# data[].attributes.attachment_link.readable_text
Oct 11, 2022

Kevin SeifertESPN Staff Writer

Close

ESPN.com national NFL writer

ESPN.com NFC North reporter, 2008-2013

Covered Vikings for Minneapolis Star Tribune, 1999-2008

One concussed NFL quarterback and two questionable flags for roughing the passer. That's all it took for the first officiating feeding frenzy of the 2022 season.

There is no evidence that Tua Tagovailoa's concussion, and its subsequent fallout, is connected to the pair of penalty flags that prompted leaguewide discussion Sunday and Monday. It makes for an easy narrative -- referees Jerome Boger and Carl Cheffers threw unwarranted flags at the behest of a league that is trying to manage its reputation for player safety -- but it's not supported by anything concrete.

Multiple league and officiating sources said Tuesday there has been no edict to further protect quarterbacks following the Tagovailoa incident. ESPN officiating analyst John Parry, a retired referee who maintains close ties with the league's officiating department, said: "There has been no directive to change anything."

So what is going on here? Why did we see Atlanta Falcons defensive lineman Grady Jarrett penalized 15 yards Sunday for "unnecessarily" throwing Tampa Bay Buccaneers quarterback Tom Brady to the ground, as Boger described it? And why did Cheffers throw a flag on Kansas City Chiefs defensive lineman Chris Jones for landing on Las Vegas Raiders quarterback Derek Carr with his full body weight, as Cheffers said in a subsequent pool report?

NFL owners will discuss roughing the passer when they meet next week in New York, and the NFL's competition committee already has plans to discuss the penalty after the season amid outrage over the two disputed calls.

Let's take a deeper look at the situation, including the revelation that roughing the passer penalties have actually plummeted this season, before considering possible solutions -- including replay review.

Did you say roughing the passer flags are down?

Yes. There have been 29 roughing penalties this season, according to the ESPN Stats & Information database. That's down from 54 through Week 5 last season, 41 in 2020 and 59 in 2010.

The NFL's competition committee was concerned that officials threw too many flags for roughing the passer in 2021. The total was 153, a 12% rise from 2020. In reviewing video of the 2021 season, the committee -- with support from the NFL's football operations department -- found too many instances of flags for mild or inadvertent contact. So the committee issued a point of clarification to remind officials that the rulebook requires "forcible" contact to merit a flag.

So why are we still seeing these types of calls?

The flags from Boger and Cheffers fall into a category the NFL added to the rulebook in 2018, and is only tangentially related to the issue of "forcible" contact the competition committee clarified this spring. The amended roughing the passer rule prohibits defenders "from committing such intimidating and punishing acts as 'stuffing' a passer into the ground or unnecessarily wrestling or driving him down after the passer has thrown the ball."

The rule goes on to say a defender "must strive to fall to the side of the quarterback's body, or to brace his fall with his arms to avoid landing on the quarterback with all or most of his body weight."

After issuing its clarification this spring, the competition committee told officials it was satisfied with the way they were calling the body weight/unnecessarily throwing component of the rule and recommended they continue on the current path.

Did Jarrett really throw Brady to the ground unnecessarily?

It's a judgment call, and that's partly why the lead referee is almost solely responsible for calling roughing the passer penalties.

Sometimes referees make mistakes, and this wouldn't be the first time this season we have seen Boger throw a flag for roughing the passer that didn't pass the eye test. You only have to go back to Week 4, when he penalized Baltimore Ravens cornerback Brandon Stephens for what he later said was "forcible contact to the head/neck" of Buffalo Bills quarterback Josh Allen. Replays showed Stephens hit Allen in the chest.

In Kansas City, what could Jones have done differently?

Jones was in an unusual situation because the ball came loose as he and Carr were falling. Jones naturally and instinctively used one arm to grab the ball, limiting his ability to brace the fall or roll to the side. Cheffers said in the pool report that he judged Jones to have landed on Carr "with his full body weight." Again, that is a judgment call, but the fumble certainly complicated the situation for Jones.

Is there any way to fix this?

The NFL will review roughing the passer in the offseason. The league, in fact, reviews every play of every season once it is over. There is no indication that the league will change anything in the short-term, however, as it typically tries to avoid overreacting to a handful of high-profile calls. While they have made in-season adjustments to administrative rules, including the concussion protocol, there is no precedent for changing the written terms of a subjective judgment call during the course of a season.

What about in the long term?

The NFL could consider three options.

First, it could do nothing.

Second, it could raise the standard for throwing a flag for the body weight/unnecessarily throwing component of roughing the passer, requiring more force and violence to merit a penalty. The league, however, rarely changes rules to provide less protection for quarterbacks. If it chose this route, it could be done through a directive to officials during the season or in a rule change during the offseason. Again, there is no indication the NFL is looking to make any in-season adjustments.

Third, it could make roughing the passer subject to replay review.

Replay review? Oh no...

Oh yes.

The Chiefs' Jones is among those advocating for such calls to be reviewed, noting how significantly they can impact the outcome of a game. NFL owners generally have been opposed to making subjective judgment calls part of replay review, with the one-year exception of pass interference in 2019, preferring instead to limit it to objective measurements such as whether a player was in bounds or if he was down by contact.

Adding roughing the passer to replay review would require a rule change that needs approval from 24 of 32 owners.

* When the Super Bowl lights went out
* Dalton looks to shake prime-time woes
* Cowboys face three games in 12 days
* Can Miami keep relying on shootouts?
* Geno leads Seattle to fourth straight W
* Week 9 takeaways: Lessons, questions

Would it work?

It would depend on the standard the NFL used to review such calls. Overturning a call on the field currently requires "clear and obvious" evidence of a mistake, according to the league rulebook. When applied to pass interference in 2019, that standard proved too high to address most challenges. The league overturned only 24 of 101 pass interference plays it reviewed.

One source with deep knowledge of officiating said, under the current standard, the Week 5 Boger call would probably be overturned but the Cheffers call would be upheld.

In order to more aggressively address disputes in replay, the standard would have to allow the play to be "re-officiated" rather than viewed for a clear and obvious mistake. That would require a significant philosophical change from owners who are already leery about game interruptions and technological intrusions on the game.

Where do we go from here?

The likeliest outcome is the status quo. Officials are human. Sometimes they make mistakes, and sometimes their calls change the outcome of games. This set of calls came with coincidental timing of a much larger and serious story. The NFL addressed the fallout of Tagovailoa's concussion by updating its concussion protocols but not, by all accounts, asking officials to elevate quarterback protection.

# data[].attributes.attachment_link.title
Can NFL fix roughing the passer penalties? How officiating the call has changed, and what's next

# data[].attributes.attachment_link.description
Oct 11, 2022 Kevin SeifertESPN Staff Writer Close ESPN.com national NFL writer ESPN.com NFC North reporter, 2008-2013 Covered Vikings for Minneapolis Star Tribune, 1999-2008 One concussed NFL quarterback and two questionable flags for roughing the passer. That's all it took for the first officiating feeding frenzy of the 2022 season.

# data[].attributes.headline
Est. that a defender cannot put his "full weight" on a QB

# data[].attributes.subject
Est. that a defender cannot put his "full weight" on a QB

# data[].attributes.attachment_link.readable_text
The NFL finds itself in an unenviable position of being at the forefront of controversy over concussions while also seeing backlash from fans in their attempts to protect quarterbacks from the very hits that could create additional injuries.

With the rules protecting passers, it seems impossible for defenders to effectively sack the opposing quarterback.

NFL Week 5 Brought New Controversy to Light

This has long been a source of fan frustration, but Week 5 brought the new rules into harsh light with two seemingly clean sacks from Grady Jarrett and Chris Jones being taken away by roughing the passer penalties that would not have been called several years ago.

These are not one-to-one issues - though the first injury to Dolphins quarterback Tua Tagovailoa, described as a back injury by Dolphins training staff and a concussion by non-diagnostic observers, was flagged for roughing the passer - the new rules surrounding the penalty emerged because of a different injury to a different quarterback.

The now infamous "body weight" rule inhibiting pass-rushers is the direct result of Packers quarterback Aaron Rodgers' collarbone injury following a sack from Vikings linebacker Anthony Barr and the emphasis on the rule is about protecting the quarterback's body more than his brain.

Nevertheless, there is tension. The NFL is simultaneously being asked to do more to protect player safety while relaxing rules designed to make players safer. That does not mean that fans are talking out of both sides of their mouth or that analysts are being hypocritical when demanding more protection for quarterbacks potentially suffering neurological issues like Tagovailoa and less for quarterbacks being escorted to the ground like Derek Carr.

But it does mean that the NFL needs to be careful navigating those waters so that one move - to liberalize contact rules on quarterbacks - does not counteract another effort to protect players' brains.

The NFL Can Reduce Roughing-the-Passer Penalties

There are a number of ways to resolve these concurrent problems. As Pro Football Network's Aaron Wilson reports, the NFL will not be considering replay review for roughing the passer penalties - a suggestion made popular by Jones when he was asked after the game about his game-changing flag.

Given the fiasco surrounding reviews of pass interference - where New York would almost never overturn the ruling on the field and all fans saw were unnecessary delays in game action - it's not surprising to see the NFL avoid this outcome, as frustrating as it may be.

Instead, the competition committee - which will be discussing the penalty next week and at the end of the season - could either change the wording of the rule back to its original wording, come up with new wording that emphasizes a judgment of intent or a higher threshold of contact, or change enforcement of the ruling without changing any of the wording.
MORE: Extra Points - MVP Race Update, the Year of the Backup QB, and More
That last would come down through a memo to officials about how to call those penalties, in much the same way that officials were told to "emphasize" illegal contact rulings this year. There's a good chance they choose this last option, as they have already done it once and it worked.

That's an unusual thing to point out after all the furor over the penalty this weekend, but the NFL did ask officials to relax its enforcement of the penalty after the 2021 season. As a result, officials were reminded that the rule required "forcible" contact. Through five weeks, roughing the passer calls have decreased 45 percent when compared to last year and are down 32 percent when compared to 2020.

If anything, it seems as if that "reminder" didn't get through to referees Jerome Boger or Carl Cheffers, both of whom took a strict interpretation of the rule when penalizing Jarret and Jones.

In the postgame pool report, Boger said, "What I had was the defender grabbed the quarterback while he was still in the pocket and unnecessarily throwing him to the ground," while Cheffers said, "[Carr] gets full protection of all aspects of what we give the quarterback in a passing posture. So when he was tackled, my ruling was the defender landed on him with full body weight. The quarterback is protected from being tackled with full body weight."

Cheffers did not think any consideration needed to be made for the fact that the ball had popped out of Carr's hands and was a live fumble.

While Jones was, in fact, bracing with one arm so as not to land his full body weight on Carr, Boger's interpretation of Jarrett's play is particularly egregious. There was no way Jarrett could finish the sack on Brady without violating the rule - either he had to land on Brady to complete the sack, or he had to spin Brady to the ground. That second choice was judged as throwing Brady down, even though the quarterback was pulling forward to get out of the sack.

And Jones' postgame interview hit on a concern that players have had about this rule since its introduction - the NFL may be demanding play outside the realm of physics. In 2018, Star Tribune reporter Ben Goessling asked Vikings safety Harrison Smith about roughing the passer penalties. Smith said, "As defensive players, we're not resistant to these [rule] changes. They just need to be ... physically possible, I guess."

Announcers in both games disagreed with officials, with Joe Buck saying, "I mean at some point you have to be realistic with where the defensive player - what's he supposed to do, disappear? I mean, he's there, the ball comes out, the ball's in his gut and I don't know where he's supposed to go" in the Raiders-Chiefs game, and Troy Aikman echoing his disbelief, ultimately concluding that "it was a bad call."

Daryl Johnston, watching Brady spin to the ground, said, "I don't understand that one... He's going to be down onto the hips of Tom Brady while he's in pursuit, so he's spinning around, too. There's no intent to hurt the quarterback right there. I just don't know how you call that. That is not in the spirit of the rule, the way it was created to protect quarterbacks going to the ground."

Johnston hits on a key point critical to the nature of the rule - on these plays, there does not seem to be a present danger to the quarterback in a way that seems outside of the spirit of the game. Football is a violent sport, and that's a major part of its appeal.

The NFL is not blind to this, and they used to sell highlight reels of big hits before it became clear that some of the celebrations of big hits might run counter to their public commitment to player safety. Any game where play is stopped by a player being taken to the ground will necessarily be violent, and removing that aspect of the game is neutering what makes it an exciting affair for players and fans.

The goal of the NFL and the NFLPA should be to maximize player safety while also preserving the essence of the game, and this type of rule enforcement does not do that.

This brings us back to the other controversy surrounding quarterbacks, one which led to Teddy Bridgewater leaving the Dolphins game without being diagnosed with a concussion, perhaps as an overreaction to Tagovailoa's return after not having been diagnosed following the first major hit.

Player Rules Aren't the Only Solution

The NFL cannot solve every problem with rules governing player behavior. It is entirely conceivable that the rules in place - already restrictive to defensive players bearing down on quarterbacks in the pocket - do as much as can be done to prevent concussions.

Instead, the NFL should continue to invest in technology that reduces concussion incidence and improve player safety following injuries. This time around, the concussion protocol did not appear to do that.

Tagovailoa took a nasty hit in the Dolphins' Week 3 matchup against the Buffalo Bills and took some time getting up. When he did get up, he shook his head before falling back down to the ground. As he got up a second time, he showcased significant motor instability and was taken to the sideline for a concussion evaluation.

As we learned from the joint investigation from the NFL and NFLPA, the unaffiliated neurotrauma consultant (UNC) and team medical staff reviewed the video of the play, and each conducted an examination of Tagovailoa - one that would include Maddocks questions as well as diagnostic questions, an eye exam and an examination of motor instability - concluding that Tagovailoa did not exhibit any symptoms of a concussion aside from the initial motor instability found on video.
MORE: A Better NFL Schedule? Mid-Week Football With No Short Weeks
There was an alternate explanation for that instability, as Tagovailoa suffered ankle and back injuries earlier in the game, something the quarterback himself brought up. They concluded that because Tagovailoa had suffered back injuries and did not demonstrate any other concussion symptoms that there was an alternate cause for his motor instability and that he could be cleared to return to the game.

There are several problems with this, however. The first is that concussion symptoms are not always immediately present, and concussions can often present with only one visible symptom in the moments following an injury.

The second is that Tagovailoa did not suffer just one symptom, he suffered several. As neurologist Chris Nowinski - who predicted that a second concussion was more likely for Tagovailoa in the Thursday Night Football matchup against the Bengals - pointed out, Tagovailoa exhibited multiple symptoms.

He grabbed his helmet following the hit (one), he was off-balance immediately after getting up (two), he "shook out the cobwebs" (three), then he fell (four) and fell again (five).

Nowinski, in particular, pointed out that there was not much reason for a player who is suffering from a back injury to shake his head side to side as if clearing his head.

The third problem compounds the second: the Dolphins did not conduct a secondary examination of Tagovailoa's back or ankle after the hit to confirm that this was the proximate cause of his instability.

This is an issue with the protocol but also a worrying sign of the attitudes in the NFL - the Dolphins were looking for a way out, not looking out for the best interests of the player, who has an incentive to misdiagnose or misreport the causes of instability in order to return to the field.

Because the Dolphins ultimately make the final call in consultation with the UNC, it is on them to make the secondary examination of any alternate explanations for instability.

In this case, the UNC only conducted an examination with the tools available to him at the game. Those tools rely on player feedback. The UNC could not perform the secondary examination of Tagovailoa's back, which was up to the team.

The reason this ignited into a scandal instead of a weeklong controversy is that Tagovailoa suffered a second hit to the head in the following game, just four days later. He suffered severe concussion symptoms, which is consistent with the increased likelihood and severity of traumatic brain injuries while still recovering from the initial concussion.

There is also the possibility of a rare condition known as Second Impact Syndrome, often fatal or disabling, to appear in this circumstance - though the condition is controversial, it should nevertheless be considered in the range of outcomes for players returning to play while not having recovered.

Concussions are notoriously difficult to diagnose and do not show up in CT scans or MRIs - only secondary symptoms, not always present, will show up in those scans - so it would have been difficult to confirm that Tagovailoa suffered a concussion after the game. But without confirmation that there was an alternate explanation for Tagovailoa's symptoms, the Dolphins were questionable at best, irresponsible at worst, in their care of their star quarterback.

After all, a back injury severe enough to cause instability is itself a reason to take the quarterback out of the game, regardless. And a back injury that significant deserves a second examination.

These severe circumstances make it all the more likely that the NFL wants to be cautious about implementing a change in the rules that, in their eyes, could increase the likelihood of player injury.

Naturally, the NFL wants to reduce the incidence of concussions, not just make sure that players are prevented from exacerbating concussions they've already received. But there are limits to what players can be protected from before making the game unrecognizable.

The NFL Runs on Informed Consent

The key element that allows gladiatorial contests like the NFL to exist at all is informed consent. Players agree to the risk of injury when playing the game, and the reason the NFL was in hot water with regards to concussions was that they had information about the risks of a particular type of injury that they did not share with players - who therefore could not make an informed decision about the risks to play.

We know this impacts player decisions even before they are diagnosed with concussions. There are direct and explicit examples, like former 49ers linebacker Chris Borland retiring early despite playing well through his rookie contract, and direct implicit examples, like former Ravens guard John Urschel's early retirement.

That doesn't include players who suffered multiple or severe concussions throughout their career that retired early because of them, like former Carolina Panthers linebacker Luke Kuechly, who may have attempted to continue playing football in a world where information about the impact of concussions was unclear.

There are also an unknown number of players out of the spotlight who may have retired for similar reasons or moved up their retirement schedule out of concerns about potential neurological symptoms down the road.

Players want to avoid injuries of all types, but the nature of brain injuries versus other types of injuries forces players to consider the difference between an injury that can alter one's career, like a torn ACL, and one that can alter one's conception of the self.

Persistent memory loss, light sensitivity, and mood changes can be traumatic, and players looking down the road will make different decisions about injuries based on how important those concerns are.

In this case, the NFL cannot regulate away the risk and will find itself compromising its own game if it attempts to do so. Instead, the NFL needs to respect the covenant between player and doctor, and enable medical professionals to protect players once the game has started.

The NFL can eliminate or significantly curtail enforcement of the body-weight rule, which has frustrated defensive players, confused fans, and made for a worse game. They can also protect players from neurological damage, a different class of damage than ligament, bone, or muscle injury.

While these goals can appear to be in conflict, they aren't. The risk is that the NFL uses one player safety controversy to mitigate their actions on another player safety controversy. They shouldn't.

# data[].attributes.attachment_link.title
In the Choice Between Reducing Concussions and Roughing the Passer, There Is No Conflict

# data[].attributes.attachment_link.description
The NFL finds itself in an unenviable position of being at the forefront of controversy over concussions while also seeing backlash from fans in their attempts to protect quarterbacks from the very hits that could create additional injuries. With the rules protecting passers, it seems impossible for defenders to effectively sack the opposing quarterback.

# data[].attributes.attachment_link.readable_text
The N.F.L. and its players' union said Saturday that doctors followed the concussion protocol in treating Miami Dolphins quarterback Tua Tagovailoa after he hit his head in a Sept. 25 game, but that the protocol will be changed because Tagovailoa's return to the field was not what was intended by the rules covering the evaluation of brain injuries.

In the second quarter of a game against the Buffalo Bills, Tagovailoa hit the back of his head against the turf after a late hit by a defender, then he grabbed his helmet, struggled to get up and fell again. He returned to the game in the second half. The players' union - the N.F.L. Players Association - initiated a joint investigation with the league into how the episode was handled by the Dolphins team medical staff and an unaffiliated neurotrauma consultant on the sideline.

That review showed that the protocol was followed and that Tagovailoa did not display concussion-like symptoms during a locker room evaluation or in the days after. Instead, he said that he aggravated a back injury, which led him to stumble and fall. The scene of Tagovailoa wobbling as teammates held him up after the hit led many people to assume that he had sustained a concussion. The team physician and the consultant did not examine Tagovailoa's back before concluding that the back injury caused his instability and sending him back into the game, the review showed.

Tagovailoa also played four days later against the Cincinnati Bengals and again hit his head when he was slammed to the field after a tackle. He was taken to the hospital and released that night. Tagovailoa is now in the concussion protocol, which requires concussed players to complete a five-phase recovery process before they can be cleared to play. Tagovailoa has been ruled out for Sunday's game against the Jets.

The amended protocol, which will take effect during Sunday's games, will prohibit a player from returning to play if he shows ataxia, a term describing impaired balance or coordination caused by damage to the brain or nerves. Under the previous protocol, which was used in Tagovailoa's case, a player with "gross motor instability" - difficulty getting up or walking, for example - could return to play if doctors decided there was an orthopedic reason for his unsteadiness.

Allen Sills, the N.F.L.'s chief medical officer, did not definitively say that Tagovailoa did not suffer a concussion in the Bills game - only that the review showed the doctors took appropriate steps and made a medical judgment based on the information they had at the time. Under the new rules, Sills said, Tagovailoa would have been ruled out and not allowed to return to that game.

"We want to become even more conservative, and if we think that ataxia is present, let's just go ahead and assume it is coming from the brain and we will hold someone out," Sills said. "Because if we are going to be wrong, we would rather hold someone out who doesn't have a brain injury but we are being cautious, than to put someone out who might have a brain injury and we weren't able to diagnose it."

If ataxia is observed during the game, the player will automatically be diagnosed with a concussion, as is the case with symptoms like loss of consciousness or an impact seizure. The player then will be required to follow the five-step return-to-play process.

The players' union took the unprecedented step of dismissing the unaffiliated neurotrauma consultant involved in Tagovailoa's care during the Bills game, a decision the N.F.L. said it did not support. The doctor's name was not released. According to the concussion protocol, while the consultant collaborates in the evaluation of the player, the responsibility for the diagnosis of a concussion and the decision to return a player to the game "remains exclusively" with the judgment of either the head team physician or the team doctor designated to handle concussion care.

The Dolphins' head team physician, John Uribe, is a board-certified orthopedic surgeon and, according to his profile on the N.F.L. Physicians Society website, received a certificate of added qualification in sports medicine in 2007. He is affiliated with the Baptist Health Medical Group in southern Florida and is also a team physician for the N.H.L.'s Florida Panthers.

The Dolphins did not respond to a message seeking comment on the results of the joint review and asking if Uribe, who accompanied Tagovailoa to the locker room during the Bills game, was the team doctor who cleared him to return.

# data[].attributes.attachment_link.title
N.F.L. and Players' Union Agree to Change Concussion Rules

# data[].attributes.attachment_link.description
The N.F.L. and its players' union said Saturday that doctors followed the concussion protocol in treating Miami Dolphins quarterback Tua Tagovailoa after he hit his head in a Sept. 25 game, but that the protocol will be changed because Tagovailoa's return to the field was not what was intended by the rules covering the evaluation of brain injuries.

# data[].attributes.headline
New Revision Concerns Ataxia- poor muscle control that leads to clumsy voluntary movements

# data[].attributes.subject
New Revision Concerns Ataxia- poor muscle control that leads to clumsy voluntary movements

# data[].attributes.body
Following the hit on Miami QB Tua Tagovailoa, backup Teddy Bridgewater was the first player to be pulled out of the game after new protocols.

# data[].attributes.attachment_link.title
Explaining the NFL’s latest concussion controversy and policy change

# data[].attributes.attachment_link.description
As the NFL heads into its sixth week, concerns around brain injuries are at a renewed high after a dramatic hit on quarterback Tua Tagovailoa prompted a change to the league’s concussion protocol.

# data[].attributes.body
The NFL-NFLPA has closed the "loophole" on gross motor instability poor co-ordination, poor balance, difficulty with hand eye coordination tasks and movements that lack fluency.

# data[].attributes.attachment_link.title
NFLPA approves updated concussion protocol, next step is for NFL to sign off on changes

# data[].attributes.attachment_link.description
The NFL Players Association’s healthy and safety committee on Friday formally approved the updated concussion protocol, meant to close the “loophole” on gross motor instability. The next step is for the NFL to sign off on the final language of the updated

# data[].attributes.body
CTE, chronic traumatic encephalopathy, causes areas of the brain to waste away. This is caused by repeated blows to the head and repeated episodes of concussion.

# data[].attributes.attachment_link.readable_text
Overview

Chronic traumatic encephalopathy (CTE) is the term used to describe brain degeneration likely caused by repeated head traumas. CTE is a diagnosis made only at autopsy by studying sections of the brain.

CTE is a rare disorder that is not yet well understood. CTE is not related to the immediate consequences of a late-life episode of head trauma. CTE has a complex relationship with head traumas such as persistent post-concussive symptoms and second impact syndrome that occur earlier in life.

Experts are still trying to understand how repeated head traumas - including how many head injuries and the severity of those injuries - and other factors might contribute to the changes in the brain that result in CTE.

CTE has been found in the brains of people who played football and other contact sports, including boxing. It may also occur in military personnel who were exposed to explosive blasts. Some signs and symptoms of CTE are thought to include difficulties with thinking (cognition) and emotions, physical problems and other behaviors. It's thought that these develop years to decades after head trauma occurs.

CTE cannot be made as a diagnosis during life except in those rare individuals with high-risk exposures. Researchers do not yet know the frequency of CTE in the population and do not understand the causes. There is no cure for CTE. Researchers are currently developing diagnostic biomarkers for CTE, but none has been validated yet.

Products & Services

Symptoms

There are no specific symptoms that have been clearly linked to CTE. Some of the possible signs and symptoms of CTE can occur in many other conditions. In the few people with proved CTE, signs and symptoms have included cognitive, behavioral, mood and motor changes.

Cognitive impairment

Difficulty thinking (cognitive impairment)

Memory loss

Problems with planning, organization and carrying out tasks (executive function)

Behavioral changes

Mood disorders

Depression or apathy

Emotional instability

Substance misuse

Suicidal thoughts or behavior

Motor symptoms

Parkinsonism

Motor neuron disease

CTE symptoms don't develop right after a head injury, but experts believe that they might develop over years or decades after repeated head trauma. Experts currently believe that CTE symptoms appear in two forms. In early life between the late 20s and early 30s, the first form of CTE may cause mental health and behavioral issues including depression, anxiety, impulsivity and aggression. The second form of CTE is thought to cause symptoms later in life, around age 60. These signs and symptoms include memory and thinking problems that are likely to progress to dementia.

The full list of signs to look for in people with CTE at autopsy is still unknown. It is unclear what kind of symptoms, if any, CTE may cause during life. Little is known right now about how CTE progresses.

When to see a doctor

CTE is thought to develop over many years after repeated brain injuries that may be mild or severe. However, see your doctor in case of the following:

Suicidal thoughts. Research shows that people with CTE may be at increased risk of suicide. If you have thoughts of hurting yourself, call 911, your local emergency number or the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255).

Head injury. See your doctor if you've had a head injury, even if you didn't need emergency care. If your child has received a head injury that concerns you, call your child's doctor immediately. Depending on the signs and symptoms, your doctor may recommend seeking immediate medical care.

Memory problems. See your doctor if you have concerns about your memory or other thinking (cognitive) or behavior problems.

Personality or mood changes. See your doctor if depression, anxiety, aggression or impulsivity occur.

Causes

Repetitive head trauma is likely the cause of CTE. Football and ice hockey players, as well as military personnel serving in war zones, have been the focus of most CTE studies, though other sports and factors such as physical abuse also can lead to repetitive head injuries.

However, not all athletes and not everyone who experiences repeated concussions, including military personnel, go on to develop CTE. Some studies have shown no increased incidence of CTE in people exposed to repeated head injuries.

In brains with CTE, researchers have found that there is a buildup of a protein called tau around the blood vessels. Tau buildup in CTE is different from accumulations of tau found in Alzheimer's disease and other forms of dementia. CTE is thought to cause areas of the brain to waste away (atrophy). Injuries to the sections of nerve cells that conduct electrical impulses affect communication between cells.

It's possible that people with CTE may show signs of another neurodegenerative disease, including Alzheimer's disease, amyotrophic lateral sclerosis (ALS) - also known as Lou Gehrig's disease - Parkinson's disease or frontotemporal lobar degeneration (frontotemporal dementia).

Risk factors

Repeated exposure to traumatic brain injury is thought to increase the risk of CTE, but experts are still learning about the risk factors.

Prevention

There is no treatment for CTE. But CTE may be prevented because it is associated with recurrent concussions. Individuals who have had one concussion are more likely to have another head injury. The current recommendation to prevent CTE is to reduce mild traumatic brain injuries and prevent additional injury after a concussion.

Show references

1. Asken BM. Research gaps and controversies in chronic traumatic encephalopathy. JAMA Neurology. 2017; doi:10.1001/jamaneurol.2017.2396.

2. Evans RW. Sequelae of mild traumatic brain injury. https://www.uptodate.com/contents/search. Accessed March 2, 2021.

3. Concussion: Mayo's multidisciplinary approach. Mayo Clinic Neurosciences Update. 2013;10:2.

4. Malec JF, et al. The Mayo classification system for traumatic brain injury severity. Journal of Neurotrauma. 2007; doi:10.1089/neu.2006.0245.

5. Lee BG, et al. A systematic review of positron emission tomography of tau, amyloid beta, and neuroinflammation in chronic traumatic encephalopathy: The evidence to date. Journal of Neurotrauma. 2018; doi:10.1089/neu.2017.5558.

6. Eapen BC, et al., eds. Chronic traumatic encephalopathy. In: Brain Injury Medicine: Board Review. Elsevier; 2021. https://www.clinicalkey.com. Accessed March 2, 2021.

7. Chronic traumatic encephalopathy. Alzheimer's Association. https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/chronic-traumatic-encephalopathy-(cte). Accessed March 2, 2021.

8. Perrine K, et al. The current status of research on chronic traumatic encephalopathy. World Neurosurgery. 2017; doi:10.1016/j.wneu.2017.02.084.

9. Turk KW, et al. Chronic traumatic encephalopathy. Continuum. 2019; doi:10.1212/CON.0000000000000686.

10. Concussion: A fact sheet for coaches. Centers for Disease Control and Prevention. https://www.cdc.gov/headsup/pdfs/custom/headsupconcussion_fact_sheet_coaches.pdf. Accessed March 2, 2021.

11. Heads up: Concussion in youth sports. A fact sheet for youth sports coaches. Centers for Disease Control and Prevention. https://www.cdc.gov/headsup/youthsports/coach.html. Accessed March 2, 2021.

12. McCrory P, et al. Consensus statement on concussion in sport: The 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 2017; doi:10.1136/bjsports-2017-097699.

13. Recovery from concussion. Centers for Disease Control and Prevention. https://www.cdc.gov/headsup/basics/concussion_recovery.html. Accessed March 2, 2021.

14. Neurological diagnostic tests and procedures fact sheet. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Neurological-Diagnostic-Tests-and-Procedures-Fact#2. Accessed March 2, 2021.

15. Bonfante E, et al. Imaging of chronic concussion. Neuroimaging Clinics of North America. 2018; doi:10.1016/j.nic.2017.10.001.

16. NIH chronic traumatic encephalopathy diagnosis conference. National Institutes of Health. https://www.ninds.nih.gov/Current-Research/Focus-Research/Traumatic-Brain-Injury/NIH-Chronic-Traumatic-Encephalopathy. Accessed March 2, 2021.

17. Knopman DS (expert opinion). Mayo Clinic, Rochester, Minn. March 13, 2019.

18. Evans RW, et al. Acute mild traumatic brain injury (concussion) in adults. https://www.uptodate.com/contents/search. Accessed March 2, 2021.

19. Yuan SH, et al. Alzheimer's dementia due to suspected CTE from subconcussive head impact. Case Reports in Neurological Medicine. 2018; doi:10.1155/2018/7890269.

20. Sparks P, et al. Neuroimaging in the diagnosis of chronic traumatic encephalopathy: A systematic review. Clinical Journal of Sports Medicine. 2020; doi:10.1097/JSM.0000000000000541.

21. Home. National Suicide Prevention Lifeline. http://www.suicidepreventionlifeline.org. Accessed March 8, 2019.

22. Brown AY. Allscripts EPSi. Mayo Clinic. March 5, 2021.

23. Ferri FF. Chronic traumatic encephalopathy. In: Ferri's Clinical Advisor 2021. Elsevier; 2021. https://www.clinicalkey.com. Accessed March 2, 2021.

24. Graff-Radford J (expert opinion). Mayo Clinic. March 3, 2021.

25. Boeve BF (expert opinion). Mayo Clinic, Rochester, Minn. March 25, 2016.

26. Abreu MA, et al. Chronic traumatic encephalopathy (CTE) and former National Football League player suicides. The Sport Journal. 2016. https://thesportjournal.org/article/chronic-traumatic-encephalopathy-cte-and-former-national-football-league-player-suicides/. Accessed March 2, 2021.

27. Bieniek KF, et al. Chronic traumatic encephalopathy pathology in a neurodegenerative disorders brain bank. Acta Neuropathology. 2015; doi:10.1007/s00401-015-1502-4.

28. Bieniek KF, et al. The second NINDS/NIBIB consensus meeting to define neuropathological criteria for the diagnosis of chronic traumatic encephalopathy. Journal of Neuropathology and Experimental Neurology. 2021; doi:10.1093/jnen/nlab001.

29. Savica R, et al. High school football and risk of neurodegeneration: A community-based study. Mayo Clinic Proceedings. 2012; doi:10.1016/j.mayocp.2011.12.016.

30. Brown AW (expert opinion). Mayo Clinic, Rochester, Minn. March 18, 2016.

31. Mielke MM (expert opinion). Mayo Clinic, Rochester, Minn. March 18, 2016.

32. Savica R (expert opinion). Mayo Clinic, Rochester, Minn. March 14, 2019.

# data[].attributes.attachment_link.title
Chronic traumatic encephalopathy - Symptoms and causes

# data[].attributes.attachment_link.description
Chronic traumatic encephalopathy (CTE) is the term used to describe brain degeneration likely caused by repeated head traumas. CTE is a diagnosis made only at autopsy by studying sections of the brain. CTE is a rare disorder that is not yet well understood.

# data[].attributes.body
After Miami Dolphins Quarterback, Tua Tagovailoa, suffered a potential career ending injury, The National Football League Players Association came together to help form newer and better concussions protocols.

# data[].attributes.attachment_link.readable_text
MIAMI GARDENS, Fla. - The NFL and NFL Players Association agreed to modify the league's concussion protocol following a joint investigation into the league's procedures after Miami Dolphins quarterback Tua Tagovailoa suffered an injury against the Buffalo Bills last month.

The league and players' union said in a joint statement Saturday that the outcome of the Tagovailoa case "was not what was intended when the Protocol was drafted." As a result, language addressing abnormality of balance/stability was added to the league's protocol list of symptoms that would keep a player from returning to action.

In the first half of the Sept. 25 game against Buffalo, Tagovailoa took a hit from Bills linebacker Matt Milano, which caused him to slam to the ground. He appeared disoriented afterward and stumbled as he tried to get to his feet.
Tagovailoa was immediately taken to the locker room and taken through the NFL's concussion protocol, after which he was cleared of any head injury. He started the third quarter, drawing criticism from viewers about why he was allowed to return to the game.

The NFL and NFLPA said they reviewed video and jointly interviewed members of the Dolphins' medical staff, the head athletic trainer, the Booth ATC Spotter, the Unaffiliated Neurotrauma Consultant and Tagovailoa.

They found that Tagovailoa did not show any signs or symptoms of a concussion during his locker room exam, during the rest of the game, or throughout the following week. But immediately after he took the hit from Milano, gross motor instability was present.

After the game, Tagovailoa and Dolphins coach Mike McDaniel said the quarterback had suffered a back injury earlier in the game on a quarterback sneak.

The review said Tagovailoa told the medical staff that he aggravated his back injury on the play in question and that his back injury caused him to stumble. It also said the medical staff determined that the gross motor instability was not due to a concussion.

In their statement Saturday, the NFL and players' union said there was not examination of the QB's back during the concussion examination, but that they "instead relied on the earlier examination conducted by other members of the medical staff." The conclusion then was that the back injury was the cause of Tagovailoa's instability.

The new protocol involves "ataxia"

As a result of the joint investigation, the league and union agreed to change the league's concussion protocol to include the term "ataxia." In the statement, they defined ataxia as "abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue."

Ataxia replaced the term "gross motor instability" and has been added to the list of symptoms that would prohibit a player from returning to the game. The others are confusion, amnesia and loss of consciousness.

"The Protocol exists to establish a high standard of concussion care for each player," the league and union's statement said, "whereby every medical professional engages in a meaningful and rigorous examination of the player-patent. To that end, the parties remain committed to continuing to evaluate our Protocol to ensure it reflects the intended conservative approach to evaluating player-patients for potential head injuries."

On Oct. 1, the union fired the Unaffiliated Neurotrauma Consultant who handled Tagovailoa's situation during the game.

Jeff Miller, the NFL's executive vice president overseeing health and safety, said in a virtual news conference Saturday that he believes this is the first time a UNC has been fired, and that the NFL did not support the decision to fire him.

Less than a week after the injury, Tagovailoa started against the Cincinnati Bengals in a Thursday night game. He suffered a concussion in the first half after taking a hard sack, and displayed the fencing response after the scary hit. He was stretchered off the field and immediately taken to the hospital. He remains in the concussion protocol and will miss Sunday's game against the Jets.

Dr. Allen Sills, the NFL's Chief Medical Officer, said that under the league's amended protocol, Tagovailoa would have been diagnosed with a concussion on Sept. 25 under the ataxia term, thus making him ineligible to come back into that game.

Sills said there's no exact timetable for return for a player diagnosed with a concussion, but it would be "extremely unlikely" for a player diagnosed with ataxia to be able to play on Thursday night. The median time out with a concussion is nine days, he added.

Sills also alluded to how difficult it is to definitively diagnose concussions. He mentioned that blood and saliva tests could help make concussion examinations more accurate.

Commissioner Roger Goodell said at a fan forum in London Saturday that the NFL will make a "change or two" to its concussion protocol.

McDaniel, asked repeatedly in the days following the incident about the decision to allow Tagovailoa to return, emphasized his confidence in the team's handling of the situation.

"This is a player-friendly organization that I make it very clear from the onset," McDaniel said last week, "that my job as a coach is here for the players. I take that very serious, and no one else in the building strays from that."

# data[].attributes.attachment_link.title
The NFL and players union agreed to an updated concussion protocol

# data[].attributes.attachment_link.description
MIAMI GARDENS, Fla. - The NFL and NFL Players Association agreed to modify the league's concussion protocol following a joint investigation into the league's procedures after Miami Dolphins quarterback Tua Tagovailoa suffered an injury against the Buffalo Bills last month.

# data[].attributes.body
Amount of concussions tracked since the 2015 NFL Pre, Regular, and postseasons.

# data[].attributes.attachment_link.readable_text
The NFL Head, Neck and Spine Committee is composed of independent and NFL-affiliated medical professionals and focuses on neurological issues relevant to the health and safety of active NFL players.

Advise the NFL on medical policies, procedures and protocols

Determine and advise the NFL on best practices

Identify and recommend medical research that impacts the health and safety of active

NFL players

Oversee research when requested by the NFL and its collaborators

Analyze injury data and propose interventions

Create and supervise focused research groups with specific goals and assignments (e.g. biomechanical engineering)

Improve public education and advocate for enhanced sports safety

Areas of Focus

Moderate and Severe Brain Injury

# data[].attributes.attachment_link.title
NFL.com | Official Site of the National Football League

# data[].attributes.attachment_link.description
The official source for NFL news, video highlights, fantasy football, game-day coverage, schedules, stats, scores and more.