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1 Amended July 7, 2020 2 NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management 3 Protocol 4 I. Overview of Injury 5 A. Introduction 6 Concussion is an important injury for the professional football player. The diagnosis, prevention, and 7 management of concussion is important to the National Football League (NFL), its players and 8 member Clubs, and the National Football League Players Association (NFLPA). The NFL’s Head, 9 Neck and Spine Committee, in conjunction with the NFLPA Mackey-White Committee, has 10 developed a comprehensive set of protocols regarding the diagnosis and management of concussions 11 in NFL players. 12 The diagnosis and management of concussion is complicated by the difficulty in identifying the injury 13 as well as the complex and individual nature of its management. Ongoing education of players, NFL 14 Club physicians, certified athletic trainers (ATCs), Unaffiliated Neurotrauma Consultants (UNCs), 15 and Neuropsychology Consultants and other Club medical personnel regarding concussion is 16 important, recognizing continued advances in concussion assessment and management. The 17 objective of these protocols is to provide Club medical staffs responsible for the health care of NFL 18 players with a guide for diagnosing and managing concussion. 19 This document updates and supersedes the initial “NFL Head, Neck and Spine Committee’s Protocols 20 Regarding Diagnosis and Management of Concussion,” issued in July, 2013, and all subsequent 21 amendments thereto. 22 B. Concussion Defined 23 For purposes of these protocols, the term concussion is defined as (adapted from McCrory et al., 24 2017 ): 25 Sport-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. 26 Several common features that may be utilized in clinically defining the nature of a concussive head 27 injury include the following: 28 1. SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body 29 with an impulsive force transmitted to the head. 30 2. SRC typically results in the rapid onset of short-lived impairment of neurological function 31 that resolves spontaneously. However, in some cases, signs and symptoms evolve over a 32 number of minutes to hours. 33 3. SRC may result in neuropathological changes, but the acute clinical signs and symptoms 34 largely reflect a functional disturbance rather than a structural injury and, as such, no 35 abnormality is seen on standard structural neuroimaging studies.
36 4. SRC results in a range of clinical signs and symptoms that may or may not involve loss of 37 consciousness. Resolution of the clinical and cognitive features typically follows a 38 sequential course. However, in some cases symptoms may be prolonged. 39 5. The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, 40 other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other 41 comorbidities (e.g., psychological factors or coexisting medical conditions). 42 C. Potential Concussion Signs (Observable) May Include (adapted from Davis, et al. 2019): 43 • Any loss of consciousness; 44 • Impact seizure or “fencing” posture 45 • Slow to get up from the ground or return to play following a hit to the head (“hit to the 46 head” may include secondary contact with the playing surface) 47 • Motor coordination/balance problems of neurologic etiology (stumbles, trips/falls, 48 slow/labored movement); 49 • Blank or vacant look; 50 • Disorientation (e.g., unsure of where he is on the field or location of bench); 51 • Behavior change (aggressive, agitated, atypically subdued, unusually emotional or 52 frightened, etc.) 53 • Amnesia, either anterograde or retrograde; 54 • Clutching of the head after contact; or 55 • Visible facial injury in combination with any of the above. 56 D. Potential Concussion Symptoms Include: 57 58 • Headache; 59 • Dizziness or Light headedness; 60 • Balance or coordination difficulties; 61 • Nausea; 62 • Amnesia, either anterograde or retrograde; 63 • Cognitive slowness; 64 • Light/sound sensitivity;
104 neurocognitive tests, 2) traditional paper and pencil tests, and 3) a combination of 105 the two (i.e., hybrid testing). The Baseline NFL Locker Room Comprehensive 106 Concussion Assessment should be administered at least every two years, while 107 Neurocognitive testing should be administered every three (3) years unless a 108 player sustains a concussion in which case new baseline examinations should 109 be administered prior to the start of the season following the season in which 110 he sustained a concussion. A structured summary of the results of any paper 111 and pencil testing performed by the Club NPC (Attachment C, “NFL 112 Neurocognitive Testing Program Data Record Form”) should be provided to 113 the Head Club ATC. The paper and pencil test results Data Record Form should 114 be sent by the Club NPC to the Head Club ATC for uploading into the 115 designated electronic medical record (EMR) system. The Club ATC must 116 upload the results of the computerized neurocognitive testing into the EMR. 117 118 C. Game Day Concussion Diagnosis and Management 119 1. Definitions/Responsible Parties 120 a. Unaffiliated Neurotrauma Consultant (UNC) 121 A UNC shall be a physician who is impartial and independent from any Club, 122 is board certified in neurology, emergency medicine, physical medicine and 123 rehabilitation, or any primary care CAQ sports medicine certified physician or 124 board eligible or board certified in neurological surgery, and has documented 125 competence and experience in the treatment of acute head injuries. UNCs are 126 appointed by the NFL Head, Neck and Spine Committee in consultation with the 127 NFLPA Mackey-White Committee and approved by the NFL Chief Medical 128 Officer and the NFLPA Medical Director, and have undergone formal UNC 129 training provided by the NFL and NFLPA. At each game, each Club will be 130 assigned a UNC to be present on its sideline who shall be: (i) focused on 131 identifying signs or symptoms of concussion and mechanisms of injury that 132 warrant concussion evaluation, (ii) working in consultation with the Head Team 133 Physician or his/her designee to implement the concussion evaluation and 134 management protocol (including the Locker Room Comprehensive Concussion 135 Assessment Exam) during the games, and (iii) present to observe (and collaborate 136 when appropriate with the team physician) the Sideline Concussion Assessment 137 Exams performed by Club medical staff. The UNCs also will be available to assist 138 in coordinating which physician will accompany a player who is transported to 139 the EAP-designated trauma center for more advanced evaluation and treatment. 140 The UNCs will work with the Club’s medical staff and will assist in the 141 diagnosis and care of the concussed player. The Club physician/UNC unit will 142 be co-located for all concussion evaluations and management both on and off 143 the field. The UNC may present his/her own questions or conduct additional 144 testing and shall assist in the diagnosis and treatment of concussions. 145 Regardless, the responsibility for the diagnosis of concussion and the decision
146 to return a player to a game remains exclusively within the professional 147 judgment of the Head Team Physician or his/her physician designee responsible 148 for the diagnosis and treatment of concussion. A UNC will also be present for 149 sideline evaluations for neuropraxia (“stingers” or “burners”) and other 150 potential spinal and peripheral nerve injuries. 151 Should the sideline UNC be unavailable to participate in the sideline evaluation 152 (i.e., the sideline UNC is treating another player in the locker room or 153 accompanying an injured player to the hospital in accordance with the EAP), 154 the Club physician may request to conduct the assessment with the second 155 sideline UNC who is present on the opposing team’s sideline. In the event that 156 the opposing team’s sideline UNC is unavailable, the Visiting Team Medical 157 Liaison (VTML; see section 1.d below) who has completed the formal NFL- 158 NFLPA UNC training) may serve as a back-up. 159 160 A third UNC will be assigned to a stadium booth with access to multiple views of 161 video (including the live broadcast feed and audio) and replay to aid in the 162 recognition of injury (Booth UNC). This UNC will be co-located with the Booth 163 ATC Spotter (see below). UNCs assigned to the booth are charged with 164 monitoring all available video feeds and the network audio to identify players who 165 may require additional medical evaluation. Prior to the start of the game, all UNCs 166 will introduce themselves to the medical staffs for both teams during the Pregame 167 Medical Team Meeting (see section 2.a below) to discuss protocol and confirm 168 that all communication devices are operational. 169 170 When the Booth UNC observes a player who is clearly unstable or displays any 171 other Potential Concussion Signs (defined in Section I.C. above) following a 172 mechanism of injury (e.g., a hit to the head or neck), he/she and/or the Booth ATC 173 Spotter will contact the Club physician and sideline UNC by radio to ensure that 174 a concussion evaluation is undertaken on the sideline. The Club medical staff will 175 then verify to the booth medical staff that the evaluation has been performed. The 176 Booth UNC shall note the time of his initial contact with the Club medical staff 177 and sideline UNC alerting them of the need for further evaluation and also the 178 time of the communication from the Club medical staff and sideline UNC 179 confirming that an evaluation has been performed. This information is to be 180 conveyed in the Booth UNC report following the game. If the Booth UNC 181 observes a player who he/she has flagged for medical evaluation return to the 182 game prior to receiving the confirmation from the Club’s medical staff that an 183 evaluation was conducted, he/she shall notify the Booth ATC Spotter who shall 184 call a Medical Time-Out (see below). For purposes of clarity, this is intended to 185 serve as a redundant communication from the Booth ATC Spotter with the Club 186 physician or sideline UNC to confirm that a concussion evaluation has been
227 to serve as a redundant communication from the Booth ATC Spotter with the Club 228 physician or sideline UNC to confirm that a concussion evaluation has been 229 performed. If no such confirmation is provided, the Booth ATC Spotter is required 230 to call a Medical Time-Out to assure the concussion evaluation occurs. 231 Booth ATC Spotters shall file a report of their activity following each game for 232 review by the Chairperson of the NFL Head, Neck and Spine Committee, NFL 233 Chief Medical Officer and NFLPA Medical Director. 234 c. Visiting Team Medical Liaisons (VTMLs) are board-certified physicians licensed 235 to practice medicine in the state in which the stadium is located and who work 236 with the visiting team to provide medical care for its players, including access to 237 leading medical centers for emergency care. As stated above (see 1.a), a VTML 238 may serve as back-up UNCs if s/he has completed formal NFL-NFLPA UNC 239 training. 240 241 2. Game Day Procedures 242 a. Pregame Medical Team Meeting. Sixty (60) minutes prior to kickoff, all 243 medical staff will meet in the referees’ locker room. Expected personnel include: 244 Head Team Physician and Head Team ATC from each team and UNCs, both 245 Booth ATC Spotters, lead EMS paramedic for the field, referee, VTML, and the 246 airway management physician. The pregame medical meeting is to be led by the 247 home team Head Team Physician. Items to be covered include: introductions of 248 medical staff; location of the ambulance, transport cart, spine board, defibrillator, 249 and advanced airway equipment; review of EAP medical facilities; and location 250 of x-ray equipment. Medical staff shall confirm who is responsible for verifying a 251 concussion evaluation of an athlete, i.e. “closing the loop.” Booth ATC spotters 252 shall review the Medical Time-Out procedures with officials. 253 254 b. “No-Go” Signs and Symptoms. If a player exhibits or reports any of the 255 following signs or symptoms of concussion, he must be removed immediately 256 from the field of play and transported to the locker room. If a neutral sideline 257 observer or a member of the player’s Club’s medical team observes a player 258 exhibit or receives a report that a player has experienced any of the following signs 259 or symptoms, the player shall be considered to have suffered a concussion and 260 may not return to participation (practice or play) on the same day under any 261 circumstances: 262 i. Loss of Consciousness (including Impact Seizure and/or “fencing 263 posture”) 264 ii. Gross Motor Instability (GMI), identified in the judgment of the Club 265 medical staff in consultation with the sideline UNC, who observe the 266 player’s behavior, have access to the player’s relevant history and are 267 able to rule out an orthopedic cause for any observed instability
268 iii. Confusion 269 iv. Amnesia 270 271 c. NFL Sideline Concussion Assessment (Sideline Survey) 272 If a player exhibits or reports a sign or symptom of concussion (defined above), 273 spinal cord neuropraxia or a concern is raised by the Club’s athletic trainer, Club 274 physicians, Booth ATC Spotter, coach, teammate, game official or sideline or 275 Booth UNCs (collectively referred to as “gameday medical personnel”) the player 276 must be immediately removed to the sideline or stabilized on the field, as needed, 277 the player’s helmet must be taken away from him, and the player must undergo 278 the entire NFL Sideline Concussion Assessment^1 which, at a minimum, must 279 consist of the following: 280 i. A review of the “No-Go” criteria reviewed above (Loss of Consciousness 281 (including impact seizure and/or “fencing posture”), Gross Motor 282 Instability [as defined above], Confusion, and Amnesia), which, if present, 283 requires the player to be brought to the locker room immediately and he 284 shall not return to play; 285 ii. Inquiry regarding the history of the event; 286 iii. Review of concussion signs and symptoms (See, Section I (C and D)); 287 iv. All Maddocks’ questions; 288 v. Complete Video Review of the injury (detailed below), including 289 discussion with the Booth UNC; and 290 vi. Focused Neurological Exam, inclusive of the following: 291 (A) Cervical Spine Examination (including range of motion and pain); 292 (B) Evaluation of speech; 293 (C) Observations of gait; and 294 (D) Eye Movements and Pupillary Exam. 295 296 The foregoing shall be: (i) conducted inside the medical evaluation tent on the 297 sideline; (ii) performed using the tablet or other technology assigned by the NFL, 298 and (iii) completion of each component of the Sideline Survey shall be confirmed 299 using the same. If any elements of the sideline assessment are positive, 300 inconclusive, or suspicious for the presence of a concussion, the player must be 301 escorted to the locker room immediately for the complete NFL Locker Room 302 Comprehensive Concussion Assessment. Also, if the player demonstrates (^1) The Club physician/sideline UNC unit will be co-located for all concussion evaluations and management both on and off the field. The sideline UNC may present his/her own questions or conduct additional testing and shall assist in the diagnosis and treatment of concussions.
347 4. As soon as practical, following the evaluation, the sideline UNC 348 shall notify the booth medical personnel that an evaluation was 349 conducted (“close the loop”). 350 351 c. NFL Locker Room Comprehensive Concussion Assessment (Locker 352 Room Exam) 353 The NFL Locker Room Comprehensive Concussion Assessment is the 354 standardized acute evaluation tool that has been developed by the NFL’s 355 Head Neck and Spine Committee to be used by Clubs’ medical staffs and 356 designated UNCs to evaluate potential concussions during practices and on 357 game day (see Attachment A). This evaluation is based on the Standardized 358 Concussion Assessment Tool (SCAT 5) published by the International 359 Concussion in Sport Group (McCrory, et al., 2017 ), modified for use in the 360 NFL (Attachment A). The NFL Locker Room Comprehensive Concussion 361 Assessment can be used to aid in the diagnosis of concussion even if there 362 is a delayed onset of symptoms. The ongoing use of the Locker Room 363 Comprehensive Concussion Assessment in conjunction with the preseason 364 baseline and post-injury testing provides detailed data regarding each 365 athlete’s injury and recovery course. Being able to compare the results from 366 the NFL Locker Room Comprehensive Concussion Assessment to the 367 baseline information obtained in the preseason improves the value of this 368 instrument. Clubs shall maintain and upload to the EMR all NFL Locker 369 Room Comprehensive Concussion Assessment exams and a copy of the 370 same shall be given to both the player and the team medical staff. 371 372 In all circumstances, the Club physician responsible for concussion 373 evaluation shall assess the player in conjunction with the sideline UNC. The 374 Club physician shall be responsible for determining whether the player is 375 diagnosed as having a concussion. 376 377 The athlete may have a concussion despite being able to complete the NFL 378 Locker Room Comprehensive Concussion Assessment “within normal 379 limits” compared to baseline, due to the potential limitations of the 380 Assessment. Such limitations underscore the importance of knowing the 381 athlete and the subtle deficits in their personality and behaviors that can 382 occur with concussive injury. 383 The signs and symptoms of concussion listed above (Section I, C and D), 384 although frequently observed or reported, are not an exhaustive list. The 385 NFL Locker Room Comprehensive Concussion Assessment is intended to 386 capture these elements in a standardized format. The neurocognitive 387 assessment in the NFL Locker Room Comprehensive Concussion 388 Assessment is brief and does not replace a more comprehensive 389 neurological evaluation or more formal neurocognitive testing. The
390 modified Balance Error Scoring System (mBESS) is an important 391 component of the NFL Locker Room Comprehensive Concussion 392 Assessment and has been validated as a useful adjunct in assessing 393 concussive injury. 394 3. Medical Time-Out 395 In the event the Booth ATC Spotter: (i) has clear visual evidence that a player 396 displays obvious signs of disorientation, is clearly unstable, or displays other 397 obvious sign of concussion; or (ii) is notified by the Booth UNC that the Booth 398 UNC has requested that a sideline evaluation be conducted; and (iii) it becomes 399 apparent that the player will remain in the game and not be attended to by the 400 Club’s medical or athletic training staff, then the Booth ATC Spotter will take 401 the following steps: 402 403 1. If the player does not receive immediate medical attention, the Booth 404 ATC Spotter will contact the Side Judge over the Official-to-Official 405 communication system to identify the player by his team and jersey 406 number. The exact wording is “MEDICAL TIME OUT” repeated three 407 times. The ATC-Spotter will confirm this at the 60 - minute meeting. If 408 the referee does not respond, the ATC-Spotter shall call the Field 409 Communicator (“teal hat”). 410 2. The Booth ATC Spotter will contact the medical staff of the player 411 involved and advise them the player appears to need medical attention. 412 3. The Booth ATC Spotter shall remain in contact with the medical staff 413 until the medical staff confirms that a concussion evaluation has 414 occurred or is underway. It is the Booth ATC Spotter’s responsibility 415 to confirm that a concussion evaluation has occurred prior to the player 416 returning to play. As detailed above, if a Booth ATC Spotter observes 417 a player returning to the game without receiving express confirmation 418 that an evaluation has occurred, the Booth ATC Spotter shall signal to 419 the official for a Medical Time-Out. 420 421 Upon being called by the Booth ATC Spotter, the Side Judge will immediately 422 stop the game, go to the player in question, and await the arrival of the Club’s 423 medical personnel to ensure that the player is attended to and escorted off the 424 field. The game and play clock will stop (if running) and remain frozen until 425 the player is removed from the game. Both clocks will start again from the same 426 point unless the play clock was inside 10 seconds, in which case it will be reset 427 to 10 seconds. The Club of the player being removed will have an opportunity 428 to replace him with a substitute, and the opponent will have an opportunity to 429 match up as necessary. No communication via coach-to-player headsets will 430 be permitted during the stoppage; no member of the coaching staff may enter 431 the playing field; and no player other than the player receiving medical attention 432 may go to the sideline unless a substitute player has replaced him. 433
474 i. The results of subsequent exams by the Club physician should be 475 communicated to the sideline UNC in the spirit of “concussion team” 476 cooperation and patient safety, especially if the sideline UNC is not 477 immediately present. 478 ii. Should the sideline examination reveal a change in the player’s condition, 479 the Club physician/sideline UNC team will be re-assembled and perform 480 subsequent locker room evaluation. 481 iii. It is important to recognize that players may be able to equal or exceed their 482 performance on the Locker Room Comprehensive Concussion Assessment 483 compared to their baseline level yet still have a concussion, underscoring the 484 importance of the physicians’ knowledge of the player. If there is any doubt 485 about the presence of a concussion, regardless of the Locker Room 486 Comprehensive Concussion Assessment results, the player is to be removed 487 from practice or play. A player diagnosed with concussion will be given “take 488 home” information (e.g. signs and symptoms to watch for, emergency phone 489 numbers) as well as follow up instructions. 490 iv. All players who undergo any concussion evaluation on game day shall have a 491 follow up concussion evaluation done the following day by a member of the 492 Club medical staff. This includes players with both a “positive” and a 493 “negative” initial game-day assessment. The follow up exam should ideally 494 be performed by the same physician who saw the patient on game day, but this 495 may not always be possible. If not, then another member of the Club’s medical 496 staff may see the patient, who should coordinate their findings with the initial 497 examining physician. 498 At a minimum, the follow up exam should consist of: a) focused neurological 499 examination, and b) complete symptom checklist. If symptoms and/or 500 neurological examination are abnormal when compared to baseline, the 501 Locker Room Concussion Evaluation should be performed. 502 v. A player diagnosed with concussion should not operate a motor vehicle on the 503 day of injury. Athletes may return to drive on a subsequent day based on the 504 advice of team medical staff. 505 506 III. NFL Concussion Game Day Checklist 507 The NFL Concussion Game Day Checklist is intended to provide a clear summary of the steps 508 required by NFL Head, Neck and Spine Committee’s Concussion Diagnosis and Management 509 Protocol, with regard both to Sideline Survey and the Locker Room Exam. The NFL Concussion 510 Game Day Checklist (Attachment C) is incorporated herein by reference. The application of the NFL 511 Concussion Game Day Checklist to evaluate potential concussions during NFL preseason and regular 512 season games is mandatory. Designated medical personnel (Club physicians and athletic trainers, 513 sideline and Booth UNCs, and Booth ATC Spotters must complete their designated steps in the NFL 514 Concussion Game Day Checklist and record the same using the designated technology. A Club 515 medical team’s failure to properly apply the NFL Concussion Checklist may subject their Club to 516 discipline.
517 IV. Return to Participation Protocol 518 Introduction 519 Each player and each concussion is unique. Therefore, there is no set timeframe for return to 520 participation or for the progression through the steps of the graduated exertion program set forth 521 below. Recovery time will vary from player to player. The decision to return a player (hereinafter 522 referred to as the “player-patient”), to participation remains within the professional judgment of 523 the Head Club Physician or Club physician designated for concussion evaluation and treatment, 524 performed in accordance with these Protocols. 525 All return to full participation decisions are to be confirmed by the Independent Neurological 526 Consultant (INC).The INC is an impartial and independent neurotrauma physician, and must be 527 board certified or board eligible in neurology, neurological surgery, emergency medicine, physical 528 medicine and rehabilitation, or any primary care CAQ sports medicine certified physician and has 529 documented competence and experience in the treatment of acute head injuries). Each Club must 530 designate at least one INC at the start of the League Year, which must be approved by the NFL 531 Chief Medical Officer and NFLPA Medical Director. For the avoidance of doubt, a UNC may 532 also serve as an INC. Neither a UNC nor an INC may have any affiliation with an NFL team. The 533 role of the INC is described below (see Section IV). 534 535 The INC should be informed when a concussion occurs and, if (s)he was not serving as the UNC 536 who observed the initial diagnosis on the field, should examine the player as soon as possible 537 following diagnosis and should be updated throughout the process to facilitate the clearance 538 process at the final Phase of the Return to Participation (RTP) protocol. The Club physician may 539 consult with the INC as often as desired during the concussion recovery period. The INC will be 540 consulted specifically to answer the question of the player-patient’s neurological health and his 541 full return to competitive participation (see Phase 5 below). The final clearance for return to play 542 is a decision made by the Club’s medical staff and must be confirmed by the INC. 543 After a player-patient has been diagnosed with a concussion, he must be monitored daily, or more 544 frequently if clinically indicated in the opinion of the Club physician, through the Return-to- 545 Participation Protocol (described below). Team medical staff should consider the player-patient’s 546 current concussive injury, including an in-depth consideration of past exposures, medical history, 547 family history, and future risk in managing the player-patient’s care. 548 After having been diagnosed with a concussion, the player-patient must progress through the 549 following protocol to return to participation. A player-patient may proceed to the next Phase in 550 the protocol only after he has demonstrated tolerance of all activities in his current Phase without 551 recurrence of signs or symptoms of concussion being observed or reported. Should the activities 552 of any Phase trigger recurrence of signs or symptoms of concussion, those activities should be 553 discontinued and the player-patient returned to the prior Phase in the protocol. The player-patient 554 must remain at his pre-concussion baseline level of signs and symptoms during the exertion itself, 555 as well as for a reasonable period of time afterward. What constitutes a reasonable amount of time 556 shall be determined on a case-by-case basis by the Club physician. Depending on the severity of (^557) the concussion and the time required for return to baseline, the progression through the steps may
595 Two, it should be administered during Phase Three. If a player-patient’s initial neurocognitive testing 596 is not interpreted as back to baseline by the NPC, the tests will be repeated at a time interval agreed 597 upon by the Club physician and NPC (typically 48 hours). The player-patient should not proceed to 598 contact activities until their neurocognitive testing is interpreted as back to their baseline level by the 599 NPC or, if a decrement is still present, until the Club physician has determined a non-concussion 600 related cause. The determination of when to proceed with contact activities is ultimately made by the 601 Club physician. 602 Once the player-patient has demonstrated his ability to engage in cardiovascular exercise and 603 supervised strength training without an increase or aggravation of signs or symptoms, he may proceed 604 to the next Phase. 605 Phase Four: Club-based Non-contact Training Drills 606 The player-patient may continue cardiovascular conditioning, strength and balance training, team- 607 based sport-specific exercise, and participate in non-contact football activities such as throwing, 608 catching, running and other position-specific activities, progressing to participation in non-contact 609 team practice activities To be clear, all activities at this Phase remain non-contact (i.e.., no contact 610 with other players or objects, such as tackling dummies or sleds). 611 If the player-patient is able to tolerate all football specific activity without a recurrence of signs or 612 symptoms of concussion and his neurocognitive testing has returned to baseline, he may be moved to 613 the next Phase in the sequence. For clarity; all signs, symptoms, and neurological examination 614 (including neurocognitive testing and balance testing) must return to baseline status before returning 615 to full football activity/clearance. Exceptions to the neurocognitive component may be considered by 616 the Club physician responsible for the diagnosis and treatment of concussion (in consultation with the 617 NPC) on a case-by-case basis in player-patients with documented ADHD or learning disabilities. 618 Phase Five: Full Football Activity/Clearance 619 After the player-patient has established his ability to participate in non-contact football activity 620 including team meetings, conditioning and non-contact practice without recurrence of signs and 621 symptoms and his neurocognitive testing is back to baseline, the Club physician may clear him for 622 full football activity involving contact in practice. If the player-patient tolerates full participation 623 practice and contact without signs or symptoms and the Club physician concludes that the player- 624 patient’s concussion has resolved, s/he may clear the player-patient to return to participation. For the 625 avoidance of doubt, if a player-patient cannot participate in practice or full contact with other players 626 due to the time of year and/or rules imposed by the Collective Bargaining Agreement, simulated 627 contact activity will suffice to satisfy this Phase. Upon clearance by the Club physician, the player- 628 patient must be examined by the INC assigned to his Club. The INC must be provided a copy of all 629 relevant reports and tests, including the sideline and booth UNC reports, the Booth ATC Spotter 630 report and team injury reports, and have access to video of the injury, where applicable, and the 631 player-patient’s neurocognitive test results and interpretations. If the INC confirms the Club 632 physician’s conclusion that the player-patient’s concussion has resolved, the player-patient is 633 considered cleared and may participate in his Club’s next game or practice.
634 Table 1. An Example of a Graduated Exertion Protocol*^ # Phases Activity Objective
- Symptom Limited Activity Routine daily activities as tolerated, with the introduction of light aerobic activity (e.g., 10 minutes on a stationary bike or treadmill with light to resistance supervised by the team’s athletic trainer. Recovery and light cardiovascular challenge to determine if concussion signs or symptoms are provoked
- Aerobic Exercise ≥ 20 minutes on a stationary bike or treadmill with moderate to strenuous resistance supervised by the team’s athletic trainer. Duration and intensity of the aerobic exercise can be gradually increased over time if no aggravation of symptoms or signs return during or after the exercise. Strenuous cardiovascular challenge to determine if there are any recurrent concussion signs or symptoms.
- Football Specific Exercise With continued supervision by the athletic trainer, introduction of non-contact sport specific conditioning drills (e.g., changing direction drills, cone drills). Introduction of strength training supervised by the athletic trainer. Add strength training and more complex movements to determine if there are any aggravation of concussion signs or symptoms.
- Club-based Non-contact Training Drills Participation in all non-contact activities for the typical duration of a full practice. Increasing football specific demands to determine if there is any aggravation concussion signs or symptoms. Add the cognitive engaging in football drills.
