How Tua Tagovailoa cleared the NFL concussion protocol to return to the Dolphins

Miami Dolphins quarterback Tua Tagovailoa is predicted to make his return to motion Sunday towards the Arizona Cardinals after lacking 4 video games attributable to a concussion he suffered in Week 2. It was Tagovailoa’s third recognized concussion in two years, which prompted league-wide dialogue about whether or not he ought to proceed enjoying soccer.

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Offered he was medically cleared to play, that call was at all times going to relaxation with Tagovailoa. He thought-about retiring after lacking 4 video games attributable to two separate head accidents in 2022 however mentioned it wasn’t a consideration this time round. He selected to maintain enjoying after discussing the scenario together with his spouse, Annah.

“Nobody’s … recommendation had affected something that I believed by way of returning,” Tagovailoa mentioned Monday. “(I) had some conversations with my spouse, however that was it.

“I really like this recreation,” he continued, “and I adore it to the demise of me.”

Requested if he would put on a Guardian Cap — the padded shells some gamers put on over their helmets to minimize the impression of collisions on the mind — Tagovailoa mentioned he wouldn’t, calling it a “private selection.” He does, nevertheless, put on a VICIS-brand helmet deemed the “most secure” amongst normal helmet choices for quarterbacks.

Like different gamers recognized with concussions, Tagovailoa needed to undergo the league’s return-to-participation program.

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What’s the NFL’s concussion protocol? The steps that happen earlier than return to play

Step one for gamers is changing into asymptomatic. Earlier than the beginning of coaching camp, each NFL participant is evaluated by his staff’s neuropsychologist to ascertain a neurological baseline. Gamers must return to that baseline to be deemed asymptomatic.

Tagovailoa mentioned he felt symptom-free the day after struggling his newest concussion, however the Dolphins nonetheless positioned him on injured reserve. There’s no required timeline to clear the NFL’s concussion protocol, however being positioned on IR meant he must miss at the least 4 video games.

“Given what the docs have instructed me that having a considerable period of time to relaxation and get well would have been good for me, I believe they did what was greatest by way of defending myself, you understand, from myself,” Tagovailoa mentioned.

As soon as the Dolphins’ neuropsychologist deemed Tagovailoa to be asymptomatic, the quarterback entered a five-phase train program. As we wrote following his Week 2 damage, the protocol consists of steadily growing exercise, and the staff is instructed to search for any recurrence of signs throughout every part.

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• Part 1, symptom-limited exercise: The participant is prescribed relaxation and is instructed to restrict or keep away from actions that improve or worsen signs. Below athletic coaching employees supervision, restricted stretching and stability coaching could be launched, progressing to mild cardio train. If tolerated, the participant can attend conferences and movie examine.

• Part 2, cardio train: Below the supervision of staff employees, gamers can start graduated cardiovascular train, comparable to on a stationary bike or treadmill. The participant can also interact in stretching and stability coaching.

• Part 3, football-specific train: The participant continues supervised cardiovascular workout routines and will mimic sport-specific actions and supervised energy coaching.

• Part 4, non-contact coaching drills: The participant can proceed cardiovascular, energy and stability coaching, team-based sports-specific train and take part in non-contact soccer actions.

To proceed to Part 5, Tagovailoa needed to be examined and cleared by an unbiased neurological professional. That physician, who doesn’t work for the NFL or the Dolphins, needed to decide Tagovailoa was absolutely recovered. Though the NFL’s concussion protocol doesn’t change primarily based on what number of concussions a participant has suffered, that unbiased professional takes the participant’s full medical historical past into consideration.

“The assessments that that physician performs — after which the steps that the participant has to clear to even get to that time — are going to be the identical no matter whether or not he’s had one or two or three concussions,” Jeff Miller, the NFL government vice chairman overseeing participant well being and security, mentioned earlier this month. “That physician’s going to think about no matter steps she or he wants to think about to be sure that they’ve reached a conclusion they’re snug with as a medical supplier of concussion care.”

• Part 5, full soccer exercise/clearance: The participant is lastly cleared by the staff physician for full soccer exercise involving contact. Tagovailoa acquired that full clearance on Wednesday.

“Each scenario and each concussion is exclusive,” Dr. Allen Sills, the NFL’s chief medical officer, mentioned earlier this month. “And so, we don’t put a time stamp on these processes as a result of they are going to differ relying on the severity of the damage. … This return-to-play course of is supposed to be conservative. It’s meant to be rigorous. … In the end, the ultimate resolution of return to play is made by the participant.”

The NFL believes it has made progress with the way it handles concussions by enhancing its concussion protocol, making rule adjustments and bettering gear. That mentioned, the variety of concussions suffered within the league has elevated yearly since 2020.

In response, the NFL launched 12 new helmet fashions this season, broadened its mandate on the usage of Guardian Caps in practices, allowed gamers to put on Guardian Caps in video games and altered the kickoff guidelines largely within the identify of participant well being and security. Throughout the preseason, the variety of concussions suffered in practices and video games dropped to 44, the bottom determine since monitoring started in 2015. Nevertheless it stays to be seen whether or not that may carry over to the common season.

Even when it does, a blind spot that continues to be for the NFL is the complete scope of the short- and long-term dangers related to gamers who are suffering a number of concussions. A 2022 report demonstrated a causal hyperlink between repetitive head impacts and power traumatic encephalopathy (CTE), however the league can’t predict the probability that gamers who beforehand suffered concussions will endure extra of them.

“We, sadly, would not have an in depth method that may predict future threat of damage,” Sills mentioned. “It’s not like we will put in your variety of concussions and the way lengthy between them and your age and a few uncommon fixed and … give you a threat. It simply doesn’t work that manner. … We attempt as medical professionals to supply our greatest guess, however that’s actually what it’s — a guess at what somebody’s future threat of concussion is.

“In my very own apply,” Sills continued, “I’ll see sufferers who’ve had perhaps two concussions in a 12-month interval after which received’t have one other concussion for one more eight or 10 years. After which, different occasions, you see those who appear to be having them extra regularly. So, there’s acquired to be one thing about genetic susceptibility and particular person physiology, however we simply aren’t on the level of our medical understanding to essentially be capable of quantify that to a level that lets us be tremendous prescriptive about that.”

Tua Tagovailoa has not performed since Sept. 12, when he suffered his third recognized concussion in two years. (Jasen Vinlove / Imagn Pictures)

The docs tasked with clearing gamers from concussion protocol are taught to take the totality of the affected person’s expertise into consideration. That features the overall variety of concussions, the interval between concussions, the period of signs after every concussion and extra. If a participant is cleared by each the unbiased and staff docs, it’s as much as him whether or not he continues to play.

Tagovailoa isn’t the primary participant with a prolonged historical past of concussions to maintain enjoying, and he seemingly received’t be the final. And, even when the league or gamers affiliation needed to step in and cease him from enjoying, there isn’t any choice allowing them to take action.

“There’s a level of medical autonomy,” Sills mentioned. “It’s actually not that completely different from day-to-day medical apply. I’m a surgeon. If I stroll in and speak to a affected person within the room and I like to recommend that they’ve an operation for a wide range of causes and I define these causes and I give them the dangers and the advantages of that surgical procedure, then in the end, it’s the affected person’s resolution whether or not they wish to have that surgical procedure finished or not.

“Affected person autonomy in medical decision-making actually issues. That’s what we now have to acknowledge goes on with our concussion protocol as properly. When sufferers make choices about their careers, it has to replicate that autonomy that’s generated from discussions with medical specialists giving them the very best medical recommendation.”

For Tagovailoa, the chance was one he was snug taking.

“How a lot threat will we take once we stand up within the morning to drive to work?” Tagovailoa mentioned. “There’s threat in any and all the things. And I’m prepared to play the chances.”