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The Worst Case

Doctors warn that repeated concussions can lead to permanent brain dysfunction

Thin November sunlight streams through a picture window, logs hiss in the fireplace, and as Al Toon uncurls his six feet four inches from a couch to stoke the fire, no living room in the world is this fragrant, this warm, this safe. "This," Toon says, "is a good day."

He is not talking about the crackling fire or the tranquil autumn afternoon. Since the terrible toll of concussions ended Toon's eight-year NFL career in 1991, the interiors of his life have been different. The 40 billion neurons in his brain sometimes do not obey orders. No, today is a good day in the one place it truly matters. Inside his head.

On days like these, Toon, 31, wants to smile. He isn't irritable. The slightest sound—an almost imperceptible buzz from a lightbulb, a hum from the computer in the study—doesn't assault him. Most mornings Nick, his six-year-old boy, walks into Al and his wife Jane's bedroom and asks, "How you feeling, Dad?" On days like these, Al answers, "Good, son."

Oh his bad days, however, a mental switch is thrown—"You know how an eye doctor puts a cloudy lens over your eye during an exam, and everything changes all of a sudden?" says Toon—and he is plunged into a part of himself that's painful to visit. He takes scant pleasure in his 40-acre spread, with its horses, polo field and riding arena, in the farm country west of Madison, Wis. He is short-tempered, fatigued, sensitive to light. He doesn't dance to his own beat; he just wants the drumming to stop.

The bad days are less frequent now, although Toon still can't watch his three children on a merry-go-round without getting dizzy. More than two years after his final concussion—the fifth or ninth or maybe the 13th of his NFL career, according to the various ways that concussions are defined and reported in football—Toon, a former New York Jet wide receiver, is suffering from postconcussion syndrome.

"People are missing the boat on brain injuries," says Dr. James P. Kelly, director of the brain-injury program at the Rehabilitation Institute of Chicago and an assistant professor of neurology at Northwestern University Medical School. "It isn't just cataclysmic injury or death from brain injuries that should concern people. The core of the person can change from repeated blows to the head.

"I get furious every time I watch a game and hear the announcers say, 'Wow, he really got his bell rung on that play.' It's almost like, 'Yuk, yuk, yuk,' as if they're joking. Concussions are no joke."

A concussion is a traumatically induced disturbance of neurological functions, most often the result of a direct blow to the head. A concussion can also occur during the rapid acceleration or deceleration of the head due to an event such as an automobile accident, even if the victim is restrained by a seat belt. There are three grades of concussion—although doctors disagree on certain points of classification—starting with the mildest and most common, the "ding" that has infiltrated the lexicon of America's Sundays.

According to a now widely accepted scale developed by Kelly, in a grade 1 concussion—the kind you might have if you bumped your head on a table and "saw stars" for an instant—a player remains conscious and suffers only momentary confusion, although he usually experiences headache, dizziness and some short-term memory loss. The athlete's head clears quickly, and no medical intervention is necessary. In a grade 2 concussion, the player suffers amnesia, as well as nausea and a ringing in the ears. A grade 3 concussion renders the athlete unconscious.

According to a somewhat different scale designed by Dr. Robert C. Cantu, chief of neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass., a loss of consciousness of from one to five minutes constitutes only a grade 2 concussion. The loss of consciousness for five minutes or more means a grade 3.

"Concussions are part of the profession, an occupational risk," says Elliot J. Pellman, the Jets' team doctor. A football player, he says, is "like a steelworker who goes up 100 stories, or a soldier."

Not only soldiers but also several field generals have been leveled in the 1994 NFL season, in which concussion has been a contagion. Quarterbacks Troy Aikman, Dave Brown, Chris Chandler, Jeff Hostetler, David Klingler, Chris Miller (page 48), Vinny Testaverde and Jack Trudeau have been sidelined by concussions. Tackle Steve Wallace, defensive end Jeff Lageman, defensive backs Ronnie Lott and Mark Collins and receivers Don Beebe, Tom Waddle, Raghib Ismail and Rob Moore are other prominent players who, in euphemistic gridspeak, have had their bells rung. A disoriented Merril Hoge, a fullback for the Chicago Bears, quit on Oct. 17 after suffering two concussions in six weeks.

League spokesman Greg Aiello says preliminary numbers for 1994 are in line with statistics on concussions for the past five years. According to data supplied by the 28 teams, 445 concussions were suffered by 341 players between 1989 and 1993. That is about four concussions per weekend, or 2.5 concussions for every 1,000 plays. On Dec. 9, Pellman, Dr. Andy Tucker of the Cleveland Browns and Dr. Ira Casson, a New York neurologist, met with league officials, including commissioner Paul Tagliabue, to discuss concussions and suggest ways to cut down on their frequency. No concrete proposals were adopted.

"Concussions are a hot topic because of the high-profile cases," says Jeffrey T. Barth, a University of Virginia neuropsychologist. "If Aikman had a knee injury before the Super Bowl, we'd be talking knees like crazy."

But, says Kelly, while damaged knees can be repaired, "the brain is the body's computer, the organ of the psyche. The evidence is clear that repeated insults will do neuropsychological damage."

Indeed, there is disturbing statistical and anecdotal evidence that concussions are the silent epidemic of football:

•Of the 1.5 million high school football players in the U.S., 250,000 suffer a concussion in any given season, according to a survey conducted for The American Journal of Public Health.

•A player who has already suffered a concussion is four times more likely to get one than a player who has been concussion-free. Quarterbacks, running backs, receivers and defensive backs are most vulnerable, although Barth's study of 10 college teams from 1982 to '86 revealed that special teams players were at the highest risk per minute spent on the field.

•Concussions are underreported at all levels of football. This is partly because of the subtlety of a mild concussion (unless a player is as woozy as a wino, the injury might go undetected by a busy trainer or coach) but primarily because players have bought into football's rub-dirt-on-it ethos. "If we get knocked in the head, it's embarrassing to come to the sideline and say, 'Hey, my head's feeling funny,' " says San Francisco 49er quarterback Steve Young, who has suffered at least a half dozen concussions. "So I'm sure we're denying it."

•Football's guidelines for players returning after concussions are sometimes more lenient than boxing's. The New Jersey Boxing Commission requires a fighter who is knocked out to wait 60 days and submit to an electroencephalogram (EEG) before being allowed back into the ring. On Nov. 21, the New York Giants' Brown was knocked out for 30 seconds when he was helmeted on the chin by Houston Oiler linebacker Lamar Lathon, but he started the following Sunday against the Washington Redskins.

•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."

These are guesses based on clinical observation. In fact, too many of the assumptions about concussions in football are based on observation instead of hard data. Take this question: Do concussions have a cumulative effect?

The answers: "Definitely" (Kelly), "Possibly" (Maroon) and "I know of no football player who has had residual neurological impairment from repeated insults to the head" (Joe Torg, the Eagles' team doctor). Torg says that boxing's punch-drunk syndrome doesn't apply to football, because rarely is a football player knocked unconscious.

Still, even one of Toon's neurons screams that concussions do add up. Toon was the Jets' emergency quarterback early in his career, taking snaps on Saturday in case disaster struck on Sunday. He knew the entire offense. Later, after numerous concussions. Toon would break from the huddle, split to his position and sometimes have trouble remembering his own assignment.

"You can see on the tapes the difference in force of the blows [that caused my concussions]," says Toon. "Each new concussion came from less of a blow, and recovery time increased. The last one, against Denver [Nov. 8, 1992], was hardly direct contact." After that concussion, Toon retreated to a dark room for six weeks, turned into a recluse and even contemplated suicide. He never played again.

Toon knew he was a different man from the one who had joined the NFL and immediately invited comparisons with Jerry Rice, but he had no way of measuring exactly how different. Only one NFL team, the Steelers, even attempts such a measure. In 1991 Pittsburgh instituted preseason neuropsychological tests. The tests establish individual baselines, measuring just how mentally aware each player is before a concussion. That gives the Steelers a basis for comparison after a concussion.

After the studies were instituted, former Steeler coach Chuck Noll "would be asking when a player would be fit after a concussion," Maroon says. "Instead of saying, 'Well, it's my feeling he isn't ready,' I had something tangible to show him."

Following his last concussion, Hoge went to Pittsburgh, where as a Steeler in 1993 he had taken a baseline test. Maroon reexamined and retested him. "His scores were significantly lower than at the start of 1993," Maroon says. "I told him. 'Look, Merril, here's where you were. Here's where you are.' " Hoge retired three days later.

To continue playing football would have left Hoge, who was suffering from postconcussion syndrome, at risk for something far more dangerous. There are fewer than 10 documented cases in sports of second-impact syndrome (SIS), a catastrophic brain swelling caused by a blow to an athlete who already shows postconcussion symptoms, and the odds against SIS are lottery long. That, however, doesn't console Lawrence and Irene Guitterez of Monte Vista, Colo. "He just thought it was something trivial," Irene says of her son, Adrian, who was a running back on the Monte Vista High team three years ago. "He had a headache and was sore, but it seemed like cold symptoms. He wasn't one to complain. He wouldn't say anything to anybody. He wanted to play in the Alamosa game."

He did play. At halftime Guitterez, who had suffered a concussion in a game two weeks before and had not yet shaken the symptoms, begged teammates not to tell the coaches how woozy he felt. When he was tackled early in the third quarter, he got up disoriented and then collapsed. Five days later he died.

When SIS is mentioned to Aikman, he is silent for 10 seconds. "We're all at risk," he says finally. "There are guys playing—and I might be one, for all I know—who have played with concussions without even knowing it. But because of the nature of the game, everyone is at risk."

The NFL has reduced some of the danger by outlawing head slaps and instituting rules to protect quarterbacks. But these measures are offset by increases in the size and speed of players, who in turn produce ever more violent collisions, and by heads bouncing off artificial turf. "That carpeted concrete is chaos," says Cantu.

After suffering concussions this season, the 49ers" Wallace and the Buffalo Bills' Beebe have turned to the ProCap, a polyurethane shell that attaches to the top part of the helmet. In laboratory tests the ProCap has reduced g-forces transmitted to the skull by an average of 30%, but a preliminary study by Torg and by Gary J. Stilwell at the University of Pennsylvania's Sports Medicine Center was inconclusive about ProCap's effectiveness in reducing the risk of concussion.

The virtual absence of brain testing is one of "the things that lead to the current problems," Kelly says. "I don't think most athletes want to know the effect an injury has had or the amount they've recovered, and I don't think most pro or college teams want their athletes scrutinized that way. They're not in the business of identifying worrisome neurological problems.

"I hope another player doesn't have to die before all this is taken seriously."



Toon (left) got out alive; Guitterez, whose CAT scan is held by Kelly, did not.



Maroon, holding the brain of an auto accident victim, introduced baseline tests for the Steelers.









Myelin Axon




[See caption above.]




[See caption above.]



Though Toon (88) suffers greatly, doctors are divided on the subject of cumulative concussion damage.



Guitterez (32) hid his symptoms until it was too late.

Anatomy of a Concussion

A blow to the head, such as a quarterback might receive from a defender's helmet, causes the brain not only to move forward and/or back in the skull but also to rotate, which distorts the axons that connect the brain cells, or neurons.

1. In a normal neuron, the axon, which is protected by a myelin sheath, is not broken or otherwise distorted.

2. After a concussive blow, an axon might twist or bend, interrupting communication between neurons.

3. If a concussion is severe enough, the axon swells and disintegrates. Less severely damaged axons return to normal.