The game of football is a beloved game in the United States of America, and many would argue, has become America’s most popular sport and national pastime. The National Football League (NFL) is the professional organization where only the best football players in the nation are given the opportunity to showcase their talents. Today, The NFL is booming in popularity. Along with the success and high-profile nature of the NFL, comes the obligation of being the gold standard for all things regarding character, honor, and safety. Although the NFL has been in the spotlight recently for all the wrong reasons regarding the decisions of players off the field, an even darker cloud is looming and has been for some time now. Hits to the head occur repeatedly over and over again during every football game (Nowinski, 2007). Concussions are going to occur in football because that is just the nature of the game (Nowinski, 2007). Therefore, it is vital that the proper diagnosis and treatment of these concussions and head injuries is occurring so that secondary and tertiary concussions can be reduced and in a more perfect world, eliminated.
The NFL has appointed a NFL, Head, Neck, and Spine Committee that has developed numerous protocols regarding the diagnosis and management of concussions in NFL players. It is important to note that NFL players are not the only football players at risk of receiving these types of serious brain injuries. On the contrary, any person that plays tackle football is at risk for these types of injuries, even children playing at the peewee level. This paper will focus on the program of the NFL and its protocol for a few reasons. The NFL is the gold standard of the sport of football. Therefore, the NFL is the leader when it comes to all things football. The programs and protocols that the NFL have implemented and utilized are going to be adapted by other organizations and levels of the sport of football eventually, if they have not already. If the NFL is not treating concussions in football as an extremely serious health issue, who will? Also, football players in the NFL, for the most part, have been playing the game the longest. Therefore, these are the players that are generally subjected to the most hits to the head because they have likely already taken thousands of these hits at the peewee, high school, and collegiate levels.
When dealing with concussions, we are dealing with a player’s health, their well-being, and their overall quality of life. Therefore, this is no small issue. Research has shown that there seems to be a cumulative effect of multiple concussions and repeated hits to the head (Nowinski, 2007). Multiple head injuries seem to increase long-term issues in a person’s life (Nowinski, 2007). Also, studies have shown connections between multiple head injuries and the earlier onset of neurological disorders such as Alzheimer’s disease (Nowinski, 2007). Research has also shown that NFL players are far more likely than the general population to develop brain damage that is very severe (Nowinski, 2007). Long term effects of multiple concussions and repeated “blows to the head” can consist of memory issues, irrational mood swings, depression, anger, anxiety, stress, erratic behavior, fixations, cognitive impairment, issues planning, and issues organizing (Nowinski, 2007).
Concussions cannot be treated until they are diagnosed and the hard truth is that not all concussions are diagnosed. Concussions are basically an invisible injury. They are hard to identify with the naked eye. Also, concussions are very hard to see in structural neuroimaging studies such as CT scans and MRIs because they are not a structural injury; they are more of a functional disturbance in the brain (Nowinski, 2007). Sometimes symptoms of a concussion do not present immediately and rather, evolve over a period of time (Nowinski, 2007). Thus, if the player has already passed a concussion assessment and is back on the field playing, major issues could arise. Furthermore, the symptoms are largely subjective and in the hands of the players to report them (Nowinski, 2007). Over fifty percent of concussed athletes are suspected of failing to report their symptoms (Gregory, 2010). Players do not want be labeled as not tough by their teammates, coaches, family members, and fans (Nowinski, 2007). Players are highly competitive and they do not want to sit on the bench (Nowinski, 2007). Players put in a lot of hard work to be able to play and they want to be out on the field to help their teammates (Nowinski, 2007). This is troublesome because players need to report their symptoms to help the team physician and medical staff out. This is especially important because players are hidden by their helmets, facemasks, and the large area of the football field and arena, making it harder for team physicians and medical staffs to recognize concussion symptoms (Nowinski, 2007). Players also get used to the concussion test that is given (Nowinski, 2007). They can pass it by knowing what to say, but still have a concussion (Nowinski, 2007). This is a major area of concern when dealing with preventing secondary and tertiary concussions.
Football has the worst ratio of games played to hard work put in (Nowinski, 2007). There is only one game a week. The regular season in the NFL only consists of sixteen games a year for each team. This increases the outside pressure put on players, not to mention the internal pressure they put on themselves, to return to play as quickly as possible. This conundrum raises more issues because every concussion is different (Nowinski, 2007). Some players will recover from a concussion faster than others (Nowinski, 2007). There are no set guidelines for time off after a concussion (Nowinski, 2007). Players are allowed to return to the field after their specific individual symptoms have subsided (Nowinski, 2007). This may be hard for players to understand. Overall, players are not thinking about their futures and their lives down the road. Instead, they are caught up in the heat of the battle. They are focused on the game going on and the next play that is going to take place. Protocols absolutely are necessary to take the decision out of the player’s and even sometimes, the coach’s hands.
A study by the NFL found that retired NFL players over the age of fifty were five times more likely than the rest of the population to receive a memory-related disease diagnosis (Gregory, 2010). Furthermore, “The Center for the Study of Retired Athletes found that the rate of depression among retired NFL players reporting three or more concussions was more than triple the rate of those without concussions (Gregory, 2010).” These statistics further demonstrate the severity of this issue. These long-term effects that many people suffer from playing the game that they so dearly love can be quite demoralizing. Thus, they need to be minimized as much as humanly possible. That is where the protocols created by the NFL Head, Neck, and Spine Committee come into play.
The NFL Head, Neck and Spine Committee has created protocols regarding diagnosis, management, and return to participation of and following concussions. These protocols include strict guidelines that must be followed and completed. There is no doubt that the creation of these protocols required a lot of planning. However, it was extremely difficult to find anything regarding how the NFL came up with their protocols. The protocol regarding diagnosis and management of concussions defines a concussion, includes observable concussion symptoms as well as concussion symptoms that only the individual player can report, and defines the guidelines of the NFL sideline concussion assessment (“NFL,” 2014 b). The sideline assessment is based on the Standardized Concussion Assessment Tool 3 published in 2013 by the Concussion in Sport Group (“NFL,” 2014 b). The Team Physician assesses the player in person during the game and thus, is the one that is responsible for determining if a player has a concussion (“NFL,” 2014 b). The Team Physician compares the results of the sideline test to baseline information (“NFL,” 2014 b). Each player is required to have a baseline neuropsychological test done before the season starts (“NFL,” 2014 b). Also, this protocol requires preseason education of players and team personnel regarding concussions (“NFL,” 2014 b).
The protocol regarding a player’s return to participation following a concussion states that the decision to return a player to action is made by the Head Team Physician and must be confirmed by the Independent Neurological Consultant assigned to that specific team (“NFL,” 2014 c). This protocol consists of a five-step process to return a player back to action following a concussion (“NFL,” 2014 c). A player can move on to the next step in the process only after showing tolerance of all activities in the current step without recurrence of any symptoms (“NFL,” 2014 c). Thus, only once a player is at his baseline level of signs, symptoms, and neurological examination, can he be cleared to proceed to the next step in the process (“NFL,” 2014 c). If the activities of a step in the process cause recurrence of any signs or symptoms, those activities are to be stopped and the player is to be returned to the prior step in the protocol (“NFL,” 2014 c). The five-step process goes as follows: rest and recovery, light aerobic exercise, continued aerobic exercise and introduction of strength training, football specific activities, and full football activity/clearance (“NFL,” 2014 c).
A plan states the activities expected of the members of an organization (Sylvia & Sylvia, 2012). These protocols define what is expected of players, teams, and team physicians. A plan establishes the criteria for the decision making of its members (Sylvia & Sylvia, 2012). These protocols establish criteria for the Team Physicians and Independent Neurological Consultants to make their decisions. A good plan permits evaluation (Sylvia & Sylvia, 2012). However, evaluation is not possible without comparisons to some standard (Sylvia & Sylvia, 2012). The baseline test of every NFL player completed before the season starts creates the standard that allows for evaluation.
Comprehensive planning should be used to solve problems that occur over and over, or when the decision is critical for a particular reason (Sylvia & Sylvia, 2012). Concussions continue to occur over and over and they are critical because we are dealing with an individual’s long-term quality of life. Planning needs to address day-to-day operations and decisions that are aimed at solving specific problems (Sylvia & Sylvia, 2012). Football practices and games occur on a daily basis. Thus, these protocols created by the NFL Head, Neck and Spine Committee have seemingly required some very good planning to address the specific problem of concussions occurring in the NFL.
The commissioner of the NFL, Roger Goodell, recently appointed John Madden and Ronnie Lott as the co-chairs of a new panel formed to explore ways of improving player safety (“Safety,” 2013). Panel members include former players, coaches and NFL executives (“Safety,” 2013). The Panel’s goal is to make the game safer long-term (“Safety,” 2013). Basically, the panel is using genius forecasting. Genius forecasting is where a group of people speculates about a program’s future environment (Sylvia & Sylvia, 2012). Genius forecasting is based on the knowledge, intuition, and hunches, of individuals with experience in a particular field (Sylvia & Sylvia, 2012). This panel should also use trend extrapolation. Trend extrapolation assumes that the future will repeat the past, and variables that have caused changes will continue to cause changes (Sylvia & Sylvia, 2012). This panel would be wise to view concussions in these terms and proceed accordingly.
A major objective of the NFL’s Head, Neck and Spine Committee was to complete the protocols discussed earlier in this paper, so that team medical staffs had a process for diagnosing and managing concussions (“NFL,” 2014 a). That way, the main goals and priorities of the committee could hopefully be addressed. The goals of the committee are to raise the awareness of concussions and the effects that they can have, diagnose concussions more successfully than in the past by giving players the best and most effective treatment, reduce the amount of concussions a player receives in his career, and to minimize secondary and tertiary concussions occurring before an initial concussion has healed. The priorities of the committee are to protect the overall and long-term health of every NFL player, protect the brain of every player, and minimize life-long effects that concussions could have on players that would reduce their overall quality of life.
The NFL is a multi-billion dollar industry. The NFL made over nine billion dollars in revenue in the year 2013 (“How the National,” 2013). The funding of this revenue comes from television rights deals, ticket sales, and merchandise sales just to name a few (“How the National,” 2013). Therefore, the NFL has more than enough money to fund the necessary medical staff to diagnose and manage every concussion suffered in the NFL in the best and most effective way possible. The NFL basically uses a PERT chart when implementing the concussion protocol regarding a player’s return to participation. A PERT chart defines a project’s final objective that works on a particular problem (Sylvia & Sylvia, 2012). PERT charts are intended to improve the management of time and resources to an end (Sylvia & Sylvia, 2012). Before an activity on a given PERT line can begin, all activities before it must have been completed (Sylvia & Sylvia, 2012). The final objective of the NFL committee is player’s health, the particular problem is concussions, and the linear aspect of a PERT chart correlates seamlessly with a player’s progression through the concussion protocol discussed above. Just as with a PERT chart, a player cannot begin the next step in the concussion protocol until all activities before it have been completed without any issues.
“The systems theory model includes a premise that the system is made up of interdependent subsystems that cannot be acted upon independently without affecting the other subsystems and the organization as a whole (Sylvia & Sylvia, 2012).” Therefore, there are inputs, throughputs, and outputs correlated with the NFL that are interconnected and all play a role in the concussion crisis. The inputs of the NFL’s committee can be divided into supports and demands (Sylvia & Sylvia, 2012). The supports are continued raised awareness of the health effects of concussions in the short and long term as well as the revenue the NFL brings in every year. The demands are for players to be able to play from the players themselves, coaches, fans, and teammates as well as the time demand of all of those people wanting the player to be cleared through the concussion protocol as quickly as possible. Also, there is a demand for the protection of player health. This player health demand is reflected in the NFL protocols already discussed and can also be protected by the law.
Regarding throughputs, effective managers must constantly assess their environments and actively search the market for new opportunities (Sylvia & Sylvia, 2012). The NFL’s Head, Neck and Spine Committee must be constantly searching for ways to improve their protocols, taking into consideration the environment that surrounds the NFL. Throughputs regarding the NFL include environmental factors such as lawsuits from former players. “More than 4,500 former players have filed a concussion lawsuit against the NFL, some accusing the league of fraud for its handling of concussions (“NFL,” 2014 a).” Another throughput is the culture of the NFL and America regarding how concussions are looked at and thought of. For too long, concussions were thought of as a minor issue and not taken seriously. The culture is beginning to change to reflect the severity of concussions but the NFL must keep being proactive regarding this matter.
The outputs of the NFL’s committee can provide services and regulations for all those involved (Sylvia & Sylvia, 2012). The direct output lowers the amount of concussions by holding the player out until their brain has healed or at least returned to baseline level. The second-order output lowers the level of short and long-term effects a concussion can have on a player by properly diagnosing and treating the concussion. Thus, increasing the quality of life for that player so that they can lead a somewhat normal life even into their later years.
Now that numerous components of the NFL protocols have been identified, it is time to evaluate the program. The evaluation will help to determine just how effective the program is currently being, as well as how effective it will be in the future. An evaluation is critical in determining whether a program is accomplishing the defined goals or not. Therefore, an evaluation ultimately helps in determining whether a program is a success or a failure.
The evaluator and program staff must turn theoretical goals into quantifiable program goals before an outcome evaluation can begin (Sylvia & Sylvia, 2012). Quantifiable program goals are the outcomes that the program staff would like to see occur. These outcomes include keeping all players safe and giving them the necessary medical treatment. These outcomes, among others, are desired because of the numerous issues that concussions can cause. Therefore, the concussion issue must be evaluated.
The evaluation process starts with problem identification (Sylvia & Sylvia, 2012). There are three different approaches that the committee will use to help identify the problems at hand. A written survey will be provided to players in training camp before the season starts. It is critical to hear concerns directly from the players. The survey will utilize the exact same criteria for each player completing it. It will be anonymous so the player can be as open and honest as they want to be without fear of their answers affecting their career. There will also be an open-ended piece at the end of the survey that will allow the player to clarify their responses, as well as raise other issues or concerns. The survey will provide a direct insight from the players on concussions and how they view the effects that can stem from them.
The participant-observer approach allows the NFL Head, Neck and Spine Committee to observe individuals as they go about their daily activities while trying to blend in as much as possible (Sylvia & Sylvia, 2012). The participant-observer approach will be completed for one game a season in which a concussion occurs, with the team physician of every NFL team. This approach will allow the committee to observe every team physician’s handling of the concussion protocol to determine whether there are any issues with the way a specific physician implements the protocol.
Lastly, the committee will complete interactive managerial audits by reviewing the medical files of randomized players and discussing these files with the team medical personnel. This approach will allow the committee to check for insufficiencies to determine whether there are any issues with documentation of concussions.
The next step in the evaluation process is solution development (Sylvia & Sylvia, 2012). Solution development involves forming a task force to develop solutions in the short term and overseeing implementation in the long term (Sylvia & Sylvia, 2012). The NFL is ahead of the curve on this as they have already formed the NFL Head, Neck and Spine Committee as well as the NFL player safety advisory panel.
Then there is the implementation of a system to help facilitate change (Sylvia & Sylvia, 2012). The implementation of an employee development work group allows for training to reeducate staff within the program on policies and procedures (Sylvia & Sylvia, 2012). The NFL Head, Neck and Spine Committee will hire a team of independent physicians and neurologists to train the NFL head team physicians every offseason. These trainings will be comprised of emphasizing the already existing information and procedures as well as teaching the team physicians new information that has come out within the past year. Also, a quality assurance work group will be used to find ways to correct procedural deficiencies by reviewing player’s charts on a weekly basis. Furthermore, a project-coordinating group will be used to compile and report evaluation data. The head of the NFL Head, Neck and Spine Committee will meet with the coordinating group regularly to see if things are proceeding as planned.
The target outcomes of the program are comprised of both primary and secondary outcomes (Sylvia & Sylvia, 2012). Primary outcomes directly impact a program (Sylvia & Sylvia, 2012). The target primary outcomes of the program that the committee desires are an increase in concussion diagnoses, an increase in player’s self-reporting of concussion symptoms, and a reduction in the occurrence of secondary and tertiary concussions; especially before the initial concussion has healed. Secondary outcomes are effects that a program can have on the people involved (Sylvia & Sylvia, 2012). The target secondary outcomes of the program that the committee desired were an increase in quality of life of all players and a reduction of long-term health issues.
The committee’s program has validity concerns. History is a validity concern because concussions were not always documented and tracked like they are today. Another validity concern is maturation due to the hits to the head NFL players take on a consistent basis. The cumulative effect of those repeated hits can change the players over time. The best way to account for history and maturation is to compare the results of the program to a control group of like persons who did not take part in the program (Sylvia & Sylvia, 2012). The control group could be the professional football players of the Canadian Football League since both groups live similar lifestyles. However, this raises external validity concerns because the Canadian Football League has its own protocols and regulations that they follow regarding concussions. It also raises internal validity concerns since there may be different characteristics between the group that are not accounted for, but could alter the results. Therefore, it is tough to use inference in this instance.
Testing effects is another validity concern because pretesting individuals can alter their performances on tests in the future (Sylvia & Sylvia, 2012). Players know that they take a baseline test before the season and they know that during concussion protocol, if their results differ from the pretest, they may have to sit out. Players also get used to the sideline concussion assessment and learn what to say and what not to say. Therefore, they lie so that they can continue playing. Using multiple sideline concussion assessments and training the team physicians to constantly be looking for observable concussion symptoms can address the validity concerns of testing effects. Another validity concern is instrumentation, as findings can vary as a result of different people performing the evaluations (Sylvia & Sylvia, 2012). Concussion findings rely on team physicians from every team and each physician might add some subjectivity into the way that they do things, relationships with players being a specific concern. Instrumentation can be addressed by the trainings every offseason for team physicians as well as emphasizing the strict protocol guidelines.
Cost-Effectiveness is the design selection of this concussion program for a few reasons. First, cost-effectiveness is done for long-term projects, which helps the necessary assessment of the long-term health of NFL players (Sylvia & Sylvia, 2012). Also, this analysis involves intangible effects, meaning impacts that are not economic in nature such as saving and improving lives (Sylvia & Sylvia, 2012). This analysis works under the assumption that rational people work to improve their personal well-being (Sylvia & Sylvia, 2012). However, NFL players hardly think this way.
Welfare economics explains that the only thing that matters in the society is the well-being of the people in it (Sylvia & Sylvia, 2012). In order to apply this principle, the committee first needs to know what is important to the players. Therefore, on the survey passed out in training camp, there will also be an open-ended question on it asking the players what matters most to them in their lives.
Due to the survey being anonymous, players were able to open up and overwhelmingly showed concerns about their long-term health regarding concussions. Players reported, on average, suffering 2.3 diagnosed concussions in their playing careers and an additional 4.6 times where they believe they may have suffered a concussion even though it was never officially diagnosed. The data collected from reviewing player’s medical files, for the most part, agreed with the player’s reports regarding concussions that were diagnosed.
Within the open-ended aspect of the survey, most players reported that they want to be able to live long, happy, and healthy lives so that they can be there for their families and enjoy all of the experiences and time spent with them. Over half of the players expressed at least some concern about their ability to do these things later on in life once their playing careers are over.
Using these findings, one could argue that NFL player’s long-term health outweighs the amount that it costs to bring these players the best treatment and care possible. However, when the copious amounts of money the NFL makes and already has are taken into consideration, it tips the scales. The NFL can withstand the high price it costs to protect its players, especially when that price helps the NFL’s former players live healthier, longer, and happier lives. There are no excuses. Therefore, the NFL’s effectiveness of protecting the health of its players by reducing concussions through strict implementation of the protocol greatly outweighs the cost.
The implications of the findings in this study show that these concussion protocols need to continue to be strictly implemented and improved upon whenever possible in order to diagnose many of these concussions that seemingly are going unnoticed, properly treat the concussions that are diagnosed, and also to reduce the amount of concussions being suffered as a whole by keeping players off the field whenever it is deemed necessary.
There were some limitations of this study. First, even though the survey was anonymous, there was still no way to tell if the players were being completely honest or not. Second, there most likely was some recall bias effecting the player’s answers on the survey. Players could have forgotten the amount of diagnosed concussions they had had, forgotten times when they may have suffered concussion symptoms, overestimated the amount of diagnosed concussions they had had, or overestimated times when they may have suffered concussion symptoms. Lastly, medical files are not usually filled out with research in mind. Therefore, the medical files reviewed could have been incomplete or had incorrect information documented within them.
The results of this study can be applied to any level of the sport of football. This is because the game of football is played basically the same way regardless of the specific league or even age of the players. Obviously, it can be assumed that the older the football players are, the more they are going to weigh. However, regardless of the age or weight of the players, it is still the game of football. Therefore, all players are taking repeated hits to the head. Now, obviously there are some limitations to the applicability of this study. Many of which have already been highlighted in this paper. However, in its simplest form, the findings of the amount of concussions suffered and concern of the players regarding these concussions can be applied to any football player.
My suggestions for the NFL are to continue to learn more and more about the issues of concussions and repeated hits to the head in the sport of football. Also, to educate all involved with the NFL and even the general public on these continued findings as well as the issues and concerns that we are already aware of. Furthermore, developing and creating safer football helmets for all players should constantly be a major goal of the NFL and all other football leagues. In regards to collecting data for future analysis, football helmets should have a computer chip in them that tracks and records the amount of hits that a player takes as well as the severity of each hit. Those findings would allow for specific data collection rather than trying to rely on subjective information reported by the NFL players. NFL players need to be treated as the human beings they are rather than just commodities in the sport of football. After all, the NFL needs their players to be healthy in order to put out the best product possible for their consumers on a consistent basis.
Forbes. (2013). How the National football league can reach $25 billion in annual revenues. Retrieved from http://www.forbes.com/sites/monteburke/2013/08/17/how-the-national-football-league-can-reach-25-billion-in-annual-revenues/
Gregory, S. (2010, February 8). The problem with football. Our favorite sport is too dangerous. How to make the game safer. Time, 175, 36-42.
Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services. New York, New York: Russell Sage Foundation.
National Football League. (2014). Federal judges approves NFL concussion settlement. Retrieved from http://www.nfl.com/news/story/0ap2000000363672/article/federal-judge-approves-nfl-concussion-settlement
National Football League. (2014). National football league head, neck and spine committee’s protocols regarding diagnosis and management of concussion. Retrieved from http://static.nfl.com/static/content/public/photo/2013/10/01/0ap2000000254002.pdf
National Football League. (2014). National football league head, neck and spine committee’s protocols regarding return to participation following concussion. Retrieved from http://static.nfl.com/static/content/public/photo/2014/08/21/0ap3000000381608.pdf
National Football League. (2013). Safety rules & regulations. Retrieved from http://www.nfl.com/news/story/0ap1000000228345/article/safety-rules-regulations
Nowinski, C. (2007). Head games: Football’s concussion crisis. East Bridgewater, Massachusetts: The Drummond Publishing Group.
Sylvia, R. D., & Sylvia, K. M. (2012). Program planning and evaluation for the public manager. Long Grove, Illinois: Waveland Press, Inc.