[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



 
                       THE IMPACT OF CONCUSSIONS
                        ON HIGH SCHOOL ATHLETES

=======================================================================



                                HEARING

                               before the

                              COMMITTEE ON
                          EDUCATION AND LABOR

                     U.S. House of Representatives

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

              HEARING HELD IN WASHINGTON, DC, MAY 20, 2010

                               __________

                           Serial No. 111-64

                               __________

      Printed for the use of the Committee on Education and Labor


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                    COMMITTEE ON EDUCATION AND LABOR




                  GEORGE MILLER, California, Chairman

Dale E. Kildee, Michigan, Vice       John Kline, Minnesota,
    Chairman                           Senior Republican Member
Donald M. Payne, New Jersey          Thomas E. Petri, Wisconsin
Robert E. Andrews, New Jersey        Howard P. ``Buck'' McKeon, 
Robert C. ``Bobby'' Scott, Virginia      California
Lynn C. Woolsey, California          Peter Hoekstra, Michigan
Ruben Hinojosa, Texas                Michael N. Castle, Delaware
Carolyn McCarthy, New York           Mark E. Souder, Indiana
John F. Tierney, Massachusetts       Vernon J. Ehlers, Michigan
Dennis J. Kucinich, Ohio             Judy Biggert, Illinois
David Wu, Oregon                     Todd Russell Platts, Pennsylvania
Rush D. Holt, New Jersey             Joe Wilson, South Carolina
Susan A. Davis, California           Cathy McMorris Rodgers, Washington
Raul M. Grijalva, Arizona            Tom Price, Georgia
Timothy H. Bishop, New York          Rob Bishop, Utah
Joe Sestak, Pennsylvania             Brett Guthrie, Kentucky
David Loebsack, Iowa                 Bill Cassidy, Louisiana
Mazie Hirono, Hawaii                 Tom McClintock, California
Jason Altmire, Pennsylvania          Duncan Hunter, California
Phil Hare, Illinois                  David P. Roe, Tennessee
Yvette D. Clarke, New York           Glenn Thompson, Pennsylvania
Joe Courtney, Connecticut
Carol Shea-Porter, New Hampshire
Marcia L. Fudge, Ohio
Jared Polis, Colorado
Paul Tonko, New York
Pedro R. Pierluisi, Puerto Rico
Gregorio Kilili Camacho Sablan,
    Northern Mariana Islands
Dina Titus, Nevada
Judy Chu, California

                     Mark Zuckerman, Staff Director
                 Barrett Karr, Minority Staff Director



                            C O N T E N T S

                              ----------                              
                                                                   Page

Hearing held on May 20, 2010.....................................     1

Statement of Members:
    Kline, Hon. John, Senior Republican Member, Committee on 
      Education and Labor........................................     4
        Prepared statement of....................................     5
    Miller, Hon. George, Chairman, Committee on Education and 
      Labor......................................................     1
        Prepared statement of....................................     3
        Additional submissions:
            ``10 Point Plan to Save Football,'' Christopher 
              Nowinski, co-director, Boston University School of 
              Medicine...........................................    57
            ``Concussion Signs and Symptoms Checklist,'' from the 
              Centers for Disease Control and Prevention.........    59
            Popyer, Niki, 17-year-old former basketball player, 
              statement of.......................................    60

Statement of Witnesses:
    Gioia, Gerard A., Ph.D., chief, division of pediatric 
      neuropsychology; director, Safe Concussion Outcome, 
      Recovery & Education (SCORE) Program, Children's National 
      Medical Center.............................................     7
        Prepared statement of....................................     9
        Additional submission:
            Rainey, Sarah B., concussed high school student/
              athlete, statement of..............................    62
    Kohn, Linda, Director of Health Care Issues, Government 
      Accountability Office......................................    18
        Prepared statement of....................................    19
        Graphic, ``Individuals Who May Observe the Effects of a 
          Concussion Incurred in High School Sports''............    65
    Monacelli, Michael T., director of athletics, football coach, 
      Caledonia-Mumford Central School District..................    19
        Prepared statement of....................................    21
    Pelton, Michelle, former high school athlete.................    13
        Prepared statement of....................................    15
    Schmutz, James, executive director, American Sport Education 
      Program....................................................    22
        Prepared statement of....................................    24


                       THE IMPACT OF CONCUSSIONS
                        ON HIGH SCHOOL ATHLETES

                              ----------                              


                         Thursday, May 20, 2010

                     U.S. House of Representatives

                    Committee on Education and Labor

                             Washington, DC

                              ----------                              

    The committee met, pursuant to call, at 9:02 a.m., in room 
2175, Rayburn House Office Building, Hon. George Miller 
[chairman of the committee] presiding.
    Present: Representatives Miller, Payne, Andrews, Woolsey, 
McCarthy, Tierney, Kucinich, Davis, Bishop of New York, 
Loebsack, Shea-Porter, Kline, McKeon, Biggert, Guthrie, and 
Roe.
    Also present: Representative Pascrell.
    Staff present: Andra Belknap, Press Assistant; Calla Brown, 
Staff Assistant, Education; Jody Calemine, General Counsel; 
Lynn Dondis, Labor Counsel, Subcommittee on Workforce 
Protections; Denise Forte, Director of Education Policy; David 
Hartzler, Systems Administrator; Ryan Holden, Senior 
Investigator, Oversight; Sadie Marshall, Chief Clerk; Alex 
Nock, Deputy Staff Director; Lillian Pace, Policy Advisor, 
Subcommittee on Early Childhood, Elementary and Secondary 
Education; Helen Pajcic, Education Policy Associate; Kristina 
Peterson, Legislative Fellow; Alexandria Ruiz, Staff Assistant; 
Melissa Salmanowitz, Press Secretary; Michele Varnhagen, Labor 
Policy Director; Mark Zuckerman, Staff Director; Kirk Boyle, 
General Counsel; Allison Dembeck, Professional Staff Member; 
Angela Jones, Executive Assistant; Barrett Karr, Staff 
Director; Alexa Marrero, Communications Director; Susan Ross, 
Director of Education and Human Services Policy; and Linda 
Stevens, Chief Clerk/Assistant to the General Counsel.
    Chairman Miller [presiding]. A quorum being present, the 
committee will come to order for the purposes of conducting 
this hearing on the impact of concussions on high school 
athletics and athletes.
    Welcome to the witnesses that will be testifying this 
morning. Thank you for your time and your expertise.
    We are kind of jamming this hearing--when we planned this 
hearing we didn't have a joint session of Congress at 11 
o'clock with the president of Mexico, and so we have moved the 
time up, and that interferes into the caucuses of both parties, 
so I want to thank Mr. Kline for being here and the other 
members that are here.
    But we felt rescheduling was going to make it more 
difficult, so we wanted the--we wanted to get this hearing on 
the record. We think it is a very important matter for this--
for this committee.
    Today we will examine how concussions experienced by high 
school athletes on the playing field are impacting their 
academic well being and their quality of life.
    We will also learn more about how schools and the medical 
community can provide appropriate management and support for 
these young student athletes.
    One of our committee's key priorities has been looking at 
how we can keep students safe and protected in school. This is 
our first hearing looking into what happens on the athletic 
field, where many school injuries occur.
    Last year, Congressman Andrews, Congresswoman Bono-Mack and 
I asked the Government Accountability Office to look into 
concussions in high school athletics after several professional 
athletes suffered debilitating and news-making head injuries 
diagnosed as concussions.
    It was clear to us that if the NFL was paying attention to 
concussions at the professional level, we should be doing the 
same at the high school level, when students' bodies and minds 
are still growing and therefore somewhat more vulnerable.
    Today, the GAO will share the findings of their report. We 
will hear about the incidents of concussions in high school 
sports and what federal programs exist to help prevent these 
catastrophic injuries from sidelining students.
    This is the first comprehensive look at what is being done 
to prevent and manage these injuries. When a student suffers a 
concussion, serious repercussions can occur both on the field 
and in the classroom.
    On the playing field, concussions can pose significant 
health risks to students. High school athletes are at greater 
risk of sports-related concussions than college or professional 
athletes because of--their younger brains are more susceptible 
to injury.
    In the last 3 school years alone, 400,000 concussions were 
reported in high school athletics, and this is--this could also 
be a low estimate. Studies show that the prevalence of sport-
related concussions is much higher than reported.
    A concussion, unlike a sprain or a broken bone, is not 
always easily detected. Ninety percent of concussions occur 
without a loss of consciousness. Concussions can cause a range 
of symptoms, from altered mental status to physical symptoms 
such as headaches or dizziness, to emotional changes like 
irritability and difficulty in sleeping.
    The number and types of symptoms may vary in each person. 
But unless a student takes time off from the field after 
suffering a concussion, he or she may be prolonging their 
recovery and their success in school may suffer.
    Unfortunately, the symptoms of concussions are not only 
difficult to detect but they are not always taken seriously. In 
the sports injury community, there is a saying, ``When in 
doubt, sit it out.''
    But recent studies show that more than half the high school 
girls' volleyball and boys basketball and baseball players who 
suffered concussions return to play too soon. This is a problem 
that isn't limited to student athletes.
    College and professional athletes also feel the pressure to 
compete and stay in--stay in the game. The pressure to play is 
overriding medical concerns and, potentially, a student's 
academic and health future.
    Failing to ``sit it out'' after concussions can negatively 
affect students in the classroom. One of our witnesses will 
tell us that almost 90 percent of girls recovering from a 
concussion reported their symptoms worsened by trying to focus 
on schoolwork.
    Any parent can tell us that participating in sports doesn't 
just get their kids up and moving, it gives them skills that 
will come in handy in school, on the job and throughout their 
lives. Our goal today is to make sure that our kids can 
continue to participate in sports safely and to continue to 
reap the benefits both on and off the field.
    I look forward to hearing from our witnesses today about 
what schools can be doing to better help support high school 
athletics and testimony on the effects of concussion on student 
achievement.
    With that, I would like now to recognize the senior 
Republican this morning, Mr. Kline.
    [The statement of Mr. Miller follows:]

   Prepared Statement of Hon. George Miller, Chairman, Committee on 
                          Education and Labor

    Good morning.
    Today we'll examine how concussions, experienced by high school 
athletes on the playing field, are impacting their academic well being 
and quality of life.
    We'll also learn more about how schools and the medical community 
can provide appropriate management and support for these young student 
athletes.
    One of our committee's key priorities has been looking at how we 
can keep students safe and protected in school.
    But this is our first hearing looking at what happens on the 
athletic field, where many school injuries occur.
    Last year, Congressman Andrews, Congresswoman Bono-Mack and I asked 
the Government Accountability Office to look into concussions in high 
school athletics after several professional athletes suffered 
debilitating and news-making head injuries diagnosed as concussions.
    It was clear to us that if the NFL was paying attention to 
concussions at the professional level, we should be doing the same at 
the high school level--when students' bodies and minds are still 
growing and therefore more vulnerable.
    Today, GAO will share the findings of their report.
    We'll hear about the incidents of concussions in high school sports 
and what federal programs exist to help prevent these catastrophic 
injuries from sidelining students. This is the first comprehensive look 
at what is being done to prevent and manage these injuries.
    When a student suffers a concussion, serious repercussions can 
occur both on the field and in the classroom.
    On the playing field, concussions can pose significant health risks 
to students.
    High school athletes are at greater risk of sports-related 
concussions than college or professional athletes because their younger 
brains are more susceptible to injury.
    In the last three school years, 400,000 concussions were reported 
in high school athletics.
    And this could be a low estimate.
    Studies show that the prevalence of sport-related concussions is 
much higher than reported.
    A concussion, unlike a sprain or a broken bone, is not always 
easily detected.
    Ninety percent of concussions occur without loss of consciousness.
    Concussions can cause a range of symptoms, from altered mental 
status to physical symptoms such as headaches or dizziness to emotional 
changes like irritability and difficulty sleeping.
    The number and type of symptoms vary widely for each person.
    But unless a student takes time off the field after suffering a 
concussion, he or she may be prolonging their recovery and their 
success in school may suffer.
    Unfortunately, we also know that the symptoms of concussions are 
not only difficult to detect, but are not always taken seriously.
    In the sports injury community, there is a saying: ``When in doubt, 
sit it out.''
    But a recent study shows that more than half of high school girls' 
volleyball and boys basketball and baseball players who suffered 
concussions return to play too soon.
    This is a problem that isn't limited to student athletes. College 
and professional athletes also feel the pressure to compete and stay in 
the game.
    What we see here is pressure to play is overriding medical concerns 
and--potentially--a student's academic future.
    As we will learn more about today, failing to ``sit it out'' after 
a concussion can negatively affect students in the classroom.
    One of our witnesses will tell us that almost 90 percent of girls 
recovering from a concussion reported that their symptoms worsened 
after trying to focus on schoolwork.
    Any parent can tell you that participating in sports doesn't just 
get their kids moving--it gives them skills that will come in handy in 
school, on the job and throughout their lives.
    Our goal today is to make sure that our kids can continue to 
participate in sports safely--and continue to reap the benefits both on 
and off the playing field.
    I look forward to hearing from our witnesses today about what 
schools can be doing better to help support high school athletes, and 
testimony on the effects of concussions on student achievement.
                                 ______
                                 
    Mr. Kline. Thank you, Mr. Chairman.
    Good morning, all. Welcome to our witnesses. We are here 
this morning to discuss research recently conducted by the 
Government Accountability Office on concussions among high 
school athletes. The findings of the GAO will be illuminated by 
experts in the field and individuals who have firsthand 
experience with this type of injury.
    Concussions are functional traumatic brain injuries 
suffered as a result of force. For instance, they could be 
caused by collision of the head or a blow to the body. Although 
the federal government is not responsible for the treatment or 
tracking of this type of injury, concussions are of interest to 
this committee because of their implications to students.
    Hearings such as this provide an opportunity to shine a 
spotlight on the issues dealt with by states and local 
communities and highlight the resources and best practices 
available to help students, parents, coaches and school leaders 
prevent these injuries and respond appropriately when they do 
occur.
    Research in this area is ongoing, but we know concussions 
among high school athletes have drawn increasing attention in 
recent years. One reason is because younger people appear to be 
more vulnerable to this type of injury than adults.
    Recent research indicates high school athletes with recent 
or repeated concussions have difficulty concentrating, lower 
attendance rates and significantly lower cumulative grade point 
averages than high school athletes with no history of 
concussion. In other words, this affects not just student 
health but also academics.
    As with many dangers to our children, prevention is the 
best medicine. That is why we will hear today about education 
programs and resources designed to help prevent concussions in 
student athletes.
    We will also hear about programs and guidance for coaches, 
administrators, parents, and medical personnel that address 
what to do when a concussion occurs or is suspected, including 
best practices for determining when athletes can most safely 
return to the field of play.
    I want to thank the witnesses for being here to discuss 
this topic and help bring attention to the steps student 
athletes and the adults who supervise them can take to prevent 
and respond to this type of injury.
    Thank you, and I yield back.
    [The statement of Mr. Kline follows:]

   Prepared Statement of Hon. John Kline, Senior Republican Member, 
                    Committee on Education and Labor

    Thank you Mr. Chairman. Good morning and welcome to our witnesses.
    We're here this morning to discuss research recently conducted by 
the Government Accountability Office into concussions among high school 
athletes. The findings of the GAO will be illuminated by experts in the 
field and individuals who have firsthand experience with this type of 
injury.
    Concussions are functional traumatic brain injuries suffered as a 
result of force--for instance, they could be caused by a collision of 
the head or a blow to the body. Although the federal government is not 
responsible for the treatment or tracking of this type of injury, 
concussions are of interest to this committee because of their 
implications for students.
    Hearings such as this provide an opportunity to shine a spotlight 
on the issues dealt with by states and local communities and highlight 
the resources and best practices available to help students, parents, 
coaches, and school leaders prevent these injuries and respond 
appropriately when they do occur.
    Research in this area is ongoing, but we know concussions among 
high school athletes have drawn increasing attention in recent years. 
One reason is because younger people appear to be more vulnerable to 
this type of injury than adults.
    Recent research indicates high school athletes with recent or 
repeated concussions have difficulty concentrating, lower attendance 
rates, and significantly lower cumulative grade point averages than 
high school athletes with no history of concussion. In other words, 
this affects not just student health, but also academics.
    As with many dangers to our children, prevention is the best 
medicine. That's why we'll hear today about education programs and 
resources designed to help prevent concussions in student athletes. 
We'll also hear about programs and guidance for coaches, 
administrators, parents, and medical personnel that address what to do 
when a concussion occurs or is suspected, including best practices for 
determining when athletes can most safely return to the field of play.
    I want to thank the witnesses for being here to discuss this topic 
and help bring attention to the steps student athletes and the adults 
who supervise them can take to prevent and respond to this type of 
injury. Thank you, and I yield back.
                                 ______
                                 
    Chairman Miller. Thank you.
    I would like now to introduce our panel of witnesses. 
Gerard Gioia is the director of neuropsycology at the 
Children's National Medical Center in Washington, D.C. Dr. 
Gioia oversees the pediatric neuropsycology program and Safe 
Concussion Outcome, Recovery & Education Program at Children's 
National Medical Center in Washington, D.C.
    Dr. Gioia is internationally recognized as an expert in 
youth concussions. His concussion management guidelines for 
youth athletes were recently adopted by International 
Conference of Concussions in Sports.
    Combining his expertise with his experience as a school 
psychologist at Howard County Public Schools, Dr. Gioia helped 
the Centers for Disease Control develop in-school concussion 
materials released this month.
    Dr. Gioia is expected to discuss the proper concussion 
management in high--in the high school setting.
    Michelle Pelton is a former high school athlete from Fall 
River, Massachusetts. Michelle Pelton suffers from cumulative 
effects of concussions she sustained during her adolescence, 
five of which occurred while participating in softball and 
basketball at her school.
    After sustaining three concussions in a row in her senior 
year, Michelle retired from sports and sought proper treatment. 
She managed to graduate from Diman Regional Vocational High 
School with the support of a 504 plan but she lost her 
opportunity to attend college with a scholarship and continues 
to struggle with work and academics.
    Michelle has helped improve concussion safety for other 
high school athletes and recently received a local community 
service award for her--for her efforts.
    Linda Kohn is the director of health care issues at the 
Government Accountability Office and is the lead investigator 
into concussions in high school sports. She will present 
findings on the incident rates of concussions among high school 
athletes and the characteristics and state laws and athletic 
association guidelines that are in place to protect student 
athletes from these injuries.
    Michael Monacelli serves as the athletic director and head 
varsity football coach at Caledonia-Mumford Central School. 
During the course of his career, Mr. Monacelli has led his team 
to five state championships many times, including this past 
season, and received many awards for his coaching from the 
state of New York.
    After coaching high school sports for over 30 years, Mr. 
Monacelli instituted comprehensive concussion management 
guidelines at his school, and his district has established 
similar standards.
    James C. Schmutz is the director of American Sports 
Education Program. Mr. Schmutz is the--joined Human Kinetics 
Publishing as executive director of the American Sports 
Education Program in March 2009.
    Previously he worked for the Special Olympics for 19 years, 
including roles in Virginia and the District of Columbia where 
he oversaw coach and volunteer recruitment and training.
    He has served as a volunteer youth sport coach for soccer, 
hockey, basketball, baseball. Jim utilizes his experience and 
knowledge to advance this mission and make sports safer and 
more enjoyable and more valuable to athletes by developing an 
educational program and resources for coaches, administrators 
and parents and officials.
    Welcome to all of you. Thank you for your time and your 
expertise, as I said earlier.
    And, Mr. Gioia, we are going to begin with you. When you 
start, a green light will go on in those little boxes in front 
of you. When you have a minute left, which will be about 4 
minutes into your testimony, an orange light will go on, and 
then a red light, when we would ask you to try and summarize 
and finish your testimony. And so welcome.

    STATEMENT OF GERARD GIOIA, CHIEF, DIVISION OF PEDIATRIC 
 NEUROPSYCHOLOGY, DIRECTOR, SAFE CONCUSSION OUTCOME, RECOVERY 
  AND EDUCATION (SCORE) PROGRAM, CHILDREN'S NATIONAL MEDICAL 
                             CENTER

    Mr. Gioia. Thank you, Chairman. Good morning to you and to 
the members of the committee, and thank you for the opportunity 
to speak today about this very important topic, the academic 
effects of sport-related concussion in our youth.
    Again, my name is Dr. Gerry Gioia. I serve as the chief of 
the division of pediatric neuropsychology at Children's 
National Medical Center and run a very active concussion 
program here in the district.
    I am also the national leader of the mild traumatic brain 
injury care system of the Sarah Jane Brain Foundation, which 
has written an extensive national plan for universal care for 
children with traumatic brain injuries, the PABI Plan, which I 
believe you have.
    As we know, much attention has been previously directed 
toward concussion in football and at the professional and 
collegiate levels.
    Well, what we are going to talk about today is moving away 
from that tip of the iceberg. We focus on a larger problem 
today which is concussion in the student athlete, in youth 
sports, and the effect of that brain injury on academic 
learning and performance.
    We know that learning in school is the child's job, and 
that job is impaired after a concussion. Concussions are a 
serious matter, and it is not simply a football matter. 
Concussions occur in all sports, and let's watch a quick video 
just to demonstrate that.
    That is hit number one. Here is our problem. He plays the 
next day. So this is the clip of two hits, two injuries, two 
concussions. The second injury was likely made much worse 
because the first was not recognized.
    Now, the athlete, when you talk with him, actually reported 
symptoms, but he didn't know what to do with them, and no one 
recognized them on the ice. So this is our first big problem, 
poor recognition of the injury. It highlights our need to 
improve that identification much more acutely.
    As a result of this injury, it took the student athlete a 
month to recover rather than a much shorter period of time had 
we identified it early.
    We also have in our presence today a guest, 14-year-old 
Sarah Rainey of Alexandria, Virginia, who is currently 
recovering from a concussion sustained in April playing soccer, 
where poor recognition of the injury contributed to her lengthy 
recovery.
    And let me tell you, I have provided written testimony, but 
if you only have limited time, read Sarah's testimony, not 
mine. I think it is much more effective.
    So what is a concussion? What happens to the student 
athlete's brain when hit? A concussion is a brain injury. It is 
a force to the head and brain that results in electrical and 
chemical changes, and it changes that brain's biological 
software. It produces a whole host of signs and symptoms, 
physical, cognitive, emotional, and disrupts sleep.
    And with our next slide here, we are going to take a look--
because what we see in this next slide is that the time to 
recovery from brain injury varies widely, from months--weeks to 
months and for some years and beyond. And this slide that is 
coming up shows the wide range of time to recover of a group of 
high school athletes.
    And the brain is impaired during this time. If the slide 
doesn't come up, that is fine. The point is that it took a long 
period of time for these kids to recover. And one of the 
aspects of that slide actually shows us is that those who have 
sustained more than one concussion took longer to recover.
    Now, how does this brain injury, then, affect the academic 
functioning? Well, if you take this combination of symptoms--
cognitive, emotional, physical--it clearly affects that 
individual's ability to learn and to remember. And it decreases 
their tolerance for performance.
    So the new learning is impaired. They cannot perform 
reading, math and writing effectively. They are slowed down. 
Their access to their knowledge and information at tests is 
also a problem.
    We also know that schoolwork places a significant demand on 
the brain's impaired software and that the symptoms worsen as 
they try to think and learn. So this is called cognitive 
exertion, and it worsens symptoms as you try to mentally 
concentrate. And we believe that this becomes a major problem. 
And if you overexert for too long, then it can delay recovery.
    This next slide that you see here is some recent research 
that we have done that shows that 80 to 90 percent of the 
students in this study in our clinic experienced these negative 
effects in the first month of injury and about half of them 
continued to have those problems well into a month and a half. 
So learning is impaired through this entire time.
    Well, how big is the academic impairment following 
concussion? Well, we don't know that at this point. What we 
know is that most of our student athletes, certainly as this 
sample shows, have impairment over a period of time lasting a 
month or longer.
    What we don't know is the extent of the long-term problems 
yet. That is something that we need to understand. And what we 
cannot predict is who that individual will be that will have 
the short-to medium-term problem and the long-term problem.
    So what we have got to do here is to work toward changing 
this. School systems must be active partners to assist in 
students' recovery. But currently schools are not prepared for 
this, so they are not aware when students come back into their 
presence, and we need to improve that medical to school 
communication linkage.
    We also need to train our school staff to understand and 
recognize concussion-related learning problems and what to do 
about them.
    The good news is we are beginning to develop these 
materials to address these problems. We have materials such as 
the ACE Care Plan, which is part of the CDC's physicians' 
toolkit that we use regularly to guide students' reentry, and 
the new CDC toolkit, ``Heads Up to Schools: Know Your 
Concussion ABCs,'' which is actually being released today, as 
we understand, on the CDC Web site, with excellent materials 
for school nurses, counselors, psychologists, teachers and 
parents.
    Also in Colorado and in Oregon they have been developing 
school concussion management programs.
    So our challenge is to implement as a nation supports for 
students with brain injuries universally and to study the most 
effective ways to help them and to reduce these problems, 
minimize the negative academic outcomes.
    So let me just sum up now by saying that youth 
participation in sports is essential. It is essential to their 
development. It is a positive thing. But concussions in youth 
and high school sports are significant with direct effects on 
their academic performance.
    Learning in school is the child's job and that job is 
impaired after the injury. We must better prevent, identify 
acutely and treat early, communicate between the medical school 
and athletic health systems, and effectively return students 
back to school appropriately.
    To do so, we need a universally accessible care system that 
really integrates all these key components together for student 
athletes with these injuries, but also for all students with 
acquired brain injuries.
    The PABI Plan is something that we have developed, a set of 
professionals across the country, to put this in place, and I 
believe you all have a copy of that. We really look forward to 
collaborative efforts between the groups--the Sarah Jane Brain 
Foundation, the CDC, NIH, Departments of Education, sports, and 
medical groups to develop this appropriate universal evidence-
based system of care.
    I would also like to acknowledge the 14 members of the 
committee who are co-sponsors of this current--concurrent 
resolution 198--Michael Castle, Yvette Clarke, Joe Courtney, 
Marcia Fudge, Raul Grijalva, Mazie Hirono, Rush Holt, Dale 
Kildee, Dave Loebsack, Donald Payne, Robert Scott, Carol Shea-
Porter, Dina Titus and David Wu--as we are really looking now 
to change the system.
    And I thank you for your attention, for your invitation, 
and I look forward to answer questions later. Thank you.
    [The statement of Mr. Gioia follows:]

   Prepared Statement of Gerard A. Gioia, Ph.D., Chief, Division of 
Pediatric Neuropsychology; Director, Safe Concussion Outcome, Recovery 
    & Education (SCORE) Program, Children's National Medical Center

About Children's National Medical Center
    Children's National Medical Center, a 283 bed not-for-profit 
academic medical center in Washington, DC, has provided hope to sick 
children and their families throughout the metropolitan region for 
nearly 140 years. The mission of Children's National is to improve 
health outcomes for children regionally, nationally and 
internationally; to be a leader in creating innovative solutions to 
pediatric healthcare problems; and to excel in care, advocacy, research 
and education to meet the unique needs of children, adolescents and 
their families. Children's National is ranked among the best pediatric 
hospitals in America by U.S. News & World Report and the Leapfrog 
Group. It is a Magnet recognized pediatric hospital, one of a handful 
of elite healthcare facilities nationwide.
Children's Safe Concussion Outcome, Recovery & Education Program
    Children's National has long been an advocate for child safety and 
injury prevention. Safe Kids Worldwide, the first national advocacy 
organization solely dedicated to pediatric injury prevention, was 
founded by Children's National in 1987. With respect to concussions, 
Children's Safe Concussion Outcome, Recovery & Education (SCORE) 
Program is the first and only program in the greater Baltimore-
Washington region that specializes in the clinical evaluation and 
treatment of concussions in children, as well as conducting research 
and delivering public health education and advocacy nationally and 
internationally. The SCORE program evaluates and treats children and 
adolescents with concussions (also known as a mild traumatic brain 
injury or mTBI). In 2009-2010, the SCORE program at Children's National 
treated more than 1,000 children in its concussion clinics.
Pediatric Acquired Brain Injury (PABI) Plan
    Pediatric Acquired Brain Injury (PABI), of which concussions are a 
large component, is a significant national issue for our youth. Because 
a brain injury is typically ``invisible,'' it remains unrecognized or 
under-recognized, thereby markedly increasing the burden of care in all 
aspects of society. The effects of a PABI are complex and require the 
integration of medical, educational, judicial and social service 
systems. A large number of brain injury professionals and family 
members have come together within the Sarah Jane Brain Foundation 
committed to develop a seamless, standardized, evidence-based system of 
care universally accessible for all children/young adults and their 
families regardless of where they live in the nation. This system of 
care is called the National Pediatric Acquired Brain Injury Plan (PABI 
Plan). The PABI Plan has been developed into seven overlapping 
``Categories of Care'' for treating brain injuries in children and 
young adults: 1) Prevention, 2) Acute Phase, 3) Mild TBI Assessment / 
Treatment, 4) Reintegration / Long-term care, 5) Adult Transition 
Phase, 6) Rural / Telehealth and 7) The Virtual Center. For each 
Category of Care, the PABI Plan establishes a nationwide standard for 
collecting translational data, a standard set of training, education 
and dissemination of information, and the ability to monitor and 
develop basic science research. I serve as the National Lead for the 
Mild TBI Category of Care and a member of the Steering Committee of the 
Sarah Jane Brain Foundation's PABI Plan.
Introduction
    Recent national media coverage has shined a bright light on sport 
related concussions and their effects on college and professional 
athletes, but less attention has been given to the effects of 
concussions on the developing brains of children and adolescents. As a 
sports medicine clinician, I am very much in favor of our nation's 40+ 
million children and adolescents participating in sports. I have three 
children who have been active student-athletes--and they have gained 
tremendous benefit in their physical, social, emotional, and cognitive 
maturity as a result of their participation in sports. But it is 
critical that we balance these significant benefits with careful 
attention to safety issues--especially when it involves the precious 
resource of the student-athlete's brain.
    The current state of affairs in addressing mild traumatic brain 
injury in our student-athletes is largely one of under-identification 
and arbitrary treatment. A concussion is an injury to the brain as a 
result of a traumatic force applied directly or indirectly to the head. 
Many prefer to use the more comforting term ``concussion''--but make no 
mistake--a concussion is an injury to the brain. Improving care systems 
for these brain injuries, and thus reducing risk to the lives of 
children and adolescents, is an attainable goal if we can direct proper 
attention, effort, and resources to the appropriate places and persons.
About Concussion/Traumatic Brain Injuries
    A concussion involves a strong, violent force applied to the brain 
that, in most people, changes the brain's electrochemistry (i.e., 
software); in some people it may alter the brain's structure (i.e., 
hardware). We know from the work with repeated concussions that if this 
injury goes unchecked, the brain's hardware can be permanently damaged 
with dire consequences for the individual's long-term cognitive, 
social, and emotional quality of life.
    The incidence of traumatic brain injuries (TBI) occurring to 
children annually is significant, but the full extent of the problem is 
as yet unknown. The existing epidemiologic methods are not yet 
developed to precisely identify the number of concussions. With current 
figures as likely underestimates, the Centers for Disease Control and 
Prevention (CDC) studied emergency department visits, hospitalizations 
and deaths between 2002-2006 and reported 1.7 million people sustain 
TBI annually, of which 52,000 died, 275,000 were hospitalized, and 
1.365 million were treated and released from the Emergency 
Department.\1\ These data do not include, however, concussions 
diagnosed in primary or specialty care office settings, or concussions 
that go unreported. Children aged 0 to 4 years and older adolescents 
aged 15-19 years, together with senior citizens over 75 years of age, 
are most likely to sustain a TBI.
---------------------------------------------------------------------------
    \1\ Blue Book, March 2010 www.cdc.gov/traumaticbraininjury
---------------------------------------------------------------------------
    Other data sources tell us that the majority of TBIs (80-90%) are 
of a ``mild'' nature. With respect to sports, recent data (Yard & 
Comstock, 2009) indicates an estimated 400,000 sport related 
concussions reported to athletic trainers at the high school level in 
five major male sports and four female sports. The true figures, 
though, are significantly higher as many other sports (e.g., ice 
hockey, field hockey, lacrosse, equestrian, rugby, cheerleading) were 
not included in these estimates, nor were non-scholastic high school or 
younger-age youth sports. In addition, a significantly higher rate of 
sport related concussion occurs than what is formally reported to the 
athletic trainer.
    The developing brain of children and adolescents is much more 
vulnerable to injury than that of adults. In fact, according to 
recently published consensus recommendations by the International 
Concussion in Sport Group (CISG)--an international panel of experts of 
which I am a member--differences in identifying and treating 
concussions in children and adolescents versus adults must be 
recognized. The CISG guidelines, published in the May 2009 issue of The 
British Journal of Sports Medicine, recommend that children and teens:
     be removed from play if any sign or symptom of concussion 
is exhibited,
     be strictly monitored; and
     be restricted from activities until they're fully healed. 
The important roles of parents and the school were also highlighted.
    When managing concussions in children and adolescents, the guidance 
strongly reiterates several key points for coaches, parents, and 
physicians:
     Injury to the developing brain, especially repeat 
concussions, may increase the risk of long term effects in children, so 
no return-to-play until completely symptom free.
     No child or adolescent athlete should ever return to play 
on the same day of an injury, regardless of level of athletic 
performance.
     Children and adolescents may need a longer period of full 
rest and then gradual return to normal activities than adults.
Academic Consequences of Sport Related Concussion
    There are significant threats to the child and adolescent as a 
result of an injury to the developing brain from concussion. Today we 
focus on the all-important consequences of a concussion on the academic 
learning and performance of the student-athlete. The effects of a 
concussion are quite significant and potentially wide ranging, with an 
adverse impact on the student-athlete's ability to think and learn 
(e.g., concentration, memory, speed of thinking--and therefore school 
performance), and his or her social and emotional functioning (e.g., 
irritability, depression). The student-athlete also typically 
experiences physical pain and/or significant fatigue. This is 
debilitating and disabling for a child's learning and social 
interactions. The length of time for a full recovery following a 
concussion--and of functional impairment--varies from days to months. 
For most, it takes at least several weeks. For others, the effects can 
be long-term. Second injuries result in a significantly longer period 
of recovery and in some instances may result in permanent disability 
and even death.
    The nature of the academic problems associated with sport related 
concussions is an understudied problem. Clinically, these problems can 
be viewed in two categories: short- or medium-term, and long-term. 
Clinically, we observe that the majority of concussed student athletes 
recover fully with no long-term academic problems. Nevertheless, almost 
all student-athletes experience significant short- to medium-term 
challenges in their academic performance during their period of 
recovery. Many experience direct neurocognitive dysfunction in their 
attention/concentration, memory, and speed of processing and 
performance. Others experience cognitive difficulties secondary to the 
effects of post-concussion fatigue or other somatic or emotional 
symptoms. As such, much of the time spent with concussed student-
athletes and their families in our clinics is associated with managing 
school learning issues.
    A smaller subgroup of student-athletes--the numbers of which we do 
not know--report persisting problems with attention and memory, or 
significant headaches and fatigue that adversely affect school learning 
for longer periods of time. The underlying reasons for these prolonged 
post-concussion learning difficulties are not fully understood, and 
need further study to identify the best treatment.
    Why does the academic learning and performance of the student-
athlete suffer after a concussion? The primary organ for learning is 
the brain. The brain is a very complex biological computer that 
requires properly working software and hardware systems. Concussions 
render the biological software systems dysfunctional, which produces 
functional deficits and symptoms, and consequently impair the learning 
process. Students with concussions experience difficulties focusing 
their attention, maintaining information process and learn actively in 
mind to, performing multi-step tasks, putting new information into 
their memories, and processing information and completing tasks at a 
normal speed. Without these neurocognitive abilities functioning 
properly, school learning and performance becomes significantly 
compromised. Academic problems can also have significant downstream 
effects, especially for the high school student-athlete. For example, 
concussions at the end of a semester can significantly reduce 
performance and grades on a final exam, reducing the student-athlete's 
grade point average. Taking the SAT prior to recovery from a concussion 
can also have a significant adverse impact on the student-athlete's 
future college options.
    To further compound the academic difficulties, a high percentage of 
student-athletes experience ``cognitive exertional effects'', which are 
defined as an increase or re-emergence of symptoms following a period 
of cognitive activity (e.g., concentrating on a lecture, reading a 
textbook, performing math calculations). The reality is that the school 
learning environment places significant physiological demands on the 
recovering brain of the student-athlete.
    In a recently completed study with concussed student-athletes seen 
in our clinics at Children's National Medical Center, over 80% reported 
a significant worsening of symptoms over the first four weeks as they 
attempted school learning activities. Half of this group was still 
experiencing the cognitive exertional effects 6 weeks post-injury. The 
typical concentration and memory requirements of school place 
significant demands on the brain's biological software. When these 
cognitive demands are placed on a brain in an impaired state, the 
result is an increase in post-concussion symptoms. Interestingly, 
symptom increase occurred less frequently with physical activity (37%) 
relative to cognitive/learning activities. We believe that if the brain 
continues to over-exert in this way during recovery, the length of time 
to recovery will be delayed. For example, attempting to do an academic 
task with a worsening headache further impairs school performance.
    In addition to these cognitive challenges, students' poorly 
controlled emotions, such as irritability and a heightened emotional 
response to stress, have a direct and adverse effect on school 
performance. As student-athletes experience ongoing challenges with 
school learning and performance, they can experience secondary 
emotional effects such as feelings of nervousness or sadness. Finally, 
the physical/somatic post-concussion symptoms of headache, fatigue, and 
sensitivity to light and noise can contribute to impairments in 
learning due to adverse effects on sustained schoolwork. Thus, academic 
challenges following a concussion can result from a variety of sources.
    The medical provider treating the concussed student needs to work 
closely with school personnel as a team to carefully manage the school 
learning activities. Thus, the majority of time spent in our clinics is 
related to planning academic treatment accommodations--both to assist 
effective learning and to facilitate appropriate recovery. With active 
management, our research demonstrates gradual reduction of cognitive 
exertional effects helping the student-athlete achieve an appropriate 
recovery.
    Our clinical work also highlights that fact that schools are not 
adequately prepared with the necessary knowledge and skills to properly 
support the return of the concussed student-athlete. Several excellent 
tools are now available to help schools transition the concussed 
student athlete back into the classroom. In 2005, Dr. Micky Collins and 
I developed the Acute Concussion Evaluation (ACE) Care Plan, to provide 
the family, student-athlete, and school team with a written plan of 
specific academic accommodations each stage of recovery. This ACE Care 
Plan is updated regularly at each clinic appointment with new 
recommendations based on the recovery progress of the student-athlete. 
The ACE Care Plan is available to download within the Centers for 
Disease Control and Prevention's (CDC) ``Heads Up: Brain Injury in Your 
Practice'' physician's toolkit (www.cdc.gov/concussion).
    While this Care Plan is useful in assisting the individual student-
athlete, often school personnel are not prepared with the necessary 
knowledge and skill to easily implement the student's recommended 
accommodations. Increasing the knowledge and skill of school personnel 
is the focus of the CDC's May 2010 release of a school concussion 
toolkit called ``Heads Up to Schools: Know Your Concussion ABCs.'' This 
toolkit provides key information for school nurses, counselors, school 
psychologists, teachers, parents, and student-athletes to assist 
students with concussions in their return to school.
    To fully address the problem of concussion/mild TBI and reduce risk 
for long-term academic and social problems, clinical, research and 
public health program development at Children's National and the PABI 
Plan focus in three areas:
    1. Prevention of the injury;
    2. Early, acute identification of the injury and protection of the 
youth athlete from further injury; and
    3. Active, early treatment to promote the fastest recovery possible 
and reduce the period of impaired function, including an active plan to 
implement effective training of school personnel with the CDC's ``Heads 
Up to Schools: Know Your Concussion ABCs'' toolkit.
Conclusion
    Sport related concussion to the student-athlete is an injury to the 
developing brain that presents a unique set of risks and challenges for 
their future. Specifically, learning in school is the job of the child 
and adolescent, and is particularly challenged by this injury given: 
(1) the direct effects of the concussion on neurocognitive functioning, 
and (2) the adverse effects of the cognitive/learning demands on the 
brain's dysfunctional biological software. A portion of students have 
persisting problems with school learning and performance long after the 
acute effects of the concussion. We do not yet understand the reasons 
for these poor long-term outcomes, and must study them further. A high 
percentage of student-athletes with concussion/mild TBI experience 
short- and medium-term problems with school learning and performance. 
These academic problems, even if temporary, can have potential negative 
consequences for the student down the road. And, if unidentified and 
untreated, these problems can have significant long-term consequences 
for the student. To address this problem, it is essential that we 
implement a national system of care for student-athletes with 
concussion/mild TBI--as outlined in the national PABI Plan and 
supported by public health efforts at the CDC. This system must include 
directed efforts at prevention, education of key stakeholders, early 
acute identification and treatment, and effective reintegration of the 
student-athlete into the school system.
                                 ______
                                 
    Chairman Miller. Thank you very much.
    Michelle, welcome to the committee. We look forward to your 
testimony. Thank you for being here.

    STATEMENT OF MICHELLE PELTON, FORMER HIGH SCHOOL ATHLETE

    Ms. Pelton. Thank you. Good morning. First, I would like to 
thank you for inviting me here today. This is a great honor to 
be here to talk about the effects of a concussion.
    When I was told about this opportunity, I quickly agreed 
because I want to make a difference and help athletes be aware 
of what could happen.
    Everyone thinks that something like this would never happen 
to them. I thought the same thing. But I am a perfect example. 
I am here today to share with you my traumatic story on how 
much concussions have affected me and my life.
    I played my first basketball game when I was just 7 years 
old and instantly fell in love with the sport. I was even named 
``rookie of the year.'' That following spring, I had the 
opportunity to fall in love with softball as well. My life 
revolved around sports.
    In junior high school my basketball coach loved how 
aggressive I was. But maybe I was too aggressive. A girl from 
the other team and I collided while fighting for the ball. We 
both fell to the ground. All I thought was, ``Ouch, my head,'' 
and just got up and continued to play.
    Even though we both fell to the ground holding our heads, 
coaches, refs nor parents had thought anything of it. That was 
the start of my series of seven concussions over the next 4 
years.
    The day following my collision, I stood home from school 
due to an unbearable headache. I then passed out and my mother 
called 911. At the emergency room, they in fact did diagnose me 
with a concussion and said I could return to play in 2 weeks or 
when my symptoms were gone.
    As would any athlete, I convinced my parents that after 2 
weeks I was symptom-free. That was a big lie. I was still 
having headaches, but I thought I was fine to go back to play. 
After all, it was just a headache.
    And as fate would have it, the first game I return to, I 
collide with a girl again, this time leaving me hospitalized 
with a second concussion. At the hospital I did not know where 
I was, what happened or even what school I attended. I had no 
idea how my life would change because of this concussion.
    In the days, weeks and months to come my daily life 
changed. Daily headaches, dizziness, memory loss, lack of 
concentration, depression are just a few of the symptoms that 
are part of my everyday life. School would never be the same, 
and no more sports.
    I had the worst case of post concussion syndrome that my 
pediatrician had ever seen. This would lead to a series of 
specialists that I would see over the next several years.
    I went to the Head Trauma Clinic at Boston Children's 
Hospital several times for evaluations and recommendations. I 
also saw a chiropractor, went for weekly acupuncture, had a 
speech therapist, massage therapy and a therapist, all to help 
me learn to live with what had happened.
    Two weeks is definitely not enough time to let your brain 
rest and recover. I learned this at my first visit with Dr. 
Neil McGrath from the Sports Concussion New England Clinic. 
During the visit I took the ImPACT test, and my scores showed 
that I was nowhere near ready to go back to play.
    At first I resented Dr. McGrath, because he was taking away 
something that I loved. However, I know now the risks involved 
with not taking care of your brain. The ImPACT test can show 
something that no x-ray, C.T. scan or MRI can.
    During my high school years, I excelled in basketball and 
even more so in softball. I had college coaches looking at me 
in softball when I was only a sophomore. I couldn't wait for my 
senior year. However, it was nothing like how I had imagined 
it.
    I received five concussions during my high school years 
that left me without half of my senior year, including 
softball. For the last 5 months of my senior year, I was home 
tutored. Each morning was a struggle to get up and face the 
day. The girl that fell in love with basketball when she was 
only seven dreaded going to practice every day.
    I had headaches, lack of concentration, mood swings, 
depression and I just did not care about anything. I lost the 
pride and the joy of finally being a senior and captain on my 
softball team. If I had played, I would have been named female 
athlete of the year.
    While all my classmates were involved in senior activities, 
I was home depressed and in constant pain, and life had become 
a blur. I wasn't involved in any senior activities or the fun 
of just being a senior. I lost potential 4-year scholarships to 
play the sport I love. My dreams were crushed.
    I cannot even begin to explain the daily struggle my life 
has become and everything I have lost because of my 
concussions. No one can see my injury, but it is there. I know 
I have learned to overcome and compensate for my injuries 
because I am so determined to keep as many of my dreams in my 
life as possible, but not without a tremendous price.
    Every day I endure memory loss, lack of concentration, 
depression, slow processing speed and cognitive effects that 
makes my everyday life a battle. Yes, I have overcome many 
obstacles and accomplished a lot considering my injuries, but 
no one but me truly understands what it is like to live every 
day like this.
    If I can prevent even one person from experiencing what has 
happened to me then my trip here was a huge success.
    Concussions have been called the invisible injury. From my 
brief story I hope this committee realizes the long-term 
effects in--of concussions are not invisible.
    Thank you for your time today and for careful consideration 
on this very important public health issue. It can and will 
impact a lot of athletes. Thank you.
    [The statement of Ms. Pelton follows:]

   Prepared Statement of Michelle Pelton, Former High School Athlete

    Good Morning! First I would like to thank you for inviting me here 
today. This is great honor to be here to talk about the affects of a 
concussion. When I was told about this opportunity, I quickly agreed 
because I want to make a difference and help athletes be aware of what 
could happen. Everyone thinks that something like this would never 
happen to them, I thought the same thing, but I am a perfect example.
    I am here today to share with you my traumatic story on how much 
concussions have affected me and my life. I played my first basketball 
game when I was just seven years old and instantly fell in love with 
the sport. (I was even named ``rookie of the year''.)That following 
spring, I had the opportunity to fall in love with softball as well. My 
life revolved around sports.
    In junior high school my basketball coach loved how aggressive I 
was. But maybe I was too aggressive. A girl from the other team and I 
collided while fighting for the ball. We both fell to the ground. All I 
thought was ``ouch my head'' and just got up and continued to play. 
Even though we both fell to the ground holding our heads, coaches, refs 
nor parents had thought anything of it. That was the start of my series 
of seven concussions over the next four years.
    The day following my collision, I stood home from school due to an 
unbearable headache. I then passed out and my mother called 911. At the 
emergency room, they in fact did diagnose me with a concussion and said 
I could return to play basketball in 2 weeks or when my symptoms were 
gone. As would any athlete, I convinced my parents that after the 2 
weeks, I was symptom free. That was a big lie, I was still having 
headaches but I thought I was fine to go back a play, it was just a 
headache. And as fate would have it, the first game I return to, I 
collide with a girl again, this time leaving me hospitalized with a 
second concussion. At the hospital I did not know where I was, what 
happened or even what school I attended. I had no idea how my life 
would change because of this concussion.
    In the days, weeks and months to come my daily life changed. Daily 
headaches, dizziness, memory loss, lack of concentration, depression 
are just a few of the symptoms that were part of my everyday life. 
School would never be the same and NO MORE SPORTS. I had the worst case 
of Post Concussion Syndrome that my pediatrician had ever seen. This 
would lead to a series of specialist that I would see over the next 
several years. I went to the Head Trauma Clinic at Boston Children's 
Hospital several times for evaluations and recommendations, I also saw 
a Chiropractor, went for weekly acupuncture, had a speech therapist, 
massage therapy and a therapist, all to help me learn to live with what 
had happened.
    Two weeks is definitely not enough time to let your brain rest and 
recover. I learned this at my first visit with Dr. Neil McGrath from 
the Sports Concussion New England clinic. During the visit, I took the 
ImPACT test, and my scores showed that I was nowhere near ready to go 
back to play. At first I resented Dr. McGrath, because he was taking 
away something that I loved. However, I now know the risks involved 
with not taking care of your brain. The ImPACT test can show something 
that no x-ray, CT scan or MRI can.
    After several months my symptoms finally got better and I was 
cleared by Dr. McGrath to go back to play sports. You see, my love for 
sports far outweighed the potential risk of playing again. To me life 
without basketball and softball just wasn't life.
    During my high school years, I excelled in basketball and even more 
so in softball. I had college coaches looking at me in softball when I 
was only a sophomore. I couldn't wait for my senior year; however it 
was nothing like how I had imagined it. I received 5 concussions (2 
playing softball, one from basketball, one from being punched by a 
client at my co-operative employment job and the final concussion 
sustained in December of 2008,a car accident) during my high school 
years that left me without half of my senior year, including softball. 
For the last 5 months of my senior year, I was home tutored. Each 
morning was a struggle to get up and face the day. The girl that fell 
in love with basketball when she was seven dreaded going to practice 
every day. I had headaches, lack of concentration, mood swings, 
depression and I just did not care about anything. I lost the pride and 
the joy of finally being a senior and a captain on my softball team. If 
I had played, I would have been named female athlete of the year. While 
all my classmates were involved in senior activities I was home 
depressed and in constant pain, and life had become a blur. I wasn't 
involved in any senior activities or the fun of just being a senior. I 
lost potential 4 year scholarships to play the sport I love. My dreams 
were crushed.
    I cannot even begin to explain the daily struggle my life has 
become and everything I have lost because of my concussions. No one can 
see my injury but it's there. I know I have learned to overcome and 
compensated for my injuries because I am so determined to keep as many 
of my dreams in my life as possible, but not without a tremendous 
price. Every day I endure memory loss, lack of concentration, 
depression, slow processing speed and cognitive effects that makes my 
everyday life a battle. Yes, I have overcome many obstacles and 
accomplished a lot considering my injuries but no one but me truly 
understands what it is like to live everyday like this. If I can 
prevent even one person from experiencing what has happen to me then my 
trip here was a huge success.
    I recently watched an ESPN special on a young man named Preston 
Plevretes who suffered only two concussions; however his second one 
changed his life forever. This shows that every concussion can be life 
threatening, even if you've had 1, 2, or 7. His second concussion 
caused him to lose consciousness; he woke for a few minutes, and then 
lapsed into a coma. He had a massive blood clot, and needed lifesaving 
surgery. His first concussion was not treated properly. I will quote 
from the young man: he stated ``I could have sat on the sidelines for a 
season, but now I will sit on the sidelines for the rest of my life''. 
Preston is now in a wheelchair, has a home health aide, and receives 
intense physical and speech therapy. Preston is only 23 years old.
    Concussions have been called the invisible injury; from my brief 
story I hope this Committee realizes the long term effects of 
concussions are not invisible. Over the last few years I have learned 
six important factors that cause concern for high school athletes
    1. From my PSY 51 college course I learned the human brain does not 
fully develop until around the age of 24.
    2. Research by the University of Pittsburgh Medical School found 
that high school athletes do not recover from concussions as quickly 
and report more symptoms than college athletes.
    3. The National Athletic Trainers Association reports that over 50% 
of US high schools do not have access to an athletic trainer.
    4. According to the Center Disease Control the main reason a high 
school athlete does not report a concussion is not the fear of losing 
playing time, but the lack of knowledge of what a concussion is and the 
potential long term effects if not reported and treated correctly.
    5. Recent studies show that more than 62,000 concussions occur each 
year in high school sports, with football for accounting for about 60% 
of them. However, this is not solely a male/football issue in high 
school. The concussion rate in high school soccer is 68 % higher for 
girls than it is for boys. In high school basketball, female concussion 
rates nearly triple the boys' rate according to a study completed at 
Ohio State. Other studies show similar % differences between girls' 
softball and boys' baseball.
    6. High school athletes are 3 times more likely to experience a 
second concussion if concussed once during a season.
    Every concussion is unique and there is no one formula that can 
handle an injury so complex. Main care for all concussions will include 
rest periods, since the only way to start the recovery period is 
usually complete rest, both physical and mental. However this Committee 
should encourage a standard Athletic Concussion School Policy that 
would be used as a guide by all schools in the US. Such an initiative 
could follow the steps that were used to ensure all public schools 
created a Wellness Plan if they wanted to participate in the National 
School Lunch Program. Such a national athletic concussion policy could 
include:
    1. Concussion education for players, parents, coaches and school 
staff.
    2. Pre-season baseline computerized testing to establish levels of 
memory, reaction time and processing speed. (ImPACT testing is the best 
researched and most commonly used tool to accomplish this task)
    3. Use of a standard sideline test that screens for common 
concussion symptoms (SAC--the Sideline Assessment of Concussion is a 
reliable tool to accomplish this initial assessment)
    4. Once a concussion has been identified, the athlete should visit 
the emergency room to be sure the injury has not caused any head trauma 
issues beyond a concussion. A follow up visit with their primary care 
physician would be encouraged.
    5. Recovery period will include follow up ImPACT testing, on=going 
medical visits, reduced academic classroom demands reflected in an IEP 
or 504 Plan and gradual return to some form of physical activity.
    6. The return to play should be decided by a team that includes 
parents, coach, trainer, teachers, school nurse, guidance counselor and 
athlete. These decisions should be based on all the clinical 
information available, concussion history, length of time since the 
concussion, performance in the classroom and lack of symptoms during 
rest and light exercise.
    Beyond this school policy this Committee could encourage the use of 
Public Service Announcements during national sporting events that 
address the dangers of untreated athletic concussions and promote the 
distribution of the Center for Disease Control athletic concussion 
products called ``Heads Up'' to all national organizations that work 
with schools and athletic associations.
    Thank you for your time today and for careful consideration on this 
very important public health issue. It can and will impact a lot of 
athletes.
                                 ______
                                 
    Chairman Miller. Thank you, Michelle, for your testimony. 
And I want to thank your mother and your stepfather for also 
being here at this hearing.
    Thank you.
    And I would like to recognize Sarah Rainey.
    Sarah, would you just raise your hand so the members of the 
committee can see where you are?
    Her testimony is in our packets, and as Dr. Gioia made the 
point, it is certainly worth the members reading.
    I would like to also, with the--move that without objection 
the committee is joined today by Congressman Pascrell from New 
Jersey who has been a leader in the efforts to treat and 
prevent concussions in school-aged children.
    He founded the Congressional Brain Injury Task Force in 
2001 and has introduced H.R. 1347, the Concussion Treatment and 
Care Tools Contact--Act, providing for, among other things, the 
establishment and implementation of concussion management 
guidelines for school-aged children.
    Mr. Pascrell, we are pleased to have you here. You don't 
have to sit there. You can come and join one side or the other 
in the--yes, you are always on the outside there. [Laughter.]
    So I just say that for the witnesses, because he will be 
joining us in the questions later on.
    But thank you for joining us.
    And I don't know if Congresswoman Bono-Mack will be joining 
us, but I extend the same request for her to sit with the 
committee and participate in the questioning.
    And, Dr. Kohn, we will come to you now. Thank you.

   STATEMENT OF LINDA KOHN, DIRECTOR OF HEALTH CARE ISSUES, 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Kohn. Thank you, Chairman Miller, Ranking Member Kline 
and members of the committee. Thank you for inviting me here 
today to talk about concussions in high school sports.
    Because it can be a very serious injury, you asked us what 
is known about the occurrence of concussion among high school 
athletes while playing or practicing competitive sports and 
about activities addressing the issue.
    In terms of the first question, the frequency of 
occurrence, we found that the available information cannot 
provide an overall national estimate how--of how often 
concussion occurs and that, moreover, the figures that are 
available likely underestimate the magnitude.
    We identified three sources of information that each 
capture one piece of the story. For example, a database at the 
Nationwide Children's Hospital in Columbus, Ohio monitors the 
occurrence of injuries, including concussion, at a sample of 
100 high schools. But it only obtains--the figures they have 
published from that database only cover nine sports, not all 
sports.
    Another database we identified is sponsored by the Consumer 
Product Safety Commission, and that captures information from 
people who are present with injuries at emergency rooms, but 
not everybody with a suspected concussion goes to an emergency 
room.
    It is not that the numbers are wrong. It is just that it is 
not the full picture. And although it is useful to know how 
often concussion occurs among high school athletes, the goal 
isn't to get a perfect number. After all, if you are a parent 
and it is your child, there is really only one number that 
counts.
    The other part of the issue is what to do when it happens, 
and we found activities targeted to this issue at both national 
and state levels.
    At the federal level, the Centers for Disease Control and 
Prevention in the Department of Health and Human Services 
sponsors the primary educational initiative that is 
specifically directed at preventing concussion in high school 
sports, and you heard it referenced before. It is called 
``Heads Up: Concussion in High School Sports.''
    It provides educational materials for coaches, athletic 
trainers and directors, parents, and athletes. The program was 
initially rolled out in 2005 and the agency continues to update 
the materials.
    At the state level, three states were identified to us as 
being key in terms of having passed legislation specific to 
concussion management in school sports, Oregon, Texas and 
Washington. All three state laws contain provisions regarding 
concussion education and also provisions regarding how quickly 
athletes can return to play after a suspected concussion, 
although the laws do vary.
    For example, in terms of concussion education, Oregon 
targets the coaches; Washington targets the coaches, athletes 
and parents; and Texas targets coaches, trainers, physicians 
who work with the teams, athletes and directors of the marching 
band.
    All three states require that an athlete returning to play 
be cleared in writing by some type of health professional.
    We also identified five sets of voluntary guidelines that 
covered--nationwide guidelines that addressed the management of 
concussion in sports. All five guidelines are similar in that 
they recommend an athlete with a suspected concussion be 
monitored on the sidelines and return to play gradually.
    Only one of the guidelines, that from the National 
Federation of State High School Associations, specifically 
targets high school sports, and that guideline recommends 
gradual increase in both physical and mental activity. So for 
example, the student may be--the athlete may be on an 
abbreviated school day, progress to a full school day, and then 
increasingly engage in physical activity.
    When we looked at these various activities across CDC, the 
state laws, the guidelines, I personally was struck by how many 
people have the potential to observe the effects of a 
concussion in a high school athlete, as the graphic 
illustrates.
    Certainly, the coaches and trainers are there, but so are 
the teammates, the parents, the teachers who may notice 
something a day after an injury, the school nurse, the family 
physician, the emergency room physician who may examine the 
athlete. There are lots of people around these kids, and 
everybody has an opportunity to contribute to making 
competitive sports as safe as they can be.
    I will be happy to answer any questions you may have. Thank 
you very much.
    [The statement of Ms. Kohn may be accessed at the following 
Internet address:]

                http://www.gao.gov/new.items/d10569t.pdf

                                ------                                

    Mr. Tierney [presiding]. Thank you, Doctor.
    Coach Monacelli?

  STATEMENT OF MICHAEL MONACELLI, ATHLETIC DIRECTOR AND HEAD 
 VARSITY FOOTBALL COACH, CALEDONIA-MUMFORD CENTRAL HIGH SCHOOL

    Mr. Monacelli. Good morning, Mr. Chairman and other 
distinguished members of the House Education and Labor 
Committee. Thank you for inviting me to speak on concussion 
management and how it is integrated into our district 
procedure.
    In 2006 at an athletic director's conference, I sat in on a 
workshop that briefed us on concussion management program 
ImPACT. Being in the coaching business for close to 40 years 
and a witness to these types of injuries, this program and 
those like it had my attention.
    After taking this information back to our district 
superintendent, it was an easy sale. Any program or policy that 
would reduce injury risk to our student-athletes is a priority 
for us.
    We were able, within our school schedule, to not only test 
our student-athletes but all our middle school and high school 
students. Each student is tested every other year. Our 
district, Caledonia-Mumford Central School, felt that an injury 
that can affect cognitive functions can happen to any of our 
students, at home, to and from school, gym class, car 
accidents, etc.
    Coverage for our total middle school and high school 
student population, and not just athletes, is important. We 
tested grades six, eight and 10 this spring.
    For me personally as a coach, it has taken the guesswork 
out of determining when a player is ready to return to action 
after a concussion. In the past, the return to play was based 
more on ``feel'' than facts: ``How many fingers am I holding up 
here?'' ``What is your girlfriend's name?''
    Basically you waited until the athlete was symptom-free--no 
headaches--if they were really honest with telling you that and 
their primary care physician this. We would keep them out for a 
day and then let them return to practice.
    As a coach under the present system, I am much more 
comfortable relying on the post-testing and the re-entry 
protocol to aid in determining when an athlete is ready to 
compete or not. No real amount of thought was put into how 
severe the concussion was in the past, just when they could 
play.
    ``Second-impact syndrome'' was not in our thoughts at all. 
Now we know that a second blow to the head while recovering 
from the first concussion is dangerous. It takes a lot less 
force to re-injure that brain.
    This testing is very important because it reveals the 
second-impact syndrome, which is catastrophic and even fatal. 
The testing establishes when it is safe for the return--the 
athlete to return to play. But there is no real standard 
recovery time.
    Our district initiated this testing in 2006. There was a 
question by parents of our student-athletes as to why we were 
doing this and if it would be restricting their playing time. 
No parent or athlete wants to hear that any significant amount 
of playing time will be missed.
    But as our community became more aware of the safety 
rationale, they have become advocates for the testing, knowing 
their child's concussion will be managed properly.
    Another aspect of our testing has been to educate our 
classroom teachers. The student-athlete that is concussed can 
have serious cognitive difficulties that will impact their 
classroom learning. Oftentimes there has not been communication 
between athletics and academics regarding how an athletic 
injury can affect classroom achievement.
    The student that is now quiet, listless, having headaches, 
dizzy, not responsive can have a legitimate medical reason due 
to being concussed, and academic aid can be used to address 
this.
    To personalize concussion management even more, this past 
season my starting tailback became concussed. The district, 
parents, medical staff followed the protocol outlined in 
ImPACT. All felt that he was ready--was well on his way to 
recovery to play again this season.
    That was until he reached Phase 4 of the re-entry protocol, 
that being non-contact skill drills that are sports specific, 
where he was having headaches. Again, following protocol, he 
had to retrace his recovery steps. He did not return this 
season as an active player.
    He did, though, fully recover, start on our basketball 
team, competitively lift during our football off-season and is 
now enjoying a good track season. He will be ready for this 
fall's football season, his true passion.
    As his coach, I did not want to lose my number one back, 
but most assuredly I did want him to be healthy and safe. That 
was the real number one in my life and in his life.
    We are in a comfort zone with concussion management in our 
district. We have full confidence in the system. Most 
assuredly, as coaches, we do not want to see these injuries. 
But we know now that a concussed student can be properly 
diagnosed and managed. The student-athlete will get better and 
will play again.
    Thank you for the opportunity to testify today, Mr. 
Chairman, and I will be happy to answer any questions.
    [The statement of Mr. Monacelli follows:]

  Prepared Statement of Michael T. Monacelli, Director of Athletics, 
       Football Coach, Caledonia-Mumford Central School District

    Good morning Mr. Chairman, and other distinguished members of the 
House Education and Labor Committee. Thank you for inviting me to speak 
on concussion management and how it is integrated into our district 
procedure.
    In 2006 at an athletic director's conference, I sat in on a 
workshop that briefed us on the concussion management program--ImPACT. 
Being in the coaching business for close to 40 years and a witness to 
those injuries, this program and those like it had my attention. After 
taking this information back to our district superintendent, it was an 
easy sale. Any program/policy that will reduce injury risks to our 
student-athletes is a priority.
    We were able within our school schedule to not only test our 
student-athletes but all our middle school and high school students. 
Each student is teacher every other year. Our district, Caledonia-
Mumford Central School, felt that an injury, that can affect cognitive 
functions, can happen to any of our students--at home, to and from 
school, gym class, car accidents, etc. Coverage for our total middle 
school and high school student population, not just athletes, is 
important. We tested grades 6, 8 and 10 this spring.
    For me personally as a coach, it has taken the guesswork out of 
determining when a player is ready to return to action after a 
concussion. In the past, the return to play was based more on ``feel 
than facts''--``how many fingers am I hold up here''--``what's your 
girl friends name'', etc. Basically you waited until the athlete was 
symptom free--no headaches (if they were really honest with telling you 
and their primary care physician this). We would keep them out another 
day after before letting the student return to practice. As a coach 
under the present system, I am much more comfortable relying upon the 
post-testing and re-entry protocol to aid in determining whether the 
athlete is ready to compete or not.
    No real amount of thought was put into how severe the concussion 
was in the past--just when they can play. ``Second-impact syndrome'' 
was not in our thoughts at all. Now we know that a second blow to the 
head while recovering from the first concussion is dangerous. It takes 
a lot less force to reinjure the brain. This testing is very important 
because it reveals second-impact syndrome: which is catastrophic, even 
fatal. The testing establishes when it is safe for the athlete to 
return to play. There is no standard recovery time.
    When our district initiated this testing in 2006 there was a 
question by parents of our student-athletes as to why we were doing 
this and would it be restricting their playing time. No parent or 
athlete wants to hear that any significant amount of playing time will 
be missed. But as our community became more aware of the safety 
rationale they have become advocates for the testing, knowing that 
their child's concussion will be managed properly.
    Another aspect of our testing has been to educate our classroom 
teachers. The student-athlete that is concussed can have serious 
cognitive difficulties that will impact their classroom learning. 
Oftentimes there had not been communication between athletics and 
academics regarding how an athletic injury can affect classroom 
achievement. The student that is now quiet, listless, having headaches, 
dizzy and not very responsive can have a legitimate medical reason due 
to being concussed and academic aid can be used to address this.
    To personalize concussion management even more, this past season my 
starting tailback became concussed. The district, parents and medical 
staff followed the protocol outline in ImPACT. All felt that he was 
well on his way to recovery to play again this season. That was until 
he reached Phase 4 of the re-entry protocol--that being non-contact 
skill drills sports specific--where he was having headaches. Again, 
following protocol, he had to retrace his recovery steps. He did not 
return this season as an active player. He did, though, fully recover 
and start on our basketball team, competitively lift during our 
football off-season and is now enjoying a good track season. He will 
now be ready for this fall's football season, his true passion. As his 
coach, I did not want to lose my #1 back but most assuredly I did want 
him to be healthy and safe. That was the real #1 in my life and his.
    We are in a comfort zone with concussion management in our 
district. We have full confidence in the system. Most assuredly as 
coaches, we do not want to see these injuries. But we know that now the 
concussed student can be properly diagnosed and managed. The student-
athlete will get better and will play again.
    Thank you again for this opportunity to testify today. Mr. 
Chairman, I would be happy to answer any question you or the other 
committee members may have.
                                 ______
                                 
    Mr. Tierney. Thank you, sir.
    Mr. Schmutz?

  STATEMENT OF JAMES C. SCHMUTZ, EXECUTIVE DIRECTOR, AMERICAN 
                    SPORT EDUCATION PROGRAM

    Mr. Schmutz. Mr. Chairman and Representative Kline, members 
of the committee, good morning. Thank you for your leadership 
on this important issue on the impact of concussions on high 
school athletes.
    Athletes first, winning second. That is the foundation of 
our approach at American Sport Education Program. My name is 
Jim Schmutz, and I am the executive director of ASEP.
    We have been providing coach education to youth and 
scholastic sport coaches since 1981, and we have touched 1 
million coaches in that time with our--with our courses.
    Since 1990 we have joined forces with the National 
Federation of High Schools to develop an instructional program 
that is responsible for educating over 600,000 scholastic 
coaches in principles of coaching and sport first aid.
    Our primary coaching text is Successful Coaching. It is 
also a best seller, recognized in the educational community and 
by coaches in the trenches.
    Clearly, the incidence and prevalence of sport-related 
concussions is a matter that we at ASEP feel compelled to 
address. In a 2009 study by Yard and Comstock using nine 
sports, they revealed that there were 395,000 concussions 
sustained by high school athletes nationally. This goes back to 
Dr. Kohn's issue about the data that is out there and the 
penetration of it.
    It is important to note that, again, this is not just a 
football issue. But one of the most alarming findings in the 
research was that 15.8 percent of football injuries returned 
more quickly, 1 day after the injury, and these were Grade III 
concussions, the most severe level of concussions.
    The authors of this study concluded that too many 
adolescent athletes are not adhering to those recommended 
return-to-play guidelines, and that coaches, sport medicine 
professionals, parents and sports administrators must work 
together more effectively to ensure that athletes do follow 
those guidelines.
    The problem is that those who are most often closest to the 
athletes when concussions occur are of significant influence in 
determining their condition. And a key figure in their return 
to action, the coaches, are seldom prepared to handle the 
responsibility.
    Coach Monacelli is a great example of what we need to 
accomplish. His level of preparedness provides a safe 
environment for his athletes.
    Even less frequently is a clearly defined and understood 
program in a place within schools' athletic departments to deal 
with concussion injuries. Again, I think Coach Monacelli is 
unique and a model for us to all look at.
    At the national level, ASEP works with organizations like 
the National Federation of High Schools, American Football 
Coaches Association, the National Interscholastic Athletic 
Administrators Association, and ImPACT, which is an 
organization that provides assessment tools and services used 
by medical professionals, all working with the CDC to 
perpetuate change at the grassroots level. And you heard from 
Dr. Kohn about the efforts on the part of the CDC.
    At the state level, state high school associations and 
athletic directors associations are doing similar work. The 
Pennsylvania State Athletic Directors Association under the 
leadership of Executive Director Bob Buckanavage has forged an 
alliance and it can serve as a model for other states across 
the country.
    By including a full range of state leaders, including 
school board associations, elementary and high school, 
secondary school, principals and the Department of Education, 
Bob has engaged all key stakeholders at the high school level 
across the state.
    This includes attention to concussion as part of a broader 
agenda to ensure a safe and healthy environment and a 
meaningful high school sports experience. The best evidence of 
success related to concussion is the fact that they have more 
high schools than any other state engaged in using concussion 
assessment tools through their relationship with Pittsburgh-
based ImPACT.
    No evidence would suggest that coaches in general are 
derelict in their duty to provide a safe environment for 
athletes. What is clear is in the case--that often less 
apparent--cumulative injuries like concussion, the uninformed, 
the untrained coach is overmatched by the role that he or she 
is expected to play in identifying and treating it.
    As Dr. Kohn pointed out, the good news is more resources 
exist to prevent and manage concussions today than ever before. 
At every turn the CDC is connected with the organizations that 
I cited in partnering to address this very serious health 
issue.
    The ``Heads Up: Concussion in High School Sports'' that Dr. 
Kohn referred to is an initiative under the leadership of Kelly 
Sarmiento, who is in daily contact with organizations across 
the country in trying to help and support the proliferation of 
this material.
    It is also obviously encouraging that those materials be 
continued--be continued to be updated.
    ASEP believes that a systematic education is critical to 
working hard to address the need to enhance and expand 
concussion education by revising our sport first aid course to 
include more comprehensive current information on concussion 
management with the intention of providing access to a full 
range of CDC resources.
    By incorporating more concussion management education into 
a sport first aid course, coaches in states like California, 
where they are required to be first-aid certified, will benefit 
without added expense.
    We have a serious problem in this country and need to do 
better. While it is clear that there is no shortage of 
resources, we also know that we have a great deal of work ahead 
of us. We need to perpetuate a culture of athlete and safety 
first.
    We need to take advantage of the CDC and other resources in 
the process of formally educating coaches so that they can 
implement preventive measures to reduce the incidence of 
concussions and be better equipped to recognize and manage 
concussions when they do occur.
    Thank you for giving me the opportunity to appear here 
today.
    [The statement of Mr. Schmutz follows:]

Prepared Statement of James Schmutz, Executive Director, American Sport 
            Education Program (A Division of Human Kinetics)

    Chairman Miller and Representative Kline, members of the committee, 
good morning. Thank you for your leadership on this important issue of 
The Impact of Concussions on High School Athlete.
    ``Athletes First, Winning Second.'' That phrase is the foundation 
of the American Sport Education Program. My name is Jim Schmutz and I 
am the Executive Director of ASEP, a division of Human Kinetics. ASEP 
has been the leading provider of coach education for youth sport and 
scholastic coaches since 1981. Since that time, more than one million 
coaches have taken part in our courses.
    In 1990 ASEP joined forces with the National Federation of High 
Schools to develop an instructional program that is responsible for 
educating over 600,000 coaches in the principles of coaching and sport 
first aid. Our primary coaching text, Successful Coaching, is the best 
selling general coaching text over the past 30 years and has received 
critical acclaim by both the educational community and coaches in the 
trenches.
    In addition, ASEP has reached more than 400,000 youth sport and 
national sport governing body coaches with a wide range of high quality 
education courses. Our mission is simply to make sport safer, more 
enjoyable and a more valuable experience for athletes by developing 
education programs and resources for coaches, as well as officials, 
administrators, and parents.
Defining the Problem
    Clearly, the incidence and, as we are discovering through more 
research findings, the prevalence of sport-related concussions is a 
matter that we in ASEP feel compelled to address. Yard and Comstock 
(2009) in Brain Injury-reported an estimated 395,274 concussions 
sustained by high school athletes nationally in 9 sports during 2005-
2008. Those sports included baseball, basketball, football, soccer, and 
wrestling for boys and basketball, soccer, softball, and volleyball for 
girls. Concussion rates were highest in football and softball.
    Moreover, the study discovered a disturbing disregard for the 
seriousness of the injury, with athletes often returning to practice 
and competition before it was safe and appropriate for them to do so.
    Average time missed do to concussions:
            3-6 days (24.4%)
            7-9 days (28.9%)
            10 days (10.1%)
            More than 21 days (10%)
    Perhaps the most alarming finding was that 15.8% of football 
players with the most severe (Grade III) concussions returned to play 
less than one day after incurring the injury. The authors of the study 
concluded that too many adolescent athletes are not adhering to 
recommended return-to-play guidelines, and that coaches, sports 
medicine professionals, parents, and sports administrators must work 
together more effectively to ensure athletes follow recommended 
guidelines. (A summary of this report can be found at: http://
informahealthcare.com/doi/abs/10.1080/02699050903283171.)
    The problem is that those who are most often closest to the 
athletes when concussions occur, of significant influence in 
determining how forthcoming athletes are about their condition, and a 
key figure in their return to action-coaches-are seldom prepared to 
handle this responsibility. And, even less frequently is a clearly 
defined and understood program in place within school's athletic 
departments and sport organizations to deal with concussion injuries.
    ASEP and others are trying to change that. And, from here on, I 
will highlight the two topics on which I was asked to speak today:
    1. The important concussion prevention training efforts that are 
underway.
    2. The resources available to coaches to help them employ effective 
concussion prevention and management measures.
Concussion Prevention and Management Training
    No evidence would suggest that coaches, in general, are derelict in 
their duty to provide for the safety of their athletes. What is clear 
is that, in the case of what are often less apparent and cumulative 
injuries like concussion, the uninformed and untrained coach is 
overmatched by the role he or she is expected to play.
    A study by Guilmette et al. (2007) found that New England high 
school head football coaches received information about concussions 
from this range of sources:
     80% from coaching associations
     79% from conferences
     65% from magazines/newspapers/TV
     31% from a CDC concussion kit
    When asked to rate the helpfulness of the information from various 
sources, 59% said the Center of Disease Control (CDC) concussion kit 
was ``very helpful.'' Next (55%) was input from health professionals, 
and third (53%) was the information gleaned at conferences.
    Tools like the CDC kit can have a positive impact on coaches' 
awareness of concussion symptoms and their ability to act when 
concussions occur. In a recent survey (Sawyer et al., 2010, Health 
Promotion) of 487 coaches from five states
    1. 50--66% reported having access to the toolkit materials (this 
varied by state)
    2. 96% of coaches without a concussion plan indicated that the 
toolkit would be used to develop one
    3. 87.9% recalled the laminated card listing the signs and symptoms
    4. 83.7% reported looking at the toolkit's materials
    5. Only 7.2% had disseminated the Fact Sheet for Athletes but 76% 
planned to do so
    6. Only 4.4% had disseminated the Fact Sheet for Parents but 75% 
planned to do so
    The good news is more resources exist to prevent and manage 
concussions today than ever before. Additionally, more attention 
through multiple channels is making concussion management a higher 
priority at all sport participation levels across the country. The 
Centers for Disease Control has taken a leadership role as a champion 
for providing a safer environment for scholastic sport participation. 
At every turn the CDC is connected with other organizations which are 
playing important roles in addressing this very serious health issue of 
epidemic proportion.
    ASEP believes, and there is evidence to support this belief, that 
systematic education and not simply a troubleshooting toolkit is 
critical for the ability of coaches to handle all of the complex issues 
associated with concussion prevention, identification, notification, 
consultation, and decision-making. We would underscore the importance 
of professionalizing the role of high school coaches if we are going to 
demand more accountability and place more responsibilities on them, 
including concussion management. Similarly, the millions of youth sport 
coaches overseeing the participation of over 74 million children 
between ages 7 and 17 must have sufficient knowledge and training to 
prevent injury where possible and act properly when it does occur.
    ASEP's two comprehensive text books Successful Coaching and Sport 
First Aid are ideal for high school coaches. Our classroom education 
courses led by certified instructors are the gold standard as activity/
exercise based instruction provides interactive opportunities for 
coaches that cannot be replicated in our online versions of these 
courses. Additionally, we offer sport specific courses that help 
educate coaches on how to effectively prepare athletes to properly and 
safely perform skills. ASEP is working hard to address the need to 
enhance and expand concussion education by revising the Sport First Aid 
course to include more comprehensive current information on concussion 
management with the intention of providing access to the full range of 
CDC resources. By incorporating more concussion management education 
into the ASEP Sport First Aid course coaches in states like California 
where they are required to be first aid certified will benefit without 
added expense. http://www.asep.com/
    In addition to ASEP the list of groups actively attempting to 
educate coaches about concussions and how to respond appropriately 
includes but is not limited to:
     The American Football Coaches Association
     The National Federation of High Schools
     The National Interscholastic Athletic Administrators 
Association
     National (Sport) Governing Bodies (US Lacrosse and USA 
Hockey)
     State Athletic Directors Associations
     State High School Associations
     ImPACT
Centers for Disease Control (CDC)
            Heads Up: Concussion in High School Sports
    Initially launched in 2005, the ``Heads Up: Concussion in High 
School Sports'' initiative continues to grow in popularity. The 
materials were developed for high school coaches, athletic directors, 
athletic trainers, parents, and athletes with the goal of raising 
awareness and improving prevention, recognition, and response to 
concussion. An evaluation study conducted by CDC in 2006, found that 
the materials lead to positive changes in high school coaches' 
knowledge, attitudes, and behavior and skills related to concussion 
prevention and management. CDC revised the content in the initiative's 
educational materials in 2009 to reflect the updates in the most recent 
international concussion consensus guidelines. The revised materials 
are scheduled to be re-released in summer 2010 to coincide with the 
release of an online training for high school coaches developed in 
partnership with the National Federation of State High School 
Associations. (See NFHS p. 5) http://www.cdc.gov/concussion/HeadsUp/
high--school.html
American Football Association (AFCA)
    ASEP has also developed strategic partnerships with organizations 
like the American Football Coaches Association to foster collaborative 
coaching education efforts. While most members are college coaches, the 
AFCA has defined the recruitment of high school coaches as a strategic 
objective. One value added benefit of membership is price discounts on 
three ASEP courses that offer Michigan State University and Michigan 
State Board of Education continuing education credits. http://
www.humankinetics.com/Continuing-Education-for-Coaches
The National Federation of High School Associations (NFHS)
    The NFHS has led the development of education-based interscholastic 
sports and activities that help students succeed in their lives. The 
NFHS launched on May 19, 2010 an online course entitled ``Concussion in 
Sports-What You Need to Know'' at no cost to the user. It will be 
available at www.nfhslearn.com. They have partnered with the CDC to 
deliver a course that will provide coaches, officials, parents and 
students information that will minimize the incidence and severity of 
head injuries. To highlight the continuing importance of this issue, 
the NFHS Sports Medicine Advisory Committee (SMAC) and each sport's 
rules committee have taken the unprecedented step of including 
Concussion Recognition and Management as a point of emphasis in each 
NFHS sport rules book for the 2010-11 year.
The National Interscholastic Athletic Administrators Association
    The mission of the NIAAA is to develop, enhance and preserve the 
educational values of interscholastic athletics. The NIAAA serves its 
members by providing resources to develop and to enhance leadership 
skills and to offer opportunities for professional growth. To that end 
they established a Leadership Training Institute to foster professional 
development in 1996. Athletic Administration courses like Legal Issues 
I (Risk Management) and Administration of Interscholastic Sports 
Medicine Programs Among are examples of the type of education course 
offering available to athletic administrators designed help them manage 
athletic address critical issues like concussion management as part of 
a holistic approach to providing the safest environment that also 
mitigates risk. http://www.niaaa.org/Leadership--Training/leadership--
training.asp
National (Sport) Governing Bodies
    US Lacrosse and USA Hockey are contact sports where athletes are 
exposed to the potential for concussions. USA Hockey provides CDC 
developed resource information to coaches via their website and 
Director of Coaching, Mark Tabrum is a strong advocate for safety as 
evidenced by the development of Heads Up Hockey technique as part of 
their beginner levels introduction to body contact. http://
www.usahockey.com / uploadedFiles / USAHockey / Menu -- Coaches / Menu 
-- Coaching -- Materials / Menu -- CEP -- Materials / 
Introduction%20to%20Body%20Contact%2008.pdf
    US lacrosse has branded the CDC Heads Up fact sheet for concussions 
and they provide it online for their coaches. Additionally, CEO, Steven 
Stenersen is a strong proponent of effective concussion management as 
evidenced by his March 8, 2010 blog in which he closed with the strong 
definitive statement ``When in doubt, sit 'em out.'' http://
www.uslacrosse.org / LinkClick.aspx?fileticket = ZakC3rKDnT4%3D&tabid = 
2351
State Athletic Directors Associations and State High School 
        Associations
    For insight on how Administrators from a number of State Athletic 
Directors Associations and State High School Associations are 
responding to this challenge please refer Appendix D.
ImPACT
    ImPACT Applications, Inc. is a premier provider of computerized 
neurocognitive assessment tools and services used by medical 
professionals to assist them in determining an athlete's fitness to 
return to play after suffering a concussion. The ImPACT test provides 
an objective measurement of memory, reaction time, attention span, and 
other factors to help a clinician diagnose a concussion and decide when 
the patient has recovered.
    ImPACT is a sophisticated, research-based computer test developed 
to help clinicians evaluate recovery following concussion. ImPACT is a 
20-minute test battery that can be administered in the pre-season for a 
baseline and post-injury to track a concussion. ImPACT promotes an 
athlete's full recovery from injury and assists clinicians in making a 
safe return-to-play decision and reducing the chance of follow-up 
concussions.
    The ImPACT baseline test is ideally administered under the 
supervision of a clinician, athletic trainer, coach, or even a parent. 
The test involves tasks that measure a variety of factors. An initial 
test or ``baseline test'' is taken before a concussion occurs and 
establishes baseline results. When a concussion is suspected, a follow-
up or ``post-injury'' test is administered to see if the results have 
changed from the baseline to help diagnose and manage the concussion. 
Additional follow-up tests may be administered over several days or 
weeks to assist the clinician with the return to play decision.
    ImPACT provides comprehensive in-person or online training in the 
interpretation of test results, advice and consultation in the doctors' 
community, and many other resources to help clinicians make the best 
use of test results.
    ImPACT is designed to provide sensitive information in the form of 
cognitive data and symptom reporting in athletes suspected of 
sustaining a concussion. This information can be used to help determine 
recovery from injury and safe return to participation and overall 
clinical management issues.
    ImPACT was founded in May 2002 by Mark Lovell, Ph.D, ABPN, Joseph 
Maroon, M.D., and Michael Collins, Ph.D. ImPACT team members have 
dedicated the past 15 years to the scientific study of sports-related 
concussion and the clinical application of this knowledge throughout 
professional and amateur sports.
Sample of Current Users of ImPACT
    All NFL Teams  Cirque du Soleil  All MLB Teams 
 USA Rugby  All National Hockey League Teams  
Irish Rugby  All Major League Soccer Teams  New Zealand 
Rugby  Major/Minor League Baseball Umpires  South 
African Rugby  USA Hockey  US Army  USA Olympic 
Hockey  US Navy  Ontario/Western Hockey Leagues 
 US Air Force Academy  USA Ski Team  180+ 
Professional Sports Teams  US Soccer Federation  2000+ 
High Schools  Swedish Soccer  700+ Colleges and 
Universities  US Lacrosse  550+ Clinical Centers 
 World Wrestling Entertainment  180+ Credentialed 
ImPACT Consultants. ImPACT Web site: www.impacttest.com
    ESPN's Questions vital to diagnosing concussion: http://
sports.espn.go.com/espn/e60/news/story?id=5162747
    Peer Reviewed Articles on ImPACT: Sensitivity and specificity of 
the ImPACT Test Battery for concussion in athletes http://
www.impacttest.com/pdf/SchatzSensitivityAccept.pdf
    It should be noted that in addition to ImPACT, Headminder 
Concussion Resolution Index and CogState Sport are two other 
organizations that have also established assessment tools.
From the CDC Did you know? File
     Each year, U.S. emergency departments treat an estimated 
135,000 sports- and recreation-related TBIs, including concussions, 
among children ages 5 to 18. (MMWR July 2007)
     Athletes who have ever had a concussion are at increased 
risk for another concussion.
     Children and teens are more likely to get a concussion and 
take longer to recover than adults.
    We have a serious problem and need to do better. While it is clear 
that there is no shortage of resources, we also know that we have a 
great deal of work ahead of us. We need to continue to move away from 
the old paradigm where the perception is an athlete is weak if they 
don't attempt to play through getting their ``bell rung''. We need to 
perpetuate a culture of athlete and safety first and action that 
results in ``when in doubt, sit 'em out.'' We need to take advantage of 
the CDC and other resources not just to be distributed only to sit on a 
shelf. We need to use the resources in the process of formally 
educating coaches so that they can implement preventive measures to 
reduce the incidence of concussions. Through that education coaches 
will be better equipped recognize and manage concussions when they do 
occur.
    Our experience at ASEP tells us that in order to achieve wide and 
deep penetration, coach education needs to be required. Our four year 
relationship with Babe Ruth League (BRL) and Ripken Baseball (RB) 
illustrates this point. Since implementing the mandate three years ago, 
over 91,000 BRL-RB coaches have been educated. Contrast that with 
multiple other youth sport organizations for whom ASEP built customized 
courses. These organizations recommend that coaches take their course 
and consequently less than 3% of their volunteer coaches opt to take 
the course. In a new collaborative effort with American Youth Football, 
President Joe Galat has made the commitment to require coaches to take 
an ASEP developed online course Coaching Youth Football the AYF Way 
online course in order to compete at tournaments. This course includes 
CDC information on concussion management.
    As right minded as we might be, until extensive quality concussion 
education is mandated at the state or local level(see Virginia Beach 
example, appendix D p.14) we won't make a significant dent. Fewer 
concussions and fewer second impact incidents can only be achieved by 
action that results in requiring comprehensive education. Once in 
place:
    1. Coaches must be held accountable by the state or local 
organization for meeting the requirement--there must be consequences 
for failure to comply.
    2. The requirement must be comprehensive and include:
    a. Coaching principles that address coaching philosophy and season 
planning that includes a detailed concussion management component
    b. Comprehensive first aid specifically geared toward coaches, 
which includes concussion management protocols that are integrated into 
season planning component, parent orientation meeting, other 
stakeholder information dissemination etc. Remember the research that 
indicated--only 7.2% of the coaches disseminated information to 
athletes and 4.4% delivered the fact sheets to parents--we need to do 
better
    c. Continued emphasis on proper sport specific skill instruction, 
for example in football that would include proper tackling and blocking 
techniques among others
    d. Information and instruction on proper equipment fitting
    e. Attention to rules like the leadership role that NFHS took (p. 5 
of this report)
    3. Key stakeholders must agree on how concussion management systems 
will be implemented. The stakeholders include the athlete, coach, 
athletic trainer (if one exists), athletic director, school principal, 
school board, superintendent. All need to be accountable on some level 
for having been exposed to information and understanding the protocol 
and committing to the system.
    4. A trained qualified doctor must be identified as part of the 
system as the final arbiter in making return to play decisions.
    5. Financial resources have to be raised and/or committed by 
organizations at the state and community based level in order to meet 
the demands of the system. ASEP's recent collaboration with the LA84 
Foundation and the LA City Section of the California Interscholastic 
Federation illustrates one potential model for alternative funding 
sources that could be applied to pursuing underwriting costs related to 
implementing a coaching education program. In this case the LA84 
Foundation provided a grant to help underwrite a portion of the 
required course fee. As a result 250 coaches who need to meet the CIF 
coaching education course requirement will access the course for $18 
instead of $38.
    6. Human resources need to be dedicated to plan, implement and 
measure the impact/success of the system.
    Over the years we have seen dramatic and positive impact of such 
educational efforts. Take for example the salt tablet and water 
deprivation. This was common practice in the 1970s. But scientists 
(nutritionists) and sports medicine specialists decried this accepted 
training tactic and studies pointed to the serious health risks 
involved, thinking on this slowly turned. And not until coaching 
education services hammered this message home and taught alternate, 
safe hydration and heat illness prevention guidelines did this 
practice, with exceptions, stop altogether. We should be mindful of 
those exceptions so that we sustain a relentless approach to educating 
every coach.
    I said earlier that this has to be a catalyst for professionalizing 
the role of being a high school coach. And we cannot be hostage to a 
bad economy and widespread school budget cuts. We must find a way to 
utilize the vast, high quality resources to educate our coaches. 
Together, we can do better. Together we can make a difference in the 
lives of millions of scholastic athletes.
    Members of the committee, coach education is the foundation from 
which success can be built in managing the impact on concussions on 
high school athletes. Our ASEP team has a great deal of respect for the 
committee's leadership on this issue. We look forward to continued 
collaboration with key stakeholders and resource developers so that we 
can help pave the way for standards of care which lead to decisions 
that are made with the athlete's health and safety as the first 
priority and only consideration.
    Thank you for giving me the opportunity to appear before you today.
    Athletes First, Winning Second
                               appendix a

      2008 Sporting Goods Manufacturers Association Survey Results

                    GENERAL YOUTH SPORTS INFORMATION
           [Source: Sporting Goods Manufacturers Association]
------------------------------------------------------------------------
                                              2008 Participants (ages 7-
                    Sport                                 17)
------------------------------------------------------------------------
Swimming....................................                 20,532,000
Basketball..................................                 13,288,000
Soccer......................................                  9,284,000
Baseball....................................                  7,268,000
Football (tackle)...........................                  5,508,000
Volleyball..................................                  5,135,000
Softball....................................                  4,247,000
Tennis......................................                  3,542,000
Golf........................................                  2,847,000
Snowboarding................................                  2,725,000
------------------------------------------------------------------------

                                              
                                              
    Category = Participation (Ages 7+) Ranking: Total Ages 7-17 (No. of 
Part. in Thous.)
                               appendix b

                                 TABLE 1: TOP TEN SPORTS BY PARTICIPATION (BOYS)
                            [Total Number of High School Athletes (Boys): 4,422,662]
----------------------------------------------------------------------------------------------------------------
                                                            2009 Participants (high     2009 Teams (high school
                          Sport                                  school boys)                    boys)
----------------------------------------------------------------------------------------------------------------
Football................................................                  1,112,303                      12,105
Track & Field...........................................                    558,007                      15,936
Basketball..............................................                    545,145                      17,869
Baseball................................................                    473,184                      15,699
Soccer..................................................                    383,824                      11,139
Wrestling...............................................                    267,378                      10,254
Cross-Country...........................................                    231,452                      13,647
Tennis..................................................                    157,165                       9,499
Golf....................................................                    157,062                      13,543
Swimming/Diving.........................................                    130,182                       6,556
----------------------------------------------------------------------------------------------------------------
Source: National Federation of State High School Associations.

     table 2: top ten sports by percentage of participation (boys)


                               appendix c

                                TABLE 3: TOP TEN SPORTS BY PARTICIPATION (GIRLS)
                            [Total Number of High School Athletes (Girls): 3,114,091]
----------------------------------------------------------------------------------------------------------------
                                                            2009 Participants (high     2009 Teams (high school
                          Sport                                  school girls)                  girls)
----------------------------------------------------------------------------------------------------------------
Track & Field...........................................                    457,732                      15,864
Basketball..............................................                    444,809                      17,582
Volleyball..............................................                    404,243                      15,069
Softball (fast pitch)...................................                    368,921                      15,172
Soccer..................................................                    344,534                      10,548
Cross-Country...........................................                    198,199                      13,457
Tennis..................................................                    177,593                       9,693
Swimming/Diving.........................................                    158,879                       6,902
Golf....................................................                     69,223                       9,344
Lacrosse................................................                     64,929                       1,780
----------------------------------------------------------------------------------------------------------------

     table 4: top ten sports by percentage of participation (girls)


                               appendix d
State Athletic Directors Associations and State High School Association 
        Related Action
    The Pennsylvania State Athletic Directors Association (PSADA) is 
one example of how athletic administrators can take a leadership role. 
PSADA Executive Director, Bob Buckanavage chairs the PA Alliance in 
Sport Committee which represents the PA School Boards Association, the 
PA Association of School Administrators, The PA Association of 
Elementary and Secondary School Principals, the PA Interscholastic 
Athletic Association, the PA State Athletic Directors Association, and 
the PA Department of Education. The group met most recently, on Monday 
May 10, 2010 to discuss relevant issues in the sport arena.
    One of the important issues has to do with concussion management 
legislation that the members of the alliance are monitoring, namely, HB 
2060 and SB 1241. Both bills appropriately address the Management of 
Concussions and Head Injuries and the alliance is fully supportive of 
this legislation.
    PIAA Executive Director Brad Cashman presented a comprehensive 
report which included the following:
    1. The National Federation of High Schools (NFHS) position 
regarding rule changes for the 2010-11 sport season and Suggested 
Guidelines for Management of Concussions.
    2. The NFHS Coach Education module ``Concussions in Sport--What You 
Need to Know.''
    3. The Center for Disease Control and Prevention has developed a 
tool kit for coaches titled: Heads Up: Concussion In High School 
Sports.
    4. The PIAA Sport Medicine Advisory Committee's decision to 
incorporate appropriate language in its Comprehensive Initial Pre-
Participation Physical Evaluation form (CIPPE ) addressing the 
management of concussions.
    The alliance unanimously approved of the report that Mr. Cashman 
presented and supports the premise that a student-athlete shall not 
return to play until they are evaluated by a licensed health care 
provider trained in the evaluation and management of concussions.
                       Bob Buckanavage, Executive Director,
                 Pennsylvania State Athletic Directors Association.

    In light of the new NFHS Rules, procedures and suggested guidelines 
for concussion management, Kansas is actively working on developing a 
protocol for our schools to ensure all coaches and administrators 
understand their responsibilities toward young people who experience 
concussion or related symptoms while participating in sports and 
activities. We anticipate promoting widespread utilization of the NFHS 
Concussion Management course when it becomes operational this summer by 
all schools as in-service for their personnel, students and even 
parents. We are currently working with legal counsel and the Kansas 
Board of Healing Arts to determine who the ``appropriate health care 
professionals'' are to evaluate kids and make determinations about 
return to play.
                        Gary Musselman, Executive Director,
                   Kansas State High School Activities Association.

    Our Sports Medicine Advisory Committee, which is made up of doctors 
and trainers, recommended updated guidelines to our MHSAA Executive 
Committee. These newly adopted concussion guidelines are in conjunction 
with the NFHS guidelines. They have been officially released to our 574 
member schools for use during the 2010-2011 school year.
                                             Ennis Proctor,
                    Mississippi High School Activities Association.

    For almost twenty years now the Virginia Beach City Public Schools 
have been offering education courses for athletic coaches. As you can 
imagine, a school division of close to 70,000 students employs a large 
number of individuals to serve as coaches at the middle and high school 
levels. That also means there are a large number of individuals who are 
representing the school system with their actions on and off the 
sidelines, some of which have no formal training in working with 
students and parents. Some may have been blue-chip athletes in their 
own right, but that doesn't always translate into a quality coach. 
Fortunately, our school system saw the need to offer courses in 
coaching in the late 1980's. From the start and because it was not 
mandatory at the time, coaches who chose to take the classes gave the 
courses high marks, for the most part, on their evaluations. But 
classes were relatively small compared to the total number of coaches 
in the school system. About five years ago, our division implemented 
mandatory coaches education as part of a plan to enhance coaches' 
professionalism. We had three years to certify over four hundred 
coaches. Although most probably were not interested in adding another 
time commitment to spend sixteen hours in the classroom and several 
more on three online tests, we always received a large, large majority 
of positive evaluations from our coaches. Once they went through the 
program, the value was apparent to them. We were able to meet our goal; 
at this point, all of our middle school and high school athletic 
coaches with two or more years of experience in our school division 
have completed our coaches education requirements. It definitely has 
not been a cheap endeavor, but it has definitely been a worthwhile 
endeavor. I feel like our coaches have a good understanding of our 
school system's expectations, and they also know that their competitor 
colleague on the opposite side of the field has heard the same 
instruction and is playing by the same rules. I am a strong proponent 
of school systems utilizing a quality coaches education program. David 
Rhodes, CAA, Coordinator, Student Activities, Virginia Beach City 
Public Schools
    The Wisconsin Interscholastic Athletic Association has been one of 
the leading state associations (if not the leader) in sports medical 
concerns in the country. Our committee meets twice a year and 
communicates amongst one another and our staff throughout the year. 
They have been out front in many areas, PES, MRSA, H1N1, and 
concussion. Our sports medical team has provided concussion management 
protocols to our member schools for years. They have created a Medical 
Policies and Procedures Manual which has been provided to our member 
schools. http://www.wiaawi.org/publications/medicalproceduresguide.pdf
    Last year, our committee implemented the Zurich conventions and 
implemented the most stringent concussion rule in the NFHS with new 
rules and guidelines:
     If you think your athlete has sustained a concussion * * * 
IMMEDIATELY take him/her out of play, and seek the advice of a health 
care professional experienced in evaluating for concussion.
     WIAA Rule: A student who displays symptoms of concussion 
and/or is rendered unconscious may not return to practice or 
competition during the same day without a physician's written approval.
     WIAA Rule: An apparently unconscious player is determined 
by the game officials. The player may not return to play in the game 
(without written authorization from a physician).
    Before every sport season, our assistant directors hold sport 
meetings. Materials on concussion, performance enhancing substances, 
heat stroke, and other materials are provided to our coaches in our 
sports. Our web site has sections which cover each of these areas and 
are used by our coaches, parents, and member schools. This year, we 
will be utilizing the materials provided by the NFHS to require our 
member schools to educate their coaching staffs, parents, and athletes 
in concussion management. I truly believe our people have done a 
tremendous job. I've copied in our Doctors to respond to your message 
as well.
                             Wade Labecki, Deputy Director,
                    Wisconsin Interscholastic Athletic Association.

    In Ohio, we have been working hard with our constituents and our 
legislature. The following is a review of what we have been doing this 
past school year. The OHSAA has made a concerted effort to provide 
educational resources to member schools on this vital topic of 
concussion management. The following are resources that are currently 
available:
    1. Suggested Guidelines for Concussion Management in Sport--a 
publication from the NFHS
    2. Questions vital to diagnosing concussion--Q& A and a video from 
an ESPN special on concussions--http://sports.espn.go.com/espn/e60/
news/story?id=5162747
    3. Concussion in Sports--What you Need to Know--www.nfhslearn.com.
    4. Centers for Disease Control--Resources to Prevent and Recognize 
Concussions--http://www.cdc.gov/Features/Concussion
    5. Fact Sheets for Parents, Coaches and Athletes--http://
www.ohsaa.org/medicine/ParentsFactsheet.pdf; http://www.ohsaa.org/
medicine/CoachGuide%20on%20Concussion.pdf; http://www.ohsaa.org/
medicine/AthleteFactsheet.pdf
    6. Video from the Washington Interscholastic Activities 
Association--Recognizing Sports Concussions http://www.ohsaa.org/
medicine/Concussion%20Stuff/DVD--1--0000.wmv
    7. The OHSAA has adopted the following sports regulation:
    Any athlete who exhibits signs, symptoms or behaviors consistent 
with a concussion (such as loss of consciousness, headache, dizziness, 
confusion or balance problems) shall be immediately removed from the 
contest and shall not return to play until cleared with written 
authorization by an appropriate health care professional. In Ohio, an 
``appropriate health care professional'' shall be a physician, as 
authorized under ORC Chapter 4731 and includes both doctors of medicine 
(M.D.) and doctors of osteopathy (D.O.) and an athletic trainer, 
licensed under ORC Chapter 4755.
    Note: This information will be included in all preseason manuals 
for coaches and officials, posted to the respective sports and 
officiating pages of the web site and presented at mandatory rules 
interpretation meetings. Deborah B. Moore, Ph.D., Associate 
Commissioner, Ohio High School Athletic Association
    The California Interscholastic Federation (CIF) has some new 
concussion bylaws which of course all sections will be following. In 
our CIF/Central Coast Section, we are working on getting a Doctor 
trained in concussions to speak at our Fall Administrators' workshops 
which all our school principals, VPs and AD's are required to attend. 
http://www.cifstate.org/health--safety/pdf/Play--It--Safer--Top--Ten--
Tips--For--Parents--in--English--&--Spanish.pdf
                                 Nancy Lazenby Blaser, CIF,
                                Central Coast Section Commissioner.
                                 ______
                                 
    Mr. Tierney. Thank you very much, Mr. Schmutz.
    Thank all of our witnesses for their testimony today. It is 
extremely helpful to all the members here. We are going to 
start on our question-and-answer section of this with 5-minute 
segments, beginning with Mr. Payne.
    Mr. Payne, you are recognized.
    Mr. Payne. Thank you very much.
    Let me thank you all for coming and in particular our young 
athlete. Just some questions, maybe starting with the coach.
    You know, the way that you have approached coaching, I 
think, is great. And I don't know whether you are the exception 
to the rule or the rule. I would hope that you are the rule, 
not the exception.
    However, having been involved in sports when I was young, I 
know that coaches tend to want to win, and that is the way it 
was and is today. I would even imagine that when you--if you 
played ball--I assume you did--coaches used to tell you, you 
know, if you are injured, just keep going, you know, if you--
not necessarily a concussion, but an injury, say, to an ankle 
or something, you know, would almost encourage you if you were 
one of, you know, the stars that you have got to--for the team, 
you have got to go out there because we have got to win the 
game, don't let your teammates down. That is the way it was 
years ago when I was playing ball.
    Do you think that there is still much of that philosophy 
still going on? And I might also ask Mr. Schmutz, since you 
have gathered information in general.
    In high school, do you think it is still that drive to win 
at all costs, Coach?
    Mr. Monacelli. I think as New York State has evolved into 
coaching education classes, philosophy and principles in 
sports--in managing sports--we have started--we are involved in 
schooling our young coaches, the new coaches, into--or away 
from this idea, win at all costs, to hey, liability is 
important. This young man has--or young woman has another life 
here besides what we think is evolved around our life, or the 
school's life, or the community's life.
    And I think that has helped a great deal in our state in 
making that mandatory to get that important principle of safety 
and liability out there, and it is--there is more to this than 
the game.
    Mr. Payne. Mr. Schmutz?
    Mr. Schmutz. In addressing your first question, I would say 
Coach Monacelli is closer to the exception than he is the rule. 
But I think it is a really good example, because he absolutely 
puts his athletes first, and yet he has won five state titles. 
I think it really emphasizes the value of putting the athletes 
first, and that if you do that, winning becomes a by-product.
    The reality is the philosophy with which coach comes to 
practice every day and instills in his players results in their 
ability to come together as a team. And if we can continue to 
use coaches like Coach Monacelli to educate the young coaches 
as he described, we will move much closer to him--other coaches 
being more the rule than the exception.
    Mr. Payne. Thank you. You know, we look at, say, the real 
contact sports--football is probably the one that comes to mind 
the most. Hockey in high school is probably, you know, less of 
a sport since many of the schools don't have it.
    But what is the danger of concussions--the problem of 
concussions only being sort of focused on football but other 
sports even where kids have less protection? You know, the 
opportunity--just like basketball, you don't think of 
basketball as being a sport where a concussion--you are worried 
about the football team.
    How is that handled? Because concussions can happen in 
whatever sports you are playing. Mr. Schmutz or anyone else?
    Mr. Schmutz. Well, I would also defer to Dr. Gioia with his 
research. But women's soccer is a really good example of a 
sport where there is a high prevalence of concussions, and 
clearly there is no equipment there.
    I think, you know, from a prevention standpoint, coaching 
education on specific skill development and how one positions 
themselves to play a ball, how one positions themself to brace 
physical contact--as much as soccer is a artistic sport, it is 
also a very physical sport.
    And so I think it underscores that this is not just a 
football issue and that, in fact, education both on the skill 
side and teaching the proper skills but also on recognition and 
prevention and management--all of that--the comprehensive 
piece--this has to be a holistic approach and can't be dealt in 
isolation.
    Mr. Payne. Doctor?
    Mr. Gioia. Yes, I think the other point is that, you know, 
certainly in our clinic and in our research we see these 
injuries happening in all sports. We think about football but, 
really, ice hockey, lacrosse, basketball, wrestling, 
cheerleading, gymnastics--you know, the--and we have already 
mentioned soccer.
    You know, these are all sports where there is either a 
direct collision or there is a high risk for that. And I think 
that the focus certainly on the education has been in all 
sports, and if we look at what the CDC has provided in their 
Heads Up toolkit, this can go to all coaches, information about 
the signs and symptoms, regardless of whether, you know, you 
are in a sport that may not have a high incidence.
    It is all about understanding what the nature of that 
injury is, the sign, the symptom, and when in doubt you pull 
them out. So I think it is important that we get that across 
broadly and universally.
    Mr. Payne. Well, thank you very much.
    And I would like to also commend my colleague from New 
Jersey for his legislation and I am really glad as a former 
coach and a former athlete to really see the attention drawn to 
this, because some of the fellows I played with are still 
suffering from concussions that--you were supposed to play 
whether you had a concussion or not, you know.
    Thank you. I yield back.
    Mr. Tierney. Thank you, Mr. Payne.
    Mr. Kline?
    Mr. Kline. Thank you. I want to thank the witnesses again. 
Excellent testimony, and it sounds like you are all doing 
excellent work. I particularly want to thank Ms. Pelton for 
sharing her story--sharing your story. It is a compelling 
story.
    Share a short story of my own--I have a staff member who 
suffered a traumatic brain injury a couple of years ago now. 
She is a mother of two, an adult, and that injury forced her to 
the point where she couldn't walk, she couldn't read, she 
couldn't write, she couldn't drive. She really couldn't be a 
mother, although she was, in fact, a mother of two, and it made 
for an interesting relationship when her emotional state was 
younger than her children.
    But she has recovered almost 100 percent. She can read and 
write and drive and function as a mother. It took a lot of 
work. And so I would recommend to you that you stay at it, and 
you will be--you, too, will be 100 percent. But it shows how in 
a blink of an eye a life can change with one of these 
concussions, one of these injuries.
    And to that end, Dr. Gioia, I was noticing that you said 
that you and your staff at the Children's Medical Center spent 
a lot of time trying to help these student athletes cope with 
an academic life, a school life. Can you just take a moment and 
kind of explain how you do that?
    Are you working with the teachers, or is this coaching the 
student athlete? Is it working through the doctors? How do you 
help them make that adjustment?
    Mr. Gioia. Yes, thanks for that question. Thanks for that 
question, because it is--as Sarah can, again, probably give her 
personal experience and actually does in her testimony as well, 
when we have kids that come into our clinic, the first thing we 
are doing is we are evaluating the extent of the injury, the 
extent of the symptoms--you know, do they reach into the 
cognitive area, do they have headaches, fatigue, are they 
having problems with light sensitivity or noise, sounds, are 
they more irritable?
    So we are looking at really that pattern and profile of 
things that are impaired. We then look at what can they 
tolerate based on that symptom profile. And the whole idea in 
concussion management is to allow recovery but also to allow 
the student back into as much as they can tolerate, and that is 
a key point here, because when we are talking about kids, and 
we are talking about school, we have to very carefully manage 
and measure what they should and should not be doing.
    And so part of our program is to identify what is that 
tolerable level up to which the symptoms do not worsen, do not 
exacerbate. And then based on that, we write out a care plan 
for every student athlete that is going back into school with 
very explicit, detailed instructions for the school.
    As Sarah knows, we go through what is first period, what is 
second period, what is third period. How do we build those 
breaks into the day? We don't want that brain to be driving 
itself down. We want to be sure that you are alert and capable, 
but when you do feel the symptoms worsen that is when you build 
that break in.
    We need the teachers, of course, to be a part of that, so 
we are always looking for that individual inside the school, 
and the school nurses oftentimes play an important role--the 
school counselors--to really, then, work with that academic 
team, to get the message out, to distribute that care plan, and 
to really work with that student to be sure that they are not 
overtaxing them.
    So it is important, again, to normalize life as much as you 
can, but only as much as is tolerable. And it is really that 
communication back and forth with the school that is critical.
    It is why that--the new school toolkit that the CDC is just 
introducing today is critically important. We have to get 
training out to the schools. Once they understand it, then the 
pressure is taken off the parent and the student to have to 
convince them of it. It is all critically important.
    Mr. Kline. Great. Thank you. Thank you very much.
    I want to shift now to the coach.
    In your testimony and in your responses so far, it is clear 
that you have achieved buy-in from the community. This is not 
just a question of you and your fellow coaches being more aware 
and having a plan and being able to deal with it, but as you 
said, you--it was kind of a hard sell for--sometimes for the 
parents and for the community, who want that championship and 
are questioning why the quarterback is not in the game.
    How do you envision that--how did you get that outreach, 
and what do you recommend be done to get that buy-in from the 
community?
    Mr. Monacelli. Well, at the beginning we put it on our Web 
site, the back--all the background was given to our school 
health nurse, who fields an awful lot of phone calls. As the 
athletic director, I took care of communication on some of that 
also.
    It was put on our district calendar that would go out to 
everybody in the district. And I think when it came to the 
point regardless of our success and sports programs there, it 
didn't take long for them to say, ``Well, this just isn't 
another test, you know? We are not--this is not a time-
waster.''
    And after the second year, and we found out that it was 
more than just athletes that we are--now we are testing 
everybody and tried to, again, educate the community that it 
was more than just the athletic injury, that it could be the 
accident at home, too, and that it wasn't just athletics, it 
was their cognitive ability, their ability to be a good 
student, then things fell into place.
    Mr. Kline. Thank you.
    Thank you, Mr. Chairman.
    Chairman Miller [presiding]. Thank you. I would ask 
unanimous consent that instead of--we keep referring to Sarah.
    Sarah, if you would like to come sit next to Dr. Gioia and 
then if you think it is appropriate to speak up on one of these 
answers, just elbow your way in there, and let us have the 
benefit of your thinking and experiences along with Michelle's. 
Thank you.
    Mr. Tierney?
    Mr. Tierney. Thank you, Mr. Chairman. That was timely, 
because I do want to ask Sarah and Michelle a question. We have 
talked about the perspective of the coaches and the teachers 
and the community on that.
    What kind of support did you get or not get from your 
fellow students when you were going through this process of 
recovery? And what do you think that we ought to be doing to 
make that an easier transition? Whichever one wants to go 
first.
    Michelle, why don't you start?
    Ms. Pelton. Well, a lot of people did think that I was just 
lazy and that I was beating the system, and they didn't 
understand at all what I was going through. My friends, you 
know, did help a lot, and my teachers--they followed the 504 
plan that I was on, which gives me, you know, extra time to do 
my work and everything.
    And I actually had a one on one with my teachers at home 
which helped a lot. That made me, you know, pass actually my 
senior year. That is one reason why I passed. And that is 
pretty much it.
    Ms. Rainey. Like Michelle said, most of the people just at 
our school thought that it was nothing, it was a headache and 
you get over it. The teachers supported me a lot, but it is 
hard to incorporate these breaks.
    You either have to, you know, take a period off or try to 
figure out a system that works so you can get work done and 
just stay in school to get your grades up. So that was a real 
challenge.
    Mr. Tierney. I bet it was.
    Mr. Chairman, I would like to yield to Mr. Pascrell. He has 
done a lot of work on this area and I would like to give him 
the opportunity early on to ask a question if he would care to.
    Mr. Pascrell. I thank the gentleman. Appreciate that.
    Thank the chairman, members of the committee.
    Interesting. Today I am going to be meeting with the 
Department of Defense because we have done a lot of work with 
them and our soldiers who had nothing up until 3, 4 years ago 
when they came back--20 percent of them have suffered traumatic 
brain injury. God knows how many have post-traumatic stress 
disorder.
    And pay a visit to Walter Reed Hospital and you will know 
what I am talking about. This is a very critical issue. Forty 
percent, by estimates, of people go back into the sport too 
early after they had--they are concussed. Very dangerous 
situation.
    I have worked very closely with Congressman Todd Platts of 
Pennsylvania in putting legislation together, the ConTACT Act, 
which has the endorsement of all--most of the major sports--
NFL--because they just cleaned up their act, too.
    When you talk to many--and Congressman Payne referred to 
this--many of the athletes who are--no human being is a 
vegetable, but they have lost everything, 40, 50 years of age. 
They were not attended to. Nobody took them seriously. Their 
teams and the league ignored them and, worse, swept it under 
the rug.
    We had a young lady in the state of New Jersey in Marlboro 
High School who has had 11 concussions, so she can't do any 
sports anymore.
    So we are trying in the legislation that we proposed, Todd 
and myself, to get some kind of a protocol, national protocol, 
going to help coaches. We don't want the protocol to be defined 
by the Congress, God forbid. We want the protocol to be defined 
by professionals as an aid, so that schools throughout the 
nation can get help.
    We have overlooked--and I am glad the two young ladies, 
Sarah and Michelle, are here today. But we have overlooked 
injuries, to a large degree, to gals, girls, ladies, females. 
You are more vulnerable and susceptible because of the position 
of the brain and the vessel within the brain that covers the 
brain, controls the brain--secures the brain, rather, because 
it is very different in males.
    And so we think that girls don't get hurt, except if they 
break an ankle or if there is blood, and we don't take any 
different of an attitude, really, as we look at our soldiers. 
No contusion, no blood, so--we have only started to get into 
helping our soldiers and their families.
    It is a whole family operation, as it is with you. Think 
about your own family and what happened after you had a 
concussion, and you told--and they found out about it, because 
your parents, many of them, want you out there in the field, 
are just as enthusiastic--are living, many times, through you 
their own inadequacies to gain favor on the basketball court or 
the soccer field or the football field.
    Coach, I don't have to tell you, how many parents have you 
put up with over the years? So you know exactly what we are 
talking about.
    But the bill first brings together a conference of 
stakeholders, as I said, to establish a concussion management 
guideline that would prevent, identify, treat and manage 
concussions. It then authorizes grants to the states for 
adopting, disseminating and implementing these guidelines.
    Look, the federal government is probably involved in too 
many things. I think it has a responsibility to lead, since the 
states are very reluctant to do it. The three states that have 
stepped up to the plate somewhat have very different protocols, 
and so there is not one that they have decided on.
    And if I could, through the chair, ask a question to Dr----
    Chairman Miller. [Off mike.]
    Mr. Pascrell. Okay.
    Thank you very much, Mr. Tierney.
    Chairman Miller. Mr. Poe?
    Mr. Poe. Thank you, Mr. Chairman.
    And thank the panel. This has been a really great, 
enlightening panel this morning. I, too, as Congressman Payne--
if you played football or participated in sports, you probably 
eventually got a lick on the head. I ended up in Congress. I 
don't know what that says about my lick on the head, but----
    [Laughter.]
    Coach, you remember--and I think the reason you have been 
successful is because you were successful and people have 
tremendous respect for you in your community. I know that from 
just listening to you.
    When the coach who has won five state championships says, 
``You sit out,'' you sit out. And I know that what you have 
been able to do because of the respect they have for you--there 
is tremendous pressure to win, and there is also tremendous 
pressure when you are an athlete.
    You have a very short time to play, and it is--and in high 
school it is probably 2 or 3 years max. You are not going to 
play as a freshman. And there is tremendous pressure on you as 
an athlete and as families, so what I think you did was--and 
what I think is--and Dr. Gioia mentioned what is being tried is 
to get a protocol and some evidence-based medicine--and I am a 
physician, and all--and because of that ended up being the team 
coach for I can't tell you--and the coach for I can't tell you 
how many different teams through elementary school and high 
school.
    So I think you have to educate the personnel, the coaches, 
and nobody rewards you when you lose. And that is a big 
pressure on the coaches and the families, too. And the other--
on young men is that, you know, you are going to play hurt if 
you play football. You are going to get banged up, and you are 
going to play hurt.
    So I think educating the coaches, educating the athlete 
that you can't be playing, and then the family and the 
community, as Congressman Kline mentioned, I think is 
imperative. So I think having a program in communities, through 
the school board or whatever, to educate--coaching clinics that 
you go to.
    Is that how you--I heard a little bit about how you did 
that. Is that how you all accomplished that in your community? 
Was it coaching clinics?
    Mr. Monacelli. I am sorry, I didn't catch that question.
    Mr. Poe. Coaching clinics and very--that is how you--or it 
has been--it has been kind of a transition, it sounds like, in 
your community.
    Mr. Monacelli. Yes. I mean, this is----
    Mr. Poe. A progression.
    Mr. Monacelli. In the coaching world, this has been the 
buzzword.
    Mr. Poe. Okay.
    Mr. Monacelli. You know? There is still some of us 
dinosaurs out there, but--and that understand both sides of 
this, and now, really, more understand the injury side.
    And we are trying to educate those younger ones coming 
through, and at the athletic directors conferences and the 
coaching conferences, this is becoming the workshop topic.
    Mr. Poe. Well, nobody ever got better academically by 
getting a kick to the head. I totally agree with that.
    When these students come in, Dr. Gioia, to your clinic 
and--do you all evaluate them with MRI, C.T., psychological--
how are they evaluated?
    Mr. Gioia. Many of the kids have had either typically C.T., 
maybe MRI, as a screening. But what we know is that 
conventional neuroimaging methods of C.T. and MRI tell us about 
the hardware of the brain, and we use that mostly to rule out 
more catastrophic problems.
    Research now is looking at some of the more advanced 
neuroimaging that allows us to look at the software systems. 
But the bottom line is those are experimental research methods 
right now.
    So what we do is we look at their neuropsychological 
functioning, their neurocognitive functioning. We do very 
specific symptom-based assessments. We ask parents and the 
student athlete to tell us about those--so that we use a set of 
information to basically look at that profile.
    The cognitive testing that we use is similar to what Coach 
Monacelli is using, the ImPACT software, and there is a variety 
of ones out there. The bottom line is we need both objective 
and good measurable tools in order to look at that level of--
well, first, impairment, and then the level of recovery and to 
guide that along the way.
    The other thing, of course--and you will know this as much 
as anybody on the panel--is that the relationship with the 
family and that--and that patient is critical. And to 
understand the nature of the sports injury is critical in the 
athlete.
    It is very difficult for them to be sitting out, and quite 
honestly, when I was playing, you know, high school football 
and wrestling and all those good sports, you know, my main 
focus was being on the field.
    I think it is where we also have to bring perspective to 
the responsible caretakers, the parents, the coaches, the 
teachers, but at the same time, we also get a message across to 
the teammates.
    A teammate that sees their friend impaired and who has 
knowledge now about the dangers of this injury really has 
responsibility for helping that teammate get off the field, 
letting the coach know. You are not snitching on your teammate, 
you are actually responsible for their health. They may not be 
able to make that decision on the field.
    So there is a variety of places where we really need to get 
that message across, and the relationship is very important.
    Mr. Poe. Okay.
    Thank you, Mr. Chairman.
    Chairman Miller. Mrs. McCarthy?
    Mrs. McCarthy. Thank you.
    And I thank you for your testimony. It certainly is a 
subject that we should be definitely doing something about. And 
I want to thank again my colleague from New Jersey for the work 
that he has done on TBI.
    One of the things that I have been working on for a number 
of years is making sure or hoping to make sure that we have 
school nurses in all schools. When I started looking at the 
issue, some schools have one nurse for 5,000 to 7,000 students, 
which is totally unacceptable.
    But with that being said, we know that some schools have 
school nurses, they have athletic trainers, as far as picking 
up the symptoms.
    But I think the most important thing for why you are all 
here--and certainly, there is a number of pieces of legislation 
to work on that--what would you all like to see as far as what 
we need to do to certainly make it more aware and to help you 
and, certainly, the coach, the doctors, the students to make 
this, certainly, as safe as possible? What would you want us to 
do?
    Ms. Rainey. Well, currently, what I have been doing is I 
have been going to two of my classes and then I have been 
taking a nap at the nurse's office during the third class and 
then trying to make it to my fourth.
    Sometimes I have had to leave early, but, I mean, having my 
school nurse there has really been a help for me in my 
situation.
    Mr. Gioia. You know, again, I think, really, what--first of 
all, having the committee recognize this problem, you know, at 
the youth level is critical. We always show the triangle, and 
we talk about the elite athlete at the very tip of that 
triangle and, really, the youth are at the majority of that 
triangle.
    We really have to work to put universal education and 
management programs in our schools, but it is--and I think it 
is important to recognize this is not simply a high school 
problem. It is also a youth sport problem below the high school 
level as well. And in fact, one might argue that that is even 
less sort of structured around that.
    I think what we need to do is to build some good coalitions 
together. And I think, certainly, you know, with the leadership 
of Congressmen Pascrell and Platts and looking nationally at 
this problem, but also looking at the state level.
    I think our individual states need to understand how can we 
put in place the education of all stakeholders, including the 
school personnel, not just the coaches, parents, student 
athletes, officials, but the school personnel, because that 
will be where the kids spend most of their recovery time, not 
on the field.
    And in doing so, you know, looking at the collaborative 
efforts that are going on right now, the American College of 
Sports Medicine together with the Sarah Jane Brain Foundation, 
a number of the national governing bodies of sports are looking 
at this together. How do we really build those coalitions?
    But the other problem is that we don't have all of those 
personnel in place. I think each state needs to look at what 
are their resources that will allow us to build that proper 
team to both identify the problem and to manage it properly so 
that child goes back onto the field when they are ready, and 
that their education is managed properly.
    Looking at that team in the school, in the medical 
community, we truly don't yet understand this injury entirely. 
I mean, when I am managing this in the clinic, I am using my 
best available knowledge. We really need more research on these 
issues.
    We know that an injury to that 6-year-old is very different 
than the 11-year-old and the 16-year-old. What we are hearing 
and what we are believing is that the difference between boys 
and girls may be really substantial.
    And then we also know that kids that come into sports with 
other kinds of developmental or neurological disabilities--
ADHD, learning disabilities--that is a different brain, and the 
response to that injury is different.
    But we don't entirely know how that plays out individually, 
so we have got to understand this research-wise and put that 
into evidence-based practice. And again, I think Dr. Kohn's 
slide was really important. It shows the community of 
individuals that really deal with this injury. It is not just 
medical. It is not just the coaches. It is the entire school, 
medical, athletic systems together.
    So I think if the committee can see, you know, what is 
that--you know, what is a universal plan that can really 
coordinate nationally but also look at individual adaptations 
per state--certainly, we have tried to articulate some of that 
in our PABI Plan as a start, and I certainly would like the 
committee to give that some serious consideration.
    But then looking at what are the resources that we need to 
then bring together the people to put this in place--and I 
know, Congressman Pascrell, you have talked about how can we 
then convene the professionals.
    Certainly, the CDC has been an important champion for this, 
and the guidelines in bringing together the American Academy of 
Pediatrics, the American Academy of Neurology, is something 
they are trying to pull together as well.
    So it is a big problem with many different facets, but if 
we can at least begin to bring the coalitions together and 
really think about what is that first road map for 
implementation, we will be much further along the way than we 
were last year. Big task.
    Mrs. McCarthy. Thank you.
    Chairman Miller. Congresswoman Woolsey?
    Ms. Woolsey. Thank you. Mr. Chairman, I would be delighted 
to yield some of my time to Sarah so she can tell us her 
question--her story, if you are willing, Sarah.
    Ms. Rainey. Well, I was playing on the right side, and a 
ball--over and I was running after it----
    Ms. Woolsey. What was your sport?
    Ms. Rainey. Soccer.
    Ms. Woolsey. Okay.
    Ms. Rainey [continuing]. When a defender on the other team 
blind-sided me from my left side and drove through the side of 
my head, and I was knocked unconscious for a couple of seconds.
    Later a trainer helped me off the field. I got a drink of 
water and the coach put me back in for the remaining 2 minutes 
of the game and overtime.
    Ms. Woolsey. And the result?
    Ms. Rainey. When I got in the car I was having massive 
headaches, throbbing, and I told my dad, and we went to the 
emergency room later that night. And I stayed home the next 
day, and I didn't return to school until, I think, Thursday, 
and this happened on a Monday.
    And school has continued to be a challenge, and I haven't 
returned to any physical activity so far.
    Ms. Woolsey. Well, thank you for sharing your story with 
us.
    Ms. Rainey. Thank you.
    Ms. Woolsey. And thank you, too, Ms. Pelton. Thank you very 
much.
    You know, I want to talk about the parents' involvement in 
all of this, how difficult this must be to--for coaches and 
doctors, et cetera, because parents get really, really involved 
in their kids' sports activities.
    I am the mother of a son who graduated college and was an 
All American football player for two--his junior and senior 
year. And when he graduated, he came home, and he said, 
``Mother, I want to take you for a walk.'' Okay. He was a 
defensive guard, so he is a big guy. Okay.
    He said, ``I am through with football, and I want you to 
get over it.'' [Laughter.]
    Okay. I mean, you know, I mean--but that is--you know, we 
were so supportive of him, and he knew, and he had not been 
hurt, and he was--he said, ``My knees are good. My feet are 
good. I want to go on and have a different life.'' So you know, 
I believe that parents play a big role in this.
    In my district, I represent Marin County, just north of the 
Golden Gate Bridge, and in March a high school student in Marin 
was hit in the head by a baseball that was hit off a metal bat. 
And thankfully, he is recovering, but he spent weeks in the 
hospital in a coma.
    And his injuries spurred the debate in the league about 
whether or not metal bats are appropriate. Well, it was the 
parents in the other districts in this league that absolutely 
insisted that metal bats continue to be used, because they did 
not want their students to be--their kids to be disadvantaged.
    Marin County is not going to use metal bats and are willing 
to take the consequences. But parents--you know, they need to 
learn, and what--you are here, and your voices and the student 
voices--because not all parents are as wonderful as your 
parents are, so be very thankful for that.
    So I just wanted to point that out. Parents need to be part 
of this, and they need to be educated.
    I do have a couple questions. One question I have of Dr. 
Gioia is can a student who has been appropriately treated 
recover 100 percent or will they be vulnerable for the rest of 
their lives?
    Mr. Gioia. You know, every injury is different, but you 
know, both through--our clinical experience and the research to 
date shows that most students do--if managed properly--
identified early and managed properly do recover to their full 
capacity.
    But there are some caveats in there. Again, what we know is 
that if you have multiple injuries that have been repeated that 
have not been managed or identified, there can be a cumulative 
effect, and so--but certainly, in the kids that we have seen, 
where it has been a single--what we call uncomplicated injury, 
meaning that there aren't a variety of other complicating 
medical factors, their recovery is actually quite good when 
given the proper time and managed individually.
    Ms. Woolsey. I thank you.
    Coach, I have a question for you. First of all, I want to 
tell you I think you are great. My question to you--and I am--
is what do you do for prevention. I mean, I am going to assume 
that your athletes are as fit as they can possibly be, because 
that--does that not make a difference in prevention in the 
first place?
    Mr. Monacelli. Well, in the scheme of things, yes. Fitness 
is. In practice, you try to match up body sizes when you are in 
drills. But when the game comes, it is different. And that is 
where, you know, your other players, as you mentioned--somebody 
mentioned they recognize that something is not right in the 
huddle. Your athletic trainer is there. And then the process 
starts, you know.
    As coaches, we are trying to do as much as we can, and you 
know, it is good--it is good she is here, but not good she is 
here, that we are looking at female athletes, too, because we 
are all looking at bigger, faster, stronger here. And it is 
both genders.
    And so, you know, the process is out there to educate the 
parents, the students, to the fact that no, they are not laying 
off this practice or these drills and they are not relaxing 
here, and same thing with the coaches, too, so----
    Chairman Miller. Thank you.
    Mr. Loebsack?
    Mr. Loebsack. Thank you, Mr. Chair. This really is an 
important hearing, and I am really glad to be here, and--to 
listen to and read the testimony of all of you, especially 
Sarah and Michelle. Thank you. It takes a lot of courage to 
come to a place like this and to offer your testimony.
    I do want to thank my colleague, Mr. Pascrell. He has been 
working so hard on TBI issues. I am on the Armed Services 
Committee and been overseas to Afghanistan, Iraq and the 
Landstuhl Regional Medical Center and done a lot with the V.A. 
hospital in Iowa City. TBI is such a huge issue for our 
military.
    But putting what you are talking about today into that 
larger context of TBI I think is really absolutely critical, 
because this is a part of a much larger problem. And again, I 
want to thank Congressman Pascrell for being here today as well 
and participating in this.
    I like the focus on community, Doctor. I think we have to 
do that in--with respect to so many aspects of education and 
athletics. We don't do enough of it, and especially the 
awareness part of it.
    Also, I think whatever we do, it does, as I think everybody 
here agrees, has--it has to be evidence-based. And I noticed on 
page three of your testimony that we really don't still have a 
handle on the exact scope of this problem, because we don't 
know the incidence of concussion in every sport.
    How do we do better, first of all, at identifying the 
problem?
    Mr. Gioia. Well, it has got to be at multiple tiers, but 
the bottom line is by making sure that we educate people at all 
levels--parents, coaches, kids, medical professionals, school 
professionals--so they have the awareness and the knowledge, 
number one. But we have to put a reporting system in place that 
really captures that information.
    Again, the good work that has been done at Nationwide 
Children's by Dawn Comstock and her group is very good data, 
except what we know is that data reported only to the athletic 
trainer is, again, another tip of the iceberg.
    When we ask athletes after the season, when their threat is 
gone for losing time, and/or we ask them a different question 
rather than, ``Did you have a concussion,'' instead we start to 
articulate what that means, we see much higher rates.
    So we have got to find and develop--and we can do this--
data systems and data capture systems that really look at the 
reality of the problem, and in ways that, you know, are 
collaborative. I know athletes feel threatened at times. But 
again, if they understand the nature of the problem, we hope 
that they will be on board a bit more with us.
    That is a tall task, but I think it is an attainable task, 
and it is going to be different than the more narrow-based 
approaches that we have right now.
    I mean, certainly, being in this field, there isn't a day 
that goes by that I don't see a friend and I hear about their 
child or, you know, their friend's, you know, concussion. And 
most of those weren't reported along the way, so we know that 
we have to have a different system in place.
    Mr. Loebsack. In some ways, it is not unlike trying to 
determine just how prevalent TBI is----
    Mr. Gioia. Yes.
    Mr. Loebsack [continuing]. Among our veterans and trying to 
screen as best we can, obviously, for TBI there.
    But to me, just finding the incidence and getting the 
actual accurate data for just how many athletes in particular 
sports in the aggregate actually suffer concussions--we have to 
have those data in the first place before we can deal with the 
issue, it seems to me.
    And I want to go back to prevention. Congresswoman Woolsey 
mentioned that. Obviously, the only way that we can prevent 
concussions in athletes is to not have contact sports, but that 
is not going to happen. None of us would like to see that 
happen, I don't think. We would like to see sports continue. 
They are wonderful for a variety of reasons.
    But can any of you--and, Coach, if you would like to speak 
just a little bit more--you didn't have a lot of time to answer 
Congresswoman Woolsey's question. But how do we prevent this 
from happening in the first place? And anyone else who might 
like to weigh in on this.
    Mr. Monacelli. Well, it is tough. You know, as much safety 
procedures that you have in place on the practice field, on the 
game field--again, I go back to what athletes are--those young 
men and women are competitors, and they want to play, and they 
want to get at it.
    Excuse the expression, but they want to play the game, you 
know? And they are going to play it hard whether it is male or 
female, and sadly, these things happen, just like the sprained 
ankle or the blown knee. The issue is now we are recognizing 
this. It is so easy to recognize the blown knee and the broken 
ankle or whatever. But it is not and it has never been very 
easy, and still isn't, to recognize this internal injury.
    So education is the preventive tool. Safety equipment is a 
preventive tool. Safe practices in practice and games is 
prevention. But that is no panacea for what is going to--the 
possibility that it is going to happen.
    Mr. Gioia. Yes, there is a--you know, a big focus right now 
on a number of those levels that the coach mentioned. Many of 
the national governing bodies are looking at their sport. How 
can we address the coaching technique? So in football--again, 
we use that--but in hockey, in lacrosse, in soccer--and how do 
we also reinforce the rule enforcement around those rules?
    Are there particular aspects of sports where we need to 
modify the game? We know that some of the most catastrophic 
injuries in football happen on the kickoff. Is there something 
we need to do to modify that?
    Then, is there equipment that can be protective? We know 
that is not the whole answer. A lot of people say, ``If I only 
had a better helmet.'' Well, no. The helmet is going to absorb 
some force, and more and more technology is being developed to 
absorb that force to an even greater extent than the foam that 
we previously had used. But we know that that is only part of 
the answer there as well.
    The good news is that many of the national governing 
bodies--and literally this past Tuesday--met with a group--our 
collaborative sports medicine group to look at what is the next 
steps we take with our organizations at all of those levels.
    Mr. Loebsack. Thank you all. Thank you.
    Thank you, Mr. Chair. Mr. Chair, thanks.
    Chairman Miller. Mrs. Biggert?
    Mrs. Biggert. Thank you, Mr. Chairman.
    Dr. Gioia--is that right? Thank you. I was surprised to see 
that according to a study by Dr. Luke Gessel published in the 
Journal of Athletic Training the sport with the highest--second 
highest number and percentage of student concussions was girls' 
soccer, and it was second only to boys' football.
    Do you have any concern--are there any concerns that girls 
and boys may react differently to head trauma? And is there any 
research in this area?
    Mr. Gioia. This has been a topic of discussion and research 
as well. What we see when we pair together similar sports--
girls' soccer, boys' soccer--we look at baseball, softball and 
basketball--those are our three closest sports. When we look at 
lacrosse, they are--the game is played differently. We have got 
hockey. It is a little bit different. There are similarities, 
but there are a lot of differences.
    What we see is there tends to be a relatively higher 
incidence of the injury in the girls' sports. What we are 
trying to understand is why that is. This is a biomechanical 
injury. Now, it may be that there is something about the brain 
that doesn't take that force as well in the girl.
    It may also be that the neck is different so that the head, 
when it is taking that force, is not buffering it through the 
whole body because it is not as solidly attached, so to speak. 
And so there may be a variety of factors. Some say maybe the 
girls are reporting the injuries more so.
    I can tell you that at the upper levels--and my own 
daughters played upper level lacrosse--they will lie just as 
simply and easily as the boys will, so I am not entirely sure 
that is the simple answer, but it may be a combination of 
factors.
    So there seem to be differences. We don't quite understand 
what those--what is behind those differences. We need to 
understand that further with more research. And again, I will 
also throw the age factor in there, too. We need to understand 
why younger kids are taking longer to recover than older--than 
college and professionals.
    Mrs. Biggert. And then are you concerned about the 
potential for head trauma from repeated sub concussive blows?
    Mr. Gioia. Oh, absolutely. I know Dr. Cantu and the group 
in Boston has been talking about that. Again, this is where 
research is going to come in. If we can put in place some of 
the things that are happening in helmeted sports, where we have 
accelerometers that can start to look at the extent, magnitude 
and direction of that force to the head, and look to see are 
there--are those producing concussions--and again, that goes 
back, then--is there a different way to coach the game that may 
reduce the amount of that sub concussive blow.
    Mrs. Biggert. Well, in one of my former lives I was an 
assistant soccer coach for girls, and teaching them to do the 
header--is that something that should be avoided? And I heard 
that it was bad, so we stopped doing it but, I mean, except for 
very, you know----
    Mr. Gioia. Yes, the data actually has not shown that 
purposeful--purposeful--heading is the reason for concussions 
in most kids. Now, there are always exceptions. Why is that? 
Purposeful heading is when you are preparing the body now for 
that blow. And again, it is all about distributing that force 
biomechanically through the body.
    When the head is hit by an errant soccer ball or you are 
not prepared for it, that is when we see the injuries. And 
again, it is a different biomechanical load on the brain at 
that time.
    Mrs. Biggert. Right. Well, then, in my district we have 
done some preliminary research or have seen some--some research 
on treating returning veterans with TBI in hyperbaric chambers 
and also looking at even autistic children. Do you see any 
potential for eventually treating athletic traumas in this way?
    Mr. Gioia. You know, the whole area of treatment--we are 
really on the forefront right now. It is just beginning. And so 
part of the issue here is we need to understand what is 
happening to the software of that brain, to then look at what 
are the treatments we want to put in place.
    My colleagues at the University of California, Los Angeles, 
UCLA, in their Brain Injury Research Center are using very 
interesting models of research in looking at this problem. We 
are starting a software imaging study where we can look at what 
are the chemical changes. That, then, will allow us to say what 
are either the medicines or the other kinds of treatments that 
we want to put in place acutely.
    Mrs. Biggert. Have you seen the hyperbaric----
    Mr. Gioia. I have seen that. It has not yet been, 
obviously, applied to the sports or to kids all that much.
    Mrs. Biggert. Okay, thank you.
    And if I have got one more time, Dr. Kohn, in your view, 
how successful have the state laws in Washington and Texas and 
Oregon and Virginia been at educating teachers and coaches and 
parents in how to identify and treat concussions?
    Ms. Kohn. All three state laws were passed relatively 
recently. The oldest one is Texas, which was passed in 2007, 
has been in place for 3 school years. Washington and Oregon 
laws were passed in 2009. The Washington law was implemented 
for just the school year that is ending. Oregon is not in place 
yet.
    So they are all really relatively newly implemented, and 
I--we were not aware of the evaluations yet that have been 
done----
    Mrs. Biggert. Okay, so you wouldn't know which provisions 
have the greatest possible effect yet, but----
    Ms. Kohn. We don't know of the evaluations that have been 
done on them yet. They are all really quite new.
    Mrs. Biggert. Great, thank you.
    I yield back.
    Chairman Miller. Thank you.
    Mr. Andrews?
    Mr. Andrews. Thank you, Mr. Chairman.
    I would like to thank the panel for their excellent 
testimony this morning. We have heard from a lot of different 
perspectives, all of them very valuable. Thank you.
    Dr. Kohn--is it Kohn or Khan? I am sorry.
    Ms. Kohn. Kohn, but I will answer to anything.
    Mr. Andrews. Okay, Dr. Kohn. Thank you for the excellent 
work that you and your colleagues at GAO do. I understand there 
are three national databases that exist that you took a look 
at, is that right?
    Ms. Kohn. That is right.
    Mr. Andrews. And the conclusion that you drew is that you 
really can't draw any conclusions from the databases about the 
incidence of concussions among high school athletes. Is that 
right?
    Ms. Kohn. Correct.
    Mr. Andrews. What could those databases do that would 
permit us to have more robust data so we could draw some 
conclusions? What is missing?
    Ms. Kohn. The database that is most targeted to the 
population of interest here, high school--high school athletes, 
is the database out of Columbus, Ohio that I referenced 
earlier. That database has produced the incidence numbers that 
have been widely cited, and it is only based on nine sports.
    Over time, since those studies have been done, as recent as 
they are, more sports have been added to the database, so they 
now cover 20 sports. So that is a growing expansion of the 
coverage of sports that we have information on.
    The databases, all three of them, also have information on 
the circumstances under which the injury occurred.
    Mr. Andrews. I assume that you would agree that the more 
data we have, the more effective we can be at diagnosing the 
causes and eventually treatments. Is that correct? You want 
more robust data.
    Ms. Kohn. More information on the circumstances under which 
the----
    Mr. Andrews. Right.
    Ms. Kohn [continuing]. Injury occurred can provide 
actionable information to develop and target programs----
    Mr. Andrews. Do you have any suggestions as to things 
Congress might do to encourage or facilitate the gathering of 
more meaningful data?
    Ms. Kohn. At the current time, CDC does support a couple of 
the databases. The one at Columbus has received federal 
support, as does the one at Consumer Products Safety 
Commission.
    Mr. Andrews. So it would be more a matter of the CDC 
continuing that support, perhaps doing a bit more with it. Who 
maintains the database in Columbus? Who is the sponsor or 
keeper of it?
    Ms. Kohn. It is at the Nationwide Children's Hospital. It 
is a private effort with public support.
    Mr. Andrews. Okay. And are the data that are in that 
database publicly available for researchers to take a look at?
    Ms. Kohn. It is not a searchable database at the moment. It 
is not available to the public. The researchers aggregate 
information. They publish it in peer-review journals. But it is 
not available to researchers.
    The database at Consumer Products Safety Commission is a 
public searchable database.
    Mr. Andrews. Now, Coach, thank you for the leadership role 
you have taken in protecting your athletes, educating your 
athletes and your peers as well. What tools do you think a 
coach needs to be sure that he or she can make the maximum 
effort that you have made? What are the critical pieces to a 
successful education, prevention and treatment program in this 
area?
    Mr. Monacelli. In New York State, we mandate that they have 
to take coaching courses, philosophy and principles and so on, 
which starts getting into just what it is, philosophy. It is 
not just winning. It is participation and all the good things 
that go along with that. That is critical.
    Also, good leadership within your own district, you know? 
We are looking at where can the government help, and we only 
have three states, really, on board. Each state really--and 
then it is trickle-down from that. The states and the--their 
local districts have to get on board to make this mandatory. 
This is important.
    Mr. Andrews. What are the actual tools needed, though? For 
instance, do you need access to--let me ask you this question. 
Do you have a team physician that works with you?
    Mr. Monacelli. We are a small district. We have a better 
situation than some small districts. We have an athletic 
trainer on site for all collision sports, but not every sport. 
It is not softball or baseball, where something can happen.
    Mr. Andrews. Is that a paid school district employee, that 
trainer?
    Mr. Monacelli. Pardon?
    Mr. Andrews. Is the school district paying the trainer?
    Mr. Monacelli. Yes.
    Mr. Andrews. Is that an employee?
    Mr. Monacelli. Yes.
    Mr. Andrews. Is that typical in your part of New York or 
atypical?
    Mr. Monacelli. Not typical. Depends on finances.
    Mr. Andrews. Yes. Can you describe to us what the risks are 
if a trained athletic trainer is not present?
    Perhaps, Doctor, you would like to join in that, too. You 
know, what if a kid has a head injury during a game? What kind 
of things does a trainer do right on spot to deal with the 
problem?
    Mr. Monacelli. Well, now it goes back to when I coach 
without a medical personnel, and we are talking athletic 
trainer, not the local physician, too, and----
    Mr. Andrews. Yes.
    Mr. Monacelli [continuing]. The local physician has--they 
have their expertise, too. But athletic injuries is a different 
wrinkle. And to have someone trained in athletic injuries and 
diagnosing those on the spot--it makes safety a heck of a lot 
easier for us----
    Mr. Andrews. I see my time is up, but if, Doctor, you would 
like to briefly answer the question----
    Mr. Gioia. Yes, Congressman Andrews, you are hitting on an 
important point here. Only 42 percent of the high schools in 
the United States have certified athletic trainers. They are 
our immediate athletic health professional that identifies and 
diagnoses that injury. They are critical. They are critical at 
the high school level. They are critical at the youth level.
    Mr. Andrews. How are they critical medically? What kind of 
things can a trainer do right on spot when the athlete gets 
hurt that could make a big difference?
    Mr. Gioia. They are doing active medical evaluation of that 
injury. You know, when somebody goes down, there are many, many 
possibilities that it could be. Some of them could be life 
threatening. Some could be, you know, permanently impairing, 
like a spinal cord injury. They are doing very important early 
diagnoses of the capacity to breathe, to move----
    Mr. Andrews. Right.
    Mr. Gioia [continuing]. Blood circulation, the important 
things there. And then they go through their checklist. They 
are live-saving individuals, in addition to disability reducing 
individuals as well. Critically important.
    Mr. Andrews. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Miller. Mrs. Davis?
    Mrs. Davis. Thank you, Mr. Chairman.
    Thank you to all of you for being here. Wanted to ask you 
about school-based health centers. There were two provisions in 
the health care bill that relate to this.
    And I wonder whether you have had a chance to look and see 
whether they play any role at all, whether schools that have 
school-based health centers do a better job educationally, do a 
better job in follow up, and just generally, I think, trying to 
disseminate better information for students about injuries that 
they receive.
    Mr. Gioia. You are asking----
    Mrs. Davis. Sure, go ahead.
    Mr. Gioia. Yes. You know, I will say that the most 
interested group that I have worked with in the school system 
are the school nurses and the school health professionals. We 
have health aides in Maryland as well.
    And I think they are a central place where both they 
identify an injury that could happen in the school--a child 
falling--but also they are the place that receives the 
information and disseminates that, then, to the--to the 
teachers.
    So I will be quite honest with you that I am not as 
familiar with the health center concept, but I can tell you 
that the individuals that populate those centers, I am sure, 
are critical folks, and they have been our greatest advocate as 
we then go from the kids back to the schools, making sure they 
get those care plans, they understand that.
    And again, the nice thing about the new school toolkit is 
it has very specific tools, assessment tools--monitoring of 
symptoms, management strategies that they can reinforce in the 
schools. So I think putting those into the health center 
concept will really be quite useful in helping kids return to 
school.
    Mrs. Davis. Coach, I don't know whether any of you have any 
experience with school-based centers, whether that provides a 
model in schools. And certainly at the state level, looking at 
that issue, that might be helpful.
    Mr. Monacelli. I am sorry, I didn't catch that.
    Mrs. Davis. The school-based health centers that are 
located on school grounds, particularly in high schools--you 
are not familiar with the----
    Mr. Monacelli. Again, with being----
    Mrs. Davis. Okay.
    Mr. Monacelli [continuing]. A small district, we are----
    Mrs. Davis. Right.
    Mr. Monacelli [continuing]. Very fortunate----
    Mrs. Davis. I understand.
    Mr. Monacelli [continuing]. To have an athletic trainer, 
you know?
    Mrs. Davis. Yes, okay. One of the things that I think is 
very positive about that is it is really the education piece, 
and that is--part of the concern, I think, is that we know that 
the incidence of reporting perhaps isn't as high as it should 
be, and that, you know, for whatever reason--because kids don't 
want to say anything, they don't recognize the symptoms--I 
don't know whether there is any disparity in terms of gender 
and whether the fact that you have more women who seem to be 
affected is by these injuries--whether reporting is any 
different, a higher incidence and recognizing symptoms. I don't 
know if that is an issue.
    I wanted to just go to--for a second, though--I think in 
Congressman Pascrell's legislation that that is being thought 
through--one of the issues is about having a baseline in order 
to determine the extent of an injury and what is going on, you 
know, with a youngster after perhaps a fall or an injury--
whatever.
    And I know that we are struggling in the Armed Services 
Committee, actually, on traumatic brain injury, and there is 
some controversy over whether there is a good baseline tool to 
determine that. Do you think that that is an area that there is 
a lot of promise in in terms of high school injuries?
    Would it be that every person playing sports would have 
some basic test to determine kind of their baseline so that you 
have something to go on later on? How do you see that coming 
together?
    Mr. Gioia. Well, I know that Coach Monacelli is doing that, 
and we are doing baseline testing in a variety of school 
systems around the Baltimore-Washington area.
    In the ideal, having a baseline on every student athlete 
would be very useful. There are some challenges, though, both 
logistically and there--the tools that we are using are not 
perfect. And one of the things that we have to respect is that 
it may be a challenge to get.
    And we are doing this, actually, in the Howard County 
school systems here in Maryland this year. We are going to have 
all of our high school athletes, with the exception of very few 
sports, baselined. But we have to start that early. Because of 
the crush of fall sports it is a challenge.
    The personnel that are available are limited. If you have a 
school without a certified athletic trainer, you are going to 
have--it is going to be hard to do that.
    You also need doctors who are familiar with the 
interpretation of that information as well. So you have got to 
build a resource system around that, as well as a logistical 
process.
    And then we also have to recognize that these aren't 
perfect measures, and that is where the clinician----
    Mrs. Davis. Is there an element of self-reporting that you 
think is helpful on the part of the students to be able to fill 
out questionnaires and--I understand that is definitely not a 
perfect tool, but----
    Mr. Gioia. Yes.
    Mrs. Davis [continuing]. I wonder, to the extent that 
schools are actually doing that and trying to ascertain the 
extent to which students have headaches----
    Mr. Gioia. Yes, I mean, that--part of the baseline test is 
actually a baseline symptom report as well. What are the normal 
degree of headache in that individual, concentration problems, 
and that sort of thing? So that is the important part to know 
ahead of time. So again, the concept, I think, is an important 
one. Implementation is going to be a challenge, and we need to 
think----
    Mrs. Davis. Sure.
    Mr. Gioia [continuing]. About the resources to do that.
    Mrs. Davis. Right. Thank you.
    Thank you, Mr. Chairman.
    Chairman Miller. Thank you.
    If I might, Dr. Gioia and Sarah and Michelle, it seems that 
the aftermath of this--of a serious concussion incident is 
somewhat of an isolating event for young people. You are kind 
of--you are thrown out of your normal schedule. You are thrown 
out of your normal activities. And you are kind of on your own 
to navigate this the best you can, and whether or not you have 
access to a knowledgeable doctor or medical personnel would be 
very important in that.
    And I just wondered, are there discussions--and maybe, Mr. 
Schmutz, you can come in. Are there efforts to try to provide 
some support groups in a region or an area for young people who 
are going through this?
    Because it challenges many of your own self-concepts about 
where you thought you were going with your future--in your 
case, going to college to play softball, Ms. Pelton, and this 
was the sport you loved, and all--and all that is kind of 
brought to an abrupt halt, and I just wondered how we deal with 
that. Are there examples of dealing with that side of it?
    Mr. Gioia. You know, one of the groups that we have not 
mentioned, and we are remiss in doing this, are the brain 
injury associations in each of the states. They play really 
important roles and are truly the advocating organizations for 
families and for kids and for individuals that have had the 
brain injuries. And many times they will provide those kind of 
support structures.
    But I also think that in their collaboration with school 
systems, if we think about whether that is a place where some 
of this education would happen, some of that support, if you 
will, would happen, that would be a good collaboration, brain 
injury associations and school systems.
    But I think it is important--you know, the--and I would 
actually leave it to Michelle and----
    Chairman Miller. Michelle or----
    Mr. Gioia [continuing]. Sarah to talk about.
    Chairman Miller. I mean, who do you turn to? Your mother 
and your stepfather are here.
    And, Sarah, your family. But this is kind of a tough 
discussion, because it is a limitation on what your normal 
activities are. You said your friends supported you. I just 
wondered if you think there should be other support systems in 
place.
    Ms. Pelton. Yes, there should be. I actually--there was a 
girl from my high school that got a concussion from--it wasn't 
sport-related, however, but I did sit down and talk with her 
and everything, and she found it helpful, because I could 
understand what she was going through.
    And you know, there is--in my dugout where I played 
softball for several years, there is going to be a sign up 
for--in the dugout for signs and symptoms of a concussion 
where, you know, coaches will know when to take the kid out of 
the game.
    Chairman Miller. Thank you.
    Sarah?
    Ms. Rainey. I think it goes back to the awareness part. I 
mean, it is hard because the teachers then--I mean, before I 
got a concussion, I didn't know what a concussion was, or stuff 
like that.
    Chairman Miller. Yes. Thank you.
    Mr. Schmutz?
    Mr. Schmutz. Yes, I am not familiar with support groups, 
but I think it underscores the point of a holistic approach as 
it relates to the education. You know, I had an experience 
where--similar to some of these experiences, where a friend of 
mine's son, 10-year-old hockey player, comes off the ice, takes 
his helmet off. Coach--he is the best player on the team.
    Coach says, ``Michael, can you put your helmet on and go 
back in the game?'' A 10-year-old kid does not really know how 
to say no to the coach but needs to understand how to 
articulate to the coach, ``I can't go back in, Coach,'' so he 
doesn't expose himself. And I think the holistic piece as it 
relates to parents even--and athletes understanding.
    Now, if they haven't experienced it, they don't know what 
it feels like--it is an invisible injury, as it has been told. 
There is no cast to sign. There is no blood. There is none of 
that. But to the extent that we can help dispel some of the 
ignorance, I think that can lead to some of these support 
systems being better positioned to support athletes who go 
through this experience.
    Chairman Miller. Thank you.
    Ms. Kohn, when you listen to the cross-section of testimony 
here and the information you have given us, are we--are there 
gaps that are still missing after we listen to the 
recommendations and the suggestions here that we should be 
paying attention to?
    Ms. Kohn. Certainly, the information in terms of the 
circumstances under which the injuries occur that can provide 
actionable information, so the number is important, but also 
just having more information to be able to take action. Action 
doesn't have to wait for any particular number to be developed.
    And also, the other part of the federal role at the present 
time is the education that is in place from CDC, and I heard 
that today in terms of the education and the convening function 
that CDC is also performing, and that also seems to be based on 
the other comments here today, that convening function seems to 
be very important as well.
    Chairman Miller. Thank you.
    Coach Monacelli, I played 4 years of varsity football in 
high school, and I played 3 years on a team where all we were 
told to be was tough, and we never won a varsity game.
    And I played 1 year on a team that was number one year 
after year after year in northern California, and all they told 
us to be was smart. And we never had any--we only had 1 day of 
contact or half a practice of contact on the smart team, and on 
the other team all we did was just run into one another, head 
first, day after day after day.
    Practice is a big part of this problem, I would assume, 
also, because people are trying to challenge one another for a 
position, a starting position, what have you. And in the 
testimony it is mentioned at different times. But that would 
seem to me that that is--there is an awful lot of opportunity 
in practice to suffer these concussions. If people want to 
comment----
    Mr. Monacelli. That is why as a coach you try to match up 
body sizes when there is one-on-one drills and things like 
that. But it is not like wrestling where it is more--the match-
ups are easier there. You have that 160-pounder going against 
that 260 on a lot of occasions, especially, you know, in game 
situations versus even team drills.
    One-on-one drills you control. Two-on-two drills you 
control. But the bigger arena you can't. So that is where you 
encourage the off-season conditioning. That is where you spend 
time as a coach making sure you, as head coach, and your 
assistants are well aware of the situations that could put an 
athlete in jeopardy.
    And then when you suspect, because of your background, and 
when you suspect, you can get them out of there and start, you 
know, a medical protocol to double-check this, and hopefully, 
you know, it is not happening. But in some sports you just 
can't get away from true safety issues other than to educate 
everybody involved.
    Chairman Miller. Thank you.
    Mr. Schmutz, in your testimony, your written testimony, you 
really lay out that we really have a lot of opportunities for 
education to take place and organize youth sports and school 
sports and the rest of this.
    And if there was ever an issue that jumps at the name of 
this committee, education, it clearly can have a huge impact. I 
mean, I always believe we solve most of the difficult problems 
in our society through education.
    And this is one where it is clear we have so many places of 
entry around the involvement of these activities that it really 
is a rich ground for education and where people's interest, 
their--you know, their self-interest and the--and alignment of 
education kind of go together, whether they are a referee or a 
coach or a player or a parent or a principal of a school or a 
school board or what have you, that it all sort of is aligned 
that this knowledge is really in your best interest to acquire.
    And it sounds like people are--through the various 
organizations they are responding.
    Mr. Schmutz. They are responding. Dr. Gioia referred to 
some of the national governing bodies. I think the key here is 
to continue the momentum. Clearly, we have come a long way in 
the last couple of years, but there is a long way to go.
    On the youth level in particular, you know, you have got 
volunteer coaches, you know, demanding more time of a parent 
coach to go to another meeting. Dr. Gioia and I were talking 
earlier, and he talked about a meeting he had with Montgomery 
Youth Hockey where he asked for 15 minutes and nobody left the 
room for more than an hour.
    So I think it is a matter of getting people to actually 
commit. That is where at a local--a team level, that particular 
meeting was required for those coaches to go. It takes somebody 
with the courage to require somebody and not be concerned with 
somebody who might say, ``Well, I am not going to do that. I am 
going to walk away.'' If their kid wants to participate, 
somebody is going to step up.
    I think we need to be more--hold these volunteer coaches as 
well as high school coaches more accountable to be--to take 
part in the education process. The resources are there. The 
need is to penetrate more.
    Chairman Miller. Anyone else? Yes, Dr. Gioia.
    Mr. Gioia. Let me just mention that, you know, I think, 
again, the examples of Coach Monacelli showing that he has a 
safe program and a successful program are really what we need 
to highlight, that using safe coaching practices, using the 
best available equipment, having knowledgeable people that can 
identify the injury--all of that together still produces five 
championships, you know, state championships, and that in that 
little state of New York that is not a small task, you know. 
That is quite a feat, having been a New Yorker myself.
    And so, you know, I think that is what we have to get 
across. This does not compromise the game, and you--but you can 
still be safe.
    Chairman Miller. Great. Thank you.
    Mr. Kline?
    Mr. Kline. Thank you, Mr. Chairman.
    And again, I want to thank the witnesses for being here 
today, Dr. Kohn for your research, and I know we have got a lot 
more to look at. We have got a limited number of states. But I 
very much appreciate your input today and your work, and I am 
sure we will be coming back to you for more work.
    And to Coach, again, congratulations. Congratulations on 
having winning season after winning season but really stepping 
up to recognize the program and get the community involvement 
as well as the coach involvement.
    Dr. Schmutz, again, thanks for everything that you are 
doing.
    And I think what I am hearing from all of you, and 
certainly including Dr. Gioia, is that in order for this to 
work you have to have Dr. Kohn's diagram work where you have 
everybody, and it is not something that can be mandated or 
dictated. You have got to get to the parents, and you have got 
to get to the coaches, and you have got to get to the school 
nurse and the teachers and the students, and that--that takes 
work and outreach.
    And so again, congratulations to you, Coach, for being 
successful in doing that. We need to see that everywhere if we 
are going to really have that awareness. As Dr. Gioia said, 
that you can have the winning season--well, maybe you have to 
have Coach Monacelli to have those winning seasons, but you can 
have winning seasons and still address this urgent need.
    And again, mostly to Sarah and Michelle, God bless you. 
Thanks for coming today and for telling us your story. We 
certainly hope that you have every success going forward in 
recovery. I know that it is very, very difficult. I told the 
story of the woman who is on my staff, and it was a long road 
and not a straight path.
    But you just have to stay with it, and I am sure you have 
got the love and support of your parents and an increasing 
awareness of your peers and your--and the people around you. 
You are going to make it.
    So thank you, Mr. Chairman. I yield back.
    Chairman Miller. Thank you, Mr. Kline.
    I would like to associate myself with the closing remarks 
of Congressman Kline and again thank all of you for being here.
    And, Sarah and Michelle, thank you again on behalf of all 
of the members of the committee, and we look forward to working 
with you. We think Mr. Pascrell has a pretty good idea here, 
but we need some help in fleshing out the details.
    So thank you very much.
    Without objection, members will have 14 days to submit 
additional materials or questions for the hearing record. Some 
members may want to submit written questions to you. If you 
could answer them, we would deeply appreciate it.
    And with that, the committee will stand adjourned. Thank 
you. Thank you.
    [Additional submissions of Mr. Miller follow:]

                     10 Point Plan to Save Football

    In the past few years, former football players have begun being 
diagnosed with Chronic Traumatic Encephalopathy (CTE), a progressive 
neurodegenerative disease caused by repetitive trauma to the brain 
which eventually leads to dementia. Some were famous NFL Hall of Famers 
like Mike Webster and Lou Creekmur. Others, like Mike Borich, only 
played through college. All died sooner than they should have, and all 
suffered terribly in their final years.
    Since the discovery of CTE in 1928, the disease has been seen 
almost exclusively in boxers, which is why it is often referred to as 
``punch drunk'' syndrome. However, it is now diagnosed regularly in ex-
football players, and in the past year, the Center for the Study of 
Traumatic Encephalopathy at Boston University School of Medicine (CSTE) 
has diagnosed CTE post-mortem in 11 of 11 former college and 
professional football players that died at ages ranging from 37-82 
years. This is significant, as the disease should not naturally exist 
in a single human being. The early stages of the disease have even been 
seen in an eighteen year-old former football player. In 2009, it is 
clear that football is in the midst of a brain trauma crisis.
    The game of football has not always been played as it is today. In 
fact, the most consistent aspect of the game has been change. In 1905 
the game was so dangerous, regularly killing participants, that 
President Theodore Roosevelt summoned the coaches of Harvard, Yale, and 
Princeton to Washington D.C. for a summit on how to make the game safer 
and threatened to take action in the absence of significant reform.
    From this meeting the American Intercollegiate Football Rules 
Committee was created, and that Committee, among other things, 
legalized the forward pass and made other changes to eliminate 
dangerous collisions. Over and over, football has had to be changed to 
be made safer. Now it faces a new challenge. CTE is a deceptive, quiet 
killer. The disease begins during a player's career and then hides, 
slowly killing brain cells until the athlete begins showing symptoms 
years later.
    Football has evolved into a something it was never intended to be.
    Football collisions may now be more dangerous for the brain than 
ever. With the combination of bigger, stronger, and faster players and 
hard-shelled helmets that are often used as a weapon to initiate 
contact, we've created a type of repetitive trauma to the brain that 
has never existed before.
    The discovery of CTE inside the brains of so many ex-football 
players has shown us that it is again time for change, and a new 
Committee. Only this time, it is a Committee to Save Football. Among 
high school students, football is the most popular sport in America, 
played by one in eight American boys. While football was first played 
by colleges, today football is a children's game, with 95% of 
participants under the age of 18.
    These children are not old enough to make informed choices. 
Therefore, in light of the new evidence of CTE in 100% of players 
studied at Boston University, it seems appropriate that we again 
reevaluate how we play the game of football before the 2010 season and 
at all levels of play: youth, high school, college, and professional.
    If we can agree that the game is broken and needs to be fixed, we 
have an incredible number of paths to a safer game without 
fundamentally changing football. If we know that practice collisions 
account for over 50% of brain trauma, the proposals below could easily 
eliminate over 75% of brain trauma and concussions today--it is simply 
a question of leadership.
    Below are 10 paths to a safer game that can and should be used to 
reduce brain trauma. This would serve as the basis for evaluating the 
options available to the Committee to Save Football.
1. Reevaluate how the game is practiced
     Greater than 50% of hits to the head occur outside of 
games. NFL teams rarely hit in practice due to risk of injury. Youth 
teams could only be allowed to have full-contact once a week. Dangerous 
drills could be banned or used less frequently.
2. Encourage mandatory brain trauma and concussion education for 
        coaches, athletic trainers, parents, and athletes
     Coaches, athletic trainers, and athletes cannot diagnose 
concussions if they aren't trained to look for them or know how to 
recognize them. Coaches, athletic trainers, and athletes will not 
voluntarily choose to rest concussions and reduce overall brain trauma 
if they don't understand why it is good for the athlete's short and 
long-term health.
3. Reevaluate protective equipment
     Investigate changes to helmets, shoulder pads, and other 
types of protective equipment to reduce brain trauma.
4. Develop better methods of concussion detection and diagnosis
     The CDC provides clipboards with concussions diagnosis 
protocols on the back at no cost. Coaches could be required to carry 
them. We can invest more in research to find simple, objective ways to 
diagnose concussion that can be utilized in any program.
5. Develop better methods of concussion management
     Return-to-play too soon after concussion can result in 
more extensive brain damage, and can actually result in death. It is 
now law in Washington state that players are required to see a medical 
professional with brain trauma expertise before return-to-play. Minimum 
return-to-play standards should be enforced at all levels.
6. Consider minimum medical resources
     Football is a dangerous game. Minimum medical resource 
standards, like having an athletic trainer or doctor on the sideline, 
should be considered.
7. Reevaluate techniques of tackling and blocking
     We can teach and enforce different methods of tackling and 
blocking that minimize contact to the head.
8. Reevaluate the rules
     Recently the NFL banned the wedge on kickoffs to reduce 
trauma. Many other rules could be changed, at all levels of football, 
to reduce brain trauma.
9. Reevaluate rule enforcement and the role of referees
     The NCAA recently began suspending players for intentional 
helmet-to-helmet hits. Referees could eject players for illegal hits to 
the head. Referees could be trained to identify concussed players on 
the field.
10. Reconsider the culture of the game
     Television announcers could stop glorifying illegal hits. 
Children could stop being pressured to play through concussions.
    The evidence now exists to support immediate and radical change to 
the game of football to dramatically reduce brain trauma. Let us not 
let this opportunity pass.
            Respectfully submitted October 28, 2009.
                                      Christopher Nowinski,
    Harvard Football 1996-1999; President, Sports Legacy Institute,
                  Center for the Study of Traumatic Encephalopathy;
                 Co-Director, Boston University School of Medicine.
                                 ______
                                 
                                 
                                 
                                 
                                 
                                ------                                


Prepared Statement of Niki Popyer, 17-Year-Old Former Basketball Player

    My name is Niki Popyer and I am a 17 year old junior in Marlboro 
High School, Marlboro, NJ and I appreciate the opportunity to submit my 
testimony regarding brain injuries in high school athletes.
    I have been playing basketball since I was in kindergarten. From 
the very first time I touched the ball, I was instantly hooked. As I 
got a little older, I started working on my skills and took every 
opportunity I could to learn and practice. Through the years, I 
progressed from rec ball, to travel, to AAU, and ultimately high school 
varsity, where I was a starting point guard as a freshman.
    Seeing my interest and dedication, my parents generously provided 
me with training, by coaches and professionals, who helped me hone my 
skills and develop into a nationally competitive player. As a freshman, 
I was already looking ahead to realizing my dream to play in college. I 
had already attended several showcases and sparked some interest. I was 
on top of the world, continuing my love for the game, achieving 
personal success, and playing with teammates from 4th grade. Some of 
them are still playing together, but without me.
    My first concussion was in seventh grade. My opponent and I dove 
for a loose ball at the same time, we collided and I hit my head on the 
floor. In my very next game, about a week later, I fell and slid into 
the wrestling mats. That was the first time we went to the emergency 
room where they checked me out, and told me to stay out one to two 
days. There were other head injuries and my parents took me to 
different doctors and each one told me something else. Having watched 
me play with broken bones, sprained ligaments, and chronic knee pain, 
no one was surprised to see me keep bouncing back. As long as they 
didn't stop me, I continued to play. I never really acknowledged how I 
felt, to myself or to anyone else.
    The last concussion I had in a game was what seemed like a minor 
hit, but my knees buckled and I hit the floor. Four weeks later I got 
accidentally hit in the head with the gym door that was pushed open by 
one of my best friends. After that, I felt lousy for a long time. I 
couldn't stand the lights or the noise, I was dizzy and nauseous. 
That's when the headaches got really bad and never went away. I cried 
all the time, I couldn't go to school, I didn't want to see my 
friends--nothing. I will never forget how I felt when the doctor 
finally told me I had to stop playing basketball forever. It actually 
made me sick to my stomach.
    I missed a lot of school and had teachers come to my house. When I 
finally went back for just a few hours a day, I was really tired and I 
couldn't concentrate at all. My grades dropped and I lost credit for 
classes I couldn't take at home. That was last year and this year I 
still can't make a whole day. I have had to move down to lower levels 
and make other changes. I struggle with subjects I used to do well in, 
so I lose interest quickly. Since there are so many things I can't 
participate in, I have lost touch with some friends. Because there are 
no crutches or bandages or casts, I look perfectly normal, and some 
people don't really believe me and that hurts. When those cynics are 
teachers, it sets a student up for failure.
    During basketball season, I attend all the practices and games, but 
the athletic trainer and athletic director sit with me to protect me. 
It's sad to be only able to watch, but at least I can feel like part of 
the team.
    Sports is only part of it. Life is much harder and I am left out of 
a lot of activities. I can't go to the movies, ride a train, swim, 
exercise, or ride the bus with my teammates. I wear earplugs to drown 
out the noise and sunglasses for the brightness, and I miss most of the 
parties. Still today, I am not allowed to participate in any physical 
activity, which is a terrible burden for someone used to being 
athletic. Because my brain hasn't completely healed, even a slight hit 
to my head makes me pass out and I continue to have setbacks like that. 
I have learned that it's not only the big hits, but even the dozens of 
somewhat minor impacts along the way that can change someone's life 
forever.
    Once, I dreamed of playing basketball in college, at any level, 
because that's how much I loved the game. Everything I did was working 
toward that. Without that goal, I have lost my direction and 
determination. Every day is a challenge and I struggle to maintain 
normalcy. Sadly, there have been teachers, among others, who have 
doubted me and derailed my recovery.
    What I want other kids like me to know is that it is much better to 
miss a month or a season or a year than it is to have your whole life 
changed. Many of my friends get hurt and refuse to tell anyone. They 
play with all kinds of injuries but with me they can't get away with 
trying to play after a head injury. I beg them to be honest with the 
school and with themselves.
    It is important for parents, athletes, teachers and coaches to 
learn more about the seriousness of concussions. I have been 
interviewed on television and in newspapers and was invited to speak at 
a press conference in the Capitol to help Congressman Pascrell and 
Senator Menendez introduce a bill that would improve awareness, set 
guidelines, and provide funding for computerized neurological testing. 
I talk to kids all over the country who are going through the same 
thing as me and I try to help them.
    I am lucky that our school now has a good support system in place. 
We have a certified athletic trainer who is knowledgeable about 
concussions and everyone uses the Impact test pre-season to get a 
baseline. Following a head injury, their return to play is based on the 
results of the post injury testing. The athletic trainer works together 
with the doctors to determine each case individually and prevent 
athletes from going back too soon. All schools should have what we have 
and all athletes must put aside their egos and bravado and stop 
thinking that they can play through anything. There is no shame in 
sitting out until you feel absolutely fine.
                                 ______
                                 
    [Additional submission of Mr. Gioia follows:]

 Prepared Statement of Sarah B. Rainey, Concussed High School Student/
                                Athlete

    Good morning, Mr. Chairman and Members. Thank you for holding this 
important hearing on the impact of concussions on high school athletes. 
My name is Sarah Rainey. I am a freshman student/athlete at West 
Potomac High School in Alexandria, Virginia. I am still recovering from 
a concussion that I sustained on May 12, 2010, during a high school 
varsity soccer match. My concussion ended my soccer season and has 
significantly impaired my ability to keep up with my school work. I 
appreciate this opportunity to share my experience with the Committee.
Soccer--The Beautiful Game
    My sport and passion is soccer. I have been playing organized 
competitive soccer since I was seven. In addition to being a starter on 
my high school varsity team, I play for a top club team and have been 
in the Virginia Youth Soccer Association's Olympic Development Program 
(ODP) for several years. I have played in competitive soccer matches 
from North Carolina to Rhode Island and in five European countries. I 
am a good youth player and hope to play in NCAA Division I in college. 
Although I'm only fourteen, I have a lot of playing experience and 
believe that I can speak knowledgeably about the risks of soccer at the 
highest youth and high school level.
    Soccer is the fastest growing sport in America. According to US 
Youth Soccer, there are now over three million registered players ages 
5 to 19 playing youth soccer in the United States. Although I don't 
know the numbers, soccer is now a major high school sport. Soccer is 
often called ``The Beautiful Game'' by its players and fans because of 
the free flowing non-stop action. However, despite the increase in 
popularity of the sport in the United States, many people still don't 
appreciate how physical the game is and that there are significant 
risks of injury to players. My attending emergency room physician was 
in that group of people. He told me how he didn't think my injury was 
likely to be serious because it is very rare that a player would get a 
concussion playing soccer. About twenty-minutes later, he was proven 
wrong, when a high school teammate of mine came into his ER with a 
concussion from the same high school game. I know that these numbers 
are not statistically significant, but out of the 18 girls on my high 
school varsity team, 2 of us have concussions now, and 3 others have 
sustained concussions within the past year. On my U-15 club team, 3 out 
of 15 players have had concussions within the past year, including me. 
My point is that it's not only football or hockey or some of the more 
obvious contact sports where players have risks of sustaining 
concussions. Also, girls play just as hard and are also at risk, not 
just the boys.
The High School Game
    Soccer is governed by an international organization called FIFA 
(Federation Internationale de Football Association). FIFA establishes 
the laws of the game. U.S. youth soccer and high school soccer use 
modified FIFA rules. Because the Committee is holding this hearing on 
the impact of concussions on high school athletes, I assume your 
legislative authority must include some oversight and governance of 
high school athletics.
    I can't speak to other high school sports, but I have a few 
observations about high school soccer. Soccer has developed primarily 
as a club sport in the United States. Most of the youth players start 
playing in non-school-related clubs and leagues in their elementary 
school years. Fairly early on, players choose to pursue either travel/
elite soccer or recreation/house league, depending on their skills and 
commitment to the sport. By high school age, the player development and 
competition at the top divisions within the travel soccer leagues is 
generally at a higher skill level and more advanced than that of the 
high school leagues. I'm not saying that high school soccer isn't good 
quality. I loved playing on my high school team and making varsity and 
starting as a freshman was a great source of pride to me. There are 
lots of strong high school soccer programs. However, my point is simply 
that the technical skill level and depth of player rosters on top level 
travel teams generally exceed those of most high schools.
    In addition to the greater variance of technical abilities among 
high school soccer players, there is also a larger variety of ages, 
sizes and fitness levels among high school players. In club soccer, 
both travel and house leagues, players compete against other players 
their same age. In travel soccer, teams are also grouped into divisions 
according to the team's skill level. For example, I play for a U-15 
(under 15) girls team in Division 1 of the Washington Area Girls Soccer 
League. This past season, to expand our competition, my club team 
played in the U-15 girls Premier Division of Region I which was 
comprised of the top 16 teams in our age group from Virginia to Maine. 
Thus, in club play, I play against girls my age or younger and at my 
skill level. By contrast, on my varsity high school team, I started as 
a freshman and played against players up to four years older than me. I 
loved playing for my high school, but there is a much bigger variance 
in the players competing against each other in high school soccer games 
and, because of this, the game is different.
    Because of the big difference in age, size and technical skill 
levels of high school soccer players, I think there is a greater risk 
of injury to players in the high school game than in the most 
competitive club leagues. However, I don't have any statistics to back 
up my claim; I'm simply stating my observation from my personal 
experience as a player. One of the most important things I think this 
Committee might do is to require the recording, reporting and tracking 
of serious injuries, including concussions. In addition to playing 
soccer, I also qualified as a youth soccer referee. In the youth game, 
most leagues require referees to submit a game report. I am not a high 
school referee, but I assume there is a similar existing game report 
requirement. In the youth leagues, officials have to report the score 
and any cards (disciplinary actions) that were given. However, in my 
experience, there is no requirement to record or report player 
injuries. It seems to me that it would not be too burdensome to modify 
the existing game report to add a check box and short description to 
record any injuries that were serious enough that a player had to be 
removed and could not return to the match. I don't know if anybody 
really knows with any accuracy the frequency that concussions occur in 
high school sports. I think it would be important and not too costly or 
burdensome to monitor. Then once you had a good handle on the magnitude 
of the problem, you could figure out how best to manage it.
    In addition to simply recording and reporting concussions and other 
injuries, I think there should be more awareness, training and 
education about the risks of concussions. I've learned first-hand that 
concussions are something that need to be taken very seriously. In 
soccer, there are generally 3 officials, a center referee and two 
assistant referees (sometimes called ``linesmen.''). The officials' 
primary responsibility is to ensure the safety of the players. It is 
not an easy job. Unfortunately, often the crowd and even some coaches 
and players give the referee a hard time. As a result, there is a 
shortage of soccer referees and, more specifically, good soccer 
referees. As I mentioned, I am not a qualified high school referee, but 
I have studied the FIFA laws and I am a qualified youth referee. There 
may be some different training for high school officials, but my 
experiences with referee training is that the courses focus on teaching 
the laws of the game and the mechanics of officiating.
    FIFA has established 17 laws governing the game of soccer. Law 12 
covers fouls and misconduct. The law lists certain fouls (e.g., 
kicking, tripping, jumping at, striking, pushing, etc.) and then leaves 
it to the discretion of the referee to determine if a player commits 
any of the offenses in a manner ``considered by the referee to be 
careless, reckless or using excessive force.'' Obviously, there is a 
lot of subjectivity in the application of the laws of the game. 
Unfortunately, although soccer is gaining in popularity, many of the 
referees at the high school and youth level did not play the sport at a 
high level, if at all, and they don't always have a good feel for what 
is dangerous play. Since the referee's primary function is player 
safety, I'd like to see the soccer referee training and education 
include more on sport-specific risks and injury prevention--not just 
how to call a foul and restart the game, but more in-depth training and 
education on how keep control of the match to prevent dangerous play 
while at the same time not blowing the game dead for every trifling 
offense. Too often referees needlessly penalize meaningless perceived 
technical offenses, but then completely miss calling dangerous play. In 
my case, the player blindsided me in the head as I was sprinting full-
speed tracking a flighted ball. I never saw the hit coming. I sustained 
a concussion, was knocked unconscious, and my season was over. The 
defender played me not the ball. It was a clear and dangerous foul. The 
same defender gave another of my teammates a concussion in the same 
game. The referee made no call in either case. Clearly, the officiating 
crew failed to recognize and appropriately deal with this player's 
dangerous play.
    In addition to better educating the officials, I would recommend 
mandatory training for high school coaches, trainers and players about 
concussions. Even though concussions are getting a lot of press lately 
in the NFL, I'm not sure there is a very good understanding about the 
risks and impacts of concussions in other sports. I know that I had no 
idea how debilitating getting a concussion could be until I got one. 
Hindsight is twenty-twenty, but I realize now that I never should have 
gone back in the game after I was knocked out. It was a division game 
and the score was tied. There were two minutes left in regulation, we 
had good momentum and it seemed that we might get the win. Even though 
I was practically carried off the field, I was put right back in the 
game, after a quick sip of water. I ended up playing the rest of the 
game and two additional overtime periods. I don't really remember it. 
Fortunately, I didn't sustain any more major blows during the rest of 
the game. Even though I was dazed, I wanted to get back in and help my 
team so I told the trainer, coach, and my dad who had come down out of 
the stands that I was OK to play. I know now that I wasn't OK and that 
we collectively made the wrong decision in the heat of battle.
The Academic Impact of My Concussion
    The biggest shock regarding sustaining and recovering from my 
concussion has been the huge impact it has had on my ability to think. 
I never thought it would actually hurt to think. I like school. I want 
to attend a good college and get an advance degree. Before the 
concussion, I earned straight A's and had a 4.5 weighted GPA. Now, over 
a month after my concussion, I'm still behind and struggling to 
complete my school work. Despite me working as hard as I am able, and 
with my parents' help, my latest progress report includes a couple of 
``F's,'' and a ``D.'' I am determined to get my grades up, but it is 
going to take a lot of hard work, a lot of patience and understanding 
from my teachers, and some luck to get back to straight ``A's.'' I 
sometimes now have to use a calculator to do simple arithmetic. It 
takes me three times as long to do anything. I have to keep re-writing 
everything and my spelling is worse than normal. I can't seem to 
remember facts and dates. My head still pounds when I try to read small 
type for more than about 15-20 minutes at a time. Bright lights bother 
me and I am over-sensitive to noises. I never realized how much 
fidgeting, finger-tapping and chair moving goes on in my high school 
classes. Even some of my teachers' lectures, when they change the 
inflection in their voices to emphasize a point, can leave me feeling 
sea-sick. Even when my head is not pounding, I always feel like I am 
wearing a compression head band.
    I knew that I wouldn't be able to play sports for a while after 
getting a concussion. I've had a number of other injuries, bumps and 
bruises, sprained ankles and even a season-ending MCL sprain. I was 
prepared to be sidelined, although I thought I would have been back 
playing by now. That's why I am a little perturbed by the CDC's 
concussion slogan, ``It's better to miss one game than a whole 
season.'' I understand their intent, but I think they minimize the 
seriousness of concussions by making it sound like you just need to 
take a game off and then you'll be good to go. I've already lost my 
whole high school, club and ODP seasons, including tournaments and 
camps.
My ACE Care Plan
    The great news is that everybody is helping me. My parents took me 
to the emergency room immediately after the game. Then they researched 
about concussions on line and called everybody they knew to educate 
themselves about what to do. My parents took me to Children's National 
Medical Center and I am lucky to be being treated by Dr. Gioia who is 
the Director for the Safe Concussion Outcome, Recovery & Education 
(SCORE) Program and one of your expert witnesses testifying at today's 
hearing. I have now been evaluated by Dr. Gioia and his staff three 
times since sustaining the concussion. Each visit, he compares my 
progress against a baseline impact test I took at my high school before 
the season started. I think it is very important and helpful to have a 
good baseline to measure recovery. One of the most helpful tools for me 
has been my individualized Acute Concussion Evaluation (ACE) Care Plan. 
After evaluating my progress, Dr. Gioia prepares a detailed report on 
my current symptoms with specific recommendations, including special 
accommodations that I still need to cope with the challenges of school. 
For example, I am supposed to take breaks during and in between classes 
when my headaches start. My teachers have been notified that I am still 
impaired and am not able to keep up with the regular pace of my 
advanced classes and have been requested to adjust my homework and 
exams schedule.
    My teachers, coaches, and school counselor have been tremendous in 
helping me. My school counselor has initiated a temporary 
individualized special education plan for me, called a Section 504 
Plan, that formalizes many of Dr. Gioia's recommended accommodations 
from the ACE Care Plans. Without the expertise of my doctor, and the 
understanding of my parents and educators, and their willingness to 
work together to help me, I know that I would go from a straight-A 
student to a failing student because of my concussion.
    Of all my soccer injuries, the concussion has been the most 
challenging. For one, it is not an obvious injury. I look fine. I am 
not on crutches, in a cast or wearing a brace. You can't see a 
concussion. I also don't think most people have as much knowledge about 
a concussion and how debilitating it can be and that the effects can 
last so long. Everybody bumps their head from time to time. Plus, I 
think that there are different levels of concussions and that some are 
worse than others and some people may just take longer to get over 
them. So as time goes by, I suspect that it is harder for a lot of 
people to believe that you are still significantly impaired. In 
addition to concussions being somewhat of an invisible injury, it is 
worse because it not only keeps you from playing sports, it's a brain 
injury, and you need your brain for school and everyday life 
activities. Unlike even a serious ankle or knee injury, a concussion 
also affects your ability to think. As a high school student athlete, 
having my ability to think impaired has been a serious disability.
In Conclusion
    A concussion can have a serious impact and consequences for high 
school athletes. I have the best care possible from a leading 
concussion doctor, a great team of teachers, counselors, coaches, 
school administrators and supportive parents. I was a straight ``A'' 
student and, despite the best help possible, I am now failing several 
classes over a month after sustaining a concussion in a high school 
soccer game.
    I recommend that the Education Committee use its authority and 
oversight jurisdiction over high school athletics to require the 
recording and tracking of sports-related concussions, to develop new 
and support existing awareness, training, education and treatment 
programs for concussions (like SCORE). I think high school sports 
officials, coaches, trainers and players should be required to learn 
more about concussions. The Committee may also want to study the 
appropriateness of requiring protective headgear to prevent or minimize 
the occurrence of concussions. In soccer, FIFA only requires players to 
wear shin guards, and that requirement only became compulsory in 1990. 
There will be strong differences of opinions whether protective 
headgear works or not, and even if it does, whether there is sufficient 
evidence that it should be mandated for the high school game. My dad 
already told me that I'll be sporting some new headgear when I return 
to play, so I won't be waiting for an act of Congress to make that 
equipment decision. Additionally, I don't know if it is already a law 
or not, but I think that high school athletes should be able to have an 
individual education plan (like the 504 Plan I have) to formalize 
necessary temporary accommodations at school for the duration of their 
impairment.
    Thank you again for this opportunity to share my personal 
experience on the impact that a concussion is having on me as a high 
school athlete.
                                 ______
                                 
    [Additional submission of Ms. Kohn follows:]
    
    
                                ------                                

    [Whereupon, at 11:00 a.m., the committee was adjourned.]

                                 
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