>> if anyone want to answer that question you'll have to do it by writing. oh you have a question? i am sorry. >> i am sorry i am late. i met another hearing. i understand the nfl participated in a program initiated by the consumer products they initiative to help them in low income communities. i really want to commend that. it is going to cost a lot more money to get to the point where all kids around the country who played football no longer where old helmet that are likely

degraded or obsolete. i'm pleased to learn of your donation. it strikes me of an knowledge meant that wearing an old helmet when playing football is not advisable. it is a statement that would be very influential. we've also heard that reconditioning those under 10 years old is important to ensure the proper phone density and that other degraded parts are replaced. want to ask you the following questions. i guess that is why i'm sitting in the seats. we realize that many issues are subject to negotiations. can they commit to supporting the habitant helmets on the field that are over 10 years old?

>> in the youth space. i plead not enough familiarity with the issue. i know there are a couple of states that would be happy to work with you to pursue it. the first question is committed to prohibiting helmets on the field of over 10 years old. can you commit to the supporting a policy positions that these present an unacceptable safety risk that is right most of the helmet industry? >> i see no reason why we would have a concern with that. it sounds appropriate. >> i recommend that the helmet should be discarded after 10 years. can the nfl committee supporting a position that helmets be discarded after 10 years? >> we would certainly support helmet companies and how they advise people to use their products.

>> we have heard stories of using players -- players using beat up helmet or adjusting them by removing some padding. 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 helmet they use as long as they pass the standards. that is something that is a point of discussion with the players association. they passed the standards. >> they were reconditioned properly. they have the appropriate padding. >> the helmets are reconditioned regularly. our management works to make sure their helmets are in good working order. >> thank you. >> thank you very much.

[no mic] >> he discusses the interpol database system and which countries use it. as always we will take your calls and you can join the conversation at facebook and twitter. "washington journal" live at 7:00 a.m. eastern on c-span.

housetinue now with the energy committee on sports and brain injuries. >> in neuroscience and medical research. physics when he arrives. so, panel ii, i will introduce you. he is the advertising practices at the federal trade commission. he is the student ambassador for the national council on sports he. if i may editorialize, i think jan did a great job of juxtaposing a days of tbi and confessions -- concussions on each panel.

this is from a more scientific-based panel. thank you for taking your day away from school. i know how tough it is to be pulled out of school and come testified before congress just like a normal high school students. dr. robert graham at the institutes of medicine. dennis, center for brain biology and behavior at the aimed university of nebraska and think you. then dr. james johnson, assistant professor at the department of neurosurgery at the university of alabama birmingham. star of screen. professor of atomic, manipulator -- binoculars and atomic physics.

a phd division of chief neuropsychology, children's medical hospital. and not quite up to the level of university of nebraska we have the harvard medical school. that is just humor. a 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 a scientists and experts. we will start. your now recognize for your -- you are now recognized for your five minutes. >> the green light is on. is it better? i am the assistant director for the division of advertising

practices at the federal trade commission's bureau of protection. i am pleased at this opportunity to provide information about the actions we have taken over the last few years with respect to concussion protection claims. claims that implicate serious health concerns, especially those potentially affect and children and young adults are always a high priority at the commission. the commission strives to protect consumers using a variety of means. section five of the federal trade commission act prohibits unfair acts or practices. in interpreting section five, the commission has determined a practice is deceptive if it is likely to mislead a consumer acting reasonably and is likely to affect the consumer's conduct, choice, or decision about a particular product at issue.

the commission does not test products for safety. it does require an advertiser have a reasonable basis for all objective claims conveyed in an ad. the commission examines specific facts to determine the type of evidence that will be sufficient to support a claim. when claims involve health and safety, advertiser generally must have confident, reliable, scientific evidence substantiating the claim. as awareness of the dangers of concussion has grown, manufacturers have begun making concussion protection claims for an increasing array of products. these include football helmets and mouth guards, but also include other products. in august 2012, the commission

announced a settlement with the makers of brain pad. the commission alleged it lacked a reasonable basis that they reduced concussions, particularly those caused by lower jaw impacts and falsely claimed scientific evidence proved the mouth guards did so. final order prevents them from representing any equipment as assigned to protect the brain from injury will reduce the risk of concussion unless the claim is true and substantiated by reliable scientific evidence. the commission sent out warning letters to nearly 20 other manufacturers of sports equipment advising them of the settlement and warning them they might be making deceptive claims about their products. the ftc has monitored these websites and is working with them as necessary to modify their claims. in some cases, to ensure the necessary disclosures are clear and prominent. commission staff continues to survey the marketplace for concussion reduction claims and alert advertisers who are making potentially problematic claims

of our concerns and of the need for appropriate substantiation for such claims. commission staff also investigated concussion reduction claims made by three major manufacturers of football helmets. the staff determined to close investigations without taking formal action, by which time all three companies had discontinued the potentially deceptive claims or agreed to do so. those cases are discussed in greater detail in the written testimony. the commission plans to continue monitoring the market for products making these claims to ensure advertisers do not mislead consumers about the capabilities or science. at the same time, we are mindful of the need to tread carefully to avoid inadvertently chilling research or impeding the

development of new technologies and products that truly provide concussion protection. the commission appreciates the committee's interest in this important area as well as the opportunity to discuss our effort to ensure the information provided to consumers, in particular to the parents of young athletes, is truthful and not misleading. thank you. >> ian, you are recognized for your five minutes. >> thank you for the opportunity to share my story. i am 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 a sophomore playing in a high school off-season lacrosse game when i sustained a serious head injury 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, performed in my school's jazz ensemble, and had an active social life. it was over in a split second. my concussion left me with only 5% of normal augmented activity. i was almost immobilized. i spent 2.5 years recovering and 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 and even moving my eyes caused headaches and nausea. i was enrolled in the program where i received ongoing evaluation and treatment for symptoms. after missing school for two weeks, i tried to go back but was not able to function. the frustration of trying to focus on lectures and the

constant sensory bombardment made a normal school day impossible. however, i eventually enrolled in a home teaching program. with the help of my tutors and family, i was able to complete my course work at my own pace. i finally returned to school in december but was still far from recovering. i have spent the 2.5 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 i needed to shut down from any kind of mental or physical activity for a day or two. these relapses were tough and discouraging. they meant i had to drop a class and miss a band trip to chicago, among other things. the worst was when i could not go to my first concert, the red hot chili peppers. the friend i gave my ticket to owes me. the spring after my injury, i

was cleared to return to sports but made the hard decision i would not play lacrosse or other intensive sports again. i know a lot of people recover and return to play, but the possibility of another concussion means i could lose everything again and not come back the next time. i now look at my recovery as something that has made me stronger. but i know i am one of the lucky ones who had resources and medical attention i needed and a school system aware of concussion issues and provided an unusually high level of support. it is not over yet. my recovery continues. my outlook is positive, and i am excited about the future as i prepare for college. i'm thinking about becoming a high school math or science teacher. i have a hard question. what can be done to create a safer sports environment to ensure when injuries do occur the support for full recovery is available? we cannot just do away with youth sports.

i played baseball, soccer, and lacrosse. being on those teams gave me a healthy outlet. it taught me important lessons. sports are one of the best parts of growing up in becoming a strong adult. they teach us if we work hard, we will become skilled and proud of our accomplishments. they teach us how to be part of a team, have pride and success, and learned 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 steps can be taken so 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 an 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 were

fear the losing status of the team is out for injury, to be willing to recover fully before returning to play. it will take a while, but if youth and professional sports are to survive, these attitudes must be embraced. when injuries do occur, we must have a way for qualified personnel to quickly assess injuries on the field, how players get immediate attention, and support recovery through schools and medical institutions. these are the things that were done for me and are the reason i have been able to return to normal. as a student ambassador, the message i hope to give young athletes is this. you think you are invulnerable and 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 is the only brain you will have. your personality is who you are. it is not worth a couple of

seasons of glory to lose the opportunity of a lifetime. thank you. >> very good. dr. graham, you're recognized for five minutes. >> my name is bob graham. i served as the chair of the institute of medicine sports related concussions and youth study. you have my testimony before you and copies of the study. i will take these minutes to give you a summary. the institute of medicine is part of the national academy of sciences, chartered by congress to provide advice to congress and the executive on various scientific issues. we were specifically impaneled to look at the evidence about the causes and consequences of concussion in youth and military, the state of concussion diagnosis and management, the role of protective equipment, and sports regulation. we had 17 members on our

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

recommendations related to research. we need the 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 an individual has had a concussion? now it is based on observation and self-report. are there physiologic markers that could be used to give us better documentation concussion has occurred? perhaps without the individual knowing it or without it being observed. secondly, we need the nih and dod to look at the short and long-term consequences of concussions. we have heard testimony of individuals who have had one or more concussions, long-term consequences.

some sense of the epidemiology and what treatment and interventions may be, and what rehabilitation may be. the fourth recommendation was to the ncaa and national federation of state high school associations to look at age-appropriate techniques and playing standards. your first panel talked a 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 the risk of concussion? there was one example from the hockey area where they changed the level where they allow body checking and felt they saw a decrease in concussion. we think that same examination should take place at the college and elementary and high school level to see whether they can

have the same impact. the fifth recommendation had to do with a better study of the role for protective equipment. your first panel talked a lot about that. the committee had a number of questions about that. our committee found there was very little evidence helmets protect against concussions. there is a lot of data. i think other panelists will be talking about that. you may come away with an equivalence degree in physics this morning. it is a complicated issue. there are a number of suggestions. we did not recommend you don't use helmets. they do protect against bone injury and soft tissue injury. but the suggestion the helmet itself may decrease the incidence of concussion, the evidence does not appear to be there to us. we think the nih and dod have a

role in looking more specifically at what we may be able to do related to the biomechanical determinants. our final recommendation had to do with the topic that has come up frequently. that is changing the culture and the way concussions are viewed. this is a significant injury. athletes need to be encouraged to report, to take themselves out of the game. coaches and parents need to be encouraged to say for your own protection, you need to be removed and give yourself a chance for recovery. thank you. >> dr. molfese, you're >> dr. molfese, you're recognized for your five minutes. >> thank you for this opportunity. if we could have the slides. go to the next slide.

yeah. the earlier group talked about a number of -- if you can go ahead and put that on powerpoint. a number of sports where the rate of concussion is particularly high. there are differences in rates for men and women. dr. gay will talk about that in terms of weaknesses of women's necks relative to men and how that puts them at more risk for concussion. the next slide. concussion accounts for roughly 75% of traumatic brain injuries in the united states. it is a brain injury. there is damage to the brain. there is discussion about whether it is permanent or temporary. in the military, the rate is 77%.

youth sports are a good model for looking at concussion in the military. most military concussions occur in situations like they do with the rest of americans. some certainly occur in theater. but the majority occur outside of theater in accidents. next slide. if we look at brain injuries overall, these are all estimates and they vary across literature. we are looking in the neighborhood of 4 million traumatic brain injuries per year in the united states. part of that is our birth rate in the united states is roughly about 4 million. this does not count other ways children are exposed to head injuries. perhaps an irate parent who slaps a child creates rotation movement that can produce a concussion. one would suspect those are largely unreported.

recovery generally is fairly quick, usually within a few hours to a few days. some will persist to two weeks or out to six weeks. roughly about 20% seem to persist beyond that time. next slide, please. this is a slide on data we have under review. these are data recorded brain electrical activity. you have 256 electrodes that fits on the head in about 10 seconds. we present a series of numbers, one at a time. all the college athletes had to do was say whether the number they see matches or does not match the number that occurred two positions earlier. on the left side, the colored circles, on the left for match and non-match.

those are images of the brain electrical activity on the scalp recorded by the electrodes after the number appears. the schematic on the right shows you the head position. it is a very rapid brain response. for those athletes with no history of concussion, we see a clear difference in the electrical activity for the match versus mismatch. a lot of yellow and green in the top. in the bottom, we see red and shades of blue from the front the back of the head. on the right, these are individuals who have a concussion history of one to two years earlier, not current. their brains cannot discriminate whether those two numbers are the same or different.

they get these tests correct ultimately, but it takes them longer. the processing speed is slowed. after two years, one might suspect that is a permanent change. the next slide. some of these are a review of what dr. graham talked about. how does concussion affect the brain in the short and long-term? we don't have much information about that. the dose requirement to produce concussion and postconcussion syndrome. how can you reliably detect when the brain is injured and when it is fully recovered? we have no ways to do that. lots of individual differences from one person to the next. we think there are genetic factors involved. there could also be a concussion history the person does not think they have. how many of us have bumped our heads getting in or out of the car?

that could produce a concussion. how does the brain recovery from tbi? finally, how we improve and accelerate recovery. we have no scientific basis for any interventions. thank you. >> thank you. dr. johnston, you're recognized for five minutes. >> thank you for inviting me to testify today alongside this illustrious panel about our experience in alabama. >> could you pull the microphone a little closer? >> is that better? following the passage of concussion legislation as well as the work we are currently doing at the university of alabama birmingham to improve sports safety. sports are an extremely important part of our culture. we take the safety of children seriously. the problem of concussion has gained prominence over the last decade.

recent studies have identified long-term health consequences including depression and other diseases associated with repeated impacts. while college and professional football gets the most media attention, it is important to keep in mind greater than 70% of all football players in the u.s. are under 14. we will need to address the issues athletes. parallel to enacting the alabama concussion law in 2011, the task force initiated a statewide concussion education and awareness program. it worked. in the first year, we observed a 500% referral increase in student athletes referred. it is a trend that has held

steady with about 350 youth athletes seen every year. to optimize care of this increasing population, we created a protocol following the zürich guidelines. they were evaluated, kept out of sports until symptom-free, referred when appropriate, and supervised in a return to play and return to think program. that resulted in better care. even though these efforts have resulted in improved recognition and treatment in alabama and other states, we believe much remains to be done to prevent injury in the first place. given the difficulty of delineating the threshold using existing technology and other ways of evaluation, researchers have begun to widen the focus to cumulative results.

animal models have demonstrated problems with complex spatial learning, cognitive impairment. definitive conclusions about threshold for impact frequency cannot be drawn from the early studies. it has become clear that sub-concussive impacts need to be studied. recent studies at wake forest suggest a significant portion of young players' impacts takes place during practices. the largest take place during practices doing outdated drills with untrained coaches. top programs don't do these. the alabama association published nonbinding guidelines to limit full contact hitting practices to twice a week.

i believe this is complementary to techniques and numbers of practices per week. pop warner has instituted similar guidelines. limiting the frequency of hitting in practicing would lower the exposure for every player. it is clear helmet standards must be updated to reflect our improved understanding of concussion. it is clear both types of impact play a role but only linear is studied from a model developed in the 1960's.

we believe having a more complete picture of the impact seen on the football field is necessary to come up with meaningful standards. engineers have recently developed a robust analysis system to analyze impacts and re-create them in a lab. the passage of legislation, community education, and recent advances in understanding have improved overall safety. we are recognizing concussions more frequently. more work remains in education and drafting policies to limit head impact exposure. i believe the development of new helmet standards is crucial. thank you for the opportunity to testify. >> thank you. dr. gay, you're recognized for

five minutes. >> i'm speaking to you as a football fan who happens to be a physicist. my main professional interest in the game is the understanding of how protective equipment works and can be improved. i wish to consider several aspects of football that are problematic as far as concussions and how we might move forward to make the game safer. american football is an inherently violent sport. that is one of the reasons we love it. the forces encountered in football can be huge. consider a big hit between a running back and linebacker at full speed. we can show the force each player exerts on the other exceeds 3/4 of a ton. this is why football is called a contact sport. two players who collide at full speed helmet to helmet are expensing the same force to their heads one would feel if he

had a 16 pound bowling ball dropped on his helmet from eight feet. medical knowledge of concussions is in its infancy. we know one thing for sure. forces to the head and that cause concussions. we've just heard how big these forces can be. here is another problem. they are getting bigger. since the 1920's, the average weight of pro-linemen has increased 60%. these players have gotten 10% faster. combining speed and mass to calculate kinetic energy, we find the amount of energy at the line of scrimmage on any given play has almost doubled since 1920. in exact opposition is the fact in exact opposition is the fact that players are shedding protective gear.

poor scholars, popular with lineman of my generation, have gone the way of the flying wedge. modern helmets are technological marvels, but players choose them not for the cushioning ability but for how cool they look. another problem is the poor state of our medical knowledge. i'm not competent to explain these issues. i think it is safe to say a roomful of head trauma physicians will not agree on the details of what concussions are or what causes them. the diagnosis and treatment have a long way to go. as our understanding improves, we may find injury rates have increased faster than we thought. finally, football is big business, especially at the college and professional levels. when monetary forces manifest themselves as they do in bounty programs and illegal doping to

improve performance, the game becomes more dangerous. what are the solutions? we need better equipment. this can get tricky. it is apparent adding more energy absorbing foam to the outside of the home it will lower the force delivered to a skull. this has been tried in the past. the problem is the added padding increases the diameter as well as the coefficient of friction, meaning the opposing player can exert more torque on your head. nevertheless, some companies are proposing the same idea for youth football. the use of the star system for rating helmets represent important first steps toward improving football safety. for a variety of reasons that disregard player safety, they are largely ignored. our understanding of the physiological and epidemiological conditions must be improved.

there is an understanding in the nfl and college level that significant research is needed. several members of this panel are leading cutting-edge efforts in this area. finally, some incremental rule changes and more stringent enforcement of existing rules are needed. some of the new rules regarding targeting are making players more hesitant on the field. these rules may increase the risk of injury. rule changes should be studied and possibly reversed. it is my belief a return to the level of padding worn in the 1970's would make the game safer. more thorough doping rules should be developed and enforced. the nfl season should be reduced to 14 games. the college season returned to 11. 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 valuable time. >> thank you for your valuable time. you are recognized for five minutes. >> thank you. i appreciate the opportunity to speak on behalf of the safety of our children in this country. i am a pediatric neuropsychologist at children's national health system in washington, d.c., and the director of the concussion program. i would like to take my time to focus my comments on the importance of public health education for youth concussion using my expertise as a clinician and researcher. i have worked for the last decade with the cdc on their heads up concussion program materials.

we all know, and i think ian said it perfectly, the 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 with careful attention to safety issues. science must drive our action oriented approach. concussions threaten the development of our youth. in an attempt to protect our youth, we have laws in all states with the good intent of protecting our student athletes through rules for educating coaches and parents and removing suspected concussions and not allowing them to return until cleared. all states include the high school at this level, but only 15 of 51 include youth sports. less than 1/3 are looking at the majority of athletes.

in preparing for this testimony, i was posed with an important question. with awareness at an all-time high, are organizations and parents more aware but still not sure what to do about it? the simple answer is yes. many coaches and parents are not equipped to know what to do with a suspected concussion. mechanisms are inconsistent and limited in scope. the health and safety of youth athletes is largely in the hands of coaches and parents at the youth level. they need medically guided training and early identification and protection. coaches and parents must receive training on recognition and response. awareness is not enough. they have to be prepared properly. we know repeated concussions present the greatest challenge. our challenge is the

implementation so we can prepare coaches and parents to know what to do and have the tools with which to do it. over the past 10 years, our program has delivered hundreds of education and training programs using the headset materials from the cdc. we have learned much about the community needs and how to deliver the message. we deliver scenario-based training where we present to coaches and parents an actual situation and what they must do to respond. this is important as we put these responsible adults in place. you have heard important other activities and examples of head safe and had smart action such as the tackling program where coaches are educated in response

and recognition but also taught techniques we believe can improve taking the head out of the game. we have to go further in all youth sports. we do not have a universal strategy to recognize and respond to these injuries. we have tools and programs, but we do not have the delivery mechanism to do that. we have to build on partnerships between organizations and medical care systems. concussions are complicated. we are not asking parents and coaches to be clinicians and diagnose. we have willing teammates as you have heard, but we need to build those partnerships. we need the help of the professional sports leagues.

we need the manufacturing world to team with us. we need the quarterback to make this happen. we have to leverage the efforts of other organizations like the national council on youth sports safety. all of this is important for us to do. we need 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. we do not need to be scared away from that or avoid participation in sports activities. we need to focus on how to teach recognition and response. our country needs a universal mechanism to implement community focused solutions. we believe that can help children as they enjoy the benefits of sports. our motto applies. it says play hard, play safe, but play smart.

thank you. >> you are now recognized for your five minutes. >> thank you. my focus will be on the radiological evidence of concussion and sub concussive blows to the head. what is known is mild traumatic brain injury is common in sports injury. when we are talking about a single mild tbi, about 80% get better. between 15% and 30% have persistent symptoms. what are most concerning our chronic disorders. that is the second one. it is repetitive mild traumatic brain injury we are concerned with.

the clearest evidence comes from postmortem studies. the next slide. this is a postmortem slide that shows protein in the brain. this is the brown areas. this is in the case of a retired professional football player who had symptoms and was presumed to have chronic traumatic encephalopathy which was confirmed postmortem. here are four individuals. this work shows injury and repetitive brain trauma look the same postmortem. 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 18 with repetitive concussions, and a 21-year-old with sub-concussive blows to the head only.

mild tbi is difficult to diagnose. that has been a serious problem. if you use conventional ct and mri, are not likely to find differences in abnormalities in the brain. many have said there is no problem. the problem is the correct tools have not been used until recently. with advanced neuroimaging, we are able to diagnose and move towards prognosis and hopefully intervention. advanced neuroimaging techniques which we have been using show radiological evidence of brain alteration in living individuals with mild tbi. if we can detect this early and look at underlying mechanisms and characterize what is going on to come up with preventative measures. the next slide. this is a study from our group

looking at hockey players in canada. the bottom line is on the right. preseason is the first. the second is postseason. the red dots are three individuals who had concussions. the increase is an increase in extra-cellular water in the brain, not a good sign. we also looked at gray matter, that is the cortex where neurons are in the brain. this is a study in former professional football players who were symptomatic. we found there is cortical thinning compared to age matched controls. what is most concerning is the blue line that shows it accelerates with age. this suggests it may indicate abnormal aging any risk for dementia we can see in living

individuals. the next slide, please. this is a study we did in germany with elite soccer players. we selected them specifically for not having a history of concussion and not having any symptoms. we found compared to professional swimmers, there was a huge difference between the groups. that control is on the left and the soccer players on the right. there's all most a complete separation between the groups with the measure of damage to myelin in the brain. what we don't know. what is a result in some and not others? why do some develop neurodegenerative disease while

others do not? what are the predisposing factors? is it exposure? are genetics involved? not every player who gets hit ends up with these neurodegenerative diseases. next slide. we need diagnosis to detect brain injury early. we have tools that can be applied. prognosis to follow recovery. we need to follow recovery and degenerative processes to predict who will have a poor outcome and a good outcome. knowing that, we might be able to intercede with treatment to halt cascade of changes. in summary, sports concussion leads to alteration of the white and gray matter. neuroimaging can detect injury following trauma.

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 will lead to a poor outcome so we can intercede. some measures of safety such as rules for returning to play are needed after observable evidence of brain trauma. thank you. >> thank you. very impressive testimony from everyone. i was impressed you all stuck to the five minutes, pretty close. i'm going to go back to dr. molfese because years juxtapose each others nicely. your research is finding the baseline of the new athletes that enter university of nebraska. is this allowing you to detect

injuries earlier? there may have been pre-existing subconcussion. how are you identifying that? what is it telling you? what is the university doing to implement some level of protections? >> one of the major changes we have seen occurring across the field is the effort to get pre-concussion data. more schools are moving to observing students before the start of the season. should a player be injured, one of the weaknesses is the players do not always self identify. we run across that a number of times in our testing. we will pick up something on our

tests that the trainers and medical team did not know about because the player did not disclose. we also try to test someone else who plays a similar position has not been injured. they act as a control over the course of the season. we are finding what occurs across the season in normal players with no history of concussion, their speed of processing does change over the four or five months of training and the season. with the players who experience concussion, we see a slowdown of about 200 milliseconds. that is four times faster than the slowdown in multiple sclerosis, for contrast. clearly, the brain has changed the way it is processing. we are moving to start intervention programs with the

players identified. there is some data with alzheimer's that suggest working memory tasks, even one week, can show continual gain and improvements. we are trying to see some of that occurring. >> thank you. dr. gay, in regard to concussions, many times it is not a direct blow. the head is going back and forth and the brain is sloshing around. you mentioned going back to 1970's type equipment. describe what you mean by 1970's equipment and how it may reduce concussions. >> the neck roll or horse collar is a piece of equipment that has

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

literature. 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, by change in play, that is what you have to do to decrease the incidence of concussion. >> thank you. i only have 11 seconds left. i will recognize my ranking member. >> in addition to the science, so much talk has been about culture. it seems that is very important. 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 win at all costs attitude among players and coaches. what would you tell teams to help them change that attitude? >> thank you. i would encourage the coaches to stress this as much as possible, as well as the parents. coaches and 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 is the cycle of teaching and making sure players no winning is not the most important thing. it feels great to win. but i would much rather lose than have another concussion.

>> you were aware of the severe consequences of brain injury. do you think youth athletes understand what the symptoms are? >> yes. i think it is getting better, especially at my school. we emphasize making sure you know the symptoms of concussions. i feel like it is spreading as well. >> when he asked the doctor. >> at this point, the education programs are being directed toward athletes. about five or six years ago, there was a study that showed that that was the number one reason why athletes were not coming out of the game, because they did not know the symptomology. they did not know what they were dealing with. we also believe athletes and

teammates need to watch out for each other. the concussed athlete may not have the wherewithal to know they are not right. their teammate often does. there is a responsibility within that team to take care of each other. that is an important focus. >> that goes to culture as well. these explain how advanced neuroimaging works. describe the type of changes in the brain your lab is able to detect that traditional imaging cannot, and also some of the imaging 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 useful? >> i have one slide that explains diffusion imaging. >> the one i did not understand

was comparing soccer players? >> i was going to show you why it is important. the injury that happens with the impact to the brain is generally a stretching of the cables in the brain, the white matter. the corpus callosum is the largest white matter track in the brain. this does not show up on traditional ct or mri. 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? he said because everyone knows you cannot see anything on the brain. brain. but nobody is using the right tools. this is a simple principle of diffusion imaging. on the left, this is ink that goes in all directions.

you are dropping ink on newspaper. newspaper has fiber so it restricts the water. this is the same principle used to look at the brain. in cfs, it is round. everything goes in the same direction. if you're looking at white matter, you are restricted in two directions. you can measure the integrity of white matter fiber bundles in the brain. that is what you need to look at in mild tbi. if you have a moderate or severe brain injury, you don't need this technology. they will be put into neurosurgery and they will do an operation. it is the subtle brain injuries that are not recognized using conventional imaging where you can recognize it if you use something like diffusion imaging.

we have shown you can see. it is not just our group. starting in 2003, people started using it because it is the most sensitive imaging tool that exists today looking at the major injury in mild tbi. what needs to be done is to look at acute injury and see what predicts outcome. at 72 hours, three months, six months. can we predict what happens at 72 hours? we have someone in our lab trying to separate water outside the brain. if you can predict from 72 hours, you can go back and say maybe we want to put in anti-inflammatory medications. we don't know enough right now.

the only way to know is to do these longitudinal studies and follow over time using sophisticated imaging technology. once you know, you can diagnose. >> this could be very promising, not only for athletes before returning veterans, and applied eventually to schizophrenia or alzheimer's. >> i am primarily schizophrenia research. that is what i have done for 30 years before i became a tbi researcher in 2008. we have a measure called free water based on imaging that shows at the first episode of schizophrenia, you see fluid around all of the brain. it is free water. it is isotropic. in the frontal lobe, you see it were restricted to tissue inside. this is a new technique

developed by a fulbright scholar in our lab from israel. >> i'm going to have to say thank you. >> thank you. the gentleman from new jersey is recognized. >> dr. johnston, you stated many sports related concussions still go undiagnosed. i would like to know why that is the case and how we can improve that. with state laws and the involvement of players, coaches, pta's, areas where we need to have improvement. >> thank you for the question. i would echo what has been said by others on the panel. i think a lot of it has to do with recognition. people are very good at recognizing when someone gets

knocked out on the field. that is a very small percentage of all concussions. as our understanding of the symptoms has arisen, it becomes incumbent on us to improve the quality of education we give to coaches, players, trainers, officials about the symptoms of concussion. my sense is in general, culture, speaking to the state of alabama, the coaches i have come into contact with are believers. they are not purposely hiding kids and putting them back in with concussions. sometimes it is hard to recognize when young athletes do not tell you how they are feeling. we brought up the importance of teammates being involved in diagnosing players. >> how close are we to a better design for helmets? >> i think we are at the beginning.

we have been using a standard that has not changed for 40 years that was designed for skull fractures. many investigators are working to improve standards to include acceleration as well as other important aspects of impact. just as the automotive industry did with safety ratings, the market can be relied upon for manufacturers to improve designs to improve sales. i think standards are important part of the equation. >> thank you. dr. gay, you discussed the fact there is a numerical rating system for helmet impact. it is designed at virginia tech, the star system. you called it the best tool we have for analyzing the merits of helmet systems.

can you describe how it works? >> basically, it involves a test where you drop the helmet from a given height, varying height, to the side, front, back. it tries to simulate the kind of impact a player would experience. numerical scores are given to the maximum acceleration the head inside the helmet feels for the given drops, based on a crude initial model of what causes concussions. it does not take into account rotation or temperature. in my opinion, the reproducibility is not as good as one would like with these tests.

i think it is a good first start. it is the best we have right now. i think it needs to be paid attention to. there is a lot of room for improvement. >> thank you. how old are you and what grade are you in? >> i am the senior. congratulations to you for going on to college. i have a daughter who is a freshman. that means he is a little older than you, but i will be happy to introduce you. i am proud of your testimony. i could not have done what you did. nation has benefited

by your testimony. >> thank you. the gentleman from mississippi is recognized. >> thank you for being here on what is a topic we are only starting to learn about. it has been in the news for several years, that is coming to the forefront. work and testimony will be beneficial to us. parent of a 24-year-old, i appreciate the work you do at the children's hospital. preparation, i had some discussion with parents back home. discussion is i

have several friends who have daughters playing youth soccer. they reported an increase in the number of concussions suffered by young ladies playing youth soccer. we have seen in the news, all the news associated with the nfl, helmet-to-helmet contact, and concussions we see on the field of play, but it appears in everything we do in life, every sporting event there is that danger and risk. that is why i think what you're doing with it in alabama, dr. johnston, what we're doing with coaches, parents, and perhaps using the teammate approach, it may be the safest thing, to have the backup position player be the one to report to the first team when they come out. that might get them off the

field. dr. johnston, educate us, what is a subconcussive impact? what does that mean? should subconcussive impacts affect rules of play, and if so, how? >> i think the definition of a subconcussive impact would be all those impacts that happen that do not result in a concussion. as has been pointed out, the rub with concussion is the diagnosis part. if you look at historical studies, is variable and a lot of that has to do with who is diagnosing it and males versus females, whether or not men or more likely to report symptoms, but a subconcussive impact, and all those other impacts where we have more information to the

work that has been done in boston and other places that even these impacts have results in terms of anatomical structure changes the brain over time. it needs to be addressed in terms of lessening the overall cumulative impact load that every player has. football is the most obvious thing in terms of how many practices a week children should do hitting, but that has applications for all sports. >> thank you. if i could ask you a question, for clarification, if i can ask them, the 77% of military, that figure, is that how many of the tbi faces have suffered concussions? >> trying to bring in -- 77% are concussions, mild tbi. >> can you talk about the work

you are doing? is it practical, something we can expect to be rolled out to the sidelines across america, to diagnose for athletes, and perhaps onto battlefields to diagnose our warriors? >> it is very possible. we published a paper last year where we took one of our e.g. systems and recorded on the sideline of the field. the biggest challenge for us in making it practical is getting the processing time down. for now it takes an hour. if we get it down to five minutes we can sell it to the coaches, because they are the ones who are going to determine. at this point, given all the other issues, the common tests used now are like the impact, which are assessment tools, questions to the player. they have to reflect, and may be

foggy because of the concussion. these tests do not have predictability after two days post injury. that is a big problem. it does not predict recovery time, severity of the injury. these biomarkers are the critical things. we hope these will be much more reliable and predictive. >> thank you for being here, and i yield back. >> thank you. generally, this would end, but we have questions, we are going to do a second round. plus, the bells are not going to go off for another seven minutes. jan has a conflict and she has given us approval that she is going to leave, but she trusts us to ask legitimate questions. >> let me thank this panel, in the previous panel as well. the intensity of the scientific research and then its

application to the playing field and so many other fields, i really want to thank you for telling us what is going on. i also wanted to thank ian heaton for coming here today. it is important to have people like brianna and ian to tell their stories and give us a face to the importance of this, and i want to thank the ftc for making sure that false claims are not made, but this is so important, so appreciated. we will have to figure out where it leaves us, that it has informed us. thank you. >> i would agree with every word of that. so this is a question to you, 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 is possible for early detection or developing a checklist for a coach or a parent to be used by nonmedical? start with you, doctor. >> no. >> that was easy. >> the symptoms overlap with depression and ptsd and has been a real problem. there was a paper published in the "new england journal of medicine" that said when you remove the effects of depression and ptsd, mild tbi does not exist. that is a disservice. it used to be that people came in complaining they still had symptoms from hitting their head, there was no evidence from conventional mri or ct, they said, see a psychiatrist. it was really not appropriate

because there is at least a small minority of people who have mild concussion who go on to have symptoms. they can go on for months, years, and then they can clear up. that is separating it from cte. you need really logical evidence, the same way you want to know values of a blood test for cholesterol or a broken leg. we are moving in that direction, and that is what we need as the hard evidence, because the symptoms are too nonspecific. >> there are studies looking at a number of citizens, and a wide variety of these symptoms people report, there's no indication to report whether somebody reports lots of symptoms versus a few symptoms, that that has any relation to how long they will recover. >> can we get to a point where

the seventh-grade coach, the seventh-grader takes a checklist that the coach could use to determine if that kid should go back into the game? >> there are guidelines out by the cdc and others that list concussion symptoms. the general bias at this point is if an individual reports these symptoms they should be pulled. if you have a concussion and played before the symptoms have resolved, the likelihood of death is much greater, not to mention further significant concussion that will take longer to recover. >> this is one for dr. johnston. one of the debates occurring in nebraska right now is you have a child or a high school student that suffers a concussion. it has been diagnosed. what do you do next?

right now the thought is you keep them home or her home, dark, no electronics. that is the norm. there is a discussion whether that is appropriate or not or to what length. what do you know? what would you recommend? >> i will tell you how we handle things in alabama, which is once an athlete is diagnosed, removed from the field of play, evaluated, we use the sport concussion assessment tool, the scat tool, which is a sideline-based tool, which has a quick mini inventory of neurological exam and cognitive function. when children have symptoms that persist, they do not return to any sort of play or escalation effect until the symptoms have resolved.

those children who have persistent symptoms are then referred to neuropsychologists. >> this is a big question at this point. this comes to what is the best treatment for this injury. let me say the field is moving on this one. the recommendations we make, and i have written several papers on this, is that acute stage of symptoms, the first few days, maybe for some little bit longer if there is a more severe number of symptoms, they really reduce their activity, cognitive and physical. what you want to do is increase that activity over time, so we did not look at kids until they are asymptomatic. that has the likely negative effects on kids being removed. we initially shut them down and then we gradually bring them back into the school and to physical activity.

that has to be individualized, based on the severity of that symptom presentation. that is where we are now. we need a lot of research to help validate that. >> thank you, and mr. lance? gentleman from missouri gets to ask another question -- mississippi. [laughter] i thought you were billy long. >> that hurt. thank you, mr. chairman, in a couple of questions i would have. if we are looking at this -- dr. gay, if i may ask a question, in your testimony you stated football players are shedding mobility. the decision which helmet to wear is their own, and that player often chooses a helmet's

looks over it collision-cushioning ability. do some positions require different levels of collision cushioning, and if so, would you recommend a special helmet for a specific position? >> a great question. currently, there are no position-specific helmets. not tould say that belabor the point, but for alignment, were you to believe we get no severe hits but a lot of concussive blows, the horse collar is crucial. that a wideoutnd where a horse collar. it is an interesting point. certainly some players might.