[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]





            IMPROVING SPORTS SAFETY: A MULTIFACETED APPROACH

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

                                HEARING

                               BEFORE THE

           SUBCOMMITTEE ON COMMERCE, MANUFACTURING, AND TRADE

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 13, 2014

                               __________

                           Serial No. 113-128


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

RALPH M. HALL, Texas                 HENRY A. WAXMAN, California
JOE BARTON, Texas                      Ranking Member
  Chairman Emeritus                  JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky               FRANK PALLONE, Jr., New Jersey
JOHN SHIMKUS, Illinois               BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania        ANNA G. ESHOO, California
GREG WALDEN, Oregon                  ELIOT L. ENGEL, New York
LEE TERRY, Nebraska                  GENE GREEN, Texas
MIKE ROGERS, Michigan                DIANA DeGETTE, Colorado
TIM MURPHY, Pennsylvania             LOIS CAPPS, California
MICHAEL C. BURGESS, Texas            MICHAEL F. DOYLE, Pennsylvania
MARSHA BLACKBURN, Tennessee          JANICE D. SCHAKOWSKY, Illinois
  Vice Chairman                      JIM MATHESON, Utah
PHIL GINGREY, Georgia                G.K. BUTTERFIELD, North Carolina
STEVE SCALISE, Louisiana             JOHN BARROW, Georgia
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   DONNA M. CHRISTENSEN, Virgin 
GREGG HARPER, Mississippi            Islands
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BILL CASSIDY, Louisiana              JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky              JERRY McNERNEY, California
PETE OLSON, Texas                    BRUCE L. BRALEY, Iowa
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
CORY GARDNER, Colorado               BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas                  PAUL TONKO, New York
ADAM KINZINGER, Illinois             JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Ohio
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina

                                 _____

           Subcommittee on Commerce, Manufacturing, and Trade

                          LEE TERRY, Nebraska
                                 Chairman
LEONARD LANCE, New Jersey            JANICE D. SCHAKOWSKY, Illinois
  Vice Chairman                        Ranking Member
MARSHA BLACKBURN, Tennessee          JOHN P. SARBANES, Maryland
GREGG HARPER, Mississippi            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    JOHN A. YARMUTH, Kentucky
DAVID B. McKINLEY, West Virginia     JOHN D. DINGELL, Michigan
MIKE POMPEO, Kansas                  BOBBY L. RUSH, Illinois
ADAM KINZINGER, Illinois             JIM MATHESON, Utah
GUS M. BILIRAKIS, Florida            JOHN BARROW, Georgia
BILL JOHNSON, Ohio                   DONNA M. CHRISTENSEN, Virgin 
BILLY LONG, Missouri                     Islands
JOE BARTON, Texas                    HENRY A. WAXMAN, California (ex 
FRED UPTON, Michigan (ex officio)        officio)

                                  (ii)
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Lee Terry, a Representative in Congress from the State of 
  Nebraska, opening statement....................................     1
    Prepared statement...........................................     3
Hon. Janice D. Schakowsky, a Representative in Congress from the 
  State of Illinois, opening statement...........................     4
Hon. Leonard Lance, a Representative in Congress from the State 
  of New Jersey, opening statement...............................     5
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................     6

                               Witnesses

William L. Daly, Deputy Commissioner, National Hockey League.....     8
    Prepared statement...........................................    11
    Answers to submitted questions...............................   181
Dave Ogrean, Executive Director, USA Hockey......................    20
    Prepared statement...........................................    22
    Answers to submitted questions...............................   188
Jeff Miller, Senior Vice President, Health and Safety Policy, 
  National Football League.......................................    27
    Prepared statement...........................................    30
    Answers to submitted questions...............................   196
Scott Hallenbeck, Executive Director, USA Football...............    42
    Prepared statement...........................................    43
    Answers to submitted questions...............................   203
Briana Scurry, Former Professional Goalkeeper, U.S. Women's 
  National Soccer Team...........................................    52
    Prepared statement...........................................    54
Richard Cleland, Assistant Director, Division of Advertising 
  Practices, Bureau of Consumer Protection, Federal Trade 
  Commission.....................................................    73
    Prepared statement...........................................    76
    Answers to submitted questions...............................   209
Ian Heaton, Student Ambassador, National Council on Youth Sports 
  Safety.........................................................    84
    Prepared statement...........................................    86
Robert Graham, Director, Aligning Forces for Quality, National 
  Program Office, George Washington University...................    89
    Additional material submitted for the record \1\.............    90
    Prepared statement...........................................    91
    Answers to submitted questions...............................   214
Dennis L. Molfese, Director, Big 10-CIC-Ivy League Traumatic 
  Brain Injury Research Collaboration............................   102
    Prepared statement...........................................   104
James Johnston, Assistant Professor, Department of Neurosurgery, 
  University of Alabama-Birmingham...............................   109
    Prepared statement...........................................   112
    Answers to submitted questions...............................   218
Timothy J. Gay, Professor, Department of Physics and Astronomy, 
  University of Nebraska-Lincoln.................................   129
    Prepared statement...........................................   131

----------
\1\ The report ``Sports-Related Concussions in Youth: Improving the 
Science, Changing the Culture'' and the accompanying slide presentation 
have been retained in committee records and also are available at  
http://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=101897.
Gerard A. Gioia, Chief, Division of Pediatric Neuropsychology, 
  Children's National Health System..............................   141
    Prepared statement...........................................   143
    Answers to submitted questions \2\                              222
Martha E. Shenton, Professor of Psychiatry and Radiology, Brigham 
  and Women's Hospital, Harvard Medical School...................   153
    Additional material submitted for the record \3\.............   154
    Prepared statement...........................................   155

----------
\2\ Mr. Gioia did not answer submitted questions for the record by the 
time of printing.
\3\ A supporting document has been retained in committee files and also 
is available at  http://docs.house.gov/meetings/IF/IF17/20140313/
101897/HHRG-113-IF17-Wstate-ShentonM-20140313-SD001.pdf.

 
            IMPROVING SPORTS SAFETY: A MULTIFACETED APPROACH

                              ----------                              


                        THURSDAY, MARCH 13, 2014

                  House of Representatives,
Subcommittee on Commerce, Manufacturing, and Trade,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:22 a.m., in 
room 2322 of the Rayburn House Office Building, Hon. Lee Terry 
(chairman of the subcommittee) presiding.
    Members present: Representatives Terry, Lance, Harper, 
Guthrie, McKinley, Kinzinger, Bilirakis, Johnson, Long, Upton, 
Schakowsky, Sarbanes, Matheson, Barrow, Christensen, and Waxman 
(ex officio).
    Staff present: Charlotte Baker, Press Secretary; Kirby 
Howard, Legislative Clerk; Nick Magallanes, Policy Coordinator, 
Commerce, Manufacturing, and Trade; Brian McCullough, Senior 
Professional Staff Member; Shannon Taylor, Counsel, Commerce, 
Manufacturing, and Trade; Tom Wilbur, Digital Media Advisor; 
Michelle Ash, Democratic Chief Counsel, Commerce, 
Manufacturing, and Trade; and Will Wallace, Democratic Policy 
Analyst.
    Mr. Terry. I want to thank everyone for being here, and we 
are now with the full committee ranking member, the gentleman 
from California joins us. We now have the ability to start our 
hearing. So I will introduce you after my statement and before 
you start your testimonies. So I will open with my opening 
statement. Morning, Jan.

   OPENING STATEMENT OF HON. LEE TERRY, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEBRASKA

    So good morning and welcome to this morning's hearing. 
Today, it is my hope to learn what steps are being taken to 
make sports participation safer for all athletes.
    Every day, parents make choices about whether or not to let 
their son or let their daughter play soccer, or what kind of 
mouthpiece to buy their son for his first day of Pop Warner 
football. Unfortunately, it seems like every day we hear about 
how participation in certain sports can be dangerous. It is 
easy to understand how what parents see in the news inevitably 
affects youth participation in sports.
    Case in point: Earlier this year, President Obama said 
publicly that if he had a son, he wouldn't let him play pro 
football. Then the First Lady wants us all to move. Seems to 
conflict. Messages.
    So now, we want a better understanding of the innovations 
being made by sports leagues, equipment manufacturers, and the 
medical community to make all sports safer. One clear example 
is the NHL which has been working hand in hand with the NHLPA 
to make hockey safer. Dating back to 1997, the NHL recognized 
the dangers of head injuries and took the proactive step of 
forming a Joint Concussion Committee. Additionally, the NHL 
also established a Department of Player Safety at its 
headquarters, the first of its kind for any professional 
league. USA Hockey and USA Football, two organizations that 
help oversee youth sports in the United States, have followed 
the lead of their professional counterparts by employing a 
multipronged approach to making participation safer. USA Hockey 
now requires coaches to complete an Online education module 
specific to the age group they are coaching at, and that 
includes safety information, concussion education, and proper 
techniques. USA Football, which is endowed by the generosity of 
the NFL and the NFLPA, was the first national governing body 
for any sport to participate in the CDC's heads-up concussions 
in youth sports.
    Initiatives and all engaged in providing youth with non-
tackling alternatives to develop their skills. Additionally, 
USA Football's Heads Up Football program encompasses 6 elements 
meant to make youth's football safer, including coach education 
and concussion recognition.
    Proactive actions like the ones I just mentioned are 
exactly what parents need in order to be assured that 
everything possible is being done to keep their child as safe 
as possible while they are on the field or ice.
    Researchers have also been hard at work to improve the 
tools that coaches and doctors have at their disposal when 
treating an athlete. For example, Dr. Dennis Molfese, sorry, 
Doc, who runs the University of Nebraska's Brain, Biology and 
Behavior Center located inside the Huskers Football Stadium, 
has been developing an MRI machine that can be used on game day 
to assess a head injury. This would allow medical staff to 
determine if a player has suffered a concussion, how severe the 
injury is, and if that player is able to return.
    Equipment manufacturers are also using technology to make 
innovation changes to helmets, mouth guards, footwear and other 
equipment, all in order to reduce injuries. I feel confident 
saying that given the recent rule changes and the rate which 
technology is advancing, playing a contact sport today is 
likely safer than it has been in the past, however, we must 
accept that there is no silver bullet, no helmet or pad is 
going to prevent 100 percent of the injuries 100 percent of the 
time. This is why we need to consider a multipronged approach 
aimed at keeping our kids safer, while still promotion youth 
participation in sports. This involves listening to how leaders 
like the NFL, NHL, youth leagues and top tier university 
researchers are partnering to make progress towards making 
sports safer. These are the types of innovations and paradigm 
shifts needed to give parents the assurance that all the 
possible steps are being taken to improve the safety of their 
child on the field.
    And I would like to thank our panelists for joining us here 
today, and willing to answer our questions. And I would 
especially like to thank Dennis Molfese and Dr. Tim Gay for 
making the trips to Washington, DC, from Lincoln, Nebraska.
    [The prepared statement of Mr. Terry follows:]

                  Prepared statement of Hon. Lee Terry

    Good Morning-and welcome to this morning's hearing.Today, 
it's my hope to learn what steps are being taken to make sports 
participation safer for all athletes.
    Every day, parents make choices about whether or not to let 
their daughter play soccer or what kind of mouthpiece to buy 
their son for his first day of Pop Warner football. 
Unfortunately, it seems like every day, we hear about how 
participation in certain sports can be dangerous. It's easy to 
understand how what parents see in the news inevitably affects 
youth participation in sports. Case in point: Earlier this 
year, President Obama said publicly that if he had a son, he 
wouldn't let him play pro football.
    We want to better understand the innovations being made by 
sports leagues, equipment manufacturers, and the medical 
community to make all sports safer.
    One clear example is the NHL, which has been working hand-
in-hand with the NHLPA to make hockey safer. Dating back to 
1997, the NHL recognized the dangers of head injuries and took 
the pro-active step of forming a Joint Concussion Committee. 
Additionally, the NHL also established a Department of Player 
Safety at its headquarters, the first of its kind for any of 
the professional leagues.
    USA Hockey and USA Football, two organizations that help 
oversee youth sports in the U.S., have followed the lead of 
their professional counterparts by employing a multi-pronged 
approach to making participation safer. USA Hockey now requires 
coaches to complete an online education module specific to the 
age group they are coaching that includes safety information, 
concussion education and proper techniques. USA Football, which 
is endowed by the generosity of the NFL and NFLPA, was the 
first national governing body for any sport to participate in 
the CDC's ``Heads Up Concussion in Youth Sports'' initiative 
and has also engaged in providing youth with non-tackling 
alternatives to develop their skills. Additionally, USA 
Football's Heads Up Football program encompasses six elements 
meant to make youth football safer, including coach education 
and concussion recognition.
    Proactive actions like the ones I just mentioned are 
exactly what parents need in order to be assured that 
everything possible is being done to keep their child safe 
while they are on the field or the ice.
    Researchers have also been hard at work to improve the 
tools that coaches and doctors have at their disposal when 
treating an athlete. For example, Dr. Dennis Molfese, who runs 
the University of Nebraska's Center for Brain, Biology and 
Behavior, located inside the Husker's football stadium, has 
been developing an MRI Machine that can be used on game day to 
assess a head injury. This would allow the medical staff to 
determine if a player has suffered a concussion, how severe the 
injury is, and if that player is able to return to the game. 
Equipment manufacturers are also using technology to make 
innovative changes to helmets, mouth guards, footwear and other 
equipment--all in order to reduce injuries.
    I feel confident saying that given recent rule changes, and 
the rate which technology is advancing, playing a contact sport 
today is likely safer than it has been in the past. However, we 
must accept that there is no ``silver bullet.'' No helmet or 
pad is going to prevent 100 percent of the injuries 100 percent 
of the time.
    This is why we need to consider a multi-pronged approach 
aimed at keeping our kids safer while still promoting youth 
participation in sports. This involves listening to how leaders 
like the NFL, NHL, youth leagues and top-tier University 
researchers are partnering to make progress towards making 
sports safer. These are the types of innovations and paradigm 
shifts needed to give parents the assurance that all possible 
steps are being taken to improve the safety of their child on 
the field.
    I would like to thank our panelists for joining us today 
and being willing to answer our questions. I would especially 
like to thank Dr. Dennis Molfese and Dr. Tim Gay for making the 
trip to DC from the University of Nebraska at Lincoln.

    Mr. Terry. And my time is over, so I will recognize the 
ranking member, Jan Schakowsky, from Illinois.

       OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Mr. Chairman. This is a very 
important hearing on improving sports safety. I look forward to 
hearing from all of our witnesses on both panels about their 
perspectives, experiences, proposals about how to make sports 
safer for everyone, from children to professional athletes.
    Athletes are continually becoming bigger and faster and 
stronger, and despite some efforts to make sports safer, much 
work remains. Three hundred thousand sports-related traumatic 
brain injuries occur annually in the United States. Sports are 
the second leading cause of traumatic brain injury among people 
age 15 to 24 years old, second only to motor vehicle accidents. 
This is a crisis and one this subcommittee should do everything 
in its power to address.
    We are going to hear today from Ian Heaton, a high school 
senior, who suffered a severe head injury during a lacrosse 
game in his sophomore year. Despite his impressive recovery, 
that hit, later identified as his third head injury, left him 
with a limited ability to enjoy the types of activities many of 
his high school students, classmates, take for granted. His 
story should serve as a reminder that youth sports injuries can 
have have devastating and lasting consequences. And we will 
also hear on this panel from Briana Scurry, an Olympic and 
World Cup soccer champion, a goalie, forced from the field 
after a career-ending traumatic brain injury almost 4 years 
ago. Her struggle to overcome the cognitive, physical, and 
psychological injuries that followed illustrate that even our 
sports heroes are vulnerable to the worst sports injuries.
    Both Ian and Briana should be commended for their courage, 
and I thank you, Briana, in their recoveries and for their 
willingness to testify on this critical issue.
    Dave Duerson, a Pro Bowl and Super Bowl-winning safety, and 
former member of my hometown Chicago Bears, tragically 
committed suicide just over 3 years ago. In doing so, he shot 
himself in the chest to avoid any impact on his brain, which he 
asked to have donated to medical research in order to allow 
scientists to study the impact of the brain trauma he suffered 
over his 11-year professional career. It was later disclosed 
that Duerson suffered from a ``moderately advanced'' case of 
chronic traumatic encephalopathy, a disease linked to repeated 
blows to the head, which can result in memory loss, depression, 
and dementia.
    The Heaton and Scurry stories prove that severe, career-
ending sports injuries can occur at any level of competition, 
and the Duerson case should make it clear to all of us that the 
impacts of brain trauma go way beyond an athlete's days on the 
field and can become more severe over time.
    We will also hear today from medical and scientific experts 
who have studied the impacts of brain injuries on athletes of 
all ages. We will hear about the importance of taking athletes 
off the field of play as soon as there is a suspicion of a 
brain injury, and keeping them off until they are cleared by a 
responsible and trained individual.
    And finally, we will hear from the NHL, the NFL, and youth 
hockey and football leagues that are responsible for mitigating 
traumatic brain injury in their sports. I hope to learn what 
changes they have implemented, and will implement, to rules, 
practice drills and other aspects of the games that will reduce 
the risk of brain injury moving forward.
    I am not advocating for an end to sports as we know it, or 
maybe not exactly as we know it right now, but I also feel 
strongly that 300,000 head injuries per year are too many to 
overlook. We should take reasonable steps to reduce the risk. 
And I look forward to hearing from all of our witnesses. I hope 
this hearing will help the subcommittee to better understand 
the safety risks in sports, and what we can and should be done 
to limit these risks.
    And I yield back the balance.
    Mr. Terry. Thank you very much. At this time, recognize the 
vice chairman of the committee, Mr. Lance, from New Jersey.

 OPENING STATEMENT OF HON. LEONARD LANCE, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Lance. Thank you very much, Mr. Chairman, and thank you 
for holding this extremely important hearing. I want to thank 
Dr. James Johnston, who will be one of the witnesses, who came 
to my office earlier this morning. Thank you, Dr. Johnston.
    Experts generally agree that a concussion can be classified 
as a brain injury, ranging in seriousness from mild to 
dramatic. The Center for Disease Control states a concussion is 
caused by a bump, a blow or a jolt to the head, or blow to the 
body that causes the head to move quickly. According to the 
CDC, the sports that reported the highest number of traumatic 
brain injuries were bicycling, football, playground activities, 
basketball and soccer.
    From 2010 through 2013, the participation rate of children 
in youth soccer and football dropped considerably, and some 
have pointed to the increased risk of TBI's as a result of 
participating in these sports as a reason for the drop in that 
participation.
    The increased spotlight on concussions in sports has 
resulted in an increased amount of research in brain injuries, 
as well as research on how to improve sports equipment in order 
to prevent such injuries from occurring. Collegiate and 
professional sports leagues have implemented standards and 
revised their rules in order to decrease the number of brain 
injury incidents. The NHL has, as has been indicated, has 
required its players to wear helmets on the ice, and the NFL 
instituted new standards for evaluating concussions on the 
sidelines after the league reported an occurrence of 223 
concussions in just over 300 games in the 2010 season.
    And State and Federal Governments have also been involved 
in tightening safety standards, and since 2009, all 50 States 
and the District of Columbia have adopted laws protecting youth 
and high school athletes from returning to play too soon after 
suffering a concussion or a potential concussion.
    This hearing will focus on what more can be done to prevent 
brain injuries from occurring in sports, and this is at the 
youth level, the amateur level and at the professional level. 
And I look forward to the testimony of our distinguished 
panels.
    Thank you, Mr. Chairman.
    Mr. Lance. I have two and a half minutes remaining. Is 
there any other member on the Republican side who would like to 
speak with an opening statement?
    Mr. Terry. OK.
    Mr. Lance. I yield back the balance of my time.
    Mr. Terry. Especially Missouri. Do they play sports? And on 
behalf of the Big 10, I want to welcome Rutgers to the Big 10. 
At this time----
    Mr. Lance. Thank you very much.
    Mr. Terry [continuing]. Five minutes to the full ranking 
member of the Energy and Commerce Committee, Mr. Waxman.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you very much, Mr. Chairman.
    Decades ago, many thought that head injury was serious only 
if a player was completely knocked out unconscious, and/or 
suffered a severe contusion, after frequent painful blows, even 
a young athlete could continue to play, but we now have strong 
indications that the effects of repeated brain trauma in 
sports, even those received during one's youth, can accumulate 
with consequences that are long-term debilitating and even 
life-threatening. These consequences can stem from injuries 
once considered minor, known as subconcussive blows, which may 
not be accompanied by any immediate adverse symptoms.
    Serious psychological and emotional disorders have been 
documented among former athletes that have suffered repetitive 
brain trauma. Researchers have, a number of times, found 
evidence of the neurodegenerative disease, CTE, when examining 
the brain tissue of dozens of deceased former NFL players. New 
imaging technologies have been able to show the metabolic 
changes in the brain associated with concussions and 
subconcussive blows.
    Brain injuries in sports can occur in a wide variety of 
situations, and different athletes' brains may respond 
differently to an injury. Sports-related brain injury is a 
complex matter, requires addressing many interconnected issues, 
so when the title of this hearing suggests we take a 
multifaceted approach to improve sports safety, I could not 
agree more.
    First, we need more neuroscience research, radiological and 
longitudinal research methods can lead to earlier, more 
accurate diagnoses, a better understanding of the risk factors, 
and maybe better treatment options for brain injuries.
    Second, doctors, league associations, coaches, parents, 
players need to work together to establish health regulations, 
game rules and a sporting culture that reflects the seriousness 
of brain injury, and put the athlete's health first.
    Third, we must address the health and safety risks 
associated with the athletic equipment, and pursue a better 
understanding of how this equipment might be improved.
    Three years ago, Congressman Butterfield and I wrote to the 
then-chairman at the time of the subcommittee and full 
committee chairman, calling for hearings about inadequate 
testing standards, lax reconditioning certifications, economic 
disparities regarding the safety of football helmets used by 
millions of American athletes. We are going to touch on some of 
those issues today, but I believe those issues merit deeper 
consideration than they are likely to get at today's hearing, 
and the subcommittee chairman might consider holding separate 
hearings on these matters.
    I think it is valuable that the National Football League is 
testifying here today, given recent and ongoing disputes 
between the league and its players on this very topic. However, 
I believe its players organizations should also testify. 
Unfortunately, the late notification of the NFL testifying made 
it difficult for us to secure players' witness.
    Mr. Chairman, today's hearing is important. I appreciate 
the subcommittee review of sports-related brain injuries, and I 
look forward to working together, all of us, on this issue in 
the months ahead. Thank you for holding the hearing, and I look 
forward to the testimony of the witnesses.
    Yield back my time.
    Mr. Terry. Still have a minute left, if the gentleman from 
Utah wanted to use it.
    Mr. Waxman. Well, I might just point out that moving 
physically and conditioning the body is not anywhere near 
dangerous as subjecting oneself to brain injuries, so I don't 
think they are contradictory.
    Mr. Terry. Yes. It is interesting, but the issue is we want 
kids to go out and play. We want them to join youth leagues.
    Mr. Waxman. And we want sports, but we want to make it as 
safe as possible.
    Mr. Terry. Absolutely. And to use your last 26 seconds, 
then, this is one of those where Jan and I both agreed was 
necessary. So this has been a bipartisan effort.
    So with that, let us move on to our witness panel. And I am 
going to introduce the entire panel now, and then we will start 
with Mr. Daly. So we are blessed to have Mr. William Daly, III, 
Deputy Commissioner of the NHL. Next to him is David Ogrean, 
Executive Director of USA Hockey. Then we have Mr. Jeff Miller, 
Senior Vice President, Player Health and Safety Policy, 
National Football League. Thank you very much for being here. 
And then Scott Hallenbeck, Executive Director, USA Football. 
Then a face of a brain injury, concussions, multiple 
concussions, within soccer, Briana Scurry, a former 
professional goalkeeper, U.S. Women's National Soccer Team. In 
the next panel we will have Ian, who is the other face of high-
school-level concussions.
    So with that, Mr. Daly, you are now recognized for your 5 
minutes.

 STATEMENTS OF WILLIAM L. DALY, DEPUTY COMMISSIONER, NATIONAL 
  HOCKEY LEAGUE; DAVE OGREAN, EXECUTIVE DIRECTOR, USA HOCKEY; 
 JEFF MILLER, SENIOR VICE PRESIDENT, HEALTH AND SAFETY POLICY, 
NATIONAL FOOTBALL LEAGUE; SCOTT HALLENBECK EXECUTIVE DIRECTOR, 
     USA FOOTBALL; AND BRIANA SCURRY, FORMER PROFESSIONAL 
         GOALKEEPER, U.S. WOMEN'S NATIONAL SOCCER TEAM

                  STATEMENT OF WILLIAM L. DALY

    Mr. Daly. Thank you. I would like to thank the chairman, 
the ranking member, and the subcommittee members for inviting 
me to testify today regarding the National Hockey League and 
the proactive steps it has taken to promote the health and 
safety of the best professional hockey players in the world.
    As its playing surface is enclosed by boards and glass, 
making it the only major professional sport with no out of 
bounds, hockey is a physical game. At the NHL level----
    Mr. Terry. Is your mic on?
    Mr. Daly. It was, yes.
    Mr. Terry. Just pull it a little lower and closer.
    Mr. Daly. I will bring it closer. At the NHL level, our 
players want it to be physical, and our fans want it to be 
physical, but importantly, all constituent groups associated 
with the game also want it to be safe. This objective 
necessarily includes promoting safe and responsible play in our 
game, and the National Hockey League, working together with the 
National Hockey League Players' Association, has gone to 
elaborate lengths to do that and will continue to do so.
    We are pleased to have this opportunity to share with this 
subcommittee some of the measures enacted in this pursuit. The 
National Hockey League was the first major professional sports 
league to launch a comprehensive league-wide program to 
evaluate players after they incur head injuries. Beginning in 
1997, the NHL/NHLPA Concussion Program has required that all 
players on all clubs undergo preseason baseline 
neuropsychological testing. After a player is diagnosed with a 
concussion, he undergoes post-injury neuropsychological 
testing, and his pre- and post-injury test results are compared 
to determine when the player is safe to return, or returns to 
neurological baseline, which is a relevant determination in the 
player's ability to safely return to play.
    Data collected and analyzed pursuant to the NHL/NHLPA 
Concussion Program confirmed to us early on that 
neuropsychological testing results had added value, and should 
be taken into account, along with player reported symptoms when 
making return-to-play decisions.
    The NHL/NHLPA Concussion Committee also has taken 
affirmative and proactive steps to issue league-wide protocols 
regarding the diagnosis, management and treatment of 
concussion. Education regarding concussions and, importantly, 
the issuance of warnings to players relating to the risks of 
returning to play before the recovery from a prior concussion 
is complete, have been a core component of the NHL/NHLPA 
Concussion Program since its inception. Education is provided 
regularly to all relevant constituents in our league, including 
our players, club personnel and NHL on-ice officials.
    In addition to enforcing existing playing rules, such as 
charging, crosschecking and high-sticking, and more stringently 
penalizing dangerous contact, several new playing rules have 
been adopted specifically to prohibit involving a player's 
head. Our current rule specifically prohibits any body contact 
with an opponent's head when the contact is otherwise 
avoidable, and the head is the main point of contact. Changes 
this season to adopt the hybrid icing rule, and modifications 
of rules regarding fighting, have further enhanced player 
safety. With respect to the fighting issue in particular, while 
it remains a small part of the game, its role is diminishing. 
Through 75 percent of the 2013-2014 regular seasons, 68 percent 
of the games played have been completely free of fighting, the 
highest such percentage since 2005-2006. In addition, the 
number of major penalties assessed for fighting is down 15 
percent from last season, and down 31 percent from the 2009-
2010 season.
    In this important area, it would be the league's intention 
to raise, discuss and negotiate any potential playing rule 
changes regarding fighting directly with the National Hockey 
League Players' Association. Ultimate enforcement of the 
playing rules through supplementary discipline is in the hands 
of the Department of Player Safety, the first league department 
of its kind in professional sports. This department monitors 
every one of our 1,230 regular season games, plus all of our 
playoff games, and assesses every hit, indeed, every play, to 
ensure the league's standards for safety and responsible play 
are being adhered to. When the Department determines that the 
standard has been violated, supplemental discipline is assessed 
in the form of a suspension or a fine, and the Department 
creates a video that explains to our players and our fans why 
the behavior merited punishment. The cumulative effect of these 
efforts has begun to change the culture of the game in a 
positive way. As we can see on a nightly basis, players 
avoiding dangerous plays and gratuitous contact that they, no 
doubt, would have engaged in just a few short years ago.
    Since the adoption of the mandatory helmet rule in 1979, 
the NHL, together with the NHLPA, has continued to impose a 
series of additional regulations regarding player equipment 
relating to player safety generally, but also to head injuries 
more specifically, including most recently a rule adopted prior 
to the start of this season that mandated the use of face 
shields by all incoming players, the effect of which should 
reduce head injuries generally, in addition to providing 
enhanced protection for players' eyes.
    The NHL also has participated in concussion initiatives 
that extend beyond the NHL, including its representatives' 
participation at each of the 4 International Concussion and 
Sport Conferences between 2001 and 2012, its support of Federal 
and State legislative initiatives regarding concussions, and 
the league's support and assistance in the development of 
concussion educational programs for youth and junior-age hockey 
players.
    To summarize, while recognizing there is considerable work 
to be done, the National Hockey League has been, and will 
remain, absolutely committed to promoting the safety of its 
players. We firmly believe it is not only the right thing to do 
for our players, but it is the right thing to do for our 
business, both in terms of promoting participation at the youth 
hockey level, and in maximizing interest by fans and consumers 
of the sport at the professional level.
    Again, I thank the chairman, the ranking member, and the 
subcommittee members for your time and invitation to speak to 
you this morning.
    [The prepared statement of Mr. Daly follows:]
   
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    Mr. Terry. Thank you. Mr. Ogrean, you are recognized for 
your 5 minutes.

                    STATEMENT OF DAVE OGREAN

    Mr. Ogrean. Thank you, Chairman Terry, Ranking Member 
Schakowsky, and distinguished members of the subcommittee. It 
is a privilege to be with you today to discuss an issue that is 
the top priority every day at USA Hockey, and that is the 
safety of our participants both on and off the ice.
    We have adapted well to changing environments over time, 
and we have two particular leaders that we wish to thank, and 
who guide a great deal of our decision-making. One is Dr. Mike 
Stewart, our Chief Medical Officer, who is the head of sports 
medicine at the Mayo Clinic in Rochester, Minnesota, the other 
is Dr. Alan Ashare from Saint Elizabeth's Medical Center in 
Boston, who is also the chair of our Safety and Protective 
Equipment Committee. That committee has been in existence at 
USA Hockey for 40 years, and it is an important group helping 
to guide our Board in making its decisions.
    We have a Risk Management Committee which is concerned with 
the safety of the playing environment and the surrounding area, 
and in 1999, in cooperation with U.S. Figure Skating, we began 
an organization called Serving the American Rinks, or STAR, 
which is essentially a trade and education organization for ice 
facilities, focusing on a variety of operational aspects, 
including safety issues in rinks.
    In terms of the safety of our participants, we believe we 
can and do positively affect the landscape through 3 primary 
areas; education, rules and rules enforcement, and risk 
management. Education related to safety happens on an ongoing 
basis at USA Hockey, and we utilize many avenues to 
communicate. We have, very fortunately, direct electronic 
communication with every single home, every player, every 
parent, every official and every coach in our organization, 
through our database. We are constantly in communication with 
them with educational bulletins and news. Our coaches have a 
huge influence in providing a safe and responsible environment, 
and our coaching education program has long been heralded in 
the amateur sports world as the gold standard for coaching 
education.
    As Congressman Terry referenced, this last year--or, excuse 
me, two seasons ago--we added an online educational module that 
is age-specific in nature, which also contains critical safety 
information, including concussion education. Officials, 
obviously, play a very important part in how our game is made 
safe as well, and they receive regular evaluation and education 
electronically, and are sent video clips and also access to our 
national reporting system which tracks penalties, to help us 
understand and assess behavior trends. We annually mail posters 
to every ice facility in the country to help deliver our 
messaging, and, over the years, those posters have focused on 
topics including concussion prevention, concussion education, 
playing rules emphases, and our heads-up, don't duck program, 
to name a few.
    As for rules and rules enforcement, we have modified our 
rules to adapt to the evolving landscape of the game on an 
ongoing basis, from mouth guard and helmet issues to rules 
aimed at eliminating dangerous behavior. Another recent 
modification in USA Hockey came in June of 2011 when our Board 
voted to change the allowable age for body checking in games 
from the peewee, or age 11 and 12 level, up to the bantam age 
group of 13 and 14. This was done despite many voices around 
the country in opposition to change, which nobody seems to 
like, but research based on both athlete development and safety 
guided our Board decision. It is worth noting that 2 years 
later, Hockey Canada followed our lead.
    Regarding equipment and its impact on safety, USA Hockey 
took a significant step in 1978 when it called for the creation 
of the Hockey Equipment Certification Council, or HECC. HECC's 
mission is to seek out, evaluate and select standards and 
testing procedures for hockey equipment for the purpose of 
product certification. It is very similar to NOCSAE, which a 
lot of you may be familiar with, that football uses in 
certifying its helmets. It is a completely independent body 
made up of attorneys, doctors, engineers, manufacturers, 
testers and sportspeople. It validates the manufacturer's 
certification that the equipment they produce has been tested, 
and meets the requirements of the most appropriate performance 
standards, and it has been an important part of our safety 
story for 35 years.
    Before closing, I would like to share with you briefly our 
newest off-ice safety program called USA Hockey Safe Sport, 
following the lead of the United States Olympic Committee, this 
is to protect our participants and educate on policies 
regarding hazing zero tolerance, locker room supervision, and 
abuse of any kind. In the early 1990s, we were one of the very 
first youth sports organizations to require screening of all 
adults that have regular access to our youth participants. We 
follow-up on 100 percent of calls we receive around the country 
of alleged abuse, and our 34 affiliate associations each have a 
volunteer safe sport coordinator that helps us as boots on the 
ground to provide the safest possible environment for our 
participants.
    Our sport has enjoyed tremendous growth in the last 25 
years, more than doubling in the number of youth players that 
we have. As we continue to provide opportunities for young 
people, we know that in doing so, we have the responsibility to 
make our game as safe as possible, and will only continue to 
grow if we are successful in doing so.
    Thank you.
    [The prepared statement of Mr. Ogrean follows:]
   
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    Mr. Terry. Thank you. Mr. Miller, you are recognized for 
your 5 minutes.

                    STATEMENT OF JEFF MILLER

    Mr. Miller. Chairman Terry, Ranking Member Schakowsky, 
members of the subcommittee, appreciate the opportunity to 
testify this morning on behalf of the National Football League 
on an issue of great importance to the league, and I commend 
the committee for taking up this issue.
    There is nothing more important to the NFL than the safety 
of our players. Commissioner Goodell has stated repeatedly in 
the past that he spends more time on the health and safety of 
our sport than any other issue that comes before him.
    Football has earned a vital place in the rhythm of American 
life. There are nearly 6 million kids who play tackle or flag 
football across our country, another 1.1 million that play in 
high school, 75,000 in college. And so whether it is touch 
games in our backyards at Thanksgiving, or games played in our 
local parks by our kids, or Friday night high school games, 
Saturdays with college, or hopefully plenty of people watching 
the NFL on Sundays and Mondays, and occasionally Thursdays, 
football plays a significant role in our lives, and we take 
that popularity seriously. With it comes a great deal of 
responsibility, and that is one that we embrace.
    We understand the decisions that we make at our level 
affect football at all levels, and probably far beyond that, 
and so I appreciate the opportunity to share the NFL's work 
with the subcommittee on the health and safety of our athletes 
who play our game.
    Now, football has always evolved. The rules have always 
changed, and so I would like to share with the subcommittee a 
few examples of that over the last couple of years, and the 
impact that that has had at our level.
    It has only been a couple of years ago that we changed the 
kickoff line at the NFL, moving it forward 5 yards. We did that 
because we had identified the kickoff and the kickoff return is 
the single most dangerous play in our sport as related to the 
number of concussions. So by moving it forward 5 yards, we 
decreased the number of concussions on that particular play by 
40 percent. That was in the first year alone, and that number 
has stayed steady in successive years.
    In addition, for those of you who are fans, you have seen a 
greater emphasis on eliminating helmet-to-helmet hits in our 
game, you have seen a greater emphasis on eliminating the use 
of the crown of the helmet in our game, and you have seen fines 
and suspensions, not to mention penalties, as a result of them. 
And these are the sorts of things that we are looking to do to 
change the culture of how our sport is played. We have 
encouraged players to lower their target zones as they tackle, 
we have emphasized through our coaching that there are better 
ways to go about what they are doing, and we have seen the 
results. In the past year alone, between 2012 and 2013, the NFL 
has seen a decrease in the number of concussions at our level 
by 13 percent. A decrease in helmet-to-helmet hits causing 
concussions has been down 23 percent in one year alone. Now, 
that is not a victory, that is a trend, and one that we find 
encouraging, but there is more work to be done as we begin to 
change the culture of the sport as it relates to that.
    And we have added other protocols to our sideline to take 
care of our players. There is one rule that governs us, and 
that is that medical concerns will always trump competitive 
ones. So we have added unaffiliated neurotrauma consultants on 
the sideline. That is a concussion expert in every city to help 
the team physician identify concussions and treat the players. 
We have added athletic trainers in skyboxes for the sole 
purpose of watching the game, and calling down to the sideline 
if they identify an injury, concussive or otherwise, to make 
sure that the player is attended to appropriately. And we have 
mandated uniform sideline protocols across all 32 of our teams 
so that everybody is working off the same playbook, and those 
protocols are based on internationally accepted medical 
guidelines. We would expect nothing less. And we know as we 
change the culture of our sport as it relates to health and 
safety, we have an impact far beyond. And so let me cite two 
examples of that for the subcommittee. One is our support for 
USA Football, and you will hear from Mr. Hallenbeck in a 
moment. Their Heads-up Program, among their other offerings, 
are changing the game in our parks, in our communities around 
the country literally as we speak. The popularity of these 
programs, which I won't steal Scott's thunder on, have been 
tremendous, and the NFL is a proud supporter of USA Football, 
and will continue to be in all that they do to change the game, 
and we are proud of his work particularly.
    In addition, the NFL used as inspiration a young child 
named Zackery Lystedt who was a 13-year-old youth football 
player in Washington State several years ago who suffered 
catastrophic injuries playing his sport. He was returned to 
play too soon after suffering a concussion. And Zackery still 
struggles with the challenges that come from that. His 
advocates were able to pass a Youth Concussion Law in 
Washington State which our commissioner said we will replicate 
in all 50 States around this country to make sure that all 
youth sports, not just football, are played more safely, that 
kids and their coaches are aware of the risks of concussion, 
that they are removed from play should it appear that they 
suffer concussion, and most importantly, not return to play 
until a medical professional has cleared them. Just this past 
month, we are proud to say that the fiftieth State passed that 
law, and now the NFL isn't solely responsible for that work, 
but we are happy to lead and to be in many of these States to 
get this done.
    And as my time expires, let me just mention two other quick 
components. We have been proud to work with the CDC promoting 
concussion materials that have gone out to millions of kids, 
posters in locker rooms, and to fund much of their Heads-up 
Program. We have also invested tens of millions of dollars in 
research; $30 million with the NIH, which is the largest grant 
that the NFL had ever given, and the first $12 million of that 
has gone out already to study chronic traumatic encephalopathy. 
In addition, we are very proud of a $60 million effort we have 
with General Electric and Under Armour, both to improve the 
diagnosis and prognosis of concussion by developing better 
tools, and then secondly to find better ways to protect against 
concussion in the first place. These are ongoing issues and 
ones that we think are going to yield significant successes in 
a short time.
    So I apologize for exceeding my limit, Mr. Chairman, but I 
appreciate the time.
    [The prepared statement of Mr. Miller follows:]
 
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    Mr. Terry. At this time, Mr. Hallenbeck, you are recognized 
for your 5 minutes.

                 STATEMENT OF SCOTT HALLENBECK

    Mr. Hallenbeck. Chairman Terry and members of the 
committee, thank you for the invitation to testify.
    USA Football creates and directs programs and resources 
that establish important standards rooted in education for 
youth and high school football. We stand with experts in 
medicine, child advocacy and sport who believe that education 
changes behavior for the better. This is precisely what we are 
seeing through our Heads Up Football program, which is already 
benefiting more than 25 percent of youth football leagues 
across the country in its first 14 months, and we expect to 
double that this year.
    We advance safety through evidence-based studies by 
independent experts, we also lead fun and dynamic instructional 
football initiatives for young players, as well as a national 
non-contact flag football program. More on these and other 
aspects of our work resides in my written testimony. The 
remainder of my time will be showing a video of how Heads Up 
Football High School Pilot Program is improving player safety 
within the Fairfax County Public School system, which earned 
high marks from parents, coaches, administrators in its first 
season. It paid close attention to hearing from the athletic 
directors and the principals and the superintendents of the 
schools on how this program is making a difference.
    [Video shown.]
    [The prepared statement of Mr. Hallenbeck follows:]
 
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    Mr. Terry. Thank you. Now Briana Scurry, appreciate you 
being here, and you are recognized for 5 minutes.

                   STATEMENT OF BRIANA SCURRY

    Ms. Scurry. Thank you very much.
    Yes, my name is Briana Scurry and I am 42 years old. I 
served as a starting goalkeeper for the United States Women's 
National Soccer Team from the years 1994 to 2008. During that 
time, I helped lead the team in winning two Olympic gold medals 
in 1996 Atlanta games and 2004 Athens, and played 173 
international games over 15 years for the United States, which 
is a record among female goalkeepers.
    In the summer of 1999, my 20 amazing teammates and I 
captured the hearts of America by beating China in a penalty 
kick shootout live in front of 90,000 screaming fans at the 
Rose Bowl in Pasadena, California. I was the one that made the 
single save during the penalty kicks before Brandi Chastain 
took off her shirt. Yes, now I will be many of you recall 
exactly where you were at that moment. It was the kind of event 
that transforms lives forever for the better. My passion and my 
mission was soccer. My ultimate reward was living my dreams and 
inspiring the dreams of countless others.
    Today, I am here before you to share my new mission with 
you. My new mission is to provide a new face and voice to those 
who have had and may suffer the long and difficult recovery of 
a devastating traumatic brain injury and concussion.
    My life story reads like a script from Oprah Winfrey's 
Where Are They Now. Like many of Oprah's guests, I too have 
been lost in deep, dark places with my face in the dirt, and 
have only recently begun to claw my way back to my life.
    On April 25, 2010, my life changed forever. During that 
day, I played a women's professional game against the 
Philadelphia Independence in Philadelphia, and in that game, I 
suffered a traumatic brain injury that abruptly ended my 
beloved soccer career. That was nearly 4 years ago.
    I struggled with intense piercing headaches that were so 
bad that, by the evening, it was all I could do not to cry 
myself to sleep. I had to take naps on a daily basis just 
because my sleep was so disrupted. I couldn't concentrate and I 
was very moody. I felt completely disconnected from everything 
and everyone. I was anxious and depressed every day, and I 
wondered if I would ever get better.
    I recently moved to DC to have bilateral occipital nerve 
surgery at Georgetown to eliminate severe headaches that 
plagued me daily. Fortunately for me, the surgery appears to 
have worked, however, I am still being treated for symptoms 
such as lack of concentration, balance issues, memory loss, 
anxiety and depression. I have purposefully and intentionally 
had my concussion recovery story documented by media outlets, 
such as the USA Today, The Washington Post and Brainline.org, 
in order to bring attention and a ray of hope to those 
suffering from TBI like me.
    In September, I was alarmed to learn that the number of 
reported cases of concussion in soccer was second highest in 
the United States, with only American football having more 
cases. Additionally, a recent article published in November 
stated that one of two female youth soccer players will suffer 
a concussion while playing. I feel the numbers of reported 
cases are likely understated, and didn't designate those who 
suffered multiple concussions like I have. Statistics like 
these have solidified my urgency of purpose to shed light on 
the high frequency of concussions in youth, and the devastating 
emotional toll that prolonged symptoms often cause, yet are too 
frequently dismissed.
    I sincerely hope that my presence here today will inspire 
increased awareness, understanding and assistance to help the 
thousands of young TBI sufferers across this country.
    I thank you all for allowing me to give testimony. I am 
grateful and humbled to have been invited to do so. Thank you.
    [The prepared statement of Ms. Scurry follows:]
   
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    Mr. Terry. Thank you very much. And that was powerful.
    So this is our opportunity now, each of us have 5 minutes 
to ask you questions.
    So, Ms. Scurry, let me ask you this one. I too was shocked 
to learn that soccer had the second most concussions, which is 
a really dominant youth sport. Are you seeing changes within 
soccer and, unlike there is an obvious top-to-bottom connection 
that we heard from the NHL and the NFL, is anything like that 
occurring in soccer?
    Ms. Scurry. Thank you for the question. I too was very 
surprised to read that statistic. I think it is so high in part 
because the explosion of players that are playing soccer now in 
the last 10 years.
    I am not finding that soccer has completely grasped the 
alarm or the situation like USA Football, USA Hockey have. Part 
of the reason I am here today is to shed light that soccer too 
should be instrumenting different protocol like NHL and the NFL 
are, and hopefully the governing body for soccer, which is U.S. 
Soccer, will start to understand that our great sport is in 
danger of having too many head injuries, and that something 
does need to be done about it, and something needs to be 
instrumented.
    Mr. Terry. All right. And thank you, and I think your 
assessment of the game that you played, and winning that 
championship over China, we all, at least I, remember that one 
event.
    Ms. Scurry. Thank you.
    Mr. Terry. It was a great game.
    Now, to Mr. Miller, the NFL has taken, I think, seriously, 
undertaken effort to get the so-called return to play 
guidelines adopted at all State levels. Can you tell us more 
about what the guidelines are and how they are developed?
    Mr. Miller. Sure, and thank you for the question.
    The Zackery Lystedt Law, which is the model law that was 
passed out in Washington State, contained three primary 
elements, the first of which would be that parents and their 
kids would have to sign off on an education sheet a 
notification about the risks, signs and symptoms, related to 
concussion before they were allowed to participate. The second 
was that a child who appeared to have suffered a head injury 
must be removed from play immediately, in other words, the 
coaches were asked to act conservatively. And finally, that a 
licensed medical Provider who has a training in the management 
and evaluation of concussions has to return every child to 
play. And that part was done in large part to eliminate the 
danger that Zackery faced when he returned to play in the same 
game too soon.
    And all these laws are very new, and so I know that there 
are academics who are studying them to see their success, but I 
just know, as one anecdote in Washington State, the one that 
had the first one, in the years after the Lystedt Law was 
passed, they didn't see a single brain injury, in other words, 
blood on the brain of any single football player in the State 
of Washington, and they had normally seen three or four 
significant brain injuries on an annual basis, and those were 
eliminated.
    Now, that is anecdotal and more work needs to be done. And 
I commend those States who are going back and making their laws 
more strict, because they need to be expanded to the youth 
level. Many of them are high school only. They need to be 
expanded to recreational spaces so it is not just school-based 
sports. And there is more that can be done, and there are those 
that are doing that, and we are happy to work with those.
    Mr. Terry. Thank you. Mr. Ogrean, have you seen a 
demonstrable reduction in concussion incidents at USA Hockey 
after implementing new techniques?
    Mr. Ogrean. We do not have the same statistical data that I 
think USA Football has invested in, and, in fact, we are 
talking to DataList, the same company, to do that sort of 
thing.
    Any concussions are too many concussions. What we have 
focused on is research, education and rules enforcement. The 
statement was made in someone's opening remarks regarding the 
culture of certain sports, and obviously, we know that a lot of 
sports at the youth level suffer from a misplaced, you know, 
macho attitude. A lot of coaches think they are coaching at the 
professional level, and they are not. And so changing that 
culture is very, very important. We have been very, very strict 
about return to play rules, and as Scott used the phrase 
earlier this morning that I appreciate very much, and we adopt 
the same thing, when in doubt, sit them out. And I think when 
you are talking about a grassroots sport, in our case, we have 
350,000 youth players in 2,500 programs, and that equates to 
about 25,000 teams, one of our big challenges is quality 
control. You can't get everybody to act the same way or to 
think the same way, but we do know, I think because of our 
emphasis on preventing head injuries, and what to do with them, 
how to recognize them, how to treat them, how to respond to 
them, and making sure the return to play decision is a medical 
decision and not a coach's decision, that the number is 
dropping.
    Mr. Terry. Great. My time is over. And so the Ranking 
Member, Jan Schakowsky, you are recognized for your 5 minutes.
    Ms. Schakowsky. Briana, my granddaughter, has played AYSO 
soccer since the first time that she could. Now she is on a 
traveling team in high school. She is 16, so I am very 
concerned about what you are saying, and even more concerned 
now after you are saying that soccer actually seems to lag 
behind other sports. And there have also been studies that have 
compared the rates of reported concussions for male and female 
athletes that tend to show that female athletes actually have a 
higher rate of reported concussions than male athletes in the 
same sports.
    So what would you say that we need to do immediately? I 
mean I really do worry about her now and what could happen, so 
what would your advice be to female athletes, female soccer 
players, and to those who coach and treat them?
    Ms. Scurry. I too find that statistic very alarming. I 
think one of the things that needs to occur with soccer is 
officials and referees, coaches need to take their heads out of 
the sand a little bit and realize that this is something that 
is plaguing our sport as well. And the video that was played by 
Mr. Hallenbeck earlier was a fantastic example of where to 
start. You start with the coaches. You teach the coaches the 
proper way to teach the players how to head, and do certain 
drills to make sure that the coaches know how to teach it 
instead of just letting players run around out there, and let 
the ball head them; instead, teach them how to head the ball, 
and also improve the strength of the neck muscles. For females, 
it seems to be part of the issue is they are not as strong as 
the male counterparts in heading. And so that needs to occur. 
And there just needs to be an understanding and an education of 
what you are looking for when a head injury does occur.
    Ms. Schakowsky. Let me ask you a question. I don't know if 
soccer is the only sport where you quite deliberately use the 
head.
    Ms. Scurry. Right.
    Ms. Schakowsky. Is that an inherent problem?
    Ms. Scurry. I don't necessarily think it is an inherent 
problem----
    Ms. Schakowsky. Right.
    Ms. Scurry [continuing]. But, obviously, I think that 
scenario, when there is a ball in the air you are going to 
head, that there is something highly probable that could 
happen, but I think if you teach it properly, you are going to 
have those head injuries no matter what you do, just like they 
said, when you play the sport, you are going to have injuries 
that happen, but I think that certain things that happen during 
a heading situation isn't the only reason or only time when 
concussions occur.
    Mine in particular happened when I was playing in the goal, 
going for a low ball from my left, the player came in from the 
right and hit me in the side of my head with her knee.
    Ms. Schakowsky. Uh-huh.
    Ms. Scurry. And that has nothing to do with heading----
    Ms. Schakowsky. No.
    Ms. Scurry [continuing]. At all, you know. Head to knee, 
head to foot, head to post isn't part of that.
    Ms. Schakowsky. Well, I would love to get your advice as we 
move forward, and anything that I can do outside of this body, 
because I certainly----
    Ms. Scurry. Fantastic.
    Ms. Schakowsky [continuing]. Worry about my granddaughter.
    Mr. Miller, I wanted to ask you a question. Retired NFL 
players face some of the most serious health challenges of any 
sport, yet benefits for former players are not on a par with 
Major League Baseball or the National Basketball Association, 
despite the fact that the NFL has more than $9 billion in 
annual revenue.
    So yes or no, does the NFL yet provide lifetime health 
insurance for former players who did not play under the current 
collective bargaining agreement?
    Mr. Miller. No. The players are able to continue their 
medical coverage when they leave the game, but they are not 
provided lifetime medical coverage.
    In the most recent collective bargaining agreement with our 
Players Association, there were in excess of $600 million that 
went to the players who played pre-1993, and added pensions and 
benefits. All of our programs are collectively bargained with 
our Players Association, and so I think during each iteration 
of our collective bargaining agreements, you have seen changes 
and improvements made, excuse me, to the programs for retired 
players including this year, for example, this past CBA, for 
example. A neurocognitive program, screening program----
    Ms. Schakowsky. Well, I understand----
    Mr. Miller [continuing]. That provides opportunities----
    Ms. Schakowsky [continuing]. But professional baseball and 
professional basketball do provide lifetime health insurance 
for former players. And while I understand the NFL's ADA Plan, 
what could be the reason to not provide lifetime health 
insurance for former players?
    Mr. Miller. Well, like I mentioned, all of our programs, 
all of our benefits, and all of the policies are collectively 
bargained with the Players Association, and so the improvements 
that we have seen as far as care for retired players, whether 
they be the ADA Plan, as you mentioned, which accounts for any 
player who suffers from a diagnosis of dementia, neurocognitive 
benefits, which help players' joint and hip replacements, all 
of those sorts of things are improvements, and are made 
available to players should they suffer from those issues, in 
addition to a number of other practices and programs, including 
help lines and our Player Care Foundation, the Players 
Association has additional programs to help players who are in 
need at little or no cost, and those programs exist today.
    Ms. Schakowsky. I yield back.
    Mr. Terry. Mr. Lance, you are recognized for 5 minutes.
    Mr. Lance. Thank you very much, Mr. Chairman.
    Mr. Miller, the changes that you have made in recent years, 
the rules change, the increased penalties, suspensions for rule 
violations, reducing full contact practice days, can you share 
with the committee data that you have that this, I hope, has 
had a positive impact on concussion incidents that might 
encourage leaders at other levels of football?
    Mr. Miller. Absolutely. We are happy to share with the 
committee, you know, some greater information than I can offer 
in my oral testimony.
    Mr. Lance. Certainly.
    Mr. Miller. But the most interesting number from my 
perspective is when you count up the number of all the 
concussions that were diagnosed in games and practices, 
preseason in preseason practices, and postseason in postseason 
practices, you see a 13 percent decrease year over year. And--
--
    Mr. Lance. Thirteen percent each year? Year over----
    Mr. Miller. Thirteen percent between 2012 and '13.
    Mr. Lance. Very good.
    Mr. Miller. And the emphasis has been on eliminating the 
use of the head in the game, and specifically helmet-to-helmet 
hits, which are a significant cause of the injury. And in those 
circumstances that we have been able to identify where two 
helmets collide, we have seen a decrease in the number of 
concussions by that cause by 23 percent in the past year.
    There is a lot more work to be done, and those numbers 
could change year over year. I don't think anybody should rely 
upon one-year data as some sort of conclusion, but I am happy 
to go into that further with the committee if you would like to 
see more of the information.
    Mr. Lance. Thank you. I think we would, and this is, of 
course, very helpful, and I hope that the improvements 
continue.
    Mr. Hallenbeck, I believe your testimony indicated that 15 
high schools in 10 districts participate in your pilot program 
last year, and that you are anticipating 500 to 1,000 will 
participate this fall. And, of course, I would imagine high 
school football is the football that most of us have 
experience, either through ourselves or through a child, and in 
my case, a son, and this is part of the American tradition.
    What are your plans for getting more school football 
programs at the high school level to participate, and what does 
your outreach entail, and how do schools across the country 
learn about your program? I think the purpose of this hearing 
is multifaceted, and one of the purposes, I would hope, is to 
inform high schools across the country about your program, as 
the video indicated, occurs here, next-door in northern 
Virginia?
    Mr. Hallenbeck. Thank you. So first of all, one of the 
common themes we are hearing, of course, is inconsistency, and 
football probably is the most fragmented of all used sports, 
and even at the high school level, there are significant 
challenges there. So what we are trying to strive for through 
this Heads Up Football program is consistent teaching, 
consistent teaching of technique, consistent teaching of 
terminology, and now getting out to the staunchly independent 
youth programs as well as now high school programs, the good 
news is they are actually being responsive. If it is their 
superintendents, if there are principals, their athletic 
directors, they are being asked, as it was mentioned in the 
video, ``What are you doing about this?''
    Mr. Lance. And you are doing the asking, or the parents and 
PTAs are doing the asking?
    Mr. Hallenbeck. It is a combination. We are talking to 
State associations, high school State associations, we are 
talking to coaches' associations, we are talking directly to 
coaches, we are working with athletic directors, we are working 
with parent groups, national PTA is involved, we are looking at 
every conceivable channel to communicate this program and the 
importance of changing behavior. And what I am sharing is there 
has been a very positive response.
    That video by itself, and really the reason I decided to 
show it, has been incredibly influential. In addition, we now 
have the Big 10, the Pac-12, the Big 12, the ACC, we will 
eventually have the NCAA, we will have all college conferences 
involved, every one of their coaches will be involved, with 
PSAs and things of that nature that help influence high school 
coaches and high school programs to embrace the Heads Up 
Football program and help change behavior.
    Mr. Lance. Thank you. Let me say that if there is one 
message I wish to leave this morning in my 5 minutes of 
questioning is that I would hope that all of those involved at 
your level of football would examine what you are suggesting, 
because after all, that touches virtually all of the American 
people, and I commend the panel for its testimony.
    Thank you, Mr. Chairman.
    Mr. Terry. Thank you, Mr. Lance. And I just editorialize, 
that is why we have NHL Youth Hockey, NFL Youth Football, is 
because it does seem that it trickles down. Whatever is said at 
the top, then it gets pushed down to the youth, and so that was 
by design.
    The gentleman from Utah is now recognized for your 5 
minutes.
    Mr. Matheson. Well, thank you, Mr. Terry.
    I first want to echo something that Mr. Waxman said in his 
opening statement. It may sound obvious but I think it is 
important that we acknowledge. This is a complicated issue. 
There are a lot of complexities to this, there is a lot we 
don't know about brain science, and I think we all could agree 
that the notion that this is an issue that merits significant 
investment and research is really something beyond even 
concussions in sports. We have traumatic brain injury in terms 
of our soldiers in the field. This is a really important issue 
that is complicated, and we ought to make sure we approach it 
in a thoughtful and comprehensive way, so, Mr. Chairman, thank 
you for scheduling this hearing today.
    I was going to ask Mr. Miller, without taking too long, 
because this is an open-ended question, but could you kind of 
walk us through the steps, as information and research has 
brought more knowledge to the NFL, how has the league 
responded, and how have you positioned yourself on these issues 
to address the issues of concussions? And just if you could 
walk us through some of the history of how it has evolved 
within your organization.
    Mr. Miller. Yes, I am happy to do it, and thank you for the 
question.
    I think the point that you made that the science has 
evolved----
    Mr. Matheson. Um-hum.
    Mr. Miller [continuing]. On neurological issues, certainly 
neurodegenerative disease, is one that the second panel, where 
there is a terrific expert lineup, can talk to, but we rely on 
the outside advice of very well known, well respected, probably 
internationally known neuroscientists to advise us as to what 
the state of the science is, and how best to go about changing 
out game to reflect that. And so that is how we ended up 
creating a unified concussion protocol and return to play 
protocol for our sideline. That is how we ended up with 
additional concussion experts on the sideline. This is based on 
the advice of outsiders who tell us this is the best way to 
handle your players, this is the best way to treat the game, 
and if you want a culture of safety, this is what you would do, 
and we follow their advice strictly and meet with them very 
frequently.
    Mr. Matheson. All right. And I notice your title is Senior 
Vice President of Health and Safety Policy. That has got to be 
a position that didn't exist 20 years ago, I bet?
    Mr. Miller. It did not exist 20 years ago----
    Mr. Matheson. Yes, so----
    Mr. Miller [continuing]. And I am proud to be in that role, 
and it is an exciting one.
    Mr. Matheson. I know this hearing is concussions, but since 
you are here, I have to ask you one other question that may be 
a little different topic.
    Over the last few years, I have communicated with the NFL 
about my concerns about the issue of human growth hormone 
testing, and I know that is something that was raised in the 
last collective bargaining agreement effort, and there is an 
agreement to agree later, but that hadn't always come together 
as much, and I know this is something that is important to the 
league.
    Can you give us an update on what is going on on testing 
for human growth hormone?
    Mr. Miller. Sure. We appreciate the question.
    Unfortunately, we don't have human growth hormone testing--
--
    Mr. Matheson. Right.
    Mr. Miller [continuing]. Yet. The league has been ready, 
able, willing to pursue it, as you mentioned, since it was 
agreed upon in the collective bargaining agreement. 
Unfortunately, our Players Association has thrown up 
obstacles--probably fair to say, from our perspective, 
excuses--for a period of time. And I think the testing goes to 
the integrity of the game, certainly. It also goes to the 
health and safety of the sport.
    Mr. Matheson. Yes.
    Mr. Miller. You don't know where this stuff is coming from. 
You don't know who is giving it to a player or players, and you 
don't know what they are putting in their bodies, and that is 
dangerous and it is also the wrong example to set. And so this 
is an important issue for us, and one that we are sorry has not 
gotten accomplished yet.
    Mr. Matheson. Well, that is an important issue to me, and 
that is why I wanted to raise it. I know that it is not this 
topic of this hearing, Mr. Chairman, but since he was here, I 
had to ask the question.
    Ms. Schakowsky. No, but if the gentleman will yield just--
--
    Mr. Matheson. Yes, I will yield.
    Ms. Schakowsky [continuing]. For one sentence. I think that 
is why we wanted to have the Players Association here too 
because, you know, that was a pretty strong criticism that you 
just made. It would be nice to have had the players as well to 
respond.
    Mr. Terry. Well, I will have to now interject. They were 
asked and they declined.
    Ms. Schakowsky. Yesterday.
    Mr. Terry. No.
    Mr. Matheson. Well, anyway----
    Mr. Terry. That is not accurate.
    Mr. Matheson. Well----
    Mr. Terry. They were contacted before yesterday----
    Mr. Matheson. I want to reclaim my time----
    Mr. Terry [continuing]. And they still rejected.
    Mr. Matheson [continuing]. For one more question though, if 
I can. I have one more question for you. Where do you see 
things going? I know when you try to crystal ball, it is 
dangerous because you never know, but where do see things going 
in the next 5, 10, 20 years in terms of where technology is 
going to take us? Do you have some things about looking out on 
the horizon that we can be looking forward to?
    Mr. Miller. Yes, I will give you a specific example. As 
part of the scientific research that we entered into with GE, 
the world's leader in diagnostics, we set aside what we call 
innovation challenges, two $10 million pots of money. The first 
was to promote new ideas on how to better diagnose concussions. 
There aren't any objective tests now. They are all subjective 
analyses.
    Mr. Matheson. Right.
    Mr. Miller. And we had people from 27 different countries 
around the world offer ideas. We eventually rewarded 16 of them 
so far, biomarkers, blood tests, these sorts of things. And 
then in addition, we just completed another challenge that 
echoes around protective ideas, how to protect the brain 
better. We had more than 40,000 people from 110 countries 
around the world visit the Web site.
    Mr. Matheson. Wow.
    Mr. Miller. We had people from 19 different countries offer 
ideas on new protective equipment, and we are reviewing those 
now. And I think that because there is a lot more attention 
paid to this, and hopefully we are one of the actors that are 
catalyzing the science, that you are going to see changes in 
all of these places relatively soon.
    Mr. Matheson. OK. Appreciate that.
    Mr. Chairman, my time is up so I will yield back.
    Mr. Terry. Thank you. The gentleman from Kentucky is now 
recognized for 5 minutes.
    Mr. Guthrie. Thank you, Mr. Chairman. Thank you for being 
here. And, Ms. Scurry, thank you for being here. That, quite 
honestly, might have been the only soccer game I have ever 
watched from top to finish. It was----
    Ms. Scurry. Thanks a lot.
    Mr. Guthrie [continuing]. About the time that my daughter 
was interested in soccer, so we were watching it----
    Mr. Terry. No pun intended with the top.
    Mr. Guthrie. Top to--OK, no pun intended. That went over my 
head, I am sorry.
    But what a great sporting event, and it is one of the great 
moments, and to be part of that is something special. And I 
think it was special because it was just so much America. It 
was youthful, you were underdogs, you were grit, determined, 
and you brought up Brandi Chastain, not I, and maybe a little 
exuberance, but it was a great moment, and I appreciate you 
doing that and sharing.
    But I played high school football. That is my claim to 
athletic prowess, I guess, but we practiced in August. I 
remember one time, in the south, 90-something degrees, and we 
are all running water breaks, we run to the water break and 
some smart aleck kicks another guy's foot so he falls, knocks 
all the water over. So the coach says, well, if you guys don't 
know how to handle that, we are just not going to have water 
today. So that was over 30 years ago, and that would never 
happen anywhere today. There was actually in Louisville a young 
man who passed away on a football field, and the coach went to 
trial over it, and turned out he wasn't convicted but--so I 
think the awareness and, you know, stuff like what I described 
in my youth would never happen on a football field anywhere 
today, or at least I hope it wouldn't, but we still have these 
injuries. And I think, Ms. Scurry, you talked about your injury 
being--it wasn't heading, it wasn't changing tactics, it was 
just--in soccer you are wearing cleats and short pants and a 
shirt, and somebody hits you in the side of the head with their 
knee----
    Ms. Scurry. Right.
    Mr. Guthrie [continuing]. And when you look at, I watch a 
lot of football, of course, then they will have targeting, you 
know, if you are in college football, you are ejected from the 
game for targeting. But a lot of the injuries you will see, if 
the quarterback gets knocked down and somebody runs and their 
knee hits them on the side of the head. And I don't know how 
you change those--and how do you deal with that kind of--I know 
you are trying to do the techniques and tackling and not 
heading the ball the right way, but just the incidental things 
that happen because you are playing a sport that you are going 
100 miles an hour. Do you have any comments on that, Ms. 
Scurry?
    Ms. Scurry. Yes, well, thanks for the question.
    That is very relevant, actually, because my hit, when I 
watched it actually last night again on video, it doesn't seem 
to be a hit that would have taken me out of the game. As it 
was, I got hit and then there were a few minutes later before I 
actually ended up coming out.
    Mr. Guthrie. Wow.
    Ms. Scurry. There wasn't even a foul called, actually. So 
that is part of the problem, right? Sometimes a hit is a 
glancing blow, and it doesn't even really seem to be anything 
that is a big deal, but I think for me, my main focus is what 
is done after a hit occurs. And to keep children and young 
players off the pitch after a blow occurs to assess them, and 
then determine whether they are ready to go return to play or 
not. I think that is the key for me and why I am speaking out 
about this, because I have been around the country talking to 
different organizations, and I am finding that kids are getting 
concussions, five, six, seven, in a very short period of time, 
because they are returning to play too soon, and that is where 
I think a lot of the awareness and education can help.
    Mr. Guthrie. Well, thank you.
    And, Mr. Miller, with that, you should do everything you 
can to stop the head-to-head and so forth, but it seems, 
because they will play them on TV over and over--this is when 
somebody gets injured and they are out, like a knee of the 
lineman hits, somebody like Jon Runyan hits the side of 
somebody else's head--I mean, it is just incidental, but I 
guess you are right, you can't really prevent that from 
happening, but it is how you react to how that happens. Is 
that----
    Mr. Miller. Well, I think that is right. One of the 
recommendations made by the Fourth International Concussion 
Conference in Zurich was to look at the playing rules of the 
game. And in our case, we have done that, and I know other 
sports have done that as well, so you create the best possible 
situation.
    Mr. Guthrie. Um-hum.
    Mr. Miller. In a contact sport, there will be injuries, and 
there will be, you know, hits to the head, and those problems 
will occur. And so where that happens, we want to make sure 
that we are treating them appropriately, and so that is where 
the focus shifts from prevention to appropriate treatment.
    Mr. Guthrie. Well, thank you. And I am about out of time. I 
just want to say, Ms. Scurry, I was sitting on the edge of the 
couch, leaning and moving as they were shooting against you, 
and hopefully you felt my assistance and were able to help us 
both together win one for our team, right?
    Ms. Scurry. Absolutely.
    Mr. Guthrie. Thank you very much. And I yield back, Mr. 
Chairman. Very good job and I am glad to meet you.
    Ms. Scurry. Thank you. You too.
    Mr. Terry. Thank you, Mr. Guthrie. Now the gentleman from 
Maryland is recognized for 5 minutes.
    Mr. Sarbanes. Thank you, Mr. Chairman, and thanks for the 
hearing, and thanks to our panel.
    Mr. Hallenbeck, I had a quick question about whether the 
school districts that you have been working with that have been 
implementing this, has that affected the like liability 
policies that they maintain as a jurisdiction? In other words, 
is there any trend towards they may be getting pushed by the 
insurance industry, for example? So in other words, insurer 
would say, well, previously, I would have provided liability 
coverage to your school district based on these measures or 
assurances that the district mad with respect to how it is 
conducting its sports program, but now that there is this 
program that enhances the safety of students and young people, 
we want to see that you have implemented that in your district 
or else we are not going to provide the policy coverage, or we 
are going to charge you a higher premium. I mean you can look 
at it the other way. You get a discount off of your premium as 
a school district because you have implemented these kinds of 
measures. And I ask that because I think that increased 
awareness of some of the risks from these sports injuries may 
lead to pressure in terms of liability on school districts. And 
you will get some that may choose, based on the premium that 
gets charged, to push the program out because they don't want 
the liability that comes with it.
    So I was just curious whether you are aware of that kind of 
effect from the program, or more generally aware of kind of how 
the liability concerns intersect with some of these safety 
efforts that are underway.
    Mr. Hallenbeck. Thank you for the question.
    At the high school level, we are literally on the front, 
you know, one-yard line marching down the field. And I will 
mention that we are having very positive conversations with the 
State of Maryland right now about participating in Heads Up 
Football across the entire State.
    So we have a lot to do there. We have not seen anything 
from a liability concern, insurance concern. With Fairfax 
County, we worked very closely with all their schools and their 
school district about those issues, but they told us, and we 
checked ourselves, they felt they had the appropriate coverage. 
However, to your point, at the youth level, we are absolutely 
seeing the insurance industry at large, and really the largest 
provider of casualty and liability insurance, step forward and 
actually stated that if youth football leagues participate in 
the Heads Up Football program, they would receive a discounted 
program, and a more comprehensive coverage. So we are 
absolutely seeing a positive response by the insurance 
industry, which, of course, has its merits.
    Mr. Sarbanes. Thank you. I yield back.
    Mr. Terry. Mr. Ogrean, are there any insurance liability 
issues at USA Hockey?
    Mr. Ogrean. Yes, Mr. Chairman, there are plenty of 
insurance liabilities, and I think unlike USA Football, for 
example, which is much more decentralized than are we, our 
participants are all insured by us as a national organization. 
So whether it is player accident insurance or whether it is 
catastrophic insurance, whether it is liability and even D and 
O for all of our leagues, all of that is part of what our 
members pay us a membership fee for.
    Those claims, or those premiums, rather, are obviously 
based upon the number of claims. And so that is another 
business reason why it is in all of our best interests to try 
to come up with every technique, every practice, every policy 
that we possibly can to make our game safer. The number one 
reason, of course, is the safety of the human beings playing 
our sport, but there are good business reasons for all of us to 
want to do everything possible to make the game safer.
    Mr. Terry. Thank you.
    Mr. Kinzinger, you are recognized for 5 minutes.
    Mr. Kinzinger. Thank you, Mr. Chairman. Thank you for your 
leadership in holding this hearing, and to all of you, thank 
you for being here and bearing through a bunch of politicians. 
I appreciate it.
    I appreciate the diverse panel that has gathered here, and 
the important insights you guys are able to provide on the 
prevalence of concussions in sports.
    According to the CDC, 175,000 sports-related concussions 
impact youth athletes each year, and I think today's hearing 
has been very constructive in helping us to move forward on 
understanding that and alleviating it.
    I have read much about the legislative action taken across 
the United States to pass concussion laws. In my home State of 
Illinois, similar legislation was passed in 2011 to require 
that education boards throughout the State work with the 
Illinois High School Association to adopt guidelines that raise 
awareness of concussion symptoms, and ensure students receive 
proper treatment before returning to the team. In addition, it 
is encouraging that professional sports leagues and teams are 
taking steps to address concussions not only in their own 
ranks, but also working with collages and youth leagues to 
bring attention to the issue.
    Last year, the Chicago Bears--go Bears--kicked off a pilot 
program to provide certified athletic trainers at three high 
school stadiums during Chicago public school football games. 
Such high profile initiatives are important to combatting this 
issue, and I applaud the Chicago Bears for their leadership.
    Again, I find these steps to be promising, but we are still 
confronted with staggering numbers of youth being impacted by 
sports-related concussions.
    I would like to ask just a few questions, maybe not take 
all 5 minutes, maybe I will.
    Let us talk about the equipment issue. I will ask each of 
you to respond.
    Where are we at today in terms of what kind of equipment is 
being utilized to protect, versus maybe where we were a few 
years ago, what kind of advances are yet to be made that you 
think we are on the cusp of making or that we should make, and 
then is this backed by medical science? Is that what is going 
into this idea?
    So, Mr. Daly, I will start with you and I guess whatever 
you want to put into that subject would be great.
    Mr. Daly. Well, thank you for the question.
    It is a very important issue, obviously. The equipment 
issue is a very important issue, and something we are focused 
on jointly with our Players' Association. We have a protective 
equipment subcommittee that is part of our Joint Health and 
Safety Committee. So we look at all aspects of equipment and, 
particularly as it relates to head injuries, how we can improve 
equipment, and perhaps reduce the amount of head injuries we 
have. We have passed some rules over time with respect to some 
of the equipment we had seen develop over the years with hard 
padding, both in the shoulder area and the elbow area, and 
those potentially causing head injuries. So we have mandated 
padding of those areas areas of a player's equipment.
    The helmet issue is a difficult issue, particularly in 
hockey, in terms of preventing concussion, and one of the 
things we are looking to work with our manufacturers on is 
research in terms of dealing with the rotational forces that 
can cause concussions, particularly in a sport like hockey, and 
whether a helmet can be designed to deal with those more 
effectively than it currently does.
    Mr. Kinzinger. Thank you, sir.
    Mr. Ogrean?
    Mr. Ogrean. I think Mr. Daly answered the question pretty 
well for our sport. There is a great deal where we rely on the 
National Hockey League to be the leader, and a lot of what they 
do is of benefit to us in a trickle-down fashion, but as I 
mentioned in my opening testimony, we do have a Safety and 
Protective Equipment Committee of 40-year standing. They do 
look at a variety of issues. The facemask, for example, is 
something that is mandatory----
    Mr. Kinzinger. OK.
    Mr. Ogrean [continuing]. In youth hockey. It is not in the 
National Hockey League, though the shields for incoming players 
are now a standard.
    Mr. Kinzinger. I am going to have to cut you off just 
because of time. Mr. Miller?
    Ms. Ogrean. That will be fine.
    Mr. Miller. Sure. Football helmets were designed to prevent 
against skull fractures, and they do a fabulous job of that. 
They were not designed to protect against concussion, and so 
that sort of technology or design, I know that the helmet 
manufacturers are working on it. We are not there yet, and the 
league is doing what it can to inspire that, especially with 
our partnership with GE and Under Armour, to get new ideas 
around that. And the other thing we do is we do regular helmet 
testing in concert with our friends at the Players Association, 
so that we can inform our players of which helmets are working 
best.
    Mr. Kinzinger. And, Mr. Hallenbeck, or, Ms. Scurry, you 
guys?
    Mr. Hallenbeck. Yes, trickle-down effect, again, is 
important there, and the only thing I would add is we are 
working now closely with the Sport and Fitness Industry 
Association and their new Football Council, so we are getting 
insight from them, and working together on how we can improve 
things.
    Mr. Kinzinger. Thanks. And, Ms. Scurry?
    Ms. Scurry. As you know, we don't wear equipment in our----
    Mr. Kinzinger. Right.
    Ms. Scurry [continuing]. Sport, but I do want to commend 
your State for their Illinois Youth Soccer Association is 
taking a real lead in concussion awareness. I actually just did 
an event in Chicago just last weekend----
    Mr. Kinzinger. OK.
    Ms. Scurry [continuing]. For the association, and talking 
about concussions. And so your organization is doing a great 
job.
    But in terms of equipment for my sport, we don't really 
have anything right now that is widely used, but hopefully in 
the future there could be something to help.
    Mr. Kinzinger. Great. Thank you. Mr. Chairman, I will yield 
back.
    Mr. Terry. Gentleman from West Virginia is recognized for 
your 5 minutes.
    Mr. McKinley. Thank you, Mr. Chairman. I had to slip out 
for another meeting, so maybe some of these questions have been 
asked, but if you could help me out on this a little bit, one 
is: Is there anything that we can learn from the Defense 
Department with concussion injuries that we are hearing from 
when we talk to our troops that come back? I am just wondering 
if there is some way that we are all talking to each other? If 
you could help out on that.
    Mr. Miller?
    Mr. Miller. Yes, I am happy to take that question. We are 
very proud of our relationship that we have fostered over the 
last couple of years with the U.S. Army and specific memorandum 
of understanding that went back a couple of years that covers a 
variety of different things.
    We have gotten current and retired players together with 
returning active service members to talk about cultural issues. 
What is it about football or what is it about the military that 
makes it very difficult for somebody to remove themselves from 
play, or, certainly in the case of the military, from a battle. 
We found a great deal of reticence on behalf of both 
populations, sort of a shared reticence to remove themselves 
from their comrades or teammates. And it instills a question as 
to how you get somebody to talk about, to tell their teammate 
or to tell their colleague, hey, you don't look right, you 
should get off the field. And so we have learned a lot from 
that.
    And let me just add briefly as well, we meet regularly with 
the Army to talk about the research that they are doing from a 
scientific perspective. We share our agenda, we share the ideas 
that we have, and they do with us as well, and it has proven to 
be a very cooperative and beneficial relationship thus far.
    Mr. McKinley. OK. Anyone else want to add to that, about 
our military?
    The second question has to do with, States have Workers' 
Compensation programs to deal with the various disorders and 
injuries. Black lung in my State, it is treated in a way that 
people don't have to take legal action to get help through the 
Workers' Comp program. Is that something that would be of 
benefit here in this program for injuries? A friend of mine has 
spent quite a few years in litigation with the NFL over this 
matter and just thinks it is such a cumbersome--and we also 
have an East Coast Hockey League team in our city, and we see 
so many injuries, and we hear from some of the players and 
coaches about that injury. Is there a time that we should have 
a Workers' Comp program for brain injuries? Should that be 
included in something?
    Ms. Scurry. If I----
    Mr. McKinley. If they are not required to file litigation 
to get help.
    Ms. Scurry. If I may. My case actually is a Workers' Comp 
case. I have gone through Workers' Comp to get the different 
doctors, to see different techniques that will help me, and 
that is part of my situation and part of the reason why it has 
taken so long because every time something is suggested or 
recommended, I have to go back to the insurance company to get 
permission to do it, and sometimes it takes a hearing to get 
everything moved forward. So maybe streamlining that somehow 
would be of great help.
    And also in your previous question you talked about how can 
we help the military service people who have TBIs. For me, one 
of the best things I think would help is more of the 
psychological side and testing depression and anxiety and panic 
attacks to make sure that each person who comes back from the 
military who has a TBI gets help in that area, the emotional 
side of it, not just the physical. That would be very helpful, 
I think.
    Mr. McKinley. OK, thank you. Any other thoughts?
    Mr. Daly. Well, Workers' Compensation laws are really 
different jurisdiction by jurisdiction, including for us in 
Canada where professional athletes are specifically excluded in 
most Workers' Compensation law, but it is certainly a mechanism 
that an increasing number of our former athletes are using in 
cases where they have debilitating injuries from their playing 
careers.
    Mr. McKinley. So what was your recommendation then? You are 
saying yes?
    Mr. Daly. Well, again, I----
    Mr. McKinley [continuing]. We should be pursuing looking at 
that, or----
    Mr. Daly [continuing]. I guess what I would say is, I think 
it is generally available to our former athletes currently, the 
Workers' Compensation protection.
    Mr. McKinley. I guess maybe that some of what we are 
hearing is different from that, that is why I want to raise it, 
but thank you for your comments about that.
    I yield back the balance of my time.
    Mr. Terry. Gentleman yields back. Now Mr. Bilirakis from 
Florida, you are recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much. Thank you very much for holding this very important 
hearing, and I wanted to specifically thank Ms. Scurry for 
really speaking out. I really appreciate it. It makes so much 
of a difference, and thanks for your sacrifices. You are going 
to make a real difference in kids' lives.
    I also want to get back to the protective gear, the 
helmets, what have you. And how does the youth, and we can ask 
all of you, how does the youth helmet, the protective gear, 
compare as far as safety, quality, to the NFL and NHL? Can you 
give me an opinion on that?
    Mr. Hallenbeck. So I am certainly no expert on exactly how 
that compares, other than--I mean, my understanding is that 
there obviously is NOCSAE, the standard bearer, and they set 
the standards, and certainly all the helmets out there have to 
pass that standard, and I think the manufacturer, if they were 
sitting here, would say they go above and beyond that. How it 
compares to an NFL helmet, I think generally speaking, the 
youth helmet is lighter but the padding and so forth is 
appropriate. I don't want to suggest I am defending them. I 
don't know the exact details. I know it is sufficient based on 
standards and so forth. Many of the kids, though, I mean the 
players, youth players, I mean by 10 and 11 and 12 years old, 
they are transitioning into what might be considered, you know, 
certainly high school or adult helmets, so they are getting the 
best available.
    And the other thing I would add is, certainly I am aware 
that the technology is improving in helmets and shoulder pads, 
and football equipment generally is definitely improving.
    Mr. Bilirakis. Mr. Miller?
    Mr. Miller. Sure. We worked on a program with the Consumer 
Product Safety Commission, our Players Association, and some 
others recently that we would put money towards reconditioning 
older helmets for youth leagues. Certainly, the leagues that 
have, you know, budget constraints, as many do, probably don't 
get around to updating their helmets or what they call 
reconditioning them frequently enough. And so we put a fair 
amount of money into that program in coordination with the 
CPSE. I know Scott, USA Football runs an equipment grant 
program as well. So, addressing those needs. We know that a new 
helmet is better than an old helmet. We know a reconditioned 
helmet is better than one that hasn't been. Most important of 
all is that coaches learn how to fit the helmets. That is going 
to be the number one safety piece to the equation as it relates 
to kids. And so we are aware of these issues and we are trying 
to make a difference there as well.
    Mr. Bilirakis. So, in your opinion, the youth helmet or the 
high school helmet is not as safe as the NFL, but you do have a 
program to help. Is that correct?
    Mr. Miller. Yes. I don't know about the----
    Mr. Bilirakis. The quality might not be as good.
    Mr. Miller. I don't know about the comparative safety of 
the helmets.
    Mr. Bilirakis. OK.
    Mr. Miller. I suppose that is probably a question that----
    Mr. Bilirakis. Can I talk to you about this----
    Mr. Miller. Of course.
    Mr. Bilirakis [continuing]. Particular program----
    Mr. Miller. No question.
    Mr. Bilirakis [continuing]. To help out, because I know for 
parents where the kids play high school football, and the 
parent will purchase a better quality helmet for their child, 
and, you know, I am concerned about the kids that don't have 
the, you know, the parents don't have the money, you know, to 
purchase that, and it is so very important. So I would 
appreciate working----
    Mr. Miller. Happy to.
    Mr. Bilirakis [continuing]. With you on this.
    Mr. Miller. Every kid deserves the proper equipment.
    Mr. Bilirakis. There is an existing grant program out 
there. I would like to hear about it. And then also, can I hear 
from the hockey as well----
    Mr. Ogrean. Sure.
    Mr. Bilirakis [continuing]. NHL?
    Mr. Ogrean. At the youth level, I think the helmets are 
just as good as the National Hockey League, the only difference 
is size. They have to be certified by the Hockey Equipment 
Certification Council. There is a 3-year expiration date on 
every helmet. You can't use a helmet that is more than 3 years 
old.
    Mr. Bilirakis. Very good. NHL wants to----
    Mr. Daly. Yes. No, I would first echo Mr. Miller's comments 
that, you know, helmets in our sport as well are principally 
designed to prevent skull fractures. They're not principally 
designed to prevent concussions, and sometimes they can 
disperse force in a way that does prevent concussion but that 
is not their principle purpose. We also have regulations that 
we make available to our equipment managers and our players 
with respect to frequent replacing of helmets. So each player 
is essentially asked to replace his home helmet at least once a 
season, and his road team helmet at least two times a season, 
because we are worried about aging effects and degradation that 
accompanies travel requirements for our team. So frequent 
replacing of helmets is a priority for our league as well.
    Mr. Bilirakis. Are their coaches educated? I mean do they 
know which size fits the child? Have they been briefed on those 
particular issues, because that is so very important? Youth 
sports, hockey and football.
    Mr. Ogrean. They are. I agree with Mr. Miller that it is a 
big difference-maker, you know, in the helmet doing its job, 
but it is a pretty fundamental part of what a coach has to do 
to make sure the players on his team all have the proper 
equipment and are wearing it in the right way.
    Mr. Bilirakis. Very good, yes. Sir, would you----
    Mr. Hallenbeck. And I would just add----
    Mr. Bilirakis [continuing]. Like to comment?
    Mr. Hallenbeck. Yes. I would just add that it is a 
cornerstone of our Heads Up Football program----
    Mr. Bilirakis. Very good.
    Mr. Hallenbeck [continuing]. Equipment fitting, because, 
frankly, at the youth and high school level, we have found they 
don't know how to properly fit equipment, so it is a very 
important element within the program.
    Mr. Bilirakis. Thank you very much for including that. As 
far as, you know, the youth, of course, the NFL Hockey stars, 
what have you, baseball, basketball, they are looked up to by 
our children, as you know. Do you all have programs where you 
can speak--that speak, you know, maybe go to the schools, 
football players, what have you, professional football players, 
go to the schools and speak on these particular issues?
    Mr. Miller. Yes, our active players are, by and large, 
terrific at this topic. One of the elements that we included or 
offered up to USA Football as part of their Heads Up Football 
program was actually what we call an ambassador. So for leagues 
that were early adopters of the program, they would get visits 
and consultation with a retired NFL player.
    We are trying to encourage our clubs, with great success by 
the way, they have really done a terrific job of embracing in 
their communities the youth leagues and others, and so that 
they are around the facility more, that they interact with 
coaches, trainers, and certainly players, which obviously 
bring--the star quality of it brings attention to it, which was 
part of the motivation in the first place. But we have found 
retired players thrilled to participate, and really active and 
helpful to the end that you suggest.
    Mr. Terry. All right, gentleman's time has expired.
    Mr. Bilirakis. Thank you.
    Mr. Terry. So if any of you want to answer that question, 
you will have to do it by writing.
    And brings me to the point that--you have a question, I am 
sorry. Recognize the gentlelady from Virgin Islands.
    Mrs. Christensen. Thank you. And thank you, Mr. Chairman. 
Sorry I am late, I was at another hearing downstairs.
    Mr. Miller, I would like to ask you this question. Many 
tens of thousands of helmets are used every year that are more 
than 10 years old. I understand that the NFL participated in a 
program initiated by the Consumer Product Safety Commission by 
donating money that would go towards new helmets for youth 
football players in low income communities, and I really want 
to commend the NFL for this initiative.
    Of course, it is going to cost a lot more money to get to 
the point where virtually all kids around the country who play 
football no longer wear old helmets that are likely degraded or 
obsolete. I am pleased to know of your donation to the CPSC 
initiative, because it strikes me as an acknowledgement that 
wearing an old helmet when playing football is not advisable. A 
statement from the NFL that would be very influential. We have 
also heard that reconditioning those under 10 years old is 
important to ensure the proper foam density, and that other 
degraded parts of the helmet are replaced.
    So I wanted to ask you the following questions for a yes-
or-no answer. I guess that is why I am sitting in Chairman 
Dingell's seat. We realize that many issues are subject to 
negotiations, but can the NFL commit to supporting prohibiting 
helmets on the field that are over 10 years old?
    Mr. Miller. In the youth space? You are talking 
specifically about youth football, prohibiting helmets that 
are----
    Mrs. Christensen. Yes.
    Mr. Miller [continuing]. Older than 10 years there? I, you 
know, I plead not enough familiarity with the issue. I know 
that there are a couple of States who have taken that step, and 
we would be happy to work with you to pursue it. The prime 
place that, as you mentioned, that we work within in promoting 
new or refurbished----
    Mrs. Christensen. Well----
    Mr. Miller [continuing]. Helmets is with the CPSC or 
through USA Football, who has a grant program as well, but----
    Mrs. Christensen. So the first question is committing to 
supporting prohibiting helmets on the field that are over 10 
years old. Could you commit to the supporting of policy 
position that helmets more than 10 years old present an 
unacceptable safety risk? That is the position that is taken by 
most of the helmet industry.
    Mr. Miller. If that is the position of the helmet industry, 
I would see no reason why we would have a concern with that. 
That sounds appropriate.
    Mrs. Christensen. Riddell and Adams strongly recommend that 
their helmets should be discarded after 10 years. Can the NFL 
commit to supporting a policy position recommending that 
helmets be discarded after 10 years?
    Mr. Miller. We would certainly support the helmet companies 
and how they advise people to use their products.
    Mrs. Christensen. We have also heard stories of players 
using beat-up lucky college helmets, or adjusting their helmets 
by perhaps removing some padding in the helmets for comfort. 
Will the NFL commit to support a policy position that all 
players should wear helmets that are reconditioned properly?
    Mr. Miller. Well, all of our players have choices in which 
helmets they use, as long as they pass the NOCSAE, the 
certification by these standards. And so that is something that 
is a point of discussion with our Players Association, and 
players have to use helmets that pass the standard. So I----
    Mrs. Christensen. And that means----
    Mr. Miller [continuing]. We are happy to support that.
    Mrs. Christensen [continuing]. That they were reconditioned 
properly, and they had the appropriate padding?
    Mr. Miller. Sure. The NFL players' helmets are 
reconditioned regularly, is my understanding, and our equipment 
managers work with the players to make sure that their helmets 
are in good working order.
    Mrs. Christensen. Thank you, Mr. Chairman.
    Mr. Terry. Thank you very much.
    [Recess.]
    Mr. Terry. All right, why don't we have our witnesses take 
their respective places? OK, if we could have everybody take 
their seats. And as you are settling in, this is, pun intended, 
the more heady part of our hearing today where we are dealing 
with neuroscience and medical research and physics--well, 
physics when Dr. Gay arrives.
    So panel two, I will introduce you from Mr. Cleland on 
down. Mr. Cleland is the Assistant Director, Division of 
Advertising Practices at the Federal Trade Commission. We have 
Ian Heaton, Student Ambassador for the National Council on 
Youth Sports Safety. And if I might editorialize, I think Jan 
did a great job of juxtaposing a face of TBI and concussions on 
each panel. And Ian, as a high school lacrosse player, is that 
face for the more scientific-based panel. So thank you, Ian, 
for taking your day away from school. I know how tough it is to 
be pulled out of school and come testify before Congress. Just 
like a normal high school student. Then Dr. Robert Graham, 
Chair, Committee on Sports-Related Concussion in Youth at the 
Institute of Medicine. Dennis Molfese, Ph.D., Director, Center 
for Brain, Biology, and Behavior at the famed University of 
Nebraska. Thank you, Doctor. Then Dr. James Johnston, Assistant 
Professor, Department of Neurosurgery at the University of 
Alabama Birmingham. Star of screen, Dr. Tim Gay, Ph.D., 
Professor Atomic, Molecular and Optical Physics, University of 
Nebraska. Gerard Gioia, Ph.D., Division of Chief 
Neuropsychology, Children's Medical Hospital. And not quite up 
to the level of University of Nebraska, we have the Harvard 
Medical School. That is just humor. Professor of----
    Voice. Ha ha.
    Mr. Terry. Yes. Professor of Psychiatry and Radiology at 
Brigham and Women's Hospital, Harvard Medical School. Thank you 
for being here for a very impressive and esteemed panel of 
scientists and experts.
    And, Mr. Cleland, we will start. You are now recognized for 
your 5 minutes.

STATEMENTS OF RICHARD CLELAND, ASSISTANT DIRECTOR, DIVISION OF 
 ADVERTISING PRACTICES, BUREAU OF CONSUMER PROTECTION, FEDERAL 
  TRADE COMMISSION; IAN HEATON, STUDENT AMBASSADOR, NATIONAL 
   COUNCIL ON YOUTH SPORTS SAFETY; ROBERT GRAHAM, DIRECTOR, 
 ALIGNING FORCES FOR QUALITY, NATIONAL PROGRAM OFFICE, GEORGE 
WASHINGTON UNIVERSITY; DENNIS L. MOLFESE, DIRECTOR, BIG 10-CIC-
IVY LEAGUE TRAUMATIC BRAIN INJURY RESEARCH COLLABORATION; JAMES 
  JOHNSTON, ASSISTANT PROFESSOR, DEPARTMENT OF NEUROSURGERY, 
 UNIVERSITY OF ALABAMA-BIRMINGHAM; TIMOTHY J. GAY, PROFESSOR, 
  DEPARTMENT OF PHYSICS AND ASTRONOMY, UNIVERSITY OF NEBRASKA-
    LINCOLN; GERARD A. GIOIA, CHIEF, DIVISION OF PEDIATRIC 
NEUROPSYCHOLOGY, CHILDREN'S NATIONAL HEALTH SYSTEM; AND MARTHA 
E. SHENTON, PROFESSOR OF PSYCHIATRY AND RADIOLOGY, BRIGHAM AND 
            WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL

                  STATEMENT OF RICHARD CLELAND

    Mr. Cleland. I am Richard Cleland. I am assistant director 
for the Division of Advertising Practices at the Federal Trade 
Commission's Bureau of Consumer Protection. I am pleased to 
have this opportunity to provide information about the actions 
we have taken over the past few years with respect to 
concussion protection claims; claims that implicate serious 
health concerns, especially those potentially affecting 
children and young adults are always a high priority at the 
Commission.
    The Commission strives to protect consumers using a variety 
of means. First and foremost, the Agency enforces Section 5 of 
the Federal Trade Commission Act, which prohibits deceptive and 
unfair acts or practices. In interpreting Section 5, the 
Commission has determined that a representation, omission or 
practice is deceptive if it is likely to mislead a consumer 
acting reasonably under the circumstances, and it is material 
that it is likely to affect the consumer's conduct or choice 
decision about a particular product at issue.
    The Commission does not test products for safety and and 
efficacy; it does, however, require that an advertiser have a 
reasonable basis for objective claims conveyed in an ad. The 
Commission examines specific facts of the case to determine the 
type of evidence that will be sufficient to support a claim. 
However, when the claims involve health and safety, the 
advertiser generally must have competent and reliable 
scientific evidence substantiating that claim.
    As awareness of the dangers of concussion has grown, 
sporting goods manufacturers have begun making concussion 
protection claims for an increasing array of products. These 
include football helmets and mouth guards, but also include 
other types of products.
    In August 2012, the Commission announced a settlement with 
the makers of Brain Pad mouth guards. The Commission's 
complaint alleged that Brain Pad lacked a reasonable basis for 
its claims that the mouth guards reduced the risk of 
concussions, particularly those caused by lower jaw impacts, 
and falsely claimed that scientific evidence proved that the 
mouth guards did so. The final Order in that case prohibits 
Brain Pad from representing that any mouth guard or other 
equipment designed to protect the brain from injury will reduce 
the risk of concussions, unless the claim is true and 
substantiated by competent and reliable scientific evidence. In 
addition, the Commission sent out warning letters to nearly 20 
other manufacturers of sports equipment, advising them of the 
Brain Pad settlement, and warning them that they might be 
making deceptive concussion claims about their products.
    The FDC has monitored these Web sites and is working with 
them as necessary to modify their claims on their sites, and in 
some cases, ensure that the necessary disclosures are clear and 
prominent. Commission staff continues to survey the marketplace 
for concussion reduction claims, and alert advertisers who are 
making potentially problematic claims of our concerns, and of 
the need for appropriate substantiation for such claims.
    Commission staff also investigated concussion reduction 
claims made by three major manufacturers of football helmets; 
Riddell Sports, Incorporated, Schutt Sport, Incorporated, and 
Xenith, LLC. In these matters, the staff determined to close 
the investigations without taking formal action, by which time 
all three companies had discontinued the potentially deceptive 
claims or had agreed to do so. Those cases are discussed in 
greater detail in the Commission's written testimony.
    The Commission plans to continue monitoring the market for 
products making these claims, to ensure that advertisers do not 
mislead consumers about the product's capabilities or the 
science underlying them. At the same time, we are mindful of 
the need to tread carefully so as to avoid inadvertently 
chilling research, or impeding the development of new 
technologies and products that truly provide concussion 
protection.
    The Commission appreciates the committee's interest in this 
very important area, as well as the opportunity to discuss our 
Agency' effort to ensure that the information being provided to 
consumers, in particular, to the parents of youth athletes, is 
truthful and not misleading.
    Thank you.
    [The prepared statement of Mr. Cleland follows:]
    
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    Mr. Terry. Thank you. Now, Ian, you are now recognized for 
your 5 minutes.

                    STATEMENT OF IAN HEATON

    Mr. Heaton. Chairman Terry, Ranking Member Schakowsky, and 
members of the subcommittee, thank you for the opportunity to 
share my story today.
    My name is Ian Heaton, and I am here as a student 
ambassador for the National Council on Youth Sports Safety. I 
am also a senior at Bethesda Chevy Chase High School in 
Bethesda, Maryland.
    I was a sophomore playing in a high school off-season 
lacrosse game when I sustained a serious head injury that we 
later discovered was my third concussion. Until then, I did not 
appreciate what a great life I was living. I got good grades in 
challenging classes, played high school lacrosse, was working 
on my second degree black belt in martial arts, had a job I 
loved teaching taekwondo, performed at my school's jazz 
ensemble and combo, and had an active social life. It was over 
in a split second.
    My concussion left me with only 5 percent of normal 
cognitive activity, and I was almost immobilized.
    I have spent 2 \1/2\ years recovering, and, at times, have 
even wondered if I would ever get that life back. It has been a 
long, slow process.
    At first, all I wanted to do is sleep. Noise, light, and 
even moving my eyes caused headaches and nausea. I was enrolled 
in the Children's Hospital SCORE Program that Dr. Gioia will 
describe later, where I received ongoing cognitive evaluation 
and treatment for symptoms.
    After missing school for 2 weeks, I tried to go back but 
was unable to function. The frustration of trying to focus on 
lectures, moving through the pandemonium of the halls, and the 
constant sensory bombardment made a normal school day 
impossible. However, through my school, I eventually enrolled 
in a home teaching program, and with the help of my tutors and 
family, was able to complete my semester coursework at my own 
pace. I finally returned to school in December but was still 
far from recovered.
    I have spent the 2 \1/2\ years since my concussion slowly 
regaining organizational skills, the ability to learn and 
retain information, and, most important, my personality. During 
this time, my friends and family learned to recognize the signs 
that meant I needed to shut down from any kind of mental or 
physical activity for a day or two. These relapses were 
particularly tough and discouraging, and meant that I had to 
drop a class and miss a band trip to Chicago, among other 
things. The worst was when I had a crash and could not go to my 
first concert, the Red Hot Chili Peppers. The friend I gave my 
ticket to really owes me.
    The spring after my injury, I was medically cleared to 
return to sports, but made the hard decision that I would not 
play lacrosse or other intensive sports again. I know that a 
lot of people recover and return to play, but the possibility 
of another concussion means I could lose everything again, just 
like that, and not come back the next time.
    I now look at my recovery as something that has made me 
stronger, but I know that I am one of the very lucky ones who 
had the resources and medical attention I needed, and a school 
system that is aware of concussion issues and provided an 
unusually high level of support.
    It is not over yet. My recovery continues, but my outlook 
is positive and I am excited about the future as I prepare for 
college. I am thinking about becoming a high school math or 
science teacher.
    I now have a hard question. What can be done to create a 
safer sports environment, and to ensure that when injuries do 
occur, the support for a full recovery is available? We can't 
just do away with youth sports. I have played baseball, travel 
soccer, and league and high school lacrosse, and being on those 
teams not only gave me a healthy outlook, it taught me 
important lessons.
    Sports are one of the best parts of growing up and becoming 
a strong adult. They teach us that if we work hard, we will 
become skilled and proud of our accomplishments. They teach us 
how to be part of a team, to have pride and success, and learn 
the lessons of defeat. They teach us that sometimes we have to 
quit thinking of ourselves and think of the good of the team. 
For these and many other reasons, I hope that steps can be 
taken so that future young athletes have these opportunities.
    There are two important things I think would make a big 
difference. The first is to change the cultures of hitting hard 
to take out a good opponent, rather than playing to win through 
skill, and brushing off injuries to get back into the game. 
While better equipment may decrease injuries, it is coaches, 
parents and players who have to back away from the need to win 
at all costs, or fear the losing status on the team when out 
for an injury, to be willing to recover fully before returning 
to play. It will take a while, but if youth and professional 
sports are to survive, these attitudes must be embraced.
    Second, when injuries do occur, we must have a way for 
qualified personnel to quickly assess injuries on the field, 
have players get immediate attention, and then support recovery 
through schools and medical institutions. These are the things 
that were done for me, and are the reason I have been able to 
return to normal.
    As a student ambassador for the NCYSS, the message I hope 
to give young athletes is this. You think you are invulnerable. 
You take risks and brush off injuries because you think you 
will recover quickly from anything happens. You won't. Don't be 
a hero, especially when it comes to your head. It is the only 
brain you will have, and your personality is who you are. It is 
not worth a couple of seasons of glory to lose the opportunity 
of a lifetime.
    Thank you.
    [The prepared statement of Mr. Heaton follows:]
  
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    Mr. Terry. Very good. Dr. Graham, you are recognized for 5 
minutes.

                   STATEMENT OF ROBERT GRAHAM

    Mr. Graham. Thank you very much, Chairman Terry, Ranking 
Member Schakowsky.
    My name is Bob Graham. I served as the chair of the 
Institute of Medicine, Sports-Related Concussions in Youth 
Study. As you have my testimony before you, and I think copies 
of the study itself, I will just try to take these minutes just 
to give you a summary.
    The Institute of Medicine is part of the National Academy 
of Sciences, which is chartered by the Congress to provide 
advice to the Congress and to the Executive on various 
scientific issues. We were specifically empaneled to look at 
the evidence about the causes and consequences of concussion in 
youth and military, the state of concussion diagnosis and 
management, the role of protective equipment, and sports 
regulation.
    We had 17 members on our committed. We worked in 2013. Dr. 
Molfese, who will follow me, was a member of that committee, 
and we came with just six recommendations. The first was that 
the CDC needed to establish a better mechanism for national 
surveillance to comprehensively capture the incidents of 
concussions. You have heard a number of figures this morning 
about the concussions in one sport or another. We know what the 
incidence is where they are measured. We do not know what the 
incidence is in sports where they are not measured, or where 
they are not more closely watched. We need to have that 
baseline to really know the degree to which we have a problem, 
and as we take corrective measures, the success rate that we 
are having in making an impact on decreasing the incidence of 
concussions.
    So, number one, we need better surveillance, we need better 
epidemeality. Number two, a couple of recommendations related 
to research. We need the NIH and the DOD to look more 
specifically at what metrics and markers are for concussions. 
How do you assess the severity of a concussion, how do you find 
diagnostically whether or not an individual has had a 
concussion. Right now, it is largely based upon observation, on 
self-report, but are there some physiologic markers that could 
be used to give us better documentation that a concussion has 
actually occurred, perhaps without the individual knowing it or 
without it being observed. Secondly, we need the NIH and DOD to 
look at more carefully and longitudinally at the short- and 
long-term consequences of concussions. We have heard testimony 
in this panel, the prior panel, individuals that have had one 
or more concussions, what are the long-term sequella of an 
individual or multiple concussions. That gives us some sense 
about not only, again, the epidemiology of the problem that we 
are dealing with, but what treatment and interventions may be, 
and what rehabilitation may be.
    Fourth recommendation was to the NCAA and the National 
Federal of State and High School Associations to look at age-
appropriate techniques, and roles and playing standards. And 
again, your first panel talked a little bit about that, mostly 
at the professional level, but can you change the manner in 
which the sport is practices, and the rules of engagement in 
the sport that may decrease the risk of concussion. There was 
one example from the hockey area where they had changed the 
level where they allowed body checking, and felt that they saw 
a decrease in concussion. We think that that same sort of 
examination should take place at the college and the elementary 
and high school level to see whether or not that can have the 
same impact.
    The fifth recommendation had to do with a better study of 
what the role may be for protective equipment. And again, your 
first panel talked a lot about that. The committee had a number 
of questions about that. Our committee found that there was 
very little evidence that helmets protect against concussions. 
And there is a lot of data in that, and I think some of the 
other panelists will be talking about that. You may come away 
with an equivalence degree in physics this morning. It is a 
complicated issue, but there are a number of suggestions. You 
know, we certainly did not recommend you don't use helmets. 
They do protect against bone injury and soft tissue injury, but 
the suggestion that a helmet itself may decrease the incidence 
of concussion, the evidence does not appear to be there to us, 
and we think that the NIH and DOD, again, have a role in 
looking more specifically at what we may be able to do related 
to the biomechanical determinates and protection against 
concussions.
    And then our final recommendation had to do with the topic 
which has come up frequently, and that is changing the culture 
and the way concussions are viewed. This is a significant 
injury. Athletes need to be encouraged to report, to take 
themselves out of the game. Coaches and parents need to be 
encouraged to say, for your own protection, you need to be 
removed and give yourself a chance for recovery.
    Thank you very much.
    [The prepared statement of Mr. Graham follows:] \1\
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    \1\ The report ``Sports-Related Concussions in Youth: Improving the 
Science, Changing the Culture'' and the accompanying slide presentation 
have been retained in committee records and also are available at  
http://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=101897.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Mr. Terry. Thank you. And then, Dr. Molfese, you are 
recognized for your 5 minutes.

                 STATEMENT OF DENNIS L. MOLFESE

    Mr. Molfese. Thank you, Chairman Terry, Ranking Member 
Schakowsky, and members of the subcommittee for this 
opportunity.
    If we could have the slides. Go to the next slide. Yes. So 
I think the earlier group talked about a number of--if you can 
go ahead and put that on Power Point--a number of sports where 
the rate of concussion is particularly high. There are, of 
course, differences in rates for men and women, and Dr. Gay 
will talk about some of that in terms of weaknesses of women's 
necks relative to men's necks and how that puts them perhaps at 
more risk for concussion.
    Next slide. Concussion accounts for, in the United States, 
roughly about 75 percent of traumatic brain injuries. It is a 
brain injury. There is damage to the brain. There is the 
discussion about whether it is permanent or temporary. In the 
military, the rate is 77 percent. So it turns out that youth 
sports are a good model for also looking at concussion in terms 
of the military. And, in fact, most of the military concussions 
occur in situations most like they do with the rest of America. 
Some certainly occur in theater, but majority occur outside of 
theater in accidents like we all are sort of prone to 
experience.
    Next slide. If we look at brain injuries overall, there are 
estimates--these are all estimates, of course, and they vary 
across the literature, but we are looking at somewhere probably 
in the neighborhood of about 4 million traumatic brain injuries 
per year in the United States. Severing part of that is that 
our birth rate in the United States is also roughly about 4 
million. This does not count other ways that children are 
exposed to head injuries. Perhaps a disciplining, irate parent 
who slaps a child, that creates rotational movement that can, 
in fact, produce a concussion. Those, one would suspect, are 
largely unreported.
    Recovery generally is fairly quick, usually within anywhere 
from a few hours to a few days. Some will persist to 2 weeks, 
even perhaps out to 6 weeks, but roughly about 20 percent seem 
to persist beyond that time.
    Next slide, please. This is a slide just on some data that 
we have under review, but it will give you sort of a sense. 
These are data recorded using brain electrical activity. So 
basically, you have a net of 256 electrodes that fits on the 
head in about 10 seconds or so. And we present a series, in 
this case, a series of numbers. One number at a time. All the 
college athletes had to do was simply say whether the number 
they currently see matches or does not match a number that 
occurred two positions earlier. And on the left side, those 
orbits, those circles you see, the colored circles on the left 
for match and non-match, those are imagines of the brain 
electrical activity on the scalp recorded from those 
electrodes, between 200 and 400 milliseconds. So 2 tenths to 4 
tenths of a second after the number appears. So the schematic 
on the right shows you the head position. So it is a very rapid 
brain response. For those athletes who have no history of 
concussion, we see a very clear difference in the electrical 
activity for the match versus the mismatch. A lot of yellow and 
green in the top left orb, and in the bottom we see red and 
various shades of blue from the front of the head to the back 
of the head. On the right though, these are individuals who 
have a concussion history of 1 to 2 years earlier, not current, 
and yet at 200 to 400 milliseconds, their brains cannot 
discriminate whether those two numbers are the same or 
different. They ultimately get these tasks correct, but it 
takes them roughly 200 milliseconds longer. That is 20 
synapses. So the processing speed is slow. And after 2 years, 
one might suspect that is a permanent change.
    The next slide, I think that--yes, so in terms of critical 
scientific gaps, some of these we do what Dr. Graham talked 
about, you know, how does concussion affect the brain in the 
short and long term. We really don't have much information 
about that. What is the dose requirement, Dr. Graham talked 
about that, to produce a concussion, post-concussion syndrome, 
CTE, how can we reliably, objectively detect when the brain is 
injured, and when, importantly, it is fully recovered. We have 
no ways to do that. Lots of individual differences from one 
person to the next. We think there are genetic factors 
involved, but there could also be a concussion history that a 
person may not really think they have. How many of us have 
bumped our head getting in and out of a car. So we have a quick 
rotational movement, and that could produce perhaps a 
concussion. And then how does the brain recover from TBI. And 
then, finally, how we improve and accelerate recovery. We 
really have no scientific basis for any of our interventions.
    Thank you.
    [The prepared statement of Mr. Molfese follows:]
   
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    Mr. Terry. Thank you. Dr. Johnston, you are now recognized 
for 5 minutes.

                  STATEMENT OF JAMES JOHNSTON

    Mr. Johnston. Hi, Chairman Terry, Ranking Member 
Schakowsky, and members of the committee. Thank you for 
inviting me to testify before you today, alongside this 
illustrious panel about our experience in Alabama following the 
passage of concussion legislation, as well as the work we are 
currently doing at the University of Alabama Birmingham to 
improve sports safety.
    As in the State of Nebraska, youth sports and youth 
football are an extremely important part of our culture, and as 
a result, we take the safety of our children very seriously as 
well.
    As well known to the committee, the problem of concussion 
has gained prominence over the past decade thanks to important 
research and advocacy work done by scientists, physicians, and 
public health professionals at many centers across the United 
States, and through the work of public officials highlighting 
this research. Of significant concern, recent studies have 
identified potential long-term health consequences including 
depression, chronic traumatic encephalopathy and other 
neurodegenerative diseases associated with repeated impacts.
    While college and professional football gets the most media 
attention, it is important to keep in mind that greater than 70 
percent of all football players in the U.S. are under 14 years 
of age. Any effort directed at improving safety in football and 
other impact sports will need to address these youth athletes.
    Parallel to enacting of Alabama's concussion law in 2011, 
as in many States, the Alabama State Concussion Taskforce, 
Children's of Alabama, and Think First Alabama, initiated a 
statewide concussion education and awareness program, and it 
worked. In that first year, we observed a 500 percent increase 
in referral of youth athletes referred to the Concussion Clinic 
at Children's of Alabama, a trend that has held steady since 
that time with about 350 youth athletes seen every year.
    To optimize care of this rapidly increasing patient 
population, we developed a multidisciplinary protocol, it is in 
my Appendix 1, following the Zurich Consensus Guidelines, 
athletes were evaluated by physicians with expertise in 
concussion, kept out of sports or school until symptom-free, 
referred for neuropsychological testing when appropriate, and 
supervised in a gradually return to play and/or return to think 
program. A formal study performed in 2012 demonstrated that 
establishing this program resulted in significantly better 
concussion care and decreased institutional resource 
utilization.
    Even though these efforts have certainly resulted in 
improved recognition and treatment of concussion in Alabama and 
in other States, we believe that much remains to be done in 
order to prevent sports-related brain injury in the first 
place. Given the difficulty of delineating a specific 
concussion threshold, as has been said previously, using 
existing helmet accelerometer technology and other subjective 
ways of evaluating athletes, researchers have begun to widen 
their focus from concussion to correlating cumulative impact 
exposure over time, with changes in advanced MRI imaging 
techniques and neuropsychological changes, even in the absence 
of clinically diagnosed concussion. Animal models of 
subconcussive impacts have also demonstrated problems with 
complex spatial learning, cognitive impairment, and, as is seen 
also in football players, compared with single impact controls 
and those who have not had these injuries.
    Though definitive conclusions about threshold for impact 
frequency hit counts cannot be drawn from these early studies, 
it has become clear that subconcussive impacts, that is, those 
impacts that don't result in concussion, also play a role in 
cumulative brain injury over time and need to be studied.
    Recent studies of youth players by researchers at Wake 
Forest suggest that a significant portion of young players' 
head impact actually takes place during practices, and the 
largest impacts happen to take place during those practices, a 
lot of time doing outdated drills, like Oklahoma Drill or Bull 
in The Ring, that are supervised by well-meaning but untrained 
coaches. Emulating top level collegiate programs, which don't 
do these practices and these drills, teams like the University 
of Alabama, Ivy League and others, the Alabama High School 
Athletic Association recently published nonbinding guidelines 
to limit full contact hitting practices to twice per week. I 
believe this type of intervention is complimentary to the stuff 
that USA Football is talking about, about techniques, not just 
the techniques of hitting but also the number of hitting 
practices per week, as well as what drills are going to be done 
during practice. Pop Warner has instituted similar guidelines 
to this, but again, that is a small section. Limiting the 
frequency of hitting at practices as well as the type of drills 
would have a large effect on safety, significantly decreasing 
the cumulative impact exposure for every youth football player 
in America.
    It has also become clear that football helmet standards 
currently defined by the National Operating Committee for 
Standards in Athletic Equipment must be updated to reflect or 
improve understanding of the etiologies of concussion. It is 
clear that both linear impact and rotational acceleration play 
a role in concussion pathophysiology, and only linear impact is 
studied by the NOCSAE system, which was from a skull fracture 
tolerance model developed in the 1960's.
    We believe that having a more complete picture of the 
impacts that are seen in the football field are necessary in 
order to come up with meaningful standards. In collaboration 
with the University of Alabama Football Program, engineers at 
UAB, led by Dean Sicking, previously of the University of 
Nebraska, and the developer of the safer barrier for NASCAR and 
IRL have recently developed a robust video analysis system to 
analyze impacts, and then recreate them in a purpose-built lab.
    In conclusion, the passage of concussion awareness 
legislation, community education, and recent advances in our 
understanding of head impact exposure in youth athletes have 
all improved the overall safety of impact sports, and that we 
are recognizing concussions more frequently, however, much work 
remains, specifically in concussion education, and drafting of 
policies to limit head impact exposure for youth athletes in 
contact sports. As part of this push to a multifaceted approach 
to a complex problem, I believe the development of new helmet 
standards is also crucial for the development of safer helmets.
    Mr. Chairman, thank you for the opportunity to testify.
    [The prepared statement of Mr. Johnston follows:]
    
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    Mr. Terry. Thank you. Dr. Gay, you are now recognized for 5 
minutes.

                  STATEMENT OF TIMOTHY J. GAY

    Mr. Gay. Thank you, Chairman Terry. I would like to thank 
the subcommittee for inviting me to testify today.
    I am speaking to you as a football fan who happens to be a 
physicist. My main professional interest in the game is the 
understanding of how protective equipment works and how it can 
be improved.
    Today I wish to consider several aspects of football that 
are problematic as far as concussions go, and how we might move 
forward to make the game safer.
    American football is an inherently violent sport. That is 
one of the reasons we love it. The forces encountered in 
football can be huge. Consider a big hit between a running back 
and a linebacker at full speed. We can show, using Newton's 
Second Law, that the force each player exerts on the other 
exceeds \3/4\ of a ton. This is why football is called a 
contact sport.
    Two players who collide at full speed, helmet to helmet, 
are experiencing the same force to their heads that one of them 
would feel if he had a 16-pound bowling ball dropped on his 
helmet from a height of 8 feet.
    Medical knowledge of concussions is in its infancy, but we 
know one thing for sure: Forces to the head and neck cause 
concussions, and we have just heard how big these forces can 
be. Here is another problem: They are getting bigger.
    Since 1920, the average weight of pro linemen has increased 
almost 60 percent, to just over 300 pounds. At the same time, 
these players have gotten about 10 percent faster. Combining 
the factors of speed and mass to calculate kinetic energy, the 
energy available to cause injury, we find that the amount of 
energy dumped into the pit at the line of scrimmage on any 
given play has almost doubled since 1920. In exact opposition 
to this trend is the fact that players are shedding their 
protective gear. Thigh and kneepads that used to be centimeters 
thick, now bear a remarkable resemblance to teacup doilies. 
Horse collars, popular with linemen of my generation, have gone 
the way of the flying wedge. Modern football helmets are 
technological marvels, but players choose them not for their 
collision cushioning ability, but for how cool they look.
    Another problem is the poor state of our medical knowledge. 
While I am not competent to explain these issues, I think it is 
safe to say that a room full of head trauma physicians will not 
agree on the details of what concussions are, or what causes 
them. This means that the diagnosis and treatment of 
concussions has a long way to go. As our understanding of these 
issues improves, we may find that injury rates due to the 
increasing energy of the game and the wholesale shedding of 
equipment have increased faster than we thought.
    Finally, football is big business, especially at the 
college and professional levels. When monetary forces manifest 
themselves as they do in, for example, bounty programs and 
illegal doping to improve performance, the game becomes more 
dangerous.
    What are the solutions? We need better equipment, but this 
can get tricky. For example, it is apparent that adding more 
energy absorbing foam to the outside of a helmet will lower the 
force delivered to a player's skull. This has been tried in the 
past. The problem is that the added padding increased the 
helmet diameter, as well as its coefficient of friction, 
meaning that the opposing player can exert a lot more torque on 
your head. Nonetheless, several companies today are proposing 
the same basic padding idea for youth football, for whose 
players the risk of collisions to the head is almost certainly 
greater. The use of the Star System for rating helmets, and the 
Hit System for monitoring collisions to a player's head, 
represent important first steps toward improving football 
safety for a variety of reasons that disregard players' safety, 
they are largely ignored.
    Our understanding of the physiological and epidemiological 
issues related to concussions must be improved. There is now an 
understanding in the NFL and at the college level that 
significant research in this area is needed. Several of the 
members of this panel, including my colleague from Nebraska, 
Dr. Molfese, are leading cutting-edge efforts in this area.
    Finally, some incremental rule changes and more stringent 
enforcement of existing rules are needed. In my opinion, some 
of the new rules regarding targeting, peel-back blocking, and 
definition of a defenseless opponent, are making players more 
hesitant on the field. These rules may, thus, actually, 
increase the risk of injury. Rule changes should be studied and 
possibly reversed.
    It is my belief that a return to the level of padding worn 
in the 1970s would make the game significantly safer. More 
thorough doping rules should be developed and actually 
enforced. The NFL season should be reduced to 14 games, and the 
college season returned to 11. Finally, more stringent 
requirements regarding when a player with a concussion can 
return to the game need to be implemented.
    These are my thoughts for your consideration. Thank you for 
your attention and your valuable time.
    [The prepared statement of Mr. Gay follows:]
   
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    Mr. Terry. Thank you for your valuable time.
    And, Dr. Gioia, I appreciate you being here. You are 
recognized for 5 minutes.

                  STATEMENT OF GERARD A. GIOIA

    Mr. Gioia. Yes. Thank you, Chairman Terry, Ranking Member 
Schakowsky, and members of the subcommittee. I appreciate the 
opportunity to speak on behalf of the safety of our children in 
this country.
    So I am a pediatric neuropsychologist at Children's 
National Health System here in Washington, DC, and the director 
of the SCORE Concussion Program. I am a clinician, a 
researcher, and a public health educator. Today I would like to 
take my time to focus my comments on the importance of public 
health education for youth concussion, using my expertise as a 
clinician and a researcher, and I have worked for the last 
decade with the CDC on their Heads-up Concussion Program 
materials.
    We all know, and I think Ian said it just perfectly, that 
sports and recreation provide important developmental 
opportunities to enrich the lives of our youth. They teach life 
lessons. But we have to balance those incredible benefits of 
sports participation with careful attention to safety issues, 
and science must drive our action-oriented approach.
    Concussions are serious injuries to the brain that threaten 
the development of our youth. In an attempt to protect our 
youth, we now have laws in all 50 States and the District of 
Columbia, all with the good intent of protecting our student 
athletes through rules for educating coaches and parents, and 
removing suspected concussions, and not allowing them to return 
until properly cleared. All States include the high school at 
this level, but only 15 out of those 51 include youth sports. 
So less than \1/3\ are looking at the majority of athletes.
    In preparing for this testimony, I was posed with an 
important question and challenge within youth sports. With 
concussion awareness now at an all-time high, are youth sports 
teams and organizations, and parents, more aware but still not 
sure what to do about it. And the simple answer to that 
question, with my experience, is yes. Many coaches and parents 
are not equipped to know what to do with a suspected 
concussion. Mechanisms to teach active recognition and response 
to every coach and parent are inconsistent and limited in 
scope. The health and safety of youth athletes is largely in 
the hands of coaches and parents at the youth level. They need 
medically guided training and early identification of 
concussion and protection. Coaches and parents must receive 
training and action-oriented concussion recognition and 
response. Awareness isn't enough, and they have to be prepared 
properly.
    We know that, as you have heard, repeated concussions 
present the greatest challenge to our youth. So our greatest 
challenge is really the universal consistent and effective 
implementation of these 51 laws so that we can prepare those 
coaches and parents to know what to do, and have the tools with 
which to do it.
    At Children's National Health System, over the past 10 
years, our SCORE Program has delivered hundreds upon hundreds 
of action-oriented parent and coach concussion education and 
training program, using the Heads-up materials from the CDC. We 
have learned much about the community needs and how to deliver 
the message. So we deliver scenario-based training where we 
present to coaches and parents an actual situation, and what 
they must do to recognize and respond. This is all very, very 
important as we put these responsible adults in place.
    You have heard about some important other kinds of 
activities and good examples of head-safe action, head-smart 
action, such as USA Football's Heads-up Tackling Program, where 
coaches are educated in concussion recognition and response, 
but also taught techniques that we believe can improve taking 
the head out of the game, but we have to go further in all 
youth sports. We do not have a coordinated universal strategy 
at this point for action-oriented, solution-driven methods to 
recognize and respond to these injuries. We have the tools, we 
have many of the programs, but we do not at this point have the 
delivery mechanism to do that. So we have to build also on 
active partnerships between youth sports organizations and 
medical care systems. Concussions are complicated. They are not 
simple. We are not asking parents and coaches to be clinicians 
and to go out and diagnose. We have willing teammates, as you 
have heard, through USA Football, U.S. Lacrosse, USA Hockey, 
USA Rugby and other organizations, but we need to build those 
partnerships, we need the help of the professional sports 
leagues, as you hearing from the NHL and the NFL and the sports 
manufacturing world, to team with us. We also need a 
quarterback ultimately to make this happen. We have to leverage 
the efforts of other organizations like the National Council on 
Youth Sports Safety, the Youth Sports Safety Alliance, The 
Sarah Jane Brain Foundation's PABI Plan, all of this is 
important for us to do. So we need, obviously, funding to do 
that to move forward.
    Can we move from awareness to action? Yes, we can. 
Concussions are serious injuries that threaten our youth, but 
we do not need to be scared away from that, we do not need to 
avoid developmentally appropriate participation in sports 
activities. What we need to do is focus on how to teach 
recognition and response, and our country needs a good 
universal mechanism to implement community focused youth 
concussion solutions, and we believe that that can help 
children ultimately as they enjoy the benefits of sports.
    Our SCORE motto applies here. It says, ``Play hard, play 
safe, but play smart.''
    Thank you.
    [The prepared statement of Mr. Gioia follows:]
   
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    Mr. Terry. Very good. Dr. Shenton, you are now recognized 
for your 5 minutes.

                 STATEMENT OF MARTHA E. SHENTON

    Ms. Shenton. Thank you. I want to thank Chairman Terry, 
Ranking Member Schakowsky, and members of the subcommittee. I 
am honored to be here today.
    My focus is going to be on radiological evidence of both 
concussion and subconcussive blows to the head. And if I could 
have the next slide.
    What is known is that mild traumatic brain injury is common 
in sports injury, and when we are talking about a single mild 
TBI, about 80 percent get better, between 15 and 30 percent go 
on to have persistent concussive symptoms, as have been 
described today.
    What is most concerning though are what has been called 
chronic traumatic encephalopathy and other neurodegenerative 
disorders, and that is the second one where it is repetitive 
mild traumatic brain injury that we are really concerned with. 
And the clearest evidence comes from postmortem studies.
    If I could have the next slide? Here is a postmortem slide. 
This is Ann McKee's work that shows how protein in the brain, 
and those are the brown areas that show up. And this is in a 
case of a retired professional football player who had 
symptoms, and was presumed to have chronic traumatic 
encephalopathy, which was confirmed at postmortem.
    Next slide, please. Now, here are four individuals, A, B, 
C, and D. What is interesting here, and this is work by 
Goldstein, it shows that blast injury and repetitive brain 
trauma look the same at postmortem. So we have a military 
person at 45 with one close-range blast injury, a 34-year-old 
with two blast injuries, an amateur football player at the age 
of 18 with repetitive concussions, and then a 21-year-old with 
subconcussive blows to the head only.
    Next slide please. So what is known? We have gone over the 
first two. The third is mild TBI is very difficult to diagnose, 
and that has been a really serious problem because if you use 
conventional CT and conventional MRI, you are not likely to 
find differences or abnormalities in the brain, and so many 
people have said there is no problem then. The problem is the 
correct advanced tools have not been used until more recently. 
And now with advanced neuroimaging, we are able to both 
diagnose and move towards prognosis and hopefully intervention. 
Advanced neuroimaging techniques such as diffusion imaging, 
which we have been using in our laboratory, show radiological 
evidence of brain alterations in living individuals with mild 
TBI. And so if we can detect this early, and we can perhaps 
then look at underlying mechanisms and characterize what is 
going on in order to come up with preventative measures.
    Next slide, please. So this is a study from our group, 
looking at hockey players from university hockey players in 
Canada. And the bottom line is over on the right. The first is 
at preseason and the second is at postseason. The red dots are 
three individuals who had concussion during play, from 
preseason to postseason. And the increase is increase in extra 
cellular water in the brain, which is not a good sign.
    Next slide, please. We also looked at brain matter, looking 
at cortical thinning in the brain, and that is the cortex where 
neurons are in the brain. And this is a study in former 
professional football players who were symptomatic when we 
looked at them. And what we found was that there is cortical 
thinning compared to age-matched normal controls. What is most 
concerning, however, is that blue line that shows that the 
cortical thinning accelerates with age, whereas the red line, 
our control group, where it is almost completely flat. And this 
suggests that cortical thinning may indicate abnormal aging and 
a risk for dementia that we can see right now in living 
individuals.
    Next slide, please. Now, this is a study that we did in 
Germany with elite soccer players, and we selected them 
specifically for not having a history of concussion, and not 
having any symptoms whatsoever. And what we found was, compared 
to professional swimmers, there was a huge difference between 
the two groups, with the controls on the left and the soccer 
players on the right. Almost a complete separation between the 
two groups, with an increase in what is called radial 
diffusivity, which is a measure of damage to myelin in the 
brain.
    Next slide please. So what we don't know: Why do concussive 
and subconcussive trauma result in some and not in others? 
Another question we don't know is, Why do some develop 
neurodegenerative disease while others do not? What are the 
predisposing factors? Is exposure or genetics involved, because 
not every football player, not every soccer player, not every 
hockey player who plays and gets hit to the head ends up with 
these neurodegenerative diseases, which is what, I think, 
people are most concerned with.
    And next slide. So what we need is diagnosis to detect 
brain injury early. We have imaging tools now that are 
sensitive, widely available, and can be applied in vivo, 
prognosis to follow recovery and degenerative processes. So we 
need to follow recovery and degenerative processes in order to 
predict who will have a poor outcome, and who will have a good 
outcome. And knowing that, we might be able to intercede with 
treatment to halt the possible cascade of neurodegenerative 
changes.
    And finally, just in summary, next slide. Sports concussion 
leads to alterations of the brain's white and gray matter. 
Advanced neuroimaging is sensitive to detect brain alterations 
following concussion and subconcussive brain trauma, and the 
impact over time is important. We need longitudinal studies to 
identify different stages of recover, and being able to pick 
out ahead of time what is going to lead to a poor outcome so 
that we can intercede.
    And finally, some measures of safety, such as rules for 
returning to play are needed following observable evidence of 
brain trauma.
    Thank you.
    [The prepared statement of Ms. Shenton follows:] \1\
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    \1\ Additional information has been retained in committee files and 
also is available at  http://docs.house.gov/meetings/IF/IF17/20140313/
101897/HHRG-113-IF17-Wstate-ShentonM-20140313-SD001.pdf.

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    Mr. Terry. Thank you. Very impressive testimony from 
everyone, and I was even impressed that you all stuck to the 5 
minutes, pretty close.
    Now, I am going to go back to Dr. Molfese because I think 
your testimony and Dr. Shenton's kind of juxtapose each other 
here very nicely.
    So part of what your research is doing is finding that 
baseline of the new athletes that enter University of Nebraska. 
So is this allowing you to detect the injuries earlier, that 
there may have been some pre-existing subconcussion? How are 
you identifying that, what is it telling you, and what is the 
university doing to implement some level of protections?
    Mr. Molfese. Well, one of the major changes we have seen, 
and I think this is occurring across the field now, is the 
effort to get pre-concussion data. So basically, more and more 
schools are moving to assess student athletes prior to the 
start of the season, and that certainly is what we are doing. 
And then should a player be injured, and they are identified 
through trainers or the medical team. One of the weaknesses 
here is that the players do not always self-identify, and so we 
have run across that a number of times in our testing, or we 
will pick up something on our test the trainers and the medical 
team didn't know about simply because the player didn't 
disclose. And then we also try to test somebody else who plays 
a similar position but has not been injured, and they act sort 
of as a game control over the course of a season. And 
generally, what we are finding is both effects that occur 
across the season and just our normal players who have no 
history of concussion being identified, their brain speed of 
processing does change over the 4 to 5 months of training and 
the season, but then with the players who are--who do 
experience a concussion, we see, in terms of brain electrical 
activity, again, the slowdown of about 200 milliseconds. That 
is four times faster than the slowdown you see in Multiple 
Sclerosis, for an example, for a contrast. So clearly, the 
brain has changed the way it is processing.
    We are just now moving to start intervention programs with 
the players that we identify. There is some data out there with 
early Alzheimer's that suggest working memory-type tasks may 
take even a week of intervention, shows a 4-to-5-week continual 
gain in improvement, and so we are trying to see if we can see 
some of that occurring.
    Mr. Terry. Thank you.
    Dr. Gay, in regard to concussions, though many times it is 
not a direct blow, but coup contra coup, it is being hit so 
that the head is going back and forth, and the brain is 
sloshing around.
    You mentioned going back to 1970s type of equipment, and 
Tom Osborne likes to talk about the neck roll. Describe to me 
what you mean by 1970s equipment, and how it may actually 
reduce concussions.
    Mr. Gay. Thank you, Mr. Chairman.
    Yes, the neck roll, what I call a horse collar, is really a 
piece of equipment that has disappeared from the game. And it 
does an important thing, it essentially immobilizes the head. 
So if concussions are incurred by the rattling of the brain 
back and forth, especially from a blow to the side, the horse 
collar will substantially damp that down. To my knowledge, 
there are no epidemiological studies of that being effective, 
but my personal opinion, even though I am largely ignorant of 
medical science, is that if you immobilize the head, that is 
going to solve a lot of the problems, especially with these 
rotational hits. Yes.
    Mr. Terry. Dr. Graham, does that make sense?
    Mr. Graham. I think whether or not the horse collar would 
have that effect, I don't know, and, of course, our committee 
was based purely on science and, you know, reviewing the 
literature, but I think the principle is, you want to find ways 
to minimize the linear and rotational forces that come into 
effect with a blow to the head, and whether you can do that by 
equipment, whether you can do that by change in play, you know, 
that is what you have to do to decrease the incidence of 
concussion.
    Mr. Terry. Thank you. I only have 11 seconds left, so I 
will yield back and recognize the Ranking Member, Ms. 
Schakowsky.
    Ms. Schakowsky. You know, in addition to the science, so 
much talk has been about culture, and it seems to me that that 
is very important. So a change in the culture means not only 
managing head injuries when they occur, but also encouraging 
safer play to reduce the risk of head injuries.
    So, Mr. Heaton, you spoke about the need to change the, I 
am quoting from your testimony, ``the win at all cost'' 
attitude among players and coaches. What would you tell teams 
to help them change that attitude, both within themselves and 
teammates, and perhaps more challenging, in coaches?
    Mr. Heaton. Thank you. Well, frankly, I would actually 
encourage the coaches to stress this as much as possible, as 
well as the parents, because the coaches and the parents are 
there to help us learn how to play these sports correctly, and 
if they can emphasize not having to worry about winning to the 
point where you get hurt, then it will trickle down to the 
players, and then the players become coaches, and then it is 
this never-ending cycle of teaching and making sure that the 
players know that winning is not the most important thing. You 
know, it feels great to win, but I would much rather lose than 
have another concussion.
    Ms. Schakowsky. Clearly, you were aware because of the 
severe consequences of the brain injury, but do you think that 
youth athletes understand what those symptoms are?
    Mr. Heaton. Yes. I think it is getting better, indeed, 
especially in my school. I mean we emphasize making sure that 
you know the symptoms of concussions, and I feel like it is 
spreading as well, but I----
    Ms. Schakowsky. Let me ask Dr. Gioia that, too.
    Mr. Heaton. OK.
    Mr. Gioia. Yes, certainly, at this point, the education 
programs are also being directed toward the athletes, and quite 
honestly, about 5 years ago, maybe 6 years ago, there was a 
study that showed that that was the number 1 reason why 
athletes were not coming out of the game, because they didn't 
know how to tie together the symptomatology. It wasn't simply 
that they didn't want to lose playing time, but they didn't 
know what they were dealing with in themselves.
    Ms. Schakowsky. Right.
    Mr. Gioia. But we also believe that athletes and teammates 
need to watch out for each other, because the concussed athlete 
themselves may not have the wherewithal to know that they 
aren't right, and yet their teammate right next to them 
oftentimes does. So there is a responsibility within that team 
to take care of each other, and that is an important focus.
    Ms. Schakowsky. And that goes to culture as well.
    Mr. Gioia. Yes, absolutely.
    Ms. Schakowsky. Yes. Yes.
    Dr. Shenton, please explain a little bit how advanced 
neuroimaging works, and describe the types of changes in the 
brain your lab is able to detect that traditional imaging 
can't, and also some of the types of neuroimaging used by your 
lab have been a significant part of the research on diseases 
like Alzheimer's and schizophrenia. Why are the same imaging 
techniques appropriate for research on these diseases and 
research on sports-related brain injuries?
    Ms. Shenton. OK, I have a slide, which is just at the end 
of my slides, that just explains in one slide diffusion 
imaging, which I think would help out here.
    Ms. Schakowsky. The one slide I really didn't understand 
was comparing swimmers with----
    Ms. Shenton. With soccer players----
    Ms. Schakowsky. Right.
    Ms. Shenton [continuing]. But I was going to go through----
    Ms. Schakowsky. All right, go ahead.
    Ms. Shenton [continuing]. And just show you----
    Ms. Schakowsky. OK.
    Ms. Shenton [continuing]. Why diffuse external injury is 
important because the injury that happens in the impact to the 
brain is generally a stretching of the cables in the brain, 
which is really the white matter, and for example, the corpus 
callosum is the largest white matter track in the brain, and so 
you get sharing. And this doesn't show up on tradition CT or 
MRI. In fact, the first mild TBI conference I went to, no one 
showed a brain. And I looked to my colleague and I said why 
would no one show a brain. And he said because everyone knows 
that you can't see anything on the brain. And I said, but then 
nobody is using the right tools here.
    And this is just a very simple principles of diffusion 
imaging. If you look on the left, this is ink that goes on a 
Kleenex. It goes in all directions, and that is called 
isotropic diffusion. If you look on the right, it says 
anisotropic diffusion. So you are dropping ink on newspaper, 
and newspaper has fibers so it restricts the water. And this is 
the same principle that is used quantitatively to look at the 
brain, so that, if you are in CSF, it is very round, and it is 
isotropic, everything goes in the same direction. If you are 
looking at white matter, you are restricted in 2 directions, 
and so you can measure what the integrity is of white matter 
fiber bundles in the brain. And that is what you need to look 
at in mild TBI.
    Now, if you have someone come in with a moderate or severe 
brain injury, you don't need this kind of technology.
    Ms. Schakowsky. Uh-huh.
    Ms. Shenton. They are going to just be put into 
neurosurgery, and they are going to do an operation. It is 
these very subtle brain injuries that aren't recognized using 
conventional imaging, where you can recognize it if you use 
something like diffusion imaging. And we have shown over and 
over again now that you can see--and it is not just our group. 
Starting in 2003, people started using diffusion imaging 
because it is the most sensitive imaging tool that exists today 
to look at diffuse external injury, which is the major injury 
in mild TBI.
    So what needs to be done now is to look at acute injury, 
and see what predicts outcome, like do acute injury at 72 
hours, at 3 months, at 6 months. Can we then predict, knowing 
that what happens at 72 hours, if we have someone in our lab 
that is trying to separate water that is outside cells versus 
in cells. If you can predict from 72 hours, then you can go 
back and say, OK, maybe we want to put in anti-inflammatory 
medications if this is a neuroinflammatory response.
    We don't know enough right now. The only way to know is to 
do these longitudinal studies, and follow over time using very 
sophisticated imaging technology, in my opinion. Once you know, 
you can diagnose. Once you diagnose, you----
    Ms. Schakowsky. So this could be very promising----
    Ms. Shenton. Yes.
    Ms. Schakowsky [continuing]. Not only for our athletes, but 
our returning veterans and----
    Ms. Shenton. Yes.
    Ms. Schakowsky [continuing]. Applied eventually to 
schizophrenia or Alzheimer's?
    Ms. Shenton. Well, actually, we have applied--I am 
primarily schizophrenia research, that is----
    Ms. Schakowsky. OK.
    Ms. Shenton [continuing]. What I have done for 30 years 
before I became a TBI researcher in 2008. And we have a measure 
called free water, this kind of imaging that shows that early 
on at the very first episode of schizophrenia, you see fluid 
around all of the brain that is free water, it is isotropic, 
but in just the frontal lobe, you see it more restricted to 
inside tissue. And this is a brand new technique that was 
developed by a Fulbright Scholar that is in our lab from 
Israel. And so----
    Ms. Schakowsky. OK, I am going to have----
    Ms. Shenton. OK.
    Ms. Schakowsky [continuing]. To say thank you----
    Ms. Shenton. Fair enough.
    Ms. Schakowsky [continuing]. Because it is very promising.
    Mr. Terry. Two and a half.
    Ms. Schakowsky. Thank you.
    Mr. Terry. Yes, thank you.
    Gentleman from New Jersey is recognized.
    Mr. Lance. Thank you, Mr. Chairman.
    Dr. Johnston, you stated that many sports-related 
concussions still go undiagnosed, and I would like to know why, 
in your opinion, that is the case, and how can we improve that 
in our State laws, and also the involvement of coaches and 
players and PTAs, areas where we need to have improvement?
    Mr. Johnston. Thank you for the question.
    I think I would echo what has been said by others on the 
panel. It is on. It is on. Sorry. I would echo what has been 
said by others on the panel, that I think that a lot of it has 
to do with recognition. Obviously, people are very good at 
recognizing when someone gets knocked out on the field, but, of 
course, that is a very small percentage of all concussions, and 
I think that as our understanding of all the various symptoms 
that can go with concussion have arisen, it becomes incumbent 
upon us to improve the quality of the education that we give to 
our coaches, players, trainers, officials, about the symptoms 
of concussion. I think that that is the main reason. My sense 
is that, in general, the culture, at least speaking for the 
State of Alabama, that all the coaches that I have come into 
contact are believers, they are not, you know, purposefully 
hiding, you know, kids and putting them back in knowing they 
have concussions, but I think that sometimes it is hard to 
recognize, especially when young athletes don't tell you how 
they are feeling, and other issues which I guess were brought 
up with the importance of teammates being involved with 
diagnosing these players so they can be pulled and 
appropriately evaluated.
    Mr. Lance. How close, in your opinion, are we to a better 
design for helmets?
    Mr. Johnston. I think that we are at the very beginning. I 
think that we have been using a standard that has not changed 
for 40 years, that was designed for skull fractures----
    Mr. Lance. Yes.
    Mr. Johnston [continuing]. That has served its purpose, and 
I think that many investigators around are working to improve 
the quality of the standards to include linear and rotational 
acceleration, as well as other important aspects of impacts. 
And just like the automotive industry did 30 years ago with, 
once you start ranking cars with safety ratings, the market can 
be relied upon for manufacturers to improve their helmet 
designs to improve their sales. So I think that is the stage we 
are at. I think standards are an important part of the 
equation.
    Mr. Lance. Thank you.
    Dr. Gay, in your testimony, you have discussed the fact 
that there is a numerical rating system for a helmet's impact, 
I think it is designed at Virginia Tech, the Star System, and 
you have called it the best tool we have for analyzing the 
merits of various helmet systems.
    Can you briefly explain how the numerical scoring system 
works?
    Mr. Gay. Yes, thank you, Mr. Vice Chairman.
    Basically, it involves a test where you drop the helmet 
from a given height, a varying height, to the side, to the 
front, to the back. It tries to simulate the kinds of impacts 
that a football player would actually experience, and numerical 
scores are given to the maximum acceleration that the NOCSAE 
head inside the helmet feels for these given drops, based on a, 
in my opinion, fairly crude initial model of what causes 
concussions. There is no effect to take into account rotation, 
there is no effect of temperature, and, in my opinion, the 
reproducibility is not as good as one would like, having tried 
to do examples of these kinds of tests in groups that I have 
been involved with.
    So I think it is a good first start. It is the best we have 
right now. I think it needs to be paid attention to, but there 
is a lot of room, a lot of room for improvement.
    Mr. Lance. Thank you, Dr. Gay.
    And finally, Ian. How old are you and what grade are you 
in?
    Mr. Heaton. I am 18 and I am a senior.
    Mr. Lance. And does that mean you will be going off to 
college in the autumn?
    Mr. Heaton. Yes----
    Mr. Lance. And----
    Mr. Heaton [continuing]. I will.
    Mr. Lance. And do you know yet where you will be attending 
college?
    Mr. Heaton. I am going to Elon University in North 
Carolina.
    Mr. Lance. In North Carolina. My congratulations to you, 
and my condolences to your parents on the cost of higher 
education in this country. It is a great school. I have a 
goddaughter who is a freshman there. That means she is a little 
older than you, but I will be happy to introduce you to her.
    And let me say, I am very proud of your testimony, and I 
could not have done what you have just done when I was 17 or 
18, and certainly, I think the Nation has benefitted by your 
outstanding testimony.
    Mr. Heaton. Thank you.
    Mr. Lance. Thank you.
    Mr. Terry. Gentleman from Mississippi, you are now 
recognized for 5 minutes.
    Mr. Harper. Thank you, Mr. Chairman. And thank each of you 
for being here and sharing your expertise on what is a topic 
that we are really just learning about, as it has been in the 
news for several years, but it is, I think coming to the 
forefront. And your work and your information, your testimony 
on the record here today I think will be beneficial to us.
    As a parent of a 24-year-old young man with Fragile X 
Syndrome, I particularly appreciate the work that you do at the 
Children's Hospital, you, Dr. Gioia, you, Dr. Johnston, but in 
preparation for this, I had some discussion with some parents 
back home, and the interesting discussion is I had several 
friends who have daughters playing youth soccer, and a number 
of them reported an increase in the number of concussions 
suffered by young ladies playing youth soccer. You know, we 
seem in the news to always associate it with NFL, and helmet-
to-helmet contact, and concussions and things that we see on 
the field of play, but it appears in everything we do in life, 
every sporting event, there is that danger and that risk. That 
is why, I think, what you are doing with the Think First 
Alabama, Dr. Johnston, the preventive part of it is how do we 
educate our players and coaches, parents, and perhaps, using 
the teammate approach, the safest thing may be to have the 
backup position player be the one to report for the first 
teamer when they need to come out, you know, that might get 
them off the field. But thank each of you for your work.
    And, Dr. Johnston, educate just a little bit on what is a 
subconcussive impact? What does that mean, and how important is 
that when addressing concussion diagnoses, and should 
subconcussive impacts affect rules of game and play, and if so, 
how?
    Mr. Johnston. Yes, so I think that the definition of a 
subconcussive impact would be all those other, the 99.9 percent 
of impacts that happen that don't result in a concussion, 
meaning a diagnosed concussion. And as has been pointed out 
previously, the rub with concussion is the diagnosis part. If 
you look at some of our historical studies about rates of 
concussion in different sports, it is very variable, and a lot 
of that has to do with who is diagnosing it and, you know the, 
you know, males versus females, whether or not men are more 
likely to report or less likely to report symptoms. But I think 
that a subconcussive impact is all those other impacts that we 
have found more and more information with the important imaging 
that has been done in Boston and other places, that even these 
subconcussive impacts have results in terms of anatomic, you 
now, structural changes in the brain over time.
    So I think that the subconcussive impact needs to be 
addressed in terms of lessening the overall cumulative impact 
load that every player has. Football is kind of the most 
obvious thing----
    Mr. Harper. Right.
    Mr. Johnston [continuing]. In terms of player practices and 
how many practices a week children should be able to do hitting 
and whatnot, but I think that has applications for all sports.
    Mr. Harper. OK, thank you.
    And, Dr. Molfese, if I could ask you a question. Just for 
clarification first, if I could ask, the 77 percent of military 
that----
    Mr. Molfese. Yes.
    Mr. Harper [continuing]. That figure, is that how many of 
TBI cases have suffered concussions, or is that 77 percent of 
all military? I wasn't quite----
    Mr. Molfese. That is of traumatic brain injuries----
    Mr. Harper. OK.
    Mr. Molfese [continuing]. Seventy-five to 77 percent are 
concussions, mild TBIs.
    Mr. Harper. I gotcha, OK. And can you tell us more about 
the sideline imaging work that you are doing? You know, is this 
practical, is this something that we can expect to see rolled 
out to sidelines across America to diagnose our athletes, and 
perhaps how about onto battlefields to diagnose our warriors?
    Mr. Molfese. I think it is very possible. We have actually 
already published a paper just this last year in 2013, where we 
took one of our EEG systems and recorded on the sideline of a 
field. The biggest challenge for us in making it practical is 
to get the processing time down. At this point, it takes us an 
hour. If we can get it down to 5 minutes, then I think we can 
sell it to the coaches, because they are the ones really that 
are going to determine.
    And I guess at this point, given all the other issues, the 
common tests we use right now are like the SCSI 3 and the 
impact, which are some neuropsych assessment tools, sort of 
questions to the player, and they have to reflect and they may 
be a little foggy because of the concussion, but these tests 
don't have any predictability or reliability after 2 days post-
injury. That is our big problem. It doesn't predict recovery 
time, it doesn't predict the severity of the injury, and so on. 
So these biomarkers that we all are talking about are really 
the critical things that we are hoping are going to be much 
more reliable, more predictive.
    Mr. Harper. Thank you very much. And thank each of you for 
being here.
    And I yield back.
    Mr. Terry. Thank you. And, generally, this would end, but 
we all have so many questions, we are actually going to do a 
second round, and plus the bells aren't going to go off for at 
least another 7 minutes. Jan does have a conflict, and she has 
given us approval that she is going to leave, but she trusts us 
to ask legitimate questions.
    Ms. Schakowsky. But let me just really thank this panel, 
the previous panel as well, but the intensity now of the 
scientific research and then its application to the playing 
field, and actually so many other fields, I really want to 
thank you for telling us what is going on. And I also did want 
to thank Ian Heaton for coming here today. I think it is 
important to have people like Briana and Ian to tell their 
stories, and give us a face to the importance of this. I want 
to thank the FTC too for making sure that false claims aren't 
made, but this is so important, so appreciated, and then we 
will have to figure out where it leads us, but it certainly has 
informed us. Thank you.
    Mr. Terry. Yes. I would agree with every word of that.
    So this is a question to you, Dr. Molfese, and Dr. Shenton, 
and it dovetails into what the gentleman from Mississippi was 
talking about as well, but are the symptoms of a concussion or 
TBI uniform enough so that it is possible for early detection 
or developing a checklist for a coach or a parent to be used, 
you know, by non-medical? We will start with you, Dr. Shenton.
    Ms. Shenton. No. The symptoms----
    Mr. Terry. Well, that was easy.
    Ms. Shenton. The symptoms overlap with depression and PTSD, 
and that has been a real problem. In fact, there was a paper 
published in The New England Journal of Medicine that said when 
you remove the effects of depression, and you remove the 
effects of PTSD, mild TBI doesn't exist. And that is a real 
disservice, and it used to be that people would claim that when 
people came in complaining that they still had symptoms from 
hitting their head, since there was no evidence from 
conventional MRI or conventional CT, they said go see a 
psychiatrist. So it was really not appropriate at all, because 
there is at least a small minority of people who have mild 
concussion who go on to have symptoms, and they can go on for 
months, for years, and then they can clear up. So that is 
separate even from CTE.
    What you need is radiological evidence for diagnosis, the 
same way you would want to know values of a blood test for 
cholesterol or a broken leg. And I think we are moving in that 
direction, and that is what we need is the hard evidence----
    Mr. Terry. OK.
    Ms. Shenton [continuing]. Because the symptoms are too 
nonspecific.
    Mr. Terry. All right. Dr. Molfese?
    Mr. Molfese. There are actually studies published looking 
at the number of symptoms, and a wide variety of a number of 
symptoms people will report. There is no data that indicates 
whether somebody reports lots of symptoms versus a few 
symptoms, that that has any relation to how long they are going 
to recover, how serious the injury is, how great the impairment 
is----
    Mr. Terry. Right.
    Mr. Molfese [continuing]. Unfortunately.
    Mr. Terry. So can we get to the point where the seventh 
grader takes a big hit, that there is a checklist, per se, that 
the coach could use to determine if that kid should go back 
into the game?
    Mr. Molfese. Well, I think in general, there certainly are 
guidelines out by the CDC and others that list concussion 
symptoms. And so I think the general bias at this point is if 
the individual reports any of these symptoms, that they should 
be pulled, because we do know that there is data to indicate 
that if you do have a concussion and then you start playing 
again before the symptoms resolve, the likelihood of even death 
is much greater.
    Ms. Shenton. Um-hum.
    Mr. Terry. All right.
    Mr. Molfese. Not to mention further significant concussion 
that is going to take longer to recover.
    Mr. Terry. All right. So this one is for Dr. Johnston and 
Dr. Gioia.
    One of the debates that is occurring in the State of 
Nebraska right now is you have a child, all right, a high 
school student that suffers a concussion during a game. So it 
has been diagnosed. What do you do next? Right now, the thought 
is you keep him home or her home, dark, no electronics. That is 
kind of the norm. There is a discussion whether that is 
appropriate or not, or to what length.
    What do you know? What would you recommend?
    Mr. Johnston. Well, I will tell you about how we handle 
things in Alabama, and I think a lot of what we do is based on 
the CDC Guidelines and the Zurich Guidelines, which is that 
once an athlete is diagnosed, they are removed from the field 
of play, and then they are evaluated. We use the SCAT, which is 
the sports concussion assessment tool, which is a sideline-
based assessment. We also use it afterwards as well. It has 
kind of a quick mini inventory of neurological exam and 
neurocognitive function. And then when children have symptoms 
that persist, you know, obviously, they don't return to any 
sort of play or even an escalation of activity until their 
symptoms have completely resolved. And then those children who 
have persistent symptoms lasting beyond the 1 to 2 weeks are 
then referred to neuropsychologists, like Dr. Gioia, and a 
traumatic brain injury program.
    So I guess I would defer to you for----
    Mr. Terry. What would you recommend----
    Mr. Gioia. Yes.
    Mr. Terry [continuing]. Dr. Gioia?
    Mr. Gioia. Yes. This is a big question at this point. This 
really comes to what is the best treatment for this injury. And 
let me just say, the field is moving on this one, and the 
recommendations that we make, and I have written several recent 
papers on this, is that in that acute stage of symptoms, 
probably the first few days, maybe for some a little bit longer 
if there is a more severe number of symptoms, is that they 
really reduce their activity, cognitive and physical. But what 
you want to be doing though is start to increase that activity 
over time. So we don't black box kids until they are 
asymptomatic. That has a lot of likely negative effects on 
kids, obviously, being removed.
    So what we do is we initially shut them down, restrict 
them, then we gradually start to bring them back into school 
and into physical activity, but that has to be individualized 
based, again, on the severity of that symptom presentation. And 
that is where we are right now. We need a whole lot of research 
to really help validate that.
    Mr. Terry. Thank you. And, Mr. Lance?
    Mr. Lance. No questions.
    Mr. Terry. Gentleman from Missouri gets to ask another 
question.
    Mr. Harper. Mississippi.
    Mr. Terry. Mississippi.
    Mr. Harper. No, I was just looking down.
    Mr. Terry. Yes, I thought you were Billy Long.
    Mr. Harper. That hurt. That hurt. Thank you, Mr. Chairman.
    And a couple of questions that I would have. One would be, 
Dr. Gay, if I may ask a question?
    Mr. Gay. Yes, sir.
    Mr. Harper. In your testimony, you state that football 
players at the elite levels are shedding equipment to increase 
speed and mobility.
    Mr. Gay. Yes.
    Mr. Harper. The decision of which helmet to wear is their 
own, and that player often chooses a helmet's looks, shape, 
feel, perhaps, over its collision cushioning ability or safety 
features.
    Do some positions require different levels of collision 
cushioning, and if so, would you recommend a special helmet for 
specific positions that would meet all current safety 
standards?
    Mr. Gay. Yes, that is a great question.
    Currently, there are no position-specific helmets being 
made. I think the helmet manufacturers try to do the best they 
can for everybody. I would say that, not to belabor the point, 
but I think for linemen, where you typically get no severe hits 
but a lot of subconcussive blows, that horse collar is crucial. 
I wouldn't recommend that a wideout wear a horse collar. That 
would really affect the quality of the play.
    It is an interesting point because, certainly, some players 
might tend--and this is why I am an advocate for the Hits 
System. It will give us much more detailed information about 
which positions get hit where. One could envision, if we have a 
large database, then improving helmet design to react to that 
kind of information.
    Mr. Harper. OK. Dr. Graham, if I could ask you. How much 
money has been spent on sports concussion research, and where 
is most of the funding coming from for that research?
    Mr. Graham. That, unfortunately, was not an issue that our 
committee looked at, nor would we have had the resources to, 
you know, to pull it out.
    Mr. Harper. Sure.
    Mr. Graham. But, you know, clearly, you can identify some 
research that is being done in the Federal sector that applies 
to this, but the private research that may be done by the 
sports leagues, by the manufacturers of equipment themselves, I 
don't know any good way to quantify that for you.
    Mr. Harper. Gotcha. All right. Well, look, I appreciate 
everybody being here, and it is a very important issue. We love 
our children going through sports, we love to watch it, and we 
don't want anybody being hurt that shouldn't be hurt. And so, 
hopefully, this increased focus will lead to better research, 
better safety equipment, detection, and, of course, prevention.
    So thank you very much. Thank you, Mr. Chairman. I yield 
back.
    Mr. Terry. Thank you, the gentleman from Mississippi.
    Mr. Harper. Thank you.
    Mr. Terry. And I just want to thank all of you. This was 
truly an all-star panel of medical experts and physics. And 
much appreciated, Ian. Thank you.
    And so that does conclude our hearing for today.
    Now, for our witnesses, we, whether we showed up or not, 
have the right to send you a question, and it is called a 
written question. We have about 14 days to write those and 
submit them to you, and I appreciate a couple of weeks, not 
over, you don't have to do it right away, but at least if you 
can get them back to us, if there are any, within about 14 
days.
    And I just, again, want to thank you for coming out here 
and providing some very, very valuable testimony for us.
    And we are adjourned.
    [Whereupon, at 1:27 p.m., the subcommittee was adjourned.]
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