication of the force a player is subjected to, a limit could be set requiring a player is evaluated if hit by a certain force regardless of whether they present with concussion symptoms. While a hit with great force may not cause a concussion, subconcussive hits have been shown to contribute to neurodegenerative brain disorders like chronic traumatic encephalopathy (CTE).
The League could also study biomarkers and employ a blood test to measure the level of tau, a brain protein linked to neurodegenerative brain disorders such as CTE, in a player. Research has shown that studying these biomarkers can help determine the recovery time of a player. While the NFL has funded research for Quanterix, a company developing a blood test to detect concussions, it should be more forthcoming with support for similar research.
Unfortunately the NFL’s concussion management improvements appear to only be for the optics, rather than ensuring the health and safety of the players. The concussion protocol’s shortcomings are just another amplification of their long history of inadequate concussion management. If the League is genuinely concerned with concussion issues, then it needs to start with their protocol. The protocol needs to be enforced strictly and the League needs to ensure teams are acting as efficiently as possible. If it seems that the concussion evaluation is not enough, the League should err on the side of caution and require these players sit out for a game.
With the NFL season concluding with Super Bowl LI, the League has the entire offseason to not only investigate where the protocol failed, but to dedicate their resources into finding ways to reduce and better detect concussions. These players are risking their brains for the League, knowingly or not, and it’s the NFL’s duty to protect them.