Education

Players and club personnel are provided with, and must review, educational material regarding concussion, including the importance of identifying and reporting signs and symptoms to the medical staff. The educational material provides basic facts about concussion, including signs and symptoms, as well as why it is important to report symptoms promptly. Additionally, players are educated and encouraged to report to the medical staff concussion signs and symptoms that their teammates may experience. The goal is to provide broad education to every participant in the game of football, so that a culture change can continue to evolve to one of self-awareness and self-reporting of symptoms.

Pre-season assessment

1. Physical examination: The team physician uses the pre-season physical examination to review and answer questions about a player’s previous concussions, discuss the importance of reporting any concussive signs or symptoms, and explain the specifics regarding the concussion diagnosis and management protocol. Team doctors also explain the various roles of the participants in the concussion protocol (eg, Unaffiliated Neurotrauma Consultants (UNC), Independent Neurotrauma Consultants (INT) and Club Neuropsychologists.

2. Neuropsychological testing: Every player must undergo a baseline physical examination as part of his pre-season physical examination which includes a traditional neurological examination and Baseline NFL Locker Room Comprehensive Concussion Assessment. This baseline information is used in evaluating the player if he subsequently sustains a concussion during the season. Each player is required to have a baseline neuropsychological test. Computerised forms of neuropsychological testing can be used, but it is also acceptable to perform standard paper and pencil testing or to utilise a combination of the two (known as the ‘hybrid’ model). For quality assurance purposes, Club Neuropsychologists will review baseline neuropsychological test results during the pre-season for the detection of invalid protocols and for determination of the need for test re-administration.

Definitions/responsible parties

Unaffiliated Neurotrauma Consultants (UNCs): These consulting physicians work with the team’s medical staff and assist in the diagnosis and care of the concussed player. During games, each team is assigned a UNC by the NFL HN&S Committee and approved by the NFL Chief Medical Officer and the NFLPA Medical Director. For all playoff games and the Super Bowl, a third sideline UNC is added to serve as a backup who can step in immediately should one of the original two UNCs be absent from the sideline while attending to a more severely injured player. In addition, another centralised UNC monitors the video broadcast feeds of all games. The centralised UNC will contact the team medical staff on the sideline or the ATC Spotter should they observe any signs or symptoms warranting further evaluation.

Each UNC is a physician who is impartial and independent from any Club, is board certified or board eligible in neurology, neurological surgery, emergency medicine, physical medicine and rehabilitation, or any primary care Certificate of Added Qualification (CAQ) sports medicine certified physician, and has documented competence and experience in the treatment of acute head injuries (as evidenced by no less than monthly treatment of such patients).

A UNC is present on each sideline during every game and is: (i) focused on identifying symptoms of concussion and mechanisms of injury that warrant concussion evaluation; (ii) working in consultation with the Head Team Physician or designated concussion team physicians to implement the concussion evaluation and management protocol (including the Locker Room Comprehensive Concussion Assessment Exam) during the games; and (iii) present to observe (and collaborate when appropriate with the team physician or his concussion physician designee) the Sideline Concussion Assessment Exams performed by club medical staff. The UNC is also present for sideline evaluations for neuropraxia (‘stingers’ or ‘burners’) and other potential neck injuries.

The UNCs also are available to assist in transportation to a medical facility based on the EAP in which that consultant has medical privileges for more advanced medical evaluation and/or treatment as needed. The team physician/UNC unit is co-located for all concussion evaluations and management both on and off the field. Should the UNC be unavailable to participate in the sideline evaluation (eg, the UNC is treating another player in the locker room or accompanying an injured player to the hospital in accordance with the EAP), the club physician may request to conduct the assessment with the second UNC who is present on the opposing team’s sideline. The UNC may present his/her own questions or conduct additional testing and assists in the diagnosis and treatment of concussions. Regardless, the responsibility for the diagnosis of concussion and the decision to return a player to a game remains ultimately within the professional judgement of the Head Team Physician or the team physician assigned to managing concussion.

In essence, the UNC acts as an independent ‘co-pilot’ or consultant for the team physician ‘pilot’ role. Each UNC files a standardised report of his/her activity following each game focused on the specifics of the observed and/or suspected concussions. The report is then reviewed for quality assurance purposes by the NFL Chief Medical Officer and NFLPA Medical Director, and feedback and education are provided subsequently to augment the physician quality improvement process.

Booth Certified Athletic Trainer Spotter (ATC Spotter): Two certified athletic trainers are assigned to a stadium booth with visual and camera access to multiple views of video and replay to aid in the recognition of injury (ATC Spotters). ATC Spotters follow the NFL Concussion Protocol and are charged with monitoring the game, both live and via video feed, to identify players who may require additional medical evaluation. Prior to the start of the game, ATC Spotters introduce themselves to the medical staff for both teams to discuss protocol and to confirm that all communication devices are operational. The ATC Spotters, UNCs and the team physician communicate in ‘real time’ by radio communication. The ATC Spotters are also connected to the on-field game officials by radio communication. The teams’ medical personnel can initiate communication with the ATC Spotter to clarify the manner of injury. The sideline medical staff can review the game film on the sidelines to obtain information on particular plays involving possible injury.

When the ATC Spotter observes a player who is clearly unstable or displays any other potential concussion signs (defined above) following a mechanism of injury (eg, a hit to the head or neck), he/she contacts the team physician and UNC by radio to ensure that a concussion evaluation is undertaken on the sideline. The club medical staff verifies to the ATC Spotter that the evaluation has been performed.

The ATC Spotter notes the time of: (i) his initial contact with the club medical staff and UNC alerting them of the need for further evaluation, and (ii) the time of the communication from the club medical staff and UNC confirming that an evaluation has been performed. This information is conveyed in the ATC Spotter’s report following the game. If the ATC Spotter observes a player who has been flagged for medical evaluation return to the game prior to receiving the confirmation from the team’s medical staff that an evaluation was conducted, the ATC Spotter calls a medical timeout (see below). For purposes of clarity, this is intended to serve as a redundant communication from the ATC Spotter with the team physician or UNC to confirm that a concussion evaluation has been performed. If no such confirmation is provided, the ATC Spotter is empowered to call a medical timeout to assure the concussion evaluation occurs. ATC Spotters file a report of their activity following each game for review by the NFL Chief Medical Officer and NFLPA Medical Director.

Game day symptoms/return to play

‘No-Go’ signs and symptoms: If a player exhibits or reports any of the following signs or symptoms of concussion, he is removed immediately from the field of play and transported to the locker room. A player who exhibits or reports any of the following signs or symptoms is considered to have suffered a concussion and is not returned to participation (practice or play) on the same day under any circumstances.

• Loss of consciousness

• Confusion

• Amnesia

• Impact seizure/posturing of limbs

All players demonstrating gross or sustained vertical instability (eg, stumbling or falling to the ground when trying to stand) must undergo a Locker Room Comprehensive Concussion Assessment where an evaluation for a concussion can be conducted.

Medical timeout

In the event the ATC Spotter (i) has clear visual evidence that a player is manifesting overt signs of disorientation, is clearly unstable, or displays other obvious sign of concussion; and (ii) it becomes apparent that the player will remain in the game and not be attended to by the club’s medical or athletic training staff, then the ATC Spotter can take the following steps:

1. If the player does not receive immediate medical attention, the ATC Spotter can contact the Side Judge over the Official-to-Official communication system to identify the player by his team and jersey number.

2. The ATC Spotter can contact the medical staff of the player involved and advise that the player appears to need medical attention.

3. The ATC Spotter remains in contact with the medical staff until the medical staff confirms that a concussion evaluation has occurred or is underway. It is the ATC Spotter’s responsibility to confirm that a concussion evaluation has occurred prior to the player returning to play. As detailed above, if an ATC Spotter observes a player returning to the game without receiving express confirmation that an evaluation has occurred, the ATC Spotter can signal to the official for a medical timeout.

On being called by the ATC Spotter, the Side Judge may immediately stop the game, attend to the player in question, and await the arrival of the club’s medical personnel to ensure player safety (ie, the player is escorted off the field). No communication via coach-to-player headsets is permitted during the stoppage, no member of the coaching staff may enter the playing field, and no player other than the player receiving medical attention may go to the sideline unless a substitute player has replaced him. The goal is to separate the coaching player replacement decisions from the medical decisions.

Once removed from the field, the team medical staff conduct an evaluation of the player as required by the governing protocols before making any decision regarding the player’s eligibility to return to play. The medical staff makes the return-to-play decision consistent with the NFL protocols. In no instance does this evaluation period last less than one play, unless there is an extended delay unrelated to the player’s removal from the game (ie, timeout, 2 min warning, penalty, etc). An injury timeout is not charged to a team who has a player removed during this process.

Following the game, the UNC and team physician document each step outlined above and their conclusions regarding the player’s status. The UNC’s report details each evaluation, including interactions with players and members of the club medical staff, and is sent to the NFL Chief Medical Officer and NFLPA Medical Director following the game again for quality assurance purposes.

Madden Rule

On game day, per the Madden Rule, a player diagnosed with a concussion: (a) must be removed from the field of play; (b) his helmet is removed from the player’s possession; (c) he is escorted to the locker room by team medical personnel; and (d) he is observed in the locker room by qualified medical personnel. The Madden Rule protects the player by providing a quiet environment, with appropriate medical supervision, to permit the player time to recover without distraction. Once a player is diagnosed with a suspected concussion, he is not permitted to meet or talk to the press until he is medically cleared, again with the goal to protect the player.

Additional evaluations and follow-up

A player diagnosed with concussion has the entire sideline examination (as well as the NFL Locker Room Comprehensive Concussion Assessment) performed on the day of injury, as tolerated medically. The components of the NFL Locker Room Comprehensive Concussion Assessment can be performed at different times on the day of the injury depending on the individual situation (eg, an exception can be made for a player who is transported to the emergency department), and an assessment is repeated prior to discharge home or prior to transportation home following an away game. A player diagnosed with concussion will be given ‘take home’ educational information (eg, signs and symptoms for which to watch, emergency phone numbers) as well as follow-up instructions. The NFL Locker Room Comprehensive Concussion Assessment is repeated the following day on all players assessed on game day to monitor for the development of concussion symptoms.

Even if a player has normal findings on an initial concussion assessment and is returned to practice or play, he is to be checked periodically during practice or play and again before leaving the venue. Performing serial concussion evaluations occur in each suspected concussion case and may be useful because concussive injury can evolve and may not be apparent clinically for several minutes or hours. Components of the NFL Locker Room Comprehensive Concussion Assessment are to be utilised in the performance of such evaluation.

1. The results of subsequent examinations by the team physician are communicated to the UNC in the spirit of ‘concussion team’ cooperation and patient safety.

2. Should the sideline examination reveal a change in the player’s condition during game play, the team physician/UNC team is re-assembled, and they perform a subsequent Locker Room evaluation.

3. We recognise that players may be able to equal or exceed their performance under the Locker Room Comprehensive Concussion Assessment compared with their baseline level yet still have a concussion, underscoring the importance of the physicians’ knowledge of the player. If there is any doubt about the presence of a concussion, regardless of the quantitative Locker Room ?format change here?

Comprehensive Concussion Assessment results, the player is removed from practice or play. A player diagnosed with concussion will be given ’take home' educational information (eg, signs and symptoms for which to watch, emergency phone numbers) as well as follow up instructions.

NFL Sideline Concussion Assessment (Sideline Survey): If a player exhibits or reports a sign or symptom of concussion (defined above) or a concern is raised by the club’s athletic trainer, team physicians, ATC Spotter, coach, teammate, game official or UNC (collectively referred to as ‘game day medical personnel’), the player is immediately removed to the sideline medical tent (or stabilised on the field), as needed, and undergoes the entire NFL Sideline Concussion Assessment. The team physician/UNC unit is co-located for all concussion evaluations and management both on and off the field. The UNC may present his/her own questions or conduct additional testing and shall assist in the diagnosis and treatment of concussions.

This initial survey takes several minutes and, at a minimum, consists of the following:

1. A review of the ‘NO-GO’ criteria reviewed above (loss of consciousness, confusion, amnesia, impact seizure/posturing of limbs), which, if present, requires the player to be brought to the locker room without a chance for return to play that day

2. Inquiry regarding the history of the event

3. Review of concussion signs and symptoms (see above)

4. Maddocks’ questions15

5. Video review of the injury (detailed below)

6. Focused neurological examination, inclusive of the following:

• Cervical spine examination (including range of motion and pain)

• Evaluation of speech

• Observations of gait

• Eye movements and pupillary examination.

The above medical evaluation is (i) conducted inside a HIPAA compliant medical evaluation tent on the sideline and (ii) performed using the tablet or other technology assigned by the NFL, and completion of each component of the Sideline Survey is checked off the list for completeness. The team physician and the UNC review available video of the suspected injury event. If any elements of the sideline assessment are positive, inconclusive,or suspicious for the presence of a concussion, the player is escorted to the locker room immediately for the complete NFL Locker Room Comprehensive Concussion Assessment. Also, if the player demonstrates worsening or progressing symptoms at any point, he is brought to the locker room for the complete NFL Locker Room Comprehensive Concussion Assessment. The player is accompanied by, at least, the team physician best qualified to evaluate concussion and the UNC. The UNC may present his/her own questions or conduct additional testing.

If, on completing the Sideline Survey, the medical staff (team physician/UNC) concludes that the player did not sustain a concussion, then the player may return to play when finally cleared by the team physician. Suggested best practices for concussion assessment include periodic checks by the team physician, UNC or others with the player to determine whether he has developed any of the signs or symptoms of concussion that would necessitate a subsequent locker room evaluation.

UNC Involvement in Sideline Concussion Assessment

1. The team physician consults in private with (i) the members of his/her team’s medical staff designated to identify, diagnose and treat concussions; (ii) the UNC and, as necessary, (iii) the club’s ATC, prior to making his/her decision regarding whether the player will return to the game.

2. If the team physician determines that the player shall not return to play (based on the criteria listed above) and therefore there is no need to complete the Sideline Concussion Assessment, the team physician and the UNC accompany the player to the locker room to evaluate the player using the NFL Locker Room Comprehensive Concussion Evaluation4 for serious injury, treat the player or activate the EAP if indicated.

3. The team physician remains responsible for all final decisions regarding return to play. However, the team physician consults with his/her UNC team member prior to reaching his/her decision. If the UNC disagrees with the team physician’s decision to return the player to play or remove the athlete, the UNC is given an opportunity to explain the basis of his/her opinion. This is discussed in a collegial fashion in private as to why the player should or should not be returned to the game. The team physician has to make the final return to play or removal decision and then communicate his final decision to the player. The NFL HN&S Committee looks at the relationship between the UNC and team physician as a collaborative co-pilot/pilot relationship. Although the team physician is responsible for all final decisions, he/she has the advantage of utilising the extra set of eyes and consultative neurological experience of the UNC to make a more informed decision on the diagnosis of concussion. To date, diagnostic disagreements have been exceedingly rare. We believe that this is a result of the collaborative culture that has developed between the UNCs and team physicians, the robust nature of the current examination and the fact that there is time to discuss the clinical assessment among the medical team.

NFL Locker Room Comprehensive Concussion Assessment (Locker Room Exam): The NFL Locker Room Comprehensive Concussion Assessment (Locker Room Exam) is the standardised acute evaluation that has been developed by the NFL’s HN&S Committee to be used by teams’ medical staffs and designated UNCs to evaluate potential concussions during practices and on game day. This evaluation is based on the Standardised Concussion Assessment Tool (SCAT5) published by the International Concussion in Sport Group,11 modified for use in the NFL, and consistent with the SCAT5.15 The NFL Locker Room Exam can be administered and repeated as needed to aid in the diagnosis of concussion, even if there is a delayed onset of symptoms. The ongoing use of the Locker Room Exam, in conjunction with the pre-season baseline testing, provides a comprehensive and detailed picture of each athlete’s injury and recovery course. Being able to compare the results from the NFL Locker Room Exam with the baseline information obtained in the pre-season (SCAT and neuropsychological test data) improves the value of this instrument. Clubs maintain all NFL Locker Room Exams (including the SCAT5) and a copy is available to both the player and the team medical staff.

In all circumstances, the team physician responsible for concussion evaluation (or other physician designated by the team physician such as a neurosurgeon or team neurotrauma specialist) assesses the player in person in conjunction with the UNC. The team physician is responsible for determining whether the player is diagnosed as having a concussion.

The athlete may have a concussion despite being able to complete the NFL Locker Room Comprehensive Concussion Assessment ‘within normal limits’ compared with their baseline, due to the nature of concussive injury and possible limitations (for example, practice effects) of the Locker Room Exam. Such limitations underscore the importance of the team medical personnel knowing the athlete at their baseline and the subtle deficits in their personality and behaviours that can occur with concussive injury. It is not uncommon that an ATC or team physician will remove a player because, although he performs at his baseline level on the Locker Room Exam, he is deemed to not be at neurobehavioral baseline (eg, behavioural agitation, emotional dyscontrol) according to the team medical personnel who know him best.

The signs and symptoms of concussion listed above, although frequently observed or reported, are not an exhaustive list. The NFL Locker Room Exam is intended to capture these elements in a standardised format. The neurocognitive assessment in the NFL Locker Room Exam is brief and does not replace more formal neuropsychological test procedures. A balance assessment is an important component of the NFL Locker Room Exam, and has been validated as a useful adjunct in assessing concussive injury.15

NFL Concussion Game Day Checklist

The NFL Concussion Game Day Checklist provides a clear summary of the steps required by NFL HN&S Committee’s Concussion Diagnosis and Management

Protocol, with regard both to Sideline Survey and the Locker Room Exam. The NFL Concussion Game Day Checklist is described in figure 1. The application of the NFL

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Figure 1

NFL Concussion Game Day Checklist.

Concussion Game Day Checklist to evaluate potential concussions during NFL pre-season and regular season games is mandatory. Designated medical personnel (team physicians and athletic trainers, UNCs and ATC Spotters) complete their designated steps in the NFL Concussion Game Day Checklist and record the same using the designated technology (ie, X2 system on tablet or other technologies which may be developed for league-wide use). A club medical team’s failure to properly apply the NFL Concussion Checklist may subject their club to disciplinary action(s).