Transcripts For CSPAN Hearing On Concussions 20160320

2005, George Herbert walker bush, senator reid made the same argument when george w. Bush was president of United States. Her to, 18 month before be bush left office, senator that there should be a presumption against confirmation. It is only fair to play by the same set of rules. Based on the conduct, based on the behavior of our colleagues when they were in the majority come up first when he filibustered judges for the first time, and later when they were in the majority before they saw the majority slip to republicans, the democratic leader packed the d. C. Court of appeals by a vote from the nuclear option, breaking the senate rules any raw display a political power in order to pack a court that many people called the secondmost Important Court in the land. For this lifetime appointment to the court is a critical check on the executive branch. A check that this administration has proved over and over again, we need desperately. And i have pointed out , this nomination will change the ideological balance of the Supreme Court for generations. Justice scalia search for 30 years. Because of that, because of all of this, i believe the American People should have their voices heard in the selection of the next Supreme Court nominee. We have already undertaken a process here of the democrats choosing the nominee for president. Republicans are doing the same. They are simply too much at stake to leave this decision in the hands of a president , who is headed out the door. A decision that will have dramatic consequences on the balance of the court and the direction of the country for generations to come. I believe we should listen to the voices of the American People and allow them to cast their vote and to raise their will in determining who make that selection. Let me conclude i know there have been some members of the press that asked, well, if not now, how about in a lame duck session of congress . I think that is a terrible idea. If you believe in the principle that the American Peoples voice should be heard, that makes no sense to have an election and do it and not honor their selection. So, i know some have expressed some concern about that. But, i for one, believe we ought to be consistent and that consistent position is the American People deserve to be heard and their voice heard. Madam president , i yield the floor. Cspan3 to the white house continues today when former president bill clinton speaks at a Campaign Rally in tucson, arizona. At theheduled to appear event, former arizona representative Debbie Giffords and her husband former astronaut captain martelli. Ive coverage begins at 5 30 eastern here on cspan. 5 30ve coverage begins at eastern on cspan. A the House Committee held roundtable discussion on concussion and treatment. The link between Football Industries and degenerative brain disease. The first time an nfl public official good afternoon. I want to welcome all of our panelists here. This is a forum, not a hearing. We will have other hearings on this discussion of concussions. Are is a time when members usually not here but just arriving. We will have members arriving throughout this forum. Hence the different approach. In thewill be sitting panel raising the right hand and swearing to tell the whole truth. You are scientists, we assume that you would you will say anyways. Joined here by my colleagues, the Ranking Member representative alone. Dr. Mike burgess of texas. We wondered his members as they come. Let me start off here with a little opening statement. I want to thank your for being here for todays roundtable called evaluating state Concussion Research and invocation of Public Health. We are here because a lot of people are paying attention to the issue. There is a new and provocative movie that some of you may of seen called concussion that is getting a lot of attention. This is bringing it to the public eye. We have mounting evidence regarding the prevalence of concussions in sports and military. We know that most of the concussions dont even can occur in sports and military. From parents and patients to athletes and servicemembers, people are worried. They hear more about the dangers and potential longterm effect. They want to know if they and their Family Members are at risk. That has not only been the case. Less than two decades ago, concussions were barely a blip on the radar screen. They said you just got to rebel wrong, saw stars or no big deal. I remember plane football years ago you got not been on the field. They weighed some ammonia in front of you and you got up and finished. We have come along way from the wave it off and tough it out attitude. The public is concerned and looking for answers. Where do you draw the line between a booboo and going to the er . When is it safe to play Contact Sports . Is my memory loss due to six years of high school and College Football or Something Else . Are my mood swings result of posttraumatic stress from a couple of chores or they somehow tied to training or the car accident that took place 10 years ago . Its a good thing we are asking these questions. As we sit here today, we do not yet have the answers. There lays the challenge. The public wants answers, but the science is not ready to provide. So we deal with the challenges of misapprehension and the fear of what we dont understand. The need to get greater clarity on the science of concussions is of utmost point importance. To death. S contribute however, it is important to know that concussions are not only limited to the athletic field. Nearly 40 of all documented traumatic brain injury were to Motor Vehicle accidents. Those 6i5 and older had highest rate of tbi related deaths. Which brings us to our task today. Chapter ingin a new the National Dialogue on concussions. We are not here to cast blame or point fingers. We are here to take a step back to gain perspective and begin a conversation on solutions. Are joined today by some of the most prominent experts in the field. This is a wonderful opportunity for members to sit back and listen from the to these individuals. They are here to help educate members and the public about the science of concussions. Know, what are the gaps, how do we address those gaps to achieve meaningful short and longterm solutions. We are here today to make one thing clear, this is not a sports or military issue only. This is a Public Health issue. Millions of americans not playing sports or in the military suffer concussions. It can happen to anyone, anytime, anywhere. Some will recover with no noticeable effect. Others will have debilitating symptoms. Why the difference . Why the disparity . Thats what we want to know. We will begin with a brief presentation from dr. Boulder from the center of disease control. Wholl provide a brief introduction to concussions in a general overview about these injuries and their prevalence to society. Then put forward a series of broad discussion questions tour participants. The questions focus on these four themes. Prominent misconceptions or underappreciated fact. Knowledge gaps in our understanding of concussions. That willbjectives lead to meaningful progress to minimizing the risk of concussions. Obstacles to achieving those objectives, including coordination with the research community. Tose questions are intended guide the conversation among participants and provide us as members the opportunity to listen and learn from the community. Obviously members are welcome to ask questions and join the discussion. It will not be formal like a hearing, but just let us know if you have a question and we will keep track of that. Assuming their time at the end, he will have more questions to ask the panelists. I would now like to thank Ranking Member to get for her support. Thank you so much. Looking forward, i recognize you. Thank you for this roundtable. Sometimes it seems like the format is a little bit unwieldy, but as chairman up to and will tell you, we did a lot of these when we worked on our 21st century initiative. It was a good way to get a lot of information packed into one afternoon. I also want to thank the panel of experts of come today to talk to us about this importance of concussion and head trauma. Understanding the effect and impacts of impacts to the head and how to prevent, diagnose, and treat injuries that come from such problems. To sports leagues, to parents of Young Athletes all around the country. Given the quality of the panelists today and the diversity of opinion, i believe we have the opportunity for a lively discussion. I hope todays event has been communicated to us the staff level is the beginning of a series of discussions and hearings on this topic. Structuredgeted in and structured discussion on this matter will be useful as we think about what congresss role is. As we move forward, the hearing process will provide us with organizational tools and structure. I dont think the most important thing is that people be under oath, i think it does help to have testimony on the record. 10 years ago, not much attention was paid to concussions as you said. As we learn more and more about the potential short and longterm effect of concussive and sub concussive hits, our constituents have many questions and can turn concerns, particularly about their childrens involvement in Contact Sports. Young athletes may be particularly at risk of lasting brain damage due to repetitive hits, even when those hits dont rise to the level of a concussion. Studies have shown that Young Athletes who do not sustain concussions but did experience repetitive hits to the head over aneurological single flex season. Additionally, according to a recently released study by the mayo clinic in december of last year, about one third of men who played amateur Contact Sports in their youth displayed evidence of cte pathology. That number surprised me and is deeply concerning. It shows that you dont have to have played the National Football or hockey to suffer longterm brain damage from Contact Sports. While we still have not established a prevalence he first cte, the study strongly suggest the disease is more prevalent than we originally thought. And frankly not just with those girlses, but also with soccer and other diseases affecting both girls and boys. I understand that any such scientific in any such scientific endeavor, there may be disagreement and uncertainty about what policy actions we should take against the backdrop of that knowledge. But uncertainty does not excuse in action. Im am interested to hear from our panel today about what actions we should take right now and then how we need to move forward in our continuing investigation. Im going to say as the congresswoman for the World Champion denver broncos, you know i had to say it. And somebody whose family has been lifelong seasonticket owners. And also somebody who graduated from a Division Hockey one school and now represents one, the university of denver, who loved playing and watching Contact Sports. We appreciate the fitness and other benefits of the activity. At the same time, the head injuries associated with some of these activities appear to have caused a close is that her, irreversible and even deadly. Therefore, if there are ways to make these activities safer not just for our kids, but also for professional athletes, we need to make sure that are being implement it. In other words mr. Chairman, we want it all. We want to enjoy the thrill of being a fan or participant but with the confidence that has much is being possible to inform players of the health risks and to minimize the risks that are associated with Contact Sports. Thank you for recognizing me. I know we have a lot to discuss and many voices to hear from. I am glad we are kicking off this effort. I yield back. I noticed the kickoff line has been moved back. Of theton, the Chairman Committee recognizes. Either long statement but i wont read it. I want to get to the business of the day. I appreciate everyone being here. I think we have a lot more to learn. Primarily this is why the format is a little bit different. As i understand it, my friend mr. Pallone has a letter for me. Working in ad to continuous space and this is not the first step. I know that we are all truly very interested in this and i intend to make sure that this happens. Iwant to quickly say that worked with my Promise Center in michigan at bronson hospital. One of the quotes we took down identified asve simple concussions are not quite as simple as they seem to be. That underscores what we are facing. I yield back. Thank you, i just want to thank all of our participants for joining us today. Concussions are critical Public Health issues affecting millions of people each year and we are strong indications that the effects of repeated brain trauma, even those received during one day could accumulate with consequences that are developed debilitating. These consequent is could stem from injuries once considered as sub concussive hits. Recent study showed that athletes exhibit evidence of significant brain damage due to hits to the head even when they dont suffer concussions. The work of a group of researchers out of Purdue University found significant structural changes to the brains of High School Football players, even among those who do not have concussion diagnosis. It was particularly what was particularly troubling is that these would show up months later, showing lasting damage. Decrease brain function, Behavioral Changes in the release of biochemical markers leak to brain damage. Researchers have repeatedly found evidence the linkage between head damage and the disease notice cte. It is a devastating disease with memory loss, dementia and depression. I am honored to welcome dr. And mckee from boston university. Her and her colleagues have been undergoing groundbreaking research in defining cte. Theyd examine the brain tissue of dozens of deceased former nfl players as well as individuals playing football at the collegiate and high school level. They have discovered the presence of cte and former as young as 25 and in many adults are played football since they were kids. Theyve confirmed that it is a unique disease with a unique signature and their work is commentated in a broad Scientific Consensus to define the character six of cte. Its unfortunate that her work has been questioned by those interested in maintaining the status quo. Some of our Great National pastimes, the sports we love and our Children Play every day may cause significant and lasting brain damage. Theit is time to check mounting evidence there is a linkage between head impacts and brain damage and it is time to do something about it. While there is research that still needs to be done to answer all the questions, or should not be an excuse for inaction. We should not only be examining the state of it, but how we can apply right now to protect our servicemen and women, are athletes and children. Today is onus finding a path forward. I hope our discussion will not serve to close confusion or two up skewer the Scientific Consensus two up skewer the Scientific Consensus. Miss mckale is not only the director family relations of the Concussion Legacy Foundation which does critical work in advancing the science of concussions and cte. She is the wife of former tampa bay buccaneer tom mckale who has cte. Especially proud to hear about lisas experience with cte. And the path forward to address the disease. Let me say chairman upton, let me conclude my remarks by suggesting respectfully and you mentioned it already that while this roundtable is a viable start to the work, we should see it as that, a start. We need to hold hearings on the suspect s subject. Given the number of lives it affects. That im sending you a letter before ivan mentioned it. I even mentioned it. I mentioned in a letter of proposal for a series of four Committee Hearings that would give concussions and sport related head trauma the attention they deserve as critical Public Health issues and the hope we can Work Together moving forward to find a way to plan future hearings. Thank you again to all of our participants and a want to thank chairman upton chairman murphy and my colleague, Ranking Member to death for putting this together. I think we can Work Together to find the best way to do the significant Public Health issue. I want to mention some of the members were here. ,ou met fred upton of michigan joe pitts of pennsylvania who is the chairman of the health subcommittee. Michael burgess is also on the subcommittee of manufacturing. Richard hudson of North Carolina , paul tonko of new york. Dr. Larry bush on. Pallone. Rank now let me try and i wont read your full bios could be here for a long time and its clear what i said before, some it is deputy decades of experience. These are not going to be in any particular order. ,aptain and dr. Mike colson director of dr. Walter corsets. From nih. Grant baldwin, director of division of Unintentional Injury prevention at the National Center for injury prevention. Jeff miller, the executive life Vice President of safety in the National Football league. Clinical professor of neurology at Indiana School of medicine. Madness, in the march indiana. In the same bracket as pitt. I dont know well see each other. Manley, chief of neurosurgery at San Francisco General Hospital and professional of neurosurgery at the university of california San Francisco. Mike mcrae, psychologist director of Brain Injury Research at the Medical College of wisconsin. A Research Psychologist in no walkie, ms. Quantum. Milwaukee misconduct , wisconsin. Seafood, the herman j flax professor and chairman department of rehabilitation. Founding director vcus center for Rehab Sciences and engineering. , universityollins of Pittsburgh Medical Center of the u. N. Pc sports concussion program. Childrens National Division cheap chief of neuropsychology. Director of safe concussion outcome recovery in education. , consultantas hack recently retired from the military where he directed the ot currently consulting a number of organizations including the ncaa and one mind. And mckee, welcome. Professor of neurology and neuropathology. Alzheimers disease center. Michaela, director family relations for concussions. Thank you all. Ae format here is going to be discussion. So let me do this, i recognize that many of the many of you here as scientists may know each ,ther by papers youve read maybe you have met and discussed this before. We want this to be an open discussion. I will fraud an initial question here. Itll be a tossup. If it is something you want to comment on, please do. Recognize we are limited, we have a hard stop time later on. If theres anything you can add more to, add. If theres something you disagree with, part of this is we have to understand theres differences. We will try and keep members questions just to keep the discussion going forward. What the giving speeches. Let me to the first toss up here. Basically, first we will have the cdc. Dr. Baldwin. Thank you very much. I want to thank chairman upton and representative murphy and the other members of the committee for your commitment to address concussions is a pressing public issue. Would also like to thank the congressional brain injury tax horse, tax task force. Been champions of tbi prevention for years. My job is to help set the stage for this discussion and provide an overview of traumatic rain injury, including share the latest data on the burden to americans. In the press release announcing this roundtable, the chairman noted there was a lot we dont know about head trauma. How would affect different subsets of the population, the short and longterm effects and other critical details. He is right. Thats why also want to highlight the national circumference concussion surveillance effort system and her efforts to help fill these data gaps. It is in our minds one of the pats forward. No one ever wants to hear or even imagine that a Family Member or friend has suffered a traumatic brain injury. Unfortunately, the serious injuries, which are caused by a bomb, blow, or jolt to the head are far too common. Tbis can occur in various ways. From a car crash to a fall in a bathtub. Colliding with another player in a soccer game, or on the battlefield than a military complex like weve seen in iraq and afghanistan. May rangety of a tbi from mild to severe. The greater severity, the greater likelihood has longterm and lifechanging issues. Most recover from a concussion in a week or two. It can go longer. The prospect of a full recovery is threatened if you return to play, school, or work too soon or sustain another concussion. Tbis are leading cause of injury related deaths and disability in the u. S. We have young one thing in common, they are percent of preventable. There were at least 2. 5 million emergency visits related to a tbi in the u. S. Either alone or in combination with other injuries. Broken down that means in our two hours together, there will be about 500 tbi related Emergency Department visits. 64 hospitalizations and 11 deaths. This may be a significant underestimate of the burden. A recent study from the philadelphia Childrens Hospital found among their pediatrics, almost 90 are from death presenting urgent care facilities are primary care settings. These are outside the scope of the data catch abilities. Tbis are costly. Tbis result in work loss and medical costs of 141 billion annually. There were about 451,000 sports admissionsion tbi made to Emergency Departments across the United States in 2012. Approximately 70 of these are 300 or 335,000 were reported among the youngest americans. Ofading cause of this sports and recreation concussions include bicycling, football, basketball, playground activities, and soccer. In 2013, the institute of medicine highlighted concussion in sports and made important recommendations, including the need to better understand and address the problem. Called upondation the cdc to establish and oversee a National Surveillance system to accurately determine the incidence of sports related concussions among youth 521 years old. Generating this data is difficult because of limitations. Our current systems do not capture concussions that occur outside of organized sports or those that are not seen an Emergency Department. They also do not document the use of protective equipment, a position played such as offense or defense of lineman in football, and the surf is used for the field of play. There is no record of concussion history or persons longterm recovery. After doing an environmental scan and consulting with experts, including the people a few people on the panel today, cdc is proposing a new National Household survey that would survey all causes of concussion in all ages across the lifespan. There are some economies of scale that we are realizing is well. Willent or caregiver report on concussions today and a randomly selected child, if there are any the Home Experience in the last 12 months regardless of cause. Using a symptombased checklist, potential concussion events will be described as possible, probable, or more definitive depending upon the symptoms experienced and their Temporal Association with the event. For example, someone who had headaches, blurred or double vision, or sensitivity to light or noise days or weeks after the event would be considered to have a possible concussion. Someone who is knocked out or lost consciousness for any matter of time at the time of the incident would be categorized as a more definitively having a concussion. This soughtafter system has been ostensibly that it by partners. If implemented we would be able to provide statelevel estimates of concussion, deliver a conference of picture Health Care Utilization following a concussion, understand differences and return to play, return to learn and return to work protocols and have a national estimate of tbi related disability for the first time. We will also no lifetime tbi prevalence. To know what we are facing and if our prevention efforts are working, we absolutely need this data. We have developed a survey and will pilot test it. We are ready to take the Surveillance System to a National Scale is the 5 million requested within the fy 2017 budget are appropriated. As we look towards the future, cdc is ready to do our part. We plan to continue to improve data related to tbis to understand the problem. Improve our understanding of the relationship to tbi and outcomes from infancy through old age. And to improve implementation of Prevention Strategies across the cost of tbi and lifespan. Partnerships are central to achieving our goals. With a diversity of partners and perspectives assembled here, they are so critical to achieving our shared goal. Thank you for the invitation and look forward to this discussion. Thank you. We will open this up. Before i do that, i want to say thank you from ms. Illinois. I found this in the metro. It looks picture, pretty benign. Its a fishing boat. Says, read the caption it more fights Knight Capital penguins game. This is interesting. Wheres the sport involved here . You dont have to be a player to get a concussion, or member this picture that recently occurred were all the fans were cowering because one man put his arm out and prevented a young boy who was there looking at is that was his own son . Prevented his son from getting injured. We prevent concussions as well. In the course of this, other than sports with a lot of things to get into. Let the throw this out as a question. What are the most prominent misconceptions or underappreciated fact about concussions . The dr. Fromver to the national for stroke. At their ask you, underappreciated fact and misconceptions we need to know about . If other scientists want to Say Something, just call. Yet of the microphone close to you. Thank you very much. Pleasure to open the conversation. Perceptions, there are many. I think there are unfortunately fueled by a lack of knowledge. And i think that it is important to think about concussion as part of the spectrum of genetic brain injury. I think this is mentioned already that dramatic brain injury goes from the mile to the severe and it is not as though we are distinction cutoffs between those in that aggression of the stage. So it is a type of dramatic brain injury. Be said thated to in the concussion there is nothing if you look in the brain, you wouldnt see anything. I think thats not true. With the ability to look with a focal microscope into the brain at the time of the concussion, theres a Symphony Orchestra of cellular changes occurring in the concussion event and so i think the biology of concussions , its not well known but i think that we will learn a lot more overtime. So it is not a purely functional abnormality, theres a lot of good a lot going on during a concussion. The other one which is artie mentioned was 20 years ago, people would sniff and ammonia and go out and play. Now it is recognized pretty widely that is not the case. Thanks to the cdc work and the work of multiple other groups like i think those have been taken up by coaches around the country and think that is really been important. One thing im sure about is the enoughat we dont know to account for parents. We do know that that repetitive concussions that give kids trouble. The initial concussion is oftentimes can be bad for sure because there is a spectrum of head injury, but the kids that i have seen and heard about who run into trouble, the first concussion they were bad for a couple days. Third when a couple months. Then its pretty clear what the story is. I think getting that out is important. Its a tough thing for the parents and kids, especially when there is a huge allegiance to the identity of the person and sports to give up and take themselves out of contention there. I think these are things i withdraw to begin with. Mr. Pundit want ask a question mr. Paul loan palone, would like to ask a question . Frank, get that my closer. My daughter was playing baseball in high school, senior year. She was hit by the baseball directly in the head. She suffered a concussion, basically this said we dont want to play again because if it happens again, youre going to have a serious problem. She went to college, shes a freshman in college now and a couple times at least once had a feigning fainted when she was in college. She doesnt play sports anymore because of what they said. Ways, its fortunate because she had the concussion and now weve been told dont play sports anymore. Dont play Contact Sports anymore. But if she had one of the sub concussive hits as you talked about in the spectrum, my you dont necessarily know about it. Guess becausei she knows shes not supposed to do anything anymore. But if youre at one of these things, how would you even know . Spectrum, but the it seems like we are hearing more and more, at least im hearing moores apparent that cause damage. She is told not to play at all. I would not want her to have a second or third concussion. Tell me about that. Tell me about the spectrum in the sub concussive, how does that relate to the spectrum that you mentioned . Sure. Is ank the terminology little bit at risk here. It depends on how you think about it. Initiallyon was thought of as a loss of consciousness. That went by the wayside. Now its a change that is really recognized at the time of injury that theres a change in neurological function. That is without loss of consciousness. I think moving back even more there are changes in your function that no one would recognize unless they were tested. The ability to actually test the person is one of the limiting factors. In the sub concussive events, i would think, this is a hypothesis, that one could study those folks and see that there is a change over time and maybe some of the other folks would comment on that. But thee nothing ultimate respect for evidence panel. There are some of us who are taking care of concussions for peoples, taking care of 20,000 brain injuries. I provide care for an nhl team. The sky is not falling. Activityd return to within a day or two of a ,oncussion, not Contact Sports being in a dark room resting, staying at home is not a good treatment for injury. In any level, including concussions. Ive had six in my life, i was a terrible athlete. I think its important, there really isnt science that reports people shouldnt play sports after concussion. It really is bad for youth, it bad for professional athletes, it bad for everyone involved to spread that believe. Andeed way more research im involved with all these motions a lot of research. There is no science that says dont play sports after a concussion. But what about a series of concussions . You get one concussion. Its extremely easy to identify an acute concussion the just occurred. Surveyery hard to use a to assess it a week or two after afterwards. Months afterwards, just about impossible. I run tbi care for the va system. Its really hard after months. Diagnosis, that person gets back to activity a day or two. Doesnt play sports, but gets back to activity. Get back to school. They are at risk to get another concussion for the first several weeks, months, even years. We are all at risk to fall down and be in front of a bus. You are much farther you are a much further risk to get fat or Heart Disease. I can provide management. She was hit in the face and told not to go in school. Its wrong. The only reason she graduated is because they let her do things after. She shouldve been activated quicker. You are told not to do Contact Sports again. If it happened a second time no, we need to stop that. How many of you think that the person had an initial concussion, whatever costed that they should return to activity really quickly . Afterel concussion . A single concussion . Ive been to your clinic and you pointed out to me that it used to be a state in the dark and didnt do anything for long periods of time and done a lot of research on this area. You comment in terms of thats a myth we need to . I agree the skies not falling. We made tremendous progress in terms of treatment of the injury. We are starting to identify subtypes of concussions. Enacting certain treatments to these clinical profiles. Though we need much more research to understand the timing and dosing of treatments. Met recently in pittsburgh and agreed that concussions is a treatable injury. , i agree withct dr. Shivas comments regarding your daughter. I think that what we dont want to do is the pendulum has swung from here to here very rapidly as we alluded to. The truth is probably in between somewhere in the fact that its worse than what we thought it was but not as bad as what is meeting out made out to be. The advances weve made in treatment are significant. I would suggest it never been safer to have a concussion than it is right now because of the advances made. We are starting to learn that active approaches advantage are much more advantageous than sitting in a dark room. Fromat a lot of problems that philosophy of putting kids in a dark room in terms of chronic anxiety, chronic migraines, i have seen kids who are suicidal. Expensive Suicidal Ideation from that type of treatment. I really believe that we need to propagate the fact that we have made tremendous advances in how we assess, diagnose, and treat kids with the injury. Its individualized in terms of how people react. Can we hear some other . You had a question on this particular part. My question would be a little bit different. Let me do that first. Dr. Mcrae. Let me make it more general background commentary and say that this is probably familiar story in medical research. Concussion has gone as many people know. Its gone from total of security 10 or 20 years ago and the largest it is dominating the national narrative. The unfortunate position we are in is we of reached the awkward stage of maturity, called adolescence. We have enormous strides over the last 20 years that puts us in a position to have this discussion today. At the same time, the topic has been elevated into the public spotlight such that all the stakeholders assume we arty know the answers to all the questions and be paid they want those answers now. He perhaps no more unenviable position a scientist to begin than to catch up with the public narrative. I think we have made Great Strides in changing how we take care of athletes on the sidelines and during the ensuing days and is mickey pointed out with a treatment regiment, the depression we often use in our program is that concussions, particularly in a sporting environment used to be managed with a switch. The day you were symptomfree or is our data for you pointed out, several days prior to be set free, the switch was flipped in your return to call full contact whenever the sport might be. We have learned a lot about the natural time course of recovery and we now manage athletes on a dial. As david pointed out, we dont look the switch the day they are symptomfree, we introduce low grade, no risk activity. Under a. No exposure contact. We allow that athlete to graduate through stages of rehabilitation, acclimate and reach a point with their symptomfree. And return to activity when they are safe to do so from a clinical recovery standpoint. We have data from the recent andy comparing our outcome reduction of repeat injuries of the same concussion in 2014 and 2015 to 1999, the first ncaa concussion study. In our early studies, more than 90 of our same season repeat concussions occurred within the first 10 days of the first concussion. In the current study, there is a 0 incident of repeat concussions in the first 10 days and the average interval for the small numbers of same season repeat concussions is 75 days. The work by a lot of people in the room here has had a direct translational impact on how we take care of athletes in military Service Members and people in our Level One Trauma Centers to protect them from the risks. As walter pointed out, we are just scratching the surface. We know very little about the underlying neurobiology of this injury and as odd as it sounds, we know a lot about how long it takes for the individual to tellis us they are completely symptomfree or recovered, but be very know very little about how long the brain takes to recover. Ultimately we would like to know the answers to those questions about the underlying physiology and recovering of the plane level. Brain level. Say, what dr. To mcrae is referring to is basically the research we are currently required acquired mostly with males. Adolescents and young adults. Not as applied to girls, not as applied to younger children. So we are making some leaps of faith in terms of how we apply , that weveger kids got to have better evidence to know. I think the simple answer simple question that is often asked by any parent is when should i allow my child to do x, y, z. We dont have those answers yet. At the same time, we also know that we want kids to be active. We know the benefits that of artie been discussed about sports summit level. So many levels. The application of our knowledge to kids. We have to be more cautious. But some of it may or may not be appropriate. It appears the girls do have both different risks and different trajectories of recovery that we have to better understand because there may be a different biological, psychological, biomechanical response to forces that has to be understood. And the same goes for younger children. Thatere is a perception number one, we know a lot more about it than we do. Then tell you that knowledge is at its lowest with younger children. I will go to dr. Manley. Thank you very much. I would like to bring this conversation back to your comments represented murphy which is that tbi affects more than just athletes. This is really as highlighted in your brief, we look at the athletes and military personnel, as our colleague from the cdc pointed out, at least 2. 5 Million People year abroad to Emergency Rooms with concussions and more moderate and severe dramatic brain injury. There are at least two to 3 Million People who never seek out medical care and even when those patients get to the Emergency Department, we have studies that show that over half of them are missed. In our ongoing nih study we are asking patients in two weeks, were you referred for a followup. These were people who were diagnosed an Emergency Department at 11 of the best Trauma Centers in the country. What the founders less than half of those patients were referred to followup. There is a very low bar in terms of following up with things that we know. We other misconception is have treated concussions in brain injury as an event and not a process. Because we look at it as an event, ivan didnt care for medical traumatic brain injuries patients for years. We dont followup like diabetes. The longterm effects are unknown to the medical community. Now that we look at it more like a disease process and the studies like track tbi and other studies we are asking questions that we never asked before. We are finding that not only just such and such is a single concussion can alter a life. I appreciate you bringing this to the forefront. There are millions the people who sustain traumatic brain injury each year. 5 million suffering from the aftereffects and we need to do more. Dr. Mckee, do you agree . I want to point out that theres a lot of misconception about cte and concussions. The movie was called concussion, it was about cte. And all of our experience, weve never seen cte after a single concussion. Cte is associated with duration of exposure to repetitive head impact. Cumulative exposure to low level head injury. So concussions have never correlated with cte. Studies,een multiple no correlation with the number of concussions. Very consistently is the years of play, the years that an individual is exposed to say playing football or boxing, that does seem to be an associated with the risks for cte. The longer you play at the higher level you play, the greater the risk. Thank you mr. Chairman. I was the heart surgeon before, i was in congress. Will be about primary prevention such as big. Education. 23 10 four kids from age age 12 and they all played hockey all play hockey, soccer. I personally played football in high school and i still play hockey. You alluded to it a little bit on my and my question is a lot of research may be done in adults, but the question is, there is obviously developmental things going on in youth that may have a different impact on this. Im not an expert, but people say the brain is still developing significantly into your 20s and so, the question i have is, what do people think we should be doing in our Elementary School and Great Schools really early . I know what with the currently available information without making parents afraid for the kids to play. That said, what is the potential differences of how these things impact youth versus how they impact adults . Should we do things maybe differently in youth and adults . Who wants to respond . Im happy to start of the conversation. Im sure there will be a number of folks interested in commenting. I am on the medical Advisory Board for usa football. In the meeting we had several weeks ago, the question was at what age do we introduce different types of the game two different individuals . Onagain defend depends your physical maturity, psychological maturity, all kinds of factors. To be jewish the game in different ways . Do we teach the game in different ways . A lot of sports are looking back now as a model system for matching the person, their developmental age, and the game and its particular skills. So can we teach or do we modify checking . Do we modify tackling and blocking . Do we modify that development the level cannot sustain it. I think it is a very important question. We need to wrap some research around those questions. I think at this point though, we can certainly reduce that risk. And by reducing the amount of contact that goes on in the sports, but still teach the game appropriately so that you are not putting somebody into a competitive situation totally unprepared is really a challenge. Its not a simple answer, certainly some of the work done with the Football Program is showing some reduction in general injuries as well as concussions. We can do more though. We still dont know the answer as to what age do we start these things at. I think it goes beyond that. We can look at our physical physical education in school and understand how we build strength. How do we build the important kinds of preventive biologic kinds of factors. How do we think about the introduction of sports at certain ages that somebody is psychologically ready for. For whatever reason, i would love contact sport. I have a son who is not the same. Thats ok, do it you want to do. We need to understand what you are cared for. That goes for boys and for girls and frankly, our bodies are built differently and we need to take that into account as well for different sports. So we need some studies done on developmental biomechanics as a relates to sports. A brief comment. Ive also coached youth hockey inners been a transition in youth hockey about what level kids can check. I can tell you, it used to be fairly young and trying to teach them how to properly check without injuring people was pretty hard. I can tell you that when the people are younger, whether it is football, or soccer or another sport. Usa hockey i think is out front on that. Its important. Dr. Bald and its going to Say Something. Most successful communication campaigns called heads up is about prevention and recognition prevention, recognition and management. We have reached contributed over six main materials to train 3 million coaches on concussion prevention recognition and management. Weve migrated from a focus on parents and coaches to school professionals. Now the next phase of the campaign is focused on kids. Andging the culture sports so keli semi intel, who leads the initiative, has really Creative Ideas about how to break into the younger population. We will, with an app in the next few months. Blaze thated rocket will teach kids about concussions and concussion prevention. One of the tools in the tool chest for us is raising awareness and education. Weve tried to do that for over a decade now. , awareness, awareness. There are 10 apps to teach kate. None will be as good as yours, but i just saw nap in holland that is unbelievable to teach kids about concussions. Its fantastic. Without the awareness of the coaches and the parents, it does not matter. The kids are 20 selfreport. If awareness is good, unless we develop Health Care Professionals that actually understand how to reintegrate people back into their lives, we will have some really frustrated parents. Because we see them all the time. Thats who comes to our center. People who were kept in a closed room and told to didnt take test for year. On this more focused fear of this amazing work and we have an less concerned about their overall wellness. A fastkid does not go to food place, he will probably do better than if he gets carefree concussion. We need to wrap this around total health of these kids if you really care about them. It isnt just the concussive force. Gettingave been concussions for 3. 2 million years of a look at archaeological evidence. We are not all demented. We willld just say that be releasing next year some guidelines for pediatricians. Can this group see them . Yes of course. Into groups i think we know the least about concussions in the young and the old. I think that the old, they were getting that way anyway after they fall and hit their head. They are actually the ones that suffer the most consequence from a head injury. They declined rapidly after that. It comes, it is down to a matter of balance. Parents should not be absolutely afraid of a head injury to prevent their kids are participating in sports. The value sports in many ways needs to be emphasized in terms of timor, exercise, personal development and responsibility. Sports has a very valuable contribution to our society. What we need to do a better job is in the area of the coaches and trainers. In the youth in particular, there are no standards across the board for anybody in coaching. A lot of times even at the high school level, it is whoever draws these short straw is the monastic coach. Is the one who has to coach. In europe, you have to have some certification for coaching kids. Some actual way that you demonstrated you have been trained. I think work needs to go on in that on that in this country. Levelms of raising the and the standardization, the knowledge of the people who are responsible for those kids. Get one other thing we were talking about earlier, this fear about what they have to do concussion that they are some there is some black or red mark on them in addition never participate again. The risk from a repeat ancussion it depends on number of factors, the most important one is the time for the previous concussion. So just one single event does not necessarily preclude you. It depends on the time from the event and the characteristics of the individual that suffer that. Miller andgo to mr. The next question from a member. Bemy comments will really looking at sport as a Public Health model. I think there are three things thatare very important address the whole culture of you sport. One is that all 48 National Governing bodies in our country are signatories to what is called the American Development model. It is a unique opportunity working with the u. S. Oc and all of the parent organizations to look at sport is a longterm Athlete Development process. That is currently not happening well enough. But everyone is on board and concussion would be a part of that. The second and the kernel admission of this, to be a coach in the country, all you have to do is hold up a single sam a coach. It is different in europe where you have hundreds of hours of Sports Science specific training. I was in california this morning and this ishis something that the ncaa has been involved in with the National Governing bodies are working with our 23 sports. Were doing sport specific conferences and then bringing it to that the whole concept of developing coaching education. It really has to start of the youth level and that is something that is exceptionally important. I think there growing momentum for that. The third is that there needs to be someone to protect our kids and so that is empowering people such as the athletic trainers. The athletic trainers are probably the single most important person that could be onsite for any sort of contact collision event. It is important that even in this country, in the state of california, said trainers are not regulated. In new york city, their 35,000 members of the Public School athletically and not one athletic trainer. They are the people who really need to be empowered. We recently passed legislation will be defined primary athletic so think if we can get the signatories to the American Development model, coaches education and empower the athletic trainers, those three things combined will probably do more to shift the safety and new smart youth sports that i know of. Thank you mr. Chairman think you for convening the group. I want to echo a fair amount of what was just said with a few more specifics. I will start with the third point around trainers. It came to our attention, i work on a lot of policy and education initiatives at the nfl. 37 of high schools around the country have a fulltime height athletic trainer. Since you 2 do not. That is ridiculous. Way toit is the easiest protect our kids. Both on the prevention side as well as the treatment site. You have kids dealing with injuries by participating in the sports. The fact we cant invest further in athletic trainers is a Public Health question we think we can address. The league has started programs to our foundation. Several hundred trainers and high schools in the last couple of years and we will have an announcement tomorrow. , absents a dramatic way of all the scientific questions that remain to be answered, to help advanced sports. Thats something we are continuing to work on. Let me add this from the policy perspective, we spent time a few aars ago, the nfl did, with number of other supporters run the country traveling state to state and getting new concussion laws passed. This came up from a young man dramaticwho suffered a brain injury is a 13yearold playing football and returned to sin and suffered catastrophic injuries. He survived thankfully and is our inspiration. Simplisticetty around identifying and ensuring the child is not returned to play. That is in any sport. There istrates i think a baseline that can be done from a policy and education perspective to arrays wariness. Those laws are not a panacea. But its the first time thats been done and i think that might be a model we can talk about as we go forward. The third point i want to mention, dr. Joy was a bit humble around the program. The design was to educate youth coaches. David just mentioned. 150,000 coaches have been trained on concussion identification as well as the way to teach the game which is essential in football like how to introduce tackling. Is 100 50,000 coaches representing well more than one million kids who did not know anything about concussion. These are huge challenges. They are not insurmountable. If the group of people here who are more experts in science than i would ever be can think of a policy and education can say you can make up Real Progress while some of these harder questions are being addressed. We will go to burgess, zukowski, green, then hudson. Thank you. I have two questions for mr. Miller and then i would like to ask mrs. Mckay a question. Ago,ars ago, 36 years roger stone back retired roge r stalback retired. I recall around his time he had said he suffered a number of concussions and it was determined he could not tolerate one more or there would be big trouble. I did not know what metric was used. What test was too used. I just assumed there was a metric or a test where you could tell that is enough. Today, what is the stateoftheart for somebody who has competitive repetitive episodes of head trauma . Him, hee case of was great in football but his post football success has been terrific. The question is medical. Physician and in the case of the nfl, weve had unaffiliated doctors both in terms of diagnostics and placing them on the sideline as well as further independent experts at have to clear a player before he can return. The standard is whatever the team medical staff in consultation with the unaffiliated independent doctors comes to. For that individual they are is no comparison. But we are going to put more people around the table and diagnostics and treatment recovery. I that was 36 years ago, would have expected the science to have advanced more than it has because of the enormous investment the nfl has at risk. Let me ask you this. I did read the book that i have not seen the movie. Of description in the book his case for forad a case pending compensation for his longterm injuries. He was eventually awarded compensation three years after his death. , is thation i have is process better now than it was 10 years ago . That a player has for applying for benefits from the disability part of the league . The disability benefit question is important. Im sure she has an answer for this. She does work as an advocate and important work as an advocate for retired players. Most recent example, the collective bargaining agreement, we allocated lane millions to retirement programs. For those who played in the years before the modern age, pre1993. There are a number of programs in place for retired player care which includes programs associated with players who have been diagnosed with dementia. Any neurodegenerative disease like i can alzheimers and parkinsons. In addition if youve received a diagnosis and i think theres more than 300 million players who have discovered this, you get more than 3 million players, you will get benefits. We will get to the benefits of future care but i would like to see if we could focus on the scientific things. The you have another question in that area . You obviously have a perspective on this, because i read about this illness. Its devastating for the individual but it is also devastating for the family, estrangement from families. There is an ongoing continuum with which the family has to deal. Could you give us insight from the familys perspective . Contribute nothing more today but i am not a doctor, i hope i can press upon just how difficult and tragic this is. Not just for the sufferer. Think of what they go through. Particularly when my husband died, he had no idea what was happening. But at least those suffering today know there is a neurological cause further struggle and probably beat themselves up less than my husband did mentally. Blaming himself for his failure just to be the man that he had been. , it is the family devastating. I cannot overstate the capacity for this disease to rip families apart. Seen, dr. Mckee, she said maybe 180 and 190. We know the clinical histories on each of those donations and individuals who have passed away with the devastating disease. Very often, there are widows who feel or exwives who often feel guilty for not Holding Things together. Manyl honesty i say so times to them i am more surprised when the family is intact then when it is not. I think that there are some benefits that the nfl is able to provide to former players and thank goodness for that. Part of it is the problem with these things, even for a former player to access and unless things have changed that i am unaware of, those players have to be vested which means playing for lead four years in the league. We cannot forget that this disease is being diagnosed and for home there are no benefits, there are no places to turn both for treatment and for compensation in terms of where they are going to find this treatment. I can tell you that families are in dire straits. There are a lot of individuals who are struggling. I appreciate your observations and want to ask you , this is probably a larger discussion but a year and a half ago this committee got involved in the question of domestic and the National Football league and it strikes me, looking at the continuum of this disease, that that may be an aspect that while we are focused on this an issue where the nfl needed to focus but also perhaps it is an index where it needs to be studied there is a component of chronic traumatic encephalopathy that is making itself apparent. I would think that is likely very much the case. I has been passed away at 45 and was a very different man than i had known but he had passed away young. Fors a very strange thing me to consider that we may have almost gotten off easy. A lot of the families that i speak with do see a lot of ugliness, a lot of scariness. Talk to women whose husbands are as young as 38 years old who are coming in and the babies cries are making him irritable and setting him off. They are afraid of their own safety and i think absolutely it is an issue that has to be looked at. There is a lot of potential when you think about the areas that are affected that they lack the ability to control impulses, emotional liability is compromised, this irritability and rage. Its a very volatile combination. I would think it would be a concern. The military standpoint, some of the symptoms we see in the military with high suicide rates. I think in dod one of the things we struggle with is the way the patient oh sorry, the way the patients come to us. They were mostly male, 85 , 18 to 30yearolds who were physically active. As a psychiatrist and many people in my care clinics clinics,are were seeing many people downstream. As a psychiatrist i need to tease out can start concussive illness with a Substance Abuse disorder, a pain disorder, any number of other things. Focused on just come to you and say they had a concussion and heres what happened. Diagnostic clarification is a huge issue. Of her disability from a couple of places. The v. A. Scheduling, they have very specific items about ptsd. Ascertaining the nexus between the insults and what happened downstream is very hard for us. It alters policy issues and the like. This from a fellow navy provider, many of the people who have been diagnosed and have ptsd have had similar symptoms to what mr. Mikael says. The short temper, nightmares, trouble with social relationships, now we are realizing it is very challenging to ascertain. It is tempting in dod to use the Sports Medicine model for preventative treatment. But we really cant because we cannot do that and meet patients were they are. I have a twoyearold that has been walking around. He has been hit several times. Before i tell him to walk it off, i asked how can i ss this because he does not give me a history. It strikes me that a lot of my patients cannot give me a history as well about what happened, when it happened, and what happened downstream. Thats what we need to move to research so much. I just want to add because i think we are getting a mixing of a couple of things. Theres the issue of a concussive incident. You concussion and how can treat that, when do people go back onto the field or wherever theyre going . The second question is the cte question, which is repeated. It could be repeated concussions but it can also be a long history of repetition for a sort am soam not a doctor, i concussive. Scientifice we have that are to support all of that. Let me take a pause for identification. I want someone in the room to identify what you look at on an mri. What you are looking at our pet scan, protein, what are you looking for . The movie was about the proteins. Can somebody describe what you are seeing . What youre looking for . The problem is we cant see what we want to see. Let me make it as simple as i can. Condition,phase stage four of the disease, the brain is severely degenerated. That will show up on an mri scan as a severe atrophy. Culprit, we think, is aggregation of the proteins in the nerve cells. Hat is the signature cte pst, multiple different diseases. It is a bad actor. The trouble is as you move back in time to people who were not severely demented, it becomes trickier to know what the differences are. But we have funded is research that has been able to look at the brain because nathan look at the dyke assist in a brain after somebody dies look at the brain and make a diagnosis at after someone dies. At the next stage theres another grant. Following people at risk to see when imaging signatures for a particular clinical syndrome characteristically up here that we can uappear that we can say that where changes. But we need to examine the brain to know somebody has it. For oneust finish up second. I know this guy. The problem is, which we have to throw the table is, i initially thought this would be a rare event. We knew it happened in boxes, and finding it in people with a thousand hits in a season, its not that much of a revelation. But to find it in people of high you mentionede, this brain bank at the mayo clinic, in all the people that play sports, we now know dont know how common this is. We do not know whether everyone is going to progress. We got it. We doubt it. We have a couple of clues but we have to work those out. There are lots of ways to diagnose early cognitive deficits. There are plenty of ways to diagnose acute rain injury. They dont involve imaging at the present time. Exams, physical neuropsychological testing, physiological measurements, testing that dr. Collins has been the leader in. Theres plenty of ways to diagnose this. If we believe this guys falling, we need a motive multimodal approach. It will never be a thousand dollar m i mri or dti. But we have clinicians that know how to do this and researchers that can put this together and have put together multimodal assessments. My research, thats what everybodys researches. Ct as well, absolutely for ct. Thats how we diagnose alzheimers. We can wait until some of the expires and look at the brain or we can look at it late stage c. T. Scan. Researchers are looking at early evidence of dementia. That does not involve imaging, and involves other testing which we all do. I would just add there have been a number of points of interest raised in the last 10 or 15 minutes that start to converge around a common theme. The unfortunate reality is this common theme is the lesson that weve taken 30 years to learn and also representing the demo that we dilemma we currently face. We have been faced with some magical discovery of a single solution theory that would explain and predict outcome across individuals. One of the burning questions in the scientific community, its no wonder that it is in households, the same question is how can it be that two individuals with seemingly the same entry have much different shortterm outcomes. And now the narrative has turned to how could it be that two individuals with seemingly very similar exposure profiles have much drastically different lives . That has to be a complex matrix of input channels that predicts risk. This condition shortterm and longterm is far too heterogeneous that there will be a single predictor variable. With respect to longterm outcome, the burning question is, what are the risks . How prevalent are they . Who is at risk and why . What are the factors that predict risk . How can we interrupt or prevent those risks . The parallel question at the or whate, is exposure we oftentimes say, how many meaning the number of total concussions, or how much total exposure is necessary, sufficient, neither, or both, in predicting longterm risk of Neurological Health problems . I think all of those remain unanswered. To move along so others have chances to ask questions. Go ahead. Im concerned that the nfl has a very troubling record of denying and discrediting scientific inquiry into the risks of playing football. When dr. Bennett published brain andf cte in the former player mike webster, nfl doctors, went on a campaign to discredit and undermine both the doctor and his work. Doctors went as far as to demand a retraction of dr. Amalus research for the next 14 years. The nfl pursued a strategy of the heavenly denying a mounting y denyingehemently th to mounting evidence. They have looked at other growing research that contradicted a growing consensus among the independent scientific community, that seeing repetitive hits and football are linked to comic rain damage. The nfl effectively suppressed critical information for current and longterm health incompletions implications. As february 24, 2016, 3 days before the super bowl, dr. Mitchell berger, the head of the nfls neck, head, and spine injuries, denied there was a link between football and cte. He begrudgingly admitted only begrudgingly that there can be an association between football and cte because some former players have developed the disease. Unaffiliated to hear and nfl affiliated individual say that a scientific connection like that is wrong is truly astonishing. And the corner they may highlight, the nfls rule change on the specialists on the sidelines at every game, they point to funding. Has committed toward reducing and managing concussions. I want to ask about that. Espn said there were changes in that. Such initiatives may be by focusing on concussions, the nfl is peddling a false sense of security, football is a high risk sport because the team does not just have diagnosable conditions. What the American Public needs is honesty about the health risks clearly more research. The risks inherent in popular sports like football. I just want to ask what i think is a yes or no question from both dr. Miller and dr. Mckee. Let me ask dr. Mckie first. Do you think there is a link between football and the generator Brain Disorders like cte . I unequivocally think there is a link. We have seen it and 90 of 94 nfl players whose brains weve examined. We have found it in 45 out of 55 College Players and six out of 26 high school players. I dont think this represents how common this disease is in the living population. But the fact is that over five years i have been able to accumulate this number of cases in Football Players. It cannot be rare. We are going to be surprised at how common it is. The other thing i want to emphasize is that its not about concussions. Its about limiting head injury. Head injury occurs on every single play of the game, at every level of the game. We have to eliminate the cumulative head impact. We need to have sensors or accelerometers, some way to gauge the impact and limit them so that we can maintain safety for our athletes, especially at the youth level. Many times, lisa and i, amateur athletes come down with this disease. Its devastating. When you see this disease in a 25yearold. We have seen it over and over. It cannot be rare. To me what our job is as american citizens is to maintain the health of these Young Athletes for the entirety of their life. Tothere is something we have do to limit the risk it something we have to do immediately. Do you think there is a link between football and Brain Disorders like cte . Research has showed a number of retired nfl players have retired with cte. The answer is yes but theres a number of questions that come with them. I guess i just want to is there a link . Because we feel or i feel that was not the unequivocal answer three days before the super bowl by dr. Mitchell berger. I am not going to speak for dr. Berger. You are speaking for the nfl . You asked whether i thought there was a link and i think based on dr. Mckies research there is one. I think the broader point and the one your question gets to be is what that means and where to bigger from here. Where do we go from here. In the incidence or prevalence i think for the medical records, i am not a medical position so i feel limited. Aroundould like to go the table for as far as what the science means around the question youre asking. I have another issue. Tribune, randy chastain, the famous soccer player, she is donating her brain to science. Obviously, she wants more research. Plus shes acknowledged she may have suffered several concussions. The article also says that new york times, no female athletes have been found to have cte. Which i found strange. It also talked, this article also talked about female athletes suffering greater rates of concussion, report more symptoms after concussion, and demonstrate greater impairment during neuropsychological testing for experiencing concussions when compared with male counterparts. The idea that there needs to be more research. 2016,tually just now, says that gender has to be a pretrial and in Clinical Trials. Animals have to have gender difference as well as the Clinical Trials. I have to ask, do we need to reconsider whether or not the sports needs to change for minors . Should we even innate headers in soccer . Whethere be considering children, miners ought to be playing tackle football at all . Do we need to have a more comprehensive view of whether or not we should subject our children to these kinds of sports . Adults who want to play professional, and they want to risk this kind of thing, it seems to me thats their decision. As long as they know the risks. But children, should we change sports. And gender issues and atrisk populations, can we put this back to a scientific level . Can some of the respond to that . There was a conference in georgetown a few weeks ago that looked at the issue of gender and concussion in particular. One of the things that i presented at that meeting was age and yourlly is gender. We have found that boys and girls are not different either in terms of their symptom expression when preadolescent, but when adolescent we see the differences between boys and girls in their expression. We dont know why. When boys and girls are not entered one young or adolescent, we dont see them talking about on concussive symptoms differently. Theres something about concussion in adolescence that is an issue. I will go back to the point i made earlier, which is that we dont understand enough about girls. And adolescent girls, are reporting more symptoms and taking relatively longer to recover than boys. No femalerue that athletes have been found to have dte . Only had true, we have four female brain donors and they were not athletes. It has been described in the literature, one was a Domestic Abuse situation where she has been abused by her husband. The other one was an autistic woman who banked her head. Banged her head. The demographics favor of men at this point and we expect this to change. But we are actively trying to recruit female brain donors to answer this question. Is there a gender difference in the outcome from repetitive head injury . Do you have an answer to that . I think the main issue is that we are talking about a complicated injury in the most complicated organ in the body. There is a lot less known at this point in time. We dont have a Natural History study from the time a kid gets injured or somebody has repetitive injuries. When Something Like cte calms, for example, we had a surgeon colleague. Look at what it did for Heart Disease, what we need today as a longitudinal study to understand what the incidence of this is. We need better diagnostic tools. We dont have anything very objective. We need better ways to predict who are those people who are not going to do so well. I think it comes down to funding. In your pamphlet, you highlight that nih is spending 93 million to understand a problem that costs over 70 billion a year. There are professional athletes that make more money and a single contract then doctors have had to fund the Research Care asking about we are asking about today. I think we need better care, better followup, better screening, and we need a bigger investment in this problem to understand this. I am overjoyed the American Public has turned to a problem that as a neurosurgeon working in a Level One Trauma Center in an urban environment, ive seen the consequences for decades. I appreciate you are interested but there has to be a more sustainable and powerful investment to understand problem. I want to speak with cautious optimism about where we may be. Ncaa and the department of the defense joined forces a little more than a year and a half ago and we have begun a study and we are getting results in realtime. This is a study that is involving 30 schools and at each school every single student athlete whether female tennis player or Football Player undergoing an exceptionally rigorous multimodal examination, and if there have been concussions repeated at 36 hours and 48 hours and armored over d, three of these being women sports with lacrosse, ice hockey, we are also getting blood markers, kids are wearing sensors and theyre getting brain mris. In a year and a half, we have done studies on 18,000 studentathletes that we tracked over 700 concussions. A large study before that have been somewhere upwards of 20 concussions. Im happy to say the people at participants in the study, our principal jeff and i met and we are using the track paradigm for the mris. Now working in a cross functional way that has never happened before in Concussion Research. There are so many that are invested just in this study alone. What we are doing and dr. Mccree can speak to this because i am not allowed to live. Research fully because ill be a conflict of interest, we were on the executive oversight of this committee but we dont have any voting power. It is set up in a way that is a nonconflict of interest study. We will be having a few things. The study is going to provide for definitive evidence that within two years on what is the Natural History of concussion. Just concussion. We will also define neurobiological recovery. Which is exceptionally important. We will have that data, mike can speak better to it. But i think probably closer to a year from now we will have definitive data on what it means to be truly neurobiological he recovered. We are coming back to washington in three days and laying the foundation to put this into a fiveyear study. Ultimately we are going to make this the Framingham Study of concussion. It will be a 35 plus year study but it does not mean we are waiting 35 years. In very active fiveyear increments we are coming in with new tools including scans and more advanced brain imaging to understand what we are seeing in these increments. Our are we seeing there are problems in certain groups of populations . One of the problems is that its not just ncaa athletes. Every cadet is enrolled and we are understanding this as well. In addition, for everyone that is concussed, the have a control in their contact collision sport and a noncontact sport. For the first time we will have real data on those who have had repetitive had contact but have not been concussed. Thats something we are going to be looking at. Ongoing, very real, and the first wave of analysis will be reported some time. Possibly in the late spring. It will be going on after that but even while we are waiting for these results, just two weeks ago, there were 15 of the most prominent medical organizations in Sports Medicine organizations in the country. We look of the first round of the results including very detailed head sensor data. A specifictting out date but you are going to see coming within the next three months some very new recommendations that will be called into association guidelines, not ncaa specifically but it will be equally endorsed by the american medical society. The congress of neurological surgeons, the American Academy of neurology, on concussive diagnosis and management with regard to our football practice, the ivy league was in contact with us. There will be a whole new emphasis on absolute recovery, which is something thats been overlooked. I am just a little optimistic that we do have something very hot in the pipeline that is very real and we are getting active results. Does anybody here think we should change the rules of the sports for our student athletes . Should we change the headers and soccer . I just feel and brian, you brought so much to this field and with the researcher overseeing. I think we need science to lead the way. Really behooves us to put science first in understanding these issues. To sports changes without understanding the consequences, i want to make a pitch for science. In about five years we will be back here. This is not a fiveyear problem so this needs to go on and headers are not the problem and soccer. Richard has a question and then you can talk. Oh did you want to Say Something too . Im sorry, i did not see your hand. I hesitate to want to wait on the science when we know the changes can have such a tremendous impact on the safety of children. I would say absolutely there can be changes to the sports and we should be having a conversation about the wisdom of putting our kids and activities where their heads are getting hit repeatedly over and over, when we know that for some individuals, those consequences can be very dire. We dont know yet about the risk factors. We dont know yet about those that will ultimately be having consequences of Something Like cte. But we absolutely know that no head trauma is good. There are ways we can absolutely make game safer without toying with the fundamentals. Soccer, absolutely. Ised the age at which they will introduce heading in soccer. Hocker raising the age at which they are checking. Tremendous differences in making kitzhaber and i think we should explore each and every opportunity to make every sport safer without getting in the way of ways that change the game but absolutely that can be changed. Let me go to mr. Hudson. Represent the home of the carolina panthers. Let me congratulate you on the super bowl victory. Sorry. Ive become interested in the issue of pediatric trauma. My interest was piqued by the wake Forest Medical center. Iny are doing a lot of work trying to look at some of these questions. They have studies for they have sensors in helmets to look at not just the big hits but the longterm outcomes. One of the things that struck me was the disparity of care. Trauma,child suffers and you have to live near a level one pediatric trauma center, your kid has a great chance of being healthy. But if you just happen to live in a part of a country that does not have close proximity, there are a lot of problems. Thats one of the things that nights at me. And as chairman, getting a study to get it across as to how care is delivered, it was interesting to me when you brought this issue of awareness. Also, how do we take research and understanding that you are developing, and have it available . Where the rubber meets the road, maybe i just kind of throw that up. I mentioned our traumatic rain injury guidelines, and another thing we have is an active area is including clinical Decision Support tools with Electronic Health records. Childrens hospital of philadelphia has been leading the way. Moving across the health care main places to that Concussion Management protocols are built into their clinical Decision Support so the care they receive regardless of the setting that they show up for care in is identical or near identical. Since i have the mike, the other thing i want to mention is another active area of inquiry. Mr. Miller had mentioned earlier all 50 states returning to play laws. We are interested in what the best practices are as well as returned to learn protocols. We are evaluating if they were, how they work, what type of laws the to be in place. Those are a couple things. Just to recognize what brian and the ncaa and others are doing, i think it is laudable and it is 18 years to advanced. We need to expand this forum to kids below the age of 18. And part of the reason that we have not is because we have not efficacy advocacy and Research Systems that have been set up to some extent the way the ncaa and dod had them. This institute is part of a consortium on pediatric brain injury. Its really trying to model what is actually happening at the collegiate and above level for kids. What are the risk exposures, what are not . How do we understand the epidemiology as well as the treatment. I do think some priorities need to be reset, not just to start collegiate athletes but really to start with the youngest kids and move forward. Goingou can link what is into the ncaa into the dod. That means the coc need that funding report to make that happen. That has the things happened in youth sports has made this more difficult and i think theres ways to overcome that. The participation in school based sports is declining on club a sports dramatically but that has become the wild west out there and we need to have some way that even if the club based sports get incorporated into systems that we develop. Make one want to point. At nih we have looked at our that thisand we agree issue of understanding the effects in children is the gap and that seems to be currently the highest priority. Thanks for that. To that point i appreciate, brian mentioning the Care Consortium. All of these things start to dimension,er with the four Corners Initiative that jerry is heading up. Within a year, the Care Consortium will have 25,000 collegiate athletes enrolled. We estimate it would be over 1200 concussed athletes who have arguably represented the most richly characterized cohort of injured athletes ever enrolled in a study. That provides a unique opportunity. I have to keep coming back to this point. The reason we are sitting here debating a number of very fundamental issues about longterm risk and outcome, is hasuse in large part, there never been a truly populationbased longitudinal study of outcome after traumatic brain injury. In military nba has invested the initiative to do that in military service veterans. But we have never done that in the civilian setting and track tbi provides the most rich cohort of civilians affected. And care represents the largest and most originally characterized cohort of athletes. As brian pointed out we not only have detailed data on clinical bloodry, we have biomarkers, genetics, imaging that tells us about the neurobiology. , i fact of the matter is keep preaching to the choir, the likelihood that this is a single variable whether it is injury or exposure, i think it has already fallen on failure. We look at to individuals with seemingly the same profile exposure or injury with drastically different outcomes even in the short range over 10 days. And over an entire lifetime. Its going to take a monumental effort. There are low hanging fruit that we can grab early on that would answer some of the fundamental questions. In terms of what is the risk associated with exposure, whether it is sub concussive or injury, whats the multidimensional nature of factors that predict outcome . We have been chasing the solution for decades, and its destined to failure. Thats the dilemma we face at present. One of the things i want to make sure we do not mess and i think we are all passionate about, youth sports, very passionate about what happens to kids, the community impact. I dont want to forget about the elderly. The Fastest Growing population of concussion and brain injury is in the elderly. There has been at least a 50 increase in the last five years and in california its been higher than that. Less than 1 of the literature has spoken to this. Weve excluded people from all prior medical trials and knowing all of these people over the years, were moving in this direction and the cancer doctors and heart doctors have been doing a wonderful job. This is going to be an ongoing problem. Theres a lot to chew and im glad we are going to at least talk about this. This is also a population we need to be very mindful of. Its incredibly important. Thank you, mr. Chair. Ct, i wouldalk of like to take a step back for a moment. Dr. Mckee or whomever is around the room, when was it recognized as a unique disease . Is there a distinct quality to it that separates it from alzheimers disease . Neurodegenerative . What likely is the biggest cause . You talk about extending beyond concussions and also head injuries. The final item i would throw all of this out there as a question, for observation. Theres talk to clusters of depression and suicide. Are there things we are already learning about the impact as it relates to suicide . Health disorders . Ct, i cant say when it was identified, it was a unique disease because its been known since the 1920s. Thee were advances in 1970s about the neural pathological and clinical characteristics. I do think it was the and i nds nds conferencei that established was a unique disease that can be established pathologically from alzheimers and aging or all of these other unusual diseases like progressives. This has been done by a panel of neurobiologists to have been examining these slides, theres a box of 700 slides and they sifted through them and took a hundred hours each. Cases, 90 of the correctly identified cte. Further and said there was a characteristic lesion in cte that theyve never seen in any other disorder. This panel of experts also said that in their combined experience, theyve never seen this disease and anyone who has not experienced trauma, typically multiple episodes of trauma. Thats about as distinctive agencies as you can hope for, at least pathologically. Struggling with is one of this specific clinical characteristics with a lot of overlaps like alzheimers. When it presents an early life in the 30, it can be depression or personality disorder. Rage, be a lot of aggression, impulsivity, aggressive violence, and suicidal thoughts. Its hard to sift through those symptoms because they are more nonspecific. But we have seen in many individuals with cte mommy look at them for support with clinical characteristics during life, depression is common, suicidality, aggression, short fuse, and memory problems. Those would be the most common disturbances. Forhe advanced Research Additional research that goes forward is the most critical step as you go forward with this. I think the new funding of the longterm prospective cohorts, they will be following former nfl and i believe from college athletes, over time they will be collecting and evaluating them yearly. They will be doing blood test s, and they will follow them to death and hopefully making images with certainty so we can make diagnostics. Then we can, if we can identify it in early life we can pull them out of the game and have a good shot of treating it. We want early identification during life. I think the sevenyear study will go a long way toward answering some of these questions. Thank you. I want to ask a question for everybody here. You mentioned some of it. What are they, blood tests out there that you can diagnose acute brain injury . In cardiac disease, i was a cbat surgeon, you have a you get it right away. But im not aware of what there is as it relates to the brain. Funded most of the work in their field when i was in the dod. There is nothing approved at this point. There are more than 20 different potential targets. Two of which have actually been through the trials and are now being analyzed and hope to be submitted to the fda by the end of this year. The data ive seen looks good. In idea is that you could fact measure in the blood something that happened in the brain. It was something that was denied until about 12 or 15 years ago. The bloodbrain barrier was an issue we could not cross. Well we have actually shown there was a high sensitive breakdown from the injury that seems to get into the blood. I hope in the next year we see approved test. It just got better. Right, but just as in Heart Disease and stroke, the awareness by the clinicians on how to make the diagnosis without using a blood test is a lot cheaper and a lot easier. Dallas use of dedication will help what we actually have tests now when somebody comes in the er. Even on the battlefield we can diagnose him now. But you do think that as a do the research they could take blood and try to develop with it. Inbut thats being done and the meantime, the rest of the world is treating these people. And weve been doing it with good rigor for years. We are to refine and objective five that. But clinicians can manage these folks and diagnose them fairly acutely. Have a hard stop time and i want to ask a question and have everybody answer. This is the oversight and investigations subcommittee. Our job is to gather up information and before making recommendations, things in the budget issues, ask does this have jurisdiction . Jurisdiction over nih . Professional sports . I want to ask this question and i want each of you to answer this in whatever room you come from but in terms of this, what do we need to know . What does Congress Need to know, whether it is a recommendation or information that we need to of causes,e areas prevention, diagnosis, and treatment . What israel take away to make sure this committee knows . Is the take away this committee needs to know . I think we need a response curve. We need to know, given the individual, what is the risk score that framingham has so we , nfl players,ents or others what the risk is. I think that will take a while. Before i lose my chance i will say one other thing which is that we should put on the table trying to understand the effects of blast injury. Many around the table are studying sports injury, they will not get a problem related to blasts unless there is particular focus on that type of injury. We have over 100,000 veterans that have been exposed. We know very little or nothing about what is happened to their brain. I think the recurrent theme is that there has been a set of fundamental questions that remain unanswered. The positive position right now as were not starting from scratch. Weve made enormous strides over the past 20 years that put us in the position where the people in this room and a number of our colleagues around the country and the world can design the studies to directly answer those fundamental questions. But the studies will be major undertakings that will require significant investment on the part of both public and private partnerships. Then we can come back to the table and answer the critical questions the Public Domain wants to know now. And we can answer those with science. Are successful, Clinical Trials to do something about this. Weve had 30 some failed Clinical Trials but we have added multiple analyses and why those have failed and yet we keep doing them the same way. Am the strongest advocate of the longitudinal studies and those kind of things, to some extent, those are just miron the problem. We need to find it treatment. We need to get to the fundamental issues of why the studies have failed, im going to hand it over to jeff. We have 40 some definitions. Multipleo know theres forms of injury here and we need better diagnostic, whether they are bloodbased biomarkers. Another exam. Be until we have a diagnosis, we cannot have a targeted treatment. Until we do we will not have a good outcome. I think the good news story here is that a lot of us are here based on common Data Elements and databases which we are all sharing. We are actually trying to Work Together in private partnerships in a precompetitive environment. One of the things we need is more funding. 94 million will not cut this. This is a very big problem in the United States. Theres a lot of money floating around and i know theres a lot of problems but weve heard from a lot of problems that this is a major health issue. Is now time to put the money where your mouth is and funded some of this stuff so we can make a difference for our patients and their families. We are going to go around and i have to stop the time so we are coming back. The failed trials are because we dont enroll the right patients. It is just like cancer, it is not one single entity. By now we treat it like one and it is multiple diseases in one. We do not enroll the right patients and the measures that are currently used to assess whether there is a difference is fundamentally flawed. It is based upon measures that have little to do with the pathophysiology of whats going on in the disease. We need to solve whats going on and we need a big effort to do that. Miss mckale, what is your recommendation . There is a lot that needs to be learned about concussions, but of the things that are known it occurs to me that had this never occurred to my husband i would be in the dark about concussions. I find that ideal every day with parents whose childrens lives have been derailed when concussion treatment and whatnot goes wrong. Theres so much more prevention that could happen by justice issue of awareness. Just this issue of awareness. Need more critical information into the hands of the people where it will make a difference. That includes not just the coaches and athletic trainers but absolutely the parents and athletes themselves. Thank you. So i think we need to diagnose accuse injuries acute injuries. An ideal world had a blood test for concussion and could monitor brain injury until its recovered. In an ideal world, the diagnosis for concussion, we need to measure the number of hits our kids are getting. We need to somehow address the cumulative, repetitive head impact and measure it so we can establish this response curve. We need to diagnose cte during life. Test, maybe pet scanning. But we need to make the that would give us the best chance to monitor treatment and develop a treatment. Lastly, we need to follow our youth athletes from youth until middle age and maybe beyond in order to really understand the multiple variables that play into the risks of Contact Sports. We all know that sports are extremely important, we want our kids to play sports, but we need to understand the risks. Thank you. Doctor . Around this table there are five massive studies going on that have all of these questions embedded in them. Overlap in these studies are actually integrated. We actually talk to each other. Studies to just continue and finish. As they are. We dont need 12 new studies or 5000 new questions. We all heard the meeting. We all have little mice that helmets on that are getting injured to ask the same questions. They go from children to elders and everything in between. We need to raise awareness, raise education. A lot of us are managing these folks effectively. You need to continue the path of the science we are doing and not overreact or under react. For the folks who have worked on these studies, for the last five years of not longer, we will have the answers and we wont have to have this fantastic meeting again with the same level of basic questions. Goesed to study as she and push forward with what we are doing. In the military, ncaa, nfl, elders. With regard to the study, i will just reiterate. I think we are really getting the answers and the funding will be important to moving forward in fiveyear increments. I think that what the world needs to hear, and i truly , amongst of the organizations working with the cdc and National Governing fores ive been working 25 years on this and ive never seen this kind of collaboration before and it leads me to be optimistic. I will end by saying that the healthagain, as a public advocate for sport and i do believe in sport, its much different from exercise, we need to focus back on the youth and understand where they are most vulnerable, the lack of coaching education. Empowereds need to be. We are doing that in our country. I truly do believe that we need athletic trainers, we need to empower them and make sure that they are more a part of every contact collision sporting event. Thank you for this opportunity. Thank you. Doctor . Thank you for the invite to be here. I want to echo what many folks have said here this afternoon. I think we need patience. I agree completely. We have never been more collaborative than right now. We have never known more than we know right now. Need to evolve the science before we make rash decisions on these issues. I think the science to answer these questions is coming soon. In pittsburgh we see 20,000 patients per year and there are kids that we see that dont get back to safely playing the sports that they love. We dont see the morbidity that is being discussed here. I think that there is a big chasm between that and what we are hearing from dr. Mckie in terms of cte. We need more research to better understand that construct is well. A lot more work needs to be done. I dont they we have ever been more collaborative. I think of the science is maturing. I think that we need more time before we make any largescale decisions. Mr. Miller . Md phd atas the non the table, we take our lead from people in the head, neck, and spike community. As i look around this group, we actually collaborate with a number of people here. Be surprised to hear that my answer resembles what many others have suggested. We put our Research Dollars into a few bucks. Dollars and treatment. , and my room for growth perspective. As we sit here now we have a Research Portfolio with public and private collaborators in those things can drive change, but it is the people who are here and the many people like them who do the hard work who are going to move the science forward. I would suggest that some of the things effort today, like a prospective longitudinal study, better education and advocacy, all of those things this fine group of people is doing, maybe just more of the same is going to get us to a better place relatively soon. Thank you. Doctor . Last but not least, im going theeinforce and reemphasize collaborations happening now are largely fewer in your teens and beyond. We really need to focus of the youngest levels to understand those risks. Also the benefits the go with it can we take,hat not take, refresh or not . How do we keep kids active, fun, competitive . Weve got to prioritize the fact that it is a full spectrum developmental spectrum injury that we have to understand. Thank you. I would say that as clinicians it says we ballot balance risks and benefits. Anything we come up with for to besal strategy needs balanced. Not moving is bad for your brain. Bad for your cardiovascular system. Which is also bad for your brain. For right now my twoyearold is not hanging out in his crib or wearing a football helmet around the house, hes moving. Thats for the science is right now. Answer thenk we can fundamental questions about traumatic brain injury without longitudinal studies. Framingham gave us a handful of papers in its first five years and then exploded. Certainly we have got our Research Priorities in order. Know that my colleagues in dod are very attuned to this problem. I think we are going to move in this next decade or so. Thank you. I think from the perspective of the cdc, we need better data. As i mentioned earlier, across mechanisms and lifespans. Different outcomes, including disability and recovery. That will help us to do two things. Understand the problem at the state level and understand if all the prevention efforts we are talking about are actually making a difference. Thank you. Thank you. Well, mr. Miller i am not a doctor either, but that never stops me from giving my opinion. I want to thank all of you for coming here today and coming to share your knowledge with us. It really is instructive and thats why we like to do these roundtables from time to time. As someone who works a lot in my career on issues of biomedical research, im really shocked at how little evidence that we have for something that weve known about geez, ive known about it since i was a little kid. Its really shocking. I also happen to be a person who thinks that we shouldnt be doing Public Policy unless its evidencebased. Are all working together on Research Studies and i look forward to getting the results of that research. I just want to say one less thing as a mom, though we dont have a lot of moms at this table at this moment. What i want to say is that if i had a five year old who was thinking about and i will confess, i did try to get my two daughters to play ice hockey. But they decided to take ballet instead. You could probably still get a concussion in ballet, but. If i had a fiveyearold, girl or boy, who i was trying to get , havingewee hockey people coming in to say we need to get more data before we can tell you, mom, about what kinds of play they should be having and when should they start checking and all of that, so dont worry in seven to 10 days in seven to 10 years we will have some data from our longitudinal study . That would not satisfy me as a mother. As i say, i really sure what youre saying about the studies and i agree with it, but at the same time i think its important that we take some of the initial data that we have and start to at least put some protocols in place for kids, just like the to try with its players to prevent some of these concussive injuries that really can have longlasting effects. I guess my sense would be better to air on the frontend for prevention of something while at the same time you are studying to really drill down for diagnosis, treatment, and development of protocols. Thank you. I want to thank everyone for being here today. I feel like i should get continuing Education Credits for this. Its amazing to have this together and im sure that you are going to continue to work in collaborative ways. As you proceed. From a standpoint here we are calling it, the we focused a lot , weather people are watching this on cspan or other members are checking in, remember that most of the cases e