Inside the Cowboys' concussion protocol: Tests, NFL requirements and aftermath

Dallas Cowboys' Rolando McClain defends against the Carolina Panthers during an NFL football game Thursday, Nov. 26, 2015, in Arlington, Texas. (AP Photo/Roger Steinman)

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Dallas Cowboys' Rolando McClain defends against the Carolina Panthers during an NFL football game Thursday, Nov. 26, 2015, in Arlington, Texas. (AP Photo/Roger Steinman)

Rolando McClain comes off the field after being kicked in the head by teammate Jeff Heath. He passes his concussion tests on the sidelines and returns to the game against Green Bay.

The Cowboys monitor him on the flight back to Dallas. There are no symptoms. McClain checks in with the training staff the next day and tells them he feels fine, but concedes he felt a bit fuzzy once he got home and took a shower.

He's been in the NFL's concussion protocol ever since.

McClain's case underscores the need for vigilance in dealing with this issue. The release of the movie "Concussion," set to open in theaters on Christmas Day, serves to intensify the conversation.

What procedures do the Cowboys and other teams follow? Who administers the tests and makes decisions? Based on discussions with club officials and players, here are the steps the Cowboys take from the time a player suffers a concussion to the time he's cleared to return.

Jim Maurer, the team's head athletic trainer, is usually the first person to make contact with the player. Dr. Robert Fowler is on the Cowboys sidelines as well. If both are attending to someone else and don't see the play, a certified athletic trainer (ATC) stationed in the press box notifies the staff that the player needs to be checked.

The ATC spotter has been part of the process since 2012 after Cleveland quarterback Colt McCoy suffered a helmet-to-helmet hit and the training staff failed to see the play or take action because they were working with another injured player.

Once Maurer and Fowler determine a concussion is a possibility an unaffiliated neurological consultant becomes involved. This person, known as an UNC, observes the exam. Each sideline has had a consultant since the '13 season. Every team in the NFL is required to identify a minimum of four unaffiliated consultants that can be used in its stadium.

Memory, concentration, visual acuity and balance are tested and compared to the player's baseline result, which is established heading into the season. It's common for teams to use the Balance Error Scoring System (BESS) where different stances on different surfaces are used to assess the player's stability.

Linebacker Sean Lee has suffered two concussions this season. He's been given six to seven numbers to recall while standing on the sidelines. He's been given a smaller group of numbers to recite backward.

"Some of the stuff is pretty challenging," Lee said.

It's a far cry from what linebacker Lee Roy Jordan was asked to do in his playing days. Jordan was with the Cowboys ('63-76) when players didn't suffer concussions, they got their bell rung.

The procedure: Jordan said a doctor or trainer would ask the player how many fingers he was holding up. It was always two. If the player didn't get the number right the first time, he got to keep trying until he did. He was then allowed to return to the game.

What McClain, Lee and others go through now is much more involved.

"They ask you on the sidelines to remember stuff and kind of how you're looking, how you respond," Lee said. "A lot of times guys, they're not themselves when they have a concussion and it's pretty easy for the trainer and the neurologist to identify it."

The test usually lasts for eight to 10 minutes, longer if needed. Some teams administer the test in the locker room. The Cowboys prefer to do it on the sideline.

The training staff makes it clear to the players twice in training camp, and again during the season, if they are unable to pass the test and are sent to the locker room during the game they will not be allowed to return, even if their symptoms abate and they feel fine. If a player passes the initial test, you will usually see them on an exercise bike or running in place. If symptoms don't appear during exercise and all signs are good, they are allowed to return to the game.

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These are the stages a player must clear to return to practice if it's determined he's suffered a concussion.

_Rest and recovery: A player can stretch and work on his balance but nothing more strenuous. The Cowboys advise their players to stay off the computer and avoid video games. No team meetings are allowed.

_Light aerobic exercise: Cardiovascular work is added. Players can attend meetings and film study but are told to get up and leave at any time during the meeting if they don't feel good.

_Increase work load: Weight training is added.

_Metabolic work: Player returns to the practice field and are allowed to do everything but contact.

_Return to practice: The Cowboys administer a computerized impact test and compare it against the player's baseline. Dr. Fowler reviews the results. If the numbers look good the player is taken to one of the four UNCs in the area for an independent evaluation. If the consultant clears the player neurologically he can return to practice.

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"They have an independent neurologist there so when you go through the protocol they're monitoring it," Lee said about what happens during the game. "Then after you're going through the protocol you go with another independent neurologist who the team uses and he clears you.

"They've done, I think, a good job of having a lot of people, a lot of resources, to look at you and make sure you're healthy and safe."

That's still not the end of the process with the Cowboys. A player can be cleared neurologically and still not feel right. Maurer and the training staff continue to monitor the player up to game day.

"Football is a violent sport and you're going to take hits where it's going to be borderline," Lee said. "Do you have a concussion? Where's the line where it is a concussion? I think they're trying to define that and it's not easy."

Lee suffered a concussion against New Orleans on Oct. 4 and another one five weeks later against Philadelphia. He knew immediately what had taken place. Not everyone does.

McClain suspected but wasn't sure until the next day. Defensive end Jeremy Mincey suffered a concussion when he butted helmets with teammate Tyron Smith in pregame warm-ups before the Philadelphia game in September but hid it from the training staff. He played that afternoon but his symptoms worsened and he missed the next game against Atlanta.

"The thing I've learned about concussions is people respond so differently," Lee said. "Some people have a ton of symptoms and they heal. Some people have no symptoms and maybe they're not healed. They still don't know enough to be like, 'You're healed' or 'you're great.' But they can go on the information they have and that of a lot of people who are looking at you.

"I think that's the best they can do right now."