Recommendations by the National Federation of State High School Associations (NFHS) that members adopt limits on full-contact practices in high school football have been gaining traction, with an increasing number of state associations adopting them, in whole or in part, or in some cases, pro-actively implementing risk reduction measures beyond those recommended by the organization.
The recommendations, contained in a position paper issued in July 2014 by a 24-member Concussion Summit Task Force including medical doctors, athletic trainers, high school coaches, and key national leaders in high school sports, and subsequently approved by the NFHS Sports Medicine Advisory Committee (SMAC) and the NFHS Board of Directors identified nine steps for minimizing head impact exposure and concussion risk in football:
1. Limit full contact practices, both regular and off-season: Full-contact should be limited during the regular season, as well as during activity outside of the traditional fall football season. For purposes of these recommendations and guidelines, full-contact consists of both "Thud" and "Live Action" using the USA Football definitions of Levels of Contact. 
Rationale: By definition, "Thud" involves initiation of contact at, or up to, full speed with no pre-determined winner and no take-down to the ground. Accordingly, the task force supports that initial contact, particularly with linemen, is just as violent with "Thud" as with "Live Action." However, the task force also recognizes that "Live Action" likely carries a higher risk for other injuries to the body than does "Thud." The USA Football Levels of Contact "Air," "Bags," and "Control" are considered no- or light-contact, and thus no limitations are placed on their use.
2. Consider variety of options in limiting contact.
- The task force strongly recommends no more than 2 to 3 full-contact practices per week.
- Consider limiting full-contact:
- on consecutive days, and
- to no more than 30 minutes per day, and
- to no more than 60-90 minutes per week.
Rationale: The task force acknowledges that there are insufficient data to specify with certainty a research-validated "best practices" standard for contact limitations. Several states (Alabama, Arizona, Maryland, and Texas) adopted varying limitations on contact prior to the 2013 football season. Preliminary High School RIO injury surveillance data suggest these states have seen a statistically significant decrease in concussion rates during practices, with no increase in concussion or other injuries during games.
3. Allow more full-contact practices in pre-season: Pre-season practices may require more full-contact time than practices occurring later in the regular season, to allow for teaching fundamentals with sufficient repetition.
A. Pre-season heat acclimatization protocols take precedence and should always be followed.
B. While total full-contact practice days and time limitations may be increased during the pre- season, the emphasis should focus on the proper principles of tackling and blocking during the first several practices, before progressing to "Thud" and "Live Contact."
Rationale: The task force acknowledges regular season practice limitations may need to be revised during the pre-season. This should be done in a specific and systematic manner to allow coaches to spend sufficient time teaching proper tackling and blocking techniques.
Emphasis should be placed on teaching inexperienced players, as they slowly work through tackling and blocking progressions with "Air," "Bags," and "Control" using the USA Football definitions of "Levels of Contact."
4. Only one full-contact practice during two-a-days: During pre-season twice-daily practices, only one session per day should include full contact.
Rationale: The adolescent brain needs sufficient recovery time following full-contact practices. In addition, concussion signs and/or symptoms may not develop for several hours after the initial injury (delayed symptom onset is more common among children and adolescents).
5. Review game action time: Each member state association should review its current policies regarding total quarters or games played during a one-week time frame.
Rationale: High School RIO injury surveillance data consistently show that competition presents the highest risk for concussion. The task force is concerned that participation in games at multiple levels of competition during a single week increases risk for head injury and unnecessarily increases head impact exposure. In addition, games played on consecutive days or those scheduled on the same day (Freshman and Junior Varsity games or Junior Varsity and Varsity games) may not allow the brain an opportunity to adequately recover.
Consideration should be given to moderating these situations as much as possible.
6. Modify policies regarding off-season football. Consistent with efforts to minimize total exposure to full-contact, head impact exposure, and concussion risk, member state associations with jurisdiction over football outside of the traditional fall football season should review their current policies to assess if those policies stand in alignment with the Fundamentals discussed within this report and, if needed, modify the policies accordingly.
Rationale: Football played outside of the traditional fall football season presents an opportunity for learning, physical activity, and skill development. However, athletes are at further risk for head impact exposure and concussion during any full-contact activity.
Consideration should be given to significantly limiting the total time of full contact. Other factors to consider include time elapsed since the previous football season and whether individual athletes have recently been, or are currently, participating in other contact/collision sports (e.g., Ice Hockey, Lacrosse, Soccer and Wrestling).
7. Develop coaching education programs integrating all levels of game. Each member state association should reach out to its respective state coaches' association on designing and implementing a coach education program that appropriately integrates youth, middle school, and high school football programs in every community. USA Football and the NFHS Fundamentals of Coaching courses should be the primary education resources for all coaches. Education for coaches should also include the proper fitting and care of helmets.
Rationale: The game of football continues to evolve and proper coaching technique at each level is fundamental to keeping the game safe and enjoyable. A properly fitted helmet may help decrease, but not eliminate concussion risk.
8. Schools should have concussion management protocols: Each member state association should regularly educate its schools on current state concussion law and policies and encourage schools to have a written Concussion Management Protocol. Schools should also be encouraged to share this information with coaches, parents, and students annually.
Rationale: Many schools experience frequent turnover of Athletic Directors and coaches. Frequent "refreshers" on state concussion laws and policies as well as sample concussion management protocols should be made available to ensure all schools are current on, and prepared for, safe and effective concussion management.
9. An Emergency Action Plan (EAP) with clearly defined written and practiced protocols should be developed and in place at every high school. When possible, an athletic trainer should be present at all practices and games.
Rationale: An effective EAP should be in place, as a prompt and appropriate response to any emergency situation can save a life. The EAP should be designed and practiced to address all teams (Freshman, Junior Varsity, and Varsity) and all practice and game sites. An athletic trainer is a key component in any strategy to minimize injury risk and optimize safety for all participants.
"The primary concern of the NFHS Concussion Summit Task Force was to limit head impact exposures and try to minimize the long-term, cumulative negative effects related to non-concussive blows to the head and body," said Dr. William Heinz, chair of the committee in a September 2015 NFHS press release. "We were also very cognizant of trying to avoid any unintended consequences of increased injury rates related to not having the players adequately prepared for game situations. We feel the recommendations achieve a good balance between the two goals."
