Tua Tagovailoa’s head injury puts NFL concussion protocol under scrutiny

A high-profile NFL injury has put the spotlight back on football’s persistent concussions, which are linked to head trauma and a variety of long-lasting symptoms, and can be worsened by rushing back to physical activity.

Miami Dolphins quarterback Tua Tagovailoa, who appeared to suffer head trauma in a prior game Sunday afternoon that was later described as a back injury, was diagnosed with a concussion Thursday night following a tackle in his second game in several days. After Tagovailoa’s head hit the turf on Thursday, he remained on the ground and held his arms and fingers splayed in front of his face — which experts said evoked conditions known as “decorticate posturing” or “fencing response,” where brain damage triggers the involuntary reaction.

“It’s a potentially life-threatening brain injury,” said Chris Nowinski, a neuroscientist and co-founder of the Concussion Legacy Foundation, a nonprofit group focused on concussion research and prevention, adding that he worried about Tagovailoa’s long-term prognosis, given that it can take months or years for an athlete to fully recover from repeated concussions. Nowinski said he was particularly concerned about situations where people suffer two concussions within a short period — a condition sometimes known as second impact syndrome — which can lead to brain swelling and other persistent problems.

“That’s why we should at least be cautious with the easy stuff, like withholding players with a concussion from the game and letting their brain recover,” Nowinski said.

The Dolphins said that Tagovailoa had movement in all of his extremities and had been discharged Thursday night from University of Cincinnati Medical Center.

The NFL’s top health official said in an interview on Friday that he was worried about Tagovailoa’s health, and pointed to a joint review the league and its players association was conducting into the Dolphins’ handling of the quarterback’s initial injury on Sunday.

“Obviously, I am upset and concerned just like any fan and just like any physician is any time one of our players suffers any type of injury,” said Allen Sills, the NFL’s chief medical officer. “We want to be thorough, and we want to be consistent and be fair to everyone involved and make sure that we have all the data on hand before we reach a final determination.”

How athletes — and the rest of us — get concussions

The causes and symptoms of concussions vary widely. Some athletes compete for years in contact sports like football without suffering a concussion, while other people can be concussed from a sudden jolt, such as whiplash from a car accident, without even hitting their heads.

But in many cases, the condition is triggered by a blow to the head, which can lead to days or weeks of headaches, memory problems, mood changes and sleep disorders. People recovering from concussions may be unable to balance themselves, see clearly or control their emotions. Neurologists also have warned that repeated concussions appear to be a contributor to a neurodegenerative disease known as chronic traumatic encephalopathy, or CTE.

“When you’ve seen one concussion, you’ve seen one concussion … there’s just such wide variability,” said Jennifer Wethe, the lead neuropsychologist for the Mayo Clinic Arizona Concussion Program, adding that it’s a common problem beyond professional sports. “Most of us at some point in our life probably will have a concussion … and if it’s managed appropriately, and [you’re] not having one concussion on top of another, we’ll end up recovering fine.”

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Medical experts who treat concussion say it can be difficult to diagnose, particularly in athletes who may conceal their injuries because they fear losing playing time and opportunities, or because they don’t experience symptoms for hours after the initial blow.

“This is a subjective injury until you get something like” Tagovailoa’s visible symptoms, said Dustin Fink, head athletic trainer for the Mount Zion, Ill., school district, who also runs The Concussion Blog. “As medical professionals, we are so reliant upon the athlete telling us what’s going on with them, to help us make a judgment or decision. Because they can pass tests that we give them.”

Fink said that on Thursday night — as millions of people tuned in to watch the Dolphins face the Cincinnati Bengals — he was working as a trainer at a freshman football game in Illinois where a 14-year-old player visibly stumbled after getting hit, but was initially evasive about his symptoms.

“He was afraid that this was concussion number X and he was done for his career,” Fink said. Under the school’s concussion protocol, Fink said the player was held out of the game and will be reevaluated Friday within 24 hours after the apparent injury.

Experts also say that the risks tend to be cumulative; a person who has suffered repeated blows to the head, such as a football or rugby player, is more likely to suffer a concussion and also incur long-lasting symptoms. A person healing from a recent concussion is also more susceptible to suffering another concussion.

“On rare occasions, receiving another concussion before the brain has healed can result in brain swelling, permanent brain damage, and even death, particularly among children and teens,” the Department of Health and Human Services warns.

The consequences are particularly severe for mental health, with experts warning of a strong association between head injuries and potentially lifelong neurological problems.

“Concussions are a cause of novel mental health disorders like anxiety, depression, self-harm and suicidal ideation,” said Nowinski.

In rare cases, a concussion can lead to a blood clot forming on the brain, creating pressure in the skull and requiring surgery to remove the clot.

What is the NFL concussion protocol?

The NFL finalized a new concussion protocol in 2011 and has repeatedly updated it amid intense scrutiny and lawsuits filed by thousands of former players, alleging the league downplayed head injury risks for decades.

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Under the current protocol, a player must be immediately removed from a game and evaluated for a concussion if he reports symptoms, or if a trainer, coach, teammate or others tasked to observe the game suspect a concussion. The player then must undergo a series of quick exams, such as repeating words back in a memory test, showing coordinated eye movement and demonstrating balance.

Those diagnosed with concussion must undergo a five-step process before returning to play, which includes being able to complete football-related activities without any symptoms — a hurdle that some players complete within a week, but that has ended others’ careers. The player must also be cleared by a team doctor, as well as by an independent physician jointly approved by the league and its players’ union.

But Nowinski noted potential “gaps” in the NFL’s protocol: A doctor can send a player back into a game, for instance, if he concludes that signs of an apparent concussion — like a player stumbling to stand after a blow to the head — are caused by something besides a head injury.

NFL players also are initially evaluated for concussion in a blue tent on the sideline of the field, which is intended to provide privacy for a diagnosis, but has often led to players returning within a few minutes of a blow to the head.

“Maybe it’s time to reconsider whether the protocol is not strong enough and that every player who’s suspected [of concussion] needs to be out and do a full 15-minute locker room evaluation,” Nowinski said, although he noted Tagovailoa did go through a locker room evaluation before returning to play.

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Sills, the NFL’s medical officer, on Friday defended the protocols, saying the league had developed them through recommendations from experts on brain and spinal trauma, most of whom do not work with NFL teams. “We’re constantly updating and looking to modify the protocol as we learn more from our own data and also as we learn more from the scientific community,” he said.

Concussion care has rapidly evolved in recent years, as experts learn more about the brain, Wethe noted. For instance, she said the maxim “rest is best” was a cornerstone of concussion therapy for years, with patients urged to cloister in dark rooms for days until their symptoms resolved.

“Now, we recognize that too long of that rest and kind of cocoon therapy can almost be detrimental,” Wethe added, saying that “one to three days of relative rest followed by a gradual return to normal activities is best. And we’ve even realized that past those acute stages, exercise can actually be rehabilitative.”

Wethe said that she and her colleagues have worked to develop a program to train parents and coaches on how to check young athletes for head injuries. “When in doubt, check them out,” she said.

Rep. Bill Pascrell Jr. (D-N.J.), who founded the Congressional Traumatic Brain Injury Task Force, said Tagovailoa’s injury underscores the need for better concussion funding, awareness and care at all levels. The congressman has spent more than a decade pushing legislation to improve concussion care, including reintroducing a bill this spring that would standardize how public schools treat athletes who have suffered concussions.

“Concussions are devastating and as a nation we must do more to protect people with brain injury — that starts with our pro sports leagues,” Pascrell wrote on Twitter.

Why Tagovailoa may have been at higher risk

Heading into Thursday night’s game, Nowinski had called for the Dolphins to bench their quarterback, arguing the team was hiding a concussion that Tagovailoa suffered just days earlier and was rushing him back to competition, elevating the risk of a more serious brain injury.

“If Tua takes the field tonight, it’s a massive step back for #concussion care in the NFL,” Nowinski wrote on Twitter on Thursday, several hours before the game.

Nowinski said he took no pleasure predicting Tagovailoa’s injury.

“Frankly, it didn’t take a genius to figure out that this was possible,” he said.

Tagovailoa on Sunday afternoon had visibly stumbled and appeared to have trouble standing following a tackle where his head snapped back into the ground. While the Dolphins initially said the quarterback had suffered a head injury, the team quickly reclassified it as a back injury and Tagovailoa returned to Sunday’s game. The move prompted an outcry from public health experts, and the league and its players association opened an investigation, although the NFL on Wednesday said the Dolphins appeared to follow the league’s concussion protocol and properly care for Tagovailoa.

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Nowinski said that Tagovailoa’s injury on Sunday “showed five separate signs of concussion,” and that it was not plausible he was suffering only from a back injury.

“First, he grabbed his helmet after his head hit the ground. Then he stood up and had [to] … step backwards because he was off balance. Then he shook his head side-to-side in a classic shaking off the cobwebs motion, which I do not know another reason why you do that unless you’re having a visual disturbance after concussion. Then he fell. Then when he stood up, he was gonna fall again if … his teammates didn’t hold him up,” Nowinski said.

How common are football concussions?

More than 100 NFL players per year report concussions, with the true number considered to be well higher.

“I’ve definitely had concussions,” star quarterback Tom Brady acknowledged in a 2020 interview with Howard Stern in 2020, several years after his wife, Gisele Bündchen, claimed that Brady had suffered multiple concussions despite never being diagnosed with the injury.

While many athletes rapidly return to play after concussions — potentially lured by the incentives or the fear of losing opportunities — others can struggle to make it back. Former NFL players like Austin Collie, Kyle Fitts and Jordan Reed have retired in recent years, citing multiple concussions.

Donald Parham, Jr., a tight end for the Los Angeles Chargers, was injured in a nationally televised game in December 2021, where — like Tagovailoa — he rigidly positioned his arms after impact and was admitted to a hospital.

While Parham, Jr., has said he has recovered from that concussion, he has not played in the NFL since that game, with the team citing a hamstring injury this season.

Why experts are concerned about Tagovailoa

Nowinski, who played football at Harvard University before becoming a professional wrestler with World Wrestling Entertainment, said he was worried about Tagovailoa’s long-term prognosis following Thursday night’s injury.

“The problem is Tua has two brain injuries in four days, which may end his career,” Nowinski said. “And I know this because I had two concussions in a month 19 years ago, and that ended my [professional wrestling] career. And I now have met dozens and dozens of people who had their career ended by too many concussions in a row.”

Physicians, lawmakers and other experts cite progress in the NFL and other leagues in combating concussions, but say athletes and teams still have incentives to hide injuries.

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Following Tagovailoa’s removal from Thursday’s game, the announcers on Amazon Prime did not immediately address his injury on Sunday, and avoided using the term concussion. (Amazon founder Jeff Bezos owns The Washington Post.)

“When are we finally going to put our foot down and say that enough is enough? ” Rep. Jan Schakowsky (D-Ill.), who has spent years pressing the NFL on its concussion protocols, said in a statement to The Washington Post. “So long as this game is played, more resources must be devoted to prioritizing player safety, The NFL must take full accountability for the harms inflicted on its players, and anyone in the Dolphins organization, including leadership, found to have broken concussion protocols must be held accountable.”