Understanding the Concussion Protocol, From Little League to the NFL

You’re watching your favorite team, and the quarterback is looking woozy on the sidelines after taking a sack. That UFC fighter you had your money on is out cold after taking a blow to the head. You’re cheering on your kid when a wild pitch strikes them right on the noggin. And they’re not getting up fast.

Concussions are a scary fact of life in sports. Changes to rules and advancements in protective equipment, like helmets and mouthguards, have made a difference. But you can’t rely on them to keep athletes 100% safe all the time.

That’s where the concussion protocol comes in.

What exactly is the concussion protocol? And how does it affect athletes of all ages?

We talked with concussion specialist and sports medicine physician Richard Figler, MD, to find out.

What is the concussion protocol?

The Concussion in Sports Group, a collective of sports medicine researchers and physicians throughout the world, developed and refined the consensus statement on concussion in sport, commonly known as the “concussion protocol.” Concussions aren’t limited to sports. But the concussion protocol is most often associated with sports-related head injuries.

The concussion protocol is a kind of roadmap for identifying and treating concussions in athletes. It’s a guide that can allow everyone — parents, coaches, athletic trainers, healthcare providers and others — to identify and initiate care for athletes with suspected or diagnosed concussions.

The goal: To protect athletes at all levels from the debilitating effects of concussions.

“Creating the consensus statement on concussion is a pretty arduous process,” Dr. Figler notes. “They delve into the latest literature and look at trends. The result is a comprehensive guide for everything from the diagnosis and initial management of the concussion on the sidelines to returning to play and all the steps in between.”

Dr. Figler walks us through some of the highlights of the concussion protocol.

1. Recognizing concussions

Anyone who has taken a hit to the head and doesn’t feel like their normal self should be evaluated for concussion.

Step one in the concussion protocol is evaluating the injury so you know what you’re dealing with. When an athlete sustains a head injury, concussion protocol dictates they be removed from the game and undergo an evaluation, which includes a variety of concussion tests.

Evaluating a concussion on the sidelines is a dedicated process in and of itself. But in broad strokes, an athletic trainer or similar person knowledgeable about concussion symptoms will look at things like:

• If you have common signs or symptoms of a concussion, like headache, dizziness, balance problems, light or noise sensitivity, confusion or just not feeling right (to name a few).
• If you know the current date and year.
• If you can memorize a list of words or serial numbers and repeat them back.
• If your balance is affected.
• If your pupils respond appropriately to light and your eyes respond appropriately to other specific testing.
• If you’re showing signs or symptoms of perhaps a more serious concussive injury, like neck pain, loss of consciousness or deteriorating consciousness, seizures, numbness, tingling, repetitive vomiting, agitation or other changes in mood, and more.

The importance of concussion tests being performed by a trained professional can’t be overstated. It takes a knowledgeable eye to spot the subtle signs of a potential concussion. And some signs may not be apparent initially to people who aren’t familiar with concussions. Awareness of these signs and symptoms — which can evolve over minutes to days — can help identify concussions earlier.

What’s more, that initial blow can leave an athlete at risk for second impact syndrome — a rare but serious brain injury that can result from a subsequent injury.

“If an athlete is hit in the head and allowed to return while they have yet to recover, their threshold for another injury is lowered and second subsequent impact can cause a loss of autoregulatory control of their brain function and their internal pressure systems,” Dr. Figler shares. “Although this can be catastrophic, it is rare and we feel avoidable with appropriate recognition of the concussion, removal from play and appropriate treatment.”

Concussion protocol suggests that if an athlete takes a blow to the head, it should be treated as a concussion until proven otherwise.

“The best advice is when in doubt, sit them out,” he states. That means erring on the side of caution. Remove anyone who may have sustained a concussion from the field of play. And seek medical attention for a full concussion evaluation.

2. Relative rest

You may have heard that old advice that you shouldn’t let a person with a concussion sleep. That advice is more than a tad inflated.

“The idea is that you want to watch out for a person who has a concussion and is passing out, losing consciousness or can’t stay awake,” Dr. Figler clarifies. “Not that you want to keep them from sleeping altogether.”

So, yes, concussion protocol allows people to sleep naturally. Sleep is important, after all, for healing their brain and for their overall health.

But strict bedrest following a concussion isn’t recommended. People who have experienced a concussion should limit their activities — particularly ones that put them at risk for further injury — but going about their daily activities is encouraged.

“The term ‘cocooning’ has been used before, where people with a concussion were encouraged to go to a dark room and stay there until they got better,” he adds. “What we found is people who get cocooned take an awful lot longer to get better than the people that start to do some activity — relative rest is key.”

That includes both the physical demands of daily life and keeping up their social relationships.

Physical activity

Physically recovering from a concussion is a matter of finding the right level of activity.

Think of it like recovering from something like a hip replacement. Back in the day, people who had joint surgery were immobilized for extended periods of time to recover. But these days, they’re encouraged to start moving quickly. That’s because movement allows your body to heal faster than sitting around and allowing lethargy to take hold.

“It’s a kind of Goldilocks scenario,” Dr. Figler illustrates. “You want to stimulate your brain to encourage the tissue to heal, but not overstimulate it to the point of aggravating the injury.”

Relative rest as it relates to concussion protocol suggests allowing an athlete to participate in daily life to a point, but not so much that it starts to exacerbate their symptoms beyond a mild increase.

“The studies have shown that absolute rest is counterproductive to healing,” Dr. Figler echoes. “Blood flow helps, for lack of a better term, to ‘flush out’ the brain. Studies show that after the first 24 to 48 hours, light physical activities like walking or stationary biking that do not increase symptoms more than just mildly, aid in a quicker recovery. But it’s important to pace yourself and not push through symptoms during recovery. This is definitely not ‘no pain, no gain’ time.”

Mental recovery

Recovering from a concussion can feel isolating. That’s particularly true for younger athletes whose relationships outside of their families tend to revolve around their teammates and their school lives.

Being away from their regular activities and people who are important to them can take a toll mentally and remove a needed network of support.

So, kids with concussions are encouraged to get back to school when they’re up for it. And to keep in contact with their support system.

“Electronics probably stimulate the brain more than we realize. And that stimulation can add extra stress to the brain, which can delay recovery,” Dr. Figler says. “But there’s a large mental health component to young athletes being able to connect with their team and their friends via electronics, like texting and social media. If you take their device away from them, it can cause a lot of emotional stress, which doesn’t help the brain to heal. The best data suggests that reducing screen time in the first 48 hours is reasonable but may not be too effective after that. Let symptoms during activities help guide when they are ready.”

Just as with physical activity, finding the sweet spot between too much and too little connectivity is important for helping athletes recover mentally from a concussion.

3. Gradual return to sport

The concussion protocol provides a framework for allowing athletes to gradually work their way back to the field. How long that takes and the exact steps involved in that return vary greatly depending on factors like the severity of the injury, how well they’re tolerating activity and whether this is their first concussion or a subsequent one.

“We take a stepwise return to play. That means allowing the athlete to do a little bit of exercise, then do a little more exercise and move up the intensity of activities until they can eventually do practice, then move to contact practice and, eventually, gameplay,” Dr. Figler reports. “We progress them along, gradually increasing activity and always monitoring any changes in symptoms.”

Vigilance is key because an athlete may not feel any symptoms as they go about their day, but they could pop up during physical activity.

Importantly, concussion protocol mandates that athletes don’t begin any contact activities until they’ve been fully cleared of concussion symptoms.

Concussion protocol: Kids and adults

The concussion protocol covers everyone from flag football to the pros. And any signs of a concussion should be cause for concern in anyone.

But there are some differences in how concussions are handled that take into account all that’s at stake with athletes at different levels of maturity.

Let’s take a look.

NFL concussion protocol

The NFL’s concussion protocol, like other professional sports, follows much of the same general guidelines as the Concussion in Sports Group’s guidelines.

The steps include:

1. Limited physical activity.
2. Aerobic exercise.
3. Football-specific exercise.
4. Training drills.
5. Full football activity.

The difference is that elite athletes, like pro football players, have access to 24/7 medical care. There are team physicians who can evaluate them at the drop of a hat. Athletic trainers who have deep experience with concussion protocol and concussion treatment. Physical therapists who can help with resultant neck pain from injury. Neurologists who come to them.

So, while professional and college-level athletes follow the same steps as other athletes, their progress isn’t likely to be held up while waiting for their doctor’s appointments.

Concussion protocol for kids

Kids sports leagues follow the same steps as the Concussion in Sports Group’s guidelines and the NFL, but you may see some differences in language. The U.S. Centers for Disease Control and Prevention (CDC) state the following steps in concussion protocol for kids returning to sports:

1. Regular activity (non-sport).
2. Light aerobic activity.
3. Moderate activity.
4. Heavy, non-contact activity.
5. Practice and full contact.
6. Competition.

Dr. Figler shares that because kids’ brains are still growing and developing, concussions can be even more damaging for them than for adults.

“When you’re developing your brain, you want to protect it as much as possible from repetitive hits,” he emphasizes. “In some ways, a younger brain has a lot more to lose than an older brain.”

What’s more, studies show that kids’ brains can take longer to heal.

For those reasons and others, concussion protocol for kids tends to be more conservative and may take longer than in adults. In no case should an athlete with a concussion return to play without proper time, treatment and a full recovery. But in kids, the threshold for removing them from games and keeping them off the field is lower.

How long is concussion protocol?

There isn’t a definitive timeline for how long a player will be out on concussion protocol.

“In general, with younger athletes, as long as we treat them appropriately, they’ll most likely return to play completely within about two to three weeks. But there are times when it takes a lot longer,” Dr. Figler says.

In comparison, nine days is the median number of days for NFL players to be cleared to return.

But how long it takes before an athlete returns to competition depends on a few factors.

The severity of the injury can affect their timeline for returning to play. Getting the proper amount of mental and physical activity (not too much, not too little) can impact how quickly they improve, too. And, again, kids tend to stay out of play longer than the pros, both because of the way concussions affect children and because pro athletes have quicker access to medical care.

Identifying and treating other problems that occur from the injury and can prolong recovery — like neck pain with physical therapy or mental health issues with qualified mental health professionals — are vital to assisting a complete recovery.

Bottom line

Concussions are a real threat to athletes of all ages. But the benefits of participating in physical activity can outweigh the risks.

“Athletic activity is good for us, both physically and mentally,” Dr. Figler states. “We want to protect athletes, but you can’t put them in a bubble. Risk reduction makes a difference.”

Rules that reduce the risk of concussion matter. Protective, properly fitting equipment matters. Learning to play the game properly matters. So does recognizing the symptoms of concussion and knowing your limits.

Remember: If you suspect it’s a concussion, assume it’s a concussion. Get treatment and follow your provider’s advice. Your brain will thank you for it.