It is my honor to introduce our next speaker colonel francis oconnor, m. D. Who is the professor and chair of military a friend medicine, took me around and it is a great place where we have training, medical training for those who be serving and providing service to men and women who serve our country. Trait he created a medical study on trying to understand sickle cell traits. He has been a mentor and a friend to john and me and doctors others. Thank you for coming here today. Thank you. , i amn honor to be here mrs. Shealy listening to your words and your passion. I will not forget. Im going to be moving away from cardiac and talking about exertional illness. I am with the department of defense and all the opinions i. Ave today are those of myself dozen one in minnesota in the midwest heat index 110,s junior vomited three times, complained of dizziness and be grand and be grand breathing heavily. 2006 Football Player collapsed on the field after exerting himself in. Early on he was showing to stress and difficulty breathing, complaining of tightness and having trouble standing and collapse. Michael, Football Player at west point. First day of Ranger School in fort benning falls ill on his first day. He adjusts completed a Training Session when he fell ill. Another Football Player, january 2017. Couldnt move his arms up to the second day. I could not even each. Is we wille seer talk a little bit about injury prevention, and focus on four entities. Heat stroke, sickle cell trait, hypernatremia and. With a specific focus on how we prevent these things. This is one of the leading models for intervention. Establish the extent of the injury. , try tothe severity establish how did this occur when injury mechanism introduce an injury and fastforward are we making a difference. On we seey to layer three different forms of prevention, primary, immunization secondary detective disease, check the Blood Pressure to identify hypertension, limit the consequences of tertiary disease. This carries right over into sports. This is alluded to and the athletes. Death and you see 56 is cardiovascular but there are others, blunt trauma, and the others. Heat stroke, sickle cell trait. Back to corey stringer on that fateful day we all know this was exertional heat stroke. We haven the military one million men and women active duty and reserves are at it is a big deal. The numbers. When we take a look at the numbers this is from 2013, 324 heat strokes. It tends to be the men over the women that have heat stroke, to toone. Pacificilitary asian islanders have twice the rate of stroke she strike than others. As the doctor talked about these things are common. 2014 and last year 470. Our numbers continue to climb but we dont have people dying because of some of these preventive measures. 1995 54 reported Football Players as a result of heat stroke. Most of these are in august, 60 . If you look at the exertion for football in 11 times greater than all other sports combined. This and exertion in mostoke is the most sports. Heat stroke we should prevent death. Shealyplayed out by mr. The Israeli Defense force looked ,t every single test death they found two items in 100 of the cases. Unmatched,fort was and absence of proper medical triage. Emergency was not ready to go. Risk factors from that early model, many of these were described by the doctor. Poor physical fitness. Transitionthese not only environment but physical. The doctor also talked about sleep. This is a powerful variable. Illness, how many kids are sick on that particular day, cap tilde drill sergeant i dont feel well. You can choose the day you are going to exercise. Drugs, i will talk about in a minute and the equipment. We take a look at what soldiers where. This is not exactly that they have an easy time in the heat with. Obesity, we have found this to be a powerful risk factor. This study was done by four bright, overweight three times more likely in the first 90 days of service. We know this is a problem in the military. Looking at football, a lot of kids running around are going to exertion. A lot of kids are on medication, medication for allergies, anything that will affect your , theseoutput, your sweat are Major Concerns that they need to be aware of as providers. Particularly in august for 2adays. Supplements, many of these, this is say soldier and this is with the pulled out his his locker. Just a is one supplement. God knows what the compensation is in this group. Prevention, what do we do . We want to make sure that if you go to a site, but the acclimatization is hydration, we need to keep kids cool. Accountability, and there is accountability to the commanders to adhere to this table you see here. This is a work rust water consumption table. Classified we then calculate appropriate cycles and how much water should be divided good if you start to get heat strokes, commander will be held accountable, did you follow the guidance to keep people safe. A hydrationoduced guideline and i was part of this document. There are important point coming out of this document was to avoid problems. Drink when thirsty, for lead athletes they may need more and drinking at first may not keep them to their edge. Individual inflation. Has one strategy for everybody. That will not work because people are different. Also published a guideline and the High School Level the leverage of acclimatization so we can change the trajectory of premature death. By ognizes the phone or vulnerable transition. No uniforms. Threece should not exceed hours. Very detailed. They are trying to propagate this throughout all states to ensure safety of Football Players. Its also clear outside of the , i want to bring your attention to the climate is Time Strategy is it takes and it is not two days. We really have to be careful with this transition. We have to keep people cool because we have to keep people in the fight. Prevent heat, simple things here you see a vacuum cool device for his hand, the military is looking at the microclimate cooling devices to keep people cool down to their underwear and simple things like to precool so they can go forward and exercise. Very important. Andtimes we need to jump in say not going to be a good day. This is from the chicago marathon in 1996 race over three hours and there were some in the heat strokes and ran out of water that they had to stop the race. To years ago the race had stop as well, 30 heat strokes. Says thereaper that is a way to determine that do not start temperature that maybe we live tos to fight another day. Follow the data and start to develop a plan that says maybe we go tomorrow, keeping you in the fight for a future marathon. Second intervention, i was moved , this isealys word what we leverage in the military, the buddy system, where somebody says johnny does not look right and they bring him to a medic. Cases whensentinel you see things pop up with one particular team or unit while having a bad trend something is not right. The other thing we do is we leverage the concept of what we call sheets heat dumping. Leveraging a hand cooling device. In the military we leveraged showers, we run kids through these all the time, the other thing is we have these cooling systems that are just towels filled with cold water, the kids do this to keep themselves school throughout. Prevention means gear ready. When somebody drops Everybody Knows the plan. Down in fort benning we have barrelsilled with filled with ice. This intervention alone will help to say that young mans life. The other thing and address should to this drill sergeant is we need rapid cooling intervention being prepared. We use a different technique where we have a gurney here forended over ice water cold water immersion. This is a picture from the marine corps marathon. With that being said it is a sheet attack. Heat attack. We have a detailed emergency races,plan for all the they had 100 heat strokes last summer. Away becauseks there is a good plan and they execute it and they practice it. Treatment here is immersion preparinghen we are to treat with reparations for transfer. It is all about a plan, practicing the plan and executing the plan. Exercised, this was an class associated with sickle cell trait. Generally thought to be a benign condition but it is clear in the sickleure will, that cell trait is associated with sudden death and other complications as you see here. If youry client are africanamerican you have 30 times the risk of sudden death in that first year if you have sickle cell trait. Has also established that africanamerican sickle cell politician , Football Player you sudden absolute risk of death. Deaths ande of these some of these sickle cell trait fall into another category. Lightning strikes that are common use that analogy. Are rare socations we need to have the right talents and the right near it up when we communicate to africanamerican athletes what is their risk and what is not their risk. What do we know about these deaths . These are drawn from case come up one athlete died in a workout. The unconditioned military recruits in that transition. , limited timeed for recovery and on cardiac arrest the athlete goes down, i cant with my legs, i cannot walk and there initially alert. This is a detailed slide taking a look at how the sickle cell trait cause death . There is a local environment here, increased temperature that somehow we are precipitant precipitating a crisis. There are a lot of different thoughts. Heat is thelieves principal culprit. Some think its all about hydration. A Team Physician oklahoma, keith is no more a trait for sickle cell trait. He believes that intensity is the key variable. This. Very interested in trill if you are sickle your ratecell trait of death is one and 1000. Same as had the why they dont doubt. That is interesting to us. What we are trying to uncover and explore is that maybe all sickle cell trait athletes are not the same. There might be Something Different in some that predisposes them. Of prevention the doctor talked about the screen 1, 2, and three that is recommended. You can wave out if you want but screen in is mandating mandated. ,he level for physicians is there are some people that said we oppose the screen. You are screening for genetic variations, this has the potential to harm potential athletes and may create a false narrative. This is a tough issue when you are dealing outside of the ncaa or athletes in the military on what to do. Commonsense guidance i give to parents of high schoolers, in journal of student athletes we ,ee here some of the key things preseason conditioning programming. A performance tests such as a serials brent sprint if it is not a normal activity for you will stay hydrated and refrain from exercising few are ill and seek ethical care. It speaks to universal commonsense guidelines and a clear recognition of transition. And they prevention doctors new document emphasizes these points. Recognize in athlete who is struggling. As we heard from mrs. Shealy this morning and when they are down to help them up. Most importantly. And finally develop an adequate Emergency Action plan that is practice and ready to go. , theso includes hydration single most important thing and africanamerican athlete can do is to stay hydrated. , we give aevention brief to everyone who comes in so they are aware of their risk and we have an Emergency Action plan on what to do if an athlete goes down and everybody from a coach to the trainer, drill sergeant is aware of this so we can execute it quickly. Tos is just an education best tool i will show you. We have different videotapes we produced in a department of defense to give you to trace people, to the doctors and to the soldiers. But we areabor this trying to use these tools to get them to the right people. Bottom line, try to be prepared. A Football Player at west point, first day, he had just graduated. This is an issue for us in the military, we track this and are hypernatremia deaths have been heightening. It has been a real problem. One person died in the Boston Marathon that became an issue. Temperaturenormal but there are changes. This is a person working at an change. Eds to be a what we know from the literature , a couple of things. 3 1 ofhat common entrance those people with longer finishing times, 10 to have a greater risk and most when theye is are down and vomiting the answer is string more get up and run. Only, shed died in the medical tent that day at ,he marine corps marathon, 36 hyponatremia and she was vomiting and was given more water. Water impact has been dialed down. We actually give less water to try to avoid hypernatremia. Increasing water stops to greater distances to avoid this complication. Is todration guidelines have to know yourself and recognize that people are different and will create different stresses. Secondary prevention you see now in races, this is from the should notman, you gain weight when you are exercising. If you are gaining weight that is a tip off that it might be a hyper no hyponatremia. Doug brenner, this is biggs is this is we are seeing an between 2013mber and 2016 our numbers one of 50 . This may be the training or it may be the pool of fitness of individuals coming in the military but this affects our ability to train and be ready. Its not just the military. This was published by a colleague of mine, offseason describediowa players militarypracticing, cohorts say we looked at 40 cadets in brockport who were run hundredmile , all these00 squats kids have done it before with the problem but then someone decided to put a clock to it and put 40 of the kids in the hospital when you put a clock up. Exertional and providers need to be alert a can be the flu, it can be ecstasy or cocaine, number of things can contribute to this. As a position you need to have your thinking caps on to its usually when a perfect storm. Omes together who is coming in, whats the transition time, whats the intensity. Many nonexercise illness, not sleeping drugs,ickle cell trait, statins, supplements. I would strongly agree where i think what mr. Shealy was trying to point out the most important variable looking at these cohorts, leadership. Heatstroke, these kids will do what you ask. It is leadership. Take this slide wherever i can. I think this is a very powerful guidance that the doctor put out in 2019 identifying the vulnerability, transition. And Holding People accountable. Ratio of 14. St workout should be documented in writing, you want to have the best of the best to our writing these programs. I saw a very powerful statement and we push it. Prevention secondary it is no joke when you are in the hospital for 39 days fighting for your kidneys or ending up in dialysis. Prevention we published guidelines on this at this point in time. Walks providers all the way through on how to manage this entity so we can get troops back to duty. I want to conclude again and honor for me to be here to speak on behalf of derek shealy. I think this is largely preventable. Commonsense recommendations as we heard from dr. Hamline, and emergencyas we say in the militd again, i truly believe leadership remains the key risk factor for the injuries i have described and it is the most important variable for improvement. Thank you. [applause] thank you dr. Oconnor. It is now my pleasure to introduce dr. Cardenas, the director of the concussion and brain injury center, the chair of the intercolette intercept interscholastic Advisory Committee. He is a leader in terms of helping advance all of the neurologists under the heading of concussion and traumatic brain injury. Just a little side note that you may not be aware of, it was not that three years ago concussion training became a mandatory part of a neurology residency training. It was always assumed that neurologists where the most knowledgeable in concussions. When i was trained, i had no formal training in concussions. It is now part of residency he is also and independent physician for the National Football league, and that has been an interesting and good experience where he believes that there has been Real Transparency on the field. Dr. Cardenas will talk about traumatic injury in sport, thank you for coming here. Dr. Cardenas thank you very much. I am honored to be here and present on this topic to the sheelys as well. I am greatly happy to do this. I will also disclose that i will be talking about traumatic brain injury, which derek died from. It is if these, whether the slides or stories from some of my own patients, become upsetting, i apologize in advance. I understand if you have to step away. A bit of those disclosures as in heard, my involvement this particular area spans all ages from youth to the itfessionals, and in this allows me to get a good understanding at how things are different, and how there could be changes, and the change is not going to be directional. It will not always come top down. There are many things that can be shared in both directions. When we are looking at catastrophic sport injuries, there are a significant number. The majority occur in high school. Fatal, and 50 serious. We will go over definitions in a moment. Competition, but some in practice. Has the greatest representation of catastrophic sports industries, and this data is primarily from high school and 55 represented versus basketball and other sports. Thisntity that is tracking is the National Center for Catastrophic Sports Injury Research center in north carolina, chapel hill. Its is a reporting system, is a voluntary system, but over the years they have been able to get more accurate data, because of social media, and they can reach out to different people in order and organizations and ask for the data to be provided. 1982,as established in and i know that many times coaches get a bad rap when it comes to football of pushing people through it, which may be the case. Established byas coaches who were attempting to analyze how these catastrophic injuries were occurring. A few definitions that you will want to know. Fatality is selfevident. None fatality is permanent, but severe injuries. This may be neurological. Serious injury is may not be severe or may not have a permanent deficit. Someone who suffers a spine fracture but does not suffer a spinal cord injury. The mechanisms, direct from participation in the sport, and indirect occurred while participation in the sport, but not necessarily direct lee from the sport. Erratically from the sport. Directly from the sport. The three hs are really the key when it comes to injuries, heat, heart, and head, accounting for 80 of these injuries. Some of the outcomes, if we look at the direct outcome, 20 are fatal, 43 serious. Looking at if we are direct injury occur in a game, some in practice. The mechanisms for a direct injury arnett, 37 and brain, 33 . Theball is represented with greatest number of direct injuries. With respect to indirect, 42 fatal. See an inversion of the numbers. And then mechanisms are also different, heat, heart, however as you heard, football is represented with the most number of indirect injuries as well. There is the National Center for catastrophic sports Century Research has a subset dedicated to football, and once again, emphasizing these direct for sizing these definitions. Some of this is to gather data outside of off the field if you will. If someone suffers a cardiac arrest in their sleep sometime after a sporting event. Most recentlyta published for 2018. It will go over some of that. Participation, football does represent the highest number of high school participants, as well as youth, 1. 1 million at the High School Level. In 2018, there were two direct in high fatalities, two school, none in college. They fatality the fan tally rate is at. 095. One was a brain injury and one was a spinal cord injury can final cord injury. The indirect fatalities, three in high school, one middle school, and three in college for 2018. Over time, we see the direct and indirect fatalities broken up and they have come down over time. Data, 2015st recent through 2018, a shorter period of time. Published in 2003ng at head looking at injuries between 1982 and 2002. They were able to investigate specific injuries, 29 out of 30 reported at the time, 27 women were injured, men and women participate. College, five times greater risk. Activities most at risk of course, the pyramid in the basket toss. There is a pyramid. There is a basket toss. 17 were head injuries, 13 skull fractures, two of them died. Eight had cervical spine fractures with three spinal cord injuries and one listed with a head and neck injuries. Another study looking at ideas for prevention. Of catastrophic injuries in High School Athletics were attributable to cheerleading. If you look at overall injury rates, by itself, cheerleading does not have that many injuries. If you look at just catastrophic rates, it clearly outnumbers all the other womens sports. Which peoples by basenjured, stunting, the or spotter is 23 , tumbling between 14 and 26 , a followup up to 25 . Risk factors include bmi of the athletes, history of previous injury, specifically head or neck industry, and a key point, the service on which the athlete lands. Athletece on which the lands. ,his analyzes an intervention 2007 academic year, the change in a rule so looking between 2002 and 2017, the idea was to find out whether or not this rule change, this policy change made a difference in injury. This was a policy that came out from the National Federation of high school association. , the basket that toss was not going to be permitted unless there was a surface for, soft them to land. They found that there were 3. 6 catastrophic injuries per year. 2. 2 per million cheerleaders, most occurred in practice, head injury accounted for 50 . Next, 30 . The basket toss, 35 . If you look at injury rate leading up to the rule change, it was 1. 5 per 1000, versus afterward,. 4 per 1000. Looking at data, taking that data, making a policy change and seeing a result which is always key. These things can occur in wrestling. It is also aggressive contact. To 1999. Most of these incidents in high school. 80 occurred in a match. The trend is competition. High risk. Defensive position for a takedown, the athlete was taken down, 74 in a down position, small percentage in a lying position. 20 had a cervical spine , theyre, 11 and up being lost the movement of arms and legs with six paraplegic, just the legs, and six brain injuries and one athlete died. Catastrophic injury and pole vaulting, an example of looking at interventions and how they betweenct outcomes, 1982 and 1998, there were two catastrophic injuries per year. Most athletes landed off the sides or back of the landing pad. A small number landed in the vault box. 2003,was a rule change, expanding dimensions of the pad. Between was analyzed 2003 and 2011. Same number of catastrophic injuries. Most of them from landing in the ball box, 24 landing on the side or back of the pad. Here is an illustration. Even though the pictures sidebyside look like they are the same size, in fact this is a larger padding. You can see it encompasses the areas where the pole sits. The arrows represent where athletes had fallen off versus injuries within vault box. Box. Based on this information, there were 19 catastrophic injuries in that second set of groupings. There were spine fractures. Asy included those catastrophic. This is because of participation had increased, it was 1. 0 in the original study. 22 in the new study. A decrease in the fatality rate. Analysis, granted this is a little while ago. Theira sport reevaluating head and spine injuries. At this time they found that there were more spines specifically cervical injuries compared to head injuries. In other sports such as american football, ohio valley having having higher rates of head injuries. Another sport that can have a significant number of catastrophic injuries, inking not just of the team sports, but also individual sports. In this study between 2003 and 2010, looking at 72 injuries, 30 in the head, 15 of them died. Some were significantly injured and were in a persistent vegetative state. 19 were net injuries, of that total wordnet injuries neck injuries. 90 they and were less than 20. These are young people who were suffering. As i mentioned earlier, i would be talking about one of my this young mans first name was derek. He and his mother have given me permission to talk about him and his case. This young man was a 17yearold senior at the time of the picture. In mid october 2012 he suffered a head injury in a game. He complained of headaches to his girlfriend, did not mention this to his coaches, his mother, or his teammates. He suffered another injury in october 26, and took a hard hit. He was motioned to come off of the field, he did not. When he did he started to have a seizure. He was airlifted to my institution. This is a picture that his mother shared with me in the intensive care unit. Bleed, a hematoma, but the biggest concern was the swelling and shift of the brain because this is a potentially lifethreatening event. He did not require surgery, he did demonstrate permanent changes on a subsequent mri. Ofrequired about one month inpatient neurological rehabilitation. He is actually about six foot two, righthanded, not lefthanded. Beltherapist has them by a because he was uncoordinated on his right arm and leg. He had about a year afterwards of outpatient neurological rehabilitation including physical and speech cognitive therapy. What does this represent. Second impactsent syndrome which is a rare ansequence of suffering second head injury before recovering from the first. It has been described as someone who collapses, and they have rapidly dilating pupils. They stop breathing. Brain swellsy are quickly. This is distinct from having a big bleed. The second hit itself might be minor. Pathology a presumed because this is under great debate, and there is not a another another model to find out what is going on. There is presumed this regulated blood flow from the first injury. From the second injury there is her niche in of the brain herniation of the brain. This is not new, it was first described in 1973 by dr. Schneider. This publication recommended the , hard football helmets materials that you heard about atlier as well as looking net injuries as well. The term, second impact syndrome came from dr. Hart law. , it he published in 1984 is popularized by bob, who seen here when he published an article on boxers, of which there were five, allmale, all young who had two impacts, one was a car add accident and the other are forward boxing injuries. They all had symptoms, and the and in the second impact is six hours to two days from the first. They all collapsed and died. Two had small bleeds. Center was utilized to look at potential cases between 1980 and 1993. Based on this data they saw they were 19 confirmed cases, 18 suspected, and they thought that this is distinct from a does it a delayed cerebral swelling. That is a dead that is a different entity that as that has its own set of controversies. The thought is that from the single impact there is something inherent that causes them to have unusual swelling due to toxic cascade. Contested, twobe doctors analyzed those same 17 cases under these four criteria, the first a medical review after a witness of first impact, meaning that both impacts were witnessed versus reported. Documentation of ongoing symptoms, once again with a second impact, and then pathology imaging demonstrating that it was due to swelling versus a large bleed. They said that there were no definite cases of second impact cases and five probable cases. Excludedcluded where because of only one impact being witnessed and they felt it was due to the swelling. If you look at the five cases they called probable, i would like to highlight that all of them had ongoing symptoms. Care for of us who individuals who sustain concussions and monitor them afterwards, the symptoms are critically important in doing so. These are some of their recent publications. You will notice that on the left and, in terms of age gender, a 10yearold female, injury andom first second injury up to 32, and then all had ongoing symptoms. Publications,ring noting that the Scientific Evidence to support this concept is nonexistent also highlights that this is not reported in other areas of the world. These are my own cases that i have experienced that may have been suspected second impact syndrome cases. This is a 15yearold young man hits,s suffered multiple head headaches and did not report them. A couple weeks later he took a major hit and had terrible headaches, vomiting, went to see hes pcp, and thank goodness, because on the mri, which you see here is this thin, hematoma. , and depending on your evaluation, you might hallucinate that there is some e dema edema on this side. The young man did very well and suffered no further injury. He actually did intensive cognitive testing and was very successful, naturally, not playing anymore collision sports. This is a 16yearold male and a wrestling tournament. Onsuffered his first injury the 21st of september, did not report his injury, i only found out when a teammate later told suffered ann injury. The following day, he took a knee to the head. He had a bad headache and had to forfeit his third match. His headaches continued so much so that his mother took him to the Emergency Department where ct scans showed a subdermal hematoma. He required neurosurgical intervention, a removal of the bone so the swelling would not prove to be fatal, and demonstrated permanent change on imaging. He indeed survived. In 2000a 17yearold 13. Unfortunately, from a Rural Community in which they had care,d access to medical and had no athletic trainer available. Beforeered a hit shortly the competition, and then he was told to simply take it easy for the next week, and then there were state tournaments. In the Fourth Corner he took a legal hit, fell to the ground, played for two more plays and then collapsed. This is his ct scan. You will notice that there is massive swelling and bleeding. This is the mri of the temporal lobes and frontal lobes suffered significant damage. He succumbed from his injuries and was declared dead on the 11th of november 2013. This is the most recent publication of a second impact syndrome case in which there was imaging after the first set and then the other. This is a 17yearold took a helmet to helmet hit. Some of his pcp had headaches, a scan, exam, ordered a ct and said he should not participate. This is the ct scan, read as normal. Five days after the injury, he did return despite the recommendation. He was and hitting drills and slow to get up. Then he said he could not feel his legs. He had a seizure and was taken to the hospital and found severe hematomas. Scanis his subsequent ct after the second hit. There is herniation and injury on imaging, and then two months later there is significant atrophy after his injury. Reduction, what are the interventions . So many of you know this story, a man suffered multiple head injuries. He ultimately collapsed at the end of the game and was airlifted and required neurosurgical intervention. He was the inspiration for the 2009 law in washington state. This is him at his high school graduation. He has paralysis and is in a wheelchair with limited speech abilities. This set the stage for three elements, education, removal from play and return to play after seeing a licensed health care provider. This is the model of legislation in which every single state in the nation and d. C. Has a theussion law that, for most part, covers those three elements. Who can tell me what is wrong with this particular image . And why it might be a problem . Indeed, the chin straps. This was an issue we felt was a problem at the High School Level because, before instagram, this is the picture that the High School Athlete would post on her locker and we did not want this. We were concerned that it would with the athletes. We made a rule at the arizona medical Advisory Committee level. It stated that if the helmet comes off during plate they had to go to the sidelines to be immediately evaluated. If they did not want to take that time or have a player come out, they could always take a timeout. The was somewhat risky as Interscholastic Association risk its membership by changing a rule with the National Federation of high schools. And notnted our data long after that there was a release recommending that all student associations have a rule in which if the helmet comes off. I do not know if there is a direct correlation or if dr. Parsons came over to the ncaa. Not long after, they released a rule about helmet dislodge meant. Issues presents football compared to other sports. When we are looking at contact practice from 2013, we wanted to limit concussions as well as exposure. We recommended a rule that during the preseason, only half could be contact season. During the regular season, no more than a third of a time. We defined what contact was in order to make sure that everything was clear. 2014. Was a summit in amongst associations and programs that had implemented limits, and this was the recommendation as well. In arizona we have a limit on the amount of heading practice that can be done during the preseason, regularseason, and how many days in the week they can do so. This is once again to reduce the concussion injury, also exposure to head impacts. There are other ways to address this, making sure that every athlete is covered by a policy, for concussion, not just catastrophic injury. Looking at other means of prevention. Physicals,ation looking at persistent symptoms related to head and neck injury. Conditioning, as we heard earlier is critical. Having an athletic trainer or oncall physician available. Beining for coaches to not involved in medical decisions and be supportive. And an unpopular one, supporting referee, especially if they are making calls based on space on safety. Other recommendations include eliminating checking from ice hockey, eliminating sliding headfirst. This is the ncaa concussion protocol checklist, all institutions are required to have it. Education,reseason for the athlete, coaches, Team Physicians, and coordinators. It also includes specifying a history of brain injury and concussion, identifying signs managing the injury afterwards on the field and for return to play, also just as importantly, returned to learn as these are students before athletes. And then, reducing exposure to head trauma. Reemphasis of dr. Documents new regarding catastrophic injury and death and the six points to be made for keeping all of our athletes safe. Thank you very much. [applause] we are going to invite the speakers from this morning to come up and dr. John parsons is going to moderate a panel of discussion and we will be inviting questions from the audience. Dr. Parsons good morning everybody. I am the managing director of the Sports Science institute at the ncaa, i am very proud to be able to moderate this session this morning. Theill entertain questions, microphones are active, i will give you a chance to organize your questions and we ask that you please approach the mike and i will recognize you. While you are preparing our questions, i will get the group started. Cases and the data that the four of you talked about today, but also the policies cut across multiple levels of sport, not just collegiate but high school and youth. I am wondering if you might comment on what you see as the policy relationship between the s that are involved involved. Is there a triple down effect at the ncaa, that the professional or High School Level should be aware of . Can you talk about your experience for mitigating risk across multiple levels of sport . Anyone. I will start by talking about the relationship between the schoold the high associations. For those of you have come to indianapolis and have seen the hall of champions. The building right next door is where the National Federation of State High School associations is. Workinga close relationship. If you could raise your hand, bob is part of the senior leadership. So, we actually sit on their committee. Bob is always on our meetings for the committee on professional competitive safeguards. There is a relationship, in antly the ncaa has has been an association. It is a federation. They can put out a guidance, not all states are part of it, and the states can really do as they youth, i think at the sport level, it starts to dissipate a little bit. The youth sport is wide open. We have representatives from usa football, but it does not oversee all of the youth landscape of football, no does bob warner. Most of it is not even under the auspices of either of those two organizations. Where there is a breakdown is not at the youth sport level. We may be talking about United StatesOlympic Committee in 1978. They were empowered by congress to oversee all of youth sport, sport78s porch 1978 act. At the grassroots level, there is not that level of oversight, and that is where i see the biggest breakdown. Indeed there are policy implementations at professional college and it is a complete breakdown at the youth level. Is important is that they are driven by the data. For example, there are epidemiologists gathering the data and in each of the professional sports, whether it be in Major League Baseball injuries, and then there can be policy changes based on it. At the ncaa, there is a body collecting the data there as well. There is the rio injury surveillance program. I mention these things because it is important to make sure that these policy decisions are made asked based on the best Scientific Evidence we have and that is specific to these two groups because they are there is going to be data present at the professional level that is not going to be present at the College Level or the youth or High School Level. However, it can clearly be informative and some of the benefits from those policy changes, whether it is leadership, for example the ncaa making a rule change i which the nhs then follow suit because it is the best interest in the best interest and safety, those are when the trends can occur. Questions from the audience . Good morning. Physiologist, that i work at the National Academy of science and engineering in medicine. Thank you for sharing this data, we are a very evidencebased institution. I want to remark on the New York Times article on the university of colorado at boulders football plan where i was trained. I walked by the football stadium every morning. There is a fantastic Sports Medicine program as well. It was interesting because two regents voted against supporting the new football coach hire, because of this increasing head trauma in football. We are seeing this at the National Academy as a widespread occurrence where leadership at the University Level are starting to be more and more hesitant about supporting football programs and we are fall out suchf with the university of maryland president who recently said he was going to resign as a result of the football investigation. You,t to ask you, all of what you think the implications of this data and these measures are going to mean for the future of football at universities when it seems to be at a very risky perception from university leadership. At the National Academy we are concerned because we care about our Research Institutions and we want to make sure that the integrity and the missions of universities are carried out and not impacted unduly by some of these hesitancys. Thank you. I think, thank you for the question. I think it is an important issue. Answer. No clearcut i am going to answer in a couple of different ways. One, we have to be data informed. What the ncaa did is that we partnered with the department of defense, because this is not about just football, it is as much about cheerleading, football, bicycle riding, or anything. How do we understand what is going on. Is concussion the issue we need to be addressing . Is it repetitive head impact . Is it Something Else . We know that from our military servicemen and women coming back from afghanistan that there have been consequences of traumatic brain injury and other injuries. To try and understand this, we joined together a cooperative research agreement, and we are studying all 24 stores sports in the ncaa. It is the largest study ever performed in history by many magnitudes. We are not just looking at concussion, it is the only study in history that is comparing concussion to repetitive head and neck exposure to training at an elite level. Not only that, it is the only study that is looking at those three issues, not just the issue milecally, but objective markers. We are doing brain studies and the high risk sports. Ice hockey, soccer, lacrosse, mens football, ice hockey, lacrosse, soccer. Why are those risk factors . We actually look at womens ice hockey and theres a higher rate of concussion than in mens football. We need to understand all of these things, and then understand what are the consequences. In those high risk pools we are doing had accelerometer data and getting genetic tests. About theor talked risk factors in sickle cell. Do is it that 1999 people not have a problem when the risk is one in 2000 . We are starting to understand that there may be genetic risk factors for recovery and repetitive head and neck trauma or in concussion. We are looking at blood and bile markers. No one has looked at what are the real risks, can we understand this in blood test. It used to be thought that concussion was a functional problem, but is it an anatomical issue. We are starting to tease apart where are the risks and what are they. If you have a brain mri that shows a change in the brain and people say, you played football and you have a change in the brain, there is proof that it causes brain trauma brain trauma, irreversible. Actually we are starting to understand it is not irreversible, and these changes can shift over time. And wee done this study, are in our fourth year. We look at 45,000 athletes from the sports academies and the air force and west point are opted in. And looking at all the sports, we have gathered data and we have tracked over 4000 concussions. The large study before this was 20 concussions. We are starting to understand what the data is telling us, and we have moved from phase one into phase two. We are looking at cumulative effects and we have developed a methodology, and the board of governors as provided half of the funding for the next 35 years of the study. What will be unique is that we will be studying the ncaa and the Service Academy athletes. In this plan, we will be able to medicalhe veterans records and do precision brett Precision Medicine and say is this an issue of concussion or an issue about some other lifestyle problems. Some say he will wait 35 years to make a change, actually we are not. From this data we have made important policy changes. We have a limited we have eliminated to a day practices. We change the kick off rule because we understood that most injuries were occurring on a single play. What we do not know, and i will say this clearly. There is a book just published and a sports neurology, handbook called the handbook of clinical neurology. All of them agree that that is the most rigorous textbook in the world. It is externally peerreviewed brian ha written by inline and robert stern. The most two unlikely people to get together and put together a handbook that addresses all of the issues that are actually implicated in your question, and there is a final chapter called future directions. In that final chapter, dr. Stern and i write the following. We do not know the Natural History of concussion, we do not understand neurobiological recovery, we do not understand what repetitive head impact exposure means. If this is aw progressive tradition. We do not understand if cte is specifically related to any sport. We do not understand if cte can happen in the general population, although we now understand that cte has been described in the general population in individuals who have had no exposure to any head trauma whatsoever. This is the final chapter of our book, cowritten i dr. Stern and myself. Has asis a chapter that many questions as it does answers, and it is a chapter that says we must come to understand these issues in a scientific manner, and a consensus trim mode driven manner and in a manner that says we need to make policy changes when we understand the data or come to understand that there is something shifting. We also make a difference between changes in the weather and climate. That is important to understand that. I do not have all of the answers to your question, because one question right in front of us is should football be banned as a sport . Youth football, because there is one football theres one paper that says the risk is higher for people under the age of 12. That one paper that was published, the author said that we have to reconsider that paper. That was not published. The New York Times is something i wake up every morning and that is the first newspaper i read, i go to the editorial pages because that is where i get my information, but i am not certain that they have all the information correct with regard to football, and i take what i they say seriously. I think this discussion needs to happen publicly, and it needs to happen in a manner with everyone addressing it from all sides. I want to be part of that and i am open to the criticisms of where we need to go moving forward. I will end by saying what the chair of the board of governors ,f the ncaa said, in this study i have no access to the data. I have no access to the prepublication. Ninds, the head of the was overseeing the study, and the president of Georgia Tech University said wherever this study goes, there must be ncaa go. I believe that we are addressing it, i think this group of esteemed panelists, and we all understand what the potential risks are, and we understand the beauty of sport and understand that maybe some sports need to be looked at differently than other sports. I think we are all in this together and will hopefully make informed decisions. Col. Oconnor just a brief comment in reference with the New York Times article, but in the same context, the country is in an epidemic of inactivity and obesity. It is estimated for the department of defense that by next year, 2020, less than one in five High School Students will be fit for military service. One in five. We have a problem of inactivity. That with obligation concussion, sudden cardiac death, head injuries, that we need to get the medical narrative right, and not fear inpatients in patients either. A young mother wants to talk about her stock her child with sickle tail sickle cell and i want to provide context. I think it is an obligation to make sure that the narrative is correct. I listen carry carefully to the think sixily, and i points, and not one of them was stopped football. They recognize that there were other errors that led to dereks death, because he loved the game. I think those are the things we need to listen to and correct those problems, because exercise and sport is good. Please. And im anis ken, orthopedic surgeon. Doctorrtners with the who has done a lot of the catastrophic research. Thank you very much for your talks. One of the things that many of you have talked about are the rule changes and guidelines to help reduce injury risk. My question is, one of the noted isat has been that a lot of the injuries that occur in football specifically are related to abusive coaching and irrational training. So, i know that there have been rule changes to note two a days. Do you think it is realistic to give coaches guidelines about training, to avoid overtraining. In so many of the coaches we have seen, there is the idea that more is better. I think we are overtraining and doing dangerous things. They are coaches, not medical people. Is there a way that we can give them better guidelines about rational training so that they actually can get their athletes improved function and improved performance without hurting them . So, i will take that first, but also my colleagues will address it as well. With regard to football coaches, i think it goes beyond football coaches and irrational training. We are really talking about indirect or nontraumatic injury in practice. Document that i referenced at the beginning that has been endorsed by 13 organizations, it is not only going to be widely disseminated, it is setting a new norm. It is specifically addressing work to restoration, sport specificity of activities. We go into great detail in transition periods that dr. Oconnor elaborated on. We talk about never having a punitive type of exercise, and, importantly, i think it is important to understand what you mean by coach. Nontraumatic inuries that occur happen strength and conditioning sessions. It was under the guidance of a strength and conditioning coach, and in the document we do not use the term. We called them specialists or professionals, and state for the first time that their recording line should not be to the head football coach, but rather into the Sports Medicine or performance science division. ,his is not just the ncaa thing this is 13 leading medical and scientific organizations. That is going to go off, but the next question is is everyone going to follow . That is a separate step in the process, and that is also being discussed at the national level, but my very strong healing is that yes, this will be followed. A quick comment, looking at all levels. Many times you have coaches that are volunteering, you have coaches of incredible turnover at different levels. Plenty of opportunities for education, but it also needs to be reeducation for those coaches, and updating the education, and finding those leaders, because i think that what you will find in some of the best coaches, i actually do not overtax their athletes. They do not hit multiple times in a week, and they have been able to be successful in games, which is where that is going. As an athlete,d, you have a tremendous respect, most of the time, for the coach, and, there was a study looking at the influence of coach on concussion, because as i mentioned, coaches should not be involved in medical decisions. However, when the athlete is injured, there is value in acknowledging the injury and telling the athletes that they need to get better so that they can be they can return in a healthy state, and participate, and help their team win. It can be both ways. Please. I have two questions, kind of along the same lines. You have been mentioning guidelines and recommendations that do not hold a whole lot of weight if not enforced. Are there discussions around setting up possible Enforcement Mechanisms to ensure that policies and sidelines are followed. My second part is, is the conversation also moving towards state and federal legislation. For the things that we know can prevent injuries, where is that advocacy taking place, and in what role can you see the ncaa playing to really try and link everything from youth sport up to usoc. So, thank you for the question. Things, when a few i started off by talked about our inner association process, and the process lead to one thing, which was the diagnosis and management of sport related concussion. Then, what happened when that came out, i did say that the ncaa was a representative democracy. Except except for 65 schools. Sometimes, they are nicknamed the power five. May have the ability to pass they have the ability to pass legislation independent of the rest of the organization because they know sometimes the concerns about infrastructure and so forth do not allow them to move as quickly as they wanted to. They took our guideline best practices on concussion and passed that as legislation, which is enforceable, and there are investigative cases on that. The rest of division i opted into that legislation, meaning they said we are all going to follow that. Now, it became legislation for division ii and division iii. Across the entire membership, they must follow the concussion safety legislation. It specifically refers to a checklist. Javier put up the checklist. That checklist is the basis of every member schools protocol that they must follow. There is a mechanism for enforcing that. Secondly, dependent medical care became legislation, first by the autonomy five schools and then in of the one d1 opted and then d2 and d3. What i showed you this morning, the best practices, it is very possible that will become associationwide policy, slightly different but equally as enforceable. Finally, taking a giant sidestep, a tennis term, but when i talk about Mental Health this morning, we put out a Mental Health test practices document endorsed by 25 organizations. The autonomy five this january said every school must divide Mental Health in alignment with the best practices document. Im reasonably confident that will become opted in by all of the d1 schools and become Association High wind associationwide legislation. It is taking place. It is being led by this interassociation process. Representatives are here from the American Academy of neurology, the American College of cardiology, they are all part of the process ultimately eating to legislative changes leading to legislative changes. I will comment a little bit about the legislation and and look at actual State Government legislation, particularly how it relates to cardiac screening. There is a lot of controversy in cardiac screening. That is to put it mildly. There have been a couple of tried, most notably texas on several occasions to introduce legislation to mandate screening for every youth athlete in that state. What does that mean . I dont know, right . That is part of the question. If you introduce legislation and do not have the workforce nor the understanding of what to do with it, you will create chaos. Legislation is likely to do, create more controversy, create more called chaos, and likely label thousands of Young Athletes with disease they do not have. That has just as much impact as trying to save the one life you are trying to save with potentially misguided legislation. There is no training in sports cardiology. Dr. Hainline said just training in urology and concussions in the past three years. There is no training in sports cardiology. No fellow training gets taught about exercise, nutrition. There is no formal training process. There is only a handful of people like me who specialize in the field of sports cardiology in the country. I cannot screen every athlete in the country. I do think screening has a role. I think it can be done well in the right hands. We just do not have enough of those hands yet, particularly in the United States. We need to be very careful when we talk legislation, particularly as it relates around cardiac screening. We have the potential to do more harm than good in the legislative fashion. We have time for one more question. I would like to thank the sheelys for their courage, honoring dereks memory this way. I would also like to thank the speakers. I had to write down my question so i do not get messed up. When trying to make recommendations, it is incumbent to support recommendations. For these reasons, it is concerning to know policies such as the recently passed football redshirt rule passed without presentation to the safeguards committee. For issues of Student Athlete Health and safety, especially when we are trying to get it right, my question is, how can we prevent stuff like that from slipping through the cracks again . I missed what slipped through the cracks in your question. The football redshirt rule. It never went to the competitive safeguards committee. Do you have a comment on that . You might understand that better. You are talking about the legislation that extends eligibility . Correct. It asm happy to speak to one of my responsibilities on staff to liaise with the committee on competitive safeguards. You are right to point to that particular example. It was a situation in which the governments process missed an important step, which was consultation with the health and safety body. Mistakes in an organization that size with a legislative and government complexity do occur. I am also comfortable telling you we have identified the problem and we have taken procedural and policy steps to make sure it does not happen again. Know watchesdy i what comes out of the ncaa, you even in thenges frequency with which the Committee Meets so it can be better aligned with important timelines that play into the legislative process. The association is everchanging. Plays in thecsmas deliberative process, even though that committee has been around for decades, is very different today than it was even five years ago. Week,ff membership staff membership, all have to monitor realtime to make sure those kinds of gaps do not open up, and if they do, to correct them. Im confident we have done that in this case and it will pay off in other cases. I want to thank you for your time and attention this morning. We are up against our lunch break. If you are staying with us, please know that there is a compliment to relaunch on the second floor. If you go out the auditorium and take a hard right, there are stairs leading to a break space where you will find a catered lunch. We will resume this afternoon at 1 15 p. M. In this room. Thank you very much. [applause] on newsmakers, she talks about the organizations strategy and priority heading into the 2020 elections. The group was founded in 1985 and aims to elect female candidates. 10 00 ands sunday at 6 00 eastern on cspan. You can also watch online or listen on our free radio app. Sunday on q a. Later, he wins in a 49state landslide. And then, it all came apart. Pat buchanan, who served as a speechwriter and Senior Advisor to president nixon, discusses his book