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 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? just if you could walk us through some of the history of how it's evolved in the organization. >> happy to do it, and thank you for the question. i think the point that you made that the science has evolved on neurological issues, certainly neurogenerative disease, is one that the second panel, where there's 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 to what the state of the science is

and how best to go about changing our game to reflect that. so that's how we ended up adding -- creating a unified concussion protocol and return-to-play protocol for our sideline. that's 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. we followed their advice strictly and meet with them very frequently. >> i noticed your title is senior vice president of health and safety policy. is that position -- that's got to be a position that didn't exist 20 years ago. >> it did not exist 20 years ago. i'm proud to be in that role. it's an exciting one. >> i know this hearing is on concussions, but since you're here, i got to ask you one other question that may be a little different topic. over the last few years, i've communicated with the nfl about my concerns about the issue of human growth hormone testing, and i know that's something that was raised in the last collective bargaining agreement effort, and there's an agreement to agree later, but that hadn't

always come together as much. i know this is something that's important to the league. can you give us an update on what's going on on testing for human growth hormone? >> sure. we appreciate the question. unfortunately, we don't have human growth hormone testing 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, if our perspective, excuses for a period of time. i think the testing goes to the integrity of the game, certainly. it also goes to the health and safety of the sport. you don't know where the stuff is coming from. you don't know who's giving it to a player or players, and you don't know what they're putting in their bodies. that's dangerous and also the wrong example to set. so this is an important issue for us and one that we're sorry has not gotten accomplished yet. >> that's an important issue to me. that's why i wanted to raise it. i know it's not the topic of this hearing, mr. chairman, but since he was here, i had to ask the question. >> no, but if the gentleman will yield for one sentence. >> yeah.

>> i think that's why we wanted to have the players association here, too. because that was a pretty strong criticism that you just made. it would be nice to have had the players as well to respond. >> well, i'll have to now interject. they were asked, and they declined. >> yesterday. >> no, that's not accurate. they were contacted before yesterday. >> i want to reclaim my time for one more question, though, if i can. i got one more question for you. where are these things going? i know when you try to crystal ball, it's dangerous, because you never know, but where do you see things going over the next 5, 10, 20 years in terms of where technology is going to take us? do you have some things about looking on the horizon that we can be looking forward to? >> yeah, i'll give you a specific example. as part of scientific research 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 concussion. there aren't any objective tests

now. they're all subjective analysis. we came back, 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. in addition, we just completed another challenge that goes around protective ideas, how to protect the brain better. we had more than 40,000 people from 110 countries around the world visit the website. we had people from 19 different countries offer ideas on new protective equipment. we're reviewing those now. i think that because there's a lot more attention paid to this and hopefully we're one of the actors that are catalyzing the science, that you're going to see changes in all of these places relatively soon. >> okay. appreciate that. mr. chairman, my time is up, so i'll yield back. >> thank you. the gentleman from kentucky is now recognized for five minutes. >> thank you, mr. chairman. thank you for being here. ms. scurry, thank you for being here. that, quite honestly, might have been the only soccer game i ever watched from top to finish. it was about the time my daughter was interested in soccer, so we were watching.

>> no pun intended with the top. >> okay. no pun intended? that went over my head. i'm sorry. but what a great sporting event. and it's one of the great moments, and to be part of that is something special. i think it was special because it was just so much america. you were youthful, underdogs, grit, determined, and you brought up brandi chastain, not i and maybe a little exuberance. but it was a great moment. i appreciate you doing that and sharing. i played high school football. that's my claim to athletic prowess, i guess. but we practiced football in august. i remember one time in the south, 90-something degrees. we're 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. the coach says, if you don't know how to handle that, we're not going to have water today. that was over 30 years ago. 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. so i think the awareness and stuff like what i described in my youth would never happen on a football field anywhere today. at least i hope it wouldn't. but we still have these injuries. 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're wearing cleats, short pants and a shirt. somebody hits you in the side of the head with their knee -- and when you look -- i watch a lot of football. of course, they now have targeting. if you're in college football, you're ejected from the game for targeting. a lot of the injuries you'll see the quarterback gets knocked down and somebody hits him in their knee with the side of the head. i don't know how you deal with that. i know you're trying to do the techniques and tackling and heading the ball in the right

way, but just the incidental things that happen because you're playing a sport going 100 miles an hour. do you have any comments on that, 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 there was a few minutes later before i actually ended up coming out. there really -- there wasn't even a foul called, actually. so that's part of the problem, right? sometimes a hit is a glancing blow, and it doesn't even really seem to be anything that's 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. then determine whether they're ready to go return to play or not. i think that is the key for me and why i'm speaking out about this because i've been around the country talking to different organizations, and i'm finding that kids are getting concussions five, six, seven in a very short period of time because they're returning to play too soon. that's where i think a lot of the awareness and education can help. >> thank you. and mr. miller, with that -- and you should do everything you can to stop the head-to-head and so forth. but it seems -- because they'll play them on tv over and over. this is when somebody gets injured and they're out. like the knee of the lineman, like john runyon hits the side of somebody else's head. it's just incidental. i guess you're right. you can't really prevent that from happening, but it's how you react to how that happens. >> i think that's right. one of the recommendations made by the fourth international concussion conference in zurich was to look at the playing rules

of the game. in our case, we've done that. i know other sports have done that as well. so you create the best possible situation. in a contact sport, there will be injuries, and there will be, you know, hits to the head and those problems will occur. so where that happens, we want to make sure we're treating them appropriately. that's where the focus shifts from prevention to appropriate treatment. >> well, thank you. i'm 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. hopefully you felt my assistance and were able to help us both together win one for our team. right? >> absolutely. >> thank you. i yield back, mr. chairman. very good job. i'm glad to meet you. >> thank you. >> now the gentleman from maryland is recognized for five minutes. >> 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've 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 them getting pushed by the insurance industry, for example? 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 made with respect to how it's conducting its sports program, but now that there's this program that enhances the safety of students and young people, we want to see

that you've implemented that in your district or else we're not going to provide the policy coverage or we're going to charge you a higher premium. you can look at it the other way. you get a discount off your premium as a school district because you've implemented these kinds of measures. 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. you'll get some that may choose based on the premium that gets charged that -- to push the program out because they don't want the liability that comes with it. so i was just curious whether your program has -- whether you're aware of that kind of effect from the program or more generally aware of how the liability concerns intersect

with some of these safety efforts that are under way. >> so thank you for the question. at the high school level, we were literally on the front -- you know, one-yard line marching down the field. i will mention that we're having very positive conversations with the state of maryland right now about participating in heads up football across the entire state. but we have a lot to do there. we have not seen anything from a liability concern, insurance concern with fairfax county worked very closely with all their schools and school district about those issues. they told us and we checked ourself, they felt they had the appropriate coverage. however, to your point, at the youth level, we are absolutely seeing insurance, 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're absolutely seeing a

positive response by the insurance industry, which of course has its merits. >> thank you. i yield back. >> mr. ogrean, do you have -- is there any insurance liability issues at usa hockey? >> yes, mr. chairman, there are plenty of insurance liabilities. unlike usa football, for example, which is much more decentralized than are we, our participants are all insured by us as a national organization. whether it's player accident insurance or whether it's catastrophic insurance or whether it's liability and even dno 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 are obviously based upon the number of claims. so that's another business

reason why it's 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's good business reasons for all of us to want to do everything possible to make the game safer. >> thank you. mr. kenzinger, you are recognized for five minutes. >> thank you, mr. chairman. thank you for your leadership in holding this hearing. all of you, thank you for being here and bearing through a bunch of politicians. i appreciate it. i appreciate the diverse panel that's 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. i think today's hearing has been very constructive in helping us to move forward on understanding that and alleviating that. i've 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's encouraging that professional sports leagues and teams are taking steps to address concussions not only on their own ranks but also working with colleges 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're still confronted with staggering numbers of youth being impacted by sports-related concussions. i'd like to ask just a few questions, maybe not take all five minutes, maybe i will. let's talk about the equipment issue in terms of -- i'll 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're on the cusp of making or should make. and then is this packed by medical science? is that going into this idea? so mr. daly, i'll start with you. i guess whatever you want to put into that subject would be great. >> well, thank you for the question. it's a very important issue, obviously. the equipment is a very important issue and something we're focused on jointly with our players association. we have a protective equipment subcommittee that's part of our joint health and safety committee. so we look at all aspects of equipment and how they, particularly as it relates to head injuries, how we can improve equipment and perhaps reduce the amount of head injuries we have. we've 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 elbow area and those potentially causing head

injuries. so we've mandated padding over those areas of players' equipment. the helmet issue is a difficult issue, particularly in hockey, in terms of preventing concussion and one of the things we're 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. >> thank you, sir. mr. ogrean? >> i think mr. daly answered the question pretty well for our sport. there's a great deal where we rely on the national hockey league to be the leader. a lot of what they do is of benefit to us in a trickle-down fashion. as i mentioned in my opening testimony, we do have a safety and protective equipment committee of 40 years standing.

they do look at a variety of issues. the face mask, for example, is something that is mandatory. in youth hockey. it is not in the national hockey league. though, the shields for incoming players are now a standard. >> i'm going to cut you off just because of time. >> football helmets were designed to prevent against skull fractures. they do a fabulous job of that. they were not designed to protect against concussion. so that sort of technology or design, i know that the helmet manufacturers are working on it. we're not there yet. the league is doing what it can to inspire that, especially with our partnership with ge and underarmour to get new ideas around that. the other thing we do is we do regular helmet testing in concert with our friends at the players association so we can inform our players of which helmets are working best. >> and mr. hallenbeck? or ms. scurry? >> trickle-down effect is important. the only thing i'd add is we're working now closely with the sport and industry fitness association and their council. so we're getting insight from them and working together. on how we can improve things. >> and ms. scurry?

>> as you know, we don't wear equipment in our sport, but i 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 last weekend for the association and talking about concussions. 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. >> great. thank you. mr. chairman, i'll yield back. >> gentleman from west virginia is recognized for your five minutes. >> thank you, mr. chairman. i had to slip out for another meeting. so maybe some of these questions have been asked. 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're hearing from when we talk to our troops that come back? i'm just wondering if there's some way we're all talking to

each other to help out on that. mr. miller? >> i'm happy to take that question. we're very proud of our relationship we've fostered over the last couple years with the u.s. army in specific. memorandum of understanding that went back a couple years that covers a variety of different things. we've 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 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. it instills a question as to how you get somebody to tell their teammate or tell their colleague, hey, you don't look right, you should get off the field. so we've learned a lot from that. let me just add briefly, we meet regularly with the army to talk about the research they're doing from a scientific perspective. we share our agenda. we share the ideas we have. and they do with us as well. it's proven to be a very

cooperative and beneficial relationship thus far. >> okay. 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's 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 a benefit here in this program for injuries? we have -- a friend of mine has spent quite a few years in litigation with the nfl over this matter and just thinks it's such a cumbersome -- and we also have a east coast hockey league

team in our city. we see some of the injuries, and we hear from some of the players and coaches about that injury. is there a time we should have a workers' comp program for brain injuries? should that be included in something? they're not required to follow litigation to get help. >> if i may, my case actually is a workers' comp case. i've gone through workers' comp to get the different doctors, to see different techniques that will help me. that is part of my situation and part of the reason why it's taken so long. because every time something is suggested or recommended, i have to go back to insurance companies to get permission to do it. sometimes it takes a hearing to get everything moved forward. so maybe streamlining that somehow would be of great help. 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 psychological side and testing depression, anxiety and panic attacks to make sure that each person who comes back from military who has tbi gets help in that area, the emotional side of it, not just the physical. that would be very helpful, i think. >> thank you. any other thoughts? >> 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 laws. it's certainly a mechanism that an increasing number of our former athletes are using in cases where they have debilitating injuries from their playing careers. >> so would you -- so what was your recommendation then? you're saying yes? >> well, again, i guess what i'd say is i think it's generally available to our former athletes currently, the workers'

compensation protection. >> i guess what we're hearing is different from that. that's why i want to raise it. but thank you for your comments about that. i yield back the balance of my time. >> the gentleman yields back. mr. bilirakis from florida, you're recognized for five minutes. >> appreciate it very much. thank you very much for holding this very important hearing. i wanted to specifically thank ms. scurry for really speaking out. i really appreciate it. makes so much of a difference. thanks for your sacrifice. you're going to make a real difference in kids' lives. i also want to ask -- i want to get back to the protective gear, the helmets, what have you. 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? i mean, can you give me an opinion on that? >> so i'm certainly no expert on exactly how that compares. my understanding is there obviously is a standard bearer and they set the standards and certainly all the helmets out there have to pass that standard. i think the manufacturer would say they go above and beyond that. how it compares to an nfl helmet, generally speaking, the youth helmet is lighter, but the padding and so forth is appropriate. i don't want to suggest i'm defending them. i don't know the exact details. i know it's sufficient based on standards and so forth. many of the kids, though, the players, youth players, by 10 and 11 and 12 years old, they're transitioning into what might be considered high school or adult helmets. they're getting the best available. 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. definitely improving. >> 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 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. so we put a fair amount of money into that program in coordination with the cpse. i know scott at usa football runs an equipment football grant as well. so addressing those needs. we know a new helmet is better than an old one. 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's going to be the number one safety peace to the equation as it relates to kids. and so we're aware of these issues and we're trying to make a difference there as well. >> so in your opinion, are the youth helmet or high school helmet is not as safe as the nfl, but you have a program to help.

is that correct? >> yeah, i don't know about the comparison -- >> the quality might not be as good. >> i don't know about the comparative safety of the helmets. i suppose that's probably a question -- >> can i talk to you about this particular program? >> of course. >> i know parents where the kids play high school football and the parent will purchase a better quality helmet for the child. you know, concern about the kids that don't have the -- the parents don't have the money to purchase that. so very important. i would appreciate working with you on this. >> every kid deserves the proper equipment. >> if there's an existing grant program out there, i'd like to hear about it. also can i hear from the hockey -- hockey as well? >> sure. 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's a three-year expiration date on every helmet. you can't use a helmet that's more than three years old. >> very good.

nhl? >> i would first echo mr. miller's comments. helmets in our sport as well are principally designed to prevent skull fractures, they're not principally designed to prevent concussions. sometimes they can disperse force in a way that does prevent concussion but that's not their principle purpose. we also have regulations we make available to our equipment managers and players with respect to frequent replacing of helmets. so each player is essentially asked to replace his home helmet at least once a season. his road team helmet at least two times a season because we're worried about ageing effects and degradation that accompanies travel requirements for our team. so frequent replacing of helmets is a priority for our league as well. >> are the coaches educated? do they know which size fits the child? have they been briefed on those particular issues? because that's so very

important. youth sports, hockey and football. >> they are. i agree with mr. miller that it is -- it's a big difference maker, you know, in the helmet doing its job, but it's a pretty fundamental part of what a coach has to do to make sure the players on his team all have the proper equipment and are wearing it in the right way. >> i would just add that that's a cornerstone of our heads-up football program, equipment fitting. frankly, at the youth and high school level, we found they don't know how to properly fit equipment. it's a very important element within the program. >> 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're looked up to by our children. as you know. do y'all have programs where you can speak -- that speak -- maybe go to the schools, football players go to the schools and

speak on these particular issues? >> yeah, one of the -- our active players are by and large terrific at this topic. one of the elements 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're trying to encourage our clubs with great success, by the way. they've really done a terrific job of embracing in their communities the youth leagues and others so they're around the facility more. that they interact with coaches, trainers and certainly players, which obviously the star quality of it brings attention to it, which was part of the motivation in first place. but we have found our retired players thrilled to participate and really active and helpful to the end that you suggest. >> the gentleman's time has expired. so if any of you want to answer that question, you'll have to do it by writing. and brings me to the point

that -- oh, you have a question. i'm sorry. recognize the gentlelady from virgin islands. >> thank you. and thank you, mr. chairman. sorry i'm late. i was at another hearing downstairs. mr. miller, i'd like to ask you this question. many tens of thousands of helmets are used every year that are more than ten years old. i understand that the nfl participated in a program initiated by the consumer product safety commission by donating money that would go towards new helmets for youth football players in low-income communities. i really want to commend the nfl for this initiative. of course, it's going to cost a lot more money to get to the point where virtually all kids around the country who play football no longer wear old helmets that are likely degraded or obsolete. i'm pleased to know of your donation to the cpse initiative because it strikes me as an acknowledgment 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 reconditioning those under ten 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's why i'm 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 ten years old? >> in the youth space? you're talking specifically about youth football prohibiting helmets that are older than ten years there? >> yes. >> you know, i plead not enough familiarity with the issue. i know there are a couple of states who have taken that step and we'd be happy to work with you to pursue it. the prime place, as you mentioned, we work with in promoting newer, refurbished helmets is with the cpse or

through usa football, who has a grant program as well. >> so the first question is committing to supporting prohibiting helmets on the field over ten years old. could you commit to supporting a policy position that helmets more than ten years old present an unacceptable safety risk, that's a position taken by most of the helmet industry. >> if that's the position of the helmet industry, i see no reason we'd have a concern with that. it sounds appropriate. >> riddell and adams strongly recommend that their helmet should be discarded after ten years. can the nfl support a policy position recommending that helmets be discarded after ten years? >> we would certainly support that helmet companies and how they advise people to use their products. >> we've also heard stories of players using beat-up lucky college helmets or adjusting their helmets by 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? >> all of our players have choices in which helmets they use, as long as they pass the certification body's standards. that's part of the players discussion with the players association and players have to use helmets that pass the standards. >> and that they were reconditioned properly and had the appropriate padding? >> sure. the nfl players helmets are reconditioned regularly and our equipment managers work with the players to make sure that their helmets are in good working order. >> thank you, mr. chairman. >> people are settling in.

this is unintended part of our hearing today where we're 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. if i might editorialize i think jan did a great job juxtaposing a face of tbi and concussions on each panel.

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 institutes of medicine. dennis malfeese, director of the center for brain biology and behavior at the famed university of nebraska. thank you, doctor. dr. james johnston, assistant professor department of neurosurgery at the university of alabama birmingham, star of screen. dr. tim gay, ph.d. professor of atomic, molecular and optical

ms.ics, university of nebraska. dr. joia, ph.d. division chief neuropsychology children's medical hospital. not quite up to the level of university of nebraska, we have the harvard medical school. that's just humor. professor -- yeah. 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. mr. cleland, you'll start. you're recognized for your five minutes. >> the green light is on. is that better? thank you. i'm richard cleland, i'm

assistant director of the division of advertising practices at the federal trade commission's bureau of consumer protection. i'm pleased to have this opportunity to provide information about the actions we've taken over the past few years with respect to concussion protection claims, claims that implicate serious health concerns, those potentially affecting children and young adults are always a high priority at the commission. the commission strives to protect consumers using a variety of means. first and foremost the agency enforces section five of the federal trade commission act which prohibits deceptive or unfair acts or practices. interpreting section 5, commission determined a representation, omission or practice is deceptive if likely to mislead a consumer acting reasonably under the circumstances and it material likely to affect the consumer's conduct, choice or decision about a particular product at issue.

the commission does not test products for safety and efficacy. it does require an advertiser have a reasonable basis for all objective claims conveyed in an ad. the commission examines specific facts of the case to determine the type of evidence that will be sufficient to support a claim. however, when the claims involve health and safety, the advertiser generally must have competent and reliable scientific evidence substantiating that claim. as awareness of the dangers of concussion have 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 makers of brain pad mouth guards. the commission complaint claimed it lacked a reasonable basis for the claims that mouth guards reduced the risk of concussions, particularly those caused by

lower jaw impacts and falsely claimed scientific evidence proved the mouth guards did so. the final order in that case prohibits brain pad from representing 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, 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 they might be making deceptive concussion claims about their products. ftc has monitored these websites and 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 the need for appropriate substantiation of such claims. commission staff investigated concussion reduction claims made by three major manufacturers of football helmets. ridell sports incorporated and zenith llc. in these matters the staff determined to close the investigations without taking formal action by which time all three companies had discontinued the potentially deceptive claims or had agreed to do so. those cases are discussed in greater detail in the commission's written testimony. the commission plans to continue monitoring the market for products making these claims to 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

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's effort to ensure that the information being provided to consumers, in particular to the parents of young athletes, is truthful and not misleading. thank you. >> thank you. ian, you are recognized for your five minutes. >> 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'm here as a student ambassador for the national council on youth sports safety. i'm also a senior at bethesda chevy chase high school in bethesda, maryland. i was playing in a lacrosse game when i sustained a serious head injury which we later discovered was my third concussion. until then i did not appreciate what a great life i was living.

i got good grades in challenging classes, played high school lacrosse, was working on my second degree black belt in martial arts, had a job i loved teaching tae kwon do. performed in 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% of normal cognitive activity and i was almost immobilized. i've spent 2 1/2 years recovering and at times have ever wondered if i would ever get that life back. it has been a long, slow process. at first all i wanted to do was sleep. noise, light, even moving my eyes caused headaches and nausea. i was enrolled in the children's hospital score program that dr. joy will describe later where i received ongoing cognitive evaluation and treatment for symptoms. after missing school for two weeks, i tried to go back but was unable to function.

the frustration of trying to focus on lectures, moving through the pandemonium of the halls and constant sensory bombardment made a normal school day impossible. however, through my school i eventually enrolled in a home teaching program. with the help of tutors and family, was able to complete my semester course work 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 mental or physical activity for a day or two. these relapses were particularly tough and discouraging and meant i had to drop a class, 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 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'm one of the very lucky ones that 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'm excited about the future as i prepare for college. i'm thinking about becoming a high school math or science teacher. i now have a hard question. what can be done to create a safer sports environment and ensure when injuries do occur, the support for full recovery is available? we can't just do away with youth sports.

i played baseball, travel soccer and league and high school lacrosse. being on those teams not only gave me a healthy outlet but 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'll become skilled and proud of our accomplishments. they teach us how to be part of a team, have pride and success and learn the lessons of defeat. they teach us 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 to be out for an injury to be willing to recover fully before returning to play. it will take a while. if youth and professional sports are to survive, these attitudes must be embraced. second, when injuries do occur, we must have a way for qualified personnel to quickly assess injuries on the field, have players get immediate attention, and then support recovery through schools and medical institutions. these are the things that were done for me and are the reason i've been able to return to normal. as a student ambassador for ncyss, the message i hope to give young athletes are this. you think you're invulnerable. you take risks and brush off injuries because you think you will recover quickly from anything that happens. you won't. don't be a hero, especially when it comes to your head. it's the only brain you'll have, and your personality is who you are. it's not worth a couple of

seasons of glory to lose the opportunity of a lifetime. thank you. >> very good. dr. graham, you are recognized for five minutes. >> thank you very much. chairman terry, ranking member. my name is bob graham. i served as the chair of the institute of medicine sports related conclusion and youth study. as you have my testimony before you and i think copies of the study itself, i will just try to take these minutes to give you a summary. the institute of med sip part of the national academy of science chartered to provide advice on very scientific issues. we were specifically empaneled to look at the evidence about the causes and consequences of concussion in youth and military state of diagnosis management, role of sports equipment and regulation. we have 17 members on our committee.

we worked in 2013. dr. molfese, who will follow me, was a member of that committee. we came with just six recommendations. the first was that the cdc needed to establish a better mechanism for national surveillance to comprehensively capture the incidence of concussions. you've heard a number of figures about the concussions in one sport or another. we know what the incidence is when they are measured. we do not know the incidence is if in sports where they are not measured or they are not more closely watched. we need to have that baseline to really know the degree to which we have a problem, and as we take corrective measures, the success rate that we are having in making an impact on decreasing the incidence of concussion. number one, better surveillance,

we need better epidemiology. number two, couple of recommendations related to research. we need nih and 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's largely based on observation, on self-report. but there are 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 nih and dod to look at more carefully longitudinally at the short and long-term consequences of concussions. we heard testimony in this panel, prior panel, individuals who had one or more concussions.

what are the long-term sequela of an individual or multiple concussions. that gives us a sense about not only, again, epidemiology of the problem we're dealing with but what treatment and intervegss may be and what rehabilitation may be. fourth recommendation to the ncaa and national federation of state and high school associations to look at age appropriate techniques and roles and playing standards. again your first panel talked a little bit about that. mostly at the professional level. but can you change the manner in which the sport is practiced, and the rules of engagement in the sport that may decrease risk of concussion. there was one example from the hockey area where they had changed the level where they allowed body-checking and felt that they saw a decrease in concussion. we think that same sort of examination should take place at the college and elementary and

high school level to see whether or not they can have the same impact. the fifth recommendation had to do with a better study of what the role may be for protective equipment. the first panel talked a lot about that. committee had a number of questions about that. our committee found very little evidence that helmets protect against concussions. there's a lot of data in that. 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's a complicated issue. but there are a number of suggestions that, we certainly did not recommend you don't use helm 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 and what we may be able to do related to the biomechanical determinance 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, 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. >> thank you, dr. molfese you are recognized for your five minutes. >> thank you chairman terry, raccing member schakowsky and members of the subcommittee for this opportunity. if we could have the slides. go to the next slide. yeah.

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 rate of concussion is particularly high. there are, of course, differences in rates for men and women. dr. gay will talk about some of that in terms of weaknesses of women's necks relative to their -- men's necks, now that puts them perhaps at more risk for concussion. next slide. concussion accounts for in the united states roughly about 75% of traumatic brain injuries. it is a brain injury. there is damage to the brain. there's a discussion about whether it's permanent or temporary. in the military the rate is 77%. so turns out that youth sports are a good model for also looking at concussion in terms of the military. 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 the majority occur outside of theater, in accidents. next slide. if we look at brain injuries overall, there are estimates -- these are all estimates, of course, and they vary across the literature. we're looking at somewhere probably in the neighborhood of 4 million traumatic brain injuries per year in the united states. a sobering part of that is 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 unrereported.

recovery generally is fairly quick. usually anywhere within a few hours to a few days. some will persist two weeks even out to six weeks, but roughly about 20% seem to persist beyond that time. next slide, please. this is a slide on some data under review. it will give you a sense, these are data using brain electrical activity. so basically we have a net of 256 electrodes that fits on the head in about ten seconds or so. 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, circles you see, colored circles, on the left for match and nonmatch, those are images

of the brain electrical activity on the scalp recorded from those electrodes between 200 and 400 milly seconds. so 0.2 to 0.4 of a second after the number appears. the schematic on the right shows you the head position. so it's a very rapid brain response. for those athletes who have no history of concussion we see very clear difference in the electrical activity for a match versus a 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 to the back of the head. on the right, though, these are individuals who have a concussion history of one to two years earlier. not current. yet at 200 to 400 milliseconds their brains cannot discriminate whether those two numbers are the same or different. they also might get these tasks correct but it takes them roughly 200 milliseconds longer.

that's 20 synapses. so the processing speed is slow. and after two years, one might suspect that's a permanent change. next slide. i think that -- yeah. so in terms of critical scientific gaps, some of these we do, dr. graham talked about. how does concussion affect the brain in the short and long-term. we really don't have much information about that. what's the dose requirement. dr. graham talked about that. to produce concussion, postconcussion syndrome. cte. how can we reliably objectively detect when the brain is injured, and when, importantly, is fully recovered. we have no ways to do it. lots of individual differences from one person to the next. we think there are genetic factors involved but also a concussion history the person may not think they have. how many of us have bumped our head getting in and out of the car. we have a quick rotational movement and that could produce,

perhaps, a concussion. how does the brain recover from tbi and finally how we improve and recover, accelerate recovery. we really have no scientific basis for any interventions. thank you. >> thank you,. dr. johnston you're recognized for five minutes. >> chairman terry, ranking member schakowsky and members of the committee, thank you for inviting me to testify before you today alongside this illustrious panel about our experience in alabama following -- >> could you pull the microphone a little closer? >> is that better? our experience in alabama, following passage of concussion legislation as well as work we're currently doing at the university of alabama birmingham to improve sports safety. as in 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. significant concern recent studies identified potential long-term health consequences including depression, chronic traumatic encephalopathy and other neurologic diseases associated with impacts. professional football gets media attention, it's important to keep in mind over 70% 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 alabama's concussion law in 2007 as in many states the alabama state concussion task force, think first alabama initiated a statewide concussion and education awareness program and it worked. in that first year we observed 500% increase in referral of youth athletes referred to the concussion clinton inof children's at 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 protocol. it's in my appendix one. following the zurich conken cuss guidelines athletes were evaluated by physicians expertise in concussion, kept out of school until symptom-free, referred for testing when appropriate and supervised in a graduated return to play and a return to play program. a formal study in 2012 demonstrated establishing this program resulted in significantly better concussion care and decreased institutional resource utilization. even though these efforts, 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 technology and other subjective ways of evaluating athletes research has begun to widen from concussion to

correlating accumulative impact exposure over time which chances advanced mmri imaging technique. animal models have problems with cognitive impairment, spatial learning. as seen also in football players compared to single impact controls in those that have not had these injuries. though definitive conclusions for threshold impact frequency hit counts cannot be drawn from these early studies it has being clear subconcussive impacts, those that don't result in concussion 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 a significant portion of young players head impact actually takes place during practices. the largest impacts happen to take place during those practices a lot of times doing outdated drills, oklahoma drill or bull in the ring supervised by well meaning but untrained coaches. emulating top level collegiate programs which don't do these practices and these drills,

teams like university of alabama, ivy league and others, the alabama 450i school athletic association recently published nonbinding guidelines to limit full contact hitting practices to twice per week. i believe this type of intervention is complementary 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 instituted similar guidelines but a small section. eliminate frequency of hitting at practice as well as type of drills would have a large effect on safety significantly decreasing accumulative impact exposure for every youth football player in america. also become clear football helmet standards defined by national operating committee for standards in athletic equipment must be updated to reflect our understanding of the epidemiologies of cup cushion. it is clear linear impact and acceleration play a role in concussive physiology and only linear impact is studied by the system which was from a skull fracture tolerance model developed in the 1960s.

we believe having multiple other -- complete impact seen in the football field are necessary in order to come up with meaningful standards, in collaboration with university of alabama football program engineers at uab, and the developer of the safer barrier for nascar and irl have developed developed a robust video analysis system to analyze impacts and recreate them in a purpose built lab. in conclusion the passage of concussion awareness legislation, community education recent advances in our understanding of head impact erk pore your in youth athletes have improved the overall safety of impact sports and we're recognizing concussions more frequently however much work remains specifically in concussion education and drafting policies to limit head impact exposure for youth athletes in contact sports. as part of this multifaceted approach to complex problem new helmet standards is crucial for development of safer helmets. mr. chairman, thank you for the opportunity to testify. >> thank you. dr. gay, you are recognized for five minutes. >> thank you, chairman terry.

i'd like to thank the subcommittee for inviting me to testify today. i'm speaking to you as a football fan who happens to be a physicist. my main professional interest is the understanding of how protective equipment works and how it can be improved. today i wish to consider several aspects of football that are problematic as far as concussions go and how we might move forward to make the game safer. american football is an inherently violent sport. that's one of the reasons we love it. the forces encountered in football can be huge. consider a big hit between a running back and linebacker at full speed. we can show using newton's law that the force each player exerts on the other exceeds three quarters of a ton. this is why football is called a contact sport. two players who collide at full speed helmet to helmet are experiencing the same force to their heads that one of them

would feel if he had a 16-pound bowling ball dropped on his helmet from a height of eight feet. medical knowledge of concussions is in its infancy. but we know one thing for sure, forces to the head and neck cause concussions. we've 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 60% to just over 300 pounds. at the same time these players have gotten about 10% faster. combining the factors of speed and mass to calculate kinetic energy, the energy available to cause injury we find the amount of energy dumped into the pit at the line of scrimmage on any given play has almost doubled since 1920. an exact opposition to this trend is the fact that players are shedding their protective gear. fine knee pads that used to be centimeters thick now bear a remarkable resemblance to tea cup doilies.

force collars popular with linemen of my generation have gone the way of a 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'm not competent to explain these issues i think it's safe to say that a room full of head trauma physicians will not agree on the details of what concussions are or what causes them. this means that the diagnosis and treatment 6 concussions has a long way to go. as our understanding of these issues improve we may find that injury rates due to the increasing energy of the game and the wholesale shedding of equipment have increased faster than we thought. finally, football is big business especially at the college and professional levels. when monetary forces manifest themselves as they do, for example, bounty programs and illegal doping, to improve performance, the game becomes more dangerous. what are the solutions?

we need better equipment. but this can get tricky. for example it's apparent that adding more energy absorbing foam to the outside of a helmet will lower 9 force delivered to a player's skull. this has been tried in the past. the problem is the added padding increases the helmet diameter as well as its coefficient of friction, meaning that the opposing player can expert 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, that 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 the 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 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 actually increase the rick of injury. rule changes should be studied and possibly reversed. it is my belief that return to a level of padding worn in 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. >> thank you for your valuable time. and dr. gioia, i appreciate you being here. you are recognized for five minutes. >> thank you, chairman terry, rank member schakowsky and members of the subskhitty. i appreciate the opportunity to speak on behalf of the safety of our children in this country. i'm a pediatric neuropsychology at children's national health in washington, d.c. and director of the score concussion program. i'm a clinician, researcher and a public health educator. today i'd 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 researcher. i've worked for the last decade with cdc on their heads up concussion program materials.

we all know, 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. 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 student athletes through rules for educating coaches and parents and removing suspected concussions and not allowing them to return until properly cleared. all states including -- include the high school at this level, but only 15 out of those 51 include youth sports. so less than one-third are looking at the majority of athletes.

in preparing for this testimony, i was posed with an important question and challenge within youth sports. with concussion awareness at an all-time high, our youth sports teams and organizations and parents more aware but still not sure what to do about it? and the simple 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 in early identification of concussion and protection. coaches and parents must receive training in action oriented concussion recognition and response. awareness isn't enough. they have to be prepared properly. we know that as you've heard, repeated concussions present the greatest challenge to our youth. our greatest challenge is the universal, consistent and effective implementation of

these 51 laws so that we can prepare those coaches and parents to know what to do and have the tools with which to do it. at children's national health system over the past ten years our score program delivered hundreds upon hundreds of action oriented parent and coach concussion education and training programs using the heads-up materials from the cdc. we've learned much about community needs. and how to deliver the message. so we deliver scenario based training where we present to coaches and parents an actual situation and what they must do to recognize and respond. this is all very, very important as we put these responsible adults in place. you've heard about some important other kinds of activities and good examples of head safe action, head smart action, such as usa football's heads up tackling program where coaches are educated in concussion recognition response

but also taught techniques that we believe can improve taking the head out of the game. but we have to go further in all youth sports. we do not have a coordinated universal strategy at this point for action oriented solution driven methods to recognize and respond to these injuries. we have the tools, we have many of the programs, but we do not at this point have the delivery mechanism to do that. so we have to build also on active partnerships between youth sports organizations and medical care systems. concussions are complicated. they are not simple. we're not asking parents and coaches to be clinicians and go out and diagnose. we have willing teammates, as you've 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're hearing from the nhl and the nfl and the sports manufacturing world to team with us.

we also need a quarterback ultimately to make this happen. we have to leverage the efforts of other organizations like the national council on youth sport safety, youth sport safety alliance the sarah jane brain foundation's plan, all of this is important for us to do. 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. we believe that can help children ultimately as they enjoy benefits of sports. our score model applies here. it says play hard, play safe, but play smart. thank you.

>> very good. dr. shenton you are now recognized for your five minutes. >> thank you. i want to thank chairman terry, ranking member schakowsky, members of the subcommittee i'm honored to be here today. my focus is going to be on radiological evidence of both concussion and subconcussive blows to the head. if i can have the next slide. what is known is that mild traumatic brain injury is common in sports injury. when we're talking about a single mild tbi, about 80% get better, between 15% and 30% go on to have persistent concussive symptoms, as have been described today. what's most concerning, though, are what's been called chronic trem attic encephalopathy and other nerve gentlemen den rative disorders. that's the second one where it's repetitive mild traumatic brain

injury that we're really concerned with. the clearest evidence comes from postmortem studies. if i can have the next slide here is a postmortem slide that shows protein in the brain, those are the brown areas that show up. this is a case of a retired professional football player who had symptoms and presumed to have chronic traumatic encephalopathy which was confirmed at postmortem. next slide, please. here are four individuals, a, b, c, d. what's interesting, 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. what is known? we've gone over the first two.

third is mild tbi is difficult to diagnose. that's 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. many people have said there's no problem then. the problem is the correct advanced tools have not been used until more recently. now with advanced neuroimaging we're able to both diagnose and move towards prognosis and hopefully intervention. advanced neuroimage being techniques such as diffusion imaging which we've been using in our laboratory show radiological evidence of brain alterations in living individuals with mild tbi. so we can detect this early and perhaps then look at underlying mechanisms and characterize what's going on in order to come up with preventive measures. next slide please. this is a study from our group

looking at hockey players from university hockey play ners 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 in increase in extra cellular water in the brain, which is not a good sign. next slide, please. we also looked at gray matter, looking at cortical thinning, in the brain. and that's the cortex where neurons are in the brain, and this is a study in former professional football players who were symptomatic when we looked at them. what we found is there's cortical thinning compared to age matched normal controls. what's most concerning, however, is that blue line that shows cortical thinning accelerates with age whereas the red line our control group where it's almost completely flat. and this suggests that court cal 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. we selected them specifically for not having a history of concussion and not having any symptoms whatsoever. what we found was compared to swimmers, professional swimmers, there was a huge difference between the two groups with the controls on the left and the soccer players on the right. almost a complete separation between the two groups with an increase in what's called radial diffusivity, damage to the myelin in the brain. next slide, please. what we don't know. why do concussive and subconcussive trauma result in some and not others. another question we don't know, why do some develop neurodegenerative disease and others do not. what are the predisposing factors. is exposure genetics involved. not every football player, not

every soccer player, not every hockey player who plays and gets hit to the head ends up with these neurodegenerative diseases which is what i think people are most concerned with. 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. we need to follow recovery and degenerative processes to predict who will have a poor out come and who will have a good outcome. knowing that we might be able to intercede with treatment, to halt possible cascade of neurodegenerative changes. finally, 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 recovery and being able to pick out ahead of time what is going to lead to a poor outcome so we can intercede. finally some measures of safety such as rules for returning to play are needed following observable evidence of brain trauma. thank you. >> thank you. very impressive testimony from everyone. i was even impressed that you all stuck to the five minutes pretty close. now. i'm going back to dr. molfese. i think your testimony and dr. shenton's kind of juxtapose each other here very nicely. so part of your research is doing is finding that baseline of the new athletes that enter university of nebraska. is this allowing you to detect

the injuries earlier that there may have been some pre-existing subconcussion? how are you identifying that, what is it telling you, and what are you then -- what is the university doing to implement some level of protections? >> one of the major changes we've seen, and i think this is occurring across the field now, is the effort to get preconcussion data. so basically more schools are moving to assess student athletes prior to the start of the season. then that certainly is what we're doing. 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. so we've run across that a number of times in our testing.

we'll pick up something on our test the trainers and medical team didn't know about simply because the player didn't disclose. then we also tried 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. generally what we're finding is both effects that occur across the season in just our normal players who have no history of concussion being identified, their brain's speed of processing does change overed four to five months of training and the season. but then with the players who are -- who do experience a concussion, we see in terms of brain electrical activity again the slowdown of about 200 milliseconds. that's four times faster than the slowdown you see in multiple sclerosis for an example for a contrast. clearly the brain has changed the way it's processing. we're just now moving to start intervention programs with the

players who we identify. there's some data out there with early alzheimer's that suggests working memory-type tasks, maybe even a week of intervention shows a four to five-week gain, continual gain in improvements. so we're trying to see if we can see some of that occurring. >> thank you. dr. gay, in regard to concussions, many times it's not a direct below but coup contrecoup, it's 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. tom osborne likes to talk about the neck roll. that -- describe to me what you mean by 1970s equipment, and how it may actually reduce concussions. >> thank you, mr. chairman. yeah, the neck roll, what i call a horse collar, is really a piece of equipment that's

disappeared from the game. it does an important thing. it essentially immobilizes the head. so if concussions are concurred by the rattling of the brain back and forth, especially from a blow to the side, the horse collar will substantially damp that down. to my knowledge, there are no epidemiological studies of that being effective, but i can't -- my personal opinion, even though i'm ignorant -- largely ignorant of medical science, if you immobilize the head that's going to solve a lot of problems, especially with these rotational hits. yeah. >> dr. graham, does that make sense? >> i think whether or not the horse collar would have that effect, i don't know. of course, our committee was based clearly on science and

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. whether you can do that by equipment, whether you can do that by change in play, that's what you have to do to decrease the evidence -- the incidence of concussion. >> thank you. i only have 11 seconds left so i'll yield back and recognize the ranking member miss schakowsky. encouraging safer play for the you know in adie rn to the science so much talk has been about culture. and it seems to me that that is very important. so a change in the culture means not only managing head injuries when they occur, but also encouraging safer play to reduce the risk of injuries.

mr. heaton, you spoke about the need to change the -- i'm quoting from your testimony -- win at all cost attitude among players and coaches. what would you tell teens to help them change that attitude both within themselves and teammates and perhaps more challenging in coaches? >> thank you. well, frankly, i would actually encourage the coaches to stress this as much as possible as well as the parents. the coaches and the parents are there to help us learn how to play these sports correctly. if they can emphasize not having to worry about winning to the point where you get hurt, it will trickle down to the players. the players become coaches. it's this never ending cycle of teaching and making sure that the players know that winning is not the most important thing. you know, it feels great to win. i'd much rather lose than have another concussion.

>> clearly you were aware because of the severe consequences of the brain injury. do you think youth athletes understand what those symptoms are? >> yes. i think it's getting better, indeed, especially at my school. we emphasize making sure that you know the symptoms of concussions. i feel like it's spreading as well. >> let me ask dr. gioia that. >> certainly at this point the education programs are also being directed towards the athletes. quite honestly, about five years ago, maybe six years ago, there was a study that showed that was the number one reason why athletes weren't coming out of the game. they didn't know how to tie together the symptom tolj. it wasn't simply that they didn't want to lose playing time but they didn't know what they were dealing with themselves. we also believe that athletes

and teammates need to watch out for each other. the concussed athlete may not have the wherewithal to know they aren't right yet their teammate next to them oftentimes does. so there's a responsibility within that team to take care of each other and that's an important focus. >> that goes to culture as well. >> absolutely. >> dr. shenton, please explain a little how advanced neuroimaging works and describe the type 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 on sports related. >> i have a slide which is just to the end of my slides that just explains in one slide diffusion imaging which i think would help out here. >> the one slide i really didn't

understand was it was comparing swimmers with -- >> with soccer players but i was going to go through and show you why diffuse 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 are really the white matter. for example the corpus colosum is the largest white matter track in the brain. and you get shearing. 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. i looked to my colleague and said why would no one show a brain? and he said because everyone knows that you can't see anything on the brain. i said, but nobody is using the right tools here. 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. that's isotropic.

diffusion. if you look on the right, it says an ice owe tropic diffusion. so you're dropping ink on newspaper. newspaper has fibers so it restricts the water. this is the same principle that's used quantitatively to look at the brain. so if you're in csf it's very round, and it's iceo tropic and everything goes in the same direction. if you're looking at white matter you're restricted in two directions. so you can measure how -- what the integrity of white matter fiber bundles in the brain. fiber bundles in the brain. that's what you need to look at in mild tbi. if you have someone come in with a moderate or severe brain injury, you don't need this kind of technology. they are just going to be put into neurosurgery and do an operation. it's these very subtle brain injuries that aren't recognized using conventional imaging where you can recognize it if you use something like diffusion imaging.

we have shown over and over again now that you can see and it's not just our group, starting in 2003 people started using diffusion imaging because it's the most sensitive imaging tool that exists today to look at diffuse external injury which is the major injury in mild tbi. what needs to be done now is to look at acute injury and see what predicts outcome. do acute injury at 72 hours, at 3 months, at 6 months, can we then predict knowing that what happens at 72 hours if you have -- we have one in our lab trying to separate water that's outside the brain versus outside cells versus in cells. if you can predict from 72 hours, then you can go back and say, okay, 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 -- >> this could be very promising not only for our athletes, but our returning veterans and applied eventually to schizophrenia or alzheimer's. >> i'm primarily schizophrenia research. that's what i've done for 30 years before i became a tbi researcher in 2008. we have a measure called free water based on imaging, this kind of imaging that shows early on at the very first episode of schizophrenia you see fluid around all of the brain that's free water. it's like the isotropic. but in just the frontal lobe you see it more restricted to tissue inside tissue. this was a brand new technique

developed by a full bright scholar in our lab from israel. >> i'm going to have to say thank you. it's very promising. thank you. >> yes, thank you. gentlemen from new jersey is recognized. thank you, mr. chairman. dr. johnston, you stated that many sports-related concussions still go undiagnosed, and i'd like to know why in your opinion that is the case, and how can we improve that? our state laws and also the involvement of coaches, and players and ptas, areas where we need to have improvement. >> thank you for the question. i think i would echo what has been said by others on the panel. it's on. sorry. i would echo what's been said by others on the panel that i think a lot has to do with recognition. obviously people are very good at recognizing when someone gets knocked out on the field. but of course that's a 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's the main reason. my sense is in general the culture, at least speaking for the state of alabama, that all of the coaches that i've come into contact are believers. they're not purposefully hiding, you know, kids and putting them back in knowing they have concussions. but i think that sometimes it's hard to recognize, especially when young athletes don't tell you how they're feeling. and other issues which i guess, brought up the importance of teammates being involved with diagnosing these players so they can be pulled and appropriately evaluated. >> how close in your opinion are we to a better design for helmets? >> i think that we are at the very beginning. i think we have been using a

standard not changed for 40 years that was designed for skull fractures that has served its purpose. i think many investigators around are working to improve the quality of the standards to include linear and rotation acceleration as well as other important aspects of impacts. 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. that's the stage we're at. i think standards are important part of the equation. >> thank you. dr. gay, in your testimony, you've discussed the fact that there is a newspapereral rating system for helmet's impact. i think it's designed at virginia tech, the star system. you 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? >> 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 knocks the head inside the helmet feels for these given drops based on a, in my opinion, fairly crude initial model of what causes concussions. there's no effect taking into account rotation. there's no effect of temperature. and in my opinion, the reproduceability is not as good as one would like, having tried to do examples of these kinds of tests in groups that i've been

involved with. so i think it's a good first start. it's the best we have right now, i think it needs to be paid attention to but there's a lot of room, a lot of room for improvement. >> thank you. and finally, ian, how old are you and what grade are you in? >> i'm 18 and i'm a senior. >> does that mean you'll be going off to college in the autumn? >> yes. >> do you know where you will be attending college. >> i'm going to elan university in north carolina. >> congratulations. my congratulations to you and my condolences to your parents on the cost of higher education in this country. it's a great school. i have a god daughter who is a freshman there. that means she's a little older than you but i'll 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. >> thank you. >> thank you. >> gentleman from mississippi you are recognized for five minutes. >> thank you, mr. chairman and thank each of you for being here and sharing your expertise on what is a topic we're really just, i think, only really learning about as it's been in the news for several years but it is coming to the forefront in your work and your information and 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 fragilec syndrome i particularly appreciate the work that you do at the children's hospital, you dr. gioia, you, dr. johnston. but this is, in preparation for this, i had some discussion with some parents some back home, and the interesting discussion is, i had several friends who have

daughters playing youth soccer and a number have reported an increase in the number of concussions suffered by young ladies playing youth soccer. we seem to always associate it with nfl and helmet to helmet contact and concussions and things we see on the field but it appears in everything we do in life. every sporting event. there's that danger and that risk. that's why i think what you're doing with the alabama doctor johnston is the preventive part of it. is how do we educate our players and coaches, parents. and perhaps, if using a teammate approach, it may be 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.

that might get them off the field. but thank each of you for your work. dr. johnston, 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 of play and if so, how? >> i think the definition would be all those other -- the 99.9% of impacts that happen that don't result in a concussion. as has been pointed out, that the rub with concussion is the diagnosis part. if you look at the historical studies, rates of concussion in different sports, it's variable. and a lot has to do with who is diagnosing it. males versus females. whether or not men are more or less likely to report symptoms. i think the subconcussive impact is all those other impacts that we have found more and more

information with the important imaging that's been done in boston and other places that even the subconcussive impacts have results in terms of anatomic structural changes in the brain over time. i think the subconcussive impact needs to be addressed in terms of lessening the overall load that the player has. football is the obvious thing 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. >> thank you. dr. molfese, if i could ask you the question, just for -- clarification first, if i could ask, the 77% of military. >> yes. >> that figure, is that how many of tbi cases have suffered concussions or is that 77% of all military? i wasn't quite sure. >> that's traumatic brain injury, 77% are concussions, mild tbis. >> i got you. okay.

can you tell us more about the sideline imaging work that you're doing? is this practical? is this something we can expect to see rolled out to sidelines across america to diagnose for athletes and on to battle fields to diagnose our warriors? >> i think it's possible. we published a paper just this last year in 2013 where we took one of our eg systems and recorded on the sidelines of a field. the biggest challenge for us in making a practical is to get the processing time down. at this point takes us an hour. if we can get it down to five minutes, then i think we can sell it to the coaches. they're the ones that are going to determine. and i guess at this point given all the other issues -- the common tests are 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 two days post injury. that's our big problem. doesn't predict recovery time, severity of the injury and so on. so these buy you markers that we are talking about are the critical things that we're hoping are going to be much more reliable. and more predict up. >> thank you. >> thank you. generally this would end. but we all have so many questions. we're actually going to do a second round and plus the bells aren't going to go off for at least another seven minutes. and jan does have a conflict and she has given us approval that she's going to leave but she trusts us to ask legitimate questions. >> but let me just really thank this panel, the previous panel as well, but the intensity of

the scientific research and then the application to the playing field and actually so many other fields, i really want to thank you for telling us what's going on. and i also did want to thank ian heaton for coming here today. i think it's important to have people like brianna 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'll have to figure out where it leads us. but it certainly has informed us. thank you. >> i would agree with every word of that. so this is a question to you, dr. molfese and dr. shenton and it dovetails into what the gentleman from mississippi was talking about, as well. are the symptoms of a concussion

or tbi uniform enough so that it's possible for early detection or developing a checklist for a coach or a parent to be used, you know, by nonmedical? >> no. >> well, that was easy. >> the symptoms overlap with depression and ptsd and that's 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's a real disservice. it used to be people would claim that when people came in complaining that they still had symptoms from hitting their heads, 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's 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. that's 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. i think we're moving in that direction. that's what we need as the hard evidence because the symptoms are too nonspecific. >> dr. molfese? >> there are a studies looking at the number of symptoms and a wide variety of symptoms people report. there's no data that indicates whether somebody reports lots of symptoms versus a few symptoms, that that has any relation to how long they're going to recover, how serious the injury is, how great the impairment is, unfortunately. >> can we get to a point where a

seventh grade coach, the seventh grader takes a big hit, that there's a checklist, per se, that the coach can use to determine if that kid should go back into the game? >> 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 if 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. not to mention further significant concussion that's going to take longer to recover. >> all right. so this one is for dr. johnston and dr. gioia. one of the debates occurring in the state of nebraska right now is you have a child or a high school student that suffers a concussion during a game. so it's been diagnosed. what do you do next?

right now the thought is you keep them home or her home, dark, no electronics. that's kind of the norm. there's a discussion whether that's appropriate or not. or to what length. what do you know? what would you recommend? >> well, i will tell you about how we handle things in alabama and i think a lot is based on the cdc guidelines which is once an athlete is diagnosed they're removed from the field of play and then they are evaluated. we use the scat, a sideline based assessment and use it afterwards as well. it has a mini inventory of neurological exam and function. when children have symptoms that persist, obviously they don't return to any sort of play or escalation of activity fl their symptoms have completely resolved. those children who have symptoms

lasting beyond the two weeks are then referred to neuropsychologists like dr dr. gioia and our traumatic brain programs. >> you recommend dr. gioia? >> yes. it comes to what's 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, little bit longer if there's more severe number of symptoms, is that they really reduce their activity, cognitive and physical. but what you want to be doing is increase the activity over time. we don't black box kids until they're asymptomatic. that has a lot of likely negative effects on kids obviously being removed. what we do is initially shut them down, restrict them, and gradually start to bring them back to school and physical activity.

but that has to be individualized based on the severity of the symptom presentation. that's where we are right now. we need a whole lot of research to help validate that. >> thank you. mr. lance? gentleman from missouri gets to ask another question. mississippi. i thought you were billy long. >> that hurt. that hurt. thank you, mr. chairman. and a couple of questions that i would have. one would be if we're looking at this -- doctor, if the i may ask a question? >> yes, sir. >> in your testimony you state that football players at the elite levels are shedding equipment to increase speed and mobility. >> yes. >> but the decision of which helmet to wear is their own and that player often chooses a helmet's looks, shape, feel, over its collision cushioning ability or safety features.

do some physicians require different levels of cushioning? would you recommend a specific helmet? >> that's 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 a lineman where you typically get no severe hits but a lot of subconcussive blows, that horse collar is crucial. i wouldn't recommend that a whiteout wear a horse collar. that would affect the quality of the play. it's an interesting point because certainly some players might tend -- this is why i'm an advocate for the hits system.

it will give us much more detailed information about what positions get hit where. one could envision if we have a large database then improving helmet design to react to the information that we got from that kind of information. >> 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 for for that research? >> unfortunately that was not an issue that our committee looked at nor would we have the resources to pull it out. clearly you can identify some research 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.

>> i appreciate everybody being here. it's a very important issue. we love our children going through sports. we love to watch it. and we don't want anybody being hurt that shouldn't be hurt. so hopefully this increased focus will lead to better research, better safety equipment, detection and of course, prevention. so thank you so much. i yield back. >> thank you. the gentleman from mississippi. and i just want to thank. this was a truly 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. it's called a written question. we have about 14 days to write those and submit them to you and i would appreciate a couple of weeks.

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. i just again want to thank you for coming out and providing some very, very valuable testimony for us. and we are adjourned. jay rockefeller is retiring after 30 years in the u.s. senate. tonight at 9:00 p.m. on c-span, a memorial service for president reagan's press secretary, jasms brady. saturday night 9:00 p.m. eastern, former secretary of state colin powell talks about world affairs. and stund evening at 8:00 on "q&action," robert tinberg talks about how as a marine in jeet

vietnam a land mine explosion nearly killed him and change his life. tonight at 8:00 on c-span2, ralph nader calls for an alliance between parties to take on the issues that plague america. saturday night at 10:00, surgeon and author on why he feels medical science should be doing more for the aging and dying. sunday just after 7:00, naomi kline on free-market capitalism and its impact on climate change. tonight at 8:00 on "american history tv" on c-span3, curator and director of the cia museum in virginia, tony hily, explains the museum's mission of preserving and presenting the agency's history. saturday at 8:00 p.m. eastern, the king george's war of the 1740s. how it helped the american columnists establish regional identities and gain valuable fighting experience for their own revolution. and sunday night on the presidency at 8:00 p.m., president ford's congressional testimony on the nixon pardon. find our television schedule at

c-span.org and let us know what you think about the programs you're watching. call us at 202-626-3400. e-mail us at comments@c-span.org or send us a tweet at c-sp c-span #comments. like us on facebook. follow us on twitter. jay rockefeller is retiring after 30 years in the u.s. senate. he's a democrat, but republican congresswoman shelly moore capato is believed to have the edge many the open senate race against west virginia's democratic secretary of state natalie tenet. they debated earlier this week. >> would you vote again today to repeal aca which would mean those 160,000 west virginians would lose their insurance? >> i would vote for is to repeal and replace. i voted for that 50 times. but i also recognized that the aca has some very good things about it. first of all, making sure people

don't get cut off their insurance a for pre-existing condition. absolutely for that. was for that before the president decided to take it into in a larger and much more detrimental direction. i believe keeping our students on until they're 26. i think that's a good thing. so there are good things. so we need to keep what's good, replace it with what will work. get rid of a business mandate. make sure our businesses are not having a 30% increase in their premiums, which we're seeing. 7,000 west virginians have lost their health care plan, because, remember the president, who i'll remind you my opponent supported and supports his policies and his health care policies, said if you like your health care plan, you can keep it period. well, that didn't work out so well. so it was sold a bill of goods basically. we're hearing people who are losing their physicians, whose deductibles have gone into the thousands of dollars. it's unaffordable.

were things wrong? yes, with the health care system, i wish we'd worked together. i wish we'd worked in a bipartisan way to find a way to keep folks who are on insurance now, the 140,000 medicaid, we want to keep them insured because that's important to us not just to them, but it's important to us as a state. >> secretary tenet, your response? >> well, there she goes again. i wish -- she says one thing and votes another way. she says she's for all of these things in the aca, but yet she has voted to repeal it. i won't vote to repeal it. because i know what it's like to go without health care. my daughter delaney had open heart surgery when she was a week old. many folks across west virginia prayed for her, and those prayers were answered because that surgery saved her life. she's a healthy, happy 12-year-old right now. but when my husband and i started our small business, we wanted to buy insurance. so he called