Andre Johnson faces detailed process under NFL concussion protocol

When Texans receiver Andre Johnson disappeared from the playing field Sunday at Reliant Stadium, he entered the mysterious world of the NFL’s “concussion protocol,” which includes several layers of tests and exams that players must pass before they can return to play — and even then, only after they are cleared to do so by an independent neurological professional.

There are some new elements this year, and they begin with the system used to monitor players during games and the manner in which they are assessed for possible concussions, said Dr. Kenneth Podell, a neuropsychologist who is co-director of the Methodist Concussion Center.

Watching from above
At each game, Dr. Podell said, there is now an “eye in the sky” observer who scans the field looking for players who may require assessment for a concussion.
“Did somebody stumble when they got up, or is there something about their behavior on the sideline?” he said. “The observer can send an FYI down to the team, or they can send a video clip to the sideline in real time to be checked out.”

In cases such as the hit Sunday by Titans safety Bernard Pollard on Johnson, teams don’t require an observer to tell them a player needs assessment. Beginning this year, players in those cases are assessed by an independent neurological observer. There is one on each sideline, assigned by the league but not affiliated with the team.

“The NFL has a formal document called the Standardized Concussions Assessment Tool, which has been modified to focus on orientation, memory, concentration, balance and symptoms,” Dr. Podell said. “They will do a neurological exam, and if a concussion is determined, the player will be removed from competition.”

The SCAT, a copy of which is available at, informs professionals that a “conservative, safety-first approach should be adopted” in such exams. Exams, which require 10 to 15 minutes, can be administered on the field or in a quieter location, and results are compared with each player’s preseason baseline test.

Any of six physical criteria, including loss of consciousness, amnesia and confusion, can result in a player’s being barred from further play. Five additional questions are designed to help determine if a player has suffered more serious brain trauma.

Players also are administered a 65-point exam that includes the month, date and year, the venue, who scored the most recent touchdown, the team’s previous opponent and the outcome of that game. One test requires a player to recall a list of words, and another requires him to repeat a list of numbers. He also must answer a list of symptoms, including “don’t feel right” and feeling “in a fog.”

Any player diagnosed with a concussion must be escorted to the locker room or training room for observation and cannot return to the field under any circumstances under league rules. After the game, it is determined whether he can return home and under what circumstances.

Long path to field
The return-to-play path can begin one to two days after the game. Players are evaluated using elements of the SCAT and monitored to determine when they are back to normal without return of symptoms, followed by another round of cognitive tests.

According to guidelines from the NFL’s head, neck and spine committee, “Once symptoms have subsided, players submit once again to the standard baseline testing, plus the 30-45 minutes required to complete more advanced versions. Sometimes there is additional testing with the neuropsychologist. Even then, there are no pass-fail grades, only additional data for doctors to interpret.”

Physical tests as well
If a player shows progress on his tests, he can be cleared for return to physical activity.

“It’s a gradual increase in exercise intensity,” Dr. Podell said. “We start with cardio, advance to intense cardio with weight lifting and position-specific drills. If athletes continue to be symptom-free, they advance to the next stage.”

NFL regulations, he said, allow a player to complete up to two stages each day. A player might be allowed light cardio activity in the morning, for example, and moderate activity that afternoon.

Further stages include a return to non-contact drills, contact drills and, eventually, a return to the playing field. But even after a player is cleared by the team doctor, he must be evaluated by an independent concussion expert approved by the NFL and NFL Players Association.

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