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>> as we're settling in this is unintended -- [inaudible] part of our hearing today where we're dealing with neuroscience b and medical research and physics. well, physics when dr. gay gets -- arrives. so panel two, i will introduce you from mr. cleland on down. mr. cleland is the assistant director, division of advertising practices at the federal trade commission. we have ian heaten, student ambassador for the national council on youth sports safety. and if i might editorialize, i think jan did a great job of juxtaposing a face of tbi and concussions on each panel. and each, as a high school lacrosse player, is that face for the more scientific-based panel. so thank you, ian, 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 dr. robert graham, chair committee on sports-related concussion in youth at the institutes of medicine. dennis molfese, ph.d. director center for brain, biology and behavior at the famed university of nebraska. then -- thank you, there. then mr., dr. james johnston, assistant professor, department of neurosurgery at the university of alabama birmingham. star of screen, dr. tim gay, ph.d., professor of atomic, molecular and optical physics, university of nebraska. gerald gioia, ph.d., division of chief neuropsychology, children's medical hospital. and not quite up to the level of university of nebraska, we have the harvard medical school -- that's just humor. [laughter] professor of -- yeah. professor of psychiatry and radiology at the brigham and women's hospital, harvard medical school. thank you for being here for a very impressive and esteemed panel of scientists and experts. and, mr. cleland, we will start. you are now recognized for your five minutes. >> [inaudible] >> yeah. the green light is on. is it were better? thank you. i'm assistant director for the department of advertising for protections, i'm pleased to have this opportunity to provide information about the actions taken over the past few years with respect to concussion protection claims. claims that implicate serious health concerns, especially those potentially affecting children and young adults are always a high priority at the commission. the commission strives to protect consumers using a variety of means. first and foremost, the agency enforces section five of the federal trade commission act which prohibits deceptive and unfair acts or practices. in interpreting section five, the commission has determined that a representation, to mission or practice is deceptive if it's likely to mislead a consumer acting reasonably under the circumstances, and it is material that it is likely to affect the consumer's conduct or choice decision about a particular product at issue. the commission does not test products for safety and efficacy. it does, however, require that an advertiser have a reasonable basis for all objective claims conveyed in an ad. the commission examines 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, reliable, scientific evidence substantiating that claim. as awareness of the teenagers of con -- dangers of concussion has grown, manufacturers have begun making claims for an increasing array of products including football helmets and mouth guards but also other types of products n. august 2012 the commission announced a settlement with the makers of brain pad mouth guards. the commission's complaint alleged that brain pad lacked a reasonable basis for his claims that the mouth guards reduced the risk of concussions, particularly those caused by lower jaw impacts and falsely claimed that scientific evidence proved that the mouth guards did so. the final order in that case prohibits brain pad from representing that any mouth guard or other equipment designed to protect the brain from injury will reduce the risk of con clutions unless the claim is true and substantiated by competent, reliable scientific evidence. in addition, the commission sent out warning letters to nearly 20 other manufacturers of sports equipment advising them of the brain pad settlement and warning them that they might be making deceptive concussion claims about their products. the ftc has monitored these web sites and is working with them as necessary to modify their claims on their sites, and in some cases insure that the necessary disclosures are clear and prominent. commission staff continues to survey the marketplace for concussion reduction claims and alert advertisers who are making potentially problematic claims of our concerns and of need for appropriate substantiate for such claims. commission staff also investigated concussion reduction claims made by three major manufacturers of football helmets,ly dell sport -- riddell, schutz and zenith llc. in these matters the staff determined to close the investigations without taking formal action by which time all three companies had discontinued the potentially deceptive claims or had agreed to do so. those cases are discussed in greater detail in the commission's written testimony. the commission plans to continue monitoring the market for products making these claims to insure that advertisers do not mislead consumers about the product's capabilities or the science underlying them. at the same time, we are mindful of the need to treald carefully -- tread carefully to as to avoid inadvertently chilling research or impeding the development of new technologies or products that truly provide concussion protection. the commission appreciates the committee's interest in this very important area as well as the opportunity to discuss our agency's effort to insure that the information being provided to consumers, in particular to the parents of young athletes, the truthful and not misleading. thank you. >> thank you. now, ian, you are now recognized if or your five minutes. -- for your five minutes. >> chairman terry, reactioning member schakowsky and members of the subcommittee, thank you for the opportunity to share my story today. my name is ian heaton, and i am here as a national ambassador for the council of youth sports safety. i was a sophomore playing in a high school off-season lacrosse game when i sustained a serious head injury that we later discovered was my third concussion. until then i did not appreciate what a great life i was living. i got good grades in challenging classes, played high school lacrosse, was working on my second-degree black belt in martial arts, had a job i loved teaching tae kwon do, performed with my school's jazz ensemble and had an active social life. it was over in a split second. my concussion left me with only 5% of normal cognitive activity, and i was almost immobilized. i have wondered if i would ever get that life back. it has been a long, slow process. at first all i wanted to do was sleep. noise, light and even moving my eyes caused headaches and nausea. i was enrolled in the children's hospital score program that dr. gioia will describe later. i received ongoing cognitive evaluation and treatment for symptoms. after missing school for two weeks, i tried to go back but was unable to function. the frustration of trying to focus on lectures, moving through the pandemonium of the halls and the constant sensory bombardment made a normal school day impossible. however, through my school i eventually enrolled in a home teaching program, and with the help of my tutors and family, was able to complete my midwester coursework at my own pace. i finally returned to school in december but was still far from recovered. i have spent the two and a half 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 signs 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 that i had to drop a class and miss a band trip to chicago, among other things. the worst was when i had to crash and could not go to my first concert, the red hot chili peppers. the friend i gave my ticket to really owes me. [laughter] the spring after my injury, i was medically cleared to return to sports but made the hard decision that i would not play lacrosse or other intensive sports again. i know that a lott of people -- of people recover and return to play. but the possibility of injury means i could not come back next time. i now look at my recovery as something that has made me stronger, but i know that i am one of the very lucky ones who had the resources and medical attention that i needed and a school system that is aware of concussion issues and provided an up usually high level of support. it is not over yet. my recovery continues, but my outlook is positive, and i'm excited about the future as i prepare for college. i'm thinking about becoming a high school math or science teacher. i now have a hard question: what can be done to create a safer sports environment and to insure that when injuries do occur, the support for full recovery is available? we can't just do away with youth sports. i've played baseball, travel soccer and league and high school lacrosse, and being on those teams not only gave me a healthy outlet, it taught me important lessons. sports are one of best parts of growing up and becoming a strong adult. they teach us that 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 pride and success 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 that steps can be taken so that future young athletes have these opportunities. there are two important things i think would make a big difference. the first is to change the cultures of hitting hard to take out a good opponent rather or than playing to win through school and brushing off injuries to get back into the game can. while better equipment may decrease injuries, it is coaches, participants and players -- parents and players who have to back away from the need the win at all costs or fear the losing status on the team went out for an injury. to be handgun to recover fully -- willing to recover fully before returning to play. it will take a while, but if youth and professional sports are to survive, these attitudes must be embraced. second, when injuries do occur, we must have a way for qualified personnel to quickly assess injuries on the field, have players get immediate attention and then support recovery through schools and medical institutions. these are the things that were done for me and are the reason i've been able to return to normal. as the student ambassador for the ncyss, the message i hope to to give young athletes is this: you think you are invulnerable, you take risks and brush off injuries because you think you will recover quickly from anything that happens. you won't. don't be a hero, especially when it comes the your head. it's the only brain you'll have, and your personality is who you are. it's not worth a couple of seasons of glory to lose the opportunity of a lifetime. thank you. >> very good. dr. graham, you are recognized for five minutes. >> thank you very much, chairman terry, ranking member schakowsky, my name is bob graham. i served as the chair of the institute of medicine sports-related concussions and youth study. as you have my testimony before you and i think copies of the study itself, i will just try to take these minutes just 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 various scientific issues. we were specifically impaneled to look at the evidence about the causes and con consequences of youth and military, the role of protective equipment and sports regulation. we had 17 members on our committee. we worked in 2013. dr. molfese, who will follow me, was 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've heard a number of figures this morning about the concussions in one sport or another. we know what the incidence is where they are measured, we do not know what the incidence is in sports that are not measured or more closely watched. we need to have that baseline to really know the degree to which we have a problem. and as we take corrective measures, the success rate that we are having in making an impact on decreasing the incidents of concussion. so, number one, we need better surveillance, we need better epidemiology. number two, a couple of relations related to -- recommendations related to research. we need the nih to look at metrics and markers for concussions. how do you assess the severity of a concussion? how do you find diagnose knostically whether or not an individual has had a con clution? right now it's largely based upon observation, on self-report. but are there some fizz logic markers that could be used to give us better documentation that a concussion has actually occurred, perhaps without the vim knowing it or -- individual knowing it or without it being observed. secondly, we need the nih and dod to look at the short and long-term consequences of concussions. we've heard testimony in this panel, prior panel, individuals that have had one or more con clutions. what are the long-term sequela of an individual or multiple concussions. that gives us some sense about not only, again, the epidemiology of the problem we're dealing with, but what treatment and intervepgs may be and what rehabilitation may be. fourth recommendation was to the ncaa and the national federation of state and high school associates to look at -- associations to look at age-appropriate techniques and roles and playing standards. and, again, your first panel talked a little bit about that, mostly at the professional level. but can you change the manner in which the sport is practiced and the rules of engagement in the sport that may decrease the risk of concussion? there was one example from the hockey area where they had changed the level where they allowed body checking and felt that they saw a decrease in concussion. we think that same sort of examines should take -- examination should take place at the college and the elementary and high school level to see whether or not they can have the same impact. the fifth recommendation had to do with a better study of what the role may be for protective equipment. and, again, your first panel talked a lot about that. the committee had a number of questions about that. our committee found that there was very little evidence that helmets protect against concussions. and this is a lot of data in that. i think some of the other panelists will be talking about that. you mentioned the degree in physics this morning. it's a complicated issue, but there are a number of suggestions that, you know, we certainly don't recommend you don't use helmets. they do protect against bone injury and soft tissue injury, but the suggestion that a helmet itself may decrease the incidence of concussion, the evidence does not appear to be there to us, and we they the nhi and -- nih and dod again have a role in more specifically what we may be able to do related to the protection against concussions. and then our final recommendation had to do with the topic which has come up frequently, and that is changing the culture and the way concussions are viewed. this is a significant injury. athletes need to be encouraged to report to take themselves out of the game, coaches and parents need to be encouraged for your own protection, you need to be removed and give yourself a chance for recovery. thank you very much. >> thank you. dr. molfese, you are recognized for your five minutes. >> thank you, chairman terry, ranking member schakowsky and members of the subcommittee, for this opportunity. if we could have the slides? go the next slide. yeah. so i think the earlier group talked about a number of -- if you can go ahead and put that on powerpoint -- a number of sports where the rate of concussion is particularly high. there are, of course, differences in rates for men and women, and dr. gay will talk about some of that in terms of weaknesses of women's necks relative to their men's necks. now that puts them, perhaps, at more risk for concussion. next slide. concussion accounts for in the united states roughly about 75% of traumatic brain injuries. it is a brain injury. there is damage to the brain. there's a discussion about whether it's permanent or temporary. in the military the rate is 77%. so it turns out that youth sports are a good model for also looking at concussion in terms of the military. and, in fact, most of the military concussions occur in situations most like they do with the rest of americans. some certainly occur in theater, but majority occur outside of theater in accidents like -- [inaudible] are prone to experience. next slide. the if we look at brain injuries overall, there are estimates -- these are all estimates, of course, and they vary across the literature. but we're looking at somewhere probably in the neighborhood of about four million traumatic brain injuries per year in the united states. sobering part of that is that our birthrate in the united states is also roughly about four million. this does not count other ways that children are exposed to head injuries. perhaps a disciplining, irate parent who slaps a child that creates rotational movement that can, in fact, produce a concussion. those, one would suspect, 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 it'll 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 two-tenths to four-tenths of a second after the number appears. so the schematic on the right shows you the head position. so it's 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 200-400 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 that's 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? what's the dose requirement? dr. graham talked about that to produce concussion, post-concussion syndrome, cte. how can we detect when the brain is injured and when, importantly, it's 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 long-term 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 state concussion 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 children's 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 symptom-free, 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 don't 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 school athletic association recently published nonbinding guidelines to limit full-contact 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, that's 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 purpose-built 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. i'd like to thank the subcommittee for inviting me to testify today. i'm 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. that's one of the reasons we love it. that's 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 newton's second law, that the force each player exerts on the other exceeds three-quarters 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. here's another problem, they're 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 i'm not competent to explain these issues, i think it's 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, it's apart that adding more energy-absorbing foam to the outside of a helmet will lower the force delivered to a player's 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 player's head represent important first steps toward improving football safety. for a variety of reasons that disregard player safety, they're 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 nfl's 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 i'm a pediatric neuropsychologist at children's national health system here in washington, d.c. and the director of the score concussion program. i'm a clinician, a researcher and a public health educator. today i'd 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 i've 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 action-oriented 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 one-third 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 all-time 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 medically-guided training and early identification of concussion and protection. coaches and parents must receive training and action-oriented concussion initiation and response. awareness isn't enough, and they'd have to be prepared properly. we know that, as you've 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 children's national health system over the past ten years, our score program has delivered hundreds upon hundreds of action-oriented parent and coach concussion education and training programs using the heads up materials from the c, the c. we've learned -- cdc. we've learned much about the community needs and how to deliver the message. so we deliver scenario-based 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. you've heard about some important other kinds of activities and good examples of head safe action, head smart action such as usa football's 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 action-oriented, solution-driven 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. we're not asking parents and coaches to be clinicians and to go out and diagnose. we have willing teammates, as you've 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 you're 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, foundation's 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 community-focused 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. i'm 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 we're talking about a single mild tbi, about 80% get better. between 15-30% go on to have persistent concussive symptoms as have been described today. what's most concerning though are what's been called chronic traumatic enaccept lop think and other neurodegenerative disorders, and that's the second one where it's repetitive mild traumatic brain injury that we're really concerned with. and the clearest evidence comes from postmortem studies. if i could have the next slide. here's 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. what's 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 34-year-old with two blast injuries, an amateur football player at the aim of 18 with -- age of 18 with repetitive concussions and then a 21-year-old 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 that's 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 there's no problem then. the problem is the correct advanced tools have not been used until more recently, and now with advance neuroimaging, we're 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 what's 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 that's 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 there's cortical thinning compared to aim-matched controls. what's 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 what's called radial tiff fewsivity which is a measure of damage to -- [inaudible] in the brain. next slide, please. so what we don't know, why do concussive and subconcussive result in some and not others? another question we don't 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, i'm going to go pack to dr. molfese because i think your testimony and drsm shenton's -- and dr. shenton's 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 you're -- is this allowing you to detect the injuries earlier, that there may have been some pre-existing 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 we've 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 we're doing. and then should a player be injured and they're identified through trainers or the medical team, one of the weaknesses here is that players do not always self-identify. and so we run across that a number of times in our the eking. we'll pick be up -- testing. we'll pick up something on our test the trainers and medical team didn't know about simply because the player didn't 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 we're finding is both effects that occur across the season and just our normal players who have no history of concussion being identified, the brain's 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. that's 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 it's processing. we have just now moved to start intervention programs with the players we identify. there's some data out there with, certainly, alzheimer's 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 we're trying to see if we can sew some of that -- see some of that occurring. >> thank you. dr. gay, in regard to coussions many times it's not a direct blow, but it's being hit so that the head going back and forth and the brain is sloshing around. you mentioned going back to 970s-type -- 1970s-type 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 that's 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 can't -- my personal opinion, even though i'm ig noter of, largely ignorant of medical science s that if you immobilize the head, that's 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 also encouraging safer play to reduce the risk of injuries. mr. heaton, you spoke about the need to change the, quoting from a testimony, the win at all costs attitude among players and coaches. what would you tell teens to help them change that attitude both within themselves, teammates and perhaps more challenging, and coaches? >> thank you. frankly, i would actually encourage the coaches to stress this is much as possible as well as the parents. because the coaches and parents are there to help us learn how to play these sports correctly. if they can emphasize not having to worry about winning to the point where you get hurt, then it will trickle down to the players. the players become coaches, and then it's this never ending cycle of teaching and making sure that the players know that winning is not the most important thing. you know, it feels great to win, but i would much rather lose than have another concussion. >> clearly you were aware because of the severe consequences of brain injuries, do you think that you've athletes understand what those symptoms are? >> yes. i think it's getting better, indeed, especially at my school. we emphasize making sure that you know the symptoms of concussions. i feel like it's spreading as well. >> let me ask dr. gioia. >> certainly at this point the education programs are also being directed towards the athlete. and quite honestly, about five years ago, maybe six years ago there was a study that showed that was the number one reason why athletes were not coming out of the game because they did know how to tie together the symptomatology. it wasn't they didn't want to lose playing time, they did know what you're dealing with. we also believe athletes teammates need to watch out for each other. because the athlete himself may not have the wherewithal to know that they aren't right and yet 13 it right next to often times those. so there's a responsibility within the team to take care of each other and that's an important focus. >> acoustical to as well. dr. shenton, please explain how advanced neuroimaging works and describe the types of changes, also some types of neuroimaging used by your lab have been a significant part of the research on diseases like alzheimer's and schizophrenia. why aren't the same imaging techniques appropriate for research on this disease and researcresearch on sports wouldg -- >> okay, i have a slide which is just at the end of my slide that just explains in one slide, diffusion imaging which i think would help out here. >> the one slide i really didn't understand was, was a comparing swimmers with beige with the soccer players. was going to go through and just show you why to use injuries important because the injury that happens in the impact of the brain is generally a stretching of the cables in the brain, which really the white matter. for example, the corpus callosum is the largest white matter tracts in the brain. so you get sharing. this doesn't show up on traditional ct or mri. in fact the first mild tbi conference i want to know when show debris. i looked to my college and i said, why would no one show a brain? he said because everyone knows that you can't see anything on the brink and i said, but nobody is using the right tools. this is just a very simple principle of diffusion imaging but if you look on the left, they think that goes on kleenex, goes in all directions and that's called isotropic diffusion but if you look on the right it says and isotropic diffusion but you're dropping into newspaper and newspaper has fiber so that restricts the water. this is the same principle that's used quantitatively to look at the brain. so that if you're in cfs it's a very around. it's isotropic, everything goes in his introduction to if if you're looking at white matter your restricted in two directions. so you can measure how come with integrity is a white matter fiber bundles in the brain. that's what you need to look at a mild tbi. if you have someone come in with a moderate to severe brain injury, you don't need this kind of technology. you will just be put into nursery to end of the and operation. it's these very subtle brain injuries that are not recognized using conventional imaging. where you can recognize it if you something like diffusion imaging. and we shown over and over again now that you can see, it is not just our group, starting in 2003 people start using diffusion imaging because it's the most sensitive imaging tool that exists today to look at this entry which is the major injury in mild tbi. so what needs to be done now is to look at acute injury and see what predicts outcome, like do a cute entry at 72 hours, at three months, at six months. and we can predict knowing that what happens at 72 hours if you have, with someone in a lab that is time to separate water that is outside the brain, outside sales versus inside. eq can predict from 72 hours then you can go back and say okay, maybe we want to put in anti-inflammatory medications. we don't know enough right now. the only way to know is to do these longitudinal studies and follow over time using very sophisticated imaging technology. once you know, you can diagnose. what you diagnose -- >> this could be very promising not only for athletes but our returning veterans, and applied eventually to schizophrenia or alzheimer's. >> actually we've applied -- i'm primarily schizophrenia research. that's what i've done for 30 just before became a tbi research in 2008. and we have a measure called free water based on imaging, this kind of imaging the shows that early on at the very first episode of schizophrenia easy fluid around all of the brain. it's free water. it's like isotropic. but in just the frontal lobe you see it more restricted to tissue, inside tissue. this is a brand-new technique that was developed by a fulbright scholar at in our lab from israel. >> i'm going to have to say thank you because it's very -- >> yes, thank you. gentleman from new jersey is recognized. >> thank you, mr. chairman. dr. johnston, you stated that many sports-related concussions still go undiagnosed. i'd like to know why, in your opinion, that is the case and how can we improve that? state laws and also the involvement of coaches and players and pdas, areas where we need to have improvement. >> thank you for the question. i think i would echo what has been said that others on the panel. i would echo what's been said by others on the panel that a think a lot has to do with recognition. obviously, people are very good at recognizing when someone gets knocked out on the field but, of course, that's a very small percentage of all concussions. as our understanding of ali their symptoms that can go with concussion have arisen, he becomes incumbent upon us to improve the quality of the education to get your coaches, players, trainers, officials about the symptoms of concussions. i think that's -- my sense is that in general, the culture, at least speaking for the state of alabama, all the coaches i've come in contact are believers. they are not purposefully hiding kids and putting them back in with concussioconcussio ns barfing it's hard to recognize especially when young athletes don't tell you how you their feeling and other issues which i guess were brought up the importance of teammates being involved in diagnosing these players so they can be appropriate value weighted. >> how close are we for a better design for helmets? >> i think that we are at the very beginning. i think that we been using a standard that has not changed for four years that was designed for skull fractures. it's served its purpose and i think many investors around are working to improve the quality of the standards to include linear and rotational acceleration as well as other important aspects of impact. just like the automotive industry did 30 years ago with once you start ranking cars with safety ratings, the market can be relied upon for manufacturers to improve their helmet designed to improve their sales. that's the stage we're at. i think standards are important part of the equation. >> thank you. dr. gay, in your testimony you have discussed the fact that there is a numerical rating system for helmets impact. i think it's designed at virginia tech, the star system. you have called it the best tool we have for analyzing the merits of various helmet systems. can you brief we explain how the numerical scoring system works? >> yes. thank you, mr. vice chairman. basically it involves a test where you drop the helmet from a given height, a varying heights, to the site, confront, to the back. it tries to simulate the kinds of impact that a football player would actually experience, and numerical scores are given to the maximum acceleration that the nazi head inside the helmet feels for these different drops -- noxi head. >> there's no account for rotation, no effect for temperature. and in my opinion the reproducibility is not as good as one would like having tried to do it, examples of these kinds of tests and groups that i've been involved with. so i think it's a good first start but it's the best we have right now. i think it needs to be paid attention to but there's a lot of room, a lot of room for improvement. >> thank you, dr. gay. finally, ian, how old are you grey dog went? >> i'm 18 and i'm a senior. >> doesn't mean you be going off to college in the autumn speak with you as i will. >> do you know where you will attend college? >> north carolina. >> congratulations to you and my condolences to your parents on the cost of higher education in this country. it's a great school. i have a goddaughter it was a freshman there. that means she's a little older than you but i will be happy to introduce you to her. [laughter] and let me say i am very proud of your testimony, and i could not have done what you've just done when i was 17 or 18, and certainly i think the nation has benefited by your outstanding testimony. >> thank you. >> thank you. >> gentlemen from mississippi, you are now recognized for five minutes. >> thank you, mr. chairman. and thank each of you for being here and sharing your expertise on what is a topic we are just really i think only really learning about. it's been in the news for several years, but it is i think coming to the forefront. your work and your information, your testimony on the richter today i think will be beneficial to us. as a parent of a 24 year-old young man with center, appreciate the work you do of the children's hospital, but this is, in preparation for this i had discussion with parents back home. and the interesting discussion is i had several friends who have daughters playing youth soccer and a number of the reported an increase in the number of concussions, suffered a young ladies playing youth soccer. we seem and is to always associate with nfl and helmet to helmet contact and concussions that we see on the field of play. but it appears in everything we do in life, every sporting event fares that danger and risk. that's what i think what you're doing with the think first alabama, dr. johnston, is the preventive part of it is how do we educate our players and coaches, parents, and perhaps using a teammate approach it may be the safest thing may be to have a backup position to be the one to report for the first team are when they need to come out. that might get them off the field. but thank each of you for your work. dr. johnston common educate us a little bit, what is a sub contested impact? what does that mean? how important is that when addressing concussion diagnoses? should sub contested impacts affect rules apply and if so, how? >> i think the definition would be all those other common 994 neighbors and backs it up and that don't result in a concussion, a diagnosed concussion. as pointed out previously the rub with concussion is a diagnosis part. if you look at the historical studies about rates of infections -- concussions, all of that has to do with who's diagnosing it and male versus female, whether not men are more likely to poor or less likely to report symptoms, i think the subconcussive impact as all those other impacts that we have found more and more information with important mission to none in boston and other places that even the subconcussive impacts have results in terms of an atomic structural changes in the brain over time. selecting the subconcussubconcus sive impact needs to be addressed in terms of lessening the overall cumulative impact blow that everybody has. football is the most obvious things in terms of how many practices a week children should be able to do anything and whatnot, but i think that its application for all sports. >> thank you. dr. molfese, if i could ask you a question. just for clarification first, if i could ask, the 77% of military, that figure, is that how many of tbi cases have suffered concussions, or is that 77% of all military? i wasn't quite clear. >> 77% are concussions, mild tbi. >> i got you. can you tell us more about the sideline imaging work you are doing? is this practical? is is something we can expect to see rolled out to sidelines across america, to diagnose for athletes come apparati but on the battlefields to diagnose our warriors? >> i think it's very possibly we published a paper just this last year in 2013 we took one of our dg systems and recorded on the sidelines of the field. the biggest challenge of making a practical is to get the processing time down. at this point it takes us an hour. if we can get down to five minutes then i think we can sell it to the coaches because they're the ones really that are going to determine. i guess at this point, given all the other issues, the common tests used right now are like the impact which are assessment tools, sort of questions to the player. they have to reflect and they may be a little foggy because of the concussion. these tests don't have any predictive of our reliability after today's post injury. that's a big problem but it doesn't predict recovery time, doesn't predict severity of the injury and so on. of biomarkers we're all talking about are the critical things. are hoping would be much more reliable and predicted. >> thank you very much and thank each of you for being here. i yield back. >> thank you. generally this would end, but we all have some questions we're actually going to get a second round. and plus the bells are not going to go off for another seven minutes. and jan does have a conflict and she has given us approval that she's going to leave, but she trusts us to ask legitimate questions. >> but let me just really think this panel, and the previous panel as well. the intensity now of the scientific research, and then its application to the playing field and actually so many other fields. i really want to thank you for telling us what's going on. and i also did want to thank ian heaton for coming here today. i think it's important that people like briana scurry and ian to tell their stories and give us a face to the importance of this. i want to thank the ftc for making sure that false claims are not made. but this is so important. so appreciated. and then we will have to figure out where it leads us, but it certainly has informed us. thank you. >> i would agree with every word of that. so this is a question to you, dr. molfese and dr. shenton, and it dovetails into what the gentleman from mississippi was talking about as well. but are the symptoms of a concussion or tbi uniform enough so that it is possible for early detection or developing a checklist for a coach or a parent to be used, you know, i nonmedical? start with you. >> no. >> well, that was easy. >> the symptoms overlap with depression and ptsd and has been a real problem. in fact, there was a paper published in "the new england journal of medicine" that said when you remove the effects of depression and you remove the effects of ptsd, mild tbi does not exist and that's a real disservice. it used to be that people would claim, when people came in complaining that they still at symptoms from hitting her head, since there was no evidence from conventional mri or conventional ct, they said, go see a psychiatrist. so it was really not appropriate at all because there is at least a small minority of people who have mild concussion who go on to have symptoms. they can go on for months, for years, and then they can clear up. so that separate even from ctv. what you need is radiological evidence for diagnosis, the same way you would want to know values of a blood test for cholesterol or a broken leg. and i think we're moving in that direction and that's what we need as hard evidence because the symptoms are too nonspecif nonspecific. >> dr. molfese? >> there are studies published look at the number of symptoms, and a wide variety of symptoms people report, there' there is a that indicates whether someone reports lots of symptoms versus a few symptoms, that that has relation to how long they will recover, how serious the injury is, how great the impairment is, unfortunately. >> can we get to the point where a seventh grade coach, a seventh grader takes a big hit, that there's a checklist per se that the coach could use to determine if a kid should go back into the game? >> in general to our guidelines out by the cdc and others that list concussion symptoms. and so i think the general bias at this point is if the individual reports any of these symptoms, that they should be pulled. because we do know that if there is data indicate if you do have a concussion and did you start playing again before the symptoms resolve them is likely even death is much greater, not to mention further significant concussion that will take longer to recover. >> all right. so this one is for dr. johnston and dr. gioia. one of the debates that occurring in the state of nebraska right now is you have a child, or high school student, that suffers a concussion during a game. so it's been diagnosed. what do you do next? right now the thought is, is you keep them home, or her home, dark, no electronics. that's kind of the known. there's a discussion whether that's appropriate or not, or to what length. what do you know? what would you recommend? >> i will tell you about how we handle things in alabama and i think a lot of what we do is based on the cdc guidelines, once an athlete is diagnosed, they are removed from the field of play and then there is evaluated. we use this gap, sport concussion assessment of which is a sideline-based assessment. we aussies afterwards as well and it's a quick mini inventory of neurological exam and neurocognitive function. when children have symptoms that persist, obviously they don't return to any sort of play or even escalation of activity until their symptoms have completely resolved. then those children have persistent symptoms calm lasted beyond the one to two weeks, i've been referred to neuropsychologist like dr. gioia, and traumatic brain injury program. i guess i would defer to you -- >> this is a big question at this point. this really comes to what is the best treatment for this injury. and let me just say the field is moving on this one. the recommendations that we may, and i've written several recent papers on this, is that in that acute stage of symptoms, probably the first few days, maybe for some little longer if there's more severe number of symptoms, is that they really reduce their activity, cognitive and physical. but what you want to be doing so is start to increase that activity over time. so we don't block box the kids until they're asymptomatic. that have a lot of likely negative affects on kids being removed. so what we do is we initially shut them down, restrict them, and we gradually start to bring them back into school and physical activity. but that has to be individualized based again on the severity of that symptom presentation. that's where we are right now. we need a whole lot of research to really help validate that. >> thank you, and mr. lance? gentleman from missouri gets to ask another question. mississippi. i thought you were really long. [laughter] >> that hurt. thank you, mr. chairman. a couple of questions i would have. one would be, if we're looking at this -- dr. gay, if i may ask the question, in your testimony you state that football players at the elite levels are shedding equipment to increase speed and mobility. the decision on which helmet to wear is their own, and other often chooses a helm which looks, shape, feel, perhaps over its collision are cushioning ability our futures. do some position or different levels of cushioning? and if so would you recommend a special helmet for a specific position that would meet all current safety standards? >> that's a great question. currently there are no position specific helmets being made. i think the helmet manufacturers try to give as they can for everybody. i would say that, not to belabor the point, but i think for linemen we typically get no severe hits but a lot of subconcussive blows, that horse collar is crucial. i wouldn't recommend that a wide out where a horse collar. that would affect the quality of the play. it's an interesting point because certainly some players might -- this is why i'm an advocate for the system. it will give us much more detailed information about which positions get hit way or. one could envision if we have a large database, then improving helmet design to react to the information we got from those kinds of information. >> dr. graham, if i could ask you, how much money has been spent on sports concussion research? where is most of the funding coming from? >> unfortunately, there is not an issue that our committee looked at, nor would we have had the resources to pull it out. you know, clearly you can identify some research that's been done in the federal sector that applies to this, but the private research that may be done by sports leagues, by the manufactures of equipping themselves, i don't know any good way to quantify that for you. >> look, i appreciate everybody being here, and it's a very important issue. we love our children going through sports. we love to watch it, and we don't want anybody being hurt that shouldn't be hurt. so hopefully this increased focus will lead to better research, better safety equipment, detection and, of course, prevention. so thank you very much. thank you, mr. chairman. i yield back. >> thank you. the gentleman from mississippi. >> and i just want to thank, this was truly an all-star panel of medical experts and physics. and much appreciated, ian. thank you. and so that does conclude our hearing for today. now, for our witnesses, wheat, whether we showed up or not, have the right to send you a question, a written question. .. i knew a part of the football plas when i was in school. this issue was a problem then and is an issue today so why has it not been taken care of in more than 30 years? is no reason for it but for the courageous actions of these young men we wouldn't be talking about it today so i want to put that on the record. and you talked about the ohio state house who has determined that our athletes are not employees just because they said it doesn't make it so. these are the same people that want to restrict voting rights. so just because they said that doesn't make it so. we do know tha know the studente scholarship athletes are treated differently than those not on scholarship. the restrictions they have is much different than students who aren't on scholarship students. first question i would like to ask mr. schwar
CanadaAlabamaUnited-statesAustraliaGermanyNorth-carolinaMissouriBostonMassachusettsZurichZüszSwitzerland 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? that's 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 it's 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 that's the cornerstone of our heads up football program. equipment fitting. we found they don't know to properly fit equipment so it's 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. they've 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. >> gentleman's time has expired. >> thank you. >> so if any of you want to answer that question, you'll have to do it by writing. [laughter] and brings me to the point that -- oh, you have a question. i'm sorry. recognize the gentlelady from the virgin islands. >> thank you. and thank you, mr. chairman. sorry i'm late, i was at another hearing downstairs. mr. miller, i'd 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 products safety 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, it's 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. i'm 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. we've 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 that's why i'm sitting in chairman dingell's 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? you're 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 we'd 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? that's the position that's 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 that's something that's 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. he's 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 scientific-based 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 johnston professor 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 children's medical hospital and not quite up to the level of the university of nebraska we have the harvard medical school. that's just humor. [laughter] professor of psychiatry and radiology at brigham women's 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 we've 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 doesn't 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 commission's 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 product's 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. i'm also a senior at the bethesda high school in maryland. i was a sophomore playing in high school off-season lacrosse game when i sustained a serious head injury but he later discussed with my third concussion. i'm told i'm a didn't 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. it's 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 wasn't 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 couldn't 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 wouldn't 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 i'm 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 i've decided about the future as i prepare for college. i'm thinking about becoming a high school math or science teacher. the support for the full recovery is available. we can't 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 i've 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 won't. don't be when it comes to your head. it's the only brain you will have in your personality is who you are. it isn't 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 self-report 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 long-term consequences of concussions. we heard testimony in the panel individuals that have had one or more concussions and what are the long-term 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 age-appropriate 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 there's 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. it's a complicated issue, but there are a number of suggestions that we certainly didn't recommend. they do protect against bone injury and soft tissue injury that's 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. there'there 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 it'll 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 two-tenths to four-tenths of a second after the number appears. so the schematic on the right shows you the head position. so it's 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 200-400 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 that's 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? what's the dose requirement? dr. graham talked about that to produce concussion, post-concussion syndrome, cte. how can we detect when the brain is injured and when, importantly, it's 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 long-term 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 state concussion 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 children's 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 symptom-free, 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 don't 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 school athletic association recently published nonbinding guidelines to limit full-contact 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, that's 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 purpose-built 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. i'd like to thank the subcommittee for inviting me to testify today. i'm 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. that's one of the reasons we love it. that's 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 newton's second law, that the force each player exerts on the other exceeds three-quarters 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. here's another problem, they're 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 i'm not competent to explain these issues, i think it's 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, it's apart that adding more energy-absorbing foam to the outside of a helmet will lower the force delivered to a player's 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 player's head represent important first steps toward improving football safety. for a variety of reasons that disregard player safety, they're 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 nfl's 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 i'm a pediatric neuropsychologist at children's national health system here in washington, d.c. and the director of the score concussion program. i'm a clinician, a researcher and a public health educator. today i'd 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 i've 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 action-oriented 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 one-third 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 all-time 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 medically-guided training and early identification of concussion and protection. coaches and parents must receive training and action-oriented concussion initiation and response. awareness isn't enough, and they'd have to be prepared properly. we know that, as you've 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 children's national health system over the past ten years, our score program has delivered hundreds upon hundreds of action-oriented parent and coach concussion education and training programs using the heads up materials from the c, the c. we've learned -- cdc. we've learned much about the community needs and how to deliver the message. so we deliver scenario-based 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. you've heard about some important other kinds of activities and good examples of head safe action, head smart action such as usa football's 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 action-oriented, solution-driven 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. we're not asking parents and coaches to be clinicians and to go out and diagnose. we have willing teammates, as you've 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 you're 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, foundation's 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 community-focused 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. i'm 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 we're talking about a single mild tbi, about 80% get better. between 15-30% go on to have persistent concussive symptoms as have been described today. what's most concerning though are what's been called chronic traumatic enaccept lop think and other neurodegenerative disorders, and that's the second one where it's repetitive mild traumatic brain injury that we're really concerned with. and the clearest evidence comes from postmortem studies. if i could have the next slide. here's 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. what's 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 34-year-old with two blast injuries, an amateur football player at the aim of 18 with -- age of 18 with repetitive concussions and then a 21-year-old 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 that's 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 there's no problem then. the problem is the correct advanced tools have not been used until more recently, and now with advance neuroimaging, we're 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 what's 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 that's 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 there's cortical thinning compared to aim-matched controls. what's 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 what's called radial tiff fewsivity which is a measure of damage to -- [inaudible] in the brain. next slide, please. so what we don't know, why do concussive and subconcussive result in some and not others? another question we don't 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, i'm going to go pack to dr. molfese because i think your testimony and drsm shenton's -- and dr. shenton's 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 you're -- is this allowing you to detect the injuries earlier, that there may have been some pre-existing 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 we've 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 we're doing. and then should a player be injured and they're identified through trainers or the medical team, one of the weaknesses here is that players do not always self-identify. and so we run across that a number of times in our the eking. we'll pick be up -- testing. we'll pick up something on our test the trainers and medical team didn't know about simply because the player didn't 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 we're finding is both effects that occur across the season and just our normal players who have no history of concussion being identified, the brain's 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. that's 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 it's processing. we have just now moved to start intervention programs with the players we identify. there's some data out there with, certainly, alzheimer's 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 we're 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 it's not a direct blow, but it's being hit so that the head going back and forth and the brain is sloshing around. you mentioned going back to 970s-type -- 1970s-type 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 that's 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 can't -- my personal opinion, even though i'm ig noter of, largely ignorant of medical science s that if you immobilize the head, that's 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 alzheimer's 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 didn't 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 don't 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 anti-inflammatory medication. we don't 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 state's 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 don't 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 lanier's 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 year-old with the syndrome i appreciate the work they do at the children's 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 non-specific >> 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.
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