Under the blue tent: How the NFL's concussion protocol went from a 'joke' to the gold standard

Richard Sherman once called it “an absolute joke.” Chris Nowinski, a prominent expert, called it “a fraud.”

Throughout its first decade of existence, the NFL’s concussion protocol quickly became a lightweight punching bag. Players, pundits and MDs ripped it to shreds. They branded it futile and faulty. And not even four years ago, in a single 32-day span, a barrage of blatant examples supported their claims.

First there was Russell Wilson, appearing to bypass the protocol altogether.

Then there was Jacoby Brissett, clutching his helmet after a concussive hit, but never missing an offensive play.

And finally, in December 2017, there was Tom Savage.

Nowinski, the co-founder and CEO of the Concussion Legacy Foundation, remembers it vividly. He remembers the Houston Texans quarterback being slammed to the turf and seizing up. An evaluation later confirmed the obvious: Savage was concussed. But first, he returned to the game.

Nowinski recalled all this in a recent interview in part because nowadays, he said, “obvious mistakes” like it are “rare.”

In fact, according to interviews with a variety of doctors and brain trauma experts, the same protocols that were for decades either nonexistent or ridiculed have become the closest thing American sports have to a gold standard.

“They don't have the best history,” Steven Broglio, director of the Michigan Concussion Center, said of the NFL. “But I think they, more than anybody, have contributed the most to moving the field forward.”

“Each year, they’ve learned and gotten better,” Nowinski said. “They've closed a lot of the gaps in the system.”

Thom Mayer, the NFLPA’s longtime medical director, is pleased as well. “I feel good about it,” he said of the current protocol.

They all acknowledged, of course, that protocols can do only so much. Protocols rely on humans, including players who are incentivized and able to fake their way through sideline evaluations. Protocols also don’t prevent concussions; they merely mitigate some risk associated with concussions. Football is still a dangerous game. It always will be. No protocol can eliminate the harm it inflicts.

But the impossibility of “safe” won’t stop doctors from striving for “safer.” And protocols are part of that push.

The NFL’s, in one sense, are distinct, and experts don’t see them as copy-and-pastable. They implicitly accept risk that not everybody should accept. There are aspects, Nowinski said, that “only make sense in a professional sports league where the players are getting paid.”

There are other aspects, though, that are part of a blueprint. Beneath the surface, within the process, said Jay Clugston, a concussion researcher and University of Florida team physician, “there are a lot of things that other sports organizations could emulate.”

Putting players’ interests first

Ten years ago, when the NFL and NFLPA signed off on a 300-plus-page collective bargaining agreement, the word “concussion” appeared just six times. Its scarcity reflected a startling contradiction: For decades, NFL players had very little say in how their brain injuries were treated. An untold number were downplayed or covered up as the league denied the increasingly obvious links between brain trauma and lasting health problems.

But it was around the time of those CBA negotiations that the players and their doctors pushed for a stronger voice. According to Mayer, the NFLPA medical chief, “despite what you might hear from the league, the genesis of the protocols came from the NFLPA, not from the NFL.”

“To be blunt,” Mayer continued, “there was a lot of pushback.” The NFL, he said, felt protocols were unnecessary. The league eventually gave in. Mayer said he co-wrote the original protocols with NFLPA legal exec Sean Sansiveri.

Ever since, the players have had input. The word “concussion” or some form of it appears 189 times in the 2020 CBA. The entire protocol and enforcement mechanisms are now included. The NFLPA is involved in every investigation of protocol failures, and every update that has strengthened them.

And that’s important, experts agree, because concussion protocols don’t serve a league or a sports organization; they serve athletes. They should, in short, be designed to optimize outcomes for players.

The difficulty, then, is in answering two questions: What, exactly, is best for players? And who should decide that?

The unsophisticated answers are “safety” and “the players themselves.” But “best” and “safest” aren’t synonyms. If the sole concern were safety, football would go extinct. Millions of people play it nonetheless. NFL players take on risks, sacrificing safety for various benefits, including paychecks. Some established players enjoy what Herm Edwards once called the “luxury of safety.” Most, though, don’t, because a cutthroat league considers them replaceable. Missing downs, never mind games, jeopardizes careers. So that isn’t a “best” outcome either.

The answer requires what Nowinski calls “tradeoffs,” between thorough concussion evaluations and the urgency of returning to play. What’s best for players is an individualized balance between safety and football, between long-term brain health and short-term ambitions. The concern among doctors is that 23-year-old men, under immense professional pressure, aren’t capable of finding this balance. Some players would readily play through concussions. Some, Nowinski said, “think that being held out when they don't have a concussion is worse than playing with a concussion.” Some have admitted to Mayer: “Doc, sometimes you have to protect us from ourselves.”

The conclusion, especially at the professional level, is that player input matters, but science must guide it. Doctors like Mayer, who “represent[s] the interests of 2,500 active players, their wives, their kids, and their families,” must distill a vast range of circumstances and priorities, find some sort of aggregate balance, and design protocols to meet it.

Under the blue tent

In 2016, the world’s most respected brain injury experts met to update their Sport Concussion Assessment Tool, a standardized and widely used framework for evaluations. Dubbed SCAT5, it specifies that it “cannot be performed correctly in less than 10 minutes.” Indeed, it’s “generally accepted,” Nowinski confirmed, that a thorough evaluation takes “at least 10 minutes.”

So why don’t the NFL’s? Why is the only requirement that they not last “less than one play”?

Because that 10-minute minimum, doctors said, is often misunderstood. It’s a rough guideline, not a black-and-white dividing line. The amount of time required to diagnose a concussion varies. Similarly, a specific amount of time required to completely rule out a concussion does not exist because symptoms can appear hours after the concussive blow.

Instead, safety and risk exist on a spectrum. The more thorough an evaluation, the more likely an accurate diagnosis. “I mean, we could spend an hour doing different incremental pieces of exam on the sideline,” Mayer said. But, he and others explained, there are “diminishing returns.” Minutes 15-30, or 30-60, would add little to a doctor’s evaluative capabilities. They would, meanwhile, take large chunks of a football game away from the player.

So the NFL and NFLPA have negotiated a happy medium that most experts in the field find reasonable. Team physicians and “unaffiliated neurotrauma consultants” (UNCs) stand on either sideline searching for observable signs of concussion. If they see one, the team doctor and the independent UNC take the player’s helmet and lead him to a blue sideline tent.

If they observe one of a few “no-go” signs — loss of consciousness, Gross Motor Instability, confusion or amnesia — no evaluation is necessary. The player is diagnosed with a concussion and ruled out for the game.

Otherwise, in the blue tent, the team physician leads a brief assessment. He or she asks the player what happened on the play, then asks about symptoms, then asks “Maddocks Questions”: Where are we? Which quarter is it? Which team scored last? Who did you play last week? Did you win?

Meanwhile, another UNC stationed upstairs in a booth reviews video of the play, scrutinizing it for “no-go” signs, and can communicate with the team physician or on-field UNC.

In the tent, doctors are also supposed to examine the player’s spine, gait, speech and eyes. If any aspects of the screening test raise red flags, back to the locker room they go for a more complete assessment similar to the SCAT5. If there are no red flags, and if both the team physician and UNC are confident that the player isn’t concussed, they can clear him to return — as long as they monitor him throughout the rest of the game.

The UNCs are the NFL’s major innovation. Experts who spoke with Yahoo Sports universally praised their involvement. While a team physician or athletic trainer can use familiarity with players to recognize when “something is off,” the UNC, in theory, controls for unconscious bias or pressure to allow a player to return to a game. Technically, per protocol, the team physician has final say; UNCs can be overruled. But one experienced doctor who has worked as a UNC at NFL games — and who requested anonymity because “the NFL can be very difficult to deal with if they don't like something you say” — told Yahoo Sports that he and team physicians “never disagreed about which direction to go in.” And he indeed felt empowered to give his opinion. UNCs in other NFL markets had similar experiences.

“It's comforting to have so much help, and have some outside opinions,” said Clugston, the University of Florida doctor, who doesn’t get that benefit in the college ranks. “I think your chances of getting to the truth are even better when you have that balance. As a team physician, I would welcome that. And what I'm hearing around the NFL, most people do.”

UNCs were introduced in 2013. The additional “Booth UNC” was added in late 2017. In a 2020 published study, NFL doctors and other affiliated researchers found that “the UNC program has enhanced the detection of concussion.” It’s an example, Mayer said, of how the protocols constantly evolve, often in response to incidents, such as the Savage play, that expose shortcomings.

And that’s one reason Mayer is pleased. He knows the protocols will never be perfect. He knows they’re debatable. Some doctors question the length of evaluations, and the lack of a “delayed recall” component to test short-term memory. Nowinski questioned the blue tent, and its proximity to the sideline, and how that can pull a player back toward the field.

Others question whether a large majority of players still conceal symptoms. Mayer remembered speaking with a second-year defensive back who’d suffered a concussion in 2019. “I shouldn't be in the protocol, all I got's a headache, I’m fine,” the player told him. Mayer acknowledged that, in the heat of the moment, some players would prefer to have concussions go undiagnosed.

Most, he said, are increasingly educated. He said that, over the past three years, “fully 50% of concussions had some element of player reporting” — either self-reporting of symptoms, or one teammate telling a doctor that another wasn’t right.

And most of all, Mayer is pleased with how the NFL has gotten to this point — with “significant,” medically-informed player input.

One size doesn’t fit all

What Nowinski worries is that the end product, the protocols that are widely published and enacted on Sundays, will become gospel. That “the rest of the world,” especially youth football coaches and players, will internalize them as best practices rather than talk about them as “safety tradeoffs.” That others will simply adopt the NFL’s risk-reward balance rather than create their own.

“There's general consensus, you can't rule out a concussion in five minutes,” Nowinski said. The NFL and its players, through collective bargaining, have decided they’re comfortable with shorter evaluations anyway. The NFL, in this sense, “is not necessarily the best example for the rest of sports,” Nowinski said. A 12-year-old shouldn’t be sent back into a game after a two-minute evaluation, like Davante Adams is. The 12-year-old’s risks and rewards are different. His salary and his career don’t depend on his participation. His future depends far more on the health of his brain. And his league doesn’t have the resources to review every play on video, or to streamline an evaluation through the hands of multiple experts.

The return-to-play considerations at amateur levels, Nowinski and others said, should be much more careful and conservative.

But the NFL is an example in how it reached its end product. “They follow the same science that we all follow,” Clugston said. They married it with players’ best interests. They formalized protocols and punishments for violators. They meet with everyone involved in administering the protocols before every season and every game. UNCs document every evaluation in writing.

They are, like any sports organization, ultimately at the mercy of individual judgement. And if they’ve created a blueprint, “it may have to be modified in kids sports, and different types of sports,” the veteran UNC said.

But, said Broglio, the Michigan neuroscientist, the NFL “has done a lot of things that other organizations have ... maybe not been able to do for financial reasons, or are just unwilling to do.”