The horrifying on-field mishandling of a Houston quarterback’s head injury highlighted the limitations of the NFL’s concussion protocol. What can be done?

In a sport of hard hits, the NFL has taken more than its share this season. Off the field issues have drawn more attention than the play on the field – particularly the debate over kneeling and the national anthem—and football’s ever-present nemesis, concussions, remains one of the NFL’s biggest problems.

Publicly condemned and legally liable for ignoring the long-term effects of brain injury, the NFL seems to have learned from its mistakes and has swiftly tried to respond, primarily through the implementation of a concussion protocol. The protocol, developed in 2009 and amended periodically over the past eight seasons, dictates the procedure for both the diagnosis and management of concussions.

Now, the first, and perhaps most important rule of the concussion protocol stipulates that a player must be removed from the game immediately when a concussion is suspected. After examination by an independent neurological consultant – in the locker room or one of those fancy new pop-up tents on NFL sidelines – evidence of observable concussion symptoms should trigger removal for the duration of the game.

The Tom Savage fiasco shows the NFL's concussion protocol is not working Read more

Once a player “enters” the protocol with a diagnosed concussion, other rules dictate how a player can return to play or “exit” the program.

However, several on-field mishandlings of head injuries have again put the NFL on the defensive. Most notably, the Houston Texans allowing quarterback Tom Savage to re-enter the game after suffering what seemed to be a concussion-related seizure on the field.

Played out in front of horrified television viewers, the concussion detection system is designed to red flag such events, chiefly through the use of medical spotters in the booth to monitor video for possible concussion provoking hits. Events like helmet-to-helmet contact; players unable to walk or stand after hits; loss of consciousness; those are the incidents that observers are trained to watch for and if needed, alert sideline officials.

Though Savage was eventually pulled after one series, an obvious sign of concussion was initially missed, highlighting the limitations of the NFL’s concussion protocol. Rightfully so, the criticism came quickly. As a result, what will happen, is a series of changes to the protocol.

One of those changes will be the presence of an independent neurological expert at the league command center for every game. This official will have the ability to contact the sideline medical staff should they observe any signs or symptoms requiring further evaluation. An extra neurotrauma consultant, in addition to the two independent neurological experts already on very sideline, will serve as additional backup.

What won’t happen, in a joint NFL-NFLPA ruling released Friday, is any disciplinary action against the Texans for the Savage incident.

So will this fix the NFL concussion protocol? While these changes will address the detection of high-risk events, part of the problem, and one less easily addressed, has to do with the nature of how concussions can present.

Symptoms from concussions – headaches, dizziness, confusion, etc – can be delayed anywhere from minutes to days, making sideline diagnoses untrustworthy. These delayed symptoms can lead players and teams to believe that a player hasn’t suffered a concussion, especially in the hurried, let’s-get-our-quarterback-back-out-on-the-field atmosphere of the NFL.

“Symptoms are a big part of the assessment, and are inherently subjective,” said Christopher Giza, director of the UCLA BrainSPORT program. “Some athletes aren’t aware a symptom may be from a concussion; some athletes purposely hide concussion symptoms; some athletes aren’t thinking clearly enough to recognize the symptoms and sometimes concussion symptoms present in a delayed fashion.”

According to Giza, in this way the concussion protocol is like other injury diagnoses, with a degree of uncertainty inherent to medicine. “However, concussion and sport-related TBI is very high profile, the stakes (in both money and health) are high,” he said, “so big sports like football can and to some extent should be held to a high standard.”

The fact is that, no matter the effectiveness of a test, diagnosis is all the more difficult if players aren’t truthful about how their head feels. It’s because, in the absence of objective test, any concussion protocol relies on the motivation of the athlete to cooperate with evaluators.

Research by the University of North Carolina’s Center for the Study of Retired Athletes found that over 50% of former NFL players surveyed had sustained a concussion at least once and did not inform team medical staff. In one high risk group, those that had sustained 10 or more concussion, 75% of players stated they had concealed concussion symptoms.

The numbers were similar to those found in a survey of college football players, one that found that nearly 70% had not disclosed a concussion during their collegiate career, a staggering statistic.

Unfortunately though, the NFL players may have reasons to downplay concussion symptoms, as there is evidence for a shorter career length and decreased performance after concussion.

In fact, one study found that, three years after sustaining a concussion, 70% of players were no longer in the NFL. In stark contrast, only 43% of non-concussed players had been released by the same point. And while the first hit was to the head, the next was to the pocketbook, as those that had suffered a concussion made, on average, $300,000 less than those that hadn’t.

Much of the attention has been concentrated on the diagnosis and treatment of head injuries but little has focused on the factors that increase risk. Several recent research studies indicate that, like any injury, external factors can play a role.

Though research hasn’t connected an increase in concussions with the shortened recovery period of Thursday games or days of rest in general, there does seem to be an increase in head injuries in the second half of the season. Giza hypothesizes that likely contributors to this association may include late season player fatigue, more ‘on the line’ as teams position for the post-season, or colder game temperatures.

The style of offense, namely how and how often a team passed, was also found to be a risk factor for concussion, primarily in those players most involved in the passing game. Wide receivers, tight ends, cornerbacks, and safeties all had more documented concussions. According to researchers, this may be because passing plays place athletes at higher risk for full speed impacts compared with running plays. Interestingly, the highest risk was with a passing attack that favored shorter routes across the middle of the field, rather than offenses that emphasized long passes.

The researchers speculate that during cross-field routes the receiver and defender are more likely to be running at each other, rather than with each other, as with longer, more downfield, routes. That means more high-speed collisions and a higher risk of head injury.

Whether these changes to the concussion protocol will make a difference in the long-term health of players is an answer that may take years to obtain. Yet, given the complexity of concussion testing, perhaps it’s unfair to condemn the NFL. However, the future of the NFL may rely on that answer.