An overview of concussion protocols across professional sports leagues

Wednesday, 05 November 2014

Governing bodies and sports leagues have a heightened awareness the risk poised to athletes from head trauma sustained in the participation of their sport following the NFL concussion litigation¹. This article looks at key regulatory and educational approaches taken by Premiership Rugby, Premier League, NFL, NHL, MLB and NBA to tackle the risk of concussion in their sport.

It is the intention of the authors that this article will to provide greater clarity as to how sport as a community is addressing this important issue.

Given the vast amount of work that the leagues cited above have undertaken we have decided to focus on the following key areas:

Baseline testing (used to assess an athlete’s balance and brain function²),
Education programmes,
Assessment protocols during competitions,
Decision making with regards to players returning to the field of play;
Concussion rate of each sport.

We welcome any comments and feedback; it is through sharing information that we hope we can improve awareness and understanding of this issue and share best practices.

English Premiership Rugby - click here for IRB protocols|closed

Premiership Rugby has adopted the International Rugby Board’s (IRB) Head Injury Assessment (HIA) process, which was formerly called the Pitch Side Concussion Assessment process (PSCA).³ The governing regulation on concussions is the IRB’s Regulation 10.⁴

Baseline Testing

Pre-season cognitive testing is conducted, but there is a concern as, with all baseline testing of this nature, that players may view the baseline testing as an obstacle in their way for getting back playing, and may therefore intentionally score low on the baseline testing to help them hide symptoms of concussion following a head injury. ⁵

Education Programme

As of October 2014, all Premiership players, coaches, and referees must complete an online concussion awareness module as part of a joint effort by the Premiership Rugby, Rugby Football Union (RFU) and Rugby Players Association to raise the level of awareness and understanding of concussion issues.⁶ The module must be completed by 11 December 2014, under penalty of an automatic fine. Further, players and coaches may be made ineligible to play or coach until such time as they have completed it.⁷

Assessment Protocol

Either the team doctor or the match day doctor (MDD - whose role is described below) is allowed ten minutes for HIA to determine whether the player has a suspected concussion (see the IRB’s Head Injury Assessment Tool⁸). The staff also has access to video replays of the incident to aid their decision.⁹ A temporary substitution allows for play to resume while the player is being assessed (however, the temporary substitute may not take a penalty kick for goal or conversion).

The player will be allowed to immediately return to play only if the HIA and neurological assessment is declared negative. Any player with a positive HIA is not allowed to return to play.¹⁰

Any player suspected of having a concussion or diagnosed with a concussion will be permanently removed from the pitch.¹¹ Every player who is permanently removed from the pitch must undergo testing (specifically, the internationally-recognised SCAT3 testing, developed by the Concussion in Sport group).¹²

Every concussion case is “independently reviewed to assess and advise the on-field management of these incidents” by two doctors with extensive experience in rugby.

Who makes the decision on when player returns to participation?

The initial decision lies with the team doctor, however the MDD has the authority to overrule the team doctor and prevent an injured player from further participation as per the IRB Regulations 15.2.1 (d).¹³ The MDD is responsible for coordinating medical services, supporting the team doctor with injured players if necessary, observing the HIA process or delivering the HIA process if assigned that role by the team doctor, and enforcing permanent removal from play if necessary.¹⁴

Whenever a player is diagnosed with a concussion, he is prohibited from competing in a match or participating in training for a minimum of three weeks, and may only return to play after he is symptom-free. However, the three-week timetable may be reduced if the player is cleared by a “properly qualified and recognised neurological specialist.”¹⁵

Concussion rate

One for every 7.6 games played (2012/13)¹⁶

Major League Baseball (MLB) - click here for MLB protocols|closed

MLB implemented a new concussion policy in March 2011. The regulations governing concussions can be found in Attachment 36 of the Basic Agreement.¹⁷

In addition, for the 2014 season, MLB and the Major League Baseball Players Association (MLBPA) agreed to a one-year test of a rule limiting home plate collisions, in part to try to reduce the increasing number of concussions suffered by catchers.¹⁸

Baseline testing

Baseline neurological testing is required for all players during spring training, or when a player joins a new team.¹⁹ The baseline evaluation consists of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) program.

Education programme

The league and the MLBPA jointly “creat[ed] and distribut[ed] educational materials for Players on the assessment and management of concussions, including a Concussion Information Sheet and a joint memorandum.”²⁰ There are also training and educations sessions for club personnel “throughout the course of the season and during the off-season.”²¹

The league also works with national organisations to advise club personnel of “concussion-related continuing education sessions.”²²

Additionally, in July 2014, MLB used its annual All-Star Game as a platform to educate youth baseball players about head injuries and the importance of wearing a batting helmet.²³

Assessment Protocol

When a player is suspected of having a concussion, he must undergo SCAT testing, which will be performed in the clubhouse by the team physician or certified athletic trainer.²⁴

When a player is diagnosed with a concussion, he goes on the concussion-specific seven-day disabled list, meaning that he must sit out for at least seven days. According to the league, the concussion-specific disabled list “[allows] concussions to clear, prevent[s] players from returning prematurely and give[s] clubs a full complement of players in one's absence."²⁵

Who makes the decision on when player returns to participation?

The final decision lies with the league’s medical director and the MLBPA’s concussion expert.²⁶ In the event that the medical director and the MLBPA’s expert cannot agree on whether the player should be returned to play, they will refer the matter to an independent expert, who will make the final decision.²⁷

The player’s club must submit a “Return to Play” form to the league’s medical director. As explained by Stephania Bell, a clinical orthopaedic specialist and ESPN’s injury analyst, “in that form, the club's head physician must establish that:

all symptoms at rest and with exertion (including baseball-related activities) have cleared ,
ImPACT results have returned to baseline , and
the club physician, in his or her judgment, feels it is safe for the player to return to competition.”²⁸

“The medical director then has the right to request further documentation or consultation with other physicians before providing final clearance. Similar return-to-field criteria will be required for umpires.”²⁹

“Additionally, each club is required to designate an MTBI (mild traumatic brain injury) specialist, who is not one of the club physicians, in its home city.”³⁰

In addition, a web-based medical records system, created in 2010, ensures that players medical histories, injuries, and treatment plans are documented.³¹ This allows for team doctors and trainers to keep track of each player’s history of concussions and make any necessary adjustments in treatment.

Concussion rate:

One for every 105.7 games played (2013)³²

National Hockey League (NHL) - click here for NHL protocols|closed

The regulations governing concussions are specifically found in the Protocol for Concussion Evaluation and Management, and generally in Article 34 of the Collective Bargaining Agreement.³³

The NHL and National Hockey League Players Association (NHLPA) concussion policy was revised prior to the 2013/14 season to “comport with recently-issued guidelines from the International Concussion in Sport conference of 2012 to prohibit same day return-to play for players who have been diagnosed with a concussion.”³⁴

Baseline testing

All players undergo baseline neuropsychological testing prior to engaging in full contact play. Typically, this testing occurs during camps at the start of the season. The baseline evaluation consists of the ImPACT program, a computerised neurocognitive assessment. Team neuropsychologists are to administer or supervise the administration of ImPACT.³⁵

Education programme

The NHL has a broad education programme directed not only at the players, but also medical staffs, on-ice game officials, coaches, general managers, executives, and owners.³⁶

The NHL and NHLPA also sponsored an educational video created by the National Academy of Neuropsychology Foundation and the National Athletic Trainers’ Foundation, which features comments from NHL players.³⁷

Beginning in 2011, the NHLPA sent its medical consultant and a neurologist to all thirty teams to educate players about concussions.³⁸ The NHLPA also sponsors concussion research and engages in fundraising activities for concussion research.³⁹

Assessment Protocol

When a player is suspected of having concussion, he is taken off the ice and brought to the locker room or a quiet room to undergo SCAT testing.⁴⁰

A player who is suspected of having a concussion may return to the ice if and when that player is symptom-free at rest and with strenuous activity and the player has returned to his cognitive baseline, which may be determined at a rink side evaluation.⁴¹

Who makes the decision on when player returns to participation?

The decision lies with the team doctor, who will work in conjunction with the team neuropsychologist and incorporate data from the team psychologist’s post-concussion neuropsychological evaluation in the decision-making process.⁴²

All of the test data is stored centrally, and when a player moves to a new club, the data follows him, which provides the new team doctor with the player’s full history.⁴³

Concussion rate:

One for every 20 games played (2009-2012)⁴⁴

National Basketball Association (NBA) - click here for NBA protocols|closed

The NBA implemented a new concussion policy in December 2011, which was codified in Article 22, §8 of the 2011 Collective Bargaining Agreement.⁴⁵

Baseline testing

Pre-season testing of baseline brain function, using neurological and cognitive assessment.⁴⁶

Education programme

The league provides “every player and coach [with] concussion education prior to the beginning of each season. Topics include information on the underlying mechanism of concussion, common and uncommon presentations of concussion, appropriate management strategies and possible complications or long-term manifestations of the injury.”⁴⁷

Assessment Protocol

If a player is suspected of having a concussion, or exhibits the signs or symptoms of concussion, they will be removed from participation and undergo evaluation by the medical staff in a quiet, distraction-free environment conducive to conducting a neurological evaluation.

If a player is diagnosed with concussion, he will not return to participation on that same day.⁴⁸

Who makes the decision on when player returns to participation?

The final decision rests with the team physician, who must first discuss the decision with the director of the NBA Concussion Program.⁴⁹

There is no defined timetable to return, and the return to participation decision is made on a case-by-case basis. Kobe Bryant played in a game just three days after sustaining a concussion in 2012, while Chris Kaman’s concussion required four weeks of rest.⁵⁰

Concussion rate:

One for every 149.5 games played (2013-14)⁵¹

National Football League (NFL) - click here for NFL protocols|closed

The NFL’s concussion policy was implemented in 2009, but was most recently updated in February 2014. The regulations governing concussions can be found in the NFL’s Head, Neck, and Spine Committee’s 1) protocols regarding diagnosis and management of concussion, and 2) protocols regarding return to participation following concussion.⁵²