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Tua Tagovailoa injury shows NFL must improve its handling of brain injuries

Evaluating Tua Tagovailoa’s concussions — and their league-wide, long-term impact.

NFL: Miami Dolphins at Cincinnati Bengals Kareem Elgazzar-USA TODAY Sports

This could have been an amazing week for the NFL. There were several excellent primetime matchups — including Josh Allen vs. Lamar Jackson, the Pederson Bowl in Philadelphia and the Super Bowl LV rematch in Tampa Bay — along with nine games that finished with a one-score margin.

But those stories were overshadowed by the senseless injury to quarterback Tua Tagovailoa during Thursday Night Football’s matchup between the Cincinnati Bengals and Miami Dolphins.

In recent NFL seasons, preventing brain injury from concussions has been a point of emphasis. Many rule changes have sought to decrease the number of times players’ heads collide with anything. In addition, there have equipment modifications — especially to helmets.

But football is a violent sport — so despite these changes, some serious injuries will still occur.

While preventing injuries is paramount, the response to these injuries is just as important — if not more important. Based on what we’ve seen in the NFL this week, it is painfully clear that the NFL’s focus has been on preventing injuries — rather than its responses to injury. Concussions and traumatic brain injuries are a growing area of research in the medical community. For the long term health and safety of its players, the NFL must continue to adapt.

Tagovailoa and the NFL concussion protocol

Tagovailoa suffered what appeared to be a head injury in the Dolphins’ 21-19 win over the Buffalo Bills in Week 3. Pushed backward by the defender, the back of Tagovailoa’s head bounced on the turf. He came to a standing position on his own, immediately shook his head and then took a few steps before stumbling. Two teammates had to help him stand.

Tagovailoa was then taken to the locker room, where he was reportedly evaluated for a concussion, passed the league protocol and returned to the game. In his postgame press conference, head coach Mike McDaniel was asked about his quarterback’s apparent head injury.

“Now, Tua, he went out with a lower back [injury],” McDaniel told reporters. “He kind of got bent back pretty significantly on a quarterback sneak earlier.

“I was kind of with everyone else. When he hit his head on the ground, I assumed it was a head injury. But his legs got wobbly because his lower back was completely loose. As he described it, he said his lower back was like Gumby or something.”

Four days later, the world watched in primetime as Tagovailoa suffered an eerily similar and more frightening injury during the 27-15 loss to the Bengals. Once again, the back of his head hit the turf, but he immediately exhibited a neurological response to injury.

Tagovailoa went into what is called a decorticate posture.

This is a neurological response to severe head trauma to the midbrain and/or the motor tracts from the brain to the extremities. It results in abnormal muscle rigidity of flexion of the upper extremities and extension of the lower extremities.

Obviously this represented an immediate medical emergency — which was handled appropriately by the medical personnel on the field.

The NFL — but more importantly, Tagovailoa — are fortunate this situation wasn’t much worse. Per reports, Tagovailoa was able to return home with the team — but has already been ruled out for the Dolphins’ Week 5 game against the New York Jets.

So where did things go wrong?

The handling of the quarterback’s Week 3 injury is currently being investigated by the NFL and the NFL Players’ Association (NFLPA). The current league concussion protocol states a player is “no-go” if they demonstrate gross motor instability (if the team’s physician and unaffiliated neurological consultant determine it is neurologically caused), loss of consciousness, amnesia or confusion. The “no-go” decision is the first step in the concussion protocol, taking place before any other testing is completed.

Based on this wording — and my interpretation of the protocol — Tagovailoa should have never returned to the field against the Bills. While he may have been complaining of back pain while he was being evaluated, there was a specific mechanism of injury to the head which could have indicated a neurological cause for his gross motor instability.

Tagovailoa also shook his head immediately — in effect, “clearing the cobwebs.” This is no different than a player grabbing their knee or shoulder with an injury to those joints.

The league and the NFLPA reportedly agreed to updates to the concussion protocol, removing any need for interpretation. Players demonstrating any gross motor instability in concussion protocol will immediately be a “no-go” for the rest of the game.

The timeline for Tagovailoa’s recovery is unclear. The effects of the second injury were seen by millions of football fans — and were extremely severe. The effects of repeated concussions are cumulative. Tagovailoa certainly displayed signs of repeated head trauma in a five-day period.

Concussions can result in both micro (small) and macro (large) trauma to the brain. Concussion symptoms can short-lived — or last a lifetime — and can develop into other medical conditions. Full recovery from even a minor concussion could take at least 5-7 days. Recovery normally consists of a gradual progression from active rest to aerobic exercise and light strength training to an eventual return to the field.

The bottom line

In the best interest of its players’ long-term health and safety, the NFL must continually adapt and modify its protocols — and its teams must follow them. The Kansas City Chiefs are fortunate that its medical staff is viewed leaguewide as among the best.

When asked about the concussion protocol earlier this week, Chiefs head coach Andy Reid said the league and its partners are continuing to work on the problem.

“I know the league and the doctors have spent so much time on this trying to figure it out and make it right,” said the head coach. “And so, I think it’s an ongoing deal. We keep learning and learning. And that’s the most important thing: that we don’t just put walls up and say, ‘This is the way it’s going to be’ — but that they’re willing to work with it. And they’re doing that. We’re finding things out as we go.”

Even though this unfortunate set of events happened in the Dolphins organization, it represents a hard lesson from which all 32 teams can (and should) learn. Concussions — and the management of traumatic brain injuries — should never be seen as a matter of Xs and Os on a football field, but should always be viewed exclusively from the perspective of a player’s long-term health and well-being.

We all love the game of football — and the players that make it exciting to watch. The NFL has some warts — and ugly moments — that were in plain sight this week. For the long-term stability of the game, these clearly need to be corrected.

There is so much more about concussions that we have yet to learn. With so much unknown, a cautious approach is always best. Proper testing, diagnosis and management of concussions must occur — for the long-term health of the players who make the game so great.

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