New NHL Concussion Guidelines: Let’s Get the Doctor Involved!

By Jo Innes

There can’t be a hockey discussion without a head injury discussion. It’s no surprise that day one of NHL GM meetings in Boca Raton has already produced policy changes that aim to increase player safety and reduce injury. Some of the changes will go into effect almost immediately; some will be implemented at the beginning of next season. Commissioner Gary Bettman laid it out in five steps:


  1. Equipment changes – reduce the size without reducing the safety.
  2. Revise concussion management protocols – have a doctor (not a trainer) make immediate return to play decisions.
  3. Hold club and coach responsible for players with repeated offenses leading to supplemental discipline.
  4. Study changes to rinks that can improve player safety – implement short-term fixes now, get rid of seamless glass for next season.
  5. Establish a committee dedicated to continued study of the issue.


Can we talk about step 2?

Currently, players with suspected concussions are evaluated by the trainer, generally on the bench. The trainer’s evaluation has two possible outcomes – no concussion suspected and the player returns

to the game immediately, or there is a suspected concussion and the player is removed to the dressing room and evaluated by the team physician. If the physician’s evaluation is suspicious for concussion, the NHL Protocol for Concussion Evaluation and Management kicks in and the player is kept out of play pending certain testing. The length of time is determined by the patient’s performance on neuropsychological tests (be patient, we’ll get into what those are), and the team physician makes the ultimate decision as to when the player can return. The current NHL protocols are stringent with regards to keeping players off the ice once they’ve had a concussion, but don’t go far enough to get them off the ice in the first place – a determined player could insist to the trainer that he’s fine and end up back on the next shift.

The new protocol requires that the player be evaluated by a physician if he exhibits any of the following:

  1. Loss of consciousness
  2. Motor incoordination/balance problems
  3. Slow to get up following a hit to the head
  4. Blank or vacant look
  5. Disorientation
  6. Clutching the head after a hit
  7. Visible facial injury in combination with any of the above

The physician will perform the evaluation in “…a quiet place free from distraction” (i.e. not the bench), and will use a standardized assessment tool – the NHL SCAT 2 (sports concussion assessment tool). After training the trainers and doctors in the specifics of the new concussion policy, Bettman stated he expects it to go into effect by the end of the week.

Neuropsychological testing? What?

Neuropsychological testing is a way of determining if someone’s brain is working properly by testing their ability to answer questions and perform simple memory and physical tasks. The roadside sobriety tests that cops perform are a great example of simple neuropsychological testing.

The big deal here is that players are going to be evaluated immediately using the SCAT 2, and not by being asked “Are you okay? You good to go back out?”. The SCAT 2 is a series of (neuropsychological) tests that was developed in 2008 at the 3rd International Conference on Concussion in Sport, and represents revisions to previous concussion assessment protocols. The SCAT 2 was designed for use by physicians, athletic trainers and other medical professionals. If you’d like to have a copy of your own, it’s available for free download.

The NHL is already using the SCAT 2 (as are the IIHF, FIFA, and several other big name sports organizations), but the bench is absolutely the wrong place to do it, and it likely wasn’t happening unless the trainer made the decision to pull the player for physician assessment.

What exactly is the SCAT 2?

Symptom evaluation:

The patient is asked if he has any of 22 different symptoms that you’d normally associate with a concussion (nausea, dizziness, headache, etc.), and grades them on a scale of 0-6 (none to severe). This assigns him a symptom severity score.

Cognitive and physical evaluation:

  1. Number of symptoms (out of 22)
  2. Physical signs: loss of consciousness or balance problem.
  3. Glasgow coma scale: Measures the ability to properly verbalize, follow motor commands, and open one’s eyes. This is a test commonly used on trauma patients to get a quick assessment of their overall level of consciousness. This is also a gross simplification on my part. Want to know more?
  4. Maddocks’ questions: A set of questions related to the game at hand and recent sport-related events (Where are we playing? What period is it? What team did we play last?”) that provides another gross overview of orientation and mental status.
  5. Cognitive evaluation: Includes orientation (Day, Date, Year, etc.), immediate memory (give the player a list of words and ask him to repeat them back to you), concentration (give the player a list of numbers, have him repeat them back in reverse order; have the player say the months of the year in reverse order).

Balance testing:

The player is asked to close his eyes and is given three 20-second standing trials – feet together, on one foot, and heel to toe.

Coordination testing:

The player is asked to sit with one arm outstretched to the side. He’s then asked to bend at the elbow and touch his nose five times in quick succession.

More cognitive testing:

The player is asked to recall the list of words from earlier in the test.

On my best day I’m not convinced this is clear now why it’s essential that this be performed in a quiet area with no distractions. The SCAT 2 assigns the player a score, which is actually not used to determine if he can return to play. What it does do is provide a great way to keep track of the player’s deficits over serial tests (i.e. give the same test multiple times and track the scores over time).

Return to Play

The SCAT 2 gives a great outline of a protocol that could be used to determine when a player could get back on the ice. First and foremost, it suggests that a player suspected of having a concussion should not return to play that same day (I’m looking at you, Crosby). It goes on to recommend that the player gradually resumes activity over a period of days (weeks, months, never) based on what he’s capable of doing – any limitation by symptoms means activity levels don’t progress upwards. The progression of activity would be:

  1. Complete rest until symptom-free
  2. Light aerobic exercise
  3. Sport-specific exercise
  4. Non-contact drills
  5. Full-contact drills after medical clearance
  6. Return to competition

The SCAT 2 and the NHL Protocol for Concussion Evaluation and Management leave plenty of room for the team physician to decide if the player is ready to get back in action. That, of course is the art of medicine. That’s also fodder for another huge debate – whether team doctors are looking out for the athlete’s best interests, the team’s interest in getting their player back on the ice, or the athlete’s insistence that he’s fine, Coach. Just fine.

Feel free to have that discussion amongst yourselves. Until I’m a team doctor, I won’t be making assumptions.