you're going to say anyways. joined by my colleague and ranking member representative pallone. dr. mike burgess of texas. any other members here yet? we'll introduce them as they come. let me start off with a brief opening statement to set the tone here. i want to thank you all for being here for the roundtable called evaluating the state of concussion research. we're here today because a lot of people are paying attention to the issue of concussions. there's a new movie some of you may have seen called "concussion" getting a lot of attention bringing there into the public eye. we have mounting evidence regarding the prevalence of concussions in sports and military and the population. we know most don't even occur in sports and the military. but from parents and patients to athletes and service members, people are worried. they hear more and more about the dangers, the potential long-term effects and want to know if they or family members are at risk. that has not always been the

case. less than dow decades ago, concussions were barely a blip on the national radar screen. whether you got hit by a pitch, or got hit by a charge, they say you got your bell rung or no big deal type of injury. i remember playing football, you got knocked down on the field, they waved ammonia in front of you and you finished the play. now we've come a long way from the tough it out attitude of the not toot distant past. now the public is concerned and looking for answers. children bump their heads all the time. where do you draw the line between the boo-boo and going to the er. is it safe to play contact sports. >> is my memory loss due to six years of high school and college football or something else that wasn't me. i didn't play college football. are my mood swings the result of post traumatic stress or somehow tied to train og or perhaps that car accident that took place ten years ago? it's a good thing we're asking these questions. as we sit here today, we do not yet have all the answers.

therein lays the challenge. the public wants answers that the science is not ready 0 provide. so we deal with the challenges of misapprehension and the fear of what we don't understand. the need for greater clarity regarding the science of concussion and brain injury is of utmost importance. it accounted for 2.5 million emergency room visits. they're not limited to athletic fields. nearly 40% of all documented cases are attributed to false, 14% to motor vehicle accidents and an those aged 65 and older have the highest incidence of related death. ed to we begin a new chapter in the national dialogue on concussions and not here to relitigate past actions or cast blame. we're here to take a step back to gain perspective and begin a conversation focused on solutions, not on problems.

we're joined by experts in this field. this is i a wonderful opportunity for the members to sit back and learn from these individuals and their decades of experience. they're hear here to help educate members and the public about the state of science on concussions. what do we know? what are the gaps? how do we address those gasp to achieve a meaningful short and long-term solution. we're here today also to make one thing clear. this is not just a sports or military issue. this is a public elt issue. every year, millions of americans not playing sports and not serving in the military suffer concussions. it can happen to anyone anytime anywhere. some recover with no effects. others will have debilitating symptoms. why the difference? we want to know. that is why we're here today. though the path may be longing to provide the public the answers we deserve, we'll begin with a brief presentation from dr. balder from the cdc who employ a previous introduction

of concussions and overview what we know about their injuries and information to provide a baseline for this conversation. we'll then put forward a series of broad questions to our prans. the questions focus on these four teams. one, prominent misconceptions or facts about concussions. two, knowledge gasp in our understanding of concussions. three, specific objectives that will lead to meaningful progress in minimizing the risk of concussions and four, obstacles to achieving those objectives including coordination within the research community. these questions are intended to guide the conversation among our participants to provide us as members the opportunity to listen and learn from these. obviously members are welcome to ask questions and join the discussion. we can keep a queue on that. it's not going to be formal like a hearing but just let us know if you have a question. we'll keep track of that. assuming we have time at the end, we'll have more questions and answer with the panelists to cover any outstanding areas of interest. i'd like like to thank ranking

member degette on this. so your wish is granted. and both of our wish. now recognize you. >> thanks a lot, mr. chairman, for there roundtable. sometimes it seems like the format is a little unwieldy. but as chairman upton will tell you, we did a lot of these when we worked on our 21st century cures initiative. it was a good way to get a lot of information packed into one afternoon. i also want to thank the panel of expert who have come today to talk to us about the importance of concussions and head trauma. understanding the effects of impacts to the head and how to prevent, diagnose and treat injury that results from trauch ma is critical to the various segments of our society from, military to sports leagues to parents of young athletes all around the country. given the quality of the panelists today and the diversity of opinions, i believe

we have the opportunity for a lively discussion. i hope today's event as has been communicated to us at the staff level is the beginning of a serious of discussions and hearings on there topic. i think targeted and structured discussions on this matter would be useful as we start to think about what congress's role is. as we move toward, the hearing process will provide us with important organizational tools and structure. and i don't think the most important thing is that people be under oath but i think it does help to have testimony in the record. you know, ten years ago, not much attention was paid to concussions as you said. as we learn more and more about the potential short and long-term effects of concussive and sub concussive hits, our constituents have many questions and concerns, particularly about their children, their children's involvement in contact sports. young athletes may be

particularly at risk of lasting brain damage due to respective hits even when those hits don't rise to the level of a concussion. studies have shown that young athletes who do not sustain concussions but did experience respective hits to the head exhibited neurological impairment over the course of a single athletic season. additionally according to a recently released study by the mayo clinic in december of last year, about one-third men who played amateur contact sports in their youth displayed evidence of cte pathology. one-third. that number is surprising and it's deeply concerning. it shows that you don't have to have played professional football or hockey to suffer long-term brain damage from contact sports. while we still have not established a prevalence rate for cte, the study strongly suggests that the disease is more prevlt than we originally

thought and frankly not just with those diseases but also with girls' soccer and other diseases affecting both girls and boys. now, i understand that as in any such scientific endeavor, there may be disagreement and uncertainty regarding what we know or what policy actions we should take against the backdrop of that knowledge. but uncertainty does not excuse inaction. i'm interested in to hear from our panelists today about what actions we should take right now and then how we need to move forward in our continuing investigation. now, i'm going to say as the congresswoman for world champion denver broncos, you know i had to say it, and somebody whose family has been lifelong season ticket owners, and also somebody who graduated from a division hockey 1 school and now represents one, the university of denver, we love playing and watching contact sports.

we appreciate the fitness and the other benefits of the activities. but at the same time, the head injuries associated with some of these activities appear to have consequences that are long-term, irreversible and even deadly. therefore, if there are ways to make these activities safer, not just for our kids but also for professional athletes, we need to make sure they're being implemented. in other words, mr. chairman, we want it all. we want to enjoy the thrill of being a fan or a participant but with the confidence that as much as being possible to inform players of the health risks and to minimize the risks that are associated with contact sports. so thank you very much for recognizing me. i know we have a lot to discuss and many voices to hear from. and i'm glad that we're kicking off this effort. i yield back. >> so to speak. >> that's right. >> i noticed the kickoff line has been moved back. fred upton, the chairman i

recognize. >> i have a long statement. it's not too long but i'm not going to read it because i want to get to the business of the day. i appreciate everyone being here. i think we've learned a lot. we have a lot more to learn. but primarily, this is to listen. this is why the format's a little bit different than normal and it is, i understand that my friend mr. pallone has a letter for me. i look forward to working in a continuous base to have hearings and this is not the first step. and i know that we're all truly very interested in this. i intend to make sure that that happens. i just want to quickly say that i visited with my trauma center in kalamazoo, michigan a couple weeks ago in february at bronson hospital. and one of the quotes that we took down what is, is this what we have identified as simple concussions are not quite as simple as they seem to be. that underscores what we're facing. we want to learn more. we want to listen and i yield back. thank you. >> mr. pallone, ranking member of the full committee. >> thank you. i just wanted to thank all of

our participants for joining us today. concussions are a critical public health issue affecting millions of people each year. we have strong indications that the effects of repeated brain trauma even those reby received during youth can accumulate with consequences that are long-term and even life-threatening. these consequences can s.t.e.m. from injuries once considered minor known as sub concussive hits. athletes exhibit evidence of significant brain daniel to hits to the head even when they don't suffer concussions. the group of a group of researchers out of purdue university found significant structural changes tos the brains of high school football not have the concussion diagnosis. these changes persisted 12 months later suggests long-term dang. sub con susive hits and significant changes in brain

chemistry decrease brain functioning, behavioral changes and the release of biochemical markers linked to brain damage. researchers have found evidence of the linkage between head impacts and the disease known as cte. cte is a devastating disease associated with memory loss, confusion, impaired judgment, depression and eventually dementia. i'm honored to welcome dr. ann micheel from boston university. she and her colleagues from the university have been conducting ground breaking research into understanding and defining cte. they've examined the brain tissue of dozens of deceased former nfl players as well as individuals playing football at the collegiate and even law school levels. they've discover odd the presence of cte in sleets as young as 25 and many adults who played football since they were kids and confirmed that cte is a unique disease with a unique signature and the work culminated in a broad consensus defining the characteristics of cte.

it's unfortunate her work has been questioned by those who have a vested interest in maintaining the status quo. i understand the unwillingness to acknowledge the linkage between contact sports and brain damage. it's what we call an inconvenient truth that some of our great national pasttimes the sports we love our chin play every day may cause significant and lasting brain damage. but it is time to accept the mounting evidence that there's a linkage between head impacts and damage and there's time to do something about it. while research still needs to be done, this should not be an excuse for inaction. we should be examining not only the state of the science but also looking to how we can apply what we know right now to protect our servicemen and women, athletes and kids. as we explore the state of the science at our roundtable, i hope our focus today is on finding a path forward. i hope that our discussion will not serve to cause confusion or obscure the scientific consensus around repetitive head trauma and the dangers that it poses.

i'm also pleased that chairman upton and chairman murphy agreed to invite lisa mchale here today. she is not only the director of family relations for the concussion legacy foundation, which does truly critical work in advancing the science of concussions and cte, but she's also the wife of former tampa bay buccaneer tom mchale who had cte. it's especially valuable to hear from her about her experience with cte, her experience and the experiences of others like her must inform the research agenda and the path forward to address this is disease. so let me say chairman upton, let me conclude my remarks by suggesting respectfully and you mentioned it already that while this roundtable is a valuable start to our work, we should see it as that, a start. we need to hold hearings on the subject given the gravity of this topic and the number of lives it affects an informal process i don't think is sufficient. you mentioned, chairman upton that i'm sending you a letter before i even mentioned it.

and asking that we jointly expand the complete's exploration of the cause us, effects, treatment and preventions and concussions. i mentioned in. the letter proposal for a series of four committee hearings that would give concussions and sports related ahead trauma the attention they deserve as critical public health issues and hope we can work together and find a way to plan future hearings. thank you again to all of our participants and thank chairman upton and chairman murphy and my colleague ranking member degette for putting this together. this forum is only the beginning. and i think we can work together to find best ways to address this significant public health issue. thanks again. >> thank you. i want to mention some of the members that are here then. you already met chairman of the full committee fred upton of michigan, joe pitts of pennsylvania, the chairman of the health subcommittee, dr. michael burgess is also on the subcommittee on

manufacturing and richard hudson of north carolina across here. paul tonka of new york. dr. layer bu salon is here with us today. there's jean green, the ranking member of the health subcommittee. you met frank pallone of new jersey and diana degette. let me try and i won't read your full bios. it's clear that when i said before the sum total of your experience is decades, i think it's in the centuries. let me run through some of these things. these are not in any particular order. so captain and dr. mike colson, fis and director of the defense centers of excellence for traumatic brain jir. thank you for being here. dr. walter core sheets, the director confident national disorders from nih. i'm sorry, i didn't see you. dr. grant baldwin, director at the national center for injury prevention and centers fordyce

control and prevention. jeff miller, national football league. where is jeff? hi. brian len line. did i say that right? chief medical director of the ncaa and clinical professor of neurology at end university school of medicine, good luck in the march madness, indiana. you're in the same general bracket as pitt. i don't know if we'll see each other. but we'll see. >> dr. jeff manly, double doctor, chief of neurosurgery and professor of neurosurgery at the university of california, san francisco. nice to have you here. dr. michael mccray, professor of neurosurgery and director of brain junior research at the medical college of wisconsin and milwaukee, wa milwaukee, wisconsin.

david see fut? a virginia commonwealth university. m.d. professor and chairman, department of physical medicine and rehabilitation, chief of physical medicine for the vcu held system and founding center for rehab sciences and engineering. dr. mickey collins,m icky. a university much pug medical center. director of the sports concussion program. gerard goyia, children's national chief of neuroschooling and director of the safe concussion outcome recovery and education score program at children's national health system. colonel dallas heck. we've met before. a consultant recently retired from the military where he directed a research program from 2008 to 2014, currently consulting a number of organizations including ncaa and one mind.

to advance research on brain health and transition progress to improve clinical practice. ann mckie, welcome. professor of neurology and pathology, director of neuropathology core, alzheimer's director. is that care or core. >> core. >> and lisa mick hale, director of family relations concussion legacy foundation. thank you al. so people are aware, the format here is going to be a discussion. let me do this. i recognize that many of the you here as scientists may know each other by papers you've read, maybe some of you have met in discussions before. we and the want this to be an open discussion. i'm going to throw out an initial question. it will be a tossup. if it's something that you know about, want to comment on, please do. recognize we're limited. we have a time later on. if it's an area you can add more to, add more. part of this is there are differences in the science.

we want to hear there. as members have comments and questions, we're trying to keep members' questions just to keep the discussion going forward, we won't be giving speeches today other than that. let me do the first tossup here. but beak, first, we're going to have the cdc. dr. baldwin is going to set this up so people have that baseline information. >> great, thank you very much. i want to thank chairman upton and representatives murphy and degette and other members of this complete for your commitment to address concussions as a press diagnose public health issue often referred to as i sue silent epidem epidemic. i'd like to thank the task force especially the coshares who have been chams of prevention for many years. my job is to help set the stage to provide an overview. traumatic brain injuries including sharing the latest data on the burden to americans. in the press release announcing

this roundtable, the chairman noted there's a lot we don't know the about led trauma pla. how it affects different subsets of the population, the short and long-term effects and other critical details. she's right. that's why i want to highlight the proposed national concussion surveillance efforts system and our efforts to help fill these data gaps. in our minds, it's one of the paths forward. so no one ever wants to hear or imagine that a family member or friends has suffered a traumatic brain injury. unfortunately, these serious injuries which are caused by a bump, blow, or jolt to the head are far too common. tbis can occur in various ways ranging from a car crash, a fall in a bathtub or on the stairs, colliding with another player in a soccer game, an assault or suicide attempt or on the battlefield in a military conflict like we've seen in iraq and afghanistan. the severity of a tbi may range from mild to severe. the greater the severity of the injury, the greater the likelihood of long-term and

life-changing disability or death. most who suffer a concussion recover within a week or two. for some, symptoms can last for several weeks, months or even longer. the prospect of a full recovery is threat anyoned if you return to play, school or work too soon or frankly sustain another concussion. tbis are a leading cause of injury related death and days ability in the united states. they're preventable. in one year, alone, as was mentioned there were at least 2.5 million emergency department visits, hospitalizations or deaths related to a tbi in the u.s. either alone or in combination with other injuries. broken down, that means in our two hours together today, there will be about 500 tbi related emergency department visits, 64 tbi related hospitalizations and 11 deaths. and this may be a significant underestimate of the burd. . a recent study from the children's hospital of philadelphia found that among their pediatric population,

almost 90% are presenting in urgent care facilities or primary care set ppgs these are outside of the scope of our current data catchment abilities. and finally, tbis are costly. unrecent estimate suggested they result in medical and work loss costs of $141 billion annually. there were about 451,000 sports and recreation al related tbi visits made to emergency departments across the united states in 2012. approximately 70% of these or 325,000 were reported among the youngest americans those 0 to 19 years old. the leading cause kafz sports and recreational related con kugsz include bicycling football, basketball, playground activities and soccer. in 2013, the institute of medicine highlighted concussion occurring in youth sports and made important recommendations including to cdc about the need

to better understand and address the problem. one recommendation called upon the cdc do establish and oversee a national surveillance system to accurately determine the incidence of sports related concussions can among youth 5 to 21 years old. generating these data is difficult because of limitations in current middleweight odds. our current systems do not capture concussions that occur outside of organized sports or those not seen in an emergency department. they also do not document use of protective equipment, the position played like offensive or defensive lineman in football and the surface used for the field of play. and finally, there's no record of concussion history or a person's long-term recovery. so after doing an environmental scan and consulting with experts including a few of the people on the panel today, cdc is proposing a new random digit dial national household survey that will surveil all causes of concussion in all ages across the life span. it's no more onerous to keep

there -- checklist actually events would be categorized. depending upon -- and outcomes

from infancy to old age and improve implementation of evidence based prevention strategies across the causes of tbi across the life span. partnerships are essential to achieving goals and the

diversity of partners and perspectives assembled here are so critical to meeting shared interests in reducing the burden of tbi. thank you for the invitation today. and i look forward to today's discussion. >> thank you. we're going to open he this up and ask a things. thank you. welcome here. i want to show you this poster i saw today on the metro when coming here. this is a picture of it looks pretty begyne. it's a fishing boat advertising for the florida keys. if you read the caption, it says more fights than a capital penguins game. isn't that interesting. where is the sport involved here? if this is what we're looking for and concussions involved with that. you don't have to be a player to have a concussion. remember this picture where all the fans are cowering. that one man put his arm out and prevented a young boy who was there looking -- that was his own son? that prevented his son from getting injured. so we prevent concussions, too.

but in the course of this, other than sports, let me throw this out as a question. join me, mr. collins of new york. what are the most under-appreciated facts about concussions? >> i'm going to turn over to the doctor. you didn't know you were going to get called on first, but i want to ask you, are there some under-appreciated facts or misconceptions that we need to know about right at the onset? if other scientists want to say something, we will call on you. yeah, you have to have the microphone close to you and turn it on. >> sure, thanks very much. pleasure to start off here and open the conversation. misperceptions, i think there are many. i think there are, unfortunately, fueled by lack of knowledge. and i think it's important to think about concussion as part of the spectrum of traumatic brain injury.

i think this was mentioned already, that traumatic brain injury goes from the mild to the severe, and it's not as though there are distinguishing cutoffs between those, in that progression of the stage. so it is a type of traumatic brain injury. the other misconception -- which i'm not sure everybody agrees with -- used to be said with a concussion if you looked in the brain, you would not see anything. i think that's not true. i think with modern evidence and the ability to use with microscopes into the brain at the time of a concussion in an animal, there is a symphony orchestra of changes that are occurring in the concussive event. so i think the bliology of concussion, it is not well known but i think that we will learn a lot more over time. so is it's not a purely functional abnormality. there is a lot going on in the

brain during these -- during a concussion. the other one which was already mentioned which was 20 years ago people would take a sniff of ammonia, go back out and play. now it is recognized pretty widely that that's not the case. so thanks to the cdc work, the work of multiple other groups like the academy of neurology's guidelines committee, put out guidelines for return to sports. i think those have been taken up by coaches around the country. and i think that's really been important. one thing i'm not sure about is the idea that we don't know enough to counsel parents. we do know that it is this repetitive concussion that gets the kids in trouble, that is -- that the initial concussion is often times -- it can be bad, for sure, because there is this spectrum of head injury. but the kids that i've seen and heard about that run into trouble. first concussion they're bad a couple days. second one a couple weeks. third one a couple months. then it's pretty clear what the

story is. so i think getting that out is very important. it is a very tough thing for the parents and kids, especially when there is this huge allegiance to the identity of the person in sports to give up and take themselves out of contention there. but i think those are the few things i throw out to begin with. >> you want to add a question to that? [ inaudible ] [ no audio ] >> fred, get that mike a little closer. >> i'm sorry. my daughter was playing baseball in high school senior year and she was hit by the baseball directly in the head. she suffered a concussion. basically they said, you know, we don't want you to play again because if it happens again, you're going to have a serious problem. she went to college. she is a freshman in college now and a couple times -- well, at least once had a fainting --

fainted when she was in college. but she doesn't play any sports anymore because of what they said. now i mean in some ways it is fortunate because she had the concussion, now we've been told don't play sports -- i mean don't play contact sports. you can jog -- she jogs -- but don't play contact sports. but if she had one of these subconcussive hits, as you talked about the spectrum, my concern is you don't necessarily know about it. so i'm lucky now because she knows she's not supposed to do anything more. but if you had one of these things, how would you even know? in other words, you talk about this spectrum, but it seems like we're hearing more and more -- at least i'm hearing as a parent more and more that anything can cause damage. like she's told not to play at all. i wouldn't want her to have a second or third concussion. but if you could just tell me about that.

the spectrum and the subconcussive. how does that relate to this spectrum that you mentioned? >> sure. so i think that the terminology is a little bit at risk here. it depends on how you think of it. concussion was initially -- people thought of it as someone lost consciousness. now that kind of went by the wayside. now it is a change that's really recognized at the time of injury, there is a change in neurological function. and that is without loss of consciousness. but i think if you move back even more, there are changes in neurologic function that no one would recognize unless they were tested. so the ability to actually test the person is one of the limiting factors. so in these subconcussive events, i would think -- this is a hypothesis, one could study those folks and see that there is a change over time.

maybe some of the other folks could comment on that. but there have been studies in college football players. >> do you want to comment? >> i have nothing but the ultimate respect for everybody on the panel. but there are some of us who have taken care of concussions for 25 years, i've taken care of 20,000 people with brain injury. i provide the care for an nhl team on concussions. the sky is not falling. you should return to activity within a day or two of a concussion. not contact sports. being in a dark room resting, staying at home is not the treatment for injury. in any level, including concussions. i've had six in my life. i was a terrible athlete. all right? i wasn't stopped. but there really isn't science that supports people shouldn't play sports after a concussion. it is really bad for our youth, it is bad for our professional athletes, it is bad for everyone involved to spread that belief. we need way more research.

i'm involved with all of these folks in a lot of research. but really, there is no science that says don't play sports after a concussion. >> what about a series of concussions? can you talk about that? >> sure. you get one concussion. first of all, it needs to be identified. it is extremely easy to identify an acute concussion that just occurred. anybody in this room could do it. it is very hard to use a survey to assess it even a week or two afterwards. months afterwards? just about impossible. i run tbi care for the va system and help set that up and in doing the research in the va for that. it's really hard to do after the fact. you have one. it's assessed. you make a diagnosis. that person gets back to activity a day or two. all right? doesn't play sports, but gets back to activity. gets back to school. they're at risk to get another concussion for the first several weeks, months, years even. but we're all at risk to fall down and to be in front of a bus.

you're at much higher risk to get fat, to get heart disease, to get psychological problems if you don't go back -- >> tim, i just wanted from my own experience. she was hit in the face. she was told not to go to school. >> i know, it's wrong. it's wrong. >> -- for the next six weeks. only reason we graduated was -- she graduated was because they let her do things after. >> she should have been activated quicker. >> i she was definitely told no contact sports again, and if it happened a second time, she -- >> i know. we need to stop that. >> how many of you think after a person's had initial concussion, whatever its causes, that they should return to activity fairly quickly? is there anyone who -- [ inaudible ] >> after a single concussion? >> what about multiples? >> dr. collins, i've been to your clinic. you pointed out to me that used to be you stayed in the dark, didn't do anything for long periods of time. you've done a lot of research in this area. any comment in terms of what -- that is a myth that we need to dispel? >> i agree wholeheartedly with

dr. cidu's comments. the sky isn't falling. we made tremendous progress in terms of treatment of this injury. we're starting to identify different subtypes of concussion and matching certain treatments to these different clinical profiles. though we need much more prospective research to understand the timing and dosing of treatments, we collectively met recently in pittsburgh and agree that concussion is a treatable injury. with all respect, i agree with dr. cifu's comments regarding your daughter. i think that what we don't want to do is -- the pendulum has swung from here to here very rapidly as we've all alluded to. the truth is probably in between somewhere in terms of the fact it's worse than what we thought it was, but it is not as bad as what it is being made out to be. and the advances we've made in treatment are significant. i would suggest it's never been safer to have a concussion than it is right now because of the advances that have been made from a treatment perspective. we're starting to learn that active approaches at management

and treatment are much more efficacious than sitting in a dark room. i treat a lot of problems from that philosophy of putting kids in a dark room in terms of chronic anxiety, chronic migraine, i've seen kids who are suicidal. extensive suicidal ideeation from that type of treatment. i think we need to propagate the fact that we've made tremendous advance in how we access, diagnose, treat, and yes, get them back to sports safely. >> isn't it somewhat individualized? >> you had a question on this part? >> my question is going to be a little different. so you want -- >> dr. mccray? >> i want to make a more i guess general background commentary and say that this is probably a familiar story in medical research. concussion has gone, as many people in this room know, has gone truly from total on

-- obscurity, 10 or 20 years ago, to now, in a sports setting and to a large extent in the military sector, dominating the national narrative. and the unfortunate position we're in currently i think is we've reached that awkward stage of maturity, call it adolescence, that we've made enormous strides over the last 20 years that puts us in a position to have this discussion today. but at the same time, the topic has been elevated in to the public spotlight such that all the stakeholders, including sports parents, assume we already know the answers to all the critical questions and they want those answers now. and there's perhaps no more unenviable position for a scientist to be in than to have to catch up with the public narrative. i think we've made great strides in changing how we take care of athletes on the sideline and during the ensuing days.

as micky pointed out with treatment regimens, rate of exertion, the expression we often use in our program is that concussion, particularly in a sporting environment, used to be managed on a switch. the day you were symptom-free, or as our data pointed out several years ago, several days prior to being symptom-free, the switch was flipped and you returned to full-contact activity, whatever the sport might be. we've learned a lot over the years about the natural time course of recovery clinically and we now manage athletes on a dial. as david pointed out. we don't flip the switch the day they're symptom-free. we introduce low-grade, no-risk activity, under a period with no exposure to contact. we allow that athlete to go through stages of

rehabilitation, acclimate, reach a point where they are completely symptom-free and return to activity when they are safe to do so from a clinical recovery standpoint. we have data from the recent carry study, carrying our outcomes and reduction of repeat injuries in the same concussion. in 2014 and 2015 to 1999 the first ncaa concussion study. in our early studies more than 90% of our same-season repeat concussions occurred within the first ten days of the first concussion. in the current study there is a 0% incidence of repeat concussion in the first ten days and the average interval for those small number of same-season repeat concussions is 75 days instead of five days. so the work by a lot of people in the room here has had a direct translational impact on how we take care of athletes and military service members and people in our level 1 trauma centers to protect them from the risks. as walter pointed out, we're just scratching the surface. we know very little about the

underlying neuro biology of this injury. as odd as it sounds, we know a lot about how long it takes for the individual to tell us that they're completely symptom-free, or recovered, but we know very little about how long it takes for the brain to recover. ultimately we'd like to know the answers to those critical questions about underlying path of physiology and recovery at a brain level to make prevention based decisions about return to activity. >> thanks. dr. joy, you had a comment on that? >> yeah, i just want to -- what dr. mccray is referring to is, basically the research knowledge we've currently acquired, mostly with males, adolescent and young adults, not as applied to girls, not as applied to younger children. so we are making some leaps of faith in terms of how we apply this to younger kids that we've got to have better evidence to know. i mean i think the simple answer -- or simple question that is often asked by any parent is when should i allow my child to do, x, y, z risk activity.

we don't have those answers yet. at the same time, we also know that we want kids to be active, we know of all the benefits that have already been discussed about sports on so many levels. and so the application of our knowledge to kids, granted, we have to be more cautious. no doubt about that. but some of it may or may not be appropriate. and it appears that girls do have both different risks and different trajectories of recovery that we have to better understand because there may be a different biological, a different psychological, a different biomechanical response to forces that have to be understood. the same goes with younger children as well. so there is the perception that we, number one, know a lot more about this injury than we do. but i can tell you that the knowledge is at its lowest with younger kids. >> dr. manley. >> thank you very much. i'd first like to bring this conversation back to some of

your comments, representative murphy, which is that tbi affects more than just athletes. this is really as highlighted in your brief here the tip of the pyramid and that we look at the athletes, we look at the military personnel. but as our colleague from the cdc just pointed out there is at least 2.5 million people a year coming into emergency rooms with concussion and with more moderate and severe traumatic brain injury. the other issue is that there is at least two million to three million people that never seek out medical care. even when those patients get to the emergency department we have studies that show that over half of them are missed. in our ongoing nih funded study, called track tbi, we're asking patients at two weeks, were you referred for follow-up. these were people actually diagnosed in an emergency department at 11 of the best trauma centers in the country. we found less than half of those patients are actually referred for follow-up. there is a very low bar in terms of following up with things that we know. other misconception is that

we've treated concussion and brain injury as an event and not a process. because we look at it as an event, even as doctors, i've taken care of traumatic brain injury patients for years. we don't routinely follow those patients up, like if you had diabetes, heart disease, or cancer. so the long-term effects are unknown to the medical community. i think now that we look at this more like a disease process and with studies like track tbi and some of the others that are funded we're asking questions that we never asked before even in the medical community and we are finding that not just subconcussive blows but even a single concussion can alter the course of someone's life. applaud the committee for bringing this to the forefront. there's millions of people that are sustaining traumatic brain injuries every year in this country. 5 million people suffer from the aftereffects and we really need to do more for this. so, thank you. >> you agree? >> i just want to point out that i know there is a lot of misconception about cte and concussion. the movie was called

"concussion." it was about cte. but in all our experience we've never seen cte after a single concussion. cte is associated with duration of exposure to repetitive head impacts. cumulative exposure to low-level head injury. so concussions have never correlated with cte. we have seen multiple studies, no correlation with the number of concussions. but we do see very consistently the years of play, the years that an individual is exposed, say playing football, or boxing. that does seem to be associated with the risk for cte. the longer you play at the higher level that you play, the greater the risk. >> thank you, mr. chairman. i appreciate that. i was a surgeon -- heart surgeon before i was in congress. so my question is going to be just to -- about primary

prevention, so to speak, education. and i have four kids all the way from age 23 to age 12. they all play hockey, all play soccer. and i personally played high school in football. i still play hockey. i love the game. you alluded to it a little bit. my question is, a lot of research may be done in adults, but the question is, there's obviously development things going on in youth that may have a different impact on this. people with -- people say the brain's still developing significantly into your 20s. the question i have is what do people think we should be doing in our elementary schools and grade schools really early? i know with currently available information, without shocking people and making parents afraid

for their kids to play, and that said, what is the potential differences of how these things impact youth versus how they impact adults and should we do things maybe differently in youth and adults. >> who wants to respond to that? >> i'm happy to start off the conversation. i'm sure a number of folks will be interested in commenting. i'm on the advisory board for usa football. in a meelth we had several weeks ago, the question was, at what age do we introduce different types of the game to different individuals? again it depends in part on your biomechanics, your physical maturity, psychological maturity. all those kinds of factors. do we teach the game in different ways? american hockey has gone to this development model and a lot of sports are looking at that now as really a model system for matching the person, their

developmental age, and the game, and its particular skills. can we teach, you know, or do we modify checking? do we modify tackling and blocking? do we modify force events in that developmental level cannot sustain it in and i think it's a very important question. we really need to wrap some research around those questions. i think, at this point, though, we can certainly reduce that risk. and by reducing the amount of contact that goes on in these sports, but still teach the game appropriately, so you're not putting somebody into a competitive situation totally unprepared, is really our challenge. it's not a simple answer. certainly some of the work that's been done with the heads up football program is showing reduction in general injuries as well as concussion. we can do more, though. we don't know that answer as to what age do we start these things at? but i think it goes beyond that. look at physical education in school and understand how do we build neck strength, what we

think may be the important kinds of preventative biologic kind of factors. how do we think of introduction of sports at certain ages that somebody is psychologically ready for. for whatever reason, i always loved contact sports. i have a son, that's not his thing. that's okay, be a return, do what you want to do. we need to understand what you are prepared for. again, goes for boys and girls. our bodies are built differently, we need to take that into account as well for different sports. we need some studies done early on developmental biomechanics as it relates to different sports types. >> i'll briefly comment. i also coached hockey, youth hockey, and there's a transition in usa hockey about what level kids can check. used to be fairly young, trying to teach them how to properly check without injuring people was pretty hard. so i can tell you, when people are younger, whether it's

football, whether it's soccer, honestly, or another thing, usa hockey is out front on that pretty well. but it's important. >> doing a good job. >> dr. baldwin will say something first. >> one of cdc's most successful campaigns, heads up, about prevention recognition and management of traumatic brain injury, we've had it around over a decade now. and have reached -- we've distributed over 6 million materials, trained 3 million coaches on concussion prevention, recognition, and management. we've migrated on a focus on parents, coaches, health care professionals, school professionals. the next phase is focused on kids. changing the culture of sports, and so the person that leads the initiative has creative ideas how to bridge into the younger population.

we're going to be coming out with an app in the next few months, a game, rocket blades, going to teach kids about concussion and concussion prevention. one of the tools in the tool chest for us is raising awareness and education and certainly we have tried to do that over a decade now with some of our heads up work. >> i mean, awareness, awareness, awareness. there's ten apps already to teach kids. none are going to be as good as yours. i saw an app in holland last week that's unbelievable to teach kids about concussion. it's fantastic. but without the awareness of the coaches and the parents, it doesn't matter. the kids aren't going to self-report. they might, i don't know. so even if awareness is good, unless we develop health care professionals that actually understand how to reintegrate people back into their lives, we're going to have some really frustrated parents. because we see them all the time. that's who comes to our center and mickey's center. people kept in a closed room, people told don't ever play

sports again, people that didn't take tests for a year. they're more focused on the fear of this amazing organ we have and less concerned about overall wellness. i mean if the kid doesn't go to a fast food place he'll do better than if he gets cared for a concussion. we need to wrap this around total health of these kids, if you really care about them, because it isn't just the concussive force. people have been getting concussions for 3.2 million years if we look at archaeological evidence we're not all demented. so i think it's important that we -- >> cdc will be releasing early next year guidelines for pediatricians for treating -- >> can we see them? can this group see them? >> yes, of course. >> dr. heck, dr. hainline. >> two groups we know the least in concussion, it's in the young and in the old.

i think the old, it's -- they were getting that way anyway, if they fall, hit their head, and actually ones that suffer the most consequence from head injury is the elderly. and they decline rapidly after that, that's another whole population. in the youth, it's a mat, comes -- it comes down to a matter of balance, first of all. it's not -- parents should not be absolutely afraid of a head injury to have kids participating in sports. in terms of teamwork, in terms of exercise, personal development, responsibility, and all of those kinds of things. sports has a valuable contribution to our society. what we need to do, i think, do a better job is in the area of the coaches and the trainers. in the youth, in particular. there are no standards across the board. for anybody in coaching. a lot of times, even at the high

school level, whatever teacher draws the short straw has to coach. and we mentioned in europe, there actually are tougher standards in europe when coaching kids. you actually have to have certification, some training and some actual way that you demonstrate that you've been trained. i think work needs to go on, on that in this country. raising the level, the knowledge of people responsible of those kids as their coaching them. i want to get to one other thing we were talking earlier and i should have mentioned this earlier. this fear about once they have a concussion, there's some black or red mark on them, that they should never participate in sports again. the risk of a -- from a repeat concussion, it depends on a number of factors. the most important one is the time from the previous concussion. one single event doesn't necessarily preclude you from it. it depends on the time of the event and the characteristic of the individual that suffered

that event. >> dr. hainline. then to mr. miller and then the next question from a member. >> thank you. my comments will really be looking at sport as a public health model. and i think there are three things very important that can address the whole culture in the youth sport. one is that all 48 national governing bodies in our country are signatories to the american development model, and it's a unique opportunity working with the usoc and all of the parent organizations to look at sport as a long-term athlete development process and that's currently not happening well enough. but everyone is on board and concussion would be part of that. the second is, and colonel hack made mention to this, to be a coach in the country all you have to do is hold up a shingle and say, i'm a coach, and it's distinctly different than europe where you're required several

hundred hours of sports science specific training. >> i was in california last night, actually, early this morning, addressing this, and this is something that the nca has been involved with, with the national governing bodies that are working with our 23 sports, that we're doing sports specific conferences and bringing into that the whole concept of developing coaching education, but it really has to start at the youth level. and that's something that's exceptionally important. i think there's growing momentum for that. the third is there needs to be someone to protect our kids. that's empowering people such as athletic trainers. the athletic trainers are probably the single-most important person that could be on-site for any sort of contact collision event. it's important even in this country, for example, in the state of california, athletic trainers are not even regulated, so anyone can hold up a shingle and say i'm an athletic trainer or in new york city, 35,000 members of the public school athletic league and there's not one athletic trainer. they're the people that need to

be empowered. we passed legislation, we defined providers as athletic trainers and team physicians. i think if we can get signatories to the american development model, coaches education and empower the athletic trainers, those three things combined will probably do more to shift the safety in youth sport than anything that i know of. >> thank you, mr. chairman. thank you for convening this group. i just want to echo a fair amount of what dr. hainline said. about trainers, a work on the policy and educational initiatives at the nfl. 37% of high schools around the country have a full-time athletic trainer. 63% don't. that's ridiculous. this is the easiest way to protect kids from injuries associated with competitive sports, whether football, which i know is a contact sport, or any other sport. both on prevention and treatment side. when you have kids suffering injuries, including catastrophic

injuries annually by participating in any of these sports, the fact that we can't invest further in public health trainers is something that we have to address. the league have added several hundred trainers in high schools just in the last couple of years and we'll have an announcement on this point again tomorrow. it is a dramatic way absent all of the scientific questions that remain unanswered to improve the public health around sports for both boys and girls in those high school ages. and that's something we're going to continue to work on. let me add, we spent some time a couple years ago, the nfl did, with a number of other supporters around the country, traveling around state to state getting youth concussion laws passed. this came from zachary liestat who suffered traumatic brain injury as a 13-year-old playing football, who was returned to play too soon and suffered catastrophic injuries.

thankfully he survived and is our inspiration. we spent four years getting 50 state laws passed and they're pretty simplistic around identifying an injury and ensuring that a child doesn't return to play. that's not football specific. that's in any sport. but it demonstrates that there's a baseline that can be done from policy and education perspective to raise awareness of people participating in youth sports. more needs to be done in this regard. those laws are n"lun÷ panacea. it's the first time that's been done. i think that might be a model we can talk about as we go forward for improving youth sports. the third point, dr. gioia was humble around usa heads of football program, the design was educate youth coaches as david mentioned. 150,000 coaches have been trained on concussion identification as well as ways to teach the game appropriately, which is essential, of course, in football, when to introduce contact and how to teach tackling. but that's 150,000 coaches representing well more than 1 million kids who three years ago didn't know anything about

concussion. so, these are huge challenges but not insurmountable ones and if the wise group of people here who are far more expert in the science than i would ever be, can think through the science initiatives, you can make progress while harder scientific questions are being addressed. >> burgess, screen, hudson. taking the order you raise your hands. go ahead. >> thank you, mr. chairman. i actually have two questions for mr. miller, then i'd like to ask miss mckee -- sorry, dr. michaela the question. 35 years ago this month roger staubach retired, i recall the press conference. the story around the retirement he suffered a number of concussions that season and somehow determined that he could not tolerate one more concussion or there would be big trouble. i did not know what metric was used, i did not know what test was used but i assumed there was a metric or there was a test

where you could tell that's enough. so in the league today, what is the state-of-the-art, if you will, for someone who has had repetitive episodes of head trauma? >> first, in the particular case of roger staubach, terrific that he's gone on to a terrifically successful post -- he was great in football but his post-football successes have been terrific. the question is a medical question. and with each team physician and in the case of the nfl, we've added unaffiliated doctors in terms of diagnostics of the injuries, unaffiliated doctors on each sideline and further independent experts who have to clear a player before he's allowed to return to play, in addition to the team physician. the standard is whatever the team medical staff in consultation with the unaffiliated independent doctors comes to for that particular individual. there is no concrete answer to that question. for the reasons why, i defer to some of the people around the

table who are going to know more about diagnostic is and treatment and recovery than i do. >> again, that was 36 years ago. i would have expected the science to have advanced more than it has because of the enormous investment that the nfl has at risk, if you will. let me just ask you this, because i did not see the movie, but i did read the book. the description in the book of, i guess what you'd call the index case for chronic traumatic encephalopathy, mike webster, pittsburgh steelers, a case pending for compensation for his long-term injuries. he was eventually awarded compensation three years after his death. so, i guess the question is, is that process better now than it was ten years ago that a player has for applying for benefits from the disability part of the league?

>> yeah, disability benefit question is an important one. i'm sure miss mckee has an answer to this. she does work as an advocate and important work as an advocate for retired players and their families. >> i think the answer is in our most recent cba, most recent collective bargaining agreement, with our players, we allocated an additional billion dollars or so towards retired player programs. that's of course, for those who played in the years before the modern age defined as pre-1993. in addition a number of programs in place for retired player care which includes programs associated with players who may% have been diagnosed with dementia, called the 88 plan, any neuro degenerative disease, parkinson's, without causation, if you received diagnosis -- more than 300 players in the scope of the program received benefits from that. you'll get care on an annual

basis in terms of the payment. >> we'll get into the benefits at some of the future hearings. i wanted to see if we can focus on the scientific things with the concussions. do you have another question in that area? >> let me ask, you obviously have a perspective on this. as i read about this illness, yes, it's devastating for the individual who contracts it but devastating for the family, estrangement from families, there's an ongoing continuum with which the family has to deal. can you give us insight from the family's perspective? >> if i can contribute nothing more today, because i'm not a doctor, but i hope that i can impress upon you all how difficult and tragic a disease this is. not just for the sufferer. i hesitate to think of what they go through, particularly the day when my husband died, he had no idea of what was happening. i think for those that suffer today, at least they have the benefit of knowing there's a neurological cause for what

they're struggling with and probably beat themselves up less than my husband probably did mentally, blaming himself for his failure just to be the man that he had been. but for the family, it's devastating. i can't overstate the capacity for this disease to rip families apart. you know, we've seen, i get, i was just asking dr. mckee if she knows what the total number is, she said around 180, 190. we know all of the families, we know the clinical histories, each and every one of those, donations and individuals who passed away with the devastating disease. very often there are widows or ex-wives, very often ex-wives who feel very guilty for not holding things together. i in all honesty say i'm more surprised when the family's intact than when it's not. you know, i think that there are -- there are some benefits

that the nfl is able to provide to their former players and thank goodness for that. part of the problem with these things is that, even for former players to access them unless things have changed, that i'm unaware of, those players have to be vested which means you have had to play four years in the league. we cannot forget this disease is being diagnosed in people who never played in the nfl for whom there are no benefits, there are no places to turn, both for treatment and compensation in terms where they're going to fund this treatment. i can tell you that families are in very, very dire straits and there are a lot of individuals really, really struggling. >> appreciate your observations. i want to ask you, probably a larger discussion, a year and a half ago the committee got involved in the question of domestic abuse and the national football league and it strikes me, looking at the continuum of this disease that that may be an

aspect of while we focused on that as an issue where the nfl needed to focus, but also perhaps it's an index where it needs to be studied that perhaps there's already a component of chronic, traumatic ensef lop thi that's making itself apparent. >> i would think unfortunately that's very much the case. my husband passed away at 45. he was a very, very different man from the man i had known, but he passed away young, and it's almost -- it's a very strange thing for me to consider that we may have almost gotten off easy because a lot of the families that i speak with do see a lot of ugliness, a lot of scariness. talked to women whose husbands are young as 38 years old coming in and the baby's cries are making him irritable and setting him off, and they're afraid of their own safety and how long -- i think absolutely it's an issue that has to be looked at. and there's a lot of potential. when you think of the areas of

the brain affected that they lack the ability to control impulses, their emotional liability is compromised and you know, this irritability and rage is a volatile combination. i would think absolutely it would be a concern. >> let me ask the captain to discuss that from the military standpoint. similar symptoms in military and suicide rates. move close to the mike. >> absolutely. in d.o.d. one of the things that we struggle with is the way that patients -- >> move close to the mike. >> sorry. the way patients come to us. we're mostly male, 85% male, 18 to 30-year-olds, physically active. the thing is, as a psychiatrist and many people in primary care clinics, we're not seeing people right after they've had a concussion. we're seeing people downstream. as a psychiatrist, i need to tease out con sussive illness,

with ptsd, pain disorder, any number of other things and folks don't just come to you saying i had a concussion and here's what happened. diagnostic clarification is a huge issue. i've heard disability brought up in a couple of places. v.a. schedule has specific items of ptsd but ascertaining the nexus between the insult and what happened downstream is very hard for us. certainly augers policy issues and the like. >> help me understand, though, and i'm discussing this as a fellow navy provider too, that is many of the people who have been diagnosed in the past with ptsd have similar symptoms to what miss mchale is saying. nightmares, troubles in social relationships and realizing a lot of that is from concussions. >> absolutely. it's very, very challenging to ascertain. it's tempting in d.o.d. to use the sports medicine model for prevention and treatment but we can't. we can't do that and meet patients where they are. so a lot more to learn.

as a physician, i have a 2-year-old, he's been walking 300 days and hit his head 300 times. before i tell him to walk it off and rub some dirt in it, i want to say, how can i possibly assess this 2-year-old because he doesn't give me a history. it strikes me that a lot of my patients can't give me a history about what happened, when it happened, what happened downstream and that's why we need to move the research so much. >> i just want to add, because i think we're getting -- mixing a couple of things. there's the issue of a con sussive incident. this is what i was trying to say before. one concussion, how you treat that, when do people go back on to the field or wherever they're going. and the second question is cte question, which is repeated -- and it's not -- i mean it could be repeated concussions but it can also be a long history of repetition for sort of, okay,

i'm not a doctor but sort of subconcussive, you know, i'm not sure we have -- we have scientific data to support all of that. >> let me ask this. take a pause here for identification. i want someone in this room to identify how you -- what you look at in an mri, before i go to you, what you're looking at, p.e.t. scan, tell me what you're looking for. the movie was all about the -- the proteins. can someone describe what you see, what you're looking for? describe that. >> this is not exactly what you like to hear. the problem s we really can't see what we want to see. let me just go make it as simple as i can. in the end stage condition, so in stage iv disease, the brain

is severely degenerated and that will show up on an mri scan as severe atrophy. and the culprit, we think, is aggregation of the tal protein in the nerve cells. and that is the signature of cte, it is also very important in alzheimer's disease, dementia, psp. multiple different diseases with think the tal protein aggregation is a bad actor. now the trouble is, as you move back in time to people who are not severely demented, then it becomes trickier to know what the differences are. so what we have funded is research that will look at the brain because now you can only make the diagnosis in a brain after someone dies, then image those brains for tal or mri signature, and then the next stage, another grant we're

funding, to move into longitudinal study to follow people at risk to find out when the imaging signatures or a syndrome, characteristic clinical syndrome appears we can say this is an accurate diagnosis, if x, y, and z are occurring. that's the situation we're in now. we're really unfortunately stuck with the problem we need to examine the brain to know if somebody has it. >> but we shouldn't shy away -- >> let me finish up. i know you're going to go for a while. i know this guy. so, the problem is, which i think we've got to throw out on the table, we initially -- i don't know about ann, but i thought this was going to be a rare event. we knew it happened in boxers. to find out it happened to people who have 1,000 hits in a season, it's not that much of a revelation. but to find it in people who have high school or college exposures or to find it in a brain bank, doctor, you mentioned the brain bank, look

at the mayo clinic to find it in 30% of people who have played sports, we now don't know how common this is. we don't know whether everyone is going to progress. we doubt it. so we really are desperate to try to figure out a way to diagnose this in people. we have a couple of clues but we have to work those out. >> yeah, there are lots of ways to diagnose early cognitive deficits or early behavior dysfunction. plenty of ways to diagnose acute brain imagery. -- brain injury. they don't involve imaging at the present time and may not in the short term. >> not specific? >> right. we have physical exam. we have psychological testing. physio logic measures, physical eye tracking, and posturology,

which dr. collins is a leader in. plenty of ways to diagnosis. if we believe this sky's falling we need to create a multimodal approach to assessment. it's never going to be a single test. it's never going to be $1,000 mri or dti, it's not in the short term. but we have clinicians that know how to do this. and researchers around the table that can put together and have put together multimodal assessments. that's what mike's research is. that's what my research is. that's what everybody's research is. >> that's not cte. >> for cte as well, absolutely for cte. that's how we diagnose alzheimer's. yes, we can wait until the person expires and look at their brain, or we can look at a late-stage ct or mri scan. researchers are looking at early evidence of dementia, you know. and that does not involve imaging. it involves other testing which we all do. >> i would add there have been a number of points of interests raised i think in the last 10 or 15 minutes that start to converge around a common theme. and the unfortunate reality is the common theme is the lesson we've taken 30 years to learn

and represents the dilemma that we currently face. we have been fascinated with some discovery, some magical discovery of a single solution theory that would explain and predict outcome across individuals. one of the burning questions in the scientific community, it's no wonder that it is in households, the same question is, how can it be two individuals with seemingly the same injury have much different short-term outcomes? and now the narrative has turned to how could it be that two individuals with seemingly very similar exposure profiles have -- lead much drastically different lives? it has to be a complex matrix of input channels that predicts risk. it's not -- this condition short term and long term is far too heterogenus that there's going to be a single predictor

variable. with respect to long-term outcome, the burning question is what are the risks? how prevalent are they? who is at risk and why? what are the factors that predict risk? how could we interrupt or prevent those risks? and it -- the parallel question at the same time is, is exposure or what we oftentimes say how many, meaning number of total concussions or how much total exposure, is it necessary, sufficient or neither or both in predicting long-term risk of neurologic health problems. all of those questions remain largely unanswered. >> i want to make sure everybody has a chance to ask questions. go ahead, jan. >> i'm concerned the nfl has a troubling record of denying and discrediting scientific inquiry into the risks of

playing football. when dr. bennett omalu published evidence of cte in the brain in former player mike webster, nfl doctors went on a commin to discredit and undermine both the doctor and his work. the doctors went so far as to demand retraction of the doctor's peer-reviewed research. for the next 14 years the nfl pursued a strategy vehemently denying the evidence of cte and -- in former players. the league also began producing biased, non-peer-reviewed research. that routine repetitive hits in football are linked to chronic brain damage. the nfl suppressed critical information for current and future players about the long-term health implications of playing tackle football. recently as february 4, 2016, three days before the super bowl, dr. mitchell berger, a

member of the nfl's head, neck, and spine committee, denied there was, a quote, link, unquote, between nfl and cte. dr. berger grudgingly admitted only, quote, can be, unquote, association between football and cte because some former players have developed the disease. to hear an nfl affiliated physician waffle and obfuscate about a basic scientifically established connection is truly astonishing. some may want to claim the league has turned a corner, they may highlight the nfl's rule change and the neurotrauma specialists on the sidelines at every game. they point to funding the nfl has committed toward reducing and managing concussions. i want to ask about that, too. espn said there was some change in that. as laudable as such initiatives

may be, by focusing on concussions, the nfl is peddling a false sense of security. football is a high risk sport because of the routine hits, not just diagnosable concussions. what the american public needs now is honesty about the health risks, clearly more research, the risks inherent in popular sports like football. so i just want to ask what i think is an -- a yes or no question from both dr. miller and dr. mckee. let me ask dr. mckee first. do you think there is a link between football and degenerative brain disorders like cte? i unequivocally think there is a link between playing football and cte. we've seen it 90 out of 94 nfl players whose brains we analyzed, 45 out of 55 college

players and 6 out of 26 high school players. i don't think this represents how common this disease is in the living population. but the fact that over five years, i've been able to accumulate this number of cases in football players, it cannot be rare. in fact, i think we are going to be surprised at how common it is. and the other thing i really want to emphasize in this discussion is it's not about concussions. it's about limiting head injury. head injury that occurs on every single play of the game at every single level of this game. we have to eliminate somehow the cumulative head impacts. we need to have sensors or accelerometers, some way of gauging the number of impacts and limiting them so we can maintain safety for athletes, especially at youth level when they don't intend to make their life about football. we have seen many times, lisa and i, amateur athletes come down with the disease. it's devastating when you see this disease in a 25-year-old. i don't think it's common, but we've seen it over and over and over. it cannot be rare.

to me what our job is, as american citizens, to maintain the health of these young athletes for the entirety of their life, and if there's something we can do to limit this risk it needs to be done immediately. >> thank you. mr. miller, do you think there is a link between football and degenerative brain disorders like cte. >> certainly dr. mckee's research shows a number of retired nfl players are diagnosed with cte. the answer is certainly yes. but there are a number of questions that come with that. >> i guess i just -- >> right. >> is there a link? >> yeah. >> because we feel -- or i feel that that was not the unequivocal answer three days before the super bowl by dr. mitchell berger. >> i'm not going to speak for dr. berger. >> you're speaking for the nfl, right? >> you asked a question whether

i thought there was a link, and i think certainly based on dr. mckee's research there's a link because she's found cte in a number of retired football players. the broader point and the one your question gets to, what does that mean, where do we go from here with the information. when we talk about a link or the incidents or prevalence, i think that some of the medical experts around the table -- for the record, i'm not a medical physician, i feel limited -- or scientist -- i feel limited in answering your question. i defer to the people around the table what the science means around the question that you're asking. >> i have another -- another issue i want to bring up. in saturday's tribune, brandy chastain, famous soccer player, they had that famous picture of her taking off her -- anyway, talked -- she is donating her

brain to science, because obviously she wants more research. plus, she has -- she's acknowledged that she may have suffered several concussions. but this article also says that "the new york times," the no female athletes have been found to have cte, "the new york times" reports. which i found strange, but it also talked, this article talks about female athletes suffer greater rates of concussion, report more symptoms after concussions and demonstrate greater impairment during neuro sk psychological testing for experiencing concussions when compared with their male counterparts. and the idea that there needs to be more research and nih actually just now, 2016, said that gender has to be a consideration in all pretrial and in clinical trials. so animals have to have gender difference as well as the clinical trials.

and so i -- i just want to put that out there. i want to ask, do we need to reconsider whether or not sports need to change for minors? should we, for example, eliminate headers in soccer? should we be considering whether children, minors, ought to be playing tackle football at all throughout their lives? do we need to have a more comprehensive view of whether or not we should subject our children to these kinds of sports? you know, adults who want to play professional athletics and want to risk this kind of thing, it seems to me that's their decision. as long as they know the risks. but children, should we change sports? >> from the standpoint of what you're asking about gender issues and at-risk populations and bringing this back to scientific level, can someone respond? first, dr. gioia and hainline.

>> there was a conference held at georgetown a few weeks ago that looked at the issue of gender and concussion in particular. one of the things i presented at that meeting was that it's -- it actually is age and your gender. we in fact, in our work, have found that boys and girls are not different either in terms of their symptom expression when preadolescent, but when they're adolescents we see big differences between boys and girls and symptom expression. we don't know why. but that also -- when boys and girls are not injured, whether young or adolescent, we don't see them talking about nonconcussive symptoms differently. so there's something about concussion in adolescents that is an issue here. i'll go back to kind of the point i made earlier, which is that we don't understand enough about girls in this kind --

>> what direction are girls different than boys? >> higher symptoms. adolescent girls are reporting more symptoms and taking relatively longer to recover than boys. >> is it true that no female athletes have been found to have cte? >> that's true. we've only had four female brain donors and they weren't all athletes. it has been twice described in literature, one was a domestic abuse situation where she had been abused for many years by her husband. another one was autistic woman who banged her head. a repetitive head banger. the demographic of sports in military service really favor men at this point. we expect this to change because of the recent increase of women in contact sports and certainly in the military. but we are actively trying to recruit female brain donors to answer this very important question, is there a gender difference in the outcome from repetitive head injury. >> doctor, do you have an answer? >> yeah. i think the main issue here is we're talking about complicated injury in the most complicated organ in the body.

and there's a lot less that is known than not known at this time. we don't have a natural history study from the time that a kid gets injured or somebody has repetitive injuries through the course of the development of something like cte. for example a colleague, cardiothoracic surgeon, look at what the framing ham study did for heart disease. it completely changed the way we look at it today. what we need today is a longitudinal study of the problem to understand what is the incident of this. we need better diagnostic tools. we don't have beyond a clinical exam objective biomarker or blood-based biomarker we need better ways to predict who are those people who aren't going to do well. it comes down to funding your pamphlet here, you highlight that the nih is spending $93 million to understand a problem that costs over $70 billion a

year. professional athletes make more money in a single contract than the doctor had to fund research that we're asking questions about today. in many ways the gap can be closed by better care, better follow-up, better screening and unfortunately we have to make a bigger investment in the problem to understand this. again, i'm overjoyed that the american public has turned a problem that as a neurosurgeon working in level i trauma center in an urban environment, i've seen this and the consequences of traumatic brain injury for decades. i appreciate you're interested in this. but there's got to be a more sustained and powerful investment to understand the problem. >> dr. hainline? >> so i want to speak with some cautious optimism about where we may be. so the ncaa and the department of defense joined forces, a little more than a year and a half ago. we have begun a study, and we're going to be getting results real-time. so this is a study that is

involving 30 schools. at each school every single student athlete, whether female tennis player or male football player undergoes rigorous multimodal examination. if they're concussed it's repeat the six hours, 48 hours, onward over six months. in seven sports, three of them women's sports, women's soccer, la crosse, and ice hockey. same thing for men and men's football. also getting genetic testing, kids are wearing sensors and getting brain mris. just in a year and a half, we've done studies on 18,000 student athletes and tracked over 700 concussions. a large study before that may have been upwards around 20 concussions i'm happy to say to people at table, mickey collins is a participant, mike mccrea is a principal investigator. the colonel and i spent probably a year putting this together. geoff manly and i met, we're

working in a cross functional way that has never happened before in concussion research. there are so many people that are invested just in this study alone. what we're going -- what we're doing and dr. mccray can speak to this, because i'm not allowed to evaluate the results first hand, because that would be a conflict of interest. walter and i and dallas, we're on the executive committee of the study. we have oversight but we don't have any voting power. so it's really set up in a way that it's a non-conflict of interest study. we will be having a few things. the study's going to provide definitive evidence. in the short term, within two years, on what is the natural history of concussion. just concussion. we're also going to be defining neurobiological recovery in concussion. which is exceptionally important. that's different than symptom recovery. we will have that data. mike mccrea can speak better to it.

but i think probably closer to a another year from now, we'll have definitive data on, what does it mean to be neuro biologically recovered. coming back to washington in three days, laying foundation s to put this into a five-year study and make this the framingham study of concussion. it doesn't mean we're waiting 35 years. it means in very, very active five-year increments we're coming in with new tools including p.e.t. scans and more advanced brain imaging, to understand what are we seeing in these increments. are we seeing problems for certain groups of populations. one of the advantages of the study, it's not just ncaa athletes. every cadet at air force and west point is enrolled and we're studying these individuals as well. in addition for everyone concussed, they have a control and their contact collision sport and noncontact sport. for the first time we're going

to have real data on those who have had repetitive head contact but haven't been concussed. so that's something that we're actively looking at. so that's ongoing. it's very real. and the first wave of analysis is going to be reported sometime -- not going to hold you to it, mike -- in the late spring. >> june. >> and it's going on after that. even while we're waiting for these results, so just two weeks ago there were 15 of the most prominent medical organizations in sports medicine organizations in the country, and we looked at the first round of the results, including very, very detailed head sensor data. i'm not putting out a specific date, but you're going to see, coming probably within the next three months, very new recommendations that are called inner association guidelines. not ncaa specific but equally endorsed by the american medical society for sports medicine, congress of neurologic surgeons, american academy of neurology on concussion diagnosis and management. with regard to our football

practice, the ivy league was in the room with us, their information was leaked earlier than they wanted. but there's going to be a whole new emphasis on absolute recovery, which is something that's been overlooked as well. i am just a little optimistic that we do have something very, very hot in the pipeline, it's very real, and we're getting active results. >> does anybody here think anybody at this table think we should change the rules of the sports for our student athletes? that's what i want to know. should headers in soccer -- my grandchildren play soccer -- be eliminated? or any way we should change football? >> i feel, and brian you've brought so much to the field, with the research you're overseeing and managing, i think we need science to lead the way. and i think it really behooves us to put science first in understanding these issues because if we make sweeping changes on sports without having science there could be unintended consequences that i see every day in clinic. >> correct.

>> i want to make a pitch for science so lead the way. >> if we don't fund this for longer than the two or five years, we'll be back in here five years. this longitudinal needs to go on. headers are not the problem in soccer. >> richard hudson has a question. then paul tonka. >> did you want to say something, too? i didn't see your hand. >> yeah. i would just say, i hesitate to want to wait on the science when we know that simple changes to a game can have such a tremendous impact on the safety of children. i would say absolutely there could be changes in youth sports and absolutely we should be having a conversation about the wisdom of putting our kids in activities where their heads are getting hit repeatedly over and over, when we know for some individuals those consequences can be very, very dire. and we don't know yet about the risk factors. we don't know yet about those that are going to ultimately

be -- have the consequences of something like cte but we absolutely know that no head trauma is good head trauma. i believe there are ways that we can absolutely make games safer, without toying with the fundamentals of the game. soccer, absolutely, they raided -- raised the age at which they will introduce heading in soccer. the usa hockey raising the age of checking, all of those will make tremendous difference in terms of making kids safer. we should explore every opportunity to make every sport safer in ways that don't change the game, but absolutely that conversation should be had. >> i want to make sure we get our members' questions in. mr. hudson. >> thank you, mr. chairman. thank you for this hearing. i represent the home of the carolina panthers, and i did marry a girl from denver. so i have to congratulate you on the super bowl victory.

[ inaudible ] i appreciate you wearing a panther blue jacket today. [ laughter ] sorry. i have become interested in the issue of pediatric trauma.