We are at the pinnacle of football season, with the Super Bowl just a few weeks away. We’ve already seen a few head injuries nationally broadcast that left players lying on the ground in the frightening fencing pose. And you don’t have to be a football fan to have heard or seen the phrase “concussion protocol” mentioned over the last few months. It’s a frequent topic in the news as concussions and traumatic brain injuries (TBIs) become part of regular sports safety discussions.
What Is a Concussion Protocol?
“Concussion protocols are guidelines and policies for diagnosing, monitoring and caring for concussions,” says Vincent Schaller, MD, DABFM, CIC, medical director and founder of Mid-Atlantic Concussion Alliance. “They should be established by medical professionals with experience in concussion care, in coordination with coaches, athletic trainers and other designated authorities who treat and manage those at risk of TBIs.”
Concussion protocols are supposed to help take the guesswork out of concussion assessment and management. Their purpose is to improve post-injury treatment and outcomes and prevent long-term post-concussion symptoms or damage for every concussed player. To that end, concussion protocols aren’t designed to treat every TBI exactly the same. Dr. Schaller notes that each individual brain injury requires a customized care approach. Early detection and proper treatment are imperative to ensure concussed individuals have returned to baseline measures of brain health. The time it takes for each individual to return to baseline brain function will vary, as will the time it takes for each athlete to fully recover from a concussion/TBI. Because each athlete and the circumstances involved with each individual injury are unique, there is no “one size fits all” for concussion recovery and safe-return timelines.
The NFL Concussion Protocol
The National Football League (NFL) concussion protocol, has evolved over its short lifetime. From its inception in 2009 to address concerns over how head injuries on the field were handled, the NFL has enhanced its protocols as more research shows just how serious neurological problems can be from TBIs. The current program outlines on-the-field protocol steps as well as rest and recovery stages.
NFL Concussion Protocol Steps During Games Include:
- Spotters assigned to closely monitor players on the field, and who can call a timeout if they see a head impact.
- Players receiving head impacts are escorted off the field to be examined.
- Team trainers, coaches, physicians, game officials and even teammates can initiate the concussion protocol.
If there are signs of a traumatic brain injury, the NFL player is taken to a medical tent, locker room or hospital so that further evaluation and testing can be initiated.
The NFL’s Five Concussion Protocol Steps for Return-to-Play:
- STEP 1: Rest and limited activities that can exacerbate symptoms
- STEP 2: Start a graduated aerobic exercise program
- STEP 3: Engage in specific football-mimicking activities
- STEP 4: Participate in non-contact training drills with the club
- STEP 5: Return to full football practice
After these five steps are completed, the player must be cleared by their club’s physician and also examined and cleared by an independent neurological consultant before returning to game play.
To put weight behind these concussion protocol measures, fines imposed by the NFL’s Head, Neck and Spine Committee for not following these safety standards can range from $50,000 to $150,000 or more, depending upon the number of previous violations or additional mishandling issues.
Concussion Protocols Are Not Just for Football
We’ve written about how common concussions are in various sports, and it is clear that the risks for TBIs go way beyond just football. Hockey, soccer, basketball and even cheerleading are among the sports that have some of the higher TBI rates reported. “We may hear about concussions in football more often, but the reality is that the connection between head injuries and long-term neurological issues needs to be understood by everybody, and that concussion protocols help establish ways of keeping all of us safer,” says Dr. Schaller.
The MAC Alliance Concussion Protocol
Download a PDF of MAC Alliance’s concussion protocol flowsheet for athletic, academic and professional recovery programs.
The concussion protocol we use at MAC Alliance was originally modeled after the concussion diagnosis and treatment protocols developed by the University of Pittsburgh Medical Center (UPMC). Athletes of all ages can be put on a supervised Five Stage UPMC Concussion Program, which is designed to allow them to maintain strength and cardiovascular activity while making a concussion recovery. The UPMC-based protocol program necessitates vestibular rehabilitation in their Five Stage UPMC Concussion Program to improve balance and clear up vestibular deficits while promoting physical activity.
“It is imperative that all recordable deficits in balance, NEAR POINT CONVERGENCE, SACCADES and VOR (gaze stability) return to normal prior to clearance for sport,” says Dr. Schaller. “These are all objectively measurable and backed up thanks to the latest technology including infrared eye-tracking systems like RightEye and EyeGuide. These technologies utilize 120 pictures per second to confirm that the eye-tracking deficits from the TBI have been fully recovered.”
In establishing our own concussion protocol, we’ve incorporated aspects of the UPMC and other leading concussion programs to come up with a thorough multiple-step evaluation process. As new TBI research and technologies emerge, our concussion protocol program is updated.
The MAC Alliance concussion protocol includes:
- An initial, thorough screening using neurocognitive, vestibular (balance) and ocular testing tools
- 3-5 days of strict brain rest as prescribed by a concussion specialist
- Gradual increases in physical exercise prescribed in a recovery plan by a concussion specialists, and then monitored by a TBI-trained therapist
- Post-injury testing with the appropriate screening tools, including ImPACT® neurocognitive testing, BrainScope® One EEG technology, RightEye® infrared eye-tracking test, Cambridge Brain Sciences® (CBS Health) cognitive assessments, EyeGuide® brain-health eye tracking , Sway Balance System, and/or other advanced tools
- Individualized symptom assessment
- Individualized return-to-play or return-to-work assessment
MAC Alliance Concussion Protocol Stages of Physical Therapy
- Stage 1: Light aerobic stretching, minimal exertion, low-level balance activity
- Stage 2: Light-to-moderate aerobic activity and increased, moderate balance activity
- Stage 3: Moderate-to-aggressive aerobic activity like jogging
- Stage 4: Aggressive training, sport-specific drills
- Stage 5: Resume full training level at 100% exertion
Other Concussion Protocols and Resources
“Concussion protocols can vary not only by sports organization, but also from state to state. That is why it is important to check what is required where you are,” advises Dr. Schaller. Organizations that do not feel their state guidelines are sufficient can certainly require more detailed or stringent protocols within their own athletic programs. The CDC’s Heads Up website also offers useful concussion prevention tips, information and resources for athletes, coaches, athletic trainers and parents.
Concussion protocols aren’t limited to just sports, either. According to Health.mil, the official website of the Military Health System, in 2021 the United States Armed Forces invested significantly in updating their own concussion protocols for safe TBI recovery and return to duty, including for active duty service members. And in concussion protocol news from the private sector, a 2020 rule established by the Ohio Bureau of Worker’s Compensation “facilitated the provision and payment of medically necessary and appropriate services for the treatment of work-related concussion injuries, to avoid prolonged disability.”
Why do Concussion Protocols Vary Between Organizations?
You may have noticed that concussion protocol timelines and guidelines can vary between organizations. Why is that? “Part of the issue is that these policies and procedures are relatively new to many youth, collegiate, recreational and professional sports organizations,” says Dr. Schaller. “They are even newer in the workforce.”
As concussion protocols become more common, public understanding of brain injuries increases and as we learn more about TBI diagnosis, treatment and recovery, it is likely that dramatic variations in programs will be less common.
Setting Up a Concussion Protocol
When creating your own concussion protocol for your organization, be sure to take into consideration the TBI risks to players or employees, your state laws, and the current concussion research and best practices. According to ImPACT® Applications, Inc., considered one of the industry’s gold standards for concussion baseline testing, the main objectives of a concussion protocol should be:
- Clearly define steps that must be followed so that all stakeholders understand concussion evaluation and management.
- Ensure that return-to-activity steps are monitored safely and comprehensively.
- Have a concussion specialist to consult with for both setting up guidelines and as the protocol is implemented.
- Treat each potential concussion with the seriousness and timeliness necessary for best outcomes.
For more on setting up a concussion protocol, check out ImPACT’s comprehensive concussion protocol guide.
Concussion Protocols Send an Important Message
“When organizations have a concussion protocol in place, TBIs are more likely to be on the radar,” says Dr. Schaller. And that can go a long way. “Fundamentally, we have learned to take concussions more seriously and treat each one properly with long-term brain health as our focus,” says Dr. Schaller. This is especially important in the sports community. “We aren’t talking about taking away anything from any sport. We are actually talking about adding to the safety of players, so they can return and continue to play at their best.”
