What is the NFL’s concussion protocol and WHY was Miami’s Tua Tagovailoa playing in Cincinnati

After officially escaping a concussion on Sunday in Miami, Dolphins quarterback Tua Tagovailoa had a different outcome in Cincinnati on Thursday, where he was diagnosed with a head injury following a medical evaluation process that is suddenly at the center of a growing controversy for the NFL.

Tagovailoa was cleared to return Sunday, despite stumbling to the ground and continuing to struggle even after getting back on his feet. Teammates needed to help keep the 24-year-old Hawaiian upright before he was removed from the game moments before halftime.

But as both he and the team later claimed, Tagovailoa was not suffering from a head injury, but rather, an aggravated and existing back problem. And his play certainly supported that assertion, as he returned in the second half to lead an upset win over the visiting Buffalo Bills. Afterwards, Tagovailoa and the Dolphins both said he was cleared by doctors, who had examined him for concussion symptoms. 

Critics weren’t buying it.  

‘If Tua takes the field tonight, it’s a massive step back for #concussion care in the NFL,’ Chris Nowinski, a Harvard-educated neuroscientist and critic of the NFL’s concussion protocol, tweeted before Thursday’s game. ‘If he has a 2nd concussion that destroys his season or career, everyone involved will be sued & should lose their jobs, coaches included. We all saw it, even they must know this isn’t right.’

The possibility of suffering a second head injury in less than a week didn’t stop Tagovailoa from taking the field on Thursday in Cincinnati, where he was briefly hospitalized after being ripped to the turf by 6-foot-3, 340-pound Bengals defensive tackle Josh Tupou. Tagovailoa maintained feeling in his extremities and was on the return flight to Miami after Thursday’s loss to Cincinnati, according to the Dolphins.

The reaction, naturally, has focused on the Dolphins’ decision to allow Tagovailoa to play in Cincinnati, where he may have suffered a potentially significant head trauma.

‘You guys should go to jail for letting him play 5 days after an obvious #concussion you covered up,’ Nowinski tweeted after Thursday’s injury. ‘If he dies from second-impact syndrome, I’m pushing for murder charges.’

Hall of Famer Shannon Sharpe tweeted: ‘That’s a serious injury . Tua shouldn’t have been out there with Sunday Thursday turn around. Sometimes players need protecting from themselves. Dolphins failed Tua.’ 

Second-impact syndrome occurs when someone suffers two concussions within a short period of time, and can cause the brain to swell rapidly. The swelling can be so intense that it can ultimately hurt blood flow to the brain, resulting in death, according to a 2009 study in the National Library of Medicine.

‘It was a scary moment. He was evaluated for a concussion and he’s in the concussion protocol,’ Dolphins coach Mike McDaniel said.

Some who watched the scary injury want to know why Tagovailoa was playing just four days after his quick return Sunday prompted a joint review by the NFL and NFL Players Association.

Many former players were critical of the decision to allow Tagovailoa to return against Buffalo and start against Cincinnati.

‘Player health and safety is at the core of the union’s mission,’ the NFLPA wrote on Twitter. ‘Our concern tonight is for Tua and we hope for a full and speedy recovery. Our investigation into the potential protocol violation is ongoing.’

NFL executive vice president Jeff Miller said the review usually takes a week or two.

Much of that time will be spent picking apart a league concussion protocol that many feel remains inadequate.

WHAT IS THE NFL’S CONCUSSION PROTOCOL?

A player who exhibits or reports symptoms or signs suggestive of a concussion or stinger enters protocol.

During each game, independent certified athletic trainers (ATC spotters) monitor the players on the field. If they see an impact to the head, they call a timeout and the player must be removed from the game, examined and evaluated. Team trainers, coaches or physicians, teammates, NFL game officials, sideline unaffiliated neurotrauma consultants (UNC) or booth ATCs also can initiate the protocol.

Any player in concussion protocol undergoes a six-step evaluation by a team physician and UNC to determine the severity of the injury and whether or not they’re fit to return to the field. The final step is a neurological evaluation featuring a cervical spine exam, including range of motion/pain, evaluation of speech, observation of gait, eye movements and pupillary exam.

If any elements are positive, inconclusive or suspicious of concussion, the player is escorted to locker room.

In the locker room, a team physician and UNC conducts a full neurological exam and complete NFL Standardized Concussion Assessment Tool.

If abnormal, the player doesn’t return to play, undergoes periodic evaluation by a medical team and has a follow-up neurological exam.

The league instituted the system in 2011 after Cleveland Browns quarterback Colt McCoy took a helmet-to-helmet hit in a game and returned without being tested for a concussion. The Browns said that the team’s trainers didn’t see the hit because they were tending to other players and that no one told them about it. After the game, McCoy was diagnosed with a concussion.

WHAT IS FENCING RESPONSE?

According to healthline.com, ‘when a person experiences an impact that’s strong enough to cause traumatic brain injury, such as a concussion, their arms often go into an unnatural position.’

Tagovailoa appeared to take that position, his fingers flexed awkwardly in front of his facemask for several seconds as he laid on the turf.

‘The fencing response is often seen when a player is knocked down or knocked out during full-contact athletic competitions such as football, martial arts, boxing, rugby, and hockey,’ per healthline.com.

It happened to Los Angeles Chargers tight end Donald Parham during a Thursday night game against Kansas City last Dec. 17. Parham was removed on a stretcher and stayed overnight at a hospital for observation after being diagnosed with a concussion.

WHAT’S NEXT FOR TAGOVAILOA?

The severity of Tagovailoa’s concussion is not known, but it’s seemingly encouraging he was allowed to fly with the team. He must undergo a five-step process before being allowed to take the field again. The fifth phase is a full practice followed by clearance from the team physician. After that, he must be examined by an independent neurological consultant.

THE NFL’S COMPLICATED HISTORY ON CONCUSSIONS

The conflict between NFL profits and player health is nothing new, although the effort to reduce traumatic brain injuries (TBIs) is, relatively speaking. And it’s that discrepancy that resulted in countless avoidable cases of brain damage, according to epidemiologist and George Washington University professor David Michaels.

An expert on environmental and occupational health who served as OSHA assistant secretary under Barack Obama from 2009 until 2017, Michaels wrote a book in 2020, The Triumph of Doubt, illustrating various industries’ strategies to suppress data on the  inherent dangers of their products.

‘It remains a fundamental contradiction within football – for both the league and the players – that more football brings in more revenue, but it also increases the number and severity of brain damage cases,’ Michaels told the Daily Mail in 2020.

‘No other profession—not one—outranks professional football in causing life-altering injuries.’

With faulty science and flawed studies conducted by conflicted researchers, Michaels argues, the NFL delayed meaningful preventative action on chronic traumatic encephalopathy (CTE) until the early 2000s – a decade after first resolving to address head injuries and nearly a century after the neurodegenerative disease was discovered in 1928.

‘The steps that are being taken now, which we think will be useful in reducing the terrible damage to the brains of players, they could have been implemented years earlier,’ said Michaels. ‘The lives of many players may have been greatly improved had that been done.’

The NFL did not respond to DailyMail.com’s request for comment in response to the 2020 interview with Michaels. However, the league did refute any similarities between itself and the tobacco industry in a statement given to the New York Times in 2016: ‘The NFL is not the tobacco industry; it had no connection to the tobacco industry.’

Before the 1990s, the NFL didn’t need such tactics. It was when journalists and fans began noticing a spike in concussions that the league took action, and that was only after then-commissioner Paul Tagliabue called it a ‘pack journalism issue’ while claiming that concussions only occurred ‘every three or four games.’

Tagliabue’s comments ignited a small controversy at the time, prompting him to start the Mild Traumatic Brain Injuries (MTBI) Committee, which was aimed at reducing the ‘injury risks in football.’

The problem, aside from its euphemistic choice of the word ‘mild,’ was that the committee didn’t do very much.

‘For eight years, the committee published nothing,’ Michaels said. ‘Evidence accumulated, but even when they started publishing papers, the papers were really covering up the problem. They asked questions in the wrong way. To me, it looked like they knew the answers they wanted to find before they even did a study.’

The NFL had claimed the MTBI committee was impartial, but when it finally did publish 13 papers in ‘Neurosurgery’ between 2003 and 2006, Michaels explained, ‘obvious conflicts of interests’ emerged.

Several members of the committee were clinical consultants for NFL teams, including the group’s chairman, Elliot Pellman, a rheumatologist who served as the New York Jets’ team doctor and also happened to be Tagliabue’s personal physician.

In fact, over a dozen of the MBTI members had connections to league franchises. And that’s not to mention Michael L. J. Apuzzo, a Neurosurgery editor who happened to be a medical consultant to the New York Giants.

It’s not known if those conflicts affected the research directly, but Michaels argued that the MBTI committee’s misguided conclusions did minimize the long-term risks of football.

For one, the concussion data was hardly comprehensive.

The records between 1996 through 2001 omitted more than 100 diagnosed concussions, according to the Times.

In response to that finding, the NFL acknowledged that ‘the clubs were not required to submit their data and not every club did.’

And while the NFL admitted that detail should have been made clearer, the league denied any effort to ‘alter or suppress the rate of concussions.’

Bill Barr, a neuropsychologist who once worked for the New York Jets, stopped short of accusing the NFL of a cover-up, but did criticized the MBTI’s findings to the New York Times.

‘You’re not doing science here; you are putting forth some idea that you already have,’ he said in 2016.

Michaels took aim at one study from Pellman and his co-author David Viano that asserted ‘mild [traumatic brain injuries] in professional football are not serious injuries’ because so many players return to the field within a week, often within the same game.

Furthermore, the paper argued, concussed players could safely return to the field, so long as they didn’t show any lingering effects.

‘These players had to be asymptomatic, with normal results on clinical and neurological examinations, and be cleared by a knowledgeable team physician,’ read the paper. ‘There were no adverse effects, and the results once again are in sharp contrast to the recommendations in published guidelines and the standard of practice of most college and high school football team physicians.’

That same six-year study claimed that ‘no NFL player experienced second-impact syndrome, chronic cumulative injury, or chronic traumatic encephalopathy (CTE) from repeated injuries.’

CTE can only be diagnosed posthumously so the absence of any confirmed cases in this study should have been expected.

In 2017, researchers at Boston University found some degree of CTE in 99 percent of former NFL players, 91 percent of players who stopped playing after college, and 21 percent of those who only made it to the high school level.

Experts caution that there is a selection bias in this study, as the families of players who had evident signs of head injuries were far more likely to donate to the BU brain bank.

Even so, the paper’s claim that ‘no NFL player experienced… chronic traumatic encephalopathy from repeated injuries’ hasn’t withstood the test of time.

But perhaps there was no greater overreach than the claim made within a paper titled: ‘Concussion in Professional Football: Brain Responses by Finite Element Analysis.’

The authors, including Pellman, posited that players who reach the NFL level might be somehow immune from concussions.

‘[T]here may be a natural selection of athletes that make it to the NFL because players more prone to concussion may have been weeded out during high school and college play,’ read the paper, which was published in Neurosurgery. ‘Brain responses shown here may represent those of players who are most resistant to the damaging effects of neural deformation during head impact.’

The MTBI committee was dismissive when neuropathologist Bennet Omalu identified the symptoms of CTE in former Pittsburgh Steelers center Mike Webster’s autopsy in 2002. And when Omalu wrote a paper for Neurosurgery in 2005, calling for further CTE study by the NFL, the MTBI committee formally called for a retraction.

‘Then, of course, when Bennet Omalu published the results of Iron Mike Webster’s autopsy in 2005, the leading members of the committee didn’t welcome the new data,’ Michaels said. ‘They attacked it. They demanded that Omalu retract his paper.’

The NFL even dismissed a league-funded 2009 study that showed former players are 19 times more likely to get dementia or other memory-related diseases.

Then-NFL spokesman Greg Aiello told the New York Times that the study did not formally diagnose dementia, claiming that telephone surveys of former players were insufficient.

Miller ultimately acknowledged a connection between CTE and football before congress in 2016.

As significant as a step as that was, it came amid other efforts to suppress unflattering media coverage.

The 2015 Sony film based on Omalu’s work, Concussion, was altered under pressure from the NFL to project a more favorable view of professional football and the league, according to reports by the New York Times and Deadspin.

‘The league has a great deal of leverage – in some ways more than a chemical company may have,’ Michaels said. ‘They know that they control the eyes of America for several hours every week. If the NFL went, took their business to other entertainment companies, then that would put a big dent in the profits of the companies that they work with.’

The NFL began changing rules in the 2000s, prohibiting dangerous tackles and formalizing a concussion protocol while threatening to fine non-compliant teams.

Team owners took further steps, pledging to fund $30 million to the National Institute of Health for independent CTE research in 2012, later giving another $100 million to Harvard researchers in 2013, and settling the aforementioned $1 billion concussion lawsuit with former players.

But even as the league’s check book remained open, critics argued that the NFL’s generosity came with strings attached.

In the face of mounting lawsuits, the tried to pull NIH funding for a Boston University CTE study over objections to BU’s Dr. Robert Stern, a critic of the league, according to ESPN.com.

‘The NFL had their own researchers that they supported,’ Michaels said. ‘When researchers who are independent of the NFL, especially the group at Boston University, was designated by the National Institute of Health to be the primary recipients of this funding, the NFL objected and wanted the NIH to bring in scientists who already have a relationship with the NFL, who essentially had a conflict of interest.

‘That effort of the NFL failed, but it did show that the NFL did not want independent researchers looking at this problem.’

Data released in February by the NFL showed 187 concussions during the 2021 season, including preseason, all practices and games. While that is up from 172 the previous season, there were no exhibition games in 2020 because of the COVID-19 pandemic. The concussion rate overall declined.

Encouraged by the trend of decreased concussions, Dr. Allen Sills, the NFL’s chief medical officer, believes much more can be done.

‘We are pleased with the concussion numbers, but we feel it’s not the full picture,’ Sills said, ‘and we really want to aggressively reduce and work to eliminate avoidable head contact.’

Miller noted that the increase from 16 to 17 games in the regular season, dropping one preseason game, did not appear to affect injury trends.

The preseason had the highest injury rate — soft tissue injuries are common in training camp and in exhibition games — and the new 18th week didn’t result in a spike of injuries.

‘We didn’t see it,’ Miller said. ‘The injury rate in the last week of the regular season was no higher than previous weeks; there seemed to be a bit of a drop-off.’

WHAT IS THE NFL’S PROBLEM WITH ‘RACE NORMING’

Two years after a pair of former players sued the NFL over the treatment of black retirees in the league’s $1 billion concussion settlement, hundreds of men whose medical tests were rescored to eliminate race bias now qualify for awards.

The newly approved payouts, announced in a report last month, were a victory for NFL families in the decade-long legal saga over concussions. The 2020 lawsuit unearthed the fact the dementia tests were being ‘race-normed’ — adjusted due to assumptions that black people have a lower cognitive baseline score. Changes to the settlement made last year are meant to make the tests race-blind.

The new results will add millions to the NFL’s payouts for concussion-linked brain injuries. A league spokesman did not return a phone call Friday or respond to emails sent in recent weeks seeking comment on the rescoring.

Of the 646 black men whose tests were rescored, nearly half now qualify for dementia awards. Sixty-one are classified as having early to moderate dementia, with average awards topping $600,000; nearly 250 more have milder dementia and will get up to $35,000 in enhanced medical testing and treatment, according to the claims administrator’s report.

Former players, lawyers and advocates say they’ll now turn to getting the word out to more players who could receive awards.

‘Our work has produced some great results and has opened many eyes,’ said Ken Jenkins, a former Washington player who, along with his wife, petitioned the federal judge overseeing the settlement to make the changes and urged the Justice Department’s Civil Rights Division to investigate. ‘Now we’re really focused on getting as many players who deserve compensation to be compensated.’

This first group of players had the best chance of success because they otherwise passed the testing protocols and would have qualified if they were white. Thousands of other Black former players can ask to be rescored or retested, but their cases might not be as strong based on earlier results on dementia, validity and impairment tests. About 70 percent of active players and 60 percent of living retirees are Black.

The fact that the testing algorithm adjusted scores by race — as a rough proxy for someone’s socioeconomic background — went unnoticed for several years until lawyers for former Steelers Kevin Henry and Najeh Davenport sued the league. Factors such as age, education and race have long been used in neurology to help diagnose dementia. But experts say the formula was never meant to be used to determine payouts in a legal case.

‘In 2022, how can you possibly think that another human being comes out of the womb with less cognitive ability? It’s just impossible to believe that that can be true,’ Jenkins said. ‘It’s unspeakable.’

Advocates fear that many former players don’t know they can be rescored or retested, especially if they have cognitive issues and live alone.

‘Men who are homeless, men who originally signed up but their cognitive function changed, men who are divorced or isolated — we are going to go looking for them,’ said Amy Lewis, Jenkins’ wife.

The couple, once critical of class counsel Chris Seeger for his response to the issue, now work with him to spread the word.

Seeger — lead lawyer for the nearly 20,000 retired players, who negotiated the settlement with the NFL — has apologized for initially failing to see the scope of the racial bias. He vowed in a recent interview to ‘make sure the NFL pays every nickel they should.’

The league’s tally just passed $1 billion in approved claims. However, appeals and audits mean actual payouts lag behind that number and now stand at about $916 million. Payouts include awards for four other compensable diagnoses: Alzheimer’s disease, Parkinson’s disease, Lou Gehrig’s disease and deaths before April 2015 involving CTE, or chronic traumatic encephalopathy.

As reviewers tackle the thornier dementia claims, the process has slowed and audits and appeals intensified.

‘Their mantra is deny, deny, delay until you die,’ said James Pruitt, 58, a wide receiver who played for Indianapolis and Miami from 1986 to 1991.

After his NFL retirement, Pruitt became a teacher and middle school principal in Palm Beach County, Florida. But in 2010, in his mid-40s, the district asked him to step down. He could no longer perform his duties. Over time, he stopped calling on friends from his playing days.

‘I don’t get out, and I don’t remember a lot of things. I’ve been told that I repeat things,’ he said. ‘I’m kind of embarrassed by the whole situation.’

After the settlement was approved in 2015, he and his wife attended meetings with lawyers who traveled the country to sell the plan to retired players’ groups.

‘We were told … this was going to be a very easy process, you just need to go to the doctors, get a qualifying diagnosis from them,’ said Traci Pruitt, 42. ‘Yet here we are six years later, and we’re still getting the runaround.’

The couple has twice been approved by doctors only to have the decision overturned — once after their first doctor was removed from the program. Their lawyer believes they’ll be successful on their third try, under the race-neutral scoring formula. They’re still waiting to hear.

Traci Pruitt, an accountant who works from home, said an award would ensure she gets the help she needs to care for her husband: ‘While I love him, I don’t necessarily have that background and skill set.’

Seeger said he believes the claims process is picking up steam after a slow start.

‘I know folks have said they weren’t moving that well for awhile. I think we’ve won some appellate battles with the courts,’ Seeger said. ‘I don’t think the NFL expected to pay $1 billion — and we’re about to cross $1 billion.’