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



 
        H.R. 6172, PROTECTING STUDENT ATHLETES FROM CONCUSSIONS
=======================================================================

                                HEARING

                               before the

                              COMMITTEE ON
                          EDUCATION AND LABOR

                     U.S. House of Representatives

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION
                               __________

           HEARING HELD IN WASHINGTON, DC, SEPTEMBER 23, 2010
                                __________

                           Serial No. 111-75
                               __________

      Printed for the use of the Committee on Education and Labor



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                    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           Vernon J. Ehlers, Michigan
John F. Tierney, Massachusetts       Judy Biggert, Illinois
Dennis J. Kucinich, Ohio             Todd Russell Platts, Pennsylvania
David Wu, Oregon                     Joe Wilson, South Carolina
Rush D. Holt, New Jersey             Cathy McMorris Rodgers, Washington
Susan A. Davis, California           Tom Price, Georgia
Raul M. Grijalva, Arizona            Rob Bishop, Utah
Timothy H. Bishop, New York          Brett Guthrie, Kentucky
Joe Sestak, Pennsylvania             Bill Cassidy, Louisiana
David Loebsack, Iowa                 Tom McClintock, California
Mazie Hirono, Hawaii                 Duncan Hunter, California
Jason Altmire, Pennsylvania          David P. Roe, Tennessee
Phil Hare, Illinois                  Glenn Thompson, Pennsylvania
Yvette D. Clarke, New York           [Vacant]
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 September 23, 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:
            Letter, dated September 22, 2010, from Roger Goodell, 
              commissioner, the National Football League.........    36
            Prepared statement of Christopher Nowinski, Boston 
              University Sports Legacy Institute.................    43
            Prepared statement of the National Athletic Trainers' 
              Association (NATA).................................    58

Statement of Witnesses:
    Brearley, Rev. Dr. Katherine E., mother of the late Owen 
      Thomas.....................................................    15
        Prepared statement of....................................    17
    Conca-Cheng, Alison, Centennial High School, Ellicott City, 
      MD.........................................................    12
        Prepared statement of....................................    14
    Gioia, Gerard A., Ph.D., chief, division of pediatric 
      neuropsychology, Children's National Medical Center; 
      director, safe concussion outcome, recovery & education 
      (SCORE) program, Children's National Medical Center........     7
        Prepared statement of....................................     9
    Herring, Stanley, M.D., clinical professor, departments of 
      rehabilitation medicine, orthopedics and sports medicine, 
      and neurological surgery, University of Washington; co-
      medical director, Seattle Sports Concussion Program; team 
      physician, Seattle Seahawks and Seattle Mariners; and 
      member, National Football League's head, neck and spine 
      committee..................................................    27
        Prepared statement of....................................    29
    Morey, Sean, executive board member, NFL Players Association 
      (NFLPA)....................................................    22
        Prepared statement of....................................    24


                     H.R. 6172, PROTECTING STUDENT
                       ATHLETES FROM CONCUSSIONS

                              ----------                              


                      Thursday, September 23, 2010

                     U.S. House of Representatives

                    Committee on Education and Labor

                             Washington, DC

                              ----------                              

    The committee met, pursuant to call, at 10:03 a.m., in room 
2175 Rayburn House Office Building, Hon. George Miller 
[chairman of the committee] presiding.
    Present: Representatives Miller, Kildee, Payne, Scott, 
Woolsey, McCarthy, Davis, Bishop of New York, Altmire, Hare, 
Courtney, Polis, Kline, Petri, and Platts.
    Also present: Representatives Pascrell and McIntyre.
    Staff present: Andra Belknap, Press Assistant; Calla Brown, 
Staff Assistant, Education; Daniel Brown, Staff Assistant; Jody 
Calemine, General Counsel; Jamie Fasteau, Senior Education 
Policy Advisor; Ruth Friedman, Senior Education Policy Advisor 
(Early Childhood); Jose Garza, Deputy General Counsel; David 
Hartzler, Systems Administrator; Sadie Marshall, Chief Clerk; 
Bryce McKibbon, Staff Assistant; Alex Nock, Deputy Staff 
Director; Lillian Pace, Policy Advisor, Subcommittee on Early 
Childhood, Elementary and Secondary Education; Helen Pajcic, 
Policy Assistant; Melissa Salmanowitz, Press Secretary; Dray 
Thorne, Senior Systems Administrator; Daniel Weiss, Special 
Assistant to the Chairman; Nu Wexler, Communications Director; 
Kim Zarish-Becknell, Policy Advisor, Subcommittee on Healthy 
Families; Mark Zuckerman, Staff Director; Stephanie Arras, 
Minority Legislative Assistant; James Bergeron, Minority Deputy 
Director of Education and Human Services Policy; Kirk Boyle, 
Minority General Counsel; Allison Dembeck, Minority 
Professional Staff Member; Brian Newell, Minority Press 
Secretary; Susan Ross, Minority Director of Education and Human 
Services Policy; and Linda Stevens, Minority Chief Clerk/
Assistant to the General Counsel.
    Chairman Miller [presiding]. The committee will come to 
order, a quorum being present.
    Good morning to everyone. Today we will be discussing new 
legislation I introduced this week to help raise awareness 
about concussions for student athletes and to improve students' 
well-being both on the field and in the classroom.
    Concussions have always been part of the conversation about 
student athletes, but for far too long we have talked about 
what has happened without taking any action to help students 
manage those dangerous injuries. When the student suffers a 
concussion, it is not just their athletic future that is at 
stake. Without proper management, their performance in the 
classroom is also in jeopardy. The student athlete needs to be 
much more about the student than the athlete.
    We simply can't talk about student athletes without really 
talking about what brain injuries really mean for a student's 
future. In the concussion management arena, there is a saying, 
``When in doubt, send it out.'' Unlike a broken leg or a 
bruise, concussions are not easily identified, but they are 
equally, if not more, dangerous.
    Ninety percent of the concussions occur without a loss of 
consciousness, and many students simply don't know if they are 
injured. A prolonged diagnosis when the pressure to play 
surpasses the need for treatment can mean dangerous and harmful 
results to students.
    In the past 4 years there were nearly 400,000 reported 
concussions in high school athletes, and experts believe that 
prevalence of sports-related concussions is much higher than 
reported. It is now commonly reported that 300,000 sports-
related concussions occur annually, and once you factor in the 
recreation-related concussions like those occurring on the 
playground, the number rises dramatically.
    We need to empower students to know when they may be at 
risk. Students deserve to know the signs and symptoms and the 
risks of concussions so they will be able to take appropriate 
next steps to prevent further injury and to prevent their 
successes in school from suffering. Student athletes with 
information about the symptoms of concussion are more likely to 
treat and manage their injuries.
    Many states have already taken action, but there is little 
regulation on the whole to ensure that the students in every 
state will have the same minimum protection. High school 
athletes are at greater risk with sports-related concussions 
than college or professional athletes, because their younger 
brains are more susceptible to injury, and female youth 
athletes are even more likely to suffer concussions.
    The Protecting Student Athletes from Concussions Act will 
help improve concussion safety and management for student 
athletes by requiring school districts to develop and implement 
a standard community-based plan for concussions safety and 
management. It will require school districts to take four 
minimum steps. These will set a floor in the terms of what 
school districts will have to do. I am confident that many 
states will far exceed these minimum expectations.
    First, similar to a plan the NFL has implemented for the 
players, schools must post information about how to prevent and 
manage concussions for students to see. The information will be 
publicly visible on a school's Web site.
    Second, when a student who is suspected of sustaining a 
concussion during the school-sponsored athletic activity, he or 
she must be removed from the game, prohibited from returning to 
play that day, and evaluated by health care professionals, and 
parents must also be notified.
    And third, schools must provide support for students 
recovering from concussions and access to special education 
services for students who are not recovering.
    This is commonsense legislation to protect our students. We 
may not fully understand the complexities of concussions, but 
we do know enough to improve the outcomes for student athletes 
now. Recent news reports about the prevalence and dangers of 
concussions have made it very clear that we will need to help 
prevent--what we need to do to help prevent the injuries at all 
levels.
    The National Football League has already taken an important 
step to protect their athletes from the risk of concussions. At 
the very least, our schools should do the same.
    And I would just like to interject here that it is not just 
about their athletes. One of the things we will hear about this 
morning is a program that the National Football League has 
entered into on behalf of all athletes, certainly playing the 
sport of football, but the impact is across all youth 
athletics, and also their work with the Center for Disease 
Control in working up educational, informational, public 
information programs on this issue.
    I think it is a very, very important partnership both on 
behalf of this legislation and on behalf of working with states 
and school districts and parents about this danger.
    Let me go back and just say that athletics plays an 
important role for student development. Team sports teach 
students about leadership, about teamwork, about commitment. 
And, unfortunately, the injuries are part of any team sport, 
and injury management should be a key component. But we have to 
do better for our students when they are hurt and need our 
support most.
    I hope my colleagues will join me in supporting this 
legislation. The bill is supported by leading groups 
representing teachers and parents, school administrators, the 
disability community, the sports medicine community, medical 
organizations and athletic organizations.
    I look forward to hearing from our witnesses about why it 
is so urgent that we help protect our students from the risks 
of concussions and keep them informed and safe. Thank you very 
much for joining us, all the witnesses.
    And I would like now to recognize Congressman Kline, the 
senior Republican on our committee.
    [The statement of Mr. Miller follows:]

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

    Good morning.
    Today we'll discuss new legislation I introduced this week to help 
raise awareness about concussions for student athletes and improve 
students' well-being both on the field and in the classroom.
    Concussions have always been a part of the conversation about 
student athletes. But for far too long, we've talked about what has 
happened without taking any action to help student's manage these 
dangerous injuries.
    When a student suffers a concussion, it is not just their athletic 
future that is at stake. Without proper management, their performance 
in the classroom is also in jeopardy.
    The ``student athlete'' needs to be as much about the ``student'' 
as the ``athlete.''
    We simply can't talk about the student athlete without really 
thinking about what these brain injuries really mean for a student's 
future.
    In the concussion management arena, there is a saying. ``When in 
doubt, sit him out.'' Unlike a broken leg or a bruise, concussions 
aren't as easily identified, but they are equally, if not more 
dangerous.
    Ninety percent of concussions occur without loss of consciousness 
and many students simply do not know if they're injured.
    A prolonged diagnosis, when the pressure to play surpasses the need 
for treatment, can mean dangerous and harmful results to students.
    In the past four years, there were nearly 400,000 reported 
concussions in high school athletes, and experts believe the prevalence 
of sport-related concussions is much higher than reported.
    It is now commonly reported that 300,000 sport-related concussion 
occur annually, and once you factor in recreation-related concussions--
like those occurring on the playground, the number rises dramatically.
    We need to empower students to know when they may be at risk.
    Students deserve to know the signs, symptoms and risks of 
concussions so they're able to take the appropriate next steps to 
prevent further injury and to prevent their success in school from 
suffering.
    Student athletes with information about the symptoms of concussion 
are more likely to treat and manage their injuries. Many states have 
already taken action but there is little regulation on the whole to 
ensure that students in every state will have the same minimum 
protections.
    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 and female youth athletes are 
even more likely to suffer from concussions.
    The Protecting Student Athletes from Concussions Act will help 
improve concussion safety and management for student athletes by 
requiring school districts to develop and implement a standard, 
community-based plan for concussion safety and management.
    It will require school districts to take four minimum steps. These 
will set a floor in terms of what school districts will have to do. I 
am confident many states will far exceed these minimum expectations.
    First, similar to a plan the NFL has implemented for its players, 
schools must post information about how to prevent and manage 
concussions for students to see. The information must be publicly 
visible and on the school's website.
    Second, when a student who is suspected of sustaining a concussion 
during a school-sponsored athletic activity, he or she must be removed 
from the game, prohibited from returning to play that day and evaluated 
by a health care professional. Parents must also be notified. And 
third, schools must provide support for students recovering from 
concussions, and access to special education services for students who 
are not recovering.
    This is common-sense legislation to protect our students.
    We may not fully understand the complexities of concussions, but do 
know enough to improve outcomes for student athletes now. Recent news 
reports about the prevalence and dangers of concussions have made it 
very clear that we need to help prevent these injuries on all levels.
    The National Football League has already taken important steps to 
protect their athletes from the risks of concussions. At the very 
least, our schools should do the same.
    Athletics play an important role for student development. Team 
sports teach students about leadership, teamwork and commitment.
    Unfortunately, injuries are a part of any sports team and injury 
management should also be a key component. But we have to do better for 
our students when they're hurt and need the most support.
    I hope my colleagues will join me in supporting this legislation.
    The bill is supported by leading groups representing teachers and 
parents, school administrators, the disability community, medicine, 
sports medicine and athletic organizations. I look forward to hearing 
from our witnesses about why it is so urgent that we help protect our 
students from the risks of concussions and keep them informed and safe.
    Thank you for joining us today.
                                 ______
                                 
    Mr. Kline. Thank you, Mr. Chairman. And good morning to you 
and to all of our witnesses and guests here this morning.
    We are here today to look at the issue of concussions among 
high school athletes and the effects of these traumatic brain 
injuries on the student's academic achievement. This is the 
third in a series of hearings examining what policies and 
practices are in place to protect students from these injuries 
and help them safely recover when injuries do occur.
    Across the country children are settling back into classes 
and school-related activities. The fall sports season is an 
especially familiar ritual for many, bringing parents, 
students, friends and neighbors together to support their local 
teams.
    Over the years we have learned a great deal about creating 
a safer field of play. Helmets, pads and other safety equipment 
are now prerequisites. Coaches, umpires and referees keep a 
watchful eye to prevent injuries. Yet despite all of the safety 
precautions, we know injuries do occur, including head and neck 
injuries that sometimes include concussions. Local 
policymakers, teachers, coaches and parents must be well-
informed and empowered to help prevent concussions and take 
appropriate action when they do occur.
    We know that what happens on the field can directly affect 
what happens in the classroom. Academic research shows that 
student athletes who suffer from concussions tend to have lower 
attendance rates and lower grades than their peers. 
Particularly when concussions are unrecognized and untreated, 
such injuries can have long-term implications.
    As we learned at our hearing in May, state and local school 
districts are continuing to step up and address this issue 
directly. Today's hearing will continue to shed light on the 
research surrounding concussions among student athletes and 
what steps are being taken to prevent and properly treat these 
injuries.
    Thank you, Mr. Chairman. I yield back.
    [The statement of Mr. Kline follows:]

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

    We are here to look at the issue of concussions among high school 
athletes and the effects of these traumatic brain injuries on a 
student's academic achievement. This is the third in a series of 
hearings examining what policies and practices are in place to protect 
students from these injuries and help them safely recover when injuries 
do occur.
    Across the country children are settling back into classes and 
school-related activities. The fall sports season is an especially 
familiar ritual for many--bringing parents, students, friends, and 
neighbors together to support their local teams.
    Over the years, we have learned a great deal about creating a safer 
field of play. Helmets, pads, and other safety equipment are now 
prerequisites. Coaches, umpires, and referees keep a watchful eye to 
prevent injuries.
    Yet despite all of these safety precautions, we know injuries do 
occur--including head and neck injuries that sometimes include 
concussions. Local policy makers, teachers, coaches, and parents must 
be well-informed and empowered to help prevent concussions and take 
appropriate action when they do occur.
    We know that what happens on the field can directly affect what 
happens in the classroom. Academic research shows that student athletes 
who suffer from concussions tend to have lower attendance rates and 
lower grades than their peers. Particularly when concussions are 
unrecognized and untreated, such injuries can have long-term 
implications.
    As we learned at our hearing in May, states and local school 
districts are continuing to step up and address this issue directly. 
Today's hearing will continue to shed light on the research surrounding 
concussions among student athletes and what steps are being taken to 
prevent and properly treat these injuries.
                                 ______
                                 
    Chairman Miller. Thank you.
    Without objection, the committee is joined today by two 
additional members of the House, who may participate in the 
hearing with questions and comments when recognized--Mr. 
Pascrell of New Jersey and Mr. McIntyre of North Carolina.
    Congressman Pascrell has been a leader on concussion 
treatment and prevention issues for school-age children. He 
founded the Congressional Brain Injury Task Force in 2001 and 
has introduced the Contact Act.
    Congressman McIntyre is the co-chair and co-founder of the 
Congressional Caucus on Youth Sports and is hosting a forum on 
this subject both for members and staff, I believe, and a lunch 
later this afternoon, so people should be advised of that.
    Thank you for joining us, Michael, and for your leadership 
on this issue.
    Our panel today, I think, will be very helpful to all of 
the members to gain additional knowledge of this issue, but 
also, importantly, hear from the victims of concussion, but 
also people who are working in partnership to develop programs 
for the diagnosis and the protection and the recovery of 
individuals who suffer concussions in youth sports.
    Our first witness will be Dr. Gerard Gioia, who is the 
director of the pediatric neuropsychology program at Children's 
National Medical Center in Washington, DC. He also oversees the 
hospital's Safe Concussion Outcome and Recovery and Education 
Program, the SCORE Program, where he evaluates and treats youth 
who have sustained concussions. Dr. Gioia has conducted 
extensive research on how to care for young athletes recovering 
from concussion and how the injury affects learning.
    Alison Conca-Cheng is a senior at Centennial High School in 
Elicott City, Maryland. Ms. Conca-Cheng is an active member of 
her community and an honor student, editor of the school 
newspaper, ``The Wingspan,'' and an avid soccer player. Alison 
is recovering from her first concussion, which she sustained 
during soccer practice this past August. She is still 
experiencing cognitive impairments as a result of her injury, 
including problems with concentration and memory, headaches and 
sleep difficulties.
    Reverend Katherine Brearley is the pastor of Longswamp 
United Church of Christ and is the mother of the late Owen 
Thomas. Her son Owen played football from age nine. He was 21 
years old, a lineman at the University of Pennsylvania, when he 
committed suicide this past April. Owen was never diagnosed 
with a concussion, but his autopsy revealed early stages of 
CTE, the disease caused by repetitive brain injury. That is the 
very disease found to be primarily in professional football 
players who have committed suicide over the last 10 years.
    Sean Morey is a retired NFL player. He played for four NFL 
teams as a special teams wide receiver over the past 10 years. 
Mr. Morey, who graduated with honors from Brown University, was 
selected as the Ivy League rookie of the year and player of the 
year and as second-team All-American. Mr. Morey was drafted in 
the seventh round in the 1999 NFL draft and later was selected 
to be captain of the Super Bowl XL champion Pittsburgh 
Steelers. Sean is also a Pro Bowl special teams player. In the 
past August just before the starting of training camp, Mr. 
Morey retired due to post-concussion syndrome.
    Dr. Stanley Herring is a board-certified physical medicine 
and rehabilitation specialist, who has been in practice over 28 
years. Dr. Herring is a clinical professor in the Department of 
Rehabilitative Medicine, Orthopedics and Sports Medicine and 
Neurological Surgery at the University of Washington, co-
medical director of the Seattle Sports Concussion Program. Dr. 
Herring also serves as one of the team physicians for the 
Seattle Seahawks and for the Seattle Mariners. He is a member 
of the NFL Head, Neck and Spine Committee and chairman of the 
Education Advocacy Subcommittee and serves as a concussion 
expert on the Football Wellness Committee of USA Football.
    Welcome. Thank you so much for your time and your expertise 
that you are going to share with the committee this morning.
    For those of you for which this is a first-time experience, 
in front of you there is a small box. When you begin 
testifying, a green light will go on. You will then have 5 
minutes to present your thoughts to the committee. With 1 
minute remaining, an orange light will go on, so if you could 
think about wrapping up your remarks. But we want you to make 
sure that you deliver your thoughts to the committee. It is a 
rather limited amount of time, but we want to also make time 
for questions from the members of the committee.
    And, Dr. Gioia, we are going to begin with you. So we will 
begin with you, Dr. Gioia. Again, welcome to the committee.

STATEMENT OF GERARD GIOIA, PH.D., DIRECTOR OF NEUROPSYCHOLOGY, 
               CHILDREN'S NATIONAL MEDICAL CENTER

    Mr. Gioia. Thank you. And good morning, Chairman Miller and 
members of the committee, and thank you for the opportunity to 
speak again on today's important topic.
    Today we continue our focus on concussion, a type of 
traumatic brain injury, and its negative effects on the 
academic learning and performance of the student athlete. 
Learning in school is the child's job, and that job is impaired 
after concussion. The consequences of a concussion can be 
significant for the academic learning and performance of that 
student athlete.
    Our current research finds adverse effects of this injury 
upon school performance of close to 90 percent of the students 
that come to us in our clinic. They report a significant 
worsening of post-concussion symptoms when they attempt school 
tasks.
    But the effects of concussion are quite significant and 
could be quite wide-ranging, with an adverse effect on their 
ability to think and for their social and emotional 
functioning. The student also typically experiences physical 
pain with headaches and significant fatigue. These symptoms can 
be debilitating and disabling for a child's learning and their 
social interactions.
    The length of time to a full recovery following a 
concussion and of that functional impairment varies from days 
to months, and for some even beyond that. Academic problems can 
also have significant downstream effects, especially for the 
high school student. For example, concussions at the end of the 
semester significantly reduce performance and grades on final 
exams, reducing the student's grade point average. Taking and 
SAT prior to recovery from a concussion can also have 
significant adverse impact on that student athlete's college 
future.
    Are our schools currently prepared to handle the academic 
consequences of these injuries? Through our clinical work we 
can clearly see that schools are very much caring and want to 
help students with these injuries. But they are often not 
adequately prepared to help them. They lack the necessary 
policies, procedures, knowledge, skills and tools to properly 
support the return of the concussed student athlete.
    In a survey we conducted this summer of 140 school nurses 
in the Washington, DC, area, they reported that less than half 
of the schools were prepared to assess a concussion, and less 
than one-third were prepared to offer academic support after 
the injury. Training with the new CDC Heads Up to Schools Know 
Your Concussion ABCs Toolkit was very effective, though, in 
increasing their knowledge of the injury and ways to assess and 
to treat it.
    So how can we help students with concussions return to 
school? We know that these students typically do not meet the 
criteria for special education services, yet they are still not 
able to handle the normal academic learning and performance 
demands. And the reality is that the school learning 
environment places significant physiological demands on that 
recovering brain. The effective management of these adverse 
academic effects is an important priority, and we have to 
provide effective support that maximizes the student's recovery 
and minimizes any long-term post-concussion problems.
    The Protecting Student Athletes from Concussions Act that 
was introduced yesterday provides an important vehicle to 
improve care and assistance for students with concussions. This 
legislation places the focus directly on the student side of 
the student athlete equation. It places the focus on supporting 
the academic learning and performance needs of that student 
athlete after this entry. It focuses on what schools can 
actually do to support the academic return of a recovering 
student.
    So this legislation asks schools to, number one, develop 
policies and methods to implement concussion education and 
training of school and related persons, including parents, 
students and coaches.
    Number two, it provides a range of academic supports to 
help those students as they are attempting to manage school.
    And third, it reinforces through its response to concussion 
elements the sport removal provisions of the Zurich consensus 
meeting and what we have seen in some of the laws, such as the 
Lysted Law. It also reinforces the need for appropriate 
evaluation to return the student athlete back to the field and 
to the classroom to support their academic needs.
    So in conclusion, a concussion is a serious injury to the 
brain that presents significant risks and challenges to the 
academic performance and learning of the student. It negatively 
affects the primary job that they have. These academic 
problems, even if temporary, can have significant potential 
negative consequences for the student down the road. And if not 
treated properly, these academic problems could become 
prolonged and result in significant long-term difficulties for 
that student.
    We must assist our schools to become better prepared to 
properly support the return of the concussed student athlete 
with the necessary assistance put in place to improve the 
knowledge and the skills of our school personnel. The 
Protecting Student Athletes from Concussion Act does this, 
seeking to develop and implement a national system of 
concussion education, protections and academic supports for 
students with concussions.
    Now, this legislation promotes more effective recovery, and 
it will help return our students back to the schools 
effectively. Next, you are going to hear from Alison, who will 
tell you about her injury and its challenges just in this way. 
Thank you.
    [The statement of Mr. Gioia follows:]

   Prepared Statement of Gerard A. Gioia, Ph.D., Chief, Division of 
    Pediatric Neuropsychology, Children's National Medical Center; 
    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 303 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.
Introduction
    Children's National Medical Center applauds Chairman Miller for 
introducing the ``Protecting Student Athletes from Concussions Act'' 
and is pleased to support this important legislation. The child's brain 
is his most precious resource and the key to a happy, successful 
future. The primary job of the child is to develop and learn. Sports 
and recreation provide important learning activities that further 
enrich the lives of our youth by teaching important lessons of 
teamwork, commitment, discipline, goal-setting, competition, and 
sacrifice, among other things. These essential developmental 
experiences are put at significant risk, whether temporary or long-
term, when the child's brain is injured. It is our responsibility to 
maximize the child's involvement in learning and sports/recreation 
activities. We must balance the significant benefits of sports with 
careful attention to safety issues--especially when involving the 
precious resource of the student-athlete's brain.
    The consequences of a concussion, a type of mild traumatic brain 
injury, can be significant for the academic learning and performance of 
the student-athlete. Our current research finds adverse effects on 
school learning, with close to 90% of students in our clinics reporting 
significant worsening of post-concussion symptoms when they attempt 
school tasks. In our clinic sample, these problems persisted well 
beyond a month for many students. At the same time, we also find that 
schools in general are not prepared to provide the necessary supports 
and accommodations to the recovering student. We must provide effective 
treatments that maximize the student's recovery and minimize any long-
term post-concussion problems. The ``Protecting Student Athletes from 
Concussions Act'' is an important vehicle to improve care systems for 
students with concussions.
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 working 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 and 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\ However, these data do not include 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 brains of children and adolescents are much more 
vulnerable to injury than those 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. The 
``Protecting Student Athletes from Concussions Act'' places the focus 
on supporting the academic learning and performance of the student-
athlete following a concussion. 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.
    Clinically, the majority of concussed student athletes recover 
fully with no long-term academic problems. Yet almost all student-
athletes experience significant challenges in their academic 
performance during their period of recovery, with direct neurocognitive 
dysfunction in attention/concentration, memory, and speed of processing 
and performance. Student-athletes also experience cognitive 
difficulties secondary to the effects of post-concussion fatigue or 
other somatic or emotional symptoms. 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. Effective management of these adverse academic effects 
is an important priority.
    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 impairs the learning 
process. Students with concussions experience difficulties focusing 
their attention, performing multi-step tasks, putting new information 
into their memories, processing information and completing tasks at a 
normal speed. Without these neurocognitive abilities functioning 
properly, school learning and performance become 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 or ACT prior to recovery from a 
concussion can also have a significant adverse impact on the student-
athlete's future college options.
    At this point in time, schools are not adequately prepared with the 
necessary systems, knowledge and skills to properly support the return 
of the concussed student-athlete. Students with more severe brain 
injuries have a vehicle of academic support services via the special 
education system, but students with mild TBI and concussion do not 
typically meet the criteria for special education services. While they 
are not ``normal'' in their academic skills and performance, they are 
also not significantly disabled from an educational perspective. This 
gap in student supports must be filled. The ``Protecting Student 
Athletes from Concussions Act'' does just this.
    To support the academic return of the 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 at each stage of 
recovery. The 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 CDC's ``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 guidance to policy development and key information for 
school nurses, counselors, school psychologists, teachers, parents, and 
student-athletes to develop and implement procedures to assist students 
with concussions in their return to school.
Protecting Student Athletes from Concussions Act
    As previously noted, the student-athlete who sustains a concussion 
is at significant risk for adverse academic consequences. Chairman 
Miller's ``Protecting Student Athletes from Concussions Act'' places 
the focus directly on the student side of the student-athlete equation. 
This bill focuses on what schools can do to support the academic return 
of the injured/ recovering student. This bill is important as 
systematic school supports are an under-recognized and under-resourced 
aspect of concussion management. All students need to return to their 
job -school -but the associated cognitive, physical, and social demands 
can be very challenging, either supporting or detracting from 
appropriate recovery. The availability of the new CDC school toolkit 
materials now provides concrete methods to guide schools toward 
effective management.
    The bill's requirements state that: (1) schools must develop 
policies and methods to implement concussion education and training of 
school and related persons (includes parent, students, coaches) tying 
into in part the youth version of the NFL posters; and (2) must include 
mechanisms for providing a range of academic supports. The bill 
reinforces the ``Response to Concussion'' or sport removal provisions 
of the Zachary Lystedt law in Washington state and the Zurich consensus 
statement, and also reinforces appropriate evaluation for return to 
play -but expands this to academic return as well. The bill ensures 
that the student-athlete does not return to school-sponsored sports 
activities and other school physical activities such as physical 
education class and recess in order to provide full post-injury 
protection. The need for these broader protections during the school 
day is well illustrated by the sad story of an 11-year-old boy in 
Wisconsin who recently died after first suffering a concussion while 
playing football and shortly thereafter striking his head during recess 
at school.
Conclusion
    A concussion is a serious injury to the brain that presents a 
unique set of risks and challenges for the academic learning and 
performance of a student. As learning in school is the job of the child 
and adolescent, it is particularly challenged by this injury due to the 
associated neurocognitive dysfunction and adverse effects that the 
cognitive and learning demands of school place on the brain's 
dysfunctional biological software. These academic problems, even if 
temporary, can have potential negative consequences for the student 
down the road. Schools are not adequately prepared with the necessary 
systems, knowledge and skills to properly support the return of the 
concussed student-athlete. We must provide the same academic support 
structure for students with concussions as we do for more severe brain 
injuries. The ``Protecting Student Athletes from Concussions Act'' does 
just this. The bill seeks to develop and implement a national system of 
academic supports for student-athletes with concussions. This system 
would include directed efforts at education of key stakeholders and the 
delivery of key academic supports and accommodations to promote the 
effective reintegration of the student-athlete back into the school 
system.
                                 ______
                                 
    Chairman Miller. Thank you.
    Alison, welcome to the committee. And go ahead and proceed.

   STATEMENT OF ALISON CONCA-CHENG, STUDENT, CENTENNIAL HIGH 
                             SCHOOL

    Ms. Conca-Cheng. Thank you, Mr. Chairman.
    My name is Alison Conca-Cheng. I am a 17-year-old high 
school senior at Centennial High in Ellicott City. I am an 
honor student, editor of my school newspaper, and active 
volunteer in my community. I also love reading and hanging out 
with my friends. I would say I am a pretty typical teenager.
    I have been playing soccer my whole life, almost as soon as 
I could walk. This year was going to be my fourth year as a 
high school soccer player. Until recently, I was hoping to play 
Division III soccer in college. I was really looking forward to 
my senior season. But circumstances changed when I suffered a 
concussion on Friday, August 20th.
    Practice was almost over, and I was playing central mid-
field on an 11 versus 11 scrimmage. I jumped up, heading an 
approaching corner kick with the right side of my head. I don't 
remember anything that followed. I was told later that my 
friend and teammate, Lauren, had also gone up for the ball, and 
we had collided. Judging from the bruise I found later up and 
down the right side of my thigh, I assume I landed on that side 
of my body, and that I hit the ground hard.
    The next thing I remember is sitting up unsteadily to see 
my teammates hovering concernedly around me. My vision had gone 
very blurry, and I had severe tunnel vision for several 
seconds. Everything was black around the edges. I was helped 
off the field, and soon my vision cleared a bit. I sat out the 
rest of practice that day.
    Immediately after the concussion and for the rest of the 
day, I discovered that I was having severe balance problems. 
Even with the slightest nudge, it was a struggle not to fall 
down. I also had a lingering headache, as well as fairly 
constant dizziness. Later that day my boyfriend said I seemed 
fairly dazed and confused, and I noticed that my mind often 
drifted from the conversation or situation. I just felt very 
out of it. It is hard to explain, if you have never experienced 
it before.
    I arrived at school the next morning for my scrimmage and 
was given some preliminary tests by my school's athletic 
trainer. I was told I had to see a doctor and either be 
diagnosed with a concussion or cleared. After a week of 
confusion with paperwork and forms, I was seen by my family 
doctor, who cleared me to play.
    Meanwhile, school had started, and I was anxious to play. I 
thought I had fully recovered. The only thing standing in my 
way at the playing field was a computerized test. Before the 
start of the season, all athletes at my school are required to 
take a baseline concussion test. It is a half-hour test that 
evaluates basic cognitive functioning by measuring memory and 
reaction time. Remember the word, click when you see the green 
light, and so on.
    About 2 weeks after I suffered the concussion, I took the 
test to see if I was functioning normally. I could tell that I 
didn't do very well, and I wasn't surprised when I was called 
back to the trainer to take the test a second time. Again, I 
knew I had done poorly. I just couldn't remember the words they 
were asking or the patterns and the numbers.
    My trainer told me my test results were ``inconsistent,'' 
with some test results significantly below my baseline data. 
Around this time I also started to notice other symptoms. The 
headaches lingered, and I began to forget things--not just day 
to day, but morning to evening, or even moment-to-moment.
    My sleeping patterns changed. I slept more, feeling 
constantly tired, yet I had trouble falling asleep, a problem I 
had never had in the past. School became more difficult, once 
we started to delve into more complicated subjects. About 45 
minutes into my hour-long class periods, my concentration would 
be completely gone, and I would develop a splitting headache.
    This has been a problem for me, as I am taking five 
advanced placement classes this year. Reading textbooks and 
articles for homework was particularly difficult. It would take 
me twice as long, and it would be a constant battle with my 
concentration.
    Because of my inconsistent test results and reappearing 
symptoms, I was sent to Dr. Gioia. He ran several tests on me, 
and my results were still subpar. After a full examination, he 
explained that I was still actively in the recovery stage and 
that my headaches and concentration troubles were indications 
that I was overtaxing my brain. I was going to have to pay 
special attention, and anytime a headache came on or my 
attention lagged substantially, I had to take a break and cool 
off.
    Homework would have to be limited to 30 minutes at a time, 
with 10-minute breaks. Dr. Gioia wrote up a care plan for me 
that I brought into school. The school and my teachers have 
been extremely understanding and accommodating. Whenever I need 
to cool off my brain, I can go to the nurse's office, and I 
have gotten extensions on reading assignments.
    These adjustments have helped, but with the added time it 
takes to do my homework and mandated breaks, schoolwork now 
dominates my evenings and weekends. I am glad to say that I am 
feeling better and making progress. I appreciate the support I 
have received from my family, friends and the best high school 
in America, Centennial.
    I am grateful that my school had a system in place to 
identify the severity of my injury and point me toward the 
medical care I have required. I am glad the committee is 
focusing attention on the issue. I have seen how it has 
impacted my life, and I worry about the student athletes who 
don't get properly diagnosed and fall through the cracks.
    Thank you, Mr. Chairman.
    [The statement of Ms. Conca-Cheng follows:]

   Prepared Statement of Alison Conca-Cheng, Centennial High School, 
                           Ellicott City, MD

    My name is Alison Conca-Cheng. I am a 17 year old high school 
senior at Centennial High in Ellicott City, MD. I am an honors student, 
editor of my school newspaper, and an active volunteer in my community. 
I also love reading and hanging out with my friends. I would say I'm a 
pretty typical teenager.
    I've been playing soccer my whole life--almost as soon as I could 
walk. This year was going to be my fourth year as a high school soccer 
player.
    Until recently I was hoping to play Division III soccer in college. 
I was really looking forward to my senior season. But, the 
circumstances changed when I suffered a concussion on Friday, August 
20th.
    Practice was almost over and I was playing central midfield in an 
11 versus 11 scrimmage.
    I jumped up to head an approaching corner kick with the right side 
of my head. I don't remember anything that followed. I was told later 
that my friend and teammate, Lauren, had also gone up for the ball and 
that we had collided. Judging from the bruise I later found up and down 
the right side of my thigh, I assume I landed on that side of my body 
and that I hit the ground hard. The next thing I remember is sitting up 
unsteadily to see my teammates huddling concernedly around me. My 
vision had gone very blurry and I had severe tunnel vision for several 
seconds. Everything looked black around the edges. I was helped off the 
field and soon my vision cleared a bit. I sat out the rest of practice.
    Immediately after the collision and for the rest of the day I 
discovered that I was having severe balance problems. Even with the 
slightest nudge it was a struggle not to fall down. I also had a 
lingering headache as well as fairly constant dizziness. Later that 
day, my boyfriend said I seemed fairly dazed and confused, and I 
noticed that my mind often drifted from the conversation or situation. 
I just felt out of it. It's hard to explain if you've never experienced 
it.
    I arrived at the school the next morning and was given some 
preliminary tests by my school's athletic trainer. I was told I had to 
see a doctor and either be diagnosed with a concussion or be cleared. 
After a week of confusion with paperwork and forms, I was seen by my 
family doctor, who cleared me to play. Meanwhile, school had started 
and I was anxious to play. I thought I had fully recovered. The only 
thing standing in my way of the playing field was a computerized test.
    Before the start of the season, all athletes at my school are 
required to take a baseline concussion test. It is a half-hour test 
that evaluates basic cognitive functioning by measuring memory and 
reaction time: remember the word, click when you see the green light, 
and so on.
    About two weeks after I suffered the concussion, I took the first 
baseline test to see if I was functioning normally. I could tell that I 
didn't do very well. And I wasn't surprised when I was called back to 
the trainer to take the test a second time. Again, I knew I had done 
poorly. I just couldn't remember the words, patterns, and numbers they 
were asking me to remember. My trainer told me my test results were 
``inconsistent'' with some significantly below my baseline.
    Around this time I also started to notice other symptoms. The 
headaches lingered. And I began to forget things. Not just day to day, 
but morning to evening, or even moment to moment. My sleeping patterns 
changed. I slept more, feeling constantly tired, yet I had trouble 
falling asleep, a problem I'd never had in the past. School became more 
difficult once we started to delve into more complicated subjects. 
About 45 minutes into my hour-long class periods, my concentration 
would be completely gone and I would develop a splitting headache. This 
has been a big problem for me, as I am taking five Advanced Placement 
classes. Reading textbooks and articles for homework was particularly 
difficult. It would take me twice as long, and it would be a constant 
battle with my concentration.
    Because of my ``inconsistent'' test results and reappearing 
symptoms, I was sent to Dr. Gioia. He ran several more detailed tests 
on me, and my results were still subpar. After a full examination, he 
explained that I was still actively in the recovery stage and that my 
headaches and concentration troubles were indications that I was 
overtaxing my brain. I was going to have to pay special attention, and 
any time a headache came on or my attention flagged substantially, I 
had to take a break and ``cool off.'' Homework would have to be limited 
to 30 minutes at a time with ten minutes of break.
    Dr. Gioia wrote up a Care Plan for me that I brought to school. The 
school and my teachers have been extremely understanding and 
accommodating. Whenever I need to ``cool off'' my brain, I can go to 
the nurse's office and I have gotten extensions on reading assignments. 
These adjustments have helped. But with the added time it takes to do 
my homework and the mandated breaks, schoolwork now dominates my 
evenings and weekends.
    I'm glad to say that I'm feeling better and making progress. I 
appreciate the support I've received from family, friends and the best 
high school in America * * * Centennial. I'm grateful that my school 
had a system in place to identify the severity of my injury and point 
me toward the medical care I've required. I'm glad the committee is 
focusing attention on this issue. I have seen how it has impacted my 
life, and I worry about the student-athletes who don't get properly 
diagnosed and fall through the cracks.
                                 ______
                                 
    Chairman Miller. Thank you very much.
    I would just like to recognize also Sarah Rainey, who is in 
the audience, who was a previous witness to this committee and 
I believe will be participating in the forum this afternoon 
that Mr. McIntyre and his youth sports caucus is hosting.
    Raise your hand so the members can see you, Sarah. Good to 
see you. Thank you.
    Reverend Brearley?

           STATEMENT OF KATHERINE E. BREARLEY, PH.D.,
                 MOTHER OF THE LATE OWEN THOMAS

    Rev. Brearley. Thank you.
    My son Owen would cringe at the thought of being the center 
of so much attention today. Although an excellent wordsmith, 
Owen would adhere to the unspoken football rule that words are 
used sparingly. In the ancient motif of oratory Athens versus 
warrior Sparta, today Owen would stand with Sparta.
    Today I speak only for myself, and I do not even speak as 
an expert on football, a sport about which I learned only when 
I came to the United States in 1982. Nevertheless, I have 
thought deeply about the cultural role that football plays in 
the United States.
    My first purpose is to put a human face on the disease 
called chronic traumatic encephalopathy, CTE. On April the 
26th, 2010, my son Owen Thomas, age 21, a football player at 
the University of Pennsylvania in the Wharton School of 
Business, committed suicide on a dreary, rainy Monday 
afternoon. Friends and family were deeply shocked, as Owen 
seemed the most unlikely person to commit suicide.
    Subsequent detailed analysis of Owen's brain tissue 
revealed that he had the onset of CTE in the frontal part of 
his brain. Owen's untimely death generates a new set of 
questions to be addressed by CTE research. He had no known 
concussions at any time when playing soccer, basketball, 
baseball or football.
    To our knowledge Owen never used steroids or abused drugs 
or alcohol. He had no history of depression. We have no family 
history of depression or dementia. Owen never complained of 
headaches or acted strangely.
    The only explanation for the presence of CTE is that Owen 
started to play football at the age of nine. He was a very 
physical and intense player, who threw himself into every sport 
he played. In pre-college football he often played offense and 
defense and was on the field for much of the game.
    Maybe he had mild concussions that he never reported. Now, 
that would be Owen, anxious to return to the game, not a coach 
pressurizing him. Or maybe CTE is a cumulative effect of 
multiple subconcussions compounded by some as yet unknown 
genetic component.
    We now know Owen, the recipient of his high school's 
Eisenhower Award for Leadership, faced an increasingly 
circumscribed future as his brain disease progressed. We would 
surely have loved and supported him no matter what the cost, 
but the bright future to which he aspired would have eluded 
him.
    Since learning that Owen suffered from CTE, I have become 
more aware of the many facets of this problem and the immense 
human sorrow that lies behind the loss of young lives. In the 
bitterness of grief, it is hard not to be angry that the 
Philadelphia medical examiner did not preserve Owen's brain as 
a complete entity or ask me if I wanted it kept separate in 
case it was needed for research.
    Clearly, changes are needed in the medical community as 
well as the sports community. We have to consider that if only 
1 percent of students who play contact sports starting at a 
young age--if only 1 percent of those students have CTE, that 
will be a large public health cost to this nation, which is a 
concern for all of us. We know that high schools that are 
concerned about their budgets surely do not want to have 
lawsuits associated with this, and parents and coaches also are 
anxious for their youth to be safe in school sports.
    Congress, this is a very widespread problem, and I 
appreciate the interest of Congress in this. And I think that 
Congress can use their goodwill, their good offices to promote 
widespread discussion of this very difficult situation.
    When we think about football, I think it is important for 
us to think that many of these--that football is not a sport in 
which most people put out their emotions for people to see. If 
we think about the Steelers coach Bill Cowher, he was an 
unusual person to put out these demonstrative, terrible jowl, 
jutting out jaw, drama on the sidelines. Much more common is 
that stoic, taciturn demeanor of the late Tom Landry.
    And so football is not a sport in which most players or 
coaches bring forth their emotions. Nevertheless, those 
emotions are very intense and should not be dismissed. So I 
think we come back to this ancient motif of what it means for 
people to be like Spartans. It does not mean that they are 
ignorant or stupid. It does not mean that they don't have 
strong feelings. Thank you.
    [The statement of Reverend Brearley follows:]

         Prepared Statement of Rev. Dr. Katherine E. Brearley,
                     Mother of the Late Owen Thomas

    If my son Owen was sitting with us today he would say, ``Mom, it's 
OK. Don't make a fuss.'' He would cringe at the thought of being the 
center of so much attention. Although an excellent wordsmith, Owen 
would adhere to the unspoken football rule that words are used 
sparingly. Actions speak for themselves. In that ancient motif of 
oratory Athens verses warrior Sparta--today Owen would stand with 
Sparta.
    In as much as I speak, I speak only for myself. Nor do I speak as 
an expert or authority on football, a sport about which I learned only 
when I came to the United States in 1982. Nevertheless, I have thought 
deeply about the cultural role that football plays in the United States 
and I hope my comments are illuminating.
My Personal Story
    My first purpose is to put a human face on the disease called 
Chronic Traumatic Encephalopathy (CTE). On April 26th 2010 my son Owen 
Thomas, aged 21, a football player at the University of Pennsylvania in 
the Wharton School of Business, committed suicide on a dreary rainy 
Monday afternoon. He hung himself in his room in the house he shared 
with four other football team mates. Family and friends were deeply 
shocked as Owen seemed the most unlikely person to commit suicide. 
Subsequent detailed analysis of Owen's brain tissue revealed that he 
had the onset of CTE in the frontal part of his brain.
    Owen's untimely death generates a new set of questions to be 
addressed by future CTE research. He had no known concussions at any 
time when playing soccer, basketball, baseball or football. To our 
knowledge Owen never used steroids or abused drugs or alcohol. He had 
never been involved in a car accident and had never been hospitalized. 
He had no history of depression. We have no family history of 
depression or dementia. Owen never complained of headaches or acted 
strangely.
    The only possible explanation we can see for the presence of CTE is 
that Owen started to play football at the age of 9. He was a very 
physical and intense player who threw himself into every sport he 
played. In precollege football he often played offense and defense and 
was on the field for much of the game. Maybe he had mild concussions 
that he never reported--that would be Owen anxious to return to the 
game, not a coach pressurizing him. No one could ever pressurize Owen 
to do anything. Or maybe CTE is the cumulative effect of multiple 
subconcussions, compounded by some as yet unknown genetic component.
    Whatever the explanation, the fact is that we now know Owen--the 
recipient of his High School's Eisenhower Award for leadership--faced 
an increasingly circumscribed future as his brain disease progressed. 
We would surely have loved and supported him no matter what the cost, 
but the bright future to which he aspired would have eluded him.
The Complexity of the Problem
    Since learning that Owen suffered from CTE I have become more aware 
of the many facets of this problem and the immense human sorrow that 
lies behind the loss of young lives. For example, in the bitterness of 
grief it is hard not to be angry that the Philadelphia Medical Examiner 
did not preserve Owen's brain as a complete entity or ask me if I 
wanted it kept separate in case it was needed for research. The brain 
was simply thrown in a bag with all the other parts. Another example: I 
received an e-mail from a woman telling me her husband was discharged 
following a snow board related concussion. He had had several sports 
related concussions previously. No discharge information was given to 
alert the family to watch for mood changes. Her husband committed 
suicide. Clearly changes are needed in the medical community as well as 
the sports community. Another facet: if CTE is found in only 1% of 
youth participating in protracted youth contact sports--that 1% will 
produce a crushing public health cost for long term skilled nursing 
care if this reaches a debilitating stage when the person is only in 
their 50's.
    In face of the complexity of this issue, and its potentially 
widespread nature, Congress is uniquely placed to use its position to 
promote serious discussion of this public health concern. Lawmakers 
will surely want to protect their cash strapped school districts from 
threats of lawsuits, and coaches and parents surely want information of 
how to protect their young players.
The Social Implications of the Problem
    It has given me great joy to learn about the character of America 
through watching professional, college, high school and suburban youth 
football. What other capital city has a sport where beefy male fans, 
dress as pigs, dressed as women? NFL and college football unite fans 
across economic boundaries and age groups. In a struggling economy 
football gives people something to cheer for, a pride and a hope.
    Few characters are as demonstrative as former Steelers coach Bill 
Cowher. It is much more common to see the silent stoicism of the late 
Cowboys coach Tom Landry. Nevertheless, behind the silent facade lie 
deep passionate complex feelings. Football is indeed the spirit of 
Sparta acted out in our own time, a careful crafting of male athletic 
skill and team work. Football provides inspiration and hope to many 
including young African American players. High School football can be 
an avenue to college football and a college education.
    In speaking out about Owen's brain disease it is my hope that 
parents and coaches will unite to improve the safety of younger 
players, so football can continue to be a powerful and exciting sport 
that unites families and communities all across the United States.
                 background information for owen thomas
     Third generation college football player
     Two older bothers played football
     Excellent athlete
     Excellent scholar
     Well liked by friends
     Fan of Philadelphia Eagles
                           owen's personality
    Owen had thick straight flaming red hair of which he was very 
proud. When it was long he liked to finish a football play and as he 
walked to the side lines he would take his helmet off and shake his 
long red hair as if he were a Viking.
    As soon as he was born Owen was a dynamic ``presence'', a confident 
type-A personality. He was energetic and funny with a great capacity to 
imitate people. He was a born actor. He loved his older brothers Matt 
and Morgan. Owen was fearless.
    One time when he was 2 years old he was dancing on a picnic table 
in a local park. He had covered his face and body in some charcoal 
ashes he had found and he was dancing and singing like an Aborigine. We 
were clapping and laughing at him, then he danced right off the end of 
the table! Luckily my husband reached out his strong right hand and 
caught him as if he were a football arriving in the end zone.
    One summer when he was 4 we arrived at a motel on the Eastern Shore 
of Maryland. Owen was hot from a long trip so he got out of the car and 
ran and jumped in the deep end of the hotel swimming pool. I had to 
jump in fully clothed straight after him and grab him before he 
drowned!
    Owen was deeply kind. Parents of bullied kids would ask him to sit 
next to their child on the bus, or give protection in the playground. 
That was the end of bullying.
    He was well organized and planned ahead. He always brought me his 
school papers to sign, with a pen, days before they were needed. Every 
school year he color coded his files, got index tabs, stocked up on 
erasers and pencil leads and got ``organized''.
    Owen was strong. On church mission trips he did twice the work that 
everyone else did, but came home starving because he didn't get enough 
food to eat. He drank gallons of milk and would stop at Wendy's to get 
4 double hamburgers with French fries. He would have food ``crazes''. 
One time it was Sweet Lebanon Bologna. Another time it was eggs. Or it 
was pomegranate juice. As long as there was lots of food around, Owen 
was happy.
    Owen was the funniest, most dynamic person you could ever want to 
meet. If he had not developed CTE he would have grown up to be a 
wonderful contributing citizen.
                            additional data
Background
     Owen Thomas committed suicide at the age of 21, at the end 
of his Junior year at the University of Pennsylvania. He had been 
playing football since he was 9 years old and was recently chosen to be 
a co-captain of the Penn football team. Owen had no known or reported 
concussions.
     His parents donated Owen's brain tissue to the BU Center 
for the Study of Traumatic Encephalopathy where it was examined by Dr. 
McKee.
     The examination revealed that Owen had mild but definite 
chronic traumatic encephalopathy (CTE), a progressive brain disease 
caused by repetitive brain trauma. Upon learning these findings, Owen's 
parents requested to make this information public.
Teaching Points
     CTE can develop even when an individual has no reported 
history of concussion.
     Whether Owen had undiagnosed concussions is unknown. 
Incidence data indicates it is likely that he did
     Perhaps subconcussive blows to the head alone, such as 
those commonly experienced by football linemen and linebackers around 
1000 times a year, can lead to this progressive brain disease.
     If a reporter mentions this is like the WVU Chris Henry 
case, where they claimed he had no concussions, mention that Henry's 
mother said Henry had concussions in high school, so it's not the same 
(but WVU apparently didn't ask her)
     This further demonstrates that CTE can begin quite early 
in life (along with the 18 year-old case from 2009), though it is 
unclear if this mild stage of CTE results in the same symptoms seen in 
older individuals with more advanced disease.
     These symptoms include memory and cognitive impairment, 
depression, and problems with impulse control; CTE eventually leads to 
full-blown dementia.
     We cannot make any direct link between Owen's CTE and his 
suicide. Suicide is a very complex issue and far too common in teenage 
boys and young men.
     We do not know how common CTE is in young athletes.
Moving Forward
     Owen's case is additional evidence that we urgently need 
more research on CTE to fully understand the severity and frequency of 
brain trauma that can trigger this neurodegenerative disease--
especially so we can make changes to sports to prevent it.
     Although more research is needed to understand this 
disease and who is at risk, it is not too early to implement changes to 
the way youth sports are played and practiced.
     Owen's parents hope their tragedy will promote education 
among coaches, parents and players.
     Owen's parents are not placing blame but they do hope Ivy 
League coaches and teams will step forward as leaders in changing the 
game to make it safe for players.
     The BU CSTE conducts this research to learn the following:
        The cause of CTE
        Why some people get this disease and others do not.
        A way to diagnose CTE in living persons
        Treatment for CTE
        A cure for CTE
        How to prevent CTE in current and future athletes
The Story of the Sports Legacy Institute
     SLI was founded on June 14, 2007 in Boston, Massachusetts 
by Christopher Nowinski and Dr. Robert Cantu in reaction to new medical 
research indicating brain trauma in sports had become a public health 
crisis. Post-mortem analysis of the brain tissue of former contact 
sports athletes was revealing that repetitive brain injuries, both 
concussions and non-concussive blows, could lead to a neurodegenerative 
disease known as Chronic Traumatic Encephalopathy. In addition, an 
absence of awareness and education on concussions, specifically proper 
diagnosis and management, was allowing the disease to proliferate. 
Finally, with brain trauma becoming the signature injury of the wars in 
Iraq and Afghanistan, this research/education model could also be 
applied to the military.
     SLI was founded to solve this concussion crisis in sports 
and the military through medical research, treatment, and education & 
prevention. The initial vision of SLI was to formalize the 
groundbreaking neuropathological research and develop treatment and a 
cure through partnering with a top-tier university medical school. That 
vision was achieved when SLI partnered with Boston University School of 
Medicine in September, 2008, to form the Center for the Study of 
Traumatic Encephalopathy. SLI would also develop ways to raise 
awareness of the issue and directly educate coaches, athletes and 
parents. As of 2009, SLI has achieved those goals through our Coaches 
Concussion Clinic program and raising awareness through media like the 
New York Times, 60 Minutes, CNN, ESPN, and many others.
Mission Statement
     The mission of the Sports Legacy Institute is to advance 
the study, treatment and prevention of the effects of brain trauma in 
athletes and other at-risk groups.
                            sli contact data
Ann C. McKee, MD, Associate Professor of Neurology and Pathology, Co-
        Director Center for the Study of Traumatic Encephalopathy, 
        Boston University School of Medicine; Director, VISN-1 
        Neuropathology, New England Veterans Administration Medical 
        Centers; Director, Brain Banks of the Center for the Study of 
        Traumatic Encephalopathy, Alzheimer's Disease Center, 
        Framingham Heart Study, and the Centenarian Study, Boston 
        University School of Medicine. Tel: (781) 687-2913; Email: 
        [email protected]
Christopher Nowinski, Co-Director, Center for the Study of Traumatic 
        Encephalopathy, Boston University School of Medicine; President 
        and CEO, Sports Legacy Institute. Tel: (617) 216-9512; Email: 
        [email protected]
Sports Legacy Institute's Minimum Recommended Guidelines for Brain 
        Protection in Youth Sports
            Why Establish Guidelines?
    Medical research has exposed a brain trauma crisis in contact 
sports. In sports like football, soccer, and ice hockey, studies show 
that every season around 50% of athletes experience concussive symptoms 
after a hit to the head. Unfortunately, only a small percentage of 
these are reported and diagnosed. Additionally, many diagnosed 
concussions are not treated properly. These undiagnosed and poorly 
managed concussions put young athletes at risk of Second-Impact 
Syndrome, which can cause permanent injury or even death. Finally, the 
evidence is now clear that repetitive brain trauma suffered in youth 
sports causes some athletes to develop the progressive 
neurodegenerative brain disease Chronic Traumatic Encephalopathy (CTE), 
which eventually leads to dementia.
    While sports provide immense value both to athletes and our society 
in general, with current practices they are exposing children to 
unacceptable levels of brain damage. Much of this brain damage, 
however, is preventable with a few simple steps.
    For the first time, the Sports Legacy Institute is issuing Minimum 
Recommended Guidelines for Brain Protection in Youth Sports, also known 
as ``SLI Guidelines.'' The list, developed by Dr. Robert Cantu and 
Christopher Nowinski, incorporating the input of multiple SLI Advisory 
Boards, comprises consensus best practices as well as progressive 
ideas. To be included, each guideline is required to be simple and free 
so that they can be adopted by any organized youth sports program. SLI 
hopes that programs choose to exceed these minimum guidelines.
    We ask that sports programs voluntarily adopt SLI's Minimum 
Recommended Guidelines for Brain Protection in Youth Sports.
                 #1--educational guidelines for coaches
    A program should require preseason concussion and brain trauma 
education for coaches, athletes, and parents. Coaches should be 
required to pass the CDC's certification program.
            Recommended Program
    CDC's ``Heads Up'' Online Training Course
            Other Recommended Programs
    1. NFHS Online Training Course
    2. USA Football for Youth Coaches Video
    3. ACTive--Athletic Concussion Training for Coaches
    4. Brain Injury Association of MA--Play Smart
            Additional Resources
    CDC Heads Up Program including:
     Fact sheets
     Posters
     Action plans
    Print out or order for free
                #2--educational guidelines for athletes
    A program should require preseason concussion and brain trauma 
education for coaches, athletes, and parents.
            Recommended Program
    Distribute CDC Fact Sheet for Athletes to facilitate discussion of 
concussive symptoms and why athletes should report them.
     CDC Fact Sheet for High School Athletes
     CDC Fact Sheet for Youth Athletes
    Print out or order for free
            Additional Recommended Resources
    1. HeadStrongPlayer.org
    2. CDC--Brandon's Story
    3. Brain Injury Association of MA--Play Smart
    4. CDC Heads Up Program including:
     Magnet
     Quiz
                 #3--educational guidelines for parents
    A program should require preseason concussion and brain trauma 
education for coaches, athletes, and parents.
            Recommended Program
    Distribute CDC Fact Sheet for Parents:
     Of High School Athletes
     Of Youth Athletes
            Other Recommended Resources
    1. Brain Injury Association of MA--Play Smart
    2. NFHS Online Training Course
    3. CDC Heads Up Program including:
     Magnet
     Quiz
                   #4--clipboard sticker for coaches
    Coaches should be required to have the CDC Heads Up Stickers on 
their clipboards for easier access to both a list of common concussive 
signs and symptoms and an action plan if an athlete potentially 
experiences a concussion.
            Recommended Program
    Use CDC Heads Up Clipboard Stickers
     For High School Coaches
     For Youth Coaches
    Print out or order for free
            Other Recommended Resources
    CDC Heads Up Program including:
     Magnet
     Poster
                     #5--cdc concussion action plan
    Programs should adopt the CDC Heads Up Concussion Action Plan.
    
    
               #6--prevention through neck strengthening
    Studies* have revealed that neck strength may be an important 
factor in reducing the forces on the brain resulting from impacts to 
the head.
---------------------------------------------------------------------------
    *Tierney, R.T., Sitler, M.R., Swanik, B.C., Swank, K.A., Higgins, 
M., & Torg, J. (2004). Gender differences in head-neck segment dynamic 
stabilization during head. acceleration. Medicine & Science in Sports & 
Exercise, 37, 272-279.
---------------------------------------------------------------------------
            Recommended Program
    There is no officially recommended training program for neck 
strengthening. Please work with a local certified strength and 
conditioning coach to develop a plan for your team.
                    #7--total brain trauma reduction
    Coaches should monitor total brain trauma and strive to reduce both 
the number of hits to the head that players receive and the severity. 
Research on Chronic Traumatic Encephalopathy from Boston University's 
Center for the Study of Traumatic Encephalopathy indicates that risk of 
CTE may be more correlated to total lifetime brain trauma than 
concussions.
            Recommended Program
    In 2010, there is no formal program available. SLI asks that 
coaches attempt to monitor brain trauma, and significantly reduce it 
going forward. SLI hopes to develop guidelines for brain trauma, 
starting with football, much like Little League Baseball has developed 
extensive guidelines for ``Pitch Counts'' to protect the elbows of 
children.
                                 ______
                                 
    Chairman Miller. Thank you.
    Mr. Morey?

 STATEMENT OF SEAN MOREY, EXECUTIVE BOARD MEMBER, NFL PLAYERS 
                      ASSOCIATION (NFLPA)

    Mr. Morey. Good morning, Chairman Miller and members of the 
Education and Labor Committee. Thank you for the opportunity to 
participate in this important discussion addressing the health 
risks of concussion in youth in high school athletics.
    My name is Sean Morey. I serve as a co-chair of the NFL 
Players Association Mackey-White Traumatic Brain Injury 
Committee along with our medical director, Dr. Thom Mayer. I 
also serve as a member of the NFLPA Executive Committee and our 
Player Safety and Welfare Committee.
    For over the past decade, I have lived my dream of playing 
in the National Football League. I have always felt that the 
true privilege of being a professional athlete was the ability 
to reach and impact the lives of our youth in a profound and 
positive way. I took advantage of talking to student athletes 
many times to instill confidence and encourage them to raise 
their expectations both in school and in life. I am here today 
to issue a different message, one of concern for their health 
and safety.
    The science of brain trauma is advancing rapidly. The short 
and long-term effects of acute symptomatic concussion and 
repetitive brain trauma are serious public health concerns. I 
applaud the work of Chairman Miller and his colleagues to 
address this issue in an attempt to educate and protect our 
youth athletes and make sports like football safer. The game of 
football has enriched my life, and I believe we must all play 
an active role to preserve the integrity of the game we love so 
dearly.
    In response to the growing concern of brain trauma in our 
game, the NFL Players Association formed the Mackey-White TBI 
Committee last season to commission leading neurological and 
medical experts to interpret the science, support independent 
research, educate players, and make progressive changes in our 
game to advocate for the health, safety and welfare of active 
and former NFL players.
    I would like to recognize and thank the members of the 
Mackey-White Committee and the NFL Head, Neck and Spine 
Committee for working together to educate and protect NFL 
players. We realize our efforts to manage concussions properly 
in our game can help protect many other athletes.
    Football is the profession I have chosen. I chose to risk 
my health to financially provide for my family, not unlike 
policemen, firefighters, or members of the military. However, 
our children's developing brain is far more sensitive to 
chemical and metabolic changes of concussion.
    In addition, we must realize that kids don't have a team of 
medical professionals on the sideline every day like I did, 
which is why we must support a bill like Protecting Student 
Athletes from Concussion Act to educate coaches, parents and 
student-athletes on how to identify concussions and get our 
kids proper care so they don't suffer additional and completely 
unnecessary secondary injury.
    Our brain is the most vital organ in our body. The NFLPA, 
NFL and Centers for Disease Control have worked together 
recently to provide information that reflects scientific 
consensus about the short and long-term risks of concussion. 
These risks can include problems with memory and communication, 
personality changes, as well as depression and the early onset 
of dementia.
    When a player sustains a concussion, there is a period of 
vulnerability where another impact can kill injured brain 
cells, which could have otherwise recovered. Proper diagnosis 
and treatment is the key to recovery and safe return to play.
    As NFL players, we recognize we serve as a model for 
millions of youth, high school and collegiate athletes. The 
most profound impact we can have on these athletes is to set a 
better example and encourage them to be honest with their team 
medical staffs, coaches and teammates about their brain 
injuries and take the necessary time to recover.
    My experience in the NFL has been incredibly fulfilling. I 
have played in every NFL stadium, in over 200 games, including 
three seasons in NFL Europe, a World Bowl, 17 playoff games, 
five conference championships, two Super Bowls and a Pro Bowl. 
I was selected to Peter King's All-Decade team as his special 
teams player. But I have also suffered more concussions than I 
care to admit.
    I have learned repetitive brain trauma, especially when 
there is inadequate time to recover, may cause permanent damage 
to our brain. I understand the pressures we put on ourselves to 
play hurt. We all share a deep loyalty to our team to fight 
through pain and finish the game. However, athletes need to 
disregard the warrior mentality when addressing brain injuries.
    Several independent neurological experts recommended that I 
retire from professional football due to post-concussion 
symptoms. On the eve of my 12th NFL training camp, I disclosed 
what the doctors told me and had to walk away from the game. I 
didn't want to have to change the way I played, take a roster 
spot from somebody else, or become a liability to my team or 
family. I took it as far as I could. I made the right call for 
the good of the team, my family and my own personal health.
    NFL players today are working to change the culture in our 
locker rooms and on the field to manage concussions properly in 
our game. By raising awareness and protecting student athletes, 
we leave an enduring legacy that will impact the lives of 
others for decades to come. The game of football teaches us to 
value selflessness, accountability, leadership and, above all, 
teamwork. Let us continue to work together to change the 
culture about sports-related concussion.
    Thank you for allowing me to be a part of this process to 
create real, meaningful and productive change, protecting our 
youth athletes.
    [The statement of Mr. Morey follows:]

       Prepared Statement of Sean Morey, Executive Board Member,
                    NFL Players Association (NFLPA)

    Good morning Chairman Miller and members of the Education and Labor 
Committee. Thank you for the invitation to participate in this 
important discussion addressing the health risks of concussion in youth 
and high school athletics. My name is Sean Morey. For over the past 
decade, I've lived my dream of playing in the National Football League. 
I was drafted as a wide receiver out of Brown University in the 7th 
round of the 1999 NFL draft to my hometown New England Patriots. I was 
a long shot. I realized quickly that if I wasn't going to be a starter, 
I had to find a way to earn a roster spot and contribute on Sundays to 
help my team win. I've survived playing in the NFL for longer than 
anyone expected, by doing a job most professional football players will 
admit they don't envy. I'm a Special Teams guy. The ability to overcome 
pain and ignore injury is an occupational requirement. My experience in 
the NFL has been incredibly rewarding, but it hasn't been easy. I've 
been cut eight times, played through my share of injuries, and suffered 
more concussions than I care to admit. However, during the course of my 
career I have played in every stadium in the NFL. I've played in NFL 
Europe, a World Bowl, 17 playoff games, 5 Conference Championships, a 
Pro Bowl, and two Super Bowls. Additionally, I serve as Co-Chair of the 
NFL Players Association Mackey-White Traumatic Brain Injury Committee 
(TBI) along with our Medical Director, Dr. Thom Mayer. I also serve as 
a member of our Executive Committee of the NFL Players Association 
(NFLPA) and as a member of our NFLPA Player Safety and Welfare 
Committee.
    During Super Bowl Week in 2008, I was approached by Chris Nowinski, 
co-founder of Sports Legacy Institute, during which he told me about 
some disturbing new research about concussions and the potential long 
term cumulative effects of repetitive brain trauma. As a member of the 
NFLPA Players Safety and Welfare Committee, I felt compelled to do my 
part to research the issue and report back to our Union leadership. I 
spent the greater part of this past year and a half burning the candle 
at both ends to learn as much as I could about the effects of traumatic 
head injuries. Since that conversation with Chris, I've spent 
significant time discussing this issue with many different neurological 
and medical experts, athletic trainers, coaches, and players to gain a 
unique perspective on how to address the issue systematically and 
responsibly. We must all play a role to change the culture in our game 
to help make it safer for future generations. I've devoted my time to 
educate and protect players and give back to the game that has provided 
so much for my family.
    The game of football has enriched my life immensely, but I also 
understand the harsh realities of the NFL and the brutal nature of our 
sport. Self preservation is an afterthought. The challenges we face 
playing this game builds character. We condition ourselves to value 
courage, mental and physical toughness, and resiliency. However, the 
science and awareness of brain trauma is advancing rapidly, and we need 
to significantly change the culture of how we manage brain injuries in 
our game. Football, and other contact sports, can provide our youth the 
ability to conquer their limitations and learn valuable lessons in 
humility, respect, teamwork, and selflessness. We must preserve the 
integrity of our game, and ensure the game is made safer for future 
generations.
    As NFL players, we recognize we serve as a model for millions of 
youth, high school, and collegiate athletes. The most profound impact 
we can have on youth athletes is to set a good example and encourage 
them to be honest with their team medical staff, coaches, and teammates 
about their brain injuries and take time to recover. Educational and 
awareness initiatives can inform parents, coaches, trainers, and 
athletes to help identify the many signs and symptoms of concussion so 
they can communicate effectively. No athlete should return to the same 
game or practice after sustaining a concussion.
    Our brain is the most vital organ in our body. NFL players have 
downplayed symptoms because we believed a concussion was a temporary or 
transient injury. We just shook it off. It's still a challenge to get 
players to buy in. We all share a deep loyalty to our fans, our 
coaches, and our teammates to ``complete the mission'', or finish the 
game. As professional athletes, we aspire to gain the approval of the 
men we respect. We don't want to let our team down. We don't want to 
lose our jobs. However, continuing to play through a concussion can 
prolong the time it takes to recover, shorten our careers, and compound 
problems transitioning into life after football. Repetitive brain 
trauma, especially when there is inadequate time to recover, may cause 
permanent damage to your brain. Playing through a concussion is no 
longer a badge of honor, it's reckless. Reporting our concussion is not 
a sign of weakness, it's a responsibility we share to advocate for our 
own health and safety.
    I've learned how to play this game from some of the most inspiring 
coaches in the league. During my career I played this game the way it's 
supposed to be played, flying around the ball and going all out every 
play for a very long time. Playing the game recklessly has taken it's 
toll on my health. I had an exceptionally rough season last year. I was 
praying I'd come around all offseason, but I still couldn't hit anymore 
without getting injured. I've been suffering chronic headaches, 
intermittent migraines, and blind spots in my vision for almost a year 
now. I've utilized prescription medication to manage my injuries and in 
turn masked post concussive symptoms for a long time. I hadn't yet 
fully recovered and wasn't healthy enough to do my job effectively at 
the start of this season. And so, I retired on the eve of my twelfth 
NFL training camp. I felt like I was abandoning my team in the eleventh 
hour. It was the toughest decision of my life, but I made the right 
call for the good of the team, my family, and my own personal health.
    As I mentioned earlier, one of the ways I am giving back to the 
game is by serving in a leadership role with the NFLPA and its Mackey-
White TBI Committee. The NFLPA formed the Mackey-White TBI Committee 
last season to commission leading neurological and medical experts to 
interpret the science, support independent research, educate players, 
and make progressive changes in our game to advocate for the health, 
safety, and welfare of active and former NFL Players. I would like to 
thank and acknowledge the individual efforts and collective 
contributions of our group of experts who serve on our Mackey-White TBI 
Committee. They have made significant contributions to pushing the 
science surrounding sports related concussions.
    NFLPA Medical Director and Mackey -White Co-Chair Dr. Thom Mayer 
has worked tirelessly to protect our players and enhance scientific 
dialogue with the NFL Head, Neck, and Spine Committee to maintain 
inclusivity and transparency addressing this complicated issue. We are 
all working together to address concussions in our game at every level. 
Last year, Dr. Mayer initiated collaboration with the NFL mid season to 
implement stricter Return to Play Guidelines intended to reduce the 
risk NFL players take when returning to the same game or practice 
following a concussion. We have also collaborated with the CDC to build 
a Youth Concussion Poster as well to educate youth athletes about 
identifying the signs and symptoms of concussion so that the younger 
athletes, medical staff, parents and coaches are all speaking the same 
language.
    We have worked together with the members of the new NFL Head, Neck, 
and Spine Committee to make progressive changes in our game to protect 
the players we represent. The NFLPA, NFL, and Centers for Disease 
Control (CDC) have worked together recently to provide information that 
reflects scientific consensus about the short and long term risks of 
concussion. These risks can include problems with memory and 
communication, personality changes, as well as depression and the early 
onset of dementia. When a player sustains a concussion, there is a 
period of vulnerability where another impact can kill injured brain 
cells which could have otherwise recovered. Proper diagnosis and 
treatment is the key to recovery and safe return to play. Repetitive 
brain trauma, especially when there is inadequate time to recover can 
cause permanent damage to your brain.
    Former athletes with a history of repetitive brain trauma, 
including NFL Players, have been diagnosed with a degenerative 
neurologic disease referred to as Chronic Traumatic Encephalopathy 
(CTE) at autopsy. The brain degeneration is associated with memory 
loss, confusion, paranoia, impaired judgment, impulse control problems, 
aggression, depression, Parkinsonism, and, eventually progressive 
dementia. The NFL and NFLPA are supporting independent research 
efforts, most notably at Boston University School of Medicine's Center 
for the Study of Traumatic Encephalopathy, targeted to identify 
specific risk factors and determine prevalence. The goal is to provide 
an effective means to diagnose, treat, and prevent CTE. The NFLPA and 
NFL will continue to work together to actively pursue definitive 
science to assure that we are doing everything possible to protect the 
interests of our players and their family's when it comes to health and 
safety.
    Among the many initiatives intended to educate and protect NFL 
players, the NFL Players Association has also been a leader in raising 
awareness of sports-related concussions with youth athletes. NFL 
Players have made significant contributions in an effort to change the 
culture in our locker rooms and on the field to manage concussions 
properly in our game. The game of football provides a platform to teach 
valuable lessons and inspire our youth. As NFL Players, our greatest 
honor is to interact with our fans and impact the lives of others in a 
positive way.
    The NFLPA has also partnered with apparel maker Muze Connects. Muze 
will design and create messages displayed on a designer T-shirts geared 
towards impacting the lives of countless youth, high school and 
collegiate athletes whom we serve as a model for dealing with brain 
injury. The T-shirts deliver an important message to players, parents, 
coaches, fans and media reminding us that we all must play an active 
role in addressing this public health concern--``What you do in life 
echoes in eternity.''
    As NFL Players, we are held accountable for reporting our own 
concussions promptly and taking the necessary time to recover, but we 
are also responsible for looking out for our teammates and ensuring 
youth athletes communicate with their coaches, athletic trainers, and 
teammates when they sustain a concussion. Playing through a concussion 
can prolong the time it takes to recover and increase the risk for 
permanent injury. We must work together to change the culture and make 
this game safer. As part of our NFLPA Grassroots Campaign to change the 
culture in our game, we are reminding athletes that if they have a 
concussion, ``don't hide it, report it, and take time to recover.''
    With fan support and involvement from youth and high school 
football programs, our partnership will galvanize local communities all 
over our country to work together to raise awareness about concussions. 
Fans and athletes can wear our T-shirt proudly to demonstrate and share 
in the solidarity across NFL locker rooms, supporting our NFLPA 
Grassroots Campaign to help make our game safer. Former NFL Players 
have sacrificed so much to build this game. It is now our 
responsibility to protect football players on all levels and ensure the 
game we love is better for us having us all been a part of it. By 
raising awareness and supporting independent research for sports-
related concussions, we leave an enduring legacy that will impact the 
lives of others for decades to come.
                                 ______
                                 
    Chairman Miller. Thank you.
    Dr. Herring?

 STATEMENT OF STANLEY HERRING, M.D., CHAIRMAN, SUBCOMMITTEE ON 
 EDUCATION AND ADVOCACY, HEAD, NECK AND SPINE COMMITTEE OF THE 
   NFL, TEAM PHYSICIAN, SEATTLE SEAHAWKS AND SEATTLE MARINERS

    Dr. Herring. Thank you, Chairman Miller and Ranking Member 
Kline and the members of the committee and guests.
    Mr. Chairman, today you should have received a letter from 
Commissioner Roger Goodell of the National Football League 
supporting your legislation, and I know that his letter says 
that the NFL is grateful for the opportunity to work closely 
with you in developing this important legislation, which will 
further our shared goals of increasing concussion awareness and 
preventing these injuries among our youngest athletes, not only 
of football, but in all sports.
    And as a member of the newly formed NFL Head, Neck and 
Spine Committee, I join the Commissioner in thanking you for 
this work. As someone who has spent his life managing athletes 
with sports concussions, this Protecting Student Athletes from 
Concussion Act is a really significant step forward. It is a 
great campaign to protect young athletes. And as a physician, 
educator, advocate and representing the NFL today, I am proud 
to testify after many years of work in this area.
    I would take a little different bent today and make my 
testimony a bit more personal. I am sure the committee has 
heard of the name Zachary Lystedt by now. In October 2006 Zach 
was a 13-year-old middle school all-star football player, who 
suffered a blow to his head with a few minutes left in the 
first half. There was an injury timeout.
    After halftime Zach returned to play. He was still having 
symptoms from his concussion. He sustained further head blows 
in the second half of the game and at the end of the game 
collapsed in his father's arms, lapsed into a coma and suffered 
life-threatening injuries. Zack survived, but he is now faced 
with a lifelong road of rehabilitation. The tragedy here, Mr. 
Chairman, is that was a preventable injury.
    A coalition of brain injury advocates and doctors and 
athletic trainers, school administrators, risk managers and 
local elected officials in the State of Washington began to 
work on a law to prevent the next child and the next family 
from suffering the way Zachary and his family did, the Zachary 
Lystedt Law. It was during this process that I personally met 
Zach.
    I take care of the Seahawks. I am on the sideline at a 
practice, and here is a young boy in a wheelchair with his 
parents. And Zach looks at me straight in the eye, and he very 
slowly and deliberately says, because he is just learning to 
re-talk, is ``The reason I am here,'' he said, ``is to help 
people.''
    And I have to tell you as a doctor who takes care of people 
with disability, that was a pretty powerful message from a 
young man who couldn't speak for 9 months, almost lost his 
life, and has had to work incredibly hard just to get some 
sense of normalcy. It is a pretty incredible statement.
    Zach had choices during his recovery. He could be angry or 
he could be content or he could be depressed or he could come 
to accept it or he could be bitter or try to find peace. And 
each choice made that young man who he is today, this 
incredibly witty and driven and fabulous 17-year-old young man 
who still struggles with significant problems. And his family 
struggles along with them. But they really are changing the 
face of youth sports across this country.
    The coalition in the State of Washington passed the Lystedt 
Law, and it had three essential components very similar to what 
is in your bill, and we just praise you for that. Seven more 
states have passed Lystedt Law since that time, and it is 
pretty easy. Educate parents and athletes, coaches and 
administrators. If there is a suspected concussion, take the 
youth athlete out at that time. And the third piece, don't put 
them back in until they have been cleared by a licensed health 
care provider who understands concussions.
    Mr. Chairman, if your bill were to become law, it would 
protect athletes in every state that don't yet have a Zachary 
Lystedt Law. Commissioner Goodell has already given you NFL's 
pledge to work diligently in support of your legislation, and 
at the same time, Mr. Chairman, we are engaged in a state-by-
state effort to pass a Zach law. We would hope to see 
legislation in California. And just this week I am very pleased 
to announce that a bill was introduced here in Washington, DC, 
a Zachary Lystedt Law.
    Also as part of our state-by-state effort, the NFL will 
convene an educational and advocacy summit next month in my 
hometown of Seattle, a how-to course for the Zachary Lystedt 
Law, and that will be available online for anyone who wants to 
learn the process, at least on a state-by-state basis, of 
making the law available.
    Passing these state laws however, takes time. But public 
awareness need not wait. That is why the NFL has taken the lead 
in promoting concussion education at all levels of sport and in 
every sport. And before the start of this NFL season, a new 
concussion awareness poster was developed by a group of medical 
experts and interested parties working in a great coalition.
    One of those experts would be Sean Morey who personally, he 
and I, worked on this poster. I even have it. This is in every 
locker room in the NFL. It is in a brochure form for every 
player, and you will notice the commissioner of the NFL, the 
NFL Players Association, the CDC, professional football 
athletic trainers and the Professional NFL Physicians Society 
all worked together, as they should, to help make sports safer. 
It was a pleasure and an honor for me to sit next to Sean as we 
worked on that together.
    The same group has developed a poster specifically for 
youth, which I know is part of your bill. And this poster for 
youth involves all sports and will be informational. It will be 
released shortly and made available at no cost.
    The NFL has been interested also in other aspects of trying 
to make concussion safety their business. Other projects with 
the CDC, USA Football, the American College of Sports Medicine, 
the National Athletic Trainers Association have been put 
together to disseminate educational materials for young 
athletes and their coaches through a variety of different media 
and educational tools.
    USA Football, which is the independent not-for-profit 
organization that serves as kind of the official youth force 
for the NFL recently, had educated 30,000 coaches since April 
10th with the concussion education module, as an example.
    Look for our Put Pride Aside campaign this fall to do just 
what Sean said to take the concussion issue and have people 
report honestly and directly. The NFL continues also to support 
the science of research for the tragedies like CTE, which are 
critical for us to understand so that we can try to make sports 
as safe as possible for as many as possible.
    In closing, Mr. Chairman, as more has become known about 
the dangers of head injury, the NFL has become a leader in 
concussion, not just for the safety of its own players, but for 
all athletes at all levels of football and in all other sports. 
And I see them every day. I see young athletes--soccer, 
basketball, lacrosse--who have been concussed. And those 
children, those young athletes can recover and play again, but 
they must receive proper treatment.
    I am proud of what the NFL has done in the professional 
game, but I am particularly pleased to share with you the NFL's 
initiative to educate and inform all sports at all levels about 
concussions. I think the NFL understands its obligation to 
continue to lead in this area and to provide a model for all 
sports. I know that the NFL looks forward to continuing to work 
with this committee and for all of the advocates for the 
benefit of youth athletes everywhere. Thank you.
    [The statement of Dr. Herring follows:]

   Prepared Statement of Stanley Herring, M.D., Clinical Professor, 
    Departments of Rehabilitation Medicine, Orthopedics and Sports 
   Medicine, and Neurological Surgery, University of Washington; Co-
 Medical Director, Seattle Sports Concussion Program; Team Physician, 
 Seattle Seahawks and Seattle Mariners; and Member, National Football 
                League's Head, Neck and Spine Committee

    Chairman Miller, Ranking Member Kline, and Members of the 
Committee, my name is Dr. Stan Herring. I am the Co-Medical Director of 
the Seattle Sports Concussion Program and a Clinical Professor at the 
University of Washington. In addition, I serve as a team physician for 
the Seattle Seahawks and the Seattle Mariners. I appear before you 
today as a member of the National Football League's Head, Neck and 
Spine Committee and the Chairman of the Subcommittee on Education and 
Advocacy.
    Mr. Chairman, today you received a letter from Commissioner Roger 
Goodell of the National Football League supporting your legislation. 
The Commissioner's letter states that, ``The NFL is grateful for the 
opportunity to work closely with you in developing this important 
legislation which will further our shared goals of increasing 
concussion awareness and preventing these injuries among our youngest 
athletes, not only in football but in all sports.'' I join the 
Commissioner in thanking you and the Committee for your work to protect 
youth athletes of all ages, of both genders, and in all sports, from 
the dangers of concussions.
    The ``Protecting Student Athletes from Concussions Act'' is a 
significant step forward in the campaign to protect our kids. As a 
physician, educator, advocate, and as a representative of the NFL, I am 
proud to testify here today after years of work in this area.
    Mr. Chairman, my testimony today is very personal. The Committee 
has heard the name Zackery Lystedt by now. In October 2006 Zackery was 
a 13-year old star football player who suffered an undiagnosed 
concussion with a few minutes left in the first half. An injury time 
out was called. After resting during halftime, Zackery returned to play 
in the second half while still having symptoms from his injury. He 
sustained further head blows during the second half of the game, and at 
the end of the game collapsed in his father's arms. He lapsed into a 
coma suffering from life-threatening injuries. Zackery survived, but 
continues to face a long road of rehabilitation.
    In the meanwhile, a coalition including brain injury advocates, 
doctors, athletic trainers, school administrators, risk managers and 
local elected officials in Washington State began work on a law 
designed to prevent the next child and the next family from suffering 
the way Zackery and his family did.
    It is during this process that I met Zackery. Seated in his 
wheelchair at a Seahawks practice with his parents, Victor and Mercedes 
by his side, Zack looked me straight in the eye and very slowly and 
deliberately said, ``The reason I'm here is to help people.'' Perhaps 
because he could not speak for nine months, or because he almost lost 
his life and has had to work so hard to regain any sense of normalcy, I 
knew how incredible that statement was. He has had choices along the 
way: anger or contentment, depression or acceptance, bitterness or 
peace. Each choice has made him who he is today--the driven, witty, 
fabulous 17-year-old young man who, along with his family, is changing 
the face of youth sports across the country.
    The coalition succeeded in passing a law in Washington State and in 
seven more states since then. Like your bill, Mr. Chairman, it contains 
three core principles:
    1. Student athletes and a parent or guardian must sign an education 
sheet that provides them with information about the signs and symptoms 
of concussion;
    2. Any youth athlete who appears to have suffered a concussion in 
any sport is removed from play or practice at that time; and
    3. That athlete must be cleared by a licensed healthcare provider 
trained in the diagnosis and management of concussions before returning 
to play or practice.
    If this bill were to become law, it would protect the athletes in 
every state that has not passed Zack's law. Commissioner Goodell has 
already given you the NFL's pledge to work diligently in support of 
your legislation. At the same time, we are engaged in a state by state 
effort to pass Zack's law. We are actively working in California, Mr. 
Chairman, and just this week are pleased that the bill was introduced 
in Washington DC.
    As part of this state-level effort, the NFL will convene an 
educational and advocacy summit next month in Seattle. It will be 
available on-line to anyone interested in learning more.
    Passing state laws can take time. Public awareness need not wait. 
That is why the NFL has taken the lead in promoting concussion 
education at all levels of sport and in every sport. Before the start 
of the season, a new concussion awareness poster was developed by a 
group of independent medical experts working with the CDC. This poster, 
and a related player fact sheet, has been distributed throughout the 
NFL. I have attached copies to my testimony. I want to thank the group 
of organizations that worked together to produce this consensus 
document--NFL, NFLPA, CDC, Professional Football Athletic Trainers 
Association, and the NFL Physicians' Society.
    The NFL, working with the Players Association and independent 
experts, ensures that professional football players receive the most 
information about concussions and the best treatment from the finest 
doctors. Yet, we also recognize that the risks of concussions go beyond 
the professional ranks and beyond football. We know that it is our 
responsibility to share what we know with all athletes at all levels. 
So, the NFL is replicating this poster idea for youth athletes in all 
sports, and together with the CDC and our other partners, we will make 
available shortly--and at no cost--a concussion education poster 
designed specifically for younger athletes.
    I am personally involved in the design of the poster. So, once 
again I would like to commend your bill for the concept of publishing 
concussion information in schools. The NFL wholeheartedly supports the 
idea and is working to distribute more information as we speak.
    In addition, the NFL is working closely with the CDC, USA Football, 
and others, to disseminate CDC educational materials for young athletes 
and their coaches. The NFL has assisted in the production of a 
concussion video developed jointly by the National Athletic Trainers 
Association and the National Academy of Neuropsychology. In addition, 
USA Football--the independent, non-profit organization that serves as 
the official youth football development partner of the NFL and its 32 
teams--will conduct a national campaign from mid-September through 
November 2010, titled ``Put Pride Aside for Player Safety'' to 
emphasize concussion awareness in youth sports, particularly football. 
The campaign challenges and instructs coaches, parents and youth 
players to make the right decision about concussions. And I am 
personally involved with another initiative that the NFL is 
supporting--the development of a training module for coaches and health 
professionals that will provide them with the information they need to 
properly diagnose and treat athletes who have had a concussion.
    Last December, in conjunction with the CDC, the NFL produced a 
public service announcement devoted to youth athletes as well as their 
parents and coaches regarding the importance of concussion awareness. 
The message aired repeatedly on national media throughout the end of 
the NFL season and the playoffs.
    The NFL is also investing in the science around concussions, 
including support for research being conducted by doctors at Boston 
University.
    Our medical committee, in conjunction with the NFL Players 
Association, will host a conference later this fall to consider new 
methods of testing the performance of safety equipment, such as 
football helmets. We are hopeful that this work will improve safety of 
athletes not just in football but other sports as well.
    As more has become known about the dangers of head injuries, the 
NFL has become the leader on concussions not just for the safety of its 
own players, but for all athletes at all levels of football as well as 
all other sports. I see them every day--boys and girls, soccer, 
basketball and lacrosse players--young athletes who have endured 
concussions. Those children can recover and play again if they receive 
proper treatment. I am proud of what the NFL has done in the 
professional game, but I am particularly pleased to share with you the 
NFL's initiatives to educate and inform all sports at all levels about 
concussions.
    The NFL understands its obligation to continue to lead in this area 
to provide the model for all sports. The NFL looks forward to continue 
working with this Committee and all other advocates for the benefit of 
youth athletes everywhere.
    I look forward to any questions.
    Thank you.
                                 ______
                                 
    Chairman Miller. Thank you very much.
    And thank you to all of you for your testimony. To Alison 
and Reverend Brearley and Sean, I just want to say that--and, I 
think, Dr. Herring speaking on behalf of Zachary--that your 
testimony in many ways is a very, very important part of this 
public discussion, because I think it gives people ownership 
and license of this debate to change and to rethink the models 
as a player, as a parent, as a coach, as a team owner.
    I mean, through the entire athletic community, I think that 
is very important. And I am very pleased with the way this 
discussion has developed nationally by working with local 
school districts, by working with the states, working with the 
Congress so that it can be comprehensive.
    And your stories are all very, very difficult stories to 
tell, just as when Sarah joined us to share about her future 
and where she was headed in sports in college and the rest of 
this, and she has had to retract some of that and rethink how 
to accomplish all that. But she is doing it, and we are excited 
about that.
    But I think for parents and students who are wondering is 
this real, is it not, the participants in this debate have 
really put together a remarkable coalition to bring this home, 
if you will, in every sense of the word, whether it is an NFL 
player's family or whether it is a parent with a child in youth 
soccer or lacrosse or Pop Warner football or high school 
sports.
    I think that is where this discussion really has to take 
place. And because of the actions of your center, Dr. Gioia, 
and what the NFL is doing and what the Mackey-White Fund is 
doing, we see that people have options and places to go for 
information. And they are places that they respect, that have 
cachet. And that is worth so much in this kind of discussion 
when the stakes turn out to be so very high for individuals.
    I know that Commissioner Goodell has also written every 
governor--I think every governor--where they don't have a plan 
in the state yet--I think 40 or 45 governors----
    Dr. Herring. Forty-four.
    Chairman Miller [continuing]. Urging them to take this on. 
And I hope that that is very successful.
    I would like to address one part of this, Dr. Herring, if I 
might, first, with you. And that is the third part of the NFL 
program, and that is that an athlete must be cleared by a 
licensed health care provider trained in the diagnosis and 
management of concussions before returning to play or practice.
    And then I would like, Alison, if you might follow up on 
what you hear here, because I am not quite sure how you got 
into the diagnosis when you were trying to think about going 
back and forth, whether that was a formal process or informal 
or where that is just with respect to your school or not.
    But first, we will hear why this decision was made on this 
part of the proposal.
    Dr. Herring. Thank you, Mr. Chairman.
    The fact that return to play after concussion is a medical 
decision is not new news. We have said this for a decade to 
multiple consensus conferences. It is not fair to make someone 
be a coach and a medical health care provider or apparent 
health care provider. That burden falls upon the health care 
community to make those decisions.
    So our hope, through work like yours where this issue 
continues to be made more aware and systematically applied 
across all 50 states, that continued education of health care 
providers and continued awareness on their part will help them 
become better providers.
    Passing the law is the first step. It helps bring 
awareness. And then, as you know, it is an iterative process. 
We begin to train all components. You want the parents to know, 
the athlete to know, the coaches to know, and the health care 
community to know, so someone sounds the alarm. But we do feel, 
and it just makes sense, that return to play after concussion 
should be made by a health care provider who understands the 
problem.
    Chairman Miller. Thank you.
    Alison?
    Ms. Conca-Cheng. Well, I know Howard County has a very 
comprehensive system as to how to deal with concussions and 
suspected concussions. Once you are suspected of having 
concussion, you have to go to a health care provider, and your 
parents are notified. And the health care provider has to clear 
you to play or come up with a care plan. And once you are 
cleared to play by a physician, you must take the computerized 
test, as I spoke of, and those test results--they consult with 
Dr. Gioia to make sure that the test results are in agreement 
with the physician order to return to play.
    Chairman Miller. Thank you.
    Sean, in this discussion back and forth here, to have this 
intervention by a health professional, to tell a player in a 
case of an NFL player or any professional athlete is a high-
stakes decision. To have that intervention by, hopefully, you 
know, a neutral medical party--do you think that is helpful, 
because that player has got to decide, as you said, am I 
letting my teammates down? How close is the game? What is our 
opportunity? And the coach has many of the same concerns. And 
this question of having independent observation--do you want to 
address that?
    Mr. Morey. Sure. And thank you for asking. I think in the 
NFL when we suffer a concussion, we have to see--and we are 
removed from play--we have to see both an independent 
neurological consultant and get cleared by our team medical 
staff to be able to return to play safely.
    I think in this situation with youth athletes, I think it 
is critical that they see a health care provider before they 
are cleared to return to play. Coaches have to be educated. 
Parents have to be educated. Kids have to know and be able to 
recognize the signs and symptoms of a concussion so they can 
communicate effectively.
    And I think it is important that in the NFL, the NFLPA 
return to play guidelines stipulate that if you demonstrate 
persistent signs and symptoms of concussion when you sustain a 
concussion--that means confusion, headache, vision 
disturbances--persistent symptoms where you are not recovering 
from the concussion is deemed that you are a danger to yourself 
and to your team, and you need to be removed from play safely. 
And that is the role of our health care providers, of our team 
doctors that are--and the team doctors are sports certified.
    So I think it is important to understand the realities of 
the NFL and the profession we have chosen as athletes, but I 
think especially with youth athletes, where their brains are 
still developing, where their brains are more vulnerable to 
acute symptomatic concussion because of----
    You know, their brains are more sensitive to those chemical 
metabolic fluctuations of ions when they sustain a concussion. 
And when you sustain a concussion, your brain in effect, you 
know, becomes overwhelmed, and it shuts down. It becomes quiet. 
And there is a period of vulnerability where the secondary and 
further damage can have permanent damage or even catastrophic 
circumstances.
    So for high school athletes and youth athletes, it is 
important to make sure that they are removed when they sustain 
a concussion.
    Chairman Miller. Thank you.
    Reverend Brearley, I want to get your response to this, but 
I am going to--excuse me, my time is up. I will come back in a 
second round, but I wanted--because obviously it appears in 
Owen's case that this was almost invisible, you know, to the 
layperson, to your son, to yourself and others, and what the 
medical intervention may or may not have been.
    Congressman Kline?
    Mr. Kline. Thank you. Thank you, Mr. Chairman.
    And again, thanks to all the witnesses.
    Dr. Gioia, it is nice to see you here again.
    Both the physicians, the medical professionals, thank you 
for your work and for your testimony and input here today.
    And to Alison Conca-Cheng and Dr. Brearley and Mr. Morey, 
thank you for your testimony and sharing your personal stories. 
I know there is a lot of pain associated with those stories, 
and we are very, very glad that you are here today to share 
those stories.
    Reverend Brearley, you said that we should be using our 
offices and other means to promote widespread discussion, and I 
certainly agree with that. And it seems to me there has been 
more and more discussion, work that the NFL has done, the 
production of the posters. There has been a lot of discussion, 
and I know that you would certainly like to have had more of 
that discussion earlier.
    Alison, it seems to me that, I mean, it was a terrible 
accident, and the damage was pretty tough for you, but it seems 
that the system works like it is supposed to work. You were 
pulled out. You talked to medical professionals. Your trainer 
said, ``No, you can't come back. You have got to go back and 
get cleared again.'' And the system was there, protecting you. 
Is my understanding correct? Do you feel like it worked like it 
was supposed to?
    Ms. Conca-Cheng. I believe that Howard County system is 
very comprehensive, and I hope that other schools would have 
the same system, because in my case the test definitely caught 
what was the more serious underlying problem than it appeared 
to be at first.
    Mr. Kline. And were you aware of the system before this 
happened to you?
    Ms. Conca-Cheng. Well, all athletes are required to 
complete the baseline test so that there are results to compare 
to post-concussion. So I think everyone has a general idea of 
the basic rules and procedures, but it is just--I mean, I think 
so most people are aware, but it is not that widespread.
    Mr. Kline. You sort of knew it was out there, because you 
had to go take the test.
    Ms. Conca-Cheng. Yes.
    Mr. Kline. Yes, all right. I got it. Tests will do that to 
you sometimes. But so there was an awareness on the part of the 
student body, but it is not something that you probably sat 
around and talked about all the time. That is fine. 
Nevertheless, the system stepped up, and it worked. And it does 
appear that that is a good model that the rest of the country 
should look at to adopt.
    And, Dr. Gioia, we have talked the last time you were here. 
When you have to develop an academic program, which, I guess, 
is what we would call that in the case of Alison--restrictions 
on how much homework time, study time and all of that--remind 
us again how that has developed. Is that something that you do, 
that another doctor does, teacher does, you do it together?
    How does that work, one more time? We talked about this 
last time, but I would just like to sort of clear that up. How 
do you get that plan in place and get it implemented so that 
she has the support that she needs to make that work?
    Mr. Gioia. Yes, great question. And basically, in our 
clinical examination of the student athlete, we have an 
understanding of where they are at in their recovery. What can 
they tolerate? What can they not tolerate? What cognitive 
functions are impaired, whether other physical or even 
emotional kinds of symptoms are still present?
    And based on that symptom profile and what is impaired and 
what they are able to do, we then build that care plan. And as 
Alison knows, we go through the class schedule. What do you 
have? When do you have it? How long does it happen? Where can 
we build the breaks in? Given that it takes, you know, about 45 
minutes before your symptoms start to flare, let us build these 
periods of your academic performance and learning into those 
45-minute periods with respiration in there.
    So we can start that and----
    Mr. Kline. Excuse me for the interruption, but you are 
constructing that in discussions in this case with Alison.
    Mr. Gioia. Yes.
    Mr. Kline. And so when does the teacher get involved in 
this? When does the school get involved in this?
    Mr. Gioia. So but we do--first of all, in our system we 
have also prepared the school nurses, the school psychologists 
and the other professionals to support this--the guidance 
counselors--so that when the care plan--literally, we make four 
or five copies, and the student brings it to the school.
    The point person at the school--it could be a school nurse; 
it could be a guidance counselor; it could be a school 
psychologist--takes that care plan and works with the team--
obviously, Alison is a major member of that; her mom and dad 
are, too--to make sure that that plan is understood and 
implemented.
    Mr. Kline. Okay. Great. Thank you.
    I see my time has expired.
    Again, thanks to all the witnesses.
    Chairman Miller. Thank you.
    I would like to ask unanimous consent to insert into the 
record of this hearing a letter from the National Football 
League and the commissioner, Roger Goodell, to the governors. 
There is no objection. So ordered.
    [The information follows:]
    
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
        
                                ------                                

    Chairman Miller. Mrs. McCarthy?
    Mrs. McCarthy. Thank you, Mr. Chairman. I thank you for 
bringing this hearing. To me it is extremely important, 
especially being a background as a nurse.
    Mr. Bishop, my colleague from Long Island, New York--we 
held a hearing on September 13th and basically had the same 
kind of hearing that we are having right now with the same 
professionals and student. And I have to say one of the things 
that we heard constantly was--a term they used was the 
``warrior mentality.''
    And we actually heard that from--and I want to say thank 
you to the NFL and NFLPA, because they supplied us with two 
retired football players, Mr. Caster from the New York Jets and 
Mr. Hall from the San Diego Chargers--they gave us an insight 
on what their life is like now from suffering so many 
concussions--to Alison, who was telling us about something 
recently.
    My concern with what we are doing--and it is a concern that 
I am going to work with Mr. Chairman Miller as we go forward on 
the health care professionals--I think that is very important 
on how we clarify that. I agree that we need a doctor to be 
able to diagnose and then work with the school. And I think 
that when we even have, certainly, the words ``health care 
professionals'' in New York State, which has passed in the 
Senate, only physicians, physicians' assistants and nurse 
practitioners are allowed to diagnose.
    As a nurse I can say, ``I think you might have a 
concussion.'' The trainer can say, ``I think you have a 
concussion.'' And I think sometimes when people forget--gosh, 
you have probably heard it all the time--it is only a 
concussion. And that is what we have to try to change around.
    There is no such thing as ``only a concussion.'' A 
concussion is an injury to the brain. And it is actually 
opposite. When a young person gets a concussion, it is actually 
more dangerous at that particular stage than someone that is 
even older. So we need to tighten up the language, and 
hopefully, I will be working with Chairman Miller to tighten 
that language up.
    I want to go back to the warrior mentality--namely, because 
from what we found in talking to students that have gotten the 
concussion, or even the trainers or even the coach, that 
basically they will say, ``Oh, you must be all right, because 
you are back to a fairly normal life, hanging out with your 
friends, laughing, smiling.'' So everybody thinks you are just 
absolutely fine, when probably you are still recovering.
    And I don't know how we deal with it, but going back to the 
poster that you have, which I think is terrific, but one of the 
things from our young student that we found out on the poster, 
they probably won't read that. I am talking about younger 
students.
    It has got to be almost like the poster that was out there 
years ago when we were trying to get kids not to take drugs. 
``This is your brain. This is your brain that is fried.'' So it 
has got to be colorful so that in the locker room, basically, 
the students will hopefully notice it with all the information 
that they need.
    And I was just wondering with the comments that I just 
made, if anybody would like to add to that.
    Dr. Herring. Sure. You are absolutely right. The 
attribution of bravery to this issue is tragically misdirected. 
And what this will require is a culture shift. And it will not 
come easily.
    And I think one of the strengths of your legislation is 
that it engages everyone. Listen, we sometimes find out it is 
the parent who figures it out. Sometimes it is the athletes 
themselves. Sometimes it is the coach, and sometimes it is the 
health care provider. Everyone is getting better. So as they 
say, when the crisis is over, the work begins.
    So changing the culture around this warrior mentality, as 
you have determined, is essential. And many steps are in place 
to do that through multiple educational efforts, through work. 
This is very powerful work that this committee is doing.
    It will have to go to coaches to reward behavior, such as 
reporting symptoms. It will, I believe, need to go to 
legislative efforts so that it is rule-driven. I don't think 
anyone should expect this to be easily modified, but I will 
suggest to you even in the last 2 or 3 years, there has been 
the first piece, awareness.
    The second piece now is behavior change in education. That 
is why this type of work is so important, though. When you make 
it a national standard, that makes the work for all of us 
involved in health care or with advocacy for players, 
neuropsychological testing--it makes it easier for us to push 
this agenda forward.
    Mrs. McCarthy. Thank you.
    My time is up.
    Oh, I am sorry. Go ahead.
    Mr. Morey. Thank you. I just wanted to mention I think the 
warrior mentality that you speak of--I think a lot of people 
think that it is a badge of honor to play through a concussion. 
And I think, realistically, more players don't ever want to 
show any vulnerabilities or do anything to demonstrate 
weakness, especially in the NFL locker room.
    Respect is earned in the NFL locker room, and it is, you 
know, we have a deep loyalty to our teammates, to our fans, to 
our owners, to our coaches who stood on the table to give us 
our jobs. We have a loyalty to sort of complete the mission and 
finish the game.
    And I think it is important to recognize that because we 
deeply care about our teammates, it is as if in that locker 
room it is kind of like family. And I think that culture has to 
shift enough so that players are looking out for each other, 
and they are telling each other and trying to limit the 
pressure that we feel to play through injuries.
    Brain injuries are different. And I think if players can 
step over to their teammates and say, ``Listen, we have got 
this. Your health is more important. We are going to take care 
of it, so get yourself right, take time to recover,'' I think 
that is the sort of a culture shift that we are all--that I 
envision.
    And I think one of the initiatives that we have with the 
Mackey-White Committee is to try to reach our players and the 
mentality to change their behavior and change the culture as 
fast as we can to protect our guys. And this is a poster that 
we have built with the NFLPA, with Veronica Jenkins and Jason 
Belger and Tom DePaso and Thom Mayer and myself. I think there 
is--and players and even trainers in the NFL that I counseled.
    I have done a lot of research and try to speak with coaches 
and trainers and players to try to address this issue in a very 
responsible and systematic way. I think we do a disservice to 
our players if we don't reach a consensus on how to address 
this issue.
    But this is a poster that is in every NFL locker room. The 
poster that Stan showed is a poster that is in every NFL 
training room to disclose the potential risks. And this poster 
here was intended to change the culture.
    It says--I will read it. It says, ``Work smart and protect 
your future. Use your head. Don't lead with it.'' And there are 
pictures here of players in their most vulnerable positions 
where they are going to have to depend on the key medical staff 
to take care of them, because when they are injured, those are 
the people that we trust to make sure that we are looked after 
and we are protected.
    At the end it says, ``All concussions are not created 
equally. If you are hurt, don't hide it. Report your head 
injury to your key medical staff and take time to recover.'' 
And I can submit this to the chairman.
    Chairman Miller. Thank you. We will make that available to 
the members of the committee.
    Mrs. McCarthy. Thank you.
    Chairman Miller. Mr. Platts?
    Mr. Platts. Thank you, Mr. Chairman. First, I want to thank 
you for holding this hearing, as well as my subcommittee 
chairwoman, for the focus on this issue. As I know you are both 
aware, our colleague, Bill Pascrell, and I are the sponsors of 
legislation very similar in the focus, moving through Energy 
and Commerce and to likely be part of your efforts in 
partnering with both of you as well as the full committee.
    I certainly thank all of our witnesses. I apologize in 
coming from another commitment, didn't hear your testimony, but 
glad to have your written statements to review. And most 
importantly, I want to thank you for being here. And as we talk 
about that cultural shift, that is what you are helping to do--
is this dialogue, this information you are sharing today is 
helping to raise awareness.
    And, Mr. Morey--is that correct?
    Mr. Morey. Morey.
    Mr. Platts. Morey.
    Mr. Morey. Yes, sir.
    Mr. Platts. I apologize. Your statements there, as you 
described the locker room setting and earning respect and 
completing the mission, loyalty to your teammates, talking as a 
former NFL player, you could have been sitting there talking as 
an American soldier or Marine, because Bill Pascrell and I, as 
co-chairs of the Traumatic Brain Injury Caucus, focus a lot on 
TBI and related issues in the military, because the signature 
wound of Iraq and Afghanistan is TBI.
    And so as you talked in that cultural shift in the locker 
room that has to occur, it is what we are also facing on the 
war front with our soldiers, because, you know, they don't want 
to admit that they can't go back out there and serve their 
country and, you know, watch the backs of their fellow soldiers 
and Marines. And so we are in a different setting, but the 
exact same challenge.
    And it is interesting, your work in the NFL and really 
helping to lead this effort of a better approach. And we saw it 
watching the Eagles game last week, and when the quarterback 
took a hit, and they kept him out and wasn't released until he 
went through several checks that, yes, he is eligible to 
return.
    You certainly would be a great messenger with our military 
as well, to partner with our military as they try to work at 
changing the cultural dynamic of the military, dealing with TBI 
and our courageous men and women on the war front.
    So as I said, all of your testimonies bring a different 
perspective, and a very important one from the medical side, 
from the athlete side, both at high school and professional 
level.
    And, Dr. Brearley, I can't say thank you enough for your 
willingness and ability to be here. I can only imagine. My boys 
are 14 and 11, active, and I am always out there, and my 14-
year-old is, you know, rappelling from one of our trees in the 
front yard about a week ago, and I am standing under and 
thinking, ``If he falls, I am going to do my best''--but that 
worry as a parent.
    And I can't imagine the heartache that you and your family 
have suffered through in the tragic loss of your son, Owen. 
Your ability to take that family tragedy, that personal loss, 
and make it a public good through your efforts is remarkable 
and especially commendable. And so I especially thank you for 
being here and all that you are doing. And certainly, your son 
Owen continues to live on through your efforts and doing good 
work by your presence. So God bless you and your family as you 
continue to advocate to make sure we do better for all the 
Owens out there in the years ahead.
    With that, Mr. Chairman, I yield back.
    Chairman Miller. Thank you.
    Mr. Bishop?
    Mr. Bishop of New York. Thank you, Mr. Chairman.
    And thank you to our panel. It is very, very important 
testimony.
    Dr. Herring, you made reference to the necessity to change 
the culture in response to a question from Congresswoman 
McCarthy. And, you know, we had this hearing on Long Island 
last week, and all four of our witnesses had a common strain on 
this with this reference to this warrior mentality. And, you 
know, my guess is that the warrior mentality in part is innate 
in the athlete that is wanting to achieve. And in part, it is 
in the athlete, because he or she believes that this is what 
the coaches want.
    And so what I want to try to focus on is how do we best 
change the behavior of the coaches, and not so much at the 
highest levels at the NFL or even at Division I in colleges, 
but how do we change it at, you know, the Pop Warner league and 
the high schools, because it seems to me that, you know, built 
into the coaching profession is this desire to excel, and a 
desire to excel in the coaching profession is rooted in how 
good their players are and having the best players on the field 
and so on.
    So how do we best deal with the coach's, basically, dilemma 
between succeeding and caring for his or her players?
    Dr. Herring. Thank you, Congressman. I think you have hit 
on the critical issue. Dr. Gioia and I can talk and lecture, 
and we have, and we have been all over the place, and you can 
change some aspects, but the relationship between the coach and 
a player is essential. Players want to please their coaches, 
and coaches want to win. And they also want to develop player 
character.
    Coaches don't want to hurt their athletes, though. You 
know, I take care of a lot of young athletes, and their coaches 
don't want to hurt them. And part of this on the coach's part 
and the athlete's part is just a lack of awareness.
    So the CDC has an educational module for coaches. USA 
Football has an educational module for coaches. In the State of 
Washington with the Lystedt Law, a coach has to pass a 
concussion education course before he or she can step on the 
field of play. Those are important steps, because information 
is power.
    I wouldn't be so naive to think that that alone will do it. 
I think there has to be a social climate. This is a powerful 
room. This law is a powerful thing. So I think that it has to 
be done by education and legislation, I think, empowering 
parents to understand concussion.
    An integral part, for example, of the Lystedt Law is that 
the parents and the athlete must read and sign an educational 
sheet about sports concussions. And in my practice now I have 
parents bringing that sheet to me saying, ``I am worried about 
my daughter.'' So we are making the educational effort--that, 
combined with legislative effort and a change in what is 
acceptable in sport.
    It is demonized, Congressman, not to give players fluids 
during practice now. That was not always the case. That was 
viewed as a sign of weakness. That culture has changed. I am 
positive, and I told the Lystedt family this, that we can work 
to change this culture so that it is just as unacceptable, just 
as socially unacceptable to play someone who is concussed as it 
is to withhold water during practice or play.
    Mr. Bishop of New York. Thank you.
    Dr. Gioia, if I understood Alison correctly, when----
    Alison, when you were in the process of being cleared or 
trying to be cleared to return to normal activity, you were 
both seen and evaluated by a health care professional, and then 
you took this examination. Is that right?
    Ms. Conca-Cheng. Yes, that is correct.
    Mr. Bishop of New York. Dr. Gioia, how common is that, that 
there is this two-step process? Or is this a particularly 
advanced assessment of the concussed athlete?
    Mr. Gioia. Well, in the State of Maryland, this is really 
the first program, the first county that is doing this. But I 
always use the example, as I am the team neuropsychologist for 
the Washington Capitals and it is a process we have had in 
place for many, many years, that if a player is injured, I hear 
about it. We institute the full evaluation process. It is a 
collaboration between the health care members.
    And the idea here and in the Howard County system is to 
have that athletic trainer as that person that is there and who 
also knows the athlete better than many of us. We have a team 
neuropsychologist that can oversee that testing process, but we 
also include that primary care pediatrician, who also knows the 
medical history of that youngster.
    And it is really that communication. It is a challenge. It 
is not simple. It is not easy. We have been working on this 
program now for several years, and it takes some work. But it 
is still somewhat unique. It is what we need to do nationally, 
though, and not just the high school level. There needs to be a 
process at the youth non-scholastic level as well.
    Mr. Bishop of New York. Thank you.
    Thank you, Mr. Chairman.
    Chairman Miller. Thank you.
    I would ask unanimous consent that the testimony from 
Christopher Nowinski, who is from the Boston University Sports 
Legacy Institute, to be made part of this hearing, if there is 
no objection.
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    Chairman Miller. I would also like to recognize the 
presence of Congressman Pascrell, who is the author of the 
Concussion Treatment and Care Tools Act, or the ConTACT Act, 
which is in the Energy and Commerce Committee.
    Welcome to our forum.
    And then I would recognize Mr. Hare, who is next for 
questioning.
    Mr. Hare. Thank you, Mr. Chair. Thank you, Mr. Chairman.
    Only having 5 minutes, there are two issues that I just 
wanted to bring up. And let me first of all just say I 
absolutely love sports. My son played soccer, and I am a big 
football fan. A lot of this--you know, and I have seen soccer 
games and, you know, butting, you know, hitting the ball with 
your head and the players colliding--one of the things I want 
to know in terms of preventative things that, you know, is 
there any equipment that would help?
    That would be my question to you, Alison.
    And also, you know, Doctor, you brought a football helmet 
with you.
    And I am interested, Mr. Morey, from the NFL's perspective, 
is there additional equipment that would help keep younger 
people and professional people safer than we have right now?
    And then lastly, when I always hear--I am watching a 
football game and I hear, ``Oh, they got their bell rung,'' and 
they get up and--I worry very much about, you know, like Hunter 
Hillenmeyer, I know, from the Bears, is probably going to have 
to retire because of the series of concussions.
    I am wondering from Alison, to your son, to you, Mr. Morey, 
how many concussions a person can have from the time that they 
are in high school or junior high school sports to the time 
they--if they are fortunate to play professional ball. I would 
wonder, Mr. Morey, do you have any idea how many--I am asking 
too many questions here--how many concussions you might have 
sustained in that time before you retired from football--I 
mean, from all the way up?
    So part of my concern is how do we keep people safer so 
that if they do hit heads, can we avoid this? And what type of 
equipment is out there? Or what do we do? Because I am not 
advocating the elimination of any of these things, but I am 
wondering what we can do from a safety perspective.
    Ms. Conca-Cheng. Well, in soccer I have seen--one of my 
teammates is a goalie, and she sustained a fairly severe 
concussion a year or so ago, I think, and she now wears a 
headband. I don't know much about it. I have also seen it in 
English Premier League; a goalie wears it. But it is the only 
two instances I have ever seen any type of protective gear 
used. And I have only seen it with goalies.
    Mr. Morey. I think, you know, a lot of helmet manufacturers 
have made advances to reduce the forces that the brain takes 
upon contact. And what we are doing in that right now with the 
NFLPA Mackey-White and the NFL Head, Neck and Spine Committee, 
we are trying to take the next steps in our helmet studies to 
try to put helmets on the field using triaxial accelerometers 
and helmet impact telemetry systems and use biomechanical 
engineers to try to correlate that data and try to understand 
the true--try to understand the biomechanics and how to prevent 
head injuries better in athletes.
    And I think it is important to know that even though 
helmets have improved, no helmet can prevent or reduce the 
severity of concussion. It is usually the injury itself. I 
mean, every person is unique and different, and each injury is 
unique and different as well.
    I think the only way we can try to limit the repetitive 
concussive and subconcussive episodes in the game is by 
continuing to make progressive rule changes to limit the 
helmet-to-helmet contact in practice and scrimmages over the 
course of a player's career and season. I think we have to 
manage concussions properly.
    I think when we talked about the culture in sports, I think 
contact sports can teach very valuable lessons about resiliency 
and humility and the ability to fight through it and conquer 
limitations. I think playing in the NFL has--I have played 
through a lot of injuries, and I have had my share of 
concussions, but I think it has taught me a lot of valuable 
lessons about myself and, you know, it talks about sacrifice, 
accountability, leadership, teamwork.
    And I think if we can--we don't necessarily want to change 
the culture of being able to play contact sports and do--and 
play physically. Coaches want smart physical and mentally tough 
players and disciplined players. And fans love our sport. And 
players love the physicality of--and the brutal nature of our 
sport. I don't think it is the culture of competing that we 
have to curb as much as it is the culture of how we manage 
brain injuries, when you sustain a concussion.
    Mr. Hare. Would you guess, Mr. Morey, that a lot of NFL 
players right now are having concussion problems and not saying 
much because of that wanting to compete and not let the team 
down that you talked about earlier?
    Mr. Morey. You know, I think that is what we are trying to 
change. Up until recently, I think most players thought of 
concussion as a temporary or transient injury, just shake it 
off. We communicated it, and we just used the words like 
``ding'' and ``just got our bell rung.''
    And I think the next steps are trying to understand the 
injury better through research so that we can determine what 
the threshold is and what type of injury you can play through 
and what type of injury you are should be removed from play.
    I think that is a very difficult thing to gauge, and I 
think you have to really, truly rely on the player being honest 
and the medical staff being very well trained to recognize the 
signs and symptoms of concussion, so that they can determine 
when it is safe to return to play. And we have to rely on our 
team medical staff.
    And then with kids' cases, they don't have the type of 
medical staffs and professionals on the sideline like we do. 
That is why this initiative to protect athletes is so critical 
with these players.
    Mr. Hare. Well, I just want to congratulate you on a great 
career and also what you are doing to help. Thanks so much.
    Mr. Bishop of New York [presiding]. Thank you, Mr. Hare.
    Mr. Scott?
    Mr. Scott. Thank you.
    And I want to thank all our witnesses for their testimony. 
We have been dealing with mostly football. The Judiciary 
Committee has had hearings, Energy and Commerce, and now 
Education. Are other sports equally at risk of concussions, Dr. 
Herring?
    Dr. Herring. This is not a football issue. It is not a boy 
sport issue. This is a contact and collision sport issue. 
Congressman Scott, the rate of concussion in high school girls' 
soccer is almost as high as it is in boys' football. Actually, 
in college sports the rate of concussion in women's soccer is 
higher than in men's football. So it is very important that we 
look at this as an issue for safety for all athletes. It is a 
great question.
    Mr. Scott. Thank you.
    Dr. Herring. And to comment on one more thing for Mr. Hare, 
there is no piece of equipment that guarantees you will not get 
a concussion. It does not exist.
    What does exist, though, what we do know is the best way to 
manage this is to identify the concussion and have there be 
complete recovery before returning to play.
    Mr. Scott. Thank you.
    Alison, is Centennial High School a public school?
    Ms. Conca-Cheng. Yes, it is.
    Mr. Scott. And all public schools in the county have that 
process?
    Ms. Conca-Cheng. I believe all the schools in Howard County 
have a similar process to Centennial's.
    Mr. Scott. Do you happen to know how much that program 
costs?
    Ms. Conca-Cheng. I have no idea.
    Mr. Scott. Okay.
    Dr. Gioia, do you know how much the program costs? Thank 
you.
    Mr. Gioia. Yes, I mean, I basically helped set it up. Now, 
what aspect? We have certified athletic trainers in all the 
high schools. We have, obviously, an educational program. We 
have the baseline and post-injury testing aspect. So all those 
are what I would refer to as the program. And is there a 
certain part of that you are----
    Mr. Scott. Per student, how much does it cost--$10 a 
student, $3 million for the county--I mean, some numbers?
    Mr. Gioia. I mean, I know that the county is probably, you 
know, about $20,000 per athletic trainer. There are 12 high 
schools. They pay $750 for the test itself, and then they----
    Mr. Scott. For the test per student?
    Mr. Gioia. No, no--for the school.
    Mr. Scott. Okay.
    Mr. Gioia. Yes, per year, basically. And then they pay me 
some for my consultation input, so I guess if you put all that 
together, it is probably for the 12 high schools, you know, 
$400,000 or less. I don't know the total number of student 
athletes of the county, but certainly, it is probably, you 
know, 50, 60 thousand.
    Mr. Scott. Now, somebody mentioned ``just a concussion'' 
when we were talking about repetitive concussions. Once you get 
to a traumatic brain injury, what is the cost of treating a 
traumatic brain injury, Dr. Herring--just an idea?
    Dr. Herring. Yes, if you have the rare but tragic 
consequence of taking a concussion and turning into a more 
moderate or severe brain injury, the cost is exorbitant--the 
acute medical costs, the lifesaving costs, and then the 
lifelong costs--hundreds of thousands of dollars to, say, Zach 
in Harborview Medical Center, the trauma center in Seattle, 
where I work. But that is just the first piece.
    Home modification, durable medical equipment, ongoing 
therapy, special accommodations at school----
    Mr. Scott. So somebody with a traumatic brain injury, 
millions of dollars in costs would not be unusual.
    Dr. Herring. Yes. Yes, and----
    Mr. Scott. And can you compare that cost to the cost of 
preventing the subsequent concussions that might lead to a 
traumatic brain injury?
    Dr. Herring. Seems to me like money well spent--pennies on 
the dollar. And I would say that the cost is not only medical. 
You should look at the cost to the family and the community 
where that young athlete lives.
    Mr. Scott. Dr. Gioia, do you want to talk about the cost-
benefit of prevention?
    Mr. Gioia. Yes, I mean, just sort of doing the quick math 
in my head, thinking about the Howard County program and the 
number of students that we have, I mean, we could argue that it 
is probably, you know, less than $25 to $50 per student to 
administer this program. And of course, the other part of it, 
too, is that the certified athletic trainers are treating all 
injuries, not just concussions, so there is benefit beyond that 
as well per student.
    So when you are talking about, you know, $50 or less per 
student next to probably millions of dollars to manage that 
injury, it is a whole different story. The cost-benefit is 
there.
    Mr. Scott. But if you add up the whole county costs, if you 
can prevent one traumatic brain injury, the money is well 
spent.
    Mr. Gioia. Yes, yes. Total cost probably, you know, as I 
said, $30,000 to $40,000 or less.
    Mr. Scott. Thank you.
    Thank you, Mr. Chairman.
    Mr. Morey. Mr. Scott, may I----
    Mr. Scott. I am sorry.
    Mr. Morey. I think it is probably prudent to mention some 
of the members of our Mackey-White Committee--Dr. Kent, Robert 
Kent, who actually serves as a senior advisor to the NFL Head, 
Neck and Spine Committee and is co-founder of the Sports Legacy 
Institute, Chris Nowinski--have implemented and proposed a 
seven-point plan that is completely free, that coaches and 
parents and kids can get online, understand the signs and 
symptoms of concussion, utilize the CDC's information, and it 
is a seven-step program that is completely free, and it is 
online.
    And I think it is something that I think every coach should 
be certified. If they are going to design the drills for full 
contact and be able to oversee some practices and assume the 
responsibility of the care and look after their players, they 
should be certified to be certified in concussion awareness so 
that they can protect their athletes.
    Mr. Scott. But, Dr. Herring, a lot of the benefit is in 
preventing the subsequent concussions----
    Dr. Herring. Yes.
    Mr. Scott [continuing]. And the additive effects. Is that 
right?
    Dr. Herring. Yes, sir, it is. Sometimes you can't prevent 
the first one. And as everyone has said, sports is a very good 
thing. I mean, the most dangerous thing you can do after school 
is not play sports. Unsupervised activity is where trouble 
really begins, so you want to make sports safer.
    And this is not that hard to do. You make it a rule, and 
you make it a culture change. And you say, ``Look, even if you 
can't prevent the first one, you get over the first one, 
because if you don't, that is where the trouble starts.''
    Mr. Scott. Thank you.
    Thank you.
    Mr. Bishop of New York. Mr. Payne?
    Mr. Payne. Let me also thank you. And I think that the 
awareness has made a big difference. I doubt if several of 
those quarterbacks would be sitting out this year--Philadelphia 
and so forth--had not the attention been brought to the fact 
that you just don't play with concussions anymore.
    I would like to certainly commend the NFL. I think that the 
commissioner is really trying to get this thing on the grips. I 
think we have got a lot of changing to do, you know, with Vince 
Lombardi playing out in zero degrees weather, the, you know, 
the old Giants in the 60s with the lineman that were, you know, 
Modzelewski and those guys. You can tell my age. I didn't dye 
my hair gray. [Laughter.]
    But, you know, and so everything was just tough. I think 
that the NCAA has really taken a strong look at this, having 
maybe now college presidents having as much authority as 
athletic director or coaches. So there are definitely changes.
    I do know that you got to get down to Pop Warner and got to 
get down to high school. I played ball in high school, injured 
ankle, not head, but so therefore it kept me really out from 
doing what I had the ability to do.
    However, it was interesting. I met a fellow 50 years ago. 
We played on the same high school team, and the thing that he 
mentioned was that you remember when we clashed in a scrimmage 
and I tackled him and he got a concussion. I mean, this was the 
first thing we talked about 50 years later. But in those days 
you just came back the next week. I mean, it was unbelievable.
    Coach used to say that, you know, I mean, it was different 
then. And the tougher you were--and this is not an NFL thing. I 
have never played in the NFL. I just did a little high school, 
played intramural in college. It is at even Pop Warner level. 
So we definitely have to.
    I think the key thing is to change the culture that you got 
to be tough, you got to play injured, you got to go back out 
there because you can't let the team down or you don't want to 
look weak. We used to have a coach that used to say, ``When you 
are injured, you just spit on it.'' That was the answer, you 
know.
    So things have changed a lot. I think that we have to 
continually, though, have the changes. I also had the privilege 
to coach in high school football for 8 or 9 years, and had to 
just counsel fellows that ``No, you can't play. It is best for 
your future.''
    And so I think that we have got to do a lot of education. 
That, I believe, is the biggest challenge, but I do have to say 
that the sports officials in the leagues are really kind of 
concentrating on let us protect the player.
    Let me just ask--this is a great--the way that you have, 
Doctor, regarding what is being done in--and as the--that you 
have had, and let me commend you. The other person that we had 
here was also a female playing soccer, so, like I said, we have 
to shift it where we feel all these injuries are coming.
    But maybe someone could answer. What happens to the poor 
school districts? You know, in my town I doubt if there are 
physicians even at a game. I mean, this is tremendous, what I 
hear is happening there, but do you know how that compares to 
inner city or rural areas, where you don't have the luxury to 
do what you are doing? Anybody do any research on that?
    Mr. Gioia. There hasn't been, although we can pretty much 
guess. I mean, you know, kids are unprotected. And again, I 
think the issue here, whether it is an underserved community or 
it is an underserved population, which again I would argue is 
probably many youth sports, whether you are in the, you know, 
highest socioeconomic strata or the lowest, they are without 
knowledge, without the skill and tools to recognize this 
problem. Everybody is, unfortunately, in that disadvantaged 
situation.
    So we have got to find some solutions to make this a 
universal issue. And I think, again, by putting the systematic 
rules in place, then we identify everybody, all kids at all 
levels at all socioeconomic strata.
    Dr. Herring. It is harder. There is no question about it. 
It is a process that will be improved, if there are national 
standards. It needs funding. I guess that is never said in this 
room. It needs funding.
    Wonderful questions from Congressman Scott. I can do a lot 
of good with a little money rather than to spend a whole lot of 
money on one unfortunate athlete. So if you want to see this 
penetrate the rural communities, there has to be education, 
legislation, and then there has to be capacity to put resources 
in place, whether it is licensed or certified athletic 
trainers, while working harder with community health care 
providers to become more knowledgeable.
    We struggle with this now. It should not deter us from the 
effort. But this is the work piece. This is the work piece that 
faces us. Once we get the awareness, we have to work on 
implementation.
    Mr. Bishop of New York. Thank you, Dr. Herring.
    Dr. Herring. Thank you.
    Mr. Bishop of New York. Ms. Woolsey?
    Ms. Woolsey. Well, thank you. I am not going to repeat 
everything everybody said and ask you--I don't think--the same 
questions. This has been a great panel. Thank you very much.
    I am most worried about parents at the moment, about taking 
hold of these issues and understanding them, particularly for--
well, not for football players--your parents have already done 
what they have done and are supportive--but youth athletes.
    And that is because all of my four children were athletes, 
and one in particular was--well, he was all-star, all-American 
college defensive tackle for small schools for 2 years. And he 
had to come home after he graduated, take me for a walk and 
say, ``Mother, I am through with football. Get over it.'' I 
mean, so you know how supportive we all were and how much we 
cared.
    He didn't start football until he was in high school. He 
has a son, who is 10, who has been playing flag football for 
the last 3 years. He is going to be very good. I mean, he is 
big, good. He is great. I mean, he will be very good. But his 
dad is very smart. He is his coach in both basketball and 
football, and he is not going to let him play Pop Warner, 
because this kid would be playing at 10 years old against 13-
year-olds because of his size.
    And I so, so respect that. And Teddy doesn't care. He loves 
football. He knows he is going to play sports his whole life 
and, you know, whether he plays Pop Warner or not doesn't 
matter. But how many parents make those decisions? We watch it. 
We see these kids out there, you know, playing on a level that 
is dangerous at their young age. How do we prevent that for the 
most part--one question for parents.
    The other is how do we get teachers to understand that 
after a brain injury, just reading is putting pressure on the 
brain, so we don't punish these young athletes for needing to 
rest their brain? So I think that could be one of the most 
difficult things to accomplish so that they don't become, you 
know--and then don't get blamed as, you know, trying to cop 
out, et cetera, Doctor?
    Mr. Gioia. If I could address the teacher issue because, 
you know, I think both Alison and Sarah, you know, are good 
examples of this. When we go into an unprepared system, the 
teachers are not aware. When we go into a prepared system, I 
can't tell you how gratifying it has been over the years to 
hear the number of families that now come into our clinic and 
say, ``The school is doing a great job. The school nurse or the 
school administration or the guidance counselor got an e-mail 
out to the teachers, explained what was going on with the 
concussion, and they are managing the academic demands very 
well.''
    Now, we have a long way to go, and we need to do this 
systematically, but it works. And once teachers understand 
this, they do jump on board when we also provide them with some 
good guidance, and we use these care plans to really specify 
what are those limits, how much can we handle. And when the 
administration in the school sets the tone saying, ``This is 
how we are handling this,'' from top to bottom it then works. 
But it is a process.
    And again, I think our new Heads Up toolkit for the schools 
is a great first vehicle for getting that information out there 
and preparing schools. And I think, again, that is where this 
legislation really provides that vehicle to take place.
    Ms. Woolsey. Okay.
    Thank you, Mr. Chairman. I will let everything go on.
    Mr. Bishop of New York. Thank you.
    Mr. Polis?
    Mr. Polis. Thank you, Mr. Chairman.
    First, I would like to thank our panel for their terrific 
stories, in particular some of the personal stories shared, of 
course, by Ms. Conca-Cheng and Dr. Brearley. Those are always 
difficult to share, but they are powerful, so I appreciate you 
sharing those stories with us.
    In the past couple of decades in my home state of Colorado, 
we have had at least three high school student athletes who 
died from on the field brain-related trauma--most recently, 
just a couple of years ago when a 15-year-old freshman football 
player, Jacob Snakenberg, collapsed on the field during a 
football game.
    And while the Colorado High School Activities Association, 
which we call CHSAA, requires that coaches now complete 
concussion education and mandates the schools to have return to 
play policies, we don't have any requirements like that for 
elementary or for middle school.
    Now, I know that there are legislators in our state that 
are going to be looking at solutions to that during the next 
legislative session, but I strongly believe that we need to 
protect all student athletes from the risk of these injuries in 
all public schools across the country, which is why I have 
joined Mr. Bishop and Mr. Miller as a co-sponsor of this very 
important legislation.
    I would like to open this up to the panel, but can you 
share with us why you think it is necessary or why we should 
pass a federal law on this issue? Not every state has acted. 
Why not push in each and every state? What are the dangers of 
not taking any federal action?
    Rev. Brearley. I would like to answer that question. And 
first of all, I think we need to understand that we need to 
approach this in as many ways as we possibly can. I think at 
the federal level there is an opportunity to give a minimum of 
guidelines or requirements for student athletes. And then 
states and school districts should themselves have the 
opportunity to adopt additional standards.
    And part of my request that Congress use its offices to 
promote discussion is because in an era when people are very 
leery of big government and in sports, where they don't want to 
be told what to do, I think erring on the side of caution of 
giving a baseline--from the federal government giving a 
baseline of what would be a minimum would be helpful. And then 
states and school districts themselves can adopt additional 
precautionary measures, especially since we are all concerned 
about unfunded mandates.
    Mr. Polis. Have any of you seen--you have all taken some 
time on this issue and seeing what different districts and 
schools are doing. Have any of you observed any best practices, 
where you sort of looked at a school or district and said, 
``Wow, they are doing a really good job in prevention of 
concussions and making sure that people who have had the 
injuries are not back on the field.'' Who is kind of really 
pushing the envelope on this? And how can we then replicate 
what they are doing nationally?
    Mr. Gioia. Well, you know, there are a number of us trying. 
And at this point, actually, in your state and in the Denver 
area, you have the REAP Program, which is something that has 
been a very important program and a first step. And we are 
actually collaborating with Colorado here in Maryland and with 
Oregon, with Pennsylvania, with some other states, to look at 
what are those best practices, because there are multiple 
elements, as you mentioned.
    There is the prevention aspect. There is really the 
athletic aspect. There is the student and academic aspect. And 
all of that takes time and people and energy. And we are trying 
to coordinate all of those activities together. I don't think 
we could say there was one single best practice site right now, 
but I think in various areas we are all doing some pretty good 
things, and we are trying to coordinate that effort.
    Mr. Polis. And to follow up on that, what metrics do you 
use? And how do you sort of figure out what is working and what 
isn't working? You know, obviously, due to small sample size, 
we know when somebody dies, it hasn't worked. But, I mean, 
beyond that, what metrics can be used to show that something is 
working?
    Mr. Gioia. Well, you know, again, you have got this 
catastrophic thing we hope we can minimize. And quite honestly, 
I think that what we are going to see with these programs is we 
are going to see an increase in the numbers of injuries that 
are recognized and reported. And in fact, if we don't, we may 
be doing something wrong, because we know this is an under 
recognized problem.
    But then the question is to what extent--when, you know, 
what is the timeframe then from identifying the injury to doing 
the active and appropriate both medical and academic kind of 
service delivery? We can begin then to look at what are the 
times taken to recovery that are supported by these things. So 
we can begin to build metrics, really, in terms of that student 
athlete's recovery profile, but also the time that the system 
took to put the things in place.
    Mr. Polis. One thing that I think policymakers would love 
to rely on to know what works would be helping to figure out 
what metrics should we be looking at, and how can we figure out 
what works and what doesn't work.
    Mr. Gioia. Yes.
    Mr. Polis. And change what doesn't work.
    Mr. Bishop of New York. The gentleman's time has expired.
    Mr. Kildee?
    Mr. Kildee. Thank you, Mr. Chairman.
    We have a similar situation in the military. My son was 
captain in the American Medical Service Corps and received his 
master's degree at Harvard in health care and now works for the 
House Armed Services Committee. And this is an increasing 
injury that comes back from Afghanistan and Iraq.
    And as a matter of fact, I am wondering whether the medical 
people in sports are comparing any notes with the medical 
people in the military, since there is a similar problem. The 
question is that, you know, in the military very often it is 
the survival of the unit, and here in sports it is more winning 
the game.
    One of the things that the Pentagon is discussing right 
now, for example, is do we give a Purple Heart to someone who 
has a closed head injury? The criteria for years has been that 
if you have been injured by enemy action, then you qualify for 
the Purple Heart. But very often unless there is blood, they 
are not sure what to do, and they are still debating that now.
    But have you had any discussions with those physicians, who 
treat many of the head injuries now that are occurring in 
Afghanistan and Iraq?
    Dr. Herring. Thank you, Congressman Kildee. The answer is 
yes. The newly formed NFL Head, Neck and Spine Committee is 
working closely with the DOD. When the commissioner comes to 
Seattle to host a course on sports concussion, General 
Chiarelli will be there.
    Mr. Kildee. Great.
    Dr. Herring. And the military's new program of ``Take a 
Knee,'' using a sports metaphor when they are injured I think 
will be helpful. As someone who has taken care of brain injury 
a long time, I would be less than forthright if I didn't tell 
you that I hope that the sports concussion piece opens the door 
to understanding traumatic brain injury more comprehensively. 
And you are right. It is an invisible injury. But simply 
because there is not blood doesn't mean there shouldn't be a 
Purple Heart.
    Mr. Kildee. Thank you very much. I appreciate both your 
information and your specific response. Thank you very much.
    Mr. Bishop of New York. Thank you.
    Mr. Pascrell?
    Mr. Pascrell. Thank you, Mr. Chairman.
    Mr. Chairman, I just want to begin by referring to what my 
good friend, Mr. Kildee, was just talking about, because in the 
last 3 years there has been movement on the Department of 
Defense to recognize Purple Hearts in those individuals without 
blood and without contusion--we have got to get, you know, 
beyond that--and are worthy of a Purple Heart and have been 
denied up until now.
    So now we are beginning to look at each case individually. 
The DOD is listening very carefully. We can learn a lot from 
what has happened on the military side to help young ladies 
like Alison.
    And by the way, Alison, there is somebody in New Jersey, 
Niki Popyer. I don't know if you have heard of her. She had 10 
concussions in sports. She is a basketball player and went back 
and went back and went back in. And you know the story. Now she 
cannot play any sports, and all she needs is a slight bump on 
the head.
    Every concussion, Mr. Chairman, is brain damage. I want 
everyone in this room to understand that. There is no way to 
say it otherwise. I am sorry. If I need to be stark, I will be 
stark.
    But we have learned so much over the last 6 or 7 years 
through the fact of this signature injury of Iraq and 
Afghanistan, which is traumatic brain injury as well as post-
traumatic stress disorder, which we are really just getting our 
hands on. It has been misdiagnosed many, many times. But it 
helps us with our young kids. It really does--what has happened 
in the past 5 years. And we can't lose sight of it.
    I am glad that the NFL--Mr. Morey and Dr. Herring, I am 
glad that the NFL came to recognize this a few years ago, 
because it didn't before. I have talked to players in the NFL. 
Many of them were near vegetation. The problem was ignored, 
swept under the rug. So I am glad that we are addressing that 
vigorously. I am also glad that you support my legislation, of 
course, but more importantly than that, because we are all in 
this together, no one has the answer.
    And I have read what you have said in your blog, Sean, and 
you are on target. And I know how you have been struggling with 
this issue--your organization, the Players Association.
    In the contact ad what we did is ask for the professionals 
to come together, Mr. Chairman, and then decide the protocol 
and the guidelines, not the Congress of the United States. We 
are not good at this. We are not good at too many things. And 
we are certainly not doctors and professionals.
    So we want them to come together, and we want them to put a 
protocol together so that protocol and those guidelines can be 
used, whether kids are in leagues that are scheduled and 
authorized or smaller leagues, other situations--kids 4, 5, 6 
years old.
    And we are not simply talking about football. Most of the 
injuries that I have gone over in the past 11 years since I got 
involved in this as a co-chair of the Traumatic Brain Injury 
Caucus are with women. We have paid very little attention to 
this. There is a different structure of the head. I am talking 
to the doctors, so I apologize for that.
    There is different protection for women--perhaps much less 
protection. And so when we are going to send someone back into 
the battle, be it soccer, basketball, regardless of what the 
sport is, we need to take this into consideration.
    And therefore, we must--as, Dr. Brearley, as you pointed 
out--must have a baseline. Now, how to get to the baseline? The 
only way to get to the baseline is have a neuropsychological 
testing of players before they go on into the field, onto the 
court. We blew it with our own armed services. We were late to 
protect them going into battle, and then we basically did a 
kabuki dance when they come out of battle.
    Many of them are getting written tests. Think about this. 
Five hundred fifty thousand were provided a neuropsychological 
test to go in, but when they come out, they are given a written 
test. If I showed you the test, Dr. Gioia, you would be 
embarrassed. And so we are trying to change that----
    Only 2,500 of the 5,500 that were tested have gotten a real 
neuropsychological test. Because appearances are so critical, 
the guy, the gal doesn't complain--no blood, no contusion, no 
nothing until later on. So we need that baseline. It is 
important. It is critical. And I believe it has saved lives 
both on the battlefield and on the sports field and will save 
many more lives.
    And that is what, I guess, we are all about. If we don't 
save lives, what the heck are we doing here? You know, we are 
humoring each other. I believe----
    Mr. Bishop of New York. Mr. Pascrell, may I ask you to 
conclude?
    Mr. Pascrell. I will conclude.
    Mr. Bishop of New York. Thank you.
    Mr. Pascrell. I realize I am here only, you know, at your 
will.
    We need to educate--I love the guy; I can say that to him--
educate, prevent, care for in recovery, and please get the 
families involved early. This is critical both on the 
battlefield and off.
    And I thank you, the speaker. I thank the committee for 
allowing me to come and say my piece.
    Mr. Bishop of New York. And thank you for your leadership 
on this issue, Mr. Pascrell.
    Mr. Kline, any concluding comment?
    Mr. Kline. Yes, thank you, Mr. Chairman.
    I just wanted again to thank the witnesses. It has been 
terrific testimony. You all are working so hard in different 
aspects of this to spread the word and to develop real tools. 
So again, thank you very much for sharing your stories.
    I yield back.
    Mr. Bishop of New York. Thank you, Mr. Kline.
    I also wish to thank the witnesses for your testimony. Let 
me give a particular word of thanks to Alison and to Dr. 
Brearley for sharing your personal stories. It is very powerful 
for us to hear them. Thank you very much.
    Without objection, members will have 14 days to submit 
additional materials or questions for the hearing record. 
Without objection, the hearing is adjourned.
    [Additional submission of Mr. Miller follows:]

   Prepared Statement of the National Athletic Trainers' Association 
                                 (NATA)

    The National Athletic Trainers' Association (NATA), a not-for-
profit society of health care professionals serving physically active 
children and adults, endorses the Protecting Student Athletes from 
Concussions Act of 2010. The NATA represents over 33,000 athletic 
trainers (ATs). As athletic trainers and health care professionals 
specializing in team sports, we are the first line of defense in the 
prevention, diagnosis and emergency treatment of head traumas and other 
athletic injuries. ATs are health care professionals who collaborate 
with physicians to optimize activity and participation of patients.
    NATA supports the Act's goals of establishing requirements for 
prevention and treatment of concussions suffered as a result of 
participating in school sports and applauds the bill's efforts to make 
physical activity, well-being, and athletic safety a focus for 
America's youth.
    All ATs have at least a bachelor's degree in Athletic Training from 
an accredited college or university, and 70% of our membership has a 
master's degree or higher. Certified ATs must pass a national 
certification exam. In most of the 47 states where they are licensed or 
otherwise regulated, the national certification is required for 
licensure. ATs maintain this certification with required continuing 
medical education. They work under a medical scope of practice and 
under the direction of physicians and adhere to a national code of 
ethics.
    Although the issue of concussions in sports has received a great 
deal of attention in the media in recent months, it is not a new 
problem. Athletic trainers have been caring for concussed athletes and 
warning of the dangers posed by this unique injury for years.
    NATA has a long history of working with research experts to explore 
the prevention and proper treatment of head injuries. In July 2009, 
NATA released a study in the Journal of Athletic Training entitled Head 
Impacts During High School Football: A Biomechanical Assessment. The 
study revealed that high school football players sustain greater head 
accelerations after impact than do college-level football players, 
which can lead to concussions and serious cervical spine injuries. 
Further, the study urged high school coaches to teach proper tackling 
techniques in order to reduce the risk of head and neck injuries among 
athletes.
    While much focus has been given to players in the National Football 
League (NFL), it is important to remember that high school athletes 
represent the single largest segment of football players in the country 
and account for the majority of sport-related concussions. In a given 
year, between four and six percent of high school football athletes 
sustain concussions, corresponding to an estimated 43,200 to 67,200 
injuries annually. In fact, there are five times as many catastrophic 
football injuries among high school athletes as college athletes. 
Estimates indicate, however, the true incidence of injury is likely 
much higher. Some research suggests that more than half of high school 
athletes who suffer concussions do not report their injuries to medical 
personnel. Even when faced with these disturbing trends and the fact 
that 7 million students participate in high school sports in America, 
NATA estimates that only 42 percent of public high schools in America 
have access to an athletic trainer. In fact, NATA estimates that across 
the country, the ratio of students to athletic trainers is 2,678 to 1.
    According to a New York Times article (Sports Imperative: 
Protecting Young Brains, August 24, 2009), ``at least four American 
high school students died last year from football head injuries. Most 
suffered from what is called second-impact syndrome, a rare but 
catastrophic dysregulation of brain activity that can occur when a 
young player sustains another hit before the brain has recovered from 
an earlier concussion. In nearly all cases, such tragedies can be 
prevented if the symptoms of concussion are recognized and heeded, 
giving the injured brain time to fully heal.''
    Furthermore, studies also show that fifty percent of second impact 
syndrome incidents result in death. Other startling statistics include:
     Female high school soccer athletes suffer almost 40% more 
concussions than males (29,000 annually). Journal of Athletic Training, 
July--September 2003
     Female high school basketball athletes suffer 240% more 
concussions than males (13,000 annually). Journal of Athletic Training, 
July--September 2003
     400,000 brain injuries (concussions) occurred in high 
school athletics during the 2008-09 school year. Compliance with return 
to play guidelines following concussion in US high school athletes, 
2005-2008
     Concussion symptoms such as headache and disorientation 
may disappear in fifteen minutes, but 75% of those tested 36 hours 
later still had problems with memory and cognition. Journal of Athletic 
Training, July--September 2003
     15.8% of football players who sustain a concussion severe 
enough to cause loss of consciousness return to play the same day. 
Center for Injury Research and Policy, The Research Institute at 
Nationwide Children's Hospital, Dr. Dawn Comstock
NATA's Policy Principles for Concussion Management
    In consultation with the NATA Secondary School Athletic Trainers' 
Committee, the NATA Government Affairs Committee and the NATA Federal 
Legislative Council, NATA has developed a set of principles surrounding 
the issue of concussion management. NATA's principles include the 
following:
     Increasing student athletes' access to a certified 
athletic trainer is the first step in helping to prevent concussions 
and manage concussions once they occur. Legislation should incentivize 
schools and school districts to increase the accessibility of an 
athletic trainer to their student athletes.
     Conducting baseline testing of student athletes prior to 
engagement in contact sports provides the greatest opportunity to 
ensure accurate assessment of a player's condition after sustaining a 
concussion. Funding should be made available to schools and school 
districts to conduct appropriate baseline testing for symptoms, 
cognitive function and balance.
     Educating parents, coaches, teachers and other 
stakeholders about the signs and symptoms of concussions is critically 
important. Programs such as the Centers for Disease Control and 
Prevention's (CDC) ``Head's Up'' program are important tools. At the 
same time, concussion education and awareness programs should not 
provide a false sense of comfort that non-medical professionals are 
able to diagnose and treat concussions. Rather, a focus should be to 
educate stakeholders about making a proper referral if the signs and 
symptoms of a concussion are present in a student.
     State Task Forces that may be established to develop and 
implement state plans for concussion management should include 
representatives of the state's athletic training association, athletic 
association, medical society, and Department of Education.
     Athletic trainers serve as the lynchpin medical 
professional who seeks input from all members of the concussion 
management team regarding the return to play decision. Athletic 
trainers' standard practice is to ensure involvement of a team 
comprised of the student athlete, family/parent, treating physician and 
school personnel such as the coach, school nurse and teachers in their 
approach to concussion management with respect to a decision about 
return to play. The athletic trainer is responsible for coordinating 
the school's emergency action plan, concussion testing program, medical 
coverage and more. In the absence of an athletic trainer, these 
responsibilities often fall to unqualified, non-medical personnel.
     Although the best case scenario is for a school to have 
access to an athletic trainer on faculty or staff, in the absence of a 
licensed or certified athletic trainer, the treating physician should 
make return to play decisions in consultation with school personnel, 
the student athlete and his/her family.
                                 ______
                                 
    [Whereupon, at 11:53 a.m., the committee was adjourned.]

                                 
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