Travel. So frequent replacement of helmets is a priority for our lead as well. Are the coaches educated into the no which size fits the child . Have they been briefed on those particular issues . Thats so very important. Youth sports, hockey and football. I agree with mr. Miller that it is a big difference maker, you know, in the helmet doing its job. But its a pretty fundamental part of what a coach has to do to make sure the players on a single have the proper equipment about winning it in the right way. I would just add that thats the cornerstone of our heads up Football Program. Equipment fitting. We found they dont know to properly fit equipment so its a very important element within the program. Thank you very much for including that. Of course the nfl hockey stars, what have you, baseball, basketball, there looked up to by our children as you know. Do you all have programs or you can speak, that speak, maybe go to the schools, Football Players, professional Football Players, go to the schools and speak on these particular issues . One of common our active players are by and large terrific at this topic. One of the elements we included or offered up to u. S. A. Football as part of their heads up Football Program was actually what we call an ambassador. So for leagues that were early adopters of the programs they would get visits and consultation with a retired nfl player. We are trying to encourage great success. Theyve done a terrific job of embracing in the dictionaries the youth leagues and other sold around the facility more, that they interact with coaches, trainers and certainly players. Place. We have found retired players thrilled to participate and really active and helpful to the end you suggest. Gentlemans time has expired. Thank you. So if any of you want to answer that question, youll have to do it by writing. [laughter] and brings me to the point that oh, you have a question. Im sorry. Recognize the gentlelady from the virgin islands. Thank you. And thank you, mr. Chairman. Sorry im late, i was at another hearing downstairs. Mr. Miller, id like to ask you this question. Many tens of thousands of helmets are used every year that are more than ten years old. I understand that the nfl participated in a program initiated by the Consumer ProductsSafety Commission by donating money that would go towards new helmets for youth Football Players in low income communities, and i really want to commend the nfl for this initiative. Of course, its going to cost a lot more money to get to the point where virtually all kids around the country who play football no longer wear old helmets that are likely degraded or obsolete. Im pleased to know of your donation to this initiative because it strikes me as an acknowledgment that wearing an old helmet when playing is not advisable. A statement from the nfl would be very influential. Weve also heard that reconditioning those under ten years old is important to insure the proper foam density and that other degraded parts of the helmet are replaced. So i wanted to ask you the following questions for a yes or no answer. We realize i guess thats why im sitting in chairman dingells seat. [laughter] we realize that many issues are summit to negotiations, but subject to negotiations, but can the nfl commit to supporting prohibiting helmets on the field that are over ten years old . In the youth space . Youre talking specifically about youth football prohibiting helmets that are older thanker the years there . Yes. You know, i plead not enough familiarity with the issue. I know there are a couple of states who have taken that step, and wed be happy to work with you to pursue it. The prime place, as you mentioned, that we work with in promoting new or refurbishing helmets is through usa football who has a grant program, but so the first question is committing to supporting prohibiting helmets on the field that are over ten years old, could you commit to supporting a policy position that helmets more than ten years old present an unacceptable safety risk . Thats the position thats taken by most of the et instry. Most of the industry. I would see no reason we would have a concert with that. We strongly recommend that the helmet should be discarded after ten years. Can the nfl commit to supporting a policy decision recommending that helmet to be discarded after ten years . Adjusting the helmets perhaps removing some padding. We have the choice is an choicet helmets they use as long as they pass but not see the certification body standards and so thats something thats a point of discussion with the players association. And they have to use helmets to pass the standard. But they would recondition properly and have the appropriate padding . They are reconditioned as my understanding and our equipment managers work with the players to make sure that the helmets are in good working order. [inaudible] [inaudible] muro science and medical research in physics. Physics when he arrives. So, panel number two, i will introduce you from mr. Cleveland on down. Hes the assistant director division of ever tightening practices at the federal trade commission. We have a Student Ambassador for the National Council on youth sports safety and if i might editorialize, i think jan did a great job of juxtaposing the face of tbi convictions and as a lacrosse player is that based on a more scientificbased panel. So thank you for taking your day away from school. I know how tough it is to be pulled out of school and come testify before Congress Just like a normal high school student. [laughter] then doctor Robert Graham the chair committee on the sports related concussions at the institute of medicine. Dennis, phd Director Center for brain biology and behavior at the famed university of nebras nebraska. Then doctor James JohnstonProfessor Department of narrow surgery at the university of alabama birmingham. Phd professor of atomic molecule or Physics University of nebraska. Gerald phd division of chief narrow psychology childrens medical hospital and not quite up to the level of the university of nebraska we have the harvard medical school. Thats just humor. [laughter] professor of psychiatry and radiology at Brigham Womens hospital school. Thank you for being here for a very impressive and esteemed panel of scientists and experts. At the bureau of the Consumer Protection i am pleased to have this opportunity to provide information about the actions weve taken over the past few years with respect to the compassion claims that implicates Serious Health concerns especially those potentially affecting children and young adults are always a high priority at the commission. The section five of the federal trade Commission Act which prohibits deceptive and unfair acts or practices and interpreting section five, the commission has determined that a representation omission or practice is deceptive it is likely to mislead a consumer acting reasonably under the circumstances and it is materi material. The commission doesnt test products for safety and advocacy it does however require that an advertiser has a reasonable basis for all object of claims conveyed. The commission examined specific facts of the case to determine the type of evidence that will be sufficient to support a claim. However, when the claims involve health and safety the advertiser generally must have competent and reliable evidence substantiating that claim. As awareness of the dangers of concussion has grown a sporting goodsportinggoods manufacturersn making concussion protection claims for an increasing array of products. These include football helmet and mouth guards but also include other types of products. In august of 2012, the commission announced a settlement with the makers of mouth guard and the commissions complaint alleged that they lacked a reasonable basis for the claims that the mouth guards reduce the risk of concussion particularly those like lower jaw impacts and falsely claim that they did so. The final order prohibits from representing that any mouth guard or other equipment designed to protect the brain from injury will reduce the risk of concussions unless the claim is true and substantiated a confident scientific evidence. They sent out warning letters to other manufacturers of Sports Equipment advising them of the brain had a settlement and warning them that they might be making deceptive concussion claims about their products. The ftc has monitored what these websites working with them is necessary to modify the claims of their sites and in some cases to ensure that the necessary disclosures are clear and prominent for the reduction claims and over to advertisers who are making potentially problematic names of the concerns. Made by the three major benefactors of football helmet of rebel sports inc. And llc. The company is discontinued the deceptive claims or had agreed to do so. The Companies Need to ensure that advertisers do not mislead consumers about the products capabilities or the science underlying them. At the same time we are mindful we need to tread carefully so as to avoid inadvertently chilling research or impeding the development of new technologies and products that truly provide concussion protection. We need to make sure that is truthful and not misleading. Thank you. Thank you. You are recognized for your five minutes. Thank you for the opportunity to share my story today. I am here as a Student Ambassador for the National Council on the youth sports safety. Im also a senior at the Bethesda High School in maryland. I was a sophomore playing in high school offseason lacrosse game when i sustained a serious head injury but he later discussed with my third concussion. Im told im a didnt appreciate what a great life i was living and i got the challenge and classes, played lacrosse and was working on my secondary black belt in martial arts and had a job i loved teaching tae kwon do, performed out of the jobs on fumble and had an active social life. The concussion left me with only 5 of the normal cognitive activity and a little most immobilized. I spent two and a half years recovering and the times ever wondered if i could get a flight back. Its been a long and slow process. At first only wanted to do was sleep. The waves, light and moving my head cause nausea. I was enrolled in the hospital Score Program that the doctor will describe later where i received ongoing evaluation and treatment for symptoms. After missing school for two weeks i tried to go back but wasnt able to function. The frustration of trying to focus on the lectures moving through the pandemonium of the holes and the constant bombardment made a Normal School day and possible. However, through my school i eventually and rolled in the home Teaching Program and with the help of my family was able to complete my semester coursework at my own pace. I finally returned to school in december but was far from recovered. I have spent the two and two af years since my concussion slowly regaining organizational skills, the ability to learn and retain information and most important, my personality. During this time my friends and family learned to recognize the science that meant i needed to shut down from any kind of mental or physical activity for a day or two. These relapses were particularly tough and discouraging and meant i had a job of class and as a band trip to chicago among other things. Worst was when i had a crash and couldnt go to my first concert the red hot chili peppers. The friend i gave my ticket to really owes me. The spring after my injury i was medically cleared to return to sports that made the hard decision i wouldnt play across or other intensive sport again. I know a lot of people will recover and return to play with the possibility of another concussion means i could lose everything again just like that and not come back the next time. I now look at my recovery as something that has made me stronger but i know that im one of the very lucky ones that has the resources and the medical attention i needed into School System that is aware of the concussion issues and provided an unusually high level of support. It is not over yet. My recovery continue continues e outlook is positive an and ive decided about the future as i prepare for college. Im thinking about becoming a High School Math or science teacher. The support for the full recovery is available. We cant just do away with the youth sports and the league and High School Lacrosse and being on the teams not only gave me a healthy outlet for talking important lesson. Sports are one of the best parts of growing up and becoming a strong adult and teach us if we work hard we will become skilled and proud of our accomplishments. They teach us how to be part of a team to have prid pride in sus and learn the lessons of defeat. They teach us that sometimes we have to quit thinking of ourselves and think of the good of the team. For these and many other reasons i hope the steps can be taken so that the future athletes have these opportunities. There are two important things i think would make a big difference. The first is the change of the culture hitting hard to take out a good opponent rather than changing the scale and brushing off injuries to get back into the game. While better equipment may decrease injuries that is the coaches, parents and players who have to back away from the need to win at all costs. When injuries occur we have the qualified personnel to quickly assess injuries on the field and have the players get immediate attention and then support the recovery through schools and medical institutions. These are the things that were done for me and the reason ive been able to return to normal. As the Student Ambassador, the message i have to give the Young Athletes is this. You think that you are not vulnerable. You take risks and brush off injuries because you think you will recover quickly from anything that happens. You wont. Dont be when it comes to your head. Its the only brain you will have in your personality is who you are. It isnt worth a couple of seasons to lose the opportunity of a lifetime. Thank you. Very good. You are recognized for five minutes. Thank you very much. Chairman and Ranking Member by name is bob graham and i serve as the chair of the institute of medicine of sports related concussions and youth study. As you have my testimony before you and i see copies of the studies i will just try to take these minutes us to give you a summary. The institute of medicine is part of the National Academy of sciences which is chartered by the congress to provide advice to the congress and to the executive on the scientific issues. We specifically were in the panel to look at the evidence about the causes and consequences of concussions in the youth and military, the state of the concussion diagnosis and management, the role of the protective equipment and sports regulations. We have 17 members on the committee. We worked in 2013. The doctor who will follow me as a member of that committee and we came with just six recommendations. The first was that the cdc needed to establish a better mechanism for National Surveillance to comprehensively capture the incidence of concussions. You have heard a number of figures this morning about the concussions of one sport or another. We know what the incidence is when they are measured. We do not know what the incidence is in sports where they are not measured or they are not more closely watched. We need to have that baseline to really know the degree to which we have a problem and as we take the corrective measures, the success rate that we are having on making an impact on decreasing the incidence of the concussion. As a commenso, number one, we nr surveillance. Amber to a couple of recommendations related to research. We need to be nih and the dod to look specifically at what the markers are for concussions. How do you assess the severity of the concussion and how do you find diagnostically whether individual has had a concussion . Right now is based on the selfreport that are there some markers that can be used to give better documentation and the concussion is actually occurred perhaps without the individual building it or without it being observed. A second, we need to look at more carefully the short and longterm consequences of concussions. We heard testimony in the panel individuals that have had one or more concussions and what are the longterm of the individual or multiple concussions. With treatment and interventiony be and what rehabilitation may be. It was to the ncaa and the National Federation of state and High School Associations to look at ageappropriate techniques and the playing standards. Mostly at the professional level but can you change the banner on which of the sport is practice and the rules of engagement in the sport that may decrease the risk of the concussion there was one example from the area where they had changed the level where they allow the body checking and felt they saw a decrease in concussions that we think that same sort of examination should take place at the college and elementary and High School Level to see whether or not they could have the same impact. This recommendation had to do with a better study of what the role may be for protective equipment and again the first panel talked a lot about that. The committee had a number of questions about that. Our Committee Found that there was little evidence that protect against concussions and theres a lot of data in that and i think some of the other panelists will be talking about that. You may come away with a degree in physics this morning. Its a complicated issue, but there are a number of suggestions that we certainly didnt recommend. They do protect against bone injury and soft tissue injury thats the suggestion that a helmet itself may decrease the incidence of concussion the evidence does not appear to be there with us and we think the nih and the dod have a role to play looking specifically at what we may be able to do related to the biomechanical determinants and protection against concussions. And then our final recommendation had to do with the topic which has come up frequently and that is changing the way they are viewed. Athletes need to be encouraged to report and take themselves out of the game and coaches and parents need to be encouraged. Ranking member schakowsky and members of the subcommittee for this opportunity if we could have the slides. Go to the next slide. I think the earlier group talked about a number of if you can go ahead and put that on the powerpoint where the concussion is particularly high there are differences of rates for men and women. The doctor will talk about some of that in terms of the weaknesses relative to how that put them at more risk for concussion. Next slide. Concussion counts for 75 of the genetic brain injuries and it is an injury there is damage to the brain. Therethere is a discussion abot whether it is permanent or temporary. In the military is 77 . So, it turns out that there is a good model for also looking at concussions in terms of the military. And most of the military concussions occur in situations most like they do with the rest of americans, some certainly occur in the other that a majority of her outside a theater and accidents are prone to experience. Next slide. If we look at the brain injuries overall, there are estimates these are all estimates and they vary across the literature that we are looking at somewhere in the neighborhood of 4 million traumatic brain injuries per year in the United States. Part of that is the birth rate in the United States is roughly about 4 million. This does not count the ways that children are exposed to head injuries. Can, in fact, produce a concussion. Those, one would spect, are. Largely unreported. Recovery generally is fairly quick, usually within anywhere from a few hours to a few days. Some will persist to two weeks, even perhaps out to six weeks. But roughly about 20 seem to persist beyond that time. Next slide, please. This is a slide just on some data that we have under review, but itll give you sort of a sense. These are data recorded using brain electrical activity. So basically, you have a net of 256 electrodes that fits on the head in about ten seconds or so. And we present a series, in this case, a series of numbers. One number at a time. All the College Athletes had to do was simply say where the number they whether the number they currently see matches or does not match a number that occurred two positions earlier. And on the left side those orbits, those circles you see, the colored circles, on the left for match and nonmatch, those are images of the brain electrical activity on the scalp recorded from those electrodes between 200 and 400 milliseconds, so twotenths to fourtenths of a second after the number appears. So the schematic on the right shows you the head position. So its a very rapid brain response. For those athletes who have no history of concussion, we see very clear difference in the electrical activity for the match versus a mismatch. A lot of yellow and green on the top left orb and on the bottom we see red and various shades of blue from the front of the head to the back of the head. On the right though, these are individuals who have a concussion history of one to two years earlier, not current. And yet 200400 milliseconds, their brains cannot discriminate whether those two numbers are the same or different. They ultimately get these tests correct, but it takes them roughly 200 milliseconds longer. So the processing speed is slow. And after two years one might suspect thats a permanent change. Next slide, i think that yeah. So in terms of critical scientific apps, some of these we do what dr. Graham talked about. You know, how does concussion affectionfect the affection the brain in the short and long term . Whats the dose requirement . Dr. Graham talked about that to produce concussion, postconcussion syndrome, cte. How can we detect when the brain is injured and when, importantly, its fully recovered. We have no ways to lots of individual differences from one person to the next. We think there are genetic factors involved, but there could also be a concussion history the person may not really think they have. How many of us have bumped our held getting in and out of a car . So we have a quick rotational movement, and that could, perhaps, produce a concussion. And how does a brain recover from tbi, and then finally, how we improve and recover, accelerate recovery. We really have no scientific basis for any of our interventions. Thank you. Thank you. Dr. Johnston, you are now recognized for five minutes. Chairman terry, Ranking Member schakowsky and members of the committee, thank you for inviting me to testify before you today alongside this illustrious panel about our experience in alabama. Could you pull the microphone a little closer . Is that better . Is that better . Yes. Following our experience in alabama following the the passage of concussion legislation as well as the work we are currently doing at the university of alabama birmingham to improve sports safety. As in the state of nebraska, youth sports and youth football are an extremely important part of our culture, and we take the safety of our children very seriously as well. As well known to the committee, the problem of concussion has gained prominence thanks to Important Research and advocacy work done by scientists, physicians and many Centers Across the United States and through the work of Public Officials highlights this research. Of significant concern, recent studies have identified potential longterm Health Consequences including depression and other neurodegenerative diseases. While college and professional football gets the most media attention, greater than 70 of all Football Players in the u. S. Are under 14 years of age. Any effort directed at improving safety in fool and other in football and ore Impact Sports will need to address these athletes. The Alabama StateConcussion Task force joined think first alabama in initiating a statewide concussion education and awareness program, and it worked. In that fist year, we observed a 500 increase in referral of youth athletes referred to the concussion clinic at childrens of alabama, a trend that has held steady with about 350 youth athletes seen every year. Rapidly increasing patient population, we developed a protocol in my appendix i following a zurich consensus yard lines, athletes were kept out of sports or school until symptomfree, referred for neuropsychological testing when appropriate and supervised in a graduated return to play. A formal study performed in 2012 demonstrated that establishing this program resulted in significantly better concussion care. Even though these efforts have resulted in improved recognition and treatment of cob cushion in concussion in alabama and other states, believe much needs to be done in order to prevented in the prevent in the first place. Be as has been said previously, using existing Helmet Technology and other subjective ways of evaluating athletes, researcher has begun to widen from concussion to correlating cumulative impact exposure over time with changes in advanced imaging techniques and neuropsychological testing. Animal molds have also demonstrated problems with complex facial learning, Cognitive Impairment and as seen also in Football Players, compared with single impact controls and those who are who have not had the injury. Hit counts cannot be drawn from these early studies. It has become clear that impacts that dont result in concussion also play a role in cumulative brain injury over time and need to be studied. Researchers at wake forest suggest that a significant number of Young Players head impact actually takes place during practices, and the largest impacts happen to to take place during those practices, a lot of times doing outdated drills like oklahoma or bull in the ring that are supervisorred by rell supervised by well meaning but untrained coaches. Emulating collegiate programs, teams like the university of alabama, ivy league and others, the Alabama High SchoolAthletic Association recently published nonbinding guidelines to limit fullcontact hitting practices to twice a week. I believe this is complimentary to the stuff usa football is talking about about techniques. The number of hitting practices per week as well as what drills are going to be doing. Pop warner has instituted similar guidelines, but again, thats a small section. Eliminating the frequency of hitting at practice would have a large effect on safety. It also becomes clear that helmet standards clearly defined by the operating committee must be updated to reflect or improve concussion. The it is clear that both linear impact and rotational acceleration play add role, and only linear impact is studied by system which was from a Skull Fracture tolerance model developed in the 1960s. We believe that having multiple other, a more complete picture of the impacts that are seen in the football field are necessary in order to come up with meaningful standards in collaboration with university of alabama Football Program, ending years engineers at uab have developed a safer barrier, a robust video analysis system to analyze impacts and then recreate them in a purposebuilt lab. In conclusion, the passage of concussion awareness legislation, Community Education and recent advances in our understanding of head impact exposure in youth athletes have all improved the overall safety of youth sports in that we are recognizing concussions more frequently, however, much work remains in and education drafting policies to limit head impact exposure for youth athletes in contact sports. As part of the approach, i believe the development of new helmet standards is also crucial for the development of safer helmets. Mr. Chairman, thank you for the opportunity to testify. Thank you. Dr. Gay, you are now recognized for five minutes. Thank you, chairman terry. Id like to thank the subcommittee for inviting me to testify today. Im speaking to you as a football fan who happens to be a physicist. My main professional interest is the understanding of how protective equipment works and how it can be improved. Today i wish to consider several aspects of football that are problematic as far as concussions go and how we might move forward to make the game safer. American football is an inherently violent sport. Thats one of the reasons we love it. Thats one of the forces encountered in football can be huge. Consider a big hit between a running back and a linebacker at full speed. We can show, using newtons second law, that the force each player exerts on the other exceeds threequarters of a ton. This is why football is called a contact sport. Two players who collide at full speed, helmet to helmet, are experiencing the same force to their heads that one of them would feel if he had a 16 pound be bowling ball dropped on his helmet from a height of eight feet. Medical knowledge of concussions is in its infancy, but we know one thing for sure; force toss the head and neck cause concussions. Heres another problem, theyre getting bigger. Since 1920 the average weight of pro line 34e7b has increased to just over 300 pounds. At the same time, these players have gotten about 10 faster. Combining the factors of speed and mass to kinetic energy, we find that the amount of energy dumped into the pit at the line of scrimmage on any given play has almost doubled since 1920. Players are shedding their protective gear. Knee pads that used to be centimeters thick now bear a remarkable resemblance to teacup doilies. Modern football helmets are technological marvels, but players choose them not for their collision cushioning ability, but for how cool they look. Another problem is the poor state of our medical knowledge. While im not competent to explain these issues, i think its safe to say that a room full of head trauma physicians will not agree on the details of what concussions are or what causes them. This means that the diagnosis and treatment of concussions has a long way to go can. As our understanding of these issues improve, we may find that injury rates due to the increasing energy of the game and the wholesale shedding of equipment have increased faster than we thought. Finally, football is big business, especially at the college and professional levels. When monetary forces manifest themselves as they do and, for example, bounty programs and illegal doping to improve performance, the game becomes more dangerous. What are the solutions . We need better equipment, but this can get tricky. For example, its apart that adding more energyabsorbing foam to the outside of a helmet will lower the force delivered to a players skull. This has been tried in the past. The problem is that the added padding increases the helmet diameter as well as its coefficient of friction meaning that the opposing player can exert a lot more torque on your head. Nonetheless, several companies today are proposing the same basic padding idea for youth football for whose players the risk of collisions to the head is almost certainly greater. The use of the star system for rating helmets and the hit system for monitoring collisions to a players head represent important first steps toward improving football safety. For a variety of reasons that disregard player safety, theyre largely ignored. Our understanding of the physiological and epidemiological issues related to concussions must be improved. There is now an understanding in the nfl and at the College Level that Significant Research in this area is needed. Several of the members of this panel, including my colleague from nebraska, dr. Molfese, are leading cutting edge efforts in this area. Finally, some incremental rule changes and more stringent enforcement of existing rules are needed. In my opinion, some of the new rules regarding targets, po back blocking and definition of a defenseless opponent are making players more hesitant on the field. These rules may thus actually increase the risk of injury. Rule changeses should be studied and possibly reversed. It is my belief that a return to the level of padding worn in the 1970s would make game significantly safer. More thorough doping rules should be developed and actually enforced. The nfls season should be reduced to 14 games, and the College Season returned to 11. Finally, more stringent requirements regarding when a player with a concussion can return to the game need to be implemented. These are my thoughts for your consideration. Thank you for your anticipation and your valuable time attention and your valuable time. Thank you for your valuable time. And dr. Guy ya gioia, i appreciate you being here. You are recognized for five minutes. Thank you, chairman terry, Ranking Member schakowsky and members of the subcommittee. I appreciate the opportunity to speak on behalf of the safety of our children in this country. So im a pediatric neuropsychologist at Childrens NationalHealth System here in washington, d. C. And the director of the score Concussion Program. Im a clinician, a researcher and a Public Health educator. Today id like to take my time to focus my comments on the importanceover Public Health education importance of Public Health education for youth concussion using my expertise as a clinician and researcher, and ive worked with the cdc on their heads up Concussion Program materials. We all know, and i think ian said it just perfectly, that sports and recreation provide important developmental opportunities to enrich the lives of our youth. They teach life lessons. But we have to balance those incredible benefits of Sports Participation with careful attention to safety issues. And science must drive our actionoriented approach. Concussions are serious injuries to the brain that threaten the development of our youth. And in an attempt to protect our youth, we now have laws in all 50 states and the District Of Columbia all with the good intent of protecting our student athletes through rules for educating coaches and parents and removing suspected concussions and not allowing them to return until properly cleared. All states, including include the high school at this level, but only 15 out of those 51 include youth sports. So less than onethird are looking at the majority of athletes. In preparing for this testimony, i was posed with an important question and challenged within youth sports. With concussion awareness now at an alltime high, our youth sports teams and organizations and parents more aware but still not sure what to do about it. And the simple anxious to that question with my experience is, yes. Many coaches and parents are not equipped to know what to do with a suspected concussion. Mechanisms to teach active recognition and response to every coach and parent are inconsistent and limited in scope. The health and safety of youth athletes is largely in the hands of coaches and parents at the youth level. They need medicallyguided training and early identification of concussion and protection. Coaches and parents must receive training and actionoriented concussion initiation and response. Awareness isnt enough, and theyd have to be prepared properly. We know that, as youve heard, repeated concussions present the greatest challenge to our youth, so our greatest challenge is really the universal, consistent and effective implementation of these 51 laws so that we can prepare those coaches and parents to know what to do and have the tools with which to do it. At Childrens NationalHealth System over the past ten years, our Score Program has delivered hundreds upon hundreds of actionoriented parent and coach concussion education and Training Programs using the heads up materials from the c, the c. Weve learned cdc. Weve learned much about the Community Needs and how to deliver the message. So we deliver scenariobased training where we present to coaches and parents an actual situation and what they must do to recognize and respond. This is all very, very important as we put these responsible adults in place. Youve heard about some important other kinds of activities and good examples of head safe action, head smart action such as usa footballs heads up tackling program where coaches are educated in con clution recognition response but also taught techniques that we believe can improve taking the head out of the game. But we have to go further in all youth sports. We do not have a coordinated universal strategy at this point for actionoriented, solutiondriven methods to recognize and respond to these injuries. We have the tools, we have many of the programs, but we do not at this point have the delivery mechanism to do that. So we have to build also on active partnerships between youth sports organizations and medical care systems. Concussions are complicated, they are not simple. Were not asking parents and coaches to be clinicians and to go out and diagnose. We have willing teammates, as youve heard, through usa football, usa la cross, usa hockey, usa rugby and other organizations. But we need to build those partnerships, we need the help of the professional sports leagues as youre hearing from the nhl and the nfl and the sports manufacturing world to team with us. We also need a quarterback, ultimately, to make this happen. We have to leverage the efforts of other organizations like the National Council on youth sport safety, the youth sports safety alliance, foundations plan. All of this is important for us to do. So we need, obviously, funding to do that to move forward. Can we move from awareness to action . Yes, we can. Concussions are serious injuries that threaten our youth, but we do not need to be scared away from that, we do not need to avoid developmentally appropriation participation in sports activities. What we need to do is focus on how to teach recognition and response, and our country needs a good universal mechanism to implement communityfocused youth concussion solutions. And we believe that that can help children, ultimately, as they enjoy the benefits of sports. Our score model applies here. It says play hard, play safe but play smart. Thank you. Very good. Dr. Shenton, you are now recognized for your five minutes. Thank you. I want to thank chairman terry, Ranking Member shah i cow can sky and members shah cow can sky and members of the subcommittee. Im honored to be here today. My focus is going to be on radiological evidence of both concussion and subconcussive blow toss the head. And if i could have the next slide. What is known is that mild traumatic brain injury is common in sports injury. And when were talking about a single mild tbi, about 80 get better. Between 1530 go on to have persistent concussive symptoms as have been described today. Whats most concerning though are whats been called chronic traumatic enaccept lop think and other neurodegenerative disorders, and thats the second one where its repetitive mild traumatic brain injury that were really concerned with. And the clearest evidence comes from postmortem studies. If i could have the next slide. Heres a post mortem slide that shows protein in the brain, and those are the brown areas that show up. And this is in the case of a retired professional Football Player who had symptoms and was presumed to have chronic traumatic enaccept lop think which was confirmed at post mort m. Now, here are four individuals, a, b, c and d. Whats interesting here, and this is work by goldstein, it shows that blast injury and repet ty brain trauma look the same at postmortem. So we have a military person at 45 with one close range blast injury, a 34yearold with two blast injuries, an amateur Football Player at the aim of 18 with age of 18 with repetitive concussions and then a 21yearold with subconcussive blow toss the head only. Blows to the head only. Next slide please. So what is known . The third is mild tbi is very difficult to diagnose, and thats been a serious problem because if you use cob vexal ct and conventional mri, you are not likely to find differences or abnormalities in the brain. So many people have said theres no problem then. The problem is the correct advanced tools have not been used until more recently, and now with advance neuroimaging, were able to doig nose and move towards diagnose and move towards prevention. Radiological evidence is shown of brain alterations in living individuals with mild tbi. And so if we can detect this early and we can perhaps then look at underlying mechanisms and characterize whats going on in order to come up with preventive measures. Next slide, please. So this is a study from our group looking at hockey players from university, hockey players in canada. And the bottom line is over on the right the first is at preseason and the second is at postseason. The red dots are three individualings who had concussion individuals who had concussion during play, from preseason to postseason, and the increase is increase in extra cellular water in the brain which is not a good sign. Next slide, please. We also looked at gray matter looking at cortical thinning in the brain, and thats the cortex where neurons are in the brain. And this is a study in former professional Football Players who were somatic when we looked at them. What we found was theres cortical thinning compared to aimmatched controls. Whats most concerning, however, is that a blue line that shows that the cortical thins accelerates with age whereas the red line is our control group. And this suggests it may indicate a risk for abnormal aging and risk for dementia. Next slide, please. Now, this is a study we did in germany we heat soccer players with be elite soccer players. And we selected them specifically for not having a history of concussion and not having any symptoms what whatsoever. And compared to professional swimmers, there was a huge difference between the two groups with the controls on the left and the soccer players on the right. Almost a complete separation between the two groups with an increase in whats called radial tiff fewsivity which is a measure of damage to [inaudible] in the brain. Next slide, please. So what we dont know, why do concussive and subconcussive result in some and not others . Another question we dont know is why do some develop neurodegenerative disease while others do not . What are the predisposing factors . Is it exposure . Are genetics involved . Not every Football Player, not every soccer player, not every hockey player who plays and gets hit to the head ends up with these neurodegenerative diseases which is, i think, what people are most concerned with. And next slide. So what we need is diagnosis to detect brain injury early. We have imaging tools now that are sensitive, widely available and can be applied in vivo. Prognosis to follow recovery and degenerative to processes processes. So we need to follow in order to to predict who will have a poor outcome and who will have a good outcome. And knowing that, we might be able to intercede with treatment to halt the possible cascade of neurodegenerative changes. And finally, just in summer next slide sports recovery, advanced neuroimaging is sensitive to detect brain alterations following concussion and subconcussive brain trauma, and the impact over time is important. We need longitudinal studies to identify different stages of recovery and being able to pick out ahead of time what is going to to lead to a poor outcome so that we can intercede. And finally, some measures of safety such as rules for returning to play are needed following observable evidence of brain trauma. Thank you. Thank you. Very impress i have testimony from everyone impressive testimony, and i was even impressed that you all stuck to the five minutes, pretty close. Now, im going to go pack to dr. Molfese because i think your testimony and drsm shentons and dr. Shentons kind of juxtapose each other here very nicely. Part of what your research is doing is finding that baseline of the new athletes that Enter University of nebraska. So youre is this allowing you to detect the injuries earlier, that there may have been some preexisting subconcussion . How are you identifying that . What is it telling you, and what are you then what is the university doing to implement some lev of protections some level of protections . Well, one of the major changes weve seen and i think this is occurring across the field now is the effort to get preconcussion data. So, basically, more and more schools are moving to assess student athletes prior to the start of the season. And that certainly is what were doing. And then should a player be injured and theyre identified through trainers or the medical team, one of the weaknesses here is that players do not always selfidentify. And so we run across that a number of times in our the eking. Well pick be up testing. Well pick up something on our test the trainers and medical team didnt know about simply because the player didnt disclose. And then we also try to test somebody else who plays a similar position but has not been injured, and they act sort of as a game control over the course of a season. And generally what were finding is both effects that occur across the season and just our normal players who have no history of concussion being identified, the brains speed of processing does change over the four to five months of training and the season. But then with the players who are, who do experience a concussion, we see in terms of brain electrical activity, again, this slowdown of about 200 milliseconds. Thats four times faster than the slowdown you see in multiple sclerosis, for example, in a contrast. So, cleary, the brain clear clearly, the brain has changed the way its processing. We have just now moved to start intervention programs with the players we identify. Theres some data out there with, certainly, alzheimers that suggests working memory type tasks may even a week of intervention shows a four to five week gain, continual gain in improvement. And so were trying to see if we can sew some of that see some of that occurring. Thank you. Dr. Gay, in regard to concussions many times its not a direct blow, but its being hit so that the head going back and forth and the brain is sloshing around. You mentioned going back to 970stype 1970stype of equipment, and tom osborn likes to talk about the neck roll. Describe to me what you mean about 1970s equipment and how it may actually reduce concussions. Thank you, mr. Chairman. Yeah, the neck roll, what i call the horse collar, is really a piece of equipment thats disappeared from the game, and it does an important thing. It, essentially, immobilizes the head. So if concussions are concurred by the rattling of the brain back and forth, especially from a blow to the side, the horse collar will substantially damp that down. To my knowledge, there are no epidemiological studies of that being effective, but i just cant my personal opinion, even though im ig noter of, largely ignorant of medical science s that if you immobilize the head, thats going to solve a lot of the problems, especially with these rotational hits. To decrease the evidence of the incidence of concussion. Thank you. I only have 11 seconds left so i will yield back and recognize the Ranking Member, jan schakowsky. In addition to the science, so much talk has been about culture. And it seems to me that that is very important. So a change in the culture means not only managing head injuries when they occur, but als the attitude among the players and coaches. What would you say to help them change that attitude . Were perhaps more challenging as coaches . Frankly i would encourage the coaches to stress stress this as much as possible in and the coaches and parents help us to learn correctly and if they can emphasize not having to worry about waiting to the point you get hurt then it will trickle down to the players to become coaches with a never ending cycle to make sure the players know winning is not the most important thing. It feels great but i would much rather lose than have another concussion. Clearly you were aware because of the severe consequences of breaking injury but you think you understand what those symptoms are . Yes. I think it is Getting Better indeed. We emphasize making sure you know, the symptoms of a concussion i feel it is spreading as well. Is certainly at this point the Education Programs are to be to wine dash directed to the athletes and quite honestly five or six years ago a study showed that was the number one reasons why athletes were not coming in and out of the because they did not know how to put together this symptomatology they did not know if there were dealing with but which the athletes and teammates need to watch out for each other they may not have the wherewithal that they are not right but the teammate often does with is a responsibility within the team to take care of each other. That goes to culture as well. Absolutely. Please explain how a advanced imaging works and describes the types of changes your brain can detect and the types of hair on imaging that have been a significant part of the Research Like alzheimers and schizophrenia. Why is that appropriate for research on these diseases . I have a slide that just explains the imaging which i think would help out. What i really didnt understand. The soccer players . I would just show you why it is important the injury that happens with the impact to the brain is generally as stretching of the white matter, the cable to the brave the of corpus clawson is the largest white matter and it does not show up on the traditional mri actually the first conference i went to nobody showed up breaking and i said why would no one shoa brain . Because everyone knows you cannot see anything and i said but nobody is using the right to wills. This is a simple principle of diffusion imaging. Look on the left on a kleenex the heat goes in all directions and is a isotropic so on the right you drop dead on a newspaper and it is the same principle accused quantitatively to look at the brain so it is very round and isotropic everything goes in this direction that white matter you are restricted in two directions so you can measure the integrity of the white fiber bundles in the brain and that is what you need to look at. If somebody comes in with a moderate or severe brain injury you dont need this technology you plug them into neurosurgery but it is the subtle brain injuries that are not recognized using conventional imaging but you can recognize it with confucian imaging and we have shown over and over you can see not just our group is starting to thousand three people started using diffusion imaging to look at the major injury. So what needs to be done now is looking at the acute injury to see what predicts the outcome at 72 hours and three months and six months then can we predict what happens that 72 hours . Someone in our lab is trying to separate outside cells versus the inside sills said you can predict it 72 hours to say maybe play in the in antiinflammatory medication. We dont know enough the only ways to do the studies a and over time using sophisticated Imaging Technologies in my opinion. Once he knew you could diagnose. Is to be promising for athletes and also returning veterans or schizophrenia . I am primarily Schizophrenia Research that is audited 30 years before 2018 and is the measure based on free water that shows early that the very First Episode of schizophrenia you see fluid around all of the brain. It is free water but just in the frontal lobe you could see it more to the inside tissue and this is a brand new technique developed by a fulbright scholar from israel. Thank you. That is very promising. Thank you. Then a gentleman from new jersey. You stated many sports related concussions go undiagnosed and i would like to know why that is the case . And how can we improve that who with the states laws with the ball and coachers and players and areas to have approved it . I see i would echo what has been said by others. I fake it pass to do with recognition people live very good to recognize when they are talked out but that is a very small percentage and as our understanding of the various symptoms that have arisen it is incumbent to improve the quality of the education to the players and the traders and officials about the symptoms of concussion. My sense is the culture that all the coaches i have come into contact with our be leaders there not purposely putting them back but sometimes it is hard to recognize the special a specially when athletes dont tell you and the importance of teammates being evolves. How close are we to a better decide for helmets . The very beginning. We have a standard that has not changed over 40 years and serving Skull Fractures and investigators are working to improve the quality of the standard with laniers acceleration and other aspects of the impact just like the Automotive Industry once you start drinking with a safety rating it could be relied upon to improve sales. I think standards are important part of the equation. Dr. , you say there is a numerical Rating System that is designed at Virginia Tech and it is the best tool you have. Can you briefly explain how that numerical score in works . Yes. Thank you mr. Vice chairman. Involves a test to drop the helmet from varying heights to the side or the front or the back and it tries to simulate the kinds of impact a Football Player would experience and numerical scores are given to the maximum acceleration how the head feels for these drops based on a fairly crude initial model of what causes concussions in my opinion there is no effect of rotation or temperature and in my opinion the reproduce ability is not as good as one would like. So i think it is a good first start and the best we have right now and needs to be paid attention but there is a lot of room for improvement. All lots of room. How old you and what grade . Diane teeeighteen and ims senior. We go off to college . Or for your attending . I am going to north carolina. My congratulations and condolences to your parents on the cost of hiring education. It is the great school a goddaughter is of freshman there but i will be happy to introduce you. [laughter] and let me say i am very proud of your testimony and i could not have done what you have just done and i was 17 or 18. I think the nation has benefited from your testimony. The gentleman from mississippi. Thank you for being here and sharing your expertise after we are only really learning over the last several years coming to the forefront coming to your testimony on the record is beneficial to us. As the parent of a 24 yearold with the syndrome i appreciate the work they do at the childrens hospital. Point we had some discussion with some parents back home and to the interesting discussion is i had several friends who have daughters playing use soccer and a reported increase in the number of concussions suffered by young ladies playing use soccer. We always see that in the nfl with helmet to helmet contact it appears everything we do give life there is the danger and the risk with the think first the preventive part is how we educate our players and coaches with that team may to approach teammate to approach it is the backup for the first team when they need to come out to get off the field. But dr. Johnson educate us what is a son of a convulsive impact . What is that when addressing concussion and diagnosis and sure that affect the rules of game and play and how . The definition would be and has pointed out previously looking at rates of confession male vs. Female less likely to report symptoms but said concessive impact is all those others where there are more and more information that even the sub concuss said impacts that the change is since the brain over time so that needs to be addressed to lessen the overall cumulative impact and how many practices is the week insisting. Dr. For clarification the 77 of military, is that how many cases have suffered concussions . 77 are mild tbi. Can you tell us more about the sideline imaging work . Can we expect this to be rolled out to the sidelines across america . And the battlefield to diagnose our warriors . We already published a paper and reported on the field but to make it practical is the processing time it takes us one hour if we could get it down at five minutes and then we could sell it to the coaches. At this point given the issues with the impact our assessment tools and they have to reflect. So with that predictability or reliability opposed to injury it does not predict severity of the injury so of these five markers are the critical things we hope are much more reliable and predictive. I yield back generally this would tend to put the bills will not go off for another seven minutes so we will have another round. But just let me thank the panel the Scientific Research application of what to thank you for telling us what is going on. I think it is important to have someone like these boys to give us a face it also thank you to the ftc but it is so important and appreciated but it certainly has informed us. Thank you. I would agree with every word of that. This is a question to you dr. But are the symptoms of a concussion or tbi uniform enough with the checklist for nonmedical . No. The symptoms overlap with depression and ptsd there was the paper published in the new england journal of medicine if you remove the effects of depression and ptsd it does not exist. When people came in complaining they still had symptoms there was no evidence from conventional mri they said. See a psychiatrist. It was not appropriate at all because there was a small minority of people who have a mild concussion to go on to have symptoms. That is separate but what you need is idiological evidence the same way you know, the values of of blood test for cholesterol or a broken leg. That is what we need is hard evidence. In the art to a nonspecific looking at the number of symptoms there is notated that indicates a lot of symptoms first is the view that has any relation to how serious the injury is unfortunately. Can make it to the point where the seventh grader takes a vague hits there is a check list the coach can determine but if they show any symptoms they should be pulled that data indicates if they do Start Playing before the symptoms result the likelihood of death is greater not to mention of the question that will take longer to recover. Greg now right now you have a job that suffers a concussion during a game and it has been diagnosed. What do you do right now . You keep them home . That is the norm. So what did you know, . I will tell you how we handle things in alabama with the cdc guidelines that once an athlete is diagnosed they are removed from the field of play and evaluated