It was a pointed question from legendary Steelers coach Chuck Noll that sparked the development of the test used by nearly all professional sports teams and more than 2,400 high schools and colleges to determine if it is safe for an athlete who has suffered a concussion to return to play.
The year was 1990. Steelers quarterback Bubby Brister had suffered a concussion. Joseph Maroon, the team neurosurgeon, told Coach Noll he wouldn't clear Mr. Brister to play the following week against the Dallas Cowboys.
"He asked me, 'Why can't he?' " Dr. Maroon recalled.
"I said, 'Well, the guidelines say such and such ...'
"He said, 'Who wrote the guidelines?'
"And then he basically said, 'Look, Maroon. If you want me to keep an athlete out of football, I want objective data that you can show me indicating that there is something wrong with his cognitive abilities.'
"It was at that point I called Dr. Mark Lovell ..."
Dr. Lovell was then a colleague of Dr. Maroon's at Allegheny General Hospital. Dr. Lovell was the director of neuropsychology. Dr. Maroon was chairman of neurosurgery.
Dr. Lovell searched the literature and told Dr. Maroon there really was no objective test that fit Coach Noll's requirement. So the two devised one on pen and paper. Coach Noll agreed to have all the Steelers take it to establish a baseline.
This was the first objective test for concussions, but it was time-consuming, and not as effective as the doctors wanted.
"We needed to develop a computer-based program to allow for more broad-based testing of sports at all levels," Dr. Lovell said.
The result of their collaboration was ImPACT (Immediate Post-concussion Assessment and Cognitive Testing), a 20- to 25-minute video game that tests different aspects of memory and reaction time. If the athlete has taken a baseline test, a post-concussion ImPACT test can determine the extent of impairment or recovery.
It took considerable time to develop ImPACT because, Dr. Lovell said, "every concussion is different. You can't look for just one or two symptoms. We needed to develop the test to test all aspects of concussions. We had to develop something that is sensitive to the effects of concussion, but not so sensitive that we were picking up other things that were not related to the concussion."
The first version of ImPACT came out in 1997, at which time Dr. Lovell was director of neuropsychology at the Henry Ford Health System in Detroit. He returned to Pittsburgh in 2000, where he was the founding director of the University of Pittsburgh Medical Center's Sports Medicine Concussion Program. The year before, Dr. Maroon had returned to UPMC as vice chairman of the department of neurological surgery.
Shortly after ImPACT came out, the National Hockey League made it mandatory for all teams. The NFL followed suit in 2007.
"One of the reasons this really works is that it makes you remember things accurately and work as fast as possible," Dr. Lovell said. "This is very difficult to do when you have a concussion, because it puts the brain under pressure to do multiple things at once."
ImPACT becomes more valuable over time, because it makes it possible to track athletes from high school through college and into professional sports, Dr. Lovell said.
"We've been doing this long enough that we now have high school athletes who are now in college and we have a file on them. We can actually follow those athletes to make sure they're not having any dropoff in their scores over time."
Another benefit of ImPACT, the researchers found, is that athletes are less likely to lie to the computer.
"A really interesting thing we've found working with athletes, is that even though they'll tell their parents and their friends and their coach that they're fine, when you put them in front of a computer, they'll actually admit to their symptoms," Dr. Lovell said.
Dr. Maroon said he hoped the publicity surrounding concussions like that suffered by Ben Roethlisberger in Kansas City will cause more athletes to realize they need to be honest about their symptoms.
It would also be good if more fans realized the importance of taking precautions after a player has suffered a concussion.
"I'm looking out at the garbage that was left on my front lawn after the Steelers lost to Baltimore," Dr. Maroon said, laughing.
Coincidentally, a football concussion he suffered at the University of Indiana set Dr. Maroon on his career path.
"It was a very significant concussion that erased two or three weeks from my mind," Dr. Maroon recalled. "It forced me to quit football and apply to medical school."
Dr. Maroon has been the Steelers neurosurgeon, an unpaid position, since the late 1980s.
"I'd been asked to evaluate [Hall of Fame wide receiver] Lynn Swann for a concussion," Dr. Maroon recalled. "Afterwards, Mr. [Dan] Rooney asked me to become more formally involved."
In all his years with the Steelers, Dr. Maroon said, "I've never been asked to change my medical opinion."
Dr. Maroon is proof that not all who suffer serious concussions suffer lasting effects.
"No more than a few percent [of those who suffer concussions] go on to have significant difficulties later in life," said Dr. Jack Wilberger, Allegheny General Hospital chief of neurosurgery. "The puzzle is, who it is that's prone and why they're prone."
Brain metabolism studies suggest brain metabolism stays abnormal for a week to 10 days after a concussion. But Dr. Wilberger indicated more research needs to be done, particularly in how and why individuals differ in their response to concussion.
The next frontier for ImPACT is the U.S. military. About half the injuries soldiers have in Afghanistan and Iraq have been from explosions, which frequently cause concussions.
"About three years ago we pretested about 5,000 soldiers at Fort Bragg [N.C.] who were scheduled to shipped to Iraq," Dr. Maroon said. "If it's good enough for an NFL quarterback, it's good enough for a soldier in the field."
Jack Kelly can be reached at firstname.lastname@example.org or 412-263-1476.