[Senate Hearing 112-324]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-324
 
                     CONCUSSIONS AND THE MARKETING 
                          OF SPORTS EQUIPMENT

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

                                HEARING

                               before the

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 19, 2011

                               __________

    Printed for the use of the Committee on Commerce, Science, and 
                             Transportation



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       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman
DANIEL K. INOUYE, Hawaii             KAY BAILEY HUTCHISON, Texas, 
JOHN F. KERRY, Massachusetts             Ranking
BARBARA BOXER, California            OLYMPIA J. SNOWE, Maine
BILL NELSON, Florida                 JIM DeMINT, South Carolina
MARIA CANTWELL, Washington           JOHN THUNE, South Dakota
FRANK R. LAUTENBERG, New Jersey      ROGER F. WICKER, Mississippi
MARK PRYOR, Arkansas                 JOHNNY ISAKSON, Georgia
CLAIRE McCASKILL, Missouri           ROY BLUNT, Missouri
AMY KLOBUCHAR, Minnesota             JOHN BOOZMAN, Arkansas
TOM UDALL, New Mexico                PATRICK J. TOOMEY, Pennsylvania
MARK WARNER, Virginia                MARCO RUBIO, Florida
MARK BEGICH, Alaska                  KELLY AYOTTE, New Hampshire
                                     DEAN HELLER, Nevada
                    Ellen L. Doneski, Staff Director
                   James Reid, Deputy Staff Director
                   Bruce H. Andrews, General Counsel
                Todd Bertoson, Republican Staff Director
           Jarrod Thompson, Republican Deputy Staff Director
   Rebecca Seidel, Republican General Counsel and Chief Investigator


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on October 19, 2011.................................     1
Statement of Senator Rockefeller.................................     1
Statement of Senator Boozman.....................................     3
Statement of Senator Udall.......................................     4
    Prepared statement...........................................     5
Statement of Senator Klobuchar...................................    61
Statement of Senator Pryor.......................................    63
Statement of Senator Thune.......................................    68

                               Witnesses

Alexis Ball, Albuquerque, New Mexico.............................    22
    Prepared statement...........................................    24
Steven Threet, Tempe, Arizona....................................    26
    Prepared statement...........................................    28
Jeffrey S. Kutcher, MD, Associate Professor, University of 
  Michigan, Department of Neurology; Director, Michigan 
  NeuroSport; Chair, Sports Neurology Section, American Academy 
  of Neurology...................................................    29
    Prepared statement...........................................    31
Ann C. McKee, MD, Professor of Neurology and Pathology, Boston 
  University School of Medicine; Director, VISN-1 Neuropathology 
  Laboratory for the New England Veterans Affairs Medical 
  Centers; Director, Brain Banks for the Boston University 
  Alzheimer's Disease Center, Framingham Heart Study, and 
  Centenarian Study; Co-Director, Center for the Study of 
  Traumatic Encephalopathy.......................................    34
    Prepared statement...........................................    37
Mike Oliver, Executive Director and Legal Counsel, The National 
  Operating Committee on Standards for Athletic Equipment 
  (NOCSAE).......................................................    46
    Prepared statement...........................................    48

                                Appendix

Hon. Frank R. Lautenberg, U.S. Senator from New Jersey, prepared 
  statement......................................................    79
Hon. Mark Warner, U.S. Senator from Virginia, prepared statement.    79
Sporting Goods Manufacturers Association (SGMA), prepared 
  statement......................................................    80
Scott Hallenbeck, Executive Director, USA Football, prepared 
  statement......................................................    84
Stanley Herring, MD, 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, prepared 
  statement......................................................    93
Letter dated October 29, 2011 to Hon. Jay Rockefeller from Ralph 
  & Joy Conradt..................................................    95
Response to written question submitted by Hon. Frank R. 
  Lautenberg to Alexis Ball......................................    96
Response to written question submitted to Steven Threet by:
    Hon. Frank R. Lautenberg.....................................    96
    Hon. John Thune..............................................    96
Response to written questions submitted to Jeffrey Kutcher, MD 
  by:
    Hon. Frank R. Lautenberg.....................................    97
    Hon. Tom Udall...............................................    98
    Hon. John Boozman............................................    99
Response to written questions submitted to Ann C. McKee, MD by:
    Hon. Frank R. Lautenberg.....................................   100
    Hon. John Boozman............................................   100
Response to written questions submitted to Mike Oliver by:
    Hon. Frank R. Lautenberg.....................................   101
    Hon. Tom Udall...............................................   102
    Hon. John Thune..............................................   119


                     CONCUSSIONS AND THE MARKETING 
                          OF SPORTS EQUIPMENT

                              ----------                              


                      WEDNESDAY, OCTOBER 19, 2011

                                       U.S. Senate,
        Committee on Commerce, Science, and Transportation,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:34 p.m., in 
room SR-253, Russell Senate Office Building, Hon. John D. 
Rockefeller IV, Chairman of the Committee, presiding.

       OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 
                U.S. SENATOR FROM WEST VIRGINIA

    The Chairman. This hearing will come to order, and it is 
going to be an absolutely wonderful hearing.
    There are actually 14 Senators in front of you. You just 
can't see all of them. It is something that we are working on 
with NASA. We become invisible at proper moments.
    I am very proud that you are here, and I am very proud of 
our two Senators over here. This one, although you would never 
know looking at him, is a football player and--or was, I guess 
I should say. Yes.
    Senator Boozman. Two stadiums ago.
    The Chairman. There you go. So I am going to make an 
opening statement, and then I wish each of them would. We try 
to keep it brief because we want to have plenty of time for you 
to talk and for us to question.
    I am so grateful for all of you being here, all of you. 
This is a massive subject. The story which I may tell about my 
son reveals that parents can't always be as effective as they 
would like to be. I haven't decided whether to do that or not, 
whether it is an invasion of his privacy. But you can advise me 
when you give your testimony.
    So, anyway, every afternoon at the end of the school day, 
millions of our children head to playing fields, gymnasiums, or 
hockey rinks to participate in team sports. I should have said 
soccer fields, too. Playing sports doesn't just make our kids 
stronger and healthier. It also teaches them important values. 
They learn about hard work, about leadership, about living with 
pain and going through it, about working together for a common 
goal.
    The camaraderie that comes out of sports units is wonderful 
to see. It is real, and it lasts forever. Most of our young 
athletes will not end up playing sports at the collegiate or 
professional level, but we hope they will all carry the 
positive lessons they have learned on the playing fields with 
them throughout life, and they will.
    So our hearing today is about the head injuries that tens 
of thousands of these athletes sustain every year while playing 
the sports they love. Many of us are reluctant to talk about 
the risks involved in playing sports because we know what a 
positive role that sports play in our communities.
    On the other hand, the last thing we can do here is not 
talk about this problem of concussions and gear and all the 
rest of it. I mean, America has to have this conversation, and 
there will be many, many hearings on it, I know.
    In fact, more of our children should be playing sports, not 
fewer. Too many kids are spending their afternoons in front of 
computer or televisions screens, instead of on the sports 
field. And that is said every day by everybody who is involved 
in healthcare. I am going to give you a couple of pathetic 
figures.
    According to the latest data compiled by the Centers for 
Disease Control, only 17 percent of American high school 
students get an hour of daily physical activity, which is our 
current health guidelines. They say that, that you need to have 
that to stay healthy--only 17 percent. One-third of our 
children are now overweight or obese, which makes it more 
likely that they will suffer from chronic health conditions, 
such as heart disease or diabetes, things which will plague 
them for the rest of their lives as, indeed, what we will be 
talking about today could do to some.
    But the risks involved in playing sports are also very, 
very real. And by now, we have all heard about the National 
Football League players who are struggling with serious mental 
and physical health problems because they sustained repeated 
mild traumatic brain injuries, which is what concussions are 
called, I guess, medically, during their playing years. And it 
is very, very sad.
    I mean, I have seen a number of these players, people that 
I had worshipped growing up, in wheelchairs. Who was the guy 
that played--he was a cornerback for the Raiders? The greatest 
interceptor of all time, Woody--come on, give me----
    No. No. Doesn't matter. Doesn't matter.
    [Laughter.]
    The Chairman. But I mean, it was awful. I was at an event 
with him, and he was seated in a wheelchair, and he couldn't 
even pull his head up. And I leaned down and whispered in his 
ear. I think I kissed him, too. I am not sure. But it was 
having seen from this to that and who knows, especially this 
was 8 years ago. Nobody was talking about it.
    We now understand, however, that this is not an injury only 
NFL players can suffer. According to research conducted at the 
Nationwide Children's Hospital in Columbus, Ohio, more than 
70,000 high school football players sustain concussions every 
single year.
    And it is not just a football problem. One of our witnesses 
today, Alexis Ball, will talk about the concussions she 
suffered while playing soccer in high school and college. 
According to Nationwide Children's Hospital, more than 10,000 
high school girl soccer players sustain concussions each year.
    So what we are going to do is we are going to hear from Ms. 
Ball and our other witnesses today, who I should name. Dr. 
Jeffrey Kutcher. Jeffrey, you are not in my opening script. So 
I have to do this, and you forgive me. Associate Professor, 
Department of Neurology, University of Michigan; Director, 
Michigan NeuroSport. And Dr. Ann McKee, Professor of Neurology 
and Pathology at Boston University and Director of 
Neuropathology Core, BU Alzheimer's Disease Center. I guess 
that is Boston University's. And Mr. Mike Oliver, who is 
Executive Director of the National Operating Committee on 
Standards for Athletic Equipment.
    We welcome all of you, and I will just close right there 
and ask if the Chairman of the Subcommittee would wish to say 
something because he has been just terrific on this subject and 
also the Ranking Member.
    Go ahead.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Well, thank you, Mr. Chairman, again for 
us holding this very important hearing this afternoon.
    As a former player, it is certainly something that I am 
interested in. But also there are so many moms and dads and 
coaches and players all across the country that also are very 
interested and probably should be more interested than what 
they realize. And I think that is the great thing about having 
this hearing is to try and get that information out and really 
discuss a potential very serious problem. Not a potential very 
serious problem, a very serious problem, period.
    Sports play a vital role in development of young men and 
women. They help build youth social relationships and learn to 
work as a team while keeping them physically active and healthy 
and having fun. According to the National High School Sports-
Related Injury Surveillance Study, participation in high school 
sports has almost doubled in the last 30 years.
    This is fantastic news, and I think it is important for us 
to highlight the benefits of playing sports. However, 
participation in athletics does carry with it significant risk 
of injury. Just last week, there was news of a tragic death of 
a 16-year-old high school football player who died after 
sustaining a head injury during a game.
    It is important that everyone--coaches, parents, 
physicians, and the athletes themselves--understand those risks 
and be able to identify injuries when they occur. Concussions 
especially have the potential for severe injury, and multiple 
concussions can cause significant repercussions later in life, 
as we are going to hear about today.
    Especially with many recent media reports of high-profile 
incidents in the NFL, we often associate football with 
concussions. As I am well aware and as Mr. Threet will mention 
in his testimony, concussions are a risk with playing football, 
but players in many sports run the risk of sustaining 
concussion, as we will hear from Ms. Ball in her story about 
playing soccer.
    It is imperative for coaches and parents involved in all 
sports to be aware of the dangers associated with concussions, 
know how to recognize the signs and symptoms and what to do if 
a player suffers a concussion. I look forward to hearing from 
Dr. Kutcher and Dr. McKee about the research to further the 
knowledge that we have about concussions, but many questions 
remain as to the causes and effects of concussions. I am very 
interested in hearing from the experts on what is known and 
where we can go from here.
    As we will also discuss, there is a wide variety of 
athletic equipment on the market that claim to use concussion-
reducing or concussion-preventing technology. Parents want to 
keep their children protected, but navigating the many products 
and claims in the marketplace, especially online, can be 
overwhelming. It can be easy to read that something offers the 
best maximum security protection and assume that their child 
will be safe from injury. That is simply not true.
    Some products may offer better protection than others, but 
we need to explore what resources exist to help parents and 
coaches know what level of safety a product will actually 
provide. I also do not know how the average parent or coach can 
be confident that the equipment they purchase genuinely offers 
a greater safety benefit or if its advertisement contains 
misleading or deceptive claims. I hope our witnesses today will 
be able to help me answer this question.
    Along with knowing the safety benefits and limitations of 
sports equipment, parents and coaches need to educate 
themselves on what to look for in the event that an athlete has 
a potential concussion. There are a number of different 
materials available for this purpose. Perhaps the most well-
known education effort is the ``Heads Up'' initiative, led by 
the CDC in partnership with dozens of professional 
organizations and individuals.
    Individual associations, like USA Football, also have their 
own education campaigns for coaches, how to teach proper 
execution of plays and tackles so athletes are in as little 
danger as possible. However, education campaigns must be 
effective in order to effect change. I am interested to learn 
if there is data that shows whether these efforts are reaching 
a wide enough audience and promoting awareness sufficiently.
    Mr. Chairman, I know today's hearing will draw attention to 
this important safety issue. Parents, coaches, and athletes 
must have the resources available to them to understand the 
severity of concussions and how to react when one occurs. As I 
said earlier, the benefits from participating in sports are 
many, and I hope that the potential for injury does not prevent 
anyone from playing.
    Mr. Chairman, again, I thank you for calling this very 
important hearing and look forward to hearing from our 
witnesses. I ask unanimous consent that a statement from the 
Sporting Goods Manufacturers Association and USA Football be in 
the record.
    The Chairman. It is so done.
    [The statement can be found in the Appendix.]
    Senator Boozman. And with that, I yield back.
    The Chairman. I thank the Senator and call upon Senator 
Udall, who has been huge in putting together all of this.

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. Thank you, Chairman Rockefeller, and thank 
you for that nice comment.
    And I very much appreciate you holding this hearing today. 
I would like to say a few words and ask that my full statement 
be put in the record. And Mr. Chairman, I greatly appreciate 
your efforts to promote brain research and, as Chairman of this 
Subcommittee, your close attention to consumer protection 
issues.
    Concussions used to be dismissed as simply ``dings'' or 
``bell-ringers.'' We know now that a concussion is a form of 
traumatic brain injury that should be taken seriously. 
According to a recent Centers for Disease Control report, 
emergency room visits for sports and recreation-related 
traumatic brain injuries increased by 60 percent among children 
and adolescents over the last decade.
    The CDC attributes this rise to greater concussion 
awareness, which is a good thing. Now that athletes, coaches, 
and parents have a better understanding of concussions, some 
sports equipment makers appear to be taking advantage. There 
are a number of so-called ``anti-concussion'' and ``concussion-
reducing'' devices on the market.
    While we should encourage any innovation to protect young 
athletes, we need to make sure that advertisers play by the 
rules. Expert witnesses today can shed some light on ``anti-
concussion'' claims used by some sports equipment 
manufacturers.
    Although we now know more about the dangers of concussions, 
we shouldn't forget how important sports and physical activity 
is for children. The CDC estimates that only 18 percent of 
American high school students participate in at least 1 hour of 
physical activity a day. That is the amount recommended by the 
Department of Health and Human Services.
    Among high school students in New Mexico, only 23 percent 
are getting it. This could lead to negative health consequences 
that last a lifetime. So we need to encourage kids to play 
sports, to exercise, and to be more physically active. Injury 
is always a risk, but the benefits far outweigh the dangers. 
And as we learn more about the dangers of concussions for young 
athletes, we can take steps to make sure that they are played 
more safely.
    I want to thank all the witnesses for being here and 
testifying today. I especially want to recognize Ms. Alexis 
Ball, who traveled from Albuquerque to share her experience 
with sports concussions.
    In reviewing Dr. McKee's testimony, I find it especially 
poignant that she discusses Dave Duerson, a former NFL player 
who tragically took his own life earlier this year. In 2007, he 
testified before this committee. According to news reports, 
Duerson informed his family that he wanted his brain to be 
studied. He hoped people could learn more about the effect of 
brain trauma so kids could play football more safely in the 
future.
    In keeping with this sentiment, I hope that this hearing 
today will advance the goal of making sports safer for our 
children.
    With that, Chairman Rockefeller, thank you very much, and 
thanks for being here and the Ranking Member for being here. 
Appreciate it.
    The Chairman. That is a pretty powerful statement.
    Senator Udall. Thank you.
    [The prepared statement of Senator Udall follows:]

 Prepared Statement of the Hon. Tom Udall, U.S. Senator from New Mexico
    Concussions used to be dismissed as simply ``dings'' or ``bell 
ringers.'' Today we know that a concussion is a form of traumatic brain 
injury that should be taken seriously. For young people between 15 and 
24 years old, playing sports is the second-leading cause of traumatic 
brain injury--second only to motor vehicle crashes.
    According to a recent Centers for Disease Control and Prevention 
(CDC) report, Nonfatal Traumatic Brain Injuries Related to Sports and 
Recreation Activities Among Persons Aged >19 Years--United States, 
2001-2009, emergency room visits for sports and recreation-related 
traumatic brain injuries increased by 60 percent among children and 
adolescents over the last decade. The CDC attributes this rise to 
greater concussion awareness, which is actually a good thing.
    Now that athletes, coaches, and parents have a better understanding 
of concussions, some sports equipment makers appear to be taking 
advantage of their new concerns about safety. There are a number of so-
called ``anti-concussion'' and ``concussion reducing'' devices on the 
market--from helmets and headbands to mouth guards, and even dietary 
supplements. While we should encourage any innovation to protect young 
athletes, we need to make sure that advertisers play by the rules. 
Claims they make about the safety of their equipment should be truthful 
and not misleading. Expert witnesses today can shed light on some of 
these concussions-related claims, and I look forward to hearing their 
testimony.
    Earlier this year, I asked the Federal Trade Commission (FTC) to 
investigate some of the safety claims used to sell football helmets. 
Given the seriousness of concussion risk and the potential for real 
injury to children, the FTC should have the ability to impose civil 
penalties, at the agency's discretion, for any violation of the FTC Act 
that involves the use of false injury prevention claims to sell 
children's sports gear.
    I also introduced legislation. This bill, the Children's Sports 
Athletic Equipment Safety Act, would allow the FTC to impose civil 
penalties for using false injury prevention claims to sell any kind of 
children's sports equipment. Again, under my bill the use of this 
enforcement power would be at the agency's discretion. It would also 
require improvements to the current voluntary safety standard for 
football helmets. I am pleased to be working on this important 
legislation in a bipartisan manner with Representatives Bill Pascrell 
and Todd Russell Platts, the Co-Chairs of the Congressional Brain 
Injury Task Force. I also want to thank fellow Commerce Committee 
member Sen. Lautenberg for his support and co-sponsorship of the 
legislation.
    I believe it is important to share with my Commerce committee 
colleagues some of the potentially misleading advertising that is used 
to market so-called ``anti-concussion'' and ``concussion reducing'' 
sports gear for children's use.
    My January 4, 2011 letter to FTC Chairman Jon Leibowitz cited 
several troubling advertisements for youth football helmets in 
particular. For example, one troubling claim comes from Riddell, the 
leading helmet-maker in the country. Riddell continues to use a 
concussion reduction claim that appears to be deceptive, misleading, 
and unsubstantiated.
    The CEO of Riddell, Dan Arment, told the House Committee on the 
Judiciary at a January 4, 2010 hearing on ``Legal Issues Relating to 
Football Head Injuries'' that:

        ``We have independent, peer-reviewed, published research in the 
        medical journal Neurosurgery, February of 2006, showing that 
        the Revolution [helmet] reduces the risks of concussions by 31 
        percent when compared to traditional helmets. . . . Today, over 
        one million high school, college, and professional players have 
        made the switch from traditional helmets to the Revolution 
        family of helmets.'' (See also ``House Judiciary Committee 
        hearing--Dan Arment opening statement.'' Video recording. 
        Available at http://www.youtube.com/watch?feature
        =player_embedded&v=v1gmwk2nqi4 accessed Oct. 19, 2011)

    Riddell bases this claim on a single study of high school football 
players using brand new Riddell Revolution helmets compared with 
players wearing used and reconditioned helmets of unknown condition. 
Scientists who commented on the article cautioned against drawing broad 
conclusions from a single study that compared the performance of new 
helmets with used headgear of unknown condition and that examined just 
136 high school players who experienced concussions.
    Nevertheless, Riddell launched a media campaign featuring the claim 
from the 2006 study that, according to its ``Riddell Revolution UPMC 
Media Campaign Highlights'' video news release, created ``over 60 
million media impressions, nearly 150 television placements, over 100 
newspaper clips, over 250 on-line placements, [and] 6 live sports radio 
interviews.'' (See http://www.riddell.com/pressreleases_upmc
study/, accessed Jan. 6, 2011.)
    Several helmet and sports safety experts have criticized Riddell's 
use of this concussion prevention claim to sell Revolution type 
helmets. In his 2007 book, Head Games: Football's Concussion Crisis 
from the NFL to Youth Leagues, Chris Nowinski notes that:

        ``As it is well established that rotational forces have a major 
        role in football concussions, and that football helmets do 
        little to reduce those forces, we could skip the discussion of 
        the benefits of the newest football helmets, the Riddell 
        `Revolution' and the Schutt `DNA.' If they make any difference 
        it all, it would be minor. But. . .. both these companies are 
        spending a lot of money to get you to buy these newer and more 
        expensive helmets. You deserve to know what's really going 
        on.''

    In his book, Nowinski also quotes Dr. Robert Cantu, a board member 
of the National Operating Committee on Standards for Athletic Equipment 
(NOCSAE), who told him that:

        ``The theory behind the [Riddell] `Revolution' is that if you 
        build a helmet that's a little bit bigger, especially in the 
        temple area, and padded more thickly, then you'll reduce force 
        more than you would if you had thinner padding and not so big 
        an outer shell. That theory is good for blows that go right to 
        the temple, but that's it.''

    NOCSAE's technical director, Dave Halstead, told the New York Times 
in an October 27, 2007 story titled ``Studies for Competing Design 
Called Into Question'' that ``. . . the [Riddell] Revolution is a good 
helmet. . . . But I have problems with that particular [2006 
Neurosurgery] study. The helmet is not shown to do what they say it 
does.'' In another October 21, 2010 New York Times article titled ``As 
Injuries Rise, Scant Oversight of Helmet Safety,'' Halstead bluntly 
told reporter Alan Schwarz that ``. . . I don't believe that 31 percent 
[reduction in concussion risk claim] for a Yankee minute.'' These 
public statements from one author of the 2006 study and other helmet 
safety experts call into question whether there is competent and 
reliable scientific evidence to substantiate Riddell's marketing claim.
    Moreover, Riddell advertisements cited in my letter to the FTC do 
not disclose that the company provided a grant to underwrite the 2006 
Neurosurgery study. Nor do they disclose that Riddell's vice president 
of research and development, Thad Ide, was one of the study authors. An 
official Neurosurgery commenter highlighted the authors' conflicts of 
interest and stated that the study's conclusions ``should be 
interpreted accordingly.'' Nevertheless, this claim has been 
extensively used in Riddell marketing of high school and youth helmets.
    Here is just one example taken from the website of Riddell's parent 
company, Easton Bell, that does not disclose Riddell's role in funding 
and writing the 2006 study:

        ``An extensive long-term study by the University of Pittsburgh 
        Medical Center was published in the February 2006 issue of 
        Neurosurgery. The results were impressive: Players wearing the 
        Riddell Revolution football helmet were 31 percent less likely 
        to suffer a concussion than athletes who wore traditional or 
        standard football helmets. For athletes who had never suffered 
        a previous concussion, wearing the Riddell Revolution 
        decreased their relative risk of concussion by 41 percent. . . 
        .* * NEUROSURGERY, FEBRUARY 2006, VOL. 58, NO. 2'' (See http://
        www.eastonbellsports.com/brands/riddell, accessed Oct. 19, 
        2011).

    The same Easton Bell webpage includes an image of a Riddell 
Revolution Speed helmet with the claim that ``[r]esearch shows a 31 
percent reduction in the risk of concussion in players wearing Riddell 
Revolution helmets when compared to traditionally designed helmets.* 
*NEUROSURGERY, FEBRUARY 2006, VOL. 58, NO. 2.'' (See image at end of 
statement.)
    Riddell also uses its reduced risk of concussion claim to sell 
youth helmets that were not actually tested in the 2006 study of high 
school football players. For example, Riddell's online store advertises 
the Riddell Revolution Youth football helmet with the claim that 
research shows a 31 percent reduction in the risk of concussion when 
wearing the Riddell Revolution helmet compared to traditional helmets. 
This webpage does not disclose that the youth helmet was not actually 
included in the published study:

        Based on the same technology that made the varsity Riddell 
        Revolution helmet possible--we offer in a Youth version--the 
        Riddell Revolution Youth. . . . After an extensive long-term 
        study by the University of Pittsburgh Medical Center was 
        published in the February 2006 issue of Neurosurgery. The 
        results were impressive: research shows a 31 percent reduction 
        in the risk of concussion in players wearing a Riddell 
        Revolution football helmet when compared to traditional 
        helmets.* * NEUROSURGERY, FEBRUARY 2006, VOL. 58, NO. 2'' (See 
        https://shop.riddell.com/riddell/app/displayApp/
        %28cpgsize=20&layout=
        7.0-
        7_2_3_75_12_13_67_77_6_4_5&carea=0000000002&cpgnum=1%29/.do?rf=y
        , viewed Oct. 17, 2011)

    Since concussion risk may differ depending on the age group and 
skill level of players, the results of a single study of high school 
football players may not be valid for younger children, especially if 
they wear a different helmet not used in the study. That the youth 
helmet was not actually tested in the 2006 Neurosurgery study may be a 
significant omission in such marketing claims used by Riddell and other 
retailers to sell Revolution youth helmets.
    As the official helmet of the National Football League (NFL), 
Riddell also highlights the use of its products ``by the pros'' when 
marketing helmets for high school and younger players. I am concerned 
by some of the product testimonial claims from one NFL head athletic 
trainer, Tim Bream of the Chicago Bears, who states in a Riddell 
Revolution Video News release titled ``Riddell Revolution UPMC Media 
Campaign Highlights:''

        ``We've had some players who have had ongoing problems with 
        head injury, and we made the switch to the new protective 
        headwear when it came out, at its inception. And these players 
        have had no problems since then, or no repeated concussions.''

    Bream does not name the players who ``had ongoing problems with 
head injury'' before switching to Riddell Revolution helmets. However, 
the NFL Injury Report website and news articles discussing head 
injuries suffered by Chicago Bears players during the 2010 football 
season seem to contradict the claim that wearing the Riddell Revolution 
helmet prevents all repeated concussions. Three Chicago Bears players 
who are listed as having head injuries during the 2010 season seem to 
be wearing Riddell Revolution helmets in press photos. Even if this 
Riddell Revolution testimonial claim of ``no repeated concussions'' 
were true at the time the video was made, one can question whether 
those who buy the Riddell Revolution helmet for youth or high school 
players would see similar results of ``no repeated concussions.''
    Riddell uses additional endorsements from this athletic trainer in 
a January 9, 2006 press release titled Research Shows Riddell 
Revolution Football Helmet Provides Better Protection Against 
Concussions (available at: http://www.riddell.com/wp-content/uploads/
2006_UPMC_Press_Release_web3.pdf, accessed Oct. 19, 2011) and a 2006 
Riddell brochure titled Revolution Helmet Research Findings (available 
at: http://www.lohud.com/assets/pdf/BH1661391028.PDF, accessed Oct. 19, 
2011). In the brochure, Bream states that the ``new data [from the 2006 
Neurosurgery study] helps our players make an informed choice when 
deciding which helmet is best for them.''
    Coaches and athletic equipment managers for youth and high school 
teams with players who have suffered concussions might also be 
particularly susceptible to such injury prevention claims. The Orlando 
Sentinel newspaper's Varsity Sports blog reported on October 17 that 
one high school football coach and athletic trainer issued a 
fundraising appeal to buy 60 new Riddell helmets that are ``the most-
up-to-date . . . concerning concussion reduction technology'' since he 
is concerned about team athletes with multiple concussions. He told the 
Varsity Sports blog that:

        ``In the last three years, we have had eight concussions on the 
        football team. . . . What brought us to this point is we have a 
        player who has had a second concussion and of course there is 
        [former South Sumter linebacker] Your highness Morgan [a 
        junior] at Florida Atlantic University but he can't play 
        because he has had three concussions in the last two years. 
        We're afraid we are putting our kids at risk. There are recent 
        studies that have shown multiple concussions can lead to a 
        lifetime of medical problems. It's twice the price of the 
        helmets we are wearing now and it's a lot of money to ask a 
        small community to raise but truly, I'm not sure how you cannot 
        afford to get these helmets.'' (Available at http://
        blogs.orlandosentinel.com/sports_highschool_varsity/2011/10/17/
        south-sumter-raising-money-for-new-helmets/, accessed Oct. 19, 
        2011.)

    New Riddell helmets may be very good products. It may also be 
advisable for this team to replace its old helmets with new headgear. 
Yet there are still real dangers to overstating the ability of 
children's sports equipment to prevent brain injury, particularly to 
coaches and parents of young athletes who have already suffered 
multiple concussions.
    Unfortunately, misleading ``anti-concussion'' claims appear in 
advertisements for more than just football helmets. There are other 
troubling examples of children's sports equipment sold with concussion 
prevention claims. Although there is evidence that wearing properly 
fitted mouth guards reduces the risk of dental injuries, Dr. William 
Meehan, director of the Sports Concussion Clinic at Children's Hospital 
Boston, writes in his 2011 book Kids, Sports, and Concussion: A Guide 
for Coaches and Parents that any ``effects of [custom mandibular 
orthotics] and other mouth guards on concussions remains unknown.''
    Such uncertainty about the ability of mouth guards to prevent 
concussions does not keep some companies from using concussion 
reduction claims to market mouth guards for youth and high school 
athletes. The product packaging for the Brain Pad Lo Pro+ junior mouth 
guard, which is sold for athletes aged eleven years and under, 
prominently states that it ``Reduces the Risk of CONCUSSIONS!'' and 
``Creates this: BRAIN SAFETY SPACE!'' On its Brain Pad Blog, the 
company highlights in a banner image the claim ``BioMechanically Tested 
and Proven to Reduce Concussions Risk by 40 percent!'' (see: http://
blog.brainpads.com/, accessed Oct. 19, 2011).
    In Brain Pad's online video advertisement titled Head Trainer 
announces ``Zero concussions with Brain Pad mouth guards!'', a head 
athletic trainer ``at one of the top 5 private [high] schools in the 
country'' who is ``responsible for the well-being of 800 student 
athletes at the school'' states that:

        ``We've been using the Brain Pad since 1995. In all those 
        years, whenever I go out on the field, especially if somebody 
        has a potential of a concussion, I always check to see what 
        type of mouth guard they're wearing. And I have never, ever 
        seen anybody wearing the Brain Pad and having a concussion. . . 
        . Since 1995, my experience with this mouth guard preventing 
        concussions has been absolutely awesome.'' (see http://
        www.youtube.com/user/brainpads#p/u/3/mtg1EF
        6LdVQ, accessed Oct. 17, 2011.)

    Similar to the Riddell Revolution helmet video described above, 
this testimonial claim of no concussions among student athletes wearing 
the Brain Pad mouth guard seems to imply that those who purchase the 
product will have similar results. This could lead to young athletes 
putting themselves at greater risk of head injury if they believe that 
they will never suffer a concussion while wearing the Brain Pad mouth 
guard.
    Another company makes the ``Tap Out Youth Mouthguard'' for ages 5 
to 11 years. The back of the product packaging states that the mouth 
guard has a ``Concussion Defense System backed by a $30,000 Dental 
Warranty.'' Although this Tap Out mouth guard claim is not as prominent 
as the previously cited claims for the Brain Pad mouth guard, it is not 
clear how the product's ``Concussion Defense System'' actually protects 
children from sports-related head injury.
    There are also sporting goods companies that sell protective 
headbands for soccer players with potentially misleading concussion 
prevention claims. Dr. Meehan notes in Kids, Sports, and Concussion: A 
Guide for Coaches and Parents that although many headbands advertise 
the ability to reduce the risk of concussion, there is little medical 
evidence to support this assertion.
    The website for ForceField FF headband describes concussions as a 
problem in soccer and notes that their headband ``can come between you 
and a head injury'' (see image at end of statement). The company 
website states that:

        ``Research on concussions in soccer has shown that soccer 
        players have concussion rates similar to football and ice 
        hockey. . . . The ForceField FF Headband will reduce the risk 
        of head injury when exposed to any type of external force.'' 
        (See http://www.forcefieldheadbands.com/sportrelated.html 
        accessed Oct. 17, 2011)

    Another webpage indicates that the result of wearing the ForceField 
headband is a ``[s]ignificant reduction of the risk of head injuries 
when exposed to all types of impacts'' (available at: http://
www.forcefieldheadbands.com/rationale.html, accessed Oct. 17, 2011). 
The company also markets this headband specifically for use by young 
children (see: http://www.forcefieldheadbands.com/children.html, 
accessed Oct. 17, 2011).
    Full90 Sports sells other ``performance headguards'' to protect 
against concussion in soccer. The company's online store claims the F90 
Performance Headguard's ``ForceBloc foam reduces impact force by up to 
50 percent, meaning fewer concussions overall and a reduction of 
severity of injury.'' The company further states that an unnamed 
``recent study'' found that ``college players not wearing a Full90 
Performance Headguard were 2.65 times more likely to receive a 
concussion than players that did.'' (See http://www.full90.com/
products/protect/club/ accessed Oct. 19, 2011).
    Full 90 Sports' website also includes a product testimonial from a 
pro soccer player supported by a photo apparently taken moments after 
he collided with another player. Wearing Full90 headgear, the player 
looks at his opponent who, not wearing any headgear, appears injured on 
the ground. The quote accompanying the image is as follows:

        ``We don't know exactly how much [the headgear] reduced the 
        force of [the impact] but I just thank God . . . I was wearing 
        that thing because I might not be here talking to you had I not 
        worn it. (available at http://www.full90.com/players/pro/ 
        accessed Oct. 19, 2011. See also image enclosed at end of 
        statement.)

    Although this photo and testimonial statement may accurately convey 
the player's honest belief in the protective properties of Full90 
headgear, it is questionable whether there is a reasonable basis to 
claim that such soccer headgear actually reduces the likelihood and 
severity of brain injury to any degree.
    Such concussion prevention claims used in advertising for a variety 
of children's sports equipment are very concerning. Paying for a 
product that does not work as effectively as advertised is bad enough. 
It is far worse when a product sold for children's use might actually 
increase the risk of brain injury due to a false sense of security. 
Enacting the Children's Sports Athletic Equipment Safety Act would 
discourage companies from misleading coaches, parents, and young 
athletes.
    Unfortunately, one even finds similar, potentially misleading 
concussion claims in marketing for dietary supplements for children's 
use. Newport Nutritionals sells Sports Brain Guard, a ``[d]aily tri-
delivery bioactive protection program'' that ``help[s] protect your 
brain from concussion injury'' (see http://www.sports
brainguard.com/ accessed Oct. 19, 2011; See also image at end of 
statement). Elsewhere on the website, Sports Brain Guard claims to 
``maximize the brain's ability to heal and reduce inflammation.'' While 
this claim may be true, it is not clear that there is enough scientific 
evidence to date to substantiate that this dietary supplement actually 
protects the brain from concussion.
    Moreover, the net impression of the product's advertising may 
improperly convey the message that athletes who are concussed or 
recovering from the lingering effects of concussion can safely ``stay 
in the game'' by taking Sports Brain Guard supplements. This ``stay in 
the game'' advertising slogan, which is used throughout the product's 
website, contrasts with the concussion safety and awareness efforts 
promoted by the CDC and various sports leagues. In fact, the CDC 
recommends that concussed athletes never return to sports activities 
``the day of the injury and until a health care professional, 
experienced in evaluating for concussion, says they are symptom-free 
and it's OK to return to play'' (see http://www.cdc.gov/concussion/
what_to_do.html, accessed Oct. 19, 2011).
    Yet, despite all this, elsewhere on the site, Newport Nutritionals 
also prominently announced on the product's homepage that Sports Brain 
Guard is ``Recommended by Dr. Joseph Maroon--Expert in head Injury 
treatment, Heindl Scholar in Neuroscience, [and] Team Neurosurgeon for 
the Pittsburg Steelers'' (See Sports Brain Guard website from Feb 10, 
2011. Internet Archive Wayback Machine. Available at http://
web.archive.org/web/20110210114509/http://sportsbrainguard.com/, 
accessed Oct. 19, 2011). In a separate webpage highlighting his expert 
endorsement, Maroon states:

        ``Over the past 30 years, as a practicing neurosurgeon, I have 
        treated thousands of athletes with sports related concussions--
        players from the NFL, NHL, NBA, NCAA and all the way down to 
        kids playing youth sports. . . . I have personally recommended 
        [this] product, Sports Brain Guard, to athletes at all levels 
        following concussions.'' (See http://www.sportsbrainguard.com/
        maroonmsg.
        aspx, accessed Oct. 19, 2011 and see also image at end of 
        statement)

    This kind of testimonial in support of the product from a doctor 
who has worked in the field of sports concussion is very concerning. It 
is seems to be intended to provided a level of consumer confidence in 
the efficacy of Sports Brain Guard supplements that does not appear to 
be justified by scientific data.
    Also of great concern, the product website homepage includes a 
``Notice to Parents'' about children and concussion risk that seems to 
indicate that this product is sold for use by young athletes (See 
http://www.sportsbrainguard.com/, accessed Oct. 19, 2011; see also 
image at end of statement). Given the intent seems to be to sell for 
use by young athletes, it is even more important that the product 
advertising claims are accurate and supported by scientific evidence.
    There are undoubtedly more examples of ``anti-concussion'' and 
``concussion reducing'' products marketed for children's use. The 
examples cited above, however, demonstrate that this is already a 
problem that could become even worse as awareness of sports concussion 
increases. As we continue to look for the best ways to tackle the 
problem of sports concussion, we should work to take false advertising 
out of the game. I hope that responsible sporting goods manufacturers 
and sports leagues--which are already working to improve concussion 
awareness among athletes, coaches and parents--will also join in this 
important effort.
    In conclusion, I want to emphasize the very positive role of sports 
for individuals and our society. Although we now know more about the 
dangers of concussion, we must not forget how important physical 
activity and sports are for children. The CDC estimates that only 18 
percent of American high school students participate in at least one 
hour of physical activity a day. That is the amount recommended by the 
Department of Health and Human Services. Among high school students in 
New Mexico, only 23 percent are getting the recommended amount of 
physical activity. This could lead to negative health consequences that 
last a lifetime.
    We know that physically-active youth have lower rates of body fat, 
better cardio-respiratory fitness, stronger muscles and bones. They 
also have less anxiety, stress, and depression. As highlighted in HSS's 
Physical Activities Guidelines for Americans, the bottom line is that 
the health benefits of physical activity far outweigh the risks of 
adverse events for almost everyone.
    So we need to encourage kids to play sports, to exercise, and to be 
more physically active. As we learn more about the dangers of 
concussions for young athletes, we can take steps to make sure sports 
are played more safely.
    Enclosures:
    1. Image from Easton Bell website, available at http://
www.eastonbellsports.com/brands/riddell, accessed Oct. 19, 2011.
    2. Image and testimonial statement from ``Riddell Revolution UPMC 
Media Campaign Highlights'' video news release available at: http://
www.riddell.com/press
releases_upmcstudy/, accessed Jan. 6, 2011.
    3. Image of product packaging (top front) for Brain Pad Lo Pro+ 
junior mouth guard.
    4. Image of product packaging (back) for Brain Pad Lo Pro+ junior 
mouth guard.
    5. Image from ForceField FF Headbands website, available at http://
www.force
fieldheadbands.com, accessed Oct. 19, 2011.
    6. Image from ForceField FF Headbands website, available at http://
www.force
fieldheadbands.com/children.html, accessed Oct. 19, 2011.
    7. Image and testimonial statement from Full90 Sports website, 
available at http://www.full90.com/players/pro/, accessed 10-19-11.
    8. Image from Sports Brain Guard website, available at http://
www.sports
brainguard.com/purchase.aspx, accessed Oct. 19, 2011.
    9. Image of Sports Brain Guard website, ``Stay in the Game with 
Sports Brain Guard.'' available at http://www.sportsbrainguard.com/
maroonmsg.aspx, accessed Oct. 19, 2011.
    10. Image of Sports Brain Guard website and text excerpt, ``Stay in 
the Game with Sports Brain Guard.'' available at http://
www.sportsbrainguard.com/maroon
msg.aspx, accessed Oct. 19, 2011.
                                 ______
                                 
                               Enclosures
























                                ------                                

    The Chairman. Ms. Alexis Ball, I would like to call on you 
first.

       STATEMENT OF ALEXIS BALL, ALBUQUERQUE, NEW MEXICO

    Ms. Ball. Chairman Rockefeller and members of the 
Committee, I want to thank you for inviting me here today.
    My name is Alexis Ball, and I am a senior at the University 
of New Mexico. Concussions have greatly altered my life, and I 
appreciate the opportunity to take an advocacy role on 
concussion awareness.
    I have played soccer since I was 4, and I have always been 
the high-achieving student athlete. In high school, I was New 
Mexico's Gatorade Player of the Year and our valedictorian. By 
my junior year in college, I was an academic all-American, 
captain of my team, and had received first team all-conference 
honors.
    However, for as many awards as I have accumulated, I have 
accrued about as many concussions. I was medically disqualified 
from playing collegiate athletics in December 2009. This 
decision came after a season of struggle, following two 
concussions I sustained in the beginning of the season.
    The Chairman. Ms. Ball, what you are saying is so important 
and so moving and powerful that I want you to slow down just a 
tiny bit so we don't miss a syllable.
    Ms. Ball. I am sorry.
    The Chairman. OK?
    Ms. Ball. During preseason, I was offered the opportunity 
to shadow a doctor in the ER. A man came in with a knee 
laceration, which I was not prepared to see. I fainted and hit 
my head. It was clear I had a concussion, due to the dizziness, 
vomiting, and seizures that followed.
    My coaches were not pleased when I called them the 
following morning, informing them of the concussion. In 
accordance with the team doctor's requirements, I sat out for a 
week. After that week, I met with him again. He asked me the 
normal concussion questions. Do you have a headache? Are you 
dizzy? Can you remember these three words?
    I was still experiencing headaches and bouts of dizziness 
at the time, but it was the week of our first game and I wanted 
to play. Thus, I supplied the necessary answers to get cleared. 
I played for about 2 weeks with minimal issues. However, in our 
third game, I took a header on the top of my head.
    I was not able to stand up and needed assistance to leave 
the field. I had sustained another concussion. I sat out for 
about a week and returned to play. However, the weeks following 
this concussion were horrible. I was playing terribly and 
simply was not myself.
    I was no longer able to sleep at night. I would fall asleep 
around 3 o'clock in the morning after lying restlessly in my 
bed since 10 p.m. the night before. I could not pay attention 
in any of my classes.
    However, the most disturbing change was the twist in my 
personality. I no longer enjoyed partaking in anything. I would 
go to practice and feel void of emotions, or I would begin 
crying randomly in the middle of practice. I would also sit in 
my room and stare into space, not comfortable in my own body. I 
did not know who I was anymore.
    I thought that Alexis, the high-achieving student athlete, 
was permanently gone. My mom was seriously concerned about my 
well-being and forced me to go see my doctor. I told him about 
all my struggles, and he, too, was rather concerned.
    In an effort to see what was happening, I took a neuropsych 
test. The test revealed that my visual memory was impacted. I 
now fall in the 20th percentile of all people for visual 
recall, and my doctor also explained that I was experiencing 
prolonged symptoms from the combination of the two concussions 
I had sustained months prior.
    I was shocked. My doctor and I also talked about the status 
of my future in soccer. We talked about implications for my 
future if I were to sustain another concussion. I had already 
accumulated 10 concussions in about 8 years, most of which 
while wearing protective headgear.
    The doctor concluded that for the safety of my future, I 
should hang up my cleats. This was a crushing blow, yet one 
that needed to be done. Ultimately, I had to separate my head 
from my heart.
    Concussions are a very serious insult to your brain. People 
frequently claim an athlete ``just sustained a concussion,'' 
like it is no big deal. Too often, coaches, athletes, and 
parents dismiss the severity of concussions because it is not a 
visible injury. If an athlete tears their ACL or sprains their 
ankle, it is apparent externally that they are injured. This is 
not the case with concussions.
    A doctor or coach often cannot see the physical 
manifestations of the concussion. Moreover, many of the 
symptoms of post-concussion syndrome are not usually associated 
with the initial blow. I had no idea that my insomnia or the 
sadness I had felt could be correlated to an injury that I had 
sustained in the months prior, which is something I really want 
to emphasize today.
    Athletes must be aware that if they sustain a concussion, 
symptoms can last longer than a few days, or weeks, for that 
matter. They can last a lifetime.
    Another issue athletes need to be aware of is the limited 
efficacy of headgear or helmets. I wore protective headgear 
since my second concussion in high school, per the 
recommendation of my trainers. It was supposed to be a 
preventive measure against concussions, and clearly, this did 
not hold true. I sustained about eight concussions since 
wearing that. It is essential for athletes and coaches to know 
that athletes are not free from concussions because they have 
protective headgear.
    Furthermore, I believe it is important to note that the 
mentality to return to play as quickly as possible is very 
prevalent in the world of athletics. There is a lot of pressure 
on athletes to just deal with their injuries, or they will be 
in jeopardy of losing their starting position or playing time.
    This cultures an environment in which it is really easy to 
lie about your symptoms, especially when it comes to 
concussions. I knew the answers needed to return to play. No 
one could prove whether I had a headache or not, so I was apt 
to lie. In retrospect, this was a very poor decision, but I did 
not understand the severity of concussions at the time.
    I continued to play much longer than I probably should 
have, due to the high number of concussions I had throughout my 
career. And I most certainly returned to play too quickly. 
People have only one brain for life. I will never regain the 
visual memory I once had. I will also not be able to regain the 
respect I lost while I struggled through my final season of 
soccer.
    I hope from my story you have learned that concussions and 
brain injury are not a minor injury. In order to prevent more 
stories like mine, concussion awareness needs to be more 
prevalent among coaches and athletes in our society. I believe 
that most coaches and athletes do not truly understand the 
long-term ramifications of concussions. And people also need to 
understand that wearing protective gear does not stop 
concussions from occurring.
    Therefore, I want to thank you again for inviting me here 
today in a step to further public education about this 
invisible injury.
    [The prepared statement of Ms. Ball follows:]

       Prepared Statement of Alexis Ball, Albuquerque, New Mexico
    Chairman Rockefeller, Ranking Member Hutchison, and members of the 
Committee, I want to thank you for inviting me here today. My name is 
Alexis Ball, and I am a senior at the University of New Mexico. 
Concussions have greatly altered my life. I appreciate the opportunity 
to take an advocacy role in concussion awareness.
    I have played soccer since I was four and have always been a high 
achieving student athlete. Throughout my career, I earned numerous 
academic and athletic awards. In high school, I was New Mexico Gatorade 
Player of the Year and our valedictorian. By my junior year in college, 
I was an Academic All American, captain of my team, and had received 
First Team All Conference honors. My coaches often spoke of my 
potential to lead our team to a place that it has never been. However, 
for as many awards as I have accumulated, I have accrued about as many 
concussions. I sustained approximately five concussions prior to 
college and five concussions throughout college while wearing 
``protective'' headgear. In fact, it was a concussion that terminated 
my collegiate career a year early.
    I was medically disqualified from playing collegiate athletics in 
December 2009. This decision came after a season of struggle following 
two concussions I sustained in the beginning of the season. During pre-
season, I was offered the opportunity to shadow an ER doctor. I 
excitedly took the opportunity because I want to be a doctor. A man 
came in with a knee laceration that I was not prepared to see, and I 
fainted and hit my head. It was clear I had a concussion due to the 
dizziness, vomiting, and seizures that followed.
    My coaches were not so pleased when I called them the following 
morning informing them of the concussion. I had already sustained three 
concussions at UNM, and no one wanted me to add any more to the list. 
In accordance with the team doctor's requirements, I sat out for a 
week. However, my rest time still forced me to be watching practices in 
the blistering hot temperatures of August in New Mexico. I met with the 
sports medicine doctor a week after the concussion in order to be 
cleared to play. The doctor asked me the normal concussion questions, 
such as ``do you have a headache right now?'' Or ``can you remember 
these three words?'' I had heard these questions all too many times 
before. I was still experiencing headaches and bouts of dizziness at 
this time, but it was the week of our first game and my coaches wanted 
me to play. Thus, I supplied the necessary answers to get cleared.
    I played for about two weeks without many issues. I did not play 
well, but I was there. In about our third game, I took a header off the 
top of my head (an area of my head which was not covered by my head 
gear). I was not able to stand up and needed assistance to leave the 
field. I had sustained another concussion. I sat out for a week again 
and then returned to play.
    However, the weeks following this concussion were horrible. Not 
only had I lost my starting position, but I seemed incapable of getting 
it back. I was playing terribly and simply was not myself. Many other 
things had changed as well. I no longer was able to sleep at night. I 
would fall asleep around 3 o'clock in the morning after lying 
restlessly in my bed since 10 o'clock at night. I could not pay 
attention in any of my classes. However, the most disturbing change was 
the twist in my personality. I no longer enjoyed partaking in anything. 
I would go home and sit in my room and stare into space, not 
comfortable in my own body. I did not know who I was anymore. I would 
either go to practice and feel void of all emotion or begin crying 
uncontrollably randomly in the middle of it. I was lost. My teammates 
initially asked if I was ok, and I would shrug my shoulders, replying 
weakly, ``yes I'm fine.''
    As the weeks progressed and my playing continued to deteriorate, I 
felt my teammates distancing themselves from me. About two months into 
the season, I had a meeting with my fellow captains. They informed me 
that they had lost respect for me and felt that I was selfish by acting 
so introverted at practices. I was in disarray, and these comments only 
worsened my fragile emotional state. Only my best friend and my parents 
remained by my side. I didn't know who to be anymore. I thought that 
Alexis, the high achieving student athlete, was permanently gone.
    My mom was seriously concerned about my well-being. She e-mailed a 
doctor that she knew with her concerns and urged me to consult with 
him. I was very resistant to this idea because I felt that not sleeping 
and having some gloomy days were such silly reasons to see the doctor. 
I finally went and talked to him. I told him all about my struggles, 
and he was rather concerned. In an effort to see what was happening, I 
took a neuropsychology test. The test revealed that my visual memory 
was impacted. I now fell in the 20th percentile of all people for 
visual recall. My doctor informed me that I was experiencing prolonged 
symptoms from the combination of the two concussions I sustained months 
prior. I was shocked.
    My doctor and I talked about the status of my future in soccer. We 
discussed the numerous concussions I have had throughout my soccer 
career. I had accumulated 10 concussions in about 8 years. We also 
talked about the implications for my future if I were to sustain 
another one. The doctor concluded that for the safety of my future, I 
should hang up my cleats. It was a crushing blow, yet one that needed 
to be done. Ultimately I had to separate my head from my heart.
    Concussions are a very serious insult to your brain. People 
frequently claim an athlete just sustained a concussion, like it is no 
big deal. Too often coaches, athletes, and parents dismiss the severity 
of concussions because it is not a visible injury. If an athlete tears 
their ACL or sprains their ankle, it is apparent externally that they 
are injured. This is not the case with concussions. A doctor or coach 
often cannot see the physical manifestations of a concussion. Moreover, 
many of the symptoms of post-concussion syndrome are not easily 
associated with the initial blow. I had no idea that my insomnia or the 
sadness I had felt could be correlated to an injury that I had 
sustained months prior. That is one message that I want to emphasize 
today. Athletes who have had concussions must be aware that symptoms 
can last longer than a few days or weeks. They can last for months and 
in some cases for life.
    Another issue athletes need to be aware of is the limited efficacy 
of head gear or helmets. I wore protective head gear since my second 
concussion in high school per the recommendation of my trainer. It was 
supposed to be a preventative measure against concussions. Clearly this 
gear did not prevent me from sustaining further concussions. It is 
essential for coaches and athletes to know that athletes are not free 
from concussions because they have protective head gear.
    Furthermore, I believe it is also important to note that the 
mentality to return to play as quickly as possible is very prevalent in 
the world of high school and collegiate athletics. There is a lot of 
pressure on athletes to just deal with their injuries or they will be 
in jeopardy of losing their starting position or playing time. This 
cultures an environment in which it is really easy to lie about your 
symptoms, especially when it comes to concussions. I knew the test 
questions and the answers needed to return to play. No one could prove 
whether I had a headache or not, so I was apt to lie. In retrospect, 
this was a very poor decision, but I did not understand the severity of 
concussions at the time. I also believe that most coaches and athletes 
do not truly understand the long term ramifications of concussions. I 
continued to play much longer than I probably should have due to the 
high number of concussions I had throughout my entire career. I most 
certainly returned to play too quickly. People only have one brain for 
life. It is not something that can be repaired via surgery like most 
other injuries. I will never regain the visual memory I once had. I 
also will not be able regain the respect I lost while I struggled 
through my final season of soccer.
    Concussions adversely impacted my life. I hope from my story you 
have learned that concussions and brain injury are not a minor injury. 
In order to prevent more stories like mine, concussion awareness needs 
to be more prevalent among coaches and athletes in our society. People 
need to understand that wearing protective gear does not stop 
concussions from occurring. Therefore, I want to thank you again for 
inviting me here today in a step to further public education about this 
invisible injury.

    The Chairman. Thank you. You did extremely well.
    Mr. Steven Threet, who is a student at Arizona State 
University, was a quarterback and is still there. A starting 
quarterback, but you are still associated----
    Mr. Threet. Yes, sir.
    The Chairman. Working with the team?
    Mr. Threet. Yes, I am coaching with the team. Yes. Yes, 
sir.
    The Chairman. OK. We welcome you.

           STATEMENT OF STEVEN THREET, TEMPE, ARIZONA

    Mr. Threet. Thank you, Chairman Rockefeller and the other 
Committee members, for inviting me.
    It is a great honor to be speaking here on a topic that has 
changed my life, and I am happy to help raise awareness about 
such a critical issue in both male and female sports. Dealing 
with concussions can be a very difficult process for the 
injured player and their family. So it is exciting for me to 
see such a prestigious and capable group of individuals who are 
willing to learn more in an effort to help better educate and 
protect all athletes.
    Throughout my playing career, I faced a multitude of 
injuries. However, none caused more confusion, both literally 
and figuratively, at the time they occurred than concussions. 
Each of the four documented concussions that I experienced were 
unique in the way in which they occurred.
    I sustained concussions from hits directly to my head by 
another player, from my head hitting the ground, and also as a 
result of consecutive impacts on separate plays. While my 
symptoms were often similar--they ranged from slight dizziness 
and blurred vision to extreme light sensitivity and constant 
headache--the severity of my symptoms had no recognizable 
pattern.
    In two of the cases, I returned to play 1 week after the 
injury I sustained. In one instance, it only took me 2 weeks to 
recover. However, my final concussion I suffered on November 
26, 2010, and the resulting symptoms were the reason that I 
decided to end my football playing career.
    During my playing days, brain injury was never a major 
concern to me. After my first concussion, which happened on the 
last play of a high school game senior season, I was able to 
start the next game. It was not until my symptoms became 
serious that my attitude about the injury changed.
    At the time when I decided to retire, I saw my decision 
simply as the right one to make. However, in the aftermath, it 
has become apparent to me that my decision can also be seen as 
an example of how dangerous brain injury is.
    I want to make it clear that my goal in speaking is not to 
deter athletes from competing. I only wish that they 
acknowledge the seriousness of brain injury and respect the 
process that comes with the recovery.
    In all sports, a certain aggressive mentality is required 
to be successful. The passion and intensity a football player 
relies on is an example of this, and it is what I think makes 
the game beautiful. As a former quarterback at premier college 
football programs, I know the importance of and took pride in 
being physically and mentally tough, outworking my opponent and 
leaving it all on the field, and playing through injury.
    However, athletes must understand that a mild brain injury 
is not a mild shoulder separation. It is not an injury to be 
played through. They must understand that playing through a 
brain injury is not a sign of toughness, but it is a sign that 
says athletes are still uninformed on the topic.
    Statistics have recently revealed that about 40 percent of 
athletes who have sustained a concussion returned to play too 
early and that up to 50 percent of concussions go unnoticed. 
This makes me believe that the only focus should be to create 
an open dialogue between athletes, coaches, doctors, and 
families that address the seriousness of brain injuries in 
athletics and the need for a full recovery before we return to 
play.
    I know it is possible to decrease those statistics, and I 
also know progress on this issue is already being made, and 
many states have passed legislation dealing with concussion 
protocols. Unfortunately, there is no brain brace. There is no 
concussion-proof helmet or magic pill for immediate recovery. 
However, I believe there is a misunderstanding about concussion 
prevention and treatment within the athlete cohort, as well as 
the general public.
    For example, a football helmet is often thought of as a 
brain protector when, in reality, it is designed to protect the 
bone structure of the individual and not the brain. If the 
helmet could guarantee concussion prevention, I would still be 
playing football.
    Once again, I would like to thank you for the opportunity, 
but more importantly, thank you for taking the time to learn 
and show your support for this issue today. And I look forward 
to the future progress that I know can and will be made on the 
topic.
    Thank you.
    [The prepared statement of Mr. Threet follows:]

                  Prepared Statement of Steven Threet

    First I would like to thank Chairman Rockefeller and the other 
committee members for inviting me. It is a great honor to be here 
speaking on a topic that has changed my life and I am happy to help 
raise awareness about such a critical issue in both male and female 
sports. Dealing with concussions can be a very difficult process for 
the injured person and their family; so it is exciting for me to see 
such a prestigious and capable group of individuals who are willing to 
learn more in an effort to better educate and protect all athletes.
    Throughout my playing career I faced a multitude of injuries. 
However, none caused more confusion both literally and figuratively at 
the time that they occurred than concussions. Each of the four 
documented concussions that I experienced were unique in the way in 
which they occurred. I have sustained concussions from hits directly to 
my head by another player, from my head hitting the ground, and also as 
a result of consecutive impacts on separate plays. While my symptoms 
were often similar, they ranged from slight dizziness and blurred 
vision to extreme light sensitivity and a constant headache. The 
severity of my symptoms had no recognizable pattern. In two of the 
cases I was cleared and played without problem one week after I 
sustained a concussion. In one instance I returned to play two weeks 
after the injury. However the most severe symptoms were a result from 
my last concussion, which I suffered on November 26, 2010. Those 
symptoms ultimately led to my decision to end my football playing 
career.
    During my playing days, brain injury was never a major a concern to 
me. After my first concussion, which happened on the last play of a 
high school game my senior year, I was able to start the next game. It 
was not until my symptoms became serious that my attitude about the 
injury changed. At the time when I decided to retire, I saw my decision 
simply as the right one to make. However, in the aftermath it has 
become apparent to me that my decision can also be seen as an example 
of how dangerous brain injuries can be. I want to make it clear that my 
goal in speaking is not to deter athletes from competing. I only wish 
that they acknowledge the seriousness of a brain injury and respect the 
process that comes with recovery.
    In all sports a certain aggressive mentality is required to be 
successful. The passion and intensity football players rely on is an 
example of this; and what makes the game beautiful. As a former 
quarterback at premier college football programs I know the importance 
of and took pride in being physically and mentally tough, out working 
my opponent, leaving it all on the field, and playing through injury. 
However, athletes must understand that a mild brain injury is not a 
shoulder separation. It is not an injury to be played through. They 
must understand that playing through a brain injury is NOT a sign of 
toughness, but it is a sign that says athletes are still uninformed.
    Statistics recently revealed that about 40 percent of athletes who 
have sustained a concussion return to play too early and that 50 
percent of concussions go unnoticed. This makes me believe that the 
only focus should be to create an open dialogue between athletes, 
coaches, doctors, and families that addresses the seriousness of brain 
injuries in athletics and the need for a full recovery before returning 
to play. I know it is possible to decrease those statistics. I also 
know progress on this issue is already being made and many states have 
already passed legislation dealing with concussion protocols.
    Unfortunately, there is no brain brace, concussion proof helmet, or 
magic pill for immediate recovery. However I believe THERE IS a 
misunderstanding about concussion prevention and treatment within the 
athlete cohort as well as the general public. For example, a football 
helmet is often thought of as a brain protector. However, it is 
designed to protect the bone structure of the head, not the brain 
itself. If a helmet could guarantee protection from concussions, I 
would still be playing football.
    Once again thank you for this opportunity but more importantly 
thank you for taking the time to learn and show your support for this 
issue here today. I look forward to the future progress that I know can 
and will be made.

    The Chairman. Thank you very, very much.
    And you talk about an elite program. You are exactly right. 
You are exactly right.
    Dr. Kutcher, bring us some Michigan and NeuroSport wisdom.

              STATEMENT OF JEFFREY S. KUTCHER, MD,

          ASSOCIATE PROFESSOR, UNIVERSITY OF MICHIGAN,

          DEPARTMENT OF NEUROLOGY; DIRECTOR, MICHIGAN

          NEUROSPORT; CHAIR, SPORTS NEUROLOGY SECTION,

                 AMERICAN ACADEMY OF NEUROLOGY

    Dr. Kutcher. I will do my best, sir.
    Chairman Rockefeller, members of the Committee, and 
distinguished guests, it is my distinct honor to join you 
today. I am extremely grateful to be given the opportunity to 
provide my testimony.
    My name is Jeffrey Kutcher. I am a sports neurologist and 
team physician at the University of Michigan. Since 2005, I 
have been the director of Michigan NeuroSport, University of 
Michigan's comprehensive academic sports neurology program.
    Our program provides clinical care for athletes of all ages 
and abilities, conducts clinical and basic science research on 
sports concussion, provides education to athletes, parents, 
coaches, administrators, and healthcare providers. In my 
clinical practice, I care for athletes at the time of injury, 
through the return-to-play process, over the course of their 
seasons, their careers, and after they retire.
    Since 2009, I have also been the Chair of the Sports 
Neurology Section of the American Academy of Neurology. The 
American Academy of Neurology is dedicated to the neurological 
care of athletes at all levels and is a leading voice in the 
arena of sports concussion.
    I am currently co-leading the academy's effort to produce 
an evidence-based clinical practice guideline on sports 
concussion, an effort that includes the critical review and 
grading of every academic paper ever published on sports 
concussion.
    Also pertinent to this topic, I have recently been named 
the director of the National Basketball Association's 
concussion program, and I also consult for the National Hockey 
League Players Association.
    Clearly, the issue of sports concussion has been gaining 
significant public and Government interest over the past 
several years. A majority of this interest has been focused on 
those athletes already in the spotlight, the ones who play our 
professional contact sports.
    While these athletes are experiencing the greatest doses of 
head impact over their lifetimes, they represent only a small 
fraction of the population at risk of being injured, which is 
why I am encouraged that today's hearing is focusing on the 
protective equipment being used by all athletes, regardless of 
level of play, age, or gender.
    It is a common misconception that concussion is a problem 
seen only in males. As Ms. Ball has demonstrated, concussions 
occur in females as well, with some data suggesting that 
concussion incidence is actually higher in females when 
compared to males playing similar sports.
    Concussion is an injury that occurs at every age, at every 
level of play. Up to 3.8 million concussions are estimated to 
occur in the United States each year from sports and 
recreational activities, and the majority of those occur in our 
youth.
    There is great uncertainty and great concern regarding the 
notion of possible long-term effects from concussion, 
especially on the pediatric population, which may be at even 
greater risk given the ongoing development of the pediatric 
brain.
    So what is a concussion? I will spend a moment just 
describing that in my own words. It is an injury to the brain 
that occurs when the brain moves fast enough or suddenly enough 
to disrupt the normal electrical function of its component 
cells.
    Given that the brain is floating in fluid inside of the 
skull and that the head can act as a pendulum when the body is 
struck, movements of the brain significant enough to cause 
concussion can occur with or without a direct blow to the head. 
As long as the skull and thus the brain inside of it is 
accelerated or decelerated with enough force, the normal 
processes of the brain may be compromised.
    The resulting concussion can take on many different forms, 
but typically includes transient disorientation, slowed 
thinking, memory difficulties, or other signs of brain 
dysfunction. Symptoms such as headache, nausea, and sensitivity 
to light are also quite common.
    Concussions cannot be diagnosed by any test. That is 
extremely important to remember. It is a diagnosis that can 
only be made after a careful clinical evaluation performed by a 
healthcare professional, and preferably one with training and 
experience caring for brain injuries.
    It is important to realize that concussion is not the only 
brain injury that can occur from head trauma. Emergent 
injuries, such as bleeding in or around the brain or skull 
fracture, can occur anytime an athlete or an object is moving 
quickly in the field of play.
    On the other side of the spectrum, there is emerging 
evidence--brought forth by Dr. McKee, for example with some of 
her excellent work--that forces from multiple impacts that may 
not even produce concussion may be having potentially negative 
long-term health effects on athlete's brains.
    Helmets have an extremely important role to play in head 
injury prevention. Without them, the potential for serious 
injury would make many of our sports and recreational 
activities unacceptably risky. In this way, helmets are 
extremely effective pieces of equipment.
    With the introduction of hard-shell helmets, for example, 
skull fractures from playing football have essentially been 
eliminated. What helmets do not do well is significantly slow 
down the contents of the skull when the head is struck or moved 
suddenly.
    Since concussions occur not as a result of the forces 
experienced by the skull, but by those experienced by the 
brain, it is extremely unlikely that any helmet can be designed 
that will prevent concussions to the same significant degree 
that they have been shown to prevent skull fractures.
    Currently, there are no convincing data in the published 
medical literature that show any particular helmet being better 
than any other at preventing sports concussion. Such data is 
hard to collect, grant you, for two main reasons.
    First, given the many variables that exist in the athletic 
population and the varied exposure to impacts, it is extremely 
difficult to perform a randomized, controlled clinical trial on 
similar populations of athletes. Second, given that concussion 
is a clinical diagnosis with no available reference standard or 
diagnostic test, any study of concussion is significantly 
limited by the ambiguity of the very clinical outcome that is 
being studied.
    For these same reasons, there are no published data 
supporting the idea that other types of protective equipment, 
such as mouth guards or soccer headbands, prevent concussion. 
Moreover, in sports such as soccer, where protective headgear 
is the exception rather than the rule, I have seen the use of 
headgear result in athletes altering their playing style in the 
wrong direction as their newfound sense of protection 
encourages more physically aggressive play.
    Every week, I am asked in my clinic by patients, parents, 
and coaches about the claims they hear and what equipment they 
should buy to prevent concussions. The simple truth is that no 
current helmet, mouth guard, headband, or other piece of 
equipment can significantly prevent concussions from occurring. 
They occur as the result of the nature of our sports.
    Concussion prevention is much more about teaching proper 
technique, playing by the rules, and limiting the overall dose 
of impacts. The potential harm that I see caused by products 
that claim to prevent concussion when they do not is far more 
than simply the financial harm of paying more for something 
that isn't likely to work as claimed. It is the harm that comes 
from having a false sense of security, from not understanding 
how the injury occurs, and what can actually be done to prevent 
it.
    The public deserves to know that equipment has a 
significant, but inherently limited ability to prevent 
concussion. There is still a tremendous amount yet to be 
learned about the nature of concussions and their possible 
effects on brain health. In the interim, I am deeply encouraged 
by today's hearing and honored to be included in the efforts of 
the Committee as we work together for the safety of our 
athletes.
    Thank you.
    [The prepared statement of Dr. Kutcher follows:]

  Prepared Statement of Jeffrey S. Kutcher, MD, Associate Professor, 
  University of Michigan, Department of Neurology; Director, Michigan 
   NeuroSport; Chair, Sports Neurology Section, American Academy of 
                               Neurology

    Chairman Rockefeller, members of the Committee, and distinguished 
guests, it is my distinct honor to join you today and I am extremely 
grateful to be given this opportunity to provide my testimony.
    My name is Jeffrey Kutcher. I am a sports neurologist and team 
physician at the University of Michigan. Since 2005, I have been the 
Director of Michigan NeuroSport, the University of Michigan's 
comprehensive academic program in sports neurology. The NeuroSport 
program provides clinical care for athletes of all ages and abilities, 
conducts clinical and basic science research on sports concussion and 
other issues in sports neurology, and provides education to athletes, 
parents, coaches, administrators, and health care providers. My 
experience allows me to speak directly to the complete spectrum of 
athletes that experience sports-related brain injuries. I care for 
athletes at the time of their injury, over the course of their season, 
their career, into their retirement, and beyond.
    Since 2009, I have also been the Chair of the Sports Neurology 
Section of the American Academy of Neurology. The American Academy of 
Neurology, the world's largest professional association of 
neurologists, is dedicated to the neurological care of athletes at all 
levels by optimizing clinical practice, research, and education, and is 
a leading voice in the arena of sports concussion. I am currently co-
leading the American Academy of Neurology's effort to produce a 
meaningful, evidence-based, clinical practice guideline on sports 
concussion, an effort that includes the critical review and grading of 
every academic paper published on sports concussion. Also pertinent to 
this topic, I am the Director of the National Basketball Association's 
Concussion Program and a consultant to the National Hockey League 
Players' Association.

The Scope of the Problem
    Clearly, the issue of sports concussion has been gaining 
significant public and government interest over the past few years. 
Fueled by increasing awareness of possible long-term effects from head 
injuries, the majority of the media coverage has focused on those 
athletes already in the spotlight, the ones who play our professional 
contact sports. While these athletes are experiencing the greatest 
doses of head impact over their lifetimes, they represent only a very 
small fraction of the population at risk of being injured. That is why 
I am encouraged that today's hearing is focusing on the protective 
equipment being used by all athletes, regardless of level of play, age, 
or gender.
    It is a common misconception that concussion is a problem seen only 
in males. Concussions occur in females as well, with some data 
suggesting that concussion incidence is higher in females when compared 
to males playing similar sports. Concussion is an injury that occurs at 
every age and at every level of play. Up to 3.8 million concussions are 
estimated to occur in the United States each year from sports and 
recreational activities, and the majority of these occur in our youth. 
There is great uncertainty, and with it significant concern, regarding 
the notion of possible long-term effects from concussion, especially on 
the pediatric population, which may be at even greater risk given the 
ongoing development of the pediatric brain.

What is Concussion?
    Simply put, concussion is an injury to the brain. It occurs when 
the brain moves fast enough, and suddenly enough, to disrupt the normal 
electrical function of its' component cells. Given that the brain is 
floating in fluid inside of the skull, and that the head can act as a 
pendulum when the body is struck, movements of the brain significant 
enough to cause concussion can occur with or without a direct blow to 
the head. As long as the skull, and thus the brain inside of it, is 
accelerated or decelerated with enough force, the normal processes of 
the brain may be compromised. The resulting concussion can take on many 
different forms, but typically includes transient disorientation, 
slowed thinking, memory difficulties, or other signs of brain 
dysfunction. Symptoms, such as headache, nausea, and sensitivity to 
light are also quite common. I should also note that a loss of 
consciousness is relatively rare in concussion, occurring in less than 
10 percent of cases. Concussion cannot be diagnosed by any one test. It 
is a diagnosis that can only be made by a careful clinical evaluation 
performed by a health care professional, and preferably one with 
training and experience caring for brain injuries.
    It is important to realize that concussion, as defined above, is 
not the only brain injury that can occur from head trauma. More acutely 
serious or emergent injuries, such as bleeding in or around the brain 
or a skull fracture, can occur anytime an athlete or an object is 
moving quickly in the field of play. On the other side of the spectrum, 
there is emerging evidence that forces from multiple impacts that are 
not significant enough to result in a concussion may have potentially 
negative effects on long-term brain health.

Equipment Limitations
    Helmets have an extremely important role to play in head injury 
prevention. Without them, the potential for bone fracture or 
intracranial injury would make many of our sports and recreational 
activities unacceptably risky. In this way, helmets are extremely 
effective pieces of equipment. With the introduction of hard-shell 
helmets, for example, skull fractures and resulting deaths from playing 
football have essentially been eliminated. What helmets do not do well 
is significantly slow down the contents of the skull when the head is 
struck or moves suddenly. Since concussions occur not as a result of 
the forces experienced by the skull, but by those experienced by the 
brain, it is extremely unlikely that any helmet can be designed that 
will prevent concussions to the same significant degree that they have 
been shown to prevent skull fractures.
    Currently, there is no data in the published medical literature 
that shows any particular helmet being better than any other at 
preventing sports concussions. Such data is hard to collect for two 
main reasons: First, given the many variables that exist in the 
athletic population and the varied exposure to impacts, it is extremely 
difficult to perform a randomized, controlled, clinical trial on 
similar populations of athletes. Second, given that concussion is a 
clinical diagnosis, with no available reference standard or diagnostic 
test, any study of concussion is significantly limited by the ambiguity 
of the very clinical outcome that is being studied.
    For these same reasons, there are no published data supporting the 
idea that other types of protective equipment, such as mouthguards or 
soccer headbands, prevent concussion. Moreover, in sports such as 
soccer, where protective headgear is the exception rather than the 
rule, I have seen the use of headgear result in athletes altering their 
playing style in the wrong direction, as their newfound sense of 
protection encourages more physically aggressive play.
    While clinical data that speaks to concussion prevention is hard to 
generate, there are many extremely well performed laboratory studies 
that provide excellent data on the amount of force a helmet allows to 
get through to a model brain in a mechanical head. This does not mean 
that these data can be used to construct an estimate of concussion 
risk. Concussions do not occur at a particular force threshold. They 
occur across a wide range of forces and are dependent on the complex 
and variable physiological nature of each individual's brain.

The Potential Harm of Misinformation
    With the increased public awareness of an injury that occurs 
frequently in children and may produce significant negative long-term 
health outcomes, it is not surprising that the marketplace for products 
designed to prevent concussions is a busy one. Every week I am asked by 
patients, parents, and coaches about the claims they hear and what 
equipment they should buy to prevent concussions. I wish there was such 
a product on the market. The simple truth is that no current helmet, 
mouthguard, headband, or other piece of equipment can significantly 
prevent concussions from occurring. They occur as the result of the 
nature of sports. Concussion prevention is much more about teaching 
proper technique, playing by the rules, and limiting the overall dose 
of impacts. Preventing bad outcomes and long-term damage, meanwhile, is 
clearly about recognizing the injury when it occurs, removing that 
athlete from participation, and allowing for appropriate recovery 
before they return.
    The potential harm that I see being caused by products that claim 
to prevent concussion when they do not is far more than simply the 
financial harm of paying more for something that isn't likely to work 
as claimed. It is the harm that comes from having a false sense of 
security, from not understanding how the injury occurs and what can 
actually be done to prevent it. This issue is a growing public concern, 
and rightly so. The public deserves to know that equipment has a 
significant, but inherently limited, ability to prevent concussions. 
For the health of all athletes, we must see that each player, parent, 
and coach becomes educated on concussion, including the use of proper 
technique, the need for reporting the injury, and the importance of 
allowing for a full recovery before returning.
    There is still a tremendous amount yet to be learned about the 
nature of concussions and their possible effects on brain health. In 
the interim, I am deeply encouraged by today's hearing and honored to 
be included in the efforts of the Committee as we work together for the 
safety of our athletes.

    The Chairman. Thank you very much, Doctor.
    And can we go on now to Dr. McKee?

          STATEMENT OF ANN C. McKEE, MD, PROFESSOR OF

       NEUROLOGY AND PATHOLOGY, BOSTON UNIVERSITY SCHOOL

          OF MEDICINE; DIRECTOR, VISN-1 NEUROPATHOLOGY

        LABORATORY FOR THE NEW ENGLAND VETERANS AFFAIRS

           MEDICAL CENTERS; DIRECTOR, BRAIN BANKS FOR

       THE BOSTON UNIVERSITY ALZHEIMER'S DISEASE CENTER,

         FRAMINGHAM HEART STUDY, AND CENTENARIAN STUDY;

 CO-DIRECTOR, CENTER FOR THE STUDY OF TRAUMATIC ENCEPHALOPATHY

    Dr. McKee. Chairman Rockefeller and members of the 
Committee, thank you for the invitation to testify today on 
sports concussions and their consequences.
    My name is Dr. Ann McKee. I am a Professor of Neurology and 
Pathology at Boston University's School of Medicine, and I 
direct the neuropathology laboratory for the New England 
Veterans Affairs Medical Center at the Boston VA.
    I am also Co-Director for the Center for the Study of 
Traumatic Encephalopathy. My testimony today reflects my 
professional opinion. I am not speaking officially on behalf of 
the Department of Veterans Affairs.
    Mild traumatic brain injury, or concussion, is a temporary 
state of neurologic dysfunction resulting from forces on the 
brain--acceleration, deceleration, lateral and rotational 
forces. Subconcussion is caused by these same type of forces, 
but the forces are milder, and no symptoms are produced.
    In all of these conditions, concussion or subconcussion, 
the brain looks normal after the injury, and there is no 
detectable damage on routine neuroimaging, such as CT scan or 
MRI, which is why these injuries are sometimes considered 
invisible. However, the acceleration, deceleration, rotational 
forces cause the brain to move rapidly within the skull, and 
the brain, which is firm, but gelatinous, is stretched and 
deformed by these forces. And as the brain as a whole is 
deformed, there is also stretch and strain of the individual 
nerve cells and support cells within the brain.
    The brain abnormalities associated with concussion and 
subconcussion occur at the microscopic, cellular, molecular, 
and metabolic levels. If an athlete returns to play before the 
symptoms resolve, the athlete risks developing post-concussive 
syndrome and second impact syndrome, or SIS, a rare, but often 
fatal condition.
    In addition, repetitive mild concussive injury can trigger 
a progressive deterioration of the brain called ``chronic 
traumatic encephalopathy.'' Chronic traumatic encephalopathy is 
a progressive neurodegeneration that evolves slowly over 
decades and usually does not become apparent until many years 
after the player has retired from the sport.
    CTE is triggered by repetitive concussive injuries 
superimposed on a brain that has not healed from a previous 
injury. This is why concussion awareness is so critical and why 
proper diagnosis and management of concussion, allowing the 
brain to completely rest and recover after an injury, is so 
important in youth sports.
    The Chairman. Perhaps even more so on the part of very 
relatively young children whose brains are still growing?
    Dr. McKee. Absolutely.
    The Chairman. They are still playing football, other 
things.
    Dr. McKee. Right. The youth or immature brain is more 
susceptible to concussive injuries than the mature adult brain. 
Children and young adults recover more slowly from a 
concussion. Youth athletes are also more at risk for concussion 
due to their disproportionally large head size compared to body 
size and the weakness of their neck musculature.
    Furthermore, young athletes are uniquely susceptible to 
second impact syndrome, which has only been reported in 
athletes under the age of 24 and most often under the age of 
18. Second impact syndrome occurs when a young athlete sustains 
an initial head injury, then suffers a second head injury 
before the symptoms associated with the first impact have 
cleared.
    Typically, the athlete returns to play too early and 
receives a second blow to the head, which may be remarkably 
minor. The affected athlete may appear stunned at first, but in 
the next few seconds to minutes, the athlete collapses to the 
ground, semi-comatose, and the outcome is often fatal or 
associated with severe and permanent disability.
    Since 2008, as Director of the Center for the Study of 
Traumatic Encephalopathy Brain Bank, I have diagnosed chronic 
traumatic encephalopathy in the brains of 58 athletes and other 
individuals, which is more than double the history of the 
world's experience with this condition. I have diagnosed CTE in 
40 football players, and that includes professional football 
players, college football players, as well as high school 
football players, 5 hockey players, and 15 military veterans.
    Chronic traumatic encephalopathy causes changes in behavior 
and personality. In particular, individuals with CTE become 
more irritable, angry, or aggressive. They develop mood 
changes, such as depression, and sometimes become suicidal, and 
develop drug and alcohol abuse. As the disease progresses, they 
develop short-term memory loss, which leads to increasing 
cognitive impairment and ultimately dementia and, in some 
cases, parkinsonism.
    Pathologically, CTE is caused by a buildup of a protein 
called tau. It forms neurofibrillary tangles within the brain. 
Under normal circumstances, this abnormal tau protein is found 
in only limited quantities, but in CTE, there is a striking 
buildup of this protein, even at young ages.
    For example, advanced chronic traumatic encephalopathy was 
found in the brain of Dave Duerson, a former defensive back for 
the Chicago Bears. Dave Duerson began playing football at age 8 
and experienced more than 10 concussions in his 11-year NFL 
career. After retiring from the NFL, he was very successful and 
had a loving family and four children.
    At the age of 46, he experienced financial difficulties and 
the dissolution of his marriage. He became hot-tempered, 
physically and verbally abusive. He developed memory lapses, 
mood swings, and piercing headaches. And on February 17, 2011, 
he killed himself inside his Florida apartment. He left 
instructions to donate his brain to my laboratory, and my 
examination showed that he was suffering from moderately severe 
CTE, even though he was only 50 years old.
    Another example is Owen Thomas, a defensive end for the 
University of Pennsylvania who played football since age 9. One 
day in the spring of 2010, he called his parents and told them 
he was stressed by school and having trouble with several of 
his courses. And 2 days later, he hanged himself in his off-
campus apartment.
    When I looked at Owen's brain, I saw unmistakable changes 
of early CTE. In fact, if you compare the brain of Owen Thomas 
to the brain of Dave Duerson, there was remarkably similar, 
although milder pathology, suggesting that if Owen Thomas had 
lived another 30 years, his CTE would have progressed to the 
advanced stage demonstrated by Dave Duerson.
    I have recently had the opportunity to study the brain of a 
17-year-old high school football player. He suffered a 
concussion 3 weeks before the day of his death and had recently 
been cleared to return to play. During the game, he intercepted 
a pass, was tackled, and hit the ground. As he walked to the 
bench, he complained of a severe headache, then collapsed to 
the ground, unconscious. He died the following day.
    Neuropathologic examination showed a thin subdural 
hemorrhage consistent with SIS and very early changes of CTE. 
He is the youngest player ever diagnosed with changes of CTE.
    I have now examined the brains of 58 individuals with CTE, 
and I have found early CTE in college and high school players, 
including players as young as 17 and 18. We know that CTE is a 
neurodegeneration associated with repeated concussive injury 
that usually occurs in an individual's teens and 20s.
    We know that once CTE is triggered, the neurodegeneration 
progresses slowly over decades to involve widespread 
degeneration of many brain structures. We know that the 
symptoms of CTE are subtle and begin in mid life with 
personality and behavioral changes, including irritability, 
short fuse, depression, suicidal ideations, impulsivity, and 
memory loss. We know there is a slow deterioration that 
progresses to dementia and parkinsonism.
    However, there are many things that we do not understand 
about CTE. We do not understand or we do not know the exact 
incidence and prevalence of this disorder, even though we now 
clearly understand that this disease exists, and it is 
surprisingly common.
    What factors determine who will develop CTE? How many 
concussions, how many subconcussive injuries, how close 
together the injuries, how severe, and at what age? All of 
these are aspects of the disease that are unknown at this time.
    Importantly, we do not know how to diagnose this disease in 
living individuals, how to stop its progression, or how to 
reverse its course. But we can make important changes to 
prevent this disease from developing in young athletes, and 
those changes include understanding what a concussion is, 
recognition of concussion when it occurs, and proper medical 
management of concussion after it happens.
    We can also teach our young athletes to play smart and keep 
their head out of the game as much as possible. Rule changes to 
protect athletes from dangerous styles of play, rule 
enforcement, and player and coach education will go a long way 
toward reducing the frequency of concussion and subconcussion.
    With these changes in the way that sports are played, 
continued education, increased scientific interest and research 
into the mechanisms of CTE pathogenesis, and the development of 
diagnostic tools and therapeutic strategies to interrupt this 
disease progression, we can make enormous improvements to 
protect the mental health of millions of young athletes and 
military service members for many years to come.
    Thank you.
    [The prepared statement of Dr. McKee follows. In addition 
to her written testimony, Dr. McKee submitted three articles:]

    Brandon E. Gavett, PhD, Robert A. Stern, PhD, and Ann C. McKee, MD, 
``Chronic Traumatic Encephalopathy: A Potential Late Effect of Sport-
Related Concussive and Subconcussive Head Trauma,'' Clinical Sports 
Medicine 30 (2011) 179-188
    Daniel H. Daneshvar, MA, Christine M. Baugh, AB, Christopher J. 
Nowinski, BA, Ann C. McKee, MD, Robert A. Stern, PhD, Robert C. Cantu, 
MD ``Helmets and Mouth Guards: The Role of Personal Equipment in 
Preventing Sport-Related Concussions,'' Clinical Sports Medicine 30 
(2011) 145-163
    Ann C. McKee, MD, Robert C. Cantu, MD, Christopher J. Nowinski, AB, 
E. Tessa Hedley-Whyte, MD, Brandon E. Gavett, PhD, Andrew E. Budson, 
MD, Veronica E. Santini, MD, Hyo-Soon Lee, MD, Caroline A. Kubilus, and 
Robert A. Stern, PhD, ``Chronic Traumatic Encephalopathy in Athletes: 
Progressive Tauopathy After Repetitive Head Injury,'' Journal of 
Neuropathology and Experimental Neurology Vol. 68, No. 7, July 2009, 
pp. 709-735
                                 ______
                                 
  Prepared Statement of Ann C. McKee, MD, Professor of Neurology and 
   Pathology, Boston University School of Medicine; Director, VISN-1 
    Neuropathology Laboratory for the New England Veterans Affairs 
   Medical Centers; Director, Brain Banks for the Boston University 
  Alzheimer's Disease Center, Framingham Heart Study, and Centenarian 
  Study; Co-Director, Center for the Study of Traumatic Encephalopathy
    Mr. Chairman and Members of the Committee:

    Thank you for the invitation to testify today on sports concussions 
and their consequences. My name is Dr. Ann McKee. I am a Professor of 
Neurology and Pathology at Boston University School of Medicine and I 
am the Director of the Neuropathology Laboratory for the New England 
Veterans Affairs Medical Centers at the Boston VA Medical Center. I 
also direct the Brain Banks for the Boston University Alzheimer's 
Disease Center, the Framingham Heart Study, and the Centenarian Study, 
and I am a co-director for the Center for the Study of Traumatic 
Encephalopathy at Boston University. My testimony today reflects my 
professional opinion; I am not speaking officially on behalf of the 
Department of Veterans Affairs.
    I received my medical degree in 1979, and I am board certified in 
both Neurology and Neuropathology. I have broad experience in 
neuropathology of neurological disease and have written extensively on 
the neuropathology of many neurodegenerative diseases, including 
Alzheimer's disease, Parkinson's disease, Frontotemporal Dementia and 
Traumatic Brain Injury. For the past 25 years, I have been studying the 
brains of individuals after death and correlating the pathological 
findings to the patient's clinical symptoms during life. For the past 9 
years I have been specifically analyzing the effects of repetitive mild 
traumatic brain injury or repetitive concussion on the brain.
    A traumatic brain injury (TBI) is caused by a blow, a jolt to the 
head or a penetrating head injury that disrupts the function of the 
brain. A TBI may range from mild--with a brief change in mental 
status--to severe, with an extended period of unconsciousness or 
amnesia after injury. Eighty percent of all TBI is mild, approximately 
10% is moderate, and approximately 10% is severe. What we are primarily 
concerned with today is repetitive mild TBI (mTBI) or concussion; the 
terms concussion and mild TBI are interchangeable. Mild TBI and 
concussion are temporary states of neurological dysfunction resulting 
from acceleration, deceleration, lateral and rotational forces on the 
brain. Subconcussion is caused by the same acceleration-deceleration-
rotational forces but the forces are milder and no symptoms are 
produced. In all these conditions, the brain appears macroscopically 
normal after the injury and there is no detectable damage on routine 
neuroimaging, including CT scan or MRI, which is why concussion and 
subconcussive injury are sometimes considered ``invisible'' brain 
injuries. However, these acceleration deceleration-rotational forces 
cause the brain to move rapidly within the skull and the brain, which 
is firm, but gelatinous, is stretched and deformed by these forces. As 
the brain as a whole is deformed, there is also stretch and strain of 
the individual nerve cells and supporting cells within the brain. The 
brain abnormalities associated with concussion and subconcussion occur 
at the microscopic, cellular, molecular and metabolic levels. There is 
mild, but widespread injury to axons, the long, slender projections of 
a nerve cell that conduct electrical impulses away from the nerve cell 
and contact other nerve cells. The nerve cell and axonal injury most 
often completely resolve with rest. Indeed, most individuals recover 
completely from a single mTBI or concussion within weeks to months, but 
in some individuals (fewer than 10%), post-concussive symptoms can last 
for months to years, especially in situations where an athlete is not 
properly treated after a concussion. If an athlete returns to play 
before symptoms resolve, the athlete also risks a rare but sometimes 
fatal event known as second impact syndrome (SIS). In addition, 
repetitive concussion or repetitive subconcussion can trigger a 
progressive deterioration of the brain called Chronic Traumatic 
Encephalopathy (CTE) (McKee 2009, McKee 2010, Gavett 2010, Daneshvar 
2011, Gavett 2011).
    CTE is a progressive neurodegeneration triggered by repetitive 
concussion and subconcussion that evolves slowly over decades and 
usually does not become apparent until many years later. Although the 
exact relationship between concussion, subconcussion and CTE is not 
entirely clear, most likely repetitive concussive and subconcussive 
injury superimposed on unresolved nerve cell and axonal injury 
initiates a series of metabolic, ionic, membrane, and cytoskeletal 
disturbances that triggers the pathological cascade that leads to CTE. 
This is the reason why concussion awareness is so critical and why 
proper diagnosis and management of concussion, allowing the brain to 
completely rest and recover after an injury, is so important in youth 
sports and all other activities that result in mTBI.
    There is also evidence that the youth or immature brain may be more 
susceptible to concussive injuries than the mature adult brain. The 
brain continues to develop and mature, laying down myelinated fiber 
tracts, until the mid-twenties. Children and young adults recover more 
slowly from a concussion than adults. Youth athletes are also more at 
risk for concussion due to their disproportionately large head size 
compared to body size and the weakness of their neck musculature. 
Further evidence of the enhanced susceptibility of young athletes to 
mTBI is second-impact syndrome (SIS), an entity that has only been 
reported in athletes 24 years and younger, and the vast majority of the 
SIS cases in the literature have involved athletes under the age of 18.
    SIS occurs when a young athlete sustains an initial head injury and 
then suffers a second head injury before the symptoms associated with 
the first impact have cleared (Cantu and Gean 2010). Typically, the 
athlete suffers post-concussion symptoms after the first head injury, 
which may include headache; dizziness; visual, motor, or sensory 
changes; confusion and memory problems. Before these symptoms resolve, 
which may take days or weeks, the athlete returns to competition and 
receives a second blow to the head. The second blow may be remarkably 
minor. The affected athlete may appear stunned, usually does not 
experience loss of consciousness but in the next few seconds to several 
minutes, the athlete, who is conscious yet stunned, precipitously 
collapses to the ground, semicomatose. The outcome is often fatal or 
associated with severe permanent disability. The pathophysiology of the 
SIS is generally believed to be caused by a loss of autoregulation of 
the cerebrovasculature. This dysautoregulation leads to precipitous 
brain swelling, high intracranial pressure, brain herniation and often, 
death. The adolescent or youth brain does not autoregulate well and is 
more susceptible to poor outcomes following mTBI (Chaiwat 2009).
    In 2008, we created the Center for the Study of Traumatic 
Encephalopathy (CSTE) with the goal of studying the long-term effects 
of sports-related mTBI and CTE. We initiated a brain donation registry, 
a clinical registry of amateur and professional athletes, and the CSTE 
Brain Bank at the Bedford VA. The purpose of the VA CSTE Brain Bank is 
to study the effects of repetitive mTBI (repetitive concussion and 
subconcussion) by neuropathologically examining brains donated by 
deceased athletes and other individuals with a history of repetitive 
mTBI.
    CTE was first reported in 1928 by Harrison Martland, a New Jersey 
pathologist and medical examiner, who described the clinical spectrum 
of abnormalities found in ``nearly one half of the fighters who have 
stayed in the game long enough'' (McKee 2009, Gavett 2011). Boxers 
exhibiting cognitive, behavioral, or motor abnormalities were well 
known within the community and were referred to by various terms, such 
as ``punch drunk,'' ``goofy,'' and ``slug-nutty'', and later by the 
more formal term ``dementia pugilistica.'' By the 1970s, a sufficient 
number of boxers with dementia pugilistica had been studied 
pathologically to support the conclusion that this distinct 
neurodegeneration was a consequence of repeated mTBI and was not 
restricted to boxers, and the term ``chronic traumatic encephalopathy'' 
or CTE, became most widely used. Over the last few decades, clinical 
and neuropathologic evidence of CTE has emerged in association with 
various sports, including American football, professional wrestling, 
professional hockey, and soccer, as well as other activities associated 
with repetitive mild head trauma, such as physical abuse, epileptic 
seizures, head banging and military service. Although the incidence and 
prevalence of CTE is currently unclear, it most likely varies by sport, 
position, duration of exposure, and age at the time of initial or 
subsequent head trauma, and additional variables, such as genetic 
predisposition.
    In 2009, I reviewed the world's literature on neuropathologically-
verified CTE and found 51 cases of CTE including 3 cases of our own 
from BU and the Bedford VA (McKee 2009). Over the past 3\1/2\ years, 
the brains and spinal cords of 97 athletes and military veterans who 
experienced mTBI or concussion have been donated to the VA CSTE Brain 
Bank. We have found CTE in 58 individuals, more than doubling the 
history of the world's experience combined. We have neuropathologically 
diagnosed CTE in 40 football players, at all levels of play, 
professional, college and high school, 5 hockey players, and 15 
military veterans and are currently preparing a manuscript for 
submission describing our experience.
    The onset of CTE is often in midlife, usually after athletes have 
retired from their sport. The early manifestations of CTE affect 
behavior and personality; in particular, individuals with 
neuropathologically documented CTE have been described as being more 
irritable, angry, or aggressive or as having a shorter fuse. There are 
mood changes, usually of depression, and increased suicidality, drug 
and alcohol abuse, and paranoia may be present. These changes are 
usually followed by short-term memory loss and executive dysfunction. 
Later in the disease, increasing cognitive impairment, movement 
disorders (e.g., parkinsonism), and speech disorders may emerge.
    Macroscopic pathological changes found in CTE include an anterior 
cavum septum pellucidum and posterior septal fenestrations. These 
changes are likely caused by the force of the head impact being 
transmitted through the fluid ventricular system, thereby affecting the 
integrity of the intervening tissue. Enlargement of the lateral and 
third ventricles is also commonly seen in CTE with the third ventricle 
disproportionately widened. In advanced cases, there is also atrophy of 
the frontal and temporal cortices and medial temporal lobe, thinning of 
the hypothalamic floor, shrinkage of the mammillary bodies, pallor of 
the substantia nigra, and hippocampal sclerosis.
    Microscopically, CTE is characterized by an abundance of 
neurofibrillary tangles (NFTs), neuropil threads, and glial tangles 
within the brain, composed of hyperphosphorylated tau protein. CTE is 
distinguished from other neurodegenerations associated with build up of 
tau protein, such as Alzheimer's disease, by several unique features. 
First, the distribution of tau pathology in CTE is strikingly 
perivascular and most dense at the depths of cortical sulci, especially 
in early stages of the disease. The tau pathology in CTE is also 
extremely irregular and superficial, largely confined to foci in the 
frontal, temporal, and insular cortices. With increasing severity the 
tau pathology spreads to involve the limbic cortices, subcortical 
nuclei and brainstem.
    Recently, in addition to severe tau neurofibrillary pathology, we 
have found that there is a widespread TDP-43 proteinopathy in more than 
80% of their cases of CTE. Ten percent of athletes with CTE and a 
florid TDP-43 proteinopathy also develop a motor neuron disease similar 
to Amyotrophic Lateral Sclerosis (McKee 2010). The deposition of both 
tau and TDP-43 as aggregated phosphorylated proteins associated with 
neurodegeneration in CTE suggests that repetitive mTBI or repetitive 
axonal injury provokes the pathologic accumulation of both proteins.
Case studies

Cognitively normal individuals
    Under normal circumstances, phosphorylated 1au protein, is found 
only in very limited quantities in the brains of cognitively normal 
people. I have examined over 70 brains of cognitively intact 
individuals ranging in age from 18-103 years using the identical 
techniques that I use in studying the athlete brains. Basically, unless 
the individual is in the preclinical stages of a neurodegenerative 
disease, there is very little ``normal'' build up of phosphorylated tau 
protein in the brain and then only in restricted regions of individuals 
aged 70 years or older (Figure 1).



    Figure 1. Coronal sections of brain from a 65-year-old cognitively 
normal individual without a history of mild TBI compared to the changes 
found in a 66-year-old former NFL player with CTE. The brain sections 
have been immunostained for phosphorylated tau protein, which appears 
as a dark brown color when the slides are viewed with the naked eye. 
The normal brain does not contain any appreciable amounts of 
phosphorylated tau protein, however there are substantial deposits of 
tau protein in many regions of the brain in the individual with CTE.

Case 1. Former professional boxer
    In January of 2003, as part of my work with the Boston University 
Alzheimer's Disease Center and the Bedford VA, I examined the brain of 
a man who died at the age of 72 after 15 years of severe dementia 
requiring institutionalization. The man had been a world champion boxer 
and had been clinically diagnosed with Alzheimer's disease beginning at 
the age of 58. However, when I looked at his brain on postmortem 
examination, I found that there was absolutely no evidence of 
Alzheimer's disease; there was no evidence of beta amyloid, a protein 
that accumulates in the brain in people with Alzheimer's disease and is 
thought by many to be the cause of Alzheimer's disease. Instead, the 
brain of this world champion boxer showed a massive build-up of 
phosphorylated tau protein as NFTs and glial tangles throughout his 
brain. The neurofibrillary and glial tangles were distributed in a 
unique pattern that is diagnostic of CTE; this pattern not found in any 
other neurodegenerative condition. When viewed microscopically it was 
clear that many individual nerve cells of the boxer contained NFTs, in 
fact they were found in nearly every nerve cell and there were almost 
no normal appearing cells. In CTE, tau protein builds up in individual 
nerve cells and prevents them from making normal connections with other 
nerve cells, eventually killing the cells. In this man's brain, there 
were massive numbers of NFTs and glial tangles, so many in fact that 
you could see the abnormalities on the glass slides without the use of 
a microscope (Figure 2). This individual, a former professional boxer, 
had been clinically diagnosed with Alzheimer's disease during life, but 
the disease that actually caused his tragic 15 year decline in 
intellect and eventual hospitalization for severe dementia was CTE, a 
disorder that would have been entirely prevented if he hadn't suffered 
repeated head injury in his younger years as a boxer.



    Figure 2. Left panel, top and bottom: coronal section of brain from 
a normal control showing the absence phosphorylated tau protein (dark 
brown). The bottom section is a microscopic view of a normal brain 
showing intact nerve cells and support cells. Middle panel, John 
Grimsley, showing marked deposition of tau protein in the amygdala and 
temporal cortex (top) and nerve cells filled with abnormal tau protein 
(bottom). The sections on the right are from a 72 year old professional 
boxer who died with advanced CTE. The top section shows dense 
deposition of abnormal tau protein in the amygdala and the bottom 
section shows a microscopic view of the dense accumulation of tau in 
nerve cells and support cells.

Case 2. John Grimsley, former linebacker Houston Oilers
    John Grimsley, a former linebacker for the Houston Oilers died of 
an accidental gunshot wound while cleaning his gun at the age of 45. 
According to his wife, he was concussed 3 times during his college 
football years, and at least 8 times during his NFL career, however, 
only one ``cerebral concussion'' was medically confirmed. He was never 
formally diagnosed with post concussion syndrome and never sought 
medical attention for residual cognitive and behavioral difficulties. 
There was no history of ever losing consciousness for more than a few 
seconds and he never required being carried off the field or 
hospitalization. He never took any performance enhancing drugs or used 
illicit drugs. He was a nonsmoker and there was no known family history 
of dementia. According to his wife and close friends, he began showing 
changes in his behavior and cognitive decline at age 40. He developed 
difficulties in short-term memory, attention, concentration, 
organization, planning, problem solving, judgment, and the ability to 
juggle more than one task at a time. For example, he would ask the same 
questions repeatedly over the course of the day and he would ask to 
rent a movie that he had already seen. He had difficulty assembling his 
tax records, shopping alone, and understanding television. His symptoms 
gradually progressed and became quite severe by the end of his life. He 
also developed a ``shorter and shorter fuse'' and would become angry 
and verbally aggressive over seemingly trivial issues. When I first 
looked at his brain, it showed the exact same pattern of changes that I 
had found in the brains of boxers with CTE. There were large numbers of 
tau containing neurofibrillary tangles throughout all parts of the 
brain and there was absolutely no evidence of beta amyloid protein or 
Alzheimer's disease. The brain of this 45 year old husband and father, 
at the prime of his life, showed profound neurofibrillary degeneration, 
changes of CTE that were identical in nature to the changes I found in 
the brains of the boxers, but were now found in a football linebacker 
some 30 years younger. In John Grimsley's brain, there were striking 
changes in regions of the brain controlling personality and behavior, 
such as the frontal lobes, profound changes in the areas controlling 
impulsivity and rage behavior such as the amygdala, and severe changes 
in anatomic structures that are responsible for memory, such as the 
hippocampus, mammillary bodies and thalamus. In Figure 2, the brain of 
John Grimsley is seen in the middle; in the top middle panel, you can 
see severe tau deposition in the frontal lobe and microscopically; in 
the bottom middle panel, you can see numerous nerve cells containing 
tau and NFTs. In a normal 45 year old, absolutely none of these changes 
would be found. Indeed these changes would not be found in a normal 65 
year old, 85 year old or 100 year old.

Case 3. Louis Creekmur, former offensive lineman Detroit Lions
    Louis Creekmur was a former offensive lineman for the Detroit Lions 
and eight-time Pro Bowler. Louis Creekmur played ten seasons for the 
Lions and was famous for suffering at least 13 broken noses and 16 
concussions. Beginning at the age of 58, he began to show increasing 
cognitive and behavioral difficulties including memory loss, problems 
with attention and organization, and outbursts of anger and aggression. 
He died from complications of dementia at the age of 82. The brain of 
Mr. Creekmur showed advanced GTE including marked shrinkage of medial 
temporal lobe structures that control memory, shrinkage of the frontal 
and temporal lobes, and marked dilation of the spinal fluid cavities 
that line the brain's interior. There was widespread and severe tau 
deposition as NFTs throughout the frontal and temporal lobes, amygdala, 
hippocampus, thalamus and brainstem in the unique pattern that is only 
found in GTE. In Mr. Creekmur's case, the abnormalities were extremely 
severe. There was absolutely no evidence of beta amyloid, Alzheimer's 
disease or any other neurodegenerative disorder, and the findings again 
indicated that if Mr. Creekmur had not sustained repetitive head trauma 
during the play of football, he would be alive and well and enjoying 
his family and grandchildren today.



    Figure 3. Coronal sections of the brain of Louis Creekmur stained 
for phosphorylated tau protein show dense abnormalities throughout the 
brain. Bottom row: microscopic views of abnormal tau deposits. There 
was extensive nerve cell loss and advanced neurodegenerative changes 
throughout the brain.

Case 4. Dave Duerson, former defensive back Chicago Bears
    Dave Duerson began playing football at age 8 and played a total of 
24 total seasons as a safety in college and as a defensive back in the 
NFL He experienced more than 10 concussions in his 11-year NFL career, 
several with loss of consciousness, although he was never admitted to 
hospital. After retiring from the NFL, he was very successful in the 
food supply industry (Duerson Foods), active in NFL Players Association 
and Benefits Board; he had a loving family with three sons and a 
daughter and was considered in generally good health. In 2007, he began 
to experience business and financial difficulties that culminated in 
the loss of his business and the dissolution of his marriage. He was 
known to be smart, charming, kind and gentle but he became 
progressively more hot-tempered, physically and verbally abusive. He 
began to experience memory lapses; mood swings, piercing headaches on 
the left side of his head, difficulty spelling simple words, and 
blurred eyesight. On February 17, 2011, Duerson killed himself inside 
his Florida apartment at age 50. He left a note that carried a request: 
``Please, see that my brain is given to the NFL's brain bank'' (The VA 
CSTE brain bank). The request was accompanied by an unusual method of 
suicide; he shot himself in the heart. At autopsy, his brain showed 
extensive changes of moderately advanced CTE, without evidence of any 
other disorder including Alzheimer's disease (Figure 4).



    Figure 4. Coronal sections of the brain of Dave Duerson stained for 
phosphorylated tau protein show dense abnormalities throughout the 
brain. Bottom row: microscopic views of abnormal tau deposits showing 
extensive abnormalities of tau in nerve cells and support cells.
Case 5. Owen Thomas. defensive end University of Pennsylvania
    Owen Thomas was a University of Pennsylvania defensive end who 
loved football and had played football since age 9. He was considered 
to be the life of the team and was unanimously voted team captain. 
There was no history of documented or undocumented concussion, 
depression or psychiatric difficulties, and no evidence of substance 
abuse. One day in the spring of 2010, he called his parents and told 
them he was stressed by school and having trouble with several of his 
subjects, two days later he hanged himself in his off campus apartment. 
Neuropathological examination of Owen's brain showed the unmistakable 
changes of early CTE with focal collections of NFTs in multiple areas 
of his frontal cortex and evidence of spread of the NFTs to adjacent 
cortical regions (Figure 6). Comparison of the brain of Owen Thomas to 
the brain of Dave Duerson shows remarkable similar pathology and 
suggests that if Owen Thomas had lived another 30 years, his CTE would 
have progressed to the moderately severe stage demonstrated by Dave 
Duerson.



    Figure 5. Coronal sections of the brain of Owen Thomas stained for 
phosphorylated tau protein show dense abnormalities throughout the 
brain. Bottom row: microscopic views of abnormal tau deposits. There 
was extensive nerve cell loss and advanced neurodegenerative changes 
throughout the brain.

Case 6. 18-year-old high school football player
    I also have had the opportunity to examine the brain of a high 
school football player who died at the age of 18. He had played 
football and other sports for 4 years and suffered several concussions. 
The brain of an 18 year old should be pristine; there should be no 
abnormalities whatsoever. But in the brain of this young man, there 
were several areas of damage in the frontal lobe that you could see 
even looking at the slides with your naked eye (Figure 6, top row). In 
those areas, there were hundreds of degenerating nerve cells containing 
tau NFTs and disordered nerve cell processes indicative of early CTE.


    Figure 6. Brain sections from an 18 year old high school football 
and rugby player showing areas of damage in the frontal lobe (top row, 
red boxes), and microscopic views of views of phosphorylated tau 
containing NFTs in nerve cells and their processes in lower row.

Case 7. 17-year-old high school football player. death from Second 
        Impact Syndrome (SIS)
    A 17-year-old high school football player suffered a concussion 3 
weeks before the day of his death and was cleared to return to play 2 
days earlier. During the game, the running back and linebacker 
intercepted a pass and hit the ground. Nothing seemed exceptional about 
the tackle; it was considered a routine play. Yet as he walked to the 
bench, he complained of a severe headache and then collapsed to the 
ground unconscious. He died the following day. Neuropathological 
examination showed a thin subdural hemorrhage entirely consistent with 
Second-Impact Syndrome (SIS) and very early changes of CTE. He is the 
youngest player ever known to have changes of CTE on neuropathological 
examination.

Summary
    I have now examined the brains of 58 individuals with 
neuropathologically verified CTE--including 40 professional and amateur 
football players, 5 hockey players and 15 military veterans.Ihave found 
changes of early CTE in several college and high school football 
players, including early changes in players as young as 17 and 18 
years. We know that CTE is a tauopathy and TDP-43 proteinopathy 
associated with repeated mTBI that most commonly occurs early in life, 
usually an individual's teens and early twenties. We know that once CTE 
is triggered, the neurodegeneration progresses slowly over decades to 
involve widespread degeneration of many brain structures. We know that 
the symptoms of CTE are often insidious and begin in mid-life with 
prominent early personality and behavioral changes, including 
irritability, short fuse, depression, suicidal ideations, impulsivity, 
and memory loss. We know there is a slow deterioration that may 
progress to include dementia, parkinsonism, gait and speech disorders. 
However, there remain many things that we do not understand about CTE. 
An autopsy case series will never establish incidence and prevalence of 
this disorder, even though we now clearly understand that CTE exists--
and that it is surprisingly common. What factors determine who will 
develop CTE--how many concussions or how many subconcussive injuries, 
how close together the injuries are, how severe, and at what age--all 
of these are aspects of this disease that are unknown at this time. 
Most importantly, we do not know how to diagnose this disease in living 
individuals, how to stop its progression or how to reverse its course 
at the present time. But we can make important changes to prevent this 
disease from developing in young athletes, and those changes include 
understanding what a concussion is, recognition of concussion when it 
occurs, and proper medical management of concussion after it happens. 
We can also teach our young athletes to play smart and to keep their 
head out of the game as much as possible. Rule changes to protect 
athletes from dangerous styles of play, rule enforcement and player and 
coach education will go a long way towards reducing the frequency of 
concussion. With these changes in the way sports are played, continued 
education, increased scientific research into the mechanisms of CTE 
pathogenesis, and the development of diagnostic tools and therapeutic 
strategies to interrupt disease progression, we can make an enormous 
improvements to protect the mental health of millions of young athletes 
and military service members for many years to come.

References
    1. McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gavett BE, 
Budson AE, Santini VE, Lee H-Y, Kubilus CA. Stern RA. Chronic Traumatic 
Encephalopathy in Athletes: Progressive Tauopathy following Repetitive 
Head Injury. J Neuropath Exp Neurol, 2009 68(7): 709-735.
    2. McKee A, Gavett B, Stern R, Nowinski C, Cantu R, Kowall N, Perl 
D, Hedley-Whyte E, Price B, Sullivan C, Morin P, Lee H-S, Kubilus C, 
Daneshvar D, Wulff M, Budson A. TDP-43 Proteinopathy and Motor Neuron 
Disease in Chronic Traumatic Encephalopathy, Journal Neuropathol Exp 
Neurol, 2010, 69: 918-929.
    Authors' reply: McKee AC, Budson AE, Gavett BE, Stern RA, Daneshvar 
D, Nowinski CJ, Cantu RC, Kowall NW, Perl DP, Hedley-Whyte ET. J 
Neuropathol Exp Neural. 2011 Jan; 70(1): 98-100.
    3. Gavett, B, Stern R, Cantu R, Nowinski C, McKee A. Mild traumatic 
brain injury: A risk factor for neurodegeneration, Alzheimer's Research 
and Therapy, 2010, Jun 25; 2(3): 18.
    4. Gavett B, Stern R. McKee A. Chronic Traumatic Encephalopathy: A 
Potential Late Effect of Sport Related Concussive and Subconcussive 
Head Trauma. Clinics in Sports Medicine, 2011 Jan; 30(1):179-88, xi.
    5. Daneshvar D, Nowinski C, McKee A, Stern R, Cantu R. Helmets and 
Mouth guards: The Role of Personal Equipment in Preventing Sports 
Related Concussions. Clinics in Sports Medicine, 2011 Jan; 30(1): 145-
63, X.
    6. Cantu RC, Gean AD. Second-Impact Syndrome and a Small Subdural 
Hematoma: An Uncommon Catastrophic Result of Repetitive Head Injury 
with a Characteristic Imaging Appearance. J Neurotrauma 2010 27:1557-
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    7. Chaiwat 0, Sharma D, Udomphorn Y, Armstead WM, Vavilala MS. 
Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score 
in severe pediatric traumatic brain injury. J Neurotrauma 2009 26(5): 
657-63.

    The Chairman. That was excellent.
    And so, we then finish with Mr. Mike Oliver. Let me repeat, 
Executive Director of the National Operating Committee on 
Standards for Athletic Equipment. And having read my 
preparation for this hearing, I am still a little bit confused 
about what you all do and what you don't do.
    Mr. Oliver. I think I can cover that.
    The Chairman. OK.

STATEMENT OF MIKE OLIVER, EXECUTIVE DIRECTOR AND LEGAL COUNSEL, 
  THE NATIONAL OPERATING COMMITTEE ON STANDARDS FOR ATHLETIC 
                       EQUIPMENT (NOCSAE)

    Mr. Oliver. Thank you, Mr. Chairman, Ranking Member 
Boozman, and members of the Committee.
    I appreciate the invitation to come here today and provide 
some testimony and answer questions of the Committee on a topic 
that is extremely important to me personally, as well as to the 
organization I represent.
    My name is Mike Oliver. Since 1995, I have served as the 
Executive Director and General Counsel for NOCSAE. NOCSAE is 
the National Operating Committee on Standards for Athletic 
Equipment. We are a nonprofit corporation which develops and 
publishes standards for athletic equipment, including helmets, 
faceguards, safety balls, and even soccer shin guards.
    We operate as a board of 18 directors representing a wide 
variety of national sports, sports medicine, and other 
interested organizations. Each organization, by definition 
through our bylaws, selects one or two of its members to sit as 
a director on the board. And in addition to the 18 voting 
directors, NOCSAE has 2 nonvoting positions, representing the 
national sports governing bodies of the NCAA and the National 
High School Federation, the NFHS.
    There is no single controlling interest or interest group 
on the NOCSAE Board, and a balance of interests and 
nondominance is inherent in the operational structure and 
function that is provided through our bylaws. NOCSAE is not a 
trade organization. There is no membership category. Funding 
for the operations and research that we undertake is received 
through licensing fees that we charge to manufacturers who want 
to certify equipment to our standards and to use our 
trademarked and registered logos, properties, and phrases.
    Although NOCSAE is not a certifying body--we do not certify 
equipment independently of the manufacturers--we do engage in 
market surveillance of certified equipment, and we monitor 
product performance through mandatory third-party laboratory 
validation testing as required by our standards, as well as 
direct product testing through an A2LA accredited testing 
laboratory with whom we contract to provide technical support 
and services.
    Decisions regarding changes to standards or the creation 
and adoption of new standards are driven exclusively by science 
and motivated by the desire of all board members to protect 
athletes, not by issues of manufacturer liability, profit, 
market share, or any other interests.
    The mission of NOCSAE since its inception in 1968, is to 
commission research and establish standards for athletic 
equipment where feasible and to encourage the dissemination of 
research findings on athletic equipment and sports injuries. In 
fulfilling that mission, NOCSAE has funded more than $6 million 
in research grants since the first grant was issued in 1994, 
and that number includes more than $5 million dedicated to 
concussion-related research.
    To be certified as meeting our standards, helmets, whether 
they are football helmets or batter's helmets, must score less 
than 1,200 severity index units on each of 16 impacts conducted 
at 12 miles per hour, including 2 high-temperature impacts and 
impacts on 2 randomly selected locations. In addition to those, 
there are four impacts at lower speeds, which have lower 
threshold requirements.
    Although the standard for helmets that NOCSAE publishes are 
not concussion specific, the NOCSAE standard does directly 
address linear forces that are involved in most concussive 
events, and a helmet that passes the NOCSAE standard does 
provide some level of protection against those concussions 
caused primarily by induced linear accelerations to the brain. 
We do not promote helmets as being concussion preventive or 
anti-concussion because there is no way to accurately measure 
the extent of protection provided.
    What the NOCSAE standard does not yet address and cannot 
yet address, and is a subject that is not addressed by any 
other helmet standard in the world, is how to establish and 
incorporate a threshold for rotational accelerations of the 
head that result from impact forces not directed through the 
center of gravity of the head. These rotational accelerations 
are directly involved in causing a significant number of 
concussions, and these types of accelerations can occur even 
without a blow to the head.
    There is no protective equipment standard available today 
from any source that specifically addresses concussion 
prevention, and the development of a concussion-specific 
standard for any protective equipment requires substantial 
scientific support that compliance with the standard would, in 
fact, further eliminate or reduce the severity of concussions 
without increasing the risk of injury in other areas.
    While helmets certified to the NOCSAE standards play a very 
important role in protecting athletes on the field of play, 
certainly helmets are not the only solution to providing better 
protection against concussion. Prevention, diagnosis, 
treatment, and management decisions about when athletes should 
return to play are equally important and, in fact, in some 
circumstances may be more immediately effective in reducing the 
number of concussions.
    Education programs that have been referenced earlier today 
address these issues and are underway for coaches, and in fact, 
NOCSAE has entered into a partnership, as mentioned earlier, 
with the CDCP to create a specific Heads Up to Parents program 
as an educational resource to promote this education among 
those who are certainly motivated to provide the best level of 
protection and education to their children.
    NOCSAE recognizes that concussions are complex events, both 
biomechanically and physiologically. And scientists are working 
hard to understand these issues so that improvements might be 
made in protection, prevention, and treatment.
    We are one of the primary funding sources for this 
research, and we are hopeful that answers will be found that 
will permit an amendment to our standards that will effectively 
and specifically address concussions. Any device, including 
helmets, promoted as being able to prevent, diagnose, or cure a 
concussion must be supported by scientific data and peer-
reviewed research. The same is true with regard to standards 
for athletic equipment.
    We fund concussion research with the intent to advance the 
science so that changes can be made to standards that will 
reduce concussions without increasing risk in other areas, and 
we have taken specific steps to be ready to do that when the 
answers are found. But without solid scientific support for a 
concussion-specific change to an existing helmet standard, any 
changes made to address concussions becomes nothing more than a 
hopeful experiment, turning players into involuntary test 
subjects. And that is something that we will not do.
    I look forward to the Committee's questions and the 
discussion today on a topic that we consider to be extremely 
important.
    Thank you.
    [The prepared statement of Mr. Oliver follows:]

    Prepared Statement of Mike Oliver, Executive Director and Legal 
  Counsel, The National Operating Committee on Standards for Athletic 
                           Equipment (NOCSAE)

    Parents, athletes, and coaches, are becoming more aware and 
informed regarding concussion prevention, diagnosis, treatment, and the 
importance of following recognized return-to-play criteria. This 
increased awareness and public discussion is vitally important to 
advancing athlete safety, but it also creates a demand for quick 
solutions. Unfortunately, there are quick solutions offered for sale 
which have neither scientific nor medical support, and which carry the 
potential for creating a false sense of security and reliance on a 
level of protection that does not exist.
    The neurobiology and biomechanics of sports concussions present 
complex and rapidly evolving areas of expertise both as to cause and 
prevention. Through its grant research funding program, NOCSAE has been 
one of the international leaders in helping to advance the scientific 
and medical knowledge relating to concussions. Despite the dedication 
of more than $5,000,000 in research grants since 1994, directed 
specifically towards the issue of understanding and preventing sports 
concussions and to developing protective equipment performance 
standards that could eliminate concussions or reduce their frequency 
and severity, scientific support for such standard does not yet exist.
    NOCSAE, the National Operating Committee on Standards for Athletic 
Equipment, is an independent and nonprofit standard-setting body with 
the primary mission to enhance athlete safety through scientific 
research, education, and where feasible, the creation of performance 
standards for protective equipment. NOCSAE efforts include the 
development of helmet performance and test standards for football, 
baseball and softball, ice hockey, and lacrosse, as well as faceguards 
and face protectors used in connection with these helmets. NOCSAE 
bylaws provide that the Board is comprised of representatives selected 
by national organizations representing a broad base of interested 
parties and expertise. Broken into three general categories, NOCSAE 
directors representing end-user or direct athlete involvement include 
two new members from the National Athletic Trainers Association (NATA), 
the Athletic Equipment Managers Association (AEMA), and the American 
Football Coaches Association (AFCA). NOCSAE directors representing 
sports medicine and related scientific research include representatives 
from the American College of Sports Medicine (ACSM), the American 
College Health Association (ACHA), American Orthopedic Society for 
Sports Medicine (AOSSM), the American Academy of Pediatrics (AAP), and 
the American Medical Society for Sports Medicine (AMSSM). NOCSAE 
directors representing product and manufacturing interests are selected 
by the Sporting Goods Manufacturers Association (SGMA) and the National 
Athletic Equipment Reconditioners Association (NAERA). In order to 
maintain balance between the interests represented and to preclude 
dominance or control by any group or interest, some organizations have 
one seat, while others have two. Currently there are 18 voting 
directors, five of which represent manufacturing and retail interests, 
7 represent the athlete and end user interests, and 6 representing 
medical and scientific interests. NOCSAE also has two non-voting 
directors, one representing the National Federation of State High 
School Associations (NFHS) and one representing the National Collegiate 
Athletic Association (NCAA).
    In support of its mission, the NOCSAE board utilizes a Scientific 
Advisory Committee consisting of independent leading experts in the 
areas of neurology, neurosurgery, orthopedics, biomechanics, and 
epidemiology. This committee meets as needed, and provides support, 
guidance, and advice in the areas of standards development as well as 
identifying areas for directed or targeted research.
    NOCSAE also maintains an ongoing independent contract with an A2LA 
accredited and ISO 17025 certified testing laboratory, and a contract 
with Fred Mueller PhD who, as the Director of Research, oversees and 
administers the NOCSAE research grant application and funding program.

History of NOCSAE
    NOCSAE was created in 1968 through the combined efforts of the 
NCAA, the American College Health Association, the NFHS, and the 
Sporting Goods Manufacturers Association to develop a football helmet 
standard that would be effective in reducing or eliminating fatalities 
from head injuries such as skull fractures and subdural bleeding that 
were occurring in organized football.
    The standard which resulted from the efforts of the original NOCSAE 
directors and scientists mandated that football helmets meet a specific 
injury threshold criteria, commonly referred to as the Gadd Severity 
Index, Severity Index, or simply SI. The SI threshold in the NOCSAE 
standard works by limiting the magnitude of linear head accelerations 
that result when the helmet is hit. The first NOCSAE football helmet 
standard was originally published in 1973 and new helmets began to 
appear on the market certified to this new standard shortly afterwards. 
Eventually a requirement of compliance with the NOCSAE standard was 
incorporated into the rules of play by the NCAA and the NFHS in 1978 
and 1980 respectively, and within a few years, helmets certified to the 
NOCSAE standards became required in all rules of play for governing 
bodies controlling football, even extending to the United States 
Military through the Department of Defense-Education Activity (DoDEA).
    To be certified as meeting the NOCSAE standard, helmets must score 
less than 1200 SI on each of 16 impacts at 12 mph including two at high 
temperatures and two randomly selected locations, plus 4 additional 
impacts at two different lower speeds which have lower SI threshold 
requirements. Although not concussion specific, the NOCSAE standard 
directly addresses linear forces that are involved in most concussive 
events, and a helmet that passes the NOCSAE standard does provide some 
protection against those concussions caused by induced linear 
accelerations.
    What the NOCSAE standard cannot yet address, and which is not 
addressed by any other helmet standard in the world, is how to 
establish and incorporate a threshold for rotational accelerations of 
the head that result from impact forces that are not directed through 
the center of gravity of the head. These rotational accelerations are 
directly involved in causing a significant number of concussions, and 
these types of accelerations can occur even without a blow to the head. 
Even less is known scientifically about concussion threshold values 
when the blow to the head results in a combination of linear and 
rotational accelerations occurring at different points in the same 
impact and with different magnitudes.
    There is no helmet standard available today from any source that 
specifically addresses concussion prevention, and the development of a 
concussion specific standard for any protective equipment requires 
substantial scientific support that compliance with such a standard 
will in fact further eliminate or reduce the severity of concussions 
without increasing the risk of injury and other areas.

Protecting Against Concussions
    While helmets certified to NOCSAE standards play an incredibly 
important role in protecting athletes in the field of play, improved 
protective equipment is not the only solution to providing better 
protection against concussion. Prevention, diagnosis, treatment, and 
management decisions about when athletes should return to play are 
equally important, and prevention can be enhanced by enforcing the 
rules of play in a particular sport.

   Teaching and enforcing proper tackling techniques, which 
        include not using the head as a weapon or primary contact 
        point. These types of changes can make an immediate and likely 
        measurable impact on the number and severity of concussions.

   Teaching athletes and active children at all ages that the 
        signs and symptoms of a potential concussion should not be 
        ignored, and should be followed up with an evaluation by 
        someone properly trained and skilled in evaluating concussions.

   Adopting and enforcing return to play criteria that will 
        prevent an athlete from returning to play until a complete and 
        objective evaluation is completed.

   Helping parents, coaches, and players understand that 
        although helmets provide a substantial level of protection, no 
        helmet can prevent all head injuries, including concussions.

    The Centers for Disease Control (CDC) estimates approximately 1.6 
to 3.8 million sports-and recreation-related concussions occur each 
year in the United States, and children and teens are at highest risk. 
Parents, coaches and trainers must exercise caution in deciding when 
athletes can and should return to play. The Center for Injury Research 
and Policy at Nationwide Children's Hospital, funded in part by grants 
from NOCSAE, found that in 2008, more than 40 percent of high school 
athletes were allowed prematurely to return to play after suffering 
concussions. And, of those players, 16 percent of concussed football 
players were actually allowed to return to play in the same game after 
losing consciousness.

NOCSAE ongoing efforts to address concussions
    As stated earlier, there are currently no helmet standards 
published in the world which contain performance thresholds specific to 
concussions. Helmet standards which limit linear accelerations do 
provide a level of protection for those concussions where linear 
acceleration may be the primary cause, but a concussion specific helmet 
standard to be effective must incorporate not only limitations to 
linear accelerations, but also reflect and incorporate an understanding 
of injury thresholds associated with rotational accelerations and 
strong scientific support for the concussion injury thresholds 
utilized. For many years, NOCSAE has dedicated its resources to 
answering those questions NOCSAE's first concussion research grant 
award of $49,000 was given in 1996 to Dr. Kevin Guskiewicz at the 
University of North Carolina to study the ``Effect of Mild Head Injury 
on Cognition and Postural Stability'' in evaluating potential 
concussion diagnostic modalities. In the past 10 months, NOCSAE has 
funded specific targeted concussion research grants totaling $2,319,000 
to scientists and biomechanical researchers at Dartmouth Medical 
School, Dartmouth Department of Engineering, Wayne State University 
School of Engineering, Ottawa University Bioengineering Laboratory, and 
the Southern Impact Research Center. From that first concussion grant 
in 1996 through today's date, NOCSAE has dedicated over $5,000,000 to 
the study of sports related concussions to advance medicine and science 
in that area to the point that concussion specific changes to the 
NOCSAE standards can be adopted. These concussion specific grants are 
in addition to other NOCSAE funded research in the areas of sports 
medicine and science, including research that eventually identified the 
biomechanics and physiology of which may be preventable through the use 
of an appropriately tested chest protector that meets an impact 
standard currently being developed by NOCSAE.
    As early as 2002 and 2003, NOCSAE was becoming aware through its 
sponsored research and from the research of others that any performance 
standard that might effectively address injury thresholds from 
rotational accelerations would require a new testing methodology in 
addition to the drop test which is utilized by all existing helmet 
performance standards. To that end, NOCSAE advanced funding for the 
fabrication of five prototype horizontal ram impactor devices, 
sometimes referred to as a linear impactor. This impactor is designed 
in such a way as to permit a testing apparatus to induce rotational 
accelerations into a helmet and headform in unlimited magnitudes, 
direction, and orientation, which no existing helmet impact drop tests 
are able to accomplish. NOCSAE decided in 2004 that the validation of 
such a testing component was necessary so that there would be no delay 
in incorporating rotational acceleration thresholds and testing in the 
NOCSAE standards once those thresholds were identified. A proposed 
revision to the NOCSAE standard incorporating this new testing protocol 
was published in 2004, and work has continued to this day in validating 
and refining the linear at five different laboratory locations around 
the country.

Public Education programs
    In addition to regular public speaking engagements, daily 
interaction with the public to telephone calls and e-mails, and 
providing and disseminating research and educational information 
through the Internet, NOCSAE has entered into a partnership with the 
CDC National Center for Injury Prevention and Control to develop and 
disseminate a concussion awareness and educational campaign called 
``Heads up to Parents.'' This national campaign utilizes multiple 
informational outlets, including social media, to present parents and 
athletes with concussion information, building on the CDC's already-
successful ``Heads Up'' initiative, featuring free tools that provide 
important information on preventing, recognizing and responding to a 
concussion. Materials can be found on the CDC's website, www.cdc.gov/
concussion/sports/. These tools are an invaluable resource for parents 
as their athletes take the field, and NOCSAE is proud to be a partner 
with the CDC Foundation to provide financial and substantive support 
for the program.

Changes to the NOCSAE helmet standards
    The NOCSAE helmet standard, unique among all existing helmet 
standards for the use of a biofidelic headform, the use of a pass fail 
criteria which incorporates both impact force and time duration (SI), 
and the requirement of low-speed and high-speed certification impacts, 
has undergone significant and substantial revisions and improvements 
since it was first adopted and published in 1973.

   In 1992, NOCSAE undertook a multi-factor revision to its 
        testing protocol, which included implementation of a 
        scientifically proven calibration method of the NOCSAE headform 
        using a specially designed impact surface, added a requirement 
        that headform calibration be performed rigid, and the air craft 
        cable guide wires were replaced with smoother music wire. This 
        decreased friction in the drop system and increased stability 
        of the carriage assembly throughout the drop impact. The test 
        impact pad was hardened from a 36 Shore A hardness natural 
        rubber surface to a 43 Shore A hardness urethane to produce a 
        more consistent impact surface. These changes resulted in 
        significantly higher impact velocities and increased impact 
        energies to the helmet, a more demanding test than in the 
        previous standard. The increased impact energies now required 
        in the testing were so significant that the impacts began to 
        break expensive head forms and attachment assemblies, which 
        required a redesign of those components.

   In 1996, NOCSAE amended its helmet standards by toughening 
        pass fail criteria for helmets. The original SI value of 1500 
        was reduced to 1200, making it is 20 percent more demanding, 
        and bringing the pass fail threshold in line with Federal Motor 
        Vehicle Safety Standards.

   In 1999 an anthropometrically correct size medium testing 
        headform was introduced along with other design changes to 
        allow the headforms to withstand the new impact energies that 
        resulted from the changes in 1992 and 1996.

   In 2003, a proprietary data acquisition system and 
        standardization of data collection was developed by NOCSAE and 
        implemented with all licensees, requiring that the pretest and 
        posttest system checks be performed correctly or all helmet 
        test data performed between these system checks becomes 
        invalid. A temperature sensor incorporated in the software 
        automatically invalidates all test data generated when the 
        temperature of the test lab is outside the specified range. 
        Additionally, the results of all impact certification tests are 
        stored in encrypted files and available to NOCSAE by direct 
        download or electronic exchange.

   In 2011, the football helmet standard was revised to add low 
        level pass/fail thresholds for drop impacts at 7 miles per hour 
        This low speed impact threshold is in addition to the 1200 SI 
        pass/fail for drops of 12 mph.

NOCSAE enforcement of its standards
    The NOCSAE name, and the various sport specific logos, phrases, and 
designs that are incorporated into the NOCSAE standards are registered 
and trademarked properties, and NOCSAE controls the use of those 
properties through a license agreement. Any manufacturer which intends 
to certify equipment to the NOCSAE standards must first sign a license 
agreement to do so. This agreement obligates the manufacturer to not 
only comply with the specific requirements of the standards, but also 
requires that each licensee provide certification testing data, quality 
assurance and quality control program documentation, and annual reports 
from third party independent testing laboratories certified compliant 
with ISO 17025 requirements proving compliance with the NOCSAE 
standards for every piece of equipment certified by that licensee in 
the previous 12 months. In exchange for permitting the manufacturer to 
use the intellectual property of NOCSAE, a license fee is also charged. 
This license fee is non-negotiable, and is assessed on a per unit 
basis. The fees per unit are extremely small, but generate the revenue 
used by NOCSAE to fund the scientific research grant program which 
supports the content of standards.
    The license agreement also obligates each licensee to obtain prior 
approval of proposed advertising which uses the NOCSAE name or 
references NOCSAE as part of its advertising.
    Although NOCSAE is not a certifying body, we do engage in market 
surveillance of certified equipment, and we independently investigate 
certified equipment performance through mandatory annual third party 
laboratory validation testing, and direct product testing through our 
own contracted and A2LA accredited testing laboratory.

Recertification of reconditioned equipment
    In addition to the standards that apply to the certification of new 
athletic equipment, NOCSAE has also published standards that permit 
previously certified equipment to be recertified as part of a formal 
reconditioning process. NOCSAE standards for the recertification of 
previously certified athletic equipment provide schools, clubs, 
universities, and even professional teams with a way to economically 
maintain the performance and integrity of their certified helmets, and 
provide NOCSAE with the opportunity to reevaluate helmet performance 
even after they have been in use for one or more seasons. The 
recertification standards require that reconditioners test a 
statistically significant number of helmets submitted for 
reconditioning and recertification. These helmets must be tested first 
in the condition they are in ``as received from the field'' before any 
repair or reconditioning is undertaken. Following completion of the 
reconditioning process which includes a thorough and complete 
inspection of every individual helmet for cracks and defects, and the 
replacement of worn or damaged padding and fitting components, these 
same randomly selected helmets are retested utilizing a proprietary 
data acquisition software program developed for NOCSAE by engineers at 
the University of Tennessee. The test results of the nearly 50,000 
helmets from both pre-and post reconditioning tests are collected and 
evaluated every year.

Conclusion
    Concussions are complex events both biomechanically and 
physiologically, and scientists are working hard to understand these 
issues so that improvements can be made in protection, prevention, and 
treatment. Any device or supplement promoted as being able to prevent, 
diagnose, or cure a concussion must be supported by scientific data and 
peer reviewed research. The same is true with regard to standards for 
protective equipment. Without solid scientific support for a concussion 
specific change to an existing helmet standard, any changes made to 
address concussions becomes nothing more than a hopeful experiment, 
turning players into involuntary test subjects.

    The Chairman. Thank you for that excellent testimony.
    We have been joined by Senator Klobuchar from Minnesota, 
where they are having quarterback difficulties.
    [Laughter.]
    Senator Klobuchar. We do have a team, however.
    The Chairman. Yes, you do. That is true.
    Senator Klobuchar. Thank you.
    The Chairman. I am from West Virginia. I deserve that.
    What is interesting--that is good, Amy.
    [Laughter.]
    The Chairman. I have spent a lot--my mother spent I think 
about 12 years dying from Alzheimer's. Actually, you couldn't 
really be sure. But die she did. My wife's father died from 
Alzheimer's. There are so many--there are 5 million people that 
have Alzheimer's in this country.
    And one of the stunning things about Alzheimer's, which, 
incidentally, if you are working in that traumatic brain injury 
area, you can do that while you are working on Alzheimer's 
because there is a lot of sort of common threads in there. The 
stunning thing is the New York Times came out with an article 6 
or 8 months ago basically saying that the last 30 years of 
research at the great institutes of research in this country 
had produced absolutely no progress whatsoever on finding out 
the cure for Alzheimer's.
    Not for preventing and not for slowing it down, not even 
yet for testing to find out whether you have it, although that 
may be on the way. But that doesn't cure it, which is what we 
want. That is a stunning figure.
    Now comes along the injuries that are sustained by 
concussions, made more poignant by the fact that they come so 
early in life and can have such terrible consequences that you, 
Mr. Threet, and you, Ms. Ball, decided not to do what you had 
spent your whole life preparing to do. It is not necessarily 
typical. I mean, it was a very mature, wise decision to make.
    So I just want to kind of throw this at all of you. You 
could develop a 50-pound helmet and all it would do is more 
securely, I think--unless I am wrong--it would just more 
securely make sure that your head doesn't get split open. But 
it wouldn't do one thing for the movement of the brain, to stop 
the movement of the brain.
    Which then, if you say that emphatically enough, it raises 
the question of what can you do medically? You can analyze. We 
do that with Alzheimer's. People--you have a registry of 
Alzheimer's brains. People leave their brains to be studied 
just like you have had, and you learn from that, from the 
synapses and all those kinds of things, the tangles. You can 
tell.
    But that doesn't do them any good. And so, I want to raise 
two questions. One is to the medical side of this. Do you think 
I am wrong? I mean, do you think that this is just because it 
is a relatively early discovery?
    To be quite honest, I didn't know at all that somebody who 
played soccer could get this until I watched that movie about 
the winning when we beat China back in 19--whatever it was, in 
1980. And that incredible, powerful back that the Chinese all 
stayed away from because she just flattened them, she had 
chronic fatigue syndrome. She didn't have a brain concussion of 
any sort.
    And you see soccer a lot now. All of us watch soccer a lot 
more, and you see people using their heads and you don't notice 
whether bands are on there or not. But just the amazingness of 
the ignorance of the American people about this problem, even 
though we now know much more than we did know about it.
    I want to know just right off the bat how hopeful you all 
are realistically about being able to find a solution to this 
so that the brain is not thrown off of its axis, you know, 
electric stimulus and all the rest of it. Can this happen?
    Dr. McKee. Well, I personally am very hopeful. We didn't 
know about this disease 5 years ago in any real way, and what 
we have learned in the last 5 years has been extraordinary. We 
have just made enormous gains in understanding how it affects 
the disease, what the disease looks like, how it progresses 
through the nervous system.
    And now we understand this disease exists. We can try to 
model it in experimental systems and come up with those 
therapies that might help us treat living patients.
    And I actually think that this disease may ultimately be a 
window or provide insight into the diseases like Alzheimer's 
disease. Alzheimer's disease is characterized by a buildup of 
this protein tau as well, and maybe by understanding how this 
disease starts and how it progresses, we may actually have 
insight into Alzheimer's disease and how it starts.
    One of the most difficult things about Alzheimer's disease 
is we don't have any idea. It starts silently. Maybe in a 
person's 50s. We can never identify it precisely, how it 
exactly starts. But this is a disease we know has a time 
course, and we know what to expect, and it develops over time. 
And I think it is going to give us an enormous opportunity for 
intervention.
    The other thing about Alzheimer's disease is most of those 
therapies----
    The Chairman. Do you mean a prevention of the disease 
because of helmets or other----
    Dr. McKee. No. I think understanding the actual pathologic 
process and intervening there, intervening maybe at the start 
of the disease where it is triggered or preventing it from 
progressing through the nervous system. There appears to be a 
transmissibility through the nervous system that it develops in 
one nerve cell, and then it causes the disease to be propagated 
in another nerve cell.
    If we could interrupt that progression, we could make an 
enormous difference in this disease, and that may be applicable 
to Alzheimer's as well. One of the issues with Alzheimer's is 
we were focused on the beta amyloid protein, and that has 
really come up pretty--we haven't come up with much. But we 
haven't focused on tau that much, and maybe that is the 
cellular element we really need to start paying attention to.
    The Chairman. Can I ask one of you two athletes, is it the 
prevention of something that you now know you already have from 
becoming worse that interests you the most? Well, the answer 
has to be yes. Or is it the absolutely vast amount of change in 
the way everybody in this country thinks about the playing of 
sports, the carrying out of sports, the responsibility that 
people have?
    I mean, there are a lot of coaches in rural states that are 
also math teachers. That probably isn't very good for either 
coaching or math. But that is the way that works. People don't 
know.
    So if you are talking about not letting it happen in the 
first place, that means you have got to tell the person to keep 
their head up. Well, try telling that to an NFL player who has 
just been chop-blocked by somebody, and he has a chance to get 
back at them. You know, human behavior is very hard. Human 
behavior under stress is very hard to control.
    And so, I don't know what the chances are or if we have 
enough time, or maybe if the shock of what people are learning 
or if we do more of this that coaches and parents--and parents 
are often a lot less helpful than they think they can be in 
this. Have a lot less influence on their kids because kids just 
want to go ahead and do it. ``I am 17. Don't tell me I can't do 
this again.'' So, I mean, you do it after you know you have it, 
and try to prevent it from happening?
    Mr. Threet. I would say yes. I mean, obviously, I believe 
awareness would be the biggest issue. If you could just 
increase the knowledge base for the general public and for the 
athletes, I feel like recovery would--that athletes would do a 
lot better with recovery. They would take time to allow their 
brains to recover.
    I don't think brain injury is viewed as a serious issue 
throughout athletes. It wasn't for me until I had a concussion 
that changed what I was able to do in school on a daily basis.
    The Chairman. In your locker room--I am way over time. I 
apologize. In your locker rooms, both of you, is there any 
discussion about all of this among the athletes themselves?
    Ms. Ball. Concussions are talked about kind of lightly 
still, at least when I went through playing. It is a lot of 
people, even if you have got your concussion one day and then 
you are resting, players are like, ``Well, I don't see them 
hurt. Why are they sitting out?''
    And I think that mentality needs to change is you see that 
your fellow athlete got a concussion. You need to give them the 
respect to let them rest, and that just comes from the culture 
that we have right now about the ignorance about concussions.
    The Chairman. I will bet our doctors, do our doctors get 
any good training on this in their medical?
    Dr. Kutcher. I would have to say not as good as I would 
like.
    The Chairman. It is like geriatrics, right? They study it.
    Dr. Kutcher. Essentially.
    The Chairman. They go into it for a while, find they can 
make more money elsewhere, and they depart?
    Dr. Kutcher. Pretty much. I mean, that wraps it up. I would 
like to make a comment on your original question, if I could, 
about am I optimistic or not? And the answer is yes. I am 
optimistic.
    But your story about Alzheimer's and the lack of 
improvement and understanding for treatments is very applicable 
to this situation, but it is also not unique to brain pathology 
in general. Think about stroke, multiple sclerosis. We don't 
have cures for these things either, and decades and decades and 
billions of dollars. So the bottom line is the brain is 
complicated.
    I do want to make a quick comment that I think we are 
talking about more than one thing here, at least two or three 
as far as diagnoses go. CTE, on the one hand, a degenerative 
neurological process that most likely is coming from repetitive 
blows to the head, and concussion are two different things. And 
I don't think for a moment that these folks here are a risk--a 
high risk of developing CTE, the neurodegenerative disease 
itself.
    I think we are at a stage now where we are just starting to 
understand the scope of the problem. As Dr. McKee mentioned, we 
don't know the prevalence of this. We are finding the tau more 
and more often in brains of athletes who have had impacts, and 
military personnel as well. But how does the tau relate to the 
neurological disease? We don't know that.
    There are people that she has found tau in that had no 
neurological problem at all. So I don't want to over alarm 
these folks over here that because they have had concussions 
that they are going to have CTE later in life.
    The Chairman. I am way over my time. I apologize to my 
colleagues.
    Senator Boozman?
    Senator Boozman. I am glad you mentioned that because I was 
going to ask Dr. McKee. She mentioned the 17-year-old that had 
one reported concussion then passed away. Were there other 
reported concussions prior to that?
    Dr. McKee. No. I don't have--I don't have any other 
reported concussions.
    Senator Boozman. So we really don't know if he played 
through----
    Dr. McKee. Right.
    Senator Boozman.--concussion or just the repeated blows of 
being in whatever position he was in. It really is a real 
problem. I think you all testified so well, Ms. Ball and Mr. 
Threet, the problem is to play athletics at the level that you 
played at, you are in pain every day that you go out there.
    Sometimes they are not significant injuries, but there are 
broken fingers--a fingernail that was pulled off, or something. 
I mean, these nagging things that can be very, very painful and 
athletes are taught you have got to play through that or you 
don't get to the level that you all were able to play through. 
So it is very difficult.
    To follow up, you really didn't feel like then that head 
injuries, the concussion aspect, really was talked about very 
much in your career?
    Mr. Threet. Yes, for me, it wasn't a serious topic until my 
last concussion I had playing quarterback. I had to be out on 
the field, whether it was shoulder separation, ankle sprain, 
whatever it was. You know, shoot it up. I am ready to go. And 
that is not the case with brain injury.
    You can't--like I said, you can't just take something to 
get rid of the pain and then deal with it later and let it 
recover at a later time.
    Senator Boozman. And sometimes not really being in horrible 
pain----
    Mr. Threet. Right.
    Senator Boozman.--compared to some of these other injuries 
that aren't that significant.
    Mr. Threet. Right. Exactly.
    Senator Boozman. Do you agree with that, Ms. Ball? You 
didn't get much education in that regard?
    Ms. Ball. I agree completely. I think now concussions are 
something that is being taught in youth sports, but when I was 
growing up, playing both high school and college, it was just a 
concussion. That is all it was.
    Senator Boozman. Dr. McKee, working with the VA, I have 
been on the VA Committee in the House and now in the Senate, 
and we really spend a lot of money trying to figure out the IED 
component of this, which is similar or the same. Do we have a 
test now that we can identify if somebody has gotten a pretty 
good blow? Is there an easy test to determine?
    Dr. McKee. No. We need lots of research to determine that. 
And that is something we don't have. We don't have a way of 
identifying definitively a concussion, other than a series of 
neuropsychometric tests, balance tests, all sorts of things. So 
we don't have an easy way of detecting it or monitoring it.
    And that is definitely a very important issue that the VA 
is addressing, as well as the Department of Defense. That is a 
crucial issue.
    Senator Boozman. You two are board certified and well 
trained, and I suppose that with your licensure, you have to 
achieve so many hours of continuing education to continue your 
certification. What I am wondering in the course of this, we 
hadn't really talked too much about the education aspect of 
people that are wanting, Mr. Threet, you are wanting to get 
into--you are coaching a little bit now, and perhaps maybe you 
are going to pursue that.
    Were you a PE major?
    Mr. Threet. No, sir. No, sir. I am coaching as my playing 
career ended.
    Senator Boozman. What I am concerned about, and maybe we 
can visit with somebody at some point, is when you are taking 
the course ``Coaching Football,'' or ``Coaching Basketball,'' 
if they are talking about this and the importance of education.
    Dr. Kutcher. I can speak to that. At the NCAA level, they 
have made essentially a policy that all athletes and coaches 
need to receive concussion education annually. You see 
conferences like the Big 10 and the Mid American Conference 
that I work with having that policy as well.
    When they started their careers, we didn't do that. At the 
University of Michigan now, every year, all of our athletes get 
a lecture from me or one of my delegates on concussion. So do 
the coaches. So things are improving.
    There is a long way to go, especially as we go down the 
levels to high school and junior high school and the Pop Warner 
leagues. We have a lot more work to do, but there is sort of a 
push in that direction to make people need to get education 
before they participate either as a player or a coach.
    Senator Boozman. No, I think that is excellent. And I do 
think that those are the little things that really are going to 
make a difference.
    And then, again, encouraging our teaching institutions to 
include that in the curriculum. And then, also in the State 
sanctions, as they do their continuing education, to make this 
something that is talked about every year would be very, very 
helpful.
    The other thing I would like to touch on very briefly, and 
you all can comment, Dr. Kutcher, Dr. McKee--and Mr. Oliver, I 
know that you are probably going to talk much more about this. 
But the idea about being able to certify a helmet as something 
that won't prevent concussions.
    The Chairman mentioned about a 50-pound helmet. 
Theoretically, as you reinforce the helmet and make it heavier, 
if you could do that, then it is more of a weapon. So you 
actually create another problem in doing that.
    But can you just comment briefly about that.
    Mr. Oliver. Certainly. Senator Boozman, I appreciate that 
comment because I think it is very apropos of the difficulties 
that we face in trying to come up with a standard to address a 
specific issue like concussions.
    To a certain extent, the mass of a helmet is protective. 
The more the mass, the more energy it takes to move the helmet 
and move the head. In theory, the ideal helmet weighs, has an 
infinite mass at the point it is struck and then goes back to 
zero mass afterwards, which is clearly impossible to do.
    But there are limits to what you can do with a helmet as 
far as mass. You get to a certain point, that extra weight 
becomes a risk in other areas, and you increase the risk of 
neck injuries. You increase the risk of other injuries by doing 
that. So there is a tradeoff in that regard.
    I do think there is progress that can be made once science 
gets to the point where they can identify those specific forces 
or combinations of forces and the resultant forces that are 
likely responsible for some of these concussive issues. The 
thing that is probably most restrictive is the fact that right 
now you can't study a living human brain at that level, at the 
molecular level or at the axonal level, while it is being 
subjected to blows to the outside to see how they respond.
    There are ways to collect data in the field to show how 
much the forces are and how much the head is seeing, and we 
just started a very large research project with Dartmouth 
University, Dartmouth School of Engineering, and Wayne State 
University to look at the use of diffusion tensor imaging, 
MRIs, which can look at actually the nerve fibers following an 
injury, to follow a football player from a concussive event.
    We know the forces. We can do the DTI imaging and then take 
that information and put it into a finite, what is called a 
finite element analysis program that Wayne State is creating 
that would then, hopefully, let us model what happens to the 
brain when it is struck in certain circumstances and with that 
model be able to start coming up with concepts about how to 
address those forces, how to attenuate certain kinds of forces 
better than they are being done right now.
    With the goal, and I am very hopeful that we will get there 
at some point, to be able to come up with a standard that we 
can confidently say if a helmet meets this standard, which 
would include these issues, then you can have a comfort level 
that it will provide against, provide protection against 
concussions.
    Now, not all concussions and it certainly would never be 
said to prevent a particular amount, but it would be designed 
to meet those specific issues that we know cause concussions. 
But having the science behind that is absolutely preliminary, 
and you can't move forward without it.
    Senator Boozman. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator Udall?
    Senator Udall. Thank you, Mr. Chairman.
    Dr. Kutcher, your testimony states, and I think you said 
this also orally here, there is no data in the published 
medical literature that shows any particular helmet being 
better than any other at preventing sports concussions.
    Last year, however, the CEO of Riddell testified before a 
different Congressional committee that Riddell has 
``independent, peer-reviewed, published research in the medical 
journal Neurosurgery, February 2006, showing that 
Revolution''--that is the name of their helmet--``reduces the 
risk of concussions by 31 percent when compared to traditional 
helmets.''
    One of the authors of the 2006 study told the New York 
Times earlier this year that he disagreed with Riddell's 
marketing the 31 percent figure without acknowledging its 
limitations. Yet Riddell has extensively used this concussion 
safety claim in its marketing, and here is just one example 
with this poster that is behind me.
    [An image of the poster follows:]

    
    

    This is an example taken today from the website of 
Riddell's parent company, and I think you can read that.
    The Chairman. I can't read it.
    Senator Udall. Do you think this single 2006 study provides 
a reasonable basis for Riddell to claim that the research shows 
that Revolution helmets reduce the risk of concussion by 31 
percent compared to the traditional helmets?
    Dr. Kutcher. No, I do not. I am aware of this study, and 
what I said was that there is no significant data to make that 
claim in the literature. I know there is data. That study is in 
the literature.
    There are mainly two problems with that study. First is the 
quality of the study itself, how it was set up in trying to 
look at two different populations, one wearing a certain 
helmet, one wearing another kind of helmet. You want those 
populations to be as equal as possible, other than which helmet 
they are wearing. And that was not very well done in that 
study, to the point where I would not really consider the study 
design to be acceptable scientific protocol.
    The second main critique is that the 31 percent figure is a 
relative percent change. So the two populations, the one that 
had the old helmet had a 7.6 percent concussion rate over the 
study period. The new helmet had a 5.3 percent rate. The change 
was 2.6 percent. The absolute percent change. That is a 
relative percent change.
    But when you put the 31 percent figure in front of people 
like that, they are going to think that there are 31 percent 
less concussions. Well, actually, it is 2.6 percent and that 
amount, given the study limitations, would more than account 
for sort of that noise in the data.
    Senator Udall. And you can see why a parent who would be 
concerned about concussions with all the awareness, increasing 
awareness that is out there would see something like this and 
see 31 percent and think, ``I am going to get a really 
protective helmet for my child.'' And really, what we are 
talking about is something that is very, very misleading.
    Dr. Kutcher. Well, I can see that, and I do see that every 
week in my clinic. I see patients coming in with their parents 
saying they want to buy the new helmet. This is the concussion 
helmet. What do you think about it? That is a very real 
conversation I have all the time.
    Senator Udall. And they are asking you that question over 
and over again?
    Dr. Kutcher. Correct.
    Senator Udall. And typically, what do you tell them? And 
then, do you know what they do afterwards?
    Dr. Kutcher. So my advice is the most important thing is to 
have a new helmet if you can get one. In other words, try to 
avoid the reconditioning situation where you don't know whether 
the helmet is still up to standards provided by NOCSAE.
    But fit is really important. Make sure the helmet is fit 
correctly. And then, after that, I say look at the different 
manufacturers, and if money is not an option, buy the highest 
one on the line because what is lost in this conversation is 
you can't have a concussion without force, right? But force is 
not the only thing going on here, right?
    So if I took 100 athletes or 100 people and gave them the 
same blow to the head I am going to get 100 different 
responses. So to say that concussion is the issue is ignoring 
the fact that it is forces acting on a brain that is very 
individualized and very dynamic.
    So, at the end of the day, if I am going to pick between a 
helmet that gets the least amount of force through versus one 
that gets a little more force through, I am going to pick the 
one that gets the least amount of force through. I think that 
is a fair thing to say. But to say that it is going to prevent 
concussion is not understanding the whole complexity of the 
issue.
    Senator Udall. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator Klobuchar.

               STATEMENT OF HON. AMY KLOBUCHAR, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Klobuchar. Thank you very much, Mr. Chairman.
    And again, I heard about this really for the first time. 
You had heard stories in my State, but at the Alzheimer's 
dinner, this big dinner they have in Minnesota. And an athlete 
actually came and spoke about the research, and I just walked 
away from that sort of blown away at some of the facts and 
things that are out there and the need for more education.
    And I then held an Alzheimer's forum this summer, and one 
of the things that I learned was that just this early diagnosis 
of Alzheimer's and the same thing what I learned was that a lot 
of the players are donating their brains, I understand, that 
get dementia to research. But how the early diagnosis of 
Alzheimer's and also of this any advancement of problems due to 
a concussion could really help us not just help the patient, 
but potentially develop a cure.
    Because the Mayo Clinic is the one that diagnosed Pat 
Summit, the most winningness high school basketball coach in 
history--college. Thank you, Mr. Pryor. And the Mayo Clinic was 
able to do that because they have these advanced ways to now 
recognize early diagnosis.
    And I finally realized that that is part of finding a cure 
because you can't practice different kinds of solutions and 
medications and things without knowing early on. If you wait 
too long, when someone is too advanced, you can't actually tell 
whether things are working or not. And do you want to comment 
on that, Dr. McKee?
    Dr. McKee. Well, absolutely. You have to have some sort of 
test that can monitor the course of the disease in order to be 
able to tell in a living patient if it is being effective. So 
the first thing we have to do is develop diagnostic markers, 
biomarkers of both concussion and these other phenomenon.
    So, concussion, post-concussive syndrome, and CTE, they are 
all quite different. But we definitely need the diagnostic 
marker so that we can monitor living patients. And in that way, 
once we develop therapies in the lab in experimental models and 
we get to the point where we are testing them in living people, 
we can actually see if they are working. Without that, we can't 
tell if they are working or not.
    Senator Klobuchar. And Dr. Kutcher, the Academy of 
Neurology headquarters based in Minnesota, we are proud of the 
work of the Neurology Association in our state, and could you 
talk about the work that is being done to develop meaningful, 
evidence-based clinical practice guidelines? I know that is 
happening.
    Dr. Kutcher. Sure.
    Senator Klobuchar. So that we are able to get guidelines 
for athletes, and if there is any scientific data available on 
that?
    Dr. Kutcher. Well, right now, if you look in the 
literature, you will see maybe a dozen or more consensus 
statements. Groups get together and come up with what the 
experts think should be the best way to approach concussion 
diagnosis and management. But to date, there has not been an 
effort that has looked at the totality of the literature in a 
critical way, looking at the quality of the data, sorting 
through the papers, and coming up with what do we have that is 
evidence based in this issue. So that is what our effort is.
    We started this 2\1/2\ years ago. It is a committee of 12 
people--5 neurologists, 7 non-neurologists. The other seven 
folks are from other medical specialties--sports medicine, 
physiatry, neurosurgery, neuropsychology. And the goal here was 
to really create a sense of where we are and where we need to 
go.
    Now there are some of our management practices that have 
some evidence, but I will tell you that most of them don't. And 
so, the goal here, and we are hoping to be published in the 
spring of 2012, is to really set forth what are the steps we 
need to take to get the data to have a good sense that we are 
doing something that is evidence based.
    Senator Klobuchar. Very good. Ms. Ball, Mr. Threet, thank 
you so much for being here today.
    I know that organizations like the Brain Injury 
Association, NFL, Athletic Trainers Association, Centers for 
Disease Control are working to increase awareness, educate the 
public. As students who had this happen, what do you think the 
best ways are to get the information out there to your fellow 
students and players?
    Mr. Threet. Well, I believe there is a lot of progress 
being made already through information, educational seminars 
that we have at the schools. I know in Arizona, I was part of 
Bill 1521 that implemented protocol for high school athletes 
that they have to attend a class, their parents have to attend 
a class, their coaches have to.
    I think just a requirement to understand what the brain is 
doing when it is injured and how serious that it is.
    Senator Klobuchar. And we did that in our state this year, 
too.
    Mr. Threet. Exactly, yes.
    Senator Klobuchar. And I would hope that is happening.
    Mr. Threet. And it is spreading, and I think it will only 
increase, to gain significance.
    Senator Klobuchar. Ms. Ball?
    Ms. Ball. I agree with preventive measures needs to start, 
we are doing high school. But if we can even start younger, 
youth sports that are like I know within soccer, there is club 
soccer, which is very prevalent among youth. And within New 
Mexico, different clubs are taking initiatives to teach the 
coaches about concussions, and I think that needs to be spread 
out to the teams and to the parents as well.
    Because once people are aware of what a concussion is and 
how serious it can be, I think that is when we finally take 
that next step forward.
    Senator Klobuchar. One last question. After you had your 
concussions and you decided not to keep playing, did you feel 
any pressure to keep playing from your peers, from other 
parents, from----
    Mr. Threet. I personally didn't. All my doctors, coaches, 
family, fellow players were very supportive of my decision to 
stop playing.
    Ms. Ball. Yes. I think people respect your decision to 
stop. Obviously, they want you to keep playing because they 
miss you playing with them. But overall, people have been very 
supportive.
    Senator Klobuchar. Very good. Thank you very much for being 
here.
    The Chairman. Thank you, Senator Klobuchar.
    Senator Pryor?

                 STATEMENT OF HON. MARK PRYOR, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Pryor. Thank you, Mr. Chairman.
    And thank you for having this hearing. It is a very 
important issue that touches this country all over the map and 
also in many different sports.
    Let me start with you, if I may, Mr. Oliver, I would just 
like a little context on the legal framework here in terms of 
are there state laws on helmets in sports? Do athletic 
conferences--like high school athletic conferences and 
associations--do they have rules about this and standards?
    And also, the NCAA and the NFL, when it comes to football, 
do they have standards? What is the legal framework here?
    Mr. Oliver. Well, the legal framework is actually fairly 
simple. The standards that we publish, for example, for 
football helmets, and that is the best example because it 
probably applies across the board to other sports. We publish 
the standards that are performance standards that indicate what 
helmets are supposed to do to meet the standard, and it is a 
multifactored standard.
    Then an organization, for example, like the NCAA will 
incorporate into their rules of play a requirement that helmets 
that are worn by those athletes meet our standard.
    Senator Pryor. In terms of the helmet itself?
    Mr. Oliver. In terms of the helmet itself. You cannot wear 
a helmet for play in the NCAA unless it has been certified as 
being--as meeting our standard.
    Senator Pryor. And then they may also change their rules in 
terms of, like, hitting the quarterback or----
    Mr. Oliver. Absolutely.
    Senator Pryor.--head-to-head contact, that type of thing?
    Mr. Oliver. Absolutely. The rules of play then control, if 
you will, how the helmets are used. But certainly, things like 
spearing or butting or ramming an opponent using your helmet as 
a weapon are also prohibited by the rules of play.
    The same process applies to high schools through the 
National High School Federation, although because it is a 
federation, it doesn't control directly each of the state 
associations. But they participate voluntarily.
    There are some states, for example, California, has a law 
that requires at the high school level that athletic equipment, 
including helmets, be cleaned or sanitized on an annual basis. 
That has been interpreted to mean that the helmets included in 
football play must be also reconditioned. And if they are 
reconditioned, then they are going to get recertified, which 
means you are going to be subject to recertification testing 
and evaluation.
    Senator Pryor. Which means new pads, no cracks----
    Mr. Oliver. Exactly. And it means they have to be subject 
to a fairly rigorous sample testing program. They are tested 
before they are reconditioned and tested again after they are 
reconditioned.
    But that is the only state to my knowledge that actually 
imposes that requirement by law.
    Senator Pryor. But on the high school level generally, is 
it voluntary?
    Mr. Oliver. For the reconditioning?
    Senator Pryor. Yes.
    Mr. Oliver. It is voluntary. There is no requirement that 
helmets be reconditioned or recertified on any frequent basis 
at the high school level.
    Senator Pryor. And how long--in your organization's view, 
how long--again, let us stay with the football helmet--how long 
is it good for? Is it good for one season before it needs to be 
reconditioned or----
    Mr. Oliver. That is really going to depend upon how hard 
the helmet is used and what kinds of use and abuse it has been 
subjected to. We strongly recommend any time I am contacted 
that helmets be subject to reconditioning and recertification 
every year, simply because there is no way to tell in advance 
whether a particular helmet needs it or doesn't.
    And we know from the reconditioning data because we get 
this data back from them every year that about 90 percent of 
the helmets that they recondition and recertify have been in 
the previous year. So a large percentage of them are done on an 
annual basis.
    What is not happening, which is something we are trying to 
address, both through the CPSE as well as individual work, is 
those football organizations at the youth level that aren't 
subject to state control or NCAA control, where very little is 
known about the nature of the population of those helmets. If 
they don't voluntarily submit those helmets to a 
recertification program or replace them on their own, there 
really is no umbrella organization that is in charge of most of 
those players in those clubs. And that is an area that does 
need to be addressed.
    Senator Pryor. One last thing, Mr. Oliver, what is the 
general life expectancy of a football helmet?
    Mr. Oliver. You know, it depends on the manufacturer. 
Riddell has for years put what is basically a 10-year life on 
their helmet. They have said that after 10 years, no warrantees 
apply. They don't allow helmets that are older than 10 years to 
be reconditioned or recertified, and that has been their policy 
for a long time.
    Schutt, one of the other major manufacturers, has said as 
long as the helmet is properly cared for and it has been 
properly reconditioned, which means parts replaced, padding 
replaced, shells inspected, at the end of 10 years, the only 
part of that helmet that is 10 years old is probably going to 
be the shell.
    And you can't replace the shell in the reconditioning 
process. If it is cracked or damaged, the helmet is done. So it 
really just depends on the helmet and the company as far as how 
long it is going to last and how well it is cared for.
    Senator Pryor. Dr. Kutcher, if I may ask one more question? 
Dr. Kutcher, what is the--and you maybe covered this earlier, 
and I am sorry I was late coming to the hearing--but what is 
the sort of age scale we are looking at for concussions in 
sports? I mean, I assume you have some at very early ages, but 
is there--do they get more common and more severe as you get 
older, as the players get bigger, stronger, faster? Is that how 
that works, or tell me what the statistics say.
    Dr. Kutcher. So the range goes down to the youngest athlete 
you could imagine, whenever they start playing organized 
sports. So 7, 8, 9 years old, I see kids with concussions that 
young.
    As they mature and get faster and stronger, you will see 
larger impacts and more injuries. I think as they go up, junior 
high, high school, you are going to see greater numbers of 
concussions. And actually, there is some data that shows that 
basically every level you go up from organized youth to high 
school, to college, to pros, the incidence will go up. And you 
can imagine why. Because the play is a little faster. Athletes 
are a little stronger.
    The other idea, though, is that the younger kids may have 
longer injuries. They may have more complex injuries, maybe 
more difficult to get them back as quick. So that sort of adds 
a different wrinkle to it.
    Senator Pryor. Mr. Chairman, if I can ask just one more 
question? Again, maybe you covered this earlier. But when I 
think of concussions and sports, I think of football, but I may 
be totally wrong on that. Is that the most common, and sort of 
what is the list of the most risky sports for concussion?
    Dr. Kutcher. I would say football is at the top of the 
list.
    Senator Pryor. It is way ahead of everybody else or----
    Dr. Kutcher. So, first, it is tough to get good data that 
compares sport to sport because you have to study it in the 
same population. There are some pretty good studies that have 
looked at in the high school population. For example, in 
Fairfax County, Virginia, researchers did some great work there 
looking at the different sports.
    And football had about a double the incidence of the next 
highest sport, which I believe was lacrosse. But women's soccer 
was right there. And then, after that, it was men's soccer, 
wrestling, basketball, softball, going down the list. Ice 
hockey wasn't in that study, but I would put ice hockey 
probably a little bit lower than football, maybe 20 percent 
lower than that in general.
    Senator Pryor. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    We can start another round. Incidentally, every time the 
bell rings, what you have to understand is that is telling you 
precisely that there is nothing happening on the floor of the--
--
    [Laughter.]
    The Chairman. It is only when it keeps ringing that we have 
to go vote.
    Ms. Ball, we are talking about soccer. And Mr. Threet, just 
like Tony Romo, you were slammed down to the ground. I mean, 
that is part of the deal, right? It is not just that you hit a 
helmet, but you slam the guy down. So his head has to hit the 
ground, which is often hard.
    There are so many ways in football to see how a revenge 
hit, just a mean player who is famous for that and loves it and 
gets endorsements because of it, commercial endorsements. 
Soccer is extremely brutal, exhausting, on a huge field where 
there is usually, what, one, two, three, or four goals scored, 
and that is it.
    So in thinking about it myself, and I have watched a lot of 
it basically because of that 1980 triumph, it is heading the 
ball. Or because I don't think that you probably are slammed 
down to the ground or tripped up, a lot of tripping up, 
deliberate tripping up. Does that mean the head hits? I don't 
know.
    But what are some of the ways, if it was ranked number 
three by Dr. Kutcher, what are some of the ways that 
concussions come about in soccer other than heading the ball? 
And if it is heading the ball, is it heading the ball from any 
part of your head?
    Ms. Ball. Concussions come about in a lot of different ways 
while playing soccer. Heading the ball tends to be relatively 
safe if you use your forehead. The concussions come when you 
take the ball off the top of your head, most likely from a punt 
because of the ball is moving at much greater speeds, or when a 
ball gets shot and you happen to be in the way, you will take 
it on the side of your head. That is how concussions can also 
occur.
    For me, the most common way of sustaining a concussion was 
actually I hit my head to the ground. It was the type of player 
I was. I would get my legs knocked out from underneath me, and 
I would hit my head on the ground. And when you watch soccer, 
you are watching where the ball is at.
    So that play might happen, and you just don't even see that 
that player goes down and hits their head. And so, that is why 
I think oftentimes those thoughts are bypassed is because you 
are not aware because you are following the ball, where that is 
going.
    And then another risky area is where you are going in 
confrontations against the goalie. The goalie is either going 
to get--I have seen goalies get their heads kicked, and I have 
also seen players going up against the goalie getting kneed in 
the head.
    And so, there are a lot of different circumstances that you 
can get a concussion.
    The Chairman. Like in hockey?
    Ms. Ball. Right.
    The Chairman. Yes. There is so much work to be done by so 
many. I think of--I am a sports fan. You know, you watch 
college and professional football, and there is almost an 
instinct to look, Mr. Threet, for the player who plays dirty. 
And then, if he does, you turn your wrath on Roger Goodell and 
the NFL for not having him ejected from the game. Referees have 
that responsibility. They can fine him or push him back 15 
yards. They should be ejected from the game.
    How do you influence--I mean, young men who play football 
are in it to win. They don't have long careers.
    Mr. Threet. Right.
    The Chairman. If you are a running back or if you are a 
quarterback, what is your career?
    Mr. Threet. Running back has the shortest, yes.
    The Chairman. Yes. So that adds sort of a desperation to 
succeed. How do you get at that stuff? I mean, somebody comes 
in and gives you a lecture, all the athletes are gathered in a 
big locker room, somebody gives them a lecture on concussions. 
I will bet half the people aren't listening because they 
haven't had them.
    Mr. Threet. Yes, and I think it is very difficult, 
especially in football, from the defensive side of the game, 
violence is probably the biggest, the biggest characteristic 
you need to be successful on defense. You have to be able to be 
violent, and that is----
    The Chairman. And known to be violent?
    Mr. Threet. Right. Yes, and that is part of--yes, exactly.
    The Chairman. You have to show your violence, right? You 
have to prove it?
    Mr. Threet. Right. Right. And that is part of the football 
game. And so, as far as that sport is considered, I feel like 
it is more of the understanding about brain injury and 
understanding of the recovery process, as opposed to, yes, you 
know, they are changing the game, getting rid of head-to-head 
contact and that aspect. But I think more of it is the recovery 
when it happens because there is always going to be big hits in 
football.
    The Chairman. And a lot of those big hits----
    Mr. Threet. And a lot of them are legal, too. But it is not 
just like the doctors have said. Exactly.
    The Chairman. Yes, a lot of them--if another, a third 
person involved clobbers the second or the first.
    Mr. Threet. Exactly. And it is blows to the body just as 
well as it is blows to the head, as Dr. Kutcher noted also. So 
I think it is----
    The Chairman. Oh, I mean, if you get clobbered in the chest 
or something, that can concuss you?
    Dr. Kutcher. Absolutely.
    The Chairman. I am sorry. I missed that.
    Dr. Kutcher. Yes. Anytime your head moves fast enough and 
the brain inside is moving fast enough. So you get a whiplash 
type of thing.
    The Chairman. What will do that?
    Dr. Kutcher. What is that?
    The Chairman. What kind of hit will do that?
    Dr. Kutcher. Hit to the body, hit from the side, anything 
that transmits enough force to stop your movement.
    The Chairman. So that means that quarterback and tight ends 
ought to be very, very large?
    Dr. Kutcher. Right. Steve gets sacked, gets hit in the 
chest and the body hard enough, his head whips back. He doesn't 
have to hit anything else, and that could do it.
    Mr. Oliver. Chairman Rockefeller, a perfect example of 
that, last year we all heard about DeSean Jackson's concussion 
playing in the game between the Atlanta Falcons and the 
Philadelphia Eagles, and I don't recall whether there was a 
fine or a penalty for that hit. But if you watch that hit in 
slow motion, and it is available I think even on the Internet, 
you will see that there was no head-to-head contact between the 
tackling player and DeSean Jackson.
    He was hit here in the shoulder. But it snapped his head 
violently forward and then violently backward as he is going 
down, and that is, I think, exactly the kind of mechanics that 
you are talking about. You have these concussions where you 
don't have a blow to the head, but the head itself is moving 
through so many different planes of motion so rapidly that the 
brain sort of doesn't have time to catch up to itself and sort 
of gets folded over and compressed.
    The Chairman. I am over my time once again. I thank 
everyone.
    I am going to have to leave. I have to go to a 
cybersecurity hearing. That is a different kind of threat, and 
Senator Udall is going to take over the hearing.
    But the Ranking Member? Oh, Senator Thune? He could have 
been a tight end.
    [Laughter.]
    The Chairman. Please?

                 STATEMENT OF HON. JOHN THUNE, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Thune. I am up?
    The Chairman. You are up.
    Senator Thune. Oh, OK. Thank you.
    Well, I appreciate that very much. Thanks for holding the 
hearing, and I thank our panelists for sharing your thoughts 
with us. And I kind of want to follow up on some of the line of 
questioning that was started earlier, but this is--you know, 
you are seeing participation at an all-time high in terms of 
kids, young people across the country participating in sports 
and an incredible number of sports-related injuries among 
youth.
    And sometimes they are head injuries, a lot of other 
injuries as well. And I think when most people think of 
concussions, as was mentioned, we think about football. I think 
there are lots of other sports where we are seeing that.
    We have got a lot of younger people participating in 
football, for example, and I know my--I have got an 11-year-old 
nephew who got a concussion. He is out for a month. And it was 
a hit where he went back and hit his head on the ground.
    But it just seems like we have got, with young people out 
there, more and more injury occurring at an earlier and earlier 
age. And my question relates to whether that is something that 
we should be concerned about? I mean, are we starting kids too 
early in sports like football, where they are experiencing 
concussions at higher rates than they have in the past?
    I mean, what is your perspective on the rise in the number 
of concussions? And I guess--are some of these kids developed 
enough, capable enough of taking the kind of shots that they 
are taking and the kind of hits that they are taking at that 
age and the types of injuries that they are sustaining at an 
earlier and earlier age?
    Dr. Kutcher. I will start. I think concussions--the issue 
with concussions being up, we are seeing more of them. I think 
it really has three main causes. The biggest one is awareness. 
I think that would explain the vast majority of the increased 
numbers that we see over the past really 5 to 6 years.
    The second one would be kids being faster and stronger at 
earlier ages and playing perhaps more violently, but also our 
games have changed, too. If you look at how football has 
evolved, for example. I had one of our ex-coaches, old-time 
coach, lecture me on how people have been blocking over the 
years and tackling over the years, and now we see a lot more 
hitting and a lot less tackling.
    When actually if you think about the point in football on 
the defensive side is to stop the ball, you do a much better 
job if you have got somebody up, bring him to the ground, 
rather than trying to launch yourself and cause this big, 
violent hit. And so, for those three reasons, I think the 
numbers are up.
    As far as concussions in the younger ages, I think there is 
always a sense for me that we have to keep track of the dose of 
hits that the kids are taking. I think the younger ages, yes, 
you want to be more careful. And do we want to postpone when 
you can hit in hockey, postpone when people can start wearing 
pads and playing tackle football?
    I think that is a very good idea, but it is more 
complicated than that because at some point, kids have to learn 
how to hit and how to be hit and how to avoid the big forces, 
and that can only come with practice. So it is a pretty 
complicated question there.
    Senator Thune. Well, I think that, you know, I look at the 
advances in equipment--just my dad played football back in the 
late 1930s. He was a senior in high school in 1937. I remember 
at that time, they had leather helmets, and he was 130 pounds. 
He played middle linebacker, and he was hitting a lot of guys 
coming across. And I know he got knocked out, got knocked cold 
in one game. And I think at that time, they treated everything 
with whiskey.
    But when I played in the 1970s, the helmets had gotten a 
lot better, and I look at the athletes today, and the equipment 
has improved a lot. I mean, the amount of padding in there, 
protective gear that athletes are able to wear. And so, we have 
made great advancements.
    But as you have said, these athletes are bigger, stronger, 
faster, and the contact, the hits that I watch just every 
Sunday watching the NFL, there are some real contact being made 
there. And so, you wonder if the type of equipment that we have 
is adequate to that.
    And that, specifically, might be more to football, but I am 
interested in knowing, too, in some of these other sports like 
soccer or rugby, water polo, that haven't traditionally 
required a great deal of safety gear, is there additional 
equipment available that could lessen injuries and concussions 
in those types of sports? Anybody on the panel who would care 
to answer that?
    Mr. Oliver. Well, I mean, I can address that in general. 
Whatever you can do to reduce the severity of concussions or 
the frequency or perhaps even eliminate some concussions in one 
sport would be the same in the other. I mean, you are talking 
about the same brain responses, the same input forces, the same 
accelerations.
    And if you can determine how that can be done from a 
biomechanical standpoint and a biophysical standpoint in 
football, you can probably figure out how to do that in other 
sports. So I think the key is first finding those answers that 
would let you to address it in a particular sport, and then you 
can extend those by reference to other sports, if you can get 
to that point.
    Senator Thune. Anybody else want to add to that, soccer 
player, no?
    OK. I see my time has expired, Mr. Chairman. So thank you.
    Senator Udall [presiding]. Thank you, Senator Thune.
    And Senator Boozman, you want to----
    Senator Boozman. Just very quickly.
    Senator Udall. Yes, you have some things that----
    Senator Boozman. It seems that 99.9 percent of the injuries 
that are suffered are not due to current equipment failure. You 
guys, when you were hurt, your pads were there. Something 
didn't break and sustain. Now I don't know about through the 
little leagues, but in the stuff that is being tested, most of 
that is working pretty well.
    I don't worry so much about the big hits that we see where 
somebody is actually having to be helped off the field because 
we all know something is wrong. I worry more about the injury 
where you tackle somebody, and as you tackle them, he knees you 
in the face and smacks you pretty good. And you are able to get 
up.
    We are conditioned or you guys were conditioned, we were 
all conditioned to play through injury, and you go ahead and 
stay out there. The way I would like to close, as we have a lot 
of moms and dads and coaches and players watching this is with 
any messages that you can send out to the parents, how they can 
be better prepared to deal with this if it does come up? And 
chances are, it probably will.
    Mr. Threet. Yes. Well, I mean, I think from the athletes' 
standpoint, just increasing their ability to be honest with 
coaches and parents and athletic trainers and understanding for 
themselves when something doesn't feel right. Light-headedness, 
dizziness, any of the symptoms. If the symptoms are known and 
they start feeling those, then it needs to be required that 
they make that known because it can happen on any hit.
    I have had ones that happened on not severe hits, and the 
Riddell helmet is 30 percent less.
    Ms. Ball. I think it is important not only to address your 
symptoms when you have them, but even once you finish having 
the symptoms is give yourself the little bit of extra time 
because that can prevent you from maybe not having to end your 
career is if you give yourself those few extra days of leeway, 
then you can prevent the long-term injury.
    Dr. Kutcher. I will add to that. I think the recognition of 
the injury issue is huge, and athletes hide their injuries. I 
know that. I see that every day. But acutely concussed people 
also don't know they are concussed often. They are not aware of 
it.
    And what that means is that falls on the responsibility of 
everybody else around--their teammates, the coaches, parents, 
whoever--to look after them. And when a kid says, ``Oh, I am 
fine. I am straight. I can go,'' you have to question that a 
little bit. So recognizing the injury, and I am actually 
starting to see teammates coming to me and saying, ``Hey, I 
think he is not right. Go check him out.''
    And as Steve said, once it has been recognized, you have to 
report that to the medical staff, to whoever, and have that 
patient or that athlete removed from participation and then 
allow them to recover fully before they get back to play. So, 
actually, it is four Rs. It is recognition, reporting, 
removing, and recovering.
    Senator Boozman. Very good. Dr. McKee?
    Dr. McKee. I guess what I would say is that I don't see 
this--I think I would say that I don't see this problem going 
away with equipment. I think equipment is going to improve this 
issue, but it is not going to solve this issue.
    And we really have to address the way sports are played, 
the nature, the style of play, the amount of hitting that we 
allow, the amount of contact we allow in the play of the sport. 
And that is what is going to make a tremendous difference, I 
think, down the road. But I don't see, even a perfect helmet, 
there is always going to be those acceleration, deceleration 
sort of whiplash forces that we can't control.
    Senator Boozman. Mr. Oliver?
    Mr. Oliver. I think I would simply echo the panel's 
comments. There are a number of interventions that need to be 
enforced and encouraged. And depending on the circumstances, 
one may be more important than another. But overall, you can't 
avoid any of them. And to the extent that you shouldn't just 
rely on better diagnosis and return to play criteria, you also 
can't rely on just having good equipment. You have to do all of 
those things.
    You have to change the attitudes of the players and the 
parents about reporting those symptoms. Take that stigma away 
from this need to be macho or strong or invincible.
    One of the things that I have seen, and it has been 
effective, is changing behavior based upon some of the data 
that has been collected at the collegiate level through the 
helmet instrumentation. They have noticed the ability to 
identify players who have more hits on the top or the crown of 
their helmet than other players, which shouldn't be happening 
because there is an association with an increased likelihood of 
concussion there.
    We see schools, I know University of North Carolina 
specifically, with Dr. Guskiewicz, identifying those players 
and going in and engaging in behavioral modification so that 
they are taking that act out of the game.
    If you start that at the very beginning with youth players 
and teach those coaches and teach those players that you don't 
hit with the top of your head, you don't hit with your head at 
all. The helmet is there to protect you in case you get hit, 
and you can't avoid it. You change all those things, I think 
you make significant reductions in the number of concussions 
and the severity.
    And you certainly can reduce the chance of having these 
catastrophic consequences of returning to play too soon or 
having multiple concussions that aren't properly treated that 
let you heal. So all of them are important, and I don't think 
you can ignore one or treat one as more important than the 
other.
    Senator Boozman. Thank you, Mr. Chairman.
    Senator Udall. Thank you, Senator Boozman.
    I wanted to return just a little bit to some of the 
misleading claims on equipment. I know there has been a lot of 
discussion about equipment, and Dr. McKee, talk a little bit 
about anti-concussion mouth guards. Have you seen ads such as 
this one for a mouth guard that is sold for use by kids 11 
years and under?
    And you can see the poster here in the background. This 
mouth guard was purchased last month. The product packaging 
states this mouth guard reduces the risk of concussions, and it 
creates brain safety space. Given your firsthand knowledge of 
the dangers of repetitive brain trauma, are you troubled by 
this type of marketing for youth sports equipment? Do you think 
young athletes who have already had a concussion might be 
particularly susceptible to advertising claims for so-called 
anti-concussion devices?
    [An image of the poster follows:]
    
    
    Dr. McKee. Well, I believe there is no clear evidence that 
any mouth guard or chin guard reduces either the rate or the 
severity of concussions. So I would have great objection to 
this claim.
    The only thing that I am aware that mouth guards and chin 
guards do is they reduce oral and facial, dental, dental 
injuries. But the nature of concussion would not be improved by 
the use of a mouth guard.
    Senator Udall. I know you weren't able to see the one I was 
holding up, and I think it has been produced down there just in 
case you see anything else on it you wanted to comment on.
    Dr. Kutcher. I agree on that.
    Senator Udall. Yes, please?
    Dr. Kutcher. I don't know what ``brain safety space'' 
really means. That term--that is little alarming, really.
    Senator Udall. Well, there is a diagram on it.
    Dr. Kutcher. Yes, I see it.
    Senator Udall. You can see it. There is a diagram, and it 
shows a space, and it says ``creates brain''--I believe 
specifically it says, ``creates''--what is the term it uses? 
``Creates brain safety space.''
    Dr. Kutcher. Again, the idea from some of the work that has 
been done with accelerometers and helmets of football players 
and seeing at what forces they end up having clinically 
diagnosed concussions, those concussions are occurring over a 
wide range of forces.
    There are 15-g hits that do it. There are 115-g hits that 
don't, right? And so, if you are taking amount of force that is 
115 and you are reducing it to 110 or so--I don't want to get 
the numbers wrong--because of a mouth guard, you might be 
reducing the forces a little bit if the hit is coming from this 
way, but concussions are occurring on a spectrum of forces that 
that won't address.
    Senator Udall. I know Ms. Ball mentioned headbands in 
soccer, and I want to ask, Dr. Kutcher, you about this one. You 
discuss in your testimony the potential harm from creating a 
false sense of security when companies falsely claim that 
products prevent concussions.
    This is not just about helmets, and it is not just about 
football. Here is another example. This is a protective 
headband sold to soccer players and other athletes. Here is an 
image taken from this company's website that says, ``This can 
come between you and a head injury.''


    Does this type of advertising for a protective headband 
trouble you? Is there a danger that a young athlete might put 
himself or herself at greater risk of injury if they believe 
that this headband will come between them and a head injury?
    Dr. Kutcher. I do believe there is a problem there. This 
type of advertising is a little more vague because it just 
mentions head injury and not concussion. So you could make an 
argument that perhaps there is a mechanism there to prevent 
some superficial lacerations and bruising and that kind of a 
thing. But for concussion, I don't believe that--well, there is 
no data that supports that they decrease the risk of 
concussion.
    I have seen in my own practice, as I testified, athletes 
who have become more aggressive and have actually injured 
themselves and others because they have the headband on. They 
go up and they head the ball more. They get involved in head-
to-head hits more when they would not have done that without 
the equipment before.
    Mr. Oliver. Senator?
    Senator Udall. Yes, please, go ahead.
    Mr. Oliver. What I was going to say is there is another 
risk here. We have seen this both with helmets as well as 
devices like headbands that a player who has sustained a 
concussion now sees this or the parent sees this as the answer. 
My kid has had a concussion. He is just now getting over it. 
But if I put this on, everything is fine.
    And so, not only a false sense of security from being 
protected from the first concussion, but being protected 
because I just had one, and this will give me this extra layer. 
And it is incredibly dangerous.
    Senator Udall. Did either of you as athletes experience any 
of this that we are talking about here in terms of the headband 
being protective or--yes, Ms. Ball?
    Ms. Ball. I wore headgear that is not this brand, but 
similar after I got my second concussion as a preventive 
measure. And I will say that I did adjust my play, whether I 
had my headgear on or off.
    And I didn't really think about it critically, whether it 
would be actually doing anything for me. If I had my headgear 
on, I would head the ball more aggressively. I would play 
differently because I thought for some reason, I would like be 
secure from getting another concussion. And if I didn't have my 
headgear on, I played much differently.
    Senator Udall. Mr. Threet?
    Mr. Threet. For me, I used a variety of different football 
helmets. I would always get a new one after a concussion. I 
would alternate brands, styles. Yes, so I would try different 
things, but they all--I guess the risk is still there.
    Dr. Kutcher. And that is really common, by the way, to 
college football or football in general. You get a concussion, 
go on to the next brand because, obviously, that brand is not 
the right one for you.
    Right? That is----
    Mr. Threet. Yes. I mean, that is the equipment managers 
would say that, well, maybe just try a different style and be 
better next time.
    Senator Udall. Let me return to the Riddell helmet 
testimonial claim, the one on no repeated concussions. In a 
July 23, 2010, memorandum to head coaches, head athletic 
trainers, and club equipment managers, NFL Commissioner Roger 
Goodell wrote, and this is a quote, ``It is important to 
remember that no helmet can prevent concussions or reduce the 
risk of concussion to any specified degree.''
    Yet one NFL head athletic trainer has made several product 
endorsements for the Riddell Revolution football helmet. And a 
Riddell video news release, titled ``Riddell Revolution UPMC 
Media Campaign,'' highlights Tim Bream of the Chicago Bears, 
states that, ``We have had some players who have had ongoing 
problems with head injury, and we made the switch to the new 
protective headgear when it came out at its inception, and 
these players have had no problems since then or no repeated 
concussions.''
    Dr. Kutcher, do you expect a youth or high school football 
team to have no repeated concussions after switching from 
traditional helmet designs to Riddell Revolution helmets?
    Dr. Kutcher. No, I don't.
    Senator Udall. Pretty straightforward in your opinion.
    Dr. Kutcher. Yes.
    Senator Udall. Dr. McKee, I don't know if you have any 
thoughts?
    Dr. McKee. I think this is beyond my level of expertise. It 
is not my area.
    Senator Udall. And Mr. Oliver, I want to ask about the 
maximum life span of football helmets. I think you talked about 
that a little bit in relation to Senator Pryor questioning you. 
The National Athletic Equipment Reconditioners Association 
announced that starting next year, it will no longer 
recondition helmets that are 10 years or older.
    NAERA executive director stated that he would not want his 
son wearing a helmet that old. NOCSAE's technical director Dave 
Halstead told the New York Times that he, and this is his 
quote, ``would never let his kid wear a helmet that is more 
than 10 years old.''
    Well, Ralph Conradt's 17-year-old son Max was unknowingly 
wearing a 20-year-old football helmet when he suffered a brain 
injury. Ralph wrote to me. It was after some of this came out. 
``How is it possible that our son was issued a helmet 3 years 
older than he was?'' Why does the NOCSAE standard not set a 
maximum life span or number of years before a helmet should no 
longer be used?
    Mr. Oliver. There are a number of reasons why we don't, and 
the first reason is you have to tell me what the helmet is you 
are looking at. If it is a 10-year-old helmet that has never 
been used or has been used two seasons, should that helmet be 
replaced simply because it has reached a birth date of 10 
years?
    There is no data that suggests that that helmet, because it 
has reached an age of 10 years, is more or less protective than 
any other helmets that are of a similar age. The other thing 
has to do with whether or not you are using a 10-year life or a 
12-year life or an 8-year life because there has been a change 
in technology.
    If 10 years ago or 9 years there was a radical change in 
the technology of helmets such that older helmets don't provide 
the same measurable level of protection, then it would make 
sense to have that life span cutoff. We have always relied on 
the manufacturers to specify if there is a safe life on their 
helmets.
    And one of the reasons we do that is because we, by intent, 
maintain our standards as design neutral. Part of the design 
neutral process is to not impose upon a manufacturer an 
obligation to use a particular kind of material or a particular 
shape of the shell or a particular design to allow innovation 
and progress in those areas.
    If a helmet company makes a helmet and they say this helmet 
is good for 15 years as long as it is regularly reconditioned 
and recertified, then they must have data to support that, and 
it is their helmet, their design. What we do know, and we know 
this from reconditioning testing data, that helmets that are 
properly cared for--they are properly reconditioned. Their 
padding is replaced when it starts to wear. They are inspected 
for cracks, and they are properly cared for.
    When they are retested after being used in the field and 
after being reconditioned, those test numbers look very much 
like they did when that helmet was brand new. No way for us as 
an association or as an organization that sets the standards to 
say from our tests that a helmet that is now 8 years old or 10 
years old that scores essentially the same as it did when it 
was new should be replaced and force schools, for example, to 
replace maybe a third or half of their helmets, when maybe the 
helmets don't need to be replaced.
    And the other question that you have to ask yourself is, 
right now, there are Revolution helmets on the market that are 
approaching 8 years old. And I am not endorsing any particular 
helmet. But there has been a great cry, if you will, to move 
from older style helmets to newer style helmets.
    If there is a helmet on the market today or being used 
today that is 8 years old and it is a new technology helmet, 
and it has been properly cared for, padding replaced, and 
retested on an annual basis, what is it that happens at 10 
years that makes that helmet suddenly need to be thrown away if 
it was safe at 9 years or safe at 8 years? And we don't have 
the data to suggest that.
    I think the position, the decision that NAERA made with 
regard to 10-year helmets was a policy decision they made that 
they just weren't going to do that for helmets older than 10 
years. And I know they see some helmets that are 15 and 20 
years old.
    Senator Udall. Does NOCSAE require the helmets have a 
clearly visible date of manufacture and a date of last 
reconditioning label?
    Mr. Oliver. We do. We require both of those things.
    Senator Udall. And do you know how many high school or 
younger football players are wearing helmets that are 10 years 
or more in age?
    Mr. Oliver. We don't know specifically. What we know is 
from the data for helmets that come back in for reconditioning 
because we get that test data back at the end of each season. 
And we know that sample, and this is a ballpark figure. But 
approximately 89 to 92 percent of those helmets are less than 
10 years of age.
    Again, it is going to vary year to year, but that is the 
best we can come up with.
    Senator Udall. And do those helmets 10 years and older 
still meet NOCSAE current helmet standards?
    Mr. Oliver. They will if they have been through the proper 
program and have been properly reconditioned and had the 
padding replaced. They will. If they don't, they get failed, 
and they won't make it through the reconditioning process.
    Senator Udall. Yes. There is--I am shifting the issue a 
little bit here to supplements, and I think both of our 
physicians realize there has been a lot of evidence recently on 
supplements. And this has kind of surprised me.
    There is a company selling supplements which claims that 
they ``protect against concussions.'' It is called Sports Brain 
Guard. What are your thoughts on these claims about supplements 
and concussions?
    [The information referred to follows:]

    
    
    And I am going to send one of these down to you, but it is 
a dietary supplement that is called Brain Guard. Do you have 
any thoughts on that?
    Dr. Kutcher. I do. What are the components of Brain Guard? 
Is that the DHA, one of the DHA products, I imagine? Much like 
the other discussions we have had, there is no data that this 
type of thing will help prevent concussion at all really.
    And I just kind of go back to a conversation we had earlier 
in the hearing about the amount of time and money that has gone 
into neuroprotective agents for things like stroke. I mean, 
decades and decades and billions of dollars, and we haven't 
found anything for a mechanism that we know much more about, 
cell death and stroke. We know that. We know how that works at 
the molecular level a lot more than concussion anyway.
    And yet we don't have any answer there. So I don't see any 
data that would support the use of this, nor would I expect 
that we would be able to find any.
    Senator Udall. Let me just briefly just say in closing, 
first of all, thank you to the entire panel. I think your 
testimony has been very, very helpful, and I think parents and 
families out there are increasingly wanting to hear more about 
this, and I think the way you have engaged this today helps 
them a lot.
    I think this issue of awareness, I think all of you have 
talked about raising the awareness level, and we need more 
education, and we need to start younger. And those are very, 
very important points.
    And then the second, which you can see that I am passionate 
about, is this whole idea about misleading claims when it comes 
to equipment. It just seems to me that there is so much work 
that we need to do there to educate people. And people need to 
realize the old statement that is always used, ``Buyer 
beware.'' I mean, you need to check out when you have one of 
these products, whether it is supplements or whether it is a 
mouth guard or a headband, you really need to look a little 
deeper than the advertising there.
    So let me thank you again, and the hearing is adjourned.
    [Whereupon, at 4:39 p.m., the hearing was adjourned.]
                            A P P E N D I X

            Prepared Statement of Hon. Frank R. Lautenberg, 
                      U.S. Senator from New Jersey

    No parent should ever have to fear for their child's life when they 
play sports. Minor injuries are always a risk, but no young athlete 
should ever walk off the field with life-threatening brain trauma. All 
it takes is one serious injury to keep a young person on life's 
sidelines forever.
    In 2009 alone, almost 250,000 people aged 19 and younger ended up 
in an emergency room with traumatic brain injuries they suffered while 
playing sports. These injuries affect girls and boys alike. Girls 
soccer and boys football are the sports where most concussions occur 
among high school students.
    This is a problem in college sports, too. In my state, Eric 
LeGrand--a Rutgers University football player--was paralyzed from the 
neck down during a game a year ago. Mr. LeGrand is improving, but his 
story reminds us we have a lot of work to do to make sports safer for 
all athletes.
    I am working with Senator Tom Udall to strengthen safety standards 
for helmets. Parents are increasingly aware of the danger of 
concussions, and they deserve safe helmets that will protect their 
children from injury. Our bill will also make it a crime for helmet 
makers to make false or misleading claims about safety benefits.
    Parents need the straight truth about helmets--not exaggerated 
claims that lull them into a false sense of security. I look forward to 
working with my colleagues to pass this bill and help parents, schools 
and helmet makers work together to protect our children.
    I thank the Chairman for holding this important hearing.
                                 ______
                                 
                Prepared Statement of Hon. Mark Warner, 
                       U.S. Senator from Virginia

    Thank you, Chairman Rockefeller, for calling this hearing. I'd also 
like to thank my colleague, Senator Tom Udall, who has been a leader in 
highlighting this important issue for our country's student and 
professional athletes. Understanding the dangerous nature of 
concussions, better educating parents, coaches, trainers, and the 
athletes themselves on the symptoms and the precautions to avoid 
concussions, is critically important. Ensuring that all parties have 
the best, scientifically accurate information also is an important step 
in both the education and precaution of all of those involved.
    I am fortunate to represent Virginia Polytechnic Institute and 
State University, Virginia Tech, located in Blacksburg, VA, which is 
home to both the four-time ACC championship team and a group of 
researchers who are doing groundbreaking research into understanding 
how different helmet construction can impact the severity of the impact 
of concussions. Led by Steven Rowson and Stefan Duma, Virginia Tech and 
Wake Forest researchers have developed a five-star rating system to 
better evaluate helmet performance for football players. Similar to the 
current star-rating systems for cars, the National Impact Database will 
provide better clarity on the construction of helmets and how that may 
impact exposure and risk of concussion. The database's first analysis 
of 10 adult helmets was published in May of this year, and it was first 
time researchers have provided the public with a bioengineering impact 
data study with comparative test results. The rating system was funded 
in part by the National Institutes of Health and the Department of 
Transportation, and this research is independent of helmet 
manufacturers.
    This research indicates that current helmet performance is not 
directly related to cost. The database can now help consumers make 
better informed decisions based on independent data that compares the 
biomechanical performance of these helmets. I hope the star-ratings may 
also help push manufacturers to come up with better designs. The 
researchers do note, and I believe appropriately, that no helmet can 
provide full protection against concussions. There is considerable 
chance involved in head injuries in football and other sports, and what 
advanced-design helmets can do is lower the risk. However, transparency 
and information certainly can help consumers, players, coaches and 
trainers make better-informed decisions.
    I understand there have been concerns that some manufacturers have 
inappropriately marketed sports equipment, including helmets, by 
overstating the protections they provide. I share that concern, and I 
believe we must educate players, parents, coaches and trainers on the 
dangers of concussion and other injuries regardless of the equipment 
used. I look forward to working with the members of this Committee to 
ensure that there is minimal confusion in the marketplace over what it 
is that sports equipment can do. Helmets and other sports equipment 
provide one layer of protection, and it certainly does not eliminate 
the need for more awareness and public education about ways we might 
prevent and better manage concussions during sports activity.
    I do, however, continue to strongly support continued research, 
based on sound science that helps us to help better understand how we 
can keep our young people safer while competing in sports activity. 
This includes--but it certainly is not limited to--the groundbreaking 
research on concussions that is currently going on at Virginia Tech.
    I thank the Committee for holding a hearing on this important topic 
and stand ready to work with the Committee on possible solutions as we 
move forward. Thank you.
                                 ______
                                 
 Prepared Statement of Sporting Goods Manufacturers Association (SGMA)

    The Sporting Goods Manufacturers Association (SGMA) appreciates 
this opportunity to submit a statement for the record of this important 
hearing. We regret not being able to be represented in person but could 
not accommodate the hearing schedule due to a long-planned Board of 
Directors meeting in Chicago.
    SGMA is the national trade association of sports footwear, apparel, 
equipment and accessories manufacturers, distributors and marketers. 
Our membership consists of hundreds of brands which produce and sell 
sports products in the United States and around the world. SGMA 
believes sports and physical activity enhance people's lives. Our 
industry's products make sports, fitness, recreation and exercise 
accessible, enjoyable, fulfilling and healthy for millions of Americans 
every day. Our member companies are proud of the role they play in 
supporting healthy, active lifestyles for all.
    The primary business for many SGMA member companies focuses on 
designing, building, selling and maintaining protective sports 
equipment. We all recognize that participation in sports activities 
carries some risk of injury. While our products are designed to reduce 
that risk, no protective equipment can completely eliminate the risk. 
No helmet, regardless of design, material construction or technology 
can prevent all concussions or for that matter, all injury. With that 
realization, our companies strive through research, innovation, 
testing, refinement and consumer education to deliver products with 
improved protective qualities and properties, thereby enhancing the 
sport experience for the participant.
    From its very inception, SGMA has been a leader in bringing the 
industry together to face challenges around reducing risk of injury. 
When SGMA was founded in 1906, national concern over football related 
injuries dominated the sports landscape. SGMA's original member 
companies banded together and joined forces with the newly formed 
National Collegiate Athletic Association (NCAA) to change the way 
football was played. Among the major rule changes implemented at that 
time were the prohibition of the Flying Wedge blocking technique and 
re-design of additionally protective football pants, rule changes that 
brought virtually immediate reduction in football injuries. The 
complementary nature of problem identification, rules modification, 
product innovation and culture change is a recurring theme in 
successful action to reduce sports injury, and one that bears 
thoughtful analysis as we address the urgent need to comprehensively 
address concussions in sport. Our experience tells us reducing sports 
injury requires a multi-disciplinary approach that engages the views 
and expertise of athletes, parents, coaches, trainers, sports league 
administrators, medical professionals, rules makers, standards setting 
bodies, scientific investigators, product developers and marketers, and 
the media.
    In 1931, the industry adopted 11 Trade Practice Rules, '' to 
provide new standards of competition, and . . . to abandon all that is 
unfair to the public and to one another.'' One of those Trade Practice 
Rules was ``to work closely with various governing bodies to assure 
standardization of equipment specifications.'' This statement 
foreshadowed the need for an independent, science-based standards-
setting organization, a subject we will revisit later in this testimony 
when discussing the National Operating Committee for Standards in 
Athletic Equipment (NOCSAE).
    That same year, legendary Notre Dame Football coach Knute Rockne 
said of the SGMA membership: ``I want to compliment the sporting goods 
manufacturers on the fine protective measures they have given football. 
Despite the much larger number of football players, there are fewer 
injuries now than in the past. The biggest factor in reducing the 
number of injuries has been the added protection which has been built 
into football equipment. Your industry is a fine asset to college 
athletics. You are making equipment right.''
    A few years later in 1934, SGMA founded its educational and 
instructional arm known as The Athletic Institute, which evolved for a 
time into a world leader in the production of educational books, films, 
and videos. One of the goals of The Athletic Institute was ``to develop 
educational/training aids for athletes and coaches.'' For many years, 
SGMA and The Athletic Institute produced and distributed more sports 
instructional materials than virtually anyone in the United States. 
While SGMA is no longer in the training video business, we do believe 
tremendous progress in reducing risk of sports injury is attainable by 
utilizing new media capabilities to teach coaches, players and parents 
about proper technique. USA Football, the national governing body for 
youth football, has created an impressive on-line program that provides 
specific guidance on teaching age and size appropriate blocking and 
tackling technique. Pop Warner also has an excellent coaching education 
program. These are the basic cornerstones of reducing risk of injury. 
Matched with the NFL's concerted effort to reduce and ban head to head 
contact, sustainable cultural change is happening across the football 
community.
    The sports products industry absolutely has a role to play here. It 
starts with product design and innovation. Helmet technology is 
steadily improving. Our companies invest heavily in research and 
development exploring new materials, design, construction, and 
durability. They explore performance and protective qualities at 
extreme temperatures and repeated use, direct impacts and glancing 
blows, linear and rotational forces. Currently, a tremendous effort is 
being directed at managing energy from low impacts, reflecting the 
possibility that concussions may be generated from lower energy forces 
than have traditionally been the focus of helmet design.
    Football helmet manufacturers study videotapes of actual impacts to 
analyze and develop responses to concussive impacts. New technologies 
are being developed and implemented that measure in real time the 
nature and severity of impacts players receive on the field. There are 
several schools that currently employ this technology in their helmets, 
with immediate data being transmitted to sideline computers for trained 
professionals to monitor.
    These innovations are not limited to football. Technology transfers 
amongst lacrosse, baseball and hockey head protection are raising 
quality of protective products in these sports as well.
    The marketplace is vibrant. Two manufacturing brands have entered 
the football helmet business in recent years. Both have created 
excitement and awareness for their product, giving consumers additional 
choices of head protection.
    A reflection of the product improvements generated by the overall 
football helmet industry may be found in a recently published paper 
from Virginia Tech University's Dr. Stefan Duma. While SGMA is not in a 
position to speak to Dr. Duma's ranking of different helmet models, Dr. 
Duma's broad conclusion merits mention. Dr. Duma stated, ``The results 
clearly show that the newer technologies across all manufacturers are 
significantly better at reducing the risk of concussions compared to 
older models.''
    In addition to creating innovative products, the sports equipment 
industry can help leverage our connection to players and parents to 
communicate critically important pieces of information. One area the 
football helmet industry is exploring today centers on the appropriate 
fitting of a football helmet. Regardless of brand or model, one of the 
most important factors in the effectiveness of a football helmet is 
that it is correctly fitted to the player's head. Correct fitting is 
fundamental to ensuring the protective properties of a helmet are 
maintained. All football helmets are designed to fit snugly, they 
should never come off in normal course of play. Yet, on any given 
Saturday or Sunday in the fall, television images of helmets flying off 
players heads are far too common. Our industry is exploring ways to 
work together in educating coaches, league administrators, parents, 
equipment managers--anyone responsible for providing helmets to 
players--on how to ensure the helmet is properly fitted.
    Further to the point of education, the football helmet industry is 
in early stages of discussing if there is a way to improve warnings--
messages to consumers as to what the product can do, and perhaps as 
important, what the product cannot do. Of course, all sports protective 
products currently carry warnings. The industry, in consultation with 
many partners and interested parties, is exploring whether standardized 
language, graphics and placement would improve the clarity of the 
message to the consumer.
    Recognizing so much that can and should be done to address 
concussions, it's important also to note some of the significant and 
specific challenges we face in developing a successful integrated 
approach to reducing incidence of concussions in sport. Most vexing is 
that scientific consensus of what is a concussion and what causes 
concussions is evolving. Clearly, the medical and scientific community 
has gained a better understanding of the symptoms, proper precautions, 
cumulative impact and long term effect of concussions. The ``Return to 
Play'' protocols being enacted around the country are a great response 
certain to improve player health. These new understandings have led to 
new helmet technology and innovation, but the direct effects of low 
force impacts and their causal relation to concussive events remain 
unclear. Influences such as ambient temperature and hydration levels of 
players may be important, along with ``g'' forces and direction of 
impact. Simply put, more research is needed. Products innovations will 
continue based on available data, but helmet manufacturers need more 
conclusive data.
    The issue of a special performance standard for youth football 
helmets arises here. At one level, it may be intuitive that a specific 
standard for youth helmets is required. However, many in the scientific 
and helmet research community have raised concerns that creating a new 
standard without understanding the risks of unintended consequences is 
bad policy. Again, lack of scientific consensus raises a red flag for 
some. SGMA members welcome the call for additional dedicated research 
on this specific question, as soon as possible.
    The National Operating Committee on Standards for Athletic 
Equipment (NOCSAE) is the primary standards-setting body for sports 
equipment in the United States. Product performance standards are 
created and managed by NOCSAE, along with test protocols to ensure 
product integrity. The 20-member Board of Directors oversees NOCSAE 
operations. SGMA sits on the Board, along with representatives of the 
American College Health Association, American College of Sports 
Medicine, American Orthopedic Society for Sports Medicine, American 
Football Coaches Association, and the American Medical Society for 
Sports Medicine, amongst others. The organization is independent and 
science-based. NOCSAE ensures the sports products industry is regulated 
and monitored. SGMA believes NOCSAE has been effective in establishing, 
promulgating and enacting strong voluntary standards, with demonstrable 
results.
    Since the advent of the NOCSAE football helmet standard, 
catastrophic head injuries in the sport have declined by 85.5 percent. 
It is important to note this reduction was accomplished during a period 
when the number of athletes playing football more than tripled and the 
size, strength and speed of the players increased exponentially. It's 
penetration of the football helmet market, for example, is total. SGMA 
believes that virtually no helmet sold in the U.S. marketplace fails to 
meet the NOCSAE Standard.
    The chart below highlights the impact the NOCSAE standard has had 
on catastrophic football injuries since it was introduced.



    NOCSAE Football Helmet Standard published 1973. Reconditioner's 
Standard Revised to NOCSAE standard, 1977.
    Source: Football Fatalities and Catastrophic Injuries 1931--2008. 
Dr. Fredrick Mueller and Dr. Robert Cantu, Carolina Academic Press.

    The NOCSAE football helmet standard has been modified more than 20 
times since it was created in 1973. The NOCSAE Scientific Advisory 
Committee consists of many of the country's leading researchers on 
helmet protection and neuroscience. They have a primary responsibility 
for recommending changes to the standard. Unfortunately, the science of 
preventing concussions is limited. The science of severity of 
concussions is constantly changing. The industry believes NOCSAE has 
brought together the best thinking on the prevention of sport 
concussions in the NOCSAE Scientific Advisory Committee to formulate 
leading edge approaches to concussion management. NOCSAE has made, and 
continues to make, substantial grants to these and other researchers to 
do concussion-related research. SGMA and its members support this use 
of NOCSAE funds.
    Though we have focused much of this statement on football-related 
matters, it is important to note that concussions are not limited to 
football, and a variety of protective products are being created to 
offer protection across many sports. Mouthguards have evolved from a 
simple piece of plastic to a more malleable product intended to better 
absorb the shock from a blow to the chin, knee braces are more common 
now due to lighter and stronger materials, eyewear is required in field 
hockey and girls' lacrosse and the use of face-masks for fielders in 
fast-pitch softball has increased. The growing use of these products is 
evidence of the sports equipment's industry's commitment to reducing 
injuries in sports. Although participating in sports comes with the 
inherent risk of potential injury, equipment manufacturers and 
governing bodies work hard to reduce injuries through innovations in 
protective equipment and rules changes to better protect players.
    In closing, the industry is aware of the need to work aggressively 
to address concussions in sports. We also know, until there is more 
definitive medical science, there is a limit in what a helmet can do to 
eliminate concussions in sports. Until there is a consensus in 
concussion science, the helmet industry is taking a multidisciplinary 
approach working with trainers to insure equipment is fit correctly, 
sport governing bodies to create rules for protecting players from 
unnecessary helmet to helmet contact and working with coaches to adopt 
proper sport play techniques changing the current football culture to 
understand the seriousness of the concussion issue. Through NOCSAE, the 
industry is working with the Center for Disease Control providing 
educational materials to consumers, helping them understand and 
evaluate the concussion risk in sports.
    Thank you.
                                 ______
                                 
                Prepared Statement of Scott Hallenbeck, 
                    Executive Director, USA Football
    Chairman Rockefeller and Members of the Committee:

    My name is Scott Hallenbeck. I am the executive director of USA 
Football, the sport's national governing body in the United States.
    Approximately 3.0 million American children age 6-14 and 415,000 
adult volunteers power youth tackle football, making it one of our 
country's most popular youth sports. USA Football is an independent 
non-profit organization with members residing in all 50 states and the 
District of Columbia. Our members are youth football coaches, players, 
league commissioners and football game officials. Within our spectrum 
of responsibility is to lead and serve the youth football community. We 
do this in several ways, including giving information in the area of 
health and safety through our work with the Centers for Disease Control 
and Prevention (CDC) and other experts.
    USA Football was endowed by the National Football League (NFL) and 
the NFL Players Association (NFLPA) in 2002 through the NFL Youth 
Football Fund. The NFL Youth Football Fund is a non-profit foundation 
created by the NFL and NFLPA in 1998. I have served as USA Football's 
executive director since 2005.
    Twenty-six (26) youth sports organizations, including USA Football, 
began working with the CDC since 2007 to educate the youth sports 
community on concussion awareness and management. Fortunately, this 
number of youth sports organizations has increased in recent years. 
Player health and safety, including concussion education and 
management, is a point of emphasis for USA Football.
    USA Football's CDC-approved concussion awareness work has garnered 
national media attention. This underscores the public's thirst for 
additional knowledge and education on this topic.
Summary of USA Football's CDC-Approved Concussion Awareness 
        Information
    USA Football's coaching education curriculum, football training 
events, and resources provide youth football players, parents, coaches, 
league commissioners, and game officials with a strong knowledge base 
of football's fundamentals. Although no physical activity is injury-
proof, coaches who understand how to properly teach blocking and 
tackling within the rules will foster a positive football experience 
and will likely lessen the chance of injury.
    The following summarizes how USA Football, with CDC-approved 
practices, educates the youth football community on how to recognize a 
concussion and how to respond if one occurs. This information is 
promoted on our website--www.usafootball.com--and is available without 
cost.
    USA Football's online tackle and flag coaching courses were 
bolstered in April 2010 with 35 minutes of video addressing concussion 
(11 minutes), heat and hydration (13 minutes), proper helmet fitting (7 
minutes) and proper shoulder pad fitting (4 minutes). USA Football 
earned national publicity for these courses promoting player safety 
(Associated Press, 4/28/10). All videos may be viewed at 
usafootball.com at no cost at usafootball.com/health-safety/videos-and-
downloads.
    Each of the tackle football coaching course's 15 chapters are 
followed by a quiz to strengthen comprehension. A coach's progress 
within the course can be tracked by a league's commissioner. A coach 
must correctly answer at least 80 percent of the questions in a chapter 
quiz in order to advance to the next chapter.
    More than 75,000 youth football coaches have been educated by USA 
Football in our organization's history. Of these 75,000 coaches, more 
than 43,000 have been trained by USA Football in the past 18 months, 
illustrating the increasing value that youth leagues place in our 
educational resources. USA Football does not operate youth leagues nor 
does it have the ability to mandate youth coaches to complete its 
coaching courses. Leagues independently decide to employ USA Football's 
courses and resources on a value-based proposition.



    USA Football's online coaching course, successfully completed by 
more than 61,000 youth football coaches, teaches how to properly coach 
football fundamentals.



    Following each USA Football coaching course chapter, coaches are 
quizzed on what they learned. A cumulative score of at least 80 percent 
on each chapter quiz is needed to advance through the course.

    Youth sports leagues--not only those pertaining to football--are 
encouraged to adopt USA Football's CDC-approved concussion awareness 
and management policy (below). USA Football recommends that every youth 
sports league employs a policy such as this:
Prevention and Preparation for Coaches (Primary Source: CDC)
    (1) Educate athletes and parents about concussion

        (a) Talk with athletes and parents about preventative measures, 
        symptoms, and proper action to take relative to concussions.

        (b) Emphasize the dangers of playing through a concussion.

    (2) Insist that safety comes first

        (a) Teach athletes safe playing techniques and good 
        sportsmanship

        (b) Review the ``Concussion Fact Sheet for Players'' found at 
        usafootball.com with players and their parents

    (3) Teach athletes and parents that it is not safe to play with a 
concussion

        (a) Explain that it is not ``courageous'' nor does it show 
        strength to play with a concussion

    (4) Prevent long-term problems

        (a) ``When in doubt, sit them out.'' Keep athletes with known 
        or suspected concussion off the field until an appropriate 
        health care professional clears them to return. Returning to 
        play must be a medical decision.
Signs & Symptoms of Concussion (Primary Source: CDC)


Observations made by Coaching Staff      Symptoms reported by Athlete

 Appears dazed or stunned     Headache or ``pressure''
                                      in the head
 Is confused about            Nausea or vomiting
 assignment or position
 Forgets plays                Balance problems or
                                      dizziness
 Unsure of game, score, or    Double or blurry vision
 opponent
 Loses consciousness (even    Sensitivity to light or
 briefly)                             noise
 Shows behavior or            Feeling sluggish, hazy,
 personality changes                  foggy, or groggy
 Can't recall events prior    Concentration or memory
 or after the hit or fall             problems


What a Coach Should Do When a Concussion is Suspected (Primary Source: 
        CDC)
    (1) Remove the athlete from play

        (a) Look for signs and symptoms of concussion if an athlete 
        experienced a bump or blow to the head

        (b) ``When in doubt, sit them out''--athletes with signs or 
        symptoms of concussion must not return to play

    (2) Ensure that the athlete is evaluated immediately by an 
appropriate health care professional

        (a) Do not try to judge the severity of the injury yourself

        (b) Coaches recording the following can help a health care 
        professional in assessing the athlete:

                (i) Cause of the injury and the force of the hit or 
                blow to the head

                (ii) Any loss of consciousness and if so, for how long

                (iii) Any memory loss or seizures immediately following 
                the injury

                (iv) Number of previous concussions (if any)

    (3) Inform the athlete's parents/guardians of the possible 
concussion and give them the concussion fact sheet for parents found on 
usafootball.com

        (a) Ensure at parents know the athlete must be seen by an 
        appropriate healthcare professional

        (b) Provide formal documentation of the injury and notify the 
        league commissioner

    (4) Allow the athlete to return to play only after an appropriate 
healthcare professional clears his or her return

        (a) A repeat concussion that occurs before the brain recovers 
        from the first can slow recovery or increase the likelihood of 
        having long-term problems
USA Football Educational Resources & Initiatives
    The following outlines USA Football's educational resources and 
initiatives, including information distribution channels.
Education
 USA Football Events: Knowing the game's fundamentals and how 
    to teach them fosters a positive football experience

   AUSA Football Coaching Schools: youth coaches are 
        instructed how to teach the sport's fundamentals properly

   USA Football Player Academies: youth players (aged 7-14) 
        are taught proper football fundamentals

   Football State Leadership Forums: commissioners learn 
        best practices, including insight on concussion

     USA Football stresses that athletes who have or are 
            suspected to have suffered a concussion must not return to 
            play until an appropriate healthcare professional clears 
            them to do so.

 USA Football's Online Coaching Education Program for Youth 
    Tackle and Flag Football

   Concussion awareness and management information is part 
        of USA Football's basic online coaching courses for both tackle 
        and flag football

     USA Football's concussion-related course content is 
            created by its Football & Wellness Committee, the CDC, and 
            the National Athletic Trainers' Association (NATA)

     USA Football's Football & Wellness Committee is composed 
            of experts in several areas, including concussion, 
            hydration, and nutrition

 National Federation of State High School Associations (NFHS) 
    ``Fundamentals of Coaching Football'' Course

   Produced by USA Football, this course teaches proper 
        coaching fundamentals to America's high school football coaches

   High school head football coaches in Arkansas and 
        Massachusetts are mandated by the high school athletic 
        associations in those states in order to successfully complete 
        the NFHS's three-part online coaching curriculum; USA 
        Football's coaching course accounts for one of these three 
        parts.
Rules
 USA Football Youth Football Rulebook

   USA Football's Youth Football Rulebook, made available 
        to all youth football leagues in the United States, is written 
        with assistance from the National Association of Sports 
        Officials (NASO) and the NFHS to establish important youth 
        football standards

   Work done by USA Football's Rules Committee in Nov. 2010 
        enlarged the scope of illegal contact made to a player's helmet 
        to increase player safety. The rule change earned coverage from 
        The Associated Press (Nov. 10, 2010).
Research
 Youth Football Participation and Safety Surveillance Studies

   USA Football continues youth football's most accurate 
        participation study monitoring players, coaches, and teams

   USA Football will invest to execute a study to learn 
        more about youth football injury rates and how they are 
        affected by varying standards of play (Age & Weight, Age and 
        Grade-based)

     Data collection will begin during the 2012 football season
USA Football Equipment Grant Program
    USA Football, through financial support provided by the NFL Youth 
Football Fund, has awarded more than $4 million in football equipment 
based on merit and need to youth and high school programs across the 
United States since 2006. More than 700 youth and high school football 
programs in 44 states were assisted through USA Football grants awarded 
in 2011 alone.
    USA Football equipment grants make youth and high school football 
safer and compliments programs' existing fundraising endeavors for new 
equipment. Selected youth leagues choose one of 14 equipment packages, 
each valued at $1,000. Selected high school programs also choose one of 
14 packages, each valued at $1,500.
    Dozens of football program leaders have expressed appreciation for 
equipment grants awarded by USA Football:
    ``This is going to enable a lot more kids to play. This grant keeps 
kids on the field. It'll definitely help us and we are so very 
grateful.''
        --Cassandra Jetter-Ivey, Newark (N.J.) North Ward Scorpions 
        Youth Football Program
    ``We appreciate USA Football's help. This allows a sense of relief 
that we're keeping our children safe from injury by placing them in new 
and sturdier helmets. Since we are supporting children who are 
predominately underprivileged, this assistance is especially valuable 
as it keeps our registration fees as low as possible.''
        --DeAndrea Singleton, Westbury Redskins; Houston, Texas
    ``The equipment grant we were awarded from USA Football will 
provide equipment and uniforms to young athletes in low-income, inner-
city neighborhoods. Most of the youths are between the ages of 5-12 
years and the majority of them are financially disadvantaged. USA 
Football helps us make a difference in the lives of our kids and we 
appreciate their non-profit office's support.''
        --Steve Billingslea, Middle Tennessee Bulldogs; Nashville, 
        Tenn.
USA Football's Football and Wellness Committee
    USA Football has assembled a Football and Wellness Committee to 
further promote best practices for America's youth football community. 
The committee, composed of 26 experts spanning football coaching, 
player health, and other areas, share insight with youth football 
coaches, game officials, league commissioners, youth players, and 
parents to lead the game's development and foster a positive football 
experience for youth and amateur players. The committee's expertise 
will be shared with USA Football members through www.usafootball.com, 
our quarterly USA Football Magazine, and our football training events, 
which are conducted in more than two dozen states.
    This committee roster represents a variety of organizations 
including the American Red Cross, the Andrews Institute, the National 
Center for Sport Safety, and several medical centers from across the 
United States. USA Football's Football & Wellness Committee Members:


        Name                  Expertise                Organization

Tom Bainter          Football expert, running    Bothell (Wash.) High
                      backs                       School
Tom Bass             Football advisor            USA Football
Marcus Boyles        Football expert, receivers  Wayne County (Miss.)
                                                  High School
Jody Brylinsky       Coaching performance        Western Michigan
                                                  University
Ron Courson          Sports medicine             University of Georgia
Ted Crites           First aid, CPR/AED, injury  American Red Cross
                      prevention
Jeremy Gold          Football expert, defensive  Chicago Morgan Park
                      line                        High School
Dr. Ann Grandjean    Medical and nutrition       University of Nebraska
                      education                   Medical Center
Dr. Brad Hatfield    Kinesiology                 University of Maryland
Dr. Stan Herring     Concussion awareness and    University of
                      management                  Washington
Kirk Heidelberg      Football expert, offensive  Rockford (Ill.)
                      line                        Christian High School
Kent Johnston        Football expert, physical   Cleveland Browns
                      skills
Dr. David Joyner     Medical expert, orthopedic  Penn State University
                      physician
Chuck Kyle           Coaching performance        Cleveland St. Ignatius
                                                  High School
Dr. John Lehtinen    Family medicine             Peninsula Medical
                                                  Center
Dr. Larry Lemak      Sports Medicine             Lemak Sports Medicine
George Maczuga       Equipment                   Riddell
Chris Merritt        Football expert, defensive  Miami Christopher
                      backs & sp. teams           Columbus High School
Dr. Joel             Neurology                   Duke University Medical
 Morgenlander                                     Center
Dr. Lonnie Paulos    Orthopedics                 The Andrews Institute
Mike Price           Insurance                   Essix Insurance
Dr. JohnEric Smith   Hydration                   Gatorade Sports Science
                                                  Institute
Steve Specht         Football expert,            Cincinnati St. Xavier
                      linebackers                 High School
Gary Swenson         Football expert,            West Des Moines (Iowa)
                      quarterbacks                Valley High School
Kim Schwabenbauer    Nutrition                   Corporate dietitian,
                                                  Super Bakery
Dr. Dave Yukelson    Sport psychology            Penn State University


Player Progression Development Model
    America's youth football community is learning how to coach and 
play the sport in a way never done before.
    Developed throughout 2010 and 2011, USA Football introduced a 
Player Progression Development Model (PPDM) earlier this year. Youth 
football coaches in 15 states completed USA Football's age-appropriate 
teaching and learning approach to the game prior to the start of the 
2011 football season.
    USA Football's PPDM develops youth football players by having them 
learn the game, increase their skills and build confidence at age-
appropriate levels. It directs youth coaches how to teach the game in a 
progression based on a player's age and physical abilities as well as 
the player's mental, emotional and social maturity.
    Player age segments within USA Football's Player Progression 
Development Model:




 Under-6 (flag      Under-10        Under-14
 football)                  (tackle)                (tackle)
 Under-8 (tackle)   Under-12
                            (tackle)


    USA Football's Player Progression Development Model is woven into 
all USA Football programming--more than 80 football developments events 
for coaches, players and commissioners and its online educational and 
skill-strengthening resources for coaches and players.
    USA Football created its Player Progression Development Model 
(PPDM) under the direction of the following experts:


                    Name                          Area of Expertise

Tom Bainter, Bothell (Wash.) H.S. Football   Running Backs
 Coach
Jeremy Gold, Chicago Morgan Park H.S.        Defensive Line
 Football Coach
Kirk Heidelberg, Rockford (Ill.) Christian   Offensive Line
 H.S. Athletic Director
Kent Johnston, Cleveland Browns Strength     Physical Abilities
 and Conditioning Coach
Chuck Kyle, Cleveland St. Ignatius H.S.      Principles of Coaching
 Football Coach
Larry Lauer, Ph.D., Michigan State           Exercise & Sport Science,
 University                                   Sport Psychology
Chris Merritt, Miami Christopher Columbus    Defensive Backs and Special
 H.S. Football Coach                          Teams
Anne Pankhurst, Independent Consultant       Physical Abilities, Growth
                                              and Maturation
Cathy Sellers, United States Olympic         Principles of Coaching
 Committee
Steve Specht, Cincinnati St. Xavier H.S.     Linebackers
 Football Coach
Gary Swenson, West Des Moines (Iowa) Valley  Quarterbacks
 H.S. Football Coach
Dave Yukelson, Ph.D., Penn State University  Sport Psychology


    ``A structured player development model is good--and needed--for 
football, particularly youth football,'' said Cleveland St. Ignatius 
head football coach Chuck Kyle, a 10-time Ohio state champion coach and 
member of the Ohio High School Football Coaches Association Hall of 
Fame. ``This is a game of innovation, rooted in fundamentals,'' Kyle 
adds. ``USA Football's Player Progression Development Model is an 
extraordinary example of how these two dynamics work together and form 
the foundation of an exceptional team sport of the mind, body and 
spirit.''
USA Football Tackle Advisory Committee
    Head football coaches with NFL, collegiate, high school and youth 
experience as well as a leading sport psychologist were selected for 
USA Football's Tackle Advisory Committee in June 2011, the first 
committee of its kind to benefit America's youth football community.
    The group of experts helps youth coaches teach tackling 
fundamentals and strengthen player safety on a national level through 
USA Football resources.
    The five-member committee has assisted in developing a tackle 
progression model--a step-by-step process for youth coaches to teach 
tackling fundamentals in proper order. The tackle progression and its 
drills were created by USA Football. USA Football's tackle progression 
model further strengthens player safety and identifies ways to build 
confidence in youth players by appropriately introducing them to 
contact.
    USA Football's Tackle Advisory Committee Members:


    Name                  Position                    Organization

Pat           Head Football Coach              Northwestern University
 Fitzgerald
Merril Hoge   Youth Football Coach and NFL     ESPN (NFL Alumnus)
               Analyst
Chris         Head Football Coach              Miami Christopher
 Merritt                                        Columbus High School
Jim Mora      Youth Football Coach and Former  Atlanta Falcons and
               NFL Head Coach                   Seattle Seahawks
David         Sport Psychologist               Penn State University
 Yukelson


    A series of 12 instructional videos within USA Football's Tackle 
Progression Model divides tackling into five fundamentals--breakdown 
position, buzz, hit position, rip and shoot--providing drills to teach 
each step, beginning in a non-contact environment and progressing to 
player-to-player contact. The instruction is designed to improve 
tackling skills, increase safety and limit helmet-to-helmet contact, 
lessening the chance for injury, including concussion.
    Within the model, a USA Football-produced Level of Contact video 
directs youth coaches on how they may incrementally introduce their 
players to contact to build their confidence and help them learn the 
game's fundamentals. Drills can be run at varying speeds, starting slow 
when they are first introduced and accelerated as players master skills 
and techniques. The video introduces contact in the following ways:

------------------------------------------------------------------------
        Level of Contact                        Definition
------------------------------------------------------------------------
Air                              Players run a drill unopposed without
                                  contact.
------------------------------------------------------------------------
Bags                             Drill is run against a bag or another
                                  soft-contact surface.
------------------------------------------------------------------------
Wrap                             Drill is run between two players until
                                  the moment of contact; one player is
                                  pre-determined the ``winner'' by the
                                  coach. Contact remains above the waist
                                  and players stay on their feet.
------------------------------------------------------------------------
Thud                             Drill is run between two players until
                                  the moment of contact; no pre-
                                  determined ``winner.'' Contact remains
                                  above the waist, players stay on their
                                  feet and a quick whistle ends the
                                  drill.
------------------------------------------------------------------------
Live-Action                      Drill is run in game-like conditions
                                  and is the only time that players are
                                  taken to the ground.
------------------------------------------------------------------------

    ``Directing youth football teams to incrementally incorporate 
contact into their practices lessens the amount of incidental contact 
that players receive through their helmets,'' said Dr. Stanley Herring 
of USA Football's Football and Wellness Committee and the NFL's Head, 
Neck and Spine Committee. ``This is a strong step forward for player 
safety in youth football that any youth sport should consider 
emulating.''
Concussion-Related Education
    USA Football works with the CDC to promote concussion-related 
education materials for its members and the entire youth football 
community at www.usafootball.com. In addition to the CDC, USA Football 
is advised by Dr. Stanley Herring on concussion awareness and 
management. Dr. Herring is a member of USA Football's Football & 
Wellness committee and is a board-certified physical medicine and 
rehabilitation specialist who has been in practice for more than 27 
years. Dr. Herring also is a clinical professor in the departments of 
Rehabilitation Medicine, Orthopaedics & Sports Medicine, and 
Neurological Surgery at the University of Washington.
    Dr. Herring is USA Football's internal advisor on concussion 
awareness material for our coaching course, which was shared with the 
CDC for review prior to being made available to the youth football 
community. USA Football informs coaches of the CDC-approved message 
that athletes who are even suspected of having suffered a concussion 
must not return to play until an appropriate health care professional 
clears them to return. Returning to play must be a medical decision.
    In September 2010, USA Football introduced a national campaign 
called ``Put Pride Aside for Player Safety'' to emphasize concussion 
awareness in youth sports, particularly football.
    ``Put Pride Aside for Player Safety'' is the only national youth 
sports initiative promoting concussion education and management uniting 
a sport's national governing body (USA Football), collegiate athletic 
conferences (Atlantic Coast Conference, Mid-American Conference, The 
Patriot League) and a professional sports league (NFL).
    Through television, radio and website media placements, ``Put Pride 
Aside for Player Safety'' continues USA Football's commitment toward 
youth sport concussion education and management. ``Put Pride Aside for 
Player Safety'' challenges and instructs coaches, parents and youth 
players to make the right decision when a concussion is suspected, 
which is to remove an athlete from play the day of the injury and not 
allow him or her to return until a medical professional deems the 
athlete symptom-free and gives clearance for a return to play.
    Key components of USA Football's ``Put Pride Aside for Player 
Safety'' campaign:

   Television PSA airing on NFL team, ACC, Mid-American 
        Conference and Patriot League programming as well as on 
        usafootball.com

   Radio PSA airing on NFL team-owned inventory

   Player safety videos (12) covering proper equipment fitting, 
        tackling techniques and concussion management on websites of 
        NFL teams, the ACC, the MAC, the Patriot League and 
        usafootball.com

   Banner ads on websites of NFL teams, the ACC, the MAC, the 
        Patriot League, and usafootball.com
Legislation
    USA Football has joined other sports and medical organizations 
across the country in testifying in person or via letters of support 
for state legislation to foster greater awareness and management of 
concussion.
    Many of these state laws, most of which have been passed since 
August 2010, require:

   Information handouts to parents and players on the signs and 
        symptoms of concussion; returned and signed by parents and 
        youth athletes acknowledging the risk of concussion and head 
        injuries prior to practice or competition.

   Removal of a youth athlete who is suspected of or sustains a 
        concussion or head injury from play--``When in doubt, sit them 
        out.''

   Written clearance prior to returning to play from a licensed 
        health care provider knowledgeable in the diagnosis and 
        management of concussion for a youth athlete who has been 
        removed from play.

   Compliance from private, non-profit youth sports 
        associations with the policies adopted in that state.

    Such laws cannot prevent an initial concussion from happening on a 
football or soccer field, a basketball court, a baseball diamond, or a 
hockey rink, but they can help prevent damaging repeated concussions 
from happening in all of these places.
    USA Football is committed to concussion awareness and management 
and would encourage other sports' national governing bodies to join us.
    Concussion is not relegated to football--or even boys' athletics. 
According to a study titled, ``Concussions Among United States High 
School and Collegiate Athletes'' in the Journal of Athletic Training in 
2007, concussion rates per 1,000 athlete exposures were as follows (an 
``athlete exposure'' is one practice or one game):

   Football: 0.47

   Girls Soccer: 0.36

   Boys Soccer: 0.22

   Girls Basketball: 0.21

   Boys Basketball: 0.07

    These numbers underscore the need for all sports to recognize the 
seriousness of concussions and the need for further education among our 
coaches, league administrators, game officials, athletes, and parents.
More Education Needed
    Concussion awareness, even within the medical community, is 
limited. The CDC has even created a concussion fact sheet for 
physicians in addition to the general public. This drives the point 
that consistent nomenclature and the coordinated cooperation of all 
youth sports stakeholders is necessary to continue this positive change 
that we are experiencing in youth sports relative to concussion.
                                 ______
                                 
                                Appendix


    Created by the CDC for USA Football, this information was placed on 
a clipboard sticker and distributed at more than 35 full-day USA 
Football Coaching Schools in 25 states in 2010. This image can be 
downloaded at no cost at usafootball.com.


    The above four-page Concussion Education brochure with content from 
the CDC was distributed at single-day USA Football Coaching Schools in 
2011.
                                 ______
                                 
     Prepared Statement of Stanley Herring, MD, 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 Rockefeller, Ranking Member Hutchison, 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 submit this statement 
to 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, thank you for calling this hearing to bring greater 
awareness to the important topic of concussion in sports. As a medical 
advisor to the NFL, I believe that the NFL values its leadership role 
on the issue of concussions, not only for professional football 
players, but for all sports at all levels. I appreciate the opportunity 
to submit a statement summarizing some of the NFL's work on this 
important matter.
    As a physician who has worked on the sidelines of Seattle Seahawks 
games for many years, I know there is nothing more important to the NFL 
than the health of its players. Effective safety equipment is one 
important component in protecting the health of athletes. Among the 
many equipment related initiatives pursued by the League was a recent 
study into the effectiveness of the helmets worn by NFL players. The 
results of this study were shared not only with the players, but also 
the equipment manufacturers and made available to the public. The more 
information people have about equipment safety, especially as it 
relates to head injuries, the safer sports will be.
    Additionally, last December the NFL hosted a symposium in New York 
to discuss the performance of safety equipment, including helmets. 
Invited stakeholders included helmet and accelerometer manufacturers, 
the Department of Defense, the National Operating Committee on 
Standards for Athletic Equipment, the NFL Players Association, and 
researchers, among others. The daylong meeting allowed the most 
informed and knowledgeable individuals working on helmet safety to 
share ideas and learn from each other's work. All of those invited 
shared the same goal--making the game as safe as possible for those who 
play it.
    There currently are no products on the market that can make an 
athlete concussion-proof. Equipment technology will continue to evolve 
over time. The NFL is encouraging the pace of this change. In the 
meanwhile, we cannot look to equipment to replace the critical role of 
medical evaluation and treatment.
    We need not wait for the development of new technology to protect 
children from the dangers of concussions. Greater awareness and 
education can protect athletes of all ages, in all sports. The NFL 
promotes broader education about concussion in all levels of sport. 
Through collaboration with the CDC, educational posters now hang in NFL 
training rooms. I was personally involved in developing a similar 
poster to be used by youth athletes and made available through the CDC. 
Additionally, with support from the NFL, I have been involved in 
developing educational materials for coaches and clinicians so they can 
be better informed in treating athletes who have suffered a concussion. 
All of these materials are available, for free, on the CDC's website at 
www.cdc.gov/concussion.
    The NFL invests in research, and our medical committee works to 
examine the latest developments in technology. In the NFL's most recent 
collective bargaining agreement with the NFL Players Association, there 
is an agreement to dedicate $100 million over the next ten years to 
medical research, the majority of which will go toward brain injury 
research.
    Youth athletes who have suffered a concussion will routinely 
recover and return to play eventually if properly treated. For this 
reason, it is important that appropriate protocol is followed when 
children suffer concussions. One way to ensure that parents, coaches 
and others involved in youth sports are aware of the best possible way 
to treat concussions is through the adoption of laws with 
internationally accepted guidelines for how to treat youth concussions. 
A year ago, the NFL announced a campaign to advocate for the passage of 
youth concussion laws across the country. The laws all contain at least 
these three key 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.

    Laws containing these provisions have been enacted in thirty 
states, as well as the District of Columbia. Twenty-two have become law 
in the last year alone. The NFL has pledged to continue its advocacy 
until every state has adopted a way to protect youth athletes.
    The importance of these laws is personal for me. In October 2006, 
Zackery Lystedt 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 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. The adoption of the Zackery Lystedt law in 
Washington is already making a difference in our state. Thanks to the 
fine work of advocates across the country to promote this law, many 
more kids will play sports safer.
    I am proud that the NFL is a leader to the benefit of athletes at 
all levels of sport. As more is learned about concussions, I believe 
that the NFL will continue to make the necessary changes to best 
protect its players and to lead and serve as a model for all sports.
    Thank you again for this opportunity today.
                                 ______
                                 
                                        Ralph & Joy Conradt
                                         Bend, OR, October 29, 2011
Chairman Jay Rockefeller,
Senate Committee on Commerce, Science, and Transportation,
Washington, DC.

                                 Re: Football helmet safety

Dear Senator Rockefeller,

    Having viewed the October 19th Senate Hearing, I have a number of 
comments regarding the statements made by equipment-industry-
representative Oliver. First though it is ironic that the 10/19/11 
hearing occurred on the ten-year anniversary of my son Max's 
catastrophic brain injury while wearing a twenty year-old football 
helmet.
    1. At the time of Max's injury, we had no reason to question the 
reconditioning process. We just assumed all helmets were tested every 
year and reconditioning consisted of more than deodorizing, painting 
and checking for cracks. Mr. Oliver stated that an old helmet, properly 
reconditioned, offers the same protection as a state-of-the-art helmet. 
Our experience is that this is not the case. Max's helmet was drop-
tested at the NOCSAE lab and failed over 50 percent of the standards of 
the year 2000. Oliver says a helmet should not necessarily have an 
established shelf life since it may sit unused for several seasons. 
Clearly Mr. Oliver clearly has never owned a product made of 
polycarbonate, commonly known as plastic. If he did he would recall 
that while exposed to air, polycarbonate becomes brittle and no longer 
effectively absorbs shock.
    2. Oliver further stated an older helmet would meet current 
standards if `new parts were installed'. This position is ridiculous, 
as the primary component of a helmet is the shell. Since helmet shape 
has changed over the years the older shells will not accommodate new 
padding, bladders, head-sizers etc. Only parts made exactly to fit the 
old technology will work. Thus, even in the best-case scenario, such a 
helmet could only meet old standards, not recent standards.
    3. It troubles to me that children are allowed to play with these 
older products once newer standards are established. Why then have new 
standards? A reporter asked Max's principal, Von Taylor of Waldport 
High School in Oregon, how Max, the quarterback of his team and 
arguably the most valuable player, be assigned a 20-year-old helmet?? 
Taylor replied that Max's was not the only helmet of that vintage.
    This sort of justification explains why young players continue to 
suffer life-altering injuries and death--the most recent death just a 
week ago in New York. In 2008 I attended a coaches' conference where a 
coach questioned why he should be so concerned about examining and 
fitting helmets and sitting out players that felt a little dizzy when 
in fifteen years he had never had a player suffer a major injury. I was 
happy to explain to him that Max's coach tearfully expressed similar 
sentiments to me in the ICU while we stood over my son's comatose body.
    4. Max assured me that in his junior year he was using a ``new'' 
helmet. Had I known that in his senior year he would be issued a 20-
year-old helmet, which was three years older than he was, I would not 
have let him step onto the field. Max and I used to race our track car. 
It was mandatory, in that sport, that helmets be replaced every ten 
years, even if they were never worn in an accident. Helmets that had 
been dropped or which showed signs of minor impact also required 
replacement.
    5. Oliver stated that a helmet's age could be readily determined 
from a stamp in the shell. There are three problems with that 
statement. (A) Most schools do not allow players to take helmets home 
for parents' inspection; (B) the date stamp is usually disguised in a 
code and (C) the code is usually obscured by padding, which only 
coaches may remove.
    6. Coaches have only recently begun to take the issue of head 
protection seriously. Les Totten is CEO of SportsSoft, a company that 
offers teams a product to track all the conditioning and parts 
replacement for equipment. Les stated to me on-camera that he has never 
been in a school's equipment room and not found a helmet that was 
clearly ineffective by date of manufacture or reconditioning.
    Lastly, shortly after my 3.95 GPA son slipped into a four-month 
coma I was contacted by Riddell representative Mark Elmblade. He was 
concerned that one of his helmets might have been worn by Max. I 
assured him that it was a Bike helmet made by Schutt. Elmblade was 
relieved, but said he had recently visited Waldport coach Donald 
Kordosky. During their conversation Elmblade picked up one of the 
helmets in Waldport's stock and exclaimed ``These are a brain injury 
waiting to happen!'' Kordosky justified the use of out-dated helmets 
because he had no budget to replace them. Parents were not notified of 
this dangerous situation and had I known of the dire budgetary 
situation I would have gladly bought new helmets for the starting 
players.
    Lincoln County School District saved a few dollars and my son paid 
with his life. He will never work, never again join me in car racing. 
He will not provide me with grandchildren or contribute to our society 
with his once-exceptional brain power.
    Had Max's antiquated helmet been relegated to the trash heap there 
is every reason to believe that I would still have a whole son. 
Hopefully in your next Hearing, Mr. Oliver will be asked to respond to 
the issues raised here.
    Lastly as a filmmaker I have on tape almost every game Max played 
in. This footage became a major source of visuals for my film ``What 
Happened, Dad?''
                                        Ralph & Joy Conradt
                                 ______
                                 
 Response to Written Question Submitted by Hon. Frank R. Lautenberg to 
                              Alexis Ball

    Question. Parents normally associate concussions with football, but 
the CDC reports that soccer has the second highest incidence and rate 
of concussions. Do you believe that parents and coaches are aware of 
the concussion risks related to sports like soccer?
    Answer. I do not think that parents/athletes tend to associate 
concussions with sports like soccer. Much of the attention generated 
about concussions in sports is centered on football and thus I believe 
that other sports get overlooked. With the high number of young kids 
playing sports like soccer, it is essential to educate coaches, 
parents, and athletes about frequency of concussions occurring in 
sports other than football such as soccer.
                                 ______
                                 
 Response to Written Question Submitted by Hon. Frank R. Lautenberg to 
                             Steven Threet

    Question. Do you have advice for young athletes who may have 
suffered a concussion?
    Answer. My advice for young athletes who believe they have suffered 
a brain injury is to report it. It is better to speak to a trainer or a 
doctor and have them be able to rule out the possibility that a brain 
injury has occurred rather than the worst-case scenario where an 
athlete would stay quiet because they don't think their injury is 
significant enough to be reported and subsequently return to play 
before their brain is ready. This reporting process is significant 
because the brain is at a much greater risk for serious or permanent 
injury as a result of a second impact, known as Second Impact Syndrome.
                                 ______
                                 
     Response to Written Question Submitted by Hon. John Thune to 
                             Steven Threet

Improper Tackling Technique and Concussions
    Question 1. I'm aware that NFL and college football teams today 
have significantly reduced the amount of time devoted during practice 
to proper tackling and other football fundamentals. I recognize that 
coaches are limiting some of the physical contact during practice to 
prevent injuries. However, my concern is that less time devoted to 
teaching proper tackling technique may be contributing to an increase 
in concussions during games. Specifically, players these days seem to 
lead with their head rather than wrapping a player up with one's arms 
and body, and keeping their head up. Do you see any connection, at all 
levels of football, to improper tackling technique and an increase in 
concussions?
    Answer. I do believe that there is a connection between tackling 
technique and concussion. I believe that this is an issue being 
addressed by the NFL as well as in the college game. There has been a 
concentrated effort to lower the strike zone and to enforce it with 
penalties and in the NFL with fines as well. There is difficultly in 
this area because the speed of the game. Often times it appears that a 
player will tackle with proper technique but then the offensive player 
will make a last second adjustment in his body position in anticipation 
of the impact and subsequently bring their head lower and back into the 
striking zone for the defensive player.

    Question 2. Do you think this improper tackling technique is caused 
by less time being devoted to teaching good technique in practice?
    Answer. I believe that as players get older less time is spent 
teaching proper technique. At elite levels of the game coaches either 
assume it is known or do not feel they can spend the time focusing on 
technique. I think this is because there are such strict rules by the 
NCAA about the time that coaches can spend with their players. The off-
season would be a great time for position players to teach their 
players but contact between coach and player in this way is currently 
not allowed. Because of time constraints the emphasis of practice is 
learning the defensive scheme in the spring and the preseason and 
preparing for the opponents during the season.

    Question 3. As part of the campaign to highlight concussion 
awareness, how much emphasis is being placed on educating coaches and 
players about using proper tackling technique to reduce concussions?
    Answer. I believe that there is some emphasis being placed on how 
proper technique can help reduce the frequency of brain injury. However 
the greatest emphasis on the awareness front is getting athletes to 
appreciate the seriousness of brain injury. I believe that as more 
people begin to recognize the problem, it will be possible to switch 
the focus of the awareness effort to include partial-solutions like a 
greater emphasis on tackling technique.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to 
                          Jeffrey Kutcher, MD

    Question 1. Concussions and other traumatic brain injuries pose a 
serious and increasing risk for our youth. In 2009, emergency rooms 
treated an estimated 248,418 sports and recreation-related concussions 
and other brain injuries among children and adolescents. These injuries 
have increased by 60 percent over the last decade even though school 
sports participation has fallen. What more can be done to prevent these 
injuries? How can we ensure that kids who experience concussions don't 
suffer long-term consequences?
    Answer. The increase in emergency room visits for sport and 
recreation related brain injury is very likely multi-factorial. First, 
although school sports participation may be trending down, the overall 
exposure to activities with an inherent risk of brain injury is more 
difficult to quantify. It may be, for example, that overall exposure is 
up, once we factor in those activities that are not school organized. 
Second, increased awareness of head injury has almost certainly led to 
a higher percentage of head injuries presenting to an emergency room. 
Thus, the 60 percent increase in ER visits over the last decade may not 
necessarily represent an increase in the absolute number of injuries.
    That being said, there is no question that a serious problem exists 
and injury prevention is key. A significant number of injuries could be 
prevented through proper education and awareness campaigns that address 
known high-risk activities. These efforts should stress the use of 
well-fitted and certified equipment, proper technique, and adherence to 
the rules of whatever sport or activity is being considered. As is the 
nature of the concussion issue, what we don't know puts a limit on our 
ability to make a difference. To truly prevent concussion, we need to 
understand much more about the injury itself, how a traumatic force 
acts to insight the injury, how the brain responds to the injury, and 
what additional factors may influence the clinical outcome.
    Currently, we do not know enough about concussion or traumatic 
brain injury to ensure that any individual can be free of long-term 
consequences. The simple answer is that long-term problems likely come 
from a combination of intrinsic (genetic) and extrinsic (environmental) 
factors, including the total lifetime dose of biomechanical forces. 
Thus, the only way to truly ensure that long-term problems do not 
develop is to avoid exposure to biomechanical forces completely. This 
is clearly not a realistic goal. Given what we know, I stress the need 
to let every concussion heal prior to returning to a contact risk 
environment. I also suggest that the overall exposure to contact risk 
be considered. For example, I advise my patients who play a contact 
sport to avoid other contact sports, giving their brains time to 
recover in the off-season. Finally, I believe that it is critical for 
any contact sport participant to undergo periodic neurological 
evaluation and screening for any signs of brain dysfunction that might 
be related to head trauma.

    Question 2. Rates of concussion and other brain injury have 
dramatically risen over the last decade as have sales of equipment that 
is supposed to protect our kids from these injuries. Are these products 
really protective?
    Answer. Equipment plays a critical role in injury prevention. The 
very nature of contact sports, such as football and ice hockey, is 
determined, in no small part, by the presence of protective equipment 
such as helmets. To this end, equipment being an integral part of the 
game means that it is both preventive and causative. Obviously, any 
football player who for some reason participates without a helmet is at 
a significantly higher risk of injury. The protective nature of helmets 
is limited, however. They are very good at preventing bone fracture and 
superficial injury, but are not very good at preventing concussion. 
Concussion can occur from direct blows to the head or as the result of 
a blow to the body causing a whiplash event. No helmet could ever 
prevent the latter. The amount of biomechanical force that is absorbed 
by helmets, in my opinion, is not enough to expect that they could ever 
significantly alter concussion risk. With that in mind, I tell my 
patients to make sure all of their equipment is properly fitted and 
certified. I also advise them that while newer generation helmets might 
not be able to greatly reduce concussion risk, they may lower the 
absolute amount of force that their brain will experience.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                          Jeffrey Kutcher, MD

    Question 1. Helmet requirements for high school football. The 
National Federation of State High School Associations (NFHS) sets 
football playing rules and equipment guidelines that are adopted by 
many state athletic associations. The 2010 NFHS Football Rules book 
requires players to wear a football ``helmet and face mask which met 
the NOCSAE test standard at the times of manufacture'' (see page 17). 
However, these NFHS rules allow a football helmet that is no longer in 
compliance with NOCSAE standards to be worn by a high school player as 
long as the helmet met NOCSAE standards when it was originally made. 
NFHS also does not require that an older helmet be reconditioned and 
recertified to NOCSAE standards. Should high school football players 
wear helmets that meet current NOCSAE requirements when they are 
actually being worn--and not just on the day their helmets were 
manufactured?
    Answer. Absolutely. I believe it is critical that high school 
football players wear helmets that meet current NOCSAE standards while 
they are in use. Every reasonable effort should be made to ensure that 
this is the case. Allowing helmets to be worn that no longer meet 
standards defeats the purpose of having standards in the first place.

    Question 2. NOCSAE drop test and helmet quality. My understanding 
is that the NOCSAE safety standard for football helmets is primarily a 
drop test method that requires helmets to score less than a 1200 
severity index (SI) level. Is there a difference in the level of 
protection offered by a helmet that tests at a 1199 SI level and a 
helmet that tests at a 300 SI level?
    Answer. Theoretically, yes. The difficulty resides in trying to 
quantify the level of protection that any helmet offers. When speaking 
about injuries that are easy to document objectively, such as skull 
fractures or bleeding events inside the skull, one can make a 
reasonable estimate of risk. When speaking about concussion, however, 
as well as possible long-term effects of brain trauma such as chronic 
traumatic encephalopathy, it is much more difficult, if not impossible, 
to quantify the risk in a way that's precise enough to allow for 
comparisons between helmet types. First, we need to advance the science 
of concussion to a point that we have a consistent and well-defined 
clinical outcome to study, and one with an objective confirmatory test. 
Then, helmet types could be studied to see how they differ in 
preventing these outcomes. As it stands now, our estimates of risk, and 
therefore the amount of protection that any helmet can provide, is 
little more than guesswork.
    That being said, it certainly makes sense from a neuropathological 
perspective that brains would rather experience less force than more, 
especially over the course of a lifetime. For that reason, it would 
seem to be an axiom that a helmet with an SI level of 300 would be 
preferable to one with an SI of 1199. Although we cannot expect this 
difference to significantly mitigate the risk of experiencing a 
clinical concussion, it is more plausible that it could account for 
some amount of decreased risk of developing long-term neurological 
effects. If this effect does exist, however, it likely represents a 
very small proportion of the overall risk, and, therefore, we should 
not expect advancing helmet technology alone to solve the problem.

    Question 3. Concussions tests. Dr. Kutcher, we hear more and more 
in the media about ``concussion tests'' used to diagnose athletes and 
determine if they are fit to return to play. Yet we also hear reports 
that some athletes may intentionally fail or ``sandbag'' their baseline 
neuro-cognitive tests in order to reduce the chance of being removed 
from play following a concussion later in the season. How effective are 
computerized neuro-cognitive tests in diagnosing concussed athletes and 
determining when it is safe for them to return to playing sports?
    Answer. Computerized neuro-cognitive tests cannot diagnose 
concussion. Actually, there is no test currently available that can do 
so. Concussion is a diagnosis that is made clinically. Computerized 
neuro-cognitive tests provide information on brain function that an 
experienced physician can use, together with other pieces of 
information, to help make the diagnosis of concussion and help 
determine when the injury is over. I am very concerned with the degree 
to which computerized neuro-cognitive tests are being used 
inappropriately in our country. The problem stems from the fact that an 
abnormal result on these tests is not specific for concussion. An 
athlete who is in pain for any reason, or one who is sleep deprived, 
distracted, or unmotivated can produce abnormal results, whether they 
are concussed or not.
    Furthermore, having a result on one of these tests that falls 
within a population-based norm does not mean that the person in 
question is not concussed. The best use of these tests comes when there 
is a pre-injury baseline result for comparison. The trick is that 
producing a baseline neuro-cognitive study truly representative of that 
individual's ability is more difficult than it sounds. Environmental 
and motivational factors frequently act to set a ``false baseline'' 
that is then used for comparison later.
    Computerized neuro-cognitive testing is, potentially, a very useful 
concept. Used incorrectly, however, it can be misleading at best and 
dangerous at worst. I strongly encourage any clinician who uses this 
modality in their practice to understand the strengths and weaknesses 
of the individual tests and to use them as extensions of their physical 
examination, and never as a diagnostic test. In the end, diagnosing 
concussion and making a return to play decision not only involves 
clinical decision-making, but is very much a medical decision that 
should only be made by a physician.
                                 ______
                                 
    Response to Written Question Submitted by Hon. John Boozman to 
                          Jeffrey Kutcher, MD

Concussion Education
    Question. Are educational campaigns, such as the CDC's Heads Up 
campaign, effectively reaching parents and coaches across the country? 
Do you feel they are reducing the number of concussions that occur and/
or changing the way people react when someone sustains one? Should 
anything be done to make these education campaigns more effective?
    Answer. The publicly available concussion education programs, such 
as the CDC's Heads Up campaign, are helping, but only to a degree. They 
are part of the larger changing landscape of increased concussion 
awareness and, as such, do have some impact on moving the issue 
forward. I do not believe they are significantly reducing the number of 
concussions, nor do I see a significant change in how concussed 
athletes are being treated. We can, and certainly should, do better. 
There are four main reasons that I see for this overall lack of 
effectiveness:
    First, I have found that the value of any educational resource 
depends on how specifically the material is designed for a particular 
audience. Most available concussion resources take a generic approach 
that appeals to the public at large. Granted, this may be a result of 
the need to produce materials that cover a wide audience with limited 
resources. Concussion education, however, needs to address every 
stakeholder in the issue. We need programs that are designed for each 
population specifically, speaking to their concerns, using their 
language, and engaging them in the learning process. We need to have 
programs that are created for athletes of different age groups, coaches 
of all levels of sport, parents, administrators, officials, and medical 
staff.
    Second, most concussion education materials I have seen are fairly 
average in quality. They provide superficial content in a non-
stimulating way. Successful education programs use creative 
instructional design and an interactive format that motivates and 
challenges the learner.
    Third, there is a significant issue with lack of quality control 
and consistency between programs. In some cases, information is 
outdated, incorrect, or contradictory. Much of this may be due to the 
fact that our understanding of concussion is evolving quickly. I'm 
afraid, however, that in an age when anybody can produce an educational 
tool using electronic media, that many programs are designed for the 
purpose of marketing a product or service. The public is thirsty for 
knowledge and deserves information that is accurate, current, and not 
driven by ulterior motives.
    Finally, while having these materials available to those who are 
actively seeking knowledge is a wonderful start, I believe the majority 
of athletes, parents, and coaches would not seek these programs out 
voluntarily. Whenever possible, we need to make concussion education a 
mandatory activity prior to playing, coaching, or consenting for a 
child to participate in contact sports.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to 
                            Ann C. McKee, MD

    Question 1. Concussions and other traumatic brain injuries pose a 
serious and increasing risk for our youth. In 2009, emergency rooms 
treated an estimated 248,418 sports and recreation-related concussions 
and other brain injuries among children and adolescents. These injuries 
have increased by 60 percent over the last decade even though school 
sports participation has fallen. What more can be done to prevent these 
injuries? How can we ensure that kids who experience concussions don't 
suffer long term consequences?
    Answer. The primary way to reduce the number of concussions 
suffered by children and adolescents is to raise awareness and educate 
the public--coaches, parents, medical doctors, psychologists and kids--
about what a concussion is, what kind of activities increase the risk 
of concussion, and how to properly manage a concussion after it occurs. 
A concussion properly recognized and medically managed is the best 
protection against the long-term consequences. Ensuring that the child 
or adolescent rests sufficiently (including cognitive rest) after a 
concussion and not allowing the resumption of play of the sport or 
other activities until fully recovered is the best way to reduce 
complications down the road. Other prevention measures include wearing 
proper protective gear when bicycling, skiing, skateboarding, etc and 
avoiding activities that are associated with repetitive brain trauma, 
e.g., leading with your head or tacking with your head in football and 
other sports.

    Question 2. Rates of concussion and other brain injury have 
dramatically risen over the last decade as have sales of equipment that 
is supposed to protect our kids from these injuries. Are these products 
really protective?
    Answer. There is no product marketed today that prevents 
concussion, including helmets, although helmets make sports safer by 
reducing catastrophic injuries. Reducing the incidence of sports-
related concussion will require changing the way many of our popular 
sports, including football, soccer and hockey, are played.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. John Boozman to 
                            Ann C. McKee, MD

Risks in Concussions/Death
    Question 1. Last month, a 16-year-old high school football player 
died from a head injury after collapsing during a game. I understand 
the possibility of further injury due to multiple concussions, yet 
according to the news report, there was no evidence of any pre-existing 
injury or condition that would have contributed to his death. How can a 
seemingly healthy 16-year-old with no previous head injury history die 
after what appeared to be an ordinary football play?
    Answer. While I'm not certain I know what specific case you are 
referring to, it sounds as though it may be a case of second impact 
syndrome or SIS. SIS occurs when a young athlete sustains an initial 
head injury and then suffers a second head injury before the symptoms 
associated with the first impact have cleared. There are many times 
when the athlete does not report the initial injury--he may not realize 
that he had a concussion, he may be minimizing the symptoms or his 
desire to return to the playing field may cloud his judgment. Before 
the first injury completely resolves, which may take days or weeks, the 
athlete returns to competition and receives a second blow to the head--
which may be remarkably minor--as in an ordinary football play. Yet the 
second impact produces sudden brain swelling, high intracranial 
pressure, and results in death or severe neurological disability. The 
pathophysiology of the SIS is believed to be dyregulation of the 
cerebrovasculature, which young brains are more susceptible to. SIS 
occurs only in young athletes and has never been reported in an athlete 
over the age of 24 years.
    Another possible cause of sudden collapse and death on the football 
field is bleeding into the brain, such as a subdural or an epidural 
hemorrhage. Although these are very rare events and would not be 
expected to occur after an ordinary football play.

    Question 2. Are injuries such as this one preventable?
    Answer. Not playing while recovering from a concussion, even a 
seemingly minor concussion, is the best prevention against this injury.

    2Question 3. How does an injury like this differ from a concussion?
    Answer. A concussion is a temporary state of neurological 
dysfunction accompanied by microscopic evidence of multifocal axonal 
injury and disordered cerebral metabolism. SIS occurs when there is a 
second concussive impact on a brain that has not fully recovered from 
the first one. The second injury produces sudden brain swelling that 
leads to brain herniation and death or severe neurological injury.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to 
                              Mike Oliver

    Question 1. Why has NOCSAE not substantially updated helmet 
standards in nearly 40 years?
    Answer. This is a common and persistent misconception or 
misunderstanding. NOCSAE helmet standards including football helmet 
standards have been updated, revised, expanded, and strengthened 
regularly over the past 40 years. Changes to the NOCSAE standard over 
time have included revisions and modifications to the pass fail 
criteria, and at other times the revisions, although appearing to be 
small simple changes in test methodology and procedures, in fact proved 
to be substantial and demanding changes that forced helmets to become 
more robust, more protective, and more durable.
    As a result of improvements and updates to the NOCSAE football 
helmet standard and advances in materials technology and engineering 
and design innovation, the average pass fail test scores for new 
helmets has dropped from 600 SI in 1998 to just under 500 SI in 2010. 
Although there is no way to quantify what this reduction means in terms 
of injury protection and prevention, it is evidence of improvement. It 
also must be kept in mind that even though the pass fail threshold is 
1200 SI which threshold is based on the science behind the Gadd 
Severity Index (``SI''), in order to meet the Quality Assurance and 
Quality Control requirements of the NOCSAE standards, helmets must 
average 500-600 SI in certification testing.
    Football helmets certified to the NOCSAE standard and used in high 
school and collegiate play are involved in over 600,000,000 practice 
and game impacts during the course of a single football season, and 
sometimes they must perform across two and three seasons of continuous 
use before they are submitted for reconditioning and recertification. 
Tests performed on these helmets before they are reconditioned 
establishes that, unless padding has been removed or altered, these 
helmets will have test results that are nearly the same as when the 
helmet was new. Under the circumstances, changes to a standard which 
already provides an extremely high level of protection and performance 
can only be undertaken and adopted when there is solid and consensus 
scientific support for those changes. NOCSAE is one of the leading 
research funding sources for the advancement of that kind of scientific 
knowledge, in the hope that additional revisions and updates can be 
made to the standards to further enhance protection and performance.
    Some examples of changes and updates to the NOCSAE standard are 
listed below.

   1990--A random location impact requirement was added to the 
        six predetermined impact locations contained in the standard. 
        As a result of this change, helmets would not be required to be 
        tested in locations in as many as 58 different locations not 
        previously evaluated. This simple change prevented a helmet 
        from being designed to meet the standard only at designated 
        impact locations, and ensured that football helmets would meet 
        the standard which struck at any location on the helmet shell 
        and within defined limits of the edges of the shell.

   1992--Implementation of a scientifically proven calibration 
        method of the NOCSAE headform using the three inch MEP is 
        introduced. Required calibration performed before testing, 
        produced increased repeatability between laboratories. This 
        change was mandatory for all NOCSAE licensees. The NOCSAE 
        carriage assembly was made more rigid and the air craft cable 
        guide wires were replaced with smoother music wire. This 
        decreased friction in the drop system and increased stability 
        of the carriage assembly throughout the drop impact. A tapered 
        bolt for locating the different impact sites was introduced. 
        The test MEP was hardened from a 36 Shore A hardness natural 
        rubber surface to a 43 Shore A hardness urethane to produce a 
        more consistent impact surface. These changes resulted in 
        significantly higher impact velocities and increased impact 
        energies to the helmet, a more demanding test than in the 
        previous standard. The impact energies and the velocities were 
        increased to the point that sophisticated testing headforms 
        were being broken and had to be redesigned and replaced at a 
        cost of $350,000.

   1996--The pass/fail threshold was toughened by 20 percent, 
        by changing the pass/fail threshold value from 1500 SI to 1200 
        SI. The SI value of 1200 corresponds almost directly with the 
        Federal Motor Vehicle Safety Standard head injury criteria 
        (HIC) value of 1000.

   1999--The new anthropometrically correct size medium 
        headform was introduced. This change produced a more robust 
        head model to prevent the excessive breaking of headforms that 
        had resulted from the earlier changes made to the drop system 
        that increased drop velocities and energies. This change 
        created a head model that is less likely to break under normal 
        use and resulted in a more demanding helmet test particularly 
        for impact sites located along the rear portion of the 
        headform. After extensive tests were carried out on the new 
        medium head model, the size small and large headforms were 
        introduced in 2002.

   In 1994, NOCSAE introduced a proprietary data acquisition 
        and analysis computer and software program and mandated its 
        implementation by all licensed helmet recertification entities. 
        This system has been refined multiple times over the 
        intervening years, and in 2003, the entire system was replaced 
        with a second-generation data acquisition system. One of the 
        strengths of this test and data acquisition system is to 
        prevent invalid helmet test results from being recorded.

    In the last five years, NOCSAE has clarified the zero defect or 
zero AQL quality assurance requirements of the standards, has added a 
third low-level impact requirement with a separate lower pass fail 
threshold, and has required that helmet impact velocities during the 
test be directly measured with a light activated velocity gate instead 
of utilizing mathematical calculations based upon acceleration of 
gravity.
    As a result of the revisions, modifications, and updates made by 
NOCSAE to its standards, football helmets certified to the NOCSAE 
standard outperform helmets certified to any other standard, whether in 
energy management, head coverage, durability, weight, low-energy and 
high energy impact performance.

    Question 2. Given the misleading claims by many manufacturers based 
on little or no scientific evidence, why has NOCSAE not developed 
marketing guidelines for products that meet its standards?
    Answer. NOCSAE is a standards development organization. The scope 
of our authority is limited to matters regarding compliance with the 
NOCSAE standards by licensed manufacturers and reconditioners who 
certified products to the NOCSAE standards. NOCSAE does exercise 
control over advertising content with regard to the appropriate and 
proper use of all registered and trademarked names, marks, and 
properties used in connection with certification to the NOCSAE 
standards. Unless the licensee improperly and impermissibly uses those 
registered properties as part of the objectionable content in 
advertising, NOCSAE has no authority to address or provide guidelines 
beyond that scope. The license agreement NOCSAE has with each 
manufacturer or reconditioner covers a licensee obligations with regard 
to certification and compliance with the standards is a unique and 
powerful control over the integrity and validity of the NOCSAE 
standards, but it cannot provide a legal basis for the regulation of 
advertising content unrelated to the proper use of registered and 
trademarked properties in compliance with the NOCSAE standards.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                              Mike Oliver

    Question 1. NOCSAE's standard development process. Mr. Oliver, many 
standards development organizations follow a code of good practice 
embodied in the American National Standards Institute's Essential 
Requirements: Due process requirements for American National Standards.
    These ANSI Essential Requirements include provisions for balance, 
openness and lack of dominance by any single interest category, 
individual or organization. Despite your description of NOCSAE's 
membership and mission, your organization falls short of the ANSI 
Essential Requirements for standards development in several important 
respects. Will NOCSAE commit to becoming fully compliant with the ANSI 
Essential Requirements for standards development? If so, by what date?
    Answer. NOCSAE voted in June 2011, to seek accreditation as an ANSI 
Standards Developer, and is in the process of preparing an application 
for that purpose. It is anticipated that such accreditation will be 
straightforward, given the fact that existing NOCSAE procedures and 
board membership already comply with the essential due process 
requirements contained in the ANSI procedures.
    Being an ANSI Accredited Standards Developer signifies that 
standards are developed using a fair, open process that ensures a level 
playing field and will meet the needs of materially affected interests, 
and NOCSAE written policies and by-laws address those core concepts and 
values.
    According to published ANSI 2010 Essential Due Process provisions, 
the hallmarks of the ANSI due process are openness, consensus by a 
balance of materially-affected interests, consideration of views and 
objections, lack of dominance by any affected interest, transparency of 
the process, and provisions to provide fundamental fairness. The NOCSAE 
By-Laws define the membership of the board of directors to create a 
balanced and diverse consensus body representing materially affected 
interests from a variety of national organizations which represent 
those diverse interests on a broad national scale. These interest 
categories include medical, consumer/athlete end-user, scientific, and 
manufacturing interests. Membership number limits each category 
precludes any single interest group from having a controlling vote or 
veto. This defined membership structure of the NOCSAE board also 
satisfies the ANSI definition of a consensus body.
    Additionally, ANSI requirements for specific written procedures to 
be followed in adopting and publishing standards that provide for 
public notice and comment periods, periodic review and reaffirmation, 
and the use of standardized nomenclature have been a part of the NOCSAE 
procedures for many years.
    The application for ANSI accreditation will be submitted before 
January 30, 2012, but it cannot be known when the application will be 
approved by ANSI.

    Question 2a. NOCSAE's market surveillance. Mr. Oliver, you state in 
your testimony that NOCSAE performs market surveillance. This seems to 
contradict what is written in the NOCSAE drop impact test method used 
for football helmets, which clearly states that:
    ``NOCSAE publishes standards but does not conduct surveillance to 
assure compliance to standards. It is the sole responsibility of firms 
that manufacture or recertify protective products to certify that all 
requirements of these standards are met, including ongoing 
statistically relevant QC protocols.'' Can you explain this discrepancy 
between your statement and what is written in the NOCSAE standard?
    Answer. The reference in the standards that NOCSAE ``. . . does not 
conduct surveillance to assure compliance to standards'' refers to 
market surveillance that is typically performed by certifying bodies, 
such as CE Notified Bodies in Europe, and certifying bodies in the 
United States such as Underwriters Laboratories and the Snell 
Foundation as part of their product certification duties. NOCSAE is not 
a certifying body and so does not conduct formal market surveillance as 
part of the standards development process, and the referenced paragraph 
is intended to make that fact clear to consumers, manufacturers, and 
licensees.
    The purpose of a market surveillance program utilized by certifying 
bodies is to protect the integrity of the certification mark, to 
prevent counterfeit and non-conforming products from reaching the 
consumer market, and as a check on the manufacturer who is placing the 
certifying body's mark on the product. ``Market surveillance'' as 
commonly used in this context involves the certifying body 
supplementing its own product certification testing on limited samples 
provided by a manufacturer with tests on a sample of unused certified 
products purchased in the market after the certified product has been 
distributed by the original manufacturer.
    But many of the policies and duties imposed by the NOCSAE standards 
and the license agreement between a manufacturer and NOCSAE involve 
activities that would fit the definition of market surveillance, and 
which accomplish the same goals as with a certifying body, although on 
a much more demanding and far reaching scope than any traditional 
market surveillance program maintained by a certifying body.
    Formal and traditional market surveillance programs test only new 
products purchased at retail to verify the accuracy of the 
certification mark, but no surveillance program tests used products as 
part of that process. The NOCSAE recertification standards involve 
testing and evaluating previously certified equipment for as long as 
the equipment is being used and submitted for recertification. To make 
an analogy, the NOCSAE product surveillance program would be the 
equivalent of Underwriters Laboratories going into homes and re-testing 
toasters that have been in use for years, and verifying that the 
toasters still comply with the original UL mark.
    Testing used helmets for the purpose of recertification is also an 
affirmation and validation of the integrity of the new helmet 
certification. If the helmet meets the standard after it has been used 
for several seasons, it is a given that it met the standard when it was 
newly certified. That fact alone obviates the need to purchase new, 
unused helmets at retail in order to verify the accuracy of the 
original certification.
    Each year, NOCSAE licensed recertifiers re-test tens of thousands 
of randomly selected helmets of varying brand, model, age and condition 
based on time elapsed since last reconditioned. This recertification 
process is regulated by NOCSAE standard, and controlled by proprietary 
testing and data acquisition software developed by and for NOCSAE. The 
re-testing process is randomized sample based, and involves testing a 
helmet both in the exact condition it was in when it last came off a 
player's head, without any repair or modification, and then testing the 
very same helmet again after it has completed the reconditioning 
process. For each helmet tested, the program collects 28 separate data 
points, including brand, model, model year, size, test headform model 
and size, test laboratory temperature, date and time of testing, the 
name of the test technician and the laboratory name and location, and 
the performance test scores for 8 separate impacts across 4 different 
impact locations.
    In the 2009-2010 reconditioning season, there were 50,508 different 
football helmets tested representing over 50 different models spanning 
more than 10 model years. Additionally there were 880 lacrosse helmets 
tested, and over 1,500 batters helmets tested.
    The NOCSAE data acquisition computer and software used by each 
recertification facility forces an internal and external system 
function and calibration check before and after each batch of helmet 
testing. If the pre-test calibration check test fails, the system 
prohibits testing until the calibration failure is resolved. If the 
system and calibration check test fails after a batch of helmets is 
tested, the test results for those helmets is voided and dumped into a 
special file, and all the helmets tested in that batch must be re-
tested. If the pre-and post-test calibration and system checks pass, 
the helmet test results are stored in an encrypted file which is 
accessible only by the NOCSAE Technical Director for review and 
analysis.
    This dataset provides market and product surveillance information 
for certified helmets new and old, as well as information on team and 
school reconditioning frequency across the country, and on the quality 
controls of each licensed recertifier. From this data an extremely 
detailed historical record of the performance over time of helmet 
models by year, age, and years since last reconditioned has been 
developed. As an example, in the 2009-2010 dataset, the before and 
after performance of several models can be compared over 15 model years 
to determine whether there is a decline in the performance of the 
helmet, and to what extent the reconditioning process has restored or 
even improved the helmet's original performance levels. There is no 
other market surveillance program in the world for personal protective 
equipment that comes close to evaluating the continuing validity of the 
equipment certification.
    A combined dataset that includes testing done from 2005 through 
2011 contains 7,728,000 separate data points on 276,000 individual 
helmets, and includes 2,208,000 helmet impact performance data points.
    This product surveillance process is supplemented by a mandate that 
each certification and recertification facility participate in round-
robin system equipment calibration programs directed by an A2LA 
accredited laboratory at least once a year, and more often if 
indicated.
    As with many international product certification programs, the 
NOCSAE standards mandate that licensees submit certified products for 
testing and validation annually to a third party testing laboratory 
certified to ISO 17025 standards, and that new products or models must 
be submitted for third party laboratory validation in advance of 
distribution. In order to receive a license agreement an applicant must 
first submit a report from an appropriately accredited third party 
laboratory confirming that the products they intend to certify to the 
NOCSAE standard actually meet the standard. Those validation tests and 
reports are a check on the accuracy and validity of the original 
certification of that product consistent with the goals and intent of a 
formal market surveillance program. NOCSAE follows almost the identical 
third-party laboratory validation protocol requirements mandated by the 
CPSC for bicycle helmets certified to the CPSC standard.
    Additionally, if NOCSAE is made aware of a potential invalid or 
incorrect certification, NOCSAE does engage in a focused investigation 
in the form of direct helmet purchase at retail, and testing to 
determine whether the manufacturer's certification is void or valid. We 
will also demand the production of all certification testing data and 
results, including all QA and QC that the licensee uses to support its 
certification of helmets, both as an independent check on the 
certification process, and as part of an investigation as to a specific 
product.
    NOCSAE does not conduct formal market surveillance as part of a 
product certification program, but the requirements in the NOCSAE 
equipment performance standards result in a product surveillance and 
validation function which far exceeds traditional certifying body 
market surveillance programs both in scope and performance demands as 
it validates and verifies helmet standard compliance certification for 
new and used helmets.

    Question 2b. Did NOCSAE ``market surveillance'' efforts, if any, 
discover problems related to compliance with NOCSAE standards at any 
helmet manufacturer or reconditioner? My understanding is that NOCSAE 
did not learn of problems at a New Jersey reconditioning company, for 
example, until after they were exposed by a Federal criminal probe.
    Answer. The only reconditioner that was the subject of a Federal 
investigation was Circle System in Easton, Pennsylvania, and that 
investigation did not involve failed helmets or a failure to properly 
test helmets. The breach in that case was the fraudulent underreporting 
of the number of helmets recertified. There was never a finding by the 
FBI or NOCSAE, following its own separate investigation, that the 
recertified helmets from Circle System failed the recertification 
tests, or that the helmets were poorly reconditioned. From what little 
has been revealed by the investigators and in the press, the owners of 
Circle System apparently defrauded their insurance company and NOCSAE 
by intentionally underreporting the total number of helmets 
recertified, thereby saving significant premium expenses and license 
fees, while at the same time double billing school districts and 
customers.
    Market surveillance testing would not have discovered this type of 
fraud. Reconditioned helmets are not sold at retail, and the helmets 
reconditioned and recertified by Circle System had been reconditioned 
several times before the fraud was discovered, and there was no data to 
support any conclusion that he helmets had been improperly 
reconditioned or incorrectly recertified.
    Although no incidents of product failures have been discovered, 
NOCSAE has discovered several situations which required a licensee to 
revise and supplement its QA and QC programs, and provide supplemental 
testing of larger samples to meet those requirements.

    Question 3. No NOCSAE requirement for maximum helmet lifespan. Mr. 
Oliver, you stated during the hearing that NOCSAE relies on 
manufacturers regarding the recommended lifespan of football helmets. 
However, NOCSAE's own technical director, Dave Halstead, told The New 
York Times he ``would never let [his] kid wear a helmet that is more 
than 10 years old.'' Another NOCSAE expert, Dr. Robert Cantu, wrote in 
review comments for the 2006 Neurosurgery study of Riddell Revolution 
football helmets that:

        ``As Vice President of the National Operating Committee on 
        Standards for Athletic Equipment (NOCSAE), the organization 
        that makes the certification standards for football helmets and 
        other athletic equipment, I am aware . . . that new helmets 
        test to a higher severity index level than older helmets. New 
        helmets out of the box before receiving the thousands of hits 
        that they will incur on ensuing seasons often test 
        significantly below the 1200 severity index that they must 
        pass. Then, with each year's passage of time, their abilities 
        to attenuate acceleration forces decline.''

    Dr. Cantu is also quoted in the book Head Games: Football's 
Concussion Crisis from the NFL to Youth Leagues (page 109) as follows: 
``The brand new helmets that come right off the shelf are about 800 
[SI], way better than the letter of the rule. Over the course of a 
season, or seasons, they get worse. . . .''
    Given that NOCSAE's own experts believe newer helmets are safer 
than older ones, will NOCSAE commit to revising its football helmet 
standards to include a maximum lifespan for football helmets?
    Answer. Questions regarding the proper life span of a helmet, 
sometimes referred to as the useful safe life, involve considerations 
unique to each manufacturer such as design function, product liability 
exposure, proper care and treatment, and materials performance 
characteristics that are outside the authority and function of an 
independent standards setting body such as NOCSAE. Helmet performance 
standards developed by NOCSAE are intentionally design neutral so that 
engineers and designers are not restricted in their approach to helmet 
function and design. That freedom has resulted in the development of at 
least three unique engineered approaches to protecting the heads of 
athletes that involve different materials, different mechanical 
properties, and even different physics principles. Because of these 
differences, life span issues that might be relevant to one type of 
system may not be relevant to the others. Because a standard, by 
definition, must apply equally to all products within its scope, any 
provision that imposes a limit on how long a helmet can be used will be 
an arbitrary decision which can unduly harm one brand while giving an 
advantage to another. The creation of a maximum life for a helmet 
through a standard also creates a risk that players and parents will 
assume that a helmet is safe and needs no attention as long as it is 
still within the defined ``useful safe life.'' Notwithstanding these 
concerns, what NOCSAE can do, and what it does, is continuously 
evaluate the performance of helmets over time to see if there are data 
that might indicate the need to further investigate this issue.
    I am personally familiar with each individual quoted, and based 
that and the actual helmet performance test data that NOCSAE has 
collected over the past 15 years, I am confident that Dr. Cantu and Mr. 
Halstead were referring to older helmets that have not been properly 
and regularly reconditioned when they were commenting on helmets of a 
particular age. Recertification test data covering hundreds of 
thousands of helmets document a helmet's performance over time and 
under various reconditioning frequencies, and the data does not support 
a conclusion that a helmet's age, standing alone, is related to that 
helmet's performance abilities. There is very little, if any, decline 
in the performance of a football helmet over the course of a season, 
absent significant abuse or intentional alteration of the padding 
system. Football helmets are designed to handle repeated impacts in 
quick succession over thousands of impacts. Current literature 
involving the in vivo collection of football helmet impacts over more 
than 7 seasons by researchers at upper division colleges and at the 
high school level has shown that a player's helmet will likely be hit 
more than a thousand times per season. In 2009-2010, new 2009 helmet 
models tested after just a single football season and before any 
reconditioning, averaged in the 500 to 600 SI range on the impact 
location which is most likely to have the highest SI values. That value 
is almost identical to the average SI values scores as new unused 
helmets, and in many cases that number is actually lower than when the 
helmet model was tested for certification as a new helmet.
    For a 10 year old helmet that has been properly reconditioned and 
has had the padding system replaced with new padding that meets or 
exceeds the original padding performance levels, the only 10 year old 
part of that helmet is the shell, and unless the shell is cracked, 
which would prevent its recertification, that helmet should perform as 
good if not better, than when it was new. And the recertification 
testing data shows that such is true.
    Tragically, catastrophic and even fatal head injuries have occurred 
to players wearing brand new helmets, which speaks more to the fact 
that there are some serious and even fatal head injuries which cannot 
be prevented by any helmet. The rapid and usually fatal brain swelling 
and auto-regulatory dysfunction that is seen in second-impact syndrome, 
which seems consistent with facts describing the injury to Max Conradt, 
can occur from very slight hits to the head and even without head 
contact through whiplash type accelerations of the head if that player 
has been returned to play too soon following a concussion. In those 
cases, the injury risk likely is unrelated to the age or performance of 
the helmet being worn.

    Question 4. Helmet requirements for high school football. The 
National Federation of State High School Associations (NFHS) sets 
football playing rules and equipment guidelines that are adopted by 
many state athletic associations. The 2010 NFHS Football Rules book 
requires players to wear a football helmet and face mask that ``met the 
NOCSAE test standard at the times of manufacture'' (see page 17). 
However, NFHS rules allow a football helmet that is no longer in 
compliance with NOCSAE standards to be worn by high school player as 
long as the helmet met NOCSAE standards when it was originally made. 
NFHS also does not require that an older helmet be reconditioned and 
recertified to NOCSAE standards. Should high school football equipment 
rules require that any helmet used by a player meet current NOCSAE 
requirements when it is actually being worn--and not just on the day it 
was manufactured?
    Answer. As with any equipment or product certified as compliant 
with a standard at the time the new product was manufactured, once 
placed in use, the continued validity of that certification is 
dependent not only upon proper use and care, but also on the designed 
durability of all component parts, and the margin between the 
standard's pass-fail threshold requirements and the actual helmet test 
performance when certified. From years of post-use recertification 
testing of all brands and models and ages of helmets, 99.86 percent of 
the helmets tested from the field after one or more seasons of use and 
before reconditioning will perform far below the threshold and still 
meet the standard by a significant margin. This extremely high 
percentage includes all helmet models, all ages, and all conditions, 
and it includes helmets which may have had altered or damaged padding, 
since the BEFORE reconditioning test of these randomly selected helmets 
does not permit repair before the helmet is tested. When tested after 
reconditioning, the percentage that passes is 99.95 percent, and the 
0.05 percent that doesn't pass is not returned to the school or club. 
So the persistence of the validity of a helmet's certification to the 
NOCSAE standard over time and use is extremely high when helmets are 
regularly reconditioned. That means that it is extremely rare for a 
helmet to be used by a player that doesn't meet the standard, even 
after significant use over several seasons.
    An important reason for such extremely high certification validity 
persistence is the Quality Control and Quality Assurance levels that 
are imposed upon NOCSAE licensees who certify their equipment to NOCSAE 
standards. In order to reach the zero defect or 0 AQL levels, the 
average passing SI value for every new helmet impact location must be 
substantially below the pass-fail threshold of 1200 SI. For all new 
2010 adult and varsity helmets in size medium certified to the NOCSAE 
standard, the average certification SI value was 497 on the front 
location, which historically has the highest SI values. This same 
general margin has existed for many years.
    With the levels of Quality Assurance and Quality Control mandated 
by the NOCSAE standard, all organizations, including high schools, 
should have the highest level of confidence that the helmets meet the 
NOCSAE standard.

    Question 5. Football helmet reconditioning. The NOCSAE website FAQ 
page states that ``There is nothing in the NOCSAE standard that 
requires any helmet to be recertified on any regular basis.'' Ralph 
Conradt states that his son Max was injured while wearing a twenty year 
old helmet that, when tested after Max's injury, was found to not meet 
NOCSAE's safety standards. Given that some high school football players 
could be wearing unsafe helmets that are twenty years old and that no 
longer meet NOCSAE standards, will NOCSAE commit to updating its 
football helmet standards to require reconditioning on a regular basis?
    Answer. How frequently a particular helmet should be reconditioned 
and recertified is dependent upon many uncontrollable variables, 
including the level and intensity of usage and condition at the end of 
a season. The reconditioning and recertification process is a 
significant budget item for most high schools, and a standard 
arbitrarily mandates annual reconditioning where the data does not 
support the conclusion that annual recertification is necessary at 
every school or with every helmet simply adds additional budget and 
expense burdens to school districts already facing severe pressures. 
NOCSAE is committed to exploring options in this regard, and currently 
strongly recommends reconditioning and recertification every year. When 
a school or club cannot afford annual recertification of all their 
helmets, NOCSAE strongly recommends the adoption of a two-year or 
three-year cycle of regular reconditioning and recertification such 
that each year one third to one half of the helmets in the program are 
submitted for reconditioning and recertification, and the remainder are 
evaluated pursuant to a written inspection and assessment program to 
identify helmets with obvious damage, missing pads or components, or 
other signs that indicate the need for reconditioning and 
recertification, even if that helmet is not scheduled for 
reconditioning.
    Data available to NOCSAE from the recertification test datasets 
establishes that, with the exception of helmets which are missing pads 
or which have been altered or may have broken shells, there is no 
statistically difference in the average SI values of helmets submitted 
every year for reconditioning/recertification and those submitted every 
other year, or even every three years. As a general rule, the primary 
benefit of annual reconditioning and recertification is that it inserts 
an experienced third party into the helmet inspection and assessment 
process, and increases the likelihood that hidden problems or 
unrecognized damage will be discovered and addressed, and it probably 
would limit the swapping of pads and padding systems among different 
helmet brands and models.

Max Conradt
    When the helmet used by Max Conradt was made and certified to the 
NOCSAE standard in 1983, the pass/fail threshold in the standard was 
1500 SI. Helmets can only be recertified to the standard applicable to 
the original certification. The testing data presented to the court in 
the Conradt case by an accredited laboratory acceptable to the court 
and to each side, established that the helmet in question, when tested 
to the NOCSAE standard after Max Conradt was injured passed all impact 
test locations below the 1500 SI threshold, and even passed all impact 
location tests to the 1200 SI threshold, with one location exception, 
and that location was not a location where it was suspected that Max 
had been hit. The Conradt helmet was manufactured in 1983, just 3 years 
after the NFHS made compliance with the NOCSAE standard mandatory for 
high school play. As recently as 2009-2010, of the 48,000 randomly 
selected helmet sample set tested for recertification, there were 28 
helmets in the sample set made before 1991, and all tested below the 
1200 threshold BEFORE (meaning as they were in use and on the field) 
reconditioning on every test impact location, even though the 
applicable threshold for those helmets was 1500.
    The type of severe and life changing head injury sustained by Max 
Conradt, although very rare, has no specific association with the age 
or SI values of a particular football helmet. Almost identical non-
fatal and fatal injuries have occurred to players wearing brand new 
2009 and 2010 helmet models, and some epidemiological data suggest that 
the rate of occurrence of these types of injuries has remained 
relatively steady over time, unaffected by improvements in helmet 
technology, SI values or helmet age.
    Certainly the best level of protection any helmet can provide is a 
function of proper maintenance, regular reconditioning and 
recertification, and following warnings and instructions. No standard 
can guarantee an outcome or even a performance level, but compliance 
with the NOCSAE standard will provide the player, coach and parent with 
the highest level of protection available today, and as much assurance 
as is possible that the helmet will continue to meet that standard as 
long as it is properly maintained.

    Question 6. Football helmets in use at high school and younger 
level. USA Football estimates that there are 3 million youth football 
players. In addition, there are an estimated 1.4 million high school 
football players. Of this group of about 4.4 million football players, 
how many are wearing:

        (1) new helmets

        (2) helmets manufactured or reconditioned in the last year

        (3) helmets manufactured or reconditioned in the last two years

        (4) helmets that have not been reconditioned in more than two 
        years

        (5) helmets older than two years that have never been 
        reconditioned?

    Answer. It is impossible to know the answers with definite 
certainty because many of those players are outside the control and 
supervision of any national governing body. We do know that on average 
there are approximately 800,000 new helmets sold each year, and 
approximately 52 percent of those are categorized as ``youth models'' 
which could include models intended for use at the middle school level. 
We also know that there are youth players who must wear adult or 
varsity helmets because the youth models are too small for them.

        (1) new helmets: approximately 800,000 are wearing new helmets

        (2) helmets manufactured or reconditioned in the last year: 2.5 
        million

        (3) helmets manufactured or reconditioned in the last two 
        years: 3 million

        (4) helmets that have not been reconditioned in more than two 
        years: it is impossible to know this number exactly. We know 
        that each year there are approximately 250,000 helmets sent for 
        reconditioning and recertification that have not been 
        reconditioned for more than 2 years, but we currently have no 
        way to know whether that number is statistically representative 
        of the helmets in the field.

        (5) helmets older than two years that have never been 
        reconditioned: unless the helmets are sent for reconditioning, 
        there is no way to answer to this question.

    Question 7. NOCSAE drop test and helmet quality. My understanding 
is that the NOCSAE safety standard for football helmets is primarily a 
drop test method that requires helmets to score less than a 1200 
severity index (SI) level. Is there a difference in the level of 
protection offered by a helmet that tests at an 1199 SI level and a 
helmet that tests at a 300 SI level?
    Answer. The answer depends on which type of injury is being 
analyzed. The 1200 SI threshold is premised upon a risk analysis curve, 
very much the same as HIC values used in Federal Motor Vehicle Safety 
Standards. The HIC and SI plotted curves are logarithmic and as the 
values pass downward through 1200 the curve flattens such that 
measurable differences between 1200, 1100, 1000, and on down become 
very small. As to those injuries for which the 1200 SI threshold is 
intended to address, no quantitative or qualitative comparisons can be 
made between SI values of 300 and 1100 as to which will prevent more 
injuries. Certainly lower (all other helmet attributes like mass and 
shape being the same) would be better in general, but there is no 
linear relationship or scale than can state with any confidence how 
much more protective a lower value is over a higher value. This is 
particularly true with regard to the kinds of engineering and design 
changes that might be necessary to obtain lower values, and whether the 
impact being tested is a high energy impact or a low energy impact.
    An SI score of 1200 is essentially equivalent to a HIC score of 
1000, which represents the ``safe'' limit of human injury tolerance, 
above which the risk of a fatal or catastrophic head injury is clear, 
and the probability of that type of injury rapidly increases with 
higher SI values. But because of the logarithmic characteristic of the 
scale, the converse is not true as the values decrease below 1200. The 
1200 SI threshold is like a doorway, once you are through it you can go 
further into the room, but outside is still outside. An SI value lower 
than 1200 represents some reduction in risk, although very minor 
(negligible), but going higher represents a near exponential increase 
in risk. The importance and validity of HIC or SI as weighted impulse 
criteria is frequently debated but the criterion remains extensively 
used because no better formulations or thresholds have demonstrated 
reduced injury risk. For example, in the USA, Europe and elsewhere, 
government mandated performance requirements for automotive seatbelts, 
airbags and other safety devices are specified in terms of a `not to 
exceed' HIC score, with no specified benefits for being under that 
limit by any percentage.

    Question 8. Clearly visible labels. Mr. Oliver, you stated during 
the hearing that NOCSAE does require clearly visible ``date of 
manufacture'' and ``date of last reconditioning'' labels for football 
helmets. However, the primary NOCSAE technical standard for football 
helmets, NOCSAE DOC (ND) 001-08m10, in section 9.4, states that helmets 
must have:

        ``A permanent and legible label or mark that denotes the month 
        and year of manufacture that can be easily read without 
        removing any permanent component. If this mark or label 
        requires a `code' to determine month and year, such code shall 
        be made available upon request.''

    This contrasts with the standard's requirements that other labels 
are ``not obscured in any manner.''

   Will NOCSAE commit to revising its standard to include a 
        requirement for clearly visible date of manufacture and date of 
        last reconditioning labels that are not obscured in any manner?

   Will NOCSAE commit to revising its standard to require that 
        the date of manufacture and date of last reconditioning be 
        easily read and understood by players, coaches and parents? In 
        other words, will NOCSAE require that such labels are not 
        written in ``code'' which can only be interpreted by the 
        manufacturer or reconditioner
    Answer. New Helmets. NOCSAE is committed to evaluating the existing 
standard requirements for the placement and visibility of a 
manufacturing and recertification date for helmets certified or 
recertified to the NOCSAE standard. The NOCSAE standards incorporate 
the considerations contained in ANSI Z535.4, and NOCSAE is committed to 
continued compliance for all helmet labeling and warning requirements. 
We are currently exploring several options for improvement, and we are 
committed to that process as we always are in maintaining NOCSAE 
standards. Deciding whether and how a specific piece of information is 
located and identified on the helmet also involves human factors 
consideration as to whether such information may dilute the effect of, 
or divert visual attention from, other specific hazard warnings and 
signal words already on the external portions of the helmet.
    ANSI warning label requirements distinguish between warning labels 
that address hazards and those which convey information that may be 
related to hazards and indicate matters such as location and 
visibility. The age of the helmet shell, which is all the manufactured 
date will reliably indicate for a used helmet, is not related to any 
identified hazard or risk of injury, nor is it a piece of information 
reasonably necessary to be accessed under emergent circumstances. There 
is also no common agreement or understanding with regard to whether the 
more important date for a consumer or user is the date the helmet was 
first used and not the date the shell was made. A helmet with a 
manufactured date of 2009 may not first be used by a player until the 
fall of 2011. Is the manufactured date for that helmet more 
representative of its quality and ability to perform than a helmet with 
a manufactured date of 2010, but which has been used for part of the 
2009-2010 season and all of the 2010-2011 season?
    To complicate matters more, there are helmets which may have their 
component parts manufactured on different dates and not actually 
assembled for a year or more. Which date is the one which should be 
provided to the consumer in those cases? If the shell was manufactured 
in 2009, the various protective energy attenuating system components 
manufactured in 2008, 2009, and 2010, and final assembly of that helmet 
did not occur until 2012, which of those dates is provides material and 
useful information for the consumer to know with regard to the ability 
of that helmet to perform? The issue of a manufactured date is not a 
simple one, and NOCSAE is committed to investigate and address the 
matter to determine if there's a better or more functional way to 
present the model year information.

Reconditioned Helmets
    NOCSAE recertification standards have required for many years that 
the reconditioning and recertification date be plainly visible and 
placed on the helmet. The recertification date and the identity of the 
entity that performed the reconditioning and recertification are 
required. All licensed recertifying companies follow the same format 
and actually use the same company to print the labels for each season. 
If the manufacturer's original certification logo is no longer visible 
on the outside of the helmet, then a recertification label must be 
placed on the outside. An example of the outside information mandated 
by the NOCSAE standard is:



    Every recertified helmet must also have a label on the inside, 
underneath the padding, which includes a statement verifying 
recertification and indicating the year and name of the company which 
performed the recertification. Placement of this information on the 
inside of the helmet shell and underneath removable padding makes it 
easily accessible, while also protecting the label and information from 
damage and removal during usage. As with the manufacturing date of a 
helmet or helmet shell, the recertification date and identity of the 
recertifying entity is not information that would need to be accessed 
quickly under emergency circumstances, but should be easily accessible 
without having to remove permanent component parts.

    Question 9. NOCSAE licensing agreement and advertisements with 
NOCSAE seal. Mr. Oliver, your written testimony states that NOCSAE's 
licensing agreement with helmet makers ``obligates each licensee to 
obtain prior approval of proposed advertising which uses the NOCSAE 
name or references NOCSAE as part of its advertising.''
    A Riddell brochure titled ``Revolution Helmet Research Findings'' 
(available at: http://www.lohud.com/assets/pdf/BH1661391028.PDF, 
accessed Oct. 19, 2011) references NOCSAE in three separate places and 
includes the NOCSAE seal in two places. This advertisement prominently 
features Riddell's claim that research shows a ``31 percent reduction 
of the relative risk of sustaining a concussion when wearing a 
Revolution vs. a traditional helmet.''

   Did Riddell obtain approval from NOCSAE to use the NOCSAE 
        seal and name in this brochure?

   If so, why did NOCSAE approve the use of its seal and name 
        in an advertisement featuring a concussion reduction claim that 
        NOCSAE technical director Dave Halstead and NOCSAE board member 
        Dr. Robert Cantu have publicly criticized?

    Answer. The authority of NOCSAE under the license agreement to 
review licensee advertising is limited to ensuring compliance with 
permitted uses of the name, phrases and certification marks which are 
trademarked and registered properties of NOCSAE. The license agreement 
does not provide NOCSAE with a blanket right or duty to review and 
approve all advertising content, nor to impose its own opinions as to 
the accuracy of claims that do not involve actual or potential misuse 
of the registered and trademarked properties. The NOCSAE seal, mark and 
name were properly used in the referenced advertising, and were not a 
part of or suggested as support for the other claims in the 
advertising. NOCSAE does not endorse recommend or indicate the use of 
any particular helmet, other than to state that the helmet meet the 
standard.
    NOCSAE board members and independent contractors, such as Mr. 
Halstead, are free to comment on matters of interest to them, including 
the references described in this question.

    Question 10. Independent Testing and Certification. Mr. Oliver, 
your testimony states that ``NOCSAE also maintains an ongoing 
independent contract with an A2LA accredited and ISO 17025 certified 
testing laboratory.''

   Is this testing laboratory also accredited to ISO Guide 65, 
        ``General Requirements for Bodies Operating Product 
        Certification Systems''?

   Does NOCSAE's testing laboratory have any commercial ties to 
        helmet manufacturers or reconditioners that could potentially 
        create a conflict of interest when certifying helmets to NOCSAE 
        standards? If so, please clearly describe any such potential 
        conflict of interest.

    Answer. It should be kept in mind that neither NOCSAE nor the 
laboratory in question certifies products or equipment to the NOCSAE 
standards. ISO Guide 65 pertains only to entities which actually 
certify products or equipment. Certification of compliance with NOCSAE 
standards is done by the manufacturer pursuant to a license agreement, 
and annual proof of compliance with the standards through third-party 
laboratory validation testing. The procedure tracks very closely to the 
self-certification made by manufacturers under the CPSC rules for 
bicycle helmets, except that the authority of NOCSAE over the 
manufacturer is based on the license agreement, not Federal laws and 
regulations.
    The laboratory with which NOCSAE contracts for technical advice and 
testing is the Southern Impact Research Center, (``SIRC''). SIRC is 
A2LA accredited and certified as compliant with ISO 17025 standards for 
independent testing laboratories to perform testing to all NOCSAE 
standards, and is also an approved and accredited testing laboratory 
under the CPSC Bicycle helmet standard, and is directly approved by the 
CPSC for independent testing under 16 CFR Part 1203 and Part 1501. SIRC 
is also A2LA accredited to perform testing under FMVSS 218 VESC-8, Sec 
8 for motorcycle helmets eye protection and many other helmets. The lab 
is under contract with the military for independent testing of military 
related items.
    SIRC is not certified under ISO Guide 65, at least for NOCSAE 
purposes, as they do not perform product certification to the NOCSAE 
standards, but SIRC is involved with product certifications with the 
Safety Equipment Institute which is a Guide 65 entity.
    The only commercial relationships which SIRC has with manufacturers 
who may also be NOCSAE licensees would be on a job by job basis where a 
licensee may contract with SIRC laboratory to conduct validation 
testing, or to submit products for evaluative testing. All board 
members and contractors are required to submit conflict of interest 
disclosure statements.

    Question 11. NOCSAE not keeping football helmet standard up to 
date. Mr. Oliver, several NOCSAE members have publicly criticized your 
organization for not doing enough when it comes to keeping helmet 
standards up to date. In an October 20, 2010 New York Times article, 
reporter Alan Schwarz quotes Dr. Robert Cantu as saying that NOCSAE has 
been ``asleep at the switch'' and that Cantu has been ``calling for a 
new standard to be written for football helmets for years, and NOCSAE 
has been sitting on their duffs.''
    The New York Times article further notes that: ``Dr. Cantu. . .said 
that the board has become as concerned about legal liability as about 
child safety. If [NOCSAE] were to supplement its helmet standard in an 
attempt to address concussions, it could open itself to lawsuits 
brought by players saying that their helmet did not prevent the injury. 
. . .''
    Dr. Blaine Hoshizaki, from the University of Ottawa, told the The 
New York Times that he lobbied NOCSAE to strengthen its standard five 
or six years ago but he says, ``It was like punching a balloon; they, 
yes, understand, and then do nothing.'' In the article, he goes on to 
say of NOCSAE: ``They say they don't know what the thresholds are; OK, 
but I can tell you that less angular acceleration is better than more . 
. . To suggest we have no idea so we'll do nothing is not an excuse to 
me. This has become a serious impediment to making a safer football 
environment.''

   Given this level of criticism from NOCSAE's own experts, why 
        should coaches and parents of young football players rely on 
        NOCSAE to maintain up-to-date voluntary safety standards for 
        football helmets?

   What steps will NOCSAE take to update and maintain its 
        helmet standards given new medical understanding of concussion 
        risk and the latest state of the art in helmet technology?

    Answer. I have attached copies of the written responses from each 
gentleman addressing The New York Times assertions with regard to 
NOCSAE. I cannot explain why the quotes in the article differ markedly 
from what the quoted speakers have said in response, nor can I explain 
why the article contains assertions that differ from the documented and 
uncontested facts
    The quotes from The New York Times do not accurately reflect the 
comments and opinions of those who were quoted. In a letter he prepared 
and sent to Mr. Schwarz, (attached as Appendix A) Dr. Cantu took issue 
with the quotes attributed to him:

        ``Since 2000, NOCSAE has provided approximately $2.4 million to 
        fund research grants looking at all aspects of concussion in 
        sports, including validation of the new linear impactor. In 
        January 2010, by motion I fully supported, NOCSAE created a 
        special ad hoc committee to examine any other possible avenues 
        to more rapidly advance science and research in the area of 
        concussion. The NOCSAE Multi-Disciplinary Expert Task Force 
        which met on October 23 on Cape Cod was one of those avenues 
        identified by the ad hoc committee. This meeting was being 
        planned and developed long before your investigation and is a 
        process which NOCSAE has followed in the past.

        These activities are not those of a group that is ``asleep at 
        the switch'' or that has been ``sitting on its duff,'' quotes 
        you attributed to me. Every NOCSAE Board member is frustrated 
        that there is yet no answer as to how concussions might be more 
        effectively addressed in our helmet standards, but the 
        frustration is not with NOCSAE, it is that despite our own 
        internal efforts and substantial research funding to outside 
        experts, science has yet to find an answer that we can 
        incorporate into our helmet standards to specifically improve 
        concussion protection.''

    As general counsel I can state with certainty that no decision 
regarding new standards or changes to existing standards was based or 
premised upon potential legal liability that might arise because of the 
differences between helmets certified under older standards and ones 
certified to the newer standards. Such a decision was in fact made when 
the first NOCSAE football helmet standard was published in 1973. That 
new standard rendered almost 80 percent of existing helmets non-
compliant. And the same decision was made when the pass/fail threshold 
was revised from 1500 SI to 1200 SI.
    To the extent any legal liability might exist at all, it would 
arise from acting arbitrarily in adopting or revising a standard 
without the valid scientific data necessary to support a conclusion 
that the change would be effective, and that it would not create an 
increased risk of other injuries. NOCSAE has a responsibility to the 
public and to players and parents to premise its standards on science 
and valid data, and it will not abandon that responsibility to cater to 
the pressures and demands of non-scientists. In order for the public to 
have the confidence that the NOCSAE standard has meaning and validity, 
it must be premised upon sound and consensus scientific data.
    Regarding the quotes attributed to Dr. Hoshizaki, I asked him for 
clarification following the printing of the article in question. The 
quotes attributed to him were personally puzzling because I knew he had 
never contacted me to discuss any of the issues identified in the 
article. I also knew that he had not attended any board meetings since 
I became Executive Director in 1995, and I was unable to find any 
correspondence or other e-mail contacts from him on those subjects. Dr. 
Hoshizaki was kind enough to respond in writing (attached as Appendix B 
to these responses), and he explained to me:

        ``As for the comments recorded in The New York Times article 
        they were the author's interpretation of what I felt is a 
        disconnect between NOCSAE and the broader scientific community. 
        My previous discussions with David Hallstead [sic] revolved 
        around understanding the process for the [sic] making decisions 
        regarding the development of the NOCSAE test standards and 
        resulting implications.''

    Dr. Hoshizaki is certainly a well-respected scientist and 
biomechanical engineer, and has published some excellent work regarding 
helmet performance and biomechanics of head injury. It appears that he 
was frustrated with his understanding of the NOCSAE process, and 
perhaps his interactions with Mr. Halstead on other standards related 
issues with other organizations. Mr. Halstead and Dr. Hoshizaki have 
worked together on many non-NOCSAE activities and are in fact at this 
time working together on a research project in this very area. There 
was never any lobbying effort by Dr. Hoshizaki as the reporter 
described, and the board meeting minutes do not contain any references 
to such attempts. Any such requests by Dr. Hoshizaki would certainly 
have been seriously considered and discussed, simply because of his 
reputation. In fact, the NOCSAE board had contacted Dr. Hoshizaki in 
the year prior to the printing of The New York Times article to request 
that he serve on a NOCSAE sponsored Concussion Task Force expert panel 
that was convened in October 2010 to help NOCSAE map out a plan for 
focusing research efforts to better address concussions through helmet 
standards.
    As for his quote regarding the injury threshold levels, all that 
can be said is that almost every peer reviewed article that has 
considered this question in the last 10 years has reached a different 
conclusion. The consensus scientific opinion on this issue is clearly 
expressed by Dr. Kevin Guskiewicz in a 2011 article describing the 
elusive injury threshold for concussions and mTBI:

        ``What is the relationship between clinical outcome measures 
        from our earlier work and biomechanical factors? The literature 
        has not adequately addressed this question. We hypothesize that 
        within the spectrum of concussion or mTBI, the biomechanical 
        threshold for sustaining the injury is not only elusive, but 
        impact severity (measured in acceleration/deceleration) may be 
        clinically irrelevant.'' Guskiewicz, K. M. and J. P. Mihalik 
        (2011). ``Biomechanics of sport concussion: quest for the 
        elusive injury threshold.'' Exerc Sport Sci Rev 39(1): 4-11.

    The Task Force Committee, with significant input from Dr. Hoshizaki 
and Dr. Guskiewicz, agreed there was no present threshold which could 
be incorporated into a helmet standard that could effectively reduce 
the frequency and or severity of concussions. The Task Force committee 
identified specific research and work that would be necessary to reach 
a point where revisions could be made to the NOCSAE standards that 
could effectively address concussion issues. Dr. Hoshizaki is currently 
doing some of that very work at the present time under a focused 
research grant from NOCSAE.
    There is no helmet standard in the world which more effectively or 
aggressively addresses head injuries than does the NOCSAE standard. 
Apart from the Federal government, there is no other organization that 
has invested more research dollars over the past 10 years to address 
concussion protection through helmet performance standards than has 
NOCSAE. As explained by Dr. Cantu and his written response to the 
inaccurate quotes in The New York Times article, these are the actions 
of a group that is leading the way for the development of helmet 
standards to address concussions effectively, not an entity sitting on 
the sidelines waiting on someone else to do the work.
    To the extent there is a ``new medical understanding of concussion 
risk and the latest state of the art in helmet technology'' referenced 
in the question, such advances exist in very large part due to the 
financial support from NOCSAE research grants, and the NOCSAE board, 
staff, and its Scientific Advisory Committee are intimately familiar 
with such developments, but this ``new understanding'' has not answered 
the specific questions necessary to support a change to the NOCSAE 
standards to address concussions.
    You ask ``. . .why should coaches and parents of young football 
players rely on NOCSAE to maintain up-to-date voluntary safety 
standards for football helmets?''
    In comparative testing performed on almost every type of protective 
helmet, whether sports, or otherwise, football helmets certified to the 
NOCSAE standard consistently and markedly outperform every helmet in 
all impact categories, whether in protecting from low-level impacts, 
high velocity impacts, head coverage, or durability. There is no other 
helmet standard in the world which demands the same level of quality 
control and quality assurance in the manufacturing and production 
process as that which is mandated by the NOCSAE standards. And although 
millions of research dollars have been and are being invested by NOCSAE 
to improve the standards and reduce the frequency and severity of all 
head injuries including concussions, football helmets certified to the 
NOCSAE standard perform at the highest levels. Helmet testing data, 
including the testing of bare head forms without helmets, show that a 
helmet certified to the NOCSAE standard will reduce the resultant head 
accelerations in large and small impacts by almost 70 percent. Between 
high school and collegiate football players, there are more than 
600,000,000 helmet impacts during the course of a single season which 
result in head accelerations exceeding 15 g's after the helmet has done 
its work. It is arguable, that without a helmet certified to the NOCSAE 
standard, each of those blows to the head would have been hard enough 
to result in a concussion or worse.
    NOCSAE is committed to improving helmet performance standards to 
effectively address concussions, and when there is reliable consensus 
scientific support for a specific change to accomplish that goal, 
NOCSAE will undoubtedly be the first to incorporate those changes. 
Until then, coaches and parents can count on NOCSAE not to experiment 
with their children's safety by making changes to the standard simply 
on the hope that a scientifically unsupported change might work.
                                 ______
                                 
                Appendix A--Letter from Dr. Robert Cantu





                                 ______
                                 
              Appendix B--Letter from Dr. Blaine Hoshizaki





                                 ______
                                 
     Response to Written Questions Submitted by Hon. John Thune to 
                              Mike Oliver

    Question 1. Improper Tackling Technique and Concussions. I'm aware 
that NFL and college football teams today have significantly reduced 
the amount of time devoted during practice to proper tackling and other 
football fundamentals. I recognize that coaches are limiting some of 
the physical contact during practice to prevent injuries. However, my 
concern is that less time devoted to teaching proper tackling technique 
may be contributing to an increase in concussions during games. 
Specifically, players these days seem to lead with their head rather 
than wrapping a player up with one's arms and body, and keeping their 
head up. Do you see any connection, at all levels of football, to 
improper tackling technique and an increase in concussions?
    Answer. In the course of a football game players will receive high 
energy hits to the head that are unavoidable and unintentional, and it 
is not likely those kinds of hits can be eliminated from the game of 
football. But the use of tackling techniques in which the player 
initiates contact with the head or targets the head of the other 
offensive player are dangerous, unnecessary, and avoidable. Not only do 
they increase the risk of sustaining a concussion or causing a 
concussion in the opposing player, or both, those techniques also place 
the tackling player at an increased risk of spinal cord injury and even 
death.
    Debate exists among experts in concussion epidemiology whether 
there is really an increase in the number of concussions, or whether 
the increase in diagnosis is a function of greater awareness and 
attention to the importance of addressing concussions. I think most 
believe that the actual rate is essentially unchanged, but recognition 
and diagnosis is much greater. But even if the rate is not higher today 
than it has been historically, the number of concussions can be 
significantly reduced simply by eliminating the intentional use of the 
head to initiate contact, and the vast majority of those events happen 
through poor tackling techniques.
    Sometimes those incorrect techniques are taught, but in many cases 
they develop from a lack of teaching and player correction at early 
ages. Dr. Kevin Guskiewicz at the University of North Carolina has been 
monitoring the players on the football team at UNC through the use of 
an in-helmet impact monitoring and telemetry system that records the 
magnitude and location of every impact to a player's helmet in 
practices and games. One of the information gleaned from this data is 
that they are able to identify those players who record far more 
impacts to the top of the helmet than other players on the team. Dr. 
Guskiewicz and his staff are able to meet with these players and 
undertake behavior modification to try and eliminate those avoidable 
hits to the top of the head. Clearly the issue of leading with the head 
is very important in the efforts to reduce the frequency and severity 
of concussions, even with elite athletes at the collegiate level.

    Question 2. Do you think this improper tackling technique is caused 
by less time being devoted to teaching good technique in practice?
    Answer. As players mature and develop, it is natural for most 
coaches to focus more on the subtle aspects and complicated skills of 
the game, and spend less time on the fundamentals. If players don't 
develop the reaction and muscle memory to effectively ``see what you 
hit'' when tackling and blocking as youth players, it is unlikely they 
will suddenly develop those skills in high school, and even less likely 
in college. The time to spend the time is when players have not yet 
developed the bad habits.

    Question 3. As part of the campaign to highlight concussion 
awareness, how much emphasis is being placed on educating coaches and 
players about using proper tackling technique to reduce concussions?
    Answer. The emphasis on concussion prevention and recognition is 
extensive and growing monthly.
    NOCSAE in partnership with the CDCP is creating a parent targeted 
concussion awareness and prevention program called ``Heads Up to 
Parents'' which designed and created to reach all parents of football 
players and provide access to an extensive online resource to address 
all aspects of concussion prevention, including proper tackling and 
blocking techniques.
    There are coaching education programs at all levels which provide 
the necessary instruction and teaching tools to help coaches instruct 
their players. The American Football Coaches Association provides such 
training and educational programs for high school through collegiate 
levels, and has teamed with the National Athletic Trainers Association 
to make education and training videos that address head and neck injury 
prevention, which can be accessed at http://www.afca.com/article/
article.php?id=968. The National Federation of State High School 
Associations (``NFHS'') provides online coaching education and 
certification in the areas of concussion prevention as well. For youth 
football, USA Football in partnership with the NFL provides a wealth of 
coaching and player education programs in person and online that 
address concussion prevention through proper playing and tackling 
techniques. These resources can be accessed at http://
www.usafootball.com/health-safety/prevention-preparation.

                                  
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