The Worst Case

•According to Ken Kutner, a New Jersey neuropsychologist, postconcussion syndrome is far more widespread than the NFL or even those suffering from the syndrome would lead us to believe. "I counsel several Giants, past and present, but they don't want their names known," Kutner told The Tampa Tribune. Kutner says that the players fear that admitting to postconcussion syndrome might cost them a job after retirement from football.

Even the medical community isn't all on the same page of the textbook on concussions. In addition to having different grading systems, doctors disagree over how long an athlete with a grade 1 concussion must be asymptomatic before he is allowed to resume playing. Kelly's guidelines say 20 minutes, while Pellman uses 10 minutes as a rule of thumb. Most grade 1 concussions never make the NFL's injury reports.

"Think of a concussion as the lights going out," says Dr. Joseph C. Maroon, chairman of the department of neurological surgery at Allegheny General Hospital in Pittsburgh and a consultant to the Steelers. "Sometimes it's insignificant, just like a bulb dimming for an instant. Does a very mild concussion need to be reported? Probably not."

A concussion occurs when axons and their synaptic connections—the fibers that transmit impulses away from the brain's neurons—are stretched or distorted by a blow to or a sudden movement of the head. When these fibers have been mildly affected, mental awareness can return in seconds or minutes. If axons are severely stretched or even sheared, the lights go out and no one will be home for a while.

"To this day I don't recall playing in the [1993 NFC] championship game at all, and I don't think I ever will," says Aikman, who got a concussion in that game and has suffered two more concussions this season. "Last season's Super Bowl isn't real clear. I remember playing and being there, but what happened during the game isn't clear to me."

There are several ways to sustain a concussion. One is through deceleration of the head, such as occurred in the '93 NFC title game when Aikman's helmet collided with the knee of 49er defensive tackle Dennis Brown. When a head in motion is stopped abruptly, the skull stops, but the brain, swimming in spinal fluid, continues forward, sometimes striking the rough inner surfaces of the skull. Another common means of sustaining a concussion is through acceleration, which occurs when a head at rest—say, the head of a quarterback scanning downfield for a receiver—is jarred into motion by a blindside hit to the body. The brain is shaken on its stem like a pom-pom atop a car antenna.

Almost all deceleration and acceleration injuries involve some rotation of the head. In those cases centrifugal force combines with linear force to damage the axons. Coming or going, if enough axons are disturbed, the brain will short-circuit.

John Norwig, the Steelers" trainer, checks dinged players for telltale signs of concussion such as dilated pupils, assesses coordination and asks what day it is, who the opponent is. what the players ate for breakfast, what the score is and whether they can read the scoreboard.

"Veterans clear more quickly than rookies," says Dr. Pellman. "They can unscramble their brains a little faster, maybe because they're not afraid after being dinged. A rookie won't know what's happened to him and will be a little panicky. The veterans almost expect the dings. You have to watch them, though, because vets will try to fool you. They memorize the answers. They'll run off the field staring at the scoreboard."

Some veterans have gone through the neuropsychological sideline drills so often that even new concussions can't make them forget. Aikman has had at least half a dozen concussions in his six years with the Dallas Cowboys. Former Philadelphia Eagle quarterback Ron Jaworski counted more than 30 concussions in his 17-year NFL career. Former Cowboy star Roger Staubach retired after having suffered 20 concussions in the NFL. "We know that people who have a concussion tend to have more concussions," says Dr. Cantu. "Why? Two logical reasons. The first is that certain people can take a blow better than others; you see that in boxing all the time. But of equal, if not more, importance is how you play the sport. If you keep playing like a kamikaze, if you tackle with your head, there's more of a chance of being concussed than if you block or tackle with the shoulders."