Combating the CTE Crisis: Concussion Protocols

In the last blog post, chronic traumatic encephalopathy (CTE) was introduced as a devastating neurological disorder associated with repeated traumatic brain injuries in football players. The previous post also explored a number of scientific advancements including new helmet technology, as well as the ongoing development of a vaccine to potentially prevent the rate of onset of CTE. In today’s blog post rules and protocols currently being implemented to diagnose and lessen impacts to the head in football players will be discussed for both the NFL and youth athletes.


NFL Head, Neck, and Spine Committee

Back in 2011 a board of independent and NFL-affiliated physicians and scientists developed the NFL Game Day Diagnosis and Management protocol. This Concussion Protocol is reviewed each year along with injury data collected throughout the entire season in an effort to ensure players are receiving up-to-date medical care regarding the identification, diagnosis, and treatment of concussions.1

            According to the Concussion Game Day Checklist, when a player’s head is impacted, the player goes into the Concussion Protocol if the player exhibits or reports symptoms or signs suggestive of a concussion or stinger (nerve pinch injury).2A teammate, coach, game official, medical personnel (physician, athletic trainer), or an Unaffiliated Neurotrauma Consultant (UNC) may trigger the protocol. Unaffiliated Neurotrauma Constulatants are located on the sidelines as well as in the spotter’s booth to monitor the game and announce possible head, neck, or spine injuries viewed.1


“No-Go” Criteria2 

        If any of the following are present, it is required that the player be removed from the game and may not return to the game:

  • Loss of consciousness (including impact seizure and/or “fencing posture”)
  • Gross motor instability (e.g., stumbling or falling to the ground when trying to stand)
  • Confusion
  • Amnesia


Sideline Survey2

If a player does not exhibit any of the “No-Go” signs or symptoms, a member of the medical personnel conducts a sideline survey in the medical tent with the player’s helmet removed. If any elements of the sideline survey are positive, inconclusive or suspicious of concussion, the player is escorted to the locker room. Some elements of this survey include:

  • History of event
  • Concussion signs/symptoms
  • Maddock’s questions
  • Focused Neurological examination:
    • Cervical spine exam (range of motion, pain)
    • Evaluation of speech
    • Observation of walking
    • Eye movements and pupillary exam


Return-to-Participation Protocol3

Every NFL player who is diagnosed with a concussion must follow a five-step process before being cleared to fully practice or participate in an NFL game. The protocol includes the specific order of proceedings, but does not include a set time frame due to the individual variability seen following a concussion. After the player has completed the five-step process his team physician, as well as an Independent Neurological Consultant (INC) not affiliated with any NFL team, must clear him. Although this process was developed for use in NFL players, the 5 steps have been adopted universally for a return-to-play in any sport following concussion.(cite) The 5 steps included in the Return-to-Participation Protocol are:

  1. Rest and recovery
  2. Light aerobic exercise
  3. Continued aerobic strength and introduction of strength training
  4. Sport-specific activities
  5. Full sport activity/clearance


Concussion in Youth Sports Legislation

Many states, schools, sports leagues and organizations have recently implemented policies and action plans on concussion in youth and high school sports. In 2009 the state of Washington passed the first concussion in sports law called the Zackery Lystedt Law.4( All 50 states have now enacted legislation regarding return-to-play laws.5However, the specific components included in each state’s concussion legislation may vary. In general, most concussion in sports laws include common action steps:5

  1. Educate coaches, parents, and athletes about concussions through training and/or information sheets.
  2. Remove an athlete from play right away who is believed to have a concussion.
  3. Obtain permission to return to play from a health care professional.


The Pediatric Return-to-Participation Protocol6   

Similarly to the NFL Return-to-Participation Protocol, the American Academy of Pediatrics officially has adopted a 6-step gradual return to play guidelines for adolescents 13 years of age and older. According to this protocol, a concussed athlete begins the 6-setp protocol and moves through the progression at 24-hour intervals as long as no symptoms occur. If the athlete develops symptoms the progression is stopped and the athlete is returned to the previous phase. Sport-specific protocols have also been published and adopted to aid in helping youth athletes return to each individual’s respective sport.



Educational Resources

Overall, educating players, parents, coaches, and medical personnel is a vital component for managing concussions and helping reduce the risk for CTE development later in life. For more information on concussions and concussion protocols, there are a number of free resources that can be easily accessed. The CDC developed “Heads Up” to provide information and free training courses regarding concussion recognition and management for a variety of individuals recognize, respond to, and reduce the risk of brain injuries. The NFL has also developed “Play Smart Play Safe”, a league-wide health and safety initiative with resources for individuals to learn more about concussions and their impact on the NFL.



  1. Protecting players: NFL Head, Neck and Spine Committee’s concussion protocol Published June 22, 2018. Accessed December 13, 2018.


  1. Concussion game day checklist. Revised June 2017. Accessed December 13, 2018.


  1. Protecting Players: NFL Return-To-Participation Protocol. Published June 20, 2017. Accessed December 13, 2018.


  1. Washington State. Engrossed House Bill 1824, Chapter 475, Laws of 2009, 61st Legislature, 2009 Regular Session. Effective: July 26, 2009. Available from: http:// SL.pdf. Accessed December 13, 2018.


  1. Get a heads up on concussion in sports policies: Information for parents, coaches, and school and sports professionals. Accessed December 14, 2018.


  1. May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA.Pediatric sports specific return to play guidelines following concussion. Int J Sports Phys Ther. 2014;9(2):242-255.